特設サイト COVID-19とフィールド・ワーカー

How Are Lower Incomes of Bangladesh Experiencing COVID-19: Preliminary findings from an ongoing research.

2020年6月24日

Ranjan Saha Partha（Jahangirnagar University）
Abul Kalam（Helen Keller International）

アジア 特別寄稿 文化人類学 バングラデシュ

Background
The impact of pandemic is universal but the nature of its impacts depends on people’s social location (age, sex, income, ethnic identity, level of education) cultural atmosphere, sex, space and place. The experiences of pandemic may vary according to the nature of pandemics, preventive measures and coping strategies. The recent impact of novel coronavirus (COVID019) is not exceptional in this regard. The World Health Organization (WHO) developed relevant guidelines on infection prevention and control of COVID-19 and these guidelines are being followed by all countries across the world. The messages and strategies that are being disseminated (by different government agencies, media, NGOs, social media etc.) to prevent and control of COVID-19 in Bangladesh (GoB) are targeted to the life style of richer people. In this context, this ongoing research is trying to explore how lower income group people, day laborers and marginalized population perceive about these messages and guidelines, how these groups of people cope with this current crisis and how they live amid this pandemic.

A number of studies have been conducted in Bangladesh to understand people’s perception on COVID-19 prevention and control messages and the suitability of these messages based on life and livelihood of Bangladeshi people. Two issues identified in those studies; firstly, the lower income people do not perceive the messages appropriately due to illiteracy (Saeed, Nasrullah and Hosen 2020; Uddin 2020) and finally, they cannot follow and practice the COVID-19 prevention and control guidelines and messages due to economic constraints (Asif, Akram, Hossain, Khan 2020; BIGD 2020). Both of these factors are important to consider in understanding the reasons why people “do not follow” the messages and guidelines, other factors such as religious values and individual’s habits (Bourdieu 2000), everyday practices, social practices, and socio-ecological aspects are understudied. These factors may motivate or demotivate people to accept the messages and guidelines. Moreover, the lower income groups are not homogenous. They have the differences in income, cultural values and understanding, level of education and practices. This ethnographic research showed that, every day practices, habits, values and social and cultural perception on disease which are inter-linked beyond economic barriers and limitation of knowledge.

Description of our study
Since 1 April 2020, we have been conducting an ethnographic research aimed at understanding how people on low incomes (i.e. rickshaw and van pullers, day labourers, housemaids, garment workers, hawkers, shoe-makers etc.,) perceive the key terms associated with the government’s campaign, as well as how they are experiencing amid this pandemic. As of 20th May, 2020, we have conducted 30 interviews in the Savar and Ashulia areas just outside of Dhaka city. The study used qualitative telephone interviews as part of practicing social distance. However, the study critically examined the ‘Social Distancing’ in regards to the lower incomes’ experiences by following emic perspective and narrative approach. The study used explanatory model of medical anthropology and critical medical anthropological theories.

Health promotion specialists and behavior change advocates urged to develop culturally inclusive and contextualized health messages to ensure receptibility by the targeted population. One big challenge of using generic messages is that, people from different social locations may not accept these messages in a unitary manner as because different people have different perceptions and understandings (Kleinman 1980) . In this regard, interpretive approach of medical anthropology is our theoretical foundation of our study. Kleinman’s theory of explanatory model (EM) is important in understanding diversity of the meanings. However, EM has some limitations. Firstly, it fails to address the global political economy of health promotion in a wider context. Secondly, the EMs gives lack of concentration on the power relations of the construction of clinical realities of health messages. Finally, it does not prioritize the societal forces and structural determinants. Hence, a critical approach is required explain the health and illness. The critical approach of medical anthropology developed as part of critiques of EM and considered as a challenge to convey the analysis towards broader societal and economic dimensions. This approach was introduced by Soheir Morsy in 1979.

Lockdown Dhaka（Photo by Ranjan, 2020）

The critical medical anthropology retained emphasis on the connection of health-related issues with the economic order and social forces. Emphasized with the macro societal determinants impacting health, the political economy of health approach concentrates its consideration on the economic, political and cultural aspects (Morsy, 1979). The critical approach of medical anthropology has influenced many anthropologists’ work while investigating how different groups of people perceived the health messages. By adopting the critical approach in this study, we try to trace out how health messages are constructed without concentrating lower incomes’ experiences of COVID-19 prevention and control messages and guidelines by exploring their everyday practicalities.

