No alternative to strong health infrastructure

Noted economist Michael Kremer said in his 2019 Nobel Prize lecture that science and human welfare must advance simultaneously: human welfare is possible only when the marginalised and vulnerable are at the centre of planning and policy-making. It is time we recall these words, for the Covid-19 crisis has exposed the neglect of accessible, affordable and trustworthy public health infrastructure by successive Indian governments.

It is due to this neglect that Indians trust private hospitals and doctors more than they do public health facilities. This is the situation although scaling up investments in health infrastructure from 1.4 to 3% of GDP has been the constant demand of health experts. Without such investments, future threats, and even the ongoing pandemic, cannot be countered effectively. 

If the present crisis goes out of hand, it will become the norm to fix a hierarchy of patients, for the health system will not be able to bear the load of all the sick. This has already happened in Italy, despite its far better health infrastructure than India. The doctors and nurses fighting the pandemic there have shared experiences of utilitarian prioritisation in dispensing care for Covid-19 patients. For instance, they prioritised young lives over older people.

In India, the Indian state has not just failed to provide doctors with personal protective equipments (PPEs). The healthcare system here is rickety to the extent that after the epidemic broke out, the nursing staff at Jhansi Medical College in Uttar Pradesh boycotted work on 25 March over non-payment of salaries for seven months. They, too, got no PPEs and expressed their inability to work during the pandemic. Delhi’s doctors also took to social media to highlight the same concern: they are being threatened with criminal negligence if they refuse to work, although their work conditions make them vulnerable to infection.

If and when the time to tackle Covid-19 on a large scale comes to Indian hospitals, it is inevitable that patients will face a huge medical divide which will be drawn along society’s many existing fault-lines. All the -isms will come alive—ageism, casteism, sexism, intellectualism, and so on. The better-placed will be protected and others face the prospect of death. The differently-abled will undoubtedly be the worst off, should such prioritisation set in. Though caused by infrastructure deficit, a misplaced sense of utility may kick in, determining who is ‘productive’ and who ‘useless’. Lack of scientific equipment and selective sense of human welfare should not be allowed to dehumanise civilisation.

There are demands for Covid-19 testing to be free, but accessible and inexpensive healthcare for the vulnerable is a long-pending demand. When in the past demands for free treatment for the poor were raised, the elite and policy-makers resisted, saying that public health should not be subsidised at the tax-payers’ cost. Now the question is whether this resistance will continue or the elite will advocate for affordable health facilities for all.

The marriage of any hierarchy of patients and privatisation of healthcare will affect the migrant workers stranded on the roads today, but it will not end there. Ventilators will need “sifarish”, private hospital beds will need a lifetime’s savings, mushrooming multi-speciality private facilities will suck a patient’s marrow dry. This will be, even for a social Darwinist, a nightmare come alive.

India cannot afford unplanned decisions any more, notwithstanding the abundant failures of the state so far and the limited resources at its disposal. We need a visionary state whose policies can factor in ground realities rather than failed top-down models. For example, today’s chaos is a result of suddenly locking down the country without consulting state governments—contrary to the ruling NDA regime’s talk about ‘cooperative federalism’. The internal migration that followed this lockdown has shown that the Centre takes decisions first, plans for contingencies later.

The Prime Minister’s address gave people four hours to arrange food, medicines and other necessities. It did not even mention essential services. A tweet an hour later—after reports of panic and chaos poured in from across the country—sought to rectify this. But this regime has displayed a pattern of unplanned decisions, such as demonetisation and the hurried implementation of GST.

It is no surprise that the panic-gripped poor and migrant workers, for whom no immediate relief was announced, began migrating en masse from Delhi, Gurgaon and Noida, on foot, to reach their native places. The Greater Noida Expressway, Lal Kuan in Ghaziabad, the Anand Vihar bus terminus, all witnessed massive crowds—and all of it inconsistent with the government’s ‘physical distancing’ objective. Instead, India ended up increasing the probability of the virus spreading indiscriminately. Now, belatedly, relief/quarantine camps are being set up for these migrants. Just two days before the Prime Minister’s speech, citizens had been made to believe that their sole duty was to take a few simple precautions against the Novel Coronavirus—wash hands, avoid contact, avoid crowds, stay indoors, and yes, clap and clang vessels.

