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COVID-19: Comparing jurisdictions - opportunities for policy borrowing?

The Indian COVID-19 episode: Unprepared lockdown and its impact

Srinivas Goli

The hasty implementation of the lockdown in India proves to be late, underprepared and ill-designed. Srinivas Goli highlights some of the unique challenges the country faces in the fight against the spread of COVID-19 due to its demographic, pre-existing public health concerns and underfunded health and education systems.

Amid the COVID-19 outbreak, on 25 March 2020 the Government of India announced a 21-day complete lockdown to prevent colossal damage to lives, which its poorly equipped health system otherwise could not manage. The country already suffers from a historically underfunded and highly privatised healthcare system, decades of insufficient investment in building basic resources and a highly informal economy, resulting in high levels of poverty and a lack of access to food, water, sanitation and hygiene for millions. Considering the absence of resilient institutions, this concurrent assessment in the middle of the outbreak predicts that the socioeconomic, demographic and health costs in India will be much higher than in developed countries, irrespective of the number of COVID-19 cases and deaths.

What went wrong?

While the lockdown is an inevitable solution to control the pandemic in a country with 1.38 billion people, its implementation was abrupt, poorly conceived and underprepared. The country’s sudden lockdown is primarily a reaction to mathematical models put forth by researchers from Europe and North America. The Indian Council for Medical Research (ICMR), under the aegis of the Ministry of Health and Family Welfare (MoHFW), has been tasked with working on the COVID-19 response strategies in the country. However, until now the design of India’s response to the outbreak doesn’t seem to be following any of the countries that have shown first successes in flattening the curve. Considering the time lag since the first case reported from China and from India to the country-wide lockdown, the preparation could have been much better. Early shutdown of international travel and closing of country borders could have prevented the import of the virus. Moreover, the opportunity to design a strategy of how to deal with the informal economy, urban migrants and livelihood options for daily wage earners, existing disease burdens and healthcare needs, and alternative options for educational disruptions under the lockdown, was completely missed.

Impact
Disarrayed poor migrant workers and homeless population

About 450 million informal workers, making up 90 per cent of India’s workforce , are not entitled to paid leave or any significant social security benefits. There are nearly 1.8 million people for whom roadside footpaths are the only place to self-isolate and maintain hygiene without basic amenities (water and soap) to continue the battle against COVID-19. During the lockdown, the fear of going hungry due to daily wage loss is outweighing their fear of the virus. In these helpless conditions, homeless migrant workers in the cities have chosen to walk hundreds of kilometers in the hope to reach their hometown, which not only increases the risk of them getting infected, alongside deaths due to exhaustion and hunger, but also carries the virus to their hometowns/remote villages. Federal and state governments are delayed in providing direction and relief packages to these workers. The announcement of such measures as a part of preparatory measures before the lockdown would have reduced confusion among these sections of the population and allowed them to stay put instead of walking back to their hometowns and villages. In response to this, merciless crackdown on and inhumane treatment of migrant workers surfaced in a few states, such as spraying chemicals on returning migrant workers to disinfect them in Uttar Pradesh, locking them in sheds in Bihar and in jails in Haryana.

Education disruptions

Due to the lack of proper planning from both the state and institutions, the decision to close academic institutions and hostels just before the lockdown, though important, will have long-term repercussions on the ongoing academic year and for mental health outcomes of the students. The abrupt shutdown has pushed them to move back to their hometowns using unsafe public transport which may have increased their chance of being infected or infecting other people during the journey and family members back home. Even if the lockdown is lifted, it is now uncertain when education institutions will reopen. Parents are less likely to send their children back to study unless the pandemic is declared to be over. The majority of academic institutions in a country with 320.7 million learners from primary to tertiary levels do not have a catastrophy resilient system, unlike its developed counterparts. Considering the lack of education infrastructure, most of the schools, colleges and universities are not in a position to conduct virtual learning classes and distribute study materials to compensate for the academic losses. Institutional obstacles set aside, a considerable number of students are not equipped to be present online either due to poor internet connectivity in rural areas or lack of facilities at home. This is likely to increase huge rural-urban and economic inequalities in educational outcomes in the country.

