Public Books and the French magazine La Vie des Idées have partnered to exchange a series of essays about the COVID-19 pandemic. Today’s essay was originally published in LVdI on May 4, 2020, and in its English-language mirror website, Books and Ideas, on April 13, 2020.
In December 2019, while Wuhan province was witnessing the beginning of the actual COVID-19 pandemic, India was facing massive and violent uprisings. Hundreds of thousands of Indians protested all over the country against the discriminatory anti-Muslim citizenship law that had just been passed by its parliament—the Citizenship Amendment Act—and as a backlash, violent attacks occurred on universities and in Muslim working-class neighborhoods by armed vigilantes. Months later, the authorities were denying the presence of community transmission of the virus—despite the first cases appearing way back in January—to finally declare a 21-day lockdown at midnight on March 24, with only a four-hour notice.
This announcement in India, as in France, has triggered migration from the cities to the countryside, but of a completely different nature: in India, the internal migrant workers, day laborers and the poor—deprived of resources—have decided to return to their native villages. This tragic and deadly exodus of migrants fleeing cities is the most visible stigmata of the profound health, economic, and social crisis that this threefold essay analyses.
Accessing Health care under the Lockdown
This pandemic has brutally exposed the vulnerabilities of some of the world’s best health systems. For the Indian health system, one of the most burdened and least funded in the world, this could be a critical moment, as government facilities are already overstretched in a highly fractured, underfunded, and geographically uneven health system.1 This invites us to examine how the current crisis risks enhancing long-lasting health inequalities and how dysfunctional health infrastructures may collapse under the strain of the coming dramatic spike in COVID‑19 cases in India.
Until the national lockdown, the government’s testing strategy was relying on the assumption that no community transmission was happening in India, and that there were only foreign, imported cases.2 Basing the testing strategy on this assumption and testing only people coming from infected areas abroad may have had unintended consequences for the spreading of the epidemic.
Indeed, with the lockdown, large numbers of workers migrated internally from existing hotspots, like Mumbai and Delhi, toward their home states, like Uttar Pradesh and Bihar. Failure to acknowledge the presence of COVID‑19 infections in the community and failure to test all symptomatics in Mumbai or Delhi itself may have exposed these states to the diffusion of the virus and led to a potential explosion of cases, in places where health infrastructures are already poorer.
At the beginning of its national lockdown, India simply did not have enough testing kits, and even if the government has given licenses to private companies to sell them in India, the constraint on testing lay in the very low number of laboratories. On March 23, India had 118 accredited labs for a population of 1.3 billion with huge geographical inequalities; Arunachal Pradesh (1.5 million) and Nagaland (3.3 million) had no testing centers; Bihar had only one accredited lab for a population of 110 million. Even if states were supplied with an infinite number of testing kits, government labs would not be able to utilize them, as their testing capacity was around 90 samples per day. In three months, India has massively increased its testing capacity to reach 901 accredited labs, but that is still insufficient for its population, and important geographic disparities remain.3
Considering the high price of private testing and all the logistical problems associated with the lockdown, most Indians still depend on the public system to get tested.4 In an already stretched and underfunded public health-care system, money spent on the coronavirus tests leaves less for other public-health problems, as India spends only 3.7 percent of its total budget on health. India’s health budget is far too limited to respond to the massive need for intensive care that has been necessary in countries already impacted by COVID‑19.
If India has a lower proportion of elderly people than other countries, its government health-care facilities are limited and disproportionately burdened with patients with comorbidities—such as undernutrition, tuberculosis, diabetes, and chronic respiratory and cardiovascular diseases5—that could aggravate the COVID‑19 death toll for India. Among all infected people, the death rate is hovering around 1 to 3 percent, but among the critically ill, it climbs as high as 62 percent.6 There are great disparities in accessing intensive-care beds, as hospital beds per one thousand people for the 12 poorest states in India (which comprise 70 percent of India’s population) are lower than the national average, which stands at 0.7 beds per one thousand (compared to 11.5 in South Korea, 6.5 in France, and 3.5 in Italy). Even by most conservative estimates, experts were predicting that 75 percent of Indian provinces would run out of beds for coronavirus patients by June. In Mumbai or Delhi, that was already the case the first week of May.
