India sees 100,000 COVID-19 deaths: What happened and what now?

India has crossed the grim milestone of 100,000 coronavirus deaths, the third-highest in the world behind only the United States and Brazil.

Despite the South Asian nation’s attempts to control the spread of the COVID-19 disease, which included one of the world’s strictest lockdowns, infections have surged at an alarming pace.

To date, India has more than 6.6 million cases, second only to the US. On Monday, it registered a single-day spike of 74,442 new cases, while 903 virus deaths in the past 24 hours took the total fatalities up to 102,685.

However, the country’s recovery rate stands at 84 percent, the highest in the world, with more than 5.5 million people recovered from coronavirus so far, according to the health ministry.

Al Jazeera spoke to four leading health experts on India’s handling of the crisis so far and what can be done in future to mitigate the spread of the respiratory disease.

Sanghmitra Acharya, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, India

India currently holds the single-day record for the largest increase in cases, set on September 17.

As per the recent serological surveys done in the capital New Delhi and the financial hub of Mumbai, the ratio of infections to recorded cases are 20:1. Thus, India has more than 120 million COVID-19 infections, instead of the recorded 6 million.

It is also evident the infection-fatality rate (IFR) is as low as one per thousand. COVID-19 deaths add up to less than 1 percent of annual deaths from all causes in India. There have been 38 coronavirus deaths per million population, compared with more than 500 in the US.

Mortality will spurt because routine health services including antenatal care and immunisation have been disrupted due to the pandemic. The COVID-19 hotspots have dispersed from prosperous metropolises such as New Delhi, Mumbai, Chennai, Bangalore and Hyderabad, which have better health systems, to the hinterlands where health services are very weak.

India’s prolonged lockdown devastated livelihoods, causing acute food insecurity, translating into higher mortality and malnutrition, especially among children. The monetary relief from PM Cares fund – set up by federal government to fight coronavirus – and announcements by the ministry of labour and employment to safeguard jobs, wages and support the self-employed remain to be implemented.

India opted for complete lockdown when the cases were low to save “lives”, but started unlocking when the numbers surged in millions for “livelihoods”. The hotspots were to be contained and not the whole country, which would have allowed people to travel home without perils. Students have been left to deal with the uncertainty of academic activities. Domestic violence has increased, causing anxiety and stress-related mental health problems.

The government denied any “community transmission” of COVID-19 for a long time. The much-talked-about front-line workers remained exposed to the infection as well as the wrath of the state if they became critical of the government’s crisis response.

The recent accolades regarding the increase in the recovery make little sense as the COVID-19 has a recovery rate of more than 99 percent in India. The state seems to be more indulgent in image-building than crisis management.

Lockdown-induced restrictions on movement have created fear, leading to anxiety and panic. It is important to restore the trust that care will be available through restoration of routine services of all kinds. Students in institutions of higher education be brought back to the physical form of learning with due measures in common spaces like hostels and classrooms, without panic.

Given the low fatality, most confirmed cases are mild and can be treated at home. So the stigmatisation of positive case needs to be minimised through right communication. This will release the already burdened health services to deal with the severe and fatal cases.

Prabhat Jha, epidemiologist, University of Toronto, Canada

India is not flattening the COVID mortality curve. Testing is affected by expanding test sites. However, since 80 percent of deaths in India occur in rural areas and mostly without medical attention, their causes of death are not known.

Mumbai has most reasonable mortality data, the city is capturing most deaths and having physicians certify them. If you look at Maharashtra state’s (where Mumbai is located) mortality curve, it is still not flattening. On the other hand, the growth rate of deaths in India is far slower than in high-income countries for reasons we do not know. The younger age distribution might be one factor.

The lockdown in India was also accompanied by a mass exodus, but the government should have banned landlords from kicking out tenants in cities. These (mostly young men) went back to their villages, taking infection with them.

