The Hindu Editorial Analysis | 31st Dec’19

Table of Contents

Amenable
Disparate
Invisibilize
Exacerbate
Axiomatic
Inconspicuous
Repressed
Emulation
Rife

Kerala leads race for UN development goals

Bihar at bottom of NITI Aayog list
Kerala tops the States in progress towards the UN’s Sustainable Development Goals (SDGs), while Bihar is at the bottom of the NITI Aayog’s SDG Index, released on Monday.
Himachal Pradesh and Sikkim have joined the four southern States among the front-runners, which scored over 65 points out of a possible 100.
Ending hunger and achieving gender equality are the areas where most States fall far short, with the all-India scores at a dismal 35 and 42 points respectively. On the other hand, the NITI Aayog has given India an overall score of 60 points, driven mostly by progress in clean energy and sanitation (88); peace, justice and strong institutions (72); and affordable and clean energy (70).
The SDGs are a set of 17 broad-based global goals adopted by the United Nations General Assembly in 2015, and intended to be achieved by 2030. With one-sixth of the world’s population, India is key to the achievement of the goals.
The UN has developed 232 indicators to measure compliance by member nations. The NITI Aayog has adapted the monitoring approach to the Indian context, with 100 indicators of its own for the Index.

Only 40% of these indicators were used for last year’s baseline index and hence, the two indices are not directly comparable. However, it is still interesting to note that Kerala has retained its top slot, while Uttar Pradesh, Odisha and Sikkim have shown the most improvement.
The second SDG — zero hunger — shows sharp divergence in the performance of States, with little middle ground. Kerala, Goa and parts of the north-east, including Mizoram, Nagaland, Arunachal Pradesh and Sikkim, have scored above 65, with Goa at 75 points.
However, 22 of the States and Union Territories have scored below 50, with the central Indian States of Jharkhand, Madhya Pradesh, Bihar and Chhattisgarh scoring below 30, showing high levels of hunger and malnutrition.

On the fifth SDG — gender equality — almost all States fare poorly. Only Jammu and Kashmir, Himachal Pradesh and Kerala have managed to cross 50 points. The indicators considered include crimes against women, eradicating sex selection and discrimination against daughters, and access to reproductive health schemes, as well as indicators showing women’s economic and political empowerment and leadership.
A sex ratio of 896 females per 1000 males, a 17.5% female labour participation rate, and the fact that one in three women experience spousal violence all contribute to a low score countrywide.
The Swachh Bharat Mission has contributed largely to the high scores on the sixth SDG — clean water and sanitation — although that was helped by the fact that four out of seven indicators dealt with toilets and sanitation, while only one indicator was related to safe and affordable drinking water.
All States and Union Territories except for Delhi have scored above 65, with the national capital scoring poorly on the percentage of urban households with individual household toilets (less than 1%) and, oddly, providing no data on districts verified to be open defecation free.
The forest cover in the country increased by 3,976 square kilometres (sqkm) but with the sharpest declines in the northeastern States of Arunachal Pradesh, Manipur and Mizoram, according to the 2019 edition of the India State of Forest Report (ISFR) that was made public on Monday.
At 7,12,249 sqkm, the forest cover constituted 21.67% of the nation’s geographical area or 0.12% more than last year.
The ISFR, a biennial exercise, assesses the forest and tree cover, bamboo resources, carbon stock and forest fires.
The top three States showing an increase in forest cover are Karnataka, Andhra Pradesh and Kerala.
Tree cover, defined as patches of trees less than 1 hectare and occurring outside the recorded forest area, grew by 1,212 sqkm. Tree and forest cover together made up 25.56% of India’s area. In the last assessment it was 24.39%.
Not a concern now’
Environment Minister Prakash Javadekar said the declines in the Northeast weren’t “yet a matter of concern.” The States had a much higher proportion of forest than most States — Mizoram (85.4%), Arunachal Pradesh (79.63%) and Nagaland (75%) — and the declines in forest were still small. The Centre had policies in place to address this over the long term.
He explained the decline in tree cover inside forests as due to tribal populations getting “land titles” (patta) and the rise in trees outside the forest area as due to an increase in tree plantation and afforestation activities.
The report, however, shows that the quality of this forest — in terms of the canopy density of the trees comprising forest patches — is wavering. While 1,755 sqkm of ‘moderately dense forest’ (MDF) became ‘Very dense forest (VDF), 2,782 sqkm of MDF regressed into lower quality ‘open forest (OF),’ Scrub forest’ or ‘Non forest.’
The forest cover within the Recorded Forest Area, or that which has been officially classified by States or the Centre as ‘forest,’ showed a 330 sqkm decrease, but ‘forest’ outside such recorded area increased by 4,306 sqkm.
Tree outside forest was found to comprise nearly 29.38 million hectares, which was 36.4% of the total tree and forest cover in the country. Maharashtra had the largest extent of such tree outside forest.
The nation’s tree and forest cover has largely hovered from 21-25% and is short of the National Forest Policy, 1988, which envisages 33% to be under such cover.

