India is on the verge of reporting 100,000 deaths from the coronavirus – a grim toll that ranks it third in the world behind only the US and Brazil.
September was the nation’s worst month on record: on average 1,100 Indians died every day from the virus. Regional anomalies continue as some states report far higher deaths than others – a sign, experts say, that the pandemic is still working its way through the country.
Here’s some of what we know about where India is worst affected by Covid-19 and why.
Maharashtra is at the top of the list
Maharashtra, one of India’s largest and richest states, has both the highest caseload – 1.3 million and counting – and death toll – more than 36,000.
The pandemic struck early in Maharashtra, spread quickly and barely let up. The number of daily reported deaths in September ranged between 300 and 500 – significantly higher than other badly-hit states which reported fewer than 100 deaths a day through the month.
And it is no longer Mumbai, the crowded financial hub, that is worrying pandemic watchers. Mumbai is still the district with the highest fatalities, but quiet, suburban Pune district has raced to second place with more than 5,800 deaths. Five of the 10 districts with the highest Covid-19 fatalities – Mumbai and Pune included – are now in Maharashtra.
Mumbai was the virus’ gateway to Maharashtra, said Dr Aurnab Ghose, who was part of a team which carried out a random antibody sampling of Pune residents. The government survey found that, in some parts of the city, half the people had developed Covid-19 antibodies.
Dr Ghose said that while Mumbai was more self-contained, the greater movement between urban and rural parts of Pune district, as well between Pune and surrounding districts, had spread the virus further in these parts.
And given the high prevalence, health systems too have been overwhelmed, driving up deaths in some instances. Pune’s ‘jumbo’ Covid centre made headlines recently over allegations of a negligent death.
Punjab is getting worse
The northern state has been reporting a case fatality ratio of 3%. That’s a measure of how many Covid positive patients die from the virus and Punjab’s figure is double that of India’s national average.
In absolute numbers, the state ranks ninth for deaths. But many of its districts are also reporting high case fatality rates – 4% and above.
“Punjab is a cause for concern,” said Dr Shamika Ravi, a senior fellow at the Brookings Institution who is tracking the pandemic. “Its case fatality rate is not only the highest in the country but it’s also rising,” she said.
That is alarming, Dr Ravi said, because it is contrary to what’s happening all over the world and in India as a whole – widespread testing and improved knowledge of treatment options is bringing down case fatality rates.
Dr Ravi said she believed Maharashtra and Punjab were both showing symptoms of a bigger malaise – limited testing, leading to higher positive rates. Lower testing could leader to a rise in death rates, she said, because authorities catch the infection only when it’s too late.
Is testing the problem?
Punjab’s positive rate – at 6.2% – is significantly lower than that of Maharashtra – 24%. But it’s also much higher than Bihar (2.5%) or Jharkhand (3.7%) – states that are doing about the same number of tests per million as Punjab – 60,000. And yet their positive rates are far lower.
“If you test less and your positive rate is still high, it means the infection is way ahead. You are catching cases too late,” Dr Ravi said.
Her argument was backed up by the picture in Maharashtra, she said – a state that has consistently reported high positivity rates, high deaths, but has not ramped up testing significantly.