Health Security Beyond Borders: India’s Search for Partnership in Times of Pandemic

Health Security Beyond Borders: India’s Search for Partnership in Times of Pandemic

K.M. Seethi

Global South Colloquy, 16 March 2020

The regional entity in South Asia—South Asian Association for Regional Co-operation (SAARC)—seems to have a new lease of life with the Prime Minister of India, Narendra Modi, taking an unexpected initiative to have a Conference of the leaders of the South Asian states to discuss the emerging health security issues in the world in the wake of Covid-19 pandemic and its implications for the region. For many observers, the step taken by Prime Minister Modi to have a video conference of the leaders of SAARC came as a surprise inasmuch as New Delhi has not been so comfortable with the regional entity for the last five years. In less than a few hours after Prime Minister’s announcement, most of the leaders of the SAARC countries responded positively. Pakistan also said that its State Health Minister would participate. These positive gestures made it possible to hold the video conference on 15 March. Besides Prime Minister Modi, Sri Lankan President, Gotabaya Rajapaksa, Maldivian President, Ibrahim Mohamed Solih, Nepalese Prime Minister, K P Sharma Oli, Bhutanese Premier, Lotay Tshering, Bangladeshi Prime Minister, Sheikh Hasina, Afghan President, Ashraf Ghani and Special Assistant to Pakistani Prime Minister Imran Khan on Health, Zafar Mirza, participated in the SAARC video conference (SAARC 2020).

Addressing the Conference, Prime Minister Modi said that though the region of South Asia has only listed less than 150 cases in eight countries (as of 15 March), the member states “need to remain vigilant” given that “the region is home to nearly one-fifth of all humanity” and that it “is densely populated.” He reminded that all developing countries, including the countries in South Asia “have significant challenges in terms of access to healthcare facilities.” This makes an obligation on all that “we must all prepare together, we must all act together, and we must all succeed together” (India, MEA 2020a; PMINDIA 2020a). Modi said, “Prepare, but don’t panic” has been India’s “guiding mantra.” Outlining the steps taken by India, he said that India was “careful to not underestimate the problem, but also to avoid knee-jerk reactions.” The “proactive steps” taken by India included “a graded response mechanism”—screening, travel restrictions, and deepening public awareness campaigns. India also made particular efforts to reach out to vulnerable groups, and provided training to medical personnel across the country besides augmenting diagnostic capabilities. Prime Minister Modi said that India responded to the call of the diaspora by evacuating nearly 1400 Indians from different countries. Besides, India helped some of the citizens of other South Asian countries “in accordance with our ‘neighbourhood first policy” (Ibid). He acknowledged that India “fully recognize that we are still in an unknown situation. We cannot predict with certainty how the situation will unfold despite our best efforts. You must also be facing similar concerns. This is why it would be most valuable for all of us to share our perspectives” (Ibid).

In the Conference, Prime Minister Modi proposed that a COVID-19 Emergency Fund “based on voluntary contributions” from all member states be put in place. He also announced India’s initial offer of $10 million for this fund and said that any of the member states can use the fund to meet the cost of immediate actions.” Modi requested the Foreign Secretaries of all countries, through their embassies and missions, to coordinate things to finalize the concept of this Fund and its operations. He also announced setting up “a Rapid Response Team” of doctors and specialists in India, along with testing kits and other equipment. Such mechanisms can speedily arrange online training capsules for emergency response teams—the model used in India to raise the capacity of all the emergency staff. Modi reminded that India “had set up an Integrated Disease Surveillance Portal” to instantly identify possible virus carriers and the people they contacted. India would be sharing this Surveillance software with SAARC partners, and training on using this. Existing facilities and institutions like the SAARC Disaster Management Centre and the Indian Council of Medical Research would help coordinating the exercise. He also said that regional body “should evolve common SAARC Pandemic Protocols” which could be applied on all borders as well as within borders in such situations (India, MEA 2020a; PMINDIA 2020d; PMINDIA 2020b). The Prime Minister of India said that “evolving a common strategy is critical to handling such challenges.” Saying that “our neighbourhood collaboration should be a model for the world,” he emphasized that the SAARC states must “fight this battle together,” and they will “have to win it together” (PMINDIA 2020c).

