India’s coronavirus crisis was decades in the making

[Khanivore]

India’s coronavirus crisis was decades in the making

Vidya Krishnan | 23 March 2020 | The Caravan

The global coronavirus crisis has been called many things: a pandemic, an unprecedented crisis, a re-run of sorts of the Spanish flu’s decimation of the human population just over a century ago. In India, from the eyes of anyone who studies public health, it is also a catastrophe that has been in the making for decades, perhaps since as far back as Independence.

In weeks of reporting since India saw its first COVID-19 cases and deaths, I am yet to speak with an epidemiologist or infectious-disease expert who is surprised that the country is utterly unprepared for what awaits us—which, they all agree, is a surge of infections and resulting deaths.

One assessment published in a medical journal in January reckoned that India had 2.3 ICU beds per 100,000 people. The medical system in Iran, for which the assessment put the figure at 4.6, is overwhelmed with COVID-19 cases. Experts in the United States, where the ratio of ICU beds was reckoned to be more than six times higher, are warning that it will soon run out of ICU beds too. India has less than one allopathic doctor per thousand people—the minimum recommended by the World Health Organisation. As of 2016, the Indian Medical Association was showing a shortage of tens of thousands of critical-care specialists. The dominant share of doctors and beds are in the private healthcare sector, which has enormous leeway to set its own prices and make its own rules—and to exploit both to put profits before patients.

The government’s response has been characteristic of the Narendra Modi administration: lacking in transparency, and prioritising PR over public need. The health ministry, which has performed woefully few tests for the virus, maintained for unreasonably long that India only had cases of “imported” infection, contracted beyond international borders, and tailored its response accordingly. While other countries showed the value of aggressively tracing, isolating and testing anyone likely to have been exposed, our officials stuck by the line that India had no “community” transmission—a view based, as one doctor pointed out, on an absence of evidence rather than any evidence of absence. Modi’s speech to the nation on 19 March drummed up voluntary self-isolation, but said next to nothing about the government’s strategy to contain the effects of COVID-19, whether on the medical or the economic front. The AYUSH ministry endorsed a supposed homeopathic prophylactic to combat the virus. Some Hindu groups, and at least one BJP activist, have held “parties” to drink cow urine, their preferred anti-viral.

Epidemics are a product of ignorance as well as disease. The coronavirus might be new, but the ignorance has been with us all along. Modi, his ministers and his party have held intellectuals and experts in disdain, and shown contempt for scientific thinking. A broken public education system is fuel to the fire. Allied to the ignorance is a willingness to look away—from the state of Indian healthcare, from the apathy of government after government, from the sicknesses already ravaging the population—even among those who should know better. Nothing brings this out better than our existing epidemic of tuberculosis.

India is the epicentre of the global tuberculosis crisis. As far as infectious diseases go, tuberculosis is the world’s biggest killer. In India, it claims nearly 1,400 lives every day. For the large majority of cases, tuberculosis has a cure—a course of medication delivered under close observation over several months. But the country’s healthcare system consistently fails to diagnose and fully treat tuberculosis patents. The more stubborn, drug-resistant strains of the disease are the products of uncoordinated and interrupted treatment, and in India they exist on a shocking scale. For decades, the country has done nothing to fix the systemic problems behind these symptoms.

Through modern Indian history, the government’s outlook on public health has largely been limited to damage control—containing outbreaks of leprosy, for instance. As the example of tuberculosis makes clear, even at that the government has very often failed. India’s founding fathers prioritised such things as industrial growth and agrarian self-sufficiency at the expense of health and education. This set the course for the history of neglect we see today. The Indian government’s outlay on health amounts to little more than one percent of the country’s GDP—far below the global average.

India signed the Alma Ata Declaration at the World Health Assembly in 1978, promising “Health for All” by 2000. As a follow up, the country unveiled its first ever formal health policy in 1983—a full thirty-six years after Independence. After ignoring the health sector in all the decades since Independence, the government realised it did not have the hospitals to keep up with the burgeoning population. Through 1979 and early 1980, the Chennai-based doctor Prathap C Reddy did the rounds of the prime minister’s office to get Charan Singh to sign off on his pet project, a hospital in his home city that he would call Apollo. This would become the first of a new wave of private hospitals in the country, with numbers growing into the hundreds and then the thousands.

