Coronavirus in India: An Illusion of Control?
Bureaucratic constraints and restrictive qualifications have made getting tested for the novel virus a nightmare for concerned citizens in the second most populous country.
Image Source: © Jewel Samad/AFP via Getty Images
The biggest countries of South Asia - India, Pakistan, Afghanistan and Bangladesh - together account for 1.74 billion people, making South Asia the most populated part of the world. Considering the weak public healthcare systems of all these countries, global healthcare authorities have been concerned about a prospective disease outbreak in the region for a long time. At the time of writing 863 people in India have been infected by COVID-19, including 47 foreign nationals, and the death toll stands at 20. Relatively speaking, the number of cases in India is low, and the “glorious” efforts of government authorities to control the outbreak have become a source of pride for many citizens. However, removing rose-tinted glasses confronts one with a grim fact - these numbers are too good to be true. A deeper, more serious outbreak has been masked.
The Indian government has undoubtedly taken several bold measures. As the spread of the virus exponentially increased globally, India swiftly took measures to update and restrict air travel, including a spontaneous ban on the arrival of its own citizens from worst-hit countries. The Prime Minister appealed for a day-long lockdown on the 22nd of March, which was soon followed by a 21- day lockdown of the entire country. Despite the low, official number of infected, this was a welcomed move considering the population density and the large number of poor it harbours, making the country extremely vulnerable to the disease. Recently, an extensive relief package for the poor was announced as well.
Issues concerning weak surveillance and low lab capacity are unveiling cracks on government healthcare systems around the globe. The situation unique to India, compared to most affected countries, is a lack of trust. Instead of looking up to the government, most Indians who can afford otherwise view the capacity of government healthcare with suspicion. A whopping 74 percent of healthcare services are offered by the private sector, which are arguably far better equipped, excluding the millions of poor in the country from this. Most private hospitals and clinics have furthermore refused to deal with suspected victims, placing the impetus on gravely under-funded government hospitals. For a 1,000 people, only 0.5 hospital beds are available. Some estimates suggest that there are between 70,000 to 100,000 ICU units, across both public and private sectors, for the entire country. This is nothing new, for since India’s independence in 1947 investment in the public healthcare system remains insufficient, and the far more expensive private sector has been propelled to take the lead. With only public hospitals authorised to test and treat victims, the government faces a monumental task of addressing the scarcity and quality of testing. To further add to the government’s woes over social distancing, in the country where the number of people aged over 60 crosses a hundred million, is not an impossible, but utopian ideal. In light of this, the lockdown of over a billion people isn’t nonsensical.
Image Source: © Rajanish Kakade/AP Photo
However, depending solely on the lockdown to control the epidemic is not the best idea; as shown by the public’s response as well as curfews imposed independently by state governments. Basic health guidelines and rules to remain inside were respected by few. Moreover, authorities have failed to locate several people who have fled isolation wards in densely populated cities. Apart from this, for the longest time India contradicted WHO’s advice to aggressively “test, test and test”. Until recently, India had an extremely restrictive criteria to qualify for a test - limiting it only to those who have come from infected countries, or have a contact history, and are showing severe symptoms. As a result, it was common for people with severe symptoms to be denied testing. Identifying the extent of “community transfer” - when cases cannot be traced to a single source - became nearly impossible. The evidence arising from restricted testing has led to the Indian Council of Medical Research (ICMR) insisting community transfers have not taken place, and lags in evolving testing strategies. This statement contradicts the cases of two infected individuals, who have not had any contact or travel history, leading many to believe that there is no doubt community transfer has already taken place. Nevertheless, facing widespread backlash, the government broadened the testing criteria on the 20th of March.
