Health Inequalities as Structural Violence

Bhejal food makes bhejal people: the contamination of food results in increased illnesses such as diabetes, stroke, and cancer, as well as major damage to the stomach, liver, and kidney (chap. 4). Although there is no unified public healthcare system in Bangladesh that collects such data nationally, the issue of healthcare was a recurring theme of precariousness among the four hundred households that I surveyed in Nodi, as well as among the twenty landless women working on temporary road maintenance projects who were my main interlocutors, their neighbors, and families in both the Lonanodi and Dhanmarti unions. Many of them suffered from “gas” (gastritis) and took several pills each day. As both Sadhu Kaka and Fupu pointed out, the young are weaker and more ill—and the costs for examining and treating such ailments falls onto the individual families and their ability to get support from their kinship circles.

I became good friends with Lakshmi, a thirty-year-old woman from Nodi. Although we were roughly the same age, I had no children at the time, while Lakshmi was already the mother of two adolescent daughters—at the end of my fieldwork, she had already become a grandmother. I spent a few days each week in her village in Dhanmarti Union learning the seasonal work from planting to carrying water, and finally ended up tutoring her children in English. We mostly sat in her earthen kitchen after she came home from a day of earthwork (shoveling earth and leveling small roads) while she prepared different food items, with the occasional neighbor or family member stopping by. Lakshmi’s husband Kamal was chronically ill with severe stomach pains and was unable to eat. He weighed only thirty-five kilograms and was unfit for manual labor, and Lakshmi therefore had to act as the breadwinner. She had worked in a donor-funded earthwork project for the past five years to repay a debt (with high interest rates) taken out from microcredit NGOs and local moneylenders. She used the credit of several hundred thousand (lakh) taka to take Kamal to India for treatment and medication, without any noticeable results. One day, while Kamal was out selling vegetables at the local market, Lakshmi exclaimed: “All the money I earn, all the hard work I do, what is it for? I’ve spent it all on him. Look at him, he’s so weak and he cannot help at all. What’s the point of taking him to the doctor?”

Karuli, a landless woman employed in a two-year road-maintenance project is also the main breadwinner in her household. Her husband is unable to work because of chronic problems with his kidney and gastritis; toward the end of my fieldwork, Karuli feared for his life: “We tried to take him to local doctors at first, it was just too expensive to go to the hospital in Khulna! Then he got so ill that my in-laws and I took [out] loans to take him to Khulna city to be examined. It cost five thousand taka, that’s more than I earn in a month! His kidney is damaged, the medicine they gave isn’t working. What if this does not cure him? We have borrowed so much money and now I won’t have a project income.”

Karuli explained that the local healthcare facilities at the Upazila level are rudimentary, while the nearest hospital is located in the district capital of Khulna over two hours away by public transport. Even there, public health facilities lack medical equipment and instruments. Community-based clinics funded through development projects are unsuitable for treating more chronic or severe problems like Karuli’s husband’s illness. They provide vaccines for newborns, painkillers, contraceptives, antidiarrheal medicines, and oral rehydration packs and illustrate how health initiatives tend to be cofinanced by donors or delivered by NGOs, just like Bangladesh’s safety-net schemes (Barkat-e-Khuda 2011).

The extremely poor condition of state-funded health infrastructure in Bangladesh, and in the coastal zone in particular (Murshid and Yasmeen 2004), is the result of decades of insufficient state expenditure. Public healthcare provides only the barest level of service for most of the population, with serious disparity of access to basic services between rich and poor (Lewis 2011, 192). Thus, while Bangladesh’s statutory health system in principle covers all citizens with a range of services free of charge, in practice a substantial number of sick people are left untreated (World Health Organization 2015). Many of the people I spoke to in Nodi believed that public healthcare professionals in Bangladesh are incompetent, and they frequently sought private alternatives.1 The best private and high-cost hospitals and clinics with major state-of-the-art diagnostic equipment and facilities are in Dhaka and Kolkata, India. Because of its proximity to the border, my Khulna-based interlocutors preferred seeking care in India. As Lakshmi said: “If it costs as much to get excellent healthcare in India, why should I go to Dhaka?”

