Editorial 1: From a republic to a republic of unequals

Context

The neoliberal ideological order shadows the constitutional vision of creating an egalitarian social order in India.

Introduction

Constitution day on November 26, 2024 marked 75 years of the adoption of the Constitution and constitutional governance in independent India. The Constituent Assembly debates show the intellectual engagement of leaders from a spectrum of ideologies, right wing to left wing, in building a single political identity that was accommodative of the interests and rights of multiple cultural groups.

• Liberal Framework: The Constitution-makers accepted the liberal framework but wanted the state to play a positive role in intervening and reducing inequality due to poor social indicators at the time of Independence.
• Liberalism as a Political Ideology: There was an insistence that there should be freedom for citizens to carry out activities without any state interference.
  • The belief was that only in a free environment could human potentialities—intellectual, moral, and physical—be realized.
  • Liberty became the core value of liberalism.

• Indian Constitution-makers’ Agreement: The Indian Constitution-makers agreed to create a liberal political state in India.
  • However, considering the social and economic inequalities, they felt that a complete withdrawal of the state would perpetuate the existing inequalities and worsen it further.
• Positive Role of the State: The state should be given a positive role to intervene and create conditions for everyone to participate equally in the development process.
  • This led to the introduction of affirmative action and reservation policies
• Affirmative action and reservation policies were designed to treat unequals in an unequal manner to achieve the constitutional vision of equality.
  • These policies became an important aspect of the Indian Constitution.

An egalitarian outlook

• Vision of Equality in the Indian Constitution: Its vision of equality aims to create an egalitarian society to minimise economic inequalities among the people.
  • Reflecting John Rawls’ egalitarian liberalism, including the three important principles of:
    • equal basic liberties
    • equal opportunities
    • difference
  • The Constitution aims to create an egalitarian society.
• Fundamental Rights and (DPSP): The fundamental rights in Part III and the Directive Principles of State Policy (DPSP) in Part IV of the Constitution reflect all the above three principles of egalitarian liberalism.
  • Thus, egalitarian liberalism aims to reduce inequality and not create an absolute equal society.

Role of the State in Reducing Inequality

• Article 38(2) of DPSP insists that the state shall strive to minimise the inequalities of income and eliminate inequalities in status, facilities and opportunities.
• The constitutional ideological framework lays emphasis on reducing inequalities and creating an egalitarian society based on equal opportunities and facilities through state intervention.
• Further, Article 39(c) emphasises that the economic system ought not to result in a concentration of wealth and means of production to the common detriment.

Supreme Court’s Interpretation

• The Supreme Court of India has reiterated this principle in many of its judgments till the end of the 1990s:
  • In D.S. Nakara & Others vs Union Of India (1982), the Court said that the basic framework of socialism in the Constitution is to provide a decent standard of life to the working people and social security from cradle to grave, reiterating the role of the welfare state in India.
  • In Air India Statutory Corporation vs United Labour Union & Ors (1996), the Court said that the ideological aspects of the Indian Constitution found in the Preamble, Fundamental Rights and DPSP aim to establish an egalitarian social order, protecting social and economic justice and the dignity of individual by providing equality of status and opportunities.
  • In Samatha vs State of Andhra Pradesh & Ors. (1997), the Court interpreted that the meaning of the word “socialism” in the Constitution is to reduce inequalities in income and provide equal opportunities and facilities to create an egalitarian social order.
  • Justice V.R. Krishna Iyer’s interpretation of Article 39(b) of the DPSP, in State Of Karnataka And Anr Etc vs Shri Ranganatha Reddy & Anr. Etc, that public and private resources fall within the ambit of community resources, was in line with the constitutional ideology of creating an egalitarian society by strengthening the state’s power of redistribution of resources for common good towards reducing inequality.
• Recent Overturning of Interpretation: But recently, the Court overturned this interpretation without locating it within Article 39(c), which empowers the state to intervene and regulate the economic system to prevent the concentration of wealth in the hands of a few towards creating an egalitarian society.

Economic reforms and inequality

• Neoliberal Economic Reforms and Constitutional Ideology: After the adoption of neoliberal economic reforms in India, the constitutional ideology took a back seat.
  • The idea of a welfare state, as envisaged in the Constitution, has withdrawn its commitments towards creating an egalitarian society.
• Research on Rising Inequality in India: Lucas Chancel and Thomas Piketty from the Paris School of Economics documented the rising inequality in India in their work, “Indian Income Inequality, 1922-2015: From British Raj to Billionaire Raj?” (2019).
  • Their research showed that:
    • In the 1930s, the top 1% of earners had a share of less than 21% of total income.
    • After Independence, due to welfare state intervention, based on constitutional ideology, this gap reduced, and the top 1% earners had a share of 6% of the total income in the 1980s.

