Was health official Lav Agarwal right in saying India’s Covid-19 peak may never come?

Lav Agarwal, the joint secretary in the Union health ministry assigned to brief the media during the early days of the pandemic, had on several occasions remarked that India’s peak in terms of daily cases “may never come”.

At the time, it seemed like a baffling claim. The conventional epidemiological understanding is that the curve of a pandemic is usually symmetric: a sharp surge of cases is followed by a peak or a plateau after which news cases start declining.

But six months into the pandemic in India, Agarwal’s words seem to have been curiously prophetic – India’s Covid-19 graph continues to shoot up with no peak or plateau in sight.

This is almost singularly unique. Most countries have seen at least one peak or plateau even as some have seen new infections rise again. (India’s graph did momentarily slow down in mid-August raising some hope, but it did not sustain).

What explains this?

India, after all, clamped down one of the world’s harshest and longest lockdowns to contain the spread of the virus.

Six months after the lockdown started, why is the graph still rising?

Multiple pandemics

Observers say the explanation is rather simple: India’s size. This has meant that different places are at different stages of the pandemic.

“While in some of the original high-burden cities, the curve has largely plateaued or even gone down, in some other places growth is picking up,” said health economist Riju M John. “The national average is just an aggregation of what is happening around the country.”

DCS Reddy, who heads the research group on epidemiology and surveillance constituted by the Indian government’s National Task Force for Covid-19, explained: “The pandemic has now entered the rural areas where a larger number of people actually leave, so no wonder the overall numbers are going up because of the sheer size of our population.”

Other countries

But how did other big countries rein in the virus then?

Epidemiologists say India’s situation cannot directly be compared to any other country. “The only country you can maybe think of is the United States,” said Reddy, a former professor and head of community medicine at the Institute of Medical Sciences at Banaras Hindu University.

The United States, Reddy said, experienced two major surges: the first driven by eastern states like New York and New Jersey, and the second largely by Texas and Florida.“These are heavily populated states,” Reddy pointed out. “After they peaked, the virus moved inwards where fewer people live.”

In contrast, in India, rural areas are heavily populated. “In fact, almost 70% of our total population lives there,” said Reddy. To make matters worse, health infrastructure is weak in these areas. “I also doubt how much the messaging of physical distancing and mask wearing has reached those places.”

India’s lockdown did not help, Reddy added, since it led to a mass exodus of itinerant workers, stranded without jobs and money, from urban centres to rural areas, carrying the virus with them.

A lockdown that did not work

T Jacob John, one of India’s leading virologists, agreed that India’s harsh lockdown had made things worse. “I would compare India to Europe,” he said, pointing out that Indian states are as large, if not larger, than European countries. “So, a nationwide lockdown was illogical – what we needed was staggered and localised lockdowns in each state depending on the stage of the pandemic in that place.”

That way, Jacob John said India’s pandemic curve could have been flatter, leading to less pressure on medical facilities and, consequently, possibly fewer deaths. “Over a long period, say a year and a half, the number of infections would be the same anyway, but we would buy time and not have such a high peak as we are now.”

Another reason the pandemic hadn’t peaked or plateaued yet in India, he said, was simply because the pandemic started late in the country compared to most Western nations.

Jacob John said the peak could finally be around the corner, but added a cautionary note: “We will reach the peak very soon, but the numbers aren’t going to sharply drop very soon. The speed of reduction will be slower than the speed of ascent.”

“If we took six months to reach the peak, it will take at least another six to reach the low month. It could be much longer, actually,” he said. “The epidemic is not going to be over anytime soon.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.