Bhambere S. Farmers’ health and safety in India: issues and the path ahead. HPHR. 2021;41. DOI: 10.54111/0001/OO2
Farming and agriculture have been the primary occupation in the Indian subcontinent. Yet, they’re one of the most neglected when it comes to securing the health and safety of their human resource. In this commentary, the author discusses the various issues farmers are facing on day-to-day basis that hamper their health and make their work unsafe for them, as well as the fresh challenges that COVID-19 brought for the farmers. The author breaks them down into the multifactorial problems that they are, while also discussing the recent farmers’ protest that brought many of the problems discussed in this piece at the forefront. Finally, the author highlights the progress that has been achieved in order to secure better farmers’ health and discussing possible future solutions to pave the road for a safer environment for farmers.
Currently, about 42% of the Indian workforce is into farming and agriculture, with about 140 million farmer families currently working within the sector. This includes crop farming, animal husbandry, milk and dairy, as well as fish farming. Together it forms the largest workforce by sector in India and one of the largest in the world. The contribution of Agricultural produce and related business is about 18 % of India’s Gross Value Added (GVA).1,2
Agriculture and farming in the Indian subcontinent dates back to 9000 BC with barley and wheat being the earliest crops to be produced. Since then, the agriculture sector has evolved to the current position and changed rapidly over the last century, and agriculture still remains a mainstay occupation for many in India. Yet, the Farmers health and safety remains largely overlooked.
Although many social and policy level changes have been brought in the past two decades, the Indian farmer still grapples with multiple health related problems. If we are to bring impactful changes for farmers’ health and safety, it is important to consider all the factors including economic, social ones and not looking at this issue narrowly just as a healthcare related issue. And although this topic is a multifactorial and multilayered one, it can be broadly discussed as these two separate arms- The direct health and safety issues and the Economics and agrobusiness issues, to then comprehend and build on them for better policy making.
Currently, limited studies address whether GOR results from enhanced discrimination and detection abilities in sensory domains or challenges in multisensory integration in the ASD population. Moreover, various measures were adopted, making it challenging to integrate study results.29 Neurobiological mechanisms in GOR were less studied in clinical research on ASD.29,35–37
A genetic variant in the taste receptor responsible for bitter sensitivity led to GOR in children with ASD.38 In a case-control study among 48 children with and without ASD, the ASD group showed lesser accuracy in identifying sour and bitter tastants than TDs.39 Adults with ASD did not show differences in threshold and hedonic responses to sweet tastes compared with healthy controls; however, ASD severity was associated with sweet sensitivity.40 In a study focusing on discrimination ability, adults with ASD showed low performance in identifying tastes and usually misidentified tastes as salty or no taste.41
Prior studies about olfactory sensory functions among the ASD population were not consistent but suggested that these functions could differ according to age, sex, and disease severity.31,29,42–44 One study pursued the association between olfactory function and brain activity in ASD using magnetic resonance imaging.45 In this case-control study (n=36), adults with ASD showed decreased olfactory function coupled with reduced activation of the piriform cortex compared to TDs.
Comparison of GOR among those with and without ASD was conducted mainly using behavioral questionnaires and neuroimaging studies. Among 15 studies conducted using the Sensory Profile (SP), one of the widely used questionnaires, individuals with ASD showed greater GOR estimated by the oral sensitivity score. Preschool and elementary school-aged children with ASD had significantly more severe oral sensitivity scores than TDs (p<0.001).46 The proportion of GOR among the ASD group varied from 36% to 64%, whereas TD was 3-7%.46,47 In a cross-sectional study, the ASD group showed both GOR and gustatory sensory craving symptoms compared with the TD group.48 In this study, those abnormal sensory symptoms were more significant in the young ASD group than in the older ASD group. Among studies using the Short Sensory Profile (SSP), the shorter version of the SP, the taste/smell sensitivity score differed between ASD and TD groups. It also differed between ASD and developmental disability groups.49 In children with ASD, the prevalence of GOR estimated using the SSP varied from 41% to 72%, whereas 80-98% of TDs did not show atypical responses.46,50–53 Similar results were repeated using different behavioral measures (Table1).54–57 In Woodard et al., toddlers (n=16) with and without ASD and demonstrated different heart rate responses after seeing food items among ASDs compared to TDs.58 Confronted to the oral stimuli, a higher proportion of the ASD group showed increased HR compared to the baseline than TD group, indicating physiological hypersensitivities.
