Thread by @Kianayema

On the impending #IndiaLockdown, a few thoughts.

(This might turn into a long-ish thread - still sorting out said thoughts.)

1. I have no objection to the move itself. I understand there will be an economic impact, and still think a lockdown is a reasonable step at this time.

2. Have been reading various pieces on how economic slowdown from lockdowns may lead to *more* deaths than the virus. Granted, these are projections, and the figure used for COVID-19 fatalities in particular is based on scant data; even so, the claim seems plausible.

3. Even assuming such projections are correct, I would still support the lockdown. Because I think the meaning of the social contract between state and citizen is that the state will take necessary measures to protect citizens from this pandemic...

4. ... not assess the lives of potential COVID-19 fatalities against others who may die of economic hardship, and try to come up with some sort of rubric for balancing. In a public health crisis, the first duty of the state is to resolve that crisis.

5. That said: a 21-day lockdown in India is long enough to lead to starvation deaths. No exaggeration. Consider how many children are already malnourished, wasted, or stunted. (India ranked 102 of 117 countries on the Global Hunger Index in 2019.)

livemint.com/news/india/ind…

6. Public health and nutrition policy is not my specialisation. I went to grad school to study conflict resolution and international law. Rather coincidentally, though, my work in 2018-19 meant looking pretty closely at employment, incomes, and health infra in India.

7. I was on the research team for "Bridgital Nation" (penguin.co.in/book/uncategor…), a book whose core case study revolves around the primary health system in India. We spent a LOT of time and brainpower on how to understand the labour force, incomes, and dependency ratios in India.

8. So I am today in the unhappy position of a) being trained to think of complex systems and b) having detailed and relatively recent knowledge of two such systems in India - public health and labour markets.

Which is why I say again: 21-day lockdown = potential starvation.

9. And I think it gets worse: the ability of the Indian state to enforce a crackdown is either very low or very high.

In the Central African Republic, there is an evocative way of describing the state - "a hurtful presence and a painful absence".

10. CAR is an example of militarisation and state neglect ad extremis; India is better off in every respect - but the pattern holds. If the lockdown is enforced coercively - meaning police & paramillitary violence - it can be very effective, at least in given places & times.

11. But if the lockdown is not backed with significant logistical efforts to ensure households that need food are able to access it - either through direct supplies or by being given the cash to acquire it - then there are two possible outcomes.

12. Those outcomes are: coercion works, members of those households remain isolated, and some of them die; or - and I think this is more likely - they break lockdown to seek work / incomes / food. Much of the goal of social distancing will be undermined if this happens.

13. Especially if - this is the nightmare scenario - people living in those circumstances catch the virus. Everything about that situation: density of persons in a given dwelling, interaction at shared water sources &/or toilets, existing levels of malnutrition, anemia, etc. ...

14. ... lack of awareness of and/or lack of willingness to seek and/or lack of ability to seek medical treatment (lack of ability because it means skipping a day of work) suggests that any one such person would potentially spread the infection to multiple people.

15. If my language in the last two tweets reads like I am stigmatising the poor, I apologise. I want to do the opposite - to demonstrate that people live in circumstances desperate enough in this country that BOTH complying or violating the lockdown can be life-threatening.

16. Again, I don't think this is exaggeration.

While working on the book, we asked a doctor who runs a charitable hospital for cancer patients in Assam: what did cancer patients in this area do before this hospital was set up.

He looked at me like I was an idiot for asking...

17. ... a naive question, which I absolutely am/was.

"They used to die."

(Said doctor grew up, as I did, on armed forces bases - so I don't know whether to call that answer clinical precision or military precision.)

The key point is: this was not a medically inevitable result.

18. People saw a cancer diagnosis as a death sentence, BUT not because they thought it was incurable (although given late detection, NE India does have higher rates of fatality from cancer than places with similar incidence rates.)

cancerindia.org.in/globocan-2018-…

19. A cancer diagnosis is seen as a death sentence because the costs of tests, treatment, and medication exceed what any household can afford, often even when some kind of financial aid is provided. (Look up "catastrophic healthcare expenditure")

ncbi.nlm.nih.gov/pmc/articles/P…

20. More importantly, for someone who works a daily wage job, or runs a small business that has infinitesimally slim margins, the opportunity cost of getting tested and treated - in terms of work days lost - is the real killer. It is unsustainable.

archive.indiaspend.com/cover-story/ba…

21. This trend is even more pronounced in the construction and retail industries - where most of India's urban poor and migrant workers are employed - because a couple of days of missed work is the same as losing the job entirely. Another worker is picked up instead.

