S. Irudaya Rajan is Chairman of the International Institute of Migration and Development (IIMAD), India, and chair of the KNOMAD (the Global Knowledge Partnership on Migration and Development) thematic working group on internal migration and urbanization, World Bank. Earlier, he was

India Migration Report 2021 presents a detailed study on the health of migrants. It highlights major healthcare challenges faced by migrant labour-ers, especially in the context of the COVID- 19 pandemic, which has forced authorities, policymakers and many other stakeholders to turn their atten-tion to healthcare delivery unlike ever before.

Bringing to the fore the health status of the migrant population both before the pandemic and during the pandemic, the essays in this volume discuss

• the ease of access of migrant labourers to primary healthcare services; • the safety challenges faced by migrant workers at their workplaces,

their exposure to various physical and psychological health vulnerabili-ties, and prevalence of potentially malignant health disorders and men-tal health issues among migrant labourers;

• gendered access to healthcare, gender- based violence at workplaces and the gender- related perceptions on topics such as employment, decision- making and general attitude;

• the role of decentralization and local self- government institutions in enabling health systems to address health problems of migrants, gov-ernment policies and programs aimed at providing welfare for return emigrants from the Gulf;

• the vulnerabilities migrant workers have encountered across the Indian states during the pandemic, with regards to food insecurity and psycho-logical distress, and the type of support they received from various stakeholders.

The volume will be of interest to scholars and researchers of development studies, economics, demography, sociology and social anthropology, and migration and diaspora studies.

India Migration Report 2021

Professor at the Centre for Development Studies, and Chair, Research Unit on International Migration (RUIM), funded by the erstwhile Ministry of Overseas Indian Affairs, Government of India (2006- 2016). Dr Rajan is the Founding Editor in Chief of Migration and Development (Taylor and Francis), Refugee Survey Quarterly (Editorial Board member) and the edi-tor of two Routledge series – India Migration Report and South Asia Migration Report. He has published extensively in national and interna-tional journals on demographic, social, economic, political and psychologi-cal implications of international migration. He has also coordinated eight major large- scale migration surveys in Kerala since 1998 (with K. C. Zachariah), Goa (2008), Punjab (2009), Tamil Nadu (2015) and instrumental for Gujarat (2011).

India Migration ReportEditor: S. Irudaya Rajan, The International Institute of Migration and Development (IIMAD), India

This annual series strives to bring together international networks of migra-tion scholars and policymakers to document and discuss research on vari-ous facets of migration. It encourages interdisciplinary commentaries on diverse aspects of the migration experience and continues to focus on the economic, social, cultural, ethical, security, and policy ramifications of national and international movements of people.

India Migration Report 2014Diaspora and Development

India Migration Report 2015Gender and Migration

India Migration Report 2016Gulf Migration

India Migration Report 2017Forced Migration

India Migration Report 2018Migrants in Europe

India Migration Report 2019Diaspora in Europe

India Migration Report 2020Kerala Model of Migration Surveys

India Migration Report 2021Migrants and Health

India Migration Report 2022 (forthcoming)Migration of Health Professionals

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India Migration Report 2021Migrants and Health

Edited by S. Irudaya Rajan

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Lists of figures xList of tables xiList of boxes xivList of contributors xvPreface xviiiAcknowledgements xxx

1 Migration and health: Charting questions for future research 1DIVYA RAVINDRANATH AND PAVITRA MOHAN

2 Internal migrants’ health in India: The need for inclusive policies and implementation 9YADLAPALLI S. KUSUMA AND BONTHA V. BABU

3 Rethinking health of migrant workers 27ANJALI BORHADE

4 Gender and the migrant experience of seeking healthcare: an exploration using narrative analysis 35MALA RAMANATHAN, SUNU C. THOMAS AND TIJO GEORGE

5 Migrants and health: a study of low-income migrants in Punjab and Assam 50RADHIKA CHOPRA, JEEVAN R. SHARMA AND ANUJ KAPILASHRAMI

6. Return migrants and the first wave of COVID-19: results from the Vande Bharat returnees in Kerala 57S. IRUDAYA RAJAN AND POOJA BATRA

7 Primary healthcare for labour migrants: The need for an inclusive policy 77BONTHA V. BABU, YOGITA SHARMA AND YADLAPALLI S. KUSUMA

Contents

viii Contents

8 Broken bricks: health status of the seasonal migrant workers 92BIJAYA DEWASHI

9 Burden of occupational morbidities among migrant auto-rickshaw drivers 103SOUMI MUKHERJEE AND K. C. DAS

10 Prevalence of potentially malignant oral disorders among migrant labourers 117TIJO GEORGE AND P RAVI PRASAD VARMA

11 Assessment of mental health disorders among migrant Brick Kiln workers of western Odisha 137BIBHISHANA BHUYAN AND K. C. DAS

12 Building better migrant worker-health system interfaces: noteworthy interventions from local self-government institutions in Kerala 149SOUMYA GOPAKUMAR, C S DIVYA, ARUNA S VENU AND

P RAVI PRASAD VARMA

13 COVID-19 pandemic and interstate migrants: documenting the response of health system and civil society 162SAPNA MISHRA, MALU MOHAN AND RAKHAL GAITONDE

14 What next for the COVID-19 return emigrants? findings from the Kerala return emigrant survey 2021 181S. IRUDAYA RAJAN AND BALASUBRAMANYAM PATTATH

15 Food security and psychological distress of migrants during COVID-19 lockdown 196SHIVAKUMAR JOLAD AND SHALAKA SHARAD SHAH

16 Livelihood, employment and health of migrant workers in the context of COVID-19 pandemic 223LEKHA D. BHAT, KESAVAN RAJASEKHARAN NAYAR, SOBIN GEORGE,

ARATHI P. RAO, JINBERT LORDSON, NAOREM ARUNIBALA DEVI,

SHABANA ROZE CHOWDHURY, MUHAMMED SHAFFI,

BINDYA VIJAYAN AND N. PRAJWAL

Contents ix

17 An exploratory analysis of gender attitudes in Tamil Nadu: new evidence from Tamil Nadu migration survey 246GINU ZACHARIA OOMMEN, S. IRUDAYA RAJAN, GEORGE JOSEPH,

SYED USMAN JAVAID, JENNIFER SOLOTAROFF AND LUIS ALBERTO ANDRES

18 Migrants and their livelihoods in the urban informal sector 277S. S. SRIPRIYA

19 Nexus of social remittances and social change: an ethnographic study of impact of Gulf migration on linguistic pattern of migrants in Uttar Pradesh 292MOHAMMED TAUKEER

20 International migration of indentured labour from Northern India, 1881–1911 306HIMMAT SINGH RATNOO AND PRADIPTA CHAUDHURY

Index 320

6.1 (a) Worriedness about their family members contacting COVID-19, (b) The effect of national shut down on work, health and safety 68

6.2 Reasons for unable to purchase the essential items by households 71

10.1 Conceptual framework (Modified Anderson model for oral health care utilization with correlates of potentially malignant oral disorders) 121

10.2 Oral intervention needed among participants 12610.3 Type of lesions among study population 12710.4 Barriers to oral health care utilization 12815.1 Profile of migrants in Pune district-based on Census 2011 20015.2 Profile of respondents – Gender and education level 20115.3 Duration of migration and state of origin of respondents 20215.4 Occupation profile of respondents 20215.5 Expenditure cut back during the lockdown by

the respondents. Figures derived from the analysis of qualitative responses. 204

15.6 Ration card possession, usage, and challenges faced by respondents 206

15.7 Four ways of processing information in a crisis situation. Adapted from CDC (2019) 209

15.8 Four types of psychological effects affecting individuals in a crisis situation. Adapted from Crisis Reactions (Young et al., 1998) 210

15.9 Word cloud – Perception of lockdown 21115.10 Word cloud – Anxiety description 21215.11 Word cloud – Stress description 213