Afghan President Ashraf Ghani said that the greatest vulnerability of Afghanistan would be “an open border with Iran.” Ghani proposed modelling diffusion patterns, creation of common framework for telemedicine and greater cooperation amongst the neighbouring countries.” Maldivian President Ibrahim Mohamed Solih acknowledged New Delhi for the medical assistance from India to deal with COVID-19 cases and for evacuating Maldivians from Wuhan. He highlighted the negative impact of COVID-19 on tourism in the country and its impact on the nation’s economy. Solih also proposed closer cooperation between the health emergency agencies of the countries, formulation of economic relief package and long term recovery plan for the region. Sri Lankan President Gotabaya Rajapaksa recommended that SAARC leaders must “work together to help economy tide over the difficult period.” He also recommended establishment of a SAARC Ministerial level group to share best practises and coordinate regional matters on combating COVID-19. Bangladesh Prime Minister Sheikh Hasina thanked Prime Minister Modi for bringing 23 Bangladeshi students back from Wuhan along with Indian students during the quarantine period. Nepali Prime Minister KP Sharma Oli apprised the SAARC leaders of the steps taken by Nepal to combat COVID-19. He said that “the collective wisdom and efforts of all the SAARC nations could help in devising a robust and effective strategy to deal with the pandemic.” Bhutanese Prime Minister Doctor Lotay Tshering said the pandemic would “not follow geographical boundaries, hence it is all the more important for the nations to work together.” He said “the pandemic will affect the smaller and vulnerable economies disproportionately, talking about the economic impact of COVID-19” (PMINDIA 2020b).The general feeling at the Conference was that there should be an enhanced regional mechanism and infrastructure to ensure health security beyond borders.

In fact, SAARC has not been on the agenda of the South Block for some time for several reasons. It was in 2014 that Prime Minister Modi had last attended the SAARC summit in Nepal. Relations with Pakistan had not gone out of track at that time, and Modi had a good time with the Pakistan Prime Minister, Nawaz Sharif. However, things began to change soon. In September 2016, India decided to withdraw from the scheduled SAARC summit to be held at Islamabad, and the boycott was followed by Afghanistan, Bangladesh and Bhutan. India and the three other countries pulled out of the Summit due to the mounting “cross-border terrorist attacks.” The boycott obviously came in the wake of terror attacks at Uri which took the lives of 18 Indian soldiers. No SAARC summit has been held since then, except the traditional meeting of the SAARC foreign ministers—on the sidelines of the UN General Assembly. Even in such meetings the mood of the gathering depended on how the foreign ministers of India and Pakistan would converse and interact. For instance, in 2019, India’s Minister for External Affairs, S. Jaishankar, had categorically stated that the SAARC’s existence was contingent upon how countries in the region take “action against terrorism.” It was a reminder to Pakistan that India’s options were very clear—nothing short of “elimination of terrorism.” Since then New Delhi has been trying to diversify its regional strategies and the trans-regional entities like the Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation (BIMSTEC) were the focus of South Block diplomacy. The unusually strained relations with Pakistan—starting in 2019 after the revoking of Article 370 and the loss of statehood for Jammu and Kashmir—made the pending summit of SAARC in Islamabad impossible to be held. It was in such a background that Modi’s overtures came as a surprise step. In fact, the Covid-19 pandemic came as an opportunity to open the hearts of all even as the borders are under greater surveillance (some border points being closed to prevent the spread).

It may be noted that India has about 15,000 kilometers’ land boundary with all neighbouring countries—from Afghanistan to Myanmar. It has its three largest boundaries with Bangladesh (more than 4000 kilometers), China (more than 3,400 kilometers) and Pakistan (more than 3,300 kilometers). The other two large boundaries of India are with Nepal (about 1750 km) and Myanmar (around 1640 km). Both Myanmar and Bangladesh provide India’s land connecting points with Southeast Asia, where the pandemic had already rung an alarm in countries like Singapore, Thailand, Malaysia etc. India and the other countries in South Asia (like Pakistan, Nepal, and Bhutan) have direct territorial connectivity with China, and Wuhan, the worst-affected region in China with the outbreak, is not far off from Nepal, Bhutan, Bangladesh and the other neighbour of India, Myanmar. On the other hand, the region of Persian Gulf and West Asia, where the Covid-19 is fast spreading, is so close to Pakistan. Iran and Pakistan have direct territorial contact through the southwest of Pakistan and its province Balochistan, from where a number of cases have been reported already. India and Pakistan have the largest number of confirmed cases in South Asia, which has almost reached 250 in less than a day after the SAARC video Conference. As of now, Pakistan has about 136 confirmed cases whereas India has 114 patients tested positive (WHO 2020). Pakistan has the largest number of cases (103) in the Sindh Province alone, which has a direct boundary with the Indian state of Gujarat. Nepal, Sri Lanka and Maldives are the other vulnerable countries in the region which receive the largest number of tourists from Europe and Asia during this season. Bangladesh being surrounded by India and Myanmar too is not far off from Southeast Asia and China. Afghanistan also has 921 kilometer boundary with Iran, a major Covid-19 affected country. The Health Ministry officials in Afghanistan said that most of the positive cases in Afghanistan have come from Iran. All this underlines the significance of India’s initiative and the need to have regional health architecture for dealing with the situation.

