India’s second wave of COVID has quickly turned into one of the worst outbreaks in the world. Since early March, official cases and deaths have skyrocketed, recently breaking world records on an almost daily basis. Meanwhile, Indian officials are warning the country’s health care system cannot keep up with the deluge of patients as supplies run thin, exposing India’s ailing health infrastructure. USIP’s Tamanna Salikuddin and Vikram Singh look at the origins of India’s second wave, its far-reaching consequences in the global fight against COVID and what the international community can and should do to help India weather the storm.

Health workers doing contact tracing check the body temperature and blood oxygen level of a man in Mumbai, India. April 15, 2021. (Atul Loke/The New York Times)
Health workers doing contact tracing check the body temperature and blood oxygen level of a man in Mumbai, India. April 15, 2021. (Atul Loke/The New York Times)

What’s the current situation, was there a catalyst that sparked the crisis, and how does it compare to previous outbreaks in other countries?

Salikuddin: According to the World Health Organization, as of April 28, India is reporting the highest number of daily cases in the world, with almost 50 percent of new cases reported worldwide coming from India and 17,636,307 cumulative confirmed cases. Among Indian states, Maharashtra has the highest number of cases (more than 4 million) followed by Kerala, Karnataka, Uttar Pradesh and Tamil Nadu (each with more than 1 million). India is also reporting the fourth-highest number of deaths in the world with 197,894; however, most health professionals warn that these number reflect severe undercounting given the scarcity of testing and many uncounted COVID deaths.

It appeared India was largely spared the worst of the first wave of the coronavirus pandemic. And according to the president of the Public Health Foundation of India, in early 2021, an opinion that India had overcome the pandemic and acquired herd immunity gained ground among policymakers, sections of the media and the public. This may have led Indians to relax many of the precautionary protocols.

But scientists are still exploring why India, and some other similar nations, were spared the high death tolls associated with their first wave, including examining the possibility of latent immunity due to existing disease burden or positive side effects from previous immunizations. Significantly, India imposed a very stringent nationwide lockdown in March 2020 that was largely seen as effective against the first wave of the virus but severely impacted livelihoods, hitting the poorest citizens the hardest.

During this second wave, the Indian government has left lockdowns to individual states. Meanwhile, many migrant workers have been traveling back to their homes in anticipation of lockdowns, raising the risk that contagious individuals will bring the virus from urban hot spots to more rural areas. Additionally, recent large gatherings, including political rallies and religious festivals, have also become super-spreader events. The second wave has also been exacerbated by new COVID variants that are more contagious and much harder to detect, even with PCR testing.

There are reports that many hospitals are at capacity and oxygen supplies are running low. What is India’s capacity to manage this outbreak, and what happens if cases exceed the country’s ability to handle them?

Salikuddin: Indian Prime Minister Narendra Modi said, “The country is working day and night for hospitals, ventilators and medicines” in his monthly national broadcast on April 25. Despite his statements, the speed and breadth of the second wave has caused health infrastructure to collapse in several cities, with the most acute shortages being oxygen and hospital beds. State governments are scrambling to build up new infrastructure, making announcements this month that suddenly commenced the construction of new health facilities and oxygen plants.

This buildup may be too late for the current crisis. India has long underspent on its health care sector — only 3.5 percent of its GDP according to the World Bank. Critics have long called out successive Indian governments for underspending on health infrastructure and public health systems while also privatizing much of the health care system. Despite being the world’s largest manufacturer of vaccines, India is also facing shortages of coronavirus vaccines for its own population. India is working now to mobilize its latent internal capacity by moving resources from one state to another, and this is now being supplemented by foreign aid. This wave has yet to reach its peak, and unless India is able to quickly increase the availability of oxygen, medicines, hospital beds and vaccines, the continued increase will completely overwhelm the health care system.

Some have accused the United States and other rich countries of “vaccine hoarding” as other countries like India struggle to contain the virus. What is the status of U.S. assistance for India, and are there plans for future aid?

Singh: U.S. assistance started flowing to India on April 29, and includes oxygen equipment, personal protective equipment (PPE), critical medicines and ventilators provided by USAID and delivered by the Department of Defense. Additional military flights and assistance from the private sector in the United States is also arriving in India. A global outpouring of support for India is helping it cope with unprecedented numbers of infections and deaths. Vaccine nationalism is a concern, but even as nations try to secure doses for their own people, most recognize that successful global vaccination will be necessary to control COVID. The United States has committed to provide $4 billion to the global COVAX campaign and is working to get additional vaccines to nations in need, including 20 million doses for India where vaccine supplies are running out.

International aid has started arriving in India from countries such as the United States, U.K., Germany and Australia, while others have pledged contributions. What’s needed to help India stem the outbreak, and how can the international community plan for preventing future waves?

Singh: According to health experts and the Indian government, the most critical requirement is oxygen to help people get through the most acute and life-threatening phase of a COVID infection. India is a large producer of oxygen, but getting supplies to the right places is difficult, especially with hospitals overwhelmed. So additional oxygen concentrators, cylinders and containers to transport oxygen are all required. U.S. businesses are providing in-kind assistance and raising funds to procure 100,000 oxygen concentrators. After oxygen, the most acute needs include medicines like dexamethasone, PPE and other hospital equipment. Ad hoc measures to add hospital capacity using stadiums, railway stations or military field hospitals will also be critical. Finally, stress on the collapsing health care system will be reduced if people know how to best care for COVID patients at home and understand when they need to seek hospital care. 

As one of the world’s most populous countries and a chief manufacturer of COVID vaccines, India’s COVID outbreak has reverberating effects throughout the region and globe. How does a sustained crisis affect the global fight against COVID?

Singh: India makes more than half of the world's vaccines, and prior to this crisis, New Delhi had shipped COVID vaccine doses to more than 70 countries through the international COVAX program and bilateral agreements. India's role as a vaccine supplier to the world is on hold, and the consequences will be dire. Vaccine campaigns around the world are depending on the COVAX program, and COVAX was expecting 1.1 billion doses for lower- and middle-income countries this year from India's privately owned Serum Institute of India (SII). That is not going to happen, as SII's CEO expects the delay will be five to six months. Even before India's crisis, COVAX had only provided 49 million out of a targeted 2.1 billion doses in 2021. The World Health Organization and GAVI, the global vaccine alliance, are starting to work with India, other nations and major charities to plan for making up shortfalls and easing bottlenecks in vaccine production and distribution.

Salikuddin: In addition to the impact on vaccine supplies, the COVID crisis in India has ramifications for both global health and the global economy. Experts have warned that if the world is not able to control the explosion of cases in India, similar outbreaks could spread around the world — especially to other countries in the region with weak health care systems and largely unvaccinated populations. Neighboring Afghanistan is already reporting cases of the potentially more-contagious Indian variant of the virus. Additionally, failing to control the Indian crisis may severely impact the global economy, specifically limiting international pharmaceutical supplies and outsourced back-office services — both areas where India is a worldwide leader.

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