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Aarogya Setu App Is Just the Latest Example of Our Obsession With Quick-Fixes

Aarogya Setu App Is Just the Latest Example of Our Obsession With Quick-Fixes

Photo: Lucas Dudek/Unsplash.

Recent tweets from the NITI Aayog could make you wonder if the Indian government’s Aarogya Setu app is the ultimate answer to COVID-19 that all of us had been waiting for. That the government would build an app ostensibly to control the spread of the novel coronavirus while throwing up many questions about potential privacy violations was a logical outcome of our contemporary record of ‘minimum governance, maximum government’. But apart from this recent history, the appeal of apps is powered by an older, more general mental algorithm in health policymaking known broadly as a techno-centric approach.

Despite the fact that most major healthcare challenges in the world arise from multiple social, economic and environmental causes, we disproportionately spend resources on only a certain convenient kind of solution – the mechanical or technological one – at the expense of others. While such solutions certainly have their uses, the skewed focus we devote to them ends up brushing away the need to tackle broader causes of ill health or even to implement major healthcare reform. Prominent examples include the attention we devoted to constructing toilets to reduce open defecation, to sterilisation for family planning, and drugs to tackle tuberculosis.

In the 1950s and 1960s, Indian scientists were at the forefront of groundbreaking tuberculosis (TB) research on how best to control the spread of this deadly disease in resource-poor nations. This was a time when bed rest and spending months in a sanatorium were the mainstay of TB treatment. Anti-TB drugs had only just been discovered in the West and officials were yet to evaluate appropriate drug regimens in the context of countries like India.

This evaluation began in 1956, under the aegis of the Tuberculosis Chemotherapy Centre in Chennai. Its primary aim was to see if there was any difference in outcomes when people were provided drugs at home (a new, untested strategy then) versus at a sanatorium (the convention). Members of the centre published a landmark 92-page report in 1959. Their main finding was “that treatment at home gave results closely approaching those of treatment in sanatorium, and the differences between the results of home and sanatorium treatment were surprisingly small.”

This meant, in a solely medical sense, that admission to sanatoria and hospitals was not necessary for routine TB treatment. But from a public health and societal sense, the interpretations were more radical. Before the study, if countries like India were to reduce community-level TB prevalence in any meaningful way, the only effective option available was to replicate the broader social, economic and environmental hygiene reforms that had successfully cut TB down in Europe and America. But now, policymakers thought, the new medicines made it possible to control TB without worrying about social conditions and poverty. In a comprehensive study of the history of TB control in India, the historian Niels Brimnes quoted a telling line from another paper of the Chennai centre: “… the successful treatment of patients in their homes need not await an increase in the standard of living.”

One could argue that the researchers were genuinely trying to do their best to reduce suffering in the context of their constrained reality. Nevertheless, any understanding of ill health purely in medical terms minus broader causes is always partial and very often counterproductive. We saw this even in the 1960s. The historian Sunil Amrith has shown that the generally reductionist framework of the Tuberculosis Chemotherapy Centre soon was challenged by findings from the Bengaluru-based National Tuberculosis Institute (NTI) in the 1960s: “… far from being a ‘magic bullet’ for tuberculosis, the success of chemotherapy [i.e. anti-TB drugs] was dependent on the improvement of socio-economic conditions, and on the expansion of health services to provide even coverage across the region and country.”

Both studies were based on robust intellectual efforts in their respective disciplines. The Chennai study was led primarily by public health experts and medical doctors/scientists, and the NTI papers were authored by social scientists. Taken together, they provided what seemed like a comprehensive plan of action for a gargantuan challenge. But as it turns out, it was only the Chennai study’s conclusions that ended up capturing the attention of policymakers and funders both in India and abroad.

And more importantly, they were selective in taking their lessons from even that study. As Amrith argued, they “made much of the Madras study’s illustration that poverty and nutritional status did not compromise the efficacy of chemotherapy, ignoring the complex combination of financial incentives, food supplementation, and follow-up of patients which were crucial to that study.” That is, they ignored the fact that the conditions of the study, where patients were treated well, followed up rigorously and provided supplemental income and food, did not reflect reality. No wonder then that the major programs for TB control in India have only had a small impact on TB’s prevalence. Currently, more than 1,200 people die every day in India of TB.

Anti-TB drugs are no doubt a lifesaving intervention. But the major problem with our TB programs was not our reliance on the drugs as such but the absence of political will and enthusiasm (despite frequent on-paper presence) for socio-economic reforms and preventive healthcare, which are indispensable for community-wide TB control. It seems certain that excessive focus on the Aarogya Setu app and other quick-fix ideas to control the coronavirus epidemic will similarly erase more important, more sustainable approaches to epidemic control from policy discussions.

Examples of the latter include paying ASHAs – India’s most peripheral healthcare workers – well and resolving longstanding issues they have raised; investing in and improving the country’s multiple healthcare-related data systems; and nurturing human resources for public health, like in Kerala. Then there are the broader social, environmental and economic causes of ill health, which sadly are considered too unfashionable to be discussed in an apps-obsessed policy milieu.

History, as well as contemporary events, show us that when given a choice, most politicians and bureaucrats will always take the ‘dry road’ – mechanical, technological solutions that seem less messy than stuff like welfare-oriented progressive reforms and equitable distribution of wealth and resources. The solution that India’s present government recently offered for the problems of performance, efficiency and corruption plaguing our decades-old government district hospitals was to sell them off to the private sector (which by no means is less inefficient or less corrupt) instead of implementing sustainable institutional reforms in government centres.

Similarly, with respect to epidemic control, the surveillance apps might end up rendering the ideas of strengthening our epidemiological and public health infrastructure politically redundant. As for the standard of living of the ordinary Indian – the most visible example of this person today is the migrant labourer: it will continue to languish in the waiting room of policy.

Kiran Kumbhar is currently studying the history of science at Harvard University, focusing on the history of medicine in modern India. He is also a physician and a health policy graduate.

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