The Puzzle Named India

This is a question more and more people are asking about India:

“How has the country, whose per capita income is just tenth of the US, avoided being flattened by the pandemic?”

The authors, Anup Malani, Arpit Gupta and Reuben Abraham start with the 3 commonly cited reasons.

Epidemic hit India later than the West: Incorrect, say the authors. The first cases landed in Kerala in end Jan. And other cases arrived in early March.

Lockdown and social distancing have worked: Maybe, maybe not, they write. The virus has a gestation period, so there is a time lag between the lockdown and its effect. In any case, there are several well-known events violating the lockdown e.g. Tablighi Jamaat in Delhi, migrants at Bandra etc. And even if the lockdown has worked, it raises a scary prospect:

“If India’s caseload is low because of the lockdown, it will not help when the lockdown ends.”

Not enough testing and thus the reported numbers are wrong/low: Yes, we don’t have enough testing kits. And their cost has been a deterrent. When in doubt, officials err on the side of caution to avoid panic. On the other hand, wouldn’t there have been a spike in total death count for any reason, if lots were dying due to the virus? Ah, say the authors, such proxy techniques are problematic. For example, consider this possibility:

“The lockdown has affected mortality in ways that are unrelated to Covid-19. By shutting down travel and factories, it has eliminated transport-linked deaths and deaths triggered by air pollution. Physical distancing measures may also lower deaths from influenza, just as they reduce Covid-19 deaths. So it is theoretically possible that Covid-19 has had a substantial mortality impact, but that total deaths have not risen because the lockdown reduced non-Covid deaths.”

And then the authors look at other reasons. Could the reason be that the fatalities are highest among people older than 80 but very low below the age of 40?

“In India, only 0.8% of the population is above 80 and nearly 75% are below the age of 40.”

Then again, is the above counter-balanced by the poor health of individuals?

“The fatality rate rises by roughly 30% if a person has cardiovascular disease, diabetes, chronic respiratory disease, or hypertension. India has roughly double the rate of heart disease as Italy, and among the highest prevalence of respiratory diseases in the world. In addition, India is home to one in six people with diabetes.”

Plus, unlike the West:

“India is home to many multi-generational, joint families. This structure places elderly Indians at considerable risk from catching diseases from younger family members, especially asymptomatic ones.”

Does India’s hotter climate serve as a natural defense? Maybe, but there’s no conclusive evidence that the virus fades away in hotter climates. Does India’s BCG vaccination help (inadvertently)? While it is true that there is indeed a correlation between countries with BCG vaccination and lower transmission, they also share other characteristics: hotter climate and poverty. So one can’t be sure of any link to BCG vaccination.

All of which is why the authors end saying:

“Ultimately, India’s relatively light exposure to Covid-19 remains a puzzle. It may have certain characteristics that protect it from the deadliest impact, but they do not suggest that it will escape the pandemic unscathed. Great care and vigilance are still necessary.”