Revisiting Pre-Covid 19 and Analyzing Post-Covid 19 Public Health Care Failure
The apocalyptic impact of COVID-19 upon the working class and poor sections of the society has pushed them deeper into an excruciating abyss of poverty, hunger and unemployment. The chaotic and miserable atmosphere replete with scenes of reverse migration, panic over food within just a few days of lockdown and public healthcare crisis are all significant indicators of a state failing massively in fulfilling its duties towards its citizenry.
Truly, the pandemic has lain bare the dilapidated structure of governance, we all inhabit in. In the face of pandemonic state of global economy, the idea of an all-powerful nation state commanding people to surrender their civil liberties has grown stronger. Increased state control in the form of suppression of dissent, social distancing, social isolation and lockdowns have become the new normal. Imposition of sanctions depriving fundamental right to life and liberty of the toiling and downtrodden masses must be seen as a consequence of State failure in developing a robust and competent public health system and mitigation strategies. India’s frail, under-resourced and ill-equipped public health infrastructure with abysmal quality of care is the lens through which the health crisis ought to be looked through. Under the ruling fascist dispensation supporting ‘minimum government, maximum governance’, public healthcare has long been struggling to receive attention. Now it is time that we understand that treatment cannot be sacrificed to governments revering market economy unmindful of human cost. The analysis by the Global Health Security Index stating that fewer than 5% of countries had a national requirement to test their emergency operation centres for responding to a health emergency on an annual basis speaks a lot of the unpreparedness of the world capitalist order, for infectious disease outbreaks and other health emergencies.
High population density, high incidence of respiratory illness patients and presence of co-morbidities coupled with tattered and overburdened public healthcare collectively make India, a ripe ground for proliferation of the pandemic. The Supreme Court in a host of judgements such as Mohinder Singh Chawla, Paschim Banga Khet Mazdoor Samity and Ram Lubhaya Bagga held that right to health was integral to the right to live with human dignity enshrined under Article 21 and the government had a constitutional obligation to provide and maintain health services. That any failure on the part of a government healthcare facility in providing timely medical treatment to a patient would be tantamount to violation of the patient’s right to life. Well, the judgements date back to 1980s and 1990s and the contours of the apex court have changed drastically since then, unabashedly inclined in the favour of the Executive organ of the bourgeois State, the most recent case being where it blatantly stated that it wasn’t an expert body to deal with lodging and feeding of migrant workers.
In such dark times which see masses perishing due to pandemic, starvation and poverty, it would be worthwhile to take a step backward and comprehensively understand the facets to Right to Health, a substantive yet nominal right as it continues to remain confined to the statute books. United Nations Office of the High Commissioner for Human Rights (OHCHR)’s Fact Sheet No. 31 titled ‘Right to Health’ describes the right as an inclusive right having determinants such as safe drinking water and adequate sanitation, safe food, adequate nutrition and housing, healthy working and environmental conditions, health related education and information and gender equality. India ranked 93 with an abysmal performance in ensuring accessibility and equity of water and sanitation as per Water, Sanitation and Hygiene Performance Index 2015. The country ranked 102 (out of 117 countries) in Global Hunger Index 2019 with peaking rates in child stunting, wasting and malnourishment. In the first quarter of 2018-19, 6.4 crore urban and rural households across India did not have adequate housing forget about adequate privacy, space, security, lighting and ventilation, location along with basic facilities at a reasonable cost which is a distant dream (‘Global Strategy for Shelter to the Year 2000’, UNGA, Dec 1988). The country figured among the bottom five countries on the Environmental Performance Index on account of poor environmental health policy and rising deaths due to air pollution. The country ranked 112 in the Gender Gap Index due to increasing disparity in women health and participation in economy. In addition to such a poor performance on crucial parameters, the broken healthcare system hampers the opportunity for a vast majority to have access to equal and timely basic health services and essential medicines.
Pre COVID-19 Analysis: Decoding The Public Healthcare Sector
Epidemics are products of the disease as well as the failure and apathy of the State machinery. The cost predisposition of the decaying capitalist order today to indulge in ruthless profit-making, have contempt for rational and scientific thought process and assign little value to public healthcare and education despite being cognizant of the alarming state of affairs is being borne by the masses today. With less than 1.3% allocation of GDP on healthcare, the Indian state has its priorities set.
