Babita Jayram has beaten the odds.

The 21-year-old sits in one corner of the hospital bed, brushing her hair with the slow, steady strokes of a purple comb. The nine months of pregnancy mostly spent at a tea garden on the eastern fringes of Assam were uneventful. There were no complications during the delivery. A healthy newborn, curled gently on her lap, sleeps quietly.

Another woman sits on the opposite side of the bed, cradling her own infant. Some of the other 27 beds in the ward even accommodate a relative or two, precariously perched on the edge.

An assortment of cloth and plastic bags hang from nails hammered into weathered walls. Thin curtains, barely green, flutter in a meagre breeze made possible by the toil of ageing fans above. Then, the power goes out on a muggy, overcast June afternoon. The postnatal ward of Dibrugarh’s Assam Medical College and Hospital, the best-equipped government hospital in all of eastern Assam, turns into a warm, dimly-lit cave packed with recovering mothers and newborns.

Reena Dutta Ahmed, who heads the college’s gynaecology department, insists they are the lucky ones.

“You people cannot imagine,” said Ahmed, a slight, wispy-haired woman. “No other faculty in any other department can imagine a pregnant lady coming with two gram or three gram.” The doctor was referring to the levels of haemoglobin in blood. The recommended level is about 12 grams per decilitre.

“She cannot breathe. You know, she cannot breathe,” Ahmed went on, describing the condition of the mothers she encounters, with some vexation. “After a few minutes she is blue, then she dies.”

India accounts for 17% of all maternal deaths in the world. The country’s maternal mortality ratio was 167 per 100,000 live births in 2013. The ratio for Assam was 301, the highest for any state in India. Within the state, the five districts served by the Assam Medical College and Hospital – Tinsukia, Dibrugarh, Sibsagar, Jorhat and Golaghat – had a collective maternal mortality ratio of 404 per 100,000 live births in 2013, which is close to the ratios in sub-Saharan Africa.

By Ahmed’s assessment, there is one main culprit: “In our hospital, 80% of the mortality is from the tea gardens.”

Hundreds of tea gardens in this region grow over half of India’s total tea. Hand-picked leaves from here find their way into nearly every second cup of tea consumed in the country. Assam teas are also supplied to makers of major global brands such as Liptons, Twinings and Tetley. Even London’s upmarket Harrods stocks a selection.

Yet Assam’s prized tea industry has turned into a veritable death trap for thousands of expectant mothers. Most of them belong to tribal communities that were brought to work in the tea gardens over a century ago.

Mothers with their newborns at the postnatal ward at the Assam Medical College and Hospital in Dibrugarh. Credit: Devjyot Ghoshal

An industry brews

Tea began trickling into Britain in the 1650s, procured by Dutch traders and shipped halfway across the world from China. The British East India Company gradually waded into the trade, bringing small quantities of tea along with its usual cargo of silks and other textiles from the Middle Kingdom.

By the 1800s, the company had built a monopoly in the market and tea imports had become the single largest item in Britain’s trade with China.

Then, in 1833, the British Parliament dissolved the monopoly.

Scrambling to find new regions that could feed the lucrative trade, the East India Company stumbled upon tea in its own backyard – Assam. The discovery had actually been made in 1823 by Robert Bruce, a major in the company’s service, who had chanced upon wild tea trees near Sadiya in eastern Assam. A decade later, the coincidence was transformed into a serious commercial venture.

By November 1838, the first consignment of Assam tea arrived in London. Eight chests of the produce were auctioned in London on January 10, 1839, fetching between 16 and 34 shillings a pound. Buoyed by such robust prices, that year, a group of merchants decided to form the world’s first commercial tea company: the Assam Company.

But there was one hurdle to establishing industrial-level tea production – Assam did not have enough labour.

“The demoralisation produced by opium, and a liking for independent labour which characterises the Assamese, throw difficulties in the way of a large production of tea in Assam,” The Chamber’s Edinburgh Journal reported on January 25, 1840.

