The Case of India

A Moral Foundation for the Impact of COVID-19 on Health and Society in the World's Largest Democracy

in The International Journal of Social Quality
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Abstract

A segmented healthcare system evolved in India by 1990s, whereby the rich population depended on private hospitals while the people at the bottom of the economic pyramid went to the poor-quality public hospitals. In a democracy of equals, unequal access to services became political when COVID-19 began to put pressure on the health system. Corruption that was normalized in a segmented healthcare system could no longer be ignored. To advance the framework of social quality, we examine the corruption that unfolded during the pandemic in India from the perspective of moral foundation theory. We study the issues raised by political parties during the pandemic and court directives responding to citizen grievances. The evidence shows there was inequality of access and that courts had to intervene to try to rectify the situation. In the absence of effective governmental intervention during the pandemic, moral norms become a useful explanatory factor for social quality.

Literature on the quality of government (QoG) has shown that democratic variables are outperformed by QoG variables (Rothstein 2011) when people's well-being is the consideration. Examination of the ability of the largest democracy in the world—India—to deal with COVID-19 is a restatement of this claim. An excess desire for profit, when the majority of the population was in a health crisis, could not be dealt with merely by recourse to the legal definition of corruption. In this article, we attempt to develop a framework, using the case of Indian society and the COVID-19 virus, for marrying QoG with the social quality approach (SQA).

We find that the impartiality principle advanced in the QoG approach is insufficient to capture the complex dimensions of social quality theory (SQT) (IASQ 2019). In this article, we bring together two schools of academic literature to advance the QoG approach to social quality. First, we take the revision of Rawlsian theory of justice by Paul Ricoeur (1994). Critiquing the contractarian approach of John Rawls (1971), Ricoeur goes beyond institutional quality and places primacy on the ethical desire to meet the criteria of the good. Second, we bring Jonathan Haidt's (2013) concept of moral foundations theory (MFT). The six pillars of MFT, as proposed by Haidt, are the principles of (1) authority/subversion; (2) care/harm; (3) fairness/cheating; (4) liberty/oppression; loyalty/betrayal; (5) sanctity/degradation; and (6) loyalty/betrayal. The development of each of these principles in human behavior was due to a survival trigger in the evolutionary process. For example, the attachment requirement cemented the care/harm principle. Today, each of these principles is triggered, not necessarily by original trigger in human evolutionary history, but by people's societal circumstances. We find that the societal impact of COVID-19 provides a useful case in which to study the triggers of the principles of MFT. How different state governments in India responded to the pandemic has shaped these triggers, allowing us to study the connection between QoG and SQT.

MFT as elaborated by Haidt (2013) aligns with David Hume's view of human nature as less deducible by reasoning. Rejecting Benthamite utilitarianism and Kantian deontology, it leans toward Aristotelian eudemonia. This is where MFT overlaps with the social quality framework. However, unlike Haidt, who treats the criteria of MFT as descriptive (2013: 315–316), we find that these elements are closely linked to the normative factors of SQT, namely social justice, solidarity, human equality, and human dignity. We will use these two frameworks—namely, QoG/MFT and SQT—in a complementary manner to understand corruption in the Indian healthcare beyond legal definitions and notions of accountability. We apply these two ideas to the handling of the COVID-19 crisis in some of India's different regional states.

Two intertwined research questions are at the heart of this article. The first is: how far do the QoG approach and the SQA converge or diverge? We find that the QoG approach's value lies in its statist lens, while the SQA's value lies in its societal perspective. The second question is: what factors of MFT support the SQT approach? These two questions are intertwined because the issue of political emotions raised through MFT mediates between QoG and SQT. We will look at this mediation by looking at how the COVID-19 pandemic triggered the six above-mentioned MFT principles.

As explained above, we are assessing the societal impact in a segmented healthcare system. Therefore, the chances of our being able to find a consensus in the states’ policy choices are low. It is here that Ricoeur's (1994, 2000) framework to understand justice in a context of conflict (compared to the Rawlsian consensus model) becomes useful.

The remainder of this article is organized into four sections. The first section provides an overview on how COVID-19 unfolded in India in two waves until August 2021. In this section, we show the differential impact of the first wave and the second wave on society. While the governmental measures taken in the first wave led to an economic disaster, the lack of governmental measures in the second wave caused a health disaster. Focusing on the objective of the article, in the second section we give a historical background to health inequality in India through showing how the country's segmented healthcare system came about. As health is a regional state prerogative within India's constitutional framework, here we elaborate how a few such states in India understand their local health systems. In the third section, we explain in more detail the method that we adopt in this article. And in the fourth section, we examine the relationship between MFT principles and SQT normative factors as triggered by the COVID-19 pandemic. From the point view of QoG, the normalization of corruption1 became visible through the litmus test of the pandemic, which strained all societal relations and thereby made Indian society a suitable case study for looking at the relationship between QoG and SQT.

The Pandemic in India

India reported its first case of COVID-19 on 30 January 2020 in the southern state of Kerala, when a 21-year-old medical student, who had returned from Wuhan, tested positive for the virus. The country's first coronavirus death was announced on 13 March 2020.2 On 24 March 2020,3 India went into a nationwide lockdown.4 This measure created a serious livelihood crisis, since millions of migrants in India's metropolitan cities were trapped without jobs, and their attempts to escape to their rural homes created a humanitarian crisis emerging from reverse migration (see Pellissery and Kaur forthcoming). Unlike most of the countries that had instituted lockdown measures when the infection rate was peaking, India was forced to exit lockdown after fifty-two days.5 Travel restrictions were eased when there were about 3,000 cases per day, but the peak was still far away. It was on 16 September 2020 that India hit the peak, with 93,617 daily reported cases. After this, the number of daily cases as well as the number of daily deaths dropped consistently for months.

On 28 January 2021, Indian Prime Minister Narendra Modi, addressing world leaders at the World Economic Forum's Davos Dialogue, announced that India was successful in the fight against COVID-19 and that the “country has saved humanity from a big disaster by containing corona effectively.”6 Prime Minister Modi also announced that India had sent vaccines and medicines to over 150 countries across the world. As you can see from Figure 1, while the vaccination rate in India was abysmally low, the Indian government had explicitly resorted to vaccine diplomacy to attract global capital that was evaporating from the country. In a country like India, where political leaders are trusted, these statements from the Prime Minister led to the resumption of “business as usual.”7 Big religious gatherings, the reopening of most public places, and crowded election rallies were triggers for the second wave in India.8 The Indian variant of the virus (B.1.617) also emerged in this second wave.

