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India's Response to COVID-19 Is a Humanitarian Disaster - Boston Review
The government enforced a strict lockdown for weeks, giving the illusion of responsible policy. Poor people are now paying the price.
bostonreview.net
India's Response to COVID-19 Is a Humanitarian Disaster
The government enforced a strict lockdown for weeks, giving the illusion of responsible policy. But all the while it has failed to provide adequate medical and economic support—and poor people are now paying the price.
Debraj Ray, S. Subramanian
Image: Flickr
It has been just over five months since the first case of COVID-19 was detected in India. With nearly a million confirmed cases, the country now has the third greatest number of infections, behind only the United States and Brazil. At least 25,000 people have died.
The outbreak began, as it did elsewhere, with an isolated case—a student at Wuhan University who had returned to Kerala in late January. Before long the infection had moved into community transmission, with over 1,000 confirmed reports by the end of March. But in the central government’s scheme of priorities, COVID-19 was initially swamped by other preoccupations: Assembly elections in Delhi, murderous communal atrocities in the aftermath of a profoundly provocative Citizenship Amendment Act passed last year, Donald Trump’s visit to India in late February, and the politics of regime change in the state of Madhya Pradesh.
With nearly a million confirmed cases, the country now ranks third, behind only the United States and Brazil. At least 25,000 people have died.
By this time states such as Kerala were already sounding alarm bells about the virus, which had claimed the full attention of the Indian media, opposition politicians, and epidemiologists. Then, in what has since widely been seen as a convulsive response, and with just four hours of notice, Prime Minister Narendra Modi announced on March 24 a full nationwide lockdown for a period of three weeks. This was extended on four occasions, to the accompaniment of some phased relaxations, until June 30. Throughout this period a mammoth population of nearly 1.4 billion people were restricted to their homes, and transport services, schools, factories, and business establishments were closed. State-level lockdowns, at varying levels of intensity, continue as we write.
These months of lockdown in India are a particularly striking instance of one feature of the dominant global response to the COVID-19 pandemic: social distancing and quarantine with a widespread suspension of normal mobility and economic activity. Especially in the context of the country’s unwieldy demographics—size and density alike—it was a model lockdown, ranking at the top of severity scales. On the Oxford University Blavatnik School of Government’s Response Tracker, which scores government implementations of lockdowns based on responses to specific questions, India’s ratings on stringency for a time were nothing short of spectacular.
Indeed, the police have enforced the shutdown with a frightening excess of zeal. On March 26 in Kolkata, for instance, a thirty-two-year-old man stepped out to buy milk, was beaten up by the police, and died. On March 31 migrant workers trekking back home were apprehended by the police in Gujarat, squeezed into a container truck, and sent back to Maharashtra. And on June 18, in Toothukudi District of Tamil Nadu, a father and son allegedly died from police violence in custody after they were arrested for keeping their shop open after hours.
But lockdowns are not supposed to be punitive. They are meant to provide time, among other things, to create, deploy, and allocate medical resources; to prepare and train a vast support network of health care and contact-tracing personnel; to rearrange commercial, infrastructural, and educational resources to meet a new era; and to psychologically prepare society for the long haul. They are also expensive. In advanced economies, the cost of a lockdown has been described as “merely” a dramatic reduction in overall economic activity. But for India, a developing country with great sectoral and occupational vulnerabilities, this dramatic reduction is more than economics: it is also the specter of lives lost—not from COVID-19, but from the severe economic and social dislocations. Especially in a poor country, a lockdown must be accompanied by an extensive and careful system of compensatory transfers to provide sustained and effective protection against this danger. In its delinquency on this front, India’s experience with COVID-19 brings out in vivid contrast these three different prongs of pandemic policy: the lockdown itself, the efficient movement of health and infrastructural resources, and a comprehensive strategy to compensate those adversely affected by the economic blow of the lockdown.
The Indian response exhibits a perverse politics of visibility: draconian on high-profile measures such as lockdown, weak on relief measures that are less easily observed.
