Second Wave – Observations from a small town
Here are a few observations on healthcare services from a district town as the second wave of Covid-19 burnt through the country. In over two months of this public health and epidemic response struggle, a few things are apparent.
India’s elected leaders, bureaucrats and the public exist in three different worlds – the aspirational, the realistic and the actual. These three worlds do not overlap except during elections. In the Covid-19 response during April and May, our district Wardha that enjoyed a very low positivity rate and fatality rate climbed up the charts rapidly. By May first week Wardha ranked among Government of India’s top 50 districts of concern with respect to Covid-19 spread.
Wardha district is spread over 6310 square kilometers. For reference, Singapore’s land area is 724 sq km. Wardha is 8.7 times that of Singapore. In this fairly large sized administrative area the healthcare infrastructure is, in short, inadequate. This is the situation during normal times (pre-pandemic). For the district to cope with the pandemic the struggle has been of a completely different order given the current state of affairs. A critical awareness of the realities of healthcare capacity (private and public) is driving the response. It has manifested in the form of strict restrictions which have had a debilitating effect on livelihoods and essential citizen services.
This is a kind of tradeoff that has been hard in many Indian cities and towns – bring down Covid-19 infections vs ensure basic income and citizen services by not using lockdowns. The district administration chose to bring the town to a grinding halt and leave thousands of people with depleted incomes and long term impoverishment.
The aspirational world occupied by elected leaders spoke of door-to-door vaccinations and income support through cash grants. It is an ineffective and poorly thought response given the state of finances of state and central governments.
The realistic world with its teeming civil servants went for lockdowns backed by extreme and brutal enforcement.
For the district’s population of 1.3 million residents living in 8 blocks (tehsils) the actual and realistic healthcare infrastructure looks as follows –
There are a total of 181 sub-sentres in the district. The Indian Public Health Standards (IPHS) guidelines stipulate that a sub-centre should serve 5000 people in a region. It should be staffed by two Auxiliary Nurse and Midwives (ANMs) and one healthcare worker. One of the ANMs must be a Staff Nurse in sub-centres where more than 20 maternity cases and deliveries take place per month.
India is typically caught between the ‘aspirational’ and ‘actual’. Wardha district is probably a typical case of this falling through the gaps in most aspects of public services l(ike agriculture extension services).
Between these two worlds, lies a ‘realistic’ one that adequately responds to the public needs and which is stable as well as consistent in its quality of service delivery. Moreover, a ‘realistic’ planning approach can lead to more public faith in government as this would be a set of goals that can be certainly achieved given the financial and administrative realities of the system.
While one may argue that a figure of 5000 people per sub-centre is realistic, it is important to note that the healthcare system has repeatedly fallen short on delivering on it. So, perhaps, realistic lies somewhere in between the two.
The larger point is that the pandemic response has been guided by the actual state of affairs in healthcare and its capacity. This is the reason that on the face of it many have found it difficult to understand the brutal and often inhumane control measures adopted by state governments across the country.
When healthcare falls short, police fills the gap. In short, this is the story of pandemic response here.