COVID-19 Situation in Bangladesh.
The official authority of Bangladesh confirmed first case of COVID-19 on 8 March 2020 and ten days later the first death. As part of responding mechanism, the government of Bangladesh (GoB) started taking initiative by closing educational institutions (school, college and universities) on 16th March. The government also instructed the local administrations to stop social, cultural, religious, political and business gatherings all over the country to prevent the spread of coronavirus. On 23rd March, the government announced the closure of all public and private offices from March 25 to April 4 except emergency services including hospitals, kitchen, drug stores etc. At that time, people also instructed to stay at home and discouraged to go outside except urgent needs. Interestingly, the inter district transportation was not suspended. As the government declared this shutdown as public holiday, as a result, many people including garment workers, day laborer, students, businessmen, government employee and temporary workers started travelling to their home village.

Along with other government agencies, the Directorate General of Health Services (DGHS) have been closely working with different bodies of Bangladesh as part of response mechanism. Interestingly, religious organizations were not included on their efforts until when a meeting held with Islamic Religious Leaders in Islamic Foundation of Bangladesh on 29th March. After that meeting, the Imam (who lead the prayer) of all mosques across the country asked to sensitize the mass people about corona preventive measures including handwashing and maintaining social distance. Since then, the Imams and other religious leaders started sensitizing the mass on COVID-19 but their engagement restricted when The Ministry of Religious Affair imposed strict restrictions to limit the congregation of saying prayer in the mosques on 6th of April 2020.

Bangladesh armed forces also deployed during this time to help local administration to ensure social distancing and quarantine. As the number of confirmed cases have been increasing and the community transmission has begun, the closure of all public and private offices extended to 14th April 2020. In addition to that, the local administrations and law enforcing agencies locked down few areas which are considered as epicenter of spreading coronavirus.

A new decision came out on 27th April to open in the ready-made garments. The garments owners strictly instructed to ensure social distancing and follow health measures for their workers while working in the garments. Along with other public health professionals, Health Minister was not convinced to start the regular activities of the garments. However, another decision came out to open the shopping malls and markets across the country prior to Eid ul-Fitr – the biggest religious celebration of Muslims. Although, the authority of many big shopping malls decided not to open their shopping malls but a large number of small and medium shopping centers opened. On 22nd of May 2020, the authority has decided to relax travel restrictions. People started travelling through their personal vehicle. As a result, thousands of people started travelling to their village home desperately to celebrate Eid ul-Fitr. As of 3 July 2020, Bangladesh has experienced 128th day amid this pandemic. According to Institute of Epidemiology, Disease Control and Research (IEDCR), as of 3rd July, out of 820,347 tests, the number of total COVID-19 positive case was 156,391 with 1,968 deaths while the number of recovered was 68,048.

Lower income people’s experience on COVID-19 related message
Considering this context, we are conducting this research to understand how lower income people perceive on those key terms, how they are responding to these messages , what are their experiences amid this pandemic and social stigma around COVID-19. In this article we will share our preliminary results on people’s perception on “Social Distancing”, “Stay at Home”, “Quarantine”, “Locked-down”, “Hand Washing with Soap” and “Hand Sanitizing”. In our study the lower income people are defined as those people who are living their lives in daily income. In particular, by lower income people we mean rickshaw and van puller, day laborer (skilled and unskilled), housemaid, garment worker, hawker, shoe-maker and other people of similar professions.

Three or four months ago I got to know from television that a virus has been spreading from China. Hundreds of thousands of people go admitted into hospitals, thousands of people are dying. From a Bangladeshi television channel, I heard a news but they used many English term. But I understood that, the medicine of this disease has not discovered. The disease is infectious. And there is a possibility of death due to this virus. Other than that, I did not understand what they were saying to prevent this disease. I cannot remember about the name of medicine, but they advised to use it on hand. Beside this, they also told to wash hands with soap. They also advised many more, but I could not understand all.

The story tells about the perception of key messages that are being disseminated as part of awareness mechanism to prevent coronavirus. Specifically, we tried to understand the concept “Stay at home”- a key messages, from an Anthropological perspective by exploring lower income people’s social reality. Generally, home is conceptualized as a place of protection or shelter but it does not have any unitary definition. Rather, it involves with socio-cultural aspects, emotion and historical aspects of a particular place and space in different cultural context. Thus, the definition of home changes according to time, difference of characters and situation (Irene 1999). In Bangladesh, home indicates residential arrangement and it is impossible to draw a sketch of home. ‘Home’ is a debatable concept in Anthropology discipline which is often expressed by “Chula”, “Bari”, “Khana” or “Roof” (Bertocci 1970; Jansen 1987). The idea of home is not homogenous depending on people’s social and economic context. For example, in the urban space many people living in open space or footpath (homelessness), apartment, private space and slum whereas in rural areas ‘Bari’ is a symbol status, remittances and migration have changed this notion. The social reality of the people who are living on the street or footpath contradicts with the notion of home as because they do not have an arrangement in regards to the popular norm home. Open space or street or footpath is home for those people which is not similar to modern apartment, flat, rural ‘bari’ neither to slum. We should consider the term home from holistic manner.

