Pathologies of Labour: How Work Destroys Health in Urban India

Abstract

While conducting fieldwork with informal doctors in low-income neighbourhoods in Delhi, I noticed that several patients consulted them for what appeared to be work-related ailments. Reflecting on these encounters at the intersection of medicine and labour, I thought about how work consumes both our time and our vitality, and how responses to the effects of work mobilize particular ideas of care and wellbeing. I wondered: if health is socially constructed, in what ways does labour construct it? In this essay, I explore how, across various urban work contexts — from informal sector work to supposedly good jobs in “India Inc.” — people experience and differently articulate a range of symptoms and conditions (such as stress, tension, fatigue, pain, injury, and various infectious diseases) in relation to their labour. Attending to the embodied and affective aspects of work, I ask: How might we benefit by critically interrogating contemporary working life through the prism of health? Conversely, how might dominant, biomedically reductive conceptions of health be expanded by tracing their relationship to work? Thus, this essay spotlights how precarity, a defining experience of contemporary working life across sectors, inscribes itself in labouring bodies and psyches in contemporary urban India.

Citation: Luthra, Tanuj. “Pathologies of Labour: How Work Destroys Health in Urban India” The Jugaad Project, Vol. 5, No. 2, 2023, www.thejugaadproject.pub/pathologies-of-labour [date of access]

On a quiet October afternoon in 2022, Guddu[1], a man no older than thirty, walked into a small single-room clinic in Unity Colony (a basti[2] in South West Delhi) with an agonizing groan. Pointing to his sides, he complained in Hindi of “kamar mein dard” (pain in the hips/waist). He impatiently asked the doctor, an Informal Health Provider[3], “kuch zordaar dijiye” (give me something powerful). When the doctor reached for a bottle of pills, he interjected, “Daktar sahab, koi aisa sui dijiye jisse jhukne mein aasani ho. Shaam ko kaam pe jaana hai.” (Doctor sir, give me an injection that will make it easier to bend. I need to go to work in the evening). The doctor — a weary middle-aged man with almost no trappings of a medical practitioner, who nonetheless commanded a degree of respect — initially advised rest, but reluctantly complied when he realised Guddu’s adamancy. Guddu, I later found out, painted walls for a living. Moments later, a pujari (Hindu priest) entered claiming he had a fever and asked for a paracetamol, a common painkiller. He had to get well right away, so that he could fulfil his promise to conduct a ritual for his client, a new homeowner. Once again, the doctor obliged. In both cases, the patients knew what they needed (an injection, a pill) based on previous experiences, and asked for it.

Reflecting on these encounters at the intersection of medicine and labour, I thought about how work consumes both our time and our vitality, and how responses to the demands of work mobilize particular ideas of care and wellbeing. I wondered: if health is socially constructed, in what ways does labour[4] construct it? In this essay, I explore how, across various urban work contexts — from informal sector work to supposedly good jobs in “India Inc.” — people experience and differently articulate a range of symptoms and conditions (such as stress, tension, fatigue, pain, injury, and various infectious diseases) in relation to their labour.

Critiques of structures and discourses of work under neoliberalism often mobilize abstract philosophical concepts of unfreedom, alienation, exploitation, and inequality to highlight work’s various injustices. While these concepts are no doubt immensely valuable, by interrogating how precarious work inscribes itself in bodies and psyches, this essay joins a chorus of voices that call for more embodied, affective, and situated critiques of work by considering its effects on “health” broadly conceived (Bhan, 2023; Bambra, 2011; Cousins, 2023; Kitanaka, 2012; Livingston, 2005; Prentice et al., 2018).

The point is not to supersede or sideline the aforementioned concepts. Instead, it is to make them concrete by calling attention to how they are felt, in ways that might be recognized as “pathological” in relation to emic and/or etic norms of health. How might we benefit by critically interrogating contemporary working life through the prism of health? Conversely, how might dominant, biomedically reductive conceptions of health be expanded by tracing their relationship to work?

