A poorly implemented lockdown and an underfunded public health system have sent India hurtling from a humanitarian crisis toward a public health catastrophe. This article was originally published in Pandemic Discourses.
It has now been more than six months since the COVID-19 onslaught began, and nearly eight million cases and 430,000 deaths have been recorded as on June 15, 2020. The 10 countries with the highest number of cases account for over two-thirds of cases and over three-fourths of deaths. The United States of America (USA) alone accounts for nearly 30 percent of cases and deaths. Significantly, these 10 countries do not include China, where COVID-19 originated.
Outbreaks of epidemics are not new. In the last two decades we have had outbreaks of severe acute respiratory syndrome (SARS), H1N1, Zika, Nipah and Ebola to name a few. But these were to a large extent dealt with effectively through public health measures and contained, even though H1N1 has become endemic in several countries, contributing to significant annual morbidity and mortality. In 2019, India saw 28,798 reported cases of H1N1 with 1,218 deaths, a case fatality rate similar to COVID-19. However, there was no lockdown in 2019, nor in 2017 and 2015 when there were 38,817 and 42,592 H1N1 cases and 2,270 and 2,990 deaths—with case fatality rates of 6 percent and 7 percent—respectively. H1N1 is here to stay like tuberculosis, malaria, chikungunya, leptospirosis, encephalitis, pneumonia and many other diseases.
With COVID-19 the political economy of engagement has been very different. Lockdowns have become the key tool globally to deal with the spread of COVID-19. Why was this deemed necessary by most governments for COVID-19 and not for the H1N1 pandemic?
“It is evident from the experience of lockdowns so far that they have favoured the economically better off— those with decent housing, regular jobs and the ability to work from home, adequate savings and access to social security.”
Air travel continued as COVID-19 spread across the world. Southeast Asia was the first to experience the cases outside China and countries such as Singapore, Taiwan and South Korea responded quickly and contained it to some extent. Mongolia and Vietnam had perhaps the quickest response and hence saw very few cases and zero deaths. They did not resort to any large-scale lockdowns but instead demonstrated exceptional planning and forward thinking. For instance, Mongolia began screening all travellers from mid-January and quarantining them. Vietnam also adopted this strategy quickly towards the end of January when its first cases emerged. Before the end of April, it had controlled the spread and life gradually returned to normal.
I have personally experienced the Vietnam public health response system. In 2007 I was in Hanoi conducting trainings on budget accountability; the venue was a hotel. During the training three participants fell sick with diarrhoea and vomiting, and the organizers informed the hotel that it may be related to food poisoning. The hotel informed the public health authorities and a public health team immediately visited the hotel, collected food samples and sanitized the hotel. All occupants of the hotel were administered 500mg of amoxicillin as a prophylactic. This may be viewed as an overreaction, but it is this approach that has saved both Vietnam and Mongolia from the effects of COVID-19 that we see elsewhere.
Pandemics spread through travelers and, in the modern era, mainly through those traveling by air. So there is a clear class character to the spread—it is mostly the middle and upper classes, expat workers and students returning home. However, it is evident from the experience of lockdowns so far that they have favoured the economically better off— those with decent housing, regular jobs and the ability to work from home, adequate savings and access to social security. Access to these resources has facilitated their physical distancing through a prolonged lockdown without much economic stress, and provided the psychological assurance that a few months down the line they will return to a normal life. In India we see this class (and caste) character of the government strategy play out very clearly.
While India recorded its first case in Kerala on January 30, 2020, and the first death on March 12, by the end of March there were over 1000 cases and 35 deaths. But only the southern state of Kerala had begun screening and contact tracing of travelers by mid-February, drawing on its experiences with SARS and H1N1. Consequently, Kerala has been able to contain the spread most effectively amongst states in India. On the other hand, the central government woke up to the seriousness of the issue only after mid-March. In characteristic fashion, Prime Minister Narendra Modi announced a complete lockdown on March 24, without giving any notice to the people of the country. This led to panic and fear and transformed what was essentially a public health crisis into a humanitarian catastrophe.
Gradually a fear psychosis has been built up so that people turn into obedient subjects. Actions such as clapping and banging utensils, lighting lamps and torches and showering petals from aircrafts have been turned into mechanisms to test people’s obedience and build a false sense of solidarity. Instead of focusing on the public health crisis at hand and the gross deficiencies of the public health system, this fear psychosis has been perpetuated by debates and discussions on news channels. While government representatives and various experts are issuing advisories to people on how they should behave and face the crisis, little is being done to meet the demands and needs of people.
