The New Normal as the Old normal

Veena Das

Much discussion on COVID-19 focuses on routes and rates of transmission of infection, case
fatality ratios and positivity rates, where the emphasis is on parsing out COVID-19 related
mortality from the general mortality figures on cause of death. Yet mortality caused by COVID-
19 interacts with other conditions. The question I want to ask is whether the Coronavirus
attacked health care systems that were otherwise well-functioning or, if the adverse
consequences such as unacceptably high rates of serious complications and mortality might be
equally attributed to malfunctioning of medical infrastructure and health care under more
normal circumstances?

Focusing on recent research on how the health care system works for the urban poor at least in
the Northern states, here are the main features. Poor people living in cities have three choices:
They can either visit public primary care clinics, government hospitals or private providers in
their vicinity. Every choice comes with its own problems. The care in public primary clinics is
often cursory with doctors asking 1 question, spending 2 minutes with the patient and moving
on. Care in government hospitals is better, but requires long waits and interactions with
patients that are snappy and short.

Not surprisingly, many patients from low-income neighborhoods tend to first access private
providers in their own areas before turning to the government run facilities. There is a
proliferation of such providers – some with degrees in bio-medicine and others with AYUSH in
Ayurveda, Siddhi, Homeopathy or Unani. And although there is clear variation in how patients
are treated, many interactions with providers, regardless of the qualifications they possess,
follow the same modes of diagnosis and treatment. On a first encounter, patients presenting
with symptoms are dispensed a packet of medicines for one or two days and told to report back
if symptoms do not improve. The medicines (nuksa in local parlance) typically include an
antibiotic, an analgesic, a vitamin tablet and sometimes a low dose steroid. The whole
interaction lasts an average of five minutes. Very often, if the disease is self-limiting such as a
viral infection, the patient gets better regardless of the medicines dispensed. However, serious
diseases such as TB go undiagnosed till the condition of the patient worsens when he or she
might be referred to a government facility or may choose to go to a different kind of provider.
Even in the case of emergencies such as an angina or heart attack, the symptoms might be first
treated as those of gas. Diagnostic delays, unnecessary injections and inappropriate use of
antibiotics is a routine feature of medical treatment for residents of low income localities,
regardless of whether they first present to a provider trained in biomedicine or in any other
stream of medicine.

The challenges of diagnosis and treatment in the case of COVID-19 have not happened on a
blank slate – the medical infrastructure for the poor was already heavily flawed. It is not a
surprise that in routine surveys about their experiences of the medical system, many patients
express great skepticism on whether they have been diagnosed or treated correctly. We
repeatedly find that patients worry whether doctors are prescribing diagnostic tests because
these are needed, or because the doctors get a cut from the laboratories. In the case of hospital
admissions patients will often speculate that they were kept extra days because of the fee that
could be extracted. Needless to say, these feelings of mistrust seep into the way providers treat
patients as they (the providers) are extremely wary of being accused of corruption and how
their reputation might affect their business. A provider faced with a complicated case that
legitimately requires further, possibly expensive, investigations often has no choice but to
slowly—over the course of many visits—convince the patient that they are not trying to extract
money; the care is genuinely required.

In this scenario of generalized mistrust in medical institutions, how are families navigating
symptoms of COVID-19 and of other diseases? Take just one example: Kusum (name changed)
was in the eighth month of her pregnancy when the lockdown happened. She had been
diligently presenting for regular check-ups in the government dispensary and since it seemed an
uncomplicated pregnancy her family planned for a home birth with a trained dai in attendance.
The area she lived in was declared as a red zone because of COVID-19 cases in an adjoining
street and she could not get the necessary papers that would have allowed her to leave the
cordoned area to access the dispensary.

Two weeks before her anticipated date of delivery Kusum began to feel that the fetus was not
moving. Her husband tried to get her admitted to a government hospital but lacking the
necessary paperwork, the hospital would not admit her. Desperate, the family took her to a
small private nursing home where a cesarean was successfully performed. The nursing home, as
per their policy, tested Kusum for COVID-19 and reported a positive result.

The medical staff wanted to shift her to the ICU but Kusum claimed she had no symptoms and
suspected that she was being falsely diagnosed as infected because the nursing home wanted
to extract money. In this and many other cases, it is hard to determine from the outside whose
claims were correct. After all, non-symptomatic persons could be infected; defective tests could
result in false positives; the nursing home could be faking the results to extract money as costs
of treating patients with COVID-19 are sky high. In fact, there are several PILs filed in courts
asking for directions to be given to state governments to regulate pricing for diagnostic tests
and treatment of COVID -19 cases in private medical facilities.
The point of this example, and many others that are surfacing, is that the coronavirus has
brought out a major pathology in our health system. Even in normal circumstances health care
for the poor whether in the government run facilities, or in the private sector is dismal and the
mistrust between doctors and patients is becoming corrosive. The uncertainties produced by
the COVID-19 pandemic have simply brought to light the pathologies of health care that the
poor have simply learned to live with or die from.

As one person I know said “COVid-19? We thought first that it was a disease of the rich – now
we know it has come to stay with us as happened with dengue, and with chikungunya, and as
will go on happening with every new and old disease.”