India’s confirmed coronavirus cases crossed the three million mark on Sunday, 23 August with nearly 70,000 new infections.

The health ministry said 69,239 cases were detected on Sunday, with 912 deaths taking the total number of fatalities to 56,706. Many experts say, however, that the real scale of the infection is much higher.

The world’s second-most-populous nation is currently leading in new infection cases as the virus marches through impoverished rural areas in the north and the wealthier but older populations of the south.

Previously the main hotspots have been the teeming megacities of New Delhi and Mumbai, home to some of the world’s biggest slums.

“At the moment we are seeing a fairly sharp rise in cases overall for India,” said K Srinath Reddy, of the non-governmental Public Health Foundation of India.

Individual states and cities have imposed localised lockdowns as case numbers have spiked in recent weeks.

Indian Prime Minister Narendra Modi’s government imposed one of the world’s strictest lockdowns in late March that has been mostly eased in recent weeks.

But the epidemic has left Asia’s third-largest economy reeling, and tens of millions of people have lost their jobs and livelihoods.

Here are some reasons why India is so affected by the virus:

Saturated Cities

India’s first cases were reported in the southern state of Kerala in late January, which was three university students studying in the disease epicentre of Wuhan, China. But community transmission took hold in cities thousands of kilometres to the north, with the financial centre of Mumbai reporting huge spikes followed by New Delhi.

The rise in new infections has since levelled off in India’s two largest cities, with serological surveys showing widespread prevalence among populations.

In New Delhi, a recent government study of 15,000 volunteers showed 29 percent had antibodies for the coronavirus, although the city of 11 million has only 150,000 confirmed cases, suggesting many undetected infections.

Dr Ullas Kolthur Seetharam, a biologist in Mumbai, conducted a survey across the city of 12.4 million in July that found more than half of the people tested in slums had antibodies compared to 16 percent of those tested in organized residential neighbourhoods.

The survey suggested that shared toilets, high population density and lack of physical distancing contributed to the spread.

“Any change in the demography will change the prevalence of the virus,” Seetharam said.

Indian laborers walk closed marketduring reimposed weekend lockdown to prevent the spread of coronavirus in Jammu, India Saturday, Aug.22, 2020.India has the third-highest caseload after the United States and Brazil, and the fourth-highest death toll in the world.(AP Photo/Channi Anand)

Geographical Divide 

India’s meagre health resources are poorly divided across the country. Government data shows a wide disparity in health indices, with India’s poorest states comparable to sub-Saharan Africa.

Nearly 600 million Indians live in rural areas, and with the virus spreading fast across India’s vast hinterlands, health experts worry that hospitals could be overwhelmed, with less testing making it all the more difficult for the authorities to track and contain the disease.

“India’s rural areas have very limited health infrastructure,” said epidemiologist Jayaprakash Muliyil. “I fear we might soon witness a spurt in cases there.”

In Bihar, nearly 90 percent of the population lives in villages. Every year, the state struggles to deal with dengue outbreaks and other seasonal diseases, and it has only one hospital bed and just under four doctors per 10,000 people, according to official data.

Bihar, which is testing 10,000 samples per day, has sought the federal government’s help to test 10 times that number. But that’s only one part of the problem. Many people are hiding their symptoms and don’t opt for tests, complicating the state’s effort to curb the spread of the virus, officials say.

Ramped up testing

Nationwide, India is testing more than 900,000 samples per day, exceeding the World Health Organization’s benchmark of 140 tests per 1 million people. But about a third of these are antigen tests, which are faster but less accurate compared to RT-PCR, the gold standard for the coronavirus.

A health worker takes a nasal swab sample to test for COVID-19 in Hyderabad, India, Saturday, Aug. 22, 2020. India has the third-highest caseload after the United States and Brazil, and the fourth-highest death toll in the world. (AP Photo/Mahesh Kumar A.)

Uttar Pradesh, with 200 million people India’s most populous state and also one of its poorest, is conducting the most tests, with an average of 110,000 daily.

But new hot spots continue to drive the surge in cases. Uttar Pradesh is now among the five worst-affected states in India, behind Maharashtra, Tamil Nadu, Andhra Pradesh and Karnataka.

Telangana, home to India’s tech hub of Hyderabad, has come under fire for insufficiently testing its 40 million people.

In Hyderabad, which is normally buzzing with activity, ongoing fear of the coronavirus has kept parks, shopping areas and roads quiet.

Telangana has reported about 79,000 total cases. But two prominent scientific bodies — the Center for Cellular and Molecular Biology and Indian Institute of Chemical Technology — have warned that an analysis of Hyderabad sewage suggests that the real rate of infection in the city alone could be six times higher than the state’s reported total.

After testing samples at 10 sewage treatment plants, the scientists reported that about 6.6 percent of Hyderabad’s population of 10 million — 660,000 people — could be infected.

India’s number of confirmed cases along with deaths related to COVID-19 are increasing. image credit: John Hopkin

Race to the top 

India has the third-highest caseload in the world after the United States and Brazil. But with the rate of infection growing in recent weeks, experts fear India could soon surpass those countries.

For 18 consecutive days, India reported the most number of newest cases in the world. At the same time, the mortality rate dropped to 1.87 percent — far lower than in the other hardest-hit countries.

“I don’t know what magic people think is going to happen,” said Dr Gagandeep Kang, an infectious diseases expert at the Christian Medical College at Vellore, in southern India.

With India’s population of nearly 1.4 billion and the way the virus is spreading through the country, she asked, “what makes you think that you’re not going to end up with the biggest numbers in the world?”

With inputs from wires