A medical worker tends to a patient suffering from COVID-19, at Safdarjung Hospital, New Delhi, May 7, 2021. Photo: Reuters/Adnan Abidi
The pandemic reached India fifteen months ago – unassumingly at first, in small, localised outbreaks. Its first wave ebbed from October after taking an unknown number of lives and livelihoods. The second wave took hold in March, one year after the first. As a rising spate of infections and deaths submerges much of the country, it seems reasonable to ask what lessons, if any, we’ve learned in the interim.
The first wave was marked by chronic shortages of beds, equipment, doctors and nurses, with people queuing (and dying) outside hospitals. Doctors and nurses, especially in public hospitals, were forced to work under exceptionally difficult conditions, but this does nothing to mitigate the innumerable incidents of ingrained callousness that came to light during this period: patients overflowing from beds to floors and corridors; many left without care, food or water; photographs of the living lying cheek by jowl with the dead.
Many private hospitals turned patients away despite ordinances to the contrary; others charged enormous sums for treatment. No professional body seemed able to set out (let alone enforce) protocols for clinical treatment and hospital care capable of cutting costs and freeing beds up.
During the first wave, India experienced an acute shortage of PPE kits and a growing shortage of ventilators. In the midst of the second, we’re scrambling desperately for oxygen, vaccines and drugs of doubtful utility. Once again, people are queuing and dying outside hospitals – only this time there are many more of them. Crematoriums and graveyards are working around the clock. A thriving black market in oxygen and medicines has sprung up. Familiar tales of profiteering and callousness are being repeated on a grotesquely enlarged scale.
By now, it’s glaringly obvious that the death toll is (and always has been) far higher than official figures suggest: this undercounting couples systematic deficiencies in data collection with deliberate falsification. In India, households are not obliged to report deaths at home (unless there’s a will to be probated); village and municipal authorities are not obliged to register them either. It was obvious from the very beginning that infections and deaths were not being properly reported. The only question was by how much. One year later, it’s nearly impossible to find an epidemiologist anywhere in the world who believes the statistics put out by state governments and local authorities (not all of them, it should be pointed out, are controlled by the Bharatiya Janata Party).
Profiteering is an organic result of the steady privatisation of healthcare that commenced in the 1950s and gained pace from the 1990s. State funding for medical education and hospitals had been closely tied (many hospitals were attached to medical colleges): once education was privatised, the decline of public hospitals gathered pace. At a rough guess, two thirds of India’s health infrastructure is currently run by entrepreneurs. In commercial terms, it makes perfect sense for a businessman to raise the price of drugs, ambulance trips or patient care when demand is high and supply restricted. During the first wave of the pandemic, some governments passed ordinances capping prices for treatment (without specifying any method of enforcing them). In Tamil Nadu, many non-profit hospitals adhered to these prices, while corporate and private hospitals charged substantially more: quite clearly, this difference bears no relation to the actual quality of care.
The association of public hospitals with callousness, inefficiency and low standards of patient care remains unchanged. These vices are real; they stem from the way the public health system is organised and administered, and cannot be refuted by pointing out that the private sector is not exempt from them either. Decades of underfunding have hollowed out its structures: hospitals are staffed by an unstable mix of permanent workers (virtually immune from dismissal even if they do not perform their duties properly) and ad hoc and probationary staff, who end up doing much of the work. Its tasks are hampered by bureaucratic and political interference; like other institutions, it is organised to respond to orders from above rather than the felt needs of patients and staff.
It’s tempting to ascribe the sheer scale of the crisis to mismanagement; Ramachandra Guha’s recent article criticising the Modi government’s attitudes and policies is a case in point. Unfortunately, there is little to show that India’s problems would be substantially different if the BJP had not been in charge. Some of the worst affected states, including Delhi and Maharashtra, are governed by its opponents.
It’s true that a different administration – one less confrontational, less centered on personalities and more receptive to expert advice – might have made a better fist of managing oxygen supplies. It might have vaccinated more people (but not very many more). It might have slowed the second wave by regulating the Kumbh Mela or forbidding it altogether; it might not have provoked the protests that helped to spread it across north India.
