It's the phone calls at all hours of the night he remembers. As swine flu ravaged northern India in 2015, a radiologist working at a hospital in a Delhi suburb said people would call begging for a bed.
That outbreak ultimately infected more than 31,000 people and killed nearly 2,000, as many died waiting for treatment. With the far more infectious novel coronavirus now sweeping the globe -- and threatening to take hold in India -- the doctor, who asked not to be identified criticizing the country's preparedness to tackle the pandemic, thinks this time will be much worse.
Cases of Covid-19 in the world's second-most populous country have ticked rapidly higher the past week, raising alarm over the ability of India, with its fragile health-care system and battered economy, to handle a virus crisis of the magnitude of China or Italy's. While India has seen 29 deaths and just over 1,050 cases, experts fear the real tally could be much higher and say the disease is already spreading in the community. Authorities say there's no evidence for this and have not significantly ramped up testing.
In the country's already stretched hospitals, though, concern is rising.
Bloomberg News spoke to more than a dozen front-line physicians across India, and while none reported the sort of spike in patients with respiratory ailments that would suggest Covid-19 is already running rampant, all agreed it's just a matter of time -- and that India isn't ready.
With its densely packed cities and under-funded medical system, India has little margin for error when it comes to the coronavirus.
It's a reality not lost on Prime Minister Narendra Modi's government, which ordered the population of 1.3 billion people not to leave their homes for three weeks on March 24, initiating the world's largest quarantine even as cases numbered only in the hundreds. But there's concern it still might not be enough, and such a large-scale lockdown will be difficult to implement, particularly in a place where the poor live in close quarters and the social distancing measures being advocated in the west are almost impossible.
The lockdown, however, has had unintended consequences. It triggered a mass migration of hundreds of thousands of daily wage laborers from cities back to their villages -- some traveling as many as 370 miles on foot after their small-time jobs dried up in the lockdown. Such an exodus, not seen since the days immediately after India's independence in 1947, risks carrying the infection farther and deeper into the hinterland where medical facilities are even more ill-equipped.
Local media have reported at least 22 deaths already among those trying to reach their villages, some in road accidents and others because of illness or starvation. That's just a few deaths less than what the infection has caused.
Along with the lockdown, India has also acted to curb inbound travelers from overseas. Should these measures fail to halt the virus' spread, though, epidemiologists say the numbers could be staggering. A University of Michigan-run study predicts the country could have 915,000 coronavirus infections by mid-May, more than the case load for the whole world right now.
"This is just an interval period," said Anup Warrier, an infectious diseases specialist in the southern city of Cochin. Warrier was alarmed when 14 patients turned up at the private hospital where he works this week with symptoms similar to acute cases of Covid-19. They all tested negative.
"I do not think this lucky streak is going to last much further," he said.
India acted relatively early to seal off entry points into the country, with international travelers the main vector for the virus' global spread. That may have stemmed an influx of cases, but the small infection tally -- which puts it below places like Finland and Chile -- could be because India is not looking hard enough for new cases, with one of the lowest testing rates in the world.
The country had tested just 35,000 people for coronavirus as of Sunday, according to data from the Indian Council of Medical Research, a minuscule portion given its population size. That's despite 113 local government laboratories and as many as 47 private labs now authorized to process tests.
The US, which has also been criticized for being late to ramp up testing, had undertaken 552,000 tests as of March 26, while South Korea, which has contained its outbreak without a mass quarantine, has tested more than 320,000 people.
In viral hot spots like China's Hubei province, Italy, Spain and now New York, a rapid surge of infections brought a wave of patients to hospitals that exceeded their capacity for critical care. Doctors have been forced to effectively choose who lived and who died through the deployment of scarce resources like ventilators.
In India, that tipping point -- if it comes -- will arrive sooner.
The country spent just 3.7% of gross domestic product on health care in 2016, putting it in the bottom 25 of nations globally, according to the most recent World Bank data. On numbers of doctors, nurses and hospital beds, India ranked similarly near the bottom. While there is a growing private hospital sector, nearly 65% of the population has no health insurance, putting significant pressure on the overcrowded, understaffed and sometimes rundown public hospitals.
"If you see the pattern of coronavirus infection in all the countries affected so far, this is the time we expect numbers to climb," said a doctor caring for Covid-19 patients in the business hub of Mumbai, who asked not to be named because of growing stigma around the disease. "I can't see why India will be any different."
Only one public hospital in Mumbai was initially authorized to test and treat Covid-19 patients. A doctor working there, who asked not to be identified because he isn't authorized to speak publicly, reported working 24-hour shifts screening cases. People are waiting up to seven hours to get tested, and quarantine areas are overcrowded, he said. Pictures of the hospital shared on Twitter showed a wash basin filled with what looked like vomit, rusted cot frames and a stray cat sitting between beds.
Mumbai, home to more than 18 million people, appears to be bracing for more cases. There are now three government hospitals allowed to test and treat coronavirus patients, and three quarantine facilities are being prepared.
'We Don't Know'
India's national government claims there's still no evidence of "community spread" of Covid-19, when infections are found that can't be traced back to a case brought in from abroad. Mass testing would be an unnecessary strain on resources, they say, with each test costing 4,500 rupees ($60). Officials also say a ramp up in testing risks sparking a panic.
Doctors, meanwhile, are starting to see potentially worrying signs. Mehul Thakkar, a respiratory specialist who splits his time between a private hospital and his own practice in the suburbs of Mumbai, said he and colleagues are seeing an influx of cold and flu cases.
"These might be mild Covid-19 cases, but we don't know yet," he said.
India could face an epidemic worse than Iran or Italy's, according to T. Jacob John, former head of the Indian Council for Medical Research's Centre for Advanced Research in Virology, with the virus spreading to as much as 10% of the population -- some 130 million people. John worries the lockdown came too late.
"It is bold and unprecedented -- it is also risky," said Paul Ananth Tambyah, president of the Asia Pacific Society of Clinical Microbiology and Infection. "If the lockdown works and the virus does not get established in India, there is a chance that the virus can be contained globally."
— With assistance by Upmanyu Trivedi, and Lisa Du
Disclaimer: This article first appeared on Bloomberg.com, and is published by special syndication arrangement.