The failures of the Indian state to deliver a compassionate, coordinated, people-centered pandemic response to the COVID-19 crisis have all been spectacular—the millions of workers marching home after the brutal lockdown, the crowded election rallies and Kumbh melas (a pilgrimage and festival), the oxygen insufficiencies, and the undercounting and denial of the death toll. Beneath the spectacle of state failure another macabre calculus of life has been playing out through the infrastructures of pandemic intervention. What lies behind the current phase of devastation in India is not only the virulence and mutations of SARS-CoV2. The virus clusters with pre-existing medical conditions like diabetes and tuberculosis, a prolonged economic recession, starvation, and the gutted public and welfare infrastructure of a state run by a blatantly mercenary political party, interacting with them and producing more death and devastation. Richard Horton rightly calls this a syndemic, not a pandemic.
In this essay, we sketch the contours of devastation in four spaces: infrastructures of care, land, wages, and spaces of resistance.
Infrastructures of care
Since 2017 the Indian state has aggressively ramped up a dual assault on the healthcare infrastructure, actively gutting the public system and facilitating private players to diversify and invest in health. Public health expenditure in India, low to begin with, has been reduced to 0.34 percent of the gross domestic product (GDP); a considerable proportion of this goes into subsidies to the private sector. To put this in perspective, India spends as much on each person for healthcare as donor-dependent nations like Sierra Leone.
The government Economic Survey from 2018-2019 revealed that 60 percent of primary healthcare centers in India had only a single doctor while 5 percent had none (these centers were all located in rural areas). The emaciated rural healthcare infrastructure means that a third of rural Indians have to travel distances of more than 3 miles to access outpatient treatment. Around 68 percent of Indians have limited or no access to essential medicines. The effect of such lack of access to medical treatment and doctors in the context of COVID-19 has been catastrophic. Medical facilities in India are so inadequate that overall hospitalization rates for the sick are among the lowest in the world. While the availability of hospital beds is much lower than the global average (0.5 in contrast to 2.8 per 1,000 people), most beds are available only through small and large private hospitals.
The two-tiered system of affordability and access is most grotesquely reflected in the imbalance between public and private care facilities. In raw numbers, hospitals, beds, intensive care units (ICUs), and ventilators in the private sector are close to double the corresponding numbers in the public sector for each category. Around 74 percent of outpatient care and 65 percent of hospitalization care is provided through the private sector in urban India. Further, not all states have private healthcare options even for those who can pay for them; in poorer states like Bihar, 120 million people have 11,664 public beds, while those who can afford it struggled over 19,193 beds in private hospitals during the second wave.
Given the failure of the state in India, much like in other parts of the world, three streams of health workers and health activists are fighting in tandem on the front lines of COVID-19. First are the Anganwadi (rural childcare center) and Accredited Social Health Activists (ASHA) workers which are part of long-standing government programs like the Integrated Child Development Services. There are also a constellation of organizations that historically arose from various mass movements that can be loosely called the People’s Health Movements. Finally, there are various community networks that provide healthcare services. 70 percent of the rural population that continues to remain outside of private healthcare networks is served by Anganwadi and ASHA workers who are poorly and irregularly paid (between $40 and $68 per month). These workers are balancing their regular maternal and child healthcare responsibilities, operating under conditions of severe stress, with poor personal protective equipment, and are largely self-trained (and share their knowledge generously). Doctors and health workers from the People’s Health Movements continue to conduct door-to-door contact tracing, medical care provision, and vaccine outreach. Alongside these, several community-based initiatives and mutual aid groups have emerged for contact tracing and containment.
Despite these heroic efforts, the class divide continues to haunt families beyond the death of their loved ones as they struggle to pay hospital and funeral bills. Based on the official Indian standard for the poverty line ($11 and $14 in monthly expenditures in rural and urban areas respectively), it has been estimated by the Public Health Foundation of India that between 2011-2012, 55 million Indians were driven into poverty due to out-of-pocket health expenses. Of these, 38 million were driven below the poverty line due to expenditure on medicine alone. This can be regarded as a representative figure in a typical year; in the extraordinary circumstances of 2020-2021, that number is much higher. The typical rate of an ICU with ventilators and isolation can run up to $122 per day. Even large 400-bed private hospitals do not have oxygen generators on their premises and depend on buying it from industrial suppliers. Within this extractive health economy, an illicit market economy of oxygen, drugs, ambulances, and vital medical supplies has flourished.
