health care access – UAB Institute for Human Rights Blog

Republic At Risk: COVID-19 in India

While the novel coronavirus (COVID-19) has impacted almost every corner of the globe, parts of Asia are still just beginning to see the systemic effects of the pandemic. As the second most populous country in the world, India has experienced a rise in COVID-19 cases and deaths which magnify current injustices across the country. This blog addresses India’s importance within the COVID-19 pandemic and its relationship with human rights issues concerning feeble governance, police brutality, migrant displacement, and Islamophobia.

As of late-July, over 1.4 million Indians have been diagnosed with COVID-19, while over 32,000 have died from the virus. India’s western state of Maharashtra is currently the country’s epicenter with over 375,000 confirmed cases of COVID-19. On the southern coastline, the state of Tamil Nadu has the country’s second-largest number of confirmed cases (210,000+), while the capital territory of Delhi in the northwest has recently exceeded 130,000 confirmed cases. Additionally, the southeastern state of Andhra Pradesh has confirmed over 95,000 cases of COVID-19. Interestingly, India’s most populous state, Uttar Pradesh, has only confirmed just over 65,000 cases which triggers questions about access to COVID-19 testing and essential resources throughout the country.

A National Lockdown

In late-March, the Indian government issued a nationwide lockdown that lasted two months. Inconveniently, the country’s 1.3 billion inhabitants were given less than a 4-hour notice of this initial 3-week lockdown. The effects of this tall order were apparent on day one since so many people throughout the country live on a daily wage or in extreme poverty. As food supply chains became compromised and manufacturing facilities closed, the country’s unemployment rate reached a 30-year low. All the while, facilities such as schools and train coaches have been converted into quarantine centers. These attempts have seemingly delayed the inevitable spike of COVID-19 cases. However, it is speculated that the low number of confirmed cases is the result of low testing rates.

This outcome has been attributed to lax contact tracing, stringent bureaucracy, and inadequate health service coordination, namely in Delhi where cases have recently surged. However, as India reopens, the number of confirmed COVID-19 cases has increased. Additionally, the introduction of newly-approved antigen kits have allowed for rapid diagnostic testing, although testing is not to be distributed proportionately. More specifically, family members and neighbors of people who have tested positive for COVID-19 claim they are not being tested. Also, in several instances, the family members of people who have tested positive for COVID-19 were not being informed about their loved one’s diagnosis. After much scrutiny, however, local health authorities in Delhi have attempted to pick up the pieces by using surveillance measures such as door-to-door screenings, drones, and police enforcement.

Policing the Police

While the recent murder of George Floyd sent shockwaves across the world, India has been confronting its own relationship with police violence. In June, two Tamil Nadu shopkeepers, J Jayaraj and his son Bennicks Immanuel, were arrested for keeping their business open past permitted hours during the national lockdown. They were then tortured while in police custody and died days later in the hospital. Due to this event garnering considerable attention and protesting, six police officers have since been arrested for their deaths. Also, Tamil Nadu police officers with questionable track records will now undergo behavioral correction workshops. However, this incident is no anomaly. According to the National Human Rights Commission (NHRC), nine Indians die in judicial or police custody every day. In comparison, official government crime data claims 70 people were killed in Indian police custody in 2018. This striking differential in reported custodial deaths suggests India’s law enforcement entities lack accountability and are riddled with corruption.

Much like the United States, India has a history tainted with police violence that disproportionately affects minority groups, namely people from the lowest Dalit caste, indigenous groups, and Muslims. With no choice but to work during the national lockdown, many of India’s poorest citizens were beaten by police. Videos of these violent acts surfaced across social media. In opposition, there have been over 300 reported incidents of attacks on police officers alone in Maharashtra. These recent events highlight the need for the Indian government to pass anti-torture legislation that curbs police violence. By ratifying the United Nations Convention Against Torture, the Indian government can help remove the colonial vestiges of power and punishment that have plagued the country for generations.

Migrant Displacement

The sudden announcement of a national lockdown had tremendous repercussions for the tens of thousands of daily-wage migrants throughout India. Overnight, businesses closed and transportation systems suspended throughout the country, placing many migrant workers in precarious economic conditions. Men, women, and children hunkered down in urban centers across the country as they waited for their workplaces to reopen but to no avail. In response, India’s major cities experienced an exodus of migrant workers attempting to return to their home states on foot, many living hundreds, even thousands, of miles away. As thousands trekked home, many died due to dehydration, exhaustion, sunstroke, and traffic accidents. Reports of pregnant women delivering, and subsequently carrying, their children in these horrific conditions have also surfaced.

