Unequal Social Arrangements

Inequality and Epidemic

Kumar Rana

[Following is a slightly shortened version of a talk given by the author at a webinar hosted by the Bengal Institute of Political Studies on 19 May 2020]

Ever since the begining of recorded history, in equality and epidemic have been closely and complimentarily related with each other. Exploited populations contribute immensely to the accumulation of global wealth through their natural resources and human labour, but they themselves are deprived of the opportunities necessary for survival, let alone leading a decent life. With this, as Rob Wallace in his Big Farms Make Big Flu (Monthly Review Press, 2016) has elaborated, capital robs the population of the natural resources and gives them big flu in return.

In terms of health outcome with huge inter-country differences (say between the US and Liberia), there are also terrible intra-country differences (rich and poor, black and white, lower caste and upper caste, men and women).Life expectancy ranges between 49 and 84 between Chad and Japan respectively. And, again, take the in-country life expectancy gap between the rich and poor–among England's richest and poorest neighbourhoods on average, a boy born in one of the most affluent areas will outlive one born in one of the poorest by 8.4 years. DAILY loss in Europe is 20,000 per 100,000, but the corresponding figure for Africa is 80,000 per 100,000 (ourworldin       

These are not natural processes or results. Inequality in health -as has clearly been shown by Amartya Sen, Paul Farmer, Michael Marmot, and others–is a result of unequal social arrangements. "In a wealthy country", Farmer writes,
[T]he specter of biological warfare, for which there is exceedingly slender evidence, triggers a sort of officially blessed paranoia. In a poor country tightly bound to the rich one, real infections continue to kill off the poor, and we are told sternly to look harder for cheaper, more "cost-effective" interventions. At best, those of us working in places like Haiti can hope for trickle-down funds if the plagues of the poor are classed as 'U.S. security interests' (Infections and Inequalities, California University Press, 1999)

Michael Marmot (The Health Gap, Bloomsbury, 2015) has shown how poor health of the population is the result of a combination of factors including poverty, illiteracy, race, gender, and power relations. Amartya Sen brings in the powerful idea of power inequality:
Power inequalities can work in many distinct ways…. The asymmetry of power can indeed generate a kind of quiet brutality… inequalities of power in general prevent the sharing of different opportunities. They can devastate the lives of those who are far removed from the levers of control. Even their own lives are dominated by decisions taken by others (Foreword to Pathologies of Power, California University Press, 2004)

Nevertheless, unequal social arrangements are not new, and the diagnosis of ill health caused by unequal social arrangements goes back to the mid-forties of the 19th century, in the description of Marx about "de-humanization" of the labourers by the capitalists (Economic and Philosophical Manuscripts, 1844), and Engels' diagnosis of the premature deaths of the workers as "social murders" (Condition of the Working Class in England, 1845). During that time, popular theories of disease and ill health were (a) popular liberal theories, where disease results from the 'inherently weak' bodies of the poor; (b) medical theories, where disease stems from a fixed, natural entity or pathogen; and (c) the evolutionary theories of Social Darwinism, where disease is natural and inevitable, eventually eliminating the weaker races and 'improving' the human species (Fran Collyer, "Karl Marx and Friedrich Engels: Capitalism, Health and the Healthcare Industry", in Fran Collyer (ed) The Palgrave Handbook of Social Theory in Health, Illness and Medicine, 2015). Marx and Engels showed for the first time that, in a capitalist society, the very bodies of the workers become the property of the bourgeoisie. The present endemic reinforces the hundred and fifty year old diagnosis–alas, at a very high cost, millions of lives, and terrible uncertainties in the coming days–uncertainty of survival, employment, food and nutrition, education, and dignity.

The present-day analyses of inequality, of course, have expanded much to take into account other elements of inequality: Race, gender, caste, and so on. However, the central point remains the same: It is unequal social arrangement that allows the powerful the "birth right" to violate human rights of the powerless.

And what about today's catastrophe—Corona Virus Pandemic!The burden of Covid- 19 is most terrible among the most deprived: ethnic/racial minorities, Black or African American minorities and Hispanic groups, lower poor, lower castes in India, and so on. As Lancet writes, [In UK] " Evidence is continuing to emerge that the pandemic could be disproportionately affecting people from black, Asian, and minority ethnic (BAME) communities…. However, despite people from ethnic minorities being younger on average than the white British population, and therefore theoretically less susceptible to infection, they were found to have higher death rates…. the death rate for people of black African descent was 3·5 times higher than for white British people, while for those of black Caribbean and Pakistani descent, death rates were 1·7 times and 2·7 times higher, respectively" (Lancet, May 8, 2020, S0140-6736(20)31102-8). In the USA, a 0 study of data compiled from hospitals in 14 US states, African Americans represented 33% of COVID-19 hospitalisations, despite only making up 18% of the total population studied (https://www.cdc. gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minori ties.html).

