1) The reign of Shivraj: On Chouhan's fourth term as CM
The Bharatiya Janata Party (BJP) leader, Shivraj Singh Chouhan, who was sworn in as the Chief Minister of Madhya Pradesh on Monday night, proved his majority in the Assembly on Tuesday.
This is his fourth term as Chief Minister. After three consecutive terms, he had lost the election in 2018.
He mustered the support of 112 MLAs for the trust vote which was hurriedly organised overnight and was missed by 92 Congress MLAs and two independents.
Two BSP MLAs, one of the SP, and two independents who were earlier supporting the Congress government that collapsed last week, voted in favour of the trust vote.
Mr. Chouhan has said his government’s immediate focus would be in tackling the coronavirus crisis that is testing the capacity and will of the State.
He has also asked all MLAs to leave for their constituencies and take the lead in managing the crisis. The downfall of the Congress government was engineered by the resignation of 22 of its MLAs.
These and two more seats in the 230-strong State Assembly remain vacant. The actual strength of the government will be tested in and after the by-elections to these seats.
It is a different question whether the Congress can regroup itself and challenge the government.
With the return of the BJP government in M.P., the political turn in the State in 2018 has been proven short-lived.
The party had faced a setback in M.P., Rajasthan and Chhattisgarh where it lost power to the Congress before bouncing back in the 2019 Lok Sabha election.
The Congress could not sustain its gains, and has now ended up losing a government. But it goes beyond that and shows the party as a weak challenger to the BJP.
To begin with, the Congress victory was nebulous and narrow in M.P., and its fortunes were compromised by debilitating factionalism within.
It cannot be a viable political alternative to the BJP unless it gets imaginative in building sustainable and strong social and class coalitions.
In places where it has done so, the party has been effective in elections and governance, including in neighbouring Chhattisgarh.
The exit of Jyotiraditya Scindia, who has since joined the BJP, could actually be used as an opportunity by the Congress to promote better rooted leaders from diverse social backgrounds, stepping beyond dilapidating feudal fortresses.
The BJP in the State will also need to achieve a new equilibrium, now disrupted with the entry of Mr. Scindia.
Mr. Chouhan has emerged as a strong leader, but there are others waiting in the wings too. The change of guard in M.P. will unsettle existing equations in both the parties, beyond State boundaries.
The BJP government will have to manage the changed political dynamics in M.P.
2) Death by fireworks: on violation of rules in hazardous industries
Unsafe working conditions and improper handling of inflammable raw materials continue to endanger lives in the fireworks industry.
Last week, 11 workers were charred at a fireworks unit in Tamil Nadu’s Virudhunagar district.
Police data show that in the past decade, at least 239 people have perished and over 265 injured in 142 accidents in fireworks units.
Such tragedies have not been confined to Sivakasi, deemed the fireworks capital of the world, where most such units are concentrated.
Illegal cracker units functioning in a few other parts of the State have also led to loss of a significant number of lives.
In and around Sivakasi, the manufacturing of firecrackers in makeshift unlicensed units, rough handling of chemicals by untrained and unskilled workers, spillage or overloading of chemicals during the filling process, and working outside permitted areas have been identified as major causes for past accidents.
In the recent tragedy too, the workers were engaged in manufacturing ‘fancy aerial crackers’ for which the unit did not have a licence. Preliminary investigations suggest that mishandling of chemicals could have triggered an explosion.
ADOPTING SAFE PRACTICES:
Occasional accidents in an industry dealing in explosive materials may seem inevitable.
But the probability of such mishaps can certainly be reduced by adopting safe work practices, complying with rules and through cohesive monitoring by Central and State licensing and enforcement authorities.
Crackdowns against violators have been few and far between despite illegal sub-leasing of works to unlicensed cottage units becoming a widely acknowledged practice in the industry.
The Tamilnadu Fireworks and Amorces Manufacturers Association has also complained about the unlicensed units, a parallel industry in itself spread across a dozen villages.
LACK OF INSPECTION & CO-ORDINATION:
The Chaitanya Prasad Committee, which examined, among other things, statutory and administrative shortcomings that led to the death of 40 workers at Om Shakti Fireworks Industries in 2012, noted the “conspicuous absence” of proper inspection mechanisms at various government departments.
It also found a lack of coordination between Central and State authorities dealing with the regulation of fireworks industries.