“Mr Bruce looks to the introduction of workmen from other parts of India, for the means of carrying on the manufacture on a large scale,” the erstwhile weekly magazine added, quoting a report by Charles Bruce, Robert’s brother.

A history of exploitation

In 1841, the Assam Company recruited a large group of labourers from the tribes of Bihar’s Chotanagpur division. Some 650 contracted cholera. Most died. The others absconded.

But the exercise continued. Arkatis, or recruiting agents, fanned out across the impoverished and famine-stricken tribal belt of eastern and central India to lure cheap labour for the fledgling colonial enterprise. The scheme worked and thousands of migrant workers from the Munda, Oraon, Santhal and Gond tribes began entering Assam’s tea industry by the late 1870s.

It was hard work in difficult conditions for these indentured labourers, who often came with bonds of either three or five years. Colonial tea planters, answerable to investors in London and elsewhere, enforced ruthless discipline.

The exploitation was so rife that even British parliamentarians were alarmed. On March 3, 1890, Samuel Smith of Flintshire questioned the government on the “high rate of mortality among the coolies employed in the tea gardens in India.”

Smith, reading out British government official’s report from Assam, told the House of Commons:

“In 1886 the largest death-rate in any garden was 270 per 1,000, while in the following year even this terrible figure was far outstripped, for in one garden the chances of life and death were almost equally divided, there having been a mortality of 465.9 per 1,000…”

Still, workers kept pouring in. At the turn of the century, the migrant-dominated labour force in the tea gardens had swollen to over 700,000, nearly 13% of the state’s population.

Many of them never went back. Instead, over the next several decades, successive generations formed a resident labour community – collectively known as the tea tribes – that helped build Assam into the single-largest tea producing region in the world.

A century later, the women of Assam’s tea gardens are still dying at a distressingly high rate.

Why mothers die

“Number one is anaemia,” said Assam Medical College and Hospital’s Ahmed. “Number one.”

Anaemia is a condition in which patients suffer from having fewer red bloods cells or low haemoglobin levels. This results in reduced amounts of oxygen in the bloodstream, which can trigger heart failure if the levels drop beyond a point. About 20% of maternal deaths globally are partly a consequence of anaemia. In Assam’s tea gardens, where overall malnutrition is rife, it is lethal.

The low haemoglobin levels also make it increasingly difficult for doctors to save patients in cases of postpartum haemorrhage, where there is loss of blood in the 24 hours after childbirth. Women with haemoglobin levels of 11 gram per decilitre and above are usually able to withstand around 500 millilitres of blood loss, explained Ahmed. “But when a woman is having 3-4 gm of haemoglobin, she can’t stand even 50-100 ml of blood loss,” she said.

The other killer, Ahmed noted, is hypertension, or high blood pressure. A 2002 study by the Regional Medical Research Centre in Dibrugarh estimated that 60% of tea garden workers in Assam suffer from the ailment.

“Increasing age, consumption of locally prepared alcohol, intake of extra salt in food and beverages and the habit of taking khaini (snus) were found to increase the risk of hypertension,” the study noted.

This copious intake of salt is actually a colonial hangover. To counter dehydration that came from working in the sun for long periods, British planters provided workers with tea that contained a generous helping of salt. The habit has persisted, even though high blood pressure in pregnant women can result in eclampsia, which is characterised by seizures that can be fatal for both mother and child.

Sepsis – a life-threatening condition caused by infection – is the third major factor, which doctors attribute to unsafe abortions and unhygienic cesarean operations. A 2005 study found that nearly 17% of all maternal deaths in India were because of sepsis. The condition causes the immune system to go into overdrive, leading to widespread inflammation, which, in turn, hampers blood flow into vital organs.

The tea garden community is even more susceptible to maternal deaths, doctors and activists allege, because of its frail economic condition. Workers can’t afford nutritious food or access basic healthcare because of low wages, they argue.

A worker in an upper Assam tea garden is currently paid a daily wage of no more than Rs 126 – on a par with the World Bank’s global poverty line, which is set at $1.90, or Rs 127. Up to the end of 2014, the daily wage was only Rs 94.