Indians do not have any hard data. But, what people know for certain is that the burden is much higher for the people living in the slums than in other neighbourhoods. And, who lives in the slums? Everybody knows. As Richard Cash and Vikram Patel write in the Lancet, "Pandemics rarely affect all people in a uniform way. The Black Death in the 14th century reduced the global population by a third, with the highest number of deaths observed among the poorest populations. Densely populated with malnourished and overworked peasants, medieval Europe was a fertile breeding ground for the bubonic plague." (May 5, 2020 S0140-6736(20)31089-8)

A little public investment in the health sector and caring about the population could have saved many lives. It is well known that the case fatality rate in Covid- 19 is much lower than in many other epidemics. And, what was needed was just proper hospitalised care. Then it required hospital beds, doctors, nurses, and other health staff, and equipment. Under the dictum of capital, country after country has gradually withdrawn from the health sector.
In India, on an average, a government doctor attends to 11,082 people, more than 10 times than what the WHO recommends (Directorate of State Health Services & National Health Profile, 2018). Shortage of medical staff, especially doctors, hospital beds, and equipment–staff, stuff, and space, in Paul Farmer's insistence–claimed hundreds of thousands of lives. So, what governments can do, and have done, is to turn the responsibilities on to the shoulders of the population: They asked the populations to protect themselves–and if people in the slums of Dharabhi, or Belgachia, or, Bhalsawa, cannot afford to keep "safe distance" from getting infected, what can the government do?

The government, had it been civilised and cared for its citizens, could do a lot. It could shift the population and make decent and safe living arrangements, it could provide immediate diagnostic and medical facilities, it could provide all things that a human being requires to live. And, as estimations say, only a tiny proportion of the wealth that the super-rich have exploited and amassed could sufficiently meet the demand for a civilised arrangement to come to term with Covid-19. Then, as Marx and Engels diagnosed in the Communist Manifesto one and half century ago, "the executive of the modern state is but a committee for running the common affairs of the whole bourgeoisie", and cannot disobey the dictum of capital.
The survival inequality is of course not the only concern. There are other–perhaps greater–concerns. A recent UN Policy Brief estimates that due to suspension of immunisation programmes in 37 countries, 117 million children risk contracting measles–in 2018, 140,000 children died of measles ( /wp-content/uploads/2020/04/Policy-Brief-on-COVID-impact-on-Children-16-April-2020.pdf). History shows that pandemic takes a huge toll on child survival: in 1918, the year of Spanish Flu, India's under-5 child mortality shoot up by 10 percent point. The policy brief says,
188 countries have imposed countrywide school closures, affecting more than 1.5 billion children and youth…The indirect effects on child survival stemming from strained health systems, household income loss, and disruptions to care-seeking and preventative interventions like vaccination may be substantial and widespread…. an additional 1.2 million under-five deaths could occur in just six months due to reductions in routine health service coverage levels and an increase in child wasting.

The UN policy brief says, "All children, of all ages, and in all countries, are being affected, in particular by the socio-economic impacts and, in some cases, by mitigation measures that may inadvertently do more harm than good.What are the harms? The effect of pandemic will be harsher for the deprived. In India, children of deprived sections, owing to lock down, are remaining hungry, getting further malnourished. They are not receiving Mid-day Meals in school–what is being distributed in the name of Mid-day meals is no more than chicken food. And, since their parents have no income, they cannot provide enough food–governmental arrangement is paltry, and social arrangements are insufficient. A document from the Bangladesh policy brief says that some of the households had to reduce their household expenditure by more than 75 per cent.

While early data indicates that the mortality rates from COVID-19 may be higher for men, the UN Chief said "nearly 60 per cent of women around the world work in the informal economy, earning less, saving less, and at greater risk of falling into poverty." In the U.S. alone, virtually overnight, 22 million people lost their jobs in early April. Economies in Africa south of the Sahara, Southeast Asia and Latin America would be hit much harder due to their relatively high dependence on trade and primary commodity exports. In India, the total job loss is estimated to be 13 crore, resulting in increasing the unemployment rate manifold to 35 per cent from 7 per cent. It is a matter of common sense that one day's income loss of a labourer has much higher implication on his life than what is the case with a salaried employed or a trader. Now, with the loss of job for months can one imagine how the labourers are surviving?

If the treatment the working class as a whole and the migrant labourers in particular are receiving is not dehumanisation, then what is it? The ruling class ably stewarded by the Indian government has been treating the workers as mere creatures–no matter if they die in hunger, malnutrition, and diseases–the consequential cycle. Capitalists have not only commodified the labourers but also commodified the virus–they have been using it for their own benefit. Using Covid- 19 as an excuse, they are depriving labourers of the bare minimum rights that they were legally entitled to. The state has been guaranteeing the profit of the capitalists but there is no grain of support to millions of workers. Before announcing the lock down the Indian government did not pay any heed to the question as to how would the migrants live? How would the labourers across the country earn their livelihood? Similarly, there is no concern for non-Covid patients across the country–many of whom have died without being able to see a doctor. The private sector–the blue eyed boy of the government–has disappeared from clinical care. It will, however, return when things become normal enough that it can plunder enough again. For the time being, however, the private sector has found a happy hunting ground in the equipment market–in connivance with the corrupt politicians and bureaucrats.

 Before the pandemic, the government had the UAPA and other laws, but they could not be applied en-masse. The pandemic gave it the opportunity to shut down all protesting voices–from civil society and opposition parties. The pandemic has given rise to a new height to power inequality.

Vol. 53, No. 22-25, Nov 29 - Dec 26, 2020