The indices and statistics stated henceforth aim at informing the depth of the rot in the system.
In the Global Burden of Disease Study published in Lancet in 2018, India ranked scored a 41.2 against the global mean value of more than 60 in the Access to Quality Care parameter. This was on account of high “out-of-pocket (OOP) health expenditure” being paid by the individuals as a percentage of total public healthcare expenditure of a country. A study titled Health Care and Equity in India alerted India way back in 2011 that close to 4 crore people were falling into poverty every year because of high OOP spending. The National Health Profile 2019 states India’s public investment in healthcare i.e. less than 1.3% to be “lower than even the low-income countries”. The Govt. may boost of injecting 1.7 lakh crores as COVID relief package which stands abysmally low in front of 18% of its GDP investment by Germany, 14% in U.K., 8% in USA and 4% in China.
IndiaSpend’s Report states that only 7% of sub-centres, 12% of primary health centres and 13% community health centres are functioning as per Indian Public Health Standards. Even after implementation of Swachh Bharat Mission, a whopping 42% sub centres, 18% PHCs and 12% CHCs lack sanitation facility. As per latest data as of March 2018, only 2903 blood banks exist, which translates into less than three blood banks for every 10 lakh population. Department of Health Research points out that only 106 Viral Research and Diagnostic Laboratories (VRDL) are functional, far too few for a 135-crore population. Moreover, the ICMR has been consistently given scarce funds towards allocation of VRDLs which play a pivotal role in enhancing capacity for early identification and diagnosis of all viral infections.
With a single state-run hospital for every 55,591 people, a hospital bed for every 1844 people, 2.3 ICU beds per 1,00,000 people, less than one allopathic doctor per thousand people (recommended by WHO), India’s overstretched health infrastructure can be blamed for misery of the majority. Almost 2667 sanctioned positions continue to lie vacant at district hospitals. Despite the shortage in health personnel, Accredited Social Health Activists (ASHAs) continue to work as casual workers devoid of social security net. The private healthcare sector has preyed in on a dominant share of doctors and beds and that has given it the liberty to set its rules and prices which squeeze out the meagre earnings of poor households. In times of COVID-19, when sanitizers, disinfectants and masks have become a necessity, 21% of the population living below the poverty line have no access to them. Data (2017) projects that 50.7% of the rural population doesn’t have basic handwashing facilities including soap and water.
If the prevalence of diseases is looked at, the population can be said to be a victim to diseases such as tuberculosis, HIV, respiratory illnesses including pneumonia, diabetes and hypertension. India, being the epicentre of tuberculosis registers 1400 lives every day. Despite it being a largely curable disease, the system continuously fails in diagnosing and treatment. One third of the country’s adults suffer from hypertension while one tenth are diabetic. As per Lancet’s Study published in 2019, close to 20 crore people in India had mental disorders which included around 4.6 crore with depressive disorders and another 4.5 crore with anxiety disorders. The above figures are telling of the plight of status quo but of course do not feature anywhere in Govt’s agenda.
Shrinking of Public Healthcare
The flagship Pradhan Mantri Jan Arogya Abhiyan (PM-JAY) or the Ayushman Bharat Scheme is nothing short of a gimmick. No study or assessment has established its efficacy. Subsequent to PM-JAY, the Health Ministry issued broad guidelines for private investment in setting up of hospitals in Tier-2 and Tier-3 cities. It unambiguously asked the states to ensure the following three things to the private investors in healthcare i.e. firstly earmark and provide land within specific times, secondly provide 40% viability gap funding (an advance payment from exchequer to help build private facilities) and lastly provide gap funding up to 50% of tax on various costs, including capital cost. A year later in January 2020, NITI Aayog came up with its public-private partnership plan premised on handing over of the government run district hospitals to private players. Budget 2020 also chipped in by incentivising state to promote private healthcare.
