Why are there so few coronavirus deaths in India?

South Asia is one of the world’s most densely populated regions and thought to be highly vulnerable to any large scale outbreak. India has a population of 1.3 billion and has seen around 3,000 deaths from 100,000 cases. In comparison, the USA has witnessed over 88,000 deaths from almost 1.5 million cases and that in a population less than a quarter the size of India’s. The same discrepancy can be seen looking at the figures for other South Asian countries like Bangladesh and Sri Lanka where deaths attributed to COVID-19 are far lower than expected.

So why are the number of cases and deaths so low? There have been numerous theories. Firstly, the low number of cases could be due to a lack of testing. Testing can come in the form of diagnostic and antibody tests. Diagnostic tests can confirm if a person is currently infected whereas the antibody tests provide information on previous COVID-19 infections. As of May 20, 2020, India has carried out over 2.5 million tests and has ramped up the daily testing figure to 100,000 tests per day. This number is identical to the UK government’s own daily target however, where the UK positivity rate is at 20%, India’s is only 4%. 

A doctor in a protective chamber takes a swab from a man to test for coronavirus disease (COVID-19) at a newly installed Walk-In Sample Kiosk in a government-run hospital in Chennai, India, REUTERS/P. Ravikumar

Perhaps it is because deaths from the coronavirus are not being reported. Deaths in hospital may be preceded by a respiratory infection and without testing for coronavirus, it may be attributed to another respiratory infection such as bacterial pneumonia. In the midst of a pandemic, it may seem foolish to waste a test on a cadaver. Aside from deaths in hospitals, it is important to note that in India, 80% of deaths happen at home and may not be reported through the healthcare system. Even the government admits that only 22% of deaths are medically certified. It is also difficult to get accurate numbers from funeral services – as the majority of India’s deceased are cremated with sporadic record-keeping of such events. However, it does seem unlikely that huge numbers of deaths (even at home) over this period of time would go completely unnoticed.

One prevailing theory is that the adoption of an early lockdown may have helped India and the other South Asian nations. Countries like India and Sri Lanka imposed a strict lockdown early on and this may have had the intended effect of flattening the curve. The number of coronavirus cases (and therefore its spread) has been doubling much slower in these countries in comparison to European counterparts. India’s lockdown was announced when the country had reported 519 coronavirus cases. By comparison, Italy waited until it had more than 9,200 coronavirus cases before it went into a nationwide lockdown, while the United Kingdom had about 6,700.

Plainclothes policemen wield their batons against a man for defying the lockdown imposed by the government to slow COVID-19 at Howrah on the outskirts of Kolkata, India, REUTERS/Rupak De Chowdhuri

Although the mass exodus of migrant workers from India’s cities sparked fears of a rapid spread of the virus. We are yet to see a spike in the number of cases and deaths in correlation to this, although this could still change. India has been particularly strict with regards to its lockdown; suspending all shops and services except those deemed essential, stopping national and international travel and prohibiting public events of any kind. By comparison, the United States, which leads the world in coronavirus cases and deaths, only restricted foreigners traveling from China, Iran, and certain European countries, but there was no blanket ban on foreigners entering the country. Even China, who had imposed city wide lockdowns, has never imposed a nationwide one. 

Migrant workers walk along a road to return to their villages, during a 21-day nationwide lockdown to limit the spread of coronavirus, in New Delhi, India, REUTERS/Danish Siddiqui

The measures in India were met with some criticism not least because the aforementioned migrant workers were effectively stuck in the cities with no livelihood and forced to make a perilous journey back home on foot. It can be argued that the strict measures, especially the halting of international travel helped India stall the meteoric rise in coronavirus cases seen elsewhere across the globe in far more developed countries. As of writing, PM Narendra Modi has extended the Indian lockdown by a further two weeks until 31st May 2020. 

There have been theories that South Asians may have some inherent resistance to the virus; that warmer climates, vitamin D or BCG vaccinations could lend India some protection but more research needs to be done to validate this. The reason for the relatively few cases of coronavirus in India remains a mystery. It could well be that the strict lockdown measures have halted the spread of the virus. But what happens when the lockdown is eventually lifted? Perhaps, the peak is yet to come in India. It remains too early to claim any victories. We will have to wait and see. In the meantime, we should still proceed with caution.