The wages seem like a pittance, barely enough for a family to survive, but the tea industry claims it can’t pay the workers more, partly because of a half-a-century old law.

Compensation constraints

At 8 every morning six days a week, Sabitri Oraon leaves her dark but orderly four-roomed house and walks to the nearby Joonktollee Tea Estate, some 60 kilometers away from Dibrugarh.

The slight woman, probably in her fifties, spends the next nine hours picking tea leaves or pruning the bushes. The only real respite is an hour-long break, till she finishes work at 5 pm.

“I am paid Rs 1,300 every 12 days,” Oraon said, putting down the bamboo basket used to hold tea leaves, which she has strapped to her back for most of the day.

Oraon is better off than many others. She is a permanent worker, which means that the tea estate is obliged to offer her work all year round and pay full wages.

Over a million workers – half of them women – are employed in Assam’s 792 registered tea gardens. The industry uses a sizeable number of temporary workers – sometimes called faltu, useless in Hindi – who have no guarantee of daily work or wages, and receive few benefits. During some periods, temporary workers even outnumber permanent workers in the region’s tea gardens.

A tea garden worker holds a bunch of plucked tea leaves at an estate in Jorhat. Credit: Ahmad Masood/Reuters

The entire sector is administered by the Plantation Labour Act. The law was born out of the need to improve the living and working condition of the tea garden community. Negotiations began in March 1948 between the government, labour unions and the tea industry, eventually culminating in the Plantation Labour Act of 1951.

The law covers matters such as hours and limitation of employment, wages and leave, while also providing clear guidelines for healthcare, sanitation, canteens, accommodation, educational, recreational and other facilities that the tea gardens must provide for their workers. The cost of these in-kind benefits, the industry argues, isn’t marginal. With the benefits, the daily wage of a worker rises to Rs 280 per day, said Sandip Ghosh of the Assam Branch Indian Tea Association, which represents 277 tea gardens in the state. This is on a par with the prescribed minimum wage for a semi-skilled worker in Assam.

The wage isn’t much but the tea industry claims it cannot afford to pay more. It’s been a difficult few years as erratic climate has hit production. Tea bushes produce the best leaf in hot and humid conditions, with a generous dose of rain. Too little rainfall and high temperatures damage the plants. Too much rainfall is just as bad. “Many years back, we could still predict a trend,” said Ghosh, “In the last 10 years, it has been impossible to anticipate the weather.” Climate change isn’t a conspiracy theory in these parts.

Such fickle weather has an impact on quantity, quality – and prices. “If the quality of tea gets affected, then prices fluctuate,” Ghosh added. The irregular climate is also forcing the industry to invest more in irrigation, pest management and other measures to prop up production. The costs keep adding up.

Tea prices, though, haven’t kept pace with the rising cost of production. It’s a bit of a conundrum, admitted Ghosh, because demand remains strong, with the end consumer often paying more than three times what producers get in tea auctions. “Why is the price not going up?” he said, “That is the question.”

There’s another burden that the industry claims it is forced to bear. Between 30% and 40% of the residents in the workers’ accommodations within tea gardens don’t actually work at the estates.

Several generations – grandparents, parents and children – often live together in the tea garden quarters, though only one or two members of the family would be permanent workers.

“This is the biggest problem for the tea industry,” said P Khaund, the chief medical officer of Amalgamated Plantations, India’s second largest tea producer. “We can’t support them for everything, no?”

The industry has mostly itself to blame for this. It persisted with an outdated colonial model designed for a labour deficit environment. Now, evidently, it simply has too many people to manage.

That’s partly why, after decades of working in near isolation, Assam’s tea industry has been pushing for the government to get more involved, particularly in healthcare.

But it has been a dissatisfying union.

Death on the road

At 4 pm, Anjan Naik realised that something was seriously wrong with his wife.

Manju, nearing the end of her pregnancy, lay writhing in pain inside their house. She was in her fifties, an age where childbirth comes with a range of complications. Naik immediately took her, a short walk away, to the small hospital in Sapoi Tea Estate, about 150 kilometers from Guwahati.