Lockdown Dhaka（Photo by Ranjan, 2020）

However, we tried to understand how lower incomes perceive about this key term “Stay at home”. Our study participants mainly depend on daily income for their living. If they unable to earn income then they have to starve. Although, government, NGOs, volunteers and other corporate organizations have been distributing relief (rice, pulse, oil, salt and sanitary kits) to those people, but the amount is not sufficient compare to their needs. One of our research participants said,

One day a group of people from a volunteer organization came to us. They gave us 5-kilogram rice, 1-kilogram dal (pulse), 1-liter oil and a liquid. They told us to use the bottle of liquid on our hand. Our food is finished. Now I have to go outside other than me and my family will starve.

Similar experience observed from other participants. The pandemic creates huge burden to the poorer people as it stopped regular economic activities. Further, the advice of staying home creates extra burden. This situation can be expressed by one participant. He said “I will starve to death if I stay at home or die of corona if I don’t”.

Women’s experience to stay at home found to be different from their counterpart, men. In the patriarchal ideology it is expected that women should stay at home and men should go outside of home. Now it is strongly advised to stay at home, irrespectively men or women. But staying at home is not exceptional for the women, particularly lower income group. However, the pandemic impacts on both men and women blindly but gender stereotypes or social and cultural construction of womanhood or ‘ideal women’ forces women to a vulnerable situation. The number of all forms of violence against women have been increased amid this pandemic. Moreover, women are suffering from extra pressure of work as they are widely considered as care worker of the family members. Along with their regular activities of the household chores, they are also responsible for caring other family members. As people are staying at home, women’s caring responsibilities are also increased. Working women’s condition is more severe. In one side, they are losing their job/work which ultimately impact on their empowerment status. On the other hand, they became burden in the family. Similarly, women headed households are also suffering from severe economic crisis. Therefore, staying at home forces women to a more vulnerable position.

Another frequently used term is Social Distancing which means keeping distance from one human to another. Specifically, keeping at least six feet distance from other people, not gathering in groups and avoiding mass gathering. The meaning of this term is mystical and inappropriate in Bangladeshi culture. Historically, the people of Bangladesh believe in social solidarity in terms of religious, social, cultural and political activities whereas the term social distancing opposite this culture. Moreover, this term often explains with some negative social behavior like self-centric attitude or ostracism. In our study we also observed similar meaning from our study participants. One of the research participants was saying,

“Social distance mean expelling someone from the society. If someone has coronavirus, she/he should be ostracized from the society. She/he should not stay in the society along with others. Even if someone dies from coronavirus, then his/her funeral should not be performed.”

The above-mentioned narrative is indicating opposite meaning of social distancing. This opposite meaning creates further complexity is responding COVID-19. We have observed many cases in the social media. A story can be outlined here:

At the beginning of COVID-19 in Bangladesh, a nurse, who used to work in a hospital in Dhaka, returned to her home town in Gopalgonj – a district under Dhaka Division. The local influential and neighbors denied her to enter her home. A temporary hut was made with palmyra leaves on the bank of a pond where she lived for 14 days .

This story also indicates the inappropriateness of the term where neighboring people forced her to stay outside from her family and expose to a vulnerable situation. As much the concept of social distance is incomprehensible for the lower income people likewise it is incompatible with Bangladesh’s culture. The people of Bangladesh historically prioritize ‘social solidarity’ in religious, social and political activities, here the concept of social distance acts as an opposition of cultural practices. It is also criticized by the social sciences’ scholars. The concept of ‘social distance’ works as an adherent to the concepts of mind’s ‘negative’ activities such as ‘loner’, ‘ego-centric’ (Foster, 2020). So when tackling a pandemic public should be inspired to use behavioral concepts such as ‘sympathy’, which can be “social solidarity in the time of physical distancing” (Holnes, 2020).

The conceptual confusion regarding corona prevention instruction and the reason of incomprehensibility or not understanding the meaning of these concepts by the local people, many complications are arising. It was observed that due to the difficulties of the meaning of ‘social distance’ – an alternative meaning developed by people. An informer named Rahman said,

“Social distance means excluding one from the society. It won’t be reasonable to let one stay in the society who is ill. This disease is a consequence of sins for that reason. No one agrees to participate in Janaja”

At present crisis it is necessary to ensure physical distance along social solidarity. We can observe that the aristocrats are offering supports to the lower income people, seek out to know about their wellbeing and distributing Zakat in monetary form. During Ramadan month, many provided food and cash support to the poor populace, and many landowners pardoned rents of day-laborers for losing job to COVID-19. These examples of social solidarity came into light through information provided by few informants during our research. These examples are ultimately reconstructing the concept of social solidarity in the age of social distance.