Drawing from ongoing ethnographic research with IHPs and their patients in Delhi[5]; social science scholarship (particularly medical anthropology); news media; and policy reports, I venture an answer to these questions by juxtaposing two starkly different working milieux. The first concerns a range of informal[6] livelihood-securing activities — in particular waste, construction, and domestic work — pursued by a differentiated population group, sometimes awkwardly glossed as the “urban working poor”. The second deals with professionals working in India’s private corporate sector. Members of this urban elite partake in a rapidly burgeoning “wellness culture” (Annavarapu, 2016; cf. Baker, 2022), that seems to have arisen in response to the vices of modern living – among which the commandment to endure “toxic” working conditions seems salient.  

The rationale behind focussing on these contrasting work contexts was twofold. First, to go beyond adverse relations between work and health in low-paying jobs, to show how this relation might be (differently) adverse even in lucrative professions. Second, to illustrate reversals in how the association between work and health is typically made in different settings. For instance, there remains a tendency to see mental illnesses as predominantly affecting middle and upper classes, who proliferate the ranks of “knowledge workers”. This framing dehumanizes the poor, robbing them of rich interiorities that are vulnerable to psychic injuries. The logic deployed is that they (“the poor”) are, somehow, mentally more “resilient” or used to withstanding inferior working and living conditions. Resilience, projected this way, becomes a cover for explaining away widespread distress. Unsurprisingly, several people who visited IHPs in Unity Colony, including those who labour in the waste, construction, or domestic sector among others, experienced symptoms of mood disorders. They used Hindi-Urdu terms to convey this, such as udaasi (sadness), uljhan/bechaini (anxiety), tenshun (tension)[7], and nashe ki dikkat (addiction)[8], which they associated with overwork.  

An equally pernicious tendency exists in reverse, i.e., the idea that white collar work is not physically strenuous. Anyone who works in a “high-stress” corporate work environment knows this to be untrue. Further, this assumption is readily belied by the ubiquity of pain management clinics, wellness centres, and spas dotting the urban landscape and accessible only to the elite. These facilities treat a range of physiological conditions and symptoms (e.g., fibromyalgia, arthritis, chronic migraines, carpal tunnel syndrome et al.), many of which are considered outcomes of work-related stress.

These examples are not meant to reify crude oppositions between immaterial and manual labour on the one hand, and mind and body on the other. Rather, by underscoring how: a) mental and emotional energies are key to physical labour, and bodily strain can be a significant part of intellectual work; and b) psychology and physiology (and their attendant disorders) are always co-constitutive[9], I point to the inherent instability of these dualities. The point to emphasize is that despite the kind of work one does, the possibility of mental and/or physical harm exists across the occupational spectrum and that these harms can be potentially realised as part of general conditions of precarity. Transcending these persistent dualisms in lay and expert discourse can help deconstruct the ways in which health and work configure one another.

***

In Court, Chaitanya Tamhane’s (2014) searing legal drama film centering a poet-activist who is falsely accused of abetting the suicide of Vasudev Pawar, a Dalit sewage worker, Pawar’s widow’s testimony in court is instructive. She claims that her husband worked without any protective gear, had previously lost an eye due to toxic sewer gases, and consumed alcohol every day to bear the stench of the gutter. Her matter-of-factly delivered account of what seems exceptional tells a tragic yet banal tale. Occupational grids of caste unevenly impair, infect, and injure socially and economically marginalized waste workers. Their vulnerability is further compounded by the surge of “superbugs” (multi-drug resistant organisms) that are rapidly rendering antimicrobials ineffectual (Doron and Broom, 2019). At IHPs’ clinics in Unity Colony, I note the uncritical prescription of antibiotics — common across formal healthcare services in India as well — to treat patients, many of whom include waste workers with infections of the gut, skin, and respiratory system.

Construction workers comprise another cohort that routinely visits IHPs to seek treatment for cuts, bruises, and fractures. Like waste workers, very few, if any, have protective equipment. Slips, falls, knocks, and burns are standard fare. I think of how some of these patients narrowly escape a more catastrophic fate on a routine basis – though not all are as fortunate. In Namita Dharia’s ethnography of construction workers in Delhi, MD, a carpenter and one of her key interlocutors, puts it bluntly: “each building takes one or two men with it” (Dharia, 2022: 48).

