Last week, Indian Prime Minister Narendra Modi ordered a three-week lockdown of the country, telling citizens that they were not to leave their homes, because of the coronavirus pandemic. The scope of this order is hard to comprehend: India is a country of more than a billion people; it has extreme poverty in many areas; and many of its cities, such as Mumbai and Kolkata, are extraordinarily dense. Since people who live in India often travel between different states for work, the lockdown also left hundreds of thousands of migrant workers stranded; many of them are trying to return home on foot. So far, there have been only a few more than sixteen hundred confirmed cases in India, and forty-five confirmed deaths, but a major outbreak in a country with huge public-health deficiencies is likely to have devastating, far-reaching consequences.

To try to understand India’s predicament, I spoke by phone with Ramanan Laxminarayan, an epidemiologist and economist who directs the Center for Disease Dynamics, Economics, and Policy in Washington, D.C., and who is currently in New Delhi. He previously served on President Obama’s Council of Advisors on Science and Technology’s antimicrobial-resistance working group. During our conversation, which has been edited for length and clarity, we discussed why India is at such grave risk from the coronavirus, the different ways that rural and urban India are likely to be affected, and what the disease has laid bare about the long-term consequences of insufficient health systems.

How would you describe what India is facing right now?

So, India is in an earlier stage of the epidemic. It’s probably running about two weeks behind the United States, and about four weeks behind Italy, in terms of when the first seeding of cases happened. Like in these other countries, it probably happened because of airline traffic—but not because of people coming from China, all of whom were quarantined very early, but likely because of Italians who had carried the virus, who were tourists here. And a number of the early cases actually involved Italians. So it arrived after it had fully seeded in Italy, and the testing was pretty small at the beginning. It was restricted to people who were stepping off the plane, or someone who had been in contact with a confirmed COVID-19 case.

And so we’ve had a very limited read on how the disease is progressing to date. It’s only a thousand cases and just over thirty deaths. [This was true during the time the interview took place; both numbers have since grown slightly.] So that’s small for a country the size of India. What we expect is that this is probably because of testing not being adequate, similar to what happened in the early stage of the epidemic in the United States, as well, where it suddenly catches fire in some population, like in Seattle—in India, it is unclear where it will actually happen—and then it really takes off.

There is no evidence that the temperature and the humidity are slowing down the virus, even though it’s still rather cool across most parts of India, especially the north of India. And we’ve got a lot of compounding problems, which are that the health-system capacity is generally weak across the country. The number of hospital beds [roughly half a bed per thousand people] is remarkably low. It’s probably a fifth of what the U.K. has, for instance.

And it’s also got a population that has tuberculosis and respiratory issues and pneumonia and high rates of smoking and air pollution. So, the trajectory of the disease in this population is going to be unclear. The other thing is that India also has a lot of hypertensives. About a third of the country’s adults are hypertensive, and about one-tenth of them are diabetic. And, so, all of this is likely to compound the problem. Of course, we don’t know anything for sure until the numbers actually start going up. But these are all the reasons why people of India are worried.

To what degree is your concern about the density in Indian cities and the inability to stop this if it reaches cities in a major way?

I think it probably has reached some of these communities. We’ve already seen cases in the slums of Mumbai, which, as you know, are some of the biggest slums in the world, with millions of people living next to each other. And, so, the virus has appeared where it sort of stays quiet until it hits the target population, and shows up in symptomatic cases, typically the elderly.

So, on the one hand, yes, we’ve got people living in close proximity to each other, but the other side of that is that a lot of these people living in close proximity with each other are young people. [Per capita,] India’s population above the age of sixty-five is much smaller than that of Italy and certainly of China as well. That’s something which has a bit of a protective effect. But, certainly, the conditions for a rapid spread of the disease are all there in the urban areas. And, without question, it’s likely that it will just rip through the population, unless something fundamentally changes in the virus itself in India, for which we have no real evidence.

The government’s shutdown order, at one level, seems sensible. At another level, it appears akin to a lot of what this government does, like demonetization: implemented quickly, without a ton of thought about how it was going to be put into effect. And you see these horrific stories of laborers trying to get back across the country from state to state with no way to do so. And the horrific human cost of this lockdown, even if it’s necessary. What have you made of the government’s decision to do what it did, and was it the only alternative? Should it just have been planned better?

At the stage we were at, the lockdown had to have happened, to slow down the epidemic. Otherwise, given all the reasons I spoke of earlier, we would have had a really sharp peak headed into April. And, generally, for politicians to act proactively to prevent death is not very popular, because the public will never give credit for deaths they averted. The public will only blame them for the damage they caused. So, from that perspective, Modi was very decisive and acted quickly.

Now, could there have been better planning of the lockdown? Certainly, yes. I think, given the complexities of India, some things were focussed on, like supplies and food and so forth, but not others, like how these migrants would get home or how people would cross borders if they lived in a different state and had to get home and couldn’t afford to live in the place where they were, or the homeless, or whatever it is.

You’re right. It was rushed. But, I think, in the case of demonetization, that’s a different experience, because there wasn’t a rush to do it at a particular time. They could have waited a week and done it probably better. In this case, I would say that there was very little time available, just because everyone is learning from everyone else. I think the scenes from Italy just shook people here. And then what started happening in the United States was even more disconcerting.