The Pandemic and Beyond : Free Quality Healthcare is a Fundamental Right

WHEN the whole of India was put under lock and key in late March, we had only 564 known cases of Novel Coronavirus infection. By the middle of May, we earned the dubious distinction of defeating eternal competitor China (which had nearly 83000 cases) at least in this field. On May 19 the tally crossed the 100000 mark and is all set to rise rapidly for quite some time.

Clearly, it has been a callously planned, brutally and chaotically executed lockdown with an extremely poor cost-benefit ratio. But then there are a good many instances - - our very own Kerala being one of them - - where lockdowns, carefully designed in keeping with actual conditions on the ground and executed in combination with vigorous contact tracing and testing on the one hand and on the other, the state supplying the people under lockdown with all necessary provisions and services, have proved quite useful. So the question is not whether lockdown per se, lockdown in the abstract, is good or bad. It all depends on how a nation plans and executes its overall strategy (of which lockdown may or may not be one of several component parts) of combating an epidemic or pandemic in correspondence with its specific socio-economic conditions. But this is about the urgent or immediate task. Closely connected with this is the broader and long-term agenda of developing a national healthcare policy and infrastructure that should have at its core not the logic of capital accumulation but the interests of the aam aadmi, aim at free healthcare for all, and strive to prevent or at least minimize the impacts of epidemics/pandemics. We propose to discuss the two-point agenda in two parts.

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Coping With Epidemics And Pandemics

Human society has encountered series of epidemics and, with the exponential growth of international commerce under capitalism, also pandemics. The dreaded "Black Death", for example, peaked in Europe between 1347 and 1351 and killed anywhere between 75 to 200 million people. Even Cholera, a disease so familiar to older people in India, spread across much of the globe seven times over the past two centuries, the one that raged between 1960s and early 1970s being the last one. Nearly a hundred years ago we had the so-called Spanish flu, followed by others like HIV (which, since 1981, has claimed the lives of more than 32 million people and at the end of 2018 around 37.9 million people were living with it), SARS (which, like Covid-19, was due to a Coronavirus known as SARS-CoV and infected an estimated 8,000 people in 29 countries in the year 2002), H1N1 or the Swine Flu (which infected an estimated 60.8 million people in 2009 - 2010, with 12,469 fatalities, of which about 80% were people younger than 65 years). A quick glance at a couple of these outbreaks, we believe, can help us in our collective fight against the scourge at hand. For although everything has changed over the decades, it is equally true that the more things change, the more they stay the same.

How the Colonial Rulers Dealt With the 1896 Plague In India

The bubonic plague of 1896 travelled from its epicenter in Yunnan, China, via Hong Kong to Bombay port. The vehicle of contagion was imported merchandise, which were often crammed with infected rodents. From Bombay the disease spread to some other areas including Punjab, the United Provinces, Bengal and even Burma. To make matters worse, the plague was accompanied by a famine that started from Bundelkhand and spread to other areas. By 1901 four lac Indians fell pray to it and by 1905 the toll was 10 lac.

According to some scholars, initially the British government preferred to remain passive because they did not want to disturb the flourishing international trade, particularly the opium trade with China. But when some of their trade partners got wind of the plague and threatened restricting trade with India, the government was forced to act.

In January 1897, Sir John Woodburn moved a very brief and hurriedly drafted bill to arm the authorities with arbitrary powers to check the spread of the disease. The basic motive was to protect British mercantile interests. As Mr. Woodburn said while introducing the bill, "foreign countries are already much alarmed at the possibility of infection from India... (and therefore) for the safeguarding of our commerce the government must be prepared to take steps to allay the fears of other nations."

The bill was enacted as "The Epidemic Diseases Act, 1897" and put into practice with brute force. Aggressive screening of passengers at railway stations and ports and forced isolation of those suspected of having been infected; house to house searches for sick persons by police and in some cases military personnel, who often ordered men and women to strip in public so that they could be checked for symptoms of plague on armpits and groins; chemically disinfecting not only houses but even human beings suspected of having the disease; fumigating and even burning down houses as well as clothes and other belongings of the people in what we call “hot spots” - repressive acts like these generated a lot of animosity among the masses, particularly in Bombay city and Puna (as they were called in those days). The people's disaffection found voice in mass protests, including an attack on a hospital that was virtually a prison for plague patients, and also in articles written by Bal Gangadhar Tilak in his Marathi paper Kesari.

