The burning pyres that line city streets, the mass anonymous graves, the bodies floating in the Ganga, loved ones choking to death outside hospitals: it is incredible how these memories of nightmares in a loop from the pandemic have so quickly faded from public memory.
In the national elections that followed in 2024, pledges that states would do enough to protect and promote the health of every person in this vast teeming land were hardly heard. India has one of the most privatised health care systems in the world, and one of the lowest levels of public spending on health as a percentage of the total gross domestic product. The tragedy of mass deaths – according to some estimates as high as five million – has not changed this.
India lags way behind most countries in the world also in promising the right to health as a constitutionally guaranteed right. Today more than half the countries in the world contain references to the right to health. India is not one of these. What the right to health mandates is that the state acts (and also does not act) in ways that enable each individual to attain the highest possible levels of health which includes both physical and mental well-being.
This requires of course the state to establish health centres, clinics, diagnostic centres and hospitals in sufficient numbers. These should be geographically close to every individual; should have sufficient numbers of well-trained health personnel, medical equipment and drugs; should not impose cost burdens on the patient that she cannot bear; should be culturally sensitive; and should not discriminate against any vulnerable and socially stigmatised minority.
But while all of this is necessary for every individual to achieve their highest level of attainable health, it is by no means sufficient. If, for instance, one is starving, malnourished, homeless, living in unsanitary habitations with no provisions for safe drinking water and waste disposal, subjected to domestic violence, lives in conflict zones, works in unsafe, unhealthy conditions, simply the availability of high-quality affordable and culturally appropriate curative health services in the vicinity of where one lives would not be sufficient to ensure that they accomplish the highest attainable health standards their body is capable of.
This is something that the finest socially embedded health practitioners and policy makers have long understood intuitively and empirically. Let me give just two redolent examples from the last two centuries.
My first story dates back to the late 19th century when the deadly bubonic plague ravaged the industrial port city of Bombay in India. It began in Yunnan province of China in 1855, spread to Hongkong in 1894 and reached Bombay in the summer of 1896. The British colonial government deployed highly repressive strategies to control the spread of the epidemic, for the first time bringing in soldiers. It authorised armed soldiers to raid homes with infected persons, to burn their belongings and clothes on street corners, to forcefully hose down homes with disinfectants and sometimes pull down their homes, shifting patients to plague camps where they died shortly after.
A British health officer recalls that they “treated houses as though they were on fire discharging into them from steam engines and flushing pumps” huge quantities of water full of disinfectants. But none of this succeeded in halting the ferocious spread of the infection. In months more than 10,000 people had died. Riots and strikes broke out in 1898 against the repressive state measures. To escape, a mass exodus of the residents of Bombay began as they returned to their villages, carrying the infection to far corners of the country. Ultimately the plague took 12 million lives in India.
A section of the colonial administrators located the cause of the epidemic beyond bacilli and rodents. Hundreds and thousands of workers with their families had migrated to the rapidly growing port city to work as cotton mill and dock workers. Mill workers were accommodated in tenements called chawls near the mills. There were no building regulations and the tenements were built without light or ventilation. Informal workers lived under tents or on pavements. There was little drainage and sewerage. Cesspools of stagnant water full of waste and excreta became ideal breeding grounds for rodents. This section of colonial administrators observed that to prevent the recurrence of another epidemic, every resident of the city had to be assured homes with three things that come completely free – air, sunlight and clean water.
This understanding led to the establishment in 1898 of the Bombay City Improvement Trust, which began the laying of roads, drainage and sewage lines. Middle class settlements came up that were airy, well-lit and well-ventilated. But the lesson was mostly forgotten for the working classes. In the Bombay – now Mumbai – of today, more than half the population lives in slums and pavement homes that continue to be unfit for healthy and dignified human habitation.
My second story is from the other side of the globe, only decades later. The extraordinary, even singular life of the Canadian doctor Henry Norman Bethune – captured in his biography The Scalpel, the Sword by Ted Allan and Sydney Gordon – has fascinated and inspired me since I was a young man.
Bethune, born in Ontario, interrupted his medical studies twice, first in 1911 to volunteer for a year as a labourer-teacher in remote lumber and mining camps in northern Ontario to teach immigrant mine workers reading and writing English. And second, in 1914 during World War I he served as a stretcher-bearer in France.