In the meanwhile the Bharatiya Janata Party (BJP) has actively abdicated the responsibility of public health and, instead, facilitated a flourishing private sector with land and tax exemptions. On August 15, 2020, amid the farmers crisis, the Indian Prime Minister announced the launch of the National Digital Health Scheme (NDHS), a blueprint of a new network of health technology startups offering telemedicine, online pharmacies, and ambulance and communication networks that will supplement the existing private hospital network. As part of the new digital revolution that began with Aadhar (the universal identity scheme), the BJP intentionally seeks to refashion healthcare along the lines of the banking and education sectors. Unironically accorded the title of “sunrise industries” (along with the infamous detention centers of Assam), these networks operate within domestic and global supply chains, mirroring emergent models for global health infrastructure. They resemble vaccine research and development models in which state (including military), university, and venture capital all enter in interlocking layers of stakeholder positions. This healthcare technology revolution is a cruel joke in a country where a majority of people do not possess thermometers.
Public health started as a colonial enterprise in India with the cholera epidemics. In the 1920s, the Rockefeller Foundation initiated public health work as part of an anti-hookworm campaign in a number of locations in the Indian Ocean region. A hundred years later, the relationship between the public and private sectors, invoked and strengthened in the name of pandemic management, reveals a new regime of extortion and extraction.
Land: Special Economic Zones, vaccine capital and vaccine maitri
The relationship between vaccine capital and the government is the second aspect of the retreat of the state from healthcare. The Serum Institute of India (SII)—the largest vaccine manufacturer in the world by doses sold—was an early network partner of Vaccitech Ltd., the venture capital-backed company that develops the viral vector technology behind the Oxford-AstraZeneca vaccine. SII subsequently emerged as a sub-licensee to AstraZeneca in April 2020, a move that has catapulted it to a dominant position in the COVID-19 vaccine market across many countries in Asia and Africa. In a longer essay we have shown the dynamics through which both SII and the Indian state are imbricated within global capital flows. Here, we highlight the ways in which SII is tethered to the nation by land.
A major boost for capital in India was provided by the United Progressive Alliance government–led Special Economic Zone (SEZ) Act of 2005, which ushered in, first under Manmohan Singh and now under Narendra Modi, the large-scale grab of prime agricultural and coastal land for extraction by private capital, leading to mass displacement and ferocious people’s resistance. SEZs are an enormous burden on the government, offering corporations billions of dollars in tax and customs duty exemptions, subsidized land, and electricity. Soon after the SEZ Act, the Poonawalla family that owns the Serum Institute invested more than $100 million to set up a biotech and pharmaceutical SEZ to secure tax exemptions. The Serum Institute manufacturing facilities are today housed in one of the twenty-nine SEZs in the state of Maharashtra, managed by a company called SBSPL (Sez Biotech Services Pvt. Ltd.), a subsidiary of the family-owned Poonawalla Group. It is possible, given the high levels of political corruption in the country, that strategic donations to powerful regional political parties like the Sharad Pawar-led Nationalist Congress Party also played an important role in the ascent of the Poonawallas.
The Modi government has been steadfast in its backing of the Serum Institute, which, given the collapse of the COVID-19 vaccination program in India, indicates a stunning and perhaps deliberate level of miscalculation and lies, especially in light of prior successful history of Indian mass immunization programs. In April 2021, the Serum Institute received $400 million, an amount that is 10 percent of the entire central government vaccine budget, to ramp up production of its Oxford-AstraZeneca vaccine (known in India as Covishield). The pricing of Covishield, when weighted by its asking price for the central and state governments as well as the private market, comes out to be more expensive than the price that the European Union or the United States are paying AstraZeneca for the same vaccine. The price differential becomes even more grotesque when one factors in the obvious difference in wealth between those nations and India. The cost of a COVID-19 vaccine in the private market in India (around $8 per dose) should be seen in the context of the official poverty line; indeed, it would be perfectly reasonable to say that the mere act of having to buy a shot would drive millions of Indians into poverty.