Lockdown is a highly visible intervention: it makes headlines and suggests progress is being made. Very visible, too, are direct deaths from COVID-19, tracked, updated, and broadcast hourly around the world. Governments everywhere are propelled to respect this visibility—developing countries perhaps even more so than their developed counterparts, lest they be charged with dereliction of duty on the international stage. But the training and deployment of health personnel, along with the allocation of resources (such as personal protective equipment and ventilators) to states and local communities, are less visible to the public gaze. More opaque still are the lost lives that accompany the economic consequences of the lockdown. These losses—through violence, starvation, indebtedness, extreme stress, and non-COVID-19 morbidities beyond the reach of treatment—are effectively invisible: they are, and will continue to be, diffuse in space, time, and proximate cause. For the most part they do not make the mainstream news, and they are not tallied in website counters such as the COVID-19 Worldometer. Only the most intrepid of researchers will pick them up as the months go by.
The Indian response thus exhibits a perverse politics of visibility: draconian on high-profile measures such as lockdown, weak on the measures that are less easily observed. The government’s inadequate and impetuous management of the pandemic reflects an effort to win international approval by following the paradigm of advanced economies, without heeding the ethical urgency of providing a robust program of relief, both medical and economic.
One way these urgent issues are rendered invisible is through a restricted interpretation of the nature of the problem. The textbook philosophy for policymaking rests on the concept of an externality, the notion that decentralized individual actions will fail to fully incorporate the welfare of the general populace. From this perspective, the policymaker’s task is relatively simple: identify the pressing externality, then use policy to move actions in the direction that enhances social welfare. Presumably, the typical individual will be negatively affected by the direct effect of this policy—after all, she was ostensibly at her spontaneous optimum to begin with. But then (or so goes the theory), this negative effect will be more than compensated by the positive externalities she enjoys from the society-wide effects of the policy.
One way urgent issues are rendered invisible is through a restricted interpretation of the nature of the problem.
The trouble with this idealized picture of policymaking is that it presupposes that some notion of social welfare is well defined and universally agreed upon. Yet it is precisely the dispute over whose welfare that matters.
In the case of COVID-19, the dominant policy response has been dictated by a largely epidemiological view of the problem—one focused specifically on infections due to the coronavirus. This is not surprising, as the medical profession has been at the vanguard of those advising governments on the matter. Under this view individual actions for distancing and prevention, spontaneously adjusted in light of the perceived threat, are inadequate for socially optimal outcomes. Those spontaneous efforts would need to be helped along—hence the case for a lockdown.
Of course, it is also possible to make arguments against lockdown from a variety of perspectives, not that we agree with all of them: that a lockdown is over-zealous in its policing, that it impinges on personal freedoms, that it takes its toll on mental health. There are also widespread economic externalities due to such a policy: shutting some businesses down will reduce economic activity everywhere, as lost incomes translate into lower demand for all sectors in the economy. Widespread income losses suppress demand, and that, in turn, generates its own pandemic of income losses for others.
Given these disputes, the welfare economist’s standard diagnostic toolkit based on externalities is therefore not as useful as one might think. In a normative tussle, one can pick and choose one’s favorite externalities—a fact that explains much of the debate on COVID-19 policy that has exploded over the last few months, and which has sorted people into two main camps.
The trouble with the textbook picture of policymaking is that it presupposes that some notion of social welfare is well defined and universally agreed upon.
On one side, epidemiological consensus largely (but not entirely) allies with those who claim that life must be valued above commodities and who therefore underscore the need for strong state intervention. An opposing side, composed of a motley crew of interest groups, plays other externality cards. There are the libertarians, mask-spurners, and freedom junkies; there are religious groupings of all stripes who feel that human injunctions to fight the coronavirus are powerless—or unnecessary, or worse, heretical—in the shadow of an omniscient God; there are immensely powerful corporate and business interests, which not only feed off the libertarian-religious coalition but also inject the more insidious (and yet more serious) argument that the price of life has its limits, and that human souls can be placed on the same weighing scale as goods and services. And there is an increasingly desperate and vocal working class who live in unceasing fear of their livelihoods never returning.