Another administration might have controlled vaccine prices for longer – how much longer, given India’s self-imposed fiscal constraints (and the toxic fusion of business with politics) is the question. The federal government has loaned Bharat Biotech and the Serum Institute of India enormous sums to create new production facilities without using this commercial leverage to negotiate lower prices. These companies are not discussing supply contracts with state governments; they’re merely announcing the rates at which they will sell. Yet, by his own account, this privileged position has not prevented Serum Institute CEO Adar Poonawalla from being politely threatened by “powerful people” bent on securing supplies. The practice of showering businessmen with favours of their own asking and unasked for threats is a well-established one (the BJP is hardly alone in doing this), but it denotes a failed rather than a functioning state.
If we accept – as I think we must – that a second wave carrying new mutant strains would have reached India sooner or later, the root of the problem lies in our institutional unpreparedness to deal with it. Over 70 years, we’ve created a system that serves, in effect, to deny healthcare to the majority of Indians. Every political party in every state (and every central government beginning with the Congress under Nehru) has pushed this process forward with the tacit consent of its middle-class constituents.
The first wave laid bare the structural deficiencies of healthcare in India. The shambles of the second wave involves a much wider complicity, one that cuts across political parties and social groups. Healthcare is a state subject: state governments determine how (and how much) to spend on public health. Some spend more, others much less – in terms of health infrastructure, Kerala and Bihar might be two different countries—but none of them spends anywhere near enough. Some health programmes are funded by central subventions; a considerable amount of money also goes to the private sector through insurance programmes that pay for care in private hospitals.
India’s public health expenditure is the sum of these (and similar) figures: 1% to 1.2% of GDP. These are academic estimates, for no reliable statistics have ever been compiled on the subject. We spend far less on healthcare than many developing countries including Sri Lanka, Bhutan and Thailand: India has a ratio of one government doctor to 11,082 people; approximately 2,000 primary health centers have no doctor at all. The World Health Organisation recommends a nurse to patient ratio of 1:483. By this standard, India had a shortage of two million nurses by 2019 (and about 600,000 doctors), one year before the pandemic began.
In 2017, the private sector accounted for 80% of all outpatient care and 60% of inpatient care. This care isn’t cheap: 25% of all rural households and 20% of urban households were forced to borrow money or sell assets to pay hospital bills. It’s largely unregulated with respect to charges and standards. For the most part, local authorities are allowed to specify what hospitals and “nursing homes” should possess in terms of equipment, space, staff and so on.
The absence of public health infrastructure on anything like the required scale is reflected in every aspect of the crisis: chronic problems of testing and treatment; crippling shortages of hospital beds, equipment, drugs, personnel; delays in vaccination, and so on ad infinitum. Despite this, attempts to improve it in the long term remain conspicuous by their absence. During the first wave, Tamil Nadu hired doctors and nurses on temporary contracts, but most states failed even to do this. Various expedients were tried out instead, from buying equipment and conscripting medical students to creating temporary facilities. All of them are being faithfully repeated. A Congress administration in Rajasthan has announced it will spend 35 billion rupees, not on building hospitals or hiring doctors and nurses, but an insurance programme designed to divert patients to private hospitals. In Bihar, district hospitals have been provided with ventilators but not the doctors and technicians capable of using them. In Uttar Pradesh, the police are silencing cries for help on the grounds that it’s a crime to show the state in an unfavourable light.
In 1979, apropos the Moro affair, the Italian writer Leonardo Sciascia remarked that for the Italian Communist Party, the state appeared to be
“… a kind of mythical and metaphysical entity, superior to anything like the rendering of services. For me, the state is nothing but a well-coordinated ensemble of services. And when these services are deficient or altogether absent, it’s necessary either to fix them or to create new ones. Otherwise all you are defending is corruption and inefficiency under the pretext of defending the state.”
