📰 PM asks States to suggest plan for staggered end to lockdown
‘Appoint disease surveillance officers in all districts, collate data from private labs’
•Prime Minister Narendra Modi, at his second videoconference with Chief Ministers, on Thursday told them that it was “important to formulate a common exit strategy to ensure staggered re-emergence of the population once the lockdown ends”.
•Mr. Modi emphasised that the collective goal of all should be to “save every Indian”. He asked the States to brainstorm and send suggestions for the exit strategy.
•He listed certain “must do steps” that need to be taken as the nation entered the second week of the total lockdown. “Our first priority for the next few weeks should be testing, tracing, isolating and quarantine. For this, all State to district level efforts must be coordinated,” he pointed out.
•Mr. Modi urged that district-level disease surveillance officers should be appointed as soon as possible to make sure that penetration of this strategy is optimum. Data collected from private laboratories allowed to test should be collated district-wise to be utilised for further strategising on tackling the pandemic.
•In his opening remarks, he emphasised that the supply lines for medical equipment and drugs and raw materials needed for the manufacture of these products need to be kept seamless, even more than supplies of other products.
Separate hospitals
•“Every State should ensure that there are separate hospitals for COVID-19 patients, and the doctors attending to them need to be protected. I would also urge you to step up online training of doctors in the treatment of COVID-19,” he said.
•This being the harvest season in many parts of the country, farmers and labourers, exempted from the lockdown, were engaged in harvest operations and they should maintain some physical distancing even on fields. “As for procurement, we must find ways to do it beyond the route of Agricultural Produce Marketing Committees (APMC). A truck pooling scheme should also be worked out with farmers for ferrying produce to the market. Harvesting will possibly need to be done in a staggered manner,” he is reported to have said.
•The Centre would release Rs. 11,000 crore from the State Disaster Relief Fund by this month, and it should be used for efforts to fight the COVID-19 pandemic.
•Iran said on Thursday it “only acts in self-defence” after President Donald Trump warned it against attacks on U.S. troops in Iraq, as a new war of words heated up despite the pandemic.
•Tensions between the arch-foes flared in Iraq where the U.S. deployed Patriot air defence missiles, prompting Iran to demand a withdrawal.
•Foreign Minister Mohammad Javad Zarif tweeted that “unlike the U.S. —which surreptitiously lies, cheats & assassinates — Iran only acts in self-defence”.
•“Don’t be misled by usual warmongers, AGAIN,” he said, addressing Mr. Trump.
•“Iran starts no wars but teaches lessons to those who do,” he added.
•Mr. Trump warned Iran on Wednesday that it would pay a “heavy price” in the event of further attacks on U.S. troops. He tweeted that “upon information and belief, Iran or its proxies are planning a sneak attack on U.S. troops and/or assets in Iraq”.
•In response, Mr. Zarif tweeted that “Iran has FRIENDS: No one can have MILLIONS of ‘proxies’”
📰 Quarantine and the law
Courts have the power to review movement curbs during disease outbreaks, but have upheld them in public interest
•It was about 196 years ago (1824) that the U.S. Supreme Court, in an en banc sitting led by Chief Justice John Marshall, affirmed the powers of the state to enact quarantine laws and impose health regulations. The world has since faced many health emergencies caused by dangerous diseases. This virus crisis is also not new.
•Quarantine is considered the oldest mechanism to reduce the rapid spread of bacterial infections and viral onslaughts. It has been legally sanctioned by all jurisdictions in the world for the maintenance of public health and to control the transmission of diseases. Since ancient times, societies have practised isolation, and imposed a ban on travel or transport and resorted to maritime quarantine of persons.
•These measures were often forcibly enforced to prevent or reduce the wider spread of disease and to safeguard the health of citizens not yet exposed to such diseases. In the list of diseases that may require quarantine, issued by the Centers for Disease Control and Prevention, the Severe Acute Respiratory Syndrome that can go on to become pandemic has been recently added to the existing ones — cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever and viral hemorrhagic fever. It shows that quarantine is a medically accepted mode to reduce community transmission. However, a constructive alternative method of treating patients exposed to infectious diseases is the imperative need in the arena of public health.
