With no sign of the epidemic curve flattening in a large number of states, the political establishment continues to stress on shutdowns, home isolation and physical distancing to reduce the spread of this highly infectious disease.
These non-pharmacological or behavioural interventions are rooted in ‘social vaccine’, an approach that emphasises on the social dimension of public health.
Social vaccine goes beyond ‘treatment and cure’ and recognises the influences of broader social, economic and political determinants on health. To illustrate, individuals who are chronically poor, less educated and or socially excluded are more likely to live in insanitary conditions and engage in a wide array of risky behaviours (such as tobacco and alcohol consumption) and are less likely to invest in health promoting activities (like exercise, nutritious diet, personal hygiene etc.).
Based on the said premise, it places prime importance to social mobilisation, which would put pressure on the government to intervene with interventions and policies needed to address the structural conditions that affect individual people’s health.
The pandemic, if the current trends persist, is unlikely to follow the trajectory of the 1918 Spanish flu in terms of mortality. But like that one inflicted a heavy toll on the working class while largely sparing the British residents and wealthy Indians, the coronavirus, in all likelihood, will prey on existing structural inequities and exacerbate them.
The virus in itself does not discriminate between humans but the distribution of social determinants of health and consequently, the health outcomes do. Social determinants of health, according to World Health Organisation, refers to “conditions of daily life-the circumstances in which people are born, grow, live, work and age…”
India’s population density is 464 per square km, one of the highest in the world. But this aggregate data conceals more than it reveals because there are wide disparities in living spaces between the rich and poor communities.
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Truth to be told, India is a deeply divided country along class, caste and religious lines and the countries’ characteristics would have a significant bearing on how the COVID-19 could pan out for different communities.
During the ongoing lockdown, the upper classes have largely insulated themselves from any kind of economic disruptions. So are those in the formal sector, as they could secure a better deal from the government in terms of entitlements, leaving them less vulnerable to any unforeseen events like pandemics.
In contrast, people at the extreme ends of the income scale lack financial protection against any calamity or health shocks. According to the Economic Survey of 2018-19 report, 93% of India’s workforce is informal and migrant workers account for a large proportion of this informal workforce.
As many as 96% of the migrant workers, as per the findings of the survey conducted by The Hindu, did not receive rations from the government and 90% did not get wages from their employers during the shutdown. Clearly, the sudden lockdown further impoverished these already impoverished workers. Aside from bearing the disproportionate economic burden of the lockdown, the informal sector workers face elevated risk of infection because of their poor living and working conditions.
About 40% and 73% of households reported living in one room and two rooms or less respectively in the last census with 32% of them having piped water in their dwelling and 62% of households consuming unfiltered water.
According to some estimates, more than a half of the households in the country use shared latrines and also do not have any arrangement for garbage disposal, increasing the transmission risk for infectious diseases. Besides, more than a quarter of the population continue to defecate in the open.
The living conditions of the poor and informal sector workers, however, are the worst in urban areas.
Mumbai’s infamous Dharavi slum is a telling illustration of cramped conditions of poorer neighbourhoods. It has a population density of 277,136 per square km, the highest in Asia. As per Census 2011, the average household size of Mumbai is 4.77, extrapolating this to Dharavi implies that at least five persons live together in a 64 square feet matchbox-size room.
A notable source of infection for urban poor is the community toilet. According to a survey by TISS, one toilet seat is shared by 190 people in slum pockets of M-East ward of Mumbai.
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Another concern is about a section of workers, labelled as “essential workers” who are made to go out without any safety gear.
In short, being deprived of basic amenities both at home and work place, majority of working class Indians find themselves incapable to comply with physical distancing norms both within and outside the house, thus increasing their daily risk of exposure and the consequences have already started becoming visible in several hotspots of the country.
With a total of 496 COVID-19 cases and 18 deaths, Dharavi has emerged an epicentre of the pandemic not only in Maharashtra but also in the country. Worryingly, the virus has now infiltrated into slum pockets and shanties in many cities.
The pattern seems clear – people from lower socioeconomic strata are at increased risk of catching COVID-19 and if the narratives of frontline healthcare providers in Mumbai are to be believed, the rate of premature death is dramatically higher amongst poorer individuals. This was to be expected in some sense.
The higher mortality rate could also be the result of receiving low quality health services. It is well-known that years of neglect in terms of cuts in public health spending have crippled the functioning of a majority of the public hospitals, though it is another matter that they have now been thrown to the frontline to win the battle against the pandemic.
While the health system in India is dominated by for profit private players, the majority of Indians cannot afford to purchase private health insurance. About 4.3% of the richest 20% individuals have private insurance in India but just 0.23% of the bottom 20% have that kind of back up. Clearly, the poor and the so-called middle class are at a great disadvantage in terms of accessing quality medical care.
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Unfortunately, at present, there is no reliable data to find out the extent of the socioeconomic differentials in COVID-19 morbidity and mortality because the government does not release official data which can be disaggregated by income, caste or religion. This is not surprising given the country’s dismal record on health equity, which has largely remained unaddressed.
Summing up, careless application of social vaccines without accompanying financial cushion and enabling structures would lead to increase in structural inequities and health inequalities. It is highly commendable that even when the lockdown has hit the people who live on margins very hard, barring a few stray incidents, they have largely observed lockdown, instead of blaming the rich for having introduced the disease.
It is of utmost importance that the vulnerable segment of the population is not left to fend for themselves.
Soumitra Ghosh is Assistant Professor at the Centre for Health Policy, Planning and Management, Tata Institute of Social Sciences.
