Coronavirus threatens to overwhelm the health and economies of many developing countries where a billion people subsist in a Hobbesian state of nature and life is ‘nasty, brutish and short’.
In response to my original article on 30 March, some people inquired about my interest in the subject and point of departure. First, my major niche interest in pandemics comes through global governance. With Thomas G. Weiss, I co-authored Global Governance and the UN: An Unfinished Journey (Indiana University Press, 2010), chapter 9 of which is ‘Protecting against Pandemics’. Thus in addition to my article and the postscript here, I’ve written an article for The Lowy Interpreter on the Sino-American geopolitical contest in the age of corona, and another for The Strategist on the need to balance national resilience measures with more but better global governance.
A Hobbesian world
Second, as someone who has seen poverty up close in many different countries, I believe the choice is not between ‘lives vs money’, but ‘lives vs lives’. We cannot have a first-world health care system and facilities if our economy tanks to third-world poverty. And in the third world, in a very real sense poverty is the biggest killer of all. In Western societies, the major causes of death are non-communicable diseases like heart problems. In poor countries, the biggest numbers of deaths are caused by water-borne infectious diseases, nutritional deficiencies and neonatal and maternal complications. Coronavirus threatens to overwhelm the health and economies of many developing countries where a billion people subsist in a Hobbesian state of nature and life is ‘nasty, brutish and short’.
The Hindi word for the Hindu-Buddhist concept of compassion, but with the added connotation of taking action to alleviate suffering, is ‘karuna’. It seems to be in scarce supply in India these days, either amongst the people or in government policy. Launching the world’s most brutal lockdown in the war against coronavirus, PM Narendra Modi imposed a 21-day clampdown from 25 March: a de facto legalised house-arrest of the 1.3bn population.
As a big emerging market, India has some unusual strengths among developing countries, including good private hospitals and a sophisticated pharmaceutical sector. Yet India’s hospital bed capacity is only 20%-25% of Western countries. Worse, India has neglected human resource development at the primary care frontline: primary health centres in villages and local urban wards, staff trained for early detection, investigation, counselling, basic tests, triage and referral, in addition to clinical care. There is also a national scarcity of epidemiologists, microbiologists, statistical modellers and research institutes staffed by experts to trace the origins, spread, projected course, and capacity gaps in the public health system.
Consequently the human and social costs will be far more devastating with primitive health systems, teeming slums, unclean water and sanitation systems, congested mass transit, no safety nets and widespread ignorance-induced prejudice. Thus it is that in the UK, a tired nurse comes home after a hard day’s work in the age of corona to a hero’s welcome from her family. But in India, people spit at and abuse health workers because they are feared as carriers of the virus. And I will attract online abuse from Indians for my lack of patriotism in mentioning this.
Lives vs lives
New York’s Gov. Andrew Cuomo has become the latest hero in the Democratic pantheon for insisting that his sweeping, expensive measures to stem the coronavirus would be worth it even if they saved one life: ‘we’re not going to put a dollar figure on human life’. This is stirring but sheer idiocy: a soundbite, not sound policy. Every single budget of every central and state government in every country of the world juggles with competing public policy priorities and, in that sense, puts a dollar figure on human life. Otherwise, if we took Cuomo’s statement literally, the health budget should cannibalise all other sectors of government expenditure. And we should abolish all museums and galleries and redirect all public subsidy into health coffers etc.
Health costs are incurred from increased loneliness and mental anxiety and social costs from emotional distress at job losses, financial stress and forced family separations. A 2014 study in Social Science and Medicine by Timothy J. Halliday showed that a 1% rise in the unemployment rate raises the risk of dying next year by 6%. US unemployment during the Great Depression was around 25%. According to the Federal Reserve’s James Bullard, who supports the Covid-19 shutdown measures as an investment in public health and survival, unemployment could climb to 30%. A report in The Wall Street Journal notes that amid the pandemic, ‘many hospitals and doctors are grappling with an unexpected side effect: a financial squeeze that could deplete the health-care resources needed to meet local surges in cases and threatens the operations of some financially struggling hospitals’.
Of course Cuomo is not stupid, any more than other politicians who feel compelled to say silly things. It’s not that they cannot think clearly. Rather, they are trapped in a ‘gotcha’ political hothouse in which they cannot be seen to be thinking logically, based on facts, and speaking and acting accordingly. In the risk-reward calculus, political leaders have less to lose from an excessive response based on preventing the worst imaginable outcome, and more to lose from a reasonable response based on the most likely trajectory. On the same political calculation, they will be too risk-averse to stop and reverse course early in case something goes wrong, compared to keeping everyone at home because they can still point to fresh cases of infection. Governments may not back off the sequester orders until citizens rebel against the de facto police state regulations and mentality as the new normal.
The coronavirus impact on India
The lockdown has produced its own version of Thucydides’ dictum that the strong do what they can, the weak suffer as they must. Under Indian conditions, saving livelihoods is no less important than saving lives. The privileged jet-setters who imported the virus can utilise the private hospitals but the poor they infect have little access to decent healthcare and will be disproportionately devastated. The rich carry the virus, the poor bear the burden since staying at home means foregoing daily income. Millions ‘fear hunger may kill us before coronavirus’.
