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Covid 19: Some Unanswered Questions in India

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Ending all speculations, the national lockdown 2.0 with all previous stringent provisions and more, expecting to bring the deadly microbe under a tight leash in India, commenced on April 15, 2020. This is expected to continue till May 03, 2020, keeping a window of opportunity open, for a case by case review, after April 20, which is today. This is now a known fact. But what is still not known to many are the answers to some critical question, such as, the following three, for example:

  • Will the standalone plan for strict compliance of prescribed social distancing norms for over 40 days and possibly much beyond, a comprehensive strategy to end the Covid 19 warfare in India?
  • As this game plan to save lives also involves livelihood of a large population, will it lead to hunger, involving many families?
  • When will the Covid19 nightmare end in India and how?

In this article, let me deal with these three questions, with illustrations.

Is social distancing’ alone a comprehensive strategy?

Experts believe that ‘social distancing’ is undoubtedly one of the key strategic components in the war against the invisible enemy Covid 19, especially to contain the spread of the virus. However, it’s not considered a standalone or a comprehensive strategy to win Covid19 warfare, for good, as it doesn’t help identify asymptomatic individuals – potential candidates for the continued spread of Coronavirus.

What scientific studies reveal?

Covid19 testing strategy in India is mainly focused on foreign returned and symptomatic individuals, alongside contact tracing. Interestingly, the study on the Covid19 outbreak in China, published by Nature Medicine on April 15, 2020, concluded – 44 per cent of those who tested positive, contracted the disease from an asymptomatic person. This happens, as the viral shedding, that can infect another individual, takes place, at least, 2-3 days before symptoms manifest.

Thus, along with containing the spread, it is equally important to trace the asymptomatic individuals at an early stage, then isolate and quarantine them at appropriate facilities, as necessary. Accordingly, many countries follow intensive testing guidelines from an early stage of disease spread. South Korea, for example, has been successful in this area, during the first wave. The same is being followed in the subsequent waves of outbreaks, till an effective antidote, like a vaccine is available to end the war. Hence, this is considered as a comprehensive strategy in the interim period. It was also well discussed and captured by the Indian media.

Lockdowns delay the peaks by about three months:

Experts indicated, ‘lockdowns merely delay the outbreak’s peak by about three months.’ They have also cautioned: ‘Asian countries risk new waves of Coronavirus infections when they lift lockdowns. The same could happen in the rest of the world.’ The world is now witnessing the second wave of outbreak in many countries.

Two seemingly contradictory messages surface:

Going by the ICMR data, according to media reports, India has conducted around 160,000 tests as on April 8, 2020 with the country’s tally of positive cases stands at 6,237 (at 6 pm on April 9). This indicates, 3.8 percent of the tests yielded positive results for Coronavirus. In comparison, the US with a much lesser population than India, has conducted 2.2 million tests. This is the highest among all countries, and a fifth of all those tests throwing up positive results.

An analysis by Worldometer  Get the data  Created with Datawrapper, of Covid-19 tests per capita of the top ten countries, by the number of tests conducted along with India, reveals something interesting. With a population of around 1.3 billion, India’s Covid-19 tests per 10,000 population has been merely 0.04. This is perhaps one of the lowest, especially considering India’s vast population with high density, poor living conditions of a large number of people, besides other risk factors.

Curiously, even the ICMR acknowledged on April 15 that it is critical to increase testing for Covid-19, as the number of cases in India is “rising exponentially.” However, on April 16, 2020, the Government again defended its testing strategy, as Coronavirus cases in India crossed the 13,000 mark on that day.

Didn’t India get a space to ‘buy time’ in 21-day lockdown period?

It was widely expected that the 21-day national lockdown was announced to buy precious time to prepare the country to roll out a comprehensive strategy. This was expected to include, identification of the asymptomatic individuals or persons with very mild symptoms, through intensive testing. Isolation and quarantine these individuals are of immense importance, thereafter, as the situation will demand.

But, why this hasn’t happened that way, as yet, by garnering requisite wherewithal, from – before, during the 21-day national lockdown period, to date, remains an unanswered question.

Will lockdown 2.0 lead to hunger in many poor families?