Thus, the State suggested public health ‘solutions’, as it may call, engender investment in exorbitant private health providers and increasing cover on insurance schemes. Offering of large discounts on land for private hospitals as well as rebates and subsidies is the recipe to repair the broken health system, is what the State has been serving to masses ever since. About 56% of the urban population while 49% of the rural population is forced to opt for private sector healthcare. Households not generally using the public health facilities are highest in Uttar Pradesh (80%) and Bihar (78%). The two states top the tally in generation of workers in the unorganized sector. Needless to say, by virtue of having a profit-above-all approach, the private sector’s aim is limited to treating the patients who can afford its services and not invest in preventive measures. In times like these, a strong public healthcare would have effectively and efficiently tracked, curbed and prevented the spread of pandemic. COVID-19 has only helped in exposing the generational neglect towards affordable public health system. With the above stated detailed picture in mind, the analysis of the State’s measures to combat COVID 19 turns out to be nothing short of a lip service to the ferocious elephant in the room.
Post COVID-19 Analysis Of The State (In)Action And Offensive
History’s largest lockdown came in with a four-hour notice on the night of March 24 and what followed was a sudden exodus of lakhs of internal migrant laborers desperately heading to their villages in the hope of food, shelter and warmth of family members. The unplanned and impromptu decision speaks volumes about the Government’s ignorant and reckless way in dealing with the pandemic. WHO also reaffirmed the point that lockdowns alone won’t eliminate coronavirus unless necessary measures like liberal testing, treating, isolating and quarantining were in place. In all probability, the short-term benefits accrued by lockdown would soon be overridden if the emergency measures and broken public health infrastructure weren’t ramped up simultaneously at a good pace.
The first case was reported on January 30. On March 13, exactly two days after WHO declared the outbreak as a pandemic, a senior health ministry official was found reassuring that it “wasn’t” a health emergency. It was only on March 19 that the Govt. passed an order putting a halt on export of lifesaving equipment. The availability of only 40000 ventilators, one isolation bed per 84000 people, one quarantine bed per 36,000, one doctor per 11600 patients and one hospital bed per 1826 patients made the health scenario murkier for India. The Government’s way of operation reeked of opaqueness, laxity and carelessness. Despite having performed woefully less number of tests, the Health Ministry maintained its stance for long, that India only had cases of contraction of disease from beyond international borders. Among the countries with more than 500 recorded cases of Covid-19 of which data related to testing is available, India ranks 4th from below in number of tests per 10 lakh people which stands at 177 tests per 10 lakh population, putting it even behind countries like Pakistan, Kenya, Ghana and Iraq (Data as of 16 April 2020). Even while other countries were resorting to aggressive tracing, testing, isolation of anyone who might have been exposed, the Govt. was still making irresponsible remarks like India did not have community transmission (Stage 3). However, recently a research study in the Indian Journal of Medical Research authored by ICMR scientists has gone on to suggest that there was evidence of community transmission in 40% of COVID 19 patients with severe respiratory illness lacking travel history from as early as March 22! ICMR had initially egregiously justified its act of not doing random testing by saying no positive case was detected in the 500 randomly collected samples of respiratory disease patients in ICUs. Early and mass testing helps in detection of virus in asymptomatic patients who could then be isolated for containing the spread and keeping mortality rates under control.
The state of Bihar is a good case study to have an insight into the fissures plaguing the healthcare system. Patna Medical College and Hospital (PMCH), one of the ‘coveted’ hospitals doesn’t have beds for potential COVID 19 patients nor a designated ward for symptomatic patients. With 1.1 beds per 10,000 people, Bihar lies way lower than the WHO mandate. The state comprises of a single research centre for testing samples which are then sent to Pune for a second confirmation. With low testing, the doctors face the risk of being infected by non-diagnosed patients. Moreover, the State as well as the Central Govts. have failed massively in providing basic safety kits and N95 masks to frontline doctors. They have instead been shoved with HIV protection kits which do not fully cover their body.