Given the severe challenges faced by the public-health system and the dominance of unaffordable private health care in many Indian states, the response to the COVID‑19 crisis must prioritize the strengthening of an affordable and accessible health-care system for all, whether rich or poor, Hindu or Muslim, from Bihar or Kerala.7 But this pandemic also revealed the extreme and appalling vulnerability of most Indians to a catastrophe that goes far beyond health care. In addition, and far beyond the risk of infection, the measure taken to contain contagions—the lockdown—will have disastrous consequences for a large part of the population.
Making a Living under the Lockdown
What does “lockdown” mean in a context where people, not just the poorest, depend on mobility and sociability to make a living? Using culturalist clichés, many media pieces have highlighted the “cultural” difficulty of accepting the principle of social distancing. Long before being a “cultural” issue—if that argument is even valid—in economies where informal employment is the rule rather than the exception, and where social stability remains the privilege of a minority, social connection and movement are simply necessary for survival and protection.
The extent of informal employment in India is estimated at 80 to 90 percent of the labor force. These jobs are informal in the sense that they exclude any form of protection, contract, or guarantee of continuity. India is also characterized by the crucial roles of internal migration and circulation.8 Largely underestimated by official statistics, these displacements are thought to affect up to 150 million workers.
While these workers have been mobile for a long time, their movements have undoubtedly increased to meet the needs of a capitalist economy always in search of cheap and disciplined labor. Internal migration includes long-distance, interstate migration, with massive flows from the poorest states in northeastern India to the most employment-intensive states, located in the west and south. Internal migration also includes short-term commuting from villages to nearby towns.
The response to the COVID 19 crisis must prioritize the strengthening of an affordable and accessible health-care system for all.
With the massive decline in agriculture in recent decades, and even as India resists the rural exodus, many villagers survive by moving daily to nearby urban centers.9 Some of these migrants settle in cities, swelling the miserable mass of slums, but most remain attached to their home villages. The Indian labor force, men in particular, is thus caught in a continuous flow, moving with the seasons and years according to opportunities, networks, and, above all, the needs of the capitalist system, while regularly returning home. Home remains the locus of family and village roots and identity.10
Movement is not about just finding jobs. These generate incomes that are both low and unpredictable. At the same time, households face irreducible and ever-increasing expenses: eating;11 maintaining housing, which is often precarious and therefore requires constant renovation and improvement; sending children to school;12 paying for electricity and sometimes water and gas; observing social and religious rituals;13 and stocking durable consumer goods (such as mobile phones or two-wheeled motor vehicles) that are now required, including for work. To these regular and irreducible expenses are added unforeseen ones: health shocks, the sudden loss of a job, legal fees, theft, seizure of land following a conflict or an unpaid debt, and so forth.
To cope with this mismatch between income flows and expenditures, individuals, both men and women, mobilize complex portfolios of financial practices in which debt is central. Savings are not completely absent, but among the poorest and for a large part of the rural population, they rarely take the form of monetary savings. Jewels, grains, livestock, as well as “social investments” (reciprocal gifts or loans) are much more common. Any surplus liquidity is often reinjected into the social network.
Debt is thus a central component of daily survival.14 Given the crucial importance of movement and sociability, we can therefore imagine that the lockdown will have absolutely devastating consequences, as it already has. Testimonies collected by phone over the first three months of the lockdown in rural South India (Tamil Nadu) point to a risk of widespread impoverishment.15
Nonfarm income, typically the main source of household survival, has come to a halt, and most migrants have returned to their homes. Not only do they have no job prospects, but some are already heavily in debt, since they were recruited on the basis of wage advances.16 Those who fare best are those who depend on farm income, either as wage earners or farmers. And those who depend on subsistence crops (which have been in decline for several decades) do much better, since the products are sold locally. Most sales of cash crops, which depend on middlemen, transport, and agribusiness, have been halted.
