* Editorial 1

States, especially in the north, are facing the brunt of the second wave, made worse by their poor health infrastructure
Getty ImagesREBECCA CONWAY

When the first wave of the novel coronavirus pandemic hit the country, the central government imposed the strictest lockdown for almost two months. For most of the migrants stuck in urban areas without incomes, jobs and food to survive, the only escape was to walk back to the rural areas where they came from. Migrants walked back thousands of kilometres to return to rural areas not because the villages were best equipped to deal with the pandemic but primarily because it provided them protection from hunger and starvation. During the second wave now, it is the rural areas which are bearing the brunt of the pandemic with most cases being reported from rural areas. And, unlike last time, there is nowhere to go.

Estimates versus the reality

The second wave was expected at least based on past experience of other countries and of earlier pandemics but also because most scientists predicted it given the changing nature of the virus and the pandemic. However, unlike the last time when it was largely in urban areas, this time it has spread to villages. Also, in contrast to the previous episode, it has spread this time to the rural areas in Bihar, Uttar Pradesh, West Bengal, Jharkhand and Odisha — States which remained largely unaffected by the spread of the pandemic during the first wave. Most of these States are those with a low availability of health professionals and a lower level of health infrastructure. The result has been a much higher level of infections and deaths. Stories of bodies floating in rivers or left buried on the banks are being reported from both Uttar Pradesh and Bihar. While these are stark visuals of the nature of impact that the pandemic has caused on infections and deaths resulting from the infections, these are all estimates; gross underestimates of the actual reality in the rural areas in many of these States.

Neglect of primary care

The scale of the misery inflicted by the pandemic was expected in most of these States, where the existing health infrastructure has been found lacking. But what made it worse was also complete apathy and a lack of governance in improving the health infrastructure despite knowledge of the second wave of the epidemic.

As in the latest report of the Rural Health Statistics 2019-20 (https://bit.ly/3hAKHNC) released by the Ministry of Health and Family Welfare (MOHFW), not only are these States which figure among the States with the worst health infrastructure but are also ones where the situation has worsened over the years. Compared to 10,337 functioning subcentres in rural Bihar in 2005, only 9,112 subcentres were functioning in 2020. The number of community health centres declined during the same period from 101 in 2005 to only 57 in 2020. Despite population growth, during the same period, the number of primary health care centres increased marginally to 1,702 in 2020 compared to 1,648 in 2005.

The situation in Uttar Pradesh, another large State, is no different with the number of primary health centres declining from 3,660 in 2005 to 2,880 in 2020. While the number of community health centres increased from 386 to 711 during the same period, sub-centres increased only marginally, from 20,521 in 2005 to 20,778 in 2020. The situation with regard to the availability of health professionals is not very different, with most States witnessing a worsening situation. For example, only 29% of specialists were in place in the community health centres in Uttar Pradesh as against the requirement based on official norms. Compared to the norm, Bihar reported the highest shortfall in availability of subcentres, at 58%, followed by Jharkhand, at 44%, and Uttar Pradesh, at 41%, as on July 1, 2020. Similar numbers in the case of primary health care centres were 73% for Jharkhand, 58% for West Bengal, 53% for Bihar and 51% for Uttar Pradesh.

Avoidable events

Given the state of the rural health infrastructure, it was obvious that the pandemic would lead to catastrophic outcomes once the rural population was exposed to the virus. The lack of governance in this case is not the state of health infrastructure that the State governments inherited but the failure to contain the spread of the pandemic despite the knowledge of the state of rural health infrastructure. This failure to estimate the scale of the havoc created by the pandemic was obvious in the case of the central government — steps were not taken to contain the spread along with augmenting the rural health infrastructure and there were decisions such as prolonged electioneering in some of the States. West Bengal, which has seen the fastest rise in cases, was witness to the longest period of electioneering this time, with no precautions such as social distancing in place. Similar adventurism in the case of Uttar Pradesh saw hundreds of polling officials getting infected and passing away due to the pandemic during the conduct of local body elections in the State. The Maha Kumbh organised in the middle of the pandemic, with millions of devotees participating, further added to the spread of the infection with devotees returning to rural areas in different States. All of these were eminently avoidable, with the resources used to augment and strengthen the rural health infrastructure.

Judiciary and the state

While all these created the perfect breeding ground for the pandemic to spread to rural areas, the severity of the infections was also a result of the misgovernance of State governments. This bordered on ignorance of the level of severity to outright denial and complete apathy of the health and humanitarian crisis unfolding in the respective States. In most cases, the judiciary at the level of High Courts has stepped in to fill the vacuum created by an absent state. The judicial intervention of the Allahabad High Court last month directing the State government to impose lockdowns in Uttar Pradesh was in turn challenged by the State government in the Supreme Court. Attempts to voice concern over the state of health infrastructure and the spread of the pandemic by helpless citizens was countered with threats of legal action by the Uttar Pradesh government until the Supreme Court stepped in.