“There was no doctor,” Naik said, remembering the incident from May 2014. “The sister [nurse] tried but couldn’t do anything.”

At 2 am, the nurse gave up. She suggested that Manju be taken to the Community Health Centre at Dhekiajuli, an hour’s drive away. Naik, who has worked at Sapoi his entire life, asked the tea garden for an ambulance, which wasn’t available. Instead, he was given the garden manager’s car. A community health worker from Sapoi and Naik’s elder brother accompanied the couple.

They arrived at the Dhekiajuli CHC around 4 am. It is a single storied structure, with a small staff of doctors. The postnatal ward abuts a reeking set of toilets. Baby goats roam freely in the antenatal ward. A handful of beds stand in the corridors.

Manju was taken inside. A doctor examined his wife, Naik recalled, and referred her to the Kanaklata Civil Hospital in Tezpur, 35 kilometers away. They reached the Civil Hospital at 7 am, but didn’t stay for long. Within 15 minutes, doctors referred Manju to the Tezpur Medical College.

No one from the group had ever been to the medical college – a shiny, new establishment halfway between Dhekiajuli and Tezpur. So the driver and the community health worker suggested Manju be taken to a private hospital, Naik said.

Doctors at Nath Hospital took Rs 300 and gave Manju an injection. Then, they told Naik to take her to the Tezpur Medical College. It was past noon by then. Manju had been on the road for some 10 hours.

“I was trying to give her some water,” Naik recalled, “and she passed away.”

Anjan Naik and his wife Manju in their younger days. Credit: Devjyot Ghoshal

The couple lived together in a small three-roomed structure, where Naik still stays. It stands at the end of a narrow concrete road, which turns dangerously slippery in the rain, bound by open drains. Naik sleeps and cooks in a square room with a single window. The floor is made of beaten earth. A leaky tin roof sits above.

It has been over two years since Manju died but Naik remains bitter. “It is the hospital’s fault,” he said, pointing in the direction of the tea garden hospital. “There was no one here who could save her.”

This is exactly the sort of situation that the tea industry and the government have sought to avoid for years.

In 2008, about two dozen tea gardens and the National Rural Health Mission began a public private partnership focused on bolstering the industry’s healthcare infrastructure. The Assam government, through the NRHM, decided to provide a single tea garden with up to Rs 15 lakh a year, which would be spent on providing basic healthcare to both workers and non-workers. Under the partnership, among other duties, tea garden hospitals were made responsible for providing comprehensive mother and child care, including provisions for normal delivery. By 2012, the partnership was extended to some 250 tea gardens, including the Sapoi Tea Estate.

This may seem like a great arrangement, where the state government’s funds are channeled through existing infrastructure to deliver healthcare to a historically vulnerable population. In practice, however, it hasn’t entirely worked.

The funds and medicines don’t always come on time, claimed tea garden officials. Well-qualified doctors are hard to find. If they do accept jobs at tea gardens, many leave soon after, daunted by the conditions and remoteness of the estates. Corruption has also crippled the implementation of the scheme, with activists alleging that some tea gardens have blatantly misused the allocated funds.

“In certain places, the ambulances [allocated under the NRHM] were used by the gardens for other purposes,” said Stephen Ekka of PAJHRA, a non-profit in Tezpur that focuses on the tea garden community.

The NRHM, as a result, has withdrawn the partnership from over 100 tea gardens. Only 149 out of Assam’s nearly 800 tea gardens currently receive funds under the NRHM. In most places, it’s not enough to save the lives of expectant mothers like Manju.

Pavan Kanoi, a director at Sapoi Tea Company, didn’t specifically recall Manju’s death, though he admitted that it may have been a result of “an error or an accident.”

“From both sides,” Manju’s husband, Naik said, “inside and outside [the tea garden], no one took any responsibility.”

At least Manju reached a medical establishment on time. Forced by circumstances, women in Assam’s tea industry often work through their pregnancy, plucking leaves and lifting heavy bamboo baskets. No work means no pay. Only permanent workers are granted three months of maternity leave, which many use to care for their newborn after childbirth. Temporary workers usually get nothing. Doctors and social workers even recall hearing of women giving birth while working in the gardens.