Figure 1. IHPs’ shelves are stocked with affordable antibiotics, painkillers, tonics, and other medicaments. As seen in the image, a boy is being treated for a knee injury.  (source: author: 2023)

Beyond the “ordinary spectacle” of severe injuries and deaths, the silent attrition of working bodies is harder to see. Yet, it might be sensed in other ways. For instance, female patients at IHPs’ clinics, several of whom work in the homes of their richer neighbours, insist on strong painkillers and injections for musculoskeletal pains and chronic fatigue. Without it, they say, managing both paid employment and care responsibilities at home becomes impossible. Perhaps unsurprisingly then, prescription drug abuse is found to be more common among women than men in India, with women’s ‘double burden’ of work almost certainly a decisive factor (Singh, 2017).

Several other substances are consumed to augment one’s capacities and help cope with work-based anxieties. These include analgesics, steroids, multivitamins, “gharelu nuskas” (home remedies), and alcohol. Morally suspect otherwise, alcohol dependence becomes somewhat socially licensed as it helps workers endure gruelling conditions at work. An IHP put it thus: “Mehnat karne waale aadmi aur berozgaar aadmi, yahaan donon sharaab ka nasha kartein hai” (hard-working men, and unemployed men, here both do alcohol addiction). The line between use and abuse is paper-thin, as several members of the community see alcohol consumption as either an outcome of “kaam ka tenshun” (tensions of work), or as a legible, if condemnable response to unemployment. Seen through this lens, alcohol dependence, like addiction to other substances, seems less a medicalized disorder of individual minds, and more a symptom of a “pathological” political economy of labour.

According to one IHP, tenshun (arising out of economic pressures or domestic disturbances) not only affects individual men and women who “take” it — “tenshun lena” ­(taking tension); but once taken, it might also be passed on to others — “tenshun dena” (giving tension). In this imagination, work-induced tenshun can both lead to problems of addiction among individuals and contagiously spread within the community.

Figure 2. A helpline for distressed residents of Unity Colony, posted at an IHP clinic during COVID-19. According to the IHP, a few of his patients tried calling it, but to no avail. (source: author: 2023)

Beyond conditions at work, broader conditions of work matter too. For the roughly 88% of the workforce employed in the informal economy with virtually no legal protection or job security, health shocks can be difficult, if not impossible, to absorb. Pushing people back into debt and poverty, these adverse health events compel workers to once again accept precarious work to make ends meet. Strikingly, as Gautam Bhan et al. (2020) underscore, these ill-effects of work seem to have thus far eluded India’s blinkered public health research and practice.

But as I stand outside a construction site bordering Unity Colony, observing a gaunt woman carrying a heavy load of iron rods on her head, I wonder what “health” means to different groups of people. When I ask them, residents of the basti often define health in functional terms, like tandurusti (fitness), as opposed to say swaasth (health/healthiness) or arogya (the absence of disease). They scoff at the feebleness of the affluent, whose bodies waste away due to disuse. Those whose livelihoods depend on their ability to bend, push, pull, or lift, are keenly aware of their relatively amplified physical capacities[10]. And to be sure, this oppositional logic based on bodily robustness often shapes their sense of collective self-worth as ‘workers’ (though, see Sargent’s (2020) fine account of the subtle distinctions and ambivalences that sustain assertions of identity among construction workers in Delhi). However, despite the conceptual instability and relativity of “health”, it is callous to ignore how environments and conditions in which the urban poor are compelled to labour become cauldrons of morbidity and premature mortality for them.

***

But what of highly sought-after “good jobs” in the upper echelons of the private sector in India? Here, concentrations of economic and social capital produce an increasingly globalised professional-managerial class (PMC), working in law, tech, finance, marketing, banking, and the like. Physically less demanding in comparison with informal economy work, corporate offices are nonetheless high-intensity environments of cut-throat competition. In the popular imagination, toughing it out or suffering through the duller aspects of these jobs is considered a virtue that is rewarded with outsized paychecks (though many do derive genuine meaning from these apparently “bullshit jobs”, to use Graeber’s [2019] now-iconic expression). This is not even to mention the uber-competitive universe of exams and careers in engineering, medicine, and the civil services — once promised lands of secure middle-class lives, now alarmingly, dead-end pursuits (Sen, 2023; Subramaniam and Farooqi, 2023). Nor is it to speak of the millions navigating the vicissitudes and everyday pressures of gig economy work in urban India (Sekharan, 2022).