Instead of expanding testing and contact tracing, attempts were made to restrict testing and report a lower number of infections, leading to a sense of complacency within the State administration. The reality in rural areas of most of these States is worse than what is being released to the public through official estimates. This is true for the number of deaths which by all measures appears to be much higher than official statistics. The absence of testing and treatment infrastructure has left the rural population at the mercy of private health providers; a large majority of the population has been left unable to avail the services of private health-care providers. The slow pace of vaccinations in rural areas despite the vulnerabilities has only contributed to the rise in infections and thousands of deaths which could have been easily prevented.

Aggravating rural distress

Rural areas provided refuge to the majority of the migrant population which had lost jobs and incomes during the first phase. It also helped the economy revive given that rural areas were largely unaffected. However, this time round it is the rural areas which are facing the worst of the pandemic as well as economic distress. Rural wage data as well as data on rural non-farm income available from official and private surveys point to a dismal economic scenario. While many have lost their primaryincome earner, even for those who managed to recover, it has come at the cost of huge private health expenditure. Many are likely to fall into a debt trap with the usurious rate of interest from the private money lenders pushing them into chronic poverty. For the rest, the loss of jobs and income has come at the cost of depleted savings. Rural areas are not just staring at the worst of the pandemic but also at prolonged economic distress.

While the pandemic with its uncertain nature is certainly responsible for it, the blame must equally lie with the government, both at the State as well as central levels, for its failure to anticipate and prevent the thousands of deaths.

Himanshu teaches Economics at Jawaharlal Nehru University

Russia and the other players in the Ukrainian crisis need to be prudent enough to resolve chronic tensions
Tatiana Belousova
APAlexander Zemlianichenko/AP

The recent stand-off between Russia and Ukraine has again captured headlines in the international news media. This geopolitical situation appears to be complex due to the indirect involvement of its multiple stakeholders, including the United States, Turkey and the North Atlantic Treaty Organization (NATO).

Increased tensions between Ukraine and Russia can be viewed as a continuation of the unresolved conflict of 2014. Since then, the ‘illegal annexation of Crimea’ has become a buzzword in international politics, and Russia has been constantly painted as an aggressor and a hostile power. In addition to this, the country has been criticised for its involvement in the Donetsk and Luhansk regions in eastern Ukraine, where Russian-backed separatists have been fighting with Ukrainian troops.

From the beginning of April 2021, Moscow has allegedly deployed thousands of troops as well as tanks and artillery near Ukraine’s eastern border. It has also mobilised troops in the annexed Black Sea region of Crimea. This was enough to send a shock wave among the political elite in Ukraine, forcing them to appeal to the U.S. and NATO and ask for an intervention, if needed.

How dangerous can this become in the short term, and to which extent is the fear-mongering of the Ukrainian administration justified by the real situation on the ground?

NATO, U.S. response

On April 13, 2021, NATO Secretary General Jens Stoltenberg invited Ukrainian Foreign Minister Dmytro Kuleba to the NATO headquarters for a meeting of the NATO-Ukraine Commission on the security situation in Ukraine. Mr. Stoltenberg said, ‘Russia’s considerable military build-up is unjustified, unexplained, and deeply concerning.’ He underlined that NATO would continue to provide significant political and practical support to Ukraine. In turn, Mr. Kuleba made a strong statement that ‘the mistakes of 2014 must be avoided this time, so that Russia cannot catch anyone by surprise’.

Besides powerful rhetoric from NATO, Ukraine seems to be desperate to receive more commitments and concrete actions. Dealing with Russia, a powerful and unpredictable neighbour, forces Kiev to rely on NATO/U.S. military support if Russia is to continue with its provocations. The question though is how far the NATO alliance can go in its support, given that Ukraine has not yet obtained membership. In June 2020, NATO recognised Ukraine as an Enhanced Opportunities Partner, along with Australia, Finland, Georgia, Jordan, and Sweden. This partnership aims to maintain and deepen cooperation between countries that have made significant contributions to the NATO-led missions and operations.

The Ukrainian President Volodymyr Zelensky has also used the current tension as an opportunity to push for NATO membership, arguing that ‘this is the only way to end the war in Donbas’.

Notably, the U.S., under the new administration, has taken a more resolute stance towards this conflict, unlike the predecessors of the U.S. President, Joe Biden. Mr. Biden seems to be less apprehensive about provoking Russia and is ready to support Ukraine militarily, if the need arises. The recent visit of the U.S. Secretary of State, Antony J. Blinken, to Kiev indicates the U.S.’s foreign policy priorities. The underlying rhetoric of this visit was to support the ‘independence, sovereignty, and territorial integrity of Ukraine’.

