India’s cities are just not ready for the COVID-19 fight

Dense neighbourhoods, inadequate healthcare and a plummeting informal workforce means India’s cities are just not ready for the COVID-19 fight. This blog post was written by Debolina Kundu, Tania Debnath, Biswajit Kar and Rakesh Mishra from the National Institute of Urban Affairs, India. This blog has been reposted from the SHLC website. 

India, like many other countries, is fighting the worst health emergency it has ever had to face. As the country’s 21-day lockdown gets underway it is unclear how a country of 1.3 billion people, many of whom live in informal settlements, will be able to stop the rapid spread of COVID-19. Urban density, poor health infrastructure and a loss of informal trading is exacerbating inequality in India’s cities and neighbourhoods.

Dense informality supporting a speedy spread

Social distancing measures intended to halt the spread of the disease and stop community transmission is impossibly difficult in India’s dense cities. Mumbai, Kolkata and parts of Delhi, are some of the densest cities in the world with more than 20,000 people crammed into each square kilometer. These dense built-up urban areas, especially in the lower-income neighbourhoods like slums and informal settlements, face a much higher risk of the disease spreading like wildfire.

Half of the population of Mumbai and a third of Kolkata live in slums, which coupled with 38.3% congestion factor means social distancing is near impossible in densely populated neighbourhoods. In closely-knit built-up areas community spread will be speedy. Already, it has spread to Asia’s biggest and densest slum Dharavi in Mumbai with one death and three other cases reported, which has created a panic situation as many fear it may lead to a spike in the number of affected people across the rest of the city.

With limited resources, once these high-density areas become a disease hotspot, it will be challenging to manage the outbreak to say the least, especially when social distancing is a pipe dream. All Urban Local Bodies (ULBs) should pay more attention people living in informal settlements by providing better basic services and supporting regular visit of health workers in order to monitor the situation.

A health system under immense strain
The global outbreak of COVID-19 is putting tremendous pressure on India’s, already under strain, health system. In the recent bailout budget, a mere INR. 15,000 crores (1.95 billion USD) was allocated to the health sector, a highly inadequate sum of money considering the country’s 1.3 billion population.

Initially, there was an acute problem with the availability of test kits with only 117 government-approved test centres capable of testing for the disease. But private pathological labs have now been permitted to conduct testing, which has seen sample collection points and testing soar. Cities have been able to develop Indian-made testing kits in record time, which will erase the burden of dependence on importing testing kits, a positive response we should commend.

India has approximately 70,000 intensive care beds and 40,000 ventilators. This might sound like a lot, but these numbers are disastrously inadequate (merely 0.5 beds per 1,000 people in 2017) to deal with the spiking number of COVID-19 cases. Every city is trying to designate at least one hospital to the care of COVID19 patients, like Kolkata Medical College in Kolkata and Safdarjung Hospital in Delhi, which have become a dedicated hospital for infected patients. In order to create more isolation wards, Indian Railways have dedicated 20,000 railway compartments to create 3.2 lakh isolation beds for COVID-19 patients. Local level primary health care facilities, like ‘Mohalla Clinics’ in Delhi, are also continuing to support neighbourhoods, but this has not been easy. A doctor at a Mohalla Clinic was infected by COVID19 from a patient who had recently returned from Saudi Arabia. The disease quickly spread to the doctor’s entire family. Despite these efforts, local health systems are not strictly implementing safety protocols or are unable to get the personal protection equipment (PPE) they need.

To get ahead of the disease curve, ‘Telemedical Services’ must begin now and draw on the expertise of undergraduate doctors and other non-medical health professionals to monitor COVID-19. Telemedicine professionals could help reduce the caseload through video consultation allowing them to evaluate, diagnose, and monitor patients at a distance.

Stop the spread, but lose your job
As Prime Minister Modi announced 21 days of national lockdown, huge numbers of migrants began to make their journey back home making global headlines all across the world. Not only did these migrants lose their city job overnight, being packed on to unbelievably crowded buses and trains, they were no doubt exposed to the disease during this panicked exodus home. Many migrants were stranded halfway to home, and some sadly died during the journey, but for those who do make it home from states or cities affected by COVID19, health screening at district hospitals is compulsory. Turns out, however, this screening is nothing more than a simple body temperature check and they may have inadvertently transferred the disease from the city to their rural native home.

Seasonal migrants were not the only workers to lose their job. Thousands of urban poor also have seen their incomes plummet. Although essential services remain open, the shutdown of the construction and manufacturing sector and the lack of liquid cash means many of the urban poor, like rickshaw drivers, petty traders and daily wage labourers, will see their daily income vanish. How will they be able to feed their family without a daily income to rely on?

State governments are arranging food and shelter to support informal traders and homeless communities, but these measures are simply not enough. The Chief Minister of the National Capital Territory of Delhi has opened many night shelters and 800 feeding centres for all the street dwellers and seasonal migrants and there are plans to expand the coverage of the service to feed 10-12 lakh on a daily basis.

Except for a hopeful few, thousands of migrants are left unsupported. This will lead to a critical situation where the hunger-related death toll could surpass virus-induced death. Both central and state governments should step up social protection measures such as direct cash transfers and provision of free rations to every poor household irrespective of their beneficiary status.

Stepping up the response
The COVID-19 pandemic is deepening the existing ruthless and exclusionary practices in India’s big cities, where elites  treat the poor as ‘disposable citizens’ clearly evident when we see thousands of poor migrants being stranded in the middle of nowhere, whereas the upper-class people continue to enjoy all the comforts of home.

The crisis is also raising questions about exclusionary policy measures and poorly managed nation-wide ‘lockdown’. The country’s COVID-19 response demands much more inclusive and sensitive measures to be taken by the government.

India should focus its energy on reviving its under-equipped healthcare system by setting up disease surveillance, testing, contact tracing, and building a trained task force to tackle this crisis with a focus on the poor.