India has crossed two bleak landmarks in its battle against the coronavirus.
The country has now reached over 400,000 infections, making it the fourth-worst-hit country in the world, overtaking Britain, Spain, and Italy. But it's also lifted its 76-day lockdown and allowed workplaces, places of worship, hotels, and restaurants to reopen.
The grim dichotomy indicates India's bungling response to the coronavirus, one that is sending the country hurtling toward a catastrophic health crisis.
New cases are rising unabated, growing at a faster rate than ever before; hospitals are running out of beds and ventilators, testing remains low; and the geographical spread of the virus is increasing, reaching new areas in rural India. And yet, with its economy reeling under losses caused by the lockdown—its central bank, the Reserve Bank of India, has already estimated that this year will see negative growth—the country is opening up in order to try to stave off economic disaster. In the process, it is walking head-on into a pandemic at its peak.
The crisis is already in full display in its top two cities, New Delhi and Mumbai, which combined account for around a third of India's total cases.
Hospitals are already full, and critical patients with a range of conditions being turned away. Earlier this month, in Delhi's suburb of Noida, an eight-month-pregnant woman died in an ambulance after six hospitals refused to admit her despite a 13-hour-long hunt. In Mumbai, a 68-year-old COVID-19 patient died because health authorities could not arrange a ventilator for her, despite repeated pleas by her relatives for two days.
The stories are grim, yet it is only likely to get worse.
Delhi alone, its Deputy Chief Minister Manish Sisodia said last week, will have 550,000 cases by the end of next month, while another estimate sees a million cases nationwide by then.
But for many public health experts, little of this is surprising.
"The pandemic is only exposing the systemic rot that we had been sweeping under the carpet all these years," said Oommen John, a senior research fellow at the George Institute, a Sydney-based global medical research center, who previously worked with the World Health Organization.
India's poorly funded health care system—the government shells out less than 1.3 percent of GDP on health care each year—means that the country faces devastating shortages even in the normal course of things.
For every 1,000 people, the country has only 0.9 physicians and 1.7 nurses, while the global average is 1.6 doctors and 3.8 nurses.
This underfunding has often led to preventable disasters. In 2017, over 60 children, many of them infants, died over five days at a government-run hospital in the northern state of Uttar Pradesh after the facility's oxygen supply ran out. In the same year, over 180 children died in a state-run hospital in Maharashtra due to the lack of oxygen supply and ventilators.
However, beyond temporary, fleeting moments of outrage, health care has seldom attracted too much attention.
Even when it does, the Indian state has often veered toward limiting its own role and increasing the role of the private sector. For instance, in the country's annual budget presented earlier this year, Prime Minister Narendra Modi's government announced plans to rope in private players to design, build, and operate medical colleges and hospitals in each of the country's 733 districts. This reliance on private capital for providing health care is not new.
Recent estimates by a group of health researchers from Princeton University and the Center for Disease Dynamics, Economics and Policy found that India has 69,265 hospitals of which over 43,000 are privately owned and fewer than 26,000 are owned by the government. The state-owned facilities, though highly subsidized, are often poorly funded and mismanaged. As a result, many patients flock to private health care. This has made private health care a flourishing business. The government estimates the sector will be worth $372 billion by 2022.
Oommen, the George Institute researcher, believes that even the little funding that health care has received has been misdirected. "We needed to build a strong, robust primary health care network around the country so that health care is accessible to all," he said, adding that such a network would have acted as a community surveillance system during the current pandemic.
"Instead, consecutive governments have only invested in big-ticket hospitals, forcing people to come to a hospital even for minor ailments, rather than being able to go to local clinics," he added.
Private health care systems have been reluctant to come to the government's aid in dealing with the surge, compounding the problem. A doctor in one of Mumbai's top private hospitals said that early on in the pandemic, hospitals feared being shut down due to the spread of infection within hospital staff. At least two major private hospitals and many smaller facilities had to shut down in the city in April after large numbers of their employees tested positive for COVID-19.
Twenty-eight-year-old Hemant Mehta (a pseudonym used on request) learned about this the hard way.
