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 Table of Contents  
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 64-83

Debating the process, impact, and handling of social and health determinants of the COVID-19 pandemic

Department of Psychiatry, Holy Family Hospital; Formerly Head, Department of Psychiatry, Chief, National Drug Dependence Treatment Centre, All India Institute of MedicalSciences, New Delhi, India

Date of Submission19-Jul-2020
Date of Acceptance22-Jul-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Sudhir K Khandelwal
Department of Psychiatry, Holy Family Hospital, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_226_20

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How to cite this article:
Khandelwal SK. Debating the process, impact, and handling of social and health determinants of the COVID-19 pandemic. Indian J Soc Psychiatry 2020;36, Suppl S1:64-83

How to cite this URL:
Khandelwal SK. Debating the process, impact, and handling of social and health determinants of the COVID-19 pandemic. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:64-83. Available from: https://www.indjsp.org/text.asp?2020/36/5/64/297137

  The Impact Top

Between January 14 and January 20, 2020, when top Chinese officials secretly determined they were likely facing a pandemic from a new coronavirus, the city of Wuhan at the epicenter of the disease was busy hosting a mass banquet for tens of thousands of people; millions began traveling through for lunar New Year Celebrations. President Xi Jingping warned the public about a new virus on the 7th day, i.e., January 20. However, by that time, more than 3000 people had been infected and traveled to different parts of the world, according to internal documents obtained by The Associated Press and retrospective infection data.[1]

On March 18, a 35-year-old man, suspected of coronavirus infection, committed suicide at Safdarjung Hospital in Delhi. The 35-year-old deceased jumped off the seventh floor of Safdarjung Hospital, according to a PCR call received by the Delhi Police. He was admitted to Safdarjung Hospital at 9 pm on Wednesday only as a suspected coronavirus patient.[2]

On March 25, a 56-year-old man in Karnataka's Udupi district committed suicide by hanging. According to police, deceased left a suicide note saying that he had contracted the COVID-19 disease and asked his family to be safe. The police said, “According to the preliminary investigation, he had committed suicide after reading extensively about coronavirus on social media which led to excessive fear about the pandemic.”[3]

A Chennai doctor, Simon Hercules, died of COVID-19 on April 19. He was denied even basic dignity at the time of his death as a mob attacked his friends and family with sticks and rods when they were transporting his body to a burial ground.

This incident has, yet again, cast a worrying spotlight on the health and safety of our frontline soldiers in the collective fight against COVID-19.[4]

A 42-year-old man was arrested late Wednesday evening for allegedly assaulting two women resident doctors of Safdarjung Hospital after accusing them of “spreading” COVID-19 in Gautam Nagar area, South Delhi, said police.[5]

Manish Kumar who was employed in a factory says, “I am looking for any form of transport which takes me anywhere close to my destination. I am going to die soon anyway of hunger. There is no one here to even beg for food. Everyone's pockets are empty.” Visual of hundreds of workers wearing gamchas, carrying heavy backpacks and wailing children, walking on national highways, boarding tractors, and jostling for space atop buses became defining images for days to come in India.[6]

A 12-year-old child recently shared that she felt very scared at home. “My parents are very stressed and they end up taking it out on me. They think it is not affecting me, but I am terrified most of the time. Stress is like polluted air, and we are all breathing it in.[7]

Sixteen migrant workers were mowed down by an empty freight train in Maharashtra's Aurangabad district in the early hours of May 8. While 14 of them died on the spot, two of them later succumbed to injuries. The workers, who were walking to Bhusawal from Jalna to board a “Shramik Special” train to return to Madhya Pradesh, were sleeping on the railway line extremely tired after marathon walking for 40 km. Expressing grief over the incident, Prime Minister Narendra Modi tweeted, “Extremely anguished by the loss of lives due to the rail accident in Aurangabad, Maharashtra. Have spoken to Railway Minister Piyush Goyal and he is closely monitoring the situation. All possible assistance required is being provided.[8]

As of July 18, 2020, there are 13,824,739 confirmed cases of COVID-19 (coronavirus infection disease, 2019) and 591,666 confirmed deaths worldwide as per the World Health Organization (WHO)'s dashboard.[9] India has confirmed 1,038,715 cases and 26,273 deaths so far.[10] India has been under lockdown since March 25, 2020, for 6 weeks (extended again with revised guidelines), and jury is still out whether to continue with lockdown or resume normal or truncated life activities.

The COVID-19 pandemic has been the fastest-moving global public health crisis in a century, causing significant mortality and morbidity and giving rise to daunting health and socioeconomic challenges. Governments are taking unprecedented measures to limit the spread of the virus, while health and social systems are struggling to cope with rising caseloads, supply-chain bottlenecks, movement restrictions, and economic strains. In humanitarian and fragile settings and low-income countries, where these systems are already weak, the pandemic is disrupting access to life-saving reproductive health services. It is also compounding existing gender and social inequalities.[11]

  Prelude Top

On December 31, 2019, the WHO China Country Office was informed of cases of pneumonia of unknown etiology detected in Wuhan City, Hubei Province of China. China had kept it as a secret from the world. From December 31, 2019, through January 3, 2020, a total of 44 case-patients with pneumonia of unknown etiology were reported to the WHO by the national authorities in China. During this period, the causal agent was not identified. On January 11 and 12, 2020, the WHO received further detailed information from the National Health Commission of China that the outbreak was associated with exposures in one seafood market in Wuhan City. The Chinese authorities identified a new type of coronavirus, which was isolated on January 7, 2020. On January 12, 2020, China shared the genetic sequence of the novel coronavirus for countries to use in developing specific diagnostic kits.

When such cases were reported in other countries, the WHO declared this outbreak as a “Public Health Emergency of International Concern” on January 30, 2020, and raised the level of global risk to “very high” on February 28, 2020. Although the WHO had not declared COVID-19 to be pandemic by that time, it asked the countries to remain prepared. The WHO finally declared COVID-18 as “pandemic” on March 13 since its spread crossed geographical boundaries affecting a large number of people.[12]

”We are fully prepared,” that is what the Hon'ble Health Minister of India is quoted to have said on March 2 or 3, 2020, on being asked by a news channel how well prepared India was, to tackle the possible spread of coronavirus.[13] By that time, that goes to India's credit, India had already started country-wide screening, entry screening of all overseas passengers reporting at the national airports and seaports, and contact tracing.[14] It is worth highlighting that India initiated required preparedness and action at field level since January 17 itself, much before the advice from the WHO. Notwithstanding Health Minister's assurance about India's preparedness, there were doubts if we had really understood what it takes to get into a “fully prepared” state. Were thermal screening and travel advisory enough measures to contain an epidemic that soon would be a designated pandemic?

Coronavirus disease that made its surreptitious beginning in 2019 in human beings (that's why nicknamed COVID-19) has taken the entire world by storm and within a few months driven the world gasping for breath. No one could fathom that even the affluent and developed countries would be caught unprepared and ill-equipped, leave-alone low and middle income countries (LAMIC) or poor countries. It is causing unprecedented morbidity and mortality cutting across all geographical boundaries, irrespective of gender, age, and socioeconomic status. Moreover, its spread and devastation have affected lives in a way no one has been able to imagine its magnitude and severity. The lockdown, which seems at this time the only strategy to contain the spread, has made a serious dent on people's lives by affecting their physical and mental health, employment, earnings and income, livelihood, training and education, social inclusion, etc., In India, it has brought out never seen before problems such as reverse migration and assault on health workers.

There is now an urgent need to study and discuss the psychosocial aspect of this pandemic. Social determinants shape and govern our responses to not only health but also overall development of societies and nations. The social determinants are the conditions in which people are born, grow, live, work, and age.[15] These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen between various ethnic and socioeconomic groups. Access to health is not uniform in India; there has been a significant difference between rural versus urban, between low-socioeconomic versus high-economic groups, and between different cast systems and ethnic groups.