However, Lakshmi became heavily indebted to microcredit-lending NGOs, local money lenders, and relatives in order to obtain healthcare in India. Similarly, Karuli borrowed money from her relatives to go see a doctor in Khulna, but she has been unable to gather the funds required to take him to see a specialist in India. The temporary donor-funded earthwork schemes targeting landless women enabled both Lakshmi and Karuli to pay off healthcare debt. Nevertheless, these funds were not enough to help these families sustain their household expenses. Furthermore, when her project came to an end, Karuli had no means of paying for her husband’s care. She expressed considerable anxiety over the uncertainty of future income opportunities. The costs of private healthcare are unaffordable to many, including the poorest and the middle classes, as it often exceeds general household consumption. This system has resulted in inequitable accesses to health services between rural and urban areas.

To access healthcare and treatment, many families end up highly indebted and enter a negative spiral of healthcare costs and poverty (Kabeer 2004; Satapathy 2016). Once a family member falls ill, the costs of visiting a doctor, undergoing examinations, and medication severely impact the economic resilience of a family (McIntyre et al. 2011; Matin, Sulaiman, and Rabbani 2008). High debt is linked to the out-of-pocket expenditure (OOP) as a percentage of private expenditure on health as illustrated in table 5.1. It shows that while individual households in Bangladesh contribute 67 percent of total healthcare expenditure through out-of-pocket payments to access health services (World Health Organization 2012), the government only contributes 33 percent of total healthcare expenditure. In India, private expenditure constituted 69.7 percent of total healthcare expenditure in 2009—one of the highest OOP in the world. India’s National Health Policy 2015 argues that the “catastrophic expenditure due to healthcare costs is growing and is now being estimated to be one of the major contributors to poverty. The drain on family income due to healthcare costs can neutralize the achievement of the goal of income increases and every Government scheme aimed to reduce poverty” (Ministry of Health and Family Welfare 2015, 3).

A WHO report highlights: “The cost of services in private health facilities is unaffordable to many poor people. Bangladesh, therefore, still needs to travel a long way to reach universal health coverage” (2015, 54). Despite recent years of increase in health spending, Bangladesh’s health expenditure remains one of the lowest in Southeast Asia. But why is this the case?

When I visited Chameli from the earthwork group in Lonanodi, her brother Liton—like many others—asked me if my country is rich and if money is readily available so that one can study as much as I have and receive good healthcare treatment without accumulating debt.

Camelia: Hmm, in Sweden we must all pay income tax to the state that then provides us with healthcare and education.

Liton: You must pay money to the state from what you have earned? You trust the state?

Camelia: You pay based on what you earn. For example, if I earn very little, say ten thousand taka per month, I do not have to pay tax. But if I earn thirty thousand taka, I pay one-third in taxes and if I earn one hundred thousand taka, I pay half in taxes. So even the richest who pays half his salary in taxes will still have five times more money than the person that only earns ten thousand taka. With this money, the state takes care of us. Because it is our money, we check on the state.

Liton: Apa [sister], that sounds like a good system. If we had that system here, we would not need to struggle so much with debt. It would be good for us poor.

SOURCE: World Health Organization (2012).

Liton expresses the desirability of a progressive tax system for universal healthcare that would benefit the poor of Bangladesh. Our conversation also reveals two common general beliefs: (1) the lack of trust in a state perceived as corrupt, and (2) rich donor countries (like Sweden) hand out benefits to all their citizens. In 2009, Sweden spent US$3,033 on per capita government expenditure on health, while Bangladesh spent US$18. Bangladesh, with a population of over 160 million, is considerably more populous than Sweden, which has around ten million inhabitants. However, to simply attribute this difference to GDP and wealth alone might be too simplistic.

