The first official cases of coronavirus arrived at Niramaya hospital in Mumbai in early May, but they did not come as much of a surprise to Dr Amit Thadhani.

Thadhani, the hospital director, had suspected for weeks that the virus was being virulently transmitted in India’s financial capital, home to 20 million people, after seeing a steady stream of patients with unseasonable viral symptoms. But strict testing restrictions – and a vehement government denial of community transmission – meant he had no way to prove or prevent it.

“Our limitations in availability in testing back then is partially responsible for the infections we have now, as we could have picked up a lot more early cases,” he said.

Five months on, Mumbai has 1.8 million coronavirus cases and on Thursday, India crossed the dubious threshold of reporting more than5 million cases nationwide. With the fastest rate of infection in the world, and no signs of the country hitting its peak any time soon, many predict India will eventually overtake the US – currently on 6.6 million – to report the most cases worldwide.

“I don’t think India has the healthcare capacity to deal with this,” said Thadhani, his voice weary. When the first Covid cases were reported at his hospital, the fear was so great that more than half of the nurses and support staff disappeared overnight, never returning to work again. In July, when the hospital became a Covid ward, all beds filled up within 24 hours and have not emptied since.

“It’s getting worse by the day; the hospital is full of patients who have moderate and severe symptoms and our intensive care unit is full,” he said. “There is a shortage of oxygen, we are really struggling to get our daily supplies, and many hospitals in Mumbai have stopped taking in new admissions because they have no more oxygen tanks.”

Thadhani said the treatment of Covid doctors by the Maharashtra state government had been “uncaring, verging on abusive” after the role of medical professionals was called into question by ruling party politicians.

“There is no appreciation for how severe the conditions are for doctors. There is always a fear, not about your personal safety but bringing the virus home and being responsible for the deaths of your family members, loved ones and friends,” said Thadhani. “This has happened to a colleague, whose entire family got infected and his mother died while he survived. He is completely shattered.”

While cities such as Mumbai, Delhi, Chennai and Kolkata have recorded the highest concentration of cases so far, data shows the virus is now spreading to rural areas, which are reporting two-thirds of new cases.

With doctors, health infrastructure and transport lacking in these areas, they are heavily reliant on a devoted brigade of accredited social health activists (ASHAs). Originally trained to help in communities with vaccinations, maternal health and education, ASHAs are now the first point of contact for rural villages fighting Covid. They work day and night on the coronavirus frontline, on a salary of just 5,000 rupees (£52) a month.

Among them is Viji Prabhakaran, 45, who is an ASHA in the small district of Mudavoor in rural Kerala. She has 1,000 villagers under her care and if anyone so much as coughs, Prabhakaran makes sure she is the first to know.

“Since the virus came, I have people calling me day and night,” she says brightly. “It is stressful and exhausting because there has never been a time like this, even when the floods came to Kerala in 2018, but I have to stay strong and show no fear in the face of Covid. That is my duty: as an ASHA I set an example to the whole community.”

The first case of coronavirus arrived in her district on 23 August, and since then the illness has spread to 15 people. Prabhakaran said she had initially been “very scared” but swiftly embraced the responsibilities hoisted on to her shoulders. She is heading a local rapid response team that alerts the regional medical officer if anyone shows symptoms.

Prabhakaran also set up a WhatsApp group for every household in the village, where she informs people about masks, social distancing and handwashing, and has written in a song in Malayalam, the local language, about the importance of hand hygiene.

As the pandemic continues to rage through India unabated, the true humanitarian toll of the virus is only just becoming apparent. Devastated by lockdown, India’s economy contracted by 24% over the last quarter, the worst recession since records began, plunging the country into an imminent economic crisis. Even since lockdown was loosened, many factories and industries have been unable to restart operations and the millions of India’s daily-wage workers have been unable to find work again.

This is palpable in the village of Nagla Vidhichand in Agra, five miles from the Taj Mahal.

Before the pandemic and lockdown, the villagers made money selling shoes or working on construction sites, but many families have been unable to generate an income for months. It was here that five-year-old Sonia Kumari died of starvation last month, after her mother, Sheila, who could not find any work, was unable to buy food for five days.

“Since coronavirus, there is no work and so there is no food and I have lost my daughter because I had nothing to give her to eat for five days so she starved,” wept Sheila, who used to rely on daily-wage work at a nearby brick factory to feed her family on 200 rupees (£2) a day.

During lockdown, local authorities and NGOs provided food donations, but since it was lifted, the food has stopped coming, and in the dire economic climate, work remains almost impossible to find.

“Since the virus, work has gone and now more than 15 houses in this village are starving like us,” said Sheila. “Please tell me: when will it end?”