  How India Processed and Handled the COVID-19 Threat? Top

Thermal screening at the airport

On January 17 itself, India began thermal screening for all the incoming travelers, though thermal screening is only a screening tool but not a diagnostic method to rule out the presence of flu-like illness. All incoming internal passengers were required to have nontouch thermal screening for detecting high temperature, since it may be an early and easy symptom to detect. If any person was found to have high temperature, he/she was put in quarantine and had to undergo further testing. However, thermal screening is not a simple, fool-proof, or inexpensive method. First, it requires extensive training of the airport staff engaged in screening process.[16] They have to be, importantly, provided with proper personal protective equipment (PPE) since the airport staff comes in contact with a large number of incoming patients within a short time. They should know how to maintain a minimum distance of at least 1 m and yet keep the thermometer at a proper distance from the passenger to take the correct measurement of body temperature. The nontouch thermometers, infrared thermometers, should be of reliable quality so that it accurately measures what it purports to measure. There have been reports that the quality of available thermometers in the market has been quite variable.[17] There has been no clarity in technical specification of these thermometers; a defective equipment would defeat the purpose of entire exercise. Multiple scanners reviewed by this report on the same human body within a span of 30 min found temperature in a range of 87.0°F–97.5°F. Temperature screening alone, at exit or entry, may not be an effective way to stop international spread, since infected individuals may be in the incubation period, may not express apparent symptoms early on in the course of the disease, or may dissimulate fever through the use of antipyretics.[18] It has been reported in mass testing that up to 75% of positive cases may remain asymptomatic, but yet be infective to others. It may be more prudent to provide prevention recommendation messages to travelers and to collect health declarations at arrival, with travelers' contact details, to allow for a proper risk assessment and a possible contact tracing of incoming travelers.

Countrywide lockdown

India had started responding to the COVID-19 threat in January 2020 itself by thermal screening, putting restriction to flights coming from countries with a large number of cases, suspected cases being put under quarantine, and issuing general advisory about social distancing, frequent hand wash, use of sanitizers, personal hygiene, etiquettes of coughing and sneezing, etc.

However, in view of the news coming from all over the world about its fast spread across geographical boundaries, and the virus of being highly infective nature, but fortunately of low lethality, Hon'ble Prime Minister of India declared nationwide strictest lockdown in the history of India under the Disaster Management Act, 2005[19] for effective management of COVID-19 starting 25th March. COVID-19 had already been declared 'pandemic' by the WHO on 13th March. COVID-19 is the first pan-India biological disaster being handled by the legal and constitutional institutions of the country. A disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community's or society's ability to cope using its own resources.

The Central Government enjoys immense powers under this Act and can issue any directions to any authority anywhere in India to facilitate or assist in the disaster management.[20] Importantly, any such directions issued by the Central Government and National Disaster Management Authority (NDMA) must necessarily be followed the Union Ministries and State Governments.

The present national lockdown was imposed under this Act as per the Order dated March 24, 2020, of NDMA “to take measures for ensuring social distancing so as to prevent the spread of COVID-19.” The Ministry of Home Affairs (MHA), being the Ministry having administrative control of disaster management, issued additional guidelines on the same day. This was to remain in force for 21 days. By this order, all activities including travel by any means, all commercial and private business establishments, industrial and manufacturing hubs, educational institutions, religious gatherings and congregations, all social and entertainment activities, and entire hospitality sector were to remain closed. There were notable exceptions for health services, essential services, defense and police personnel, ration shops, essential supplies such as milk, fruits, and vegetables. By its revised Order dated April 15, 2020, the MHA further extended the lockdown by another 3 weeks till May 3 with further relaxations made to ease the ground situation. Please refer to the MHA's Order for details (No. 40-3/2020-DM-I (A) dated April 15, 2020). This was further extended till May 17 vide MHA's Order number 40-3/2020-DM-I (A) dated May 1, 2020, with some relaxations on the movement of people, transport services, movement of goods, and opening of limited commercial activities. The lockdown had one further extension till May 31 with considerable relaxations, and more powers are being given to the states to take necessary actions regarding the extent of lockdown and opening of travel and commercial activities.

The COVID lockdown effectively halted people's movements and closed all avenues of income generation, but health services had no clear guidelines about what services to remain open and how to gear a hospital toward COVID preparation. How loss of income will impact the laborers and daily-wagers would remain unfathomable as discussed below. As an economist has warned, “continued lockdown will mean a loss of 2 lakh crore every week, while the expenditure on 'testing, tracing, isolating' 1%–3% of population will cost 75 thousand crore a year.”[21]

Testing for virus

One effective strategy to beat the spread of COVID virus is presumed to be quarantining of people with suspected or confirmed virus infection. It required screening by testing for the presence of virus in a body fluid (throat swab for COVID-19) in general population. India started testing, under the guidance of Indian Council of Medical Research (ICMR) with the objectives of containing the spread of COVID-19, and to provide reliable diagnosis to all individuals meeting the inclusion criteria for COVID infection. Initially, the strategy had been to test all the symptomatic cases of international travel, all symptomatic cases of confirmed laboratory cases, all symptomatic health workers, all hospitalized cases with severe acute respiratory symptoms, and asymptomatic high-risk contacts of confirmed cases. The ICMR had validated the Truenat Bet Cov test on Truelab Workstation as a screening test. All positive cases were needed to be reconfirmed by a separate confirmatory assay for SARS-CoV-2. Initially, only laboratories in the government setup were authorized to carry out the testing, and the capacity to test in the community had remained limited.[22] The daily count of positive cases in first few weeks had been low since we were able to test only limited number of cases due to constraints of trained workforce, kits, and number of laboratories. That was the main criticism by the experts, when the WHO had been saying, “test, test, and test.” It took a while before government agreed for private laboratories to begin testing with the ICMR providing guidance. As of the time of submission of this write-up, there were 885 government laboratories and 368 private laboratories engaged in various tests, viz., Real-Time RT PCR for COVID-19: 643 (government: 395 + private: 248), TrueNat Test for COVID-19: 507 (government: 453 + private: 54), and CBNAAT Test for COVID-19: 103 (government: 37 + private: 66).

As of July 18, 2020, India has tested 13,433,472 samples with daily testing of nearly 200,000 samples; there are 358,692 active cases, 653,750 recovered, and 26,273 deaths. On March 10, India had reported just 50 cases till then.

”Are we testing enough?” that has been a constant refrain from various experts in the media. There seemed to be two diametrically opposed positions on COVID-19 testing in India. On the one hand, the Indian government claimed that there were no problems with the testing process or the number. The evidence, according to the government, is the low positivity rate (ratio of positives to total persons tested) for India, which was 4.76. On the other hand, critics of the government strategy pointed to the low testing rate (ratio of total persons tested to the total population) as the evidence of serious problems in India's COVID-19 testing process.[23] According to Deepankar Basu, Associate Professor, Department of Economics, University of Massachusetts Amherst, writing for The Week, vide supra, “Low testing rate does not fully account for the low prevalence of COVID-19 in India, contrary to what critics might claim. But, India needs to keep ramping up testing. A rough number to use as a benchmark is a TPR of 2%, i.e., India needs to keep ramping up testing till its TPR falls to, and then stabilizes at, 2%. For this, India needs to carry out more than 16 million tests.” However, India has to strike a balance considering the finances, capacity, and geographical spread of the virus. In the beginning, when the government was scaling up the testing and had roped in private laboratories, it fixed up their charges as Rs. 4500/- per test. That is an expensive proposition for a country like India. In response to a PIL, the Supreme Court ordered the government to carry out the test free for all but did not clarify who would reimburse the private laboratories. Without a free test, it was a big question how India would scale up its testing strategy. On Government of India's plea to the Court, the Supreme Court in its revised Order dated April 13 stated the government would reimburse the private laboratories up to 500 million tests through its flagship public health insurance scheme.[24] This again focuses on the poor funding of public health at just 1.3% of India's GDP. The insurance cover is limited and largely unregulated. It is high time now that the public health receives major investments, and there is a proper policy framework for covering even the poor people under insurance schemes.

