Even as the death toll in the U.S. from COVID-19 climbs to 63,583 and increasing numbers of Americans are forced to decide whether to forgo potentially life-saving treatment or face bankruptcy, we are bombarded daily with pro-corporate rhetoric opposed to universal health care systems. We are told that the market is the most efficient mechanism for distributing goods and services, including health care, and that social democratic policies like Medicare for All are a fiscal “fantasy” that would leave us with inferior quality care.
But the COVID-19 crisis has thrown up a stubborn challenge to this pro-market logic. Despite high levels of private sector health care spending, the U.S. not only has fewer hospital beds per capita than other wealthy nations but also has huge regional disparities in how those beds are distributed. Doctors find themselves turning to the black market for personal protective equipment (PPE), ventilators and crucial medications as supplies dwindle. In the chance that an effective vaccine is developed in the next year or so, private pharmaceutical companies pose a serious threat to affordable access.
This story is eerily familiar to other nations ravaged by neoliberal economic policy, like Italy and the U.K. As one analyst put it, the U.K. is scrambling to rebuild a “safety net after destroying it for a decade.”
Yet there is one ray of hope in this disaster: The neoliberal consensus is slowly but surely unraveling. Social democratic policy interventions are also becoming more appealing to the masses. While the typical media coverage of the topic does not reflect it, recent polls show that a majority of U.S. Democratic Party voters, for example, prefer a government-run universal health care system to private insurance.
The insurgent campaign of Democratic Party presidential candidate Sen. Bernie Sanders, which has foregrounded Medicare for All, has played no small part in this radical shift in public opinion. Similarly, in the U.K., former Labour Party leader Jeremy Corbyn has aggressively advocated for the restoration of a fully public National Health Service. But, while these high-level endorsements of universal health care are extremely important, they are not enough to get us on the pathway to health care as a universal right. That effort will require a sustained and militant mass movement, with widespread participation from the working classes.
In building this movement, it will benefit the left to examine the successes and failures of various movements for universal health care across the world. In this regard, the history of the communist party rule in the South Indian state of Kerala should be part of our curriculum. It is an example of how a territory with the population of California squeezed into a land mass the size of Vermont and New Hampshire can achieve remarkable health outcomes despite low industrial capacity.
At the same time, as Patrick Heller pointed out in his pioneering work on communist rule in Kerala, the key to these successes lies not only in a people-centric policy approach which has been shaped since the late 1950s by a coalition of left parties known as the “Left Front” led by the Communist Party of India (Marxist), but it is also, crucially, defined by the degree of grassroots participation in the everyday affairs of the state. This has led to impressive public health outcomes in Kerala, including, most recently, in its response to the coronavirus pandemic.
Since the moment the state detected its first case of COVID-19 at the end of January, it has been leading the way in the national battle against the pandemic. Kerala’s approach to pandemic relief offers valuable lessons not only for India but also — perhaps especially — for advanced capitalist countries which have been hit the hardest by the outbreak.
Kerala’s Response to the Outbreak
Given the large number of Keralans who work or study internationally, it is unsurprising that India’s first cases of COVID-19 were detected there. It has, so far, experienced two waves of infection. The first was at the end of January, when a handful of students from Kerala who had been studying in Wuhan’s Hubei province returned home and tested positive. The second began a month later, when a couple returned from Venice to the district of Panthanamthitta and failed to alert the authorities of their travel history.
Thinking on its feet, the district administration culled data from the family’s phones and from CCTV cameras in the area. Based on that, it developed a detailed flow chart of all of the exact locations visited by the patients along with approximate dates and times. The flow chart was then widely circulated on social media along with a hotline for those who may have come into contact with the family. The hundreds of calls the administration received in the days that followed helped it plug the gaps in the flow chart.
Such epic contact tracing initiatives, though tedious, have been at the heart of the state’s “people-intensive” pandemic response. People who are identified in contact tracing are — depending on their situation — sent for testing and kept in hospital isolation wards or monitored at home for 28 days. On April 13, the state also announced a new policy of “reverse quarantine” where the most vulnerable sections of the population, such as elderly people or patients with respiratory illness, are isolated at home.
But surveilling so many people for long periods of time has not been easy. It has required, in addition to the usual frontline labor force, a veritable army of 235,000 health care volunteers and the help of various local governance bodies — including (but not limited to) the flagship poverty eradication and women’s empowerment scheme known as the “Kudumbashree,” which has over 277,000 neighborhood units across the state. This force of civil society activists and volunteers has carried out essential activities ranging from manufacturing over 145,000 masks and 2,000 liters of hand sanitizers to delivering books, medicines and groceries to people in home quarantine. They also staff the new state-run call centers which check up on the mental health of those who are home-quarantined.
The state has also taken a number of important macro-level measures to curb the economic and mental hardships faced by the general population. A ₹20,000 crore ($2.6 billion) stimulus package announced on March 19 is enabling the early distribution of elder pensions, midday meals for low-income children and food grain rations for everyone respective of their economic status. It is also funneling ₹2,000 crore ($261.4 million) into a fund controlled by the Kudumbashree Mission to distribute low-interest loans, and ₹1,000 crore ($130.7 million) to bolster the state-run Rural Employment Guarantee Scheme. And while the state is not undeserving of criticism for its treatment of the most precarious section of its workers — migrant laborers — it has, still, outperformed the rest of the country. Data recently obtained from the Home Ministry showed that Kerala, which constitutes merely 2.76 percent of the Indian population, has set up 69 percent (over 4,000) of the nation’s relief camps and shelters for migrant workers.
