Public Health during Pandemics and Beyond

We are living in the times of a public health crisis given the outbreak of the coronavirus pandemic. Now known as COVID-19, it is an extremely infectious disease that has infected more than a million and has crossed 1,00,000 deaths world over. In India, it has infected 5,709 persons and around 199 of them have died as on 10 April 2020. Based on the available findings, it becomes clear that the disease is fatal amongst the elderly, and those above 60 years of age or having underlying ­conditions of cardiovascular diseases, hyper­tension, diabetes, chronic respiratory ailments and cancer. This unprecedented health crisis is exerting enormous pressure and having disastrous consequences for the health systems of different countries. The immediate ­impact on the lives of marginalised sections of the population—migrants, farmers, and labourers working in insecure and informal jobs—is more severe.

One thing that the pandemic has clearly made visible is the role of the government in controlling the transmission and in the financing as well as provisioning of testing and healthcare facilities for those affected. Given the fact that there are no vaccines or an effective drug available, the focus has been on controlling the spread of the disease by adopting various preventive measures.

Defining Health

As per the ancient belief of the theory of contagion, diseases often spread through contact and, hence, the solution recommended strongly was quarantine and fumigation to prevent the spread of disease. Given the costly nature of quarantine measures, some public health ­reformers advocated that the disease spread through miasma or bad air in the environment. This understanding made quarantine largely redundant (Porter 1999). Based on the miasmatic spread of disease, the interventions were largely seen in terms of improvement of environment to prevent the disease at the community level. Further, measures were also undertaken to improve sanitation, housing, water supply, proper disposal of wastes, along with incre­ased wages for workers. The actions taken were much broader and holi­stic in nature. Further, it was increasingly understood that socio-economic conditions of living were the major determinants of the disease.

However, with the ­invention of the microscope, the germ theory of disease was developed. Diseases were now linked to particular bacteria and viruses that act as agents causing physiological changes in the human body. The dominant approach of controlling an epidemic chan­ged to eliminate germs through drugs and vaccines, thereby shifting the focus on understanding the disease processes and outcomes in individuals. However, it also led to the neglect of ­the social context of health and disease as well as the broader interventions in relation to the environmental health of a population.

Turshen (1989) argues that the germ theory was seen as the creation of the times when capitalism was expanding in Europe, and the theory affirmed individualism by ­focusing on disease processes within each individual. Health was no longer seen as a collective res­ponsibility and largely became the individual’s res­ponsibility. Hence, one of the oldest ways of understanding “health” was to look at the absence of disease. Diseases were seen to cause a breakdown of the human body that functioned as a machine, and the role of medicine is to repair and make the body functional again. This approach looked at the individual devoid of their socio-economic context.

In contrast, understanding health from a political-economy perspective atte­mpts to focus on the multifactorial app­roach to health and disease in popu­lations. It understands health outcomes by locating them within the social-structural factors and power relations in the ­society (Birn et al 2017). Poverty, malnutrition and inequalities across gender, caste, class, religion and region determines who falls sick and who has access to treatment.

Inequality Pandemic

It is important to note that, given the ­social hierarchy and inequalities in ­India, it is the marginalised sections of the Indian society—the Dalits, tribals, women, migrants, and Muslims—that will bear the disproportionate burden of the epidemic, be it in terms of increased mortality, loss of livelihood and incomes, or in terms of accessing health services in case of being infected. The majority of them are landless and suffer acute deprivation both socially and economically. Though we are all toge­ther in this, as the World Health Organization ­Director General Tedros Ghebreyesus keeps emphasising in all his press meetings, the impact of the pandemic will be different based on where we are located in the social hierarchy. Hence, there is an urgent need for the government to provides universal and comprehensive public health services. It should not only mobilise the entire health system to deal with covid-19 but should also focus on broader determinants of health in terms of food, income, safe drinking water, sanitation facilities, etc.