Social distancing

A major strategy adopted the world over, and advised by the WHO too, to contain the spread of the virus has been social distancing or physical distancing, i.e., to maintain a distance of at least 1 m from other persons while in the public.[25] It also means not gathering in public and staying out of crowded and mass gatherings. COVID-19 spreads mainly among people who are in close contact for a prolonged period. Spread happens when an infected person coughs, sneezes, or talks and droplets from their mouth or nose is launched into the air and land in the mouths or noses of people nearby. The droplets can also be inhaled into the lungs. Recent studies indicate that people who are infected but do not have symptoms also play a role in the spread of COVID-19.[26]

Advisory by the Ministry of Health and Family Welfare on social distancing [27]

  1. Closure of all educational establishments (schools, universities, etc.), gyms, museums, cultural and social centers, swimming pools, and theaters. Online education to be promoted
  2. Possibility of postponing examinations may be explored
  3. Encourage private sector organizations/employers to allow employees to work from home wherever feasible
  4. Meetings, as far as feasible, shall be done through video conferences. Minimize or reschedule meetings involving large number of people unless necessary
  5. Restaurants to ensure hand-washing protocol and proper cleanliness of frequently touched surfaces. Ensure physical distancing (minimum 1 m) between tables; encourage open air seating where practical with adequate distancing
  6. Keep already planned weddings to a limited gathering, and postpone all nonessential social and cultural gatherings
  7. Local authorities to have a dialog with organizers of sporting events and competitions involving large gatherings, and they may be advised to postpone such events
  8. Local authorities to have a dialog with opinion leaders and religious leaders to regulate mass gatherings should ensure no overcrowding and at least 1 m distance between people
  9. Local authorities to have meeting with traders associations and other stakeholders to regulate hours should exhibit Do's and Don'ts and take up a communication drive in market places such as sabzi mandi, anaj mandi, bus depots, railway stations, and post offices, where essential services are provided
  10. All commercial activities must keep a distance of 1 m between customers
  11. Nonessential travel should be avoided, i.e., buses, trains, and airplanes, to maximize social distancing in public transport besides ensuring regular and proper disinfection of surfaces
  12. Hospitals to follow necessary protocols related with COVID-19 management as prescribed and restrict family/friends/children visiting patients in hospitals
  13. Hygiene and physical distancing have to be maintained. Shaking hands and hugging as a matter of greeting are to be avoided
  14. Special protective measures for delivery men/women working in online ordering services have to be considered.
  15. Keep communities informed consistently and constantly.

India strictly followed the norms of social distancing to break the spread of virus and prevent community transmission. India succeeded in enforcing it to a large extent; however, there were clear violations not only by some individuals (marriage in a prominent politician's house, or birthday bash by another politician) but also by a religious group that led to spread in many parts of India where virus had not yet made its appearance till that time.

Dr. Shekhar Saxena, Former Director, Mental Health Division, WHO, prefers the term “physical distancing” rather than social distancing (emphasis added), “We are all talking about social distancing. Actually, what we need is physical distancing, not social distancing – because that conveys the wrong message. In fact, in this time of stress, we need more social togetherness; we need more social support than social isolation. You talk to people on the phone, on any other media, you support people in each other's difficulties and that is what the community needs to fight it together. Saying 'social distancing,' which means you are alone, increases your stress. International organizations and national authorities are all exercising 'social distancing' when actually, what they should be saying is physical distancing but social togetherness.[28]

It may be a question of semantics, and if the social distancing was considered inevitable, it still has potential of impacting mental health of people. Prolonged and forced isolation is likely to take its toll on one's ability to cope with tension and anxiety, and we are already noticing a spurt in cases presenting with anxiety-, depression-, and stress-induced mental health problems.[29] The impact is likely to be felt more by elderly, children, and people with disabilities. Another fallout of social distancing has been stigma; there are reports of local people shunning those who arrived home from other cities and shopkeepers refusing to engage with them.[30]

Aarogya Setu app

In its fight against the COVID-19, Government of India launched its Aarogya Setu app on April 2 this year.[31] Aarogya Setu, a GPS and Bluetooth enabled app, is a mobile app to track COVID-19 and is developed by the National Informatics Centre, Ministry of Electronics and Information Technology. With the launch of this app, the governments seeks to limit the spread of the COVID-19 cases in India via technology and artificial intelligence, as well as helps create self-awareness among the citizens with relevant information on the infection. Aarogya Setu has four sections.

  1. Your status (tells the risk of getting COVID-19 for the user)
  2. Self-assess (lets the user know the risk of being infected)
  3. COVID-19 update (gives updates on local and national COVID-19 cases)
  4. E-pass (if applied for E-pass, it will be available).

It tells the user how many COVID-19-positive cases are likely in a radius of 500 m, 1 km, 2 km, 5 km, and 10 km.

Very soon, this app became the fastest downloaded app in the world and by May 11 had 98 million users; 1.4 lakh people got alerted via Bluetooth tracing of their possibility of coming in the vicinity of an infected person. On April 29, the MHA vide its Order No. 40-3/2020-DM-I (A)[32] made it mandatory for all government and private sector employees to download this app on their phone. Gradually, it became obligatory for all people visiting hospitals, traveling by air, trains, and buses, and people living in containment zones.

As soon as the app was launched, there have been misgivings about its “true” purpose; it being a sophisticated surveillance app, its security issues, and fear of violation of privacy rights.[33] On May 12, Former Supreme Court Judge Justice B. N. Srikrishna termed the government's push mandating the use of Aarogya Setu app “utterly illegal.” He said so far it is not backed by any law and questioned under what law, government was mandating it on anyone.[34] Although many countries have developed some kind of tracking apps and have encouraged their citizens to use this app to remain aware of their surroundings, India remains the only democracy that has made it mandatory.[35]

Notwithstanding above concerns, there are other reasons why the stated purpose of the app may be defeated. Epidemiologists reckon that for a contact tracing app to be successful, 60% of population should be using it.[36] There is a huge digital divide in India between urban versus rural areas and men versus women. In spite of a very high teledensity in India, smartphone use and availability of internet are a dismal (24%). Even in urban areas, it remains only 51%. By making the Aarogya Setu app mandatory for any kind of movement, it will make difficult for people, especially women, to access public services including health. While the app is being promoted as a tool to contain the spread of virus, our rates of COVID testing continue to remain low.

Ministry of Finance

The Hon'ble Minister of Finance Nirmala Sitharaman announced the first package of Rs. 1.78 lakh crore to help mitigate the suffering of a large segment of India's population. On May 12, the Hon'ble PM of India announced a total package of Rs. 20 lakh crore as a stimulus to the economy and to help the marginalized sections of the society, such as farmers, daily-wagers, construction workers, and street vendors. Since May 13, the Finance Minister announced five financial packages on each consecutive day. It was hailed as a massive package to the size of nearly 10% of India's GDP and comparable to packages announced by leading economies of the world such as the USA and Japan.

”Seen against the scale of economic distress, and expectations raised by the Prime Minister's announcement of a Rs. 20 lakh crore package, the measures announced by the Finance Minister over the past few days have been underwhelming,” says the Editorial in Indian Express dated May 18.[37] It further states, “A crisis of this magnitude needs to be tackled at multiple levels – relief for the most vulnerable, support to specific sectors, short-to-medium term measures to boost demand, and structural reforms. But, so far, the government's response has centered around only providing some relief measures, extending liquidity to select sectors, and stating its intent to push through contentious pieces of reform.”

It is a foregone conclusion that the health crisis posed by the COVID-19 is likely to continue for a longer time than it was assumed earlier. During this time, people's income and spending power must improve through a timely and aggressive economic and fiscal stimulus. It is essential to break the cycle of loss of income, poverty, starvation, and poor health and death for a large section of our population, that is, young.


Through a Gazette Notification from the Government of India, CG-DL-E (14052020)-219374; Notification no. MCI 211 (2)/2019(Ethics)/100659 detailed guidelines have been issued for the Registered Medical Practitioners to use telemedicine to assess and advise the needy patients.[38] It states, “Disasters and pandemics pose unique challenges to providing healthcare. Though telemedicine will not solve them all, it is well suited for scenarios in which medical practitioners can evaluate and manage patients. A telemedicine visit can be conducted without exposing staff to viruses/infections in the times of such outbreaks. Telemedicine practice can prevent the transmission of infectious diseases reducing the risks to both healthcare workers and patients. Unnecessary and avoidable exposure of the people involved in delivery of healthcare can be prevented using telemedicine as patients can be screened remotely. It can provide rapid access to medical practitioners who may not be immediately available in person. In addition, it makes available extra working hands to provide physical care at the respective health institutions. Thus, health systems that are invested in telemedicine are well positioned to ensure that patients with COVID-19 kind of issues receive the care they need. The government is committed to providing equal access to quality care to all and digital health is a critical enabler for the overall transformation of the health system. Hence, mainstreaming telemedicine in health systems will minimize inequity and barriers to access. India's digital health policy advocates use of digital tools for improving the efficiency and outcome of the healthcare system and lays significant focus on the use of telemedicine services, especially in the Health and Wellness Centers at the grassroots level wherein a mid-level provider/health worker can connect the patients to the doctors through technology platforms in providing timely and best possible care.”

As per the data available as of December 2019, India's mobile penetration stands at approximately 87%.[39] The rates in India for mobile phone use are among the lowest in the world. Hence, it is hoped that, given choice, people will come forward to take consultations over mobile calls or internet audio-video conferencing. The medical community also has to adapt itself to the new reality of telemedicine.