Shortly afterwards, the Chapekar brothers from Puna shot dead the Bombay municipal commissioner WC Rand, who was leading a repressive campaign in the name of plague control, and his military escort. The government took this opportunity to frame several of its opponents on charges of sedition, i.e., instigating or assisting the murder. Foremost among them was Tilak, who was charged for sedition at the Bombay High Court. Justice Arthur Strachey in his charge to the Jury came up with a biased and distorted interpretation of sedition. He said that one was free to criticize the government, but if a journalist made his readers hate the government, that would amount to sedition. He further added that an article "published at a time of profound peace, prosperity and contentment" could be ignored, but not one which was written "at a time of agitation and unrest", when "ignorant people" would "become indisposed to obey and support the government"; in the latter case it would certainly amount to sedition. The Jury (most of them Europeans) found Tilak guilty and he was sentenced to eighteen months in prison. About a month later, the Chapekar brothers were caught and summarily sentenced to death.

In sum, the colonial government, guided by its own interests, delayed taking action and then sought to tackle the situation with inhuman repressive measures, as if it was a law and order problem. Instead of trying to de-rat imported merchandise, houses and streets, it tried to chemically disinfect or even burn down whatever they assumed to be contaminated. The municipal authorities never took the 'natives' into confidence and imposed arbitrary restrictions on their movements without prior announcement, even as white and brown 'sahibs' were free to move around. In mortal fear of both the disease and the 'treatment', general people in their thousands fled from cities to their villages, unwittingly helping spread the disease. Whatever the authorities did, however, was done with legal sanction provided by the Act of 1897.

Today it is the same Act that the government of the day has taken up as its main instrument of repression and has also got it amended through an ordinance so as to render the old Act even more barbaric. Following in the footsteps of their colonial forefathers, the fascist rulers are now using the present period of health-cum-humanitarian crisis to frame their foremost critics and political opponents on false charges. And in most cases even the apex court, like the Bombay High Court in 1897, is taking a biased and authoritarian stance in favour of the government, failing to protect the constitutionally guaranteed democratic rights of activists and intellectuals.

But there was another dimension - a popular-democratic heritage - of the struggle against plague. A good many social/religious organisations and individuals, such as Vivekananda and his followers, participated vigorously in plague and famine relief work at great risk to their own lives. And today also we see ordinary people coming forward to help their fellow citizens in all possible ways, even as left activists brave lockdown conditions to combine relief work with agitations to force the authorities do the needful for people in distress.

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1918: The Pandemic that Taught Governments to be More Responsible

The so-called Spanish flu spread across the world in three waves (early 1918, late August and early 1919) and claimed at least 50 million lives. Among all countries, the highest toll was in India with 14 to 18 million deaths. As in 1896, Bombay was the gateway of India for the deadly virus, the main vehicle on this occasion being ships carrying troops from war fronts in Europe. From Bombay the men went back to their home States, carrying the disease with them. This time too, a failed monsoon and famine-like conditions in parts of the country left people hungry, weak and more susceptible to disease.

Like typhus and cholera, flu was considered one of the "crowd diseases", i.e., diseases which spread like wildfire whenever and wherever large numbers of people share small spaces, as in slums or during social or religious congregations, or in trenches during war. The very term ("crowd diseases") had an elitist overtone and theories of social Darwinism and eugenics were quite influential at the time. The prevalent common sense among the upper strata of society was that the poor people were poor and sick because they did not care about personal hygiene and lacked the merit and the enterprise to achieve a higher standard of living. In other words, they themselves were responsible for their plight and the maladies they routinely suffered from. Hardly was the state held responsible for improving the pathetic living conditions of the working people and for prevention of epidemics.

The 1918 flu demolished such notions at least in the context of epidemics and pandemics. While casualties were usually higher among the poor, the rich and the highborn showed no signs of a superior immunity and were infected in great numbers. It was now as plain as day light that blaming the poor and treating them in isolation was not only unjust but absolutely irrational and ineffective. Epidemics needed to be tackled at the population level, irrespective of class and social status, and this could be done only by the state. It was not the first time that such ideas had emerged, but thanks to its vast global spread the 1918 pandemic had a more effective impact on policy makers, pushing them towards state-sponsored healthcare.

An additional stimulus came from the healthcare policy of revolutionary Russia. Immediately after the revolution (November 1917) the Soviet government announced comprehensive social insurance for workers and for the urban and rural poor, covering illness, injury, maternity, widowhood, old age and unemployment. The entire cost of insurance was to be borne by the employer, in most cases the state. No empty promise this, the first socialist state seriously got down to work (more on this later) and managed to build up a rudimentary public healthcare system that proved effective in treatment and prevention of epidemics and other health issues. The socialist model attracted international appreciation and helped mould public opinion in favour of comprehensive state intervention in the health sector.