With regard to debt, another condition for daily survival, most of the usual sources have dried up. The “formal” sources (which account for only a small share of total debt) are frozen, following a moratorium by the Reserve Bank of India. Informal sources, most often based on interpersonal knowledge and trust, are also frozen. While usually the slightest surplus is lent or given away, what is observed at present is a complete withdrawal. From landowners to housewives, all testimonies converge: given the prevailing uncertainty, everyone tends to keep their stocks, whether of cash or grain. The loss of confidence in the future causes the loss of trust in others.
In such a context, how do people manage? For now, they are “adjusting,” as we are told. They are drawing on the few savings available. While monetary savings are limited, many families, often through women’s efforts, have a few hundred or even a few thousand rupees secretly hidden, intended to cope in case of a hard blow. To get some cash, people pawn their jewelry, their vessels, sometimes even their land. They seek the protection of the local landlords, from whom they had earlier tried to extricate themselves through migration. They save on food. But this coping strategy is not sustainable.
Dying of Hunger under the Lockdown
Upon the lockdown announcement, middle-class Indians were seen rushing to shops and markets to buy food provisions. This was particularly triggered by the lack of official efforts to reassure people that they would still be able to access food shops under the lockdown.17 But others simply did not have the advance funds to save for food, and the phrase “I won’t die of corona. Before that, I will surely die of hunger” crudely summarizes many poor people’s precarious condition.
During any economic shock, the lack of savings and the high share of food in total spending are two ingredients of a nascent humanitarian tragedy. Looking at food security reveals how vulnerable Indian households are. The average share of food in total household spending amounts to 43 percent in urban India and rises to 53 percent in rural India.18
As a point of comparison, French households spent about 20 percent of their total expenditures on food and beverages in 2014.19 According to Engel’s law, the poorer a household, the larger the share of total expenditures spent on food. India’s poorest 5 percent of households in rural areas dedicate about 61 percent of their total spending to food, while in urban areas, for the 5 percent richest, this share was only 28 percent. Any economic shock is very likely to impact access to food, particularly among the poor.
Far beyond the risk of infection, the measure taken to contain contagions—the lockdown—will have disastrous consequences for a large part of the population.
In the present context, two economic consequences with regards to food are expected. The first and most dangerous consequence applies to all households that are losing their source of income. With little savings, those households who belong to the poorest segments of society are the first to be affected by the situation. This cohort includes the daily-wage earners, and especially urban migrants, who have often been left without any resource or even shelter.
A second expected effect will apply to all segments of society: the food-supply chain has been disrupted. The harvest of the spring crops was complicated, because it happened right after the lockdown, and the usual agricultural laborers could not take part in it. Besides, excess rainfall in March and April is also likely to have resulted in crop losses. Due to difficulties in food transport and export, many producers of perishable items (such as milk, fruits, and vegetables) found their revenues falling and their production lost. This has also been due to the restriction of operations in wholesale markets (mandis), which sometimes had to close because of the spread of infections. As a consequence, while procurement prices for farmers have fallen, retail prices for consumers have increased.
First reports of hunger crises cannot let anyone remain indifferent: in Bihar, an eight-year-old died of hunger just six days after the lockdown started. Since then, the database of COVID-related deaths maintained by the Impact of COVID‑19 Policies in India website has reported 138 deaths as a direct result of economic distress or hunger. More cases are unfortunately expected, given India’s nutritional situation, characterized by chronic malnutrition (lack of food balance) and, to some extent, by acute malnutrition (a visible form of undernutrition).20To fight against hunger and malnutrition, India has a long history of in-kind social programs, which were placed under the umbrella of the National Food Security Act (also known as the Right to Food Act) in 2013. Given the current emergency, the Central Minister of Finance Nirmala Sitharaman announced measures reinforcing these existing social programs and other schemes a few hours after the lockdown declaration.