Figure 1.
Figure 1.

India COVID trajectory (Source: ourworldindata.org)

Citation: The International Journal of Social Quality 11, 1-2; 10.3167/IJSQ.2021.11010206

About six months after the peak of the first wave, cases started rising sharply in March 2021, and number of daily cases crossed the 100,000 mark for the first time on 4 April. The second wave was deadlier than the first, with India accounting for as many as one-third of deaths worldwide during this period (Rampal 2021). Learning from the lessons of the first wave, no nationwide lockdown was announced. Instead, the decision was left in the hands of the regional state governments, which could decide the duration and intensity of state lockdowns based on local conditions. By 9 May, the majority of Indian regional states had initiated full lockdown procedures, and they started relaxing norms only by the end of first week of June 2021. With lockdown measures in place, cases eventually started slowing down by the first week of June (the highest number of daily cases reported was on 6 May, and the number was 414,433).

The economic losses that India suffered during the pandemic exacerbated the economic slowdown that had begun before the COVID-19 outbreak.9 Aggravated by the pandemic, during the 2020–2021 financial year Indian GDP shrank by 7.3 percent. Though a moratorium on bank loans was announced for a period of six months, and an economic stimulation package worth 15 percent of GDP was announced, the government was not able to sufficiently revive the economy and stem the tide of job losses. The impact of COVID-19 on the well-being and future prospects of vulnerable sections of the general population was tremendous. The National Commission for the Protection of Child Rights in an affidavit for the Supreme Court mentioned that 9,346 children became orphans due to COVID-19. In country with a digital divide (with only 45 percent of the population as internet users), turning to online education has disproportionately affected the future prospects of young people. Vulnerable households started sending children to work without any possibility of further education.

Compared to the first wave, where a livelihood catastrophe occurred due to an unplanned lockdown, in the second wave a health disaster unfolded due to a segmented healthcare system that had long been entrenched in India.

Segmentation of the Healthcare System

Idea and practices of modern healthcare were introduced in India in the mid-nineteenth century to serve the British officers administering India. These origins of healthcare in the colonial context had two major impacts on Indian society: first, the federal state (even postcolonial) devalued the Indigenous health systems;10 and second, a class-based healthcare model was built into its administration. These two structural factors significantly contributed to the making of health inequality in India.

After independence in 1947, India's health expenditure patterns have been abysmal,11 further widening the inequality already created. Health expenditure in the first two decades of the Indian Republic (GoI 1976) shows that more than 50 percent of spending was focused on disease control programs. As a result, both infrastructure development and medical education have suffered tremendously. There have been very limited efforts to get the few trained medical professionals to rural areas in order to serve the public.12 Informal employment, which is widely prevalent in India (over 90 percent of those employed gain their livelihood in that sector), also prevented the development of a robust insurance system, where an employer would pay the premium of health insurance. Thus, over 75 percent of health expenditures in the country consist of out-of-pocket expenditures from citizens (Duggal 2007).

Devoid of the public interest objectives in health policies, private investment in the health sector mushroomed. By early 1990s, corporatization had completely gripped the healthcare system in India: “As the number of private practitioners increased over time, by the 1970s and 1980s, they became a powerful interest group that captured the Indian Medical Association, influenced the self-regulatory body, the Medical Council of India (MCI), and did not allow any other kind of regulatory efforts” (Priya and Ghodajkar 2018: 14). This internal factor was fueled with an externally imposed policy compulsion. A series of developments within a decade changed the landscape of healthcare, and the government of India quietly forgot the Alma-Ata vision of “health for all.”13

The World Bank loan that India took to implement its disease control program in 1993 effectively took away the ability to steer health policy from the Indian government. The World Bank advised it to replace the comprehensive primary care program with an essential health service package, and allowed the entry of marketized medical care into the country (Rao 2017). In 1995, the Drug Price Control Order (DPCO) lifted restrictions on manufacturers with regard to the pricing of drugs, and allowed them to enjoy high margins (the results this order will be seen below, when we discuss the unfolding of the pandemic). In 2000, the Reserve Bank of India had permitted 100 percent of foreign direct investment to be directed toward the hospital sector.

Corporatization led to a segmented healthcare system, where the poorest sections had the low-quality public healthcare system,14 and the rich sections of society relied on private nursing homes and hospitals. An assessment (National Commission on Macroeconomics and Health 2005) reported that though India is predominantly rural—according to the 2011 census, over 68 percent of the population lives in villages—over 80 percent of the country's health infrastructure and personnel are available to the 32 percent of the total population that live in urban areas.

Research Methodology

The Constitution of India made healthcare a regional state responsibility.15 Thus, there are different health outcomes and different health situations in different states. We use two well-known indices to classify the quality of government (QoG) vis-à-vis health services. The first is the NITI Aayog Health Index16 (the NITI-Aayog is a government-appointed think tank that is chaired by the Prime Minister), and the second is the Public Affairs Index17 (the Public Affairs Centre or PAC is a nonprofit a think tank in the civil society sector) on governance. Our use of one government report and another civil society report is meant to avoid bias as well as to get convergence between two indices. Using these indices (the exact position in each index is provided in parentheses), we have picked up the cases of the state of Kerala (NITI: 1; PAC: 1) and Punjab (NITI: 5; PAC: 2) as examples of well-performing states, Karnataka (NITI: 8; PAC: 9)and Chhattisgarh (NITI: 11; PAC: 18) as medium-performing states, and Madhya Pradesh (NITI: 16; PAC: 21) and Uttar Pradesh (NITI: 20; PAC: 27) as poorly performing states. The impact of COVID-19 on these six states and their respective health infrastructures are presented in a comparative table below (Table 1). Our purpose in selecting states with varying grades of healthcare for this study is not to make a strict comparison to conclude reasons for differences among them. Rather, our aim is to understand how the societal impact from governmental action is different in different states depending on the quality of their respective healthcare infrastructures.

Table 1.