‘Trentino’ to quarantine
•The first law on medical isolation was passed by the Great Council in 1377, when the plague was rapidly ruining European countries. Detention for medical reasons was justified and disobedience made a punishable offence. The law prescribed isolation for 30 days, called a ‘ trentino ’. Subsequently, many countries adopted similar laws to protect the people. When the duration of isolation was enhanced to 40 days, the name also changed to ‘quarantine’ by adopting the Latin quadraginta , which referred to a 40-day detention placed on ships.
•In common parlance, ‘quarantine’ and ‘isolation’ are used interchangeably, but they convey two different meanings and are two different mechanisms in public health practice. Quarantine is imposed to separate and restrict the movement of persons, who may have been exposed to infectious disease, but not yet known to be ill. But, isolation is a complete separation from others of a person known or reasonably believed to be infected with communicable diseases.
•The current COVID-19 crisis, with its closure of shops, academic institutions and postponement of public examinations, has put the people in a de facto quarantine. Nonetheless, the question whether a public authority or state can promulgate an order for quarantine is a legal issue.
•When an employee of the World Wildlife Federation was diagnosed with Human Immunodeficiency Virus (HIV) in 1990, he was terminated from service and detained for 64 days in quarantine-like isolation under Goa Public Health (Amendment) Act, 1957 (GPH). The Bombay High Court (1990) felt that solitary detention was a serious infringement of basic human rights guaranteed to the individual, but held that under unusual situations and exceptional exigencies, such isolated detentions are justifiable for the cause of public health. Such isolation, undoubtedly, has several serious consequences. It is an invasion upon the liberty of a person. It can affect a person very adversely in many matters, including economic condition.
•But in matters involving a threat to the health of the community, individual rights have to be balanced with public interest. In fact, individual liberty and public health are not opposed to each other but are well in accord. The reason assigned by the High Court to uphold the quarantine was that even if there was a conflict between the right of an individual and public interest, the former must yield to the latter.
•In 2014, Kaci Hickox, a nurse and health worker who voluntarily rendered service to Ebola patients and returned to New Jersey, was quarantined in the U.S.. It was opposed by her peers serving in public health. But the dreadful consequences of the disease, and the possibility of its spreading at an alarming rate, made the forcible isolation rational and reasonable.
•In India, the Epidemic Diseases Act, 1897, a law of colonial vintage, empowers the state to take special measures, including inspection of passengers, segregation of people and other special steps for the better prevention of the spread of dangerous diseases. It was amended in 1956 to confer powers upon the Central government to prescribe regulations or impose restrictions in the whole or any parts of India to control and prevent the outbreak of hazardous diseases. Quarantine is not an alien concept or strange action and it has been invoked several times during the bizarre situations caused by the cholera, smallpox, plague and other diseases in India.
Judicial review
•The Director of World Health Organization (WHO) on March 30 determined that the outbreak of COVID-19 constitutes a public health emergency of international concern and issued interim guidance for quarantines of individuals. The guidance permitted the restriction of activities by separation of persons who are not ill, but who may have been exposed to an infectious disease within the legal framework of the International Health Regulations (2005). It also distinguished quarantine from isolation, which is the separation of ill or infected persons from others, so as to prevent this spread of infection or contamination. As per the WHO guidelines, possible quarantine settings are: hotels or dormitories and well-ventilated single rooms or homes, where a distance of at least one metre can be maintained from other members.
•The Centers for Disease Control and Prevention, U.S., in its order on quarantine, expressly made it clear (Rule 9) that the people whose right is affected by an order of quarantine by a public health authority have the right to seek judicial review including the right to habeas corpus. Previously, it was in 1900, in response to an outbreak of bubonic plague, that an order of quarantine imposed on a Chinese citizen was struck down by the Federal Court in the U.S. because it was racially motivated and ill-suited to stop the outbreak. Therefore, courts have exercised their jurisdiction and powers to review and reverse quarantine orders.
•The Supreme Court suo motu took cognisance of fears over the COVID-19 pandemic affecting overcrowded prisons in India, on March 16. The difficulties in observing social distancing among prison inmates, where the occupancy rate is at 117.6%, were highlighted and directions issued to prevent the spread of COVID-19 in prisons in India.
•The setting up of isolation cells within prisons across Kerala, and the decision of the Tihar Jail authorities to screen new inmates and put them in different wards for three days are appreciated as reasonable preventive measures. Further, notices were issued to all States to deal with the present health crisis in prisons and juvenile observation homes.
•Quarantine rooms may have strong closed doors or may be water and air tight compartments, but the rays of justice from the courtrooms have the powers to intrude in them. Of course, under the sun every object is subject to judicial review and quarantine orders are not exempted from it.
