As you might have seen from my earlier posts on this blog, I am very fond of India. It is a fantastic country, with a wonderful landscape and even more wonderful people. I have had the privilege of visiting India every year since 2019 (except for the lockdown in 2021), and I really enjoyed every minute I spent there.
India’s Covid history
India has had a rough time over the Covid pandemic. Its attempt at Zero Covid in early 2020 went spectacularly wrong (note that on the 0-100 scale of the Stringency Index, India reached 100 and the UK only 80 during the 2020 lockdowns). I still remember videos of Indian police beating those escaping the lockdowns with bamboo sticks.
Relaxation of the rules in mid-2020 coincided with the late 2020 and mid-2021 outbreaks and the rise of the Delta variant (which originated in India before spreading throughout the world). The Omicron wave in the winter of 2021-22 was similarly devastating, although, by that time, vaccination helped reduce the death toll.
Although the primary vaccination cover is remarkable for a country of this size and with social and economic conditions, 67% were vaccinated compared to 75% in the UK. The booster programme was not as successful – only 16% compared with nearly 60% in the UK.
Reporting
But the biggest problem with the official statistic has been its massive underestimation of cases and deaths. It is particularly visible for the Omicron wave in 2021/22 and casts doubts on the current records.
Compare the official notifications and the estimations of excess deaths below. Excess mortality is a difficult thing to calculate, but it is a fairly reliable measure of Covid impact. The official death toll, in turn, relies on reporting which is often unreliable.
Firstly, the estimates of excess deaths in India are way larger than the actual records. In fact, most Indian deaths which can reasonably be attributed to Covid (deaths in excess compared to pre-pandemic years) are not recorded at all.
This is in contrast with the US, where the two lines follow each other pretty accurately. There might be some argument that some excess deaths in the US are attributable to non-Covid causes (e.g. lack of medical care during lockdowns) or long-term effects of lockdowns, but most of them are clearly attributable to Covid.
Secondly, there is a big difference between how the second (Delta) wave and the third (Omicron) wave look for recorded Covid deaths and for excess deaths. In official records (see the first graph in this post), the number of deaths in the Omicron wave is much lower than for Delta.
But, for the excess deaths – which arguably better capture the impact of Covid – the difference is much smaller. This suggests that the deaths in the Omicron wave were even more severely under-reported than in the Delta one.
Thirdly, there is a massive uncertainty in the estimation of excess deaths in India throughout the pandemic. Contrast this with the US, where the excess deaths are well known, except for the last few time points. India simply does not keep a good record of births and deaths.
Return of Covid
When I was in India in February, there were no signs of an ongoing pandemic. People mixed freely and there were only a few masks seen around. In fact, I have repeatedly heard people talking about the pandemic as something from the past. A nightmare dream that it is now gone.
And indeed, at that time, the number of cases and deaths was very low. From December to about mid-February, India was reporting only about 100 cases per day, more than 100 times fewer than the UK – despite being 25 times larger. Even accounting for under-reporting, Covid seemed to have almost disappeared.
But, this period has not lasted long, and the Indian government was aware of the change already in March. The rise of a new variant – XBB.1.16 – has been creating a new wave.
Indeed, the increase in the virus prevalence is now seen both in official records:
and in wastewater measurements:
We are still far from the previous waves, but the current growth is indeed something to be concerned about, particularly due to a very low booster vaccination cover.
What is the future?
Is India likely to be a source of another global variant similar to the Delta outbreak in 2021? It is definitely possible, but there is hope that we are globally in a different position now than we were two years ago.
Globally, we are in a much better position now than even a year ago. The combined “immunity wall” of both vaccine- and infection-induced protection probably still holds. Yes, we are likely to see repeated outbreaks, but they are likely to be limited in size and duration.
Unless, another Covid variant appears that manages to break the wall…