The HIV and TB patients, children in need of immunisation and quarantined migrant workers continue to bear the draconian impact of lockdown. Scroll’s Report highlights how scaling down of daily operations by hospital OPDs, transport restrictions, disruption of supply chain of essential goods and services for TB, HIV/AIDS, cancer, diabetes and other life-threatening diseases, stoppage of ante natal care outreach programmes were jeopardising the lives of many in the process of addressing on one public health crisis. Without timely medication being afforded to HIV and TB patients, India was to see a spurt in multi drug resistant TB in which it was already topping the charts. The quarantined migrant population describes their experience as traumatic. Overcrowding, unhygienic conditions, no social distancing, scarcity of food and lack of medication within such centres had exacerbated their condition.
Differential Impact Of Lockdown Upon The Physically Vulnerable Migrant Workers
It is the toiling migrant workers, landless agricultural laborers and unorganized sector workers who are most in need of an affordable, accessible and functional public healthcare to overcome the vicious cycle of unemployment, poverty, hunger and death by starvation. The Prime Minister may have made the pompous announcement of ₹15,000 crore stimulus to improve healthcare, most of which would go into meeting the emergency requirements, import of safety and testing kits, how much of it goes into rebuilding of healthcare infrastructure remains a mystery.
The newspapers are replete with reports of migrants who are starving, with little or no money in their possession. The ration shops are mostly closed and when they happen to be open, they do not provide ample quantity earmarked by the Govt. suggesting corruption. For the ones not having ration cards, they have to face the technological hindrance of filing an online form and obtaining bar code. If the worker is fortunate enough to receive grains, even then the problem doesn’t get solved due to shut down flour millers and chakki shops due to fear of police action. In a recent incident, the dehumanising experience for the workers notched up when a bunch of them were sprayed by the harmful sodium hypochlorite solution, a disinfectant used to clean hard surfaces as a ‘preventive’ measure.
The presence of co-morbidity alongside malnutrition and hunger undoubtedly makes them highly vulnerable migrant population to the pandemic. Various studies have highlighted as to how malnutrition is the primary cause of immunodeficiency worldwide and often suffer from undernutrition. They were anyways barely able to access govt. food security schemes due to non-availability of local identity cards and the lockdown has snatched the little that was going into their mouths, rendering them a penalty of death.
Healthcare Workers On The Frontline Forced To Surrender Their Right To Life
Healthcare workers comprising of doctors, nurses, ASHA workers and Block Functionaries and sanitation workers are going through what could be called a multi-layered fear and agony. Multiple risk factors like state apathy in the form of lack of personal protective equipment (PPE) and masks to insulate themselves, possibility of them transmitting virus to family members, facing societal wrath in the form of ostracization, harassment both physical and verbal, facing administrative flak in the form of suspension or deduction of salaries for voicing concern about the lack of basic facilities and the policy of coercing pregnant, lactating or immune compromised health workers to turn up for service have started to render the workers vulnerable to psychological distress, depression and anxiety.
The Kerala based Nurses’ Association has approached the Supreme Court citing the life-threatening situation the workers were deployed in. The petition rightly pointed towards hazards such as “pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma and physical and verbal violence” and called for an urgent formulation of a National Management Protocol for COVID-19. The middle class’s acceptance and compliance of the Government’s gimmick of plate-banging and lighting lamps has provided it with a comfortable escape from addressing the revolting conditions.
