After a 39-day lockdown, what will be the shape of things to come? How should one strike a balance between ensuring livelihoods, minimising strife, and maintaining social distancing? In a discussion moderated by G. Ananthakrishnan , Reetika Khera, and Giridhar R. Babu examine the options. Edited excerpts:
With less than a fortnight left for the lockdown to be lifted, there are seemingly conflicting requirements of having to prevent group activity, and restarting economic activity...
Reetika Khera: We need to keep our socioeconomic conditions firmly in focus while deciding on a health strategy to deal with the epidemic. Only 17% of the employed have salaried jobs; one-third are casual labourers. According to the World Bank, 76% are in ‘vulnerable employment’ in India. There is no provision for unemployment doles. Overall, what we should try to minimise is hardship and deaths from the pandemic. In the past few weeks, we have seen reports of hunger, homelessness, vagrancy — even deaths — from the lockdown, coupled with government apathy to these issues. We, therefore, need to ensure that the poor are not forgotten or abandoned as we protect ourselves, roughly the top 30%, from the viral infection. For the poor, an extended lockdown poses a health risk because they live in cramped spaces and may not have running water to wash their hands; it is also economically disastrous, because they do not have savings or an assured monthly income to keep themselves going. Greater sensitivity and better planning are urgently required.
Giridhar R. Babu: I do not see any conflict in continuing physical distancing and measures to prevent large congregations in the near future. In most circumstances, such as in the IT sector, work from home options should be made mandatory for the next few months. Similarly, annual fair, marathon events, and all such events which require large gatherings for non-essential purposes should be postponed until we have a drug or a vaccine. When it comes to essential activities such as public transport, ensuring physical distancing, face mask use, and enforcing respiratory hygiene such as cough etiquette is essential.
There is a view that the lockdown cannot be lifted completely. Can governments plan welfare and public health measures under uncertainty? What happens to the self-employed and migrant labourers?
Reetika Khera: The lockdown will probably be partially lifted allowing some activities and [then] gradually phased out, red zones remaining locked. But it must be accompanied by a massive increase in the relief budget, currently at about 0.5% of GDP, for the most vulnerable. Existing programmes of social support, such as the Public Distribution System (PDS), the National Rural Employment Guarantee Act (NREGA), and pensions need more financial allocations.
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The PDS today only covers about 60% of the population, even though the legally mandated coverage under the National Food Security Act (NFSA) is two-thirds of the population. This is because the government is using population figures from the 2011 census to determine coverage. Due to the lockdown, a significant portion of those who would not have been covered anyway — the one-third outside the NFSA — now need support; workers in the gig economy, taxi drivers, delivery boys, etc., for instance. This under-coverage is especially criminal today because at the moment, the government is hoarding grains on an unprecedented scale: three-and-a-half times the buffer stock norms, before wheat procurement has even started. The first step should be to universalise the PDS, for up to a year, by allowing anyone from the 40% without ration card the opportunity to apply for a temporary card. The Centre needs to make grain available to the States and they can do the rest.
As far as the NREGA is concerned, there are two issues. One, whether such works can be opened without increasing the risk of community transmission at worksites. Two, how to make payments in a convenient manner? Density of bank branches is very low in rural areas and, even in normal circumstances, they are very crowded and far from people. Banking correspondents, who could have eased these pressures, are unsafe at the moment because they use biometric authentication at the time of disbursal of wages. For this reason, the government needs to allow greater flexibility to States in deciding how to disburse cash. Several States have successfully disbursed cash in hand in the past, and have done so without much corruption. Odisha pays pensions through panchayat secretaries; Rajasthan and Tamil Nadu used to pay NREGA wages at the worksite before 2009.
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For migrants, the government must provide transport, assisting them to return home, just as it flew back Indians stuck abroad and helped the students stuck in Kota. Those who are willing to stay, must be provided dignified shelter in schools, community halls, along with cooked food.
Giridhar R. Babu: The plight of migrant labourers and those who depend on daily wages is miserable. While their healthcare needs are to be addressed by the public health system, the government has to ensure their subsistence by providing necessary ration and medicines. The situation has exacerbated distress in the informal sector, which constitutes around 303 million people. The nutritional issues around food quality are significant. If these are addressed, a scientific decision tree can be developed by the Indian Council of Medical Research and Ministry of Health and Family Welfare to guide the deployment and lifting of lockdowns in the future. We should lift the lockdown in a staged manner and assess the containment measures at the district level using data.
Taking the NREGA as a workfare programme rather than welfare, can it be used to scale up health infrastructure, such as by building primary health centres?
Reetika Khera: I believe that as far as health is concerned, the really big crunch is the availability of medical personnel. As far as physical infrastructure is concerned, we need hospital beds, personal protective equipment (PPE), ventilators, etc. But more than physical infrastructure, we need to ensure more frontline workers in the health system — ASHA workers, anganwadi workers, auxiliary nurses and midwives — and to employ them on fair terms. For instance, ASHA workers get honorarium and ‘incentives’, rather than a salary. They earn less than ₹2,000 per month generally. Similarly, anganwadi workers are still underpaid in many States.
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Giridhar R. Babu: More often than not, most health system-strengthening efforts are used for activities such as constructing buildings. As a result, there are buildings which are vacant and equipment kept unused. For any meaningful change, significant investments will have to be made in strengthening human resources. Investments should primarily address the public health challenges such as [those linked to] nutrition, ensuring behavioural modifications to prevent non-communicable diseases, screening, early diagnosis, and timely treatment.
