Though the COVID-19 crisis hit India hard – over 9 million cases have been reported and more than 138 thousand people have died – the mortality rate from COVID-19 is inexplicably lower compared to other countries.
For instance, while the US leads the world with more than 14 million cases and over 276 thousand deaths, according to the John Hopkins Coronavirus Research Center, India accounts for only 10% of deaths globally and has the highest number of recovered patients of COVID-19 at 94%, even though its coronavirus caseload is second only to the US.
With such a significant share of the world’s coronavirus cases, shouldn’t COVID-19 have been more devastating in India?
“Something strange has been happening within the Indian subcontinent and neighboring regions,” said Rao. “For some strange reason our mortality rate per million is one eighth and our total cases seem to be in the region of one sixth per million.”
As COVID-19 began its inexorable spread across the world, the WHO recommended safety precautions to protect against the virus – physical distancing, wearing a mask, well ventilated rooms, avoiding crowds and close contact, and regularly washing hands.
But in an outcome that has puzzled epidemiologists and scientists alike, India seems to be experiencing a low mortality rate from the coronavirus, stated Rao, despite the crowded conditions in which many urban Indians live.
A large proportion of urban dwellers in a developing country like India lack access to adequate healthcare facilities and maintain poorer sanitation and hygiene practices which are known to be responsible for a higher incidence of communicable diseases. So the virus was expected to have caused many more deaths in densely populated communities in India than it has.
Urban Indians are ‘badly housed,’ explained Rao, using Mumbai as an example to explain why crowded Indian cities offer a fertile petri-dish for catastrophic coronavirus outbreaks. “I would say that close to 60% of the population of urban India lives closely packed together in slums.”
In a metropolis like Mumbai, home to over 20 million and India’s largest city, nearly one million people live cheek by jowl in Dharavi, one of the world’s largest slums.
“Houses are no more than two feet apart. Each house is no larger than a 10 by 12 room,” said Rao.
Each home houses about 10 to 12 people, closely packed together. It makes social distancing nearly impossible, while access to basic hygiene essentials, including toilets and hand washing are limited.
“There is only one public toilet per every two or three hundred slum dwellers,” explained Rao, highlighting the less than hygienic conditions in slums like Dharavi. “Face masks, social distancing…are close to non-existent. We take things like face masks, temperature checks and sanitizing very lightly,” he claimed.
“If it were a pandemic that was ravaging us because of a lack of social distancing,” asked Rao, why are the slums relatively less impacted than expected? And, despite overcrowding on the suburban railways, he adds, “the crisis has hit us less hard than anticipated.”
While epidemiologists attribute India’s low mortality rate to under-reporting, and even though Rao himself expected undercounting, he alleged that at least in Dharavi, there is no evidence of it. “I don’t see the bodies piling up in the streets… or the hospitals,” nor has he noted any alarming rises in the body count.
Rao claimed he is voicing “a mainstream belief” felt across economic classes and demographics in India, that the coronavirus is not causing the high mortality rates that were anticipated.
In Dharavi, officials say that concerted public health efforts to trace, track, test and treat cases, have helped to contain community spread.
Now, recent research by Indian scientists seeking to explain why India’s death rate is so low, suggest that more Indians may be immune to COVID-19 because they live in unsanitary conditions which have created an unexpected shield from the virus.
According to one study, more than 70 percent of all COVID–19 deaths have occurred in high income countries like Italy, Spain, UK, France and USA. It hypothesized that more people died in richer countries with older populations, because better hygiene and safe sanitation practices lowered levels of immunity and made people more susceptible to the virus.
In another study scientists report, “It appears that countries with better health care, clean environment, clean food and water have higher COVID associated mortality, whereas developing and underdeveloped countries have lower mortality in terms of deaths per million population.”
Both research studies (not yet peer reviewed), suggest that in low GDP countries like India, lives of people in densely populated areas may have been saved because of poor hygiene and sanitation practices. Unsanitary conditions and exposure to diseases from childhood may have increased their ability to ward off infections, and boosted immunity against COVID-19. Experts also suggest that the early lockdown and a younger population helped stave off a higher death toll in India.
The science is intriguing. Does greater exposure to a variety of viruses in the slums of low income countries provide a better level of protection against the coronavirus, than the overly sanitized environments of richer nations?
“Paradoxically, better sanitation leads to poor immune training and thus could be leading to higher deaths per million,” says the study. But it cautions that while the research offers a possible explanation, poor hygiene is not a solution to the pandemic.
India, and Dharavi in particular, may have pulled off a remarkable reprieve against COVID-19 for now. But the pandemic is far from over and science is still learning about this young virus. So, public health experts warn, SMS (social distance, mask, and sanitize) must remain the global mantra to keep Covid 19 at bay, until vaccines become easily available to the general public.
Meera Kymal is the contributing editor at India Currents.