For three months during the national lockdown and the Unlock 1.0 phase, a torrent of confusing and bewildering orders from the Union home ministry, instructing citizens on every aspect of their daily lives, was the primary mode of Covid-19-related communication between the government and the people. As the lockdown lifted and cases surged, it became clear that the “orders” did little to achieve their goal of disease containment. But they have served to entrench a policy approach that privileges coercion and compliance as an instrument to manage Covid-19.
The State will “order” you, discipline you (lockdowns have been enforced with the visible use of the stick) and survey you (using technology aids) to control Covid-19. Yet, as any public health expert will tell you, globally, public participation is the critical ingredient that makes health interventions successful. This requires a relationship of trust between citizens and the State. And trust is the one missing link in India’s current practices of Covid-19 management.
Historically, the relationship between the State and citizens and ironically, that within the hierarchy of the bureaucracy, has been mired in distrust. In responding to Covid-19, this distrust has become sharper in three distinct ways, shaping bureaucratic communication, the relief response and the health response.
First, bureaucratic communication, through endless orders laced in legalese. Ethnography has traced the bureaucratic penchant for orders to a culture of distrust rooted in the dynamics of colonial rule. In my research on the local bureaucracy in India, I have witnessed first-hand the deep control of the “government order” on the everyday functioning of the bureaucracy. Compliance with orders is the primary instrument through which superiors monitor their subordinates. And in turn, it is the orders and associated penalties for non-compliance that drive performance on the ground. Faced with the challenge of Covid-19, the bureaucracy relied on the one instrument it was familiar with — the orders, except this time it became their default mode of communicating with the public, leaving in its wake confusion and fear.
Second, the relief response. Historically, distrust has also shaped the dynamic of myriad everyday interactions between bureaucrats and citizens. Access to bureaucratic paper — ration card, voter identification — is the key to determining whether citizens are eligible for benefits. And, the onus is on citizens to furnish these documents and prove their eligibility. The absence of such documents is an important reason why the bureaucracy found itself unable to provide foodgrains to migrant workers at the peak of the lockdown, requiring them to apply for e-passes and other paperwork, even though giving grains to anyone who asked for them, was what was so urgently needed. In the eyes of the citizen, the State’s failure to respond to their needs has only widened the trust deficit.
Third, the health response. Here, the trust deficit poses an even greater challenge. In the public health response, the urgency of citizen participation is amplified because of the many uncertainties about the disease, its spread and appropriate medical responses. Participation is critical to ensure symptoms are reported to enable early detection and speedy provision of medical care. It is also essential to ensure long-term behaviour shifts (think: masks and social distancing). As health economist, Jishnu Das, argued in a recent interview, the public health response for Covid-19 needs the government to get people (and governments) to act together. The State has failed to do this for most infectious diseases but Covid-19 presents unique challenges in two ways.
One, stigma and fear have spread far and wide. Newspapers have daily reports of Covid-19 patients being shunned by communities they live in and even by health workers, who in turn are victims of stigma. Indian politics has only exacerbated this. The blaming of one community in the Tablighi Jamaat incident set the stage for a discourse on Covid-19 that blames patients rather than emphasises the provision of care.
Two, India’s failed health system which has long broken any semblance of trust that citizens may have with its ability to provide affordable and quality care. Ironically, it is the informal private market that most of India relies upon. Yet, when it comes to Covid-19, from testing to the provision of care, it is the government that is now in charge. This is necessary. Infectious diseases have large externalities (and costs on the poor), which require governmental intervention. But the lack of trust in the government risks driving the epidemic underground as people may not be willing to enter the government system. This is evidenced by the fact that in cities such as Delhi, one decision that changed the game was a shift in strategy from government to home isolation for quarantine and mild cases.
The answer to this challenge does not lie in getting the government out of the way. It simply can’t exit. Rather, the focus needs to shift to building trust in the public health system. The repeated use of orders and coercion to change behaviour, combined with the continued lack of transparency in data and decision-making at the national and state level (why for instance, has West Bengal chose to undergo a two-day-a-week lockdown while Bihar is in a month-long lockdown?) are significant barriers to building trust. This needs to change.
At the same time, proactive efforts need to be made to reach out credibly to communities. Where the government did this, in Dharavi for instance, it has been effective. But these successes need to be understood in the context of the enormity of this trust deficit. Only after governments and public health experts acknowledge this can we shift gear in the direction of a long-term sustainable, community-led approach that will allow India to live with Covid-19 well and successfully.
Yamini Aiyar is president and chief executive, Centre for Policy Research
The views expressed are personal