The feeder pipe of illness is filled with people of several risk factors for infectious as well as non-communicable diseases. Instead of addressing this, most money is spent on curing only part of the resulting conditions. Inaccessible healthcare, in combination with an unhealthy lifestyle, is a deadly cocktail; no amount of healthcare through reimbursing costs can alleviate the disease burden. For example, one in three adults has hypertension; over 50% of hypertensives are not diagnosed or treated. The risk factors for hypertension are not reduced. However, the government reimburses low-cost surgeries for any cardiovascular complications following long-standing hypertension. While it might take a few paise per capita to invest in prevention, the government is spending lakhs of rupees for so-called low-cost surgeries. Nearly 80% of all healthcare expenditure should be on preventive services.
Like Aadhaar, there is emphasis on getting people to accept the Aarogya Setu app. There are fears of lost privacy, stigma and discrimination...
Reetika Khera: Many people have already warned about over-reliance on technology. One, the app needs smartphones. Less than one-fifth of Indians own smartphones. Two, the reliability of the technology [using bluetooth to detect contacts] has been questioned by computer scientists in India. Three, it entails an unnecessary and unjustified privacy invasion, which nevertheless is projected as necessary. Authoritarian governments across the world are using the pandemic as an opportunity to normalise unprecedented levels of mass surveillance. Finally, Kerala shows us that contact tracing can be done, and possibly better, by utilising human resources. We must guard against techno-solutionism as well as privacy invasions.
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Giridhar R. Babu: Any effort to track the cases or their contacts should involve strengthening the human resources, including [through] capacity building. Technology should complement health system strengthening and not [be used] as a shortcut. This application provides people with important information, including ways to avoid corona infection, its symptoms... provided they take measures to ensure privacy and data, it will be easy for the government to track the spread of infection by tracking symptomatic and asymptomatic persons. In the future, this app can be extended to strengthen disease surveillance for influenza-like illness, polio, TB, vector-borne diseases and other disease surveillance.
How can we prepare for a future pandemic?
Reetika Khera: I feel that we must understand that we have been cheated for more than 70 years by the political class, that used every possible excuse to underspend on health. Today, public spending on health in India is barely 1% of GDP, compared with more than 10% in countries like France and Germany. There needs to be a serious discussion on resetting our priorities — not focusing on overall GDP growth only, but also on where GDP growth is coming from. Expenditure on health (nurses, doctors, hospital beds etc.) adds to GDP as much as roads and fighter jets do.
There also needs to be a serious rethink about the health system. At the very least, we should be regulating the (for-profit) private health sector, in a similar manner as Germany and Japan. These countries do not have socialised healthcare like the National Health Service of the U.K. But Germany has not-for-profit social insurance funds; in Japan, the government regulates what private practitioners can charge patients. In India, the private health providers seem to dictate terms to the government, as happened recently with respect to pricing for the COVID-19 test. This must change right now.
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Giridhar R. Babu: It is time that we start investing in strengthening the public health system. There is disproportionate spending on curative services and heavy reliance on insurance. Pandemic preparedness is a small component of health system strengthening. Public health is the art and science of preventing diseases and promoting health through the organised social efforts. Any aspirations for an increase in GDP allocation should, therefore, be prioritised for the public health system, towards preventing diseases and promoting health. Preventing the disease includes addressing behavioural changes, adequate nutrition, improved living conditions, screening, early diagnosis, and treatment. A significant portion of this should be towards prevention, including strengthening disease surveillance. Public health should be managed by a specialist cadre —_epidemiologists, social scientists, economists, bio-statisticians, behavioural scientists. Our response has been mostly reactive — in terms of measures such as scaling up purchase of equipment during a crisis.
Considering the experts’ view that the lockdown would have to be lifted in stages, with students and young workers being able to resume activity first, is that a feasible option? What about testing?
Giridhar R. Babu: While allowing children and young adults to resume their activities is advocated based on their relatively stronger immune response, one should not forget that they become the carriers for other vulnerable [people] in the community. Using seroprevalence service should help in identifying the areas of transmission, and appropriate actions planned. Depending on the infection burden at the district and State levels, the government should implement a graded response to lift the lockdown. Nearly 100 districts across the nation are severely affected by coronavirus, and the government has planned to seal those hotspots. Where the incidence of COVID-19 cases is less, restrictions could be lifted to allow for economic activity. Industries may be permitted to operate under certain conditions like ensuring strict physical distancing. State authorities should monitor these conditions. It is imperative to expand the testing capacity to confirm the severity of community transmission before such decisions are made.
There’s too much emphasis on the testing as if that’s the end in itself and not the outcome. We should follow the syndromic approach to identify cases and then subject them for tests.
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If the government has to extend the lockdown beyond May 3, what should be its priorities?
Giridhar R. Babu: It appears very unlikely. In the future, we should follow an evidence-based approach in deciding to extend the lockdown, the priority should be to help migrant labourers reach their homes. Once the lockdown is lifted, the virus transmission will ensue in every part of the country. We have a golden opportunity to find every possible case in every area and isolate, thereby containing the transmission.
Nearly 90% of the IT workforce can be permitted to work from home, with minor logistical measures. Strict enforcement of cough etiquette, use of masks, and physical distancing should be the new normal. Avoiding large congregations, malls or events should help at least for the next few months till a vaccine or a drug is available. The government should focus on importing test kits and equipment, but also on developing and manufacturing our test kits.
Giridhar R. Babu is the head of Lifecourse Epidemiology at the Public Health Foundation of India; Reetika Khera is an associate professor at the Indian Institute of Management-Ahmedabad.
