India is set to report 100,000 deaths from the coronavirus – a grim toll that ranks it third in the world behind the United States and Brazil.
September was the worst month on record in the country: on average, 1,100 Indians died from the virus every day. Regional anomalies continue as some states report much higher deaths than others – a sign, experts say, that the pandemic is still spreading across the country.
Here is some of what we know about the regions where India is most affected by Covid-19 and why.
Maharashtra is on top of a the list
Maharashtra, one of India’s largest and wealthiest states, has both the highest number of cases – 1.3 million and over – and the number of deaths – over 36,000.
The pandemic struck early in Maharashtra, spread rapidly and barely slowed down. The number of daily deaths reported in September ranged between 300 and 500 – a figure significantly higher than other hard-hit states which reported fewer than 100 deaths per day throughout the month.
And it is no longer Mumbai, the crowded financial center, that worries pandemic watchers. The quiet suburb of Pune rose to second place with more than 5,800 dead. Five of the 10 districts with the highest deaths from Covid-19 – 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 that carried out random antibody sampling from residents of Pune. The government investigation found that in some parts of the city half of the population had developed anti-Covid-19 antibodies.
Dr Ghose said that while Mumbai was more self-sufficient, the greater movement between urban and rural areas in Pune District, as well as between Pune and surrounding districts, had spread the virus further to those parts.
Pune’s ‘giant’ Covid center recently made headlines on allegations of death by negligence.
The Punjab Empire
The northern state reported a case fatality rate of 3%. It is a measure of the number of Covid-positive patients who die from the virus and the Punjab figure is double that of the Indian 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 more.
“The Punjab is a source of concern,” said Dr Shamika Ravi, a senior researcher at the Brookings Institution monitoring the pandemic. “Its death rate is not only the highest in the country, but it is also increasing,” she said.
This is alarming, Dr Ravi said, because it is contrary to what is happening around the world and in India as a whole – widespread testing and better knowledge of treatment options are lowering case fatality rates.
Dr Ravi said she believed Maharashtra and Punjab both exhibited symptoms of greater discomfort – limited testing, leading to higher positive rates. A drop in testing could lead to higher death rates, she said, as authorities only detect the infection when it’s too late.
Test 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 perform roughly the same number of tests per million as Punjab – 60,000. And yet, their positive rates are much lower.
“If you test less and your positive rate is still high, it means the infection is early. You catch cases too late, ”said Dr Ravi.
Her argument was supported by the image of Maharashtra, she said – a state that has consistently reported high positivity rates, high deaths, but has not significantly stepped up testing.
Not everyone is convinced of the correlation between the two. “I don’t know of any direct relationship,” said Dr. Gautam Menon, professor and researcher in infectious disease models. “You don’t test enough, that means you miss a ton of cases. But what fraction of those cases lead to deaths is hard to say. “
Dr Ghose said he believed there might be a more roundabout connection – that less awareness and less ability to get tested – resulting in limited testing – could also lead to subsequent hospitalizations , increasing the risk of death.
A recent study in the states of Andhra Pradesh and Tamil Nadu found that the median time between hospitalization and death for patients with Covid-19 was 13 days, which led researchers to conclude that ” a substantial proportion of patients’ in both states were likely diagnosed late. .
And yet Tamil Nadu is a state that constantly tests at high rates and also has a low death rate. In absolute numbers, it has reported more than 9,000 deaths, the second highest in the country, but daily deaths have been declining since July.
But epidemiologist Dr Jacob John said this was because early diagnosis of infection was not always going to affect a patient’s treatment plan, as in many cases doctors follow that very plan. without diagnosis.
“In order for poor tests to have bad results, one has to assume that the tests will change the way a patient is managed,” said Dr John.
Instead, a higher death rate is the result of a poor health care system, he said, and the same system also provides limited testing and treatment once a person ends up in the hospital.
Urban districts report increase in deaths
The 10 hardest-hit districts so far are urban, and so are those with the highest death rates.
Urban districts have so far accounted for nearly 80% of India’s death toll from the virus. Many of them have higher than average case fatality rates.
This is not surprising given that the virus thrives in dense populations where social distancing is nearly impossible. And it also explains why most of the worst affected districts are in wealthier states like Maharashtra or Punjab. These states are much more urbanized, and many districts outside of the major cities still have large and concentrated populations.
Experts believe that urban districts also report higher deaths because residents of surrounding districts tend to travel there for treatment.
“The data from Pune is clouded by the fact that there is a lot of influx from surrounding districts,” said Dr Gautam Menon, professor and researcher on infectious disease models.
Rural districts also have lower comorbidities, which would reduce the risk of death from the virus, Dr Menon said.
Poorest states have fewer deaths
Under-reporting is certainly a factor, but India’s poorer states, which everyone feared would be plagued by the virus, have yet to collapse.
But we are not yet at the end of the pandemic, warned Dr Ghose. “The worst is over for Maharashtra and, probably, for Delhi, but the rest of us still have a way to go,” he said.
“Every state is at a different time during the pandemic. Fortunately, it started in richer states like Maharashtra. If it had started in Bihar, it would have been a disaster. “
Learn more about our original coverage of the pandemic in India