NIKHIL EAPEN19 April 2020

A daily wage labourer queues for free food at a construction site in Delhi. Historical experience and general epidemiological evidence add a medical imperative for tackling the deprivation resulting from the COVID-19 lockdown. ADNAN ABIDI / REUTERS

In the winter of 1908, a malaria epidemic swept through Punjab, killing 300,000 people in around ninety days. Although malaria epidemics were common in the region, the 1908 outbreak was the most lethal in at least forty years: 18 out of every 1,000 residents of Punjab succumbed to the illness. The death toll was even higher in the mud huts of landless labourers, artisans and servants. An official inquiry led by Major SR Christophers, a Liverpool-born doctor, found that malaria infected the rich and the poor alike, but it was much more likely to kill in poor households.

“If we examine in detail any town affected by the epidemic, we shall find the heaviest mortality has been in those classes, which are the poorest and living in the greatest squalor,” the inquiry report, released in 1911, stated. It concluded that “the determining causes of the outbreak were excessive rainfall and ‘scarcity’; the former is an essential while the latter is an almost equally powerful influencing factor.”

“Scarcity” was an administrative term used to denote destitution and famine. That excessive rainfall contributed to spikes in malarial infection was well known to the British administration. That destitution and starvation exacerbated fatalities from disease was not. Christophers argued that the massive incidence of death in 1908 was a function of “compromised immune competence,” which refers to a body losing its capacity to sustain an adequate immunological response under conditions of acute hunger and starvation. “What acute hunger means is insufficient food below the requirement of the basal metabolic rate—the level below which the body starts using its own storage,” Sheila Zurbrigg, a physician and malaria scholar, told me. “At this stage, the body starts to waste away because it has to survive.”

As the nationwide lockdown in response to the COVID-19 pandemic brought the economy to a halt, with no prior planning for how to mitigate its economic effects, millions who live hand-to-mouth as labourers faced the possibility of hunger and deprivation. The International Labour Organisation warned that 400 million Indians in the informal economy were at risk of falling deeper into poverty. Newspapers quoted many who were convinced that if the COVID-19 did not kill them, hunger would. A survey conducted in the early days of the lockdown, of over three thousand migrant workers from north and central India, by Jan Sahas, a human-rights group, found that over four in ten did not have any food, and two-thirds did not have cash to last a week.

The relationship between undernutrition and COVID-19 is yet to be tested, but its effect on other infectious diseases such as tuberculosis is direct and clear. Undernourished people are more susceptible to acquiring the disease, to long recovery times, to treatment failure and as a result, to death. In Chhattisgarh, a study of 1,695 adults with pulmonary tuberculosis found that severe undernutrition at diagnosis was associated with a two-fold increase in mortality. Research shows there may be a broad link between poor nutrition and viral diseases. A 2016 paper in the journal Cell, titled “Opposing Effects of Fasting Metabolism on Tissue Tolerance in Bacterial and Viral Inflammation,” found significant benefits to feeding viral infections, but starving bacterial ones. The intake of food can modulate the types of inflammation in the body caused by viral and bacterial infections, the paper noted.

“I am reminded of this paper in the context of SARS-CoV-2”—the viral strain that caused the COVID-19 pandemic—“and the food deprivation in this country mediated by the current lockdown,” Satyajit Rath, an immunologist at the Indian Institute of Science Education and Research in Pune, told me. “What the paper says is if you are infected with a virus and you don’t get enough food, health outcomes are likely to be worse. The paper directly speaks to coronavirus disease and the impact of food insecurity caused by the lockdown on the vulnerable working classes in India.” Generally, Rath said, with viral infections, “immune responses are dramatically affected by severe undernutrition.”

This is a serious worry in India, whose rank on the Global Hunger Index fell to 102 in 2019, lower than Rwanda and Bangladesh. India holds a quarter of the world’s hungry and about 195 million people in India are undernourished, according to the World Food Programme.

If hunger is rising with the lockdown, as reports suggest it is, then it may well exacerbate India’s struggles with COVID-19. Historical experience and general epidemiological evidence add a medical imperative for tackling the attendant deprivation, reinforcing the already pressing moral case for doing so. But the rise in hunger, even if it maps on to the COVID-19 outbreak now, will not retreat hand-in-hand with the disease.

By all predictions, the economic fallout of the virus will outlast the lockdown and perhaps even the pandemic. COVID-19 is hardly the only infectious disease to take root in Indian soil—the country has the world’s largest burden of tuberculosis, not to mention a shocking prevalence of malaria, dengue, cholera and more. These, and many other chronic conditions, already ravage India’s public health, and hunger only makes them more deadly. The government is trying to spare its citizens the worst damage the COVID-19 can do directly, and even at that, its performance has left much to be desired. If it does not act with equal urgency to reign in the long hand of hunger—in a country with threadbare social-security support to begin with—then even purely from a health perspective, the worst may yet be to come.

