Abstract
In the absence of specific drugs and vaccines, precautions at the personal level (hygiene, maintaining physical distancing and so on), people’s participation in population-level interventions (such as sharing scientific information, case-tracking and strategic area-specific lockdowns) and health service system preparedness are the three key available measures against the COVID-19 pandemic. However, the necessary ingredients for these three measures are missing— induced by poverty and structural inequality; a lack of people’s trust and a crippled public sector in health with a low resource base; shrinking, fragmented and weakened infrastructure that has lost on inter-institutional referral links and monitoring and surveillance systems. Not only has an ill-planned lockdown crippled an already struggling economy and depleted health systems and overshadowed containment efforts but the time has not been utilised to strengthen primary healthcare (PHC) services and secondary and tertiary public sector healthcare infrastructure. A phased relaxation of the lockdown with a comprehensive fiscal stimulus to jump-start the economy, coupled with the strengthening of health systems that put the needs of the poor at the forefront, is suggested.
Keywords
Introduction
‘Flatten the curve’ is the current war cry but how, why and for whom are questions left to bewildered citizens to interpret or follow unquestioningly. While experts are busy locating and comparing ‘data’, mathematical models are flying around, frightening ordinary humans out of their wits with ominous predictions: ‘If we had not done this … one lakh … two lakh even three lakh [people] would have suffered’. Central expert committees like the Inter-Ministerial Central Team have been appointed, initially to check and monitor the work of mainly four states, three ruled by the opposition—Maharashtra, West Bengal and Rajasthan—and Madhya Pradesh, all with a heavy load of the COVID-19 infection. Kerala was told not to stray from the central guidelines for relaxation of the lockdown. West Bengal was criticised for not maintaining social distancing norms, protecting health personnel and controlling vehicular movement. In Maharashtra, a staggering deficit in isolation wards and ICU beds was highlighted. These four states, it has been noted, had an above-average doubling time of the infection (The Hindu, 2020d, p. 10). Interestingly, while the state governments have complained of resource shortages, the centre wants all the expenses of the central teams to be borne by the states (ibid).
Among such confusion, this article is an attempt to look through the cloud of hype and fear to understand some key aspects of the COVID-19 pandemic as it has unfolded within the socio-political context in the largest democracy of the world: until recently, India was looking down at the USA when it came to comparing the trajectory of their COVID-19 prevalence graphs. We therefore begin with the simple statement that though this infection is not as lethal as previous flu pandemics, which did not make life stop at a standstill, its fast spread and lack of any treatment or vaccine, with about 4 per cent of the serious pneumonic forms requiring critical care, make it a subject of concern. Although it is known that an older population is the most vulnerable group, the fear that one might be the exception to this rule, the loss of cultural acceptance of death after a full life among the middle class and a total faith in medical technology, in general, to keep us going helps building up the acceptance of police rule and the curtailment of basic rights under a 123-year-old draconian law, Epidemic Diseases Act (EDA) 1897 and the Disaster Management Act 2005 when a disaster had not occurred.
Is it true then that this is a disease of the rich, as some scholars claim, because richer countries are more severely affected irrespective of their age structures and the in-built egalitarianism of their economies? The data that is put out in India tells us that about 40 per cent deaths in India are among the under-60-year age group but it gives us no inkling of their economic backgrounds. Yet we know that the higher likelihood of chronic conditions puts them at a higher risk (Ahmed et al., 2020) so this hype and aggressive means of flattening the curve will make the poor even more vulnerable to disease and death which is final, irrespective of its cause—the pandemic or a fallout of its control measures. The fact that hunger makes one vulnerable to infection, that the poor in the cities who service the carriers of this disease (its elite) can neither afford distancing from them—masks, soap, water and healthcare—nor maintain physical distance in their own dwellings adds to their woes. Already early evidence from the USA suggests that the Black population is more vulnerable (Garg et al., 2020). To unpack and understand the contextual coating of the COVID-19 infection in India then, we examine the conditions in which it arrived and spread across the states ( Table 1 ) until the middle of May—starting from Kerala and then capital cities.
India COVID-19 Cases by States/UT (Until 16 May 2020)
Source: Compiled from various state health bulletins, as reported in
Note: Minor adding-up issues in few states due to the migration of some cases.
Pandemic and Priorities
Once upon a time, when Indian planning was a respectable part of governmental activity, its health sector was trying to develop an infrastructure where basic healthcare was expected to be people-centred, its services fully state-supported, responding to people’s preventive and curative health needs according to their context, available resources and ability to be self-reliant. The Bhore Committee of 1946, which laid the scaffolding of the country’s basic health service infrastructure, assumed its consistent expansion in the cornel of a socio-economic developmental process that was going to be equitable. Until the 1990s, people were encouraged, however grudgingly, to participate as users, decision-makers and providers. Secondary and tertiary levels of care institutions supported primary healthcare (PHC) institutions to constitute an integrated system. This system developed a nascent mechanism of handling epidemic and endemic diseases through its monitoring system and its institutions that had the required expertise. Cholera, plague, encephalitis, dengue fever, malaria, flu and so on were handled by it without the Home Ministry’s help. Yet infectious diseases such as tuberculosis, malaria, filarial and leprosy remained due to inadequate financial attention, despite available technology. With the receding welfare state and the introduction of health sector reforms in the 1990s, this assumption got discarded and things changed drastically. The shifts in policy since then have not only thwarted this system and destroyed its monitoring and surveillance systems but has also fragmented and weakened it by introducing casualisation, a rollback of resources, opening it to markets and promoting public–private partnerships (PPPs). This became a way to enhance the transfer of resources from the state to the private sector in the name of efficiency and quality where, in the absence of a level playing field, the private sector penetrated and drew from the resources of the public sector and distorted it (Chakravarthi et al., 2017). The public sector in health is today characterised by its very low resource base (one per cent of the GDP) resulting in a shrinking, fragmented and weakened infrastructure that has lost on inter-institutional referral links and paucity of manpower, medicines and equipment. Above all, a disheartened professional manpower, a visible section of which, attracted by the glamour of technology and remunerations has, shifted to the private sector, projected as being efficient and of a higher quality (World Bank, 1993, p. 12).