In India, unfortunately, the state is defined almost exclusively in metaphysical or in Hobbesian terms. For some nationalists, it’s the living embodiment of India’s glorious past (and manifest destiny). For others, it’s an instrument of development and modernisation. For dominant castes, it’s a tool of social and political control. For political parties, it denotes an organised system of patronage. For liberals, it’s the fruit of a unique experiment in democracy. These definitions are not necessarily exclusive – the Indian state is some of these things and more. But what it is not and never has been is “a well-coordinated ensemble of services”.
In most developed (and many developing) countries, education and healthcare are regarded as a common good to be achieved by public spending. In India, this obligation has never been accepted: for more than seventy years, the state has meddled in the economy in every conceivable way without providing the services that are an indispensable precondition of late industrialisation. The pandemic does not reveal the fragility of India’s health infrastructure, but its absence so far as most Indians are concerned. The middle-class has always turned a blind eye to this fact – until now, when the structures of private healthcare constructed exclusively for its benefit are crumbling before its eyes.
Reform can only be accomplished by expanding public health infrastructure many times over and regulating private health providers effectively. But to bear fruit, this expansion must go hand in hand with radical changes to work culture and practices: by putting professional structures of administration in place, enforcing accountability, improving standards of care (and productivity) through transparent, time-bound and effective measures. There is no real reason why a state capable of making complex defense deployments, building satellites and rockets, conducting the world’s largest elections and executing vast (if mostly useless) engineering projects should not be able to provide basic services.
Are there any circumstances in which healthcare could be reformed? Perhaps, but for that, public anger over the charnel house of the second wave will have to be much more durable than the last time around. At least some politicians, policymakers and businessmen will have to accept that a developed economy with an advanced manufacturing sector cannot be created by fiat alone, without improving the skills and productivity of India’s workforce. At least some political parties will have to make services a central plank of their election campaigns (in any case, the BJP has carried the politics of identity to a pitch beyond which it can hardly go). The widespread reluctance to support practical measures of upward mobility for plebeian castes will have to be modified.
This is conceivable – or at least it’s not inconceivable at a time when the failures of the health system can be counted in the dead bodies piling up around us. As for the fiscal argument against social spending – that state governments lack the money to build schools and hospitals or pay the salaries of more teachers, doctors or nurses than they have already – this merely reflects a long-standing reluctance to increase revenues through progressive taxation. At the same time, most Indians – not unjustifiably – view the state as a morass of corruption and inefficiency: the effect is to predispose them against paying more (and sometimes any) taxes.
The only way to regain their trust is by improving services first. Nothing prevents parliament – should it wish to – from passing laws to regulate the private sector and setting binding targets for spending on public health and education (with corresponding measures of administrative reform) for state governments to meet; the funds can be obtained by cutting defence expenditure (this would have the added advantage of encouraging us to adopt a less bellicose and more realistic foreign policy), restoring corporate taxes to normal levels, taxing the wealth of the obscenely rich, and, on the part of state governments, by reducing spending on subsidies and welfare.
Welfare in India takes many forms: from pensions, school meals and employment programmes to cheap food and gifts of bicycles, television sets, computers etc. Not all of them raise levels of subsistence (and nor are they always intended to). Some of this expenditure could usefully be redirected into services; we know from historical experience that a dense, well-run network of state schools and hospitals is the best, if not the only guarantor of social change and upward mobility.
In the final analysis, the structures of education and healthcare can only be reformed by reforming the state: by refashioning it from an instrument of patronage and development into “a well-coordinated ensemble of services.” The obstacles are formidable – private health providers, for one, will fight to retain their dominance tooth and nail – but the chief impediment lies in a collective failure of imagination. This goes all the way back to the 1950s when the Nehruvian elite adopted the structures of the colonial state, its inherent opacity and the privileges accorded to its functionaries virtually without change. But if the second wave of the pandemic tells us anything, it’s that the difference between reform and the status quo can be, quite literally, a matter of life and death.
Shashank Kela is the author of a historical monograph, A Rogue and Peasant Slave: Adivasi Resistance 1800-2000 (2012); a novel, The Other Man (2017); and many articles and essays. He can be reached at shashankkela at gmail dot com.