While welfare economics is conducted in the pristine glow of a single, undisputed objective function, positive political economy is not: whose welfare is often a far more important question than the textbook criterion of “market failure” relative to some universally accepted social welfare function—one which, furthermore, preserves the fiction of the “symmetric” treatment of all individuals in society. This illusion of symmetry is reflected in the COVID-19 narrative that “we are all in this together,” when the truth is that we very much are not. In the United States, for instance, the disease has disproportionately impacted people of color and the poor in what some have characterized as the “politics of disposability.” A similar dynamic is playing out in India, a sort of politics of invisibility.
The flip side of this invisibility is the laser focus on lives lost from the virus. The international visibility of COVID-19 deaths, heightened by their predominance in “the West,” plays no small role in this story. And it is a visibility greatly bolstered by the epidemiological perspective. Particularly dominant in economically advanced countries is the idea that unlike the suspension of economic activity, COVID-19 claims lives in a predatory manner that is ethically unacceptable. On this view, a welfare contest between lives lost to COVID-19 and the disruptions caused by a cessation or reduction in economic activity should be no contest at all. This no-contest position is crystallized in statements such as those made by New York Governor Andrew Cuomo:
Though economists do routinely estimate a finite price of life in many different ways, we agree with Cuomo in this sense: no drop in economic activity per se is worth lives. If we opened our own externality toolkit, and stared down a lockdown that destroys some economic value and protects lives, we would unhesitatingly take the lockdown.
Lockdowns are not supposed to be punitive. Among other things, they are meant to provide time to create, deploy, and allocate medical and economic resources.
In other words, to borrow some economic jargon, we agree that the “first-best” (or “unconstrained”) approach to tackling a sufficiently threatening novel viral epidemic is a fully implemented lockdown, accompanied by a comprehensive package of welfare measures designed to compensate for the negative impacts—strictly or “merely” economic, as well as medical—of a drastic contraction in social activity. It would be a lockdown to buy time, while we raced to gear up health capacity for the inevitable swell in the disease to come. It would be a lockdown marked by sustained transfers of economic resources to the most vulnerable among us. It would be a lockdown that would require everyone to make some economic sacrifice, not just workers and small, self-employed businesses. But this position-in-principle inevitably provokes the pragmatic question: what if the state does not implement these accompanying policies—for reasons that could range from financial constraints, lack of expertise, and unpreparedness to just plain ignorance, unwillingness, and incompetence?
In that case—in India especially, and in poor countries more generally—policymaking would no longer turn on a question of lives versus economics. It would instead be a question of lives versus lives, or rather the visible lives, lost to COVID-19 from the non-marginal sections of society, versus the invisible lives lost among the great numbers of the poor, not just to COVID-19 but to an array of equally fatal, non-infectious causes. The latter are easier to avoid responsibility for, if for no other reason (though there are other reasons) than that they are so hard to pin down and identify. For instance, this website attempts to track these deaths through newspaper reports, a thankless and hopelessly difficult task. Yet it has recorded close to a thousand non-COVID-19 deaths traceable to the lockdown, each noteworthy enough for a newspaper mention.
This distinction between visible and invisible lives lost is not new to welfare thinking. The economist Amartya Sen, for instance, has noted that starvation deaths in a time of famine attract a great deal more attention than do “everyday” deaths from under-nutrition. Likewise, sporadic state action on regulating child labor in “hazardous occupations” such as fireworks attracts more immediate attention than would a long-term, systematic engagement with the phenomenon of schoollessness, or child work in family activities. That dichotomy returns with COVID-19 policy. As the historian Hari Vasudevan put it on April 22, “Starvation is peculiar. It does not kill quickly.”
For elites a draconian lockdown is not too difficult to implement. For the overwhelmingly large and relatively marginal constituency that fails to register on the visibility scale, what needs to be done is far more difficult.
Alas, the Indian government has succumbed to this bias of visibility. For elites a draconian lockdown is not too difficult to implement, logistically and politically. For the overwhelmingly large and relatively marginal constituency that fails to register on the visibility scale—the casual worker, the dislocated migrant, the subsistence farmer—what needs to be done is far more difficult. That includes upgrading the medical infrastructure to meet the COVID-19 challenge; maintaining essential health facilities to preserve existing preventive and palliative measures against other morbidities; and providing extensive social security to those adversely impacted by the lockdown. As the virus now begins to tighten its noose in India, the harder options look unlikely to ever be implemented—the inevitable corollary of a policy that prioritizes visibility above other goals.