Trade-off between COVID-19 and non-COVID-19 health care

When you look at India, it is very different than looking at Italy which is among the worst cases cited internationally, because India has so many pre-existing causes of mortality that are part of the public health landscape and which are very distinct from those of Italy. The assessment of data presented by Brookings for February/March, when COVID-19 deaths were at a peak in China, shows that the disease was still ranked 49th as cause of death for the country . The existing global evidence suggests that more people die because of TB, malaria, HIV and other diseases than COVID-19 annually (even if we account for the projected number of COVID-19 deaths). Although we do not have reliable comparable statistics of deaths for March/early April 2020 in India, considering the Medical Certification of Causes of Death (MCCD) data for urban Maharashtra, I would argue that it is hard to believe that COVID-19 will rank among the top 20 causes of deaths in the country even at the end of its lifespan.

In India overall, an average of 6.9 million people visit hospitals and clinics for outpatient care and 1.10 million for inpatient care daily, out of which private healthcare service providers cater to 66 per cent of these services. Even before the lockdown, the lack of access to healthcare services was causing nearly 3,600 pregnancy-related deaths per month and 2,800 under five-year-old child deaths per day. As many as 49,481 births take place per day of which private hospitals perform 55 per cent of the caesarean and complicated deliveries.

Closing a majority of private hospitals and clinics in medium and small towns as part of India’s lockdown will badly impact on healthcare access for an uncountable number of people.

Women and girls will be hit hard

Considering India’s strongly patriarchal society where housework is primarily the responsibility of women and their young daughters, the lockdown may increase the burden of care activities for them, alongside increased risks of domestic violence , which ultimately affects their mental and physical health adversely. As the reports of a shortage of food in poor and migrant families are surfacing, it is likely that this will affect women more because often they eat last in the family, especially in rural areas. Further, when the outbreak was at its peak in China, sanitary pads were short in supply , leading to an extreme crisis in the maintenance of menstrual hygiene. Considering already low levels of menstrual hygiene knowledge and management in India, further obsticles to access to hygienic menstrual absorbents could lead to serious health consequences for adolescent girls and women, especially female frontline health workers. Finally, women carry a greater risk of losing their livelihood as they are largely confined to the informal sector. The women left behind, especially the elderly, will face the toughest conditions accessing basic amenities and livelihoods.

Lessons for now and the future

This perspective sends a strong message for India to initiate measures to contain the damage not only for now, but also to build resilient social, economic, educational and healthcare systems to face future epidemics.

In the absence of any other international influences on policy design of the response to the spread of the virus, it begs the question which model is most appropriate. For now, I would advocate that the country must quickly adopt the South Korean model of containing the outbreak by tracking, testing and treatment. The World Health Organisation has been suggesting that lockdown alone is not a solution and that countries must test widely. ICRM data suggest that the proportion of positive cases out of the total tested sample is 4.02 per cent – much higher than the 2 per cent in Australia . So far, India tests 60 per million population against 11,610 per million in Australia. This suggests that India is testing primarily high-risk groups – probably due to the limited number of testing kits available. However, this approach may contribute to the situation getting out of hand.

In the long run, considering the share of the health budget of the Indian Gross Domestic Product (GDP) has been at just over 1 per cent for the past five decades , more attention to the development of a more robust healthcare infrastructure is much needed to secure long-term benefits, otherwise a pandemic like this will cost even more. The country also needs to invest more in building pandemic and catastrophy resilient education systems and communities. Greater investment into clinical, biomedical, and microbiological and public health research for early detection of threats and into the development of affordable diagnostics must be a priority. Furthermore, continuous capacity building for more solid understanding of socioeconomic, demographic and gendered impacts of major policy decisions will help to anticipate both positive and negative consequences. Alongside awareness raising for hygiene measures, India must continue to provide the support of means to uphold such measures if it wishes to fight the spread of the virus while avoiding considerable detrimental impacts on the health and wellbeing of the overall population.

Dr Srinivas Goli is an AII New-Generation-Network Research Fellow with UWA Public Policy Institute, UWA. Before joining UWA, he was an Assistant Professor at JNU (2015-to-present), GIDS (from-2013-to-2015) and a visiting faculty at the University of Gottingen, Germany.