With economic activity grinding to a halt in cities after the lockdown, migrant workers who constitute a large part of the informal workforce lost their livelihoods. They became restless to leave cities and return to their home in other states and districts. The states, however, did not respond with any meaningful assistance. Before the end of April, migrant workers had lost patience completely as they had no money to pay rent or to buy food. Thus began their mass exodus from cities—on foot, in scorching heat.
NGOs and other civil society organisations came to their rescue, providing food, soap, sanitizers, masks etc. as well as facilitating transportation where possible. Despite surplus food stocks accumulated in warehouses and large-scale contributions to government relief funds, the state was not stirred into action. The response of the public health system was weak and inadequate but the response on the humanitarian front was miserable, because even with available resources and machinery most states failed to deliver. If the lockdown which precipitated the humanitarian crisis disproportionately affected the poor, the mass exodus has led to the next stage of the public health crisis in the form of community transmission.
As the infection spreads to poorer communities, social discrimination is clearly visible with people being denied access to medical attention not only for COVID-19 but also for non-COVID cases. Tuberculosis detection rates have fallen drastically as has access to treatment for conditions where the supply of drugs and nutrition supplements has been adversely affected. People with other medical emergencies are being sent away from hospitals, resulting in unnecessary deaths.
While the public health sector has been overburdened, the private health sector which accounts for three-fourths of care has exploited the opportunity and profiteered. Media reports detail the unusually high costs that people are being asked to pay in private hospitals, and state governments have failed to rein them in to provide care at reasonable cost. This is an emergency situation and governments have the constitutional right to take over private healthcare for public benefit; but state governments have so far failed to do this despite many of them announcing taking over a certain proportion of beds in private hospitals for COVID-19 care.
States and union territories in India such as Kerala, Mizoram, Puducherry, Goa, Sikkim and Himachal Pradesh have had very few cases and deaths and the reason for this is obvious—they spend over 2.5% of their gross domestic product (GDP) on public health as compared to the mere 1% of GDP at the national level.
State governments have a political opportunity to restructure the healthcare system by focusing on strengthening primary healthcare. Health and wellness centres, which are rural primary healthcare facilities, need immediate and rapid expansion—as demonstrated by Kerala and Tamil Nadu with doubling of budgetary commitments for them. Instead of being operated as public-private partnerships as advocated by the NITI Aayog, district hospitals need to be upgraded to teaching hospitals with tax funding. If needed, as a transitional measure, private hospitals could be taken over by state governments until their own facilities are made robust enough for delivering universal access to healthcare.
This transformation of the public health system will make us better prepared to handle the present and any future public health crisis that may emerge. Testing and contact tracing need to be ramped up immediately, especially in hotspots, and a scientifically designed random sample survey across the city and state to assess prevalence needs to be carried out. Besides, there is no need to convert existing hospitals into COVID hospitals–separate sections should be created for COVID and non-COVID cases with adequate precautions, and asymptomatic cases should be quarantined in non-health institutions. Also, there should be an assurance that access to non-COVID care and treatment will not be affected. And of course, all COVID testing and treatment, whether in public or private facilities, should be made free so that households that are under economic stress are not further burdened. These measures would mean a substantial increase in budgetary allocations for health, and not a token amount of ₹15,000 crore (approx. US$ 1.98 billion) for the entire country as announced by Narendra Modi.
As regards the economy, India needs to open up rapidly so that people can return to their livelihoods. In hotspot areas, strategically defined lockdowns may continue but with a more humane approach and not by instilling fear. People in such containment zones should be provided all essentials and support they may need. For the state this is also an opportunity to move towards universal social security wherein livelihoods and social wages of people are protected when a crisis like this strikes. For example, an assured minimum wage if there is loss of livelihood and coverage of all workers, including informal workers and the self-employed, needs to be provided under schemes such as the Employees State Insurance Scheme, the Employees Provident Fund and the National Pension Scheme. A rethink on the lockdown strategy needs urgent attention so that people’s lives are secured and returned to normalcy.
Ravi Duggal is a sociologist, actively associated with the Peoples Health Movement, the Medico Friend Circle and the Peoples Budget Initiative in India. He has recently completed a tenure with the International Budget Partnership, coordinating the India country program. Prior to this, he worked with the Centre for Enquiry into Health and Allied Themes (CEHAT), SWISSAID and Foundation for Research in Community Health (FRCH), as well as served as visiting faculty at Tata Institute of Social Sciences, Mumbai and the Achutha Menon Centre for Health Science Studies, Trivandrum.