India’s Covid-19 danger is spreading south

The Lowy Institute

Will South India’s health system hold up to its promise in the second wave of Covid?

Relatives mourn a loved one who died of Covid-19, outside a mortuary in Chennai, Tamil Nadu state, 5 May 2021 (Arun Sankar/AFP via Getty Images)

Relatives mourn a loved one who died of Covid-19, outside a mortuary in Chennai, Tamil Nadu state, 5 May 2021 (Arun Sankar/AFP via Getty Images)
Published 12 May 2021

Images of the pandemic in Delhi that currently saturate the international media depict ailing patients struggling to find beds, oxygen and medical attention. Amid a highly privatised healthcare terrain with underfunded public hospitals, access to Delhi’s hospitals has long depended on one’s own jugaad (capacity to develop “workarounds”), personal networks and ties to “big men” who lean on hospital officials to provide beds – characteristics that have played into Delhi’s pandemic scenario in a disastrous way.

As the second wave of Covid-19 sweeps south, there is hope that the different nature of South India’s health system will prevent the pandemic from taking hold in the same way.

Tamil Nadu, the state in which I live, has long had a clear commitment to providing quality health services at affordable cost, which stems from its history of democratic action and inclusive social policies. Access to hospital care is more equitable and transparent than in the North, and the state’s public health insurance is higher than in most other states (at approximately A$2500 per year).

Tamil Nadu has a streamlined model of centralised purchasing and distribution of essential medicines. This reduces the black market for medicines, as illustrated currently by the long queues to buy antiviral drug Remdesivir at regulated prices at government pharmacies in the state’s cities. Rural health infrastructure is more developed than in the northern states, which removes pressure from city hospitals. The neighbouring state of communist-led Kerala shares many of these characteristics.

“We’re totally confused. We’re getting two types of information and don’t know what to believe.”

While the 2020 Covid wave was fairly well controlled in Tamil Nadu, with cases peaking at 600 per day, the second wave poses more of a challenge. This wave appears to be largely driven by a virus variant found in India determined by the World Health Organisation as of “global concern”, and the rising caseload in Tamil Nadu currently sits at 29,000 per day.

Since Tamil Nadu’s recent change of government – a coalition led by the Dravida Munnetra Kazhagam party was sworn in on 7 May, following April elections – the existing Covid measures have been expanded. The state has implemented a Covid command centre modelled on Mumbai’s “war room” initiative, which manages an online system of triage to track hospital bed availability and funnel patients to them. Oxygen buses have been established outside hospitals in the state’s capital city Chennai, and a full lockdown began this week throughout the state. In rural areas, health officials have been posted in each district to implement Covid measures and oversee village health workers. Hospitals are full, yet there is an absence of stories of people being unable to access beds or oxygen.

While these characteristics may make the Tamil Nadu healthcare environment appear more resilient and able to manage a predicted further upswing in Covid cases, local beliefs and practices pose a significant challenge to the course of the pandemic here.

In the villages near me outside Pondicherry, there is a diversity of beliefs, largely divided along generational lines. Middle-aged and elderly people ­– who are generally illiterate or semi-literate in this area – tend to believe that Covid is not a serious illness, given that the first wave in 2020 did not amount to much in this area. Election rallies held in March and April this year were strongly attended throughout Tamil Nadu, with few people wearing masks. Distancing is generally not practised in daily life, and community transmission is now widespread. Older people largely distrust vaccines and feel that vital information about side effects is hidden from them. Some believe coronavirus has been created or leveraged by authorities in order to reduce the population. Covid-positive deaths that occur in vaccinated people – whether in the village or among Tamil celebrities – reinforce the belief that vaccines are dangerous.

A volunteer inside a bus converted to provide oxygen to Covid-19 patients waiting to be admitted at a government hospital in Chennai, 5 May 2021 (Arun Sankar/AFP via Getty Images)

Younger people feel torn between different belief systems. They are mostly high-school and university-educated, and their access to technology exposes them to an array of ideologies. Government messaging interrupts mobile phone calls with upbeat audio messages encouraging people to wear masks and get vaccinated. Information circulated on WhatsApp mostly promotes traditional immune-boosting supplements that are popular in the South (turmeric, neem, ginger). Less benign memes shared on social media promote anti-masking, anti-vaccine messages and big-pharma conspiracies.

As one university-educated youth told me, “We’re totally confused. We’re getting two types of information and don’t know what to believe. We were born at home with the help of traditional midwives and ‘grandmother’s medicine’ [local remedies]. We’re wary this is a medical scam of big companies, to get people to buy medicines.”

Public-health measures in rural areas reinforce the fear of stigmatisation of being identified as Covid positive. For example, health workers in a nearby village place wide circles of sanitising white power around the homes of people identified as Covid-positive, which visibly marks a family and home as a site of contagion. It’s therefore understandable that villagers decline testing, and pass off their coughs and fevers as just a cold. Now that community transmission is widespread, contact tracing becomes mostly a matter of encouraging close contacts to self-isolate.

Tamil Nadu’s health system holds the promise of greater resilience than North India’s health sector, yet it remains to be seen in the weeks ahead how it will withstand the anticipated upswing in demand. Australians of Indian background have been vocal on social media recently, expressing their deep distress about loved ones unable to access healthcare in North India. Hopefully, South India’s health system will withstand this Covid wave better, and Australians of South Indian background will not experience the same sense of helplessness and frustration for their relatives.

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