It may be recalled that way back in 2003, following the widespread threats brought about by the emergence of the Severe Acute Respiratory Syndrome (SARS), an Emergency Meeting of SAARC Health Ministers was convened in Male in April 2003 to develop a regional strategy to deal with the deadly epidemic. The Meeting had decided to take measures to prevent and control spread of SARS in the region as well as to adopt comprehensive preventive measures, such as screening it at entry points, transfer of possible SARS patients to quarantine or isolation facilities and ensuring effective contact tracing. The Ministers adopted the Male Declaration on a Collective SAARC Response to SARS (SAARC 2012). SARS Corona Virus (SARS-CoV), first identified in the Guangdong province of southern China in 2002 had affected 26 countries (like Hong Kong, Taiwan, Singapore, and Vietnam etc) and resulted in more than 8000 cases in 2003. However, it did not affect the South Asian countries badly (WHO 2003).

The health ministers of SAARC, in their first meeting in November 2003, stressed upon the need to cooperate on health issues amongst the Member States, not only in the field of traditional system of medicine but also on the whole gamut of health issues confronting the region. They had also decided to increase the inter-country cooperation to address the problem of emerging and re-emerging diseases. The situation called for strengthening the mechanism for surveillance, reporting, diagnosis and management by exchange of expertise and sharing of infrastructural facilities amongst SAARC Member States. The meeting emphasized on the importance of developing a common regional strategy to combat HIV/AIDS, TB and other deadly communicable diseases and also recommended setting up a SAARC Surveillance Centre and a Rapid Deployment Health Response System (SAARC 2012). The second and third meetings held in Islamabad and Dhaka in 2005 also stressed the need for regional architecture in dealing with health issues. The Dhaka Declaration’s motto was “A Better Health Profile for South Asia.” The fourth meeting of SAARC Health Ministers held in Male in April 2012 recommended strengthening the SAARC mechanisms to scale up interventions for vulnerable groups. The SAARC Regional Strategy on HIV/AIDS (2006-2010) also stressed the importance of halting the spread and impact of HIV and AIDS. The regional strategy was to guide the regional response to the epidemic (SAARC 2012).

While South Asia had escaped from many spells of pandemic diseases, its closest neighbourhood, Southeast Asia, a region with enormous economic pay-offs, has been a “hotspot for emerging infectious diseases, including those with pandemic potential.” A study in Lancet says,

Emerging infectious diseases have exacted heavy public health and economic tolls. Severe acute respiratory syndrome rapidly decimated the region’s tourist industry. Influenza A H5N1 has had a profound effect on the poultry industry. The reasons why Southeast Asia is at risk from emerging infectious diseases are complex. The region is home to dynamic systems in which biological, social, ecological, and technological processes interconnect in ways that enable microbes to exploit new ecological niches. These processes include population growth and movement, urbanisation, changes in food production, agriculture and land use, water and sanitation, and the effect of health systems through generation of drug resistance (Coker et al. 2011).

For South Asia, the public health challenges are formidable, for demographic and social reasons. India, Pakistan, Bangladesh, Nepal, and Sri Lanka are home to two-thirds of the world’s population living on less than $1 a day. South Asia’s low life expectancy and high rates of malnutrition, infant mortality, and incidence of TB and HIV/AIDS are second only to those of sub-Saharan Africa. The region has been facing not only these and related health problems—poor sanitation, poor maternal health, poor access to healthcare services, and widespread malaria—but also “an emerging chronic disease epidemic.” Though “the magnitude of these interrelated challenges” was high, these five countries on an average used to spend less than 3.2 per cent of their gross domestic products on health, compared to a global average of 8.2 per cent. CSIS indicated that this marked “the world’s only region to see its health expenditures fall from 2000 to 2006” (CSIS 2010).

