As part of The Third Eye’s Public Health edition, we spoke with a wide spectrum of experts, community leaders and practitioners — what works, why it does, and what an equitable public health system could look like.
Clifton D’Rozario is a practising advocate with Manthan Law, Bengaluru. He is the National Secretary, All India Central Council of Trade Unions (AICCTU), and the State Secretary CPI (ML) Liberation, Karnataka. D’Rozario works with a wide range of stakeholders in public health from safai karamcharis in Karnataka to rural labour unions and food security activists. Here, D’Rozario talks about how the struggle for equality should be paramount in policy creation, whether for education, food security or public health.
Can we talk about the Right to Food campaign and the issue of food security as part of public health?
The Right to Food campaign is the basic acknowledgement of the malnutrition and hunger that exist in India. It made the courts take cognizance of continuing hunger. I have my differences with that [symptomatic relief] approach: the Right to Food Campaign, I mean, because the courts are never going to address the reasons for chronic poverty. You get the national food security scheme or meals arranged through anganwadis but none of that is enough.
You have to address the reason why I don’t have food on my plate today. It’s not because I am lazy. It’s because I have no work. Or I have work and I work so hard but I don’t get paid commensurate with the work. I don’t have job or social security. If I fall ill, I have to pay through my nose.
What did the events of the last year reveal about our food security policy?
When you put the entire country into a lockdown with a four-hour notice, what does that even mean? You can’t say you don’t know. You just don’t care that the majority of the country will not have food to eat the next day. Then it took more than 10 days for the government to come up with the Pradhan Mantri Garib Kalyan Anna Yojana. Five kgs of rice and two kg of chana for two months. That policy decision was so disrespectful and lacked an understanding of ground realities. When you took away their right to earn, they did not have cash in hand. They had no cooking gas. They could not buy oil or masalas. These are things that people buy on a weekly basis. Anyone who has lived in a daily wage household would know this. By giving just rice and chana, you think you are doing something great.
Cut to this year. Take Karnataka. We are almost now three weeks into the lockdown. When the lockdown was declared, the state government had absolutely no policy for meeting food security needs. Instead, what it has said now is that Indira Canteen food packages will be will be distributed to the poor three times a day. And in rural areas, gram panchayats will distribute food packets to those who need it. You expect the working class to stand in queues every single day, three times a day. From a policy point of view what has the state government learned from last year? Zilch.
When I was recently arguing the matter in Karnataka High Court [concerning the management of the Covid-19 pandemic in the state], I said you can't make people stand in the queue every day for a meal. It's disrespectful of people; you are undermining their dignity. You have brought down the lockdown on these people who work hard every single day. You have taken away this ability from them and now you expect them to stand in a damn queue every single day to beg for food.
Or look at the right to shelter. People don’t have money to pay their rent. Last year the central government issued an advisory that landlords should not receive rent for the lockdown period or take a delayed payment. That of course was not implemented. This year there wasn’t even that facade. Lockdowns have been declared in state after state and there is no protection of right to shelter. Already you’re hearing stories of people who are being threatened with eviction.
Or look at loans. Forget about banks. Let’s look at self-help groups. Last year, from our party, we ran this very big karza maafi campaign after the lockdown. We were specifically targeting the microfinance institutions, because [the terms] are insane. You take a loan from a self-help group, if you don’t even pay one instalment, ten women will land up outside your house to ask you what the hell is happening, you better pay right now. Basically this maana-maryade [status and honour] thing that’s what they play on. Look at the cumulative impact from last year’s lockdown. Look at the Centre for Monitoring Indian Economy (CMIE) report and you see the massive the job loss, rising unemployment rate, dipping wages. But there is no protection of the working class from loan sharks or from a microfinance institution, nothing. It’s very difficult to find any kind of policy statements or scientific thinking.
Your position is that it’s not possible to fix public health even in the short term without looking at food security, shelter, financial exposure and other factors. When you were arguing in High Court recently what were your recommendations to the Karnataka government?
What we have suggested to the state was cash assistance to be given to families to help them get through these times. We recommended free rations by which we mean free ration kits — you know, rice, dal, masala, cooking oil, cooking gas, whatever fuel that they’re using, all of those things.
We asked that an order be passed under the Disaster Management Act, prohibiting the eviction of any people from their houses for non-payment of rent. We asked for a waiver of all electricity and water bills and a moratorium on all loans on the repayment of any loans to microfinance institutions, private lenders, and of course, nationalised banks.
We also asked that under the National Food Security Act, via the anganwadis, the government meet the nutritional needs of children below the age of six, pregnant women, lactating mothers, and adolescent girls [and these] should be delivered to their doorstep. And also midday meals for school going children. You might ask why do we need to recommend it, isn’t it a statutory order? But they didn’t do it last year. Midday meals were not given in Karnataka to school going children because the schools were closed. The order was that they would give the children equivalent grain, which they can cook in their houses. Our government didn’t do [this] for several months. So we had to move the court to make that happen.
If you think about public health as a larger concept, beyond where we are currently in the pandemic, has there ever been an attempt to make it a reality and think it through in terms of policy?