At this juncture, a week into a near-absolute shutdown across the country, those people who clapped and cheered the perceived ‘victory’ over the pandemic are being put under pressure of an ‘idea of guilt’. In other words, their sense of guilt and shame over having celebrated with taalis and thaalis will not allow them to question the state and point out its mistakes.

Other than this deft co-option of the elite sections, the events of last week show how the marginalised groups are being invisibilised by the lack of vision and top-down policies of the Indian state. When the Uttar Pradesh government announced it will transport people to their respective places in buses, Bihar Chief Minister Nitish Kumar categorically pointed out the risks involved and said that they should instead be set up in temporary camps and provided food and medical services there. Delhi Chief Minister Arvind Kejriwal has also said that camps are being arranged and migrants need not panic. Beyond party politics, these are more appropriate responses to the unfolding crisis.

Such steps, if taken earlier, would have minimised the spread of Covid-19 to rural and remote areas. The working class is highly vulnerable to this virus—or any other illness—for it works in close contact with the frequent-flier class, which brought the pandemic to India in the first place.

No matter which conspiracy theory on the virus some of us may subscribe to, still our response has to be administratively and medically sound. There is no escape from a secure and dependable health system, even if some of us now want to call it a ‘biological defence infrastructure’. A health calamity, whatever its trigger, needs to be faced without creating anxieties and sudden changes. It cannot be left to an individual to “improve” his or her immunity. What we need immunity from is the system’s failure.

For instance, when China was fighting this menace, India should have started making preparations too, but the government was busy organising United States President Donald Trump’s visit. Also, since most carriers of Novel Coronavirus are from the upper echelons, the government and bureaucracy are very concerned to ‘contain’ it. From the experiences of the working class—who have been left to defend themselves, immunity or no immunity—it is clear that the government would not have been as serious if the affected were from the marginalised and poorer sections.

Truth be told, India is demonstrating its lack of imagination during this crisis. It has never plugged loopholes in any state-led system with genuine concern and intention to improve. Be it education, healthcare, administration or even policing—these institutions have never re-energised themselves with fresh modes of thinking and conduct. And that is why none of them are truly prepared to face this challenge. India does not even have a proper counselling/social work infrastructure to help people cope with the effects of prolonged isolation. Encouraging research has also never been part of our make-up. The phrases, “Kitabi batein mat karo—Don’t indulge in bookish talk”, or “theory mat do—don’t theorise” are pat responses when issues that do not directly affect people are raised before them. People, too, must nudge the state to implement what really works for people, instead of blocking out contrarian views and new ideas.

Every country has a Covid-19 patient today. All these nations have realised that it is not Novel Coronavirus that is killing their people but a combination of pre-existing conditions. Health experts refer to this as ‘co-morbidity’, which is high among the elderly and the marginalised. Many of these sections may be suffering from health problems, even be unaware of them. For instance, in many parts of rural India, tuberculosis is endemic. As also, people who are already suffering from hunger are more prone to die if they are infected by new pathogens. Therefore, it should be basic common sense for the state that the poor and the migrant population needs not just NGOs and Good Samaritans but helpful and practical state policy.

Fact is, India always maintained a social distance in how it dispensed healthcare and other facilities. Its system excludes the unprivileged actively. Reports now say that those who have arrived in villages after their recent long march from cities are not being allowed to touch water sources, when clean drinking water was one of the reason why they had started walking back. This basic essential was denied to them by our brutal city life. If these fault lines are not addressed, we could create multiple new sources for infection and deaths in coming years.

From protection of doctors and nurses and the marginalised to the overall well-being of our people, India needs a strong health infrastructure and well-planned decisions. Privatisation is never the solution: this much we have learned from how badly our depleted public healthcare infrastructure is faring during this pandemic. The state must now take responsibility and create well-planned institutions in every sphere of life. Or there will be dire consequences from this one, and the next crisis down the road.

Tarushikha Sarvesh is an assistant professor of sociology at the Advanced Centre for Women’s Studies, Aligarh Muslim University and Abdul Hafiz Gandhi is an assistant professor of law at Unity PG Degree and Law College, Lucknow. The views are personal.

First published in NewsClick.