On the outskirts of New Delhi, empty apartments are being repurposed as quarantine centres. Schools, colleges, malls, cinemas, restaurants and tourist sites across India — including the Taj Mahal — have been shut down. Hospitals have been asked to defer elective surgery.
The country is now bracing itself for a wave of coronavirus infections — even as Narendra Modi, the prime minister, appealed to 1.3bn Indians to stay at home as much as possible in the coming days to avert the kind of “explosion” of cases that has overwhelmed far more developed countries.
“For the last few days we have seen that people think we are safe from coronavirus,” Mr Modi said on Thursday evening in a rare primetime television address. “This is not right. It’s not OK to get complacent.”
Likening the situation to wartime, he urged Indians to “show resolve and restraint” to curtail their activities. “I appeal to citizens in the coming weeks to step out only for essentials as far as possible,” he said.
Mr Modi also asked all Indians except essential service workers to observe an all-day “people’s curfew” on Sunday, remaining inside their homes from 7am until 9pm as a symbolic display of national resolve.
But despite Mr Modi’s appeals for behavioural change and the gradual ratcheting up of restrictions — the state of Maharashtra, home to financial capital Mumbai, this week ordered all workplaces to close until March 31 — public health experts say what happens over the next few weeks will be critical. Events will determine whether India can prevent the type of devastating coronavirus outbreak that would overwhelm its chronically underfunded and already overstretched health system.
If not, the country — where much of the population is crammed into congested cities — faces the prospect of the virus sickening millions, many of whom will die due to poor underlying health or their inability to access appropriate care.
Even at the best of times, India’s health system is severely strained, with just one doctor for every 1,600 people — far fewer than the 1 per 1,000 recommended by the World Health Organization.
“This is a crucial period for us,” said K. Sujatha Rao, a former health secretary and author of a book on the weaknesses of India’s health system. “It is in this window that we will get to know whether it’s going to be a major, long-drawn battle or else, hopefully, that we have been lucky.”
As the pathogen began its global spread, India moved quickly to try to insulate itself, imposing a growing web of restrictions on travellers from the worst-hit countries, starting in early February with a de facto ban on Chinese visitors. On March 11, New Delhi closed India to virtually all foreign visitors until April 15.
At home, officials have screened Indians returning from foreign trips and tested those with symptoms of the disease. If people tested positive, their contacts, including family, friends and work colleagues, were traced and put under surveillance.
So far, India’s declared caseload has remained manageable. As of Saturday, the country had 275 confirmed cases, including foreign tourists — mainly from Italy and Indonesia. Of those, 20 have recovered and five have died.
Health officials insist there is still no evidence that coronavirus is circulating widely in community and that all infected Indians had recently been abroad or were in direct contact with someone who had.
“In India, there is no evidence of community transmission as yet,” Lav Agarwal, a senior health ministry official, said on Thursday. “We expect to really work hard — and take the support of the community at large — to remain that way.”
But independent experts fear India may be seriously underestimating the magnitude of its caseload because of the country’s restrictive testing protocol, in which only returned travellers who show symptoms, or their direct contacts, are tested. As of Friday, health officials had tested around 15,000 people, one of the lowest test rates in Asia.
“I think they are not testing nearly enough — they should be testing 10 to 20 times the number,” said Ramanan Laxminarayan, senior fellow at the Center for Disease Dynamics, Economics and Policy. “[That would] give us a true sense of caseload and improve their contact tracing, at least.”
The danger was that people with minor symptoms may have already unwittingly spread the virus, he said. “It’s extremely transmissible,” he said. ““It’s a perfect storm that we are up against.”
As cases have climbed sharply in recent days, New Delhi has further tightened travel restrictions, announcing on Thursday that no commercial passenger flights would be permitted to land for a week, starting at midnight on Saturday.
Authorities are hoping that Mr Modi’s television appeal will induce Indians to isolate themselves to the extent possible in a densely populated, family-oriented society. Domestic transport services are also being curbed to discourage public movements.
But ultimately health experts say India needs to radically scale up its testing if it hopes to contain the virus. “The curve is getting steeper and steeper and I honestly believe we must test more — what you can’t measure, you can’t control,” said Shahid Jameel, chief executive of Wellcome Trust / DBT India Alliance, a biomedical research charity.
Health authorities also trying to bolster the health system, which is though to have about 70,000 intensive care beds. “The system is going to have to really hustle in the next 10 days and set up a lot of capacity,” said Mr Laxminarayan. “It’s got to be like a wartime effort.”
Additional reporting by Stephanie Findlay in New Delhi.