Beyond borders

In June, while the Covid-19 pandemic was at its peak in the Indian capital Delhi, a young YouTube-based reporter stationed himself outside a hospital and recorded the stories of frustration, panic and anguish as distraught relatives tried to find treatment for their loved ones within an all-but-collapsed medical system.

One man recounted how, after getting no information, he had asked a guard to take a phone in to his father within a hospital only to have the guard return to inform him that he had died.

Another man was waiting for the police to turn up. He had heard nothing from or about his father from hospital staff for six agonizing days, until finally being told that his father was missing. ‘I have no idea where he is. Is he even alive or not? Tell us something, it has been six days.’

Yet another began calmly enough. His father, who had been in a government hospital, had not even had access to oxygen and had asked his son to arrange to move him to a private one. When, finally, a bed was found, he was told that the treatment would cost $5,000-$7,000 for 10 days; $13,500 if a ventilator was required. Private hospitals across the country had started price-gouging in the wake of the pandemic. Scrambling to arrange the cash, he got his father admitted, but later received a call from the patient in the bed next to his father’s.

Here his composure crumpled. The patient told him how his father had been scared after seeing conditions in the private hospital from the start. One evening, as he took a few steps, the father collapsed and was helped back into bed by the patient. Then they started calling for help, but to no avail. ‘If they had put him on oxygen or a ventilator, your father would have survived,’ the patient told him. ‘He died in torment here.’

At the time of writing, random sample tests suggested that nearly one in four of all Delhi’s residents had been exposed to Covid-19.

Up until mid-July the obvious contrast to much of the rest of India’s straining health services was the communist-run state of Kerala, which had had the country’s first coronavirus case back in January. A combination of solid investment in public health, high literacy, public engagement and a clued-up, pandemic-ready health minister in the form of former secondary-school teacher KK Shailaja led to remarkable early successes.

Kerala’s public-health effort focused on prevention and containment through aggressive testing, contact-tracing and immediately quarantining people suspected of being infected, while seeing to it that they were properly fed. Those who landed up in hospital found the experience much better managed and more humane than what was unfolding elsewhere in India. Shailaja was lauded in both the national and international press. By May, this state of nearly 35 million people was reporting days with no new cases.

But it was a case of cheering too soon – July saw a surge, which is largely being blamed on an influx of people returning from the Gulf and other Indian states where they had found themselves suddenly out of work, and consequent community transmission. The numbers overwhelmed the system. Still, the state has the lowest case fatality rate in the country and the Kerala government is creating hundreds of Covid-19 treatment centres in the villages where the disease has spread.

Showing the way

Perhaps unsurprisingly, showing the way in terms of public health in these privatized times is Cuba, which has the highest ratio of doctors to citizens of any country in the world. Reluctant to lose out on tourist dollars, the country held out until 20 March before stopping new arrivals. But it had already got a ‘prevention and control plan’ ready in January, and when the first infections were confirmed, it was actioned. Aside from getting the highly educated Cuban public ready with information about symptoms and precautions, starting track and trace and isolation for those who may have come into contact with the virus, this involved sending doctors, nurses and medical students into the community to screen every home on the island every single day.

Testing was ramped up, despite the expense. Every person testing positive was hospitalized so they could be better monitored. For sure, the heavy state that ensures isolation is institutional rather than at home and mandates people not wearing face masks in public are penalized, even jailed, is the flipside to this success. But Cuba has kept overall numbers low and seen a sharp drop in cases since mid-April. The United States has, by contrast, 59 times the rate of infections per million people.

Choppy waters

Government interventions around the world have demonstrated that privatized healthcare, which is essentially unequal healthcare, is incapable of dealing with a public-health crisis. Additionally, tackling the pandemic through lockdowns on the one end and expensive tertiary medical care on the other, has tested the wealthiest of nations, let alone the poorest. The demand for well-provisioned healthcare as a public good is resurgent, contrary to years of rightwing economic dogma. In many parts of the Global South, as governments try desperately to resuscitate public-health systems all but killed off by the diktat of international financial institutions, the pain is most acute.

Bobbing about as we try to negotiate the ever-changeable waters of this pandemic, it becomes clear that international medical solidarity could corral the largest number of lifeboats. Yet consider the fate of the World Health Organization (WHO), the only body qualified to make a useful international intervention, during the pandemic. It struggles to collect its membership dues – the biggest laggard being the US, which eventually announced it was pulling out altogether as a result of Trumpesque pique. Caught up in the political wrangling of the US and China, the WHO has had to walk an unnecessarily careful line, where it cannot be seen to be critical of political leadership while it tries to advance a public-health agenda which is pulled this way and that by political interests. It is forced into being cautious when the need of the hour is for it to be a bold champion of health equality.

Whose vaccine?

In May the WHO adopted a proposal for a Covid-19 Technology Access Pool calling for ‘the voluntary sharing of knowledge, intellectual property, and data, and a guarantee of free access and use by WHO member countries of drugs and vaccines that are developed’. The need of the hour, one could be forgiven for thinking, yet it was endorsed by only 30 countries, of which only 4 were high income, and was shunned by the pharma giants collaborating on Covid-19 vaccines and treatments.

Typically, there are parallel and competing initiatives running to try to secure the holy grail vaccine for low-income countries should it arrive, among them the Gavi (the Vaccine Alliance) Covax Advance Market Commitment (AMC), which seeks to raise billions to guarantee the bulk buying of promising vaccine candidates in order to stimulate manufacturers to bump up production capacity. Such AMCs have been criticized for not ensuring the lowest price and the initiative itself is a public-private scheme that has come under attack for its secretive way of operating as well as for the likelihood that it would tie up a huge chunk of aid money when global aid budgets are shrinking.

And beyond that there is vaccine chauvinism, with the US, that egregious PPE-hijacker, in the lead. Other wealthy countries are also throwing money at promising vaccine candidates with their own AMCs in order to secure huge pre-orders of doses, in the hope that if one works their populations would be covered. The UK government is reported to have bought in on up to 12. In this me-first scramble to hoard, the poorest nations of the world have no say.

Meanwhile the pandemic continues to accelerate, bringing with it massive disruptions to other vaccination programmes and health interventions that will result in an overall rise in the disease burden, beyond Covid-19.

The current model of vaccine development usually involves public (and sometimes philanthropic) funding at the research and development stage, carried out in academic laboratories, with subsequent licensing to a big pharmaceutical player for manufacture and distribution. AstraZeneca, which has paired up with the University of Oxford researchers, has said it will make no profit from their vaccine candidate (which has had good results so far in trials), if successful, and make it available at cost. Global justice campaigners view such claims with deep suspicion. Time and transparency will tell.

But many medical experts – and indeed thinking laypersons – find that this model is far from the best we can do. Vaccine development has been sliding anyway since the pharma companies are less interested in one-shot drugs. As an international group of 6,000 academics put it in a public statement: ‘Profitability is an intolerable yardstick when it comes to our health.’ Can we imagine a future where such essential medical innovation remains public and free of patent, right from research through to production and dissemination? Where nations join hands to pursue global health over profit?

So far Covid-19 has taught us many things about inequality and division. We should be learning that this crisis won’t be sorted by either the market or nationalism. And we should be asking what it would take to make healthcare a right and a public good and then doing our damnedest to achieve that outcome.

Numbers of cases and fatalities were correct at the time of writing.