You have seen those harrowing pictures. Patients dying outside the hospitals while waiting for a bed. People on oxygen masks gasping for air-sharing beds. Dead bodies piling up in morgues. Overstretched crematoriums and burial grounds. COVID-19 hit India very hard in April 2021. This is the second wave of disease in the country. They largely escaped the first wave and were confident by the end of 2020 that they had defeated COVID-19.

But COVID-19 is a different animal. You can’t make any predictions about this new disease which has baffled even developed countries with robust health systems. In India, scores of health care workers got infected, placing a tremendous strain on health care delivery during the current surge. The lack of availability of medications such as remdesivir is also making the situation grave.

Why did this happen? While the U.S. and other countries were going through a second surge of COVID-19 cases during the latter part of 2020, the number of cases in India was decreasing dramatically. The total number of deaths due to COVID-19 was also declining. See the following figures for a comparison of COVID surges in the U.S. and India.

Experts cite at least four reasons for the emergence of the current COVID-19 surge in India.

1. Pandemic fatigue and complacency. By 2021, people had enough of the pandemic restrictions as in any other part of the world. India was under a massive lockdown during most of 2020, which helped stop the virus’s spread. Coupled with this, politicians encouraged huge in-person political rallies for local and state elections. They gloated that India has conquered COVID-19. Mask-wearing became less prevalent. Large religious gatherings and massive sporting events were also allowed.

2. Low vaccination rates. India is said to be the powerhouse of global vaccine production. During the current crisis, there were hiccups. India offered to produce and distribute Oxford University formulated AstraZeneca vaccine globally to developing countries under a WHO plan. One of the major vaccine makers in India, the Serum Institute, was constrained by a lack of funds and a lack of imported raw materials, severely affecting their production capacity. Moderna and Pfizer vaccines were also not approved in India. In addition to the AstraZeneca vaccine India depends on, a homegrown vaccine called Covaxin to vaccinate its population. The end result was a low availability of vaccines with a huge demand in a country with a 1.3 billion population. Only 25 million people are fully vaccinated in India, which constitutes less than 2 percent of the population. In contrast, 31.5 percent of the population in the U.S. is already fully vaccinated.

3. New variants. Coronavirus variants identified in South Africa, the U.K., and Brazil were circulating in India. Other new variants also have been reported from India; the most concerning is the local strain identified as B.1.617. Two mutations, E484K and L452R, which have led this variant to be dubbed a “double mutant,” are the characteristic of this strain. This new variant has been blamed for higher infectivity and the ability to evade antibodies though the scientific proof for this hypothesis is still lacking.

4. A fragile health care system. India has a very fragile health care system, to begin with, even though several hospitals are world-class and famous for medical tourism. COVID testing rates were low in India. Some states implemented contact tracing and strict quarantine to control the infection during the first wave in 2020. However, the second surge caught them by surprise, with thousands of patients showing up at the hospitals. When the infection surge goes to that level, contact tracing is extremely resource-intensive, practically difficult, and less effective. Even developed countries such as European countries and the U.S. were unable to handle surges of COVID cases, as witnessed by the chaos in New York in 2020.

All these factors, coupled with the massive movement of people confined in small spaces, probably also contributed to the current surge of COVID-19. India has a population density of 1066 per square mile in contrast to 87 per square mile in the U.S. India also has several of the most congested cities globally; for example, the population density in Mumbai is 76,790 per square mile.

The current Indian COVID surge should be an eye-opener to other countries, especially those with limited resources and low vaccination rates. The current surge also affected rural areas more frequently than the mainly urban pattern observed during the first surge. Individuals aged 30 to 50 are also more affected, probably because they ventured out more for work. There are also several unknowns about the virulence of the emerging variants and their susceptibility to neutralizing antibodies. We do not have an array of specific medications to counter the virus. We are not out of this pandemic yet. This pandemic is not over yet. Any cluster of cases or surges should be handled with caution and great anticipation.

P. Dileep Kumar is a board-certified practicing hospitalist specializing in internal medicine. Dr. Kumar is actively engaged with professional associations such as the American College of Physicians, Michigan State Medical Society, and the American Medical Association. He has held a variety of leadership roles and has authored more than 100 publications in various medical journals and a book on rabies (Biography of Disease Series). Additionally, he has presented more than 50 papers at various national and international medical conferences. Several of his papers are widely cited in the literature and referenced in various textbooks.

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