So under the twin impacts of the 1918 pandemic and the rise of socialist medicine, governments in many countries started building comprehensive public healthcare systems. The trend gained more traction in the context of the New Deal in the USA and the welfare state policy in Europe, while the establishment of the World Health Organisation in 1946 provided a further boost to the process.

All along, however, there was considerable opposition to public healthcare from vested interests like pharmaceutical companies, private hospitals and so on. In course of time deficiencies in state-run healthcare infrastructures also came to light, making them less popular than before. Finally, with the rise of neoliberalism from the late 1970s, public healthcare concerns receded more and more into the background and private medical institutions and medical insurance companies flourished as one of the most profitable business options. The drift continued over the decades, until Covid-19 happened and shoved the state once again to the forefront. We shall come to this in the next issue.

Coping with Epidemics and Pandemics

OVER the period between May 19 and June 22, Covid case count in our country has risen from 1 lakh to about 4.25 lakhs (nearly 14 thousand deaths) while the global count is nearly 9 million (nearly 4,62,000 deaths). In both cases, the numbers are rising precariously.

However, human resistance against the virus continues, and different countries, even different regions or states within the same country have their own stories to tell. Let us briefly review some of these.

How the Original Epicentre Fights the Outbreak

The first phase of China’s fight with novel Coronavirus was tainted with the scandalous and tragic episode related to a bright young doctor who selflessly served his people and was punished for that.

It was the fag end of December 2019. Dr. Li Wenliang, an ophthalmologist in the Central Hospital of Wuhan, learned from Dr. Ai Fen, director of the emergency department of the same hospital, that seven patients from a local seafood market were diagnosed with a respiratory illness resembling severe acute respiratory syndrome (SARS). He studied the matter very closely and shared the information and his views over WeChat with former classmates, asking them not to make it public. But a screenshot of this communication got leaked and went viral. Dr. Li was summoned to a police station and was pressured to sign an admission of guilt. He and the other doctors -- all frontline warriors against Covid-19 -- were reprimanded by local police officials for ‘rumor mongering and ‘disrupting social order’.

In mid-January Wenliang was diagnosed with Coronavirus infection in course of treating his patients and hospitalised. On January 28, China's Supreme People's Court issued a statement which condemned Wuhan authorities' investigations into people like Li who shared early information about the virus. "It might have been a fortunate thing for containing the new Coronavirus, if the public had listened to this 'rumor' at the time, and adopted measures such as wearing masks, strict disinfection and avoiding going to the wildlife market," the commentary said.

While undergoing treatment, Li continued to post to his Weibo account and speak out against misinformation. "I was wondering why official notices were still saying there was no human-to-human transmission, and there were no healthcare workers infected," he wrote on January 31. He breathed his last after seven days.

A tremendous outpouring of grief and public anger followed, with trending hashtags on Weibo such as "Wuhan government owes Dr. Li Wenliang an apology" and "We want freedom of speech". A group of top Chinese academics signed an open letter calling for the central government to issue an apology to Dr. Li and to protect freedom of speech. Li Wenliang was hailed in China and abroad as a heroic whistleblower, and Ai as the one who provided the whistle.

Under tremendous pressure, the Chinese Communist Party’s Central Commission for Discipline Inspection investigated the matter. Its report recognised that Dr. Li and other doctors were mistreated and placed all blame on local police officials, refusing to accept that numerous such instances of suppression of democratic rights actually flow from the government’s policy itself and that was what needed to be drastically changed. Those officials were then subjected to some sort of disciplinary action. The Wuhan police department revoked the admonishment and tendered a “solemn” apology to Li and his family members. In April, Li along with thirteen other eminent fighters against the Coronavirus was commended as martyr.

Thus ended (or did it?) the true story of Li Wenliang, a bright young doctor and a member of the Communist Party (as the Central Commission mentioned in its report) who deserved to be felicitated for his vanguard role not posthumously but when he was alive.

Meanwhile, the fight against the pandemic was picking up steam.

Owing to shortage of protective gear and lack of information about the virus, nearly 3000 healthcare workers were infected in the first few weeks of the outbreak, but the gaps were soon overcome. Identification and sequencing of the unknown virus were done pretty quickly and the genetic information passed on to the WHO. This enabled scientists around the world to immediately start developing test kits, treatment options and vaccines.

On the ground initially there was a good deal of chaos and confusion. The health infrastructure was really overwhelmed with a ceaseless -- and growing -- influx of patients. A few cases of people suffering unattended were reported. Like we have seen Haryana and UP sealing their borders with Delhi, China also witnessed scenes like Henan authorities digging up trenches to block roads connecting Hubei so as to keep contagion at bay. But the central government intervened quickly and asked the provincial governments to follow the principle of "block one, not three", that is, block the virus from spreading, but don’t block roads, traffic (especially of emergency supplies and essential goods) and internet access.