The package, called the Pradhan Mantri Garib Kalyan Yojana (the Prime Minister’s Poor Welfare Scheme), involves about 21 billion euros. More recent announcements are mostly focusing on loans delivered to the private sector. These measures have met with criticism from economists. Jayati Ghosh, for example, deemed these schemes “embarrassing” given the small amount put on the table and “inadequate” because it is not targeting the most in need. Ultimately, Ghosh accused the central government of being “sadistic.” The Indian Society of Labour Economics, comprising leading economists, wrote a letter to the prime minister and state chief ministers noting that the assistance needed amounted to 434 billion euros, more than 20 times the amount in the planned scheme.22
Jobless and, for many, still stuck in urban areas, migrant workers are the worst hit and cannot claim any social benefits. The phenomenon is particularly stunning in terms of food transfers: access is conditional on owning a ration card, which most of them do not possess. The Public Distribution System has accumulated a large excess of food grain, because it is hoarding much more than usual, but it cannot deliver the grain, since there is no universal delivery of rations. In the end, this excess amount may be spoiled because it cannot be adequately stored. While ration cards and biometric authentication systems are meant to avoid corruption, it would certainly make much more sense to universalize the food distribution system, at least temporarily.
Facing the emerging crisis, private initiatives—from NGOs organizing food-distribution centers in urban areas to Sikh temples hosting and feeding the homeless—have flourished.23 Yet not only has the voluntary sector considerably dried up over the last two decades, but without huge public support, local initiatives are not sufficient. The paradox is certainly that, after chasing NGOs away in recent years, the central government had to ask for their help. As Jean Drèze warns the government: “Poor people are used to taking a lot of things lying down—when people are hungry and feeble, they are not necessarily well placed to revolt. But food riots could happen, who knows.”
In such a historic moment, one would expect national unity to be prioritized above all, and stigmatization—as well as religious, ethnic, and caste- and class-based polarization—to be relegated to the backstage. But nothing is less certain. As migrants return home, they face attacks and are ostracized by fear of infection. And it was not long before hateful discourses surfaced in this crisis, with Muslim, northeastern, tribal, or Dalit Indians all being accused of spreading the virus.24 It is yet to be seen whether and how the government will take the opportunity of this crisis to further divide or to reunite its people. The immediate concern is for the well-being of the poor and the minorities, who, as we have seen, will be the first to suffer from this crisis. For them, the consequences of the lockdown will be dramatic. They will die at home, in silence, maybe from a much deadlier thing than the virus itself: the profound socioeconomic inequalities that divide Indian society.
Given the large diversity of situations on the Indian subcontinent, regional public responses seem more adequate to circumvent the economic and humanitarian tragedy. Several states have been at the forefront, implementing ambitious emergency solutions for the most needy, including Kerala, Delhi, Odisha, and West Bengal, even though their actions are partly thwarted by stalled cash transfers from the central government. The informal sector, though badly hit by the lockdown, has also proved incredibly resilient in past crises, and this provides hope in these unprecedented circumstances. But this will obviously come at the cost of reinforcing already deep inequalities.25 Beyond the impoverishment due to the lockdown, some Indian states have already deregulated certain labor laws in order to boost economic recovery after the lockdown.
- Veena Das, Affliction: Health, Disease, Poverty (Fordham University Press, 2015); Jean Drèze and Amartya Sen, An Uncertain Glory: India and Its Contradictions (Princeton University Press, 2013); Public Health and Private Wealth: Stem Cells, Surrogates, and Other Strategic Bodies, edited by Sarah Hodges and Mohan Rao (Oxford University Press, 2016). ↩
- Testing is crucial to gauge the extent of COVID‑19 transmission in any country. India has one of the lowest rates of testing in the world, which may have masked coronavirus cases. ↩
- As of June 16, the country conducted 4.29 COVID tests per one thousand people, the lowest rate among the BRICS countries. South Korea carried out 21.35 per one thousand people, the United Kingdom 70.7, the USA 73.96, and Italy 77.66. ↩
- The government has allowed private players to conduct COVID‑19 tests; as of June 15, 27 percent of accredited labs are private ones. Unfortunately, the price cap of 4,500 INR (around 55 euros) per test in private labs is too high for most Indians. ↩