Like other strongmen with authoritarian instincts, Modi has prioritised the expansion and consolidation of state power over the development of state capacity. Democratic India is using brutal tactics to enforce the world’s harshest lockdown, for example by spraying desperate migrant workers with chemical disinfectant. On the one hand, Modi’s exceptionally high level of trust in the Indian public gives him room for tough and decisive action. On the other hand, weak capacity in turn means that authorities will have correspondingly greater difficulty in contact-tracing, for example the people, including many foreigners from Southeast Asia, who have attended the sweet spot of a religious event spread over many days at a mosque in New Delhi that may have contravened social-distancing orders already in place and set off six separate clusters in several regions. But stupidity does not discriminate by religious belief. On 2 April cabinet minister Shripad Naik boasted that India’s ancient herbal medicines-based Ayurveda had helped cure Prince Charles of Covid-19. The next day the prince’s spokesperson said he had ‘followed the medical advice of the NHS in the UK and nothing more’.
India has the world’s biggest pool of poor, illiterate, sick, hungry, underweight and stunted children, and sexual assault victims (think also domestic violence during prolonged confinement in homes). Widespread poverty diminishes the state’s capacity to provide adequate nutrition needs of its people and being malnourished makes people more vulnerable to coronavirus. The lockdown could cripple India’s already struggling economy, ballooning the unemployment crisis, destroying the livelihoods of daily wage workers, forcing thousands of inter-state migrant workers to return home under highly stressful conditions, distressing the agricultural sector and causing massive food wastage with broken supply lines.
According to Deepak Nayyar, a one-time chief economic adviser to the government and former Vice Chancellor of Delhi University, under 10% of India’s workforce is in regular, salaried employment. In the 90% at-risk categories, 52% are self-employed, 25% are casually employed on daily wages and 13% work in the informal economy with no social protection. Construction, transport, and hospitality workers are the most vulnerable to big economic shocks.
How exactly does a rickshawallah survive in a 21-day lockdown? How do you implement physical distancing in slums where multi-member families sleep in one room, eat together in an adjacent room and share communal water and sanitation facilities in crowded conditions in the congested population clusters?
The most expeditious spread of the virus occurs when it finds a sweet spot: a cruise ship in Sydney, a football stadium in Italy, a church in South Korea, a mosque in India. India’s geographical size, physical distances and antiquated transportation networks mean broken supply lines for food and other essentials. For the almost totally corrupt police force at the coalface of interaction with ordinary (that is, non-VIP) people, every draconian regulation is an opportunity for fresh extortion. Stories abound of people being harassed and beaten up and trucks stopped to check if their goods include non-essentials.
It’s possible the worst fears of the coronavirus pandemic will prove wildly exaggerated. In the panicky predictions of a runaway swine flu pandemic in 2009, instead of the feared 1.3% fatality rate, the actual rate was 0.02%. In the UK it was 0.026%. The total worldwide deaths was about 280,000 (range 151,700-575,400), and in the US about 12,500. According to a September 2010 study from Wisconsin’s Marshfield Clinic, the swine flu was no more severe and posed no greater risk of serious disease than the 2007–09 seasonal flus. The World Health Organisation came under severe criticism for having served the interests of Big Pharma in selling unnecessary vaccines. Governments were left with costly surplus stocks for disposal. Peoples in the poorer Southeast Asian and African countries were killed in disproportionate numbers, reflecting the sad reality of inferior access to prevention and treatment resources.
Alternatively, Covid-19 may end up with a fatality rate of 1%, ten times the seasonal flu, or worse. Even then, an exit strategy might still require a managed process of herd immunity in the population at large. If we are lucky, this will come through the development of a vaccine shortly. More likely, it will require a progressive but targeted lifting of the very tight restrictions currently in place that are unsustainable over any length of time. This is the recommendation from Professor Graham Medley in the UK, an expert in the spread of infectious diseases who is a key adviser to PM Boris Johnson. He is worried that the government may have ‘painted itself into a corner’ with the imposition of widespread restrictions with the potential to cause more damage than the disease itself.
In the US too, Dr Alex Berezow, a microbiologist who is vice president at the American Council on Science and Health, cautions against a panic-driven policy. ‘The consequences of … draconian measures are potentially devastating and irreversible …. a total economic collapse would tear at the fabric of society and also pose a threat to public health’. He also points out that in general, the relationship between the infectiousness and lethality of a disease is inverse.
As more data come in, Covid-19 might reveal itself to be either highly infectious with a low case-fatality rate or poorly infectious with a high case-fatality rate. The nightmare scenario of a highly infectious, highly lethal coronavirus is the least likely outcome
The equation has clear if uncomfortable implications for all countries with poor public health infrastructure. The government has a critical and indispensable role to play in public health during pandemics: prompt, accessible and affordable universal testing, ramped up hospitals to cope with a surge in demand, accelerated supplies of protective, preventive and therapeutic medicines and equipment, etc. But poverty hollows out state capacity to do all this. They might do better to focus on managing herd immunity in the society at large rather than killing millions through economic lockdowns.
A final sobering thought. It is highly unlikely that India would have locked down had the Western countries not led the way. If the most advanced economies and the world’s leading exemplars of liberal democracy had not taken to extreme policies of quarantines and social distancing in order to slow the spread of the virus and keep the patient loads manageable, India almost certainly would not have caught the panic virus either.
Ramesh Thakur, a former United Nations Assistant Secretary-General, is emeritus professor in the Crawford School of Public Policy, Australian National University