View: As the politicians took over, time-tested public health principles took a back seat

In the chronic underinvestment and neglect of public health in this country. India has one of the lowest allocations to health among all the countries of the world.

By T Jacob John and Zarir F Udwadia

India’s Covid-19 count recently crossed 1.5 million, with no end to the horror in sight. Indeed, modelling analysis from MIT predicts that by early 2021, India will have overtaken the US and Brazil to have the most Covid cases in the world, with 2,90,000 new cases every day. This would be the right time to assess errors made along the way, since crucial lessons for the future are inherent in them.

Remember that up to the point when the prime minister, with less than 4-hour notice, declared the world’s largest, longest and most restrictive lockdown in history, there had been less than 500 cases and 10 deaths from the Covid pandemic in India. What then caused the steep exponential rise to the current staggering numbers? Critics argue that India was the only country that lifted its lockdown at a point when the number of cases was steadily rising instead of stabilising.


The lockdown was a blunt tool, at best a temporary measure. A lockdown is an opportunity to increase preparedness and shore up medical facilities. But decades of neglect are impossible to fix during a few months of lockdown. Indeed, if the deaths of many cruelly disregarded migrants, and the toll from other non-Covid diseases which were neglected because people were unable, or too afraid, to seek medical help are factored in, many more lives may have been lost than saved by India’s lockdown.

But the real roots of this problem lie much deeper: In the chronic underinvestment and neglect of public health in this country. India has one of the lowest allocations to health among all the countries of the world, consistently less than 2% of GDP. This pandemic cruelly exposed our weakest link – badly equipped and understaffed public hospitals, chronic shortages of hospital beds and unmotivated, poorly trained staff.

India has one of the lowest densities of health workforce, with a paltry 7 physicians and 17 nurses per 10,000 population as against the global average of 13.9 and 28.6 respectively. As Paul Farmer, medical anthropologist and physician reminds us, “Excellence without equity looms as the chief human rights dilemma of healthcare in the 21st century.”

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Along with the novel coronavirus causing the pandemic, a more sinister, bizarre and unique “second virus” affecting the minds of national leaders also became a pandemic. It made them believe that the response to the coronavirus pandemic must be led directly by presidents or prime ministers, no less. Most country leaders fell victim to the second virus.

Those leaders who relied on time-tested public health principles protected their countries from severe consequences of Covid. Others disregarded available public health expertise and principles and made pivotal decisions they weren’t equipped to make. The consequences would reverberate, impacting on lives and livelihoods of millions.

As envisaged in our Constitution, pandemic management is the central government’s responsibility for which it has several institutions in place: Directorate General of Health Services (DGHS), National Centre for Disease Control (NCDC), Department of Health Research (DHR) and Indian Council of Medical Research (ICMR). These agencies have not functioned harmoniously in the best of times: Perhaps it was asking too much to expect them to weave into a cohesive unit at this pivotal time. The Centre bypassed them, designating the country’s pandemic response to the National Disaster Management Agency (NDMA) and invoked the Epidemic Diseases Act of 1897, giving the Centre extraordinary powers to mitigate the consequences of the pandemic – as if the pandemic demanded not public health but political and civil administrative responses.

Since healthcare is constitutionally each state government’s responsibility, India’s 28 states and 8 Union territories were conveniently left bereft of a plan, guidance or adequate funds. States were assured of mysteriously hidden protection, but little leadership on how best to proceed. The Centre took on the role of umpire instead of coach, sending inspecting teams to selected states as if they needed umpiring.

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ICMR, India’s apex medical research organisation, made several perplexing decisions. In the initial weeks of the pandemic only the ICMR’s lab, the accomplished National Institute of Virology (NIV) in Pune, served as the sole testing lab for a country of 1.38 billion people. When apparent that testing capacity needed to urgently expand, only public sector labs were initially permitted, excluding all private labs. Eventually such meaningless restrictions were lifted.

Even today, as the pandemic approaches its peak, there are only around 1,200 labs across the country. UP, for example, has just 1 PCR testing lab per 30 million population. In the initial months of the pandemic ICMR also insisted all patients be hospitalised, despite it being clear that the majority could be managed with equal success by home isolation. Initial discharge criteria were equally stringent, with 2 negative PCR tests being mandated before a patient could leave hospital, resulting in a waste of precious resources. And the preposterous hype that “India’s first indigenous vaccine against Covid-19 would be launched by August 15” went contrary to all available evidence.

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What if another pandemic appears on the horizon? Surely our response should be governed by science and strategy and overseen by experts? Now is the best opportunity to create a health management infrastructure that is commensurate with India’s needs and potential. Can a country that doesn’t know how to control TB, typhoid, cholera, and malaria (to name just a few diseases endemic in India), learn how to manage a new disease, aptly described by a Niti Aayog expert as “one more animal in our zoo”? India has world class experts; why not use them and seize the day?

(T Jacob John is former Professor of Clinical Virology, CMC Vellore. Zarir F Udwadia is Consultant Physician, Hinduja Hospital & Research Centre, Mumbai)
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