Lockdown Diaries #6

Hi y’all! How is everything? I’ve forgotten how many weeks it’s been now, although I’ve definitely been out a little bit more in the past few weeks, with masks and gloves on. Oddly, I’ve adapted to it a little bit now, found a sort-of routine and forced myself to stick to parts of it most of the time. 

This week, I wanted to get a lot more serious than I’ve been in the past, so it’s going to get heavy, and many of you might want to disagree, but I thought it’d be pertinent to talk about this because of where we find ourselves in this moment of time. I’ve been wondering for the past two months, how is it that in 2020, more than a hundred years after the last pandemic, we’re basically not much better off than our counterparts in 1918? And how is it, that despite having a pandemic pop up once every 100 years or so since we’ve basically learned to document history, we find ourselves in a situation caused directly due to our sense of invincibility? 

The more I thought about it, the more some pieces of the puzzle fell into place. I’m not a social scientist, an epidemiologist, or even a public policy expert, but I am an avid reader, and a lot of the reading I’ve done in the past two years have revealed themselves to be enlightening in this moment of time. 

Let’s start with what we know of pandemics so far, beyond the simple fact that as long as humans have lived, pandemics have been our constant partners. There was the bubonic plague of the sixth and fourteenth centuries, the latter killed close to 200 million people by some estimates. Then there was the great London plague when Shakespeare lived, the Philadelphia Yellow Fever in the late eighteenth century, cholera epidemics and malaria in India, the Spanish Flu of 1918, and the several epidemics that wiped out large swathes of Native American populations as a result of weaker immunity and the introduction of diseases by their colonizers. 

Historically, there have been many reasons for pandemics, including poor hygiene, lack of understanding of infectious diseases and how they spread, colonization of poorer peoples, not just in the Americas but in Asia and Africa, where lives of black and brown people were treated with callousness, and epidemics were often made worse by conditions of drought, and famines. We also know, usually, the epidemics and famines are always hand in hand, and the WHO has warned us of the same this time around too. But there is one thing that has remained consistent over all of these epidemics and pandemics — the people who are the most likely to die from the disease and the famine that follows are people who are compromised by dire living conditions, have low income and a smaller safety net financially, the ones who have less power and less privilege to make it out safely. 

The irony is that over a thousand years of documented pandemic history, for those whose social conditions have improved marginally over the last millennium, time has basically stood still. The fact that this is a comparison we can make and that continues to hold true is in itself the biggest reproach to human civilization in the way we exist today. 

Many have argued with me in the past about class distinctions and how they will always exist except in utopia. Mix that with race and sexuality, we’ve got the classic race-class-gender trifecta that makes our power structures infallible, and based on what some would say, inevitable. Perhaps, they are inevitable. That doesn’t mean we can’t strive to make power structures less power structures and more structures for empowering. 

But let’s not leave it at a hypothetical argument here. Let’s actually walk into this argument with the belief that mankind has made massive progress in the past two centuries, from industrialization to urbanization, science and technology, let’s acknowledge that even the marginalized today have a slightly better chance at survival than their counterparts a hundred years ago. It’s a weak belief, but it’s a glass half full. 

Despite that progress, how is it that we’re here? 

The short answer is — by promoting self-interest over collective interest. 

Observing trends around the world, overall health expenditure has increased in high-income countries in the past 20 years. In lower income and middle-income countries expenditure used to be similar 20 years ago, but in recent years, countries in the middle-income group, like India, have decreased health spending in favor of other development. 

If we look at how much governments and public health agencies spend per capita though, the numbers start looking dismal.  In the US in 2016, private spending outweighed public health spending per capita by $172 at 51% of total health care spending; In Canada, which is a welfare state, the government expenditure per capita was 70% of total health spending. In comparison, public health spending in the UK with it’s fairly robust NHS, constituted 80% of spending per capita and that in Norway a whopping 86%. Brazil, which is an emerging economy had low overall spending on health per capita, but 55% of per capita health spending came from public agencies. In India, overall spending was the lowest among all emerging economies in absolute dollar values per capita, with the government accounting for only 30% of total spend.

What these numbers show us collectively, is that despite GDPs growing overwhelmingly in the past 30 years, what we call “growing economies”, health care spending per capita has relied in most developing and even some developed nations on an individual’s ability to spend on health. Researchers Simon Grima et al studied health care spending in Mediterranean nations within the EU, which as a whole has increased health spending in the last 6 years, and found that per capita public spending had gone down in these countries compared to the other EU nations. Consequently, out-of-pocket expenditure, or spending by private entities had gone up sharply in these countries.

