We are together in the storm, but are we in the same boat?

We do not yet know how history would write about our response to the COVID-19 pandemic, but the consequences and outcomes of this unprecedented contagion are rapidly coming into focus. Ever since the first case of COVID-19 was discovered in late 2019, nearly 150 million people world over have been infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over 3 million have succumbed to the disease, and the figure is growing as the virus refuses to leave us, appears, and reappears in waves, each stronger than the previous one. India has been one of the worst-hit countries in this pandemic. We have a caseload of over 17 million and a death toll of 200 thousand, with an upsurge and second wave, threatening to be deadlier than the first one.  

Our efforts to contain the disease have resulted in an economic recession, pushing millions out of their jobs, and causing a huge spurt in unemployment. We have also witnessed a groundswell of mental and behavioral problems in people, compounded by social and economic stress and uncertainties that may cause a health burden for years to come.

Our response to the COVID-19 pandemic has emerged from the contagion and our understanding that we are all in this together. We believe that the virus does not discriminate, and anyone irrespective of class, creed, religion, or social status, can contract the virus. Infectious diseases have always been the paradigmatic example of diseases that show how our health is interlinked.

Is it really true that COVID-19 does not discriminate? Is it really true that we are together and equal in this suffering? When we look around, we can see that the effects of COVID-19 are far from being indiscriminate. People with resources, money, and power are better able to physically distance, work from home, and retain their employment or resources. Hence, the more affluent groups, not only have lower risks of becoming infected or dying from COVID-19, as reflected in a combination of factors, including better access to healthcare but also carry a lower underlying burden of morbidity that predisposes to worsen COVID-19 outcomes.

It thus turns out that we are in the same storm, but some of us are on a ship with sails, some on a boat, and some are trying to swim without gear and fear drowning. COVID-19 thus discriminates, and those who are already vulnerable - for example, people surviving on low incomes, those living in unhygienic conditions, those with poorer education and healthcare, and individuals with less access to nutritious food - are more likely to become infected with the virus and die from COVID-19.

Thus the impact of COVID-19, like many other diseases, follows deeply entrenched patterns of health divides and inequities. COVID-19 can infect all, but it predisposes the vulnerable populations to a higher risk of disease, and of recovering from the pandemic and its after-effects. In fact, COVID response efforts also contribute to health divides, e.g., lockdown resulting in economic consequences, that would inevitably be borne by those who are vulnerable and marginalized, to begin with. The efforts are likely to result in the long-term widening of health inequities, consigning many people to worse mental and physical health for years to come.

Prolonged pandemic periods are likely to push more and more people into economic vulnerability and the consequential greater health divide. There would be a time when the higher echelons would be protected and be able to flatten the curve, but it would be the vulnerable and marginalized who would continue to face the threat. This can be seen in the prevalence of diseases like cholera, malaria, dengue, tuberculosis, etc, all having higher rates of occurrence in the poor and marginalized populations. Once COVID heat and dust settle down and it becomes a part of our lives, we would inevitably find the poorer populations having a much higher number of COVID cases.

This thought of COVID resulting in a greater health and healthcare divide in the country is alarming. This is contrary to our idea of equal and fair societies and a sustainable planet which the world is trying to address through Sustainable Development Goals. This is contrary to our idea of a developed and progressive India.

There is an immediate need to address this eventuality and factor it into our thoughts, policies, and processes. Any response to contain COVID has to keep the poorest and the most disadvantaged into consideration. There has to be a recognition at the top policymaking and government levels that there is a twin problem of demographic issues and distributional disparity which hampers the emergence of equal and equitable access to healthcare services in the country, and that COVID-19 can further push us towards a greater disparity and divide.

We must prepare a nationwide health infrastructure development roadmap with adequate budget provisions to reach every village and every nook and corner of the country. Resource allocation and deployment must be in accordance with the population of each state, district, and village while considering the prevalence of specific health issues and diseases in each region.

Primary healthcare has remained vestigial in India for a variety of reasons. This means that the healthcare load of the population lands almost entirely on hospitals, which is not only an expensive way to serve the people with basic ailments but also inaccessible to most. Thus setting up a robust primary care system can go a long way in correcting the anomaly. While providing for primary care centers at the smallest administrative units, it must also be ensured that the quality of personnel and services is not compromised. At the same time, quality secondary and tertiary care centers as also a few super-specialty hospitals must be built in tier II and III towns. Low-cost, high-quality service models need to be worked out to cater to the underserved segments. With the private sector taking the lead in setting up secondary and tertiary care facilities, the government can extend full support through simpler and relatively inexpensive land acquisition policies, tax incentives, and modest utility costs, among others.

We also need to provide civic amenities and services such as those relating to hygiene, garbage disposal, pure drinking water, sanitation, and drainage, etc., up to the last mile since communicable diseases are primarily caused by a lack of these factors. If such amenities are made available, it can certainly reduce the health burden in the country.

We should invest in the conditions that make all of us healthy while removing the underlying disproportionate burden of preventable diseases that accrues to vulnerable populations. Our response to COVID-19 should not only be to contain the spread but also to focus on mitigating the consequences of our efforts, which can bring about disproportionate harm to those who are most vulnerable in this pandemic. Our response should recognize that we cannot put the burden of disease squarely on people with lesser resources. 

This moment, thus calls for a careful reflection and reinvestment in building a compassionate and holistic healthcare system that provides equality and equity at all levels. COVID-19 has shown us that a healthy person and a healthy nation or a healthy world are the same.