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Science’s COVID-19 reporting is supported by the Pulitzer Center.

One morning in mid-May, Nasim Qureshi suddenly developed a fever, cough, and shortness of breath. Qureshi, a member of Mumbai, India’s street vendor union, rushed to a small private hospital, where doctors gave him a check up but refused to admit him. Later the same day, he was turned away from two more hospitals before he finally found a bed at a municipal hospital. By then, his breathing trouble had worsened—and the hospital only had a few ventilators.

By the time one was made available, his friends say, Qureshi had died.

Stories like Qureshi’s have been unfolding across Mumbai, a city of more than 12 million that has been the epicenter of India’s COVID-19 epidemic, with 33,000 of the country’s 150,000 confirmed cases. A shortage of hospital beds and poor coordination has overwhelmed public hospitals and left authorities scrambling to ramp up capacity. Media have reported grim stories about people dying before they even got their test results, patients lying next to dead bodies, and kidney patients failing to get life-saving dialysis.

Similarly dramatic scenes could soon play out in other parts of India. So far, the country’s COVID-19 cases have been concentrated in a few states and cities. But last week, the government began to lift travel restrictions imposed on 25 March as part of the world’s largest pandemic lockdown, affecting all 1.2 billion Indian citizens. Millions of jobless migrant workers are now making their way back from cities to rural hometowns. Domestic flights also resumed on Monday. The lockdown has slowed the spread of the coronavirus, but not by nearly enough, experts say, with cases still doubling every 14 days. The lifting of restrictions promises a new surge, because many of those now fleeing Mumbai and New Delhi may be infected.

“The country has been in different stages of outbreak,” says Giridhar Babu, an epidemiologist with the Public Health Foundation of India. “But the state dynamics may now change.”

In late March, when India had only 600 confirmed cases, all transportation in the country was stopped within 4 hours after the lockdown was announced; few migrant workers were able to go home. But keeping them trapped for almost 2 months has made the situation worse by exposing many of them to the virus that causes COVID-19, says Vikram Patel of the Harvard T.H. Chan School of Public Health. “You deny the right of people to move when the cases are few, and you allow them to do so when the epidemic is rising,” Patel says. “I cannot imagine a more insane policy.”

The government faced great pressure to reopen the economy. The lockdown has had enormous costs in a country where most people eke out a precarious living in the informal sector. Two-thirds of Indian workers lost employment, and those who still have work have seen their weekly earnings plunge by 61%, according to a survey of 4000 people across key states by Azim Premji University. Eighty percent of urban households have already reported cutting back on food consumption.

The working poor who power urban economies have been hardest hit. Deprived of income or transport, some walked the hundreds of kilometers home. Many more are now traveling. The exodus includes young children, pregnant women, and elderly people. Some have died of exhaustion or accidents. Sixteen workers who lay down for the night on railway tracks, believing all trains had stopped, were killed when they were run over by a goods train on 8 May.

The government is now organizing special transport to take migrant laborers back to their home states. In line for a bus for migrants in Mumbai, 50-year-old Laxman Singh, who has lost his job in a restaurant, told ScienceInsider he would prefer to be in his distant mountain village in the state of Uttarakhand rather than facing the monsoon without work or money in a city slum.

The challenge now is: How do we reduce deaths? Nothing else matters.

The big question now is whether the destination states can deal with the expected rise in cases. The state of Bihar, for instance, which has lower than average numbers of medical facilities and health care personnel, has already received half a million people and is braced for another half-million in the coming days. Bihar is scrambling to expand quarantine centers where new arrivals have to stay for 7 or 14 days before they go home. The state is likely to struggle with any surge in cases, Babu notes.

The pandemic has highlighted India’s inequalities—even in Mumbai, a commercial and medical hub. Infections are slowing down in some better-off pockets of the city but rising in slums that host 42% of the population. Many infected people are being isolated at temporary facilities around the city, including at the Nehru Science Centre and the Nehru Planetarium, two popular attractions. At one such center, a small community hall in Dadar, a crowded neighbourhood in central Mumbai, all the patients have mild symptoms, a health worker there told ScienceInsider last week, but they would be unable to self-isolate in their one-room homes with community toilets.

Underresourced public hospitals have borne the brunt of the pandemic so far, with the private hospitals that dominate Indian health care strikingly absent. In Mumbai, an early round of infections among doctors and nurses at private hospitals interrupted service. But the hospitals also “don’t want to get into epidemic treatment,” says Sanjay Nagral, a senior surgeon and a public health expert who is affiliated with two local hospitals. They fear unpaid bills after expensive care. Many Indians don’t have health insurance, and insurance does not cover extras such as personal protective equipment.

Last week, the state government in Maharashtra, which includes Mumbai, announced a takeover of 80% of private hospital beds and, in the wake of astronomical bills received by some patients, capped the fees hospitals can charge. “As the numbers increase, so will the critical cases, and we are increasing facilities for that,” says Sanjay Oak, chairman of the state’s COVID-19 task force.

The government has asked private doctors to volunteer for duty in public hospitals and invited doctors and nurses from Kerala, a state that has successfully dealt with the epidemic, to help ease medical staff shortages in Mumbai. Officials are also setting up a real-time data board on bed availability to reduce the time beds are empty after a patient is discharged or dies—a lag that has contributed to bed shortages. Because of the high number of cases, Mumbai has kept some of the restrictions in place even as the national lockdown is lifted.

One bright spot is that India has not needed as many ventilators as some other countries. For most patients, oxygen support using a mask or nasal tube has sufficed to fight hypoxia. Oxygenated beds are cheaper and easier to scale up, experts say, than ventilators and intensive care units.

Whether the new measures, along with continued restrictions in Mumbai, will be enough remains to be seen in the months ahead. “The challenge now is: How do we reduce deaths?” Babu says. “Nothing else matters.”