Public Health Ethics and COVID-19
COVID-19 disrupted health care systems and has highlighted the shortfalls in human health resources, equipment, and infrastructure.
Humanity is facing a test in the form of the COVID-19 pandemic. Nations across the world are scrambling to contain the spread and minimize the impact of the pandemic. COVID-19 has exposed many fault lines that exist in our society. The pandemic accentuated the existing vulnerabilities of the Indian economy with a devastating and differential impact on the poor and marginalized sections of the society. Migrants, people dependent on the unorganized sectors, small trade, agriculture, and allied occupations are most affected. COVID-19 is also aggravating rural distress. The social fabric of the society was also disturbed leading to fractured families. Cases of domestic violence increased across the country. Intolerance against people belonging to the north-eastern region and Muslims was reported during the early phases of the pandemic. Some were justifying caste-based exclusion arguing that “social distancing” is a traditional virtue.
The pandemic disrupted health care systems and has highlighted the inadequacies in human health resources, equipment, and infrastructure. We witnessed severe shortcomings in diagnostics testing capacity, surveillance systems, and medical care. The government-initiated measures to address these gaps through increased spending on the health care to augment vaccination, critical care infrastructure, and promote preventive health. In addition to being a pandemic, COVID-19 is also an “infodemic” of complex and dynamic information—both factual and incorrect. This has not only caused significant challenges for health care systems all over the globe but also fueled the surge of numerous rumors, hoaxes, and misinformation, regarding the etiology, outcomes, prevention, and cure of the disease. This has resulted in declining compliance with public health-related rules, and increasing skepticism regarding the interventions including vaccines, lack of public trust in public health services, harassment, and sometimes assault on the frontline health care workers and stigma.
Early COVID-19 response of the government of India was focused on preventing entry of virus from other affected countries. Subsequently, the government-initiated measures for partial lockdown followed by complete lockdown for 21 days. The government’s campaign emphasized social distancing (maintaining physical distance) to prevent community transmission. Lockdown was espoused as a bold initiative but at the same time, there were many criticisms too. WHO and many public health experts have acknowledged the impact of complete lockdown in slowing down the transmission of the virus. To mitigate the impact of complete shutdown, during the second wave the government of India did not impose a national wide lockdown and various states implemented localized and calibrated lockdowns to curb the spread of the virus.
To alleviate the impact of complete lockdown on the poor, center and state governments introduced a slew of measures. A social welfare relief package to the tune of 1.7 lakh crores to benefit the most vulnerable sections of the population was declared by the center. Some benefits that were announced included direct benefit transfer for the needy, free food grains, and pulses, etc. However, a large section of the population both rural and urban regions were left out.
To ensure robust social protection policies, it is critical that the social security measures are framed in a rights perspective that will ensure that the interventions are substantial and sustainable to mitigate the long-term impact of the pandemic.
Emphasizing ethical principles in such times of pandemics may sound idealistic. Particularly when a response has to be aggressive and decisive usually based on incomplete knowledge. However, this situation called “the public health paradox” by Prof. Gostin, a public health law expert, poses many ethical and legal challenges.
WHO suggests an ethical framework that helps in maintaining public trust, promote compliance, and minimize social disruption and economic loss during pandemics. While dealing with influenza pandemic preparedness planning and action, experts reflected on the following areas:
- Equitable access to health care
- Ethics of public health actions taken up in response to the pandemic
- Obligation of the health care workers and society’s obligation to health care workers
- Obligations of states and international organizations
- Balance individual rights and the public good
Experts distilled the following eight basic principles that should guide response to COVID-19:
- Principle of utility: act so as to produce the greatest good
- Principle of efficiency: minimize the resources needed to produce an objective or maximize the total benefit from a given level of resources
- Principle of fairness: treat like cases alike and avoid unfair discrimination
- Principle of liberty: impose the least burden on personal self-determination necessary to achieve legitimate goals
- Decision-making process that follows principles that include: Transparency, Participatory, Review and revisability, and Effectiveness in the translation of other principles into practice
Some ways to operationalize these basic ethical principles could be:
It is important to have pandemic response policies aligned to an ethical framework based on the principles of social justice, equity, utility and efficiency, liberty, reciprocity, and solidarity embedded in our social and cultural context.
Health should be a central axis for development planning. Right to health will ensure that the social determinants linked to health such as food, water, housing, and sanitation are addressed. Access to quality health care should ensure equitable and inclusive services. If the government health care system is infused with required human resources, infrastructure, drugs, amenities, and more importantly quality, it certainly will develop trust in the system and acceptability and uptake of services. Primary and preventive health care services should be bolstered by creating a public health care.
India has committed to universal health coverage as a part of achieving SGDs through Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. This program includes two major components: improvement in primary health care by investing in Health and Wellness Centers (HWCs) and National Health Protection Scheme. However, the allocation of resources for public health care has been far from desirable. Our current public health expenditure hovers around 1.3 percent of the GDP. That’s nowhere close to achieving the targeted public expenditure of 2.5 percent by 2025 under the National Health Program. Government has to increase public health spending as it is a key investment to ensure economic growth.
Central government response to any pandemic requires a cohesive action along with states in a transparent and participatory manner. While the central government is leading the response with control on various aspects, the onus is on the state governments to implement as health is a state subject. It is important to balance the central administrative authority and state responsibility in such situations. Even within the states, inter-sectoral coordination is essential to ensure a holistic outlook towards health. Co-opting private enterprises, civil society organizations and more importantly, community engagement is critical.
Community engagement to ensure people’s participation in health and to enable action on the social determinants of health has been a part of the national health mission. While there is limited evidence on the functioning and effectiveness of village health committees and Mahila Arogya Samithis, etc., the transformative potential of these community-based committees in countering the social justice issues including gender and caste-based discrimination in the community is established. In many places, where participatory processes have been facilitated by NGOs, these committees emerged as alternative social spaces that empowered women, ultimately resulting in more equitable health and developmental outcomes.
Community engagement is also an important strategy to develop an integrated approach to balance individual liberty and the public good. While public health surveillance is an important pandemic containment strategy, there is a risk that such technology and tools deployed to ensure physical distancing, contact tracing may turn intrusive, unless the extraordinary surveillance powers are “ratcheted back” after the threat of the pandemic recedes. It is important to mitigate the damage done to the social fabric through confidence-building measures promoting social solidarity.