India’s Long Struggle to Breathe

The government’s disastrous response to the Covid-19 oxygen crisis has a lot in common with its mishandling of decades of smog.

The tweet went out at 9:46 p.m. on April 21, Indian Standard Time. “This is an #SOS call,” wrote Fortis Healthcare, a medical company headquartered in northern India. One of their hospitals, they said, had only 45 minutes of oxygen left. Roughly fourteen hours later, Max Healthcare, a hospital chain based in Delhi, sent out a similar message: “SOS – Less than an hour’s Oxygen supplies at Max Smart Hospital & Max Hospital Saket.” They tagged Delhi’s chief minister, India’s health minister, and Indian Prime Minister Narendra Modi. Sixty-one minutes after that, news broke that Sir Ganga Ram hospital, also in Delhi, had actually run out of high-pressure oxygen. Likely as a result, 25 patients had died.

Over the past two weeks, India has posted more than 4.5 million Covid-19 cases, shattering global pandemic records. Hospitals have run out of beds and supplies, stranding many of the country’s sickest patients. The government has recorded more than 200,000 pandemic deaths. That is by itself an enormous number, but given the country’s uneven, substandard health care infrastructure—and the deliberate efforts by some of India’s 36 states and territories to avoid tallying fatalities—it is almost certainly an undercount.

India’s Covid-19 crisis is a singular catastrophe. It’s also not the nation’s first respiratory disaster. Most years, much of the country is blanketed in thick smog. According to the World Air Quality Report, six of the planet’s ten most polluted cities are in India. Delhi clocks in at number five, making it earth’s smoggiest capital. On average, particulate matter in the country’s urban air is more than five times what the World Health Organization (WHO) considers acceptable.

These two tragedies may be epidemiologically related. A study by researchers at Harvard University found that even a mild increase particulate matter is connected to an 8 percent increase in Covid-19 deaths. Scientists at the University of Cambridge discovered a link between the severity of Covid-19 infections and long-term exposure to pollution. As a result, since the beginning of the pandemic, experts have worried that India’s perennial smog could make its citizens exceptionally vulnerable to the illness.

But there’s a connection between the pandemic and smog disasters that extends beyond lungs and into politics: massive governmental failures, especially at the national level. Despite advance warnings, public officials did not transport enough oxygen out of plants in the east before the second wave began to rise in March, and they failed to sufficiently increase production elsewhere. India could at least mitigate its air quality crises, as many other countries have, but policymakers have not properly enforced antipollution laws that would decrease smog. Instead, officials have downplayed the severity of the pandemic and the pollution, blamed both disasters on opponents, or been silent altogether. In the case of Covid-19, leading politicians actively encouraged mass gatherings even as caseloads reached new heights.

It is impossible to measure the exact toll of each malpractice. There are not yet (and may never be) statistics on how many coronavirus patients would have survived if the government had properly managed a second wave. But given all the desperate pleas for supplies, the skyrocketing prices for cylinders, and the fact that states have literally sent armed guards to try and guarantee that their oxygen shipments aren’t hijacked, it’s safe to assume the number is high. Estimating pollution-related deaths is also tricky, but in a study published inThe Lancet, researchers concluded that smog caused 1.24 million premature deaths in India during 2017 alone. Experts at the University of Chicago calculated that Delhi residents lose close to a decade of life owing to the pollution. In India, politicians’ bad planning and policies are depriving citizens, sick with Covid-19 and not, of the air they need to survive.

In 1981, the Indian government passed the Air Act—its first systematic attempt to control high levels of smog. The law gave existing water pollution control boards at the state and central level the power to curb emissions. It forbade, for example, individuals from starting or running particularly polluting businesses, such as those that produce fertilizer and petroleum, without first receiving permission.

Well intentioned as it was, the act was poorly enforced and largely ineffective. State and federal governments then took additional steps to fight smog: vehicle emissions standards, bans on burning crop stubble, new metro systems. Once more, the results were uneven at best. The stubble-burning ban, like the original Air Act, goes mostly unheeded. Smokestacks are commonplace across polluted Indian cities. Delhi’s metro is clean and widely ridden, yet the rate of car ownership in the city has gone up.

Shortly after winning office in 2014, Prime Minister Modi pledged to clean the air, but he’s taken few tangible measures to do so. Smog levels remain astronomical. In 2018, the WHO declared that air pollution was “the most important single risk factor for premature disability and death in India,” and it is unclear how much the prime minister cares. As pollution levels soared during the fall of 2019, prompting Delhi’s chief minister to call his city a “gas chamber,” Modi said almost nothing.