Things improved after an apex group of top officials from all ministries and led by Premier Li Keqiang was formed. It started guiding and reviewing in detail various aspects of the work on a day-to-day basis, thus ensuring good coordination and prompt implementation of policies. Thousands of military medical personnel as well as soldiers were mobilised to assist civil authorities.

liA good many stadiums and other places were converted into makeshift hospitals. In Wuhan two new hospitals -- one at Huoshenshan and the other at Leishenhan -- with 1,000 and 1300 beds respectively, were erected in about 10 days, using prefabricated units. They became functional from early February. Both are fitted with latest state-of-the-art equipment and systems such as specialized ventilation systems and depressurized rooms to prevent airborne microorganisms from spreading out of the hospital.

Hubei province and its capital Wuhan was put under lockdown from 22-23 January. The rest of the country remained partially open, but under different degrees of restrictions depending on the spread of infection. In areas under lockdown, proper arrangements were made for supplying all essential commodities to the doorsteps of residents. E-commerce giants like Taobao, Alibaba were allowed to work with stipulated precautions, so supply chains of medicines, food items etc. were not as completely shattered as in our country. And of course, there was hardly any report of man-made crisis of migrant labourers.

Like many other events, the Chinese New Year celebrations due to start from 25 January were canceled, but by that time a large number of people travelled out of Wuhan and other parts of Hubei. However, by using its expertise in AI (Artificial Intelligence) the authorities were able to trace most of these people and began monitoring their health in quarantine centres or hospitals.

Apart from AI, China extensively used other digital technologies such as big data, cloud computing, blockchain, and 5G internet. The government saw to it that private as well as state-owned companies make their algorithms publicly available, researchers share data and firms step up access to video-casting tools for educators and those working from home. For example, Alibaba Cloud made its AI computing power available to public research institutions around the world to accelerate the development of new pneumonia drugs and vaccines. The 5G+ remote consultation system was widely used to connect hospitals across the country to the best experts in Beizing , thereby further improving the efficiency of diagnosis and treatment.

After two-and-a-half months of lockdown, Wuhan and Hubei reopened, with abundant caution, on April 8. The country started limping back to a new normal with rigorous safety protocols. The government made it clear that there was no room for complacency. To guard against a possible resurgence of cases, Wuhan tested its entire 11 million population in May. Since then, some positive cases are being reported here and there, including Beizing, and authorities are taking prompt action. The key idea now is restraint, not lockdown.

In his recent book Pandemic! COVID-19 Shakes the World, Slavoj Žižek observes that China dealt assertively and successfully with the outbreak in Wuhan. But, he says referring to the Dr. Li Wenliang episode, without an open space for citizens' critical reactions to circulate, mutual trust between the people and the state is impossible to sustain. That is China's great challenge.

And that in a way sums up the Covid-19 experience of China.

A Vigorous “Trace, Test, Treat” Regime

Between January 19 and February 18, South Korea had recorded a total of 30 cases and no deaths. Within the next 10 days, there were more than 2,300 cases because the 31st patient turned out to be a super-spreader who, before her diagnosis, travelled to many crowded spots in Seoul and other cities. Hundreds of people at a church she had attended and in the surrounding areas tested positive.

A task force was created, comprising all government ministries and, crucially, all regional and city governments, too. This“joined-up strategy”yielded quick results. When one region ran out of hospital beds for example, nearby cities or provinces were asked to open up beds in their hospitals.

The moment the virus DNA pattern was confirmed in Wuhan, Korean medical teams and bio-companies were able to develop new testing kits with surprising speed. Learning from its experience of handling the outbreak of MERS (Middle East Respiratory Syndrome, which is also caused by a Coronavirus) in 2015, a vigorous regime of “trace, test, treat” was put in place. Anybody in Korea who has symptoms or reasons to be tested can get the test within minutes at a ‘drive-thru’ or ‘walk-thru’ testing centres and receive the result by text message the very next day. In all complicated cases, hospitals test the patients several times before releasing them. This strategy has yielded remarkable results in controlling the spread of the virus and mortality rate, without declaring a nationwide lockdown.

When parliamentary election was announced for April 10, many voiced concerns for infection. But elaborate safety measures including repeated disinfection of the polling booths were made and people turned out with great enthusiasm and in record numbers (66.2 per cent, the highest in 28 years) and re-elected president Moon Jae-in’s Democratic Party (DP). The latter got a clear majority on its own and a more reassuring majority with its ally Platform Party. This was in stark contrast against the last election in 2016, when turnout was low and no party got a clear majority. Naturally, the brisk voting and the comfortable victory are being attributed to Moon’s successful handling of the crisis.