Writing about work trends in corporate America a decade and a half ago, Sylvia Ann Hewlett and Carolyn Buck Luce (2006) identified the increasing prevalence of what they termed “extreme jobs”. Among other things, these jobs included unending work weeks, punishing deadlines, the blurring of lines between work and “life” (a trend exacerbated by the pandemic), and diminishing social lives. If this sounds familiar to Indian readers, it is because in post-liberalization urban India, these professional norms have become entrenched. In step with this, terms like tension, stress, and burnout, have infiltrated living room conversations. Linked with non-communicable diseases and mental disorders, tension, Nandini Gooptu and Sneha Krishnan (2017) write, “is labelled the ‘silent killer’ of aspiring and hard-working youth in India’s growing private corporate sector, in the face of unprecedented competition and demanding work”.

It is hardly a coincidence then that earlier this year, NIMHANS (the National Institute of Mental Health and Neuro Sciences) developed India’s first ever tool to measure work stress (called TAWS-16) (Navya, 2023). Companies can use this questionnaire to assess their employees’ stress levels and take appropriate measures (such as recommend counselling or stress management training and organise yoga-centred programmes). Tellingly, the most common images that come up on typing “stress in India” into most major browsers show office workers with their head in their hands (e.g., Image 3). The stressed individual is almost always isolated, in office-going attire, and perched at a desk in front of a computer – very evidently embodying all the markers of the PMC. It would appear, according to this imagery, that the labouring poor do not undergo stress. Indeed, TAWS-16 asks after the employee’s role in the organisation, career advancement, and the organisational environment — categories that are unintelligible in most informal jobs.

Figure 3. Screengrab of image results for a Yahoo search for “stress in India”. September 18, 2023.

The corporate sector is responding to this incipient crisis in workers’ wellbeing in two ways: concessions and surveillance. Wellness retreats, company offsites, and mental health days constitute the former, while tech-and-data driven apps that enable employee health surveillance (companies use more neutral terms, like “monitoring” or “tracking”) are examples of the latter. While both approaches miss the forest for the trees by individualizing workers’ health issues, health surveillance is particularly troubling, as it often links promotions, bonuses, and incentives to the maintenance of numerically (and narrowly) defined metrics of “good health”.

The professional classes too consume a variety of substances to bolster health, or more accurately “wellness”. Caffeine, herbal teas, nutraceuticals, Ayurvedic prophylactics in paste or pill form (churans) — all of these coexist with pharmaceuticals for blood pressure, diabetes, thyroid, and high cholesterol. Collectively, these substances keep pained, fatigued, or “diseased” working bodies plugged into the occupational matrix.[11]

Further, a troubling “healthism” seems to be ascendant among elites in India. This is the idea that maintaining good health is both within individuals’ control, and an individual moral responsibility. Conversely, the elite urban Indian self is the result of such practices of self-regulation. In its current guise, intense moral judgement about others’ lifestyles in tow, this has coincided with a dilution in the state’s responsibility towards people’s health. Theorists of neoliberalism call this tendency ‘responsibilization’ — a process that renders individuals responsible for aspects of their lives (say, education or childcare) that were previously responsibilities of the state or other social agencies (Juhila et al., 2017).

In contemporary times, these trends go beyond health and medicine to mobilize a more “holistic” notion of “care” — that places physiological, psychological, spiritual, and aesthetic wellbeing on the same ethical plane. India’s booming self-care industry, with its exorbitantly priced body products and mind-numbing self-help bestsellers, is a case in point. With healthism, we once again see the spectre of resilience – this time projected inward, rather than onto the poor. Within the Indian nation, all citizens are urged, by the Prime Minister no less, to be atmanirbhar (self-reliant). In this context, the exhortation to self-mastery in matters of health dovetails nicely with free-market ideologies that hail the productivity and efficiency of “good” workers as moral values. The ideal worker must care about her health, so that she can energetically give herself over to the interests of the corporation.