In July 2018, the Johns Hopkins Center for Health Security, Washington, held a meeting on global health security in South Asia. The aim of the meeting was to address the health security challenges in South Asia and to identify opportunities for implementation of health security initiatives. The Report of the meeting said that all South Asian countries “face a number of shared challenges, including populations with similar biological disease risks, health surveillance limitations, and concerns about emerging or reemerging infectious diseases.” It said that the region “is vulnerable to changes in climate and weather patterns, which increase the risk for vector-borne disease transmission.” The Report drew the attention on the World Bank estimates which said that by 2050, changes in weather patterns “will decrease living standards in Bangladesh, India, Pakistan, and Sri Lanka, adding to current societal and environmental pressures.” It also mentioned “the highest disease burdens” with the rise in typhoid fever, endemic polio transmission in Pakistan and Afghanistan, and the approximately 40 per cent of total tuberculosis cases. In addition, diseases such as Nipah, Crimean-Congo hemorrhagic fever, and chikungunya were also mentioned in the Report. A participant observed that a “health threat anywhere” could be a “health threat everywhere” and that “globalization has greatly increased the pace and severity of infectious disease outbreaks.” He said that “the 2003 SARS epidemic spread to more than 37 countries and 3 continents in only 4 months, with an economic impact of $40 billion; from 1997 to 2009, 6 major zoonotic outbreaks caused a total economic loss of over $80 billion” (Johns Hopkins Center for Health Security 2018).

The study pointed out that the major outbreaks “can have other significant economic impacts as well, including loss of workforce and loss of travel and trade, as well as an impact on supply chains that have global effects.” Another speaker said that “ecologic factors allow for rapid pathogen mutation and host adaptation, and these are often worse in areas of disorder, insecurity, and conflict.” These are, no doubt, major challenges when coupled with population movement (Ibid).

A few years back, a Brookings India study pointed out that from “the perspective of developing SAARC policies, there are several challenges that can be addressed while recognizing India’s contribution to medical services in the SAARC region. Some key areas for policy development must include a liberal visa regime, insurance and cross border payments, connectivity between countries and political relations between the SAARC countries” (Ravi 2014). The study also made a reality-check of the ground situation in health. It said,

Less than one fifth of all international tourists to India are from the SAARC countries. Yet, more than half of all foreigners who visit India for medical treatments are from SAARC countries. Together the two statistics imply that while India gains a lot more from rest of the world in the tourism sector, it gains significantly from SAARC countries in the healthcare sector. Therefore, an important opportunity for India within SAARC lies in the healthcare sector. India’s vision and policies for SAARC must build on this important opportunity (Ibid).

Though India is yet to match up with international standards of domestic healthcare, and majority of the population, especially the rural folk, “struggle for access to primary healthcare, most medical tourists come for tertiary care where India has emerged as a regional leader.” It noted that the healthcare as a sector in India has been expanding and “so is India’s reputation for medical tourism and affordable drugs.” The study underlines that with “many nationally and internationally accredited healthcare facilities, India represents quality healthcare infrastructure within the SAARC region.” Such projections come even as the World Bank data showed that every SAARC country “has less than 1:1000 doctor to population ratio which is an area of concern.” Qualified doctors in the rural areas are very few and people tend to fall prey to fake physicians and “alternative medicines.”It may be noted that India’s current health expenditure is very low ( a little more than 1 per cent of the GDP).  India’s National Health Policy, 2017  had announced that the Government is committed to increasing the health expenditure “as a percentage of GDP from the existing 1.15 per cent to 2.5 per cent by 2025 (India, MH & FW 2017: 5).

More than 50 per cent South Asian population accounts for nearly 1.17 billion lives in rural areas that often led people travelling to cities “to access secondary and tertiary care raising tough accessibility barriers” (Asian Development Bank Institute 2016). The SAARC countries are beginning to grapple with a new pandemic which has unprecedented dimensions. Though the epicenter of the Covid-19 is now shifting from China to Europe, West Asia, Southeast Asia, East Asia and North America, South Asia is also susceptible to the fast-spreading corona virus due to a host of factors—the most important of which is the role of Indians living abroad—the country having the largest diaspora in the world (more than 300 million). Their fate in the host countries and even their travel, back to India, could be problematic given the fear that the Covid-19 transmission intensity would be very high with the current pace of international travel. This is the most profound challenge that India and the other countries in South Asia will have to engage in the coming weeks and months.

