Ahmedabad: Routinely excluded from urban healthcare systems, India's migrant workers struggled to find medical help for Covid-19 and other diseases during the second wave of the pandemic, a recent survey by labour rights organisation Aajeevika Bureau found. They also had trouble accessing free Covid-19 vaccines.

Of the migrant workers interviewed in the first week of May 2021, 27% had Covid-19 or other diseases during the second surge. Of them, 70% struggled to find treatment, 58% got no support from their employers and 62% were forced to borrow heavily to cover the healthcare costs, shows Aajeevika's telephonic survey of 195 migrant workers in Ahmedabad.

In a two-part series based on the survey, we explore the impact of the sporadic state lockdowns on the lives of migrant workers who have chosen to remain in cities. The first part dealt with job and wage losses. In this, the concluding part, we examine the health impacts of the crisis and trace these to the structural exclusion of migrants from urban health systems, lack of support from employers and a deep mistrust of the public healthcare system.

32% of sick workers dismissed

Swati Saktavat, a community leader who works with tribal migrant workers in Ahmedabad, recounted the experience of Shamliben*, who caught a Covid-19 infection in April 2021 while she was in her village in Dahod district, eastern Gujarat. Though she was diagnosed in Ahmedabad where she works, Shamliben chose to return to her village when her condition worsened because she did not trust the government health facilities in the city.

"Having spent upwards of Rs 25,000 towards her hospitalisation in the village, she struggled to repay her debt. Days after getting discharged, she was forced to return to the city, during the second wave in the hope of finding some work at the labour naka," said Saktavat.

Our survey also revealed an absence of support from employers. Up to 58% of the workers who had Covid-19--or other diseases--were not paid for the period when they were ill; 32% were dismissed.

Choosing between safety and sustenance

Rajanben Parmar, a leader of a workers' collective in Ahmedabad, says that unlike the 2020 outbreak of Covid-19, in April 2021 every tenement in her building complex in Narol had a positive case and the fear of infection was palpable. Aajeevika's survey found that 73% of the migrants feared contracting Covid-19 during the second wave because it would mean loss of income as well as heavy medical expenses.

She recounted the tragedy of a migrant household in her building where a mother and daughter spent an entire day looking for a hospital bed for a critically ill relative who was also the family's sole earning member. He eventually succumbed to the disease and with no support system in the city, the family returned to their village.

In the absence of wage security, workers found themselves trading-off their safety for sustenance. "Ghar se aadmi naukri par ja rahe hai. Dar bhi lag raha tha. Ghar se nikle ya nahi? (My husband goes to work outside. I am also scared. Should one go out of the house or not?)," said Parmar about the fears migrant families faced.

Covid-19 vaccines being administered at a homeless shelter where male migrant workers find temporary accommodation.

Ayushman Bharat-Pradhan Mantri Jan Aroyga Yojana (PMJAY), the Centre's flagship health insurance scheme which allows vulnerable families to avail free medical treatments of up to Rs 5 lakh per year, was extended to migrant workers for Covid-19 treatment in 2020. However, a June 16, 2021, India Today inquiry found that in Gujarat, not a single Covid-19 patient had been able to avail this scheme.

Pankti Jog of Mahiti Adhikar Gujarat Pahel, a social activist, explained that Covid-designated hospitals were not necessarily empanelled under the PMJAY and Mukhyamantri Amrutam Yojana, Gujarat's own health insurance scheme for poor families. And hospitals had received no directives either to treat cardholders for both schemes.

Many have questioned the effectiveness of the Ayushman Bharat scheme with its exclusive reliance on private healthcare infrastructure. Even government data from 2020 bear this out.

'Had to borrow for treatment'

The second wave of the pandemic put a severe strain on Ahmedabad's healthcare system even as it compounded the workers' vulnerability to health shocks. Up to 68% reported excessive medical expenditures, and 62% reported borrowing for medical expenses and treatment, our study found. In interviews with authors, some workers revealed that during the second wave private clinics and chemists had begun charging 2-3 times higher than the usual consultation fees, adding to their financial burdens.

Manju Meghwal*, a domestic worker in Ahmedabad, caught the infection from a family she cooked for. She got no help from the households that employed her and incurred a medical bill of around Rs 20,000, which she paid off by borrowing from neighbours.

Neglected by urban health networks

Domiciliary requirements, language barriers, stigmatisation and logistics have precluded migrants from accessing local public healthcare systems in the city. Outreach by Accredited Social Health Activists (ASHA) and other health workers to migrant households is also erratic as migrant settlements are not recognised by local authorities.

"Migrant workers who face health issues in the city are not able to access government medical support in Ahmedabad," said Mahesh Gajera of Aajeevika's Ahmedabad centre.

A pre-pandemic study of migrants' access to urban governance system conducted in 2020 said that 90% of those interviewed preferred private clinics, and this included consultations with quacks and pharmacists, over urban health centres (small clinics that provide free primary health care) or public hospitals (for secondary treatment). They paid anywhere between Rs 100 and Rs 3 lakh out of their own pockets for these consultations.

Mistrust in public healthcare

Ranjanben Parmar added that during the second wave, government health workers had started visiting migrant neighbourhoods in Narol every day, but migrants were reluctant to consult them because of mistrust and fear of forceful containment in hospitals and separation from families.

This mistrust can be traced to the weak public healthcare systems in rural areas, Pavitra Mohan, co-founder of Basic Healthcare Services, a non-profit working in southern Rajasthan, pointed out in an interview to IndiaSpend. He added that this anxiety was worsened by stories about the forcible quarantining and coercive testing of migrants returning from cities last year.

Vaccine: exclusion and hesitancy

With the onset of the second wave, attention shifted towards speeding up mass vaccination in Gujarat. As of June 30, 19.8 million of Gujarat's 18+ eligible population have been administered the first dose, whereas in Ahmedabad, up to 2.3 million people have been covered, according to government data.

At the time of the Aajeevika survey, the rollout for the 18- to 44-year age group had just begun and none of the migrant workers within that age group had taken the vaccine. Our survey found that 60% of them were willing to be vaccinated. However, even among those willing, many expressed a lack of confidence in the vaccine.

"Now that the pandemic situation is getting better, workers are growing even more reluctant to get vaccinated saying that they are all healthy, and there is no need for the vaccine," says Mahesh Gajera.

Up to 40% of the migrants stated that they were not willing to get vaccinated, citing hearing of bad experiences among distant relatives and misconceptions about possible side-effects. Surat also reported a growing mistrust in the vaccine among migrant workers.

The requirement for digital registration for vaccination has also been one of the biggest hurdles faced by workers willing to be immunised. The Supreme Court's direction to review this policy and the recently announced free-vaccination drive with on-site registration could change this.

However, limited slot timings may create logistical hurdles for workers in 12-hour shifts. Also, up to 62% of workers said that they would have to lose a day's work and wage to take the jab and recover from its potential side-effects.

Workers will have to be incentivised with wage-loss compensation and targeted outreach, suggested Gajera. Odisha's scheme for returning migrants that offered Rs 2,000 as compensation for a 14-day quarantine during the first lockdown is an example of an effective incentive.

*Names changed to protect identities

The authors are grateful to Dipti Makwana, Durgaram, Geeta Parmar, Mukesh Parmar, Pannalal Meghwal, Rajendra Kumar Balai, Ranjeet Kori and Swati Saktavat of Aajeevika Bureau's Ahmedabad Centre for their insights and assistance with the interviews and survey.

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