Positivity, healthcare and responsibility of the citizenry!

A modern civilised nation is governed by rule of law and is held together as a society by cultural imperatives, codes of collective morals and ethics. It relies on shared history and common future aspirations to keep the nation together, united as one force. A large enough group of people can’t remain united without any of these in place. Time and again though when one of these forces begin to grow weak under the influence of temporary developments, the ruling class throws into the mix a ‘common enemy’ to galvanise the masses with the goal to dissolve differences thereby gaining the lost grounds of cohesion. Nature has done its part this time around in uniting the whole of humanity by allowing the virus to have a ball. Yes, to put things on record, I do not buy into the conspiracy theories that point to COVID-19 being a Chinese laboratory mishap. To my mind science of the day is not that evolved, and in my assessment it can’t accomplish something of this proportion, just yet. Nations, rich and poor, have proved to be inadequate, across the globe in the face of the challenge that the virus has posed. The US languished in the 1st wave but made a decisive recovery by being thoughtful with its vaccine strategy. The UK did not fair well too in the first wave but made wise corrections from the 2nd onset and followed it up intelligently with an effective vaccination drive. Tales of the rest of western Europe are also more or less the same; fell first and then gathered themselves up.

This however can’t be said about Indian management of the crisis, we stand apart – truly in a league of our own. Unlike any other sizable sovereign on the planet that first goofed up and then corrected itself by imposing restrictions to break the chain of transmission followed in quick succession by inclusive vaccination program; we managed the first wave relatively well and then messed up completely in the 2nd wave and we did not stop there we also gave the game away by completely throwing the vaccination strategy in the bin. We have earned the dubious distinction of having the most unscientific response to the virus imaginable. Helpless poor Indians dying by the thousands as a result of acute shortages of everything necessary from oxygen, to hospital beds to medicines to doctors to nurses and even ambulances, stand testimony to the failure of the current regime. Ugly misery has spread itself visibly on the roads and the streets of the nation so starkly that it has overwhelmed the strong hold that the Government has on the media and as a result of which it is finding it impossible to keep the damage under the covers, hidden from the scrutinizing gaze of the world. Social media carried the painful cries of the Indian people to all parts of the world connected with the internet. Monumental mismanagement could no longer be hidden. Taking a clue from it the Government has quite cleverly come up with ‘positivity spin’ to harvest favorable coverage for itself and to take the attention away from its own failings. 

In the first half of this article let me present to you three such events, which are utterly disconsolate, but have been presented to the nation as courageous, smart, considerate and inventive moves by the citizens – the ‘positive spin’, as it were, has been given to the negative news. 

Social media preceded the coverage of reputed newspapers and subsequently the ‘event’ was also given space in the new-age internet media; images of Indians quarantining on trees! We learn about history from the text as well as images, later being more profound. Billions of pictures are taken every day, especially in our time and age, cameras embedded in ubiquitous mobile phones have made capturing moments easier than ever before. When history of this time is written, it will be impossible for histographers to not include these images which speak of our poverty, the pervertedness of the ‘system’ and the collective helplessness of the society, both loudly and clearly in equal measures. These pictures are an antidote to the product of the well-oiled propaganda machinery of the rulers of the day. When I say these things, I am mindful of the fact that every story, every narrative, every detail; in an argumentative society has many layers. Nuance is not always welcome and superficialities sometimes do outrun deeper truth. And perhaps, when current affairs are filtered in the funnel of time, the dust and impurities of passion, pomp and show, I hope, will get eliminated and what will come out will be an unadulterated, accurate and unemotional representation of facts, the truth of our times.

This is why it has been said that journalistic reports and commentary on events of the time are the first draft of history. I wish therefore to accommodate the ‘positive’ version that has come out too, in which people praised the ingenuity of these villagers who not only took the threat from Covid19 seriously but also took effective steps, at the cost of their convenience and despite the lack of means, needed to safeguard their near and dear ones from the deadly pathogen. I have provided here a link to just one such news report from the source that I trust for my information. It must however be said that it is not the only source, this story has been covered extensively. 

Hindu Coverage: Coronavirus | Migrant labourer completes quarantine on a tree 

I see the ‘positive praises’ in the same light as I received the ‘pleasant’ weather reports in the national capital region of India this week, knowing fully well that it is at the cost of severe devastation and deaths caused by the cyclone Tauktae on the western coast of the country. We enjoyed cool afternoons, our air conditioning devices could catch some rest only because at another place, thousands of KMs away from our residences, some of our own people were suffering. While they were waiting for help to arrive both nervous and anxious in equal measures, some of us in the north wanted this weather to extend as much as possible.