Figures

6.1 Characteristics of the Return Emigrants, 2020 616.2 Particulars on the return journey of emigrants 636.3 Industry engagement of the Return emigrants 656.4 Shortage of essentials in Gulf during COVID-19 676.5 Various sources of information on COVID-19 696.6 Attitude and Knowledge of return emigrants on COVID-19 696.7 Variation in the remittances being sent to LBHs 716.8 Choice made by the households unable to purchase

essential items 726.9 Emigrants household members experience of COVID-19 737.1 Peripheral health workers’ visits to the migrants’ habitations 817.2 Reception of antenatal care services by women during

most recent pregnancy 817.3 Reception of first antenatal care 837.4 Type and place of childbirth among women 847.5 Reception of various components of antenatal care 857.6 Reception of vaccination card by migrant children 857.7 Reception of vaccines appropriate for age among migrant

children 869.1 Prevalence of occupational morbidities among migrant

auto-rickshaw drivers by occupational morbidities in last 1-year preceding survey in Mumbai, 2012–13 106

9.2 Prevalence of morbidities among migrant auto-rickshaw drivers by the factors affecting occupational morbidities in last 6 months preceding survey in Mumbai, 2012–13 107

9.3 Treatment-seeking behavior, expenditure incurred of various occupational morbidities among migrant auto-rickshaw drivers in last 6 months preceding survey in Mumbai, 2012–2013 110

9.4 Percent distribution of migrant owner auto-rickshaw driver and migrant non-owner auto-rickshaw drivers by treatment-seeking behavior and expenditure incurred in Mumbai, 2012–13 111

Tables

xii Tables

9.5 Percent distribution of respondents by post-accident experience at work in Mumbai, 2012–13 113

10.1 Socio-demographic characteristics of the study groups 12210.2 Diet-related and other adverse health-related habits

along with their frequency and duration 12310.3 Age-standardized tobacco usage 12410.4 Self-reported health issues and oral health characteristics

and awareness among study population 12510.5 DMFT and BMI categories of the study group 12610.6 Crude and age-standardized prevalence of OPMD 12710.7 Proportion of people who utilized oral health care services 12710.8 Socio-demographic factors, personal habits, morbidity

and health system factors significantly associated with oral care seeking 129

10.9 Risk of OPMDs in migrants as compared to residents 12910.10 Correlates of OPMDs in study population 13010.11 Subgroup analysis of factors affecting oral care seeking

in migrants 13010.12 Tobacco use among migrants in Kerala 13211.1 The scoring pattern, mean score of individual items and

Cronbach’s alpha score while deleting individual items of GHQ-12 142

11.2 Prevalence of experiences of specific symptoms and behaviours by respondents 143

11.3 Prevalence of mental health conditions in seasonal migrants by background characteristics 144

14.1 Frequency of primary reason for return by REM type 18514.2 Distribution of REM type by district 18614.3 Occupations of REM-by-REM type 18814.4 Future Plans of REM-by-REM type 19014.5 Distribution of the number of immovable assets owned

by the future plan of REM 19016.1 Socio-Economic profile of the participants 22716.2 COVID, Migrants and Vulnerabilities 23016.3 Measures to reduce the Risk of Transmission (to Self) 23916.4 Measures to Reduce Risk of Spreading the Infection

(to Others) 24016.5 Disinfection Measures Adopted 24116.6 Lockdown Impact on Feelings and Behaviour 24217.1 Distribution of households in TMS 2015 24717.2 General Gender Attitudes by Locality 25617.3 General Gender Attitudes by Education 25717.4 General Gender Attitudes by Gender 25817.5 General Gender Attitudes by Wealth 25917.6 General Gender Attitudes by Religion 25917.7 Employment Attitudes by Gender, Locality, and Wealth 260

Tables xiii

17.8 Employment Attitudes by Education and Religion 26117.9 Decision-Making Attitudes by Locality 26217.10 Decision-Making Attitudes by Education 26317.11 Decision-Making Attitudes by Gender 26417.12 Decision-Making Attitudes by Wealth 26517.13 Decision-Making Attitudes by Religion 26617.14 Attitudes on Gender-Based Violence by Locality 26717.15 Attitudes on Gender-Based Violence by Education 26917.16 Attitudes on Gender-Based Violence by Gender 27017.17 Attitudes on Gender-Based Violence by Wealth 27117.18 Attitudes on Gender-Based Violence by Religion 27318.1 Distribution of respondents according to gender by type

of products 28518.2 Distribution of respondents according to gender by average

earnings per day 28618.3 Number and Percentage distribution of Mobile Vender’s

Average Earnings per day by Background characteristics and Place of origin 287

18.4 Distribution of respondents according to gender by major constraints faced while selling products 288

19.1 Stock of South Asian Migrants in GCC states since 1990 up to 2019 293

19.2 Multistage sampling for selection of sample Areas 29419.3 Trends of labour migration from pop five states of India

to GCC states in selected years since 2008–2020 29619.4 Top three districts of Uttar Pradesh in labour migration

to GCC states in Middle East in selected years since 2008–2020 297

19.5 Common popular Arabi words in migration-based community at root 302

20.1 Demand, dispatch and registration of colonial recruits and price of food, 1888–1911 309

6.1 Experience at the quarantine centre 646.2 How was the emigrant exposed to the virus corona 6613.1 Persisting vulnerabilities despite systematic interventions – the

Kerala story 168

Boxes

Anjali Borhade is a founder president of Disha Foundation, a leading NGO working in areas of migration and development in India.

Anuj Kapilashrami is Professor, School of Health and Social Care, University of Essex, United Kingdom.

Arathi P. Rao is with Prasanna School of Public Health, Manipal Academy of Higher Education, Karnataka.

Aruna S Venu is associated with Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

Balasubramanyam Pattath is a Ph.D candidate at Graduate Institute of International and Development Studies, Geneva, and also Research Fellow at the International Institute of Migration and Development, Kerala.

Bibhishana Bhuyan is a researcher associated with the International Institute for Population Sciences, Mumbai.

Bijaya Dewashi is an independent researcher.

Bindya Vijayan is with Global Institute of Public Health, Trivandrum, Kerala.

Bontha V. Babu is Scientist- G and Head, Division of Socio- Behavioural & Health Systems Research, Indian Council of Medical Research, New Delhi.

K. C. Das is Professor at the International Institute for Population Sciences, Mumbai.

C S Divya is associated with Health Action by People, Kerala.

Divya Ravindranath is a researcher based at the Indian Institute for Human Settlements, Bangaluru.

George Joseph is a senior economist, South and Transocean Asia Sub- region, World Bank.

Contributors

xvi Contributors

Ginu Zacharia Oommen is a member of the Kerala Public Service Commission, Kerala, India.

S. Irudaya Rajan is Chairman, The International Institute of Migration and Development, Kerala.

Jennifer Solotaroff is a senior social development specialist at the World Bank.

Jeevan R. Sharma is Senior Lecturer in South Asia and International Development, School of Social and Political Science, The University of Edinburgh, United Kingdom.

Jinbert Lordson is with Global Institute of Public Health, Trivandrum, Kerala.

Himmat Singh Ratnoo is Associate Professor, Department of Economics, Maharshi Dayanand University, Rohtak, Haryana, India.

Kesavan Rajasekharan Nayar is Professor and Head, Global Institute of Public health, Kerala.

Lekha D. Bhat is with Department of Epidemiology and Public health, Central University of Tamil Nadu, Thiruvarur, India.

Luis Alberto Andres is a lead economist at the World Bank.

Mala Ramanathan is Professor at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

Malu Mohan is a public health researcher affiliated with the Women’s Social and Health Studies’ Foundation, Thiruvananthapuram, India.

Mohammed Taukeer is D.Phil Scholar at G B Pant Social Science Institute, Allahabad, India.

Muhammed Shaffi is with Boston University, United States of America.

Naorem Arunibala Devi is with Martin Luther Christian University, Shillong.

Pavitra Mohan is a community health physician, paediatrician and public health practitioner. He is a co- founder of Basic Health Care Services (BHS).

Pooja Batra is associated with the Indian Institute of Management, Indore, and is affiliated as a Senior Research Fellow at the International Institute of Migration and Development.

Pradipta Chaudhury is Professor, Centre for Economic Studies and Planning, School of Social Sciences, Jawaharlal Nehru University, New Delhi.

N. Prajwal is with Department of Human Geography and Spatial Planning, University of Utrecht, The Netherlands and Institute for Social and Economic Change, Bangalore.

Contributors xvii

Radhika Chopra retired as Professor, Department of Sociology, University of Delhi.

Rakhal Gaitonde is Professor at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

P Ravi Prasad Varma is Additional Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala and Health Action by People, Kerala.