He commenced a very lucrative private practice in Detroit as a successful surgeon, and led a hedonistic private life, interspersed with bouts of heavy drinking. Making more and more money became the driving force of his life.
But then he was diagnosed with tuberculosis. In the 1920s, this medical verdict was like signing a death warrant. He was sent to a sanitorium to await almost certain demise. Before he went to the sanitorium he divorced his wife to spare her suffering. He wrote to her later from the sanitorium of how he awaited “the angel of death”.
In the sanitorium one day, bored of reading a novel, he turned to a medical book and read in it of a radical new treatment for tuberculosis of artificially collapsing the tubercular lung, allowing it to rest and heal itself. Called pneumothorax, physicians believed this procedure was too new and risky. But since only one of his lungs was infected, Bethune insisted they experimented with him. The procedure was successful, and he fully recovered.
He remarried his divorced wife, but returned to what he regarded as his rebirth to a new life. He was 37, and he looked at the ruin and waste of the years he left behind him. “Never again would any living being lie under his scalpel as a remote and separate organism posing a mere problem in mechanics,” he resolved. “A man was flesh and dreams; his knife would save the dreams as well as the flesh.”
In this, Bethune devoted himself obsessively to the treatment of TB. He was no longer interested in his regular practice, in the making of money. He developed new and innovative techniques of surgery in the treatment of TB. His compulsive single-minded dedication led his wife to divorce his wife a second time, and many clashes with his peers. But his reputation grew, but he encountered a paradox. “The more advanced our curative surgery, the more cases of TB we would get”, he would say. Scientific knowledge about the disease had peaked, but the hospitals and sanitoriums were overflowing with more patients than they could accommodate. For every case he and his colleagues cured, 10 more would appear.
Why, he asked. His answer was that there was a disease engulfing the world which was far more lethal than medieval cholera or the tubercular bacilli. This was poverty. It was 1929. Banks, factories and mines were plunging into bankruptcy. The newspapers were full of reports of the depression and unemployment, in city slums and starving farmlands. Bethune found that all his successes over five years inside the operation theatre were being undone by the mounting impoverishment outside. “The poor man dies” he lamented “because he cannot afford to live”. Hunger was rampant, yet Canada burned its wheat. Millions were without clothes, yet the United States ploughed down its cotton fields.
He joined public demonstrations for food and milk. He declared he would provide treatment free of charge to any patient who could not afford to pay. He found himself drawn more and more to communism, especially when he found that Russia’s socialist policies had brought TB down to half. Workers had priority in treatment, exactly the reverse of what prevailed in his own homeland, and hospitals and sanitoriums were far more lavish than anything in his country.
He developed a charter of what he called “socialised medicine”, that called for the abolition of private practice, “taking private profit out of medicine”. Medical reforms like limited health insurance, he said, were just bastard forms of socialism born out of belated humanitarianism out of necessity. Health services should become a public good, supported by public goods, available to all based not on income but on need. All health workers should be paid out of public funds.
Medical ethics, he was convinced, should be reformed from being a professional etiquette between doctors to “a code of fundamental morality and justice between medicine and the people”. Doctors should not ask “how much do you have?”. Instead they should ask – how best can I serve you?
Bethune’s socialist beliefs took him next to Spain to join the fight against fascism in 1936. There he pioneered blood transfusion in the frontlines of war, taking blood donated by civilians in bottles for wounded soldiers in battle zones. In 1938 he went to China, where he is still honoured for pioneering forms of guerrilla medical service and the idea and practice of the barefoot doctors.
It is extraordinary how Bethune’s charter of what he called “socialised medicine” anticipated in many ways the frontiers of our most radical thinking today on the right to health. On the high table of policy making in new India, these conversations have barely begun.
I am grateful for research support from Rishiraj Bhagawati.
Harsh Mander, justice and peace worker and writer, leads Karwan e Mohabbat, a people’s campaign to counter hate violence with love and solidarity. He teaches at FAU University of Erlangen-Nuremberg, and Heidelberg University, Germany; Vrije University, Amsterdam; and IIM, Ahmedabad.