  Critical Analysis Top

Although there were initially some dissenting voices about the utility/futility of nationwide lockdown, now all public health and epidemiology experts believe that lockdown was necessary to arrest the spread of virus. Although, by itself, lockdown does not eradicate the virus, it flattens the curve of new cases, impacting morbidity and mortality rates. India has managed to keep the COVID-19 threat under control till date, through proactive and preemptive interventions. The Hon'ble Health Minister expressed confidence, “We will continue to develop plans to flatten the curve and space out the occurrence of COVID-19 over a longer time period to enable our health systems to respond to the increased clinical workload.”[40]

The time, thus gained, is then best utilized in preparing the country to gear up its health services: strategizing the response, mobilizing special COVID teams, optimizing virus testing in the community to see if there is any sign of community transmission (so far, it is believed that there is no community transmission in India), creating special COVID wards and hospital and ICUs, organizing availability of drugs, masks, PPE, and ventilators, and putting in place robust economic measures to look after the poor, vulnerable (street dwellers, homeless), daily-wagers, and large pool of unskilled and semiskilled labor force who would be deprived of their livelihood by shutting down of all commercial activities.

Since the lockdown due to COVID-19 has been enforced in the country, under the Disaster Management Act, 2005, it is prudent to understand certain terms to understand the social implications of a disaster like situation.

  1. Risk is likelihood or expectation of a loss
  2. Hazard is a condition posing threat of harm
  3. Vulnerability is the extent to which person and place are likely to be affected
  4. Resources are the assets in place that will diminish the effect of hazard
  5. Social vulnerability refers to the demographic and socioeconomic factors that affect the resilience of the communities

Socially vulnerable are more likely to be adversely affected; they are more likely to become ill in face of a disaster and more likely to die because of no access to health services or other rescue measures. Effectively addressing social vulnerability [41] decreases human suffering and reduces post disaster expenditure on social services and public assistance.

Another set of factors one has to keep in mind is the social determinants of health [42],[43] in measuring health outcomes, such as morbidity, mortality, life expectancy, health status, healthcare expenditure, and functional limitations.

Social determinants can be summarized as follows:

  1. Healthcare systems: health coverage, health providers, quality of care
  2. Community and social context: social integration, social systems, community engagement, discrimination, stress
  3. Food: availability of food, healthy options
  4. Neighborhood and physical environment: housing, transportation, safety, parks, playground
  5. Education: Literacy, primary education, vocational training, higher education
  6. Economic stability: employment, income, debt, population at the lower rung of income, and spending.

As the COVID-19 pandemic continues, social determinants of health such as occupation, income, food security, transportation, social support, and environment will prove to be increasingly significant as some populations, already compromised on these parameters, will be disproportionally affected by the pandemic.

Let us examine how various measures that the government has taken to control COVID-19 have impacted our health and social indices.

Loss of livelihood

Dubbed as the strictest lockdown in the world, all commercial and industrial activities of any kind or size, construction, infrastructure development, nd agriculture came to a grinding halt. The hardest hit was daily-wagers and self-employed unskilled laborers, farmers, and migrant workers, whose lives depended on their daily income, with no savings or reserves to fall back upon. According to the 2011 Census, the number of migrant workers under the category, “migrants for work/employment” was 41.42 million. It is the government's constitutional duty to ensure a safety net for the economically weaker sections of the society. The Preamble of the Constitution makes “Economic Justice” one of the founding goals of our polity. Article 21 recognizes that every person has a Fundamental Right to Life. The Supreme Court has reiterated several times that this Right includes the “Right to Livelihood,” “Everyone has the right to life, liberty and the security of person. The right to life is undoubtedly the most fundamental of all rights. All other rights add quality to the life in question and depend on the pre-existence of life itself for their operation. As human rights can only attach to living beings, one might expect the right to life itself to be in some sense primary, since none of the other rights would have any value or utility without it.”[44]

There is no doubt that, subsequent to the lockdown, a large section of India's population will slide down precipitously in their capacity to earn and will be forced into below the poverty line. Poverty will become a major risk factor for their survival. Poverty creates ill health because it forces people to live in environments that make them sick, without decent shelter, clean water or adequate sanitation, or access to healthcare.

Two days after the lockdown was announced, the Union Finance Minister Nirmala Sitharaman declared a package that aimed to provide, for the next 3 months, free food to the “poorest of the poor,” some income support to farmers and unorganized sector workers, a Rs. 50 lakh medical insurance cover for healthcare staff and a Rs. 500 transfer to women Jan Dhan account holders, Rs. 2000 transfer to the farmers, and increased rate of payment to the MNREGA workers. She also unveiled the Pradhan Mantri Garib Kalyan Yojana to provide free wheat, rice, and pulses to nearly 80 crore people across the country or two-thirds of the country's population. Finance Minister pegged the cost of the package at Rs. 1.70 lakh crore. Free gas cylinders would be provided to 8 crore poor families registered under Ujjwala for the next 3 months.

Several state governments including Delhi, Maharashtra, and Kerala were among those which announced measures such as free food, use of worker welfare funds, and minimum income.

Ostensibly, many experts and politicians are not happy with the financial package. It must be, nevertheless, understood that relief measures are never adequate. What must, however, be insured by the governments, both central and state, that these relief measures reach the targeted population on time and in full measure.

Loss of job and income will create a vicious cycle of poverty, homelessness, poor sanitation and environment, ill health, poor access to health, and premature death.

Migration of migrant workforce

The lockdown was enforced in the country at a 4-h notice. Overnight, all the labor force in cities such as Mumbai, Delhi, Ahmedabad, and many industrial towns became jobless. With no support coming from their adopted cities, no government plan in force for their travel, shelter, or food, and those having no wherewithal themselves to survive the lockdown period, a large number of migrants started on their homebound journey on foot with women, children, old parents, carrying nothing much (food or money) to subsist on their long and arduous journey. Their plight became evident by the heart-rending stories that started trickling in the print as well as electronic media. The most tragic incident has been that 16 people near Aurangabad (Maharashtra) who got run over by a goods train while they were resting and sleeping on the railway track after a day-long tiring walk in their quest to reach the safety of their homes in Madhya Pradesh.[45] For a long time, these visuals will define India's response to the COVID lockdown. Blamed for leaving their rented homes in defiance of the lockdown, hungry and cash strapped migrants struggled in packed shelter; those who managed to reach home were shunned by their own neighbors. What made it more ironical was the fact that vast majority of migrant labor force did not qualify for the welfare measures announced by the central or state governments. Sadly, a number of these people died en route their homes due to hunger, dehydration, and exhaustion. On March 31, the Supreme Court of India, giving its ruling on a PIL filed by advocates, asked the police and authorities to treat migrant workers journeying home in fear of COVID-19 in a humane manner. “We expect those concerned to appreciate trepidations of the poor men, women, and children and treat them with kindness. The anxieties and fear of the migrants should be understood by police and other authorities. Considering the situation, we are of the opinion that state governments, union territories should endeavor to engage volunteers along with the police to supervise the welfare activities for the migrants,” a Bench led by the Chief Justice of India, S. A. Bobde said.[46]

Those people who manage to reach their destinations braving all the odds will remain vulnerable for a long time for physical and mental morbidities, owing to the vicious cycle of poverty, poor health, and inability to access any kind of healthcare.[47]

This, never experienced situation in independent India before, should lead to major policy changes for the welfare of migrant laborers on long term for protecting them from falling into poverty, despair and distress, and chronic poor health. In the absence of long-term solutions to end their economic and health vulnerability, there is a real risk of their ending up into the trap of chronic deprivations.[48] Besides being in a huge number, they contribute significantly to the economy of the country. Many states depend on the remittance sent by these workers. Yet, they continue to live in hazardous and unhygienic environment, with no health insurance, and not being eligible for a number of welfare measures and compensation packages.

Impact on children's health and development

Children have been said to be less vulnerable to this pandemic, but their risk being among its biggest victims. While they have thankfully been largely spared from the direct health effects of COVID-19 – at least to date – the crisis is having a profound effect on their well-being.[49] All children are being affected, in particular, by the socioeconomic impacts and, in some cases, by mitigation measures that may inadvertently do more harm than good. The harmful effects of this pandemic could be lifelong. These are expected to be most damaging for children in the poorest countries and for those in already disadvantaged or vulnerable situations. A large number of children are likely to fall into poverty and ill health, with incomplete or no immunization, malnutrition, and risk to their survival. Because of their family's poverty as a consequence of pandemic, a large number of children will become homeless losing the security and safety of their homes. It will also seriously impact their learning curve.

