The images were some of the most searing of the pandemic. Overflowing hospitals. Social media posts begging for oxygen. Crematoria that operated all day and all night. The bodies of COVID victims burning in the streets. The avalanche of COVID cases that inundated India in spring 2021 was one of the worst of the pandemic. It heralded the arrival of the more infectious and more deadly Delta variant that would soon dominate the globe and became a worst-case example of what can happen when COVID catches a nation off guard.
But now India seems to be an example of how soon a nation can forget.
The highly transmissible Omicron variant is fueling a spectacular rise in COVID cases in India. This week, the country’s daily caseload hit 150,000, a nearly 10-fold increase since the start of the new year and a threshold not breached since May of last year. But even with the Omicron surge, authorities in India have introduced only modest restrictions to contain its spread. Worse yet, the country is displaying the same traits that exacerbated its 2021 wave: complacency, this time owing to reports that Omicron causes a more mild disease, and a refusal to disrupt the nation’s upcoming elections. In 2021, massive, mostly unmasked campaign rallies preceded a jump in Delta cases.
In some ways, India is better prepared to endure an Omicron wave. Around 65% of its adult population is vaccinated with two doses, and its hospitals have made improvements to better respond to a surge in cases. But experts warn India is reverting to bad habits that will leave it vulnerable to a new wave of devastation.
Cases doubling every five days
On Tuesday, India reported 168,063 new COVID cases; on Wednesday, new cases hit 194,720. The nation’s case count is doubling roughly every five days led by surging infections in Delhi, Mumbai, Kolkata, Bengaluru, and Chennai.
As of Wednesday, the percentage of people testing for infection had soared to 11%, up from 0.8% on Dec. 29, according to government data.
Ameera Shah, managing director of laboratory chain Metropolis Healthcare, predicts an enormous swell of infections that may not crest until February.
“My sense is that with this virus, because it’s so much more transmissible, the peak will come a little bit earlier [than the previous wave],” she said. “I am expecting it in 30 days.”
Two of India’s largest cities, Delhi and Mumbai, have responded to the threat of Omicron with modest curbs such as limiting the number of people allowed at restaurants, gyms, and wedding venues and imposing a nightly curfew.
Several states have closed gyms and movie theaters and limited the capacity of public transportation like buses.
But no state or city has imposed a complete lockdown comparable to those the federal government enacted during India’s first wave in March 2020 or the ones individual states introduced during the second wave.
India’s stock market also seems unfazed by the surge. Since the beginning of the year, the benchmark Bombay Stock Exchange index has gained nearly 6%.
“Only when people start getting hospitalized will the seriousness of the situation sink in,” says K. Srinath Reddy, president of the Public Health Foundation of India.
A milder COVID?
Research from early Omicron hotspots showing the variant causes more mild disease has fueled public complacency.
“We will face whatever comes our way. Our whole family was infected during the first wave in August and therefore have some natural immunity,” says Jaideep Dutta, an independent wealth adviser, who traveled from New Delhi to the northeastern Indian state of Assam’s capital, Guwahati, at the start of the year with his wife and two school-age children.
Dutta and his wife have received two doses of a COVID vaccine and think the jabs, along with their previous COVID infections, will protect them in the Omicron wave.
People who have been infected with Omicron are mostly showing mild symptoms that do not require hospitalization, says Sudhir Kalhan, chairman at the Institute of Minimal Access Metabolic Bariatric Surgery at New Delhi’s Sir Gangaram Hospital.
A government survey in July found that two-thirds of India’s 1.3 billion population have COVID antibodies that may give them some level of protection.
T. Jacob John, former chief of virology at Christian Medical College, estimates that between 600 million and 800 million Indians were infected with COVID in India’s second wave this spring, but those people may still be susceptible to Omicron, given its ability to evade immune defenses, he says.
Data from other countries suggest Omicron is also far more likely to infect vaccinated individuals, especially those who haven’t gotten a booster. Ninety percent of India’s adult population have received one dose of a vaccine, but just 65% are fully vaccinated. India only started administering boosters to health care workers and adults over 60 with comorbidities on Jan. 3.
So far, hospitalizations have not increased at the same pace as COVID infections, as was the case in India’s second wave. The share of infected people who have been hospitalized is currently 3.7% in the Indian capital, Delhi, and 5% in financial hub Mumbai, compared with 20% in both cities during last year’s wave, Vinod Kumar Paul, scientist and member of government think tank NITI Aayog, told a press briefing last Thursday.