Support from Turkey

On April 11, 2021, Mr. Zelensky visited Istanbul to mark the 10th anniversary of Ukraine’s strategic partnership with Turkey. This was also an opportunity for him to be reassured by Turkish President Recep Tayyip Erdoğan, that Turkey stands by Ukraine amidst the current tensions with Russia. Both leaders discussed the security issues in the Black Sea region. During the bilateral meeting, Mr. Zelensky emphasised that ‘the visions of both countries regarding geopolitical threats coincide with each other’. In other words, the visit was a diplomatic success for Ukraine as it had obtained the necessary guarantees from Turkey should tensions with Russia escalate.

It is worth recalling that Turkey has not acted in synchrony with Russia during several conflicts, e.g., in Syria, Libya, and, most recently, in Nagorno-Karabakh.

Russia’s moves

So what is Russia’s end goal? Arguably, the cornerstone of the Russia-Ukraine conflict is insufficient communication, especially on the part of Vladimir Putin’s Russia. It is very difficult, if not impossible, to speculate on the overarching rationale behind Russia’s tactical decisions towards Ukraine. There are more questions than answers regarding the strategic calculus of the Russian administration. A deficit of explicit messages from Moscow creates room for misinterpretations and exaggerations on the part of Ukraine and its western supporters. This misunderstanding can be best illustrated by the Russian explanation of its recent ‘military build-up’ in western Russia. According to the Russian Defence Minister, Sergei Shoigu, it was just a ‘three-week drill’ meant to test combat readiness to respond to NATO’s threats.

Russian President Vladmir Putin has been known for his geopolitical adventures, especially in West Asia. In the case of the eastern Ukraine, it is highly unlikely that he would be willing to make further territorial gains this time around. He possesses enough diplomatic (and pragmatic) skills not to indulge in yet another geopolitical endeavour, that might entail serious repercussions from the international community. Mr. Putin is aware of the ‘red line’ that should not be crossed. Hence, from the Russian perspective, the current ‘military build-up’ can be viewed as another round of muscle flexing and an attempt to perpetuate the narrative of a powerful and capable Russia.

For a peaceful resolution

All the stakeholders in the ongoing crisis should focus on establishing a constructive dialogue among themselves using clear and unambiguous language. The only way forward is to seek a peaceful resolution to the Russia-Ukraine conflict rather than exacerbating the reality and using quid pro quo tactics. Both countries do need support from the global community, but not in a military form. There is a need for a platform (similarly to the Minsk Agreements) that will facilitate negotiation, mutual consensus and possible compromises, as well as engagement with mediators.

The long-term solution should be sought out in order to break the vicious cycle of animosity and misunderstanding.

Tatiana Belousova is Assistant Professor, International Institute for Higher Education Research and Capacity Building (IIHEd), O.P. Jindal Global University, Sonipat, Haryana. She also teaches the course on the ‘Evolution of the Post-Soviet Space’ at the Jindal School of International Affairs (JSIA)

Accurate forecasts and resilience-building hold the key to handling severe cyclones

Millions of people wearied by the onslaught of the coronavirus have had to contend with a furious tropical cyclone that has left a trail of death and destruction before making landfall in Gujarat. Cyclone Tauktae swelled into an extremely severe cyclonic storm, dumping enormous volumes of water all along the west coast, and caused loss of life in Kerala, Karnataka, Goa, Maharashtra and Gujarat, before weakening overland. To thousands who had to be evacuated to safe locations, this year’s pre-monsoon season presented a double jeopardy, caught as they were between a fast-spreading virus variant and an unrelenting storm. Many coastal residents would have felt a sense of déjà vu, having gone through a similar experience last year, when the severe cyclonic storm, Nisarga, barrelled landwards from the Arabian Sea, pounding Alibaug in Maharashtra as it came ashore. The cyclones in both years spared densely populated Mumbai. The twin crises have, however, strained the capacities of multiple States, especially the coastal ones, although the impact of the storm was considerably mitigated by disaster response forces. Once again, the value of creating a trained cadre, supported by the defence forces in rescue and relief work, is seen. The heralding of the 2021 monsoon season by a cyclone comes as another reminder that the subcontinent is at the confluence of more frequent, extreme weather events originating in the Bay of Bengal and the Arabian Sea every year.