I have to confess that the cool breeze that soothed me on the exteriors caused me pain on the inside, just as much as, reading lauds for the individuals on the treetop, made my heart sink.

Let’s analyse yet another instance of the state failing miserably in its primary function of saving the lives of its citizens. Last month, a report made many of us gloat, over 85 years old, now late Narayanrao Dabhadkar, giving up his bed to save the life of a young man.

Indian Express report: Viral claim about 85-year-old RSS worker giving up his bed for younger man runs into questions.

The brave selfless soul died three days after his discharge. The country, in one voice, praised him. Enthusiasts among the supporters of the current regime also dug out his connection with RSS to incinuate that, that is exactly how all men of the self-proclaimed nationalistic Hindu organisation the RSS, are ‘selfless’ and ‘righteous’. Thankfully, we know to ignore these baseless collective claims with ease. The tragedy has been given a massive ‘positive spin’ but is it not impossible to overlook how the state failed in providing an old man with a bed and other necessary medical treatment as a result of which he died. What we collectively and blithely ignore in this ‘positive spin’ is the fact that ‘right to live’ is not an either-or proposition but something that is applicable to all Indian citizens under our constitution. The old man deserved to live no less than the middle-aged patient for whom he sacrificed his life. 

I bow in respect of the supreme sacrifice but at the same time, I also feel ashamed for being part of a country that can’t save its citizens from an illness that has been known for over a year.

The propaganda of positivity is not only restricted to colouring the news reports with rosy tint but it also has been deployed with the sinister intention of concealing facts that reveal the poor delivery of the union government. There is no way for us to know precisely of all declared and accepted Covid deaths by the Government, how many could have been saved if they got timely and able medical assistance? Some experts believe that a little over half of those who perished prematurely could have survived, though with diminished quality of life, if they got what their medical condition commanded. Whose responsibility was it to ensure that everything needed was provided for? It is that of the elected union Government, when I say this I am mindful of the fact that ‘health’ is a state subject. Let us not forget though that the epidemic act of 2005 that the union government invoked last year is still in force. And therefore, I say, this pandemic is totally and completely the responsibility of the Modi government.

We know that not only have they failed spectacularly in doing what was required of them but they have also brazenly abandoned responsibility and made a concerted attempt to push blame of the failure over to the states. Indian states have neither the expertise nor the financial resources to deal with the calamity of this pandemic and yet, they are having to muscle it all by themselves. Image conscious PM has held multiple meetings with the district magistrates in which he gave no ‘objective’ detail, and got away instead with generic ‘feel good’ comments. As the meeting ended a bunch of photographs and video clips were released to the public and the media, who in turn plastered them everywhere to create an impression that PM Modi is hard at work. The ‘positive spin’ you see.

The truth however could not be any further from the claims. Very simply if he worked, so many would not have died in such precarious circumstances.

Let’s now turn to the state of healthcare in our country.

The subject requires a much deeper dialogue, discussion and debate. Decades of studied underinvestment has impoverished the infrastructure immensely. To give you a sense, I quote from a WHO study.

Quote 1

“World Bank data (https://bit.ly/3u4cHfg) reveal that India had 85.7 physicians per 1,00,000 people in 2017 (in contrast to 98 in Pakistan, 58 in Bangladesh, 100 in Sri Lanka and 241 in Japan), 53 beds per 1,00,000 people (in contrast to 63 in Pakistan, 79.5 in Bangladesh, 415 in Sri Lanka and 1,298 in Japan), and 172.7 nurses and midwives per 1,00,000 people (in contrast to 220 in Sri Lanka, 40 in Bangladesh, 70 in Pakistan, and 1,220 in Japan).”

