I: COVID-19 pandemic and the politics of risk: Perspectives on science,state and society in India

Introduction

In the British officers’ accounts of the late 19^th-century epidemics of colonial India, we find references to the Indian population’s refusal to cooperate with the state-imposed quarantine regulations and the disposal of corpses of suspected victims, and this was attributed to the unruly character of the colonial subject. In the 21^st century, however, it has been possible to announce consecutive and total lockdowns through televised speeches of the Prime Minister (PM), without much institutional preparation and protocol. The population living in the cities, which were the main sites of infection, seemed to have followed the rules and remained a more or less disciplined public during the lockdown despite the distress it produced. Whether it was the populist communication strategy of the PM, the role of the various forms of media, fear of the disease, awareness about microbes, the stringent enforcement of a nationwide lockdown, nationalistic sentiments or any combination of these that produced the compliance among the urban lower-middle and middle classes, this is in itself a subject worthy of study.

How far a social group’s health behaviour is conditioned by existential imperatives and to what extent it is influenced and shaped by the surveillance of different authorities is an important sociological question. Have we arrived at the moment when the ‘lifeworld’ is invaded by the ‘system’ in the terms that Habermas (1987) proffers? The lifeworld refers to the world that is experienced by subjects as something given and self-evident. It is shaped by language and symbols and characterised by practical rationality. The system, on the other hand, denotes the expertise and technical rationality of science and technology that serves the purposes of institutions. The influence of the system is necessary and important for society in Habermas’s view, ¹ but the phrase ‘invasion’ of the lifeworld by system indicates concern over the fact that strategic and technocratic rationality emanating from expert institutions might increasingly be conditioning our consciousness, expelling communicative and mutual interaction that normally characterises the lifeworld. In this vein, Emily Martin (2000) demonstrates that scientific rationality gets disseminated through popular communication especially when she talks about the idea of the ‘immune system’, which dominated the American imagination after the World Wars, and superseded the earlier anatomical view of the body. The role of medical sciences in shaping the lived experience of laypeople and creating a market for health products is a pervasive theme in the sociology of health.

While the pandemic does provide a crucial vantage point for examining the intricate relations between science, state, and society, there are no unambiguous answers to questions about the forces invading the lifeworld in the context of culturally diverse, highly stratified, and state-centred societies like India. Besides, the process is not uncomplicated as phrases like ‘invasion of the system’ or, ‘rationalisation’ present it to be, because they assign the primary and lead role to science, technology and capital as the driving forces. In India however, science, technology, capital and traditional knowledge are entangled with the state, which in turn is constituted by certain political and social classes, defying the logic of linear conceptualisation. I could however, put a few pointers in place. For the limited purposes of this article, I focus on shifts in health behaviour distinguishing it from the responses to the total lockdown which produced far-reaching effects in themselves and would constitute an independent field of inquiry.

Three interrelated aspects of the pandemic, touched upon in the sections to follow, promise to be useful lines of inquiry: how the pandemic was framed, the stakes on the vaccine as the sole saving force that relates to such framing, and the influence of these expert discourses and the state-enforced regulations on the health behaviour of the people.

Framing the pandemic: Infection and the ‘risk’ of infection

An infection caused by a germ is an ontological representation in that the germ can be identified and visualised with the help of tools and localised in the individual body (Canguilhem 1991). The ‘risk of infection’ in a population, on the other hand, is an estimation of the probable spread of the pathogen in a collective or social body and is thereby based on certain assumptions. Different scientific disciplines project the risks based on their mandate—geography deploys spatial distribution; social epidemiology uses real statistics and social medicine turns to analyses of systemic public health responses in prior outbreaks along with socio-economic data. For instance, in assessing the ‘plague’ outbreak of 1994 in Surat, there was a difference of opinion between the scientists and microbiologists appointed by the Centre and the committee of the State government consisting of social medicine and public health experts with ground experience as to whether it was the plague at all (Sivaramakrishnan 2011). The former took a strictly germ-centered view, called it the plague and searched for its bacterial origins and characteristics, while the latter saw it as a consequence of mindless industrialisation, poor civic hygiene and human behaviour.

In the case of COVID-19, mathematical modelling projections for India had put the risk of spread of infection at several crores ² and predicted four crore deaths due to COVID-19 ³ which propelled the state to act hastily. But mathematical models lack empirical detail, especially in new situations and they operate from abstract assumptions. Unlike numbers ‘which belong[] in a stable state of being’, mathematical models are ‘enumerated entities’ based on imagined possibilities (Verran 2015: 367, as cited in Rhodes and Lancaster 2020: 179); they tend to exclude the numerous possible intervening variables between the pathogen and population.