Our arguments, we should stress, are not directed against lockdowns per se. No intervention—the sort of policy currently insinuated by top leaders in the United States (and others of their ilk)—is a recipe for humanitarian disaster. In other work we have written in support of a “relaxed lockdown” in the Indian context, coupled with age restrictions on work, care for the elderly, widespread testing, and the deployment of massive resources into health care. These “second-best” measures, we argue, work better than a lockdown unaccompanied by widespread economic measures to protect the vulnerable when the ideal “first-best” approach we have described is infeasible.
Instead, from the very beginning of the lockdown period, India’s response engaged in what might be called a nationwide project of virtue signaling. While it is impossible to say what would have happened in the absence of an intervention, India’s trajectory looks ominous—and the country has already been exhausted by the lockdown.
Noticeably absent is a serious public health response, despite months spent under lockdown. The country has been starved for resources precisely at the local levels where it is needed.
Noticeably absent is a serious public health response, despite months spent under lockdown. Consider one report on the state of Karnataka, by Dr. Sylvia Karpagam. She lists (a) an overwhelmed system, unable to cope with the load of COVID-19 patients; (b) the neglect of non-COVID-19 patients; (c) a serious shortfall of testing, arising from inadequate or faulty testing equipment, and inadequate laboratory and personnel resources; (d) the conversion of super-specialty hospitals (such as those usually devoted to the treatment of cancer) into COVID-19 centers; (e) the chronic unavailability of basic personal protective equipment for frontline health workers, many of whom are contracting the infection; and (f) a high order of dereliction of duty by private hospitals, resulting in an intolerable additional burden of caseloads upon an already enfeebled public health sector.
All this has happened despite the fact that Karnataka is one of the relatively “advanced” southern states in India. The report leaves the reader contemplating with deep apprehension the likely status of public health infrastructure in the relatively less advanced northern states. A single coronavirus testing laboratory in the city of Benares (Uttar Pradesh), for instance, caters to a population of thirty million distributed across ten districts.
Public health in India falls under the jurisdiction of individual states rather than under the central government, yet the states have been starved of resources instead. Disbursements of revenues from the new Goods and Services Tax have been slow in coming, while the central government has implemented a financing scheme that allows it, but not states, to benefit from corporate social responsibility donations required by a 2014 law. In short, the country has been starved for resources precisely at the local levels where it is needed.
At the same time, coronavirus vaccine trials have been speeded up, with the central government pushing for results by August 15 of this year. It is certainly true that India is a world leader in the production of generic drugs and vaccines, but this fast-tracking of vaccine trials is a very risky prospect, one that has been met with dismay by a large section of the scientific community and human rights activists. It is also the highly visible thing to do.
In addition to failures of public health mobilization are the seriously disruptive consequences of lockdown and the lack of a comprehensive system of protective transfers.
Two more examples clarify our misgivings with the public health dimension of India’s response. The first has to do with testing. It is no secret that aggressive testing followed by contact tracing is key to battling this pandemic. As of early July, India had tested just over 8,000 people per million. Economically comparable countries are doing better: Brazil and South Africa exceed 20,000 to 30,000 per million, respectively. India’s rate of positive cases per test is low as well, around 7 percent. (Compare to 37 percent and 13 percent for Brazil and South Africa.) That’s puzzling: the lower the testing capacity, the greater the likelihood that it would be used to triage the seriously ill. But the miniscule harvesting rate under Indian testing suggests that even these limited resources have been hijacked to service the relatively well-off. The effective testing of the poor in India is possibly not significantly different from zero.
The second has to do with India’s apparently low case fatality rate (the number of confirmed deaths out of the number of confirmed cases), which stands at an impressive 2.7 percent compared to around 6 percent for the world as a whole. The Indian government has taken credit for this fact with some alacrity, an aspect of self-congratulation that entirely ignores the fact that India is a young country. The skewness of the Indian population’s age structure in favor of its younger cohorts is scarcely a fact that presents itself as a creditable public health achievement.