A Developing Country with Few Cases and No Death

Vietnam confirmed its first Covid-19 case on January 23, declared a national emergency within seven days and swung into action. It banned entry of Chinese tourists and imposed a 14-day institutional quarantine for all foreign arrivals. To arrest the spread of the virus it relied on a few relatively low-cost solutions: swift development of its own set of testing kits which were more affordable and got CE and WHO certification; quick strategic testing (e.g., of anyone showing even feeble symptoms and her contacts) aggressive contact tracing, vigorous public communication campaigns and targeted lockdowns of hotspots rather than a undifferentiated countrywide lockdown. And it worked fine. Though it has a long border with China, Vietnam has so far reported 349 cases with zero deaths and 326 recoveries. However, some of the measures (e.g., everyone entering a hospital or government building or a big city must, apart from undergoing thermal screening, fill in a health self-declaration form stating recent contact details as well as medical and travel history; anyone refusing to do so or furnishing false information being liable to be criminally charged) have been criticized for violation of civil liberties including right to privacy.

Kerala Revisited

In our previous issue, we carried two pieces on the encouraging experience of Kerala -- one by Dr. E P Mohanan and the other by comrade Venu. Here we bring you an interesting district level story (one that Dr. Mohanan referred to, but with some more details) and an essential update.

Thus goes the story, excerpted from What the world can learn from Kerala about how to fight covid-19 by Sonia Faleiroarchive, published in MIT Technology Review, April 13, 2020.

“On March 7 it was learned that about a week ago, a family of three -- father, mother and adult son -- had arrived from Italy. They skipped a voluntary screening for covid-19 at the airport and took a cab to reach their home in the town of Ranni, Pathanamthitta district, 200 kilometers away. When they started developing symptoms soon afterward, they didn’t alert the hospital. [Later,] all three tested positive for the virus, and infected two of their elderly relatives. They were now in isolation at the district hospital but didn’t want to declare the full extent of their movements.

Under the leadership of PB Nooh, District Collector of Pathanamthitta, a large team consisting of some 50 police officers, several paramedics, and volunteers, was organised. They quickly retraced the family’s movements using GPS data mined from the family’s mobile phones and surveillance footage taken from the airport, streets, and stores.

They found that over the seven days since arriving in Kerala, the family had gone from one densely crowded place to another -- a bank, a post office, a bakery, a jewelry store, a number of hotels and even even a police station.

By March 9, Nooh’s teams had a map and a flow chart listing each place they had been, when, and for how long. The information was circulated on social media, and people were asked to dial a hotline if it was possible that they had interacted with the family. Nooh’s office was flooded with calls: the family had met with almost 300 people since arriving in town.

Now the teams had to track down all these people, gauge their symptoms, and either send them to the district hospital for testing or order them to self-isolate at home. The number of people self-isolating quickly rose to more than 1,200. Still, Nooh knew that people who agreed to self-isolate wouldn’t necessarily do it. So he set up a call center in his office, bringing in more than 60 medical students and staff from the district’s health department, whose job was to call everyone isolating, every day.

The callers ran patients through a questionnaire meant to assess their physical and mental health, but also to catch lies. If anyone was caught sneaking out, “we had the police, the revenue department, and village councils ready to act,” Nooh says. But the carrot was as important as the stick: his office also delivered groceries to those in need. The district was placed on high alert. …”

This was how the district brought the disease under control. Indeed, good macro-level policies are not enough, much depends on efficient micro-management.

Now for the update see box.

Kerala in the Second Phase of the Battle

AS of June 19, Kerala have had a total of 2,912 Covid-19 patients. While 1532 persons recovered and left hospitals, 21 patients lost their lives till date. The remaining patients are undergoing treatment in various government hospitals, while 130,655 and 1,914 persons are under home quarantine and institutional quarantine respectively.

The period from January 30 to May 3 marked the first stage of Covid-19 in Kerala, when Keralites from abroad and other states had not yet started returning to the state in large numbers. In this stage, there were just 499 patients. Only 3 persons of advanced age and with factors of co-morbidity died.

The second phase began from May 4 with the arrival of migrant Keralites. Up to June 17, as many as 84,195 persons from foreign countries and another 179,059 from other parts of India returned to Kerala. This led to spikes in both positive cases and mortality. Still, the rate of secondary transmission was brought down to 1 for 10 cases while it was 1 for 3 in the first phase. Overall, the rate of contact spread for these two phases taken together is approximately 1 for 7 (14.28%) , which is much lesser than the rate noticed elsewhere in India and many countries abroad. The data recently released by the central government also specifically mentions Kerala’s achievement in having minimized the rate of contact spread from 33% in the beginning to about 10.45% at present. This was made possible by more effective quarantining in homes and public institutions thanks to better co-ordination between local communities, volunteers and health workers. Even better results could be obtained if tests could be properly conducted for all returnees at the entry point itself.