Basically, of all of this is to say, when public share of funding goes down, the quality of health care you receive becomes directly proportional to the amount of money and financial security you have as an individual. It also means, without public funding on health research, it is left to private entities to fund medical research leaving the door wide open for vested interests to change the narrative to suit their interests. Just like letting Exxon fund studies on climate change will always result in climate change denial, letting Big Pharma fund medical research will lead to false PR of medication, and worse, glorify private expenditure. More importantly, core social research at the intersectionality of healthcare and class will not be funded, because that does not inform business decisions.

What it also means is that someone who works three part time jobs will likely never get quality healthcare even when they need it, but because of their socio-economic conditions are also going to be more likely to need it than those who work steady income 40-hr week jobs with employer health insurance readily available. And when to move that into a pandemic setting, where job security gets shot to hell, it basically means, all that private funding for health is lying unused because those without jobs have no access to insurance and are effectively reliant on public funding or their own funding from savings. And this is just in high-income nations. 

Translating this for medium-to-low-income nations, where absolute funding was already meagre to start with, it means many more people are vulnerable, particularly in the unorganized labor sector, which by accounts for 60% of the global economy primarily in agriculture, according to a 2018 report by the International Labor Organization. 

“In Africa, 85.8 per cent of employment is informal. The proportion is 68.2 per cent in Asia and the Pacific, 68.6 per cent in the Arab States, 40.0 per cent in the Americas and 25.1 per cent in Europe and Central Asia.
… 93 per cent of the world’s informal employment is in emerging and developing countries.”

Well, there you have it. There is not only no concept of individual health insurance for people in this sector, there is no financial or social security for these people, nor do they have decent working conditions or unions to demand their workers’ rights are protected. 

In fact, the share of informal labor in many emerging markets has either remained constant or increased, in some cases as large as in the 85 – 92% range over the last 30 years, although the distribution might have changed from the agriculture sector to organized sectors where they are employed as contractual workers. Either way, their conditions have remained largely the same. 

As an electorate, over the last 30 years, people around the world have voted less and less for basic needs like healthcare and education. We have voted more and more for jobs and “the economy”, an ephemeral term that neither you nor I can truly explain. We have been led to believe that “the economy” and development is about using more concrete, building more roads, and in the absolute terms creating more jobs. Great in theory. Until governments can’t create jobs anymore because a virus messed with plans. And then all of a sudden you realize, all these jobs that were created never came with guarantees, that employers were not borrowing in the right way, there were no checks and balances, or the hated word in business — regulations — to ensure that companies and employment entities could weather all of the costs associated with keeping employees even when production and demand were low. All of sudden, we have a situation, where private entities have done what they were always meant to do, take care of self-interest when the going gets tough, and the government has no power to embrace all of the people left in the lurch by private entities, because it and we, indirectly with our votes, have defunded and stripped the government of all its powers in the last 30 years, in the interest of free markets, free trade, better movement of goods and the temporary slosh of jobs these trade agreements create. 

Now, governments are in a bind — opening the economy is going to kill the marginalized from the disease, because they are more likely the people who work jobs where there’s human contact – construction, essential services, and all of the low-paid service industry. Keeping the economy closed is going to create a scary domino effect where rents won’t get paid, people won’t have any income for food or necessities, and will die of hunger or poverty. 

Either way, governments have twisted their panties into a nice little wedgie, because there’s no winning this one. You can manage it better, and you can manage it worse, but you’re not going to win. 

And all of it could have been avoided fairly easily, if we had collectively thought about the role governments ought to play in our lives. If we had voted for people who weren’t in the pockets of corporate interests, if we weren’t drinking the koolaid that foreign investment in emerging economies were the only form of development that mattered instead of improving maternal health and nutritional health of our populations, instead of building more accessible health care systems and robust ways of distributing food. 

And that’s how, I think, a 102 years after the Spanish Flu demolished a 100 million people, we are back to where we started. With the poor racking up the statistics on COVID-19 deaths, with economies in free fall and with governments woefully underprepared to manage this crisis in any meaningful, sustainable way. That’s a lesson we learnt, that most of us will forget as lockdowns open and vaccines come out, but it’s a lesson we would do good to remember our next election cycle. 

A stupid, unintelligent virus has brought the most intelligent species to their knees, and yet we have the arrogance to continue thinking that driverless cars, robots that can clean our rooms and rocket launchers that can detect life in space have made us invincible to every known threat in the universe. It’s time to course correct, and think about what made us the most resilient species till date to start with, and technology a’int it. Human values, empathy and our ability to derive and create new social systems is what has made us resilient. Let’s not disappoint ourselves by maintaining our belief that what we have today is perfect, perfection shouldn’t fail, and here we are failing yet again, fumbling in the dark, gasping for breath and no math models or AI can get us out of it. 

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