The committee recommended making sub-leasing of works by licensed units a cognisable penal offence; mandated inter-safety distances between sheds covered with earthen mounds; and provision of a smoothened pathway with a width of 1.5 metres, as part of industrial safety measures.
Ground reports suggest these recommendations continue to be ignored, with sub-leasing of works still rampant. Regulators understandably complain of a lack of manpower in checking violations.
The number of players has exponentially grown since the 1980s with 1,070 licensed units employing an estimated 10 lakh workers now. But safety is non-negotiable.
The governments must walk the extra mile to enforce rules in a hazardous industry and prosecute violators. The industry too must self-regulate in its own interest.
Violations of rules in hazardous industries can be tolerated only at the cost of human lives.
3) Ironing out wrinkles in India’s pandemic response
Much concern about the novel coronavirus in India is understandably about the number of cases and related deaths.
It is important to remember that the vast majority (80%) of COVID-19 cases will be mild.
The estimated mortality rate varies considerably between 3% to 0.25% of cases, and is much higher among the elderly.
Mathematical models and the experience of China, Italy, and now the United States, suggest that COVID-19 is likely to infect a significant number of Indians, though this can change due to current physical distancing and lockdown measures.
Notably, wealthier countries with stronger and better financed health systems such as Italy and China have struggled with containing COVID-19.
As such, it is prudent to understand how well India’s health system can respond to COVID-19, especially since it is unclear how long this disease will persist.
We believe that there are some critical weaknesses in India’s health system that can prevent a credible response to COVID-19.
In truth, we do not really know how widespread the epidemic is in India because such a small number of people have been tested and many mild cases go undetected.
To what extent India’s ongoing efforts to control COVID-19 using physical distancing and isolation will be successful is yet unknown.
It is likely that, as in other countries, there will be regional or sub-regional disease hotspots, rather than a nationwide outbreak.
The higher number of confirmed COVID-19 cases in States such as Kerala and Maharashtra suggest this (though this could also be due to more testing).
This highlights the importance of approaching India’s COVID-19 response from the perspective of State health system capacity.
Second, it is unlikely that States which experience a COVID-19 hotspot will have the resources to manage the outbreak independently.
As such, it is critically important to put in place well-functioning between-State and within-State coordination mechanisms that enable efficiently leveraging resources such as doctors, nurses, equipment, supplies from elsewhere and direct them to regional/sub-regional hotspots.
RAMPING UP HOSPITAL CAPACITY:
Addressing the scarcity of hospital and intensive care unit (ICU) beds in India is critical for providing clinical support to severe COVID-19 cases.
Without flattening India’s COVID-19 epidemic curve, our current hospital capacity is so low that it will be quickly overwhelmed if infections surge.
India has around 70 hospital beds and 2.3 ICU beds per 100,000 people. To put this into perspective, China (Italy) has 420 (340) hospital beds and 3.6 (12.5) ICU beds per 100,000 people, and both these countries struggled to care for the severely sick.
According to our rough calculations, based on estimates from recent studies, in a hypothetical State with a population of 50 million (about the size of Andhra Pradesh);
with the national-level endowment in hospital and ICU beds and bed occupancy of 50%;
assuming there are currently 10 COVID-19 cases with a doubling rate of five days (5% of the cases hospitalised and 16% of hospitalisations need ICU care, median length of stay 12 days),
without any mitigating measures, the ICUs will fill up in six weeks and hospital beds in about eight weeks from now.
This will happen sooner in States with lower hospital capacity.
It is critically important that India puts in place a strategy to ramp up hospital and ICU capacity, as well as provision for essential equipment such as ventilators and personal protective equipment for health workers.
In both China and Italy, hospitals were rapidly constructed to accommodate infected patients. It is doubtful that we can construct new hospitals as quickly as China or even staff them adequately.
Therefore, it is important to consider alternatives, such as, extending current hospital capacity, hospital trains that can easily move from one location to another, or converting university dormitories into treatment centres.
Tapping the resources in the private sector is particularly important. India’s health system is highly privatised and most of the country’s health-care capacity in terms of human resources, hospital beds, laboratories, and diagnostic centres is in the private sector.
Recognising this, several State governments have initiated action, such as enlisting private laboratories for testing and using the private hospital bed capacity to treat positive patients.