22. That dynamic alone is going to create a prisoners' dilemma for daily wage workers: abide by the lockdown and find that someone else opportunistically took the jobs they were doing, or break the lockdown while taking on all the attendant risks?

23. My hope is that if a national lockdown holds, labour contractors - e.g. in construction - will not be employing *anyone* for the next 3 weeks. So at least this prisoners' dilemma scenario won't play out.

Police & DMs - please hold meetings with contractors.

24. Please get them to assure their workforces that - even if they are not paid for the next 3 weeks - the jobs will be there when they return.

(In fact, contractors could be a key conduit for information and food / water / sanitary supplies to workers, esp. migrant workers.)

25. Ideally, of course, contractors would pay workers the ENTIRE 3 WEEKS WAGES UP FRONT TOMORROW. Solve a cash crunch, vastly increase ability of workers to abide by the lockdown. Clients should pay contractors this wage amount in addition to whatever amount was agreed.

26. If contractors aren't going to do this, someone else has to. Central, State, or local government needs to either give each such household enough cash - up front, lumpsum - for 3 weeks, or assure them of provision of basic necessities - food, water, soap - for this period.

27. While I've used construction workers & labour contractors as my example so far, this is applicable to people in any form of precarious employment - including app-based / gig workers such as delivery persons. Again, either the employer or the govt has to give them cash...

28. ... up front, right now - and as a one-time grant, NOT AS AN ADVANCE. For people living on slim incomes and margins, to say you will recover this amount - unless it is over, say, the next 21 months - is no different from lending at penurious interest.

29. (Again, all moral / ethical questions aside - if you say here is 3 weeks advance now but I will give half pay in the next 6 weeks once we resume, you are incentivising the worker to break the lockdown, because they will need to earn now to offset that lowered earning later.)

30. Despite all of the DBT schemes of the Govt of India, despite all that we've heard about financial inclusion, Jan Dhan, PM-Kisan Yojana etc. etc., any such grant was notably missing from the PM's speech today.

This is no different from incentivising people to break lockdown.

31. Why worry about any of this? It wouldn't matter all that much if our health system were able to detect, isolate, and treat all persons who caught the infection.

As the PM himself noted, even countries with better health systems than ours have not been able to do this.

32. In other words, even well-established health systems can crumble in the face of exponential transmission - especially once infections among health workers rise.

India's health system could not be called well-established even by the most charitable observer.

33. It's not just that we have huge shortages of doctors, nurses, various kinds of medical technicians. It's not just that we have very low ratios of hospital beds to population.

It's that infection control inside any public hospital in India is a joke.

34. Public hospitals in India are frequently so overcrowded that two or more patients are asked to share a bed. Patients and/or attendants may sleep on the floor between beds, or in corridors / on benches, with minimal sterilisation when they go in to the wards.

35. And of course there is a shortage of PPE; in many places, there are shortages of medication as well. Where terrain or screwed-up procurement messes with other deliveries, even items like disinfectant can be in short supply at times.

36. Isolation beds / wards, ICU beds, and ventilators - being a fraction of all available infrastructure - are in desperately short supply. If India reaches the kind of infection rates Italy has, there is ABSOLUTELY NO WAY we have enough hospital infrastructure. NONE.

37. Again, the PM did not get into such statistics in his speech. Even so, I do hope the availability of such facilities is being monitored, district by district, at the highest levels of the government. And it was helpful that he said increasing healthcare capacity is priority.

38. That said, 3 or even 6 weeks likely cannot help India surge healthcare capacity broadly & evenly enough to deal with a high transmission scenario.

This is because the other feature of India's healthcare system is that it is wildly skewed towards large/rich cities.

39. All around the world, there is nothing unusual about the best hospitals - tertiary, super-specialty, with star doctors / faculty - being in the major cities.

What happens in India is
a) at least among public hospitals, big urban hospitals handle everything from primary to...

40. ... super-specialty cases. There is not much room to triage by institution, so people who should be at PHCs or CHCs still show up at district or state capital hospitals.

b) doctors are heavily concentrated in urban India. Rural primary health facilities = huge vacancies.

41. Is the plan to transport infected persons to cities? (What are the risks involved?) Or to send doctors from major cities to smaller population centres? (How?) Or to treat in situ with limited doctors / nurses / staff? (again, how?)

42. The *utter nightmare* scenario is that a daily-wage worker catches the virus, leading to the infection spreading in multiple such vulnerable households; that economic hardship or loss of jobs lead some of those person to then return to somewhere in rural India...

43. ... leading to a new COVID-19 cluster arising somewhere in rural India, among a population already vulnerable for reasons of existing (mal)nutrition levels, where the health system is utterly unequipped to deal with that number of cases.