A recent Supreme Court order has urged the well-being of India’s 100 million internal migrant workers affected by the hardships of COVID-19 by requiring the government to register, feed, shelter, and transport them until they return home. However, these efforts are seemingly inadequate because most internal migrant workers have not qualified for these “relief packages”, while those who have qualified are experiencing limited coordination between state governments. All the while, India has ended its national lockdown and many migrant workers are trying to return to their places of employment. Some employers are sponsoring the return of their lost workers, while some must find their own means to return. As such, some states have sought local help to accommodate the loss of migrant workers which places many Indians in even greater economic uncertainty.

Migrant workers walking on the shoulder of a highway during the nighttime. — The Indian Lockdown Migration – IV (PB1_4728). Source: Paramvir Singh Bhogal, Creative Commons.

Pathologizing Islam

COVID-19 in India has contributed to a surge in anti-Muslim rhetoric that suggests this religious minority group is purposely spreading the virus. The rumors began after Tablighi Jammat, a Muslim missionary group, held a congregation outside of India and, soon after, many members tested positive for COVID-19 in New Delhi. Videos on WhatsApp and various television channels have proliferated this misinformation to the Indian public alongside the usage of phrases such as “corona jihad” and “corona terrorism”. To make matters worse, the Bharatiya Janata Party (BJP)-led government, which is notorious for its Hindu nationalist sentiments, has begun incorporating Tablighi Jamaat-related statistics to its daily COVID-19 briefings. Such rhetoric has influenced a slew of Islamophobic acts such as prohibiting neighborhood entry, restricting sales by street vendors, and even violent attacks.

These recent events fuel an existing fire that posits Muslims as reproducing at a pace to outnumber Hindus and compromising “Mother India”. However, recent efforts between Muslim Indians and allies has been quick to respond to this COVID-19 misinformation because they have been protesting India’s new citizenship law that offers amnesty to various non-Muslim immigrants and a nationwide citizen count that necessitates proof of documentation dating several years back. The BJP has made it apparent that Muslims are not welcome in India and weaponized the COVID-19 pandemic as a part of its Islamophobic campaign. As such, these efforts corner Muslim Indians into political and economic insecurities that pressure apartheid at a time when unity is paramount.

Masked medical professionals walking with a crowd in the background. — coronavirus-india-rep-image-hyd. Source: Anant Singh, Creative Commons.

Human Rights in India

As displayed, India has an array of prevalent human rights issues that have compounded since the arrival of COVID-19. Among the efforts that could protect Indians from these concerns are labor protections, health care reform, civil rights for minority groups, food security, and income equality. However, Prime Minister Narendra Modi has propagated a narrative of self-reliance that undermines these systemic inequalities. Service provision has highlighted these discrepancies because resources are scarce, and those with power and privilege are placed to the front of the line. In addition, many Indians cannot abide to the recommended sanitation and social distancing measures due to living in poor, dense settlements in the heap summer when water sources are limited.

Although tearing through communities and disrupting daily life in India, the COVID-19 pandemic can be viewed as an opportunity for social change. More specifically, it is well within the power of Parliament, the media, civil society, and local governments to right these wrongs by ending communal bias and impartiality within state institutions. Addressing these corrupt and oppressive practices will not only remediate the effects of COVID-19 but help shape an equitable future for a country that is rapidly becoming a global super power and expected to be the most populous country in the world by 2027. Real change and equity in the world’s largest democracy could send a much-needed shockwave of justice across the globe.

STD Rates Among the Poor and Homeless in Alabama

by Kelsey Johnson (guest blogger)

As of 2018, approximately 38.1 million people in the U.S. live below the poverty line. Furthermore, on a given night, over 550,000 people experienced homelessness.

Of those numbers, more than 800,000 Alabama residents live in poverty, making it the sixth poorest state in the U.S. Approximately 3,434 people experience homelessness in Alabama on a given night.

Poverty and a lack of adequate housing are considered human rights violations, as they interfere significantly with an individual’s ability to live safely and with dignity. For people experiencing poverty and/or homelessness, these situations impact all aspects of their lives, especially their physical health.

One way that these health issues manifest is in the prevalence of sexually transmitted diseases (STDs) and HIV/AIDS among these populations. Overall, rates of STDs, particularly chlamydia, gonorrhea, and syphilis, are at an all-time high in the U.S., according to a 2019 report from the Center for Disease Control and Prevention (CDC). In 2017-18, there were nearly 2.5 million total reported cases of the three STDs, including over 1.7 million cases of chlamydia, 583,405 cases of gonorrhea, and 115,045 cases of syphilis.