Post-pandemic pricing and royalties are expected to be substantially (perhaps ten times) higher, if projections by pharmaceutical companies are any indication. The Serum Institute is slated to make profits amounting to $1 billion from the COVID-19 vaccine by 2021, and there are projections that its profits could soar to $4 billion by 2022. The Modi government strategy to secure the vaccination of the Indian people has brilliantly succeeded by one metric and one metric alone: the transfer of immense public money into private capital.
There is another important aspect to the relationship between vaccine capital and the Indian state: regional extraction under the cover of aid. The central pillar of Indian government vaccine diplomacy is the flagship Vaccine Maitri (Vaccine Friendship) project—the vehicle through which the Covishield vaccine manufactured by the Serum Institute (as well as the domestically manufactured Covaxin) are being supplied to around one hundred countries across Asia and Africa. Announcing the launch of Vaccine Maitri on January 19, 2021, Modi tweeted: “India is deeply honoured to be a long-trusted partner in meeting the healthcare needs of the global community”—underscoring the potential of vaccine diplomacy to serve as a counterweight to international perceptions that Modi’s commitment to the principles of liberal democracy is suspect, especially in the wake of the farmers protest, the Citizenship Amendment Act, and rampant political arrests.
Supply of vaccines to neighbors like Bangladesh, Myanmar, Sri Lanka, and Nepal enhances Indian hegemony in the region under the cover of humanitarian aid. The extractive brunt of vaccine capital is most acutely experienced by populations of these countries. In the Bangladeshi private market, for example, the Serum Institute prices the Oxford-AstraZeneca vaccine at a level that is six times more expensive in direct dollar terms than what AstraZeneca charges the European Union for the same vaccine. Pricing in Sri Lanka or Africa is also similarly at levels that are higher than what the EU or the U.S. are paying. It should be noted that less than 15 percent of vaccines supplied by India to other countries are in the form of a grant; the remaining 85 percent are commercial sales by the Serum Institute or sales under the aegis of COVAX. This is important, since extraction is dressed up as “vaccine gifts” by propaganda. Even the name Vaccine Maitri signifies a certain national-philanthropic vision that at once establishes Indian hegemonic control in the region and does so in the international relations parlance of “aid”. Unfortunately, popular movements have not challenged this language.
In fact, even domestically, pandemic aid offers improvised vehicles of direct extraction from the people. For example, the PM CARES Fund, set up by Modi in March 2020, raised more than $1 billion in donations with the stated purpose of fighting COVID-19. This money was raised from public sector companies, constituency development funds allocated to BJP members of parliament, and mandatory salary donations from various government employees. A large number of celebrities and sports players with ties to the government promoted it. Yet the fund has largely remained unaccountable to the public, stonewalled several Right to Information Act requests, and evaded public scrutiny by claiming that it is not a “public authority” (despite being hosted on a gov.in domain and being fully controlled by the government).
The myth that all Indians will eventually have access to vaccines—logistically and price-wise—should be evaluated against the harsh evidence of immiseration that vaccine capital, aided by current regime policies, is inflicting on the Indian people. Vaccine capital and government policies have all but ensured a future that will be marked by endemic deaths among the working poor; a future of tiered systems of healthcare with a tiny minority that has access to palliative care in the form of oxygen and preventive care in the form of vaccines, and a vast majority that does not.
Pressure points: food, wages
Along with the cavalier abdication of centralized responsibility for healthcare, the state has denied adequate welfare provision that could have buffered the people from the onslaught of multiple crises. Actions and consequences are well aligned. The Economist noted in April 2020 that Indian government stimulus spending during the pandemic, standing at 0.8 percent of GDP, was among the least in the world. The brutal lockdown imposed by the central government after a full four hours of deliberation during the first wave inflicted untold suffering on the working people of the country. One can celebrate the Indian success during the first wave or be surprised at the second wave fiasco if one brackets out the suicides and privations that followed the lockdown. According to the State of Working India 2021 report brought out by Azim Premji University:
the number of individuals who lie below the national minimum wage threshold ($5.12) per day as recommended by the Anoop Satpathy committee) increased by 230 million during the pandemic. This amounts to an increase in the poverty rate by 15 percentage points in rural and nearly 20 percentage points in urban areas.
Over 114 million people lost their jobs in April 2020 during the first wave Modi government lockdown, according to a CMIE report. 47 percent of working women suffered a permanent job loss, not returning to work even by the end of the year. Nearly half of formal salaried workers slid into informal work, and those from marginalized castes and Muslims moved predominantly into precarious daily wage labor. Indian fiscal response to the pandemic at the start of the second wave in 2021 stood at only 1.5 percent of GDP. This is the landscape on which the deaths brought on by the second wave are unfolding.