Even in high-income countries like the United States, millions of citizens are financially crippled in a marketized healthcare system (Sanger-Katz 2016) where out-of-pocket payment made up 52.3 percent of total healthcare costs in 2009, compared to social democratic welfare states like Sweden where the equivalent figure was only 18.5 percent (see table 5.1). Thus, the share of government expenditure versus OOP on healthcare is a political decision, where Sweden has a high share of public spending and public sector activity along with a well-developed, progressive taxation system (OECD 2015)—even though inequality is rising as taxation has steadily reduced in recent years (OECD 2011). Bangladesh, in contrast, has a weak revenue generating capacity and its collection of direct taxes remains one of the lowest in the world (Lewis 2011).

Low government allocation to healthcare expenditure in Bangladesh is ultimately tied to a wider restructuring of the state, which began in the late 1970s. Longstanding aid dependency on donors driven by a promarket and antipublic spending agenda of the World Bank hindered the development of a fully functional and national public healthcare system, education system, and responsive job market (Broad 2006; 2007). The founding father of Bangladesh, President Sheikh Mujibur Rahman, sought to unite and build up the country on the four pillars of secularism, nationalism, socialism, and democracy. Inspired by the Soviet Union and socialism, he nationalized Bengali-owned businesses when he came to power in 1971. Foreign investment was to be permitted, but only in joint venture with the public sector, with a maximum of 49 percent foreign equity (Lewis 2011). However, the international donor community, led by the World Bank, opposed Mujib’s new economic policies.2

In 1975, a state coup resulted in the assassination of Sheikh Mujibur Rahman and his family in their home in Dhanmondi, Dhaka. The government of Major General Zia-ur-Rahman followed the “guidance” of the World Bank and “rehabilitated” the private sector by meeting the demands of business elites and donors. The Ershad regime implemented denationalization and the return to private ownership beginning in 1982; there was strong trade-union opposition to the assault on the public sector, yet the regime opened up Bangladesh through trade liberalization policies (Lewis 2011). This formed part of a global phenomenon in the 1980s where the World Bank and International Monetary Fund gave loans to low-income countries in Latin America, Africa, and Asia experiencing debt crises after the global economic downturn of the 1970s. These loans were made conditional upon macroeconomic policy reforms, called Structural Adjustment Policies, based on the neoliberal doctrine of privatization, trade liberalization, and deregulation (Harvey 2005). The conditionalities were also known as the Washington Consensus, a list of “ten commandments” with an implicit promise that if a country implemented these macroeconomic reforms, it would experience economic growth (Rodrik 2006; Williamson 2004, 205). By encouraging economic growth and foreign exchange, the countries would be able to repay their loans (Easterly 2006).

In practice, debtor countries like Bangladesh were to privatize and deregulate state-held enterprises and utilities such as healthcare, water, electricity, transport, and natural resources while denationalizing the public sector. They were required to implement trade liberalization: removing existing (protective) tariffs and export taxes as well as deregulating currency markets (H. White 1996). In Bangladesh, SAPs escalated in the years following 1986, with more extensive actions beginning in 1992 (Tait 2003).3 It was during this time that donors in Bangladesh promoted high-yielding intensive agriculture, export-oriented commercial aquaculture, and the contentious Flood Action Plan.

Structural Adjustment Policies represented a decisive moment in the remaking of global capitalism with a high degree of external intervention on the national policies of sovereign countries, impacting the citizens of debtor countries (Checchi, Florio, and Carrera 2009). They came to be extremely unpopular in the implementing countries as these reforms involved selling off precious state assets to foreign firms at fire-sale prices, massive deindustrialization, increased unemployment, and a sense of “recolonization”—where “neoliberalism” came to refer to a fundamentally different situation than it did in Western Europe and North America (Ferguson 2010). The denationalization of the public sector, lifting of market restrictions, and integration of the national economy into the world economy was part of a global pattern of taking crucial economic issues out of the hands of national governments.