Finally, despite facing the near-universal challenges of possessing an insufficient quantity of PPE and ventilators, Kerala has astoundingly displayed one of the highest rates of patient recovery anywhere. Out of its 497 total recorded cases, 383 people have recovered so far and only four have died. More Keralans have succumbed to the coronavirus in New York than in Kerala. This stunning fact can partially be explained by the generally above-average quality of care in Kerala, but more so because the state was able to keep the health care system from being overwhelmed through its two-pronged approach: rigorous contact tracing and strict isolation measures.
The state’s impressive response to the pandemic is only the most recent move in a long line of development achievements by the communist-led state, including land reforms, a literacy rate of over 90 percent by 1990 (when the all-India rate was only 52.2 percent), infant mortality at a fifth of the national average, life expectancy at least 10 years higher than the national average, and numerous effective interventions targeting reproductive health. The remarkable feat of attaining social development indices comparable to the Global North at a low cost has been dubbed the “Kerala Model” of development.
Movements Are Essential to Kerala’s Success in Fighting the Pandemic
It is widely recognized that without collective action this model — even with radical and committed action by the state — would have failed. Popular movements have often held the state’s feet to the fire and enforced accountability. For example, most recently, the Kerala Sathra Sahithya Parishad (KSSP), which describes itself as a revolutionary people’s science movement, has been scrutinizing the governments’ pandemic response. On April 11 it issued a statement against “sanitizer tunnels” installed in some localities in the state, arguing that the tunnels were unscientific and warned that the hypochlorite solution being sprayed is not meant for use on the human body.
Historically, KSSP has also authored numerous important reports, including a landmark study on the morbidity load across the state and its “relationship to socio-economic variables,” as well as an extensive household survey on the health impacts of aerial spraying endosulfan, a chemical pesticide, on cashew plantations. Groups like KSSP don’t just act as a pressure mechanism — without them the state may not have achieved many of its development goals; for instance, KSSP alone mobilized over 20,000 volunteer teachers for the mass literacy campaign mentioned above.
Movements have long been part of the fabric of Keralan society, even predating the communist rule in the state. In the late 19th century, massive numbers of marginalized people — particularly women and Dalits, members of the formerly “untouchable” caste — waged highly militant successful struggles against the hundreds of esoteric and caste-based practices upholding regional feudal power relations. Some have called this period Kerala’s renaissance for its democratization of education, eradication of irrational thought and expansion of personal freedoms. The communists’ strength came from the fact that they built their base among these very movements of the downtrodden, developing a vast network of trained cadre who could deliver the party’s message to every village.
But, being a social democracy in the context of a capitalist country is not without contradictions. Most problematically, the state entered into a prolonged fiscal and economic crisis starting in the 1980s, from which it has not fully recovered. Kerala was pressured to liberalize its economy in line with the rest of the country, although Kerala never fully embraced it in the full-fledged way that the Communist Party of India (Marxist) did in West Bengal. Social inequality still expanded dramatically, which has also been reflected in the health care sector. In the period from 1986 to 1996, for example, the number of beds in public hospitals increased by 5.5 percent (to 38,000), whereas the number in private hospitals rose 40 percent (to 67,500). Today, as much as 70 percent of the poor rely on the private sector and are forced to spend as much as 40 percent of their income on health care as against 2.4 percent by the rich.
Perhaps sensing the need to put forth an alternative to bourgeoning neoliberal doctrine, the Left Front introduced the People’s Campaign for Decentralized Planning (or PPC for short) in 1996. The PPC aimed at building up local self-government bodies, which would carry out projects and programs formulated through people’s participation. Initially, 35-40 percent of the state’s budget was allocated for these local deliberative bodies, and they involved over 1.8 million people in the first two years. Here, the KSSP also played a central role in helping to identify local resources and capacities to carry out activities ranging from the production of eggs and vegetables to the revitalization of public health. This was a major feat; unfortunately, as various kinks arose in implementation in the following years, the PPC’s effectiveness has diminished. Such efforts like the PPC need to be revisited and revived. One hopes that the coronavirus containment effort, dependent as it is on these existing networks, will be a major impetus to do so.
There are many other concerns with Left Front rule that can’t be ignored, including the way it has failed to address the oppression of marginalized groups like Dalits, Adivasis (Indigenous people) and women, and has sidelined serious environmental issues. These are concerns that the left in the U.S. must take seriously while drawing on the best achievements of Kerala’s social democratic movement.
In the U.S., we are at a crossroads in our history of social struggle. In the past 10 years we have seen an unprecedented growth of movements like Occupy, Black Lives Matter, #MeToo, Red for Ed, the Climate Strike and Standing Rock. These struggles — and the tremendous racial, gender and economic inequality which has generated them — paved the way for an open socialist, Sen. Bernie Sanders, to run a highly energetic presidential bid. Yet, in the wake of the suspension of Sanders’s campaign, there are a number of left-wing thinkers who are cautioning against a “return to movementism” and elevating elections as the only arena of “mass politics.”
The Kerala experience offers a valuable lesson to the U.S. left: Medicare for All — let alone a Sanders-type presidency — would be tremendously limited without militant working-class participation at all levels of society. Kerala’s impressive social-democratic achievements, including its battle against COVID-19 were undergirded by the robust participation of ordinary people. As we assess the post-Sanders landscape, the correct strategic question is not how to avoid descent into movementism at the expense of electoralism, but how can we build up independent movements which can act as levers for progressive electoral candidates, so that the best of Sanders’s policies may succeed.
In the time of COVID-19, and the much bigger looming threat of climate catastrophe, the survival of humanity depends on the power of the people.
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