In a BBC Report, the doctors narrated their ordeal as to how they were ‘chased away from homes’, directed at with abusive and vulgar language by patients, pelted at with stones as well as ostracization of them and their families by neighbours due to exposure with COVID 19 infected. A senior Nursing Officer in the capital deployed at a COVID 19 ward said as to how only the healthcare staff coming in direct contact with pandemic affected patients were given PPEs while the rest had been asked to carry on their tasks with surgical masks and OT gowns. A senior doctor in Bihar got suspended in return for demanding low cost Rapid Testing Kits on account of a sharp spike in cases in Bihar. It is important to note that the doctor pointed out towards a massive corruption in PCR kit as commission was being derived through its sale. On the contrary, a low-cost rapid testing kit didn’t allow any margin for money making. AIIMS, country’s coveted medical institution issued a notice to its doctors and staff asking them to disinfect their N95 masks and reuse it at least four times. Ironically, the notice was in direct contradiction with AIIMS’s Guidelines which discouraged disinfecting masks as it leads to substantial compromise in the quality. The ASHA workers and the Block Functionaries were also found to be functioning under poor working conditions in Maharashtra. For covering up close to 50 houses for undertaking a survey, they were paid a miniscule Rs. 30 per day. Having been given only two sets of gloves and masks with no sanitizer or hand wash, they were compelled to go for field work, a task ridden with danger due to high possibility of catching infection accelerated further by non-availability of PPEs. Several doctors have already started using makeshift protective gear like ‘raincoats and helmets’. When the doctors sought accountability from the administration and took to social media for publicizing the inhumane working conditions, they were asked to pull down the social media posts and were apprehended for further questioning. Some of them were even issued a transfer order. When the junior doctors at JNMCH, expressed their inability to work due to absence of protective gear, the district administration instead shot off a letter to JNMCH’s Superintendent asking him to furnish all details of the protesting doctors to law enforcement cell. The medical personnel were told that non-performance of their duties would invite slapping of sections under IPC and Epidemic Diseases Control Act. In some places, the hospital administration has silenced doctors by providing HIV kits. The shoddy state of affairs for the firefighter frontline healthcare staff only goes on to affirm the worthlessness assigned to their lives by the State. In a broken system for the patients, the doctors were being commanded to trade off their lives for others.
The Way Forward
Keeping the abovementioned scenario in mind, the utter disregard for human life and the sheer inability of the capitalist order, rapidly imposing neoliberal policies since the last few decades, in containing and effectively tackling such epidemic stands exposed. While public health analyst, economists and experts have recommended a slew of measures to the Indian Government to contain the pandemic’s spread, the Indian State has completely lacked in implementing the same. The policy of aggressive testing, as recommended by the WHO Director General on 16 March 2020 has not been adopted as a policy by the Indian Government yet and the number of tests being done by it with respect to the population is abysmally low.
It is evident how ‘developed’ countries of the Global North promoting neo-liberal policies of liberalization, privatization and globalization and boasting of having the world’s finest healthcare systems have bit the dust in handling the Covid-19 pandemic. While Spain has nationalized its entire healthcare system, the USA has been compelled to invoke the almost forgotten Defence Production Act which directs private companies to produce needed goods, conservative PM of UK Boris Johnson who stands as a staunch opposer of ‘big government’, couldn’t help but shower praises upon and thank the public-funded National Health Service (NHS) for saving his life after his successful recovery from Covid through the NHS itself. It is also evident that countries, even though not adopting a socialist mode of production, but have adopted socialist and welfare policies, like Cuba and China have not only been successful in containing the spread of the virus but have sent medical aid and assistance to even other nations, while the European Union saw deepening of divisions among its members.
Hence, the way forward must be to part away with the neoliberal and pro-capital policies and adopt a policy of free, quality and universal healthcare including free and aggressive testing for Covid-19, upgradation of hospital facilities by procurement of beds and equipment, allocation of funds for primary health and wellness centres, along with human resource management by making PPEs available for the frontline workers, deployment of doctors at service clusters where outbreaks might take place, training of community health care workers with protocols and effective centre-state coordination mechanisms for efficient sharing of expertise, strategy and resources, constitution of a task force to interpret and analyse the latest information and share findings with the public to counter the widespread disinformation among numerous other policy measures. Naturally, such a fundamental measure would require enormous amount of fund and capital stock, which is available in more than sufficient quantity with the big capitalist class in forms of hospitals, labs, human resource, holdings etc. A fully functional and comprehensive system of free and universal healthcare can be created almost instantly by expropriation of the private property as mentioned above of the big propertied or capitalist class. While this may sound like an extreme measure, but considering the crisis of Covid-19 which has gripped the entire world and has the potential of wiping out a chunk of the world population due to the sheer inability of the world capitalist order in taking us out of this crisis, extreme measures in order to save lives have become the need of the hour to save humanity from the virus of Corona as well as Capitalism.
Originally published in Scientific Socialism: PRC’s Theoretical & Political Weekly Commentary on Current Issues (Issue 1 / 15-21 April ’20)