“Immunization acts as a protective shield, keeping families and communities safe. By vaccinating our children, we are also protecting the most vulnerable members of our community, including new-born babies. Only 65% of children in India receive full immunization during the 1st year of their life. This is unacceptable in a world where affordable, life-saving vaccines exist” (emphasis by authors).[50]

Despite the progress, infectious diseases continue to contribute to a significant proportion of child mortality and morbidity in India. Nearly one million children die before their fifth birthday in India. About one of every four of these deaths are caused by pneumonia and diarrhea – two leading infectious causes of child deaths worldwide, even though many of them can be saved by interventions, such as breastfeeding, immunization, and access to treatment.

It is pertinent to look at India's record in taking care of its child population. There are 472 million children in India below the age of 18 constituting 39% of India's population as per the 2011 Census of India.[51] 25% of these children (99 million) have not gone to school or have dropped out. Only 32% complete their school education age-appropriately. There are 10.13% of child laborers (between age 5 and 14 years) in India; as much as half of the child population in many parts of the country is engaged in labor, many of which are hazardous. The crime against children has been increasing every successive year as per the 2016 Report of the National Crime Record Bureau available (National Crime Record Bureau, 2019).[52] Number of suicides has been increasing in each successive year. A large number of street children are abusing a variety of addictive substances (Accidental and Suicides in India, 2014).[53]

India's children are facing this pandemic from an already disadvantaged position. The poor development indices, health indices, and social indices related to children will get poorer and poorer over the years. The rich dividend India has been reaping of its young population in the world market will be seriously dented. It is high time India looks after its children in serious earnest.

Gender discrimination

Women always face the consequences of disasters and pandemic in disproportionately higher number by the way of increased morbidity and mortality. They also remain at the periphery when it comes to receiving any welfare measures provided by the governments. The United Nations Population Fund [54] has estimated that there will be huge surge in unwanted pregnancies over the next 1 year, owing to nonavailability of contraceptive measures during the lockdown period. Similarly, the number of women facing domestic violence is set to rise.

The Delhi High Court Bench of Justices J. R. Midha and Jyoti Singh recently directed the Centre and the Delhi government to hold top-level meetings to deliberate on measures to curb domestic violence and protect the victims during the coronavirus lockdown. The April 18 Order came on a nongovernment organization (NGO)'s plea seeking measures to safeguard victims of domestic violence and child abuse amid the COVID-19 lockdown. The NGO, All India Council of Human Rights, Liberties and Social Justice had claimed that there was increasing number of domestic violence incidents since the nation was put under lockdown and sought an urgent intervention by the court.[55]

Recently, the Jammu and Kashmir High Court too had taken a suo moto cognizance of domestic violence during COVID lockdown directing the state government to create special fund for the victims and creating safe spaces for their well-being.

An HT analysis [56] of cases recorded across the country reveals two important aspects. One, some states have reported a decline in complaints related to violence against women, while others have reported a spike in the calls received by helplines, indicating that the incidence of domestic violence during the lockdown depends upon the ability of victims to make complaints while they share domestic spaces with perpetrators. The Delhi Police recorded (by mid-April) nearly 2500 women calling emergency helpline numbers triggering the Emergency Response Support System of the state police; these calls were for abuse, domestic violence, and rape. It is quite possible that many victims could not make calls while their perpetrators were living in the same domestic spaces. It is also true that services of many shelter homes and NGO helplines have been seriously curtailed due to the lockdown and nonavailability of staff and volunteers.

Women, in India, continue to remain in a disadvantaged position, and in spite of the efforts of various sectors, the situation has been improving very slowly. All the efforts toward women empowerment have paid only lip service to their cause. They lag far behind in education and social, health, and economic parameters. There have been grave violations of their rights and dignity, and they are subjected to mental, physical, and sexual abuse, seriously impacting their ability to access opportunities. If India has to progress and aspires to be called as a civilized nation, it has to look after its girl child and women. It needs a long-term social, legal, and human rights-based approach for women to enjoy a healthy, safe, and dignified life, irrespective of any disaster or pandemic like situation.

People with preexisting morbidities

In our anxiety and panic to contain the COVID-19 pandemic, we seem to have forgotten that, at any given time in a society, there will be a growing number of people living with multiple chronic diseases. It has been a consistent finding that people with multiple comorbidities represent 50% or more of the population.[57] Further, it has been estimated that 80% of the total deaths occurring in LAMIC countries are due to chronic multiple diseases.[57],[58] It is evident that, at any given time, a substantial number of people in a society will require regular and long-term healthcare for noncommunicable diseases (NCDs) such as cardiovascular disorders, diabetes, mental health problems, cancer, and respiratory diseases. With COVID lockdown coming into being, all these people have been tragically deprived of much needed healthcare. Nonavailability of much-needed care will push these patients toward increased morbidity and mortality.[59]

Immunization, antenatal checkups, and nutrition drives have been hit hard due to drafting of public health workers into governments' plan to contain the outbreak of COVID-19.

Responding to a PIL last month, the Bombay High Court asked the Maharashtra government and the central government not to ignore treatment of non-COVID patients.[60] According to a report from the National Health Authority, the private sector has a huge role to play in managing non-COVID patients, especially when the public sector is intensely involved in looking after COVID patients, and its hospitals and workforce from all fields to be deputed for COVID.[61] Normally also, private sector provides 70% care to the population;[62] at this time, it must rise to occasion to not turn away care of non-COVID patients. Neglecting care of non-COVID patients and other health services will prove to be a costly mistake in the long run. Sylaja et al. recently wrote for the Annals of New York Academy of Sciences (emphasis added), “The stroke 'chain of survival' and care pathways in India have likely been affected in one way or the other because of the pandemic and lockdown. The shortfall of health insurance coverage and rehabilitative care centers ensures that most of the burden of illness is borne by out-of-pocket payment by patients and families. A large percentage of specialized health services, such as advanced stroke care, are provided by corporate hospitals. However, many of these centers are currently unable to extend care for stroke in persons suspected of having COVID-19, as COVID-19 care in India is mostly confined to designated hospitals under the state and central governments. Individuals from poorer sections of society and daily-wage workers are the worst affected owing to their already limited access to a healthcare facility. The priority has shifted from health to daily sustenance for economically weaker populations.”[63]

Over the years, India has had a dubious distinction in controlling its burden of communicable diseases. However, the burden of NCDs has increased disproportionately. NCDs are characterized by their chronic course and are directly related to lifestyle and social determinants of health, viz., health and social systems, nutrition status of the society, physical environment, education, and economic stability. NCDs have become a major public health problem in India, accounting for 62% of the total burden of diseases and 53% of total deaths.[64] Cardiovascular disorders, respiratory diseases, diabetes, mental disorders, and cancer will continue to put a serious economic burden limiting society's ability to earn; they will also cause increase in out-of-pocket expenses by families, pushing them toward poverty.[65],[66],[67] If India has to control the burden of NCD, it has to make major investments in public health services and social determinants of health. That will keep India ready to face any unexpected arrival of any epidemic or pandemic or a disaster.

Vulnerable groups

In any society, poor and homeless people, people under lockup in the prisons, LGBT community, patients with severe mental illnesses, children, women, and old people are the most vulnerable groups during peace time and more so when faced with any disaster or social calamity. They remain the most neglected lot, and interventions and relief measures do not reach them. It is said that a civilized society is the one that takes care of its most marginalized sections of the society. By that yardstick, India has to traverse a long distance to be counted among civilized societies. In the current pandemic, it is feared that these groups will not reap benefits of economic or health measures, pushing them further toward the vicious cycle of poor health, poverty, and early death. This paper has already discussed the impact of COVID among children and women and to some extent on the groups, such as migrant workers, unskilled laborers, and farmers.


There are close to five lakh prisoners in India. Mental disorders and infectious diseases are more prevalent in prisoners than in general population.[68],[69] Prisoners are also at risk for increased mortality, suicides, self-harm, violence, and victimization. The contribution of prisons to illness outcome is unclear although shortcomings in treatment and aftercare provision contribute to adverse outcomes. Research has highlighted that women prisoners, older prisoners, and juveniles present with higher rates of many disorders than do other prisoners. The contribution of initiatives to improve the health of prisoners by reducing the burden of infectious and chronic diseases, suicide, other causes of premature mortality, and counteracting the cycle of reoffending should constitute a major exercise in improving the overall public health systems.[68] Reforms in the Indian prison system is long overdue as has been exemplified by the National Human Rights Commission of India time and again.[70] With public health funds and workforce being directed toward other areas during the pandemic, prison population will more likely than not suffer increased rates of morbidity and mortality.