Food selectivity among ASD is common, especially persisting longer periods in life.24,46,62–64 Trajectory studies reported subgroups among ASD in which severe feeding problems continued to persist during adulthood.65,66 Furthermore, it is closely related to problematic mealtime behaviors, which causes more familial distress to the ASD population.24,32,67–69 Food selectivity persisted even when adaptive functioning was adjusted: within the same level of adaptive functions, 67% of the ASD group continued to have problematic feeding and eating behaviors as opposed to 33% of the TD.68
GOR to texture, smell, tastes, colors, and mixtures of foods could contribute to food selectivity in the ASD population.18,21,46,70,71 Among ASD children, GOR and other sensory modulation dysfunctions were associated with food selectivity.72 GOR was still associated with eating problems after adjusting the age, intellectual disability, and comorbid ADHD.21 ASD children with GOR were reluctant to try novel foods, refused to eat certain kinds of foods, consumed limited types of foods, and were more likely to eat less owing to negative emotions.46,47,73,74 Youth with ASD reported that they disliked certain textures and strong tastes, and more children with ASD pointed out textures and flavors as the reason for refusal.20,75,76 Textures were the most common factor for GOR in ASD, whereas the colors of foods also accounted for GOR.77 That is, individuals with ASD and SOR occasionally prefer white or colorless foods, which might decrease the sensory overload.77 Sex-difference in GOR might exist. Females with ASD endorsed more eating problems and GOR than males.78 Researchers also pointed out that the motor impairments per se could cause aversive responses to gustatory stimuli. Children with ASD who more often refused foods had a greater prevalence of malocclusion of teeth and poorer periodontal health.79
Consequently, food selectivity among children with ASD may result in insufficient nutrient consumption. Studies investigating whether food selectivity among ASD individuals is related to the inadequate intake of specific nutrients remain controversial.32–34,80,81 Nonetheless, some cases have reported extreme deficiencies of nutrients, such as vitamin C, vitamin A, vitamin B3, and iron.82–86 These severe nutrient deficiencies like scurvy and pellagra are rare in developed countries, resulting in delayed diagnosis and severe outcomes, such as pulmonary hypertension and intracranial hypertension.34,82,84,87 In addition, insufficient intake of protein, calcium, and phosphorus is associated with lower bone mineral densities among ASDs.88 A trajectory study found that children with ASD had a limited repertoire of foods even with time passed and were prone to weight gain.89 Although the sample size was small (n=18), participants with ASD included in the obesity/overweight strata increased from 28% at baseline to 50% after six years of follow-up. While both underweight and overweight issues have been reported to be associated with GOR, the prevalence of obesity among children and adolescents with ASD is higher than TDs in developed countries like the U.S., deeming significant chronic health risks.90–93
Additionally, dental care problems among the ASD population have been reported.79,94–97 While children with ASD are exposed to high sugar content, about half were treated for dental care.96 Also, ASD children with SOR reported more difficulties in dental care at home and clinical settings than ASD children without SOR.97 A systematic review of 10 studies found a worse outcome in oral, gingival, and periodontal hygiene care among children with ASD younger than 18 years with ASD compared to TD counterparts.
Most Indian farmers work in and around farms that are not regulated in terms of infrastructure or sanitation requirements. Daily wage working farmers end up drinking unhealthy water, food and work in unhygienic conditions.13,14 Many farms will lack clean toilets, access to sanitary napkins heavily affecting the health of female farmers.