Ensuring the functioning of other essential services, be it for maternal and child health services or immunisation and chronic health problems, is equally necessary and the government should provide these services as well. One reason why our general health services did not develop is mainly because we adopted a number of vertical disease control programmes, such as malaria control programme, family planning programme, smallpox eradication, polio elimination progra­mme, that negatively affected the way in which health services developed in India. These vertical disease-control programmes were seen as the magic bullet to solve the health problems of the country (Rao 2009).

However, while some of the diseases were eliminated through these programmes and people might not die of those diseases, they suffer from other health problems, and most rampant is the problem of widespread hunger and malnutrition in our country, despite the availabi­lity of surplus food stocks. The onslaught of neo-liberal reforms resulted in a substantial reduction in budgetary allocation to health and neglect of public health services. At the same time, there was rapid expansion in curative care provided by the private sector and corporate health industry with tremendous support and pat­ronage from the government. Hence, we had created two parallel health systems, whereby the rich access and utilise private medical care, and dysfunctional public health services were largely available for the poor. In times such as these, we are paying a much higher price of ­having the most commercialised health sector in the world. The pandemic has clearly highlighted the fragmented healthcare across the country and how it will indict adverse consequences on the marginalised sections of Indian society, as they will face enormous difficulties in accessing health services.

Rural Challenge

While much of the focus of the health systems and the media is on the urban areas and cities, there is limited information available about what is happening in rural areas. Given the reverse migration of labourers to the villages due to an unplanned and abrupt lockdown, there is a high likelihood that the coronavirus will also spread in rural areas. The conditions in which the workers were forced to travel have exposed them to high risks of getting infected with the coronavirus. Further, the lockdown and the loss of livelihood will increase poverty and vulnerabilities of a large section of population who do not have the privilege of stocking food. Hence, it is very important that massive relief measures, in terms of ensuring provisions of ­rations and food along with cash assistance, are implemented effectively and on time.

While in the hurry to control one disease, there will be massive inc­rease in hunger and starvation across the country. The health needs of the people in rural areas are much higher, given the extreme living conditions and widespread poverty and inequality, but people face a number of difficulties in accessing medical care in villages. In the past, the focus was only on developing the tertiary medical facilities at the cost of ­neglecting primary healthcare facilities such as the sub-centres and primary health centres. Hence, it is very important that the public health infrastructure and primary health services as well as front-line health care workers such as the Accredited Social Health Activists (ASHAs) and nurses are properly trained and provided with protective equipments, sanitisers and masks to handle this situation. Bihar and ­Uttar Pradesh, which witnessed the outbreak of Japanese encephalitis and deaths of children in the last few years, are clear examples of how ill-prepared the health systems are in these states. There are also examples of converting stadiums and railway coaches into isolation facilities. While this will be useful for the short term, we also need to ensure that the government will actually invest in building health infrastructure according to the population norms as this shortage is one of the major factors that will hamper the delivery of medical care.

The treatment for COVID-19 is of a prolonged period of almost two weeks and hospitalisation is necessary in severe cases where patients develop complications. It is important to note that the costs of hospitalisation in public hospitals are much less compared to the private hospitals. While the government had allowed certain private laboratories to do testing by regulating the price of testing at `4,500, it is expensive and inaccessible for the majority of the population whose monthly income will be much less than the cost of testing. Further, it is also costly in the case of two or three members of a middle-class family having to undergo tests.

One important reason for making government facilities the ­nodal zones for testing and treatment is to ensure that there is proper reporting of all cases, which is difficult if patients are treated in private facilities. During epidemics, it is also very important that the government provides correct information and communicates pro­perly with the population as this will enable them to understand the spread of the disease. Many people are of the opinion that public hospitals will not be able to manage the increased burden of the COVID-19 patients. It is true, given the huge shortage of beds, health personpower and ventilators, that the already fragile public health facilities will suffer. However, we also need to remember, that at present, it is the public hospitals that are managing and are also being geared up to provide treatment and isolation for Covid-19 patients.

