South Asia’s coronavirus cases may be the tip of the Iceberg

The number of reported cases of the new coronavirus continues to rise across South Asia. Pakistan, which borders both Iran and China—two of the world's three worst-affected countries—has seen its number of cases double for a second consecutive day (the latest tally is 236). But across the region, a paucity of testing means those figures are just the tip of the iceberg. Despite being home to one-sixth of the world's population, India has conducted fewer tests than South Korea, which has only 51 million people. According to the New York Times, South Korea has tested 4,800 people per million while India has tested just five per million.

After initial delays (as recently as last week, groups of hundreds of people were still gathering for Holi celebrations) most South Asian countries have now put in place strict restrictions on travel and large gatherings. The question is whether such moves have come too late to prevent widespread community transmission, especially given how densely populated the region's cities and towns tend to be.

At this point, there are several causes for serious concern.

As testing expands—India, for example, has only 52 testing centers—more cases of the coronavirus will be discovered. But there are missing metrics. In India, a country that could serve as a proxy for the region, only 77 percent of deaths are actually registered. Just 22 percent of deaths are certified by medical practitioners. In other words, there could already have been deaths due to COVID-19 that have simply not been recorded.

If community spread of the coronavirus is already underway across South Asia, the region's health care system will come under unprecedented stress. Consider hospital beds, for example. According to data from the OECD, India has just 0.5 hospital beds for every 1,000 people. The United Kingdom has five times as many per capita (2.5), Italy has more than six times as many per capita (3.2), and South Korea has over 24 times as many per capita (12.3). If the number of infections in India rises exponentially, the country's hospitals will struggle to cope. India has just 0.8 doctors for every 1,000 people, while the corresponding numbers for the United Kingdom, Italy, and South Korea are 2.9, 4.0, and 2.3 respectively.

Other South Asian countries have just as much cause to worry. In an interview this week with the Associated Press, Pakistani Prime Minister Imran Khan candidly expressed his fears: "If [the coronavirus] spreads, we will all have problems with our health facilities. We just don't have that capability. We just don't have the resources."

There is a counterpoint, although it is not one I am convinced by. Sometimes, broken systems can offer unlikely advantages in a crisis. Health experts have long criticized the region's pharmacies for selling antibiotics without a prescription, for example—a practice that is already contributing to antibiotic resistance. If the coronavirus spreads, and patients can fight secondary bacterial infections with easily available antibiotics, they may lower the region's death rates. But it's a dangerous hope to rely on, as is the theory that the region's youthful demographics will automatically shield it from outbreaks.

As Sumit Ganguly writes in FP, India's emergency response systems sometimes hold up remarkably well. In 2018, the state of Kerala curtailed the spread of the Nipah virus, and the nation has a history of successful contact tracing in influenza outbreaks. But the question now is whether the number of coronavirus cases will grow too high, too quickly, and overwhelm the country's hospitals. Have South Asia's countries missed their chance to flatten the curve?
It will be several weeks before we'll have real data and answers. Whatever happens, the pandemic will be a reminder to South Asia's governments that they have long neglected health care infrastructure, especially for their lower-income populations. As the chart below shows, South Asian nations have among the lowest rates of spending on health care as a proportion of their GDPs.