Farmers all over the world work right on the ground, in the middle of soil, mud, water, rain and sun all the time. The problem in India and many other developing economies is that the farming sector is still evolving and the farmers access to preventive gears, boots and other safety gadgets is limited, especially for the poorer farmers or daily wage workers. Snake bite, thorns, skin infections and foot trauma are all too common in the farmers. Upper limb or hand injuries are extremely common in farmers as these are the parts, they use the most in driving the tractors or using farming devices.15
Farming is a highly stressful occupation, demanding both physically and mentally. Farmers put in all the effort to grow crops for months, put in immense amount of investment and physical effort, and all this while being at the mercy of multiple factors that they cannot control. Farm workers can barely make ends meet, let alone seek help for mental health issues. The suicide rate in farmers in India is about 11 % of the total suicide cases.16 Poverty, lack of support, illiteracy, growing debts, uncontrollable weather conditions, all these together create a damning situation for the farmers. Most health insurance schemes do not cover mental health services. There is only 1 psychiatrist per 250,000 people and less than 1 mental health worker for every 100,000 people in the nation.17 These factors along with very few inpatient psychiatric units make receiving timely mental health support very difficult.18
As for anyone else in the world COVID-19 impacted agriculture and the life of farmers hugely. While the big farm owners or the corporate groups might have felt the heat of the pandemic, the major brunt was borne by the small-scale farmers and the farm labor.19 With their jobs already being labor intensive and a group work, following social distancing while working made it more difficult. For people who suffered from COVID-19 infection receiving the right treatments in the rural setting, especially in the early period of the pandemic has been tough. Not to mention the feat of going back to work in the early days of recovery from the disease or having to lose the income for all the missed workdays in absence of any sick leave pay was financially taxing. What added to this already precarious situation is the migrant crisis during the pandemic. Thousands of labor workers living in the cities went back to their villages during the lockdown period because of drastically reduced work opportunities in the cities. This disrupted the worker supply in the rural areas creating more unemployment in the agriculture sector. 20
The newer generation of farmer families, and the young farmers are seeking education. Many even studying agriculture and farming related programs. But this still remains a smaller group of farmers. Also, many farmers who do not own the farmlands and simply work as laborers on daily wages barely have primary education. It goes without saying that the Illiteracy adds to the health inequity. Health literacy then becomes a distant dream. Agriculture, marketing and sales of the produce as well as many healthcare services using telemedicine all rely in part on use of digital technology today. Digital literacy in the rural areas is already low as compared to the cities (61% in cities vs 25% rural) and within the rural population is even lower in the agricultural workers (13%) as compared to 53% in non-agricultural workers. 21
Most of the farmers, especially the ones who do not own the land that they work in are under the poverty line. The farming system is cruel in itself, that the farmer works many times over the entire year to finally have the crop ready for sale by the end of months, sometimes a year. and only then can they sell it in the market and make an earning. This is all the more complicated by the added complexity of middlemen and laws related to sale of crops.22 The farmers that work on daily wages are entirely dependent on their daily physical work and presence on the farms to make a living. Imagine being sick and not being able to go see a doctor, because you can’t miss a day’s pay and also can’t afford to travel or pay for the medicines. When draughts or famines strike, the farmers suffer the most, many a times losing all the money that they had invested in growing the crops or taken up debts for.16, 23
While there are farmer unions that look after the benefits of farmers, there still aren’t enough and the existing ones do not always represent the daily wage farm labor. Only recently have the unions been coming together in a unified manner to look after the farmer welfare. Lack of local farmer unions leave too many loose ends and give way to problems like longer work hours, lower or uneven minimum wages, lesser farmer safety precautions, workplace harassment and abuse to name a few.23,24 The Employee State Insurance Corporation (ESIC) in one of its coverage circulars, states that “The main characteristics of workers in the unorganized sector are acute incidence of under employment, the scattered nature of workplaces, high incidence of home-based or, low collective bargaining power and the absence of an employer-employee relationship.” 25
In terms of economics, agriculture is the biggest sector in India. This obviously leads to a monopoly from top to bottom. While bigger national and international corporations have started building a stronghold on the agricultural sector, the local markets have traditionally been controlled by government agents and middlemen.7 This in turn creates an imbalance of power leaving the farmers at their mercy, leading to lower rates for the produce, stock hoarding etc. This has a huge impact on the financial, mental and emotional wellbeing of the farmers in India.
