With no vision for public healthcare, Govt’s Covid preparedness remains a hoax

It is worth wondering why anyone should die of diarrhea in today’s age, when it can largely be remedied by making safe drinking water available to the people. Why should one die of tuberculosis that is sensitive to anti-tubercular drugs, when in England and Whales, between 1838 and 1945 they got rid of more than ninety five percent of incidence and prevalence of tuberculosis, even before the first anti-tubercular drug was invented, simply because people increasingly had access to better nourishment.

These are hardly the times for a laid back philosophical take on disease. The Global Burden of Disease Study, 2017 shows that 1,970 and 1,045 Indians die every day from diarrheal diseases and drug sensitive tuberculosis respectively. Sounds disconcerting, but please be assured that if various eminently preventable causes of mortality are taken together, the picture shall get far grimmer. For example, in the early phase of the nationwide covid lockdown itself there were five lakh avoidable non-covid deaths.

As and when the corona pandemic ends, a simple aggregation of the numbers shall show corona cases and deaths to be just a fraction of similar statistics for just diarrhea and tuberculosis. This should do well to underline the crucial importance of taking on the challenge of corona pandemic while simultaneously providing effective care for non-covid morbidity, rather than neglecting the latter.

The question still remains what drove this outpouring of concern now?

The private health sector can only be expected to be as committed to the cause of ‘public health’ as it has ever been. When it comes to the cause of large scale public health contingencies the buck always stops at the doors of ‘public sector’ health services. However, on April 7, 2021, the All India Institute of Medical Sciences, New Delhi issued an order stating:

“In view of increased need to minimise possibility of community spread of ongoing pandemic and to optimise diversion of available manpower and material resources for treatment of suspected/confirmed patients of COVID-19, it has been decided to temporarily close down routine walk-in OPD’s registrations, including special clinics in the hospital and all the Centers ….”

It was further deemed necessary that different departments should fix a limit to the number of new and follow-up patients coming to the institute through the online registration. In the words of acting medical superintendent of the hospital, Siddharth Sathpathy, the action was deemed necessary in view of the proportion of patients coming to AIIMS through ‘walk-in’ (i.e. without prior appointment) increasing over past few months.

It was later clarified by AIIMS that the measure would only restrict the ‘walk-in’ patients who constitute just 10 to 15 per cent of the OPD cases. The commitment to those with prior online appointment shall be fulfilled.

There is an old way of testing the quality of rice. You take half a scoop of hand of rice to have a look and smell it. If it passes the visual and olfactory standards, the quality of a sack full of that rice can be testified. Even though a bit stretched, but if one were to take a methodological cue from this to judge how well India’s public health system has been prepared to effectively infringe upon an ominous march of covid pandemic, then one only needs to learn from how the best and the most ‘robust’ of its medical institutions are performing. The peripheral ramparts – the Primary Health Centers, the Community Health Centers, the District Hospitals, or even the mofussil medical college hospitals have since long ceased to inspire public confidence.

Understanding this better may require assistance of some public health insight for the readers. The above statement issued by AIIMS itself acknowledges that at the end of one year of pandemic, the walk-in patients (which had been the norm before digitalization) had been reduced to being just 10 to 15 per cent of the total OPD patients. The rest could have access only through the digital gateway. Given the country’s digital divide, it isn’t difficult to figure out which section of people end up being at the receiving end of such arrangements. Moreover, such digitalization privileges the sweet will of AIIMS regarding the number of patients it wishes to take in, rather than choice of patients to have them seen at AIIMS driven as they might be by the dilapidation of health services nearer home, or the unaffordability of the private sector.

Such digitally governed access to health care does nothing to bring about the more desirable differentiation between cases that need be treated at lower level of health facilities, and those requiring the attention of a tertiary level facility like AIIMS. For such differentiation to occur, proper functioning of the ‘ramparts’ – the PHCs, CHCs, and district hospitals is a necessary condition.

But the ramparts never really had sunk deep foundations in India, and whatever was erected was only greeted with malevolent indifference by the ruling elite. The National Health Policy 2002 stated – “In the context of the very large number of poor in the country, it would be difficult to conceive of an exclusive Government mechanism to provide health services to this category. It has sometimes been felt that a social health insurance scheme, funded by the Government, and with service delivery through the private sector, would be the appropriate solution.”