Compared to some of his colleagues in the Hindu nationalist Bharatiya Janta Party (BJP), Modi’s quiet was an excellent response. The country’s environment minister addressed the smog crisis by blaming the Delhi government for “politicising” air pollution. It later turned out that the minister had canceled three meetings with his state-level environmental counterparts. A BJP minister in Uttar Pradesh, India’s largest state, defended stubble burning and recommended that governments hold religious festivals to please Lord Indra, the God of rain. “He will set things right,” the official said.

The national health minister, Harsh Vardhan, was just as cavalier. In 2019, he addressed the smog crisis by advising that Indians eat carrots. The vegetable, he tweeted, helped fight “pollution-related harm to health.”

Vardhan is still India’s health minister. In this role, he’s helped preside over a Covid-19 response that often looks disquietingly like the government’s response to the surge in pollution, and that often looks worse. In early April, as caseloads climbed, the health minister blamed opposition-controlled states for rising infection rates—a shirking of national duties not entirely unlike Donald Trump’s admonition, early in the Covid-19 crisis, that America’s 50 states were to blame for whatever went wrong. At the same time that Vardhan was attacking opposing politicians, Modi held massive election rallies, defying the dictum of no mass events during the pandemic. The chief minister of Uttarakhand, a member of Modi’s party, encouraged people to travel to his state for a multi-month mass religious event. “Nobody will be stopped in the name of Covid-19,” he said. “The faith in God will overcome the fear of the virus.” Hundreds of thousands of pilgrims apparently listened, helping further fuel infections. On April 29, as India posted a world-record 379,257 Covid-19 cases, Vardhan claimed that India’s pandemic fatality rate was “the lowest in the world.” (It isn’t.)

Meanwhile, India’s oxygen supply chain collapsed. The country manufactures enough of the gas to meet even pandemic demand, but the major production facilities are located in the east, whereas needs are currently highest in the north and west. The government had time to move oxygen into place; scientists warned at the end of February that a second wave could hit India. But the country’s leaders didn’t act until it was far too late.

Even without expert warnings, the national, state, and local governments should have reformed their oxygen systems after the first wave, when they also faced shortages. They could have also learned from oxygen crises that predate the pandemic. In August 2017, for example, more than 20 children died at a state-run hospital in Uttar Pradesh after distributors cut off its oxygen supply. The hospital’s leaders had written multiple letters to their superiors in the government, telling officials that the state was dramatically behind on payments. But the entreaties went unanswered.

After the children suffocated, the state government responded by claiming they died of natural causes. It simultaneously arrested some of the facility’s staff, including, most famously, the pediatrician who was on duty when supplies ran out. The Indian Medical Association declared that the doctor had been framed. He was eventually acquitted.

Perhaps the most damning evidence against the Indian government’s oxygen failure—as well as the failures of some regional governments—comes from the southern state of Kerala. It currently has India’s fourth-highest infection rate, but unlike Delhi, Uttar Pradesh, Haryana, or Maharashtra, it isn’t suffering from shortages. That’s because after Covid-19 first came to India, the state helped build new oxygen plants, some publicly owned, some privately owned, and ultimately upped local production by 60 percent. Now, it has excess supplies that it’s sending to the rest of the nation.

Cleaning India’s air is trickier than increasing the supply of medical oxygen. But that doesn’t mean it’s impossible. After the United States passed the Clean Air Act, national emissions of a variety of pollutants, including particulate matter, dropped by an average of 73 percent. London has long suffered from smog, but recent policy changes that cut back on driving and improved emissions standards have been quite successful. From 2015 to 2019, Londoners living in areas with high levels of nitrogen dioxide fell by 94 percent. Even Beijing, once the global face of pollution, has been getting better air after the government reformed parts of the city’s energy and industrial infrastructure.

Many Indians know cleaner air is attainable. In spring of 2020, as the coronavirus first rolled across the country, the government implemented a lockdown. Enforcement could be shoddy and social distancing in this densely packed nation, soon to be the world’s largest by population, is often impossible. But the order did cut back on automobile traffic. With fewer people on the roads, the skies across northern cities cleared so much that photos of distant mountain ranges, typically made invisible by pollution, went viral. In a FaceTime call, a friend of mine in Delhi gushed about the lack of smog. He took his phone outside so I could experience it myself. Pointing his camera up, I saw something that—in my time living in the city—I never witnessed: pure, blue skies.

But as the first wave subsided, the Modi government declared victory and reopened much of India. Traffic and smog returned. With more Indians congregating in mass numbers and with newly infectious variants, the virus came back, too. A few weeks ago, my friend and I made plans to catch up again. But a couple days before we were due to talk, he canceled. He had caught Covid-19 and needed to rest.

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Daniel Block

Daniel Block is the executive editor of the Washington Monthly.