India in COVID-19: A Tragedy Foretold

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.

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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).²⁰

To 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.”

 

Conclusion

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.