Coronavirus outbreak has revealed big gaps in healthcare, law enforcement in India; time for reforms is now
India has no national mechanism to track and manage data for all coronavirus positive persons across the country. Where they go, what happens to them, how they fare, what their trajectories are
The month-long coronavirus lockdown is likely to extract $225 billion (Rs 15,75,000 crore) from the Indian GDP. Perhaps a lot more, if pre- and post-lockdown decelerations are considered.
With the announcement of a three-week lockdown on 24 March, Prime Minister Narendra Modi has essentially lopped off a months’ production (nominally) from our GDP. It took India two years of back-breaking hard work to earn that growth. COVID-19 will wipe it out in months; to say nothing of the calamitous impact it will leave on India’s mostly unorganised and daily-wage dependent workforce.
Talking heads are divided in their opinions about the lockdown: some consider it a master-stroke, others a death knell. It is this author’s assertion that given the scale of the problem, and the sheer lack of resources at his command (both qualitative and quantitative), a total lockdown was probably the least bad choice. It was a choice between people losing their lives or their livelihood. Modi wisely chose the latter.
A much better solution, however, was possible. Were India to have robust and competent healthcare and public health system and competent law enforcement and justice system, this therapy could have looked less like a shotgun and more like a sniper rifle: more results and lesser collateral damage.
Let's start with healthcare. Though India has earned an enviable reputation for producing and employing some of the world’s finest clinical talent the country's healthcare system isn’t quite that good.
Consider the response to COVID-19. Though India was alerted of the challenge early, the country's health system just didn’t mobilise fast enough to do one thing that mattered: test.
India has simply not tested enough: as on 24 March 2020, India has tested fewer than 20,000 patients. At the same time, Australia, the United States, and even Russia have tested over 100,000. As a result, India has less than 500 confirmed COVID-19 cases; tiny Singapore (with barely 60 lakh lives) has tested more than 60,000 individuals, diagnosing over 600 cases.
Our response was typical: when the alarm bells rang, the government went it alone. With the standard governmental disdain for the private sector (which, ironically, provides over 80 percent of all care), testing was restricted to a few highly centralised government labs. Private players were allowed to test only later, despite having a larger infrastructure. This has cost India precious time, especially in establishing traces for a virus so virulent, a clinical presentation so stealthy that most carriers remain utterly asymptomatic!
As if that were not enough, India has no national mechanism to track and manage data for all positive persons across the country. Where they go, what happens to them, how they fare and what their trajectories are — the absence of these data creates crucial gaps in our understanding of the problem and in responding to them.
But with COVID-19, it promises to get more ominous, especially as India shall inevitably pass from stage 2 to stage 3 (broader presence with community to community transmission). Without a serious backbone of data, analysis and information flow, the contours of battle India is facing will remain unclear.
Who should one focus on? Which patients, in Indian circumstances, tend to fare well, or, badly? Which cities/towns/risk groups are our vectors of illness? What are Indian infection and transmission rates? Who is at risk of complications, or, of death? What can India learn? These are non-trivial questions which India struggles to answer.
If western models are to be believed (and India has no choice since the country has no data to make its own models), 50 percent of the nation may turn COVID-19 positive within six months. If this is true and applicable, India may face the grim reality of 60 crore people turning positive in the next six months. Or, 10 crores a month. Can a country with barely 20 lakh beds and possibly such a heavy disease load, afford to remain ignorant and unprepared?
This utter disregard for public health management is not a new phenomenon in India. For over 70 years, disease and health have remained grossly under-measured. All lab tests use western ranges for defining ‘normal’. India does not have reference ranges for even common tests, where ample evidence exists that Indian and western levels may not align! The absence of a data and a fact-driven culture of decision-making in healthcare was a key driver for India being one of the last countries to vanquish polio.
Déjà vu, COVID-19, where India seems to be flying blind at the moment, would have been fine had our aircraft been robust, but it is not.
Seventy years after existence, India continues to bumble on without an effective law-enforcement system. Policing and ordinary enforcement is nonexistent. And serious crime is hardly ever punished by a Kafkaesque legal system famous for endless proceedings and no outcomes. Neither police nor courts have any obligations or accountability to the public. In fact, their leaders are constitutionally protected from private citizens!
As a result, though the nation responded quickly and smelt trouble brewing with COVID-19, law-enforcement could not contain the trouble. In the earliest stages, patients began simply absconding; others jumped quarantine and physically ran away from hospitals – events unimaginable in most half-developed states. Some others took to spreading their infections with zeal, aided and abetted by local thugs, goons and community leaders, while cops merely watched.
Even after the lockdown was ordered, the police was unable to enforce the law: certain sections of society openly defied social distancing, including on religious grounds.
There have been several reports of miscreants assaulting healthcare workers handling COVID-19 cases as well as policemen. The phenomenon of law enforcement succumbing to the lawless is not uncommon: one reason India took so long to eliminate polio was that the country's law enforcement machinery was unable to ensure the physical safety of polio health workers within certain communities which claimed that the polio vaccine was a conspiracy to render their children infertile.
Our legal system has already blinked too. The apex court of the state threatened to go into a bunker if taxpayers didn’t "behave themselves" and didn’t stop crowding courtrooms.
It is perhaps a painful awareness of the deep failings of the law enforcement and the justice system that forced the prime minister's hand to order a total lockdown: he knew that the health system would struggle to accurately pinpoint the current state of the epidemic. He also probably knew that law enforcement cannot be counted on intelligently and dynamically deploying itself in a fast-changing environment.
Could the Indian police effectively cut off a city so that no one got out or in? Could it provide security to the healthcare workers doing rounds of targeted testing?
It was probably an awareness of this crisis and the extent of the rot that forced the prime minister to decisively choose life over livelihood and shut down the nation for a month. After all, if you cannot see your enemy, a shotgun is a better weapon than a sniper rifle. The prime minister took a safer bet and shut down the country.
However, even as one may be sympathetic towards the prime minister for his handling to date, it would be unfortunate if the burning platform presented by COVID-19 isn’t used to usher in sweeping reforms. The highest imperative for these sectors (indeed, for the government as a whole) is creating accountability.
Public corporations and their leaders must be made constitutionally accountable to the public – like the accountability expected from the CEOs of traded corporations. Civil servants, administrators, judges, as well as senior government leaders must be made quantifiably and measurably accountable: financial rewards for outperformance, termination for failure and incarceration for criminal misconduct must be made to apply.
Competence must be made the sole criterion of appointment to critical roles; India cannot afford anyone other than true experts with true skin in the game for these roles anymore.
Indians should be sympathetic towards the prime minister for focusing on ensuring the citizens live through the current crisis. But too much has been lost, and the country cannot and should not remain sympathetic if obvious gaps are not rapidly and decisively fixed. Now is the time to do it!
The author is a Mumbai-based physician and public health expert. Views expressed here are his own.
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