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State priorities: Pandemic over endemic?

www.medium.com | April 18, 2020
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India has mustered all its energy to crack down on Corona. It’s lockdown of the country for 21 days and its 19-day extension is unprecedented in its entire history. Nothing of this scale has ever been taken up, be it Spanish flu pandemic, World War-II, Partition, or the communal riots post-independence. India’s response has been considered as the strictest lockdown in the world, according to the Oxford COVID-19 Government Response Tracker (see article in Economist). It has shut down the economic engine of the nation, ceased all air, train and bus travel, sealed the borders of states, cities, and even localities. The Police are tracking people who are violating the lockdown and stopping the migrants from reaching their hometowns.

The government has invoked the Epidemic Diseases Act -1897, and Disaster Management Acts for Lockdown. The legality of lockdown can be questioned as it restricts our fundamental rights given under Articles 19(1)(d) and 19(1)(g): the right to move freely throughout the territory of India and the right to practice any profession or to carry on any occupation, trade or business. However, the state justifies it under the “reasonable restrictions” sub-clause and Article 21, while conveniently forgetting that it takes away the right to life of millions of children every year due to malnourishment, poor sanitation, dysfunctional public health system.

The lockdown has turned millions of migrants into internal refugeescrashed the economy, consequently pushing the marginalized workers to starvation and deaths. It has put the nation’s 138 crore, $3-trillion economy on the ventilator, with losses estimated to be $4.5 billion a day. India’s taxes and revenue generation has sunk to the bottom. The unemployment rate (23–30% by CMIE) is estimated to be worse than the US during the great depression. The nationwide extension of lockdown without a sound analysis of the regional variations has created a socio-economic crisis leading to a surge in distress deaths. The distress deaths result from hunger, suicides, police atrocities, domestic violence, and sexual assault. The cumulative daily count of deaths, tabulated by Corona Policy Impact Group (see Figure 1) is only the tip of the iceberg. It hides several unreported and unrecorded deaths induced due to Corona.

Figure 1: Number of infection deaths and distress deaths during COVID-19 pandemic, India, March 18-April 12, 2020, source: https://coronapolicyimpact.org/2020/04/14/distress-deaths/

When does the state act and when it does not?

Whoever talked about the weak state capacity in peacetime, should rethink whether it is the capacity or the lack of will? With a strong political will, the state can use all its machinery and fiat to turn itself into a superstate, controlling the actions of every person in the country. As my colleague Chaitanya Ravi points out, the “pandemic has led governments to taste the elixir of unprecedented power and virtual full-spectrum control over citizens”. Indian state can turn into a monster while imposing bans, blockades, and lockdowns. But it turns impotent when it has to revive the economy, universalize health care, protect human rights, and curb communalism.

State action is primarily driven by the urge for self-protection. Self-preservation is the first instinct of Policy Making (Haas,1953 , Halperin and Clapp, 2007 ). Corona is democratic and does not make distinctions on class, race, caste, religion, gender, or nationality. It affects the rich and the elite as much as the poor. It did not spare British Prime Minister- Boris Johnson, Actor Tom Hanks, or the Prince of Wales. There is no vaccine or cure which can give selective advantages to the privileged over the poor. Corona does make a distinction between the young and the old in terms of severity. The impact of Corona, especially deaths, is disproportionately higher in the older age group to which the elite power circle and policymakers belong. The state acted because the prime actors of the state and their kith and kin are affected by it. It is in their self-interest to contain the epidemic, barring which their own life and the state machinery is under peril.

State Action and Inaction

For the state, all lives are equal, but some are more equal than others. If saving lives was the primary motive for the draconic lockdown by the state, then what explains the reluctance of the state to seriously act on other communicable diseases which kill millions of poor children and adults in India? Consider Tuberculosis (TB), In 2018, 26.9 lakh people were infected by TB in India, out of which 4.5 lakh people died (WHO TB Report, 2019), more than four times the total deaths by Corona worldwide to date (April 10, 4 months after the outbreak). The TB deaths in India at 1,232 every dayis five times the cumulative deaths of all Corona Cases in India as of April 10, 2020.

TB is an age-old disease. The BCG vaccine, which offers protection to 80% of cases, is more than 100 years old. TB treatment through drugs and quarantine (which ranges from 8 weeks to 24 months depending on drug resistance) is quite effective. Worldwide, nearly 90% of cases of TB and 48% of cases of drug-resistant TB are cured. Yet, we don’t have real time-TB tracker like COVID-19. TB deaths don’t flash on TV screens, create newspaper headlines, no public statements are made by state heads, no special wards are created in TB prone regions. As Vikram Patel of Harvard Medical School Points out TB has always been a disease of Poverty and squalor , people who will not be boarding International flights, and pose no threat to the rich and powerful countries who have largely eliminated it. In the US and Canada, the TB incidence rate is less than 2.7 per hundred thousand, in contrast to 199 per hundred thousand population in India. It fails to attract the attention of political circles and popular media, as it largely bypasses them and their families. TB control requires the elimination of dirty and squalid environments, vaccination of the poor children, and addressing malnourishment. Endemic TB bypasses all the attention, while the Pandemic gets into the limelight.

Figure 2: Burden of Disease in India, 2017: Source- Global Burden of Disease Study 2017.