Most of the health workers are working in extremely difficult situations without personal prote­ctive equipments, masks, sanitisers, etc, and are exposing themselves to incre­ased risk of infection. It is because of the lack of preparedness by the government that our health workers are paying the biggest price and are also dying. Given the rapidly increasing positive cases amongst nurses and doctors, ­entire hospitals have been sealed in some cases. It is important to note that hierarchy within the health system increases the vulnerability of the front-line health workers and nurses, along with the cleaners and sanitation workers, who are exposed much more to the risk of ­infection (Nagral 2020).

Private Health Sector

There are reports that some states, such as Chhattisgarh, Rajasthan, Andhra Pradesh and Madhya Pradesh, are roping in the private sector to provide free treatment to COVID-19 patients (Baru 2020). However, it is still not clear what steps are being taken at the national level to make the private sector work for public health. Two big private hospitals in Mumbai have had to be sealed as most of the doctors and nurses were tested positive for COVID-19 after treating patients who initially did not show any symptoms. The treatment costs of COVID-19 might be within the reach of the rich and those with insurance coverage, but it will be very difficult for a substantial section among lower middle-class families and the poor not covered under Ayushman Bharat to foot expenses. While the central govern­ment has announced that the beneficiaries under Ayushman Bharat can avail free testing and treatment for COVID-19 at private laboratories and empanelled hospitals (PTI 2020), there is not much clarity on how this will­ actually be implemented. During public health emer­gencies, the need to forge solid institutional partnerships between the public and private sectors in order to save lives and ­improve the health of the population, is of utmost necessity.

It is also important to note that illness increases vulnerability and uncertainty about life and survival, and people need to access medical care. However, in this situation, they may not be in a position to make a rational decision about seeking medical care. Further, in the case of medical care, there is an asymmetry of information between the patient and the doctor. Once you enter the healthcare system, the decisions are largely made by the physicians regarding diagnostics tests, surgery, medicines, etc. Given the uncertainty and asymmetry of information between the patients and doctors, Kenneth Arrow had argued for state intervention in medical care (Arrow 1963 cited in Birn et al 2017).

The way in which the disease is rapidly spreading across different states of ­India shows that the numbers are going to increase exponentially. However, as we have narrowly defined the criteria to test for COVID-19, we tend to exclude a large majority of people who might be asymptomatic but spreading infection. We are, at present, only testing people having a history of foreign travel, or contacts of positive COVID-19 patients, ­patients in hospitals showing symptoms and health workers with symptoms who are treating COVID-19 patients. It is ­because of the way in which we have ­restricted our testing that the numbers of cases is extremely low compared to our total population. This low testing and low numbers are then given as justification to argue that India is at a relative advantage because of heat or temperature, or inherently having some resistance to COVID-19 (JSA and AIPSN 2020).

However, this is a completely wrong way of looking at the pandemic, given the fact there is a direct relationship with more testing and more cases. We are in denial mode in many cases. Accepting that we have problems would mean­ undertaking actions, which, in our country, is always delayed to a large extent because, till now, the health problems that we kept denying have hardly affected or infected the rich. This is particularly with reference to widespread hunger and starvation deaths as well as high levels of malnutrition amongst children in India. The Government of India, like a student who prepares at the last minute for an examination, woke up quite slowly to the challenge put forward by an epidemic. It did not study till the last moment, and when the examination was hanging over its head, it haphazardly started allocating funds, restricting testing and ordering masks and personal protective equipment. If the impact of a pandemic has to be reduced, we need to prepare and focus on preventive and ­curative measures well in advance and not wait for its onset or occurrence. It is also important that the government should not waste time in victim blaming, which is very appealing and popular to conservative governments and is the dominant way of abdicating the responsibility towards healthcare (Turhsen 1989).

Humane Approach

The pandemic of COVID-19 has raised certain important questions that are ­extremely crucial if we look at the inter-relationships between individuals and its impact on the health of the “populations.” It has also created unique challenges in its prevention, control and treatment. Given the highly infectious nature of the disease, individuals in themselves are not protected even if they adopt all preventive measures to keep the infection away from themselves. Constantly washing hands with soap every 20 minutes for 20 seconds, wearing masks and staying at home are privileges in themselves, which are not available for a large section of India’s population who have no access to piped water supply or money to buy masks or the comfort to work from home.

