COVID-19: Why India’s Younger Population Won’t Offset its Poorer Health

Featured image: A homeless man and his son cover themselves with a plastic sheet to protect themselves from rain as they walk to a shelter, during a nationwide lockdown to slow the spreading of the coronavirus disease (COVID-19), in Kolkata, India, April 27, 2020. Photo: Reuters/Rupak De Chowdhuri

There is now a general consensus that the coronavirus pandemic is affecting many more individuals above the age of 65, with the possibility of dying being as high as 15% for people above 80 (and 8% for 70-79 and 3.6% for 60-69 years age group), as opposed to 3.6% for all.

Not unexpectedly, it is now becoming clear that countries with a large share of ageing population are in a worse position in combating the pandemic. It has been suggested that because of India’s favourable demographic profile, India could selectively relax the lockdown that has been imposed. However, we would like to point out that demography is just one of the factors that affect the vulnerability of the population to COVID-19 deaths. The strength of the healthcare system and the base level of health in the general population are two other important factors that matter crucially.

In terms of the age profile, some European countries appear to be at a particular disadvantage than their Asian counterparts. India is an important case in point – with only about 6.18% of its population above 65 years of age, the country seems to be in a relatively comfortable position on that count. Prime Minister Narendra Modi, however, did not take any chances and imposed a lockdown on 24 March at a relatively early stage when the government’s official figures reported less than 500 infection cases and 9 deaths in a country of 1.3 billion. The pertinent question is whether an early lockdown is enough to save a country with a relatively young population.

Table 1. Progress of the coronavirus and the announcement of lockdown in selected European countries and India

Let us start by comparing four European countries: Germany, Italy, Spain and the UK, all of which have comparable ageing populations, but have fared quite differently in terms of infected cases and deaths. Table 1 shows the date of the lockdown and the total number of infections and deaths at the start of the lockdown in these nations. Clearly, Germany with 55 deaths at the start of the lockdown, was much more proactive than other nations in Europe: in Spain the authorities took the decision after 191 deaths, in the UK it took 281 deaths, and in Italy it took as many as 366 deaths.

The final two columns show the total number of infections and deaths as of April 10, 2020, which highlights the disastrous outcome in all the countries barring Germany, even when two out of three of these countries had younger populations than Germany.

In comparison, India’s figures seem almost too good to be true. A key problem facing the Indian government has been the quality and lack of testing facilities. India had the lowest testing, 133 on April 11 as against Germany’s 15,850 per million people as of April 8. Without the crucial data from testing, Indian health officials are almost blindly making life-or-death decisions about who does and who does not carry the COVID-19 virus, thus explaining the low reported figures.

In terms of India’s official figures and Oxford COVID-19 tracker of government responses to the pandemic, India has been at the top of the league, but serious questions remain in its implementation of the lockdown rules. Shutting down a country of 1.3 billion has its own challenges, especially when accompanied by the illiteracy, poverty, religious beliefs and social norms prevalent in the country. The problem gets worse when one accounts for the unscientific approach to the crisis by the elite in power.

What lessons can we learn from the European experience of tackling the crisis? Surely, a higher share of elderly in the population can explain, at least in part, the astonishingly high infected cases and death rates in many European countries. World Bank data demonstrates that as of 2018, Germany is not very different from Italy in terms of the share of its ageing population (see Table 1). But Germany has been many times more successful in limiting the total number of deaths.

Also read: India’s COVID-19 Testing Conundrum: Why the Govt and Critics Are Both Right

If we look at Spain or the UK, the picture is even more striking: both having the ratio of ageing to total population less than that of Germany, but with the number of deaths being significantly higher than that of the latter. All these figures point to the strong possibility that although ageing is an important factor behind the severity of the pandemic, other factors, e.g., early and effective lockdowns, general health of people and quite importantly, existing healthcare facilities offering quality mass testing and treatment cannot  be ignored.