‘Risk of infection’ is more of a political concept as the perception of risk could be selective. The concept of risk has of course received considerable attention from social science theorists. For instance, studies show how the perception of risk in the case of 21^st-century pandemics has excessively focused upon pathogens coming from a limited species of birds than those present in human beings, owing to the economic value of the birds (Dingwall et al. 2013). Further, risks for certain sections of society may be put above the risk to others or risks of another kind depending on the perception of decision-making authorities.

COVID-19 initially came across as a primarily metropolitan and urban affliction from which the regions with low population density and poor connectivity were spared. In India, the states with higher urbanisation and transport amenities saw a concentration of cases and fatalities, whereas the predominantly rural and remote regions were fortunately protected by their weak connectivity or some unknown factor. Most epidemics in post-Independence India have been localised in urban and industrial hubs or rapidly developing regions. This historical insight got lost when pure modelling schemes were relied upon to decide a massive, total country lockdown instead of a regionally adapted shoe-leather approach to public health (Priya et al. 2020). The lockdown ⁴ transferred the economic burden of preventing the risk of infection onto the urban and rural working population, whose risk of death by accidents and exhaustion and the risk of malnutrition and other infections was obliterated. While the idea of prevention may sound benign, social science research shows that prevention often curtails the liberties of the marginalised to protect the privileged (Mykhalovskiy and French 2020: 5). The very path of primary transmission of COVID-19 after the initial outbreak in the Chinese city of Wuhan reflects class inequalities. Again, the role of people travelling to China on business and returning home or infected people holidaying with their families in Ski resorts in Northern Italy, France, and Austria (Arber and Meadows 2020, as cited in Scambler 2020: 144) has been commented upon extensively.

The COVID-19 pandemic has indeed created an unprecedented situation, but my point here is that ascertaining its nature is the real challenge. In the first wave, the morbidity and mortality rates have been quite diverse for different regions within the country and they have been lower for Asia and Africa from the very beginning which could be due to any number of genetic and environmental factors: genetic climatic protection against the virus, cross-immunity from other viral infections or trained immunity from BCG (Bacillus Calmette–Guérin) vaccines and/or younger age structure of the population ⁵ and high temperatures ⁶ . Interpretation and counter-interpretations of data have made the evaluation of the projected risks fraught and the question as to whether a total lockdown was indeed required can perhaps never be answered. In the maze of averages and ratios, scientific viewpoints, and images in the media, the truth about the pandemic remains a negotiated one; the projections cannot be validated as they are not falsifiable, to put it in Popperian terms (Popper 1959). The lack of modelling predictions for the second wave ⁷ and the helplessness of the scientific community stands in strange contrast to their proactive role during the first wave.

The significance of the vaccine should also be seen against the background of these uncertainties in framing the risk of infection and what it augurs for the future of public health in India.

The politics of prevention and the role of vaccines

Although governments of the world have been compared for their performance and analysed threadbare for their failures, incompetency, and omissions in the past months, the COVID-19 vaccine has been accepted with a big sigh of relief as the only way out of the crisis. This marks the final triumph for the heroic form of clinical medicine imploded by the economic interests of the pharmaceutical industry, which has hitherto had to face consistent opposition from the protagonists of social medicine who advocate an effective mix of civic measures, community involvement, and well-distributed primary health care services.

India’s pharmaceutical capacities have grown multi-fold in recent decades, and it is among the global players in medicinal production. This pharmaceutical prowess and the cheap availability of antibiotics and medicaments have protected the vulnerable sections from outright mortality from infectious diseases (Hathi and Srivastav 2020). But it has kept them in a permanent state of morbidity due to repeated infections in the absence of fundamental amenities such as sewage, drinking water, and nutritious food (Chaplin 1999), and perhaps this explains the Asian enigma of lower mortality even with high malnutrition. Pharmaceutically driven public health did not promote health even in the West. Ironically, ‘health consumption grew exponentially, but that did not mean that people were healthier’ (Zachariah et al. 2010: 10).