Sapna Mishra is pursuing her doctoral research at Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute of Medical Science and Technology, Kerala, India.

Shabana Roze Chowdhury is an independent Public Health Practitioner, Kolkata, West Bengal.

Shalaka Sharad Shah is Assistant Professor (Psychology) at Department of Social Sciences, School of Liberal Education, FLAME University, Pune.

Shivakumar Jolad is Associate Professor (Public Policy) at the Department of Social Sciences, School of Liberal Education, FLAME University, Pune.

Sobin George is with Institute for Social and Economic Change, Bangalore.

Soumi Mukherjee is Researcher associated with the International Institute for Population Sciences, Mumbai.

Soumya Gopakumar is associated with Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, Health Action by People and Government Medical College, Kerala, India.

S. S. Sripriya is Senior Research Fellow at the International Institute of Migration and Development, Kerala, India.

Sunu C. Thomas is Researcher at Society for Health Information System Program (HISP India), New Delhi

Syed Usman Javaid is Operations Officer, World Bank Pakistan Country Management Unit.

Tijo George is Ph.D Scholar at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

Yadlapalli S. Kusuma is Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi.

Yogita Sharma is a Researcher, Division of Socio- Behavioural & Health Systems Research, Indian Council of Medical Research, New Delhi.

It is my pleasure to introduce the 12th India Migration Report as the Chairman of the International Institute of Migration and Development, India (www.iimad.org). At the time of writing this preface in June 2021, India has reported 30 million COVID- 19 cases and is occupying the second position globally just behind the United States of America (35 million). In terms of human lives lost due to the virus, it stands at 400,000 at the third rank, just behind the United States of America (600,000 deaths) and Brazil (500,000). The lockdowns, both globally and in India, severely affected both internal and international migrants in sustaining their lives and liveli-hoods. In this context, IMR 2021 will focus on health of the migrants, and IMR 2022 will examine the migration of health professionals from India. Before we delve deep into the issues raised in IMR 2021, let us recap briefly the earlier Indian Migration Reports.

The focus of the first IMR (2010) was migration governance. It dealt with various policies concerned with migration and recruitment. It brought to focus some of the challenges faced by migrants in their host destinations and the malpractices in labour recruitment. The second IMR (2011) exam-ined various facets of internal migration and various economic, social and political consequences associated with it. The studies included the impact of internal migration at the state, national and international levels. The use of migrants as a tool to further political gains, the failure of existing policies to address the challenges posed by migrants and migration, and the inter-play of caste and ethnicity in migration in the recruitment process of migrant labourers were some of the issues discussed. IMR 2012 discussed the impact of the global financial crisis on migration, return migration and remittances in the origin, as well as the destinations of migrants, particularly the South Asia- Gulf migration corridor. The articles contained in the third volume elucidated the global scenario, as well as the ramifications of the economic slowdown in certain prominent countries of origin, such as India, Pakistan, Nepal and Bangladesh.

The fourth IMR (2013) brought to the spotlight various facets of the social costs of migration, which are often overlooked in global migration research, and highlighted multiple challenges faced by children and older adults based on studies conducted in Kerala and Tamil Nadu, the primary

Preface

Preface xix

states of origin, and in the United Kingdom and the United States of America, the main countries of destination. It also touches upon the plight of women left behind by their migrant spouses. IMR 2014 was dedicated to the Indian diaspora for their stellar contribution towards the development of India. The chapters were designed to impart a theoretical understanding of diasporic diversity to the readers. Various issues faced by the Indian dias-pora also found a mention in this volume. The fifth IMR (2015) dealt with the crucial linkages between gender and migration. The volume focused on changing gender dynamics brought about by migration and its impact on individuals, households, economy and society. It also touched upon issues like marriage migration and the intersections of gender, caste and migra-tion. In addition, it also offered insights into the vulnerabilities faced by women migrants in their destinations, with a special reference to the Gulf countries. IMR 2016 was dedicated to studies on Gulf migration, with sev-eral insightful chapters on the socioeconomic and cultural ramifications of large- scale migration to Gulf countries in their places of origin, as well as the destinations. Most of the studies were based on extensive fieldwork among the migrant population in the Gulf region.

The forced relocation of thousands of citizens for various developmental projects across the country was the focal point for the eighth IMR (2017). A compilation of 21 chapters by scholars from different disciplines unrav-elled the deprivation of basic rights and amenities of the evictees and the subsequent risks they are exposed to, following forceful evictions to make way for large- scale investments. The fascination that Europe offers to pro-spective migrants was the topic of discussion for IMR 2018. The chapters dealt with policies and trends associated with the migration of Indian stu-dents and professionals to Europe. The challenges and uncertainties caused by Brexit found a mention in the articles along with the impact of prevalent migration policies in different European nations on the future of migration patterns to Europe. The 10th IMR (2019) featured the life and history of the Indian diaspora in Europe. A compilation of 20 chapters from diverse disciplines explored the socioeconomic conditions of the Indian diaspora in several European nations, along with the challenges they face in the wake of the rise of populist regimes in the continent. The series also explored the possibilities of harnessing the untapped potential of Indian migrants, much to the mutual benefit of India and Europe.

The last IMR (2020) examines the massive corpus of information and data collected from the Kerala Migration Surveys over two decades. The special focus of the issue was to highlight the contribution of Kerala Migration Surveys, its replication in various states and the prospects of a proposed all- India survey on migration. It explored various facets of migra-tion and the ramifications of migration on society, culture, gender relations and the economy of Kerala. The issue also explored the politics and policies of migration and return migration.

The current IMR presents a detailed study on the health of migrants. The COVID- 19 pandemic has forced authorities, policymakers and many

xx Preface

other stakeholders to turn their attention to healthcare delivery unlike ever before. The pandemic has exposed the fault lines in society as well, as exist-ing gaps in the creaking health infrastructure. The healthcare system has been of little avail to migrant labourers, who are mostly from the lower rungs of the social ladder. It is the aim of this series to bring to the fore the health status of the migrant population, both before the pandemic and dur-ing the course of the pandemic. It is hoped that the lessons learnt from the devastation wreaked by the pandemic would ensure better healthcare facili-ties for migrant labourers. Next, I provide a brief review of each chapter, followed by a longer discussion.

The first three chapters offer snapshots of existing policies on the health of migrants and the lacunae in them. They describe in detail the inadequa-cies of various policies such as the Inter- State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1978, Building and Other Construction Workers (Regulation of Employment and Conditions of Service) Act, 1996 and the National Health Policy, 2017. The first three chapters set the groundwork for future studies into the intersection between migration and health, and the access of the migrant population to the healthcare system of the country.

Chapter 4 deals with a topic that has received little attention in migration studies. Although there have been studies on the impact of migration on health and the interface between gender and access to healthcare, the man-ner in which both gender and migration affect health as intersecting vulner-abilities has not been given sufficient attention. This chapter addresses the topic through an ethnographic account of the author. Chapter 5 explores the challenges faced by migrant labourers in accessing basic health facilities in Indian cities. Based on studies conducted in Jalandhar and Guwahati, the paper identifies key concerns of migrant labourers such as housing, welfare, education, safety and violence. Chapter 7 discusses the access of migrant labourers to primary healthcare services, based on a field study conducted among migrant labourers in 13 Indian cities. The basic services catered to by the primary healthcare services such as general healthcare, maternal health and immunization services are discussed, with reference to the migrant population. Chapter 8 discusses the challenges faced by migrant workers in the brick kilns of West Bengal. Apart from physical infirmities, they also have to endure severe psychological distress owing to poor work-ing and living conditions in the kilns. The exposure of migrant auto- rickshaw drivers in Mumbai to various health vulnerabilities is examined in chapter 9. As the migrant auto- rickshaw drivers continue to be exposed to various hazardous situations, their health situation worsens on a daily basis, which calls for the reformulation of the existing road policy as well as urban policy. Chapter 10 deals with a comparative study on the preva-lence of potentially malignant oral disorders among migrant labourers, as well as the general population of Kerala. The study reveals a greater preva-lence of potentially malignant disorders among the migrant population due to the use of alcohol and tobacco products. Chapter 11, along with chapter

Preface xxi

8, examines the mental health status of migrant labourers working in the brick kiln industry, which is a major labour- intensive industry, based on a study conducted among migrant labourers in the highly impoverished Kalahandi- Balangir- Koraput region of western Odisha. The nationwide lockdown, announced at short notice in 2020 to curb the spread of the COVID- 19 pandemic, wreaked untold suffering on the migrant population of the country.