These values were enshrined at OCCUCON 2023, the Indian Association of Occupational Health’s annual national conference[12], where I was in attendance earlier this year. The guest of honour was a saffron-clad gentleman named Swami Nijamritanand Puri, administrative director of Amrita Hospital in Faridabad, one of India’s largest multi-specialty private hospitals. In his keynote address, Mr. Puri broke down the Sanskrit word for health “swaastha” into its constituent elements: swa (meaning self), and astha (meaning standing). Glossing swaasth as “being in oneself” or “understanding what is inside”, he highlighted its lexical connections with “swa-tantra” (or self-rule) and “swa-vlamban” (or self-reliance). This etymological excursus, he claimed, is not a trivial exercise. Rather it tells us that ever since the Vedic period we have known that it is the self that is ultimately responsible for its own health. He went on: “The workplace environment is all well and good, but attention should be given to what lies within me — my mind and body”.

Far from rhetoric, this ideology is reflected in India’s National Health Policy, 2017. Breaking down the “social determinants of health”, the policy report attributes a staggering 50% of diseases to “lifestyle” (whatever that means), with biological and environmental factors accounting for merely 20% each — figures uncritically lifted from a 1996 US Surgeon General’s report about health conditions in America! (Bajpai, 2018) Thus, in India, the market-driven injunction to care for the self by making “better” choices finds elective affinity with an ostensibly ancient Hindu vision of healthy living. And together, these inform our contemporary national politics of health.

***

If the concept of ‘work’ appears too arbitrary in this essay, it is because I have deliberately foregrounded a diverse, seemingly unrelated set of activities, institutions, and discourses. However, the two contexts of work above are not sealed off from one another. Taken together, they constitute what I call “economies of wellness”[13], unequal relations between working bodies, where those in the first context (the working poor) must stay well so that those in the second (professional elites) can stay well. So, akin to the painter and the priest in the vignette with which this essay opened, the domestic worker must remain healthy to ensure that her mistress’s child is fed on time. The waste worker must collect the trash on time, so disease-carrying pests do not gather outside his master’s house. The construction worker must go to work to build the house in which elite occupants will soon move in.

These relations were strikingly accentuated during the COVID-19 pandemic. In Delhi, as in other metropolitan cities, residents of gated colonies fortified already impenetrable walls to further control the comings-and-goings of domestic workers. The former relentlessly tested, segregated, and confined workers in ways even more demeaning than under “normal” conditions. Lamenting this ill treatment, more than a few working-class residents I met in Unity Colony asserted that, in fact, there was no coronavirus in their basti (a claim I heard in other low-income neighbourhoods in Delhi as well). They claimed that since most people here worked hard under the scorching sun, the virus was emitted from their bodies along with their sweat. If anything, it was “they” (their upper-class neighbours) that brought and spread the virus in the first place, so why should “we” pay the price? Without remarking on the accuracy of workers' aetiological claims, here, hard work is framed as both a source of immunity from the virus and a symbolic assertion of dignity against the cruelty of employers.  

The complex, dynamic linkages between health and work make it difficult to be prescriptive about what is to be done. But a potential starting point could be to look to societies and periods of history where the work-health relation was taken seriously. Take for instance Japan, where widespread social and cultural acknowledgement of work’s detrimental consequences on health have in the past few decades led to the popularization, and even legal recognition, of terms like karoshi (overwork death) and karojisatsu (overwork suicide) (Kitanaka, 2012). Or consider the contribution of workers’ struggles in the first half of the 20th century towards the creation of the British National Health Service in 1948 (Burtenshaw, 2019). Or look to the many socialist movements in the 19th and 20th centuries that fought for limits on the workday, paid vacations, and sick and parental leaves (Broder, 2019).

In countries like India, where in the absence of robust social security systems most people must work tirelessly to secure their livelihoods, working through illness is seldom a choice, leading many to ignore or delay seeking care. Stronger labour protections, greater autonomy over work, and fairer wages will undoubtedly make work less taxing. But equally importantly, and perhaps hopefully, these steps can afford people greater freedom to spend time as they wish. This free time, in turn, could be invested in cultivating salubrious hobbies, or in nourishing one’s relationships. Indeed, according to one of the longest-running studies of human life conducted by researchers at Harvard, more than genes, exercise, and diet, it is fulfilling social relationships that contribute most saliently to longer and happier lives (Mineo, 2017).