- In 2018, India accounted for a quarter of the global tuberculosis burden, with 2.15 million active cases and an estimated total of 450,000 TB-related deaths. Diabetes and chronic respiratory and cardiovascular diseases were estimated to account for 3 percent, 11 percent, and 27 percent of all deaths. Sources: WHO-India Noncommunicable Diseases (NCD) Country Profiles, 2018 and India TB Report 2019 (consulted on April 4, 2020). On the malnutrition burden, see the detailed analysis provided in the section of this article called “Dying of Hunger under the Lockdown.” ↩
- Most deaths are due to hypoxia, an insufficient supply of oxygen to the body’s tissues, or multi-organ collapse. Around 5 percent of the infected patients in India will require intensive care, and half of those admitted to the intensive-care unit will require mechanical ventilation; up to one million ventilators at the peak of the COVID‑19 epidemic may be needed. As per Ministry of Health estimates, as of March 24 there were 8,432 ventilators in public hospitals, a number that could reach 50,000 if we factor in private hospitals. Even the meager numbers quoted above hide extreme disparities in access. Intensive-care facilities, especially ones that offer mechanical ventilation, are concentrated in big urban areas and richer provinces; Mumbai alone has one thousand ventilators and Kerala five thousand, which means there is a significantly smaller number of ventilators available in some of the poorest and most rural provinces of the country. ↩
- Knowing that the average cost of private hospitalization in 2017 was 31,845 rupees (roughly 384 euros), that India’s monthly per-capita income stands at 11,254 rupees (roughly 135 euros), and that a majority of Indians do not have any health insurance, the majority of patients will not be able to afford private care once the modest public facilities are overwhelmed. ↩
- Jan Breman, Labour Bondage in West India: From Past to Present (Oxford University Press, 2007). ↩
- According to NSSO data, in 2011–12 the agricultural sector accounted for 62.7 percent of India’s employment, against 77.6 percent in 1993–94. “India Labour Market Update,” International Labor Organization, 2016. ↩
- David Picherit, “Labour Migration Brokerage and Dalit Politics in Andhra Pradesh: A Dalit Fabric of Labour Circulation,” Journal of Ethnic and Migration Studies, vol. 45, no. 14 (2018). ↩
- Self-consumption, long a pillar of food security for rural families, has declined sharply over the last decades; see the next section. ↩
- Schooling rates have risen sharply in recent decades, including for girls, the lower castes, and Adivasi, and this is to be welcomed, but it entails significant expenses, even when school is free, as a large share remains the responsibility of families (transport, school materials). ↩
- Often presented as “unsustainable” or “superfluous” expenses, these expenses turn out to be real investments that make it possible to maintain the social networks that people sorely need to protect themselves. ↩
- Yet debt implies movement and sociability, either on the part of a family member who has to move to meet a lender, or on the part of a financial provider, since some provide doorstep services. Financial-diary methods, aimed at tracing all of a household’s financial flows over a given period, confirm the intensity of movements related to financial transactions. This is even more true for women, since they are often the ones in charge of managing family budgets. A survey of this type conducted in 2017–18 in the states of Pondicherry and Tamil Nadu shows that the number of transactions (borrowing, repaying, lending, getting repaid, giving, receiving) can reach peaks of 30 transactions per week for women, 20 for men. Elena Reboul, Isabelle Guérin, Antony Raj, and Govindan Venkatasubramanian, “Managing Economic Volatility: A Gender Perspective,” Working Papers CEB 19-015, ULB (2019). ↩
- A comparable analysis in slums and refugee camps can be found here. ↩
- In some sectors, such as brick molding or sugar-cane cutting, recruitment and control of the workforce is based on a wage advance. This advance is usually repaid over the course of the season, depending on the productivity of the workers. Since the season had barely started (January), most of these migrants find themselves with a debt between 70,000 and 100,000 INR (or six to eight months’ salary for two workers). Fearing that they will not be reimbursed, employers and recruiters are claiming workers’ property titles. ↩
- See Rohan Venkataramakrishnan, “Coronavirus: What Does It Say When PM Modi Has to Tweet ‘Don’t Panic!’ after His Own Speech?” Scroll.in, March 25, 2020. ↩