But Omicron is still a concern because its high transmissibility means the sheer number of people who may get infected in coming weeks could strain health care infrastructure, even if those hospitalized experience less severe disease, Kalhan says.
Hospitals gear up
Indian government health officials say hospitals have enough medicine, supplemental oxygen, and critical care infrastructure in place to handle up to 600,000 daily Delta variant–type infections, or around the peak of the second wave, and more facilities are being added to deal with the third wave.
“We have ample beds available with us. But we are adding beds [in parallel] in case the situation worsens,” says Ashutosh Shukla, medical adviser to Max Healthcare, one of the largest private hospital chains in the Indian capital, Delhi, and nearby cities.
In addition to severely sick patients, hospitals also run the risk of being inundated with people seeking COVID tests or treatment for mild symptoms, since India has not developed means for tending to COVID patients outside hospitals.
“One of the things that have not been adequately developed is early home-based diagnosis and home care of patients by primary health care teams,” says Reddy. “Unless you identify people with symptoms at home for mild and moderate cases, it will put a lot of pressure on primary health care centers.”
Another concern is that Omicron could lead to an uptick in pediatric patients, similar to what’s happening in the U.S., says Shah.
“I am worried about the pediatric capabilities that we have, because the ICU beds, for example, required for children are different from ICU required for adults. You can’t use the same ventilator; you can’t use the same machines,” Shah says.
Boosting—but is it too late?
India only started vaccinating children over age 15 earlier this month when it launched its booster campaign for some over age 60 and health care personnel. Reddy worries that Indian hospitals may face staffing shortages owing to sick workers since it started giving doctors, nurses, and support staff third vaccine doses so late.
That said, India’s vaccination drive remains one of its best defenses against its third wave. Unlike during the second wave, India has no shortage of jabs, so stepping up inoculations would help counter Omicron, says Amir Ullah Khan, a former policy adviser for the Bill & Melinda Gates Foundation.
India is primarily deploying three vaccines: Serum Institute of India’s Covishield version of the AstraZeneca vaccine, Bharat Biotech’s Covaxin, and Russia’s Sputnik V. Covishield provides “reasonable protection” against severe disease and death, including from Omicron, says Reddy. Omicron results for Covaxin are still pending from India’s National Institute of Virology.
Still, concerns about the resilience of India’s health care system have not caused an obvious change in public behavior or a major shift in government policy.
It’s election season—again
Five Indian states—Punjab, Uttar Pradesh, Uttarakhand, Goa, and Manipur—are due to hold elections starting Feb. 10. In the run-up, political leaders are expected to address rallies attended by thousands of people, fueling concerns about super-spreader events. So far, the only concession to that danger is a decision by India’s election commission to ban rallies until Jan. 15. Every polling station will be equipped with hand sanitizers, face masks, and thermal scanners, the commission says.
Last year’s second wave arrived as thousands of people gathered—often maskless—at election events across the country.
“Rallies should continue, but those leaders whose rallies don’t follow COVID protocols should be barred from fighting elections for the next five years,” says Khan.
Preserving the economy
India’s leaders are scrambling to keep an economic recovery on track even as they gird against the latest COVID surge.
In the first year of the pandemic, India’s economy contracted by 7.3% for the year ending March 2021, following one of the world’s most stringent lockdowns that hit the country’s supply chain.
The country’s economy has rebounded since, even through the devastating second wave. India’s GDP increased by 8.4% during last year’s July–September quarter, making it one of the world’s fastest-growing among major economies, according to government data.
A third wave could hit “contact-intensive” segments of the economy, but the manufacturing sector should fare better than it did in past outbreaks, Sonal Varma, Nomura’s chief economist in India, told Fortune.
“Past and global experience also suggests that as economies are learning to live with the virus, the negative growth impact of each pandemic wave is lesser, and economies can see a swift rebound once cases peak,” she adds.
India’s largest private bank, HDFC, said in a report on Tuesday that an increase in COVID-related restrictions on movement could dent the country’s GDP growth by 20 to 30 basis points from a projected 6.1% for the fourth quarter of the fiscal year ending March 2022.
Indian industry officials have opposed any lockdowns over Omicron, citing the need to bolster growth.
Many Indians fear new restrictions that threaten their livelihoods.
Vegetable vendor Raghu Dayal, who’s 50, defied a weekend curfew to wheel his cart around the streets of New Delhi on Sunday evening.
“My business is down, and it means that I have to work harder,” Dayal says. “I can’t afford to sit at home.”
Never miss a story: Follow your favorite topics and authors to get a personalized email with the journalism that matters most to you.