Dr. Amartya Sen, the Nobel Laureate and the Harvard University professor  explained the situation in an article, published on April 08, 2020. He wrote: “If a sudden lockdown prevents millions of laborers from earning an income, starvation in some scale cannot be far off.” Even the US, which is considered a quintessential free enterprise economy, has instituted income subsidies through massive federal spending for the unemployed and the poor, Professor Sen wrote.

The current situation was anticipated by global experts, well before it surfaced:

Even before it surfaced so strikingly, Professor Sen cautioned, the more affluent may be concerned only about not getting the disease, while others have to worry also about earning an income, which may be threatened by the disease or by an anti-disease policy, such as a lockdown. For those away from home, such as migrant workers, finding the means of getting back home, could also be a huge emotional concern that needs to be addressed with empathy. The emerging situation in this regard, also increases the risk of disease spread in various different ways.

Another renowned economist, Professor Ricardo Hausmann at Harvard University has, reportedly, said, further lockdowns could have dire consequences. Strict social-distancing measures mean that people must stay at home, so many cannot work, particularly those on a daily wage. Developing nations, such as India, do not have much financial flexibility to pay, for these migrants to stay at home for long, he added. Let me hasten to add, India has already announced a financial package for this purpose. But…

Would the announced stimulus package mitigate the economic and social needs?

1.7 trillion rupees (US$ 22.6 billion) stimulus package that India has announced for the poor, is termed modest by the economists, considering the population of the country. India has to weigh the numbers of deaths that will be caused by the loss of livelihoods against those caused by the disease. “For those who have to stay at home, they starve to death,” Professor Hausmann said.

Thus, the question of charting a clear pathway – striking a right balance between life and livelihood, in the face of Coronavirus pandemic in India, also remains an unanswered question.

When will Covid19 nightmare end and how?

It is virtually impossible to win the war against Coronavirus, decisively, only through social distancing as a standalone strategy. Even ‘The Lancet (Infectious Diseases)’ study of March 23, 2020, concluded: “In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to reduce mixing of susceptible and infectious people through early ascertainment of cases or reduction of contact.”

‘Early assessment of cases or reduction of contact’ will call for a comprehensive strategy-mix of social distancing – intensive testing of asymptomatic individuals – isolation and quarantining those who will test positive. The paper also underscored: “The effectiveness and societal impact of quarantine and social distancing will depend on the credibility of public health authorities, political leaders, and institutions. It is important that policy makers maintain the public’s trust through use of evidence-based interventions and fully transparent, fact-based communication.”

‘If’ and ‘but’ exist:

Interestingly, in the ‘The Lancet’ study, the authors estimated that 7·5 percent of infections are clinically asymptomatic. Whereas, the study published in Nature Medicine on April 15, 2020, concluded that 44 per cent of those who tested positive contracted the disease from an asymptomatic person.  Moreover, The Lancet paper acknowledged that higher asymptomatic proportions will influence the effectiveness of social-distancing interventions. But, the question remains, when will Covid19 nightmare end and how?

Primary ways to end the war:

This issue has been deliberated with scientific reasons in many articles. One such is titled, ‘Herd immunity is the only way the Coronavirus pandemic will end — and it would require a vaccine. Here’s how it works.’ This was published in the ‘Business Insider,’ on April 14, 2020. Like other papers, it also reiterated that individuals could gain immunity to the new Coronavirus, if they develop antibodies. This can happen, primarily in two ways:

  • Herd immunity or after people get infected and recover
  • Vaccination

According to Gavi, herd immunity is the indirect protection from a contagious infectious disease that happens when a population is immune either through vaccination or immunity developed through previous infection. Even people who aren’t vaccinated, or in whom the vaccine doesn’t trigger immunity, are protected because people around them who are immune can act as buffers between them and an infected person. Once herd immunity has been established for a while, and the ability of the disease to spread is hindered, the disease can eventually be eliminated, e.g., eradication of smallpox.

However, many scientific papers indicate that pursuing herd immunity through infection by allowing the virus to spread, rather than through a vaccine, would lead to hundreds of thousands more deaths. Moreover, some evidence indicates that a recovered person’s immunity may not be permanent. Hence, developing immunity through vaccination will always be a prudent choice.

Although, how fast an effective vaccine will be available for mass vaccination remains a key question,the good news is, a British scientist who is developing a Coronavirus vaccine, expects it to be ready by September, 2020. Meanwhile, I reckon, a disease specific antiviral drugs will be available to treat the infected persons and prevent death.

