Inside India's COVID-19 Surge

By Dhruv Khullar, The New Yorker

06 May 21

ajat Arora, an interventional cardiologist, is the managing director of the Yashoda Hospital and Research Centre, a medical system that operates several hospitals in and around New Delhi. For the past year, Arora and his team have designated two specific hospitals for their system’s COVID-19 patients. Situated in the city of Ghaziabad, just east of Delhi, the hospital that Arora looks after is large and modern, with a full range of subspecialties; it has two hundred and forty COVID beds, including sixty-five in the adult I.C.U. and fifteen in a pediatric I.C.U.

India, like the rest of the world, has struggled with the coronavirus. The number of patients at the COVID hospital reached a hundred and thirty in the fall. Still, by December of 2020, life in Delhi had almost returned to normal. Temples had been opened for worship, political rallies had resumed, and India’s famously large wedding celebrations were back on. Arora’s COVID hospital was never stretched beyond capacity and was always flush with supplies and medications; in February, it was caring for fewer than ten coronavirus patients at a time, and many had symptoms of long COVID, not acute infection. The rest of the hospital provided cardiac care, elective surgeries, and labor and delivery services. It came as a surprise to Arora, therefore, when he contracted the virus, in late January. “Everyone said, ‘COVID is gone—where the hell did you get COVID? This is such a random time to get COVID,’ ” he told me. All around him, he recalled, a sense of triumph had settled in: people asked, “Are we immune to this disease?” and “Did we win the war?”

For Arora, as for many Indians, the apocalyptic COVID-19 surge the country now faces was unexpected. In March, cases started to rise in the western state of Maharashtra, home to Mumbai. “We thought it would be like the first wave,” Arora said. “We thought things would pick up but pretty much be manageable. You always reason from your past experience.” Today, India is home to the worst coronavirus outbreak in the world—a medical and humanitarian crisis on a scale not yet seen during the pandemic. Though the reported case numbers are in the hundreds of thousands, some experts estimate that millions of Indians are infected each day; thousands are dying, with more deaths going uncounted or unreported. More than one in every five coronavirus tests returns positive—a marker of insufficient testing and rampant viral spread. Hospitals are running out of oxygen, staff, and beds; makeshift funeral pyres burn through the night as crematoriums are flooded with dead bodies.

Arora, like leaders at other Indian hospitals, now regularly hears that critical supplies and medications could run out at his hospital in days or hours, if they haven’t already. He is constantly working the phones to procure what’s needed for basic COVID-19 care: oxygen, ventilators, immunosuppressive medications, antiviral drugs, and the like. Day and night, these calls are interspersed with pleas from increasingly desperate patients or their families, who ask and sometimes beg for admission. Almost always, Arora has to refuse. His hospital can admit around thirty patients per day, based on the number of discharges and deaths; he estimates that he and other hospital administrators receive upward of a thousand requests daily. Arora’s cousin, a woman in her thirties, is currently admitted. After arriving, she required escalating doses of oxygen and needed I.C.U.-level care, but Arora was unable to get a bed for her until nearly half a day had gone by. “There’s nothing we can do until someone gets better or someone dies,” he said. “If I put up a thousand-bed hospital today, it would be full in an hour.”

Not infrequently, Arora receives messages from families of patients to whom he refused admission and who later died. The other day, a loved one of a previously healthy, thirty-nine-year-old man texted Arora that if he had given her just two minutes of his time the man would have survived. Not long afterward, Arora received a message from another man’s son: “My father left us,” he wrote. “I begged you Doctor.” Last week, a young girl called him in the middle of the night on behalf of her father, whose breathing was rapidly deteriorating. The I.C.U. was filled past capacity, and Arora couldn’t admit him. The next day, the girl told Arora that her father had died and that now her mother was struggling to breathe. Arora treated the mother in the emergency room, and she survived.

In addition to a shortage of beds, Arora’s hospital doesn’t have enough medications. Supplies of the immunomodulator drug tocilizumab, which is given to patients to treat the immune-system storm that can devastate the lungs and other organs, are in short supply. The scarcity of the antiviral drug remdesivir has given it an almost mythic status. Some studies have found that the medication confers a modest benefit—shortening the duration of COVID-19 symptoms by a few days—but others suggest that it’s no better than a placebo. (It’s routinely given in the U.S., but the W.H.O. recommends against it.) Nonetheless, “everyone is desperate for it,” Arora said. “We don’t have much else in our armamentarium.” He estimates that his hospital has enough remdesivir for about a fourth of eligible patients. At some Indian hospitals, patients are able—even encouraged—to bring in scarce medications and supplies, if they can procure them. Some of Arora’s patients have turned to the black market, paying thousands of dollars for a vial of remdesivir, only to learn that it’s counterfeit. “Families buy these vials, desperate to save their loved ones,” Arora said. “Then we find out they’re filled with coconut water and milk.”