India houses the world’s largest vaccine-producing capacity in the private sector and has trained manpower in handling vaccination due to decades of targeted campaigns for specific diseases. But this strength conceals the major gaps and weaknesses in its health care delivery system. The neglect of the health sector infrastructure in India began to show up in the nineties with liberalisation (Qadeer et al. 2001) and has led to a situation in which the vaccine has emerged as the only viable solution available to us. Prolonged lockdowns, economic stagnation, and the huge burden on the limited numbers of health workers and medical staff have increased the premium on vaccines, such that emergency approval of vaccines for public use has had to be made without completing phase three of clinical efficacy trials. ⁸ A huge chunk of the health budget has got allocated exclusively for the purchase of vaccines ⁹ which have become a ‘global public good’ to the exclusion of other damaging diseases such as diarrhoea and respiratory diseases at the local level that tend to be ignored (Das 2015: 183). While the discovery of a COVID vaccine in India and upscaling its production is a commendable technocratic solution to an emergency, this can neither be a substitute for better health infrastructure, nor is it sustainable in the long run. Does this mean that vaccines have to be invented and deployed for every new germ and its mutation and our people have to take more and more vaccines by the year? Is it not beneficial for health outcomes to consider options that strengthen the host instead of attacking the pathogen? This brings me to the last section on how far the framing of the disease and institutional interventions have influenced the health behaviour of the people.

Schooling society and health behaviour

Beck (1992: 23) suggests that unlike the logic of wealth distribution where class determines consciousness, in the distribution of risk, ‘consciousness determines being’. As mentioned in the very beginning, the urban population in India has shown a reasonable degree of compliance to the pandemic-related health messages from the state administration.

Consider the case of the deadly 1896 plague outbreak in Mumbai said to be brought by a steamship from Hong Kong, which caused 12 million deaths ¹⁰ and was first diagnosed by an Indian practitioner of Western medicine. Radical measures of control were adopted by the British administration in its wake such as appointing spies to check on houses, forcible quarantine, preventing annual pilgrimages and making village officials responsible for providing food and accommodation to those who were quarantined. At that time, the Indian subjects suffered from pauperisation, primitive medical facilities, poor sanitation in the cities and workhouses, and lack of clean drinking water. The colonial administration characterised the impoverished subjects as unclean, filthy, and resistant to hygienic practices. Religious beliefs were seen as deterrents to rational health behaviour as well. Here,

[T]he fear of forced isolation and the stigma attached to being a carrier of the disease induced people to smuggle out their symptomatic relatives to ‘safer’ areas, hide them in attics, inside cupboards, under furniture, or in secret rooms whenever the state’s search parties showed up. ¹¹

When radical enforcement measures, such as those which were followed in Hong Kong, were adopted there was fierce resistance from the people; in fact, in 1897, the Indian Civil Service officer Walter Charles Rand was assassinated in Pune for his high-handed interventions (ibid.). ¹² In some plague-hit pockets, riots took place in 1901 as people refused compulsory hospitalisation and quarantine. In 1902–03, the application of the Haffkines vaccine in Punjab led to the death of 19 people in a village and it invited public anger. Arnold (1987) notes,

… the very strength of the political and cultural backlash against the plague administration is a reminder of the practical limitations to that power and of the extent to which regulatory systems tend to be less absolute and less one-dimensional, than the writings of Foucault and Goffman would lead us to believe. Only through an awareness of the dialectical nature of such encounters is it possible to avoid assumptions of mass ‘passivity’ and ‘fatalism. (Arnold 1987: 56)

In Europe of the 19^th century, compliance of the population was achieved over a century of intensive state surveillance and regulation (Armstrong 1995). Health behaviour was shaped and modified by penal codes, by secondary socialisation through medical discourse (Foucault 1980), and by civic experiments in sanitation (Sujatha 2014). Alternative medical traditions were banished or forced underground, and biomedicine emerged as the sole arbiter of the body (Sujatha and Abraham 2012). By the 20^th century, this power of biomedical science through the state was so complete as to seem internalised by the people. In the USA and Europe, psychiatric ailments such as ‘germophobia’ ¹³ and obsessive and compulsive handwashing behaviour have come into existence from the entrenched anxiety about microbes.

But it seems that the colonial state in India could never achieve that kind of absolute control over the body of its subjects or school them completely. Despite the Medical Registration Act 1919 disenfranchising traditional medicines and practices, all kinds of shamanism and therapies continued well into the 1990s even as full-blown professional biomedicine had made its advance.

The COVID-19 pandemic, however, does represent a breaking point in that it has unleashed a new cultural politics of the germ theory among the urban middle classes. The huge spike in sales of sanitisers and soaps ¹⁴ and sample surveys in rural pockets and urban settlements conducted during the pandemic ¹⁵ indicate that hand hygiene has increased despite the shortage of water, though there may be variations in the number of its instances and duration. This is worth noting because hand hygiene even among urban educated classes was not found to be satisfactory until recently. The wearing of masks and social distancing were enforced by the state and the latter has been the most difficult to achieve.

Phrases such as ‘flattening the curve’, ‘case fatality ratio’, ‘reproduction rate’, and the like, have become part of common parlance, as is the administratively promoted term ‘the new normal’. At the same time, a rich repertoire of home remedies, rituals as well as fake news that circulated on WhatsApp, Facebook, and the print media took it upon itself to correct misconceptions by way of upholding a scientific ethos.