Conclusion:

Many of us in India, at various times, behave in a difficult to understand or even a mutually contradictory way. For example, at the call of crisis leadership in the country, in the midst of a Janata Curfew on March 22, 2020, people clapped or got engaged in beating pots and pans from their respective balconies, together at 5 pm. This happened with a huge participation, ‘as a mark of respect for the frontline health workers and medical professionals who were working day and night to contain the COVID-19 pandemic and selflessly treating patients who are affected by it.’ Later on, the same health care professionals and workers were assaulted, abused and even stigmatized, as they try hard to fight the virus. Intriguingly, many of the same people earlier participated in beating pots and pans to show respect for them.

Similarly, ‘citizens across the country lit Diya, Candles and flashed their mobile and torch lights on Sunday following our Prime Minister’s appeal, for a 9-minute blackout to dispel the “darkness” spread by Coronavirus.’ Ironically, in later days, many of these people – from the super rich to poor, acted in contrary to this purpose, for totally different reasons. This happened. But, understanding why it happened in India – right from the call – to its immaculate execution and the contradiction that followed on the ground, is a complex task for many. Perhaps, as complex to understand as, why containing the Coronavirus disease spread, through social distancing alone, is being considered as the only way to win the war against Covid19.

All countries in the world, as the experts say, will reach and pass the peak of the first wave of Coronavirus outbreak at some time. This will possibly not mean the end of the Covid19 war, before a vaccine is available. Thus, long term protection of people against Covid19, in the shortest possible time, is the name of the game. In the midst of these, life moves on – with some critical questions still remaining unanswered. Nonetheless, the resolve to fight and win this war, against an invisible enemy, be it only through social distancing, or with a more comprehensive and scientifically explainable strategy and ultimately a vaccine, continues to linger.

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Healthcare in India And Hierarchy of Needs

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“Russia and India climb World Bank’s Doing Business rankings”, was a headline in the Financial Times on October 31, 2017. India jumped 30 places – from 130 out of 190. Almost instantly, the domestic media flashed it all across the country, as the prime news item of the day. It brought great satisfaction to many, and very rightly so.

The news is also worth cheering as it ignites the hope of a large section of the society that sometime in the future more business will come into the country, more jobs will be created, and in that process India will emerge as a more healthy and wealthy nation, just as many other countries around the world.

This loud cheer, in tandem, also transcends into a hope for a well-oiled public healthcare system functioning efficiently in India, alongside greater wealth creation. This is because, while expecting a healthier nation, one can’t possibly keep the public healthcare system of the country out of it, altogether. Thus, I reckon, it won’t be quite out of place to have a quick look at India’s current ranking on other healthcare related indices too, such as ‘Healthcare Index’ and ‘Human Development Index’ and ‘Hunger Index’:

Healthcare index:

With that perspective, when go through the Global Burden of Disease Study 2016, published in The Lancet on September 16, 2017, it will be difficult to wish away the fact that India ranks 154 among 195 countries in ‘Healthcare Index’. Surprisingly, India ranks much behind Sri Lanka (72.8), Bangladesh (51.7), Bhutan (52.7) and Nepal (50.8) though, of course, above Pakistan (43.1) and Afghanistan (32.5). This is what it is, regardless of the fact that India’s Healthcare Access and Quality (HAQ) index has increased by 14.1 – from 30.7 in 1990 to 44.8 in 2015.

Human Development Index:

The ranking of India in the Human Development Index (HDI) is also not encouraging, either. Many would know, HDI is a composite index of life expectancy, education, and per capita income, which are used to rank countries in human development. As life expectancy also depends on the quality of healthcare, HDI has a significant bearing on this count, as well.

The ‘2016 Human Development Index Report (HDR)’ released by the United Nations Development Program (UNDP) in March 2017 shows that India has slipped by one rank from 130 to 131, among 188 countries. According to UNDP, ‘in the past decades, there has been significant gains in human development levels almost in every country, but millions of people have not benefited from this progress. This report highlights who have been left behind and why?’

I shall dwell on the ‘Global Hunger Index Report’ below at an appropriate context.

Why is this comparison between different indices…and now?