In villages under lockdown, infection would be mostly confined to homes and not spread as much as if there were no lockdown. Thus, there might be notable but undocumented increase in deaths within homes in rural areas.

To know this, restarting the Million Death Study could be useful. The study takes a random sample of homes to conduct a “verbal autopsy” to determine the cause of death.

To help this, the government may ask mobile phone companies to give metadata on where migration occurred from the big cities. In those rural areas, teams can be sent to find out the possible hotspots.

In terms of what India is doing right and where it is lagging in terms of containing the pandemic, testing has expanded well, and availability of PPE kits seems to have improved. But data collection and dissemination must improve quickly.

The Indian government must get all municipalities to release weekly total death counts for 2018-2019 and for the completed weeks of 2020. This is a simple way of seeing if the total mortality curve went up and is coming down.

Bhaskar Chakravorti, economist, Tufts University, United States

First of all, it is important to acknowledge that India remains one of the world’s most complex environments for tackling a pandemic, especially one that is difficult to contain and displays as much variability in its symptoms and fatality.

India is not only one of the most densely crowded countries, it also has significant exposure to travellers from various parts of the world. Its population, while young, has been affected by many previous underlying conditions – cardiac, respiratory or diabetes-related issues that complicate the impact of the disease – and its healthcare infrastructure is very poor and unevenly distributed.

In such a context, containing COVID-19 would be a challenge for any administration. That said, [Prime Minister Narendra] Modi administration failed miserably in even doing the best it could despite the circumstances.

The government imposed one of the strictest lockdowns anywhere in the world (according to an Oxford study) and did so with no warning at a time when the infection rates were very low. It also did so in an environment where hundreds of millions of informal sector migrant workers would, predictably, be left without work overnight. Even those with “regular” employment would have to contend with digital readiness that ranked India 42nd out of 42 countries that we had studied as part of our “social distance readiness” study.

The Indian economy was already on a deceleration path, which turned into a catastrophic economic slowdown after the lockdown. The Modi government essentially gave up and, once again without any preparation, reopened the country, when infection rates and deaths were rising. There has been inadequate investments in healthcare or helping families devastated by losses of loved ones and livelihoods.

One of the biggest casualties has been the shutdown of schools. As it is, schools around the country had to contend with numerous challenges. But now children are getting their lessons online or over television. And when a family shares a single phone or a TV set, it is highly unlikely that children will get anything close to what resembles adequate education.

The Modi administration seems to believe its Digital India campaign will solve the problem. Regrettably, Digital India has been a combination of a government branding campaign and a corporate campaign by a private player to dominate India’s digital landscape, and the benefits have yet to trickle down to the people who are most in need of digital technologies.

Vish Viswanath, professor of health communication, Harvard University, United States

It requires a great level of humility to make any prognostication. If COVID-19 has taught us anything, we can’t take anything for granted. The science is evolving every day.

We don’t have good examples of how to completely eliminate this, especially in a country that is as densely populated as India. If you see what is happening across the world, even in countries we thought had a good handle on things, the number of cases is increasing. Meanwhile, the US completely mishandled it.

I think India’s initial policy of lockdown and restricting people to confined spaces was fine. The challenge is: How do you execute it?

It is not easy to do so. Even if 70 percent [of people] comply with your recommendations to stay at home, the other 30 percent don’t. That is still a huge number. When you shut a country down, people’s basic needs don’t disappear.

Given what is happening, all sectors – government, corporate and non-profit – should come together for public health communication campaigns to promote the so-called non-pharmaceutical interventions: face-covering, social distancing, and hand washing. Just a penal approach of punishing won’t work. We need people to support these measures and become invested in them.

In addition, testing should be aggressive, contact tracing extensive and efficient, followed by necessary isolation and treatment. The measures have to be more targeted and there should be massive investments in training front-line health workers and execution of public health emergency measures.

We need more data on infection and more transparency in that data. Lastly, some groups will be disproportionately affected, such as the poor, and we need to take care of them.