By Krishna Ballabh Chaudhary
COVID-19 has broken the supply chain and institutional orders. Trust deficit between nations and global institutions makes it further difficult to work in this fragmented world. In the current situation, can we really afford to trust anyone blindly? Can we trust medical experts because they are experts? Can we trust our governments because they claim to be working in our interest? Or, can we trust the companies building much necessary infrastructures, such as ventilators, hospitals, care centers etc., in such times? In manipulating the data, governments may have their own share which Donald Trump made very clear with his statement “if we stop testing right now, we’d have very few cases”. Similarly drug developing companies, medical experts, vaccine and ventilator making companies may also have their economic interests. All of them are motivated by their own interests and hence, people need to decide very wisely on what to select and what to reject.
The responses to the crisis coming from all the corners, corporate or government, need to be scrutinized before accepting them: how we respond in the end determines the result of our response. It is thus important that not only we respond but also try to understand and improve on how we respond. The world we live in constantly shapes and gets shaped by ideas. To know our current situation, therefore, we must know the ideas that shape our actions and policies and to understand them, we need to understand the popular discourses(1) in which they have been constructed.
Two major discourses, the biomedical and the neoliberal, have changed the whole world in recent times. The biomedical discourse translates a concern into biomedical language and, through this, assigns biomedical meaning and significance to the concern(2), while the neoliberal discourse tries to make human beings accountable for their predicaments and circumstances instead of looking at the larger structural and institutional forces(3).
Biomedical discourse shaping our responses to COVID-19
The biomedical discourse relies on modifying the person, assuming any difficulty to be lying in the individual’s deviation from ‘normal’ rather than in the lack of an accommodative environment. Disease and other malaises, according to this argument, are deviations from normal biological functioning and thus, biological testing and intervention focus on addressing these deviations and correcting them(4).
This is illustrated very well in the fact that the governments have argued against community testing. It has to be understood that COVID-19 has not affected us at individual levels but at a mass level and thus the governments should have done extensive testing in a decentralized fashion to control this pandemic effectively. Instead of doing that, most countries relied on individual testing, except for a few like Germany, Italy & South Korea(5).
Medicalization(6) of non-medical problems pose another great challenge for all of us to deal with. The Coronavirus has taken this to a further extent when many misappropriately associated physical and ethnic traits with a particular disease. American president Donald Trump and few others calling the Coronavirus a Chinese virus is just an example of this. Another example is when Medicalization is being mixed with racism to put people from north-eastern states of India in more vulnerable positions of getting attacked and humiliated throughout the country(7).
Neutral ventilators and vaccines?
Meanwhile, the recent race of companies towards making ventilators points us to the very same fact. Formula One racing teams have also joined the effort(8). Dyson, a vacuum cleaner company, has already received an order for 10,000 ventilators. But this is what Maurico Toro, a Colombian engineer who was part of a group that completed three different designs of open-source ventilators, has said about developing ventilators: “If they fail, the patient is very likely to die. This is what makes them so challenging to build.”(9) So the question arises, can anyone without any experience in the medical sector be granted permission to manufacture such critical products?
Similarly, the level at which the development of drugs, test kits and vaccines is focused upon by the world needs appreciation. But this should not become the reason for ignorance towards the harassment done against people with meagre resources in the name of clinical trials. In many instances it has been found, how in the name of charity, drug development companies get people to agree to clinical trials(10). By providing little support, people are made obliged to go under trial who otherwise might not have undergone, seeing the risks involved(11).
“Medicine is a scientifically neutral enterprise” does in no way mean that it is also a socially or politically neutral enterprise.(12) There are a lot of examples of abuses of medicine. There have been incidents where generic medicine manufacturers have ignored the quality and instead focused on their profits(13). The economic and political interests of a few people can manipulate the medicines to harm the broader social interest.
Hegemony of medicine
The hegemonic view of seeing vaccines as the only solution(14) also arises out of the biomedical discourse, which gives expert status to the doctors and other medical professionals. Their expert status gives them the power to define and lead intervention efforts. It is based on the view that doctors and pharmacologists know the best of an individual’s health conditions. Even if they know it best, what is the guarantee that they will act for the best of people and not for their own profits? The fine line of knowing best gets crossed, and acting best in the interest of people becomes the rhetoric as a result of the notion that experts can’t be questioned. These questions are necessary not because they will give an answer but because they can hold those in authority responsible.
The biomedical discourse, thus, suggests the universal nature of the diseases, forgetting that responses can never be universally the same. There are many social and cultural differences based upon the regions which shape the responses. During India’s former prime minister, Indira Gandhi’s time, the mass-sterilization program(15) had been responded to with hostility. Even polio vaccination programs were thought to be sterilization programs, and people became hostile towards the health workers. Considering the diverse impact of the coronavirus on different people, including both symptomatic and asymptomatic people, and on people of different ages, vaccinating everyone might be questioned. All these aspects need to be considered while dealing with the virus.