A desolate room inside the Sapoi tea garden hospital. Credit: Devjyot Ghoshal

Failed safeguards

Vikram Ekka grew up in a tea garden near Dibrugarh before he left to become a priest.

He didn’t stay long in the seminary, instead finishing college outside, cutting his teeth as a student activist before entering journalism. He now runs a school in the tea estate where he spent his childhood. Ekka, 39, is an exception in a mostly uneducated community.

The widespread lack of education has had significant consequences for the tea garden workers. There is little awareness of good health practices. Many, for instance, still depend on herbal medicine and quacks. Open defecation is not uncommon. Illiterate workers don’t always understand how to access government schemes and entitlements. Some don’t even know their rights as workers.

It is such a dire situation, Ekka argued, that the tea workers have been cheated by their own union – the Assam Chah Mazdoor Sangha.

Founded in 1958, the ACMS is the main union representing the state’s one million tea garden workers. For decades, the union has been led by Paban Singh Ghatowar, a five-time member of parliament of the Congress Party, which was in power in Assam between 2001 and May 2016.

No other union comes close to matching the ACMS’s clout and reach, which puts it in an extraordinary position of leverage to improve workers condition. But the top leadership of the ACMS has apparently sought to line its own pockets and allowed political parties to harness the tea garden community as a vote bank. It is an allegation repeated by workers, tea industry management and even bureaucrats who have dealt with the union.

Last year, for instance, the ACMS was accused of siding with the tea industry management and not endorsing a government proposal to significantly hike the wages of workers to Rs 177 per day.

Dileshwar Tanti, general secretary of the ACMS, was unperturbed by such charges. “People will always say things like this,” he said. “If anyone has done anything for the workers, it is the ACMS.”

He sought to transfer the blame to the deposed Congress government, even though he was a legislator of the party for several years. “We got nothing,” he said.

Some of the resentment for the previous administration stems from its inability to secure “Scheduled Tribe” status for Assam’s tea community, which would ensure better political representation and other benefits. Even Tanti admitted that the workers have been used as a vote bank. “All political parties are like this,” he said. “We are second class citizens.”

Legal impunity

There is another critical safeguard for Assam’s tea garden community that has failed: the enforcement of the Plantation Labour Act, which underpins the functioning of the entire industry.

The Assam government’s labour department houses the office of the chief inspector of plantations. The inspector is responsible for monitoring the proper implementation of the Plantation Labour Act across all of the state’s 792 registered tea gardens. Yet, according to a retired bureaucrat, the department only has 68 labour inspectors and 28 labour officers.

“They cannot complete inspections of all tea gardens,” the retired bureaucrat said, requesting anonymity. The result, he went on, is that at least 20% of tea gardens in the state don’t even submit annual returns under the PLA, which is mandatory by law. “The government hasn’t been able to do much because the officers think that is a small offence.”

Of the remainder, about 20% of the gardens comply with less than half the provisions mandated under the Plantation Labour Act, he estimated. Only approximately 25% of Assam’s tea gardens have a compliance rate of 80% and above.

Prosecutions don’t have much impact, the former official said, because the fines are frankly ridiculous, often ranging in the mere thousands of rupees. In any case, the already stretched staff rarely has the stamina to relentlessly pursue repeat offenders.

“Unless they are made to do it, the [tea garden] management will not do everything for the workers,” he said. “But the government has the ultimate responsibility.”

To Vikram Ekka’s mind, it isn’t just one institution that has hurt Assam’s tea garden workers. “The politicians have their own interests. The company has its own policies. The ACMS has its own agenda,” he said. “In between, the tea tribes are getting squeezed.”

Thousands of mothers in Assam’s tea gardens are paying with their lives for this collective failure.

Babita Jayram isn’t one of them. Resting inside a crowded ward in Dibrugarh’s Assam Medical College and Hospital, the young mother has beaten the odds. But this is only the beginning of the survival game. Assam has also one of the highest infant mortality rates in India.