When his 77-year-old grandmother started developing COVID-19 symptoms, including dry cough and breathlessness, last week, the Mumbai businessman immediately called some of the most expensive private hospitals in the city.
"We did not mind spending money at all. At that point, all we wanted was medical attention for my grandma," he said.
He spent the day calling half a dozen hospitals. All of them declined to take in his grandmother, saying they had no beds.
Finally, a small private hospital not far from his house in Mumbai's wealthy Juhu neighborhood agreed to admit her. "But when we got there, we realized the hospital was in such a bad state—the staff seemed untrained and there was no doctor around. The nurses were struggling to administer oxygen to my grandma," he said.
Less than 24 hours later, she was dead. Her test results, received by the family only after her death, showed that she had tested positive for COVID-19.
To ensure that private hospitals don't refuse patients, governments across India have adopted punitive measures. In Mumbai, authorities have taken over 80 percent of beds in all private hospitals. Authorities in Delhi announced a similar move on Sunday.
These moves, however, might be far from enough.
Data from the two hot spots of Mumbai and Delhi show the deep trouble that these two cities are in.
As of June 14, Mumbai, with 55,357 cases, had only 17 intensive care unit beds and 12 ventilators available, while Delhi, with over 41,000 infections, had only 26 ventilators and 62 ICU beds available.
And as figures grow, they may represent only the tip of the iceberg, given the relatively low levels of testing. The global online database Our World In Data shows that India has performed 4.66 tests per 1,000 people, as compared to 111.84 tests in Russia and 79.91 in Italy.
Laboratories across the country are swamped with samples, leading to massive delays in patients getting their test results. At a government hospital in central New Delhi, a government doctor, on condition of anonymity, said that such delays only contribute to the spread of the infection.
"This week, we saw a patient with some symptoms who had been waiting for 10 days for his COVID-19 test results," she said, adding that this was a common occurrence.
This, experts say, is leading to many unknowing carriers of the virus walking around undetected.
A new survey report released by the state-run Indian Council of Medical Research indicated that 0.73 percent of the population in 83 sample districts had shown a history of being infected with COVID-19. If extrapolated nationwide, this figure could mean as many as 9 million infected cases so far, despite the official tally only being just under 400,000 infections. This, experts say, indicates the lack of adequate testing.
"The testing numbers have plateaued. One reason behind local governments not testing enough may be to control panic, and to target resources only toward those who are severely infected," said Oommen Kurian, a senior fellow and head of the health initiative at the Observer Research Foundation, a New Delhi-based think tank.
Such an approach, he added, might be counterproductive: "In some ways, you are solving the smaller problem today but also making the big problem even bigger in the immediate future."
The lack of testing is also making it difficult to ascertain to the actual deaths due to the virus—so far, India has officially recorded around 13,000 deaths, a relatively low figure compared to over 41,000 deaths in the United Kingdom and over 27,000 deaths in Spain, despite lower number of infections than India. "Since many are not able to access tests here, there will be many who will die of the virus without being tested. These will not be counted as deaths due to COVID-19," said Oommen, the medical researcher.
But even as it braces for the peak, India has another medical crisis coming its way.
Combining with the inevitable peak of coronavirus cases is the fear that hospitals will see a surge in admissions through the next three months, when the country's monsoons bring the annual upswing of such diseases as malaria and dengue. In 2019, the country saw over 334,000 cases of malaria and over 136,000 cases of dengue.
Kurian said that the country's health systems will be tested: "There will be even more competition for the few beds that we have. Plus, the symptoms of many of these diseases are also similar to COVID and hence, it is going to be a complex situation."
In Mumbai, authorities are worried. Already, social media timelines in the city are filled with urgent appeals from across society—with everyone expressing their concerns, from overworked doctors to patients inside hospitals surrounded by dead bodies to relatives begging for medical care.
A senior city government official, speaking on condition of anonymity, called it a "very bleak" situation.
"For us, we hope this is the peak. Any bigger a wave and we will be in deep, deep trouble."
Kunal Purohit is a journalist in India.