The many failures of the response, however, are clear. We have failed to utilize the lockdown effectively by scaling-up testing; our rates remain among the lowest in the world. The heavy hand of bureaucracy is everywhere, given the confusing rules at each stage of our lockdown. Then this crisis has seen the scapegoating of Muslims—and trapped migrant workers are being driven to the edge of death as they make the long journey home in the heat of the Indian summer. Finally, in protecting the country from one urgent disease, we have abandoned everyone with practically every other disease.
Getting past these debates, however, allows us to recognize what the last two months represent: The most expensive and effort-intensive public health intervention in modern Indian history. Our response to the coronavirus pandemic—mainly manifested by the lockdown—cost us in the region of $5 billion a day.
India’s efforts at keeping 1.3 billion people indoors, across 28 states and 8 Union territories, involved the coordination of every facet of the central and state governments. No matter how one evaluates the government’s response to the pandemic, one must acknowledge the cost and scale of the operation. We now know the massive extent to which the government is capable of mobilising in order to protect public health.
That said, the Indian government’s response to this crisis leads us to an obvious question: Why have we done so little to stem the steady and shameful tide of other preventable deaths that blight the modern Indian state? 1,500 children die every single day in India due to a lack of vaccination; 1,200 people die every single day from tuberculosis (TB). Those figures combined represent more deaths in just one day than the total number of official deaths from covid-19 in the last three months of the crisis.
There is, of course, one crucial difference between these other preventable deaths and the coronavirus: Not only are rich people affected, they also cannot buy their way out just yet. Until treatments and vaccines emerge, even the rich are at risk at this moment. Much less equally than the front-line medical personnel who bravely do their jobs, and the working-class who cannot afford to stay home since the state offers them no safety net—but at risk nevertheless.
That changes everything. In the past, we might have shrugged off the numerous preventable deaths that besiege us, writing them off as failures of income and livelihood, not as failures of care and civic duty. But this time is different. This time, the entire country is aware of the crucial interdependence of our lives.
How can we use this moment, and this massive mobilization, to redirect state response towards truly improving public health for all? One way is to look at other urgent public health concerns which are similar to the coronavirus pandemic, but around which we have done nothing remotely comparable in terms of investment, effort or scale.
The other diseases
First among those concerns, as we battle against deaths from a disease we do not fully know and has no cure, are deaths caused by diseases that we do know and that we can cure.
Consider TB. Two relatively recent therapies have given hope to people living with advanced forms of TB, like multidrug-resistant TB (MDR-TB). These drugs—bedaquiline and delamanid—are monopolies: they are owned by two giant pharmaceutical companies, Johnson & Johnson and Otsuka. Together, they represent a lifeline for the 150,000 people who develop MDR-TB every year.
However, the best the Indian government could do for the first few years was obtain a minuscule portion of the need for both these medicines—as charity. Now, with the charity window closed, India faces a subsidised yet substantial bill of $400 a patient for bedaquiline, and over $1,000 for delamanid.
At these prices, the cost of these two drugs alone would sink the annual TB budget, and because they are both monopolies, with several patents protecting them, there is no one else we can negotiate with. In the interim, millions are dying.
Or consider pneumonia. PCV-13, the latest version of the pneumonia vaccine, is the monopoly property of Pfizer. PCV-13 retails for over $800 a course in the US. In India, it is offered through a subsidy to the government at $10 a course. It sounds like a good deal, but multiplied by the approximately 13 million babies born every year, it is unaffordable.
As a result, 127,000 infants continue to die from pneumonia in the country every year, even as the vaccine that could save them has become Pfizer’s biggest rainmaker, bringing in $5 billion in annual revenue.
Pneumonia has been a preventable disease since 1983. MDR-TB has been a treatable disease since 2012. The fact that thousands of people in India continue to die every single day from a lack of access to treatments for both diseases, in 2020, is a travesty.
India has the legal and industrial infrastructure to produce high-quality, affordable medicines and vaccines, but we have hobbled it. The Indian patent system needs urgent attention. It needs to be implemented correctly, by denying monopoly protection when undeserved—at the moment, the system is running at an error rate of 72%, which means seven out of every 10 patents it grants are mistakes under our law.
The system needs to be updated to keep up with new technologies it doesn’t understand, instead of gifting them monopolies without analysis—like in the case of biologics, which dominate the global treatment horizon, or CAR-T therapy, which uses re-engineered T-cells to fight cancer.
Finally, we need to use our laws fearlessly, by issuing compulsory licenses, opening competition, and reducing the cost of treating fatal diseases, by significant amounts.