It is against this background that the COVID-19 virus has been imported into India with its first known case detected in Kerala in India on 30 January 2020, the very same date when the outbreak was declared a ‘Public Health Emergency of International Concern’ by the World Health Organization (WHO). The international organisation declared COVID-19 a pandemic on 11 March when 118,000 cases were reported globally (13 times that of China) in 114 countries. But more than 90 per cent of these cases were in just four countries, and two of those, China and the Republic of Korea, had started showing significantly declining epidemics. According to WHO guidelines, each country was to assess its risks and rapidly implement necessary measures at an appropriate scale to reduce both COVID-19 transmission and its economic, public and social impacts. It has been inferred from data on confirmed cases elsewhere that 80 per cent of the affected can have a mild infection, 15–20 per cent may need hospitalisation, of which 4 per cent will actually need critical care. Even though small, this number can become worrisome if the disease spreads so fast so that it infects half the population of the country and critical cases peak within a short span of time. The challenge as one understands by the pandemic’s features is to ‘flatten the curve’ of the disease (that is, reduce the infection’s prevalence and deaths) in its early phase so that the health services are not overwhelmed by a huge load of morbidity and can be prepared to cope with the manageable additional burden. These relative proportions depend upon the pace at which the virus reproduces itself (RO), the efficiency of case detection and care provided. The RO in turn depends upon the virulence of the COVID-19 sub-type circulating (there are three subtypes as of now), human resistance, both specific (which is bound to be low given it’s a new infection) and general (which is low among chronic ailing persons and undernourished populations). Proximity with the infected is the third critical factor and this in turn depends upon equity and inclusiveness of their larger systems. The fortieth-day cumulative prevalence varies hugely from country to country pointing to the variations of these determinants.
The first 50 COVID-19 cases in India were reported in a span of 41 days, spread across 12 states and 18 cities/districts (Rawat, 2020a). The first six cases were diagnosed between 30 January and 3 March. The numbers jumped to 28 the next day, going up to 30 on 5 March and 39 on 8 March. Within two days, there were 19 cities across Tamil Nadu, Telangana, Karnataka, Maharashtra, Uttar Pradesh, Delhi, Haryana, Rajasthan, Punjab, Jammu & Kashmir and Ladakh in which a total of 50 cases were detected. The Indian Council of Medical Research (ICMR) initiated its sentinel surveillance to detect community transmission of COVID-19 on 15 February. Despite reassuring results the sample was too small to rule out community transmission and ICMR’s position has now gradually shifted from ‘no community transmission’ to ‘localised transmission’ and ultimately to its being ‘inevitable’ (Jayachandran, 2020), given that in its assessment airport surveillance missed around 46 per cent of cases.
Did we then lose time from the beginning of February to the middle of March for concerted planning, rigorous airport surveillance and setting up systems for contact tracing, monitoring and beyond? Did we not realise that the loopholes in this monitoring were serious as visitors once they landed took different modes of travel, it was reported that they swallowed an antipyretic pill (to conceal their fever) before disembarking, or forgetting about contacts, changing their route to enter from a non-COVID-19 infected country or even travelling within the country with fever? Also, in tracing contacts, the service staff of host households were often overlooked. Had we not learnt enough from the Chinese experience that these initial months are the most critical? To prevent a crisis from emerging, our health infrastructure needs strengthening at all levels, especially at the grassroots and with a long-term perspective. The most critical time in containment has thus been lost between January-end, when the first case was reported on 30 January to 4 March–11 March when cases shot up from five to fifty. By 14 March, the numbers doubled to the country’s first hundred. The monitoring and contact tracing in cities with major airports, where travellers from affected countries disembarked into the cities of Uttar Pradesh, Jammu & Kashmir, Rajasthan, Maharashtra, Haryana and so on where their contacts resided, did not have stringent systems of checking and tracking except for Kerala with its experience of extensive planning in handling epidemics. No other mode of transport, barring air, was monitored though visitors were free to make use of any form of travel.
Options and Choices
In the absence of specific drugs and vaccines against the virus, possibly useful interventions available the world over are at three levels—personal, social and public health. At the personal level, there are hygienic practices that include hand washing, dietetic care for building immunity, sanitisation, sunlight and so on. Then there is the social practice of maintaining physical distance called social distancing—that many point out the Indian upper class is adept at—which not so unwittingly has become the signature tune of the official COVID-19 containment campaign, despite the WHO’s director’s plea and Supreme Court directive to use the term physical distancing and not social; and finally there is the use of masks.
At the population level, a key principle of planned interventions is building trust between state and society and between different sections. For this, mobilising different strata and communities, allay fears, generate their creative energies by assuring their rights to express their views, needs and how best they can contribute to these interventions. In the process, a two-way trust generation becomes key to supporting measures like sharing scientific information (that has mutated into prohibition of misinformation); case-tracking of contacts by health workers, their quarantine for 14 days and testing, if required, symptomatic cases of those suspected of COVID-19 infection to be referred to for testing and isolation, if positive. Isolation of mild cases may not need hospitalisation but will need facilities, others will require hospitalisation and a planned lockdown in an attempt to slow down the rate of spread if its pace is very fast. This protocol has varied in its stringency across countries that have used it but calls for ensuring social security and subsistence for the affected.
At the level of health service system preparedness, sufficiency of materials and trained manpower in the infrastructure will be important. The most critical levels for India are the following four elements:
The strengthening of the PHC infrastructure within districts that will be called to cope with the major load of COVID-19 infections. Ensuring training and personal safety for frontline doctors, nurses and other caretakers, along with health workers at the grassroots level, such as Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and multipurpose health workers (MPWs). They have the knowledge of their communities, can mobilise them in case of identification and tracing contracts, follow-up on surveillance and monitoring as well as propagation of personal preventive measures. They can also explain the reasons behind physical distancing, handwashing and mask-wearing within the given constraints of localities. Other than protective gear they deserve additional pay for the extra work they take on. Mobilising Panchayats to organise spaces and buildings for quarantine and, if necessary, isolation of cases not needing hospitalisation. Unfortunately, until now maintaining primary level personnel has been widely considered ‘wasteful expenditure’ in India’s reform’s strategy as it has absorbed 70 per cent of institutional resources. Hence to acquire monetary efficiency, workers have been casualised on a large-scale or laid off. This winding up of disease monitoring systems and causes of death have undermined PHCs. For the 20 per cent serious cases, district and state hospitals need to be strengthened with separate isolation beds, additional staff, ensured oxygen supply and drugs and equipment. Beds with continuous oxygen supply and, more than ventilators, critical care trained personnel fully supplied with Personal Protective Equipment (PPEs), need to be rationalised depending upon the experience of need and availability. Appropriate protective gear for all hospital staff and field workers is necessary.
