Why India's response to Covid was in striking contrast to the reaction against TB

By Nihir Gulati*

On January 16, 2021, the first-ever dose of the Covid vaccine was administered in India. With the Ministry of Health and Family Welfare claiming to have administered both doses to a mere 10% of India's 94.5 crore adult population, I reached out to Bobby Ramakant, director, for policy and communications at Citizen News Service (CNS), to gain a deeper insight into the snail-like pace of covid vaccine administration in the country.

According to a Delhi  and West Bengal study, more than 75% in each State were willing to get vaccinated. Hence, that is not an issue that is causing the population not to get vaccinated.

Health infrastructure

To get a glimpse of the healthcare system in India, we deep dive into a discussion about tuberculosis. This disease has been plaguing India since the time that Bobby was at college. Contrary to popular belief that TB is a disease of the poor, Booby believes that it is not limited to the lower class of society. However, he does agree that TB is prevalent among the poor because one of its major causes is malnutrition.
India's motto against tuberculosis is: "Pakki jaanch, pakka ilaaj," meaning that if we can detect TB with surety, we can treat it definitely. Sadly, this is not the case, and India has the most number of deaths due to tuberculosis than any other country.
One of the main reasons for this dubious distinction is India's lack of public healthcare infrastructure and awareness. Here is how - 13 different drugs can be used to treat tuberculosis. However, a combination of four out of these 13 drugs is chosen for each person based on their genetic makeup.
This test of genetic makeup is done by a piece of medical equipment known as gene expert. This test helps determine the combination of four drugs that would be the most potent against TB for that person. Successful treatment requires regular medication for a certain period of time. Failing to take those medications on time causes drug resistance, i.e., the bacteria causing tuberculosis become immune to the drug.
Once the drug resistance develops, a new combination of four out of 13 drugs has to be created for that person, and the treatment has to start all over again. The main reason that this happens is poverty and lack of awareness in India.
Although the drugs are free of cost in the government centers in India, the transportation is not, and many people from the poor and remote villages in India failed to reach the government centers for their regular dosage against tuberculosis.
This problem was handled well by the State of Kerala, where they ensured a zero default rate, ensuring that no one missed their medication once the treatment began. This was done by conducting regular surveys and outreach by the government center. If the people cannot reach the government centres, they deliver the drugs to the remote villages to reduce the default rate.
Although this was an excellent reactive strategy, India, with the highest number of TB deaths globally, needed a more proactive approach to counter tuberculosis. Eradication, rather than treatment, should be the goal here.

Contrast with Covid

The response to Covid was in striking contrast to the reaction against TB. Until as late as 2010s, TB in children was treated by giving them partial doses made for adults by breaking the capsules according to the child's weight – a grossly unprofessional method.
On the other hand, the manufacturing of Covid vaccines had already been done before the clinical trials, with the plan that shipping would start as soon as the clinical trials were completed.
However, such urgency and importance were not given to other scientific breakthroughs in the healthcare domain like TB medicines, female condoms, etc. Although the initial enthusiasm was overwhelming, Covid did uncover some gaping holes in the public healthcare system in India.
During Covid's peak, India had one of the lowest number of beds per unit population in the country, and there was an acute shortage in both the private and the public sectors.

To provide health as a human right, we need safer roads, a cleaner environment, better public health systems, more robust public transport

A robust public healthcare system became a need. We need to introduce sustainability in public health by reducing the privatization of and profiteering from healthcare. There is a need to reduce the catastrophic healthcare costs and make sure that emergency healthcare doesn't push people into poverty.
An example of healthcare exploitation is the per-dose cost of Covid medicines which went up from Rs 250 to Rs 780 for Covishield and to Rs 1,450 for Covaxin within 1.5 months (May 1, 2021 to June 21, 2021). These costs made the coronavirus vaccine out of reach for the general public.

Holistic development

Bobby, taking inspiration from Professor Sandeep Pandey (current IIMA professor, previously IITK professor), emphasized the need for developmental justice - a holistic improvement in human development in the country.
He talked about the subtle difference between Universal Health Care and Universal Health Coverage – the former being a proactive approach projecting health as a human right and the latter being a reactive approach concerned with the provision of insurance for the affected. A country should always aim for Universal Health Care rather than coverage because it is a sustainable and stable approach.
To provide health as a human right, we need safer roads, a cleaner environment, better public health systems, more robust public transport, less malnutrition, etc. We would have to progress on all fronts simultaneously to achieve health as a human right.
Bobby proposes that the litmus test for any intervention should be that if it benefits the poorest of the poor in the country, it should be accepted. He firmly believes that the opposite of poverty is equality, not opulence.
An activity that changed Bobby's perspective about development was shunning motorized vehicles and taking up cycling. He realized that the system of highways and wide, fast roads were designed in favor of car-owners, who are less than 5% of the total Indian population.
Road safety, he surmised, was not just about helmets and airbags; it is also about caring for the non-motorized vehicle owners – the pedestrian, cycle rickshaws, etc.
As a cyclist, he felt the safest in the crowded lanes of Lucknow's old city and not on the so-called developed highways. Authentic development, he says, would occur when the collective feeling of safety goes up, not just the safety of the car owners.

Political motives

Taking the example of Thailand in the 70s, where, at the time of recession, the healthcare infrastructure budget for the large cities was instead used to develop the small basic healthcare facilities in the small villages. They have the 30 Bhat scheme, where the state covers all the healthcare costs for 30 Bhats annually (equivalent to Rs 60).
Even in India, we saw the response of the State of Kerala towards TB was superior to that of the other states. They aimed for healthcare rather than economic benefit, which should be the target of all public policy.
After this discussion with Bobby, one thing is clear to me: the only way to change is when we, the citizens and our elected representatives, unlearn our definition of development and healthcare. We need to pressure policymakers to introduce interventions that are socially just and ecologically sustainable.
Rather than treating gender upliftment, environment protection, and universal health care as three separate silos, we need to understand the complex interlinkage between them and simultaneously better the country in all the fundamental human development areas – because only then it will be real development.

---

*PGP 2020-2022, Indian Institute of Management, Ahmedabad