Changing the Consumer Behavior Pattern
Till date, no effective medicine or vaccine has not discovered yet. Therefore, public health specialists and health authorities are urging to maintain prevention measures. The Government of Bangladesh is emphasizing and recommending to change everyday practicalities and habit. These suggestions include, consuming nutritious food, following health and hygiene practices, wearing masks, using sanitizer, maintaining social distance, living separately from the infected person, using separate toilets etc. Crucially, however, the income of low-income people in Bangladesh is further reduced due to COVID-19. To prevent the spread of coronavirus infection during lockdown from 26 March to 31 May, nearly 3.6 crore people lost their jobs in 66 days (Barakat, 2020) .

Along with other heath precautions it is widely suggested to eat nutritious foods (i.e. milk, vegetables, eggs, fruits, fish or meat) to boost immune system. Even in normal situations when the wheels of the economy are in motion, people with low income cannot afford to consume these foods. In addition, during general holiday or especial confinement, day-laborers have to spend their time in unemployment. It is important to consider if it is viable to suggest add nutritious food into the diet of those who are dependent upon relief due to unemployment. The instruction that were given since the announcement of general holiday from March 26th are not compatible with the realities of the lower incomes.

Many day-laborers are providing foods to their family by collecting relief. Generally, in relief rice, lentil, soap and oils are provided. Foods that are designated as nutritious food are not included in the relief packages provided by the government and volunteer organizations. A research participant mentioned,

Government suggested to eat fish, meat, and fruit but gave rice, lentil and salt. What they provide can’t be consumed after eating once, and eating well. Those are food of rich peoples. Where would we find those? People who speaks on the TV are rich, lives in cold room, eats fish-meat, and gets governmental salary. They gets salary even if they stay at home, is there anything for them to worry about? Don’t say these to us. Even if they had got out we could have pulled rickshaw, they don’t even come outside. Easy to say these form home. How would those food come when there is no income?

General Holiday or confinement is reconstructing existing social inequality, people of low income who lost their jobs are being classified as ‘new poor’ (BIGD, 2020 ; BIDS, 2020) . It is being said in the classification of ‘new poor’ that they are eating one third less than what they used to eat. Rate of nutrition has reduced 23 percent in urban areas and in rural areas 15 percent. From the experience of informers, it came into light that, these ‘new poor’ category of people where they used to eat thrice in a day, now lost the abilities to eat ‘salt-rice’ two times or in some cases one time or in full stomach with their family. For that reason the suggestion of eating nutritious food which is essential at preventing disease is unsuited here.

Due to living under the poverty line they do not have the affordability to purchase nutritious food, sanitizer and mask and their ability to consume these has reduced considerably as they do not have a job or work. But they are experiencing legal and social harassment in public places for not using these. From interviews with low-income day-workers, it found that, in order to cope with a new lifestyle in COVID-19 situation, they had to change their consuming behavior. Additional money is required to follow the key instructions. Due to legal and social obligations, products such as masks and sanitizers are used inside the work premises or anywhere outside the residence or work place. They are unable to use them at home due to economic constraints. The COVID-19 condition, on the one hand, has been reducing income and, on the other hand, increasing the cost of consumer goods to become habituated to the new lifestyle. Such economic, social, health hazards and apprehensions are making the lives of low-income marginalized people to even marginalized.

Religion and COVID-19
While religious norms and practices are core human life and philosophy but religion has been relatively absent in responding this pandemic in Bangladesh. There have been many discourses arising between spreading of coronavirus and religion amid this crisis. The culture of blaming religion for spreading COVID-19 seen during this pandemic in South Asian countries including Bangladesh. Taking example from the Muslim religious practices, Tablighi Jamaat was highly criticized for spreading coronavirus from an event in Delhi, India. Similar situation observed in Malaysia. In Bangladesh, a huge crowd took participate in a funeral event of a Muslim religious leader in Brahmanbaria district in Bangladesh. These gatherings highly criticized in the social, electronic and other medias. These criticisms put coronavirus infection against the religious norms which is widely discussed in religion versus public health proposition.

