Health Of The Nation In The Times Of COVID-19

Health has become top priority for governments and people around the world, thanks to the novel coronavirus (SARS-CoV-2) disease 2019 (COVID-19) pandemic which has caused disruption at a scale unprecedented in recent history. Until 29th March 2020 (09:15 IST), there were 664,924 confirmed cases, 30,847 deaths as well as 140,156 recoveries at the global level – the figures being 987, 24 and 84 for India respectively (Johns Hopkins University’s Coronavirus Resource Center).  

To contain its spread, countries are encouraging / enforcing social distancing – in India, the Prime Minister imposed a 3-week national lockdown starting March 25th. Although India has, thankfully, not been as badly affected as several other countries – including some of the most developed – it is potentially the world’s most vulnerable country from a human, economic and other perspectives.  

India’s vulnerabilities to the coronavirus 

Table 1 highlights some of the vulnerabilities that the country faces. It only has 2.3% of the world’s land for 17.7% of world’s population. Population density is widely seen as one of the determinants for the spread of communicable diseases. However, its potential health impact could be mitigated. For instance, while Kerala had a higher population density than Uttar Pradesh (UP) – 859 and 828 persons per sq. km. (Census 2011) – it had the lowest death rate due to respiratory infections and tuberculosis, while UP had the highest, in India – 36 and 105 per 100,000 population respectively in 2017 (Global Burden of Disease). Kerala’s performance in terms of its economy,1 nutrition2 and public health governance3 seem to have helped in mitigating the health impact of population density. 

At the national level, compounding the challenge of population density is India being home to the world’s – 2nd largest 60+ year population; largest population below international and other poverty lines (with 82% of the national population living below US$ 5.50 a day); a little less than one-third population (half of its own) with nutritional deficiencies; and 2nd largest population with diabetes. Such demographic, economic, nutritional, health and other risks make India a potential hotspot for the worst impact of SARS-CoV-2. It already has been the world’s largest contributor to deaths due to communicable diseases since comparable international data is available (1990) – accounting for more than a quarter of such deaths globally in 2017. Its Integrated Disease Surveillance Program (IDSP), which focuses on epidemic-prone diseases, reported 5,999 outbreaks in 3 years (2016-18).  

India needs a comprehensive, complex and targetted approach  

Even if the contagion has been contained so far, given India’s vulnerabilities, a national lockdown might have been the best strategy. However, our approach should be comprehensive, complex and targetted at the same time. A comprehensive and complex approach is needed for the surveillance, understanding and tackling of different vulnerabilities – keeping in mind their mutual interactions, synergies, impacts and triggers at an ecosystemic level. 

Firstly, as the migrant outflux from Delhi illustrates, the lockdown has already exacerbated India’s economic and nutritional vulnerability. Steps taken by the Delhi government or the INR 1.7 trillion relief package announced by the Centre, argued as ‘outrageously small’,4 clearly failed to dent the economic and nutritional anxieties of the poor. The better-off hoarded essential items, highlighting their own nutritional, if not yet the economic, anxieties. The Prime Minister urged G20 leaders on 26th March to ‘put human beings rather than economic targets at the centre of our vision for global prosperity and cooperation’.5 While there has been an acknowledgment as well as efforts to mitigate economic hardships arising out of the lockdown, they seem to have been based on assumptions rather than facts on the ground. The manner in which the lockdown has been enforced has been crude rather than complex, which aggravated widespread economic and nutritional vulnerabilities, which, in turn, triggered hoarding and migrant outflux. The latter, in its turn, might lead to large-scale transmission in the rural hinterland, which would be calamitous, given the state of health awareness, infrastructure, manpower, etc. and 68.84% of India’s population being rural (Census 2011). 

Secondly, from a health perspective, as table 1 highlights, the death burden of non-communicable disease (NCDs) was 3 times higher than that of communicable diseases (CDs), with cardiovascular diseases (CVDs) alone killing more Indians than all CDs put together. High blood pressure is the biggest risk factor for NCDs in general, CVDs in particular. On top of all the nutritional risks, the lockdown has imposed limits on physical activity, which could be done with social distancing. The WHO argues that ‘failure to enjoy adequate levels of physical activity increases the risk of cancer, heart disease, stroke, and diabetes by 20–30% and shortens lifespan by 3–5 years’, and ‘burdens society through the hidden and growing cost of medical care and loss of productivity’.6 Can we let the actual burden of NCDs worsen to tackle the potential impact of the coronavirus, which is one of the ‘∼1,400 known species of human pathogens’ (disease-causing microorganisms)?7 We need to keep in mind that coronavirus is not the only risk we are dealing with in the country. A horizontal rather than a vertical approach is required for the surveillance, understanding and tackling of risks. 

While India’s approach to the lockdown has been comprehensive, its approach to testing has been targetted – just 18 coronavirus tests per million population vis-à-vis 313 in the US, 2,800 in China, 3,499 in Italy,8 not to talk of European countries who have tested much more aggressively (for e.g. 37,300 tests per million in Iceland, 11,410 in Norway, 7,715 in Spain and 4,952 in Germany.9 Our approach needs to be more comprehensive here. As Dr Mike Ryan, WHO’s Executive Director of Health Emergencies Programme, has argued – ‘once we’ve suppressed the transmission, we have to go after the virus’.10 India needs to complement the lockdown with a comprehensive ‘test, trace, treat, isolate’ strategy advocated by the WHO.11  

With more comprehensive testing, India will have more local evidence on infection and death rates by various background characteristics which can help have a more targetted approach to lockdown. At the moment, our strategy seems to be upside down, which needs to be reversed immediately to contain the contagion as well as multidimensional economic, nutritional and health vulnerabilities facing the country. A comprehensive approach to the health of the nation is the need of the hour. 

Table 1: Selected indicators, India 

Source: Geography – World Development Indicators, The World Bank; Demography – World Population Prospects 2019, United Nations; Poverty – Poverty & Equity Data Portal, The World Bank; Health – Global Burden of Disease, Institute for Health Metrics and Evaluation, University of Washington.