Health Infrastructure and COVID Outcomes in Six Selected States

StatePopulation Size (in Millions for 2021 Estimates) [Density in Parentheses]First Reported Case Date (Traveled from in Parentheses)Total COVID Cases (a)Tests done as Percentage of Population (b)Death as Percentage of Total Cases (c)Percentage of Population Fully Vaccinated (d)No. of Public Hospitals per 1,000 People (e)No. of Private Hospitals per 1,000 People (f)People per Doctor (g)
Kerala37.4 (962)30 January 2020 (Wuhan, China)2,702,8236.60.0045.820.03420.0551535
Punjab31.1 (616)9 March 2020 (Italy)585,9861.80.0262.550.02200.0527789
Karnataka68.4 (356)8 March 2020 (USA)2,747,5393.70.0114.140.04150.1146507
Chhattisgarh28.6 (211)18 March 2020 (UK)985,6913.30.0133.840.00750.00644,338
Madhya Pradesh81.3 (263)20 March 2020 (UAE)787,5720.90.0112.170.00570.006217,192
Uttar Pradesh223.7 (928)3 March 2020 (Delhi)1,701,6680.70.0131.530.02070.05573,767
India1,355 (412)30 January 2020 (Wuhan, China)11,21,6712.10.323.330.01900.03211,511

Once the states were selected for this study, we adopted two methods to understand the governmental impact on societal life in the context of COVID-19. Our empirical inquiry is devoted to issues raised by political parties as well as in the courts during the months of April and May 2021 (the peak of the second wave). First, we looked up the issues raised by opposition parties in various regional states with reference to COVID-19 management. In a competitive democracy, opposition parties identify shortcomings of the ruling party. How the ruling party responds to such criticisms from the opposition reflects upon how responsive the government is toward its citizens. Second, we looked at the court cases filed in the High Courts of the respective states. In the Indian context, it has been noted that courts have become the last resort for the citizens to get justice.18 Therefore, studying the courts’ directives to the government becomes an important way in which to understand how members of the public seek redress for their grievances. In addition to the state-level cases, we also looked at national-level politics and the cases that came up in the Supreme Court of India.

As indicated in the introduction to this article, our aim is to contribute to the understanding of social quality through the case of governmental action around the COVID-19 pandemic in India. In pursuit of this aim, we attempt to understand the impact of said action on society through the lens of MFT. In the preceding sections of this article, we have provided an overview on how COVID-19 unfolded in India, and what kind of institutional arrangement existed in India for healthcare. In the next section, we will apply MFT theory to the societal impact of COVID-19. The six pillars or principles of MFT theory, and how they got triggered during COVID-19 are summarized in Table 2. In rest of this article, we will elaborate each pillar and explain how it connects to SQT.

Table 2.

Connection between MFT Categories and Normative Factors of SQT

MFT CategoriesTriggers during COVID PandemicNormative Factors of SQT
Authority/SubversionChaos created due to governmental inaction, and court interventions for healthcareEqual value
Care/HarmDemand for equitable allocation of healthcare hampered by inadequate health infrastructure, and heavily privatized health systemEqual value
Fairness/CheatingVaccine hoarding, hospital pricing, and collusion of doctors with diagnostic centersSocial Justice
Liberty/OppressionPublic backlash against hospitals and healthcare workersSocial Justice
Sanctity/DegradationOpportunities for decent burialHuman Dignity
Loyalty/BetrayalGovernmental action to use relief to deepen patrimonial relationsSolidarity

Findings

Governance from the Courts (Authority/Subversion)

The MFT category of authority/subversion is triggered by a quest for order and stability in society. Yet, a democratically elected government could hibernate during a crisis, when it knows that its authority is not likely to be subverted (weak opposition, crisis often prevents mobilization, and so on). The constitutional separation of powers and the role of the judiciary19 on such occasions are imperative for the reestablishment of social quality in public life. The inaction of the Union Government of India during the pandemic on criminal matters and how Supreme Court of India stepped in to take action is an example of this moral foundation.

While the first wave of the COVID-19 crisis made the federal state visible through its extraordinary lockdown measures, the second wave made it invisible. As the number of reported positive cases crossed 200,000 per day (early April 2021), hospitals had no capacity to admit patients. Even in hospitals where beds were available, the necessary items, such as oxygen and life-supporting machines, were absent. As the hospitals were running out of life-supporting beds (ventilators, oxygen beds), individuals kept sick loved ones at home, and started procuring medical essentials from the black market. Chaos and mismanagement prompted social activist Arundhati Roy to write an open letter to Prime Minister Modi (dated 4 May 2021) titled “We Need a Government. Desperately. And We Don't Have One.”20 The judiciary took suo moto cognizance of the crisis, and intervened stating that the court could not be a “mute spectator,”21 and took it the executive role of government and health policy matters into its own hands.22 This was clearly an example of the Supreme Court entering into the role of the executive, and challenging the well-established principle of the separation of powers.

The judiciary may err if it attempts to deal with matters of resource allocation and efficacy (Bilchitz 2003; Govindjee 2019). But, when the government fails to design a resource allocation mechanism, there is a grave danger to the rule of law. The rule of law, wherein even the highest individual is not above the law, crumbles when citizens are left to their own devices to manage their health during a pandemic. Competition based on raw political resources exhibit “naked preferences” over the rule of law (Sunstein 1984). In a society like India with deep economic and social inequality, pandemics leave vulnerable citizens to look on while well-off citizens grab the available resources (be it a hospital bed or a respectable funeral).

Previous paragraphs may raise the question as to whether the Indian government is dysfunctional. In fact, past policy initiatives undertaken by the Indian government show a tremendous political will to achieve the objectives it sets out for itself. Protests were erupting in the country against the Citizenship Amendment Act when COVID-19 reached India. The government used the cover of the pandemic to evict all protesting groups from the streets. The Indian Parliament passed legislation to replace existing farm laws, against which massive protests erupted in the month of October 2020, alleging that new laws and regulations were providing profit opportunities for the corporate houses at the expense of farmers. Despite the eleven rounds of discussions with farmer unions between October 2020 and January 2021, a middle ground could not be found, and farmer protests continued. Two other laws—one on the environment and another on labor—have also been regressive, and their introduction during the pandemic saved the government from the protest it would have faced, had they been introduced in non-pandemic times. In the first week of June 2021, the central government implemented strong information technology rules, where big social media giants like Facebook and Twitter were forced to reveal information that the government asked for.

