Almost four decades ago, the late Bal Thackeray of the Shiv Sena and the technologist Sam Pitroda found themselves on the same stage. 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.
India’s health sector is faced with this kind of a fork in the road 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 using technology to reach more people in remote areas to expand the reach of our limited physical health infrastructure. A number of companies are playing with business models in telemedicine, remote monitoring using Machine Learning and Artificial Intelligence and tuning their models to optimise demand-supply in a time of shortage of skilled physicians. 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 the existence of diabetic retinopathy and glaucoma.
The solutions carry the capacity to revolutionise healthcare, but they must work in an ecosystem where even today at least a 100 people die of snake bite every day and likely more have died as the Covid-19 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 remotely, 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 on us by the epidemic and the response of a government that has proved unwilling or unable to rise to the challenge. The forced and sudden lockdown, the beating up of people and the system into submission by the 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 huge jump in the burden of disease. This will inevitably translate to increased deaths and the reversal of hard-won gains in whatever successes had been achieved over the years.
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 nearly 23 million children without oral antibiotics for pneumonia, over 27 million children without DPT vaccinations, more than 4.7 million women without access to facility-based deliveries, and some 40 million 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 the child mortality in India could increase by 40% and maternal mortality by 52% 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 could 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-19, could 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 $3.2/day), increasing the number of India’s poorest to 915 million so that the proportion of poor grows from 60% to 68%, 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 healthcare, linking to increased cases of tuberculosis, for instance, 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 24) 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 five years — adding up to an increase of over 1.5 lakh (5.7%) 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%, to nearly 512,000 in the 2020-2025 period.
Consider polio. India was declared polio-free in March 2014, but there are worries that the disruption in the polio programme will cause the virus to return; suspected cases have been reported from Jharkhand and Punjab. With the focus on the vaccine to fight Covid-19, we do not have a fuller picture of what else 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 us 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 increasingly anaemic, poor and often ill-informed to demand the services people deserve. This, built on a system that was already bad. Data from the recently released NFHS-5 shows that the number of anaemic women increased in the years 2014 to 2019.
India’s education sector similarly faces new challenges. While urban centres struggle with patchwork solutions on online platforms like Zoom, 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. Anecdotal evidence and media reports also point to a rise in child marriages in many parts of the country. Mid-day meals have stopped, which means the hard gains made over decades in improving nutrition levels have been lost, and that circles back to challenges in health.
Here is the bottom line: Health and education are the two legs on which any policy on sustained growth and development stand. When these legs are weak, there is nowhere to go, let alone run.
(The writer is a journalist and faculty member at Bhavan’s SPJIMR)
(Views are personal) (Syndicate: The Billion Press)