Chapter 12 examines the role of decentralization and local self- government institutions in enabling health systems to address health prob-lems of migrants in Kerala. Chapter 13 deals with the health of migrants and the response of health systems and civil society organizations in the context of COVID- 19. Chapter 14 discusses government policies and pro-grams aimed at providing welfare for return emigrants from the Gulf. The focuses of Chapter 15 are food insecurity and psychological distress of migrants in the wake of the lockdown induced by the pandemic. Chapter 16 is based on a qualitative study that explored some of the major challenges faced by migrant labourers in the context of the COVID- 19 pandemic, with a special focus on the vulnerabilities they encountered across the states and the type of support they received from various stakeholders. The perception of gender- related topics such as employment, gender- based violence, decision- making and general attitude are discussed in Chapter 17, based on a survey among migrant, non- migrant and return migrant households of Tamil Nadu. The focus of Chapter 18 is the living conditions of migrant mobile vendors and is based on a study conducted among the train vendors of Mumbai, who represent a significant proportion of the growing informal sector of the national economy. Chapter 19 discusses the nexus of social remittances and social change in Uttar Pradesh, and the last chapter seeks to challenge widely held notions regarding the migration of indentured labour to overseas plantations in the 19th and 20th centuries.

In the introductory chapter, Divya Ravindranath and Pavitra Mohanhighlight the key health challenges faced by migrant labourers and the gaps in policies and studies associated with the health of migrants, with a special focus on internal migrants. There is a dearth of studies on the impact of migration and the nature of working conditions on the health and well- being of migrant labourers. This calls for the formulation of an inclu-sive health policy aimed at improving the health and safety of migrant labourers. This paper places the health challenges within the broader frame-work of the working environment of migrant labourers. Some of the key health challenges identified by the authors from their fields of study are occupational diseases, spread of infectious diseases like HIV/AIDS and TB, and the lack of proper maternal and child healthcare facilities.

The rapid rise of urban centres as engines of development, the neo- liberal policies which were initiated in the 1900s, and waning prospects of agricul-ture drove working populations from the villages to the cities. Most of the migrant population comprise people from the lower sections of the society who would be exposed to the vulnerabilities of the new urban environment

xxii Preface

following their migration. Yadlapalli S. Kusuma and Bontha V. Babu pro-vide a detailed description of the challenges faced by migrant labourers, especially with regard to their health status and access to healthcare facili-ties. The gaps in the existing policies such as Inter- State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1978, Building and Other Construction Workers (Regulation of Employment and Conditions of Service) Act, 1996 and Rashtriya Swasthya Bima Yojana (RSBY), point to the lack of enthusiasm from the part of the governments towards the plight of migrant labourers. The paper cites the devastation caused by the pandemic and the lockdown on the migrant population as an example to substantiate the apathy of policy formulators towards migrants. The authors call for the formulations of inclusive and migrant- sensitive policies to address their concerns in the long run.

Lack of employment opportunities in rural settings and the economic benefits being offered by the burgeoning urban space draw thousands of migrant labourers to major Indian cities from the villages. Despite their stellar contribution to the day- to- day affairs of urban life, migrant labour-ers are often denied basic rights and amenities, regardless of the existing policies and laws aimed at their welfare. The Interstate Migrant Workers Act, 1979, The National Health Policy, 2017, and the National Population Policy, 2000, have done little to improve the travails of migrant labourers, mainly due to the lack of political will to implement the policies. The health-care facilities do not reach the migrant population due to the nature of their migration status, timing of work and distance to the services. Anjali Borhade calls for a revamp of urban medical services, and their extension to migrants. Gaps in existing policies may be addressed by advancing a comprehensive migration policy, with special emphasis on data collection of migrants, por-tability of healthcare facilities and social security schemes at the source as well as destination of migrants.

The combined effect of gender and migration on the health of migrant populations has not been a widely studied topic. This is because of the complex nature of the intersections of gender and migration on health. Although both gender and migrant status may be overlapping vulnerabili-ties, the way they affect health outcomes is difficult to assess. This calls for employing innovative means to explore the dual axes of these vulnerabili-ties. Taking cue from ethnographic practices that transcend boundaries of disciplines, Mala Ramanathan, Sunu C. Thomas and Tijo George rely on the personal narratives of one of the authors recalled from memory and reconstructed with verification of medical records of using state immuniza-tion services in Kerala to draw out specific characteristics of gender and migrant status that affect healthcare utilization in a specific context. The authors posit that those migrants whose socioeconomic characteristics are sound have better access to healthcare facilities than those who are from less- privileged settings. The extensive use of technology can also help migrant women to gain access to healthcare settings, considering the limita-tions imposed on migrant women being the caregivers of the families as

Preface xxiii

well. Health systems in societies that receive migrants ought to instil trust among the migrant population. This would ensure better healthcare for migrant women and their assimilation within the local communities.

Radhika Chopra, Jeevan R. Sharma and Anuj Kapilashrami explore the challenges faced by migrant labourers in accessing basic health facilities in Indian cities. The authors posit that migrant labourers left for their places of origin from the cities in the wake of the lockdown as the healthcare sys-tems in the cities are skewed against them. The authors present results from a study funded by ICSSR- ESRC, which identified key areas of concern with regard to migrant labourers, which are housing, welfare, education, safety and violence. The study involved in- depth fieldwork- based ethnography in two tier- two cities in India – Jalandhar in Punjab and Guwahati in Assam. The study presents mixed picture of the migrants’ access to healthcare facil-ities. While employers generally do not take care of the sick or injured migrants and their access to state facilities are limited, longer- term migrants in these cities do find a way to get access to healthcare facilities. Social networks among migrants play a vital role in availing healthcare facilities. Wherever state provides healthcare, migrants tend to access it; wherever it is denied, they leave for their places of origin.

The COVID- 19 pandemic has brought to the fore the challenges faced by migrants, both internal and external, in an unprecedented manner. As the pandemic tightened its grip across the globe, thousands of Indian nationals were repatriated by the Indian government under the Vande Bharat Mission. S. Irudaya Rajan and Pooja Batra explore the impact of COVID- 19 on the emigrants who came via Vande Bharat Mission and private chartered flights. The chapter also aims to investigate the impact of the pandemic both at the individual and household level from the emigrant’s perspective. This study is based on a survey conducted by the senior author in 2020 among 850 emigrants who had returned to Kerala from different host nations and investigates the socioeconomic consequences of the COVID- 19 pandemic on return emigrants and their left- behind households (LBHs). The study identified loss of job as the primary reason for their return. It also exposed the social and economic hardships faced by the returnee emigrants and their immediate family members. The chapter also brings to focus the inadequa-cies and defects of existing policies intended to protect the interests of migrants. The structural fault lines exposed by the pandemic underscore the need for a comprehensive policy to deal with the plight of migrants.

India has a significant migrant population, especially in major cities. With rising migration and migrants occupying a large share of the urban popula-tion, migrants’ access to healthcare systems has become a relevant topic for consideration. Strengthening primary healthcare facilities enhance the attainment of Universal Health Coverage (UHC). Bontha V. Babu, Yogita Sharma and Yadlapalli S. Kusuma discuss the accessibility of primary healthcare facilities to migrant labourers based on a quantitative study among migrant labourers in 13 Indian cities. The study dealt with various aspects of primary healthcare such as general healthcare, maternal health

xxiv Preface

and immunization services. The authors argue that by and large, migrant labourers are deprived of primary healthcare services due to a number of reasons including their alienation from the urban environment and the apa-thy of frontline health workers towards migrants. Long- term urban policies aimed at mitigating structural barriers and minimizing socioeconomic inequalities faced by migrants could improve their standard of living and access to healthcare services.