The latest National Health Policy, 2017 distils it further by proposing “to consider forms of resource generation, where corporate hospitals and medical tourism earnings are through a high degree of associated hospitality arrangements and on account of certain procedures and services, as a form of resource mobilization towards the health sector. ……….. To expand public provisioning of tertiary services, the Government would additionally purchase select tertiary care services from empaneled non-government sector hospitals to assist the poor.” That’s so caring of the government. Isn’t it?

In fact, the draft version of this policy (in 2015) had stated – “Given that the private sector operates within the logic of the market and that they contribute to the economy through their contribution to the growth rate and by the national earnings from medical tourism, there need not be any major effort to persuade them to care for the poor.” With this being the expressed intent, the people have little option but to throng to the few citadels still left standing.

In February 2020 China added 2,600 extra beds for covid patients by erecting two temporary hospitals in the epicenter city of Wuhan, in brick, mortar, and cement replete with wards, ICUs, CT scans, MRI, and other latest diagnostics, along with toilets and bathrooms in a matter of days.

But in India, in last one year no extra beds have been added to AIIMS, no recruitment of doctors, nurses, technical and other paramedical staff over and above the previous numbers has taken place. As of date, AIIMS is hard pressed to provide beds for its own students, faculty and staff if they were to require inpatient treatment. Friends in AIIMS faculty told that plans are being drawn up to quarantine resident doctors and students in their hostel rooms in case they get infected. Among the foremost concerns now is to ensure the safety of available personnel in order to ensure their services for tackling the deluge of corona patients, as also the exigencies of the non-corona cases.

There never was anything ‘given’ about the present situation. The mandarins and their political masters responsible for effective management of the situation have actually affected quite the contrary. Taking budgetary allocation as a measure of ‘political commitment’ to health, at Rs 73,931.8 crores the allocation for health in the Central budget 2021-22 was even less than the revised estimate of Rs 85,089 crores for the year 2020-21.

The potential demographic dividend of India’s overwhelmingly young population has been in the waiting since long. How much longer can this wait be-- is anybody’s guess, but covid seemingly occasioned a dividend on this count. India’s young population was held out as one of the reasons for low covid mortality. Once past its peak in September 2020, the prevailing wisdom seems to have been that covid is on its way out; the remaining low levels of infection shall further enhance the herd immunity. As for the rest, vaccination can be deployed to do the mopping up. Unfortunately the picture turned awry way too soon.

Corona warriors have been dying all through. As against the government’s initial promise of providing all doctors involved in the fight against corona with a sizable health insurance, the country’s health minister stated on the floor of the Parliament that the government did not have any data of doctors who had died likewise.

The galloping infection rates have dwarfed all peaks assailed earlier. This time around it is those below the age of 45 years who constitute the infantry of the spreading virus. The very cities and states which had borne the maximum brunt of the pandemic, and accordingly should have had maximum herd immunity remain the most pulverized once again. Science and a scientific approach to fighting the pandemic stand defanged and utterly vulgarized by this government.

This couldn’t but have a stultifying effect on the scientific community at large, while those of its members occupying high positions of responsibility have set higher standards of servility to the regime turning grave diggers of their own expertise and reputation. There is no dearth of people in his majesty’s cabinet who can outdo each other to take the role of jester in the Delhi durbar, then why should scientists leading major national medical institutions partake in specious arguments to proclaim success of corona lockdown, or blame a particular religious community for spreading corona in the country, or bearing the ignominy of ordering vaccine trials to be started and wrapped up within a month’s time only to provide cover for predetermined results?

I would end by narrating a short story. A lion cub, separated from its pride, happened to be raised by a pack of wolves. Sometime later another group of lions saw this young one of their species and rescued him from the wolves. Unable to hunt as this young one was, and anguished by his timidity, the liberators beseeched – ‘You are a lion cub. You may take time to pick hunting, but you can at least roar.’

The moral of the story is that all these institutions of medical science and the scientists of repute occupying hallowed positions ought to prove true to their most fundamental trait – ‘Serve the People.’ As regards the lion from Gujarat, he shall do well to realize that it takes more than a roar to be counted as one among the greats in the comity of nations.

By the way, I wish all readers a very happy ‘Teeka Utsav.’ It can only be hoped that this prepares us in earnest to defeat Corona.

Views expressed are personal