Why did a strong government that could implement these laws appear weak when there was a health crisis? From the history of privatization (explained above), it could be discerned that the rich class that could subvert (or at least challenge) governmental authority would take private healthcare, and the poor classes would fail to mobilize while they would be seeking emergency healthcare, going from one hospital to another. The priority of the government was clearly on matters that were not pandemic-related.

A litmus test for the misplaced priority of government was the legal battle that took place on the Central Vista Project (a construction project to replace the existing Parliament and Ministerial Secretariat buildings with a cost very similar to what the Union government had allocated for vaccines in the annual budget of 2021–2022). The case was filed in court: the plaintiffs wanted to delay the project during the national health crisis that was the pandemic. The response of the government was that they had a legal right to their executive actions. Though the petitioners lost the case in court, in the public arena,23 and among public intellectuals, the priorities of government casted a strong sense of doubt as to whether the authorities were going ahead with the project in the public interest: they started to think that they were just pursuing their own self-interest.

In the movement from justice to goodness, Ricoeur identifies a paradox of legal justice based on the contradiction between legal coercion and ethical reconstruction (Kandil 2018). Governmental inaction and the success of the rule of law, through the intervention of the Supreme Court (as explained above) is an example of the paradox of legal justice.

The MFT pillar of authority/subversion, along with care/harm (which we discuss next), supports the SQT normative factor of the equal value of human beings. However, while the authority/subversion pillar generates a systemic mechanism, the care/harm pillar generates a societal mechanism for promoting equal value.

A Caring Society and a Cold State (Care/Harm)

Human responses to fellow human beings in situations of violence or victimization are the triggers for the MFT pillar of care/harm. How far they raise political emotions in collective contexts varies among countries significantly. Contrasting the nature of society and state in India has been elaborated by several scholars who have studied India (Fukuyama 2011; Piketty 2020). Policy approaches to deal with poverty have also suffered from a “thick society and thin state” syndrome (Pellissery and Mathew 2013).

In the context of a “thin state,” one of the approaches that have become successful in India to deal with disasters is volunteerism. A cadre of “COVID warriors,” drawing from volunteers, was created. Media reports were full of heartening stories of the heroism of these volunteers. This is not to undermine the dedication that the medical doctors and nurses have shown. Over 1,400 doctors24 and just as many health workers have died due to COVID-19 in India. Though at the individual level this dedication was visible, at the system level it was more of the harmful effects of the intervention that came to be known. In particular, this was visible when hospitals refused to admit COVID patients. In all the states we studied, the High Courts ordered 50 percent of beds in private hospitals to be reserved for COVID patients. In some states, the administration threatened private hospitals with closure if admissions were denied to COVID patients.

Among the six states we studied, Madhya Pradesh and Uttar Pradesh had very minimal arrangements to monitor bed availability, despite the respective High Courts directing the government to do so. There was huge gap between public information on bed availability and the reality on the ground. The Chief Minister of Uttar Pradesh claimed that there was no shortage of oxygen while hundreds were dying due to a lack of oxygen cylinders in the local hospitals. Compared to this situation, the states of Karnataka and Kerala25 created what is called “COVID war rooms,” where dedicated teams of volunteers worked around the clock to take calls from patients, and to direct them for testing and hospital admission. These war rooms maintained real-time data on bed availability. However, in Karnataka this arrangement created a scam when employees at private hospitals colluded with volunteers in some COVID war rooms.26

One important dimension of the care/harm pillar is specific to the doctor–patient relationship, which is an asymmetric power relationship. The issue, however, was fiduciary in nature. In privatized healthcare, this relationship becomes critical. During COVID-19, an important debate occurred in India among doctors as to whether CT scans could be used for COVID-19 diagnosis. Collusion between doctors and diagnostic clinics through the referral system is one of the hallmarks of the corrupt healthcare system in India (Priya and Ghodajkar 2018). Orders for expensive diagnostic procedures for COVID-19 and the overdoses of medication that this brought about are just one example of how the system as a whole did actual harm, while most individual doctors were, of course, caring.

Another instance of systemic harm was when several politicians argued that the COVID pathogen as a weak entity that could be prevented by cow urine (similar to Donald Trump's exhortation in the United States leading a few people to consume disinfectant. In India, the cow is holy animal because of its veneration in Hinduism) (Press Trust of India 2021). Some business endeavors also used this as an opportunity. At the peak of the second wave, there were reports of single-use PPE (personal protective equipment) PPE kits being resold by a biowaste disposal plant in the state of Madhya Pradesh.

Government Effectiveness and Treatment Pricing (Fairness/Cheating)

The societal trigger for the MFT pillar of fairness/cheating emerges from the human quest for equality, reciprocity, and proportionality. When these expectations are not met in a relationship, a sense of unfairness is experienced, and this experience could trigger hostile emotions toward those who perpetuate such unfairness. In a pandemic situation, when large numbers of members of society underwent similar suffering, there was a raised level of expectation of reciprocal cooperation from institutions (i.e., of the state, market, and society).

As the second wave was peaking, by early April 2021, the Central Drugs Standard Control Organisation (CDSCO) was aware that a health crisis was coming. It wrote to the drugs controllers of all regional states on 7 April 2021, informing them that, for drugs like Remdesivir, this crisis “may lead to its hoarding and black marketing.” Remdesivir vials are centrally distributed to the regional governments, and from there they are delivered to various hospitals. The drug is not available with pharmacists, and therefore individuals cannot and—during the pandemic—could not access it without first being hospitalized. However, doctors started prescribing Remdesivir when it was not available in the hospital.27 The only way this was possible was the creation of a black market, where relatives of patients would access this medicine (and other like it) and make it available to the hospital. At the same time, it is important to note that the centrally distributed Remdesivir was only able to enter the black market through the hospital. Instead of administering the medicine to patients (and sometimes instead of returning medicines to the hospital after a patient's death), doctors or other employees deliberately pushed medicines to the black market for the purpose of profiteering. It is exactly for this reason that several hoarding cases were filed in court against doctors, ward boys, and members of hospital administrations.28

In five of the six states that we studied, several politicians (particularly ruling party members) directly procured both medicines and vaccines. Media visibility of political leaders as saviors of the people dominated over the effectiveness of government machinery. This was particularly because the politicians sat on the boards of directors of many of the private hospitals. Some hospitals displayed the photographs of these political leaders on the banners advertising the vaccination drive. These systems of signaling to voters in a democracy came at the cost of strengthening public institutions and citizens’ faith therein.