Then again, use of certain terms may be problematic in light of an already happening crisis. While talking about identifying the human protein with which the virus interacts, medical practitioners and researchers have been using the phrase “targeting host factors”. The target word is used for describing an area that has to be attacked. Practitioners of social work need to be extra careful while using such terms. It can be taken otherwise very easily by persons outside the medical field.
One more thing that needs attention here is the interplay of biomedical and neoliberal discourses that has led to the ineffectiveness of the public healthcare system. The biomedical discourse followed the neoliberal argument of spending less on health services, perceiving health to be an individual’s responsibility(16). Following this neoliberal argument, countries across the globe have cut down their expenditure on public health. Now that they find it impossible to conduct extensive testing, they are using the biomedical discourse again to hide behind.
Neoliberal discourse shaping our responses to COVID-19
The neoliberal discourse(17), as an extension of capitalism to save it, surged in the 1970s with a re-emphasis on the economic principles of the free-market. Part of the neoliberal ideology is that free-market concepts in health and social services bring better and cheaper services than those by the government. This is an argument that legitimizes the privatization of welfare service, thus letting governments cut the costs incurred on public healthcare expenditure.
The current discourse of universal vaccination gets its support from quasi-market concepts as well. The quasi-market concepts are based on the consumer’s limited capacity to pay. But ridiculous is the fact that neoliberal discourse sees limited capacity to pay as an inability to make choices and thus advocates for making decisions on a person’s behalf. While educating people about the benefits of the vaccine and assuring them completely free care, it should be left upon them to decide whether they want vaccination or not. The word ‘consumer’ reveals the intention itself. Thinking of people in terms of consumers reduces their worth and goes against the fundamental humanitarian principles which emphasizes the dignity and worth of the individual.
The principle of taking decisions on behalf of its consumers is carried forward in policy-making by the neoliberalists. It is argued that everyone acts in self-interest and it is best to leave all the actors free. Thus, it is the duty of experts to design policies and programs based on the principles of rationality and efficiency. The fact that bureaucrats, well-versed policy planners or some academicians form this group of experts contradicts the values that neoliberalists cherish, i.e. everyone acts in self-interest. If everyone acts in self-interest, so will the service users, which means they should be leading the policy-making which is going to impact them directly.
The past situation in India when migrant workers’ demands to go back to their respective villages were denied reiterates the above philosophy of neoliberalism. Delhi’s government pushed migrant workers out of the state while workers in Gujarat were not provided with facilities to return for a very long period. In the name of the public good and knowing best in workers’ interests, the governments didn’t facilitate their safe return which led to many migrant workers walking back to their homes on foot. The neoliberal principles undermine human dignity and freedom by putting forth arguments like “the government can do best for its citizens”, limiting choices of individuals that can be exercised.
The popular notion now rings with social media, where these workers are seen as problematic rather than with problems. Viewing workers as problematic associates the problem with them and not the system, thus seeing police control measures as solutions. This view goes in tandem with the social control policies(18) of the neoliberal state.
Even as railways resumed partially to facilitate workers’ return, it seems very difficult to make it possible for all of the workers, who are huge in numbers. This has been exactly the excuse of the government for why workers weren’t sent home while foreign nationals were being airlifted back to their countries(19). But the question arises, can this excuse of the government to wash off their hands be accepted? Is it not the responsibility of the government to take care of every citizen? These excuses are to hide the face of a neoliberal state according to which it is not the state’s responsibility to take care of individual citizens. So why did the state airlift Non-Resident Indians then? And can a community of migrant workers be reduced to a group of individuals instead of a community entitled to be taken care of by the state? The neoliberal ideology is to save private properties and thus, a certain class. With this understanding, it becomes quite clear why Non-Resident Indians can be airlifted, and migrant workers be left with their plight.
These are the same neoliberal principles guiding middle-class thinking, where tit-bits of relief packages given to the poor are seen as a waste of public money. Sadly, this notion has gotten into the thinking of the poor as well who think of it as ‘freebies’ too, instead of their rightful share.
Neoliberalism shaping biomedical discourse
Neoliberal philosophies have shaped even the biomedical field. This is evident from the fact that efficient, cost-effective propositions of neoliberalism resonate with the doctrines of biomedicine today. Drug-discovery and production are all subject to cost-consideration. Health care is also seen with managerial lenses. That’s not to say that these practices have not brought any good to the health care or social sector. But they have mostly negated the relationship-based practices as inefficient. Health care has to deal with human history, along with many other factors that impact the service users and these need relationship-based practices.
The biomedical discourse also legitimizes the neoliberal principle of surveillance on which many governments’ surveillance policies are based on. The Aarogya Setu app, developed by the Indian government to tell people of the risk of coronavirus around them, requires a person to keep GPS and Bluetooth always on. A French hacker has listed a number of issues with the application(20). The public is at greater risk of breach of their privacy. There has been speculation of under-the-skin surveillance, which would mean regular medical check-ups, the data of which will be monitored by the government. The current requirements shouldn’t force people to move in a submissive regime but shall give them the power of scientific knowledge which they can utilize to monitor their health.