In India, when despite the propagation of individual and social practices of physical distancing and individual hygiene, the cases continued to rise by mid-March and pockets of households with cases necessitated house-to-house surveillance, the possibility of the failure of airport monitoring of disembarking visitors became very strong. Instead of balancing livelihoods and saving lives through refurbishing services, an unexpected lockdown was declared on 25 March 2020, initially for a few weeks. This, without first taking people into confidence and planning assured subsistence for everyone. The emergency programme director of WHO called ‘comprehensive and robust’ India’s response measures which covered traveller’s surveillance, contact tracing, laboratory and research protocols, risk communications, prevention and control training, and cluster containment plans. ‘Once transmission is suppressed we have to take the fight to the virus’, he is reported to have said. Heeding the ‘Janata Curfew’ and the 21-day lockdown, the UN called for ‘aggressive action’ (Deccan Herald, 25 March 2020). The ICMR director supported this line by rationalising that India, in the middle of March, was at Stage 2 of the pandemic and hence had a 30-day window to halt the beginning of community transmission. It was being argued that community transmission even when it was happening was localised and controllable (Pulla, 2020). The language of ‘aggression’,’ fight’, ‘war’ and ‘control’ and ‘elimination’ that dominated the political vocabulary also began to enter the domain of scientific dialogue and the focus remained on international travellers and getting back Indians stranded abroad.
The fact is that this new virus is part of our long and destructive interaction with each other in which biological control through vaccines is a part of a business model. Simultaneously, an equally destructive relationship with the environment that impacts our health did get addressed at the global intellectual level, but the powers to be were not inclined to acknowledge that the problem requires a collective redressal. The wisdom that we should have by now acquired, given the lurking doubts about all disease elimination programmes, that the aggression to end this microbe is not necessarily to the advantage of humankind but that a vigilant, committed scientific approach seems to allude us. That India must resist interventions at the population level, without keeping centre stage its extremely stratified and volatile society, brimming with social, economic and political conflicts and its underlying contradictions that have eroded mutual trust, was sidelined in the way public health has been officially perceived. The very fact that the draconian EDA 1897 1 could be mobilised to beat, humiliate, control and force decisions taken unilaterally in the name of the greater good for the public highlighted the loss of the very essence of public health. A science that was understood as the science and art of an organised effort to meet the health needs of a population based on their participation that enhances self-reliance. Instead, we have been offered a lockdown—social and economic—managed by the police while the directorate of health simply acts as a steward defending the unilateral decisions of the bureaucracy. They have even sidelined medical services, the only support the state can offer to the affected.
Lockdown: Not Just an Extreme Form of Social Distancing
By now, it is understood that as the number of cases keep rising with increased testing, the COVID-19 infection has yet to reach its peak (Ghosh & Qadeer, 2020). Increased case identification, contact tracing and quarantine, isolation and treatment to those who require medical assistance is the only way to contain the spread. The lockdown by restricting human contact may help reduce the rate of spread and delay the peaking of the pandemic but by itself it can serve no purpose as the virus does not get eliminated and bounces back once restrictions go. The assumption that it can break the chain of infection is false. The lockdown if prolonged or too harsh becomes counterproductive. It undermines the economy and affects subsistence which leads to another set of problems of hunger and non-COVID-19 diseases. In India, the lockdown initially did provide time for planning even though it was late. The challenge is to first work out with sensitivity steps to tackle the challenge of subsistence for over 401 million informal workers (non-agricultural) and their families (International Labour Organization, 2018) and over 428 million agricultural workers. Second, to begin immediately the systematic and concerted strengthening of the government’s PHC services and the much starved secondary and tertiary public sector healthcare infrastructure required to manage the pandemic with a long-term perspective and investments that cover past deficits, and more. This in fact, is a task that every annual plan has neglected despite policy promises. The share of the National Health Mission (NHM) has continuously declined, as did the allocation to the maternity, child health and communicable diseases control programmes within it. Not only have district hospitals been squeezed out of resources but even premier institutions like the All India Institute of Medical Sciences (AIIMS) under the Pradhan Mantri Swasth Suraksha Yojana have stagnated. Only the PPP-based insurance schemes like the Pradhan Mantri Jan Arogya Yojana (PMJAY) have continued to draw resources (Ghosh & Qadeer, 2019). It need not to be mentioned that a strong infrastructure alone can address the challenge of handling the COVID-19 pandemic. What did India gain by the lockdown is the question we explore here.
India has been lucky in that the country saw a relatively slow rate of increase in COVID-19 infections and a lower number of deaths as compared to Italy and the USA even by the middle of March. This historical characteristic of Asia, that is the lower number of infections was seen in past influenza epidemics as well. Perhaps this has been due to India’s younger population, higher levels of non- specific immunity in the population against corona group of viruses ecology and the virulence of the sub-strains of circulating viruses. But the reality is we do not know specifically in absence of scientific evidence (Khan, 2020). The month preceding the middle of March, when COVID-19 was travelling west and south-east finding a home in India, was a busy one for the authorities. They were facing protesting secular citizens concerned with their citizenship, preparing for the first visit of the US President and also ‘handling’ the unique virus of communalism, indigenous to India, that had erupted in Delhi at the end of February. Hit by the sudden jump of COVID-19 cases to 100 in early March, overwhelmed techno-bureaucrats who had stuck to focussing on disembarking international visitors at the airport and tracing their contacts during February opted for a lockdown in a knee jerk reaction without any clarity of purpose or a comprehensive strategy for containing this epidemic. A controlled restriction on movements, excluding selected economic and essential activities of vulnerable sections, was not being considered, irrespective of its relevance even for 92 million urban informal workers as self-employed, regular or casual wage earners (International Labour Organization, 2018) who would be immediately impacted. That the population will develop immunity (herd immunity) under a strong public health system ready to take on the burden of caring for serious patients and monitoring community trends was obviously being ruled out because there was none. Reluctance to analyse data for patterns of death and the disease in different socio-economic strata and sub-regions, the fear of uncontrolled exponential growth of cases and perhaps their inability to convince the political leadership of the importance of such investments, provided the political imperative for a lockdown: a lockdown that put aside all criticism using the EDA 1897 from the colonial era (Harrison, 1994, pp. 142–143) gave police absolute power, unmindful of consequences and forced interventions—all in the name of a war against the evil enemy—a virus. People were being told to come together to fight a common war and not politicise the crisis; yet shaming and pointing fingers, and the exclusion of specific communities from services have continued (Ellis-Petersen & Rahman, 2020; Menon, 2020). Not just this, camps set up for victims of the violence that was spreading in India were being arbitrarily wound up (Sharma, 2020b), and the students and young activists who had been participating in the secular movement against the National Population Registration, National Registration of Citizens and Citizenship Amendment Act were being arrested (Karnad, 2020; Press Trust of India [PTI], 2020). Lockdown thus became a multipurpose instrument of an illiberal model of governance in the service of the nation.