Bijaya Dewashi explores the vulnerabilities of interstate seasonal migrant labourers working in the brick kiln industry. The author researches the impact of working and living conditions on the health of seasonal migrant labourers in the brick kilns of West Bengal. The brick kiln industry in India, being a labour- intensive sector, employs a large number of men and women. The migrant labourers in the brick kiln industry are exposed to several adversities such as debt trap, poor living conditions, lack of proper sanita-tion facilities, and physical as well as psychological infirmities caused due to hazardous working conditions. This paper also highlights the vulnerabili-ties of women labourers as they work in the brick kilns and in their families. The healthcare access of brick kiln labourers is constrained by their low income and reliance on quacks for quick remedies. The enactment of legis-lation, including the Factories Act, has not improved the conditions of brick kiln labourers. The author proposes some measures such as periodic change of the nature of work, use of trolley to carry heavy loads and frequent breaks between working hours to improve their working environment. The draft National Migrant Labour Policy of NITI Aayog is presumed to be a step in the right direction to improve the lives of migrant labourers.

Public transport drivers are among the most affected groups with regard to occupational safety and hazards as they work under immense pressure and are constantly exposed to various pollutants. Soumi Mukherjee and K. C. Das deal with the ergonomics of migrant auto- rickshaw drivers in Mumbai and attempt to explore their occupational morbidity, type of healthcare facility availed and expenditure incurred. The authors employed qualitative and quantitative methodologies to gather data from 280 migrant auto- rickshaw drivers in Mumbai. The study brings to light the deteriora-tion of health among auto- rickshaw drivers due to long working hours, body vibration, and unhealthy food and drink habits along with erratic sanitary patterns. These problems are exacerbated by poor quality of the vehicles used and the use of tobacco and alcohol. Also, about 80% of the drivers surveyed had met with some kind of an accident during the course of their career. Considering the hazards lurking among auto- rickshaw driv-ers, the authors suggest the formulation of favourable job and road traffic policies to ease their burden. Increasing the availability of primary health-care services to rickshaw drivers would also alleviate their hardships to some extent.

Although the presence of migrant labourers has been a boon to Kerala’s economy, their living conditions marked by high rate of unhealthy behav-iours such as poor diet, smoking, alcohol and betel nut products usage are

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often attributed to stressful conditions and tiring work. Tijo George and Ravi Prasad Varma attempt to find the difference in its prevalence and cor-relates of potentially malignant oral disorders among migrants and the gen-eral population in Kochi, Kerala. This study also seeks to analyse various factors affecting the utilization of oral healthcare services among interstate migrant labourers in comparison to the general population. The study was a community- based comparative cross- sectional study among 164 male migrant labourers and 136 men in the general population aged 18 years or above. The study shows a greater prevalence of potentially malignant oral disorders among the migrant population. This can be attributed to the widespread use of tobacco and alcohol among the migrant community. This situation calls for targeted programmes among the migrant population to reduce the usage of tobacco and alcohol.

Bibhishana Bhuyan and K. C. Das discuss the mental health status of migrant labourers who are engaged in the brick kiln industry in western Odisha. The brick kiln industry is one of the most labour- intensive and arduous sectors in the country. Crop failure drives migrant labourers from the highly impoverished Kalahandi- Balangir- Koraput region of Odisha to the brick kilns in south India, especially in the suburbs of Hyderabad. This study is based on a survey conducted among 301 migrant households of Belangir district in western Odisha. The study uses the General Health Questionnaire (GHQ) developed by British Psychiatrist Goldberg in 1972 to assess the mental health of migrant brick kiln workers. The GHQ is one of the most popular and widely used screening instruments for the recogni-tion and measurement of mental health. The study infers that a significant proportion of the study population suffer from mental health conditions, unbeknown to them. Arduous working conditions and the distress caused by incessant crop failures contribute to their mental health status to a large extent. Effective implementation of the National Mental Health Policy (NMHP) is suggested as a measure to resolve the crisis.

Despite the enactment of several legislations aimed at improving the work and living conditions of migrant labourers, there has not been much of an improvement in this regard. The unending plight of migrant labour-ers, which was evident in the wake of the announcement of lockdown in 2020, points to a failure of the state. However, Kerala’s response to the challenges plaguing migrant populations has been remarkable. This has been made possible by the active participation of local self- government institutions (LSGI). Undertaken as part of a larger study on decentralization in Kerala and the role of local self- government institutions in enabling the Health System to better address health problems, Soumya Gopakumar, Divya C. S., Aruna S Venu and Ravi Prasad Varma employed a qualitative methodology for data collection and analysis. Participation of local self- governments brought about substantial changes in the approach towards addressing the health concerns of migrant labourers by means of improving living conditions, periodic health camps to assess the health of migrant populations, and cultural events to bridge barriers. Considering the fluid

xxvi Preface

nature of migrant populations, a flexible approach on the part of LSGIs would yield encouraging outcomes in terms of migrant health and social inclusion. Considering the lacunae in the existing strategies to address the health concerns of migrants, Kerala’s experience with the LSGIs could be replicated at the national level.

Sapna Mishra, Malu Mohan and Rakhal Gaitonde deal with the health of migrants and the response of the health system and civil society organi-zations in the context of the COVID- 19 pandemic and lockdowns imposed to curb its spread. In doing so, the chapter highlights the existing gaps between policies aimed at safeguarding the interests of migrant labourers and the implementation of these policies on the ground. The authors argue that migrant labourers were largely left to fend for themselves during the pandemic and the way the lockdown was imposed in the wake of the pan-demic brought to the fore the structural fault lines in the society. The pan-demic and the measures taken to curb the spread of the pandemic have unequally affected migrant labourers. The authors cite the efforts taken by a number of civil society groups to support fleeing migrants in some major cities of India. However, the authors highlight the migrant- friendly policies in Kerala even before the onset of the pandemic, which held the migrants in good stead despite the uncertainties caused by the pandemic. This is largely attributed to the state’s commitment towards more equitable and redistributive policies aimed at ensuring just outcomes. Given the failure of the existing policies to respond proactively to the plight of migrant labour-ers, it is imperative to formulate a comprehensive and systematic policy so as to ensure every migrant labour is assured of his or her health as a funda-mental right.

The devastating effect of the COVID- 19 pandemic has triggered an unprecedented crisis among the migrant population across the world. Kerala, which has the largest share of Indian emigrants overseas, witnessed an immediate large- scale influx of return emigrants in the wake of travel restrictions imposed to curb the pandemic. An estimated 14.33 lakh emi-grants returned to Kerala between May 2020 and April 2021. S. Irudaya Rajan and Balasubramanyam Pattath examine the prospects of the return emigrants in Kerala, based on a survey, using computer- assisted telephonic interviewing (CATI) method, conducted among 1985 return emigrants. The survey was conducted keeping in view the variety of motivations, experi-ences and the identity of the respondents in the wake of the crisis induced by the pandemic. Although most of the return emigrants were aware of government policies and programmes aimed at their welfare, Rajan and Pattath call for a greater visibility of such programmes so as to enhance the benefit of such schemes among the return emigrants.

The rising spread of COVID- 19 infection in its initial phase in India led the authorities to impose a nationwide lockdown on March 24, 2020, which was announced on short notice. The sudden announcement caught the migrant population of the country unawares and caused widespread distress among them. Shivakumar Jolad and Shalaka Sharad Shah explore

Preface xxvii

the nuances of the impact, including the psychological trauma, of the nationwide lockdown on a group of 234 migrants from the city of Pune, which is a hotspot of migration in western India. The survey was conducted via telephone calls as well as in- person interviews. The survey analysis fol-lows a mixed- methods approach with specific distress indicators studied. The study reveals some of the immediate impacts of the lockdown, which includes loss of employment, food insecurity and expenditure cutbacks. The psychological impacts include anxiety, stress and a feeling of worthlessness. The authors suggest certain steps to address the challenges posed by food insecurity and psychological distress by strengthening the public distribu-tion systems (PDS) and providing telecounselling services to the distressed migrants.