AFSPA extended in Nagaland for six months

Entire State declared a ‘disturbed area’
The Ministry of Home Affairs (MHA) has declared the entire State of Nagaland as a “disturbed area” for six more months, under the controversial Armed Forces (Special Powers) Act (AFSPA) which empowers security forces to conduct operations anywhere and arrest anyone without prior notice. The AFSPA has been in force in the Northeast since 1958. Nagaland got statehood in 1963.
In a notification, the MHA said the central government is of the opinion that the area comprising the whole state of Nagaland is in such a “disturbed and dangerous condition” that the use of armed forces in aid of the civil power is necessary.
“Now, therefore, in exercise of the powers conferred by Section 3 of the Armed Forces (Special Powers) Act, 1958 (No. 28 of 1958) the central government hereby declares that whole of the said State to be a ‘disturbed area’ for a period of six months with effect from December 30, 2019 for the purpose of that Act,” the notification said. Presently, AFSPA, 1958, is operational in the entire States of Assam, Nagaland, Manipur (except Imphal Municipal area), three districts namely Tirap, Changlang and Longding of Arunachal Pradesh and the areas falling within the jurisdiction of the eight police stations in the districts of Arunachal Pradesh, bordering Assam.
Centre’s notification
The notification declaring Manipur and Assam as “Disturbed Areas’ has been issued by the State governments. For Nagaland, the notification is issued by the MHA. The Act has not been withdrawn despite a framework agreement being signed on August 3, 2015 between Naga insurgent group NSCN-IM general secretary Thuingaleng Muivah and government interlocutor R.N. Ravi in the presence of Prime Minister Narendra Modi.
Student protesters have exacted their first concession from the powers that be. The Prime Minister has denied any official intent to compile a countrywide National Register of Citizens (NRC), nor to build detention centres to contain those classified as non-citizens. The implication is to delink any connection between the NRC and the Citizenship (Amendment) Act (CAA), 2019.
This signals an official intent to shift the focus of public attention from the NRC to the CAA. The reworked message: What could be more benign than an Act that reaches out to oppressed religious minorities in the neighbourhood? Those who continue to protest must either be misinformed, misguided or ill-intentioned.
The larger picture
There is a fourth possibility: the student protesters may be right. To make sense of the protester’s point of view, one needs to look beyond the list of those included, which is indeed the benign half of the picture. The other half is the list of those excluded. Only a grasp of reasons that explain both sides of the list, those included and those excluded, can give a sense of the whole picture.
Why does the list of minorities include only those from Pakistan, Bangladesh and Afghanistan? Why not from other neighbours such as Sri Lanka, China and Myanmar? Could it be because the ruling powers in these countries are not officially Muslim? I can think of only one reason why a government pledged to Hindutva would exclude ‘persecuted Hindu’, such as the Tamils of Sri Lanka, from the list — because their oppressor does not claim to be an official representative of Islam. Here is one clue to the logic that informs the CAA: the legislation intends to present the perpetrator as Muslim, and only Muslim.
No ‘victim’
For a second clue as to the kind of reasoning that informs this double process of exclusion and inclusion, let us focus on the exclusion of the most persecuted minorities in the region, such as the Rohingya of Myanmar or the Uighurs of China. Just as the legislation recognises only Muslim perpetrators, it recognises no Muslim victim.
To complete the list of those excluded, we need to focus on oppressed Muslims in countries where the ruling power officially claims to be Muslim. Those oppressed may be targeted as groups such as Ahmadiyya or Shia, or they may be identified as individual critics. One such instance was headlined by the Karachi daily, The Dawn, of December 23, 2019: “Academic Junaid Hafeez Sentenced to Death on Blasphemy Charges by Multan Court.”
Whether intended or not, it is these reasons that make the CAA a demonic rather than a benign legislation. More than helping out persecuted minorities, its effect will be to demonise and isolate one group, Muslims, as exclusively a group of perpetrators. The official discourse thus seeks to present Muslims as a politically and morally legitimate target for persecution by a government-mobilised majority.
It is this stratagem that student protesters have exposed.
The student protesters consciously claim to follow an earlier generation of nationalist leaders — evoking names such as Gandhi, Ambedkar, Azad. Inspired by the Independence movement, they pledge non-violent action. Indeed, these non-violent protests have exploded in the face of brutal official repression.
A continuing process
Like the Independence movement, the protest is not a standalone event, but an ongoing process. It resembles what the South Africans used to call “rolling mass action” at the peak of anti-apartheid mobilisation. Few have bothered to draw up a blueprint or even define a destination for the protests.
Though many demand “independence”, the call does not adequately sum up what these protests are about.