Even if it had been well intentioned, there was no previous warning or plan to first establish the minimum food and social security or financial assistance required for those whose livelihood was to take a hit by the lockdown. The war then actually turned against the unsuspecting working class who after banging their thalis (steel plates) discovered that they had no work and no subsistence following the lockdown. Thus the privileged—then reported as over 64,000 international travellers—and their class appropriated all urban basic facilities in the urban spaces while a large section of the over 92 million urban informal workers opted to return to their villages and families whom they trusted more than the promises of shelter and support in the cities. Thus was reasserted once again the principle of ‘social distancing’; a brutal fact of life for India. The tragedies that befell the desperate but brave men, women and children who chose to walk home hungry at all costs, to find food and security and dignity will continue to pour out. Some died walking, some in accidents, how many made it one does not know but large contingents have been stopped, arrested, herded and humiliated by the new health personnel—the Indian police. They were even being sprayed like pests with disinfectants meant for the buses.
We have no information on how many tested positive for real-time quantitative reverse transcription PCR (RT-qPCR) due to herding itself or the conditions under which they were quarantined. It was only when they did not stop taking the roads, that trains and buses were promised to reach them home for which they were heavily charged—for some perhaps their states paid. The majority of the middle class solidly supported the lockdown blaming the mindset of this ‘untrusting’ lot—the migrants.
Until 25 March, officials insisted that there was no community transmission of the virus. Data to understand the pattern of death and disease spread in different strata, districts and blocks were not made public. Tardiness in setting up testing facilities, delays in establishing the right criteria for patient selection, stringent contact tracing and community surveillance, inadequate efforts for strengthening the health services from the expert groups and ensuring safety for health providers (not only physicians and nurses but all caregivers and support staff of the hospitals and community-level workers at risk) characterised the war against COVID-19. It reflected that there was little comprehensive public health planning. Over and above this, states had very little say in managing their affairs as the centre called the shots through financial control and the promulgation of the EDA 1897 and the Disaster Management Act 2005. In an effort to overcome some of these problems, testing was increased by early March, 51 private labs were allowed to join in, restrictions on gathering of more than 15 were imposed by 16 March, and three days later, the testing criteria were liberalised with patients of pneumonic symptoms being included even without breathlessness (Ghosh, 2020). Soon after, the landing of flights was stopped but by then 80 districts were declared under lockdown with hot spots (Hebber, 2020).
It was only after the exodus of workers began that the finance minister announced an allocation of a ₹170,000 crore relief-package aimed at providing a safety net for those hit the hardest by the lockdown along with an insurance cover for frontline medical personnel. This was partly from the state’s allocation and from already budgeted allocations without mobilising from unnecessary expenditures. Interestingly, independent, self-reliant and self-respecting working people were overnight turned into dependents and became poor to be offered temporary welfare under the Pradhan Mantri Garib Kalyan Yojana, while the National Food Security Act, 2013, was not strengthened. About 800 million people were to get free cereals, cooking gas and cash through direct transfers for three months (The Economic Times, 2020). A total of ₹15,000 crore was going to be allocated for strengthening health services (PTI, 2020c) which was one-fourth of the annual budget and need to be enhanced at least five times to come to a level that can fulfil the policy drawn in 2017 to provide a bare minimum infrastructure and the additional demands for COVID-19 management. Even this came unfortunately after the social calamity of reverse migration was created, not before. This large-scale migration might have made the urban lockdown manageable for the administration but the probability of serious implications for small towns and rural areas needs to be assessed.
Pandemic Under the Lockdown
The end of March provided a distraction when a religious congregation of an Islamic evangelistic group called the Tablighi Jamaat in Delhi’s Nizamuddin became the focus of attention as its over 2,300 anticipants had to be forcefully evacuated, quarantined and 334 admitted to hospitals. Over 4,000 positive cases in 23 other states could be linked to this cluster (PTI, 2020a). The exponential growth over early April was freely connected to this and it became a tool for Muslim baiting. When the pandemic curve did not relent by early April, Prime Minister Narendra Modi started asking states to suggest plans for staggering the lockdown. The states in return began demanding funds for handling the crisis and were hesitant to suggest withdrawal. The centre thus absolved its responsibility of extending the lockdown and yet extended it until 3 May. The media in the face of increasing numbers kept projecting a hopeful picture, either in terms of a ‘no significant rate of increase’ or ‘no evidence of community transmission’ as the head of ICMR was claiming despite the results of their own epidemiology division study as early as end-March showed evidence of community transmission (Kaur & Mahapatra, 2020; Koshy, 2020a). The media was also highlighting the ministry’s justification of the lockdown on the basis of the ministry’s projections of 820,000 cases by April where the ICMR’s technical wing overseeing epidemiology and testing was not involved and providing much lower projections (Koshy, 2020b). These projections were anyway unreliable in the absence of adequate testing and tracing. Apart from the linearity of the curve, not an exponential rise, the ministry was pointing out the slowing of the doubling rate under the lockdown. ‘Now an extension was needed to break the chain of infection,’ its representatives are reported to have said (Perappadan, 2020).
