India’s Federalism is in the ‘Pink of Health’: Pandemic Governance in India’s States

Ever wondered why the rather arcane Epidemic Act of 1897 was invoked by the Maharashtra Government in Pune prior to the National Lockdown to enforce ‘social distancing’ to manage the COVID-19 outbreak? 

India since the colonial era has a rich history of public health governance as several epidemics have left its imprint in a visceral manner. 

The Bombay of 1896, the city of eight hundred and fifty thousand souls was known then as a nerve centre of the global cotton trade, with a dense concentration of mills. Within a year of the outbreak of the plague, the population reduced by half more out of fear of the draconian rules enforced by the Bombay governmental authorities to contain it. 

These measures were surveillance and segregation in the ‘chawls’ or congested urban housing for the mill workers, as the infections were initially detected there. The mill workers mostly migrant labour went back to their villages. Do these words evoke contemporary emotions? 

The reality is that the pandemic containment playbook is based on segregation or social distancing and surveillance or contact tracing. This has clearly not evolved much since 1896, hence the same epidemic act has been imposed for a pandemic 123 years later.

A pandemic is a once in a century event (hopefully), although regional epidemics are more frequent such as SARS, MERS, Nipah and Ebola. Health systems are nurtured over decades as complex socio-technical systems which are essentially assemblages of the perfect science and society juxtaposition. 

Health systems are also deep institutional repositories of social, human and cultural capital. Hence health systems in every state are reflective of the cultural terrain of the region. 

Health is also a concurrent list subject with the federal government along with the states responsible for the governance of health. 

An Urban Local Body such as the wealthy Brihanmumbai Municipal Corporation or BMC controls health assets as hospitals and medical colleges which add another layer of institutional complexity in the delivery of the public goods. 

The very basic step in disease prevention such as fumigation is usually carried out by the local municipal government, and the last mile implementation of health promotion information is also under its ambit.

This nuance is vital in dissecting, diagnosing and offering solid deliberations on pandemic response in the country. 

Why does Kerala have a superior pandemic governance architecture to a Punjab when both states are equally wealthy as a result of a vibrant NRI economy for many years? 

The answer lies in good literacy levels and a highly skilled medical workforce in Kerala. Malayali nurses and doctors form the backbone of public health systems in many states in India and serve globally from the UK NHS to the UAE. 

A recent brush with Nipah Virus a couple of years back, prepared the state for a coordinated infectious disease response. The time for a victory speech post win is not there yet as Kerala is preparing for thousands of its respected denizens from the Khaleej to return once the flight embargos are lifted. 

UAE has already notified countries to take back their citizens. Most of the inflections in Kerala are due to its returnees from Dubai. 

West Bengal has been in the news for masking health data due to COVID-19, reflecting the Chinese distaste for authentic numbers. Kolkata has the only China Town in Tangra (known for excellent food and leather products) but this is indeed stretching the envelope as good data is the edifice of a robust intervention. 

West Bengal is the harbinger for leftist politics in India but has a poor healthcare system in comparison to Kerala, which invested in socialised healthcare inspired from Cuba. 

No wonder the schism between the powerful Kerala lobby of CPI (M) and the now weakened Bengal unit led by Sitaram Yechury. Even within a party, different states follow forked trajectories on public health, which is not even a random sample of the diversity within the country. 

This is very distressing as Kolkata had established the first public health institute in India in 1932. For getting any small medical procedure done; Bengali’s rush to Vellore and Mumbai. 

Odisha is another stellar example where past capacity building has come into force. As a state which has been in the receiving end of cyclones and consequent rehabilitation activities, local bureaucracy is empowered with the powers and the resources to prepare for lockdowns and to provide during/post emergencies. 

The National Capital Territory of Delhi, a super municipal corporation/half state under the newly right wing Aam Admi Party has been known for welding welfare with a cultural nationalist agenda. The national capital has the best medical facilities in the country as well as essential services delivery at the doorstep which makes the lock down very effective. 

Populous states which have weak health governance such as Uttar Pradesh and Bihar, are major migrant exporters internally within India. India is a common economic grid which works smoothly as it does because people from all over the country travel where the demand is, work and move back to their villages when the work dries up. 

This circular migration makes India federal in spirit. The poultry shop operator in the small urban village of Devachi Uruli, where I live on the outskirts of Pune is from Mushirdabad in West Bengal and has lived in Pune for a decade and all the Kirana shops are owned by Marwaris. 

In this tiny microcosm, migrants dominate the commercial landscape. But as this is Maharashtra, a prosperous industrialised state this urban village has three clinics and a couple of pharmacies. No one worries about a paucity of treatment or testing.

A robust local economy having the capability of absorbing migrants for work is indicative of an expanded market space where new player can ply their ware. 

This includes doctors who open clinics and nursing homes, laboratory services and pharmacies configuring a micro health care value chain. The private sector has a critical part to serve in creating institutional capacity in the face of a pandemic. 

Drawing on Naomi Klein’s thesis on disaster capitalism, a crisis is an economic opportunity while serving the community. The pandemic has compelled to rethink what constitutes healthcare from a reductionist Human Development Indicator ranking to a holistic human security paradigm that factors in the cultural and historical context. 

Federal healthcare competitive z quantified in infections and recoveries as seen in this pandemic may be a proxy political theatre for earning brownie points, however, is a window into the diversity of the nation. 

Manishankar Prasad

Manishankar Prasad is an environmental engineer, sociologist, researcher and writer. He has studied at the National University of Singapore and Nanyang Technological University, Singapore. He has published across numerous national and international platforms such as the New Indian Express and the Huffington Post, been a panellist on Al Jazeera International and BBC World, and has been interviewed by Forbes and The Guardian.

The views and opinions expressed in the article are those of the authors and do not necessarily reflect the official policy or position of The Tilak Chronicle and TTC Media Pvt Ltd.

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