More of this is needed, as well as, engaging private hospitals in planning and coordinating the COVID-19 response.
HEALTH WORKERS ARE CRUCIAL:
Health-care workers are a critical resource for the COVID-19 response. They go into communities to carry out preventive care, trace potentially exposed people, and treat the infected.
The success of countries such as South Korea and Singapore in controlling the spread and mortality due to COVID-19 has been credited to the ability of health workers to locate, test and treat cases.
This requires a substantial number of health workers, and India faces an acute shortage of them. India has around 3.4 qualified doctors and 3.2 nurses and midwives per 10,000 population; in contrast, China (Italy) has 18 (41) doctors and 23(59) nurses per 10,000 population.
Moreover, health workers in India are mostly concentrated in the urban areas and there are huge disparities between States (Bihar has 0.3 and Kerala has 3.2 doctors per 10,000 population).
Importantly, nurses have been in the forefront of caring for infected people elsewhere; India, has far fewer nurses than both Italy and China.
These characteristics of India’s health workforce will affect its COVID-19 response, particularly in rural India and in States with fewer health workers.
While increasing the health workforce in the short term is difficult, it is important to consider task shifting and multi-skilling strategies where a variety of health-care workers (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy doctors, nurses, as well as general and specialist doctors) are engaged.
Because it is highly likely that certain regions in India will become COVID-19 hotspots, to contain these outbreaks it is important that human and other resources can be flexibly shifted to these areas from other parts of the country.
Primary-care providers, whether they are formally trained (e.g. medical officers, nurses, auxiliary nurse and midwives, pharmacists), or lay workers (accredited social health activists) or informal workers (rural (not registered) medical practitioners, or RMPs, drug shops) will likely be the first contact health workers for COVID-19 patients.
For example, more than 70% of the outpatient visits in India are to private providers, the majority of whom are RMPs.
Engaging these primary-care providers in the COVID-19 response is important. For one, they are critical for contact tracing, a strategy that has been successfully used in South Korea and Singapore to contain the virus.
Because primary-care providers will encounter patients in early stages or with mild forms of the disease, they play a crucial role in treating and referring patients. While this may not be easy to accomplish, COVID-19 response strategies should involve engaging these primary-care providers and providing them information on preventing the spread of COVID-19, danger signs or where to refer in case of serious illness.
HEALTH WORKER SAFETY:
Health workers also take on a disproportionate share of infections. Health worker safety is particularly important for India because it already faces a shortage of doctors and nurses.
In China and Italy, the fight against COVID-19 has taken a huge toll on health workers.
One of the enduring images from Italy is of an exhausted nurse lying face down on her desk.
As a recent article in The Lancet notes;
estimates from China’s National Health Commission show that more than 3,300 health-care workers have been infected as of early March and, by the end of February at least 22 had died;
in Italy, 20% of responding health-care workers were infected, and some have died.
Health workers also face physical and mental exhaustion, which affects their morale, in addition to the infection risk.
Protecting health workers in the forefront of the COVID-19 response will be critical. Procuring and ensuring the widespread use of personal protective equipment (e.g. masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms needs to prioritised.
Such actions will be particularly important if there is a prolonged response to COVID-19.
India like other countries faces important health system challenges in mounting a credible response to COVID-19.
Many of these issues are not new. Addressing these health system issues will require much effort, financing, and, in some cases, not even entirely possible to remedy in the near future.
How India deals with these health system issues in the days to come will make all the difference.
4) In riot aftermath, it’s scorched health care too
The impact of riots on health services receives scant attention, more so when there is a communal angle to it.
While the narrative around deaths receives some attention, the deeper insidious effects are glossed over.
This will also impact not only the health of the population but also crucial medical responses in a time like the outbreak of the coronavirus pandemic.
Here is one such story, although not unique.
After the riots in north-east Delhi, in February, a volunteer called our medical team:
“Twenty-two-year-old Noor Jahan (all names have been changed), a pregnant woman, is scared to leave her house. Could you please send a doctor to examine her?”
On visiting her, we learnt that the woman had lost all her belongings, including her prescriptions and medications, while fleeing her house in Shiv Vihar as it was being torched.
Seeking refuge with her distant relatives and with her delivery date just a week away, she was gripped by fear and anxiety at the prospects of visiting the Guru Teg Bahadur (GTB) Hospital which was nearby.