How to deal with the huge influx of returnees is a difficult question at this moment. As per figures available with Non Resident Keralites’ Affairs (NORKA), total number of Keralites registered for returning home is a whopping 4.27 Lakhs. In this context, the Government of Kerala now insists on (a) primary anti bodies detection tests (which takes hardly half an hour) for all chartered aircraft passengers before take off and (b) carrying those tested positive and others in separate flights. This is indeed necessary because carrying 200 or more people in an air-conditioned aircraft is likely to result in a big flare up of Covid-19 even if one or two among the passengers happen to be already infected. On the other hand, if Covid -19 infected and non-infected passengers are brought in separate flights, prior arrangements can be made at the entry point for effective quarantining and hospital care as might be needed. So at this particular juncture this procedure, though perhaps rather inconvenient for some, is necessary in the broader interests of the passengers themselves and of their compatriots in India.

- By Venu with inputs from Dr E P Mohanan who is a Consultant in Kerala Health Services; also courtesy to Dr V G Pradeepkumar, former President of IMA Kerala Chapter.

Socialist Medicine: Real Life Experiences

We have just surveyed various strategies of combating Corona adopted in different countries and regions in keeping with their economic conditions, systems of governance, etc. Yet there is one common feature that invariably stands out in all countries across the world: the enormously expanded role of the state in tackling the crisis. To mention just two examples, in a drastic departure from the holy principles of neoliberalism, the Spanish government put all private hospitals and other healthcare providers under state control for an indefinite period of time and also mobilized the military in the struggle against the virus, even as UK partially re-nationalized its railways. Such measures are, however, partial and meant to be temporary. But we also have at our disposal a rich experience of the state taking full responsibility of healthcare (along with food, education and nearly everything else) for its citizens as a matter of basic policy. Why not take a look back?

November Revolution and the Rise of Socialist healthcare

The first socialist state was born in a situation of all pervasive crisis. As if the ravages wrought by Czarist Russia’s involvement in the first world war were not enough, the country had to withstand three years of civil war since 1918 . Famine and hunger, shortages of practically everything from food and medicines to fuels and other essential items, refugee and migration problems arising from wars, the high incidence of TB - - such was the backdrop when the nascent socialist state had to confront not one but a series of epidemics: typhus, cholera, the Spanish flu and localised outbreaks of smallpox. To make matters worse, elementary medical supplies such as iodine, sterile gauze, vaccines, disinfectants and even soap were in short supply. Worst of all, a large number of doctors and health workers remained engaged in the war fronts and many of them succumbed to infections while treating typhus and other contagious diseases. Last but not the least, the Bolshevik government had to function in the face of ferocious opposition from not only the bourgeoisie but also from Mensheviks and Socialist Revolutionaries.

It was against such heavy odds that the revolutionary people led by the Communist Party started building a novel healthcare system as an integral part of the socialist project. Its basic principles and features were as follows.

  1. The right to health was enshrined in the Soviet Constitution and medical services, like education, was completely free and available to all.
  2. Both preventive and curative medicine were considered necessary, but the main focus was on the former.
  3. Like almost everything else, healthcare was centrally planned and executed by the People's Commissariat of Health (the Soviet alternative for health ministry, one can say the first health ministry in the world) but was powered by enthusiastic involvement of local communities through mass organisations of youth, women, workers and others. It had specialised departments under it, the most important one being the department for protection of motherhood and infants.
  4. Mass sensitization programmes on all kinds of health issues - - from personal hygiene to food habits and lifestyles to epidemic prevention - - were conducted throughout the year by means of amateur theaters, film shows, interactive lectures, and the like. Here also, workers' clubs and other bodies played a vital role.

The health infrastructure was put in place in big cities in a few years after revolution, for other cities and towns it took some more time and spread to the vast countryside only in the late 1920s and 1930s. The problem of rural health was sought to be solved with some offbeat, imaginative measures in the second country to tread the socialist path.

From Barefoot Doctors and Traditional Medicine to Integrative Medicine

When China was liberated in 1949, it was economically far more backward than India, one of the main reasons being the deep scars left by the war of resistance against Japanese aggression and the civil war against the Kuomintang government. The healthcare system was in a shambles and almost non existent in rural areas. The underdeveloped country sought to address the problem by sort of recycling and improving whatever resources were available at hand: the so called barefoot doctors and traditional Chinese medicine or TCM.