When talking about the health and safety of farmers, it is important to note the recent farmers’ protest in India as the bill would in any form have an impact on the financial, mental and physical health of the people in the agribusiness. One of the biggest farmers protests across the world happened in the country in this last year. The protest that began in November 2020 and ended only recently went on for about a year. The protest was mainly against the three farm laws brought about by the Indian government, passed by both the Lok Sabha and the Rajya Sabha. The three farm laws were -The Farmers’ Produce Trade and Commerce (FPTC)Act 2020, the Farmers’ Empowerment and Protection Agreement on Price Assurance and Farm Services Act 2020, and the Essential Commodities (Amendment) Act 2020.26,27,28 The government and the farmer unions both came face to face on this topic as both believed it to be crucial for the health, safety and financial future of the farmers. The government claimed that the bill would help the farmers by removing the intermediaries and giving the choices of whom to sell their produce and at what prices.29 Many farm unions believe that the way contractual farming has eroded the agribusiness, the leverage of farmers and their choices in the western nations, the farm bill would similarly take away the leverage from farmers in India and leave the power in hands of big corporate giants, with no guarantees for safeguarding of the minimum support price (MSP) for the produce creating even more inequity for the farmers. The actual impact, either positive or negative that the bill would have had will never be known as the government yielded to the demands of the farmers and on November 29th, 2021, passed the Farm laws repeal bill following which the protests were ended in the next few weeks.30
Under the National Rural Health Mission, the government has strived to create equitable health resources for the rural population and the underserved groups. While the progress is notable, there still needs to be substantial additions. More health centers in rural areas, Satellite clinics near farmlands for primary health checkups can help improve the farmers health.31, 32 COVID-19 created the need for continuous testing centers across the world. It also proved that even most urban areas do not have enough health infrastructure to support a large-scale health crisis. Farmers and other agriculture labor work in a community setting with a high amount of contact with others making them more susceptible to community transmission. During the Pandemic, the government ramped up its healthcare services, even creating temporary health centers and also continuously providing guidelines to the farmers for their ongoing work in the COVID-19 crisis. Taking lessons from this, it is important the government sustain this ramped up health support to the farmer community even after the pandemic. The lower vaccination rate and hesitation in the rural Indian population has shown to affect the overall vaccination rate, which means that it is also important at the same time to improve the educational infrastructure, or the health awareness programs focusing on the farmer community.3 Private investment in this and other aspects of social infrastructure building should be encouraged so that the burden doesn’t just fall on the government programs and funding.34
Bundled and free health plans need to be created specifically for the farmers, and proactive healthcare should be encouraged.35, 36 Preventative checkups, training the farmers in identifying common health problems they could be facing need to be initiated, paid and encouraged by the government on national, state and local levels. Although there are no special health insurance plans or programs like the Employee State Insurance Scheme (ESIS) for farmers at the moment, there are other government health plans that can cover services for them in many cases. The “Rashtriya Swastha Bima Yojana” by the Ministry of Labor and Employment, government of India provides some level of social security benefits or coverage for those who fall under “below the poverty line (BPL)” 25 That being said, it is not enough to have bits and pieces of benefits to cover the healthcare of the agricultural labor. It is important that the government create special units within the local health center or have support helplines that can help the farmers figure out the best options for them. It is also high time; the government creates more health insurance programs specifically focused on the farmers.
The government has been putting a good chunk of the agricultural budget into caring for the financial aspects of the sector. But what has been ignored for a long time is that farmers are a specific group of people in an already low resourced, vulnerable population with their own health and safety hazards related to their occupation. It is imperative that special and subsidized Health programs be created for them. The government has been training farmers for decades since the green revolution on the best practices in farming and use of chemical fertilizers.37 Newer programs that focus on not just their safety when using the materials, but also how to gradually move from chemical intensive farming to a more conservative or organic one need to become part of the mainstream agricultural trainings across the nation.38 Providing the farmers with free safety gears, boots etc., along with a training in using the chemicals, pesticides and general guidance around that is a great way to prevent related hazards.39,40 Training and sensitizing the healthcare professionals towards the local issue of the farmers is also necessary.
COVID-19 shut down business and work across the world, and agriculture was no exception to this. It brought to light the need of reserve financial support for the farmers and other agricultural labor in case of calamities, not just like the pandemic, but also the ones that are extremely common, like drought, famine, untimely rain or even the gradual effects of global warming.25
Poverty and lack of financial independence is at the core of health inequity for the farmers in India. The government needs to make more policies to bolster the financial support for the farmers and create a safety cushion against the risk of losing their investment in the crops when the produce is affected by natural factors.
The Indian government recently issued about 15 million “Kisan cards”- farmers credit card to farmers and fishermen and made available a credit of about $191 Billion in 2019-2020 to the agricultural sector. 41, 42 This is a great step towards better farmer financial health, but it needs to be made sure that it reaches the farmers at the bottom of the poverty line to make the most impact.
Under the “Pradhan Mantri Fasal Bima Yojana” the crops are insured by the Indian government.43 This is a great step in the right direction. Farmers in India often lose their entire year’s investment and income due to the bad crop produce or natural disasters like drought or famine having affected the crop. Having the crops insured will help reduce the preventable crisis like farmer suicides.
The Farmers protest also brought to forefront the problem of fair pricing for the agricultural produce. The government currently offers a guaranteed MSP on some crops and not all.44 This leads to farmers having to stick to certain types of crops and little diversity. The financial constraints with the limited flexibility of farming choices are a huge blocker. The government can bring policies that help offer fair pricing on a wide variety of crops along with insurance for the produce. Farmers have time and again said that MSP and easily available market information helps them in getting better prices for the produce. 45
The joint efforts to improve health and safety for farmers in India have come a long way but will still need major policy changes and programs to achieve adequate health and safety of the farmers.