Quote 2

“Centre for Economic Data and Analysis (CEDA), Ashoka University, shows that this has been stagnant for years: 1% of GDP 2013-14 and 1.28% in 2017-18 (including expenditure by the Centre, all States and Union Territories) (https://bit.ly/3bw3O7Y). Health is a state subject in India and State spending constitutes 68.6% of all the government health expenditure”

** Note that both of these quotes are from the editorial published in The Hindu, dated 21st May 2021.

It should also be acknowledged that additional healthcare capacity can’t be augmented in the short term. You can erect buildings, buy equipment, procure most advanced medicines but healthcare professionals who can use the infra to cure people, take time, a lot of time to come by. Medicine is a highly specialised field. To give you a sense, if we decide to improve the ratio of doctors per 1000 Indians today, the impact of it will only be seen in 10 years, that is how long it will take. But as you know elections happen every 5 year and electorates do not necessarily punish the politician for what is ‘not there’, the social awareness around these aspects are yet not developed among the masses.

A country that has wilfully not chosen to spend on healthcare for decades together can’t expect its infrastructure to have the capability to see the surge of a kind that we witnessed and to some extent are still witnessing in the 2nd Covid wave through, without widespread apocalyptic damage, death and destruction. So, as much as we would like to not believe; these deaths are a result of deficiencies that are not only systemic and structural but also deeply rooted in the thinking of the policymaker. Our problems are as old as the Indian democracy itself. We would have absolved the Narendra Modi government of what clearly is an unpardonable sin of mis-governance easily, if he elected to make any headway in the right direction in the course of the last year. Sadly every piece of evidence points to the contrary. He collected massive sums of money in his private fund named ‘PM CARE FUND’, a fat sum of 30K Cr. has been put aside in the union budget for vaccine-related expenditure and yet, he did not order vaccines in time. Even now, the states have been left to fend for themselves. PM CARE FUND is as opaque as opaque can be, significant efforts have been made by the PMO to hide it from the gaze of RTIs.

The misfortune of the Indian people is that the executive head of its republic is a man who cares about elections and elections alone. It should not be forgotten that he organised “Namaste Trump” in Gujarat, right at the beginning of the 1st wave of Covid, last year. He went ahead with it, despite India having discovered the first lot of patients suffering from the virus. Not just that, he waited for the Congress-led MP Govt to fall and Shivraj Singh Chouhan from his party BJP, to regain power, before declaring the 1st lockdown. Right in the middle of the 2nd wave he himself, his entire cabinet and party leadership were busy gathering huge crowds in all 5 states elections. Mercifully voters did not choose him in WB, Kerala and Tamil Nadu. He did however manage to keep power in Assam and win the UT of Puducherry for this party. 

In the last two essays :

#1 Indian an evaporating state: https://lavkush.co.in/india-an-evaporating-state/ 

#2 India floating lifeless : https://lavkush.co.in/india-floating-lifeless/

We’ve dissected the cause of the failures, some of its seen and many of its unseen effects, in the rest of this write up let’s turn our focus to what changes should be made in the state of healthcare so as to ensure that, the next pandemic does not inflict upon us the same degree of devastation as this one lamentably has.

In a democracy, everything is an outcome of politics; from administration to economy to healthcare. Politicians, by way of policies and allocations, try to answer the questions that people ask of them. In the name of carrying out the will of the people, they fulfil their ideological commitments to their political parties. The debate on which set of ideologies is better than the other is an endless one and we should not get into it. Instead, our focus should be on making the things that matter important to the politicians. The core issue is that we vote on ‘vague’ promises. ‘Development, Employment, National security are agendas on which we the voters have been surrendering our fates to. We do not ever ask, how? Where will the money come from? Who is going to be a part of the executive team? How will the manifesto become a reality? The action plan, as it were.

India needs to take a clue from the United States of America – the way it has secured its institutions. It was the institutional integrity of the US that brought an end to the mistake that the voters made in choosing Trump. In India, we the citizens, instead of holding the elected representative to account we work hard to opt-out of the government. We send our children to private schools. When unwell, we seek the care of private hospitals. People with substantial wealth trust private security agencies to keep them safe. Our demand from the Government has still not matured beyond clean pothole free roads and bridges. We do not ask for universities and quality academic institutions. We do not fight for their research freedom, instead, we frown upon them.

The direct tax-paying vocal middle class in this country chooses to ignore that poignant state of the healthcare facilities. There is a strange acceptance of government-run facilities to be poor in cleanliness and deliveries. So much so that, when we see things not moving fast enough, we often remark, “Why is this moving at the speed of Government”. We have normalised under performance. Tied in unavailing and outdated concepts like religion, region and caste; we do not unite our voices on basic questions of healthcare, education, safety, financial wellbeing, improvement in the standard of living – we just do not. Election after election, we just vote someone, without ever assessing their objective performance.