The above question is indeed a very valid one. Nonetheless, it is important to do so. I am quoting these rankings to flag the sharp contrast in our mindset to rejoice the good rankings, and lampooning the adverse ones, citing one reason or the other.

It is obvious from the general euphoria witnessed by many on such good news –  highlighted so well by the print, television and social media, with high decibel discussions by experts and politicians. There is nothing wrong in doing that, in any way. However, similar media discussions were not evident for taking effective corrective measures, soon, when ‘global burden of disease rankings’ or ‘Human Development Index Report (HDR)’ or the ‘Global Hunger Index’ rankings were published in September, March and October 2017, respectively.

Does it therefore mean that effectively addressing issues related to crumbling public healthcare infrastructure in the country attracts much lesser importance than ensuring ease of doing business in the country? Do both the politicians and the voters also consider so? Perhaps the answer is yes, as many would envisage in the largest democracy of the world.

What’s happening elsewhere?

In many developed and also the developing countries of the world, general public or voters’ expectations for having an affordable and robust public healthcare delivery system from the respective Governments seem to be high. Consequently, it also directs the focus of the politicians or lawmakers on the same. This scenario includes even the oldest democracy of the world – America. Such expectations on comprehensive healthcare covers the need for affordable drug prices too.

That voters are greatly concerned about healthcare in those countries is supported by many contemporary surveys. Just before the last year’s American Presidential election, Kaiser Health Tracking Poll: September 2016, substantiated this point. It said, besides considering personal characteristics of the candidates, the voters clearly articulated their priority on patient-friendly healthcare laws and affordable drug prices, as follows:

  • Over 66 percent of voters expressed that healthcare law is very important to their vote
  • 77 percent said prescription drug costs are unreasonable, expressing widespread support for a variety of actions in order to keep healthcare costs down

Accordingly, The New York Times on September 17, 2017 reported: “The public is angry about the skyrocketing cost of prescription drugs. Surveys have shown that high drug prices rank near the top of consumers’ health care concerns, and politicians in both parties - including President Trump — have vowed to do something about it.”

I haven’t come across such widespread demand from the voters getting captured in any survey, before either any State Assembly or the Parliament elections in India. Hence, public healthcare continues to languish in the country, as various Governments come and go.

What happens post-election in the oldest democracy?

We have enough examples that post-election, the oldest democracy of the world tries to satisfy the well-articulated healthcare needs of the voters, on priority. To illustrate the point, let me help recapitulate what happened in this regard, immediately after the last two Presidential elections in America.

After swearing in on January 20, 2009, then American President Barack Obama, as expected by the voters and promised by him accordingly, enacted the Affordable Care Act (ACA), popularly known as ‘Obamacare’, almost within a year’s time – on March 23, 2010. Similarly, within a few months of swearing in as the American President, Donald Trump administration is mulling to address the voters demand and his electoral promise to make the prescription drugs more affordable.

Public demand and outcry for affordable healthcare, including affordable drugs have led to several serious consequential developments in the United States. Let me illustrate this point with another example of recent lawsuits filed against alleged price fixing of generic drugs – many of these are new, but a few started in the last few years.

Vigil on drug prices continues:

As high drug prices are a burning issue even in America, a lot many steps are being taken there on that issue – just as many other developed and developing countries are taking.

It is rather well known that even after enactment of the Affordable Care Act (ACA) in 2010, the Department of Justice of the country expanded probing into the allegation of price fixing by many generic drug manufacturers operating in America. One such illustration is October 31, 2017 public notice of the State Attorney General (AG) of Connecticut. It states that the AG is leading a coalition of 46-states in new, expanded complaint in Federal Generic Drug Antitrust Lawsuit. It further mentioned: States allege broad, industry-wide understanding among numerous drug manufacturers to restrain competition and raise prices on 15 generic drugs, where some senior executives have been sued.

Interestingly, in this notice the AG said, “The generic drug market was conceived as a way to help bring down the cost of prescription medications. For years, those savings have not been realized, and instead the prices of many generic drugs have skyrocketed.” He alleged that the defendant companies’ collusion was so pervasive that it essentially eliminated competition from the market for the identified 15 drugs in its entirety. ‘Ongoing investigation continues to uncover additional evidence, and we anticipate bringing more claims involving additional companies and drugs at the appropriate time,” the Attorney General further added.