Instead of investing in the public healthcare system, the government consistently chose exorbitant public-private partnerships with private health providers. A rising tribe of medical entrepreneurs such as Reddy, Naresh Trehan and Devi Shetty encouraged the government on this path. Now, public-health “solutions” revolved around the state purchasing care from private hospitals and increasing cover on government insurance schemes, all at great cost. The government also offered massive discounts on land for private hospitals, as well as other subsidies and tax rebates. In effect, Indian taxpayers gave free funding to private hospitals where Indian taxpayers had to pay for care. Now, the Modi government is in the process of allowing the private sector to take over government-run district hospitals, as laid out in a recent Niti Aayog document.

The sweetest of the sweetheart deals offered to the private sector was “self-regulation.” The government let private clinics, labs and hospitals govern themselves. Parliament has passed the Clinical Establishments (Registration and Regulation) Act, but not even half the states have ratified it to give it force in their territories. Among those that have, many have still not laid down rules that clinical establishments must follow. As evidence of the government’s deference, the Modi government—which did away with more than four-fifths of the currency without warning, unilaterally stripped Jammu and Kashmir of statehood, changed citizenship laws without consultation—has deferentially “appealed” to the private sector to provide free testing for COVID-19. The health sector now exists under under near-complete regulatory capture by unaccountable private companies.

All of this was sold to the public as a way to fix India’s broken health system. Four decades of evidence expose that it has not. Patients are shuttled between a patch-work of private mom-and-pop clinics, overwhelmed public hospitals where they must wait too long for care, and overpriced private hospitals that very often leave them destitute. The country has a huge burden of infectious diseases, tuberculosis just one among them, not to mention cardio-vascular disease, diabetes and other ailments of unhealthy lifestyles. The private sector treats paying patients with these conditions, but it does not invest in preventing them. That work falls to a public sector drastically starved of the needed funds. Private healthcare will not track and contain the spread of an epidemic either.

Public-health experts have been warning the government about all of this for decades. These days, my conversations with them revolve around how the sick system can prepare for a surge of coronavirus cases. All they can offer are small ways to do the best in terrible circumstances. There is no way to reverse in a few weeks the generational neglect of public healthcare.

Public healthcare will have to shoulder a great responsibility for blunting the COVID-19 epidemic. China, which appears to have arrested the spread of the virus, has relied heavily on a massive government-run health system. Spain, since its explosion of coronavirus cases, has taken the radical step of bringing all private hospitals and healthcare providers under public control. India, with its reliance on private healthcare, will also face the question of how to weigh public interests against private ones. The private sector will have to play its part. With some glittering facilities and achievements to its credit, there is no doubt that it is capable of delivering good care—when it chooses to.

One way for the government not to be hostage to the private sector in the COVID-19 crisis would be to finally bring it under commonsensical regulations—the kind already in place for many other sectors. Another would be to reduce dependence on it by reinforcing public healthcare on a war footing, even if here the government faces historical handicaps of its own making. But no matter what the government now does, across both public and private healthcare, the coronavirus threatens to strip India’s health system bare, and show it for what it is. Of all the countries that COVID-19 has already devastated, nowhere has it yet found quite the combination of conditions India has prepared. The virus travels through close human contact; India has hundreds of millions of people living at some of the highest population densities on the planet. The virus attacks respiratory systems; India has more lungs ravaged by air pollution and tuberculosis than perhaps any other country. The virus preys especially on people with underlying conditions; India has millions with diabetes and heart disease. The virus has overwhelmed some of the most developed health systems in the world; India has one of the worst ones.

COVID-19 will forever change how we live our lives. The question is not simply how many people get infected or die, but how we, as a society, chose to respond to the pandemic. Maybe at the end of it the Indian health system can be treated for its own underlying conditions, and return strengthened to life. The tragedy is that far too many Indians won’t get the same chance.

Vidya Krishnan is a health journalist based in Goa. Her first book, on the rise of antibiotic resistance and the threat to global health security, is slated to be published in 202