Less than two months ago, India’s health minister declared that the country was “in the endgame” in the battle against the coronavirus. But, in the past week, India has seen a surge of coronavirus cases, with the daily number now surpassing two hundred and seventy thousand. The surge is most pronounced in the state of Maharashtra, home to Mumbai, but cases are rising across the country, and cities are beginning to lock down, sending workers back to their home states and fuelling fears of even greater spread. India, which has more vaccine-manufacturing capacity than any country on earth, has exported tens of millions of vaccine doses, but now must speed up its vaccination rates at home. Currently, less than ten per cent of the country has received a first dose, and several states are facing vaccine shortages.

Last April, as COVID-19 was beginning to spread in India, I talked about the situation with Ramanan Laxminarayan, an economist and epidemiologist who is the founder and director of the Center for Disease Dynamics, Economics, and Policy, in Washington, D.C., and New Delhi, and a senior research scholar at Princeton. We spoke again last week, while he was in New Delhi. During our conversation, which has been edited for length and clarity, we discussed why the pandemic is worsening in India, the mixed messages about its seriousness from Prime Minister Narendra Modi’s government, and how long it will take for the majority of the country to become vaccinated.

How would you characterize where India is right now with COVID-19?

We had a first big lockdown approximately a year ago, and the purpose behind that lockdown was simply that the system was not ready. That was when you and I last spoke. Doctors didn’t know what to do. We needed the system to get prepared. And we had a big wave, but things proceeded a lot more smoothly than they would have without the lockdown. What was amazing about that lockdown was that it was done with just five hundred cases. No country of more than a billion people normally shuts down over five hundred cases, but it was based on a projection that things were going to be very bad. The government was very decisive, and I thought it took extraordinary leadership in putting in place the lockdown.

Now, there were certainly things to disagree with, in respect to migrants, or how the government prepared, and so forth. But the evidence is that the lockdown had a strong and material impact on the trajectory of the infections, and put a lid on COVID. Back in January, things were getting better and back to normal, but further moves toward normalcy, such as opening schools and workplaces, were likely to be accompanied by another uptick in cases. So we had an artificial situation where we reached an equilibrium, but, when we got back to normal, there was room for cases to go up. And that is exactly what has happened. There has been complacency and this idea that COVID is behind us, with vaccines arriving. But, in truth, we are seeing today what we would have seen one year ago without a lockdown.

Are there things the government should have done over the past year that it did not do?

Absolutely. Because the country was in a lockdown situation, the progression of the epidemic was difficult but not overwhelming, unlike the way that it is right now. Today, there are two patients per bed in the big hospitals in New Delhi, and that’s if you can get into the hospital in the first place. There are literally lines of ambulances that are fifty or a hundred long. The crematoria are full. And this isn’t just in New Delhi or Mumbai—it is in many parts of the country, including in places like Uttar Pradesh, which did not really have a big COVID issue last year. Things are really bad right now.

What should have been done to prepare are two things. One is that, if there had been better information coming out—in terms of saying, “Listen, this is a serious disease, and we need to not drop our guard, and keep the masking and the distancing, and not go to mass gatherings, or large weddings, or rallies”—that would have made a huge difference. But that was not done, simply because there was a sense of complacency. If you don’t communicate risk accurately to people, then you cannot expect them to wear masks.

The second part is the preparation of the infrastructure. Some of that preparation did happen. India has ventilator and mask production that didn’t exist a year back, so to some extent a lot of those gaps were filled. But other gaps, like adequate numbers of trained doctors and I.C.U. facilities, take much longer to fill. That just hasn’t happened in the course of the last year in a significant way, and that’s why you see shortages of beds and doctors. The human resources are just not available.

How has mask-wearing been generally?

Mask-wearing dropped as soon as there was the sense that COVID was under ten thousand cases, and after declarations that India had won the war against COVID, which was said many times. There is some dissonance of that message with one to wear your mask.

In Mumbai and every big Indian city, there are huge numbers of workers from other Indian states that are poorer. With lockdowns coming, they now appear to be returning to their home states. Are you concerned about this causing spread, and are the places that laborers are returning to prepared?

I was very worried about that the last time around, because this was a disease that essentially went from a few working people to the urban poor, and then spread out across the country, but didn’t take hold in terms of the numbers we are seeing right now. I think that introduction into the hinterlands has already happened, and it is not going to happen more because of the people leaving now. I think it is much more of a humanitarian crisis, because these are people who went back to their villages last year because of the lockdown, and with great hesitancy made it back, and now are leaving again. So I worry more about the humanitarian aspect and livelihoods of people, which have been jeopardized not once but twice.

There is a Hindu religious festival going on right now, called Kumbh Mela, where a number of cases have already been diagnosed. Is there any chance that the Modi government, which is quite religiously inclined, would try to limit it or discourage people from attending?

The Kumbh Mela is going to continue for another couple weeks, but you have to remember that it is not just about the Kumbh Mela. There were cricket matches—and cricket is actually another big religion in India—and they were going on with full attendance, without mask-wearing. Weddings, which is the other thing that Indians love, have been going on in full swing. Ironically, in Delhi, there is a weekend curfew but you can get an exception if you are going to a wedding. How insane is that? So it is not just about the festivals or the government of the day, but simply a sense that, across the board, we can have our mass gatherings, whether religious or social or sporting, and still somehow keep the virus at bay. But that is simply not possible.

Modi is extremely popular, and his political opposition is extremely weak. Is there much political debate about his handling of COVID?

Putting aside the political parties, if you look at this from the perspective of the man on the street, I think the past three weeks have been extremely difficult. It’s hard to get a COVID test. It is virtually impossible to get a hospital bed, even if you are well connected. Forget about the man on the street. How that translates into how people perceive government performance is not clear. But, certainly, there is a great degree of difficulty on the ground, and people are not happy.

You mentioned testing, which was initially a problem in many countries. Is testing still lagging in India?

It has improved tremendously over the past year, but it is still not where it needs to be. And you have to remember that testing is highly variable across states. Some states, like Tamil Nadu and Andhra Pradesh and Karnataka, are testing at high levels, whereas testing levels in some other states, in the north, are much lower. Some health systems were strong, but not in all cases.

India is well known for having great disparities between some southern states and poorer northern states, with health systems in southern states like Kerala being famously strong. How much are we seeing that manifest in COVID cases and treatment?

That’s an interesting question. People look at Maharashtra, which is a highly industrialized state but which has a large COVID problem, and ask why it is doing so poorly. I think my response is that we see the problem in Maharashtra precisely because it is urbanized and has a good health system: it is really hard to fudge the data or really hold back in terms of reporting cases. So you see a more visible epidemic in states like Maharashtra or Punjab, but the epidemic is everywhere.

In India historically, in some states, a huge number of deaths go unrecorded, or are recorded without a cause. Is it fair to say, even if things are getting worse now, we still don’t know the toll that COVID has taken in India over the past year?

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