By the way, the expanded complaint of the states reportedly also includes several large Indian companies, such Dr. Reddy’s Laboratories, Emcure, Glenmark, Sun Pharma, and Zydus Pharma. Curiously, the expanded complaint also names two individual defendants, one among them is the promoter, the chief executive officer and managing director of a large Indian pharma manufacturer.

Examples such as this vindicate, even if a robust public healthcare system is put in place, the regulators would still keep a careful vigil on drug prices.

Getting back to the key link between some indices:

Let me now get back to where I started from – the link between ‘ease of doing business’ and ‘becoming a healthy and wealthy’ nation, over a period of time. This would subsequently bring us to the link between healthy nation and the existence of a robust and functioning affordable public healthcare system in the country.

From that angle, I raised a key question. Why the general public, and specifically the voters in India aren’t making effective delivery of an affordable public healthcare as one of the top priority areas while voting for or against a political dispensation? The question assumes greater relevance when one sees it happening in many other countries, as discussed above. Is it, therefore, worth pondering whether this issue can be explained, at least to a great extent, by applying the well-known ‘Maslow’s theory of hierarchy of needs.’

Maslow’s hierarchy of needs and hunger index:

As the literature says, ‘Maslow’s hierarchy of needs’ is a theory of motivation in psychology developed by Abraham Maslow in 1943. He believed people move through different stages of five needs that motivate our behavior. He called these needs physiological, safety, love and belonging (social), esteem, and self-actualization.

As we see, the first two basic needs are physiological and then safety. Maslow explains the ‘physiological needs’ as food, water, sleep, and basic biological functions. When these physiological needs are adequately met, our safety needs would usually dominate individual behavior.

Similarly, Maslow’s ‘safety needs’ in the modern era are generally expressed as the needs of job security, financial security, and health and well-being, among a few others. Thus, the need for healthcare falls under ‘safety needs’, following the most basic ‘physiological needs’.

As Food is one the first basic needs, India’s current ranking in the ‘Global Hunger Index (GHI)’, would suggest this primary need of having at least two square meals of nutritious food a day, has not been adequately met by a large population of Indians, not just yet.

India’s ranking in the Global Hunger Index (GHI):

The Global Hunger Index (GHI) has been defined as a multidimensional statistical tool used to describe the state of countries’ hunger situation. The GHI measures progress and failures in the global fight against hunger. It is now, reportedly, in its 12th year, ranking countries based on four key indicators – undernourishment, child mortality, child wasting and child stunting.

The International Food Policy Research Institute (IFPRI) report, titled ‘2017 global hunger index: The inequalities of hunger ’, indicates that India ranks below many of its neighboring countries, such as China (29th in rank), Nepal (72), Myanmar (77), Sri Lank (84) and Bangladesh (88), but ahead of Pakistan (106) and Afghanistan (107). Just for the sake of interest, North Korea ranks 93rd while Iraq is in 78th position.

The primary basic need of food and nutrition does not seem to have been fully met for a large Indian voter population, as yet. Many of them are still struggling and searching for appropriate means of earning a dignified livelihood. It includes support in agricultural production and the likes. Thus, many voters don’t feel yet, the second level of need that prompts a vocal demand for an affordable and robust public healthcare system in the country. The same situation continues, despite ‘out of pocket’ expenditure on healthcare being one of the highest in India, alongside the cost of drugs too.

Conclusion:

This brings us to the key question – When would the demand for having an affordable and robust public healthcare system in the country, assume priority for the general public in India, and the voters, in particular?

Sans Government’s sharp focus on public healthcare, including the cost of drugs, devices, and education, it will be challenging for a democracy of India’s size to make a decisive move, for a long term – from average to good – and then from good to great, even in the economic parameters.

Applying Maslow’s hierarchy of needs onto various health related global indices, it appears that the primary basic need of food and nutrition has not been fully met for a large Indian voter population, as yet. This possibly makes a large section of Indian voters to move into the second level of need, raising a widespread vocal demand for an affordable and robust public healthcare system in the country.

Rejoicing country’s advancement in the World Bank’s ranking on the ease of doing business by 30 points in a year has its own merits. However, in the same yardstick, doesn’t health care losing the priority focus of the nation also highlight the demerits of misplaced priority in a country’s governance process, and just because the voters are not quite demanding on this issue?

By: Tapan J. Ray 

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.