In this light, it is very interesting to see an argument(21) explaining the dilemma faced by medical professionals at such times. This argument comes from Victor Cheng, who is a former consultant at Mckinsey & Company.
He argues that under normal circumstances, The US, and similarly most of the countries prescribe to “do what is best for the patient,” but in case of Mass Casualty Incidents (MCI), the guidelines change to “do the most good for the most people.” This has major implications on who gets the support during MCI. MCI is a situation when the number of patients exceeds the capacity to care for them. It thus happens that extremely severe patients are intentionally not treated to provide the limited care-giving resources to those whose survival chances are more.
The current situation is similar and it is difficult to provide all with the support. The exponentially growing COVID-19 cases in Italy forced their healthcare system to ignore the extremely ill and old age patients.
Towards the end, Cheng argues that while he was in his training phase, it was a very difficult decision for him to take on whether to leave an extremely ill patient during MCI to support those with higher chances of survival or to treat them with equal care. In a resource-constrained environment, it forces healthcare workers not to treat a patient who may consume too many resources or is not likely to survive even after the treatment. He further argues that death due to resource unavailability is a preventable death and we should not let this happen.
When we look at how low capacity in terms of medical necessities pushes a professional towards following MCI rules, it seems very important to allocate resources for building capacities as well as for responding to the more immediate needs of people.
Let’s take responsibility to face the crisis
This is not the dilemma of any single profession. Social workers are also facing a similar dilemma where there are many people in need, but the capacity to address them falls short. It will require efforts on both fronts to effectively deal with the issue. The shortage of professionals in all the fields and necessary equipment needs to be addressed on one side, and people affected by the coronavirus need to be given proper response on the other.
The above argument elaborating the dilemma comes from a management professional. He might have limited himself to understanding the dilemma and allocating resources accordingly. But social workers have a greater responsibility not just towards the people but also the profession. They should take up the responsibility to reach out to all other professionals with the values and principles which keep people-centric approach to the core of it.
In such grave situations, we must revisit the discourses and create one which is more suitable to the world’s needs. Elements of neoliberal and biomedical discourses that are good and useful shall always be there in the new discourse but it must have a people-centric approach in which all have the same dignity and value. This shall not be the discourse of one or a few fields but of all the fields. Our economy, policies, laws, medical practices and all other aspects of life should primarily be concerned for our lives.
In the light of this new discourse that we intend to create, we shall reshape our response to the ongoing pandemic. It will not just change the way we engage with each other but will also guide our practices. The long-awaited reforms in the subtler aspects of our lives, i.e. popular discourses can be achieved if we think now with an open mind. This pandemic can be taken as an opportunity to do away with what is not working for the world and come up with something which is fresh and dynamic.
- Discourses, as we call them, are sets of ‘language in practice’ that define our thoughts, practices, and even our identities. They are capable of legitimizing certain sets of knowledge while devaluing others. They also shape what is regarded as ‘appropriate’ ways of understanding and responding to various needs. They are, as Parton argues, ‘frameworks or grids of social organizations that make some actions possible whilst precluding others.’ This notion of discourse emphasizes it as something practiced by society as a whole rather than individuals.
- Sointu, E. (2016). Discourse, affect and affliction. The Sociological Review, 64(2), 312-328
- Wilson, B. (2007). Social justice and neoliberal discourse. Southeastern Geographer, 47(1), 97-100. Retrieved from jstor.org.
- Biomedical Model Of Health.
- Coronavirus testing: how some countries got ahead of the rest.
- It is when a non-medical problem is explained in medical terms.
- Reports of people spitting on the face of a student in Delhi and expelling paying guests out in Hyderabad tell how disastrous it becomes when medicalization of racism occurs.
- Britain orders 10,000 ventilators from F1, aerospace consortium.
- Covid-19: The race to build coronavirus ventilators.
- Clinical trials are research studies performed in people that are aimed at evaluating a medical, surgical, or behavioral intervention: What Are Clinical Trials and Studies?
- Indian example of unethical clinical trials: Thousands of Indians die in unethical clinical trials.
- Is Medicine Neutral and Universal?
- ‘Bottle Of Lies’ Exposes The Dark Side Of The Generic-Drug Boom.
- Covid-19 vaccine ‘only solution’, but may never be found, warns UK PM Johnson.
- India’s dark history of sterilisation.
- Section II: How has globalisation affected health in different countries (P. 18): Globalisation and Health.
- It has been defined by David Harvey as “a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets and free trade. The role of the state is to create and preserve an institutional framework appropriate for such practices.“
- Social control policies.
- Indians being airlifted: From Thursday, 64 flights to airlift 15k Indians stuck abroad in a week.
- Aarogya Setu Security Issue Exposed PMO, MHA Employee Data: Hacker.
- Read the full argument here: Coronavirus: Who Gets a Hospital Bed?
Illustration by Dhrupadi Ghosh
About the author
Krishna Ballabh Chaudhary is currently pursuing his bachelor’s in Social Work with specialization in rural development from Tata Institute of Social Sciences, Tuljapur (Maharashtra).