In the states of Uttar Pradesh and Karnataka, opposition parties pointed out the procurement of medicines, ventilators, and diagnostic equipment at a rate that was 500 percent above the market rate (News18 2020; PTI 2020). Our study of court cases showed that in all the states the High Courts directed the state government to issue a cap on medicines, hospital pricing, and treatment pricing. However, the will to implement them varied among the states. It was found in the inquiry that in one of the cases a female patient was charged 822 percent more than the fixed fee by a private COVID-19 hospital for a 24-hour stay (Chauhan 2021).

In a segmented system of healthcare, politicians have to reward the private sector, which gives them money for elections, as well as appear to be doing good for the voters. The vaccination policy of the central government clearly showed this double dependency. Though the media reported vaccine shortages, vaccines were available in private hospitals at exorbitant prices. Private hospitals had procured vaccines, whereas state public procurement systems failed to do so. Golf clubs, resident welfare associations, religious groups, private business groups, and even WhatsApp chat groups made arrangements with private hospitals for vaccinations. Where individuals were paying for vaccinations (often three times more than the stated price of the vaccine), there was no scarcity of vaccines. At the same time, there were no vaccines at government-supported Primary Health Centres (PHCs), which is where poor people went to get vaccinated. Thus, the segmented system not only perpetuated health inequality, but members of the middle class also accepted the payment of exorbitant prices as something they would have to live with if they wanted to be vaccinated or receive other medical services.

The origins of this uneven situation can be traced back to the vaccination pricing strategy that was allowed to take shape. The Union government refused to procure vaccines directly from companies. Instead, it allowed vaccine-producing companies to have a three-tier pricing system.29 As different regional state governments were competing among themselves through tenders, prices went up. It was only due to the sustained intervention by the Supreme Court that the Union government announced a reversal of its vaccine policies. With effect from 21 June 2021, the central government would procure 75 percent of its vaccines from companies producing them in the country and supply them to state governments free of cost. This has enabled the state governments to provide free vaccines to the public. It is still worth noting that 25 percent of vaccines are reserved for private hospitals, who administer vaccines at a cost.

Fairness/cheating as an MFT pillar, along with liberty/oppression, supports the social justice normative factor of SQT.

Violence as Reaction to Governmental Intervention (Liberty/Oppression)

Haidt defines the liberty foundation of morality as “motivation to unite as equals with other oppressed individuals to resist, restrain, and in extreme cases kill the oppressor” (2013: 201). In the previous sections of this article, we have shown two trends that would trigger the need for common people to mobilize their righteous anger: the first is a segmented system of healthcare generating anger over being deprived of quality care that other citizens are enjoying; and the second is the inaction of the state, inaction that leaves citizens at the mercy of healthcare workers who are overburdened.

In the state of Madhya Pradesh alone, a report30 found that out of 3,620 sanctioned posts of specialists only 765 were currently filled. Over 75 percent of required positions were vacant in the public health sector. In the same state, over 3,000 doctors went on public strike when the COVID crisis was at its peak, demanding adequate work conditions.

In all the states we studied, violence against doctors and nurses were reported. Most of these violent acts took place in private hospitals or in COVID care centers. In some instances, acts of violence were organized by family members when a patient passed away without getting an ICU bed or oxygen cylinder. In a bizarre incident, twenty-two patients were alleged to have died when a private hospital carried out mock drill by switching off the oxygen pipeline. Crowds gathered in front of the hospital in the city of Agra in Uttar Pradesh, and the local government sealed off the hospital.

Though violence is in conflict with the rule of law principle, the MFT principle of liberty/oppression is essential for a society to establish itself as anti-authoritarian. Populist anger contained in this element goes along with courage as a virtue. In turn, this supports the normative factor of social justice in SQT.

Graded Dignity (Sanctity/Degradation)

The sanctity/degradation principle is triggered when people want to protect themselves from disease, pollution, or uncleanliness, or when there is talk or impurity. It addresses the “broader challenge of living in a world of pathogens and parasites” (Haidt 2013: 179). In other words, this MFT pillar is important when it comes to the creation of a moral community. Liberal ideas primarily fueled by the harm principle of John Stuart Mill are “inadequate as the basis for a moral community” (Haidt 2013: 174), because Mill's principle fails to recognize people's sentiments. Overemphasis on the autonomous individual leads to a scenario where feelings, emotions, and ideas of purity and pollution are reduced, as they are merely considered as illusions that do not rationally fit within a utilitarian framework.

One of the most gruesome experiences of the pandemic during the second wave was regarding the disposal of dead bodies. From a purely utilitarian point of view, what is being done to the bodies does not amount to harm. It is exactly here where emotions and sentiments bring a moral foundation for respecting dead bodies and giving them a decent burial or cremation. The way in which the pandemic brought pressure on India's burial infrastructure created graded dignity. Those who could afford the expenses of burial were able to respect their emotions toward the dead body of a relative. In all the states we studied, there were reports of relatives spending hours queuing at crematoriums to get a slot. The nadir of human dignity came when television screens displayed hundreds of semi-decomposed dead bodies being feasted on by vultures and dogs in the states of Bihar and Uttar Pradesh. Impoverished villagers, without resources to buy wood for cremation, had floated the dead bodies down rivers. Bribes were demanded both in public crematoriums as well as by middle-men to execute the task.

This inability to give loved ones a decent burial or cremation, at least for the poorer sections of society, is indicative of how the pandemic disintegrated the concept of a moral community. In normal circumstances, violent reactions and punitive measures could be expected for dumping dead bodies in common resources such as rivers. Those norms became irrelevant when coping with personal grief or guilt, which was conditioned on a class basis: the rich could cope, while poor people could not.

Systemic corruption does moral harm, and Mill's principle stating that “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others” (1910) is too weak.31 The Ricoeurian conception of the good, going back to Aristotelian reciprocity, on the other hand, emphasizes good “with and for others” (Ricoeur 1994: 180). Ethical desire would prompt people to have a vicarious sense of respect. This interconnection between sanctity/degradation and the need to respect one another is how MFT reinforces the normative principle of human dignity in the SQT framework.