Perhaps more accurate is the accompanying call for the defence of secularism, specifically as incorporated in the Indian Constitution.
Secularism does not necessarily translate into denouncing the presence of religion in the public sphere. Instead of a simple opposition between secularism and religion, protesters tend to distinguish different trends within secular and religious realms. They embrace secularism which accommodates diversity, but not the French-style laicity that openly shuns it. A recent Op-Ed favourably contrasted religious sentiment that reaches out to embrace as opposed to fundamentalisms that thrive on exclusions.
Their pledge to emulate the earlier generation of nationalists also hides the important ways in which the protests depart from the Independence generation in significant ways.
The protest leadership comes from loosely coordinated student groups. There are hardly any luminaries in the protest, whether from the world of finance or industry or entertainment.
They keep a distance from political parties. Indeed, many of these youthful protesters seem disillusioned with party politics.
Rather than look to representative democracy as the guarantor of people’s rights, they are in search of new and popular ways of defining and defending these rights.
In pointing to new possibilities, they seem to follow a trend that can be discerned at a global level, in places such as Lebanon, Sudan, Algeria, France, Chile, Hong Kong, and so on, in what we may define as the contemporary post-Arab Spring era.
One repressed, inconspicuous theme can be discerned across the timeline of development of healthcare in the United States since the early 20th century. As the Mayo brothers’ initially modest set-up (Mayo Clinic) prolifically expanded into the prototypical ‘multispecialty group practice’ in the U.S., concerns that such arrangements would be bereft of the personal touch in patient care were vociferously raised.
This continued through the evolution of more and more organised structures like Health Maintenance Organisations (HMOs) in the forthcoming years, which were criticised for turning healthcare into a marketable commodity sold by unfeeling healthcare providers in supermarket-like institutions, destitute of traits like empathy, regard and loyalty. That such concerns didn’t pick up systemic momentum in the U.S. is axiomatic, as much as the fact that U.S. healthcare ended up as one of the most impersonal healthcare systems.
Problematic proposition
The NITI Aayog’s proposed 15-year plan for Indian healthcare entitled “Health Systems for a New India: Building Blocks — Potential Pathways to Reform” outlines prospects of such an infelicitous turn in Indian healthcare. While the report makes otherwise commendable proposals for health system strengthening — including elimination of informality, merging of fragmented risk pools, and reduction of out-of-pocket health spending — the proposal to consolidate small practices into larger business-like organisations appears problematic on multiple fronts.
That nearly 98% of healthcare providers have less than 10 employees is identified as a negative trait, to be dealt with through a set of incentives and disincentives favouring consolidation. Apart from cost and competition-related concerns, an enthusiastic pursuit of it could portend an exacerbated commodification of healthcare from the bottom-up. The report’s bent towards the U.S. HMO model further adds to such a foreboding.
Loyalty and longitudinality form vital pillars of the patient-physician relationship.
The edifice of these is built upon a substratum of mutual trust, warmth, and understanding that accrues over time between a patient and their personal physician. Momentary and haphazardly physician-patient interactions in a system that limits access to one’s ‘physician of choice’ are incapable of fostering such enduring relationships. It is in this context that the role of a family physician becomes instrumental. Apart from providing comprehensive care and coordinating referrals, a family physician’s longitudinal relationship with their patient helps in a better understanding of the patient’s needs and expectations and in avoiding unnecessary clinical hassles and encounters — which in turn reflects in better outcomes and increased patient satisfaction.
Widespread commercialisation of care over the past few decades has entailed that the family physician is a dying breed in India today. And it would be of little surprise to learn that this has a sizeable role in impairing the doctor-patient relationship, manifesting popularly through violence against healthcare providers. In a setting of overcrowded public hospitals, and profiteering healthcare enterprises, where the patient-physician interaction is largely fleeting and transactional, mistrust in the healthcare provider and its gruesome implications are not difficult to anticipate.
Advantage of small clinics
Studies have demonstrated that healthcare received in small clinics indeed scores higher in terms of patient satisfaction than that received in larger institutions. This increased satisfaction manifests as better compliance with the treatment regimen and regular follow-ups, culminating in improved clinical outcomes. Kelley JM et al, in a systematic review and meta-analysis of randomised controlled trials, have established that patient-clinician relationship has a statistically significant effect on healthcare outcomes. Indeed, disregard for this aspect in health services design is bound to entail a sizeable cost to the health system.