While the decision- makers of the country prioritized controlling the spread of the pandemic, the concerns of thousands of migrant labourers took a back seat. Lekha D. Bhat, Kesavan Rajasekharan Nayar, Sobin George, Arathi P. Rao, Jinbert Lordson, Naorem Arunibala Devi, Shabana Roze Chowdhury, Muhammed Shaffi, Bindya Vijayan and Prajwal discuss the problems of migrant workers especially regarding employment, liveli-hood and health- seeking behaviour. It also seeks to explore the everyday realities of migrants in their encounters with the prevailing COVID- 19 pan-demic in India with a special focus on three selected states in South India – Kerala, Maharashtra and Karnataka – and three states in the northeast – Mizoram, Nagaland and Arunachal Pradesh. The authors employed a qualitative, exploratory framework to give a strong foundation for future research. The paper gives a detailed description of the vulnerabilities that the migrant labourers were exposed to during the course of the lockdown. The study reports variations across the states with regard to the support rendered out by the governments and other stakeholders. The paper also highlights severe mental health distress among the migrants due to the strict imposition of the lockdown. The authors underline the need for an inclusive policy to deal with such contingencies in the future.

The status of women in Tamil Nadu has been relatively stable in line with the “southern” egalitarian trend. Public debates and push for gender equal-ity by means of socioeconomic development campaigns and the self- respect campaign spearheaded by reformers like Periyar have bolstered their posi-tion in the society. Despite the legacy of campaigns for gender equality, a closer reading of the available literature does throw up some worrying trends that indicate the underlying gender inequity even in a progressive state like Tamil Nadu. Ginu Zacharia Oommen, S. Irudaya Rajan, George Joseph, Syed Usman Javaid, Jennifer Solotaroff and Luis Alberto Andres discuss in detail contemporary gender- related attitudes in Tamil Nadu using primary data generated from the Tamil Nadu Migration Survey (TMS) 2015, The data used for the study has been generated from 35 gender- related questions about 20,000 households. A general trend of the survey results reveals the prevalence of a conservative stream among the wealthier, less educated and rural households, even in the midst of predominantly

xxviii Preface

women- friendly views. Surprisingly, the survey showed women held more regressive beliefs than men, which is a pointer to internalized patriarchy among women.

Street vending activity, which is the source of livelihood for about 10 million people in the country, constitutes a major segment of the urban informal sector. It is an important component of the burgeoning informal sector of the Indian economy, with an estimated contribution of 60% to the national GDP. Given the dearth of literature on the contribution of mobile vendors to the life and economy of the city, Sripriya undertook a study among 150 mobile vendors in the local trains of Mumbai to examine their socioeconomic backgrounds, networks, migrations, and average earnings and profits. The study brought to light the poor socioeconomic status of these migrant vendors. Considering the competition with other vendors to sell the products and the bargaining tendency of the customers, the vendors hardly make any profits from their sales. The author posits that poverty and lack of availability of reliable employment opportunities drive migrants to become entrepreneurs taking several risks. Some of the recommendations to improve the living conditions of mobile vendors include creation of more employment opportunities in the industrial/agricultural sector in their home states, formulation of a single inclusive policy governing street vendors and the assimilation of mobile vendors into formal credit lending mechanisms.

Although the economic prosperity of the source state brought about by remittances from the host community is one of the major contributions of migration, the impact of social remittances has largely evaded an in- depth study. Mohammed Taukeer explores the nuances in the nexus of social remittances and social change, as a result of the flow of ideas, feelings, emo-tions and cultural beliefs between the root community and the host com-munity. Such social changes can be observed in those communities with a substantial share of migrant population. The GCC region being an impor-tant host community for migrants from Uttar Pradesh, this paper explores the changes in linguistic patterns in Uttar Pradesh. The author zeroed in on the target population using multi- stage sampling and the data was collected using the ethnographic method, which included participant and passive observation and informal interviews. It was observed that the exchange of social remittances in the form of physical and non- physical culture pro-duced a new type of linguistic pattern included to mix patterns of Hindi and Arabic in the root community. This was manifested in their day- to- day con-versations, religious practices and social norms. This study sets the stage for future research into the social remittances of migration in the root communities.

Himmat Singh Ratnoo and Pradipta Chaudhury seek to challenge the widely held notions regarding migration of indentured labour to sugarcane plantations overseas in the 19th and 20th centuries. While the abundance of the supply of labourers and the failure of crops in north India are generally attributed as the major push factor for indentured labour, statistical figures point to a different trend. Although the abundance of the supply of labour

Preface xxix

may have contributed to the large- scale migration of labourers, the authors argue that the sufficient and decisive reason for actualizing migration was the demand for labour, which was communicated through proper channels. In the absence of the possibility of a primary data collection by means of surveys or interviews, the authors relied on government records for statisti-cal analyses to examine the correlation between abundance of harvest, crop failure and the rate of labour migration. The authors postulate that labour migration to the sugarcane fields overseas cannot be explained by explana-tions of abundance or lack of labour due to various complex factors.

Acknowledgements

Over the last 12 years, the India Migration Report (IMR) series have received overwhelming support and global recognition from readers that include development practitioners, policy makers, researchers, as well as activists, and the IMR series have emerged as prime reference works in the field of migration. I take this opportunity to thank all the contributors who have helped to make every report in the series a must- read. In particular, I take this occasion to thank all the contributors for the IMR 2021 for pro-viding stimulating and thought- provoking articles on the health of migrants, both in the origin and destination, both at the time of migration as well as during the health crisis unleashed by the COVID pandemic.

The IMR series was my dream in 2006, conceived formally in 2008 and commenced in 2010, with the first IMR made possible with the support and guidance of the erstwhile Ministry of Overseas Indian Affairs (MOIA), Government of India, which established the first Research Unit on International Migration (RUIM) from 2006 to 2016, at the Centre for Development Studies, where I worked as the Chair Professor. I express my gratitude to all the secretaries of the MOIA, especially to S. Krishna Kumar, K. Mohandas and Dr A. Didar Singh, without whose help, this series would not have begun and become what it is today.

The 12th IMR is the first one being organized after my departure from the Centre for Development Studies in April 2020 to the newly established think tank, The International Institute of Migration and Development (IIMAD) (www.iiimad.org). I would like to take this opportunity to thank the board members, in particular, K. C. Zachariah and U. S. Misrha and, and the research team – Sunitha, Sreeja, Migdad, Anand, Roshan, Nelgyn, Anjana, Arya, Lathika, Nikhil, Aneeta and Ashwin – of the IIMAD for their hard work and enthusiastic support in putting the series together.

I am eternally grateful for the emotional support, patience and understand-ing I have received from my wife Hema and our three children – Rahul, Rohit and Mary Catherine – without which none of this would have been possible.

Last but not least, I would like to put on record my appreciation for the hard work of the editorial and sales team at Routledge for bringing out this report on time.

S. Irudaya Rajan

DOI: 10.4324/9781003287667-1

1 Migration and healthCharting questions for future research

Divya Ravindranath and Pavitra Mohan

1.1 Introduction

In recent years, the field of migration and health has received considerable impetus globally. There is greater recognition today that while migration provides opportunities for social and economic mobility, it also has adverse impacts on the physical and mental well- being of migrants. Existing litera-ture suggests that in many parts of the world, migrants face health inequi-ties due to discrimination, social exclusion, legal status, gender inequalities, poor living and working conditions, language barriers, lack of information and absence of healthcare financing (Spitzer et al., 2019). Furthermore, con-cerns of accessibility, affordability, equity and entitlement reduce migrants’ ability to seek healthcare. Given this, researchers have acknowledged the need to examine migration as a social determinant of health (Castañeda et  al., 2015; Davies, Basten, & Frattini, 2009) and mainstream migrant health into the public health discourse (Wickramage, Simpson, & Abbasi, 2019). However, much of this deliberation has occurred in the context of international migration, in particular with respect to movement of people from developing to developed countries (Kapilashrami et al., 2020). This is despite the fact that some of the most prominent international migration corridors exist between developing countries and that there are thrice as many internal migrants worldwide in comparison to international migrants (Abubakar et al., 2018; Skeldon, 2018).

In India, a large proportion of migrants are labour migrants that move within the boundaries of the country. It is estimated that approximately a hundred million people undertake seasonal or semi- permanent migration – wherein they move circularly between their place of origin and single or multiple destinations – in search of work (Deshingkar & Akter, 2009). This form of migration is more common among historically marginalized com-munities such as Scheduled Caste (ST) and Scheduled Tribe (ST) groups that engage in informal work in urban areas as ‘low skilled’ or ‘unskilled’ daily- wage labourers in brick kilns, construction industry, garment factories, manufacturing sector and other services (Deshingkar & Start, 2003). Even though households use migration as a critical livelihood strategy to over-come landlessness, poverty or income deficit in non- agricultural seasons,

2 Divya Ravindranath and Pavitra Mohan

labour migrants continue to remain vulnerable even in the destination region due to the precarious nature of informal work (De Haan, 2002; Jayaram & Varma, 2020; Mosse et  al., 2002; Zeitlyn, Deshingkar, & Holtom, 2014).