The Coming of the White Tiger for Relief (Loyalty/Betrayal)

“Finding your own people” is a game in politics as much as in society.32 This original trigger of the MFT pillar of loyalty/betrayal shapes the politics of relief. In a widely read book, Everyone Loves a Good Draught (1996), the system in which politicians, bureaucrats, and middle men flourish amidst the suffering of the poor was brought out vividly by the journalist/author Palagummi Sainath. COVID-19 was a reiteration of this lesson. A cohesive group33 (with the loyalty principle as an internal incentive) of relief providers faced a widely dispersed group seeking relief.

In the context of the COVID-19 pandemic, all the states in India were forced to introduce relief programs of different types—food for people who had lost the capability to buy food for themselves, travel for people who were trapped due to lockdown, cash transfers for people who lost their livelihoods, a moratorium on loans for those who could not make their repayments, exemptions for those who could not pay their electricity bills, support for schoolchildren to be able to access online classes, and so on. However, in a democracy these relief measures are construed as a relationship between voter and politician. It is precisely here that the MFT principle of loyalty/betrayal operates (of course, this goes along with the care/harm principle we dealt with above). The requirements for substantial relief measures in India due to the COVID-19 pandemic were a major departure from previous modes of relief.

Two avenues existed in India to raise necessary resources and to distribute them when disasters took place—the PM National Relief Fund (PMNRF, created in 1948) and the National Disaster Response Fund (NDRF, created in 2005). In March 2020, when the COVID-19 pandemic struck the country, a new fund called The Prime Minister's Citizen Assistance and Relief in Emergency Situations Fund (PM CARES Fund) was created. Unlike the other funds, the newly created fund (PM CARES) was exempt from transparency measures such as the right to information.34 The cabinet was not consulted. Though the Prime Minister was declared as the chairman of the fund, there was no information available on who else may be the trustees of the fund. Tax exemption was provided to corporate houses and individuals who made donations to this fund; government employees were urged to contribute a portion of their salaries to the fund; and foreign donations35 were accepted. However, the financial statements of the fund were audited by a private accounting firm.

A public interest case36 was filed in the Supreme Court with an aim to bring more transparency to this new fund. Though the government declined to be transparent, holding the view that the fund was created under a registered charitable trust (and that it was not a public fund which was transferred to the government), the petitioners threatened prosecution over the former's use of the national emblem for a charitable trust. At this stage, the government admitted in the Supreme Court that the fund was public, but argued that it was exempt from transparency legislation such as the Right to Information Act. The Supreme Court refused to intervene in the matter, citing “financial planning as the prerogative of the government.”

The fund despite of being in operation for more than 18 months still has not revealed how much money it has received. Media reports suggest, loyal corporate groups to the ruling party have been leading contributors to the fund. Money raised has been spent for purchase of vaccines, for the welfare of migrants and for vaccine development.

Relief in contexts of disaster is an important tool for solidarity (Titmus 1970). However, in deeply divided societies, relief tools— coupled with political corruption—could solidify existing societal divisions. Solidarity as a normative factor may be most difficult to nurture to advance the social quality of deeply diverse societies.

Conclusion

The empirical case study of the societal impact of COVID-19 in India has revealed how divisive societies struggle to maintain social quality. Two waves of the COVID-19 pandemic offered contrastingly different outcomes. The first wave presented a livelihood disaster due to an ill-planned lockdown. The second wave presented a health disaster that was due to government inaction.

In the Indian case of healthcare intervention during COVID, we have seen that as corruption was normalized through collusion between the private interests of politicians and the profiteering motives of hospitals, exploitation and the discrimination along the lines of class incapacitated many citizens. Yet, the Supreme Court's interventions to establish the rule of law partly brought about socio-legal order, but the latter was shaken when the Union government rescinded its authority.

The paradoxical experience of a caring society and a cold state could be peculiar to societies where a communitarian ethos prevails and the state is seen as a distant entity. In India, politicians thrive on the desolation and penury of the citizens, bringing the conditionality of loyalty for relief. As a result, there was a breakdown of the sense of moral community at the height of the COVID-19 pandemic. This was most evident in the context of the above-mentioned graded dignity between the rich and poor classes when it came to burial and cremation. Thus, even the established norms of sanctity/degradation were discarded. These instances of societal impact provided triggers for all six MFT principles, which we studied in this article in terms of how they supported the normative factors of SQT.

We find that the equal value of human beings as a normative factor of SQT is supported by the MFT categories of authority/subversion and care/harm—one systematically and the other through societal mechanisms. MFT's two principles of fairness/cheating and liberty/oppression together shape the normative factor of social justice in SQT. Similarly, human dignity and solidarity are supported by the MFT principles of sanctity/degradation and loyalty/betrayal, respectively.

Moral foundations theory (MFT) deepens our understanding of SQT's vertical line (refer to “Figure 1” in IASQ 2019) on the continuum between biographical transformation and societal transformation. Our case study of the Indian government's interventions during COVID and their societal impact does not fully capture all the potential that the theoretical convergence between MFT and SQT offers. This is particularly because, in a segmented healthcare system, corruption overshadows several positive features. Yet, the case study shows that MFT directly supports the normative factors of SQT. How far MFT would support the constitutional and conditional factors of SQT as presented in one of the main social quality studies (e.g., Van der Maesen and Walker 2012) would require further research.

A society like India, where deep-seated inequality has stifled the emergence of “the social” (Pellissery 2021), the case (India's segmented healthcare system) presented in this article itself may be distorting the relationship between MFT and SQT. Depending on the orientations of societal transformation and governmental interventions, all societies may not show similar weight for all moral norms. This is a matter for comparative empirical examination.

Notes

1

We do not aim to engage in the definitional issues of corruption in this article. The literature is voluminous in this respect. However, we like to state that a legal definition of corruption such as private gains from public office or corruption as neglect of the public interest are insufficient while trying to understand social quality. How corruption is emerging from systemic public mistrust and a lack of social cohesion should be considered. See a review of these different concepts in Pellissery and Bopaiah (2021).

2

The victim was a 76-year-old man who had returned from Saudi Arabia.