However, there was denial tendency observed among the Bangladeshi Muslims and religious leaders when government of Bangladesh imposed limitation in saying prayer with congregation. This opposite attitude put religion against science or faith versus facts. But it is not a good strategy to exclude religion from public health intervention in the context where religion has vital role in the political economic context of South Asia including Bangladesh. In Bangladesh, religion-based, particularly Islam, education system is prominent both in urban and rural setting. Islam based education system can be divided into two categories; 1) Madrasah Education Board and 2) Qwami Education Board. According to a recent statistics 1.4 million students are studying in 14000 Qawmi Madrasahs while near about 30000 Madrasahs are enlisted under Madrasah Education Board. Most of the cases, the Madrasah authority arranged residential facilities for the students. The students and teachers do not have access to the mainstream media including television. Similar situation observed for the followers of Tablighi Jamaat who spend their times in the mosque. Therefore, it is difficult to reach them with different critical messages including COVID-19 preventive awareness or sensitizing activities. Therefore, an alternative approach is required to include this group of people during this pandemic.




Lockdown Dhaka（Photo by Ranjan, 2020）

The normative teachings of cleanliness across different religions are very relevant in preventing and responding COVID-19. Culturally, religious norms on cleaning is critical for this pandemic when frequent handwashing with soap is one of the preventive measures to stop COVID-19 infection. Taking example from Islamic “sacred-profane” concept, the Muslims have to clean their body prior to saying prayer. Similar norms observed among other religions including Hinduism, Christianity, Buddhism. Moreover, religious institutions or praying places are not only place for practicing religious rituals but those have social and cultural value. If we take example from Muslim culture, mosques are considered as important social institutions during health, natural and other crisis or disasters. In Bangladesh, for example, during expanded program on immunization (EPI) events mosques are playing important role in conveying messages to the mass people. In recent times, it was also observed that, mosques were playing role as important source of information for disaster when other mediums were unavailable due to different reasons. During the weekly Jummah (on Friday) prayer, the Imams usually discuss different everyday life issues among the attendants. In addition to that, culturally and socially, the Imams are very influential and acceptable group to mass people at national, regional and local level. Interestingly, this influential institution and group of people were not included in the COVID-19 response mechanism in Bangladesh from the starting point of this crisis.

Response from NGOs and development sector
The national non-governmental organizations (NGOs) and international non-governmental organizations (INGOs) were closely observed the situation when coronavirus impacted in Wuhan, China in December 2019. In Bangladesh, after the confirmation of first cases, the international and national organizations allowed their staff members to work from home and limited the implementation of field level activities. As part of government’s declaration of closure, stopping public transportation, and maintaining social distancing to avoid human to human contact, the field activities of donor funded development activities and programs also postponed. However, a number of organizations are responding COVID-19 by distributing relief, sanitary kits (soap, mask and sanitizer) and disseminating key messages to the lower income people. BRAC – the largest NGO in the world is also assisting the Directorate General of Health Services (DGHS) to install walk-in sample collection booths (kiosk) in different areas of Dhaka and outside. As part of the initiative, BRAC is currently recruiting medical staffs, collecting samples and transferring those samples to government designated testing labs.

A recent analysis shows, the NGOs have provided around Tk155.87 crore in support for Covid-19 response from March 5 to May 25 this year. The support was provided to 49 districts by 212 national and local NGOs. Of the amount, Tk140.22 crore came from donors and Tk15.67 crore from own funds of the NGOs. The major areas supported by the NGOs were awareness programmes (37.1 percent), food (32.2 percent), health (19.2 percent) and cash assistance (11.5 percent). Soap and hand wash support was at the top, followed by emergency food items and masks, leaflet, and personal protective equipment. However, the NGOs initiatives is having far-reaching impacts on health and economy, especially on the poor and vulnerable communities across the country.

Conclusion
The people of Bangladesh are living with different socio-cultural experiences, diversified life style, variation in the level of education and with different type of positive and negative economic transaction. In this context, this research conducted to explore how slum lower income population perceive about these messages and guidelines, how these groups of people cope with and how they live this pandemic. Analysis revealed that, people have different perceptions on the preventive and control guidelines which is beyond biological understanding. The results on people’s experiences of pandemic and disaster also revealed that, the sufferings are social and economically constructed. Those people are at highly vulnerable position whose socio-economic condition is not suitable to respond in the pandemic crisis. This particular group of people are at higher risk, though they have different ideology, life style and religious practices. The key concepts of COVID-19 preventive messages fail to recognize social and cultural reality realty of lower income people. In this case two problem can be seen – firstly: avoiding instruction due to vague meaning of the concepts and secondly: getting involved in such work which can increase social tension. In this context these key terms should be contextualized and culturally inclusive according to cultural norms and perceptions. Moreover, creating enabling environment to practice the key messages is also equally important.

References:

PAGETOP