The picture of the tests being conducted also was not very different. Despite the insistence of the experts, the private sector managed to get its right to charge heavy fees legally with the ICMR’s officials support even though the bulk of testing was done by public labs. By the middle of April, when the 364 of the country’s 736 districts were reporting cases and active cases were 9,015 of the 10,439 (The Hindu, 2020e, p. 1), the ICMR reported to have done 206,212 tests, of which only 1,913 were done in 69 private labs, while the bulk was being performed by the 156 government-run laboratories (The Hindu, 2020e, p. 8). These rising numbers often did not match between ICMR responsible for tests and the ministry as the nodal reporting point for states. The testing rate defined as number of tests per persons identified (and not per million population which is not the denominator in purposive identification through tracking cases) remained low compared to countries that succeeded in lowering the peak of the pandemic (Ghosh & Qadeer, 2020).
While the focus remained on implementing the lockdown, efforts to purchase bulk equipment and relief material by the state were reported through independent organisations. Governmental purchases were also reported to overcome huge shortages of ventilators and PPEs by an official familiar with these decisions (The Hindu, 2020c, p. 1). On the other hand, according to the empowered group under the NITI Aayog CEO, 20,000–30,000 ventilators have been lying unused either for want of services or parts (Sharma, 2020a, p. 5). Despite this confusion, these needs became a source of business as industry began to eye the manufacture of 50,000 ventilators per day based on a Brooking India report with requirements rising to 110,000–220,000 units (The Hindu, 2020c, p. 1). The empowered group joined forces with the private sector to promote the production of PPE. It is reported that 39 local manufacturers were authorised to meet the shortages and provide 1 million PPEs in a week’s time (The Hindu, 2020a, p. 1). The Minister of Petroleum and Natural Gas in fact proposed the use of surplus rice for producing ethanol for hand sanitisers (The Statesman, 2020). The Health Minister announced that ‘India was unlikely to face an unmanageable crisis since it has enough infrastructure to tide over should matters deteriorate’. He is reported to have said that the availability of 500 dedicated COVID-19 hospitals, 200,000 beds and 50,000 ICUs will ensure preparedness and ‘[t]he efforts at improving the services made COVID-19 pandemic a blessing in disguise for services’ (The Hindu, 2020a, p. 1). Despite these sporadic news items, with a slow rate of growth initially India had 7 per cent of the total global cases and 4 per cent of its deaths in early May (Reuters, 2020 p. 12). Despite these statistics, there has been no systematic and needs-based plan for immediate, intermediary and long-term requirements with actual financial needs. The guidelines from the ministry too keeps wavering from quarantine outside to quarantine at home and then to home isolation of the very mild cases (GoI, 2020a).
Science, Reason and the Lockdown
Prior to the lockdown, the government set up a high-level technical committee of ‘public health experts’ for COVID-19 to guide the prevention and control activities in the country. It was headed by NITI Aayog member, Dr V. K. Paul, the union health secretary and co-chaired by the director-general, ICMR. The director, AIIMS, director of National Centre for Disease Control, Delhi, director of Institute of Infectious Diseases, Pune and additional chief secretary of Kerala were among the members of the task force (News Services Division, All India Radio, 2020). Perhaps shaken by the horrific images of the exodus, 10 empowered groups for quick planning and implementation of strategies to deal with the COVID-19 outbreak and an eleventh strategic task force to sort out issues related to the lockdown and stranded workers was set up on 28 March. These empowered groups headed by bureaucrats from the Prime Minister’s Office (PMO), Ministry of External Affairs, the National Disaster Management Authority and some technocrats were conspicuous by the absence of independent researchers and practitioners from institutions of public health even as ordinary members. As reported, the groups were to address the identification of problems, effective solutions and formulation of plans for medical emergency management, availability of hospitals, isolation and quarantine beds, availability of critical medical equipment, human resources supply chain management, coordination with the private sector, economic and welfare measures, communication, technology and public grievances (Sharma, 2020c). These groups now acquired the muscle of high-powered bureaucrats and representatives of the PMO as heads of these groups. Planning was highly centralised without actively engaging academic institutions or the states at the highest level, even though health is a state subject. The success of central plans depends upon relative local conditions and requirements that only the states can assess best, another strong reason for their participation in planning at the top that was ignored. It is reported that the government did not consult even the ICMR-appointed task force before key decisions were taken, and that meetings was often not held and the members felt they were used (Krishnan, 2020). (The ICMR rejected this allegation as false.) The members who spoke, however, preferred anonymity. The chairperson of the expert committee, Paul, publicly defended the decisions taken as scientific and correct and the rationale behind extending the lockdown until 17 May as the ‘Real goal of lockdown was to suppress the chain of transmission of the virus’. This will be lost if the lockdown ends abruptly. He expected the ‘…coronavirus positive cases to stabilise anytime soon’ (PTI, 2020d). For her reporting, Krishanan has been heavily criticised on social media but unfolding events have compelled her readers to think.
These contradictory and confusing claims underline the importance of data transparency and the importance of crosschecking before it is used for planning (Krishnan Ananth,). In its attempt to discipline media, the government went to the Supreme Court seeking a directive that journalists do not report on COVID-19 without official clearance from it. While the court rejected this but at the same time directed news outlets to ‘to refer to and publish the official version’ (Committee to Protect Journalists, 2020). The government’s plea was that screening will help avoid possible misinformation leading to ‘false alarm and public panic’ as in the case of large-scale migration. The court thus has absolved the government of any responsibility for not taking the public into confidence and not foreseeing distress migration. Sharing data with academic institutions has the advantage of emerging insights, viewpoints and greater involvement from which the state could choose but today it is only some that have that privilege at the cost of universities. Scientists in strategic planning groups should know that science grows with sharing not through claustrophobic inbreeding.
