• epidemiology
• health economics

India faces multiple major challenges on the COVID-19 front. It is densely populated: 464 people/km² compared with Italy’s 206, Spain’s 91, Iran’s 52 and the USA’s 36. It has a huge population: 1380 million (USA 330 million, Iran 83 million, Italy 60 million, Spain 46 million). Social distancing without total shutdowns is unthinkable, especially in the big cities with crowded streets, trains, buses and offices. Cough hygiene is largely absent. Hand hygiene is equally suspect. The latest data from the government National sample survey organisation say that only 36% of Indians wash their hands with soap before a meal.1 Even more distressingly, 160 million Indians do not have access to clean water to wash their hands.2 The research suggests that diabetes and hypertension worsen COVID-19 outcomes: the prevalence among Indian adults of diabetes and hypertension is 10% and 25%, respectively. India has high rates of TB and pneumonia. People have resisted being screened and flouted quarantines with impunity.3 The awareness about disease dynamics is very poor, even among the wealthier and more educated parts of the population: after the national voluntary ‘people’s curfew’ called by the prime minister on 22 March, which was by and large a success, people came out on the streets and celebrated with no attention to social distancing, achieving the exact opposite of what the curfew was supposed to achieve. Imposing a lockdown is next to impossible in India’s vast rural hinterland, home to 900 million people (65% of the population). Seventy per cent of the rural population …