When we think of bonded labour – the most widespread form of modern slavery – we don’t instantly think of diarrhoea, or any health issue for that matter. However, the research that we are carrying out on bonded labour in India and Nepal, suggests that diarrhoea and ill-health, poverty, loans and bonded labour are all interlinked.
The cycle of bonded labour
When adult bonded labourers get ill they have to borrow money (in addition to the advances or loans they already have). The money is usually borrowed from a moneylender who demands their labour as a means of repayment. Typically they work and live in conditions with limited or no freedom of movement, earn less than the minimum wage and cannot sell their labour to anyone else in the open market. Since they are already working full time without a clear end date to pay their existing high interest loan, the only way they can pay back this additional loan is to give a relative – often a male child as a worker – to those they owe money, who then puts the child to work as a bonded labourer, possibly through a middle man for a year, or sometimes two or three years.
These children usually have to work so hard – up to 16 hours a day, sometimes 7 days a week – that they also get sick. Many are already weak, through malnutrition and lack of access to clean water and sanitation. When they get sick and need help the parents take out a new loan. The only way they can pay for this is by sending another family member into bonded labour and so the cycle goes on. Whether they take out these loans to compensate for lost income to pay for household expenses or for problems that directly result from diarrhoeal diseases is something that needs to be explored further. In spite of investments to improve public health services, prevention and primary care by the Indian state, the poorest are still paying huge private expenses that keep whole families locked in poverty.
These patterns were revealed through a three-stage process of participatory research. Firstly we worked with eight NGO’s to collect 358 life stories using open ended questions. Unsolicited, over 70 of these highlighted the way in which loans for health are related to bondage. We drew out the causalities from the individual stories and depicted the collective patterns on huge system maps on the wall. We used this process to construct indicators for a major participatory statistics process. This was extended to over 80 villages and collected data from around 3500 households. In this study the link between health, risky loans and bondage showed as being even stronger.
The burden of health expenses
We also worked with a sample of 3466 households comprising 1686 that had no bonded labourers, 764 with at least one person from their household in bonded labour, and 1016 households with exclusively bonded labourers. We found that whilst 50.7% of households with no bonded labourers had a loan, this rose to 74% of those with at least one slave, and 86.2% for households with all bonded labourers. Most of these loans – almost 60% by households with bonded labourers – were for health expenses. Furthermore, whilst both bonded labourers and non-bonded labourers borrowed fairly equally from money lenders, non-bonded labourers had much greater access to banks and other lending schemes. While bonded labour is a complex problem it is clear that investments in health are needed, and that in the face of a failing public health system local action needs to be taken
As a result of these findings many of the NGOs selected this issue for the third stage of the research process, which was to set up community based action research groups. In Mid-November we visited an action research group of local people that has evolved near Muzzaffapur, in a village of 300 households. After a period of group formation, they have started to inquire into the local linkages between health and loans and bondage.
Village level data
Through discussion they identified that diarrhoea was the main illness affecting the village. They are now collecting comprehensive data at village level to verify this. Diarrhoeal diseases and malnutrition result in a wide range of chronic and acute health problems. When people get diarrhoea they are often unable to access local state health facilities and are unaware of the preventative actions that are available to them, so they choose to use local informal health providers (often described as quacks). They choose these informal health providers because they are local, have flexible hours, can visit the home in an emergency and will accept payment later. But these bills add up and have to be paid back which leads people to the moneylender.
A lack of water and sanitation and poor hygiene (handwashing for example) leads to illnesses and life threatening diseases like diarrhoea. Bodies weaken with every episode as it depletes the body of vital nutrients. Recurring diarrhoea is therefore connected to chronic malnutrition, stunting and many other illnesses and death. Bonded labourers pay large sums of money for treatment for these illnesses, but their health usually continues to deteriorate, and their debts increase.
Prioritising primary health care
The vicious cycles and structural connection between poverty and ill-health has been well known for decades (WHO 2002, Farmer 2001, Scheper-Hughes N. 1993). It should therefore not come as a surprise that these dynamics are also found among bonded labourers in India or elsewhere. But somehow health does not seem to have been a priority in bonded labour eradication efforts. While states have a responsibility to provide universal access to the best available health care, local communities can also take action themselves to improve their health. Social participation, intersectoral community action, and cultural sensitivity are key principles of primary health care.
The use of participatory methods created a safe space in which people could tell their own story, highlighting what they thought was important, and in which there was enough trust for communities to share the information that showed these linkages between poverty, bondage, loans and ill-health. Although diarrhoea is distinctly unsexy, primary health is now on the agenda of local grass root NGOs and communities as a priority for action.