References

Asian Development Bank Institute (2016): “Innovation in health care in South Asia,” by Anshul Pachouri, 9 August, https://www.asiapathways-adbi.org/2016/08/innovation-in-health-care-in-south-asia/

CSIS (2010): “Public Health in South Asia,” Centre for Strategic and Internationa Studies, 15 July, https://www.csis.org/analysis/public-health-south-asia

Coker, Richard J., Benjamin M Hunter, James W Rudge, Marco Liverani, Piya Hanvoravongchai(2011): “Emerging infectious diseases in southeast Asia: regional challenges to control, “ The Lancet, Vol 377 February 12, 2011, https://www.thelancet.com/action/showPdf?pii=S0140-6736%2810%2962004-1

India, MEA (2020a): “Prime Minister’s Opening Remarks at Video Conference of SAARC Leaders on combating COVID-19,” Ministry of External Affairs, 15 March, https://mea.gov.in/Speeches-Statements.htm?dtl/32537/Prime_Ministers_Opening_Remarks_at_Video_Conference_of_SAARC_Leaders_on_combating_COVID19

India, MEA (2020b): “PM’s Remarks on Way Forward at Video Conference of SAARC Leaders on combating COVID-19, Ministry of External Affairs, 15 March, https://mea.gov.in/Speeches-Statements.htm?dtl/32538/PMs_Remarks_on_Way_Forward_at_Video_Conference_of_SAARC_Leaders_on_combating_COVID19

India, MH & FW  (2017): National Health Policy 2017, New Delhi: Ministry of Health and Family Welfare, Government of India.

Johns Hopkins Center for Health Security (2018): Global Health Security in South Asia, Washington, DC.: JHCHS, http://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2018/180913-global-health-security-south-asia.pdf

PMINDIA (2020a): “ PM’s Opening Remarks at Video Conference of SAARC Leaders on combating COVID-19,” 15 March 15, https://www.pmindia.gov.in/en/news_updates/pms-opening-remarks-at-video-conference-of-saarc-leaders-on-combating-covid-19/?comment=disable

PMINDIA (2020b): “PM proposes set up of COVID-19 Emergency Fund for SAARC countries,” 15 March, https://www.pmindia.gov.in/en/news_updates/pm-interacts-with-saarc-leaders-to-combat-covid-19-in-the-region/?comment=disable

PMINDIA (2020c): “PM’s Concluding Remarks at Video Conference of SAARC Leaders on combating COVID-19,” 15 March, https://www.pmindia.gov.in/en/news_updates/pms-concluding-remarks-at-video-conference-of-saarc-leaders-on-combating-covid-19/?comment=disable

PMINDIA (2020d): “PM’s Remarks on Way Forward at Video Conference of SAARC Leaders on combating COVID-19,” 15 March, https://www.pmindia.gov.in/en/news_updates/pms-remarks-on-way-forward-at-video-conference-of-saarc-leaders-on-combating-covid-19/?comment=disable

Ravi, Shamika (2014): “SAARC and India’s Healthcare Opportunities,” Brookings India Briefing Book, 20 November 20, https://www.brookings.edu/research/saarc-and-indias-healthcare-opportunities/

SAARC (2012): “Health: Health and Population Activities,” http://globalsummitryproject.com.s197331.gridserver.com/archive/saarc/saarc-sec.org/areaofcooperation/detail547f.html?activity_id=11

SAARC(2020): “Press Release- The Leaders of the Member States of the South Asian Association for Regional Cooperation (SAARC) held a Video Conference on 15 March 2020 to discuss measures to contain the spread of COVID-19 in the region,” http://saarc-sec.org/news/detail_front/pres-release-the-leaders-of-the-member-states-of-the-south-asian-association-for-regional-cooperation-saarc-held-a-video-conference-on-15-march-2020-to-discuss-measures-to-contain-the-spread-of-covid-19-in-the-region

WHO (2003): “SARS (Severe Acute Respiratory Syndrome),” https://www.who.int/ith/diseases/sars/en/

WHO (2020): “Coronavirus disease (COVID-19) outbreak,” https://www.who.int/emergencies/diseases/novel-coronavirus-2019