When something grave and dramatic befalls us; we shut down our tribalistic instincts  for a while and then go back to nourishing our caste, religious and region biases over again. Politicians exploit this weakness to legitimise substandard results. Collective ignorance causes deaths as we have witnesses up and close in the last 18 months.

The other problem is that of data, we just do not know. Governments collect data selectively, they decidedly paint a picture that makes them look pretty, irrespective of the situation on the ground. Did the health minister not proclaim that Covid is in its endgame here in India, in the 2nd week of March this year? Have elected chief ministers not gone on record saying things are all right in their state? Have they not strenuously denied shortages of Oxygen, beds and medicines in their states? All of this when the truth is unravelling right in front of our eyes? Imagine how truthful and forthright they must be on items that we do not have intimate knowledge of?

What gives the politicians the courage to bullshit their way out of a difficult situation? The answer lies in the fact that ordinary Indians do not look for data and objective evidence to validate the claims that are made by their leaders. It won’t be a stretch to say that they trust what they hear from those in positions of power. Call it our collective naivety, innocence or plain stupidity. That is what it is. Politicians won’t work on things unless we make them work on them. We will need to come to the position from which we can set the agenda of the day, and not be blindly led by the whims and fancies of those in electoral politics. We will need to stop voting for a symbol unrestrainedly and start scrutinising the qualities of the candidate, their past, their ability and their plans not just their plain promises before we cast our ballot in their favour. 

To make healthcare the priority of the politicians we will need to ask and seek data/information on these questions.

1. How aware are we of the major health crisis of the city or the area that we live in?

2. Do we value the glitz of the property more than the actual treatment that is being rendered?

3. How easily and frequently we self medicate? 

4. Do we let quacks decide the course of our treatment?

5. Do we try to find out the scientific basis of the various forms of advertisement and endorsement that we are subjected to?

6. How much do we spend on the prevention of a condition?

7. How strongly do we demand laws to crush the nexus between the medical establishment and pharmaceutical and pathology outfits? 

   
   

Any form of data, from unemployment to college dropout to causes of death is “exotic” in our country. Have we ever made the ‘quality of information’ an election issue? 

On community health, have we ever questioned?

1. How are people feeling?

2. What is the form of ailment that is causing distress in the area?

3. Report on the state of water and air in the region? 

4. How long do we wait on common infections; fever, cold and pain etc before seeing a qualified doctor?

What effort have we made to improve the quality of conversation that we have been having with the health care providers, doctors and nurses alike?

1. How long does the conversation last? 

2. Do we ask the doc why a certain med is being recommended? 

3. Why is a certain investigative test important? 

4. How informed is the decision that we take?

   
   

What kinds of incentives have we provided for both the political class and the healthcare professional to behave ethically and in our interest? 

We are responsible for the mess that we find ourselves in. We refuse to ask questions, we refuse to bring them to book for not doing their jobs!

Let me give you a data point, India is among the countries with the highest out of pocket expenditure, as much as 64%, on total healthcare expenditure. Individuals, can’t have the knowledge needed to assess the correctness and the applicability of the treatment being provided therefore it is needed for the Government to legislate and being a layer between citizens and the healthcare system.

We can call it insurance or give it another name. If there is one thing our PM does right, it is naming schemes, I am sure he can come up with something fun.

Below items could form the outlines of the legislation. A law to regulate the flow of money into the healthcare system.

1. Citizens who can afford to pay the insurance, should pay a proportionate amount, it could be made another tax at the source of the income.  For those who can’t, the Government steps in for them.

2. The agency on our behalf keeps the hospitals in check. 

3. Grantee of care and outcome is ensured by performance metrics and related rewards and penalties.

4. Direct payment has to be completely ruled out.

5. The agency works in consonance with the public health care function of the government to make sure that hospitals anticipate health care issues and stock supplies to facilitate seamless care.

6. Every piece of information, from input to output; is made publicly available.

7. Modernisation of the healthcare system is made into a mandate. 

   
   

For things to improve we will need to become citizens. An informed citizenry, asks questions of the establishment, uncomfortable and difficult ones. Keeps the power in check. Sadly, in the last 7 years, we have been reduced to subjects. We are fed propaganda and we indulge in worship and that precisely is the reason for such grand apathy from the Government.

It is high time we change!