Burden of Disease in India

Public action on health should be guided by an assessment of the health status of the population. Focusing only on mortality excludes the disease morbidity which reduces the productive life span. Burden of disease describes death and loss of health due to diseases, injuries and risk factors. The Disability Adjusted Life Years (DALY) is a standard measure in public health to estimate the disease burden. It is the sum of years of life lost (YLL) due to death and years of life lived with disability (YLD) due to disease (see Figure 2- DALY for India from Global Burden of Disease Study). A child’s death before one year leads to a loss of 69 years of life in India; whereas a man of 50 years dying of any disease would have lost 26 years of expected life span.

Over 33% of all DALYs and 27% of all deaths are still attributed to communicable diseases in India. Lower Respiratory Infections contribute to 20 million YLL and 2 million YLDs (See Figure 3). Diarrhea, caused by poor hygiene, unsafe sanitation practices, and water contamination in India, is the most common cause of death for children under 5. DALY for Diarrhea is 1700 per hundred thousand. India lost 520,000 people and 20 million life years are lost (YLL) due to Diarrhoeal deaths every year. According to UNICEF report, about 8.82 lakh children under 5 died in 2018, more than 1/3rd of which can be attributed to malnutrition. Undernutrition is the underlying cause of child deaths due to diarrhea, pneumonia, malaria, and measles. News media rarely reports the magnitude of the staggering loss of death and disability, sociologists and economists rarely assess its impact on the nation and the society, the politicians hardly take notice of such disease burden study.

Figure 3: YLLS and YLDs for selected diseases and major causes in India, in 2017.

Public Health in India

Many endemic communicable diseases are preventable with improvements in public health, hygiene, and sanitation. In the non-pandemic times, Public Health rarely enters the public discourse. It gets a passing reference, if at all, in the election manifesto. Rarely it is spoken in the election speeches and political debates. Deaths due to endemic diseases are rarely discussed in the Parliament. Public spending on health in India is just 1.15–1.5% GDP, far from 3% demanded by public health experts, and half of the Government’s own commitment of 2.5% GDP in the National Health Policy. Ayshaman Bharat — the government’s health care insurance scheme got a paltry sum of 6,400 crore in 2020–21 budget, for 10 crore families. It does not cover the OPD and non-hospitalization expenses. The Government Health Insurance schemes in India have not made a dent in the out of pocket expenditure of the poor. India’s physician to population ratio of 82 per hundred thousand (PHT) continues to be one of the lowest (Canada has 260, UK- 272, Cuba 820, according to WHO data), with huge Intrastate variations (Tamil Nadu -400 PHT, Jharkhand has just 12 PHT).

Functionality of the Health System

India has a wide network of sub-center (SC), and Primary Health Care (PHC), but many of which are poorly functional due to manpower shortage, infrastructure, and supply chain bottlenecks. Swachh Bharat Abhiyan, with its excessive focus on toilet building, has not addressed the social norms, attitudes, and caste equations of open defecation. Furthermore, the Integrated Disease Surveillance Program (IDSP) of India, started in 2004 to monitor disease trends, to detect and respond to outbreaks in early rising phases is crippled by poor participation of Private health sector, lack of interdepartmental coordination at districts and state level, and poor laboratory capacity for timely identification and response to outbreaks (Singh et. al. , 2014 ).

The response to tracking and analysing COVID-19 in India has been overwhelming. Every corona case and deaths are now tracked in real-time, analysed through various groups across the world. Shiny apps float around the web tracking cases on a log scale, searching for the flattening of curves, projecting future scenarios of Corona. News media, twitter activists, WhatsApp warriors are sharing the daily counts of Corona and commenting on its spread, many (prophesying) dire future predictions. Never in history have individuals been so active in the epidemiology of a disease.

Far more lives could be saved if similar enthusiasm is shown by the people, media, and the state for the endemic diseases. Systemic improvements in public health, water, and sanitation should be the state priority, along with strengthening IDSP, creating a geospatial real-time tracker for all communicable diseases, coordination between people, the local and state government can go a long way saving millions of lives.


Are Distress Deaths Necessary Collateral Damage of Covid-19 Response? The Experience of First Three Weeks of the Lockdown in India, 2020
Vikas Rawal, Kathik A Manickem and Vivek Rawal, https://coronapolicyimpact.org/2020/04/14/distress-deaths/

Haas, E. (1953). The Balance of Power as a Guide to Policy-Making. The Journal of Politics, 15(3), 370–398. Retrieved April 11, 2020, from www.jstor.org/stable/2126103

Halperin, M. H., & Clapp, P. (2007). Bureaucratic politics and foreign policy. Brookings Institution Press.

WHO TB Report — Country Profile https://www.who.int/tb/data/GTBreportCountryProfiles.pdf?ua=1

Global Burden of Disease Study 2017. Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018. Available from http://vizhub.healthdata.org/gbd-compare/

Menon, G. R., Singh, L., Sharma, P., Yadav, P., Sharma, S., Kalaskar, S., … & Yadav, J. (2019). National Burden Estimates of healthy life lost in India, 2017: an analysis using direct mortality data and indirect disability data. The Lancet Global Health7(12), e1675-e1684.

Singh, V., Mohan, J., Rao, U. P., Dandona, L., & Heymann, D. (2014). An Evaluation of the Key Indicator Based Surveillance System for International Health Regulations (IHR) -2005 Core Capacity Requirements in India. Online Journal of Public Health Informatics6(1), e121. https://doi.org/10.5210/ojphi.v6i1.5036

- Prof. Shivakumar Jolad, Associate Professor - Public Policy

*Views expressed are personal.

(Source: https://medium.com/@shiva.jolad_46811/state-priorities-pandemic-over-endemic-ece2ddd0d56a)