Certainly, in the past, we have faced the wrath of big pharmaceutical companies and rich countries for taking this perfectly valid action. But in this environment, with a global recognition of the sovereign right to protect health, India can take decisive action with no fear of unjust pushback—in fact, countries as diverse as Canada, Germany, Israel, Chile, Peru, and Ecuador have already done so, with no negative consequences.
The systemic changes
The second concern is around diseases that have no cures, like covid-19, with one difference: We have lived with them for decades as they kill millions, unlike covid-19, which is just three months old, and has killed thousands.
India, along with several other poor countries, is home to “neglected" diseases, whose patients are too poor to merit Western pharmaceutical industry interest. New medicines to treat dengue and kala-azar would change the lives of over 50 million people in the country; new vaccines for hookworm infection and elephantiasis would save the lives of 110 million people.
If we genuinely cared about solving diseases that affect us, we could commit to incentivizing research and development for therapies that would cure these diseases. We could go at it alone, or better still, with other countries. We have existing multilateral arrangements that would be fit for purpose, the most viable of which perhaps is the grouping of Brazil, Russia, India, China and South Africa (BRICS). We can take the lead in solving problems that are uniquely ours.
The third concern is environmental factors that are within our control to regulate, but which require outsize coordinated action along the scale of the nationwide lockdown. We have come to accept the distinction of having 13 out of the 20 most polluted cities in the world (and owning the top seven spots on this list) as facts of life. This notorious distinction has several fatal consequences. Asthma-related deaths in India are of the order of 1 million people a year. There is no reason why a pointless programme like Swacch Bharat could not be given teeth and extended to include air pollution.
India could take that idea even further, by creating an umbrella policy solely oriented around public health, along with a significant reorientation of our budgetary and administrative priorities, to help coordinate actions around air pollution and other complex problems.
Vesting an authority to have public health at the centre of decision-making, in the case of air quality for example, would require engaging pollution boards, and the transport, energy, and industry ministries, at the very least—as well as designing regulations that prioritize human lives.
But in doing so, decisions about closing down coal-fired plants, finding ways to reduce stubble burning, using tax policies to incentivise electric vehicles, raising taxes on polluting fuels like diesel, subsidizing LED lanterns, and other solutions, would then become part of a coordinated set of policies with clear aims, under a single national authority whose sole mandate is to save human lives.
Paying for it
Can we afford these critical public health initiatives? India has already shown willingness to upend the economy for the sake of public health in ways that would have seemed impossible just three months ago. We have been willing to forego enormous output and expend resources at a moment when the economic situation was already precarious. We now know that saving lives is a priority, whatever the economic environment.
Public health in India is a gigantic undertaking. In this account of possible futures, we have deliberately not mentioned the more expensive priorities we know are justified—expanding and improving public health facilities, training more doctors and nurses, increasing the reach of the system through community health workers, and other fundamentals.
The costs associated with addressing the concerns we have raised will amount to a minuscule fraction of the costs incurred in the lockdown, while the number of lives we could save as a result are of much greater magnitude.
Having said that, there is no reason to shy away from the bigger, harder and more expensive public health needs that confront us. India is underspending on health. Long before the pandemic, the government committed to moving health expenditure up from 1% to 2.5% of our gross domestic product.
While the recent announcement of an additional $2 billion in health spending is welcome, this government will have to spend far more to reach its own target, which stands at $48 billion more than the current outlay. And the focus of this increase, narrowly directed at the pandemic, will have to widen if it wants to target the diseases that actually affect us.
We could do that by accounting for health as an investment, not a cost. In the medium term, health and economic growth are positively correlated. In the long term, however, it is clear that economic growth will not necessarily result in better health without a concerted effort to ensure it does. There are good reasons to make that effort.
We have compelling evidence that a healthier society is more productive, and also more resilient—Kerala’s standout success in containing the coronavirus pandemic did not come about by accident.
We might not know how or when yet, but this crisis too shall diminish, and eventually pass. And as it does, we may find our solidarity wearing off, the old ways setting back in. That would be a worse tragedy than anything this crisis brings. We cannot afford our old ways any longer.
Morally and epidemiologically, the health of each of us has always been linked to the health of all of us, but perhaps not for a hundred years, since the last great influenza pandemic, has this been as urgently and palpably true. We can, and must, make this moment count. All the anxiety, suffering and loss of the present will count for nothing unless we forge a better future from it.
Arjun Jayadev is Professor of Economics at Azim Premji University and Senior Economist at the Institute for New Economic Thinking.
Achal Prabhala is a fellow at the Shuttleworth Foundation and coordinator of the AccessIBSA Project, which campaigns for access to medicines in India, Brazil, and South Africa.