[If you look at the pandemic] the Kerala model, of course, is a decent one. Their numbers are very, very high, but the deaths are very low. That indicates that at least access to health is being taken care of over there. I’ve not heard a single report of somebody dying because they didn’t have oxygen or didn’t have a bed. The moment they declared a lockdown, they declared a food pack ration kit package for every household. That’s a very respectful way of treating people. There are some indicators of an urban model in Mumbai’s triage system. Those are elements that seemed to have worked right now.
Given the way Covid is spreading to the rural areas, if Uttar Pradesh is anything to go by, there are dire consequences of being not prepared. Every single gram panchayat must have a Covid centre. You cannot expect people to self-quarantine in their houses, given the poverty and very small houses. To ensure quarantine can take place, to ensure that testing can take place, villages must have Covid centres, and at least basic supply of oxygen and medicines. In case of an escalation, people in a village know they can go to the Covid centre and there will be one doctor, ASHA workers and ANM workers who can ensure that this person is taken to a hospital. That’s the most basic thing that needs to be done.
Have any important public health debates shifted from the background to the foreground because of the pandemic?
Given the crisis mode most people are in and that we cannot have agitations at this point, these debates have not become a public discourse. And knowing the middle class, they could well go back to where they were. Right now, they are more than happy going to their private hospitals and trying to get vaccinated.
Still, there is definitely an attempt to talk about the amount of money that is spent on public health infrastructure. If you look at the state of the public health institutions, it’s not the same across the country. In some states [they’re] better and in some places they are absolutely crumbling. Without a doubt [the system] needs an upgrade.
Two, the manner in which oxygen supply and when drugs like Tocilizumab and Remdesivir have been totally centralised. The central government now decides which state gets how much. Even in the case of vaccination, everything is decided by the central government which has basically made a for-profit model. In a federal structure like ours, that is worrisome. The pandemic has only revealed the assault on federalism, the rights of state governments to take decisions. The demarcation of responsibilities and duties has become very muddled. That is something that will have to be sorted out as quickly as possible.
The third thing is our understanding of who works in public health. ASHA workers and sanitation workers are part and parcel of the public health system. Sanitation workers are called frontline workers. ASHA workers are called healthcare workers. They're the forefront of this battle against this pandemic, but look at their condition.
Sanitation workers across the country are contract workers, don’t get paid minimum wages and are already working in a very exploitative system. Then the pandemic happens. The garbage that comes from a household where there is a corona-positive person has to be treated differently from other garbage otherwise Covid is going to spread again. Sanitation workers are denied even access to basic protection. They collect with their bare hands, exposing themselves to this pandemic. The number of deaths of sanitation workers is [among other things] because of the lack of basic safety equipment.
And here it is not just a class question, it is also a question of caste and gender. It’s about how seriously the government is concerned about sanitation workers or ASHA workers. Also in hospitals. The majority of nurses are on precarious contracts. As is the Group D staff who are predominantly women; ward boys, lift operators, sweepers, toilet cleaners, gardeners — they are all on contract. Again, they are in the same oppressive working conditions and at the forefront of fighting this pandemic. They are still treated so disrespectfully without any care for their lives. That’s another very serious concern that one hopes is rectified soon.
What would you say are the changes we need to lay a foundation for public health, which are not so obvious when we think about health only in terms of hospitals and drugs?
One, living wages would ensure better public health. We still live in a time where we're talking about minimum wage, which is nothing but starvation wages -- Rs 10,000, Rs 8,000. The Constitution actually talks about living wages. In our estimate, even a minimum wage at this point at this point will be around Rs 25,000. A living wage would be way above that.
Second, this entire very calculated contractualisation and informalisation of workforce that has taken place over the last 30 years now. If that could be undone, all the wages would automatically go up and they’d enjoy some notion of job and social security, some economic security. If a person is guaranteed a life where you didn’t have to worry about shelter, a public distribution system where you didn’t have to worry about food… For me the idea of ensuring equality in all realms, you know, that’s very fundamental. Many people cannot work for any number of reasons. A monthly guaranteed kind of income for every household ensures that they can live as human beings.
As far as the health system is concerned, I’d say it’s about nationalising the hospitals, especially in times like this. Like Spain did in 2020. If you’re not going to do it, under the Disaster Management Act the government has the power to take over necessary resources. They can say that given the kind of situation we are in, every single health establishment is going to be under the government till we get through this crisis.
Do you feel like massive decentralisation of healthcare, policy and decision-making would help us, if not nationalisation?
I imagine it would but again, it depends where it happens. If it’s going to happen under this particular system [of governance], it’s not going to work. Kerala, to some extent, has a very strong decentralised kind of a governance structure. The panchayats over there are not just rubber stamps. They actually take most of the big decisions from planning onwards. Decentralisation is necessary but there has to be financial stabilisation alongside. You cannot expect a village in a poorer region like north Karnataka, say to them okay now, these three villages, you guys do whatever, everything is in your hands. You have to ensure there is financial stability, they have access to resources to ensure decent living for all of its residents.
The fundamental question here then is how does one address these structural inequalities and the structural hierarchy that exists in our society. That is something that is not going to go away with the one policy decision.
Look at the education system, right? You are basically breeding an unequal race over there. A public health system cannot become egalitarian without a sense of egalitarianism in society.
