'Condition of migrants has severely tested the idea that we are one country'

Four months after the arrival of the first patient from China who had tested positive for COVID-19, the country has crossed the 3-lakh mark in the total number of confirmed cases. After four phases of lockdown, the Centre announced unlock 1.0, easing restrictions even as the infections continued to spike.

Amid that, The Federal reached out to Ganesh Ramakrishnan, former deputy director for the Global Health Program at the Bill & Melinda Gates Foundation, for his brief views on the current pandemic in India. We asked him about what could be done going forward and what sort of ‘Impact Investments’ could one look forward to in the current context.

Ganesh Ramakrishnan has nearly three decades of experience across health, technology, and finance in public and private enterprise. He had a long and impactful stint with the Bill & Melinda Gates Foundation. He focused on strengthening PPP (Public Private Partnership) to address the financial needs in global health.

Currently, as a part of the Center for Global Development as a Non-Resident Fellow, he serves as the foundation’s lead to the G20 Finance Minister and G7 Health Minister summits. As someone who had head ‘Avahan’ in India, Ganesh has been at the thick of policy and execution when it comes to Infectious disease in India. Avahan was an initiative sponsored by the Bill & Melinda Gates Foundation to reduce the spread of HIV in India.

Here are the excerpts from the interview:

The Federal: Do you think India was prepared for a pandemic like COVID-19?

Ganesh Ramakrishnan: Yes and No. India took Ebola very seriously and the then Health Secretary Mr Lov Verma directed a strong national response that allowed India to effectively screen and track (from a data perspective) any potential carriers of the pathogen. This laid the foundation of a system that allowed the country to respond in an orderly and informed manner to the COVID-19 threat. The challenges here are not just scientific, but bureaucratic since it requires multiple government agencies across both national and state (each of which have distinct legal jurisdictions) to coordinate.

Additionally, some states like Kerala, which had dealt with subsequent epidemic crises like Nipah were exceptionally well positioned, showing great foresight in their approach, with comprehensive social and biomedical responses, and the ability to stay a step ahead of the disease. Whatever the weakness in the response, the fact that the government was able to make decisions and react in such a speedy manner shows that there was a foundation they could leverage. The weakness, however, was that there was a starkly different response across state governments, showing that the lessons from Ebola had not further evolved into a comprehensive national plan, with weaknesses showing up in particular on the social response side. This is somewhat inexcusable because India has dealt with multiple social crises and strong playbooks for a response do exist.

TF: When we look at data, it appears that India (currently) has not been as badly hit as some models estimated it to be, what do you think could be the reasons behind this?

GR: It is too early to say, and anything one says now is pure speculation. Certainly, factors such as the median age of the population, relatively lower prevalence of smoking, and seasonal weather patterns could be contributors. For example, part of the mortality difference between South Korea and Italy has been attributed to the fact that the Korean epidemic was largely an epidemic of young women (median age 20). with almost no smoking behaviour, while in Italy, it disproportionately affected men (with a median age of 45) in a country that has one of the highest rates of tobacco consumption. It is also true that the infection has not peaked in India and very likely that the data is incomplete.

TF: As someone who understands the Indian public health system quite well, what purpose do you think these lockdowns serve in the Indian context?

GR: Although one can find many flaws with the nature of the lockdowns and in particular the treatment of migrants, there is no question that without lockdowns, the virus would have precipitated a health crisis of international proportions and a public health issue that India would not have been able to deal with given its health infrastructure. What a lockdown serves is two things—the ability to limit the transmission of the virus by physically separating hosts (this is a common public health practice) and thus reducing its reproduction rate, so that the peak of severe cases is ideally in line with the ability of the health system to respond; and second, it buys time for the government to implement a multifaceted response—across health, economic and social lines.

TF: What sort of medium/long term sociological impacts do you foresee in India because of the COVID-19 pandemic?

GR: More than anything, I hope this forces governments to invest in public infrastructure. Basics of health and hygiene that are advocated for not only COVID but also other infectious diseases that have a far greater impact in India like TB or Cholera are impossible given the lack of access to clean water and sanitation. On a sociological basis, I suspect that this will cause a medium-term reaction from migrants who have cruelly been exposed to the lack of protections that exist for them—their condition has severely tested the idea that we are one country. I suspect many will be reluctant to return to their adopted homes. However, in the long term, economic pressures will likely cause them to do so again, unless state governments invest aggressively in their own economies. Second, I do see a potential reimagining of how we all live and conduct our lives. For a couple of decades now, we have all been sold on the need and ability to travel (whether local, national or global) to conduct businesses and rely on global supply chains. I think these might change, as people restrict their travel footprints, both from a safety but also a “cost of personal time” basis. We may see a return to more localised living with more self-sufficient neighbourhoods. This will also significantly reimagine self-sufficiency and, in turn, will likely spur investments in key sectors.

TF: I am sure you know about the case of migrants in India who have been left to fend for themselves. What do you think went wrong? What sort of policy measures would you advise going forward?

GR: For a country that has survived partition, this was particularly painful. I am not sure how or why this was overlooked. It is honestly surprising because this was not something that could not have been foreseen. In fact, India has dealt with this before. Assuming that it was NOT a complete blindspot, I can only assume this was due to two things—1. A failure on the part of the national government to agree to terms with state governments on responsibility for the migrants from an economic perspective. Causing them to “shelter in place” in their adopted homes would have placed the burden on assuming rent/food responsibility on the governments of their adopted states. 2. Not communicating clearly with migrants—which likely caused a rush to return home by a few which in turn, triggered a mass panic amongst many.

TF: What sort of impact investment opportunities exist for entrepreneurs and businesses in India in the present context?

GR: Impact investments are probably better suited than traditional investments in this context because they typically have a longer horizon and are less short term return focused than traditional growth investments. And the number so far shows little impact on the overall availability of capital in this space. The opportunities that are likely to get greater focus are those in areas such as remote education, cashless transactions and digital health. With a renewed focus from the national government on urban planning to accommodate post-COVID living, areas such as social housing could also offer opportunities.