Covid-19 in India: Time for bold experimentation
Involve the private sector in testing; ramp up the contact tracing apparatus; invest in research; experiment widely
To counter the Covid-19 crisis in India, many have recommended raising the annual health expenditure, primarily for testing, tracing, isolation, and universal mask-wearing. This view places financing above governance concerns that lie at the heart of the health care sector in India. The availability of more resources might not be sufficient for the country to implement a Vietnam, Tamil Nadu or Kerala model across all states. While we have been demanding greater health spending for nearly two decades, varying State capacity to implement programmes remains a fundamental constraint. For example, a recent study in ,on national, regional, and state-level all-cause and cause-specific under–five mortality (2000–2015), revealed large variations across states, ranging from 9.7 deaths in Goa to 73.1 deaths in Assam (per 1,000 live births). These disparities cannot be explained as being due to the shortage of health funds alone, as the study highlighted that; “…evaluation of health initiatives shows varying programme governance and accountability across states. Therefore, high and consistent commitment from local government is crucial to ensure that programmes work as intended.”
In the current pandemic, ubiquitous testing seems logical and necessary. There are, however, several practical considerations which suggest alternative interventions. Research from the previous SARS epidemic has shown that there was wide variability in individual infectiousness; 10% of cases were responsible for 80% of the spread, implying that super-spreader events caused outbreaks.
Therefore, we should use the existing contact tracing data to identify if there is dispersion in individual infectiousness, and more important, whether there are identifiable factors that affect the transmission of the disease, such as crowded working conditions, confined locations, age, gender and co-morbidities.we should utilise our existing resources to build relevant local intelligence on transmission, and the testing strategy should be prioritised accordingly. A recent study from Japan also shows how cluster analysis can be used to identify and isolate super-spreaders — thereby containing the overall outbreak.
The role of the private sector is critical for India to control this pandemic. If firms are to function under the current uncertain environment, then there is a possibility of a Coasian bargain between an employer and employee to mitigate the risk of infection. Market solutions will emerge with a willingness to pay for testing, masks, and enforcing strict social distancing norms. We must explore alternative mechanisms where the private sector pays to mitigate uncertainty. Moreover, the prevalence elasticity of demand for self-protection also means that demand for self-protection will go up significantly. Government testing should then perhaps focus on areas where market-based solutions will not work.
Beyond testing, it is important to put more thought and resources into contact tracing efforts. Research on the Ebola virus has revealed that delayed and ineffective contact tracing was a significant contributor to the outbreak in 2014–2015. Challenges include identification of all contact persons; this requires investigation and probing skills. In Kerala’s Kasaragod, the local police played an essential role in effective contact tracing. Given their training in debriefing and verification, local police personnel are naturally suited to extensive contact tracing. Therefore, what is needed are special personnel with skills in contact tracing that could be hired temporarily at the level of a police station. Another challenge is the logistical issue of physically tracing the identified person, mainly, where addresses are not well-defined. This requires extensive use of technology such as monitoring call and Internet data records, and in some cases, CCTV footage to physically identify persons concerned. After all this, the traced people have to be assessed daily for a significant period, which requires cooperation, willingness and, most important, trust. Management and performance of contact tracers must also be addressed upfront. While there have been suggestions about using additional ASHA workers, this is based on the assumption that optimal tools for contract tracing exist, and what is needed is for ASHA workers to merely learn these tools and implement them on the ground. Our experience with contact tracing in this pandemic suggests that the ministry of home affairs (MHA) has to work closely with the ministry of health. Given the significance of contact tracing, standard operating procedures (SOPS) are required to be developed by MHA. SOPS should be circulated across local police stations and health departments.
Most important, this crisis could be an opportunity for policymakers and researchers to work together and exploit insights from epidemiology and other observational studies to design a series of ethical, economic and psychological cost randomised control trials as suggested by Haushofer and Metcalf in (May 21) to identify “non-pharmaceutical interventions” that could have a significant impact on human health with low societal and economic costs. Interventions range from encouragement and recommendations to regulations and sanctions — which ones work best in a pandemic?
In brief, given that we know so little about what works and what doesn’t, it is time to experiment. We should increase budgetary allocation for research and experimentation and design data-driven policies. In summary, to resolve the uncertainty till a vaccine is discovered and widely available will require several trial-and-error experimentations and a willingness to learn.