LGBT community

Another highly vulnerable group needing care and attention is the LGBT community. There are over 487,803 lakh transgender people in the country, according to the 2011 census of India. Prolonged nationwide lockdown to control COVID-19 outbreak has spelt trouble for the transgender community in India. With little savings and no social security benefits, this community has a massive challenge to deal with, due to depleting food supplies, and no cash reserves for any emergency. While several state governments announced relief measures for the marginalized, only the Kerala government doled out temporary housing and food facilities for transgenders in the state.[71] Many in the LGBT community suffer from a compromised immune system and so are more prone to infections and respiratory problems and may also be suffering from HIV/AIDS. Because of the stigma, they will not access health services, where priority has shifted to contain COVID.[72] Meanwhile, the Delhi High Court declined to entertain a PIL on the protection of LGBT community during the lockdown.[73]

Elderly population

Elderly population. There has been specific health advisory for elderly in India [74] and globally.[75] The life expectancy is increasing in India year after year; currently it is 69.73 years. As per the census of 2011, there are 104 million people above the age of 60 years. What is peculiar of old age in India is that most of this population has multiple health problems and disabilities.[76] Even during normal times, this population does not have easy access to health services. In absence of dedicated public health system geared towards elderly population, this increasing section of society will be further put to hard times.

Vulnerability of health workers

The health workers remain vulnerable because they are directly exposed to a highly infective virus while looking after a COVID-positive patient.[77] They need specialized protective gear while working in the COVID wards and intensive care units (ICUs).[78],[79] There were numerous complaints that the doctors and nurses were either not getting PPEs or getting the substandard ones. It took a few weeks before India got its act together to procure or produce its own PPE, masks, and other requisite equipment.[80],[81],[82] No wonder that so many of our doctors, nurses, and other workers got infected and a few perished.[83] However, the most disturbing trend that emerged during this pandemic was the frequent assaults on the health workers in different parts of the country.[84] These attacks became so frequent that the government had to bring out an ordinance to punish the assailants.[85] The sanitation workers, police personnel, and anyone who was involved in the COVID duty were victims of these vicious attacks. The doctors have been subjected to harassment and physical assault in India for a long time. As per the 2017 IMA study, as many as 75% of its members had faced violence related to their work, and some employed private security at their clinics.[86] However, the attacks now happened when these health workers, including doctors, nurses, and technicians, were assaulted by mobs when they were doing their assigned public health work in the community.[87] It cast a worrying spotlight on the safety and well-being of our frontline workers in nation's fight against COVID-19. Such instances became too frequent progressively, but the most shameful incident happened in Chennai, when a doctor, who had died of coronavirus, was denied even basic dignity at the time of his death as a mob attacked his friends and family with sticks and rods when they were transporting his body to a burial ground.[88] It reminded the author of the famous couplet by Bahadur Shah Zafar that he composed while being incarcerated in Rangoon prison, “kitna hai badnasib Zafar dafn ke liye, do gaj jameen bhi na mile, kuche yaar mei” (how much unfortunate is Zafar, not even two yards of land in kuche yaar).

Health workers have also been trolled on the social media, barred from their rented accommodation, and driven out from the market place.

Ultimately, only when the IMA threatened to go on nation-wide protests, did the central government finally come up with an ordinance, wherein a guilty person could be punished by imprisonment up to 7 years, along with a fine of 5 lakh rupees.[89] Allaying all concerns of the medical fraternity regarding their security in the fight against the novel coronavirus, the Home Minister Shri Amit Shah assured members of the IMA that the government would leave no stone unturned in ensuring their well-being and security. Reflecting on the development, Prime Minister Narendra Modi said, “the Epidemic Diseases (Amendment) Ordinance, 2020 manifests our commitment to protect each and every healthcare worker who is bravely battling COVID-19 on the frontline. It will ensure safety of our professionals. There can be no compromise on their safety.[90]

Health is a fundamental human right, and by attacking and chasing away health workers, the citizens are sabotaging their own rights and depriving themselves of basic health care, which is worse since it is because of the risks the health workers are taking that the society can feel safe in both short term and/or long term.

Health infrastructure

The following information about India's health infrastructure and workforce is from the publication, National Health Profile-2019 of Central Bureau of Health Intelligence.[91]

Health infrastructure is an important indicator for understanding the healthcare delivery provisions and welfare mechanism in a country. Infrastructure has been described as the basic support for the delivery of public health activities. It also signifies the investments and priority accorded to create the infrastructure in public and private sectors. In the last three decades, India has progressed at a rapid pace to create its infrastructure. The number of medical colleges, dental colleges, nursing colleges, and paramedical staff has grown exponentially, yet the demand has far outstripped the supply.

There are now more than seven lakh hospital beds in the country. There is a huge rural–urban divide, with more than two-third beds located in urban areas. This should be kept in mind that rural population constitutes about 66% in India and has dismal health infrastructure.

Rao et al.[92] analyzed the June 2012 data of the National Sample Survey to produce the estimates of health workforce in India. Findings suggest that in 2011–2012, there were 2.5 million health workers in India; however, 56.4% of all health workers were unqualified. After adjusting for the qualification, the density of the health workers is estimated to be 9.1 per 10,000 of population. This is around one quarter of the WHO benchmark of 22.8 health workers per 10,000 population. Of all qualified workers, 77.4% were located in urban areas.

Despite a rapid surge in the number of medical and other health institutions to produce a large number of doctors and other health workers, the availability of workforce or health facilities per capita of population in India remains very poor and highly skewed. India spends only 1.3% of its GDP for its 1.3 billion population. The developed countries spend 10% or more of their GDP on health. The government claimed that the lockdown period has been gainfully utilized to ramp up health infrastructure by the way of organizing procurement of PPE and testing for the virus.[93] However, reports from across the cities indicate a health system in distress even after 70 days of lockdown as shortage of beds and healthcare workers prompts hospitals to turn away patients seeking testing and treatment for COVID as well as other illnesses.[94] However, the most tragic has been the death of an 8-month pregnant woman in an ambulance in Greater Noida after a frantic 13-h hospital hunt failed to find her a bed as over half-a-dozen facilities, including three government ones, denied her treatment on June 5.[95] The incident brought to force the issue of medical negligence and unavailability of care during the ongoing COVID-19 pandemic.

The National Human Rights Commission on Monday has issued a notice to the Uttar Pradesh government over media reports of medical apathy to the pregnant woman.

”Health infrastructure is creaking at this stage of the pandemic because of mismanagement, unprofessional planning, greed of private institutions, and unjustified fear. Health delivery in India is concentrated in urban areas and in metro cities. Majority of private hospitals in rural areas have either stopped giving services for COVID-19 patients or are extorting huge money. Therefore, patients are moving to bigger cities. ICUs with ventilator and available anesthetics or pulmonary medicine professionals are not available at even district-level hospitals,” said Dr. Jugal Kishore, a member of the government's rapid response team on COVID-19 and Head, Department of Community Medicine, Safdarjung Hospital.[94]

Public sector versus private sector

The COVID-19 remains a public health epidemic, yet the health services have been disrupted for various reasons. The private sector, which is a Rs. 2.4 lakh crore industry, accounts for 70% of total bed-strength, has 80% of total ventilators, yet is looking after just 10% of entire COVID caseload. Private sector is shying away from providing even the routine non-COVID care, and so, it is the public hospitals, doctors, and nurses that are facing the real burden of COVID care.[96]

As per the Economic Survey of India, 2019–2020, India spends close to 1.3% of its GDP on health that includes expenditure on medical and public health, family welfare, sanitation, and water supply.[97] It does not look realistic if the country will be able to reach an expenditure of 2.5% of GDP by 2025 as envisaged in the National Health Policy of India-2017.[98]

India's per capital expenditure on health is Rs. 4116, of which household's out-of-pocket expenditure on health is Rs. 2494 per capita; that is, 60% of health expenses are borne out of pocket by people.[99] That is a huge amount for a country like India, where per capita income is already low, and health expenditure remains a major reason for pushing households to below the poverty line.

The Indian Constitution makes the provision of healthcare in India the responsibility of the state governments, rather than the central federal government. It makes every state responsible for “raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.”[98]

In practice, however, the private healthcare sector is responsible for the majority of healthcare in India, and most healthcare expenses are paid directly out of pocket by patients and their families, rather than through health insurance.[100],[101] The government health policy has thus far largely encouraged private sector expansion in conjunction with well-designed but limited public health programs.

Over the years, India has neglected its public health sector by not opening enough hospitals, or equipping the existing ones with essential medical gadgets such as ventilators, or recruiting sufficient workforce. If one lesson we wish to learn now, is not to neglect the public health sector in India.

