Crescent Kashmir

Buying time with Covid- 19 lockdown won’t work. India’s healthcare can’t scale up in 21 days

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Is the coronavirus lockdown justified? One school of thought holds that any societal cost is worth paying to save a life. This seems sensible at first, but we do not honor this dictum in normal times, either in India or globally. We tolerate people dying for lack of resources, often on a mass scale, in developing countries.

A pandemic raises questions about the processes of decision-making and prioritising in a democracy, such as India.

Rough estimates suggest that India has at best a similar number of ventilators as does the United States, but it has four times the population. A high proportion of these ventilators were very likely being used already before the pandemic struck. Even if there is a massive increase in hospital capacity, the case for slowing the spread of Covid-19 in India must be centered on preventing serious illnesses rather than on ensuring the availability of ventilators by spreading their use over time.

But suppressing the virus temporarily may not prevent it from becoming widespread later. The absence of a vaccine coupled with the limitations of poor health infrastructure in India will make doing so challenging. Hence, a lockdown may be successful than anticipated. Twenty one days is insufficient to ensure the exhaustion of the virus within households. Even with perfect compliance with the lockdown, it may well resume its spread, unless arrested by climatic or other factors (such as a vigorous mass testing and quarantine program, for which India presently has little capacity).

Need higher health spending

India’s average expenditure on health is far below that of other developing countries, showing it to be a relatively low governmental priority.

Health expenditure in India amounts to 3.7 per cent of the GDP, of which only around a quarter is government expenditure. This is substantially below the low- and middle- income country average of 5.4 per cent, of which nearly half comes from the government.

Moreover, those who die are often young.  This is one reason that India’s life expectancy of 68.5 years, despite rapid increases in recent years, is still 10 years less than in the US and 17 years less than in Spain. There were roughly 1 crore deaths in India in 2018 of which more than 12 per cent are attributable to air pollution. Nearly 7 per cent were caused by diarrheal diseases, 5 per cent by tuberculosis and more than 2 per cent by road injuries.

In each of these cases, there was considerable room for public policy efforts to reduce deaths further, through prevention as well as cure.

The risk of death, in particular from preventable diseases, is unevenly distributed by class, caste, region, and gender. But Covid-19, as a highly infectious disease, seems to threaten people, especially the elderly, of all classes. Some of the other causes of death are known to be disproportionately experienced by those who are poor or socially disadvantages.

Lockdowns alone won’t do the job

Against this background, it is not easy to make full sense of the coronavirus lockdown. It’s not that we should not try to avoid premature deaths due to the current pandemic. But if we care so much about avoiding deaths, we should have done, and should do, a great deal more to avoid those that arise from other sources too.

The cost of installing a single ventilator to save a life in India is likely to be much higher than the cost of saving lives in other ways. This is not a reason for not installing ventilators, but for doing things that can save and extend lives in more ways, even in normal times. Planned increases in public expenditure on health can take India in the right direction. An improved health infrastructure would also help in the monitoring of, and response to, public health emergencies such as the coronavirus.

The lockdown-induced economic and social disruption will have consequences for health and well-being because restrictions on freedom of movement make it hard to maintain health programmes, to run schools, to ensure that people are nourished, or that they avoid domestic violence. A state that claims to value equally all lives, or years lived by different people, must express that commitment in its actions. It should do so at the least by designing measures to safeguard the public health which do not worsen it.

Lockdown implementation lacks foresight

The discrepancy between the stated aim of promoting the public health and its pursuit is stark. It is underlined by the implementation of measures, announced with apparent haste and decisiveness, which reveal a lack of foresight about the most basic issues.

The decision-makers appear to have paid little or no attention to the difficulty that people would face in maintaining livelihoods and gaining access to food. These sudden restrictions have triggered mass movements and brought about crowding in neighbourhoods, increasing the potential for disease transmission. They also appear to have overlooked the prospect that the police forces charged with enforcement of the ban would implement it with untargeted brutality, thereby themselves becoming a danger to the public health.

Prime Minister Narendra Modi’s declaration that no one needs to worry about the supply of food and adequacy of income, was belied by the reality that turning a market economy into a centrally planned one would take more than 21 days, even if it were a good idea. Many other countries that implemented a lockdown announced clear exceptions for essential services and allowed them to function much as before.

The avoidance of natural calamity, however desirable, cannot be a warrant for the creation of an avoidable societal calamity. Although countries are dealing with similar disruptions of supply and demand, caused by state responses to the pandemic, India’s action is perhaps the most draconian in the world, and its consequences perhaps the most perverse. Today, the Modi government must deal with a challenging situation created in part by its own conceit of power. Its actions have caused the entire society to live in a purgatory, between anarchy and totalitarianism, combining the worst of both worlds, even if for seemingly sound reasons.

Are we asking the right questions?

The pandemic does not merely demand an answer, but it also raises a question: What exactly is public health? Taking sensible decisions in the presence of deep uncertainty requires more than decisiveness. It requires rational evaluation of the difficult choices to be made. And in a democracy, it also demands efforts at justification, before and after the actions are taken, informed by different societal perspectives.

Whatever the trajectory of the disease, one should ask that choices made in the name of the public are justifiable to them, including the most vulnerable.

A pandemic is a rare instance that seems to call for a strong executive, even in a democracy, but it also brings to the fore its potential weaknesses. An informed, reasoned and robust public discussion of what is right to do, at each phase of the crisis, must take place.

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