Two urban areas in Alabama, Montgomery and Birmingham, are among the top 20 U.S. cities reporting the highest rates of STDs, including HIV, syphilis, gonorrhea, and chlamydia. Mobile and Huntsville also ranked in the top 100. Alabama has the fourth highest rate of gonorrhea infections in the country. Additionally, as of 2016, there were 12,643 people in Alabama living with HIV.

While the CDC report examined STD prevalence among various demographics, it did not focus on STD rates among low-income or homeless populations. However, a literature review published in 2018 in the journal Sexually Transmitted Diseases found that STD prevalence ranged from 2.1% to 52.5% among the homeless adult population.

This study also identified many of the factors that increase the risks of contracting an STD among homeless individuals. A number of these risk factors also apply to individuals living in poverty, even if they have stable housing. Additional studies offer more insight into the recent rise in STD cases, as well as recommendations for how to decrease their spread among all populations.

Factors contributing to STD prevalence among low-income and homeless populations

There are several factors that contribute to the prevalence of STDs in low-incomes and homeless communities, including lack of access to affordable prevention and treatment options; lack of comprehensive sex education; the comorbidity of issues like mental illness or substance abuse, and the stigma surrounding STDs.

According to a 2019 report by the National Coalition of STD Directors, “…poverty is both a cause of infection, and a barrier to the ability to seek care. Poorer populations are less likely to receive appropriate sexual health education, suffer higher rates of substance abuse, and may have more trouble accessing sexual health services.”

Poor or homeless individuals are less likely to have health insurance, or resources to pay for out-of-pocket healthcare costs. Many individuals living in southern states, including Alabama, fall into what is known as the coverage gap, meaning they make too much money to qualify for Medicaid, but not enough to pay for health insurance.

Even if individuals have health insurance, their coverage may be limited to certain providers or services, and may exclude STD testing or treatment. The time and money it takes to travel to healthcare facilities, especially in predominantly rural states like Alabama, also present a barrier to care, even for insured individuals.

Additionally, budget cuts have forced many STD clinics to close or reduce their services. The loss of these clinics is harmful because not only do they often provide STD testing and treatment on a sliding fee scale, they are staffed by individuals with specialized knowledge in diagnosing and treating STDs.

The other primary factor in higher STD rates is a lack of comprehensive sex education. As the NCSD report states, “States typically define the broad parameters of sexual health education in public schools. Not surprisingly, these parameters vary widely among states.” Studies show a correalation between insufficient sex education and higher STD rates. Kathie Hiers, the CEO of AIDS Alabama, says the state represents a “perfect storm” for the spread of AIDS and other STDs, in part because of its “poor educational systems that often ignore sexual health.”

This lack of education about STDs also perpetuates the stigma surrounding them, which prevents people from seeking treatment, according to Hiers. Other conditions that are prevalent among poor and homeless populations, including mental illness, incarceration history, and intravenous drug use, also make individuals more susceptible to STDs, and present barriers to seeking treatment.

How to prevent the spread of STDs among low-income and homeless populations

The studies and experts cited in this post offer several recommendations for steps that can be taken, nationwide and in individual states, to decrease the spread of STDs among low-income and homeless populations, including:

Removing financial barriers to healthcare, including adopting Medicaid expansion. The Alabama Hospital Association estimates that by adopting Medicaid expansion, an additional 300,000 residents would be eligible for health insurance.
Increasing or restoring funding to public health agencies and STD clinics that provide free or low-cost testing and treatment.
Improving access to healthcare facilities through transportation and operating on evenings and weekends.
Providing comprehensive sex education in schools. In 2019, the Alabama House of Representatives failed to address a bill that would have made the state’s sex education curriculum more scientifically and medically accurate. The bill would have updated the curriculum’s language to address “sexually transmitted diseases” as “sexually transmitted infections,” which is considered less stigmatizing.
Expanding resources to support homeless individuals, and increasing their access to stable housing. A 2016 report by the Homelessness in Alabama Project offered several specific recommendations for addressing homelessness in Alabama.

Additional Resources

COVID-19 and Healthcare

COVID-19 has had a significant impact on the lives of billions across the globe from a disruption of our daily lives to the loss of loved ones to the severe financial burden that has been placed on the world economy. One aspect of society that has been disproportionately affected is the healthcare system. Aside from the financial impact on healthcare systems the way we receive our general healthcare is changing rapidly with this new pandemic. While our primary concern internationally is getting control of this pandemic, non-infectious and chronic conditions are still prevalent and at an increased risk of being neglected.

