The success and shame of postcolonial health care

More than perhaps any other, the events of 1857 and 1947 had the most dramatic impact on Southasia. While the political issues related to these experiences are widely discussed and debated, there remains little understanding of how these and the following years had a bearing on the health parameters of the region – which some would say is more important than any one of the political upheavals.

By the 19th century, the East India Company (described by some as the first trans-national corporation) had established near-monopolistic control over large areas of the Subcontinent, and enjoyed considerable political and economic influence in the UK. During this time, however, the Company was also facing insurrections from several quarters. Previous upheavals had been confined to the British officers (the 'white' mutinies in Bombay of 1683 and Mysore of 1809) or to particular regions (such as the Vellore mutiny in 1806). But over time, these events cumulatively had a vast depletory effect on the company's financial viability, while also raising doubts about its management.

As such, after the uprising of 1857, the takeover of the company's assets and the subsequent imposition of direct rule by the Crown allowed the British government to consolidate its business and streamline its trading operations. Instead of being divided among the shareholders of the East India Company, the ensuing profits were now available to the state. The scientific and industrial revolutions had already occurred, but the widespread dissemination of those advances remained limited – at least until the Empire began to achieve commercial success. Significant investments were thereafter made in developing extensive British infrastructure: in public transport (the London underground was laid during this time), sewage and water supply (which expanded rapidly during the last half of the 19th century all over Great Britain), as well as public health and hospitals. All of this had an immediate impact on life expectancy in the UK, and the lasting boon is evident even today.

In 1997, Max Perutz, the Nobel Prize-winning chemist, analysed the number of centenarians then living in the UK, an analysis that was facilitated by the tradition of the Crown greeting all British centenarians on their 100th birthday. In 1952, when Queen Elizabeth II took over the throne, birthday greetings were sent to 225 people; a quarter-century later, in 1997, the number of individuals receiving the greetings was up to 5218. Perutz suggested that this exponential increase was due directly to causes that included wage hikes during the 19th century, leading right up to continuous improved health care during the 20th.

A more detailed analysis of Perutz's research shows that real wages increased in the UK only during the latter half of the 19th century. Despite the industrial revolution having occurred over the previous century, real wages had remained stagnant and life expectancy had hardly changed during the first half. It turns out that the post-1860 wage increase occurred almost simultaneously with when the capital surplus from the colonial enterprise became available to the UK population, as opposed merely to the shareholders of the East India Company. In addition, the better medical-care and public-health measures that were implemented were quickly reflected in the better survival of British children, which inevitably led to a gradual increase in the number of those surviving to 100 years – especially for those born after 1857.

Dr IMF
Though ostensibly under the same benign 'mai-baap' rule of the benevolent Empire, similar investments in the public's health were prominent by their absence in Southasia. Thus, life expectancy, one of the simplest parameters of health status, offers a study in contrasts. In the census of 1871, the difference in life expectancy at birth between India (eg, the Bombay Presidency) and the UK was 11-12 years. But by 1951, that difference had increased to a staggering 50 years. Robert Cornish, the surgeon-major for Madras who compiled the life tables for the 1871 census, expressed the view that "the aged are rare, and youth superabundant, in an Indian community". During just those 80 years, the investments in public services made in the UK, and the lack thereof in India, clearly had made a major and immediate impact.

After 1947, investments in public health improved considerably in Southasia. Over the past 60 years, the gap in life expectancies between the UK and countries in the Subcontinent has been reduced to 15 years, nearly to the level of 1871 – India and Pakistan are both currently around 62 years, while the UK is around 77 years. But that spread also belies a significant distinction. At present, most Western countries spend almost 10 percent of their gross domestic product on health. But as part of the structural adjustments imposed by the Bretton Woods institutions, developing countries are being urged to limit their health-related spending to just 1-3 percent of GDP.

After India underwent economic liberalisation, from 1990 until 1999, central spending on public health in India declined from 1.9 percent to 0.9 percent. This is certainly a far cry from the 15 percent suggested by the Bhore Committee in 1946, following three years of study at the end of the colonial period. (In part, the committee's conclusions read: "If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about.")

There is clearly a need to challenge the mindset that participation in the free-trade economy requires a reduction in public-welfare spending. But apart from being a noteworthy example of the 'do as I say, not as I do' approach, this type of policy prescription is bound to have a massive impact on the health of the people of this region – as well as the economic viability of the developing world in general.

Indeed, this trend towards a reduced public-health outlay could be coming at exactly the wrong time. The gradual improvement in public health and increasing life spans in Southasia look set to result in increasing prevalence of what are referred to as 'late-onset' disorders, often erroneously described as 'lifestyle diseases'. The latter label creates an aura of personal responsibility, as if those affected have brought the afflictions upon themselves, thus indirectly absolving the state from responsibility for their care. Unlike the across-the-board benefits of public health and accessible primary health care – both of which are relatively inexpensive – interventions in these types of diseases are significantly more costly.

Late-onset disorders include such afflictions as cardiovascular disease, cancer, neuro-degenerative and chronic psychiatric problems. Health care for these ailments is largely driven by technology and pharmaceuticals, access to which is almost exclusively controlled by patent regimes. As such, proportionately, patients in Southasia will most likely end up either paying more, or our societies will evolve distorted health-care systems that depend more on the capacity to pay (and the greed of the medical industry) rather than on the needs of the people. The disparities of the early-20th century could thus very easily be repeated during the 21st century, as 'out-of-pocket' expenses come to define what type (or amount) of health care people in India can receive. The improved access to health care that Perutz talked about, which enabled an exponential increase in centenarians in the UK, is simply not being allowed to happen in Southasia.

What is necessary at this time in Southasia is increased investment in 'soft' primary health: adequate and appropriate nutrition, clean air and water, sports facilities for children and the public, and other similar approaches. These strategies have been proven to result in lower costs when it comes to tackling the late-onset diseases. Diabetes, for example, is more common in children who have experienced malnutrition, either in utero or soon after birth. Likewise, fractures are less likely in elderly citizens who spent significant amounts of time playing as children. The costs of tertiary care, on the other hand – for diabetes, cancer, etc – place an unbearable and crippling burden on the poor, while the people in the 'organised' sector (less than five percent of the Indian population) have insurance and/or access to subsidised health care. Thus, planning is necessary for both.

To paraphrase the great pathologist Rudolf Virchow, the whole point of politics is to practice medicine on a large scale. Taking this sentiment to heart, we can see that if we neglect access to health care, we run the risk of allowing all of the efforts of Southasia's independence and democracy movements over the past 150 years to come to nought.

~ Sanjeev Jain teaches at NIMHANS, Banglore. His interests include molecular genetics and history of psychiatry.