The scientists within ICMR at the same time published a set of papers by end-February in their journal proposing a community-and civil society-led quarantine and monitoring (Koshy, 2020c). This was ignored by the government as it was lowering its own assessment of the value of lockdown in reducing cases from 40 per cent to 20–25 per cent. Even that was assessed as temporary if not accompanied by other recognised interventions. This study came after a week of lockdown yet it did not influence the decisions on repeated extensions (Abrol et al., 2020). All through April then, there has been this undercurrent of conflict with the experts finally tailing the empowered committee head without standing up for their science. As a result, the lockdown continued through May as did the arduous march of workers who were heading back home. The effectiveness of the lockdown has remained questionable as the curve has continued to rise though apparently at a slower pace given inadequate testing and irrespective of differential patterns across states. Between 17 April and 26 April, Rawat tells an important story. While the media reported on the districts that showed positive results and states that did well, such as Odisha, Rajasthan and Kerala, at least 42 new districts were added (spread over 14 states) to the COVID-19 infected districts where positive cases had not been recorded earlier. With the incubation being mostly not more than 14 days, these cases definitely occurred during the lockdown and its reasons can be the fallibility of the lockdown, the tracking and testing system, infected essential service providers or the fluidity of population movement (Rawat, 2020b). Given these uncertainties, the exit from the lockdown is not visible and the centre no more wishes to take responsibility. So after its unilateral imposition, it is now using federalism to get out of a bind of its own making. There is no denying though that the rate of growth of the COVID-19 infection has been relatively slower. Some questions remain: With all the investments the health ministry talked of how did the health services fare in terms of preparedness, how did India use the time it gained?
Healthcare Infrastructure
Public Sector Services
Gaps in India’s health system and its preparedness for any major emergency is well recognised and commented upon (Rao, 2017). Despite the constructive criticism of the last annual budget, health services have been at near-stagnation in financial support and an internal adjustment that has followed previous year’s patterns of shifting resources to the private sector in the name of partnerships and cuts in key sectors such as the NHM, the last bastion of any semblance of providing any basic service. Despite promises of strengthening district hospitals and state medical colleges, allocations have remained minimal and there have been proposals to hand over beds for non-communicable diseases to be managed by private partners and convert district hospitals into private medical college hospitals. These steps are certainly not meant to strengthen public sector infrastructure. According to data collected by the Union Health Ministry in COVID-19 affected states as of 17 March there is one isolation bed per 84,000 Indians, and one quarantine bed per 36,000 Indians. This paucity has perhaps inspired the idea of a lockdown (Ghosh, 2020b). Until 4 March, only 111 testing centres were working and that too unhygienic and overflowing with garbage and patients (Changoiwala, 2020). India has 713,986 beds spread across 25,778 government hospitals (GoI, 2019c). In addition, the railways run 122 hospitals across the country with a cumulative 13,355 beds; government hospitals have about 8,432 ventilators across the country, while private hospitals have about 30,000 such devices. Fifty military hospitals dedicated or mixed across the country are ready to deal with COVID-19 and have six labs for testing (Kulkarni, 2020). Although in all it comes to 0.55 bed per 1,000 population and although this is considered very inadequate, it shines when compared to what we have in rural areas. The network of community health centres (CHCs), PHCs and sub-centres that has a shortfall in numbers by 20 to 30 per cent (Ghosh, 2015), continues to be poor in quality according to the National Health Profile 2019 (Government of India, 2019b). Preparedness for COVID-19 infections for this rundown network is in fact a misnomer.
A document of the Ministry of Health and Family Welfare entitled, ‘Enabling Delivery of Essential Health Services during the COVID-19 Outbreak: Guidance’ (GoI, 2020b) makes it clear that not much is being done to expand or strengthen the existing infrastructure. It passes the onus on to users noting that it is likely that health seeking may be deferred because of social/physical distancing requirements or community reluctance owing to perceptions that health facilities may be infected. Focussing on COVID-19 related activities and continuing to provide essential services is important, it claims, not only to maintain people’s trust in the health system to deliver essential health services but also to minimise co-morbidities. Unfortunately, most assessments from the ground, though at times overwhelmed by the lack of ICUs and ventilators (Ghosh, 2020), personal interviews with village residents in Bihar and UP do not confirm that this wish has actually materialised. In many states, manpower is sparse and diverted so basic services such as immunisation and maternal services have been derailed.
According to ministry guidelines, all non-COVID-19 community-level activities of the Village Health Sanitation and Nutrition Committees/Mahila Arogya Samitis need to be deferred until restrictions are lifted. States need to designate institutional facilities or separate blocks within them for fever clinics and COVID-care centres. Help can be sought from the not-for-profit private sector in the provision of non-COVID essential services, particularly for secondary and tertiary care where public sector capacity needs to be supplemented. The PMJAY has been extended to include COVID-19 infection and a new scheme of an express empanelment of private hospitals has been launched for expanding COVID dedicated institutions as well as others where serious co-morbidities can be treated without fear of contacting COVID-19 infection (The Hindu, 2020, 11 April, p. 10). The guidelines advise mobile medical and dedicated services for level 24×7 hospital emergency units, maybe set up in suitable CHCs/sub-district hospitals for non-COVID emergencies, and maternal health and multipurpose workers and private providers could be mobilised for necessary services along with retired nurses, ANMs and lady health visitors (LHVs). The funding is to come from the starved local level additional funding provided through the NHM. Prioritising at all levels and if possible, temporary structures outside the building could be set up to facilitate triaging (separating services for quarantine, isolation of simple cases and hospitalised cases). Reporting severe acute respiratory illness (SARIs), including pneumonia and influenza-like illnesses (ILIs) but also all fever cases, including dengue, TB, malaria, Japanese encephalitis must be ensured. Workers must know infection, prevention and control (IPC) programmes and be provided appropriate PPEs, especially in COVID areas.
It is evident from this advisory that while the workload of frontline workers has increased tremendously, there is little addition in terms of manpower, buildings, and materials and money. Yet the ministry expects its financing from the state itself and assumes that shortage, skewed distribution and misalignment between health worker competencies and population health needs could be tackled by the re-assignment of staff (The Hindu, 2020, 11 April). It advises redeployment of staff from non-affected areas facilities, mobilise resources from the railways, public sector units and Employees’ State Insurance Corporation (ESIC), requisition retired, non-governmental and private sector health workforce capacity for temporary engagement without creating any long-term liability. In addition, it proposes web-based platforms to provide key trainings, the use of AYUSH doctors, non-health sector workers and COVID volunteers for mapping of clusters and record keeping, financial management and so on (GoI, 2020b).