However, the subtle, fuzzy, and perceived non-urgent nature of this problem keeps it from assuming significance to policy- makers — as a result of which doctor-patient relationship considerations are largely invisibilized in the policy discourse in favour of more pressing concerns like lack of funds and manpower. Time and again, however, this omission has surfaced in the performance of health systems worldwide. As India looks forward to a long-term healthcare plan, neglecting this consideration could be of sizeable consequence.
The need for empathy
A popular myth often floated is that considerations regarding emotive aspects of healthcare such as empathy and trust are disparate from, and thus cannot be realistically factored into, hard-headed health policy and system design considerations. But, in reality, these are entirely amenable to cultivation through careful, evidence-based manipulation of the health system design and its components. It would necessitate, among other measures, installing an inbuilt family physician ‘gatekeeper’ in the health services system who acts as the first port of call for every registered patient.
The NITI Aayog’s long-term plan provides a good opportunity to envisage such long-called-for reforms, but that would require not the U.S. model but the U.K. model to be kept at the forefront for emulation. We have already taken a minor, yet encouraging, step of sorts by introducing Attitude, Ethics, and Communication (AETCOM) in the revised undergraduate medical curriculum.
One hopes that the pronouncement of this long-term healthcare plan doesn’t indicate adoption of U.S.-like healthcare policies. The plan needs to be revisited to ensure that healthcare clinics delivering patient care don’t transform into veritable supermarket stores marketing medical services any further.
For some time now, in political and bureaucratic circles, a smugness has crept in that India has arrived, that it is no longer impoverished and that whatever be the problem, be it scarcity of onion or shortage fighter jets, it can buy itself out of trouble.
In reality, India is desperately poor; it is a country where malnutrition is rife, where children continue to drop out of school in alarming numbers every year and where millions of untrained young people enter the workforce unfit for anything more than manual labour of the hardest kind. In a brake-less hurtle, India’s potential demographic dividend is morphing into a nightmare.
All this is best captured in the UN’s Human Development Index (HDI) rankings where India is a lowly 129th out of 189 countries. China, by contrast, occupies the 85th spot and Sri Lanka an even better 71st position.
Low per capita PPP
One of the reasons for the illusion about India’s wealth is a seductive but dubious country-to-country comparison. In GDP (PPP), India comes a flattering third after China and the United States. The rub is when we start measuring per capita GDP (PPP) as the latest IMF figures indicate.
India’s GDP (PPP) is 43% that of China and only 59% that of Indonesia. It is only slightly higher than that of Vietnam, a surprising star in education, which will get past India sooner than expected. At 118th place, the country is already ahead of India in HDI.
In terms of per capita GDP (PPP), India is much behind France and U.K., each with no more people than Tamil Nadu or Rajasthan. The GDP (PPP) of ASEAN is 80% of India’s, while its population is less than half. Once we strike off its poorest (Myanmar, Cambodia, Laos and Vietnam) the regional grouping’s stellar performance shines more lustrously.
India of course, has the strength of numbers. A recent issue of The Economist states: “as a single country,” it “has tremendous negotiating power.” But all this will cease to matter as other economies in Asia pick up.
Common sense doesn’t prevail
In a recent essay, former Governor of the Reserve Bank of India (RBI) Raghuram Rajan observed that the present government, “instead of building gigantic statues to national or religious heroes,” should be building “more modern schools and universities that will open its children’s minds, making them more tolerant and respectful of one another, and helping them hold their own in the competitive globalised world of tomorrow.” But when did common sense ever prevail in a country that for decades has shown a tendency to pursue the trivial and the unimportant with indefatigable vim?
As Asia integrates, India is busy painting itself into an isolationist corner. Talking about a $5-trillion economy is not going to get us there but a larger vision of what can be achieved e.g. one which envisages embracing Asian economic integration, should help pay attention to things that are enabling East Asian countries to fire — educating and skilling their young and creating infrastructure that works for all.
The Regional Comprehensive Economic Partnership (RCEP), which India refused to join after years of negotiation, is a case in point. It is precisely the kind of programme India should have joined with one of the most vibrant economic regions in the world, one with the potential to bring immense prosperity to not just itself but South Asia as well. But then, as Ramesh Thakur writing in the Japan Times on the country’s refusal to join the RCEP observed, “India has an unmatched capacity to look an opportunity firmly in the eye, turn around, and walk off resolutely in the opposite direction.”