With the increase in COVID-19 cases in every part of the country, people are being discouraged from coming to hospitals and doctors for non-emergent care. This means that primary healthcare visits either have to be postponed or done through telehealth, which is a remote visit. While telehealth is a great way to have normal checkups without having to go to a doctor’s office, many insurance plans don’t cover telehealth, which makes it harder to afford necessary visits safely.

Additionally, many people no longer have the financial stability they used to. With the downturn in the economy, not only are people who are working making less, but there are also some that have been laid off or furloughed and no longer have access to insurance through their employer. A quarter of those that remain insured have deductibles that are $2000 or higher, which they can no longer afford. This means that in addition to postponing primary care visits, more emergent and necessary visits are being put off.

Those with chronic conditions face more barriers than before to receiving health care. Those with underlying conditions are more likely to have a severe case if they contract COVID-19. However, they need continual care that must be done at least occasionally face-to-face. For example, people with cancer must continue to receive treatment, but many times that treatment makes them immunocompromised. Because of the increased risk, many hospitals no longer allow visitors in, which can decrease patient morale. Many patients also run the risk of having their treatment delayed due to coming in contact with someone that has tested positive for Covid-19. Many chronic conditions, like cancer, are time sensitive, so delays in treatment can be devastating.

Another group of people that have had their healthcare greatly impacted by COVID-19 is pregnant women. There are many check-ups that women are recommended to attend when expecting a baby to ensure the best health possible. However, with the pandemic, that has become harder. There is no evidence that pregnancy makes it more likely to have a severe case of COVID-19. Additionally, there is no evidence that it can be transmitted to a fetus. It’s still important that pregnant women do everything they can to prevent coming in contact with COVID-19. To help in that effort, many OB/GYNs have reduced the number of visits pregnant women should attend in person, switching these visits to telehealth visits.

While a mother cannot pass COVID-19 to her unborn baby, the baby can contract it after birth from her or any other caregivers. To prevent spread to new babies, nurses, and doctors, many mothers are tested when they arrive at the hospital to give birth. Additionally, those that have scheduled C-sections are sometimes tested at home.

doctor performing a checkup on an infant — Dusti Tellez, a registered nurse at Naval Hospital (NH) Jacksonville’s maternal infant unit, holds a newborn baby for a checkup. Source: U.S. Navy, Creative Commons

According to UNICEF, around 116 million babies will be born during the COVID-19 pandemic. These babies along with the babies born shortly before the pandemic will be missing important doctor’s appointments. The appointments in the first two years of a child’s life play a large role in the child’s overall health for two reasons. First, children will typically receive vaccinations at these appointments, which will keep them from contracting deadly, but preventable diseases. The growing number of children who will not be receiving their vaccinations on time raises concerns about outbreaks of diseases that we’ve kept at bay while also still in the midst of the COVID-19 pandemic. Second, these visits are a good way to track the health of children early as screening for conditions, such as developmental delays, are frequent, and catching them early can give kids with these conditions a helpful jumpstart. Because of these two reasons, many experts advise parents to keep children’s visits up to date, but parents are still hesitant.

In addition to regular checkup visits, people are hesitant to go to the emergency room when they need to for non-COVID-19 related illnesses and emergencies. Hospital visits in the Baptist Hospital system in Memphis, TN were down 27 percent between March 15 and April 15 compared to the month before. Additionally, they noticed that the people that were coming in were more likely to have to be admitted instead of treated and sent home. This means sick people are staying at home longer for fear of COVID-19, and some are dying at home from treatable conditions.

Finally, there are areas of healthcare that are overlooked when we mention essential healthcare workers. My mother is a home health physical therapist, which means she goes to people’s homes to work with them. She mainly works with elderly people, and often visits nursing homes and assisted living facilities. According to her, these places have stricter requirements than before when it comes to letting people in: visitors have to have their temperature checked and have a symptom screening. Some facilities don’t even allow visitors anymore, even for wound care or physical therapy. While therapy might not seem essential, it is often used in this population to prevent accidents, like falls, that would send them to a hospital, where they would be even more at risk of contracting COVID-19.

While many of the changes to the healthcare system are temporary, like the decrease in general healthcare visits, some may become permanent. Telehealth has been shown to be beneficial for healthcare visits that don’t require tests and scans. In fact, many shy children have felt more comfortable with these visits. Additionally, the precautions taken by nursing homes and assisted living facilities when it comes to screening visitors make sense during flu season as the flu kills the over 65 population at a disproportionate rate. While the pandemic has changed some things for the worst, it has also helped us find where some changes need to be made to increase our safety in the future.