India lifts its lockdown and braces for what’s next

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NEW DELHI – The flight attendants are wearing full protective gear, and some passengers face quarantines at their destinations. But for the first time in months, India’s skies are open.

The resumption of domestic flights this week is a clear signal that India is moving to end the world’s largest lockdown, an unprecedented experiment that affected more than 1.3 billion people. The restrictions caused massive job losses, widespread food insecurity and an exodus of workers from India’s cities.

Now India is bracing for what comes next. While the lockdown slowed the spread of the novel coronavirus, experts say, the number of fresh cases is rising. India ranks fourth in the world in the number of new cases a day: Only Russia, Brazil and the United States are adding more. India has more than 150,000 cases.

In recent weeks, the government has relaxed restrictions on movement, transportation, commerce and manufacturing. Large gatherings remain prohibited, and international flights are still banned. But experts say loosening the restrictions means cases will increase at faster rates. That will intensify pressure on hospitals already under strain and will affect access to health care overall.

India’s two largest cities – Mumbai and Delhi – are preparing for a surge in cases. In Mumbai, the nation’s hardest-hit city, beds in some coronavirus wards are already full and the local government asked another state to send doctors and nurses to help. In Delhi, authorities are turning yet another major government-run hospital into a center for coronavirus patients and just ordered all private hospitals to reserve 20% of their beds for such cases.

“It is going to be a mess,” said Jayaprakash Muliyil, a leading Indian epidemiologist. In a city as densely populated as Mumbai, “trying to control any viral transmission is next to impossible.”

Mumbai, India’s financial capital, now has more than 31,000 confirmed cases. “Our covid wards have been full for the past three weeks,” said Lancelot Pinto, a pulmonologist at P.D. Hinduja Hospital, a large private hospital in the city. “We’ve had to turn away patients.”

India’s government has dramatically shifted its approach to the pandemic. In March, Prime Minister Narendra Modi announced one of the strictest lockdowns in the world with hours’ notice at a time when the country had a little over 500 recorded cases. Staying indoors for 21 days would be necessary to “break the chain of infection,” he said, expressing confidence that India would “emerge victorious.”

When Modi addressed the nation this month, however, talk of stopping or defeating the virus was gone. The virus will “remain part of our lives for a long time,” he said. Restrictions would be loosened, with much of the decision-making left to individual states.

The shift is an acknowledgment of the economic devastation caused by the shutdown in a country where there is little social safety net. The Indian economy is expected to shrink in this fiscal year for the first time since 1980, and more than 100 million people have lost their jobs.

Government officials have highlighted the fact that India’s death toll remains comparatively low, with 4,100 deaths recorded and a mortality rate of 2.9%. In the United States, that figure is 5.9%.

The lockdown gave India crucial time to prepare without facing an “overwhelming” number of infections, V.K. Paul, a member of the government’s planning arm, said in a briefing last week. The country is “ready for the coming challenge,” he said.

Paul declined to share predictions for how fast cases would rise (as recently as last month he shared a chart indicating that they would fall). A model developed by statisticians and epidemiologists at the University of Michigan is predicting that India will have nearly a million cases by July 15 if there is a “cautious” resumption of activity after the lockdown.

“In India, the curve hasn’t turned the corner,” said Bhramar Mukherjee, a biostatistician who leads the project. “You have deferred the peak.”

There remains skepticism about whether the official figures on cases and deaths capture the true scope of the outbreak. The country has significantly increased its testing capacity over the past two months – it now conducts about 110,000 tests a day – but in a nation of India’s size, that translates into a tiny percentage of the population.

Testing in India remains “inadequate,” added Sujatha Rao, who served as the top civil servant in the country’s health ministry. The stigma surrounding the disease also represents a “serious deterrent” to getting people tested in the early stages of the illness, she said.

The nationwide figures obscure considerable variations in the pandemic response across a vast nation. The southern state of Kerala mobilized its robust public health system to track, treat and isolate people who tested positive. The number of active cases in the state dropped to 16 earlier this month. But confirmed cases in the state are rising once again as residents begin to return from other parts of India or via special repatriation flights from abroad.

The virus is exposing well-known weaknesses in India’s rickety health infrastructure, particularly in government-run hospitals that are the primary option for the country’s poor. A panel of judges in the western state of Gujarat recently said that the main public hospital for treating coronavirus patients in the city of Ahmedabad was “as good as a dungeon, maybe worse.”

Accessing health care – which can be a challenge for the poor even under normal circumstances – is becoming even more difficult in some places. During the long lockdown, many hospitals postponed elective surgeries and shut down outpatient departments altogether to minimize the risk of infection. Some hospitals in Mumbai and Delhi temporarily suspended some operations and stopped taking new patients after members of their staffs tested positive.

Singh Pundhir sold tractors in the north Indian city of Agra, home to the Taj Mahal. The 64-year-old had kidney disease and needed regular dialysis treatment. In April, his normal clinic shut down after positive cases were found nearby, his daughter Akansha Pundhir said. A few days later, he woke up with difficulty breathing.

His family rushed him to a nearby public hospital, which said it did not have the ability to do dialysis. A private hospital told him to come back later, then asked for a test to show that he did not have covid-19, the disease the coronavirus causes. But it was already too late: Pundhir died in a car parked outside the hospital. His test result came back negative later the same day, his daughter and a neighbor said.

“We couldn’t believe what was happening,” said Pundhir, 23. “We kept thinking some hospital would take action.” The death of her father was “completely avoidable.”