3

Total number of confirmed positive cases was just around 500 at the time of lockdown. Several people have criticized these measures, including a petition submitted to the Supreme Court of India about the lack of preparations prior to lockdown.

4

Indian measures were appreciated internationally, especially by the WHO, since several European countries were hesitating to go into lockdown despite the daily reported number of cases being above 1,000. India's decision was also appreciated by many in the country since the Indian health infrastructure was very weak, and early lockdown measures would help to prepare the health infrastructure for what was to come.

5

In fact, on 1 May 2020 special trains started carrying distressed migrant workers back to their hometowns, covering over 2,500 km. Travel restrictions were eased from 17 May. However, systematic “unlocking” procedures started only from 31 May 2020.

6

PMO Office website (https://www.pmindia.gov.in/en/ [accessed 21 November 2021).

7

The Edelman Trust Barometer finds that 70 percent of Indians trust their elected leaders, which is the second highest rate in the world after China. See https://www.edelman.com/trust/2020-trust-barometer (accessed 8 November 2021).

8

Prime Minister Modi attended sixteen political rallies to win a regional state election in the eastern part of the country, West Bengal, when the second wave was peaking.

9

Protesting the mismanagement of the economy prior to the pandemic, two central bank governors had resigned.

10

India had variety of indigenous healthcare systems compared to allopathic modern medicine. Some of them included Ayurveda, Unani, and Siddha. These are viewed as low-cost options when allopathic medicine was primarily sponsored by the central state (Muraleedharan 1992). For a long time, licenses were declined for practitioners of non-allopathic medicine. Since 2003, there has been a ministerial department at the national level named AAYUSH to integrate indigenous systems of health with allopathic systems. However, this effort has been confused with nationalism since 2014, when it was transformed into a full ministry under the Bharatiya Janata Party (BJP) regime. It is worth noting that one of the well-known Yoga gurus (Baba Ramdev) challenged the COVID vaccination program as a ploy to spread atheism in India. The Medical Council of India, dominated by allopathic practitioners, filed a defamation suit against the guru.

11

In the annual budget of 2020–2021, India set aside only 0.34 percent of GDP for health.

12

The backbone of India's public health is 30,045 PHCs and 1,047,324 Accredited Social Health Activists (ASHAs). ASHA workers facilitate people's access to health and related services. Though the norm is one ASHA per 1,000 people, this ratio has never been achieved.

14

The population in the lowest quintile spends about 14 percent of their income on healthcare, whereas the population in the top quintile spend only 0.65 percent (Barik and Thorat 2015).

15

The Indian Constitution divides responsibilities into Central List, State List, and Concurrent List (on matters where both the central government and state governments could legislate). A comparison of social policy outcomes through such a governance approach is presented in Pellissery and Anand (2017).

16

The NITI Aayog Health Index yields a composite score incorporating twenty-three indicators covering key aspects of health sector performance (overall performance). The Index is created using administrative data on health outcomes (ten indicators), governance and information (three indicators), and key inputs and processes (ten indicators). We take twenty large states categorized into three: those above an index score of 62 are categorized as well-performing states (seven states listed), those with an index score between 48 and 62 (seven states), and those below the index score of 48 (six states). It is important to note that even within well-performing states, there is huge variation. The best-performing state, Kerala, has an index score of 74.65 while the second best-performing state only has a score of 65.31. The lowest score in this category is 62.92. In other words, Kerala is clearly an outlier. But, when we take the worst-performing states that is not the case. The lowest index score, for Uttar Pradesh, is 29.16 while the next just above it in the list is Bihar with an index score of 32.43.

17

The PAC Index (2020) examines governance among different Indian states through the monitoring of both outcome indicators and process information. The Index calculates the overall performance of Indian states in three domains of equity (twenty-three indicators), growth (twenty indicators), and sustainability (seven indicators). The most relevant measurement among them is the subdomain of “government effectiveness” within the domain of “growth” measured through fourteen indicators. Some of these indicators directly measure health outcomes such as immunization. We looked at the index score of twenty-nine large states and divided them into three groups (just like the NITI Aayog Health Index does) and took two states each from the first group, the second group, and the third group that match with the NITI Aayog groups.

18

It has been estimated that in 45–75 percent of cases in India the government is the litigant against the citizenry (Rajagopalan 2018; Former Chief Justice T. S. Thakur also expressed the same concern in a conference in 2015 as reported by the Press Trust of India on 12 February 2015). In an imperfect democracy (see how the public choice model, which is about keeping politicians accountable for the public interest, in the context of widespread identity politics and illiteracy, fails in India in Keefer and Khemani 2005), the judiciary becomes the last resort for substantive justice.

19

In the Indian context, the executive is subservient to the legislature, though constitutionally mandated separation of powers gives autonomy to them. This subservience is one of the prime causes of rampant corruption.

20

https://scroll.in/article/994022/arundhati-roy-we-need-a-government (accessed on 4 May 2021).

21

The Supreme Court made this statement on 27 April 2021. This exceptional move by the Supreme Court of India is not an indicator of the absence of collusion between the judiciary and executive in India. Judicial corruption has been rampant in a system where executives have lured sitting judges with attractive postretirement positions (see a summary in Gopal 2011). Though the Indian government has been demanding to appoint judges, the Supreme Court collegium has retained its autonomy on the matter of making appointments.

22

The Court looked into demand for oxygen and the measure that should be undertaken to monitor and increase supply. It looked into the basis of bed and oxygen allocation and their availability. It even ventured into the drugs and vaccination policy, including pricing.

23

Mobilization in the form of a signature campaign against the chief architect (Mr. Bimal Patel) of the project took place in a university where he was chairperson.

24

These numbers are heavily contested. The GoI (Parliament) verified the death of only 178 doctors. The Indian Medical Council has refuted this number and estimated that 748 doctors died in the first wave and 636 in the second wave.

25

In Kerala, this was done at the decentralized level in the districts and even in the subdistricts.

26

Upon news of a bed vacancy, the bed is quickly booked under the name of an asymptomatic patient and later allocated to another patient in a few hours either based on monetary considerations or the influence of the authorities.