Structural Changes Post-Neoliberal Reforms

• After the implementation of neoliberal reforms in the 1990s, major structural changes occurred in the Indian economy.
  • These changes prioritized private capital investment.
  • There was a slow withdrawal of the welfare interventionist state.
  • The state took a positive role in creating and strengthening markets, rather than working towards creating an egalitarian society as envisaged in the Constitution.
• As a consequence:
  • The top 1% income share reached 22% of total income, pushing the inequality situation back to a level worse than that of the pre-Independence period.

Findings from Recent Research

• Chancel and Piketty reiterated this inequality status in their 2024 research, highlighting:
  • The top 1% of income and wealth shares reached 22.6% and 40.1%, respectively, by 2022-23, which is considered very high.

The “State of Inequality in India Report” (2022)

• The “State of Inequality in India Report” (2022), prepared by the Institute for Competitiveness and commissioned by the Economic Advisory Council to the Prime Minister, highlighted the Periodic Labour Force Survey 2019-20.
  • It recorded that the top 10% earn an average monthly wage of ₹25,000 (₹3 lakh per annum).
  • The remaining 90% earn less than ₹25,000 a month.
• This situation shows extreme inequality and how the majority are being pushed into poverty, violating the constitutional ideology of equality.

An overlap with social inequality

• The report titled “Towards Tax Justice and Wealth Redistribution in India” (2024 by the World Inequality Lab at the Paris School of Economics) has brought evidence to show how economic inequality and social inequality overlap in India.
  • By 2022-23, 90% of the billionaire wealth was held by the upper castes in India.
  • Scheduled Tribes are not present in billionaire wealth.
  • Other Backward Classes (OBC) have a mere 10% presence in billionaire wealth.
  • Scheduled Castes have a 2.6% representation in billionaire wealth.

Shifting Wealth Distribution Between 2014 and 2022

• Between 2014 and 2022, the OBC share in billionaire wealth has reduced from 20% to 10%.
• The upper caste share in billionaire wealth has increased from 80% to 90%.
• The upper castes are the only group that owns wealth more than its proportion of population, reiterating how social capital and economic advantages are overlapping in India.

Rise in Billionaires and Income Inequality

• Oxfam International highlights the rise in the number of billionaires in India:
  • From 9 billionaires in the year 2000 to 119 billionaires in 2023.
• The report compares income inequality:
  • It will take 941 years for a minimum wage earner to earn what a top corporate executive earns in a year in India.

Conclusion

The constitutional vision of creating an egalitarian social order by minimising income inequality and eliminating social inequality is under threat from the neoliberal ideological order. Violating the constitutional ideology, inequality levels are widening, strengthening wealth concentration among the few. Further, social inequality overlaps with economic inequality to give the upper castes a greater advantage in contemporary India. Constitution Day has passed, but there is an opportunity for us to critically evaluate our political and economic practices within the constitutional framework, to assess our achievements and failures, reiterating Babasaheb’s words that social and economic inequality will put political democracy in peril.

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Editorial 2: An ideal way to treat India’s corneal blindness problem

Context

A ‘consent-driven donation’ approach is a step that can eliminate avoidable corneal vision loss.

Introduction

Despite strong support for eye donation in India, with millions, including popular film actors, pledging to donate, an acute shortage of corneas persists. There is a need to perform about 1,00,000 corneal transplants every year, but only 30% of this need is being met.

• On the demand side, many fellow citizens lead a lifetime of avoidable sight loss, waiting for sight-restoring tissue.
• The solution on the supply side are the millions dying in Indian hospitals every day who are eligible to donate their tissues — but do not.
• What if we ‘presume consent’ and treat them all as cornea donors?
• News reports note that, indeed, a ‘presumed consent’ amendment to the Transplantation of Human Organs and Tissues Act (THOTA), 1994, is in the works to allow cornea retrieval from all eligible deaths in hospitals.