The tale of the Indian pandemic is both mysterious and familiar. For much of the past year, the world’s largest democracy—with a population of some 1.4 billion living on a landmass a third the size of the U.S.—escaped the worst. Researchers have advanced all sorts of theories to explain this outcome. They point out that India is a young country, with a median age of twenty-eight; that it instituted an early and strict lockdown; that it has undercounted cases and deaths; and that Indians may have had some level of preëxisting immunity to the novel coronavirus, owing to exposure to similar viruses in the past. Studies have indicated, perplexingly, that more than half of the residents in some dense urban centers had previously been infected, even though their hospitals hadn't filled up. None of these explanations have been fully proved, and, separately or in combination, they may not account for why India was spared last year. That debate will likely continue for a long time to come.

The reasons for the country’s current surge, on the other hand, appear straightforward. Since the New Year, there’s been a substantial relaxing of public-health precautions. Mask-wearing declined; sporting events, political rallies, and religious festivals brought large numbers of people close together. Lacking a sense of urgency, the country’s vaccination campaign proceeded slowly: India is the world’s leading manufacturer of vaccines for a wide range of diseases, but has fully immunized roughly two per cent of its population against COVID-19.

Many assume that the rise of more contagious variants is accelerating the damage. Almost certainly, B.1.1.7—originally identified in the U.K. and now dominant in many countries, including the U.S.—is contributing to India’s viral spread. But a new variant, known as B.1.617, has also captured headlines and the attention of scientists and the general public. The predominant form of the variant, misleadingly referred to as the “double-mutant”—it has at least thirteen mutations—was first detected in December. B.1.617 has several mutations on its spike protein, including E484Q and L452R, which seem to increase the virus’s ability to bind to and enter human cells, and which may improve its capacity for evading the immune system. Some scientists have hypothesized that another mutation, P681R, could improve the variant’s ability to infect cells.

Still, the role played by B.1.617 in India’s crisis is uncertain. India has sequenced only about one per cent of positive coronavirus tests, rendering claims about the relative contribution of variants hard to disentangle from other factors, such as a rise in unrestricted gatherings in a densely populated country with limited health-system capacity. In any case, Covaxin—India’s domestically developed COVID-19 vaccine—appears to work against both B.1.1.7 and B.1.617. Arora told me that, although several fully vaccinated clinicians at his hospital have recently contracted the virus, none went on to develop severe disease—exactly the kind of protection the vaccines are designed to deliver.

Last week, the Biden Administration announced that the U.S. would send a hundred-million-dollar aid package to India, including testing kits, ventilators, oxygen cylinders, and P.P.E. The U.S. has also removed restrictions on exporting raw materials for vaccines so that India can increase its production. Last weekend, syringes, oxygen generators, and ventilators poured in from across Europe, and a hundred and fifty thousand doses of Sputnik V, Russia’s vaccine, landed in Hyderabad. The Indian diaspora has committed tens of millions of dollars in aid.

Whether these interventions will be enough remains to be seen. In a country as large, diverse, and bureaucratically complex as India, the logistical challenges of converting aid into impact cannot be overestimated. Meanwhile, the Indian experience holds a deeper lesson for the world—especially for wealthy countries that have hoarded vaccines and supplies. The constellation of forces that led to India’s crisis—pandemic fatigue, the premature relaxation of precautions, more transmissible variants, limited vaccine supplies, weak health-care infrastructure—is not unique; it’s the default in most of the world. Absent a paradigm shift in our approach, there’s no reason to believe that what’s happening in India today won’t happen somewhere else tomorrow.

When we spoke, Arora told me that most patients arrive at his hospital in taxis or in vehicles driven by their families. Few can afford the luxury of an ambulance, either because none are available or because private companies have raised prices amid endless demand. When they arrive, many patients linger in emergency rooms, where they can receive some oxygen—and a modicum of relief—even if they are ultimately refused admission to the hospital. At other hospitals, people have died in the parking lot.

As hospitals, emergency rooms, and the streets fill with younger and younger COVID-19 patients, Arora said, an all-consuming, unrelenting despair has taken hold among health-care workers. At Arora’s hospital, even the pediatric I.C.U. is now full, with children as young as six struggling to breathe. (In India, more children than in the first wave now seem to be falling ill; data is limited, and it’s not clear whether there is a higher proportion of children getting sick or just a higher over-all number.) Many of the deceased are people middle-aged or younger.

“Our staff is struggling,” Arora said. “Many are on the brink of a complete breakdown. Every day, they come to work and see nothing but death. They go home, and their own family has gotten COVID and can’t breathe or have died. This is the situation. There’s no end in sight.”