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COVID-19: the billion nation story
  1. Rakesh Agarwal1,
  2. Rashmi Baid2
  1. 1 Cardiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
  2. 2 Department of Reproductive Medicine, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
  1. Correspondence to Dr Rakesh Agarwal, Cardiology, Institute of Postgraduate Medical Education and Research, Kolkata, WB 700020, India; dr.agarwal.rakesh{at}

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The mammoth problem that India faced with the COVID-19 epidemic was its huge population that lives in closely clustered spaces. A catastrophe was imminent. With its limited healthcare resources—estimated hospital beds in India are 1.3 per 1000 people as against a recommended of 3.5—fuelled by years of low expenditure on health budget, a triage was needed to be deployed rapidly.1

The nation faced a double-edged sword—allowing economic activity to continue or, forcing a shutdown. Indeed, millions of people in India are dependent on daily living wages for their livelihoods, and forcing a lockdown would lead to profound loss of livelihood and lives. But then there was a risk of a rapidly accelerating pandemic that, if left unabated, could leave the country in ruins. It was a hard choice for the policymakers, and they chose what they believed was the lesser evil. The government invoked the provisions of the Epidemic Diseases Act, 1897, and the nation went into a complete lockdown on 24th March 2020 which was extended again and again, until 31st May. Gradual resumption of activities was allowed after that in phases.2

Did the lockdown halt the COVID-19 pandemic in India? The answer is obviously a resounding no. India accounts for the second largest number of COVID-19 cases in the world at the time of writing this article.3 It was not a 21-day battle as the government had declared but a prolonged war. What the lockdown did was buy the nation time. Ill-prepared as it was, India rapidly accelerated its testing capacity and hospital beds. There was rapid advancement of manufacturing capacity for personal protective equipment, N95 masks and ventilators. The government used the time to educate the public about the constant need of scientifically driven preventive methods including hand washing, wearing masks and maintaining social distance.

India’s efforts did show positive effects. Despite its humongous population, the number of COVID-19 cases per capita population has been low (6193 per million population) (all data at the time of writing the article), and so have been deaths (92 per million population) (all data at the time of writing the article). India has consistently been carrying out over 1 million tests per day (total tests stand at over 85 000 per million population) (all data at the time of writing the article), the highest in the world for some time now. India’s positivity rate has been declining even as the country opens up slowly and steadily.3 The country has managed to deploy its scientific minds into researching for a vaccine and COVID-19 treatments, and its vaccine programme has reached phase III of clinical trials.4

India’s COVID-19 response was not without hiccups. It was marred with controversies as well. The Indian Council of Medical Research (ICMR), the apex government organisation at the forefront of COVID-19 fight, recommended hydroxychloroquine (HCQ) prophylaxis for healthcare workers and asymptomatic household contacts of confirmed cases. There were concerns that such a recommendation was without robust evidence and could lead to acute shortage of the drug, which could be troublesome for patients who take HCQ for other indications. Also, the side effects of the drug could uncommonly be life-threatening.5 Another school of thought considered it a prudent approach with a justified risk–benefit ratio for HCQ prophylaxis. The ICMR continues recommending HCQ prophylaxis so far.6 This is despite convincing evidence against the use of HCQ for pre-exposure or post-exposure prophylaxis against COVID-19 infection. Large observational and randomised studies have failed to prove the drug’s efficacy in prevention of infection or mortality from it.7 8

The Indian government’s plans of mass testing were set back as rapid testing kits that came in during the initial part of lockdown were found to be ‘faulty’ and could not be deployed. There was mass exodus of daily workers and migrants, and the government drew much flak for its handling of the situation as well. Like places elsewhere, India had its own share of super-spreader events and there was a rapid ascent of COVID-19 cases despite the lockdown as the country began to open up.9

Thankfully, India has so far largely been spared the horror that it had so much feared: of overloaded hospitals and absent ventilators. In the war on the pandemic so far, India’s response had been mixed. There were laudable steps by the healthcare community and policymakers. Yet, there were mistakes that could have been avoided. There are lessons to be learnt. The fear still looms large and no complacency can be allowed.

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  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

  • Contributors RA was involved with the acquisition and analysis of research for the said work, and drafting the work, editing of the manuscript and final submission. RB contributed to research and planning of the manuscript and research work for this manuscript. She was also involved with editing the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.