Medical teams in urban public institutions who are working overnight don’t necessarily get to use appropriate PPEs except in big hospitals. Significant numbers are contracting the infection, and they have to cope with inadequate supplies of drugs, oxygen, equipment gloves, masks and sanitisers. When they catch the infection themselves, they have poor quarantine and isolation facilities and at times are mistreated by their neighbours. While the doctors have protested and come under regulations for protection, frontline rural workers have only the promise but not the protection. If this system is not strengthened and the epidemic really takes roots in rural areas after migratory workers reach home and the lockdown is relaxed, this system may not be able to cope with a second wave that might be stronger. It appears then that the lockdown even if it has slowed the rate of growth failed in its primary function of strengthening the public sector infrastructure.
Private Hospitals
Given the past experience with epidemics of plague in Surat and dengue in Delhi when private providers either left the city itself or charged exorbitantly for simple testing, it is not surprising that the private sector that was so vocal about ensuring the viability of private healthcare, especially releasing the money stuck with the Central Government Health Scheme (CGHS) and more funds for critical care, initially quietly waited in the wings; not even volunteering to take the responsibility of conducting tests at a reasonable price unless the state supplied them kits free of cost. Those who did speak from the private sector wanted the transformation of public institutions into COVID care units and proposed they could take the serious patients into their ICUs (Varghese, 2020). One of the empowered groups in the expert committee that oversaw the cooperation with the private sector inevitably promoted the policy of stewardship of the government of the private sector pleading with them to participate especially in the business of production of materials and equipment as mentioned earlier. While the ICMR group of experts insisted on free testing for all and in fact got a court order for that, a representative of the private sector went to court pleading that the deferment of the order on remuneration was adding to the patient’s suffering. This plea got the support of the officials of the ICMR that pleaded against its own proposal and so the testing fee has been fixed at ₹4,500 (Krishnan, 2020). Since then testing has been opened to private sector labs. It is also been reported that the National Centre for Disease Control that falls under the Ministry of Health and Family Welfare does not share its data with the ICMR and has not made it public since February (Krishnan, 2020). With the new empanelment scheme, the Hospital Empanelment Module (HEM) Lite under PMJAY, profits are being ensured via shifting co-morbidities and serious COVID patients. The PPP model is being promoted at all levels with the ministry guidance that serious non-COVID patients can be referred to private institutions which account for two-thirds of hospital beds in India, and almost 80 per cent of available ventilators. Yet, they are handling less than 10 per cent of this critical load (Raghavan et al., 2020). Those institutions which are taking COVID cases are profiteering and charging exorbitantly for both ICUs and admissions to wards. It costs approximately ₹110,000 for 10 days for the ward and ICU care adds to ₹50,000 per day. For 15 days, a bed and other added expenses cost ₹750,000 (Ganguly, 2020; Singh, 2020). This may be linked to reports that leading private hospitals have sustained revenue losses of up to 90 per cent of their revenues since March, primarily due to the loss of foreign patients who are not coming due to travel curbs and fear of COVID.
The National Sample Survey Organisation (NSSO) 2017-18 data reveals that government hospitals provide care to 42 patients per thousand population (rural, urban included) per year; thus for a district with a 200,000 strong population, if additional isolation beds are not provided about 52,000 patients will become vulnerable under the requirements of isolation of COVID patients (Government of India [GoI], 2019a). Yet, mortalities and miseries caused by other diseases are being disregarded to divert resources for COVID-19 care. This mistake has occurred twice, once when controlling smallpox led to a massive resurgence of malaria and deaths caused by it which the system could not hide for long. Then, in the polio eradication drive. The claim that India was a polio-free nation is undermined as not only the reactivated oral polio vaccine virus is known to cause paralysis but also annually 50,000 Indian children suffer from a polio-like acute flaccid paralysis which often hides the reactivated vaccine-induced polio (Mackay, 2019). This is despite over 14 years of investing heavily in this vertical programme.
By diverting resources to COVID-19 management in the public sector, not only are its users penalised but also forced to go to the private sector that they can barely afford. It is in this context that the decisions of four states, Chhattisgarh, Madhya Pradesh, Rajasthan and Andhra Pradesh, for boldly taking over private hospitals, though selectively, and have tried to support these institutions through either the PMJAY or resource flows from the Disaster Management Act 2005 or through the funds of the states. With Outdoor Patient Department (OPD) closed down and the General Practitioner (GP) not working, the resources of private institutions do have a role to play provided their costing is regulated under the Clinical Establishment Act. This experiment has generated a debate as to how best this takeover can be regulated so that it opens up a new route to actually strengthening tertiary care with strict cost and quality regulatory mechanisms. While these are steps for the short-term, a long-term plan for a future public sector infrastructure build up and regulated partnership must flow out of this experiment.
Two Sides of the Crisis
The pandemic very clearly creates a crisis of handling COVID-19 and non-COVID ailments, especially life-threatening ones. Public health experts have not emphasised reviving and strengthening systems to make them part of long-term planning; they only offer adhoc solutions. For example, it is clear that severe and critical patients need tertiary care support but there is no roadmap for strengthening its own hospitals that are three times cheaper than the private sector. Similarly, the PHC infrastructure cannot run on borrowed manpower, particularly when case-tracking becomes an important task. Extensive research on malaria and tuberculosis (Bhargava et al., 2014; Padmapriyadarsini et al., 2016; Zurbrigg, 2019) has pointed out the association between under-nutrition and infections and the role of under-nutrition in enhancing immunological vulnerability of population. Instead of idly waiting for the corporate global world to give us the COVID-19 vaccine, food supplies must be ensured to strengthen general human immunity. Food as dole should soon be replaced by food with the dignity of work and augmenting the National Food Security Act, 2013. Transportation of food grains then should have been exempted from the lockdown. Instead, movement has been restricted by force and punishments have been meted out under the 123-year-old, vague and draconian law, EDA 1897 and the home ministry rather than the health ministry has taken centre stage in overseeing the protocols of lockdown. Even the EDA while empowering authorities ‘to take special measures and prescribe regulations as to dangerous epidemic disease’ clearly decrees it is ‘by public notice’ which was never given. Second, the fact that a prolonged lockdown as a public health measure has had a negative health impact, especially for the older population, children and chronically ill, is being ignored as has the needed emergency care due to refusals and delays in temporary passes. Suggestions on COVID-19 management were invited from political parties or the states but without transparent discussion or their involvement in decision-making. The onus of continuation/discontinuation of the lockdown too has been on the states without the central assistance they required. The shutdown of economic activities has simultaneously squeezed supply and effective demand in the economy which also comes at a time when the economy is still struggling to recover from the shocks of a hastily implemented GST and an ill-conceived demonetisation.