Based on mounting criticism of the Washington Consensus and how it reduced the role and power of nation states, the World Bank moved toward the Post-Washington Consensus (PWC) in the 1990s to expand on development as economic growth and to incorporate poverty reduction and human development, focusing on literacy, life expectancy, increased income, and so on (World Bank 2006). However, the PWC was referred to as “sugar-coated structural adjustment policies” (Muhammad 2003, 121) as it effectively depoliticized the debate on poverty reduction by removing discussions of political economy, just like SAPs did before it (Dijkstra 2011). Like SAPs, Poverty Reduction Strategy Papers (PRSPs) had a negative view of the state: limiting its role to that of ensuring that markets function. Good governance was cast as the opposite of the state’s bad governance, to help create institutions that enable markets by reducing transaction costs and rents (often referred to as corruption).4

In line with this focus on governance in the PWC, donors and IFIs (International Financial Institutions) introduced partnership to the 1990s development discourse, where national governments must own their development strategies and civil society must participate in their formulation. Such a partnership would ensure transparency and accountability (or “aid effectiveness”) in the implementation of development (Dijkstra 2011). During the 1990s, civil society soon came to be equated with—or rather reduced to—nongovernmental organizations (Elyachar 2003; Sukarieh 2012). Under the PRSPs, donors increasingly directed funds to NGOs and away from governments, causing an explosion of NGOs (Pfeiffer and Chapman 2010).

SAPs undermined Bangladesh’s ability to provide public sector services for the poor. After the 1990s, public healthcare receded and education was outsourced to “service delivery” NGOs by the Bangladesh government and donors (Vaughan, Karim, and Buse 2000). Wood (1997, 81) terms this outsourcing of state responsibility for the delivery of universal services and entitlements (such as healthcare and education) to nonstate bodies like NGOs as the “franchise state” that ultimately renders “the purpose of democracy toothless and meaningless.” By 2000, there were more than twenty-two thousand NGOs in Bangladesh, with multimillion dollar budgets, high-rise offices, and not-for-profit business concerns (Lewis 2011). Anthropologist Delwar Hussain (2013) further points out that structural adjustment policies and the opening up of Bangladesh in the 1990s reduced state capacity in a context where it had not been in a position to provide services for the majority of its citizenry in the first place. This proved to be the beginning of the abdication of what many of his interlocutors came to expect of the state, such as establishing public infrastructure. This contributed to a system where Bangladeshis were increasingly reduced to “beneficiaries” in donor-funded development projects, rather than citizens who pay taxes to a state that is responsive to their needs.

Arguably, the ideologies of the Washington Consensus and good governance agenda thwarted the development of strong state institutions, including those for public infrastructure such as revenue collection and a universal public healthcare system (Tait 2003; Hussain 2013; Hossen and Westhues 2012; R. I. Rahman and Ali 1996). In lieu of public healthcare and education, rural Bangladeshis like Lakshmi and Karuli now indebt themselves in order to pay for private services that could help save family members from early death. Such structural socioeconomic inequality does not “fit” into existing climate change–centered assumptions of problems in Bangladesh. The reduction of healthcare for the poor in the wake of structural adjustment policies has become an enduring problem of inequality in South Asia. Akhil Gupta (2012) argues that the life-denying consequences of chronic poverty in India have largely disappeared from public discussion: “Despite the rhetorical importance given to the eradication of poverty in government policy pronouncements, the scandal of the state lies in its failure to acknowledge that condemning an estimated 250 to 450 million people to a premature and untimely death constitutes a crisis of grave proportions. . . . How is violence [like exceptional poverty] taken for granted in the routinized practices of state institutions such that it disappears from view and cannot be thematized as violence at all?” (Gupta 2012, 4–5).