Primary healthcare

The response strategy to the COVID and the degree of control and success that has been achieved in various states and union territories of India has not been uniform. Some states have succeeded in not only flattening the curve but also bending it downward. Their recovery rate and death rate are superior to national average. For example, Kerala which was the first state to report a positive case successfully arrested the progress of COVID; as on May 9, its total caseload has only been 503, cured or discharged 484, and only four deaths.[102],[103] Similar are the stories from Tamil Nadu (only 40 deaths amongst 6009 cases), Telangana, or Andhra Pradesh.[104] However, states such as Maharashtra, Madhya Pradesh, or Rajasthan have not been so lucky in these numbers.[105] The major reason behind the success of former states has been the development of primary healthcare and vigorous mapping of their population and data gathering and robust teams of health workers at all levels. Even as of July 19, 2020, death rates due to coronavirus have been low in Andhra Pradesh (1.13), Tamil Nadu (1.45), Kerala (0.34), and Telangana (0.93) as compared to the national figure of 2.48%.[14]

Primary healthcare should have remained the backbone of healthcare in India; however, it has been equated with providing healthcare to rural India, with no relevance to urban areas. With neglected development of our rural areas (economy, agriculture, housing, sanitation, and safe drinking water), primary healthcare has also been relegated to an insignificant spot.

After the Alma Ata Declaration, 1978, of “Health for All by 2000,” the Government of India commissioned a report, “Health for All–An Alternate Strategy” by the ICMR and Indian Council of Social and Scientific Research in 1980.[106] The Report concluded that to achieve “Health for All” by 2000, existing health services and workforce had to be increased substantially. It is not rocket science to analyze and conclude that we as a nation have failed miserably in improving our health indices over the years. While some states have health parameters comparable to the West, there are others which are worse off than our neighboring countries in the SAARC. The states, which have taken health of their citizens seriously, have been reaping rich dividends in terms of health in normal times as well as during disaster like situations.[107]


Stigma is a very disturbing response as has been seen in the past epidemics of infectious diseases.[108] It will certainly play a part in this pandemic also. Stigma is an evolutionary response, and humans are hard-wired to distance themselves from others who could infect us. This stigma may lead to social rejection, gossip, physical violence, denial of services, and poor access to healthcare. It may lead to exaggerated depressive symptoms, increased stress, and substance abuse. Unfortunately, stigma extends to people who are involved in looking after sick persons, such as family members and health workers, as is discussed below.

Deepa Rao et al.[109] discuss the impact of stigma, “Stigma can aggravate disease processes and add numerous socioeconomic, psychosocial, and health burdens on people who hold marginalized identities or status, including reduced educational attainment, exposure to psychosocial stressors, and challenges in accessing healthcare. Behavioral scientists have studied the severe negative consequences of stigma for individuals coping with various health conditions and have learned that stigma can deter individuals from optimally engaging in treatment for their condition, which has serious impacts on morbidity and mortality. Strikingly, when disease morbidity and mortality are low but the condition is highly stigmatized, the burden of stigma may exceed the burden of the disease in its impact on social, emotional, and work functioning, thus negatively affecting the overall quality of life. Researchers have long recognized that stigma operates on interpersonal, organizational, and structural levels, and as such, stigma is conceptualized as an inherently multi-level phenomenon” (emphasis added).

However, the research in this area has shown that stigma may not be an inevitable response as is evident from social neuroscience research.[110] Strategies such as emphasizing “social distancing, and not social isolation,” education, inclusion, acceptance, dispelling stereotypy, and investing in wellness programs that help in promoting resilience, will go a long way in tackling this menace.

Mental health

During disasters, disaster-like situation, or any upheaval in the society, including pandemics, mental health of people is seriously compromised. Scientific literature has been full of the effects of disasters, wars, and civil strife on the emotional health of affected population. According to the World Health Report, 2001, such situations take a heavy toll on the mental health of the people living in developing countries, where capacity to take care of these problems is extremely limited. Between a third and half of all the affected persons suffer from mental distress. Most common diagnoses made are anxiety, depression, and post traumatic stress disorder (PTSD). Besides, a large number of people continue to suffer multiple psychological symptoms for a long time.[111],[112]

Migrants, refugee, and asylum seekers have an elevated need for mental healthcare but simultaneously have less access to it. Reasons for this gap include stigma and shame regarding mental illness, cultural beliefs, and lack of language proficiency, as well as financial constraints. Furthermore, real economic barriers and perceived social consequences could impede service seeking because migrants, refugees, and asylum seekers often lack health insurance.[46],[113]

Prolonged isolation leads to frustration, stress, followed by symptoms of sleeplessness, loss of appetite, anxiety, depression, obsessions, loneliness and boredom, and an increased use of tobacco and alcohol. Although media in India has been regularly publishing about the impact of the COVID on mental health of people under lockdown, there are no precise data available to gauze its magnitude in the society. However, if previous studies are any indications, it is quite likely that more than 50% population will be having significant emotional and psychological problems to warrant some interventions. People with existing mental illnesses are further vulnerable due to nonavailability of health services and running out of their drug supply. The author has received numerous requests from his patients for help, since the local chemists had refused to honor old prescriptions. It is likely that a number of patients with severe mental illnesses will see worsening of their symptoms or a frank relapse, if their drug compliance is interrupted for no fault of theirs. A way out had been suggested for providing teleconsultations,[114] but a large number of patients and many clinicians are not adequately equipped with the skills. Even, the guidelines from the government had lacked clarity earlier; fortunately, with the efforts of many institutions, revised guidelines have been made on employing “Telemedicine” to provide healthcare to people to improve accessibility of healthcare.[115] The issue of prescribing psychotropic drugs online still remains.

Ministry of Health and Family Welfare (MoHFW), as well as institutions such as All India Institute of Medical Sciences, New Delhi, National Institute of Mental Health and Neurosciences, Bengaluru, Institute of Human Behaviour and Allied Sciences, Delhi, and some others have put up guidelines and webinars on their websites advising people on how to look after their mental health during the COVID pandemic. However, a major limitation of such measures will be the digital divide between people who have access and who do not. Moreover, India has very low number of mental health professionals, mental health services, and hospital beds for its population (Mental Health  Atlas More Details);[116] the mental health gap remains as high as 75%. We are likely to see a huge surge of mental health problems for some time to come, resulting in increased rates of morbidity, mortality, and disability.


A disturbing trend, which began soon after measures such as quarantine and lockdown were enforced in India, was people committing suicide. A disturbing trend, which began soon after measures like quarantine and lockdown were enforced in India, was people committing suicide. At the time of writing this paper, suicide has been the leading cause of death in 338 non-corona deaths during lockdown.[117] People committed suicide due, ostensibly, to reasons like fear of infection, stigma, loneliness, hopelessness, alcohol withdrawal symptoms, and total income loss. It must be understood that like any other study on suicide, such figures are underestimates of actual number.

Kedia et al.,[118] reviewing the sudden spurt in suicides case during COVID-19, discuss various reasons for this, “The novel coronavirus (COVID-19) has caused the worst pandemic seen in the 21st century. In the last 5 months, it not only has caused significant health-related complications and morbidity but also has plunged the world into a lockdown and eventual economic crisis. Across the globe, the pandemic has sparked a number of suicides, even in individuals with no prior history of any psychiatric disorder or mental health complications. A plethora of studies have shown that natural calamities such as tsunami, or Spanish flu of 1918, economic upheavals such as the “Great Depression” have spiked the suicide rates. The current suicides triggered by hopelessness, altruism, stigma, or uncertainty resonates with Durkheim's sociological viewpoint, which speculated that, “when a society is disturbed by some painful crisis or by beneficent but abrupt transitions, it is momentarily incapable of exercising its moral influence; thence come the sudden rises in the curve of suicides. In the current pandemic, suicide is already becoming a pressing concern. Therefore, the prevention of suicide needs immediate consideration. We need to move beyond general mental health practices and pick strategies that are rooted in a more psychological and sociological understanding of the phenomenon.”

