Almost four decades ago, the late Bal Thackeray of the Shiv Sena and the technologist Dr. Sam Pitroda found themselves on the same stage. Dr. Pitroda talked of innovation that could grow watermelons square-shaped so that they could be packed efficiently and transported with ease. Thackeray came on to say that was amazing but that he was more concerned about building toilets so that people don’t defecate on the streets.
This kind of fork faces India’s health sector as we come to terms with the ravages wrought by the pandemic and the possibility that the worst of Covid-19 may be behind us by mid or end 2021. On the one hand, there is exciting talk about use of technology to reach more people in remoter areas to expand the reach of our limited physical health infrastructure. A number of companies are playing business models in telemedicine, remote monitoring using AI and ML to optimise the shortages of skilled physicians are adjusting to demand and tuning their models accordingly. It is possible to look at images delivered by a digital eye fundus camera and use technology to detect macular degeneration as an early warning signal or existence of diabetic retinopathy and glaucoma. The solutions carry the capacity to revolutionise healthcare but they must work in an eco-system where even today at least more than 100 people die of snake bite everyday and is likely more have died as the Covid enforced lockdown made it difficult for citizens to access health services. There is also more grounded and remarkable work, like the efforts at the government-run Tata Memorial hospital, where more people were reached by remote, with authorities going to the extent of bulk negotiating with distributors to ensure that patients received timely and affordable drug supplies and kept their treatments going.
Exceptions like this apart, the nation must wake up to the enormity of the calamity that has been forced by the epidemic and the response of a government that has proved to be unwilling or unable to respond to the challenge. The forced and sudden lock down, the beating of people and the system into submission by police forces armed with the British era instrument of the Epidemic Diseases Act and the complete lack of understanding of the many moving parts of a complex puzzle have brought us a criminal jump in the burden of disease. This will inevitably translate to increased deaths and the reversal of hard-won gains in whatever successes have been achieved.
Consider these astonishing numbers from mathematical models published by the Global Financing Facility of the World Bank Group: Large service disruptions in India have the potential to leave 22,729,900 children without oral antibiotics for pneumonia, 27,230,100 children without DPT vaccinations, 4,742,000 women without access to facility-based deliveries, and 39,829,900 fewer women receiving family planning services.” What does this mean? The report tells us that a result of disruptions in all essential services means that child mortality in India could increase by 40 percent and maternal mortality by 52 percent over the next year. In short, all gains made in our slow progress in areas of reproductive and child health will be more than wiped out, and these impacts will begin to show up and stay with us long after the pandemic is tamed.
The picture is the same everywhere – from cancers to tuberculosis to a range of other concerns that will virtually explode in our face and take the Indian dream and hopes of growth down a dangerous and slippery path of disease and death. The poor, already rendered poorer by Covid, can be sucked into a vicious cycle that will deprive them and their families of the capacity to earn as they sink deeper into poverty. The risk remains real in these circumstances of technology solutions of the kind growing in the Indian system of being run for the better off and the rich so that the gap between the upper end and the lower end of healthcare widens and worsens. These are the wages of a leadership that has ignored the complex and deep connections between health, education and development.
Forecasts tell us that 104 million additional Indians will sink below the poverty line (income under USD 3.2/day), increasing the number of India’s poorest to 915 million so that the proportion of poor grows from 60% to 68%, which is levels seen a decade ago, according to an analysis by the United Nations University. This poses new challenges on issues of poverty, which brings poor nutrition, poor access to information and health care, linking to increased cases of tuberculosis in a nation where 2,000 people die a day of TB alone.
The poverty and TB data is discussed in a paper authored this month in ‘The Indian Journal of Tuberculosis’ by Dr. Zarir Udwadia of Mumbai’s Hinduja hospital and others, who note that weekly counts of reported cases of TB dropped by 75% in the three weeks following lockdown commencement (March 24th) compared to an average of 45,875 weekly cases during the previous weeks of 2020. These dramatic reverses appear not to have picked up even late into the lockdown. They will lead to severe long-term consequences. A study by the STOP TB Partnership (in collaboration with Imperial College and Johns Hopkins University, Avenir Health and USAID) that said each month of lockdown in India could cause an additional 40,685 cases annually from TB over the next 5 years adding up to a total of 1,51,120 (5.7%) increase in TB deaths in India in a scenario of a two-month lockdown and a period of two months to restoration of services. In a worst-case scenario (a three-month lockdown, which we exceeded, and 10 months to restoration of services), cases of TB would go up 12% with excess deaths of 19%, or 511,930 cases in the 2020-2025 period.
Consider polio. India was declared polio-free in 2014 but there are worries that the disruption in the polio programme will cause the virus to return; suspected or confirmed cases have been reported form Jharkhand and Punjab. With the focus on the vaccine to fight Covid, we do not have a fuller picture of what is brewing.
It can be argued that some of the numbers here represent the worst-case scenarios. Some have argued that social distancing means TB cases can drop. Under attack, officialdom tends to paint a neater picture. But diseases, virus and bacteria and indeed the dynamics of our health infrastructure don’t change with image makeovers. We are in the dumps and it will take a deep change in the way leadership responds for this to get back on the path to recovery again.
The stories and worries are the same on many fronts. They present a picture of rising burden of disease and death in a health system that is falling apart, serving a population that is anaemic, poor and often ill-informed to demand the services people deserve. This built on a system that was bad. Data from the recently released NFHS-5 shows the number of anaemic women increased in the years 2014-2019.
India’s education sector similarly meets new challenges as the companion piece here argues. While urban centres struggle with patchwork solutions on platforms like Zoom online, rural areas have seen dropouts who are not going to return and will probably enter the labour market at the bottom of the scale under exploitative conditions. Mid-day meals have stopped which means nutrition is bad and that circles back to the challenges on health.
Here is the bottom line: health and education are the two legs on which any policy on sustainable growth and development will stand, When these legs are weak, there is nowhere to go, let alone run.
(Jagdish Rattanani is a journalist and faculty member at Bhavan’s SPJIMR) (Views are personal) (Syndicate: The Billion Press) (e-mail: editor@thebillionpress.org)