A rich body of literature in India captures the relationship between migration and informal employment and their economic and social implica-tions (see India Migration Bibliography, Tumbe, 2012), but fewer studies have sought to examine how the process of migration and the nature and conditions of employment shape migrants’ health and well- being (see sys-tematic review by Kusuma & Babu, 2018). In the absence of reliable official data, there is an urgent need to scaleup evidence from the field to inform and design inclusive health policy frameworks and health systems that can respond to migrants’ unique needs.

With an aim to build on this discussion, by way of examples, in this com-mentary piece, we highlight key health challenges encountered by labour migrants. We would like to note that this is not an exhaustive account of all issues pertaining to migrant health but an attempt to explicitly locate it in the broader environment within which migrants experience the same. Based on our own work  – the first author’s doctoral and post- doctoral work focused on maternal and child health among migrant households and the second author has headed several public health initiatives at both the source and destination regions for over two decades – we provide a snapshot of migrant health concerns at the destination region. In this, researchers may find useful motivation for future work.

1.2 Occupational safety and health

The overall aim of occupational safety and health (OSH) is to promote physical, mental and social well- being of workers. The International Labour Organization (ILO) notes that preventive measures must focus on OSH management systems to create a culture of safety such that it reduces expo-sure to hazardous environments and risks at work (ILO, 2013). The recent Occupational Safety, Health and Working Conditions Code 2020 in India covers several aspects of workers’ safety. The code includes provision of safety equipment, basic facilities like water and sanitation, ensuring main-tenance of all machinery that are operated by workers to avoid injuries or accidents. Employers are required to undertake risk assessment that is par-ticular to sector and place. In most sectors, migrant workers are hired by contractors, which blur the relationship between the principal employer and the worker, making it difficult to claim support, compensation or estab-lish any form of liability in case of illness, injury or death. While the code explicitly mentions inter- state migrants, it is silent on intra- migration, which is more dominant in several states.

Labour migrants often work in the most hazardous jobs that prove to be detrimental to their overall health and well- being. Some of the common challenges at informal worksites include high humidity, heat stress and high

Migration and health 3

temperature, noise levels that are beyond permissible limits, poor ventila-tion, unsanitary conditions and presence of toxic material (Venugopal et al., 2016). For instance, in the construction sector, lack of safety audits can make workers susceptible to risk of injury or accidents. At the same time, large number of workers develop lung diseases, musculoskeletal injuries and noise- induced hearing loss due to constant exposure to dust and cement. In the absence of other housing arrangements, migrants working in looms or garment units tend to live within the work premises, thereby, having prolonged exposure to environmental pollutants that have severe health implications.

OSH has been better understood in formal enterprises and the manufac-turing sector but has not been studied adequately in the informal sector, where norms are routinely flouted. The lack of research can perhaps also be attributed to the fact that migrants work at informal worksites that are highly guarded spaces, hidden from public eye. More research is needed to understand occupational health as being closely linked to public health. This can be done by identifying the ways in which work environments pro-duce or exacerbate poor health outcomes, instead of looking at them as isolated instances of morbidities or illnesses that require intervention. For migrant women employed in sectors such as domestic work, garment facto-ries and construction work, there are additional constraints caused by lack of sanitation facilities or continued physical burden of arduous tasks even during pregnancy. The intersection of gender and occupational health needs more attention. OSH must be recognized as a priority in dealing with migrant health as workers spend most of their time at worksites. Risks associated with OSH are among the many first challenges they encounter in the destination region.

1.3 Infectious diseases

Population movement has been associated with spread of infectious dis-eases. Human immunodeficiency virus (HIV), tuberculosis (TB) and, more recently, the COVID- 19 pandemic are some examples. This line of thinking may not only have an epidemiological reasoning but also typecasts migrants as perpetrators or carriers of diseases without recognizing the various vul-nerabilities that exacerbate their exposure to infectious disease. It is impera-tive to understand that the incidence and spread of infectious diseases among migrants is a manifestation of migrant unfriendly health systems in the cities and unsafe living and working conditions that worsen their conditions.

Male migration, in particular, is considered to be an important risk factor with reference to HIV (Dave et al., 2012; Halli et al.,2007; Ranjan et al., 2015; Saggurti et al., 2008). While studies point out the correlation between migration and HIV transmission, there is little data on barriers to health-care, such as systematic exclusion from services and stigma and discrimina-tion that intersects with other forms of vulnerabilities. Researchers must

4 Divya Ravindranath and Pavitra Mohan

examine what conditions in cities determine their high- risk behaviour. How can those conditions be altered to reduce their risk and implement preven-tion programmes?

TB is highly prevalent among migrants, yet it remains grossly understud-ied. It must be examined alongside migrants’ experience of multiple depri-vations, which have a determinantal effect on treatment and recovery. At the workplace, migrants often experience food insecurity, resulting in poor nutrition and reduced immunity. TB spreads rapidly to other co- workers and co- inhabitants due to the highly congested work and living arrange-ments. Work settings, as seen in the garment and construction industry, further intensify the risk of acquiring the disease by the damage to their lungs caused by smoke, fine dust, lack of ventilation and other pollutants.

Future research should explore the impact of informal work and migra-tion within the framework of social determinants of infectious diseases. This will also help evaluate the avenues for systematic interventions for diagnosis, surveillance, prevention and control of infectious diseases. The location and mode of delivery are other points of query – should this take place in the source or the destination region? As we discuss later, the lack of continuity in care reduces migrants’ ability to overcome TB. How can employers/contractors be incentivized to improve work conditions and facilitate access to healthcare? Though challenging to imagine, the last question is pertinent as infectious diseases have the potential to affect an entire population of workers.

1.4 Maternal and child health

In the process of migration, women experience gendered health inequities, specifically with reference to their sexual and reproductive health needs. The uptake of maternal healthcare services is lower among migrant women in comparison to non- migrant populations. Studies have shown that migrant women are less likely to receive complete antenatal care, have insti-tutional births or adequate postnatal care (Abrol, Kalia, Gupta, & Sekhon, 2008; Badge, Pandey, Solanki, & Shinde, 2016; Kusuma, Kumari, & Kaushal, 2013). The Maternity Benefits Program and the Janani Suraksha Yojana, which seek to compensate women for loss of wages due to child-birth and promote institutional birth respectively are inaccessible to migrant women. This is because the conditionalities imposed by these programmes have a strong sedentary bias. Women find it difficult to fulfil conditionalities while they migrate from one location to another (Ravindranath, 2019). Without maternity protection, migrant women tend to work very late into their pregnancy and return to work within a few weeks of childbirth. We need greater focus on the structural, institutional, household- level barriers and enablers that affect maternal healthcare- seeking behaviour. Research on modes of delivery of programmes at both the source and destination region is important. Another emphasis could be on pathways to improve maternal health outcomes and access to services among migrant women.

Migration and health 5

When women migrate, there is a higher possibility of children migrating with them, especially if the child is in infancy or deemed to be in need of maternal care. Migrant families working at construction sites, garment fac-tories or as domestic workers tend to live at labour camps or informal set-tlements that have limited or no access to clean water, sanitation, nutritious food and childcare facilities. Children are severely impacted by these condi-tions. Studies have reported poor nutritional outcomes, high prevalence of diarrhoea and eye infection, low rates of immunization (Biswas, Mandal, & Biswas, 2011; Ravindranath, Trani, & Iannotti, 2019). However, a few studies posit that children of migrants living in the source region encounter nutritional insecurity due to severe resource constraints (Lei, Desai, & Chen, 2020; Mohan, Agarwal, & Jain, 2016). The evidence from other parts of the world on children left behind is mixed. While some point out that remittances improved health and nutritional security in households, others suggest that separation from family can lead to long- term psycho-logical and societal costs (Fellmeth et al., 2018). There is a paucity of data on this front in India. We need more data at the village and district level, as well as in- and out- migration regions to improve nutrition outreach.