- The “Consumer Expenditure Survey” data from the National Sample Survey Office (NSSO) provides the most comprehensive household-expenditure data to look at and dates back from 2011–12. Unfortunately, more recent data from the NSSO are not available. Even though a newer household-consumption survey was conducted in 2017–18, the data were never released, despite explicit demands from the research community. The central government took the pretext of survey-instrument biases to never release the complete raw data of the most comprehensive survey to study household consumption in India. But, in fact, press reports leaked that the total household spendings between the last two surveys fell for the first time in four decades. The impact of the 2016 demonetization may have affected Indian households’ expenditures in the long run, a point that the government is reluctant to acknowledge. More recent surveys from other institutions do not have the same methodological robustness, geographical coverage, or access to detailed results. These figures are derived from Tables 6C-R and 6C-U, pp. 106–7, from the report Level and Pattern of Consumer Expenditure, 2011-2012. ↩
- This figure is based on the French National Institute of Statistics and Economic Studies estimates from the survey Budget de Famille, 2014. ↩
- According to the latest 2019 estimates, India ranked 102 out of 117 countries on the Global Hunger Index, the lowest among South Asian countries (despite higher GDP per capita). The 2019 edition of the State of the World’s Children from UNICEF points out the enduring problem of hunger in India: about half of all deaths among children under five are attributable to undernutrition. Child underweight, measured as “weight-for-age,” which entails aspects of both chronic and acute malnutrition, was at a 36 percent high in 2015–16 (the World Health Organization stipulates that a level of underweight higher than 30 percent reflects a “very high prevalence”). These figures conceal important regional and socioeconomic disparities. Underweight is noticeably higher in north central and especially eastern states of India (see map): in Jharkhand (48 percent) and Bihar (44 percent), while it is much lower in Kerala (16 percent). Clearly, some regions face a heightened burden in the present lockdown. Akshay Swaminathan et al., “Burden of Child Malnutrition in India,” Economic and Political Weekly, vol. 54, no. 12 (2019). ↩
- Note: the figures are computed from the National Family Health Survey 4 (2015–16) and are plotted by district. Child underweight is computed following this definition: weight for age <–2 standard deviations (SD) of the WHO Child Growth Standards median. Population of interest: all children below five years old. Image provided by the authors. ↩
- In the announced package, cash support was set up using existing direct-transfer schemes, in particular the Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA), a cash program that provides a hundred days of guaranteed paid work for rural dwellers to fight against underemployment. But the announced increase in MNREGA wages is pointed to as just adjusting for an already planned one. This program could benefit internal migrant workers left without economic resources, but only under the condition that they manage to get back home, where they are administratively registered. Besides, recent reports from villages in different parts of the country are wary of the effective implementation of this program. As for in-kind measures, the government wants to expand the Public Distribution System, by supporting the main food-calorie intakes in India: cereals (more than 50 percent of the total calorie intakes) and pulses (about 12 percent, an important source of protein in a country consuming few animal products). But the promises may not be enough to cover the needs. Officials have also pointed out that this stock will be difficult to deliver, since private millers are facing a shortage of labor. ↩
- Ashwin Parulkar and Mukta Naik, “A Crisis of Hunger: A Ground Report on the Repercussions of COVID-19 Related Lockdown on Delhi’s Vulnerable Populations,” Centre for Policy Research Report, March 27, 2020. ↩
- See, for instance, the controversy around a caricature published in The Hindu identifying Islamic terrorists with the virus, now taken down, or a Muslim gathering identified as a virus hotspot, as analyzed in Billy Perrigo, “It Was Already Dangerous to be Muslim in India. Then Came the Coronavirus,” Time, April 3, 2020. Also see Prabhjit Singh, “Muslims Beaten Up and Abused in Rural Punjab,” Corona Policy Impact, accessed August 6, 2020. A testimony on the rise of stigmatization against northeastern people in New Delhi can be read here: Rinchen Norbu Wangchuk, “Stop Calling People from the Northeast ‘Coronavirus.’ It’s Unacceptable,” Better India, March 18, 2020. ↩
- Lucas Chancel and Thomas Piketty, “Indian Income Inequality, 1922–2015: From British Raj to Billionaire Raj?” Review of Income and Wealth, vol. 65: S33–S62 (2019). ↩