As India comes to terms with China’s dastardly act on the border, it should be a time for a new resolve in India to craft an openeyed policy response. This is not going to be as easy as some social media warriors assume. But when it comes to the most serious strategic challenge India has ever faced, easy should be the last thing on our minds. Tragedies such as the one India has had to endure this week often lead to a clarity of vision, a vision that was clouded by the misplaced sense of our ability to manage China. Now, after the loss of precious lives along the border touted as being stable, New Delhi should also lose its innocence when it comes to China. Prime Minister (PM) Narendra Modi has underlined that India wants peace but “will give a befitting reply” if provoked. External affairs minister S Jaishankar has conveyed to his Chinese counterpart Wang Yi that the Galwan Valley development will have a “serious” impact on the bilateral relationship.
In its attempt to unilaterally define the Line of Actual Control (LAC), Beijing has disregarded the central tenets of all pacts it has signed with India since 1993 to keep the border peaceful. And this will significantly alter the trajectory of the Sino-indian relationship, which has been premised on an understanding that even as the boundary questions remain unresolved, the two nations can move forward on other areas of engagement — global, regional and bilateral. That fundamental assumption has now been seriously undermined.
In some ways, China’s assertiveness today is understandable. As long as China was the dominant party along the border, it could continue with the facade of upholding peace and tranquility. After all, that was on its terms. It is India’s assertion of its interests in the last few years that has emerged as the sticking point. The militarisation of LAC is taking place at an unprecedented pace today partly because Indian infrastructure is in much better shape and Indian patrolling is far more effective. A more heated LAC is a result of the Indian military’s presence in areas where the Chinese military is not used to seeing it. That India is ready to take on Chinese aggression head-on is also reflected in the scale of casualties that both sides suffered this week in the Galwan Valley. The Indian military is operationally more nimble and prepared than ever been. Therefore, if a lasting solution to the border problem is not found, we should be prepared for more such action along LAC.
China remains a significantly more powerful entity and its infrastructure is still in much better shape. But Indian infrastructure development has reached a critical point. And it is not without reason that the Chinese opposition to the 255 km-long strategic Darbuk-shyok-daulat Beg Oldie road has been so vehement. Connecting Leh to the Karakoram Pass, this all-weather road is India’s frontal challenge to China’s expansionist designs in the region. Despite Chinese objections, India has continued to pursue this project given its strategic importance. China raising the temperature on the border is a pre-emptive move to dissuade India from moving ahead.
China’s recent behaviour cannot be delinked from the global situation where Beijing has come under pressure and is facing a global backlash for its mishandling of Covid-19. That India has emerged as a more credible global actor at a time of severe distress is something that China is wary of. The top leadership of the Communist Party of China is facing internal turmoil as its policies on Hong Kong, Taiwan and Belt and Road Initiative (BRI) are not only facing global opprobrium but are also being critically dissected at home. For Chinese President Xi Jinping, an easy answer to managing this turmoil is to create problems abroad to generate a sense of nationalism among a disillusioned populace.
Indian foreign policy has been at the front and centre of challenging China’s nefarious global designs. New Delhi was the first country to warn the world of the dangers of BRI at a time when almost every other country was willing to buy into Beijing’s narrative. Today, India’s framing of the BRI problems is widely accepted by most major global powers. Given that BRI is Xi’s key vanity project, India’s role in shaping the global opposition must be particularly jarring. India has also managed to shape the global discourse on the Indo-pacific and is now working closely with likeminded regional players into giving it operational heft. Despite China’s continued objections to the term, Indo-pacific maritime geography is now widely accepted. And at a time when the Donald Trump administration is seriously beginning the process of trade and technology “decoupling” with China, Washington and New Delhi are closer today than ever before. Chinese attempts to marginalise India on the global stage have not worked and New Delhi’s cache has only increased.
And so in its wisdom, China decided to wield the blunt instrumentality of force, hoping that this would “teach India a lesson”. The reality is Chinese actions will produce exactly the opposite effect of what they probably intended to do. Indian public opinion, which was already negative about China, will now become even more strongly anti-chinese. Those who have been talking about maintaining an equidistance from China and the United States will find it hard to sustain that position. And New Delhi will now be even freer to make policy choices, both strategic and economic, which will have a strong anti-china orientation. There will be costs for India. But China’s actions have ensured that today India is ready to bear those costs. For this, India should thank Xi’s China.