The experiences of children have been excluded from mainstream migra-tion studies, which are labour- centric. The absence of official estimates is the foremost lacuna and poses as a roadblock for service delivery of critical programmes, such as the Integrated Child Development Services (ICDS), that have not been made available to migrant households in the destination region. There are some models of creches run by employer- NGO collabora-tions at informal worksites; however, they are an anomaly and not the norm.

1.5 Access to healthcare services

While it has been noted that urban centres present a more established net-work of infrastructure, including the promise of better healthcare facilities, for migrant workers proximity to healthcare services does not necessarily translate into increased accessibility (Vlahov et  al., 2007). As a result of economic constraints caused by low wages, long hours of work and irregu-lar wage patterns, migrants are rarely able to seek care or are compelled to wait until the medical condition is advanced. Lack of sick leave, unfamiliar-ity with health systems, likelihood of out- of- pocket expenditure, inability to undertake repetitive health check- ups and follow- ups severely constrain their ability to seek short and long- term care (Kusuma & Babu, 2018). In many cases, once it does get advanced, unable to work anymore, migrants return to the villages with no recourse to care. This further aggravates their health conditions as seen in the case of TB.

From the health systems point of view, there are two major challenges: in the destination region, migrants are a hard- to- reach population due to the dispersed (and temporary) nature of their worksites and settlements; many illnesses require long- term care that goes beyond diagnosis. Migration imposes challenges for service delivery as seasonal migrants consistently

6 Divya Ravindranath and Pavitra Mohan

move between the source and destination. More research is required to pro-vide evidence- based solutions that can enable outreach and continuity of care through programmatic interventions to mobile populations.

1.6 Post-Script

In 2020, in response to the spread of COVID- 19 pandemic, India declared a stringent lockdown suspending all economic activities. The pandemic and the lockdown severely impacted millions of migrant labourers, who abruptly lost livelihoods, and access to food and shelter. As reported in the media, the crisis exposed a deep lacuna in our governance structures that failed to acknowl-edge the role played by migrants in sustaining our cities. Without a political voice, migrants are invisibilized. Their concerns and needs have never been incorporated into national, state and local level plans and policies.

The pandemic and the associated lockdown are likely to have unprece-dented impact on the nutritional security, health and well- being of migrant workers and their families. To address this immediate concern and envisage a long- term strategy that tackles health concerns even after the pandemic, it is necessary to plan sustained efforts that prioritize and explicitly integrate migrants into our country’s health policies. A first step towards this is to take cognizance of the fact that migration streams in the country are hetero-geneous and vary by gender, caste, region, duration and sector of work (Srivastava, 2020). The process of universalizing healthcare must be such that it incorporates all of these social and economic features. Universal health has been outlined as a central goal in the United Nations Sustainable Development Goals (SDGs) and migrant health cuts across several SDGs (Wickramage & Annunziata, 2018). India’s commitment to the SDGs should pay attention to the call to “leave no one behind”.

References

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Badge, V. L., Pandey, M., Solanki, M. J., & Shinde, R. R. (2016). A cross- sectional study of migrant women with reference to their antenatal care services utilization and delivery practices in an urban slum of Mumbai. Journal of Family Medicine and Primary Care, 5(4), 759.

Biswas, T., Mandal, P. K., & Biswas, S. (2011). Assessment of Health, Nutrition and Immunisation status amongst under- 5 children in migratory brick klin population of periurban Kolkata, India. SudaneseJournal of Public Health, 6(1), 7–13.

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Migration and health 7

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8 Divya Ravindranath and Pavitra Mohan

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Migration and health Abrol, A. , Kalia, M. , Gupta, B. P. , & Sekhon, A. S. (2008). Maternal health indicators amongmigrant women construction workers. Indian Journal of Community Medicine, 33(4), 276. Abubakar, I. , Aldridge, R. W. , Devakumar, D. , Orcutt, M. , Burns, R. , Barreto, M. L. , … &Zhou, S. (2018). The UCL–Lancet Commission on Migration and Health: The health of a worldon the move. The Lancet, 392(10164), 2606–2654. Badge, V. L. , Pandey, M. , Solanki, M. J. , & Shinde, R. R. (2016). A cross-sectional study ofmigrant women with reference to their antenatal care services utilization and delivery practicesin an urban slum of Mumbai. Journal of Family Medicine and Primary Care, 5(4), 759. Biswas, T. , Mandal, P. K. , & Biswas, S. (2011). Assessment of Health, Nutrition andImmunisation status amongst under-5 children in migratory brick klin population of periurbanKolkata, India. SudaneseJournal of Public Health, 6(1), 7–13. Castañeda, H. , Holmes, S. M. , Madrigal, D. S. , Young, M.-E. D. , Beyeler, N. , & Quesada, J.(2015). Immigration as a social determinant of health. Annual Review of Public Health, 36(1),375–392. Dave, S. S. , Copas, A. , Richens, J. , White, R. G. , Kosambiya, J. K. , Desai, V. K. , &Stephenson, J. M. (2012). HIV and STI prevalence and determinants among male migrantworkers in India. PloSOne, 7(8), e43576. Davies, A. A. , Basten, A. , & Frattini, C. (2009). Migration: A social determinant of the health ofmigrants. Eurohealth, 16(1), 10–12. De Haan, A. (2002). Migration and livelihoods in historical perspective: A case study of Bihar,India. Journal of Development Studies, 38(5), 115–142. Deshingkar, P. , & Akter, S. (2009). Human Development Research Paper 2009/13: Migrationand Human Development in India. London. Deshingkar, P. , & Start, D. (2003) Seasonal Migration for Livelihood in India: Coping,Accumulation and Exclusion, Working Paper No. 220, Overseas Development Institute, London. Fellmeth, G. , Rose-Clarke, K. , Zhao, C. , Busert, L. K. , Zheng, Y. , Massazza, A. , … &Devakumar, D. (2018). Health impacts of parental migration on left-behind children andadolescents: A systematic review and meta-analysis. The Lancet, 392(10164), 2567–2582. Halli, S. S. , Blanchard, J. , Satihal, D. G. , & Moses, S. (2007). Migration and HIV transmissionin rural South India: An ethnographic study. Culture, Health & Sexuality, 9(1), 85–94. ILO. (2013). Prevention of Occupational diseases. Policy Development Section: Employmentand social Protection Segment. Jayaram, N. , & Varma, D. (2020). Examining the ‘Labour’inlabour migration: Migrant workers’informal work arrangements and access to labour rights in Urban sectors. The Indian Journal ofLabour Economics, 63(4), 999–1019. Kapilashrami, A. , Wickramage, K. , Asgari-Jirhandeh, N. , Issac, A. , Borharde, A. , Gurung, G., & Sharma, J. R. (2020). Migration health research and policy in south and south-east Asia:Mapping the gaps and advancing a collaborative agenda. WHO South-East Asia Journal ofPublic Health, 9(2), 107–110. Kusuma, Y. S. , & Babu, B. V. (2018). Migration and health: A systematic review on health andhealth care of internal migrants in India. The International Journal of Health Planning andManagement, 33(4), 775–793. Kusuma, Y. S. , Kumari, R. , & Kaushal, S. (2013). Migration and access to maternalhealthcare: Determinants of adequate antenatal care and institutional delivery among socio-economically disadvantaged migrants in Delhi, India. Tropical Medicine & International Health,18(10), 1202–1210. Lei, L. , Desai, S. , & Chen, F. (2020). Fathers’ migration and nutritional status of children inIndia: Do the effects vary by community context? Demographic Research, 43, 545–580. Mohan, P. , Agarwal, K. , & Jain, P. (2016). Child malnutrition in Rajasthan. Economic &Political Weekly, 51(33), 73. Mosse, D. , Gupta, S. , Mehta, M. , Shah, V. , Rees, J. F. , & Team, K. P. (2002). Brokeredlivelihoods: Debt, labour migration and development in tribal western India. Journal ofDevelopment Studies, 38(5), 59–88. Ranjan, A. , Babu, G. R. , & Detels, R. (2015). Knowledge, attitude and perception aboutHIV/AIDS among the Wives of Migrant Workers of Muzaffarpur District in Bihar. Journal ofCommunity Medicine and Health Education, 5(361). doi:10.4172/2161-0711.1000361.

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