In addition to failures of public health mobilization are the seriously disruptive consequences of, and accompaniments to, the long and stringently enforced lockdown. These include massive supply chain disruptions in both agriculture in the rural areas and economic activity in urban centers and the easing-up of labor laws and the resulting damage done to an entire history of workers’ struggles for more humane terms of employment. There is also the predicament faced by millions of migrant workers, with many of them being forced to actually trek back hundreds of kilometers to their rural homes without cash, food, or the prospect of re-employment. There have been reports of increased levels of domestic violence in a lengthy period of enforced co-habitation between intimate partners, suffering from other morbidities left untreated for reasons of immobility or unaffordable expense, and severe discrimination against religious minorities, disadvantaged castes, and women. Then there are the reports of brutal police enforcement and the initiation of action against political opponents and human rights activists under cover of the lockdown.
To top it off, there has been an equal failure in developing a comprehensive system of protective transfers. On the one hand, it is quite remarkable how quickly several detailed and practical measures for relief have been developed at short notice by citizens and scholars alike. Equally remarkable, on the other hand, are the attenuated measures that have actually been implemented by the government. To put it mildly, the government’s policy response has been unimaginative, neglecting both the institutions deployed for distributing relief among those most vulnerably placed and the many scholars of the Indian economy who have publicly called for such measures.
The government’s economic response has neglected both the institutions deployed for distributing relief among the most vulnerable and the many scholars of the Indian economy who have publicly called for such measures.
Both distributional and macroeconomic considerations have been given short shrift. Two fiscal packages for economic revival were announced in the aftermath of the pandemic, one on March 27 and another on May 12. Their fiscal stimulus has been underwhelming in both quantity and quality. In large part the packages are devoted to expanding liquidity: they are supply-side interventions in a general environment of severe demand deficiency, one that actually predates the current crisis. With limited government spending and a great deal of monetary easing in a situation where banks are reluctant to lend money in the first place, the government’s strategy appears remarkably unthinking—if not deliberately neglectful of the predicament of the most vulnerable.
Once accounted for various aspects of double counting, anterior budgetary provisions and already implemented liquidity expansions, the true extent of net government spending (or revenue waived) is only around 1 percent of GDP, an order of magnitude significantly lower than the claimed 10 percent. Going by figures provided by the website Statista, India at 1 percent compares most unfavorably with Japan (21.1 percent) the United States (12.2 percent), Brazil (11 percent), Canada (9.8 percent), Australia (8.5 percent), Turkey, France, Germany and Argentina (all around 5 percent), and even with a very poor South Africa (10 percent). (To be fair, some of these packages could also be inflated.)
What can one say of such policy? If it is the fear of an inflationary storm unleashed by a generous fiscal policy, we can say: there is no such fear. There is liquidity in the system that is there for the taking, say through the judicious issue of government bonds: India is by no means an overheated economy at the moment. And even if overheating were a genuine worry, why not temporarily raise taxes? (For instance, the government has brought charges against some senior Indian Revenue Service officers who leaked a report in which it was recommended that a wealth tax should be reintroduced and levied on the “super rich.”) Is this to be viewed as an opportunity to strengthen business interests at the expense of labor, or to arrogate power at the center, depriving Indian states of their fiscal powers? It appears that the politics of visibility are in full spate.
Why, in the end, the forceful emphasis on a draconian lockdown in India? We claim that it is precisely because COVID-19 poses a visible threat that the elites of the country all know about and are vulnerable to. In catering to these fears, the Indian government also obtains international recognition as being on the frontlines against the pandemic. And yet we must value those lives that are classified as invisible by a cynical politics that responds only to perceived clout and anticipated reward.
Visibility politics is not necessarily a bad thing. But we must always ask which kind of visibility is pressed into the service of what kind of policy.
Visibility politics is not necessarily a bad thing. It can be harnessed for social good, as the courageous Black Lives Matter movement in the United States illustrates. The global spread of that movement has surely been aided by its pronounced and deliberate co-optation of visibility, which has been pressed in turn into the service of policy change. But we must always ask which kind of visibility is pressed into the service of what kind of policy. Sadly, India’s response so far does not give us any hope that a system imbued with empathy and a desire for amelioration is in the works.
Editors’ Note: This essay is adapted from the authors’ longer essay, “India’s Lockdown: An Interim Report,” from late May.
