The Rural Front Line

To control COVID-19, we must make better decisions in the face of uncertainty

03 April 2020
Even till the seventh day of the countrywide lockdown to contain COVID-19, chaos reigned at the Jan Swasthya Sahyog’s hospital in Ganiyari village of Chhattisgarh’s Bilaspur district. Due to the lockdown, the number of patients coming to the hospital everyday has fallen by ninety percent. 
Even till the seventh day of the countrywide lockdown to contain COVID-19, chaos reigned at the Jan Swasthya Sahyog’s hospital in Ganiyari village of Chhattisgarh’s Bilaspur district. Due to the lockdown, the number of patients coming to the hospital everyday has fallen by ninety percent. 

This is the second piece in a series titled “The Rural Front Line,” by Yogesh Jain and Naman Shah, about the COVID-19 pandemic. Jain and Shah are both doctors working with Jan Swasthya Sahyog, a public-health initiative based in rural Chhattisgarh. Over the course of the series, they will address the issues they witness on the ground while dealing with the virus and discuss how policy decisions affect the lives of India’s rural residents. 

Even until the seventh day of the countrywide lockdown to contain COVID-19, chaos reigned at the Jan Swasthya Sahyog’s hospital in Ganiyari village of Chhattisgarh’s Bilaspur district. Due to the lockdown, the number of patients coming to the hospital every day has fallen by ninety percent. We discharged 28 patients on 25 March, from neighbouring Madhya Pradesh, but they remain trapped in the hospital as they could not travel back. One tuberculosis patient, from rural Bilaspur district, unexpectedly died on 27 March. The police had prevented him from travelling to the hospital a day earlier, according to his family. A woman, pregnant with twins, laboured in the forest throughout the day on 28 March as she was unable to find transportation. She arrived at night, bleeding profusely, and thankfully, delivered two preterm but vigorous girls weighing 1.3 kilogrammes each.

The overall vision to combat the pandemic remains a mystery—the government seems to be making it up as they go. We were and still are, entirely unprepared. While poorly planned, the lockdown allowed a semblance of action. Follow-up steps are now trickling in to correct the mistakes made while enacting it. Our state of Chhattisgarh, among others, expanded the eligibility criteria of the public-distribution system and has given additional rations. States seemed to wake up to the horrific plight of migrants only after being prodded by public outcries and civil society. It was only on the third day of the lockdown that the government exempted categories required for agricultural work—essential for survival in rural India—from the lockdown guidelines.

Epidemics bring a need to move fast, compounding the usual difficulties associated with policy making. At times, public policy requires making decisions even if there is a dearth of information. Examples abound to show that such decisions were taken with respect to COVID-19 as well. What was the decision-making process for the restrictive testing policy for the coronavirus? Why did we start using the anti-malarial drugs chloroquine and hydroxychloroquine for preventing COVID-19 infections in health workers? 

Sometimes a lack of information leads to paralysis in policy formation, due to a fear of mistakes. Other times, this results in knee-jerk reactions—often, too little too late. Principles offered by three economists provide insight for navigating the challenge posed by uncertainties. 

The first is to remember “the fact that research is a scientific act, and policy advice a political act,” as Jean Drèze, India’s leading development economist, wrote in 2018. Drèze explained that economists should be cautious in offering evidence-based policy advice. According to him, the road from evidence to policy is long and fraught with danger. It entails making value judgments and dealing with stakeholders who have different priorities. Plus, there are operational, ethical and legal considerations, which economists may not be familiar with. 

A parallel caution exists for doctors and epidemiologists. Understanding the clinical characteristics of coronavirus along with its determinants and distribution forms the foundation of any response. But we suffer from the same dangers listed above. Pandemics require communication, coordination, logistics and social planning in equal measures, besides health recommendations. One mistake was to treat COVID-19 solely as a health problem under the leadership of an individually talented, but collectively narrow, Delhi-centric task force. It was only on the fifth day of the lockdown that the government set up eleven empowered groups, with individuals from a wide range of sectors, to tackle a comprehensive set of issues.   

The second principle is to publicly explain the rationale behind decisions, including areas of uncertainty. The economist and philosopher Amartya Sen elaborated in his 2009 book, The Idea of Justice, how reasoning in public helps negotiate the varying demands placed by different groups in society while making decisions, and thus, makes democracy more effective. This relationship allows us to understand democracy not just as counting votes, but in its full potential as a “government by discussion.” 

Alongside timely, considered decisions, the act of explanation has been absent in India’s pandemic response. Without knowledge, many of those at the least risk from the virus, or its containment measures such as the lockdown, are enamoured with how swift or bold some of the government’s actions appear. The paradox of the coronavirus epidemic is that from entrepreneur godmen to surgeon entrepreneurs—men of a similar breed, despite their outward differences—everyone is now an expert, while those entrusted with responsibility remain shockingly silent. Policymakers need to cultivate a culture and skill of justifying their actions to the public.

Third, we must learn to walk before we run. The story of Indian policy is that grand ideas fail during implementation. While these failures involve many factors, not considering the capacity of the state is common. Ajay Shah, at the National Institute of Public Policy and Finance, has elaborated on the concept of “premature load bearing,” which permeates many of our institutions. Systems without the ability to meet the aim collapse when we overload them. Overloads result from a combination of lacking the ability to process many transactions; when ill-equipped front-line officials need to exercise a high amount of discretion; and when the stakes involved in the service are high. The result is a gap between policy objectives and ground behaviour that settles into persistent dysfunction. To prevent this, we should strategically not take on certain things, design policies according to load-bearing capacity, and master smaller problems first and then only take on more complex tasks. 

In our public health system, multi-purpose front-line staff, including nurses and community-health workers, are overburdened with an impossible list of duties. They are set up to fail. So, when they expectedly underperform, it is difficult to hold them responsible for specific tasks, thus, creating a vicious cycle of unaccountability. The Pradhan Mantri Jan Arogya Yojana seeks to expand hospital-based care—a wonderful aim—but through insurance, a mechanism difficult to administer even for advanced countries. The programme diverts funds—and even attention, an often overlooked element—away from fixing primary care and public health. The low-quality system we have in place for dealing with the outbreak is what makes India’s spread so frightening. Those who call on India to emulate the strategies of South Korea and Taiwan, glossing over vast differences in capacity, endanger their credibility. 

This is set of principles from our colleagues who have been trained in economics. To this, we would add two more from our experience of working in public health in rural India.

Naman Shah is an infectious disease epidemiologist and family-medicine physician at Jan Swasthya Sahyog. He has worked in pandemic influenza planning, disease-control research, and programme management with health departments, the Indian Council of Medical Research and the World Health Organisation.

Yogesh Jain is a pediatrician, public-health worker and co-founder of the Jan Swasthya Sahyog. He is a graduate of AIIMS and an active physician, and contributes to state, national and international policies.

Keywords: The Rural Front Line COVID-19 Chhattisgarh