📰 Making the private sector care for public health
India needs a national policy providing for free testing and treatment of COVID-19 patients in private hospitals
•As India enters the second week of a national lockdown imposed in response to COVID-19, it is still unclear how well prepared the healthcare system is in dealing with the pandemic. Given the resource constraints of both the Central and State governments, it is clear that government hospitals alone will not be able to manage the fallout. Moreover, even within the government system, tertiary care and public health are the weakest links.
•A preparedness plan has to address all levels of care in terms of infrastructure, equipment, testing facilities and human resources in both the public and private sectors. However, so far, the Central and State governments have given little indication of bringing an increase in public expenditure on health. So, an already overburdened public health system will be unable to meet the increase in moderate and severe cases of COVID-19 that would require hospitalisation. While some individual private sector companies have come forward with offers of creating capacity and making it available to COVID-19 patients, there is a need for a comprehensive national policy to ensure that private healthcare capacity is made available to the public. Some States like Chhattisgarh, Rajasthan, Madhya Pradesh and Andhra Pradesh have already roped in the private sector to provide free treatment.
The government’s silence
•The governments at the Centre and in States have to take responsibility for providing universal health services free of charge and accessible to all. This will require governments to not just expand the capacity within the public sector, but also to tap into the available capacity in the private sector. Faced with a serious health emergency, the silence of the government on the expected role of the private sector is intriguing.
•The National Health Authority has recommended that the testing and treatment of COVID-19 be included in the PM-Jan Arogya Yojana (PM-JAY) but this proposal is still awaiting clearance. The governance of the health service system is clearly fragmented and has created anxiety among the public. There is lack of a visible central command, which should be created under the supervision of the Union Health Minister, aided by a team of experts. They should be tasked to make policies as and when required and communicate them to State governments, taking into account an evolving situation.
•There have been some tentative measures taken by States to allow individuals seeking testing for COVID-19 to access private laboratories at subsidised rates. At present, the government has put a cap on the cost at ₹4,500 per test, which is a burden for even a middle class patient. The poor will clearly have no access to this and the government itself does not have adequate facilities to meet the increasing demand. It is here that the government needs to ensure that there is no cost to the patient.
•At this point, and certainly before the lockdown is lifted, it is absolutely essential that adequate testing and quarantine facilities are created. The Central government has already taken over some private hotels to accommodate persons quarantined for COVID-19. One way of expanding such facilities would be for the government to ‘take over’ private corporate laboratories and hospitals for a limited period. A graduated approach to this is possible by asking tertiary private hospitals to create ICU facilities and isolation wards to care for the moderate and severe cases under the supervision of the government. The political directive for such a move needs to come from the Central government while ensuring that the Ministry of Health provides standard treatment protocols for health personnel.
The Spanish parallel
•This may not be as impossible as it sounds. Consider the experience in Spain. The Spanish government issued an order bringing hospitals in the large private corporate sector under public control for a limited period. This tough decision was taken with the understanding that existing public healthcare facilities would not be able to cope with the sudden, if short-term, rise in COVID-19 cases.
•In Britain, given the rise in the number of COVID-19 cases, the health workforce in the National Health Service has been under a lot of pressure. British trade unions have demanded that the government make the 8,000 beds in 570 private hospitals in the country available. They have argued that while beds in private hospitals are lying empty, there is severe shortage of beds in the public hospitals. The unions have also been critical of the U.K. government decision to rent these beds at an exorbitant cost to the exchequer.
•In India, private corporate hospitals have, in the past, received government subsidies in various forms and it is now time to seek repayment from them. They are also well poised to provide specialised care and have the expertise and infrastructure to do so. So, why is it that the government does not deem it fit to bring them under public control? Does less government mean no accountability even amidst this humanitarian crisis? Is it that the overburdened public health service should be made to care for the rising number of needy patients, while most private hospitals remain reserved only those who can afford to pay?
•The government may argue that treatment for COVID-19 has been included under Ayushman Bharat, and this will take care of the poor. But, what about the large, differentiated middle class, many of whom are employees in the services sector? They do not have secure employment, nor do they have insurance cover. Crisis situations help reveal deeper realities to societies. Universal public healthcare is essential not only to curb outbreaks, but also to ensure crisis preparedness and the realisation of the promise of right to health.
