Towards an equitable response

When COVID-19 hit India, the country, just like many others hit by the pandemic, was forced to apply a nationwide lockdown. Lockdown, as prescribed by public health experts, was seen as the most effective means of enforcing physical and social distancing. This was also endorsed by experts across disciplines. The objectives were to protect people at risk of serious complications due to COVID-19 and to reduce the peak prevalence of serious illnesses, especially the adult respiratory disease syndrome, which requires the use of mechanical ventilation and intensive care. Whilst public health orders were followed extensively across the globe, with just a few countries being the exception, these policies were pursued in a context of high uncertainty and limited evidence. However, the impacts on society, especially the dramatic reduction of economic activity, the disruption of delivery of healthcare and education, and the impacts on social determinants of health, were at that time not part of the public discourse.

More than six months into the pandemic, concerns are being raised that nationwide lockdowns, however effective at reducing the spread of infection, have had significant impacts on vulnerable and disadvantaged groups. In the last couple of weeks, numerous stories have appeared suggesting that the benefits of lockdowns in terms of prevention of illness and the impacts of societal disruptions are not evenly distributed and these policies run the risk of promoting inequity. Some vulnerable groups are obviously bearing disproportionately higher costs of lockdown. As we enter into a different stage of the pandemic, with increasing evidence that interventions need to be specific to local areas through increased testing rates and appropriate isolation of suspected as well as confirmed cases, reduction of travel from zones of high to low prevalence, and a better understanding of the expected need for acute care beds and ventilators, we argue that a stronger emphasis needs to be put on assessing the equity impacts of public orders to balance the costs and benefits for vulnerable populations.

This is especially important for people at the intersection of many vulnerabilities and suffering from the cumulative impacts of disadvantages. They are the elderly population, those living with chronic diseases, lacking formal education or living in poverty. However, they are also those that live in communities lacking adequate health infrastructure and response systems. Under this lens of intersectionality, there would be inequalities between the states as well as within the states which need to be considered in balancing the costs and benefits of lockdown in the future.

From an ethical perspective, any intervention, be it at the individual or at the societal level, should not make people's condition worse by imposing more costs than providing benefits. Now we know that the lockdown policies have had a crucial role in protecting our elderly population and those with chronic diseases, such as diabetes and chronic respiratory illnesses. Given this reality, the key question now is about how to apply physical and social distancing in a way that protects those at risk of COVID-19 without disproportionately affecting those who are not in these high-risk categories? Furthermore, from an access to healthcare perspective, is the balance of risk and benefits the same in a state with high capacity for intensive care and use of ventilators compared to states where that capacity is extremely limited to start with? What are the ethical issues in imposing economic hardship on a population living in poverty that would face significant barriers in accessing these intensive care beds and ventilators in the first place? In other words, we now need to consider how indiscriminate lockdowns could exacerbate inequalities (or inequities) across socio-economic groups within India and between states.

The use of large scale household survey data (such as National Sample Surveys, National Family Health Surveys) and a better understanding of local systems' capacity to respond to the diseases could support a stronger reliance on local circumstances and local information as a way to drive the right balance of lockdown and other pandemic control policies. For example, the diagram given alongside the text, estimated from the latest round of National Sample Survey data (2017-18), shows how the percentage of elderly (60 years and above), individuals with reported diabetes, heart disease or asthma and individual who required urgent medical attention due the nature of their diseases by expenditure class. Higher socioeconomic groups are those with more people at risk of complications from COVID-19 and could be those benefiting most from lockdown policies and being impacted the least by their economic impacts.

Going forward, we argue that appropriate consideration of social and demographic characteristics of communities need to be taken into account in designing pandemic response policies with an increased focus on localised public health orders so that possible costs and benefits and their impacts on equity can be balanced. Nation-wide lockdowns, whilst promoting a clear policy, could now be challenged as the best way to balance risks and benefits across groups. It is obvious that reducing movements across states, by stopping inter-state bus service, international and domestic flights, passenger trains, can benefit everyone by reducing transmissions from high to low prevalence zones. However, the decisions that relate to individual movements within localities need to be framed in a manner that minimises the economic impacts and the barriers to the access of basic services. Only by ensuring this can we avoid imposing a double burden on those already economically vulnerable and disadvantaged, as has been tragically demonstrated during the Great Indian Lockdown. Investments in public health, through testing regimes, case investigations and appropriate isolation of cases, could help control spread of the disease and provide considerate resort to physical and social distancing and localised lockdowns, a route now taken in many countries, in the Indian context in the future.

S Mukherjee is an Associate Professor at the Institute of Development Studies Kolkata. JF Levesque is a Conjoint Professor at the Centre for Primary Health Care and Equity of the University of New South Wales, Australia. Views expressed are personal