Preliminary findings from the COVID-19 outbreak in New York showed that it was twice as lethal among African-Americans and Latinos than white people in the city, likely a consequence of economic inequalities and poor access to health care for marginalised communities. In Chicago, African-Americans accounted for a disproportionate 72 percent of COVID-related deaths, and more than half of confirmed infections. They make up less than a third of Chicago’s population. “Like in the United States, we should collect data on the economic, social and health status of people who have tested positive,” Balachandran Ravindran, an infectious-disease expert and former director of the Institute of Life Sciences in Bhubaneswar, said. “Any relationship between nutrition and susceptibility to the coronavirus infection and death needs to be rigorously investigated.” The data could guide mitigation strategies to protect vulnerable individuals as the pandemic progresses, Ravindran added.

Vijaylakshmi, a 65-year old resident of Kurauni village, on the outskirts of Uttar Pradesh’ Lucknow, joined eleven others inside their crumbling brick shanty when the lockdown began, on 24 March. On 28 March, as part of a handout by the Uttar Pradesh government, the household received two kilograms of rice and another two of wheat flour, 500 grams of dal, a kilogram of salt, 200 millilitres of mustard oil and two spice sachets. Their food stocks quickly ran dry. Earlier, Vijaylakshmi’s four sons worked as daily-wage labourers–on farms and construction sites and in brick kilns—and scraped together about Rs 700 per day. “Now, the cash has dried up,” Vijaylakshmi said. The family used their last savings to buy some grain, but it was not enough.

“We eat once a day and just enough to kill the hunger,” Vijaylakshmi said. “Some of our meals are just a chew made from wheat flour and salt.” In late March, the central government announced that it would distribute five kilograms of foodgrain and one kilogram of pulses at no cost to existing ration card holders, in addition to their regular quota of subsidised grain. But Vijaylakshmi does not have a ration card.

Days after the lockdown began, she developed a fever and an incessant cough. Her health deteriorated as April progressed, but she had not been able to visit a doctor or buy medicine. “When there is no money, how can I buy medicine?” she asked.

“Roughly a third of the country’s population do not have ration cards,” Reetika Khera, a professor of economics at the Indian Institute of Management in Ahmedabad, told me. “The central government should distribute free grain to families without ration cards and to state government-run community kitchens.” Khera said this was entirely possible because the government currently holds more than three times the “buffer stock” it is required to keep.  “We have got to ensure that everyone is able to access some food at this time.”

“We have epidemiologies of microbe transmission,” Zurbrigg told me. “But we don’t have an epidemiology of hunger in the human host, understood historically as meals per day, even though there was a lot of both acute and chronic hunger all the time.” In her book Epidemic Malaria and Hunger in Colonial Punjab, Zurbrigg outlines how five of the nine major malaria epidemics in Punjab between 1868 and 1908 owed to a combination of heavy rainfall and soaring food prices, translating to acute hunger. The other four were facilitated by poor economic policies and planning.

In 1876, for example, though food prices were low and rainfall just above average, autumn fever deaths were off the charts. Zurbrigg argues that the deaths were linked to the monsoon of 1875—a season of extremely high rainfall that caused large crop losses. The administration withheld flood relief in 1876, and denied farmers’ applications to suspend land taxes. This was despite both cattle and harvests being destroyed in some areas, farms being heavily mortgaged, and whole villages having been swept away.

Yet, the death rates of the 1875 winter fever did not show a considerable rise, probably owing to the encouraging kharif season that preceded the rains. But the toll of a failed winter crop compounded by government taxes brought marginal farmers many months of economic pain and food insecurity. In the winter of 1876, the districts hit hardest by the floods of 1875 experienced the highest malarial death tolls.

Another trigger of hunger was the improper distribution of grain. In 1892, wheat exports continued to rise despite a below-average wheat harvest. The land revenue and administration report from Punjab for the year stated, “prices were generally high throughout the year, but the reason was not the scarcity of produce but heavy exports to Europe.” High prices “benefited the agricultural classes, but have been severely felt by the poorer classes.” The stage was set for a malaria epidemic that year.

Malaria claimed many lives during the Bengal famine of 1943 as well. There, even if undernutrition did not depress immune response, Satyajit Rath told me “it is quite possible that anaemia was a serious problem,” and malaria added to the burden. He explained, “Making some food available to starving people made a measurable difference to their mortality simply by improving the compounding problem of anaemia.”

During her research on the malaria epidemics in Punjab, Zurbrigg told me, she found in the archives occasional references to the despair and destitution that accompanied the epidemics. The archives also described a sudden rise of prostitution as well as the practice of mothers giving away of their children in desperate hope that they might be fed. The scourge of epidemics on mental health has followed us into the present day.

paper in the American journal of preventive medicine argued that food insecurity can trigger stress responses that may be partly responsible for anxiety and depression. Obtaining food by begging, standing in line at a charity or other socially objectionable ways can provoke feelings of alienation, shame, helplessness and guilt, all identified with depression. Thejesh GN, the chairman of Datameet—a data science website—made a tracker called the COVID-19 Non-Virus Deaths Tracker. According to it, by 16 April, day 24 of the lockdown, over 74 people committed suicide—some of them driven by the desperation of hunger and unemployment.

Tucked away on page 109 of Christophers’ 135-page report are the words, “malaria merely reap[ing] a harvest prepared for it by the famine.”