People will die of the virus then.

44. So it all still comes back to: effective containment is our only hope; effective containment requires compliance with social distancing / lockdown; and for millions - possibly a billion* - of Indians, compliance with a 21-day lockdown will require social security/support.

45. *Why "possibly a billion"?

Did some back of the envelope math on this - again, the book has a much more robust analysis, but here's the rough version:

India's workforce is barely 500 million.
(This is a travesty in itself - 1 in 2 working-age adults not working.)

46. The last Employment/Unemployment Survey to be officially released - 2016 publication, so FY 2014-15 data - found that 82% of male workers and 92% of female workers earned Rs. 10,000/month or less.

(Data and analysis can also be found at cse.azimpremjiuniversity.edu.in/state-of-worki… )

47. Still using rough estimates: that is approx 330 million male workers and 70 million female workers making Rs. 10,000/month or less.

Every worker is, by definition, supporting 1.6 dependents besides themselves (1.3 billion people / 0.5 million workers).

48. Of course the number of workers and dependents in a household will vary from that average. Still, if we take the average Indian household as 5 members, and assume 2 working adults, that remains 1.5 dependents per worker.

49. Put those two figures together: ~400 million workers, each with 1.5 dependents + themselves to support = ~1 billion persons, living on an income that works out - IN THE BEST CASE - to a bit over Rs. 300/day (or about Rs. 2000/week). Actually, for many people, it is lesser.

50. In a country of 1.3 billion people, it is fewer than 100 million workers (supporting approx 250 million people, including themselves) who earn even the minimum amount necessary to be liable for income tax.

That's what labour markets & income inequality look like in India.

51. BTW these are *pre-demonetisation* statistics. Every reason to believe that incomes have gone down, unemployment & dependency have gone up, and labour force participation rate continues to drop from 2016-2020.

@IndiaSpend did a stellar series on this: indiaspend.com/sahab-kuch-kaa…

52. All of these effects are likely more pronounced for women (read @namitabhandare on women disappearing from the workforce) , lower castes, and religious minorities; a woman-led lower-caste or minority household is probably in the most dire circumstances.

53. Did I mention already that anemia is endemic among Indian women, and again with higher incidence rates among lower-caste and minority women?

Imagine facing the choice of going to work - with all the attendant risks - or abide by lockdown despite no money/food while anemic.

54. I think what I am trying to convey is that there are a very large number of Indians who will need direct support if the lockdown is to be successful, and not counterproductive.

Again, I really hope this is understood and being attended to at the highest levels of govt.

55. (And I really wish the PM's speeches had given us greater reassurance that such is indeed the case. Wouldn't have occasion to write all this, were it so.)

~ FIN. At least for now. Don't promise no post-scripts. Still sorting out thoughts, though this writing has helped.

Actually, one post-script already, albeit something I've tweeted about before: another group for whom the combination of lockdown (limiting means of transport) and risk of infection presents an impossible choice is people currently undergoing medical treatment, esp. for cancer.

(57.) This is no longer purely an academic argument, in that my father - who left us in 2019 - was being treated for cancer for the previous 2 years. He had limited mobility, and we relied heavily on a regular cab driver to take us to his treatment sessions.

(58.) We were fortunate that, as a retired officer of the Indian Navy, he received a very high standard of care, and medical expenses were not a concern. Even so, the trips to Tata Memorial or Naval Hospital Colaba from our home were a draining exercise for him, my mother, & me.

(59.) Mom & I spoke earlier this evening about what a difficult position anyone who has to seek treatment - like dad did - would be in today. Especially if they were, like him, an older male with weakened immunity - i.e. very high risk for COVID-19. We would be paranoid.

(60.) Millions of Indians do in fact travel - often long distance, multi-day trips - to receive treatment for cancer or other chronic conditions. This won't stop due to COVID-19. My heart goes out to them & their families as they navigate this lockdown & the risk of infection.

(61.) AGAIN: I would have liked to hear even one line from the PM reassuring them: we understand you are facing a dilemma, and we will ensure dedicated resources to support you are available in each district. Call ... if you are a regular patient & you will be advised/assisted.

(62.) I understand that crisis communication is about clear and implementable messages. (Unlike public health, this is a field I do study!)

Crisis communication is also about assuring people that they are seen, heard, & supported. That means providing information & detail.

(63.) It's not like DD was going to cut the PM off to air a sitcom or something at 8:30. He spoke for 30 minutes only because he decided that was the time he was going to use.

It would/will be useful for authorities - starting with the PM - to take the time to go into details.

~ FIN. Now for real.