ICMR statement on testing strategies issued on March 20
This came as a welcome measure, but a closer analysis reveals the ground-level issues related to this change, which have not been rectified so far. Testing can be conducted only by the central government, rendering state network and resources, which could be used to test more people, effectively useless. While in theory private labs can carry out testing as well, a very small number of labs have received authorisation to do so. The few which have, have also fallen victim to unnecessary bureaucratic loopholes. To get tested by a private lab, people are required to obtain a written prescription by a physician advising them to do the same. With lockdowns in place, most private clinics have closed and those which remain open are directing people to government hospitals. This erodes the very purpose of at home testing by private labs; avoiding government hospitals and by extension a risk of catching the virus. This fear is not unsubstantiated. It is common for cities with millions of inhabitants to have a single centre for prescribing, testing and quarantining. Coupled with a repulsion towards public healthcare, the relatively wealthy are choosing to stay home instead of risking being quarantined in government hospitals, despite showing symptoms. This repulsion has materialised multiple times in the past few weeks. A woman from Agra resisted isolation, despite her husband demonstrating strong symptoms, due to the ward’s unsanitary conditions. A similar situation surfaced in Mangalore. In Manesar, the police had to intervene to calm the ruckus created by patients demanding better facilities. Such instances have adopted a pattern of regularity as of late.
Clearly, the incapacity of public healthcare stems not only from the sheer numbers of the infected, but also the amount of funding they receive. India spends only 1.28% of its GDP on public health, which is lower than some of the weakest, most poorest countries in the world. While this has always been the trend since the country’s independence, over the past few years funding has declined even further, as the government has increasingly started to outsource district hospitals as profit-generating venues. Instead of being a provider, it has become more of a purchaser of healthcare. Naturally, when such epidemics happen, the millions of poor could be worse affected since private hospitals are largely concentrated in towns and cities, and are far more expensive. Health workers have been requesting the central government to provide more testing kits, masks, sanitisers, and better quarantine facilities for a long time now. According to Taarini Johri, a medical officer in the city of Ahmedabad, the medical sector is simply not prepared to deal with the outbreak. Doctors in isolation wards are well-equipped, but the doctors most at risk - those carrying out initial screenings - do not have enough safety equipment.
Experts have been saying that to have a chance at controlling this outbreak, India must secure far more ventilators and immediately convert stadiums into isolation centres by early April, which has not been done so far. What the administration has done however, is quickly impose the British-era Epidemics Act of 1897, which gives the central government monumental powers to fine, detain and imprison people for breaking rules. The public has been divided on this, and many consider it a necessity to ensure discipline under the lockdown. However, pro-democracy activists have been actively voicing their concern of the government using COVID-19 as a scapegoat to crack down further dissent over citizenship laws and in politically sensitive areas, particularly Kashmir.
WHO has praised India’s effort to combat Coronavirus, calling it robust and comprehensive, especially when it comes to laboratory testing and containing the spread amongst other fronts. While things may seem under control for now, it is only a few months, or perhaps even weeks, before the illusion of a robust healthcare system collapses and exposes India to a disaster comparable to that of Italy or China. Similar hurdles exist in neighbouring countries: Pakistan spent less than 1 percent of their GDP on healthcare in 2018 alone, fears of a crisis in the Rohingya refugee camps in Bangladesh increase day by day, Afghanistan has witnessed the arrival of over a hundred thousand citizens from its neighbour country, Iran, amidst a brewing political crisis, and this daily trickle of thousands shows no signs of exhausting. Every single country in South Asia has been affected by the epidemic and considering their poor public healthcare systems, the most populous region of the world may slowly be descending towards its fall into the abyss global healthcare authorities have been fearing for a long time. As for India, these hurdles are not causing an issue for the first time. The country is still recovering from the Tuberculosis epidemic, in which the limitations of public health care had a central role to play.
Stronger measures need to be taken domestically, quick.
Sab changa nahi si.*
*"sab changa nahi si" means "everything is not okay" in Punjabi. As of late, the phrase has acquired a political meaning and has been adopted by CAA protestors as a slogan of retort against Modi and his government. On his tour of the US he was seen talking in multiple languages of India, spreading messages like "sab changa si" or everything is good to the crowd. The phrase has been seen graffitied and printed on many posters saying, "sab changa si?", and many tweets saying going abroad and saying "sab change si" does not mean everything is ok.
Disclaimer: the article above was written for the date it was published - we apologise in advance for any new developments and changes to the information and data published since.
Note that opinions expressed in the article above do not represent the overall stance of Asiatic Affairs, Students' Union UCL or University College London. If you have read something you would like to respond to, please get in touch with uclasiaticaffairs@gmail.com.