As Coronavirus Cases Rise, India and Pakistan Gamble on Looser Lockdowns

By Saeed Shah in Islamabad and Vibhuti Agarwal

Despite rising numbers of Covid-19 cases, India and Pakistan are loosening their lockdowns, counting on deaths to remain low and their hospitals to be able to cope with the envisaged rise in serious cases, according to public-health specialists.

The bet is that the surprisingly low level of deaths so far signals a milder pattern to the disease outbreak, meaning that the economic pain of the lockdown isn’t justified by the health risks. Experts say it could go badly wrong if the virus spreads out of control as restraints are lifted, overwhelming the two countries’ underfunded and overstretched health-care systems.

The South Asian nations, two of the most populous developing countries wrangling with the pandemic, are encouraged by their being among countries with the fewest number of confirmed cases per person. India, with a population of 1.3 billion, has recorded 74,281 cases; Pakistan, with 220 million people, has recorded 34,336.

“We are not seeing the kind of surge that we see elsewhere,” said Giridhara R. Babu, an epidemiologist at the Indian Institute of Public Health in Bangalore who sits on an Indian government coronavirus task force. “This virus is behaving well in India, and we will still have to find out the real reason why.”

But, even more than in richer countries, the disease is bound to have spread far more widely than the number of confirmed cases indicates. Like many countries in the developing world, India and Pakistan are testing far fewer people than some developed nations—less than 1.5 tests per 1,000 people, compared with around 26 per 1,000 in the U.S., according to Our World in Data, a nonprofit scientific effort based at the University of Oxford.

Yet the two countries are also encouraged by how few people have died from the disease: just 2,415 in India and 737 in Pakistan, according to their tallies.

Hospitals haven’t been nearly as stressed as some models of the disease said they could become. An influential study in March by Imperial College, University of London, said that even with social distancing and restrictions on movements, peak demand for critical-care beds in a typical low-income country could outstrip supply by a factor of 25 times. At the peak, hospital capacity in India and Pakistan may be exceeded, health officials say, but by nowhere near that degree.

Pakistan will have sufficient overall hospital capacity to manage well into June, according to a government health official. Unreleased internal modeling in Pakistan predicts 100,000 cases by the end of this month and 600,000 cases by the end of June—currently seen as the likely peak.

Some hospitals in India’s biggest cities and infection hot spots have received more patients than they are set up to handle. But so far, the health system hasn’t been broadly pushed beyond its capacity, according to authorities and public-health officials.

Part of the reason appears to be that fewer cases are serious enough to require hospitalization. Only 2.2% of confirmed cases in Pakistan and 3.3% in India have been fatal, according to data compiled by Johns Hopkins University, compared with 14.3% in the U.K., 5.5% in China and 6% in the U.S.

Public-health officials in both countries say youthful populations could be the biggest reason. People over the age of 65 are among the most susceptible to serious complications from the disease and die at far higher rates, while many young people experience only mild symptoms—not requiring hospitalization—or none at all.

“Countries with younger populations will potentially have lower case fatality,” said Anna Vassall, a professor at the London School of Hygiene and Tropical Medicine, though she noted that depended on what other diseases were prevalent in those nations.

Only 6.4% of India’s population and 4.3% of Pakistan’s is older than 65, according to a United Nations report, compared with 19% of Spain’s and 16.2% of the U.S.’s. The mean age is 23 years old in Pakistan and 27 in India—compared with 46 in Italy, one of the worst-hit countries.

Authorities in both India and Pakistan have advanced other possible factors behind the low number of confirmed cases, hospitalizations and deaths. Some health experts have speculated that being routinely exposed to more pathogens than in richer countries strengthens people’s immune systems. Some believe a tuberculosis vaccine commonly administered in both countries but less commonly in developed nations is providing some protection, though this theory is still being scientifically tested.

Heat and the prodigious sunlight in parts of both countries could also slow the spread of the disease, some say, as they seem to shorten the life of the virus on surfaces, though the effect hasn’t been established. Coronavirus is ravaging Brazil, a developing country with a hot climate.

Still, locking down for more than a month failed to slow the spread of the disease, according to public-health officials in both countries.

In India, the latest seven-day period has been the worst so far for new cases, including 4,213 Monday, the most to date. Wednesday’s total was 3,525. Pakistan recorded 2,255 new cases Wednesday, its highest daily total so far.

Given both countries’ large populations of people on the financial edge, authorities say the cost of keeping so many out of work outweighs the benefits of the lockdowns. Pakistani Prime Minister Imran Khan has repeatedly argued that fears of coronavirus were overblown compared with the burdens imposed by the restrictions, particularly on the poor.

Pakistan’s minister in charge of the pandemic response, Asad Umar, has said the country must base its policy on the data it sees, not on how the virus has behaved elsewhere. Many shops and markets were allowed to reopen Monday.

In India, self-employed people were allowed to resume work this week, and some factories and neighborhood shops have started to reopen, though at partial capacity. The national rail company has set up special trains to help hundreds of thousands of migrant workers travel to their home villages, often far from the cities where they have been locked down.

Health officials in both India and Pakistan said the pandemic didn’t really begin to take hold in their countries until much later than in China, Europe or even the U.S.

But the lockdowns may have merely delayed the rapid spread of virus. That means the peak of its impact may not occur until sometime between June and August. Neither country has put in place the massive testing, contact tracing and quarantine capacity seen in nations praised by experts for responding well to the crisis.

“During the lockdown period no effort was spared to contain the people. But the question remains: Did we manage to contain the virus as well?” said Lalit Kant, executive director of the Influenza Foundation of India. “My assessment is that it is the gradual buildup before the storm.”

—Eric Bellman, Rajesh Roy and Krishna Pokharel in New Delhi contributed to this article.

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