Fragile India, Strong India

As India’s second wave of the COVID-19 pandemic begins to recede, it has become clear some parts of the country have met the surge better than others. The state of Kerala in southern India, for example, has dealt with the pandemic in an exemplary fashion—with its mortality rate being the lowest in the country at 0.4 percent—even though it was home to the first COVID-19 case in all of India at the end of January last year. At the other end of the spectrum is Uttar Pradesh, the most populous state in the country, where the pandemic response has been little response at all.

What explains the markedly different experiences of various states? The answer is mostly twofold. States that seem to have done better have benefited from a strong, existing health care infrastructure along with political leadership that prioritized science-based medical care.

It is no particular surprise the state of Kerala has fared relatively well. It has long prioritized extensive social welfare provisions thanks to a legacy of Communist rule in the state harking back to the 1950s. Relative to people from other states in India, Kerala’s residents have a longer life expectancy, a lower infant mortality rate, and superior access to health care. For most of the state’s history, such social welfare provisions were ensured even as its economy remained stagnant. When faced with the pandemic, meanwhile, its health minister, a former high school physics teacher, quickly launched an extensive testing regime and systems to track the spread of the disease and supplies.

The contrast could not be more striking with Uttar Pradesh, which lags behind in terms of its social statistics ranging from infant mortality to maternal well-being. Years of neglect, inattention, chronic underfunding, and flawed policy choices—for the most part—explain the dire health situation in the state. To compound matters, its chief minister, Yogi Adityanath, a Hindu mendicant, also has a profoundly populist bent. His performance during the pandemic—which has included holding religious festivals and opening a temple while hounding those who dared to question his policies—has been inept, callous, and authoritarian. As a result, in late April, at the beginning of the second wave, the state saw at least three deaths every two hours.

Under India’s constitution, the vast gulf between the pandemic response in Kerala versus Uttar Pradesh is perfectly sanctioned. The constitution empowers the states to determine public health policy and set health spending decisions based on resources allocated from the central government. Most states have chosen to underinvest in their health care systems, oftentimes leading to ill-equipped and understaffed hospitals and strikes among health care professionals. Indeed, facing grim conditions, absenteeism among health care workers has become a serious problem. A prominent pre-pandemic study said nearly 40 percent of India’s health care workers are absent from work on any given day.

India’s poor health infrastructure has complicated the battle against the COVID-19 pandemic in several ways. Because medical facilities are in short supply, patients often cannot get the treatment they need. And given this lack of treatment, citizens come to doubt the trustworthiness of health care. Instead of proactively seeking treatment, health care facilities become the place one goes only when one has exhausted all other options. That makes it even harder for health care workers and experts to work with the public to control infectious disease outbreaks.

Complicating the picture is even if a state has a relatively strong health care infrastructure, political leadership can potentially derail health care responses. A number of politicians in India preach the virtues of home remedies or other unverified practices. Although there is undoubtedly some merit to some of these approaches, politicians—particularly those associated with Prime Minister Narendra’s Modi’s Bharatiya Janata Party—often champion them as superior to allopathic approaches. That makes it more difficult for the public to seek science-based health care when they need it.

To be sure, some may point to COVID-19 case rates to argue the data actually looks worse for Kerala than for Uttar Pradesh. Kerala does have more confirmed cases per 100,000 people than any state except for Goa and is above the national average in deaths per day per 100,000 people. Meanwhile, states like Uttar Pradesh report numbers that seem too good to be true. With almost six times as many people as Kerala, Uttar Pradesh has claimed a seven-day average of just 3 cases per 100,000 people.

Unfortunately, Uttar Pradesh’s stellar numbers must be taken with a large grain of salt. Journalists have noted such low numbers do not mesh with body disposal. Hundreds of bodies have turned up in the Ganges river, and cremation prices are through the roof. According to one report, the price of cremations in one of the state’s major cities has increased from about $50 to more than $400.

According to some estimates, India’s COVID-19 pandemic is potentially 20 times worse than what government statistics claim because many people across the country are avoiding testing or seeking treatment if they are affected. Therefore, most states are not able to keep detailed public health records, and some states seem to be deliberately encouraging undercounts to burnish their image. Kerala’s greater capacity to track and test may be one reason why its numbers are higher, although even there, health officials may be underreporting after New Delhi decided to sideline the World Health Organization and change the process of case and fatality reporting early in the pandemic.

India’s second wave of the COVID-19 pandemic will perhaps be recorded as one of the greatest human tragedies of the 21st century. To ensure history does not repeat itself, scholars and practitioners must not only identify the public health practices that worked, but they must also weigh deeper political questions: Why does health care infrastructure vary between states? And what can be done to prevent political leaders from making a bad situation worse? What aspects of the health care system should be nationalized, and what role should local and state governments play?

We should not expect Uttar Pradesh to adopt the Kerala model overnight, but the answers to these political questions can help convince—or even cajole—governments into meaningfully strengthening their public health systems.