Barefoot doctors, or traditional practitioners of Chinese herbal medicine, who came mostly from peasant or artisan backgrounds and did not have any institutional training, had long been a common site in rural China. In the 1960s a program was launched for training and regularisation of a section of them. Those to be trained were selected by corresponding villages and after training, sent back to their own villages. This helped reinforce the existing bonding between the physician and the people. The training covered both herbal and western medicine. However, Chinese herbs being more easily available and affordable, in rural areas these were more in use.

Although bereft of advanced medical knowledge or skills, the barefoot doctors helped a lot in providing primary/emergency care, treating common ailments as well as public health/epidemic prevention campaigns, etc. Thus they played a crucial role in reducing the town-country hiatus in medical services.

In the 1980s and '90s this system was abolished in course of a modernization drive that embraced all aspects of life in China. However, many of the barefoot doctors continued to serve as registered and regularised village doctors or auxiliary health workers.

TCM, including acupuncture and moxibustion, has all along been enjoying full state support, and has witnessed considerable progress and standardization. State-sponsored research in these areas has yielded quite encouraging results. For example, Professor Tu Youyou was awarded the Nobel Prize in Physiology or Medicine in 2015 for her "discoveries concerning a novel therapy against malaria". At the same time, the government is putting more money into R & D in modern medicine and related technologies. The two-pronged approach has been called the Chinese version of integrative medicine. At this moment, the Ministry of Science and Technology is funding many of the Covid-19 vaccine trials in China and the country has emerged as an acknowledged front-runner in this field.

Over the past three decades or so the medical scene in China, like everything else, has undergone drastic transformations including technology upgradation and infusion of Chinese private capital as well as foreign capital. While the public healthcare system is still predominant in terms of numbers of hospitals and patients served, private services are growing rapidly.

We don’t have the space to go into the pros and cons of all these; let us turn our attention to a small country that is valiantly struggling to hold aloft the flag of socialism in most difficult circumstances.

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The Country known for “Medical Internationalism”

Soon after the Cuban revolution of 1959, the Fidel-Che government embarked on developing a unique healthcare system by enlisting some 750 physicians and medical students for what they called the Rural Medical Service. The aim was to provide “disease prevention and revitalize health services for those most in need, whether because they are poor, in precarious health or live far from urban centres”.

Gradually a full-fledged infrastructure was developed, which is divided into three sectors or layers. The first is the neighbourhood-based consultorio. All Cuban physicians are required to work at a consultorio for one to two years after graduating from a medical school. During this time they are partnered with a nurse and together they deliver medical care in the neighborhood assigned to them. In the morning they see and treat patients in the clinic and in the afternoon they make home visits -- separately or together -- to check on patients who may need home care.

The nurse is seen as the lynchpin in this mechanism. The physician may choose to leave after completing the required residency period, but the nurse stays on, may be for the rest of her tenure or even her entire life. The basic idea behind this programme is that primary care should be provided at the community level with an emphasis on assessment, health promotion, and disease prevention by healthcare providers living and working in the same neighborhood as their patients. Thus, they would get to know the people they care for and experience the same problems and exposure to disease.

The second layer is the polyclinic which are staffed with pediatricians, and other specialists who provide necessary therapies and referrals to patients as well as training to healthworkers. Most of the polyclinics now offer services previously available only in hospitals, such as ultrasound, optometry, endoscopy, thrombolysis and so on.The polyclinics are also responsible for keeping health statistics and reporting these to the Ministry of Public Health. The third link in the health care chain consist of hospitals and specialty institutions.

It is highly deplorable that an excellent healthcare system like this has been suffering from a serious funds crunch, which negatively impacts the quality of services, largely owing to economic sanctions imposed by the US. However, Cuban medicine is still recognised as one of the best in the world. Rich Warner, an American citizen who spent seven years in Cuba as a medical student, gives an impartial and balanced account of the medical scene in this underdeveloped country (see box for excepts from his article published in The Conversation on November 30, 2016 (retrieved June 14, 2020)).

Is the Cuban healthcare system really as great as people claim?

THE Cuban healthcare system, born out of its revolutionary socialist ideology, regards accessibility to healthcare as a fundamental right of its citizens. It focuses heavily on a preventative approach to medicine and offers the simplest check-up to the most complex surgery, free of charge. Dental care, medicines and even home visits from doctors are all covered by the system.

As an American citizen, I was always impressed by how much Cubans were able to accomplish with so little. The professionalism and humility displayed by healthcare workers was without doubt commendable. It is these people who, though receiving paltry salaries (doctors earn about £52 a month), are in many instances overworked because thousands of their colleagues were sent to other countries such as Venezuela and Brazil to participate in healthcare missions.