Unless and until we look at each other as human beings who are equally vulnerable and exposed to the same ­virus, we will not be able to protect ourselves in isolation. The focus should be in ensuring that the state intervenes ­actively to save every life by creating enabling structures and facilitating public health education in order to enable people to adopt practices that will help them prevent the disease. Given the extreme inequality and discrimination prevalent in our society, the whole question of adopting social distancing in itself is problematic because, historically, we have practised social distancing through the cruel practice of untouchability and discrimination. In many cases, the disease has just heightened this practice to a large extent and has made it worse as people are increasingly becoming socially indifferent. What is the need of the hour is best summarised in the slogan shown by Kerala that emphasises physical distancing with social solidarity and ­equity (Prashad and Dennis 2020).

Finally, it is high time to realise, as T Sundararaman (2017) argues, that healthcare must be produced by organisations not as a commodity to be sold for profits but for consumption, which is in the spirit of solidarity. People who are using health services are not only the consumers of a product but they are participating in the creation and production of good health for all. Their participation at both individual and collective levels is important. Hence, it is important to note that the expenditure incurred on public health services is an investment that the government makes in saving lives of its populations and creating good health and not a waste of resources, as the advocates of neo-liberal policies aggressively wanted everyone to believe.

State intervention is the need of the hour to ensure universal and comprehensive access to healthcare services. The government needs to ensure equity in access and utilisation of public health services and at the same time, should provide food and income to people who have lost livelihoods and migrants stranded in different cities. In the absence of these measures, poverty, inequality and hunger will kill more people than the coronavirus. We need to create new capa­cities and evolve institutional mechanisms to coordinate efforts by increasing financial allocations so that India’s strengthened healthcare system can serve its people well beyond the pandemic of the coronavirus.

References

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Birn, A, Y Pillay and T Holtz (2017) Textbook of Global Health, Newyork: Oxford Unvisersity Press.

JSA and AIPSN (2020): Weekly Update on COVID-19 Situation, Jan Swastha Abhiyan and All India Peoples Science Network, 2 April, viewed on 3 April 2020, https://aipsn.net/2020/04/04/2nd-april-weekly-update-on-covid19-situation/.

Nagral, S (2020): “Covid Round 1: The Bottom of the Healthcare Pyramid,” Mumbai Mirror, 10 April, viewed on 10 April 2020, https://mumbaimirror.indiatimes.com/coronavirus/news/covid-round-1-the-bottom-of-the-healthcare-pyramid/articleshow/75075123.cms.

Porter, D (1999): Health, Civilisation and the State: A History of Public Health from Ancient to Modern Times, London and New York:Routledge.

Prashad, V and S Dennis (2020): “An Often Overlooked Region of India is a Beacon to the World for taking on the Coronavirus,” viewed on 9 April 2020, https://www.counterpunch.org/2020/03/
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PTI (2020): “Coronavirus: Ayushman Bharat Beneficiaries to Get Free Tests, Treatment,” Business Today, 5 April, viewed on 8 April 2020, https://www.businesstoday.in/latest/trends/coronavirus-ayushman-bharat-beneficiaries-to-get-free-tests-treatment/story/400183.html.

Rao, M (2009): “‘Health for All’ and Neoliberal Globalisation: An Indian Rope Trick,” Morbid Symptoms: Health ­Under Capitalism, L Panitch and C Leys (eds), Socialist Register: 2010, New Delhi: Leftword Books, pp 262–78.

Sundararaman, T (2017): “Introduction-The Why and How of These Case-studies,” The Archetypes of Inclusive Healthcare: Where Healthcare for the Poor is Not Poor Healthcare: Case Studies of Organisations of Healthcare Services from across India, School of Health Systems Studies, TISS; NHSRC and World Health Organisation, India Country Office, New Delhi, pp 1–8.

Turshen, M (1989): The Politics of Public Health, New Jersey: Rutgers University Press.