Community Spread Has Begun in South Asia

Most South Asian countries locked their borders down last week or even earlier, but the number of confirmed coronavirus cases keep rising, particularly in Pakistan and India. This trend suggests that the region has likely moved from phase two of the virus outbreak, when transmission is traced to people who have arrived from foreign countries, to phase three, when the disease is spreading more widely among communities.
“We don’t have public evidence we’re in phase three in India,” said Ramanan Laxminarayan, the director of the Washington, D.C.-based Center for Disease Dynamics, on the phone from New Delhi. “But there’s anecdotal evidence. The data and modeling show we should be in phase three. And it’s very hard to prevent this next phase from taking place.”
We’ve seen this pattern in China, Iran, Western Europe, and the United States: The coronavirus spread starts off slow and then grows exponentially. “And by then you’re far behind, and catching up is really difficult,” said Ashish Jha, the director of the Harvard Global Health Institute. Jha believes it’s more likely that India has between 5,000 and 10,000 cases—10 or 20 times the official numbers—but that most are undetected due to limited testing. If the number of cases doubles every five days, India and its neighbors are less than a month away from a potentially unmanageable number of cases and deaths.
It’s not as if South Asian countries aren’t taking action. India, the region’s largest economy, has ground to a halt since the weekend. Authorities urged people to take curfew orders seriously, shutting down domestic commercial flights and rail services. In a televised address to the nation on Tuesday, Prime Minister Narendra Modi announced a strict 21-day nationwide lockdown. “If we are not able to manage the next 21 days, we will be pushed back by 21 years,” he warned. “For 21 days, forget what it means to step outside your home.”
In Pakistan, the military has been called in to impose restrictions on public gatherings. Nepal’s government declared a countrywide lockdown until at least March 31, with people barred from leaving their homes except to buy medicine or groceries. In Sri Lanka, the government extended a nationwide curfew to promote social distancing and accepted a $500 million loan from China for its public health efforts. Even in Afghanistan, where the Taliban are skeptical of global health organizations, a spokesman for the militant group confirmed that it was ready to cooperate with World Health Organization.
“The lockdowns are pretty serious measures,” said Laxminarayan, referring to India’s move. “And people are taking social distancing seriously. But it’s not so easy to practice physical distancing in the way that’s needed.”
Last week, I pointed out how India has lower ratios of hospital beds and doctors per capita than developed economies—a shortage that also holds true for its neighbors. Barring the Maldives and Afghanistan, most South Asian countries underspend on health care. Bangladesh, Pakistan, and India spend 2.4 percent, 2.8 percent, and 3.7 percent of their GDPs respectively on health expenditure, compared to 8.9 percent for Italy and 17.1 percent for the United States.
But there are several other problems that will manifest as the region attempts to slow the spread of the coronavirus.
First, consider the workforce. According to data from the International Labor Organization, in India, Nepal, and Pakistan, a respective 80.9 percent, 90.7 percent, and 77.6 percent of the population is employed in the informal sector—working for daily wages, usually without contracts, health care, or pensions. (Bangladesh is a relative bright spot, with only 48.9 percent in the informal sector.) For most of these informal workers, taking a day or two off from work—let alone a month—can be ruinous. It’s quite likely that these workers will continue to seek work, potentially exposing themselves to the coronavirus.
Second, social distancing is easier said than done for migrant workers and slum-dwellers who live in close quarters with several other people, often with shared public toilets and limited access to clean water and disinfectants. South Asia has some of the world’s most populated cities, and also the most densely populated ones: Mumbai, Kolkata, and Karachi are the top three. That makes unfettered community spread more likely. South Asia’s cities are also among the world’s most polluted, meaning people are likely to suffer from asthma or other respiratory illnesses, weakening their bodily response to COVID-19.