The magnitude of the problem

• Indian policymakers’ consideration: Indian policymakers are seriously considering the ‘presumed consent’ approach to corneal donations due to the scale of the problem.
• Cornea: The cornea is the thin, clear outer layer of the eye.
  • Infection, accidents, or congenital conditions can cause it to become opaque.
• Corneal blindness in India: Corneal opacities are the second major cause of blindness in India among those aged 50 years and older, and the primary cause in younger individuals.
  • An estimated 1.2 million people in India live with corneal opacities.
  • Approximately one-third of these cases can be treated with a corneal transplant.
• Corneal blindness in a global context: These numbers make India one of the largest populations with corneal blindness in the world.
  • Most corneal blindness is preventable or treatable.
• Treatment for corneal Blindness: Corneal transplant surgery is an effective intervention for those eligible for treatment.
  • It is the most frequently performed transplant in the world.
• Role of eye banks in Corneal transplants: Eye banks are critical to enabling corneal transplants. They handle ethically sourced corneas, process them, and make them available to eye surgeons.

Challenges in India’s Eye Care System

• India lacks enough eye banks of the necessary standard.
• There is a shortage of corneal surgeons.
• There is a need for 50 high-functioning eye banks (currently, there are 12 to 14).
• India needs 500 active corneal surgeons, with each performing an average of 200 transplants annually.
• With appropriate legislation enabling presumed consent for corneal donations, the target of 1,00,000 corneal transplants a year can be reached.

Presumed consent versus required request

• Presumed consent addresses the problem of cornea scarcity by eliminating red tape such as:
  • Permissions
  • Waiting for post-mortem examinations
  • Effort of convincing next-of-kin
• Unless the deceased has left explicit instructions “not to donate,” it is presumed they are a tissue donor.
• Since corneas need to be retrieved within 8 to 10 hours after death, reducing delays increases tissue viability.
• Universal ‘opt-in’ could boost the supply of corneas, helping to eliminate corneal blindness in India.

Risks of the Universal ‘Opt-In’ Approach

• The universal ‘opt-in’ approach risks undermining a key enabler of corneal donations: consent.
• Corneal donation and transplantation involve a sensitive partnership between:
  • The public: including both cornea donors who voluntarily donate and recipients who value the donation and comply with follow-up care.
  • Corneal specialists: who facilitate the donation and transplantation process with their expertise.
  • Policymakers: who support the system with appropriate legislation.

Potential Issues with ‘Presumed Consent’

• Presumed consent distorts this partnership by eliminating the need for consent from the next of kin.
• While it could speed up cornea retrieval, there is little evidence suggesting it is necessary to solve the problem of corneal scarcity.

Examples of Successful Organ Donation Systems

• Countries with the best organ donation rates (Spain, the United States, Portugal) do not operate a presumed consent system.
• Instead, they use policies like ‘soft opt-in’ or a ‘Required Request’ policy, where formal consent is sought from families before corneas are acquired, even though all citizens may be considered potential donors.
• Public education and investments across the entire cornea transplantation pipeline are key to their success.

A model that works: India’s Successful Model of ‘Required Request’ Corneal Donation

• India too has a successful model of ‘required request’ corneal donation: a hospital cornea retrieval programme (HCRP).
• General hospitals handle a lot of mortality and are thus sites for motivating corneal donations.
• In an HCRP, a grief counsellor approaches the kin of the deceased and initiates a conversation, gently motivating them to consider a donation.
• The donation is processed only after receiving explicit consent from the kin.
• While it is a delicate task, grief counselling has had remarkable success in increasing the availability of corneas for transplantation.

Impact of HCRP at the L.V. Prasad Eye Institute (LVPEI)

• Of the 1,40,000 corneas harvested by the Ramayamma International Eye Bank at the L.V. Prasad Eye Institute (LVPEI) in Hyderabad, in 35 years, over 70% have come from HCRP.
• This year, the LVPEI marked over 50,000 corneal transplants performed, thanks to this approach.
• In the States of Andhra Pradesh, Telangana and Odisha, there is no waiting list for corneal transplants, unlike other parts of the country with months-long waiting lists.

Conclusion

It has also been found that the ‘Required Request’ approach encourages cornea donation. It offers some closure to grieving relatives.Donor families often mention the sati sfaction in knowing that their loved ones’ eyes live on, letting others see. It is therefore possible for India to eliminate avoidable corneal vision loss by investing in a consent-driven donation paradigm, 50 high-functioning eye banks, and by activating 500 corneal surgeons. Let us act now.