As many of us are painfully aware, social distancing is an impossibility for much of India (and a lot of other regions). Measures such as hand-washing, keeping oneself at home if symptomatic, working from home can be followed without any major life repercussions only by a tiny minority of the country – i.e. the socioeconomically privileged. This reality came through quite poignantly in a recent blog post by three Tamil Nadu-based physicians. These doctors (Vijay Gopichandran, Sudharshini Subramaniam, Vinod H. Krishnamoorthy) describe their interactions with a 50-year-old woman who came to them with fever, cough and breathlessness. These symptoms will make any healthcare professional today consider the possibility of the novel coronavirus infection. Hence, while the woman was put on appropriate treatment according to existing protocols, the doctors suggested some social distancing measures to her, just to be on the safe side.
This is the response they got:
“Doctor, what you are saying is not practical. Our house is a little hut and all four of us live in the same room. We have enough room just to lie down and sleep. Keeping a 1-metre distance is impossible. Three of us are women and it is not safe for women to sleep outside the house. There is also the threat of scorpions and snakes outside.”
After describing the insuperable difficulties of social distancing and shutdowns in the Indian scenario, the doctors argue that “by creating a social shut down, and halting the spread of the virus, we will save lives, no doubt, but how many lives will we be harming in order to save those who may be killed by the coronavirus?” This is a very loaded ethical question. The doctors proposed one way out:
“If a vast majority (more than 80%) of people who get the coronavirus infection are going to make it safely then we might actually be smarter in allowing the virus to take its course, closely watching and intervening for anyone who might have a turn for the worse.”
I honestly do not know if this proposal makes ethical and pragmatic sense. For now, let’s consider the basic idea at stake here: the idea of risk. Over the past few weeks, what everyone from governments to organisations to individuals has been reacting to – whether in terms of closing borders or cancelling events or hoarding supplies – is their own conceptions of the risks associated with the new virus, coupled with feasibility. For example, those who consider the risks to be high and can manage to work from home (or don’t have to worry too much about money), are indeed practising social distancing. When it comes to India’s poor and marginalized, one can imagine there are two principal risks they face:
- The (relatively distant) risk of falling ill with COVID-19.
- The (absolutely immediate) risk of not surviving: of starving, of hungry children, of financial losses, disrupted medical treatments and mental stress if very strict shutdowns are implemented.
It is pertinent to consider how lack of privilege changes the way one approaches health-related risks. Consider what is one of the most common scenes in India’s government hospitals: a low-income person from a village, looking weak, comes into the OPD and says she has been experiencing pain in her tummy for some weeks. When you begin to physically examine her, you discover she has a very large swelling in her lower abdomen. You ask her how long this has been, and she sheepishly says, “A year.”
How can someone tolerate a growing mass in one’s abdomen for months without acting on it? Cancer is not unknown in rural India, nor is the association of swellings with cancer. Besides, the fundamental human instinct of self-preservation is, well, fundamentally human and present in her too. But while for an urban school teacher that instinct might manifest as keeping everything else aside to make an urgent visit to the doctor, for an agricultural labourer, it manifests as keeping the swelling aside to preserve oneself and one’s family until the next day. In the disastrously unjust and unequal world we have collectively created and sustained, the labourer is forced to heed her instinct for long-term self-preservation only when it merges with her instinct for short-term preservation. So, she comes to the big hospital to get checked by the big doctor only a year later, when the abdominal swelling has begun to seriously interfere with her capacity to earn her daily farm wages.
Thus, while the risk of COVID-19 might be substantial for most low-income Indians who continue to be out and work, it might well be the case that many of them are consciously accepting that risk because of the severity of the absolutely immediate risk.
Hence, the three doctors are not in favour of shutdowns or other similar measures since they will end up disproportionately harming India’s underprivileged. (They also provide examples of similar shutdowns in the country, when the poor could not access emergency services and died due to lack of care.) Their radical proposal is to continue life as usual and allow the virus to “take its course” in the country. This, they are aware, will also involve disability and death – but will cause, in their view, lesser overall harm.
But then, are there ways in which we can implement public health measures like shutdowns, and at the same time take care of the survival-related crises those measures throw up for the poor? To go back to the woman with the swelling, what if she had a well-run primary health centre or sub-centre at her village, providing affordable, respectful, good quality care? She would have most probably gotten her swelling checked early, without having to worry about losing wages worth several days.
Similarly, we should find ways to take care of – for the duration of the pandemic to begin with, and later permanently through universal health care – the survival challenges faced by underprivileged people. The good news is that Kerala is already providing some humane ideas. With inequalities and systemic problems that run deep, we might only partially be able to achieve this, but it would represent a much-required start.
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.