Finally, while noting how work is an important social determinant of health, it is just as necessary to ask what we mean by health. Afterall, how we conceive of health feeds back into what we take its determinants to be. For instance, we often choose to keep working through acute mental or physical distress, refusing to acknowledge it as a problem. In other words, we “normalize” distress. This may be because we prioritize other aspirations or values (say self-sacrifice). But this could also be on account of framing health narrowly in terms of “medicine” or “safety”. When health is framed biomedically, disease is only recognized when empirically identifiable disorders of individual biology can be established. And when the framework of safety prevails, the assumption is that health remains unaffected unless there is detectable injury. If we accept these dominant conceptions of health, we run the risk of ignoring or normalizing distress which falls outside well-defined objective boundaries of pathology.

Perhaps instead of foreclosing concepts of health around rigid norms and models, we ought to, as philosopher of medicine Monica Greco (2004) advocates, emphasize the inherent indeterminacy of health, in both policy and theory. This, she argues, could foster a much-needed plurality in ways of conceiving and achieving health. We might move in this direction by placing contemporary intertwinements of work and health at the forefront of analysis, rather than keeping these domains apart. In doing so, health could be imagined otherwise – beyond the mere absence of disease or debility, and instead for instance, in terms of “capabilities” (Sridhar, 2013) or “flourishing” (Willen, 2022). An expanded conception of health, along with a fuller understanding of work as one of its key determinants, is a step towards the goal of reimagining work as a source of vitality rather than distress.

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Endnotes

[1] I have used pseudonyms for names of people and places to maintain the anonymity of my interlocutors.

[2] Basti is the Hindi-Urdu word for settlement, and the term most commonly used by urban poor residents to refer to the areas in which they live in.

[3] Informal Health Provider (IHP) is a term I use for a heterogenous category of formally untrained doctors, or doctors formally trained in traditions other than biomedicine (e.g., Ayurveda, Unani, Siddha et al.) but who nonetheless primarily practice in allopathy. In Delhi, they are locally called bangali daktar, or RMP (which stands for Registered Medical Practitioners, even though they are not registered under any state medical council).

[4] I use work and labour interchangeably in this essay to capture a diverse range of income generating activities. While these terms also apply to unpaid care activities, to which I allude in section 2, these are not the focus of the essay.

[5] My doctoral research focusses on the everyday care work of informal health providers, who offer medical care to urban working-class populations in low-income neighbourhoods in Delhi (Luthra, 2023).

[6] The formal economy comprises those enterprises and economic activities registered with and regulated by the state; whereas the informal economy includes enterprises and activities outside the state’s regulatory ambit. Formal and informal economies are inextricably linked in India, as in other ‘Global South’ contexts, to the extent that it is often hard to know when one ends and the other begins. Here, I use these categories heuristically, rather than empirically.

[7] See two recent ethnographies (Weaver, 2017; Simpson, 2023) that tease out “tension” as a common “idiom of distress” among women in India’s aspirational middle classes. In different ways, both highlight the burdens of upholding middle-class ideals of domesticity as key sources of tension.

[8] It should be noted that these lay terms are approximations of, and not collapsible with, the psychiatric concepts to which they correspond.

[9] See Kirmayer (1988) for an evocative account of the roots and instrumentalizations of the mind-body dualism in biomedicine.

[10] See Waite’s (2005) ethnographic account of how seemingly frail bodies are enabled to perform arduous labour in rural India.

[11] See Joe Dumit’s Drugs for Life (2012), in which he powerfully elucidates Big Pharma’s logics of profit extraction. He shows that by lowering risk thresholds for “lifestyle” diseases, progressively larger cohorts are classified as diseased and put on expensive, lifelong medication, without ever needing to opt out of the workforce.

[12] Occupational Health is an interdisciplinary field of research and practice aimed at promoting and maintaining workers’ health, safety, and welling.

[13] I thank Sarah Hodges for this turn of phrase.