The attitudes and responses to COVID-19 in different Indian context, however, have varied widely though they could be mapped into class and location quite unambiguously. Paranoia, isolation, compulsive behaviour, and stigmatisation were found among the urban, metropolitan upper and upper-middle classes while further down the continuum we find moderate caution, a more casual approach, indifference, and outright rejection, as in the local markets, election campaigns, and through the raging farmers’ protests ¹⁶ seized with the larger interests of livelihood and survival. The fear of the consequences of the lockdown on livelihoods seems to have been greater among self-employed, rural, and working populations than the concern about the contagion.

Despite the uneven impact on the health behaviour of different social strata, the COVID-19 pandemic did mark a watershed in the health behaviour of the people by etching the virus in public memory. I argue that this was caused almost exclusively by the lockdown announcement of the central government and not because of consciousness of the virus which has been more of a derivative effect. Other epidemic fevers in the recent past such as Avian Flu and Dengue never produced this effect on the public though health messages were disseminated. Besides, traditional recipes that are meant to strengthen the host mechanism have been revived in this crisis. The consumption of various herbal teas, decoctions, ¹⁷ vitamins, and home remedies increased phenomenally as indicated by the boost in their sales, according to a consumer sentiment survey between April and May 2020. ¹⁸ The sale of Chyawanprash ¹⁹ alone went up by 230 per cent. The Indian government also promoted traditional medicines as preventives for COVID-19, though the move came under flak from professional biomedical associations.

The pragmatism of Indian health seekers who adopt remedies from divergent systems of medicines without much fuss over their ideological and theoretical differences has been reaffirmed by scholars over the years (Das 2015; Khare 1996). Interestingly, there is a marked civilisational difference in the consumption of traditional herbal preparations as preventives and adjuvants for COVID-19. It was widely found to have increased after COVID-19 among the Asian, African, ²⁰ and Latin American people ²¹ while this is rarely found or reported among the North American and European populations, ²² though complementary and alternative medicines have been growing in a big way in the West for the past five decades (Sujatha 2020).

Conclusion

In 19^th-century France, Latour (1993) shows how the microbiologist Louis Pasteur earned glory from his discovery of the vaccine. He was also able to persuade the French public to stop spitting and accept vaccinations alongside galvanising support for his research. By contrast, in India of the 21^st century, the framing of the pandemic and the promotion of the vaccine have been carried out at the behest of the state. The lockdown and the vaccine have been instrumental in enhancing the authority of the state over the people and contribute to its international image-building, in which certain forms of science and technology have been selectively utilised. Sporadic and diplomatic utilisation of science and technology could, however, be inconsistent. ²³

Given the fact that android-based social media and television have penetrated deep in the Indian subcontinent, we may safely conclude that the awareness of the pandemic has reached vast sections of the population including the remote areas due to messages about the pandemic relayed on all mobile networks. There is evidence of positive alterations in health behaviour as well as increased consumption of health products among certain sections of the urban population. That 30 million people have received the first dose of the vaccine in India ²⁴ and that lakhs of upper-middle class septuagenarians have registered for vaccines in private hospitals is as much true as the fact that only 60 per cent of the vaccine capacity has been utilised until ²⁵ now even when it has been free and vaccine hesitancy is widely reported among health professionals themselves, leave alone the rest.

The lifeworld consisting of culturally grounded meanings and the practical rationality of subjects does accommodate systemic incursions, though it is never completely engulfed by it. Studying low-income settlements in Delhi, Das (2015) explains how the state is present in numerous ways in the everyday life of the people whether it is in the shape of documents like birth and death certificates they require for availing government schemes or in the form of officials they interact with. Yet the micro-politics of family, kinship and neighbourhood in their lifeworld has an ethic that is vastly different from that of the state. The return of millions of urban workers to their homes in the villages after the lockdown also reveals that family and kin groups continue to absorb the shocks delivered to ordinary people by the state and the urban economy.

One thing that we can say with certainty is that the mediated awareness occasioned by the COVID-19 pandemic constitutes a crucial symbolic resource for the government that can be mobilised for future epidemic campaigns and to gain greater compliance, irrespective of whether the fundamental beliefs about the disease among the lay population has changed or whether their health status has improved. Reports of angry relatives of deceased patients attacking doctors and residents in government facilities for negligence are often heard as are the pleas of over-burdened doctors seeking protection from them. Yet India has not seen any popular movement against the huge inadequacies in its public health system after independence, in a way that education, law, reservations, land, and livelihood have attracted attention.