Anecdotes of the communal hostility her neighbours had faced at this hospital had left her unnerved. She ended up delivering her child at the faraway Sucheta Kriplani hospital, in an unfamiliar environment.
A ZONE OF POOR HEALTH:
North-east Delhi is the most underdeveloped region of Delhi and is marked by all the socio-demographic determinants of poor health outcomes:
a significant proportion of the population is from the migrant and minority communities;
there are high rates of illiteracy,
rampant unemployment and poverty;
overcrowding; unsanitary conditions, and;
a non-existent health-care infrastructure.
Yet, despite the fear, a medical camp in Chand Bagh, set up for a few hours using a mobile van, immediately draws the attention of more than 600 people.
While the most common complaints are fever, a runny nose, and body aches, a disconcertingly high proportion of young adults complain of ‘ghabrahat’ (anxiety).
On further questioning, they report poor sleep and appetite, inability to concentrate, and experiencing constant worry, all signs of underlying mental health problems.
Further, due to adverse social circumstances, many patients with chronic medical conditions have not been able to visit their doctors.
We saw several of these patients who now have a worsening of chronic diseases such as elevated blood pressure and asthma.
Naeem, 25, was in agonising pain. He had a deep cut above his left eyebrow, and was bruised all over after having been beaten up by a mob.
Yet, he did not see a doctor. Alarmed by the large number of incarcerations, he had stayed at home. His fears were not unfounded.
In the follow-up after the riots, the Delhi Police are estimated to have rounded up over 1,000 individuals, most of them young Muslim men.
Interference of the police in health systems and a lack of patient privacy protection laws have changed the health-seeking behavior of certain sections of the populace.
Zeeshan, 36, had been admitted to hospital with fractures in both legs and a stab wound in his left arm. After two days of hospitalisation, they wanted to discharge him.
His pleas to stay on as his house had been vandalised and his health was poor had to be turned down.
The resident doctor had to tell him that despite their understanding of his concerns, he had received all the care needed and that as the hospital was overflowing with patients, beds were needed.
Zeeshan had to be told that the hospital could not do anything to help him even if he did not have a safe place to go back to.
During our visits to the riot-affected localities, we noted many burned and looted houses. Even more malicious was that goons had damaged water pipes and looted water purifiers.
With open drains and an unplanned sewerage system, there is a real threat of Salmonella bacteria seeding these pipes.
Salmonella, the bacteria responsible for typhoid fever, will be hard to eliminate.
If not managed properly, people will suffer from recurrent typhoid fevers and diarrhoeal infections, leading to downstream consequences such as child malnutrition and antimicrobial resistance.
WAY FORWARD IS COLLABORATIONS:
These examples demonstrate how the riots have exposed and deepened chasms in the health systems.
A broken health system and a population that has lost trust in health-care providers will amplify the challenges of managing the COVID-19 epidemic in Delhi and worsen all other health-care indicators.
Rectifying these shall necessitate a deliberate and comprehensive strategy by the State not only at the infrastructure and policy levels but also at the moral and philosophical levels.
The government must collaborate with local municipal bodies, partners in civil society and members of the local community to devise sustainable solutions.
They must build a maternity ward with labour room services so that women do not have to travel to faraway, unfamiliar and hostile hospitals to deliver.
A mohalla clinic for primary care is a must in the area as demonstrated by large queues outside the medical camps, which are often organised in an ad hoc manner depending on available resources.
Psychologists are needed to provide therapy to the riot-affected children, adults and citizens confined to their houses out of fear.
Similarly, physiotherapists should be recruited to prevent long-term physical disability. The sewerage systems should be fixed, water pipes restored and measures such as chlorination for water hygiene instituted at a house-to-house basis.
People should be at the core of health systems and policy design. Systems and policies that drive citizens away from hospitals have to go.
An initiative by the Delhi government, in the form of the “Farishte Dille Ke” (The Angels of Delhi), offers hope.
Similarly, it ought to set an example for other States by changing health-care privacy laws to protect patients from police interference and also empower them to get medical care.
What is most shocking is the loss of trust in health-care providers on account of the communal underpinnings of the situation.
In the short run, the medical community and the government should conduct peace marches in north-east Delhi to assuage fears.
In the longer run, just like the “happiness curriculum” in schools, it should start a “humanities curriculum” for medical professionals so that they provide more empathetic and compassionate care.