Germany, a nation that spends 11.1% of its GDP on healthcare, turns out to be at the forefront in Europe as regards existing healthcare infrastructure. Germany leads the critical care infrastructure with critical care beds of around 30 per 100,000 of the population, for Italy the number is 12.5, while for the UK – despite the National Health Service (NHS) – the figure is only 6.6. Spain is somewhere between Italy and the UK, but once again the figures highlight how important health spending can be.

In addition, Germany tops the list in terms of testing of suspected Coronavirus patients, currently carrying out about 100,000 tests per day (which is a figure the UK hopes to achieve by the end of this month, but which is regarded by the NHS as bit of a stretch). Crucially, Germany started testing people even with milder symptoms relatively early on, meaning the total number of confirmed cases may give a more accurate picture of the virus’s spread than in other states. Also, Germany has more ventilators than it needs and has in fact lent 80 to the UK. Germany has performed Europe’s first large-scale antibody testing in an effort to aid researchers assess infection rates and monitor the spread of the virus more effectively.

All these serve to demonstrate how, with a sound healthcare infrastructure, even a country with an ageing population can combat the pernicious threat of COVID-19 much more effectively than others. Given that the proportion of GDP allocated to healthcare in India is only a little over 1%, there is not only a lack of testing, but also a real scarcity of hospital beds, critical care beds as well as ventilators.

The public healthcare in the country is poor while the private health care is expensive. India has only 0.8 doctors and 0.7 hospital beds (compared to 4.1 doctors and 3.4 hospital beds in Italy) per 1,000 persons. A recent UN report as well as the report by the Comptroller and Auditor General has highlighted the dismal state of India’s healthcare sector, urging the government to comply with the targets set by the UN-mandated Sustainable Development Goal by 2030.

Poor general health of the infected patient emerges as a key driver of deaths in COVID-19 cases, and, in this respect too, India and Germany are on very different footing. Malnourishment is a general cause for concern in India as it weakens the body’s power to fight any infection. Fifteen percent of Indians remained chronically malnourished in 2017, constituting about 24% of the world’s malnourished population. In terms of hunger rankings India has slipped from 95th rank in 2010 to 102nd in 2019.

Also read: Face It: The Indian Government Is Peddling Pseudoscience

Further, coronavirus thrives with specific pre-existing health conditions like cardiovascular diseases, chronic respiratory diseases and diabetes. Relative to Germans, there are more Indians suffering from chronic respiratory diseases (double) and diabetes (four times), raising concern for a country like India. While the average COVID-19 death rate is around 3.6%, it increases to 7.3% for those with diabetes and 6.3% of those with chronic respiratory disease. Surely, this is more of a concern because of India’s dismal healthcare facilities.

As community transmission spreads in India, its healthcare system will be tested severely and may even collapse. While some states like Kerala seem better-placed, concerns remain for the larger North Indian states and Kashmir. The efforts at curbing the spread of the pandemic in Kashmir have been constrained by the lack of internet access as well as a growing mistrust of Kashmiris in the Centre since the withdrawal of Article 370 last October.

What then may the lessons for India, with a relatively ‘young’ population, be? As Germany has demonstrated thus far, an ageing population may not necessarily be the bane for countries struggling with COVID-19, providing they act swiftly to trace and test affected patients, effectively impose lockdowns, and have a sound healthcare infrastructure already in place. But a young population with poor general health, dismal healthcare facilities and severe lack of testing may not provide succour to a country even when the government has been proactive early.

The growing severity of the pandemic necessitates urgent release of central resources to enhance testing in all states rather than it being centralised as well as to increase the critical care facilities on a war footing until a vaccine is available. Despite having some initial advantages, India does not seem to be ready for the crisis unfolding.

Sugata Ghosh is at Brunel University, London and Sarmistha Pal is at the University of Surrey, UK and IZA, Germany.

Reprinted with permission from Ideas for India.