With nearly 2 billion people, South Asia is the world’s most populated region as well as its most densely populated. It is also extremely poor, with abysmal levels of healthcare.

However, till now, the region has escaped relatively unscathed from the coronavirus pandemic, compared to much wealthier places such as China, Europe or North America.

As of April 20, the entire region – tabulated here using data from India, Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan – had just around 28,000 cases of Covid-19. It had 817 deaths as a result of the disease.

To put that in perspective, New York City alone has 134,436 cases and 10,022 deaths.

While more than 20% of the world lives in South Asia, the region has only 1.2% of Covid-19 cases. In terms of fatalities, that proportion dips even lower: 0.5%.

Credit: Nithya Subramanian

Credit: Nithya Subramanian

Other statistics from South Asia also warrant further explanation. For example, the case fatality rate (ratio of the number of deaths by the number of confirmed cases) in the region is just 2.87%. It is 5.34% in the US and 13.38% in the UK. The global average is 6.87%.

Credit: Nithya Subramanian

To add to this, the number of tests per confirmed case in South Asia is fairly high. The Indian government has used this to argue that India’s testing numbers have been adequate.

Credit: Nithya Subramanian

BCG and heat

South Asia’s low Covid-19 cases have led experts to offer several theories. One of them is the Bacillus Calmette-Guerin vaccine, used against tuberculosis. The BCG vaccination is universal in South Asia and has been connected, by some studies, to low instances of Covid-19. Similarly, some studies also show that heat could adversely affect the virus.

Experts, however, advise caution on how much these two factors can be credited for low numbers in South Asia given what is known currently. “So far we have no concrete evidence of these two factors helping,” explained Jayaprakash Muliyil, epidemiologist and the former principal of Christian Medical College in Vellore. “We can’t base our actions on hope.”

Virologist Jacob John agrees. “Even if they exist, you can’t count on it,” said John. “If you win a lottery that’s good. But you can’t spend half your salary on buying tickets.”

Data doubts

Instead, these experts point to another factor that is endemic to the region and about which there is little doubt: poor collection of data related to health. “The recording of deaths and the cause of death is very poor here,” noted Jayaprakash Muliyil.

A 2018 paper by the medical journal Lancet, for example, showed that suicides were severely undercounted in India. Official data in the country missed as many as one lakh suicides every year.

According to data released by the government of India, even before the pandemic, only 22% of all registered deaths were certified medically in India. Medical certification of deaths in poor states such as Bihar (6.8%), Jharkhand (4.7%) and Uttar Pradesh (8.6%) is practically non-existant.

As bad as things are in India, they might be even worse in other parts of South Asia. One study published by the World Health Organisation found that less than 14% of deaths in 2013 were registered in Bangladesh’s official records. A 2013 assessment by the Pakistan government found that there was practically no death registration mechanism at all.

Test positivity ratio

However, if low numbers of cases could be explained by poor data, what explains the low ratio of positives overall, even in people tested? For example, India conducts nearly 26 tests to uncover one positive case. In the United States, this figure drops sharply to 5.3 (see chart 4). This low number has led American experts to argue that the disease is spreading quickly in their country. So, conversely, is it a good sign that the number of tests per positive case is high in India?

Experts say things are more complex. For India, which accounts for two-thirds of all fatalities in South Asia, experts have pointed to the fact that this number might actually be explained by faulty screening criteria rather than being an accurate reflection of the prevalence of Covid-19 in India. “This might be an indicator of the fact that we are looking at the wrong place,” said Jacob John. “This is because you are mostly testing contacts.”

John continued: “On the other hand, if you tested all people with symptoms, then this ratio might shoot up.” India expanded testing beyond people with travel and contact history several weeks into the outbreak. “It’s the difference between searching for your lost key where you dropped it – or where there is light.”

Fatality rate

This, says T Sundararaman, the former executive director of the National Health Systems Resource Centre, an advisory body to the Union health ministry, might also explain why the fatality rate is so low. “Eighty percent of Covid-19 cases in Tamil Nadu are asymptomatic, so they are hardly likely to die,” explained Sundararaman. “Anybody with a fever or cough of more three days should be necessarily tested.”

John, however, adds that one factor might help in genuinely lowering the fatality rate: South Asia’s young age profile. “A younger population helps,” he said. “In other countries where average age is higher, there might be more deaths.”

An additional reason for the low numbers of Covid-19 cases, till now, simply might be that the peak has still not been reached. “Since this is coming from above in the form of international travellers, it might take some time to affect the masses,” posited T Sundararaman. “It could be that we see it spread amongst the poorer sections after the lockdown is lifted.”

Note: Unless otherwise mentioned, all statistics are as of April 20.