27

Similarly, when oxygen was not available, hospitals either displayed a notice or told the relatives of the patients that the responsibility of procuring an oxygen cylinder was that of patient and not of the hospital. Thus, a black market for oxygen cylinders too was created during the second peak of the pandemic. Disposable oxygen cylinders (9l to 12 l), which had a pre-COVID price of RS300–350, were sold at as high as RS1,500–2,000 in the black market. Similarly, pulse oxymeters, for which also demand shot up in the market, increased in price by 10 percent in the months of April and May 2021.

28

Remdesivir, whose price was capped between RS900 and RS4,000 by the GoI, was selling for the black market price per vial of RS50,000! The Delhi Police alone reported filing 303 cases in the matter of black market of COVID medicines until 7 May 2021 (Kaushik and Manral 2021).

29

The AstraZenaca vaccine was being sold to the Union government at RS150, to state governments at RS400, and to private hospitals at RS600.

30

As reported in the W.P. No. 8753/2021 (at the High Court of Madhya Pradesh) purportedly based on the Annual Report 2019–2020.

31

Cf. The Declaration of the Rights of Man (1789), whose Article 4 runs as follows: “Liberty consists in the freedom to do everything which injures no one else; hence the exercise of the natural rights of each man has no limits except those which assure to the other members of the society the enjoyment of the same rights. These limits can only be determined by law.” See the Avalon Project at https://avalon.law.yale.edu/18th_century/rightsof.asp.

32

The section title refers to a famous novel by Arvind Adiga (2008) titled White Tiger, which describes an entrepreneur who could do unscrupulous things to achieve whatever objectives he sets up, but according to his own moral reasoning.

33

Haidt (2013) calls this a “life instinct” for survival.

34

This was a progressive case made in 2005 that was a result of a long, drawn out social movement to hold government accountable.

35

Note that it was at precisely this time that foreign donations to nongovernmental organizations (NGOs) were tightened by the Union government's restructuring of the rules, which adversely affected the NGOs doing welfare work during the COVID-19 pandemic.

36

Centre for Public Interest Litigation v. Union of India Writ Petition (Civil) No. 546 of 2020.

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Contributor Notes

Sony Pellissery is Director of the Institute of Public Policy, National Law School of India University, Bangalore. His research interests include distributive justice, social policy, and the interface of law and public policy. Email: sony.pellissery@stx.oxon.org

Vijay Paul is an Assistant Professor in the Department of Humanities and Social Sciences, Graphic Era University, Dehradun. He is also the Coordinator of Centre for Advanced Studies at the same institution. His research interests are agriculture, rural development, and state capacity. Email: vijayp@nls.ac.in

Khushi Srivastava is a Student of Economics at the University of Delhi. She has a keen interest in public policy, corporate social responsibility, and social entrepreneurship. Email: srivastavakhushi13@gmail.com

Drishti Ranjan is a Law Student at the Army Institute of Law, Mohali. She has an interest in constitutional law, public policy, and the judicial system. Email: drishti.ran7an@gmail.com

The International Journal of Social Quality

(formerly The European Journal of Social Quality)

  • Barik, D., and A. Thorat. 2015. “Issues of Unequal Access to Public Health in India.” Front Public Health 3 (245). doi:10.3389/fpubh.2015.00245/full.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Bilchitz, D. 2003. “Towards a Reasonable Approach to the Minimum Core: Laying the Foundations for Future Socio-Economic Rights Jurisprudence.” South African Journal on Human Rights 19 (1): 126. doi:10.1080/19962126.2003.11865170.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Chauhan, A. 2021. “Lucknow: FIR against Hospitals for Fleecing Patients.” The Times of India, 13 May. https://timesofindia.indiatimes.com/city/lucknow/lucknow-fir-against-hospitals-for-fleecing-patients/articleshow/82594050.cms.

    • Search Google Scholar
    • Export Citation
  • Duggal, R. 2007. “Healthcare in India: Changing the Financing Strategy.” Social Policy & Administration 41 (4): 386394. doi:10.1111/j.1467-9515.2007.00560.x.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Fukuyama, F. 2011. The Origins of Political Order. New York: Farrar, Straus and Giroux.

  • Gopal, G. M. 2011. “Corruption and the Judicial System.” Seminar 625 (T024943): 3135. https://www.india-seminar.com/2011/625/625_g_mohan_gopal.htm

    • Search Google Scholar
    • Export Citation
  • Government of India (GoI). 1976. Health Services and Medical Education: A Programme for Immediate Action. (Srivastava Committee). New Delhi: Ministry of Health.

    • Search Google Scholar
    • Export Citation
  • Govindjee, A. 2019. “Concluding Reflections: Transformative Constitutionalism as a Framework for Law and Policy Integration in Global South.” In Transformative Law and Public Policy, ed. S. Pellissery, B. Mathew, A. Govindjee, and A. Narrain, Delhi: Routledge.

    • Search Google Scholar
    • Export Citation
  • Haidt, J. 2013. The Righteous Mind: Why Good People Are Divided by Politics and Religion. New York: Vintage Books.

  • IASQ (International Association on Social Quality). 2019. Ideas and Suppositions about the Application and Elaboration of the “Social Quality Approach” (SQA) in Eastern Europe: The Case of Ukraine. IASQ Working Paper No. 17. https://socialquality.org/wp-content/uploads/IASQ-Working-Paper-17-4.pdf.

    • Search Google Scholar
    • Export Citation
  • Kandil, F. 2018. Ricoeur, Rawls and the Aporia of the Just. In The Ambiguity of Justice: New Perspectives on Paul Ricoeur's Approach to Justice, ed. G. Dierckxsens, 169205. Leiden: Brill.

    • Search Google Scholar
    • Export Citation
  • Kaushik, K. and M. S. Manral. 2021. “Delhi: Drugs to Oxygen, amid Covid-19 Surge, Black Market Flourishes.” Indian Express, 15 May. https://indianexpress.com/article/cities/delhi/drugs-oxygen-remdesivir-amid-covid-surge-black-market-flourishes-oxygen-cylinders-7315522/.

    • Search Google Scholar
    • Export Citation
  • Keefer, P. and S. Khemani. 2005. “Democracy, Public Expenditures, and the Poor: Understanding Political Incentives for Providing Public Services.” The World Bank Research Observer 20 (1): 127. doi:10.1093/wbro/lki002.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Mill, J. S. (1859). 1910. On Liberty. London: J. M. Dent & Sons.

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