Gupta refers to this as a form of “structural violence” following sociologist Johan Galtung (1969, 168), who defines violence as arising “when there is a difference between the potential and actual somatic and mental achievements of people”—that is, whenever outcomes are unequal, violence is present. Violence is structural, Galtung suggests, when “it is impossible to identify a single actor who commits the violence. Instead the violence is impersonal, built into the structure of power,” where it is invisible (Galtung 1969, 170–71). Though Lakshmi and Karuli work and indebt themselves through various microcredit loans to pay for private healthcare for their ill and underemployed husbands, they have been unable to ensure that their husbands receive appropriate treatment and recover fully.5 Galtung (1969, 168) suggests that “if a person died from tuberculosis in the eighteenth century it would be hard to conceive of this as violence since it might have been quite unavoidable, but if he dies from it today, despite all the medical resources in the world, then violence is present according to our definition.” Similarly, because of the high levels of private out-of-pocket expenditure for healthcare in Bangladesh, many poor families are unable to realize basic life expectancy.

The political, administrative, and judicial action—or inaction—that perpetuates a system of inherent inequality of life expectancy and health arguably constitutes “structural violence.” Excessive out-of-pocket payments and subsequent high indebtedness for healthcare thus reflect structural conditions of inequality by which certain segments of the Bangladeshi population can afford adequate healthcare and others cannot. Yet such factors are often overlooked as individual experiences of poverty (Farmer 2005). Currently, inequitable access to healthcare, and the subsequent livelihood erosion, indebtedness, and early deaths attached to this, is not part of public debates that individualize experiences of poverty and focus on “vulnerability.” To address “weakened livelihood capacities” anthropologists cannot only look at issues related to climate (Crate 2011), but must also engage with the inherently unequal power structures that enable structural violence embedded in bureaucratic structures despite long-standing efforts to “reduce poverty.”

Unequal Education and the Crisis of Masculinity

While Karuli and Lakshmi were concerned over how to afford healthcare with their short-term earthwork projects ending, Lipi expressed anxiety over her inability to continue her daughter Hetal’s education. Though Hetal is the daughter of a single mother who earns little as a day laborer, she dreams of continuing her studies to become a pilot. The mother-daughter pair live with Lipi’s frail widowed mother, and are surrounded by Lipi’s brothers and their families in a crowded patrilineal homestead compound located in Lonanodi village. When I went to visit Lipi, we sat on her cool mud porch while she was cooking. The earthen walls of the homestead were crumbling, and the surrounding land was barren, with no trees or vegetation. Once the earthwork project ended, Lipi would no longer have a regular income. There were few work opportunities for women in her village: “My daughter is so smart and does well in school, but how am I to pay for her tuition and guidebooks? They are so expensive! I don’t want to take her out of school, but I am I’m barely making ends meet by washing dishes and clothes in other people’s homes; they give us food [rather than cash]. I don’t know how long I’ll be able to keep my daughter in school.”

Although primary school is free for girls until the age of fifteen and the government provides core textbooks, these textbooks are poorly structured and overly complicated. Without “guides” [guidebooks], most children are unable to comprehend the textbook and pass their exams. Private “tuition,” often with the un(der)paid schoolteacher, is necessary to help explain both the guides and textbooks. Parents would, in addition, pay a fee to the schoolteacher to attend class. These costs range from five hundred to one thousand taka per month (sometimes per subject). For these women on temporary earthwork projects, this is a substantial amount of their disposable income of three thousand taka per month. The tension over how, and for how long, they could send their children to school was integral to their hopes and aspirations of “making a life worth living” (Narotzky and Besnier 2014). In one study, half of the surveyed single mothers in Bangladesh were unable to send their children to school because of inadequate income (McIntyre et al. 2011). Noshima (introduced in chapter 3) is a single mother living in Lonanodi village. She was unable to pay the two thousand taka required for her thirteen-year-old daughter Nisha’s class-eight examination, resulting in Nisha dropping out of school. Noshima did not have money for a dowry, which meant that Nisha was unable to enter into a marriage arrangement and thus spent all of her days at home. This illustrates how the high out-of-pocket expenditure required for schooling limits a child’s ability to gain education when s/he is limited by the family’s financial resources. Educating girls in Nodi, whether through conventional schools or single-sex madrasas, was often a means to delay marriage. As a secondary school certificate is now required for work in the Dhaka ready-made garments industry, some families expressed a greater interest that their daughters study to secondary-school level, something Noshima also wanted but was unable to afford as her brother used his contacts to get his wife the earthworking contract instead. Nisha ended up married as a child and quickly divorced, because of her mother’s inability to keep her in school. Depending on the family’s socioeconomic status, some girls are married off as children, while others marry of their own choice as adults. Such a difference in social outcomes arguably constitute structural violence just as much as inequitable access to healthcare.