How well India is prepared to handle cyclones depends on developing greater expertise in forecasting and disaster mitigation, and crafting policies to increase resilience among communities. Last year, the India Meteorological Department (IMD) launched an impact-based cyclone warning system from the October-December season designed to reduce economic losses by focusing on districts and specific locations, and incorporating such factors as population, infrastructure, land use and settlements. The IMD also claimed that its accuracy of forecasts, for instance, in plotting landfall location, is now better. Together with ground mapping of vulnerabilities, this is a promising approach to avoid loss of life and destruction of property. The importance of precise early warnings cannot be overemphasised, considering that the Arabian Sea has emerged as a major source of severe cyclones, and their intensity is aggravated by long-term rise in sea surface temperatures linked to pollution over South Asia and its neighbourhood. Climate-proofing lives and dwellings is a high priority now, a task that warrants a multi-sectoral approach: to build sturdy homes of suitable design, create adequate storm shelters, provide accurate early warnings, and ensure financial protection against calamities through insurance for property and assets. Governments must rise up to the challenge.

The ICMR must assess evidence and be very specific with recommendations on treatment

The Indian Council of Medical Research (ICMR) has finally dropped its espousal of convalescent plasma therapy (CPT) as treatment for moderate COVID-19 in its latest guidelines. In its guidelines of April 22, CPT was already on its last legs, with the advisory recommending that it is advisable only in early moderate disease, or within seven days of symptoms. These updates flow from periodic reviews of medicines and treatment protocol by a task force of doctors and experts of the ICMR. Practising doctors are not legally bound to follow these recommendations to the T but are expected to circumscribe their treatments within the guidelines. Last year, the ICMR, in one of the definitive clinical trials in the world, demonstrated that CPT neither saved lives nor improved patient outcomes but was equivocal about it in public. This gave leeway to some States, particularly the Delhi government, which openly disavowed the ICMR’s findings, encouraging several doctors to put the onus on hapless caregivers to source such plasma from those who had recovered from the illness. The clamour for plasma had birthed its own kind of ecosystem. There were apps designed to connect donors to recipients, an inevitable black market, and, if the plasma did not seem to be working, the tendency was to blame the quality of plasma rather than recognise the futility of the treatment.

Last week, it took a letter by a clutch of concerned public health professionals to India’s Principal Scientific Adviser as well as results from a trial, published in The Lancet, spanning around 11,000 patients — that again found no benefit — to demote CPT. Further evidence is emerging that CPT may be contributing to the evolution of coronavirus mutations that, together, may have been the final nail in the coffin. However, this is not the end of the road for treatments with limited scientific basis finding a mention in the ICMR guidelines. Hydroxychloroquine and the anti-parasitic drug, ivermectin, continue to find a place for the treatment of mild disease despite a specific mention of “low certainty of evidence”. There is an argument that doctors, battling a disease that has so far defied a predictable treatment regime, cannot always observe the necessary clinical equipoise. Unlike doctors on the frontline, a collective of experts such as the ICMR taskforce, has the comfort and the distance to dispassionately assess evidence and be very specific with its recommendations. Publicising these at regular intervals serves to educate the public about the evolving nature of treatment and be better prepared as future patients and caregivers. This will work better towards easing the pressure on doctors as well as in improving trust in systems that are designed to offer the best possible expertise.

CBI action

It is unfortunate that just when the administrative machinery has begun to roll in West Bengal, spokes are being put in the State government’s wheel (Page 1, “Two TMC Ministers among four held by CBI in Narada scam”, May 18).

It is mysterious how an old case bundle pertaining to alleged criminal offences by a few prominent political leaders in the TMC has suddenly found importance. Nothing barred the premier investigation agency to undertake this exercise all this while. The timing only strengthens the perception of political vendetta after the election loss and derailing governance than in taking a long-pending criminal case to its logical end. Similarly, it does not behove the status of a seasoned politician like Mamata Banerjee to barge into the premises of the CBI and create an unpleasant scene when avenues are available to express dissent and displeasure.

V. Johan Dhanakumar,

Chennai

 

The selective arrests are surprising. The brazen acts of omission and commission by the central agency while dealing with a case, and its differential treatment of the accused not only hurt the credibility of the institution but also the fate of the case itself. It would be a disservice to the nation if a responsible investigation agency is bowing to pressure. If political influence is evident in its call of duty, only god can save it from falling from grace of the people.

Dr. D.V.G. Sankararao,

 

Nellimarla, Andhra Pradesh

 

Stopping the wave here

Now that the COVID-19 virus has entered rural India, there is a need for remedial action before this wave turns into a tsunami. The main requirement is to stop the spread of the virus through contact with positive cases. In many villages, families live in congested households, making it almost impossible to arrange for home isolation. It is imperative that makeshift isolation centres be put up by the panchayats, which can serve clusters of villages. All suspected cases should be moved to these centres immediately on detection and given medical aid. These centres can be financed by various bodies under the watch of the local MLAs or MPs. These can be manned by nurses of primary health centres and also assisted by family members.

Nitesh Mandwariya,

 

Neemuch, Madhya Pradesh

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