Rising Unemployment
According to the estimates by the Centre for Monitoring Indian Economy (CMIE), the unemployment rate has increased to 27.1 per cent in the week ending 3 May (Vyas, 2020). In April 2020 alone, 127.3 million people lost their work; a majority (91.3 million) being daily wage labourers and small traders (like hawkers). About 17.8 million salaried persons have also reported job losses in April. Quite expectedly, a section of the retrenched labour sought to find employment in the agricultural sector resulting in a rise in farm employment (5.8 million), most of which might be essentially disguised unemployment (Vyas, 2020).
A Looming Agricultural Crisis
On the agricultural front, the COVID-19 pandemic may impact the rabi crop (particularly wheat) harvesting and procurements, in some of the main wheat-producing states such as Gujarat, Madhya Pradesh, Rajasthan, Maharashtra, Punjab, Haryana and Uttar Pradesh (Samant, 2020). As of 11 May, 62 per cent of the targetted 407 lakh tonne of wheat has been procured, according to the latest Food Corporation of India (FCI) data. 2 Below optimal functioning of wholesale markets due to labour shortages and physical distancing protocols of staggering arrival of produce in the markets is making the selling process tedious and costly for farmers in many of these states (Jayan & Vora, 2020). As a result, farmers are selling their produce to traders at prices lower than the minimum support price (MSP) in some states (Sehgal, 2020). We calculate that modal wheat prices are lower than ₹1,925 per quintal MSP in 63 per cent and 40 per cent of the APMC wholesale markets in Maharashtra and Rajasthan, respectively.
The effects of these might spill over and affect kharif production as well. A collaborative primary study among rural households shows that 28 per cent of the respondent households report a postponement of agricultural tool purchase, while 69 per cent reportedly lack seeds for the upcoming kharif cultivation (PRADAN et al., 2020). Preliminary findings from the same study also show an overall deterioration economic and livelihood conditions, including reduction in food consumption, reduction in incomes, increasing drudgery for women and so on.
Contraction of Industrial Production
On the industrial front, we can see a heavy contraction in production. Manufacturing of food products, beverages, tobacco, textiles, apparels, leather and related products are major employers. Manufacturing of motor vehicles and related products is a sector that has received considerable government support in the recent past and touted as an emerging employment generating industry. The month-over-month growth rates of production of these industries in the last one year (from April 2019) has either stagnated or declined and all of them show significant contraction in March 2020 ( Figure 1 ), which surely will have a major negative impact on employment.
Source: Compiled from various state health bulletins as reported in
Lack of Fiscal Stimulus
What India urgently needs is a comprehensive fiscal stimulus that can make up for lost incomes and revive aggregate demand in the economy. However, as of 17 April, though it is the fifth most stringent among 30 most affected countries in terms of lockdown and physical distancing measures, India ranks twenty-eight in terms of the size of the fiscal stimulus as a percentage of GDP which will make up for economic losses due to such measures (Dasgupta, 2020). The 13 May and 14 May announcements of economic package primarily focus on liquidity infusion into financial institutions and easing credit for businesses. However, the businesses will not borrow to invest if demand for products does not increase due to a lack of income (Bose & Rohit, 2020).
However, the current economic crisis is not limited to the aggregate demand problem per se. Aggregate demand itself is linked to how the spread of the infection continues. If the lockdown is gradually withdrawn and adequate fiscal stimulus boosts the economy, the increased level of activity will increase the chance of a faster spread of the infection. It will endanger lives not only because of the spread but also because of increased vulnerability due to hunger and starvation. Also in turn, the level of the economic activity itself will be restricted. To counter that a much needed gradual withdrawal of the lockdown and an adequate fiscal stimulus for the economy must go hand-in-hand with strengthening nutritional and health services. Pitting the issue of health against the economic crisis is unimaginative.
Conclusion
What we see then is: first, a mixed attitude towards the pandemic—laxity in acknowledging its importance for India early; then having lost time and not preparing for a phased strengthening of health services infrastructure and different types of public health interventions; rushing into an unplanned lockdown without taking people into confidence and trampling the interface between public health and economic activities by shutting down the economy and neglecting state-run nutritional services and health infrastructure. The management by the police and the internal conflicts of scientists, techno-bureaucrats and state institutions has kept the larger scientific community out of constructive participation and the public had to depend on a biased media. The key levels of the health infrastructure were forced to manage by withholding services that were mandatory and the workers became vulnerable to the ire of the public, often ill informed about the constraints of the public sector healthcare providers and the nature of the disease. The regional requirements for ICUs and ventilators were not openly assessed and rationalised and a general emphasis on their shortages in controlling deaths became a business focus, delaying local production. A centrally controlled information system that was thin on transparency and planning, that ignored specific local conditions and community participation ended up in assertions of success. It did so by hiding behind averages derived from a few better performing states and those that did nor report significant number of cases without analysing any real state experiences of success or failures. The lockdown overshadowed the efforts of containment as well as mitigation and its impact was on the socio-economic and political determinants of health depriving the working people of livelihoods and dignity, and increasing class and social distance only as they were too squeezed to create physical spaces around them.
For saving the situation now, the lockdown needs a phased relaxation to allow productive work crucial for lives with dignity and to save small units endangered by it. But to get the disillusioned workers back is going to take time. Constantly comparing ourselves with the USA and Europe suits the worldview of the ageing middle class now desperate to increase the numbers of ventilators and ICU alone. The workers who walked miles to reach their families and who are unable to harvest their crops have a different perspective. Although COVID-19 deaths are higher in the over 60 year age group, 40 per cent do come from 60 years and below. The average life expectancy of the poorest two quintiles of males in rural areas is 62 and 66 years, respectively. Hence to assume that deaths are of the rich alone is wrong and more so given the well-documented linkage of acute hunger and severity of infections and deaths (Zurbrigg, 2019). In our very stratified society, public health is being instrumentalised to create a controlled and exclusive society, not the one for which developing nations came together at the Alma Ata conference on primary healthcare, invoking distributive justice, and proclaiming the embeddedness of public health in overall development. That choice has to be made yet again.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.