In addition they do this without access to the latest in diagnostic technology or have to wait weeks for basic equipment to arrive at hospitals to perform procedures, even at times without electricity or running water. They still find the strength to push through all these obstacles and challenges to deliver a service worthy of praise.

…The government gains about US$8 billion annually as a result of its overseas medical missions. Sending thousands of doctors overseas, though a commendable action, leaves a domestic system under pressure. With fewer doctors and specialists at home, queues at hospitals and clinics are longer, and so are waiting times. Doctors have more work to cover in a stressful profession with limited resources. A patient may end up travelling to another province to visit a specialist because the one stationed nearest to him or her has been sent to Venezuela. This may be the reason why many more medical professionals are currently being trained across Cuba to help fill the void left by those sent around the globe.

… Some of the clinics and hospitals in operation are in dire need of repairs. …[There is] urgent need of more modern medical equipment and stable electricity and water. [A major factor behind this is] the trade embargo placed on Cuba by the US government …

The island continues to offer hundreds of scholarships annually to foreign students including those from the US. These scholarships are generally open to students from low income families who may not have been able to attend medical school because of their socioeconomic background. The Latin American School of Medicine is one of the largest medical schools in the western hemisphere with thousands of students from over 100 different countries.

The Cuban healthcare service has stood the test of time. It has afforded a foreigner like myself the opportunity to study a career free of charge while many of my colleagues are thousands of dollars in debt after attending medical schools in the US. It ensures that open heart surgery doesn’t result in lifelong indebtedness. It has created globally competitive biotechnology and pharmaceutical industries. It doesn’t turn people away because of their socioeconomic status. It is a system that has been there for its people. Yes, it has its flaws and challenges which need remedying, but it is not merely a propaganda tool for the powers that be.

Along with a unique socialist healthcare system that is centrally planned yet thrives on a deep integration with the masses, Cuba boasts a fine tradition of medical internationalism. The Latin American School of Medicine (ELAM) in Havana, operated by the Cuban government, is one of the largest medical schools in the world as well as a prominent part of Cuban healthcare system. Since 2005, ELAM has graduated tens of thousands of physicians from low-income communities. Mostly enrolled are students from outside Cuba -- mainly from Latin America and the Caribbean but also from the United States, Africa and Asia. ELAM’s motto is simple: “To provide free medical education to bright students who are passionate about becoming doctors, but lack the financial means to do so and this will drive them to return to serve in communities like their own”.

Starting from 1963, when the evolving socialist state sent a medical mission to help the Algerian war of independence, the island nation has been regularly sending best medical professionals to help other nations. In addition to countries like Venezuela (where it sent and trained medical personnel in exchange for oil) Bolivia and Nicaragua -- which have been co-fighters against US imperialism -- it has so far sent health workers to more than 90 countries.

In 2014 WHO promoted the deployment of medical personnel from Cuba to Africa to fight the Ebola epidemic. In the current war against Coronavirus Havana has sent medical personnel to Lombardy -- the wealthy but hardest-hit region in Italy -- as well as to Angola and several Caribbean states such as Suriname and West Indies. On 16 March, the cruise ship MS Braemar, with over 1,000 passengers and crew on board, was given permission to berth in Cuba after it was rejected by the Bahamas for fear of infection. In Cuba at least five passengers tested positive for novel Coronavirus. Thanks to the Cuban authorities, the patients received proper medical care and the worried passengers were able to fly back home.

Conclusion

The three public health systems we have just discussed were built up in conditions of extreme poverty, hunger, and general backwardness. The driving force, in each case, was not huge capital investment but a commitment to serve the people, the confidence that what is apparently impossible can be achieved by relying on the masses, and a bold, determined leadership. In fact today the material conditions in our country – and in many other countries - - are far more matured compared to the immediate post-revolutionary conditions in those countries for putting in place an elaborate and upgraded public health infrastructure. So why shouldn't we immediately fall for it with the same urgency with which we are now combating Covid-19?

Our experience over the past three months have laid bare the utter unwillingness and incapacity of the pampered corporate hospitals in providing large-scale life saving services. Everyone can see that it is the government hospitals, subsidiary health services and various special arrangements made by the state that, for all their shortcomings, are taking care of more than 80% of Covid cases. Given that the incidence of epidemics, pandemics and other serious maladies like cancer, TB, diabetes are sure to grow by leaps and bounds in the coming years and decades (as virologists, epidemiologists, doctors, and scientists working on environment and ecology testify) we urgently need a stable and strong public health ecosystem, committed to free quality healthcare for all and powered by a flourishing democracy with a participatory system of governance.

Yes, right to health, as part of right to life, is a fundamental right. We must have it. Now.