In a single day people experience many different emotions—from the anxiety of illness, to the urgency of treatment, to the sadness of death—all unfolding on a canvas of the routine ordinariness of everyday work. People occupy the same spaces but have nothing to say to each other. A teacher runs around trying to organize an oxygen cylinder or a hospital bed while her 18-year-old students worry more about organizing funerals than about survival. No consolidated lists exist of those who are dying but unions, institutions, and movements are trying to grapple with the loss. The teachers unions reported that seven hundred school teachers who were posted for poll duty for elections in the state of Uttar Pradesh lost their lives. From the last count we have seen, Delhi University and its eighty institutions lost around two hundred teaching and non-teaching members, while Aligarh Muslim University lost about 95 members. Meanwhile exams, evaluations, classes, and extra work continue in schools and colleges. Over 532 journalists who have worked as frontline reporters and record keepers of death have themselves died from COVID-19. The loss of so many teachers, comrades, movement activists, and journalists is an incredible loss of knowledge and of friendships. Many are languishing in jail. The People’s Health movement has written over 26 protest letters documenting these zones of assault.
There is a widespread consensus among experts that the number of COVID-19 deaths being reported by the Indian government is a vast undercount. The factor may be large: even for malaria, annual deaths officially attributed to the disease by the government are likely undercounted by a factor of 15 to 200, depending on World Health Organization data or projections by experts. Criticism of government handling of the pandemic—even pleas for oxygen on social media—are being met with threats of arrest and repression. The colonial Epidemic Diseases Act (1897), which provides enormous scope for the exercise of discretionary police power, has been deployed to harass and arrest hundreds of people for dissent, information sharing, and at times even for seeking health care, creating a suffocating dissonance between the reality of the pandemic and the state response to it. Incongruity has become the basis of being and of truth in India.
It is important to be mindful that this is unfolding within the fascistic turn of the state-society within which technologies of surveillance and political repression have proliferated, making it the third largest surveillance state in the world (behind only Russia and China). Indeed, the rapidly accelerating growth of a digital surveillance state in India, with its modern roots in the Aadhar program and most recently honed in its experiments with the Citizenship Amendment Act, is likely to reach fearsome proportions under the cover of contact tracing and vaccine access. The language of medicine is likely to provide “secular” cover to Hindutva (Hindu nationalism), as the digital battle over infection statistics and medical care spills over to its authoritarian agenda.
After denial and death
Through the past year, while millions of Indians have lived at the precipice between precarious life and death, a high-tech dystopian population management system is being worked out. As the social world in India ruptures at an alarming speed and intensity due to rising COVID-19 cases and deaths, an invisible reconstitution of the state, society, and capital is underway. There is a calculated instrumentalizing of death, a cynical contempt underlying the profit calculus of vaccines, hospitals, and illicit markets of drugs. A hierarchical caste economy and repression of dissent have bred a sycophantic culture of impunity: as violence has escalated, so has the legitimacy of the state, suggesting the seriousness of the state-social fascist turn. The syndemic has also revealed the hierarchies of what it means to be human in India. These calculations are not simply for the reasons of the state; they permeate through all of social life.
As we come to terms with the death of our friends and comrades in order to build a new resistance, we would do well to remind ourselves of the words of James Baldwin, “Not everything that is faced can be changed. But nothing can be changed until it is faced.”
The authors would like to thank Atreyi Dasgupta for insights that improved our understanding and for a careful reading of previous drafts.
Featured Image Credit: Wikimedia Commons. Modified by Tempest.
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Swati Birla is a doctoral candidate in sociology at the University of Massachusetts, Amherst. She is currently completing her dissertation The Past is a Foreign Country: The Politics of Colonial Re-territorialization in 20th Century India that connects the histories of partition in the South Asian subcontinent with the violence perpetrated against Dalits (lower castes) and Muslims in contemporary India. She has a Masters in Public Health and has been associated with the people’s health movement in India.
Kuver Sinha is an Assistant Professor of Physics at the University of Oklahoma, where he also holds the Carl T Bush Professorship of Theoretical Physics.