Doting on the Son-in-Law: Stories from Nodi

One day when Lakshmi and I were walking to a nearby football tournament and were far away from her family and neighbors, she expressed frustration over how supporting her family had become her responsibility. In her community, husbands are expected to support their wives and buy them food and clothing, yet Lakshmi’s husband did not even symbolically act the role of husband: “Did you know that in the twenty years we’ve been married, he’s never once bought me a sari?”

Although young, beautiful, and strong, Lakshmi, like Karuli, has a dark complexion. Fair skin is the beauty ideal in Bangladesh while dark skin is connected to ideas of impurity and lower status—often associated with manual labor in the sun. Dark-skinned girls (kalo meye) must pay higher dowries to their in-laws to “compensate” for their appearance as few families accept a “dark” daughter-in-law. Dowry demands from men with stable incomes and without prior failed marriages are too high for many girls from poorer backgrounds—particularly those with a dark complexion or without fathers like Nisha. These girls therefore tended to end up with men who did not demand a dowry, either because they do not work, are older (and divorced), suffer from substance abuse, or have other problems that reduced their ability or willingness to provide for their families.

Afrina resides with her adult children in Dhanmarti village, together with an aged, bed-ridden, and chronically ill husband. During the hot and dry mango month of Jyostho, we sat inside their cool room atop the simple wooden bed covered with a bamboo mat under the cool breeze from their solar-driven mini-fan. Her mother was twice a widow with four daughters and one son. Afrina, the youngest of her siblings, was married off at the age of twelve to a married man forty years her senior solely because he did not want a dowry. He was ill and unable to work, and Afrina had to provide for her family from the onset. She has lived a physically demanding life; she is in her mid-forties, but her face is covered with leathery skin and deep wrinkles, her hair completely gray. Despite her own experience, Afrina married off her daughter Parul at the age of twelve to a family in a neighboring village across the river who said that they will “take” the girl without a dowry. As her son was only nine years at the time, Afrina was the sole breadwinner and could not afford a higher dowry, so she agreed to the marriage proposal.

Soon after their marriage, Parul’s husband demanded that she bring money from her mother to buy him a van to drive; she was also responsible for bringing all the household furniture and kitchen utensils. As Riparna warned, those who do not demand an upfront dowry are the worst ones. Parul’s husband beat her frequently when she failed to bring money from her natal home. Afrina recollected this gruesome period:

He beat her with any object available. He hit her, kicked her, and beat her with sticks; he was ruthless. She still has a broken tooth and a broken finger that hasn’t healed properly. When they got married, we didn’t know he smoked marijuana and drank alcohol, the marriage broker [ghottok] did not tell us, perhaps my son-in-law’s family paid him off. My son-in-law kept torturing Parul to the point that she was hospitalized, and I had to go and take care of her. I decided it would be better to bring Parul home where she would be safe. We filed for divorce as he was never happy with anything we’d give him. His greed was endless.

A son-in-law (jamai) holds a special status in Bengali custom. He is given special treatment, whether it be food, gifts, affection, or terms of respect. For single mothers, or families that struggle with just one income, it can become difficult to sustain such doting on a son-in-law. Thus, the greed of Parul’s husband illustrates how continuous dowry becomes enmeshed with this precedence of showering the son-in-law with gifts as a way of showing affection (ador). Unfortunately, Parul’s story was not unusual; every family I met had at least one example of such incidences of violence. The inability of a woman and her natal family to supplement the son-in-law’s income was often a contributing cause of divorce or abandonment. Either he would leave her for another or she would be subject to such violence that she would decide to leave her husband and return home.