The strategy to prevent suicides and suicidal attempts in India must adopt public health measures.[119],[120]

National Disaster Management Authority

This pandemic has been compared to something like disaster. NDMA has given guidelines on managing mental health and psychosocial issues seen during or subsequent to a disaster.[121]

Ten important components of the guidelines

  1. Integration of psychosocial support and mental health services into various health programs, NMHP, DMHP and evolving of legal instruments necessary for the implementation of such policies under the guidance of National Subcommittee on Psychosocial Support and Mental Health Services constituted by the MoHFW
  2. Development of skilled and competent human resource at all levels with the help of nodal institutions through standardized training practices
  3. Mainstreaming the knowledge about preventive and mitigation strategies for adverse psychosocial effects of disasters into education system. Training of community-level workers, NGOs, and various professionals for providing psychosocial support and mental health services in the aftermath of disasters
  4. Normalization of survivor's psychological impact could be hastened by providing “Psychosocial First Aid.” Later, provision of psychosocial support during rehabilitation and rebuilding phase would be integrated into the overall community development interventions
  5. Research and development for effective intervention should focus on community needs, integration of professional referral system with existing community best practices, and vulnerability and epidemiological factors that compounded the psychosocial impact on any emergency
  6. Systematic documentation, procedures to enhance community participation, elements of Psychosocial Support and Mental Health Services in deliverables such as relief, transportation, care of vulnerable groups, and psychosocial first aid supported by adequate infrastructure will be undertaken as planned objectives
  7. Inclusion of Psychosocial Support and Mental Health Services in hospital disaster management planning, effective communication and networking, counseling session areas, pooling of resources among network of healthcare services, and identification of all the critical issues in state/district health disaster management planning
  8. Identification of designated institutions for training under Disaster Mental Health Programme and models of PublicPrivate Participation will be developed, tested, and practiced
  9. Long-term management of mental health interventions will be undertaken through standardized and structured need assessment tools followed by scientific studies and evaluation and development of specific intervention modules thereupon
  10. Adoption of international best practices, provisions for special care to vulnerable groups, care to caregivers, role of Psychosocial Support and Mental Health Services.

COVID-19 and civil society's response

In the aftermath of the lockdown, the Prime Minister reached out to the NGOs, to help the government during the lockdown by providing basic necessities to the underprivileged, supplying medical and protective gear, and assisting with awareness campaigns on social distancing.[122] Exactly a week later on April 6, NITI Aayog, the think-tank of the Union government, communicated with more than 92,000 NGOs, industry associations, and international organizations seeking their assistance in delivering services to the needy through cross-sectoral collaborations.[123]

Besides the public and private sectors, this is the third sector, the civil society, in any nation that fulfills a crucial role during peacetime, and in face of any crisis. They have skills and expertise and enjoy a tremendous goodwill across all sectors and segments. They can mobilize resources and are backed by a large, committed, and motivated force of volunteers. They assume a significant role in providing not only material support to the needy but also extend much-needed care and emotional support to the vulnerable during disasters. During the COVID-19, a large number of civil society organizations and NGOs have been coming to forefront to provide food to hungry, distribute protection kits to the hospitals and administration, and work as volunteers in hospitals and quarantine centers. NGOs have been providing services in those areas, where the efforts of public or private sectors are often lacking, for example, health, education, empowerment of under-privileged sections, enhancing skills, and earning potentials of communities living in remote areas of the country. In the last few years, a large number of NGOs were at the receiving ends from the government, and many have shut the shop. It is high time that the intrinsic value of these organizations is appreciated and their strength is harnessed for much-needed succor that a large segment of our population will continue to desire.

  Inspiring Stories Top

There have been numerous instances of individuals rising to the occasion and help elders take care of their daily needs, allow house-help to stay home without fear of their wages being affected, organizations coming forward to manufacture personal protective equipment, provide meals from factory kitchens, and administration opening up stadia and public buildings to provide space for those who need shelter or isolation. Central banks have brought in massive policy measures to help tide over the crisis, and governments have provided the weaker sections of society with cash and food.

Instances of doing generous deeds during this crisis are too numerous to be enumerated comprehensively; however, together, they have re-established that society has a heart.

  1. An act of kindness by a police inspector in Hyderabad is receiving plaudits from far and wide, including from the Himachal Pradesh Chief Minister. A few days ago, Inspector B. L. Lakshmi Narayana Reddy of Kukatpally Police Station under Cyberabad not only rescued a stranded man from Himachal Pradesh by admitting him to a hospital but also paid for his medical expenses. Lalit Kumar, a native of Hamirpur district in Himachal Pradesh, was stranded in Kukatpally and in need of an emergency operation [124]
  2. Joining the fight to stem the rise of COVID-19 infections in the country, First Lady Savita Kovind on Wednesday stitched facemasks at Shakti Haat in the President's Estate. These masks will be distributed at various shelter homes of the Delhi Urban Shelter Improvement Board. The First Lady was seen covering her face with a red cloth mask while stitching the masks [125]
  3. The Greater Chennai Corporation, which runs over 400 Amma Canteens in Chennai on Thursday, announced free food to people at all its eateries till the lockdown ends.[126] Local Administration Minister S. P. Velumani tweeted that the Chennai Corporation with the largest number of canteens in the city has made food free in all its 407 canteens until the end of the COVID-19 shutdown
  4. An entrepreneur in Chhattisgarh, in association with a women's self-help group, has developed a hand sanitizer liquid with alcohol distilled from Mahua flowers as its main ingredient.[127] Hand sanitizers are currently in great demand because of their use to clean hands helps keep COVID-19 at bay. Yellow Mahua flowers are one of the major forest products during summer. They are also believed to have medicinal properties. “The idea to develop hand sanitizer from Mahua spirit came to me when I could not obtain enough hand sanitizer liquid for the employees at my petrol pump,” said Samarth Jain, who runs a company in Jashpur that makes agricultural and herbal products
  5. From their home in Bibwewadi, four sisters of a family are fighting coronavirus (COVID-19) on two frontlines – the hospital and the street.[128] Two are in the police force and two are nurses. “There is a high chance that one or all of us will get infected. That's the nature of our job. To protect the rest of our family, we have sent our parents, younger brother, and children to our village in Satara. What pained me most was sending my two children – a 9-year-old son and a 2-year-old daughter – away with them,” says the eldest sister, who is aged 27 years and is a police Naik. She does not want her family's identity to be published. “My daughter is too young to understand what is happening, so I have asked my relatives in the village to send me videos of her. I watch her skipping and playing in the videos and I don't know when I will hold my children again. But, this is the time that the country needs healthcare officials and law-keepers, so we are on duty,” she says. The policewoman adds that “the educated and uneducated classes” were equally guilty of violating lockdown rules. “They should stay home for the sake of the elderly and children in their families,” adds the police Naik. After work, on the occasions when the sisters meet for dinner, they turn on the television. “We opt for an entertaining film and turn to news afterwards for updates on the coronavirus situation,” says one of the sisters.

  Corona Crisis: Its Present Ramifications and Future Portends Top

It is abundantly clear that the multiple crises unleashed by the COVID-19 pandemic are not going away any time soon.

Health and economic upheavals aside, a major humanitarian challenge is facing us. It has brought into sharp focus all that is wanting and apparent in our health systems, in our social inequalities, in our widely practiced discrimination, in widespread poverty, and in the continued stigma and superstition.

India became a nuclear power on May 18, 1974. It has been launching satellites into the space since 1975. It joined an elite space club when in 2008 it successfully put its Chandrayaan-I to orbit around the moon and in 2014 became the fourth country in the world to reach and orbit around the Mars. It has its own Missile technology. These are stories of India's stupendous success in the field of science and technology. But have all such achievements made India a great civilized nation, when India's health and social indices still leave a lot to desire?

India ranks 129 in the Human Development Index report released by the United Nations in 2019.[129] “For countries like India, which have shown great success in reducing absolute poverty, we hope that the 2019 Human Development Report sheds light on inequalities and deprivations that go beyond income. How we tackle old and new inequalities, ranging from access to basic services such as housing, health, to things like access to quality university education, will be critical to whether we achieve the Sustainable Development Goals,” said Shoko Noda, UNDP India Resident Representative in an official release.[130]

India has been making heroic efforts to control the morbidity and mortality associated with the COVID-19 pandemic. Yet, the number of cases has been relentlessly increasing every day. The end is not in sight, the treatment protocols are still being evolved. Moreover, vaccine development and its market availability is a painstaking and slow process and will not be available to masses any time soon.

What has this pandemic brought into our consciousness is the plight of the poor, under-privileged, and marginalized sections of the society. A civilized country is not one that has skyscrapers, fast moving cars, instruments of modern warfare, or by its progress in science and technology; howeer, a society is considered civilized when it is judged by how well it looks after its disadvantaged citizens.

This now raging pandemic will too go away sooner or later, but it has seriously dented the fabric of Indian society. It has given its wake-up call. It would have served its purpose if we now focus on taking long-term measures to launch sustained programs to look after vast sections of the society and to achieve the development goals enunciated by the United Nations. That will empower our society to fight any disaster or pandemic with a measured response by not pushing any section of the society into desperation, now so very visible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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