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Where is the Public Health in India’s Response to this Public Health Emergency?

By Sayan Das
on June 4, 2020

The World Health Organisation declared COVID-19 a Public Health Emergency of International Concern on January 30 2020, the same day India reported its first confirmed case. The country, so long oblivious to this developments-except for the southern state of Kerala which had a preparedness plan ready by mid-January-quickly sprang into action. Screening at the airports commenced, followed by suspension of International flights on March 22. That day itself, as requested by the Prime Minister on March 19, Indians maintained a day-long voluntary curfew which ended with loud banging of pots and pans.  Two days later a nationwide lockdown was announced on four hours’ notice. The total number of cases at that point was 519. Two months have since passed, and we’re now in the fourth phase of the lockdown, with 2,07,191 diagnosed cases and 5,829 deaths (as of June 2).

While the numbers are not huge compared to India’s population size, they have been offset by the widespread social disruption and unprecedented humanitarian crisis that resulted due largely to the nationwide lockdown. The sudden announcement of the lockdown forced a vast number of migrant workers, now without work, money or safe shelter, to walk thousands of kilometres to return home. The situation soon escalated into a major humanitarian crisis, plagued further by reports of many distress deaths. Simultaneously, ‘covidisation’ of healthcare priorities resulted in a near-total breakdown of routine healthcare services. The Tuberculosis programme became the worst casualty with notification of new cases hitting rock bottom. Unemployment, already high, scaled unprecedented heights. These developments then bring us to the question: should Public Health concern itself with these issues, or do they lie outside its ambit?

Public Health has been famously defined as an amalgam of science and art for preventing disease, prolonging life and promoting health through social action. Charles Winslow, credited with the definition above, may have concerned himself with only physical health back in the 1920s, things have changed quite a bit in the hundred years since then. Health is now widely recognised as encompassing physical, mental as well as social dimensions. That underlying social contexts contribute significantly to shaping health differently for different sections of the population is well-established, at least in Public Health theory. This understanding of health, where the social is embedded within the biological, is central to the universe of Public Health, not a medical system primarily engaged with disease management.

In practice, however, we often witness the contrary, and that is exactly what we saw unfold in India during the pandemic. Held to ransom by the virus and swayed by global modelling exercises -much of whose projections later proved to be way off the mark- the country hastily implemented a nationwide lockdown-one of the most stringent in the world-without consulting its own Public Health experts or considering the tremendous socio-economic implications until it was too late. India’s unemployment rate is at a sky-high 27.1% now with 122 million having lost their jobs in April alone. A group of researchers tracking news reports found that more than 600 people died due to hunger, financial distress, police action, or simply being unable to access medical care for other ailments during the lockdown. These, unfortunately, are only the reported cases.

 While maintenance of health in the present is crucial, much of Public Health is also about organised efforts by the society to ensure health and wellbeing in the future. What is health promotion if not about improving the social and economic condition of the deprived so that they also flourish? What is prevention of disease if the need for adequate nutrition is not met now to build up immunity for a fighting chance tomorrow?

Unfortunately, India, already bearing a third of the global burden of malnutrition, failed to feed all its poor and starving in this moment of crisis by refusing to universalise the public distribution system, a long-held demand by the Right to Food Campaign. It was certainly not due to a shortage of food stock as the government comfortably sat on four times the required buffer stock of food grains throughout the lockdown. These developments are likely to have far reaching consequences in the future, especially for the already vulnerable.

In fact, the emphasis on collective action to ensure health of ‘every individual in the community’, immortalized in Winslow’s original definition, puts a further moral imperative on the society, primarily the state, to look after all its people, leaving no one behind. In a highly unequal country like India, this would mean extending additional support to the most vulnerable and also pre-empting the unintended consequences of interventions, as difficult situations tend to deal the worst hand to the already weak. Having about 40 million migrant workers or 82% people employed in the unorganised sector with little to none social security, it was the job of the government and its experts to also model the impact of the lockdown on these people, in addition to the virus.

In our zeal to control the pandemic, we tend to forget that we’re dealing with human beings and their existing contexts here, not merely a virus. Community engagement, beyond expecting people to obey guidelines from the top, but to encourage their own initiatives-of which there have been multitudes- has been surprisingly missing from the strategies employed in India. It is understandable that the health sector alone would be unable to operationalize the multi-pronged responses required in this epidemic. The principles of community participation and inter sectoral coordination, enshrined in another milestone Public Health document some 40 years ago, thus become critical in mounting a coordinated front, along with the communities, against the virus.

Evidently, all these issues beyond the biomedical have been very much central to Public Health thinking over the years. In practice, however, we have faltered for a variety of reasons-the dominance of technocentric biomedicine, commercial interests, even authoritarian inclinations. But the uncertainties around this pandemic have forced us to look back on the time-tested lessons that have worked well and, importantly, worked for the most. It’s time therefore to bring the social back to the biological and precisely that is how we make the science and art meld in the crucible of Public Health, towards a better health for all.

Note: Winslow’s original definition :”Public Health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health; organizing these benefits in such fashion as to enable every citizen to realize his birthright of health and longevity.”

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