Sayma, whom we met in chapter 4, is a widow with four daughters—two married as adolescents and two in madrasa. Her oldest daughter’s marriage took place only a few months before Sayma’s husband died. As a widow with two daughters in school, Sayma was unable to provide for both herself and the needs of her oldest jamai. Throughout the year, the violence against her oldest daughter Tashu continued to increase as Sayma was unable to satisfy her son-in-law’s demands for money. He threatened to leave her and beat her so much that she returned home on several occasions—bruised and battered—to heal. At the end of my fieldwork, Tashu was on her way of returning home to her mother as she could no longer stand the violence. Afrina’s and Sayma’s stories illustrate how mothers who are single earners (or whose husbands are addicts, disabled, or unable to earn an income) are unable to satisfy the monetary demands of their sons-in-laws and their families even when indebting themselves.

Whether enduring violence or rejection, many young brides return to their natal homes to support themselves. They may remarry and leave their children with their mothers, like Parul ultimately did. Violent and abusive marriages were highly prevalent when the dowry was low or nonexistent; a lack of dowry often turned into continuous demands to support the husband and his family. The increased incidence of dowry-related violence can in some instances become conflated with the custom of the special treatment of jamais. Like Rozina once said while we ate lunch after their work on the canal in Lonanodi: “Some women think it is better to die by their husband’s hands than suffering the shame of returning to their natal homes as divorced women. Others feel that it is better to return to their natal home than to die at the hands of their husband.”

Conclusion: Misreading Coastal Vulnerabilities

Attention to the fabric of everyday life, livelihood anxieties, and hopes among landless women in Nodi frames an alternative reading of coastal—and gendered—“vulnerabilities.” More than half the women in both the Lonanodi and Dhanmarti earthwork groups I interviewed were married to chronically ill men unable to work. All of them struggled with the high costs of social reproduction, healthcare for ill family members, and education for children. Their livelihood anxieties were further exacerbated by the costs for (continuous) dowry demands made by their daughter’s husbands and in-laws, bribes, and the extortionate fees of brokers to arrange overseas work. These out-of-pocket expenses are internalized as private costs and families often end up in debt spirals, taking out one loan to pay off another and having to take the help of moneylenders and microcredit loans from several NGOs. Development interventions like rural employment schemes bring temporary relief in the constant day-to-day struggle, but they also exacerbate the problem by disguising the insecurity of living without safety nets in a political economy filled with precarious underemployment. This debt arises for social services that are citizen entitlements in the countries funding development projects in Bangladesh.

Development aid is ultimately paid for by the taxes of citizens in high-income countries and is used for a plethora of NGO activities in Bangladesh. These NGOs, donors, and development bureaucrats are largely exempt from tax, as are the multinational corporations benefiting from Bangladesh’s export-oriented industries. Although this is in line with a neoliberal development agenda that treats local people as “beneficiaries” of external charities, the development industry evades the issue of the state’s responsibility to provide social provisions for its citizens. This perpetuates a problem that arose from SAPs decades ago. Despite living in an area of waterlogging, tidal surges, and occasional cyclones, my interlocutors were mostly concerned with social reproduction, with how to make a life worth living for themselves and their families in the present and in the future, while having to deal with substantial precarity in an unequal society. Coastal vulnerabilities in this region are thus not limited to uncertainties in the face of climatic change, but to a different level of precarity that all the people living there face. To address their social and economic needs requires an active and long-term involvement of the state at various levels: as a creator of jobs (e.g., rural employment schemes targeting the landless), creating a working public healthcare infrastructure that addresses the health needs of all its citizens, and addressing the continued social issues of domestic (dowry-related) violence and child marriages that perseveres despite decades of focusing on “girls.”