Long years ago, as we were making our tryst with destiny and Nehru was delivering his historic speech, a few hundred soon-to-be independent Indians were gasping for breath, plugging an artery, or bursting a blood vessel and dying for want of medical attention. At the stroke of the midnight hour, when the world slept, India awoke to life and freedom and a mostly imaginary public health system.
At the birth of the nation, how healthy was its inherited healthcare? Until 1943, no comprehensive study of public health had ever been attempted in India. That year, as World War II raged on and the Indian freedom struggle approached culmination, the government of British India appointed the Health Survey and Development Committee - better known as the Bhore Committee after its chairman - to make plans for the postwar development of healthcare. War conditions restricted the rail travel of its members, who - over 26 months - toured every province of undivided India except Assam and Baluchistan, and made a ‘broad survey of the present position concerning health conditions and health organisation in British India’.
Since they were required to present their report as early as possible, ‘detailed investigation was impracticable’ and compelled their inquiries ‘perforce to be shorter and more cursory than we should have liked them to be.’ Still, they managed to record the condition of public health centres in the provinces and princely states, dwelling on a dark hospital kitchen ‘situated only ten yards from the dysentery and cholera ward, and which was not fly-proof’. Incorporating testimony from memoranda sent by, and interviews of learned medical men (and - thankfully - nurses), the Bhore Committee’s report was published in 1946. It created a framework for the public health system of newly independent India.
I am among the many guilty of bemoaning the state of the latter, without acknowledging its numerous successes over 72 hard-fought years. Between the decade before Independence and now, India has lopped two-thirds off its death rate, and three-fourths of its infant mortality rate. The life expectancy at birth for both male and female babies born in that decade was just 26 years; these have now lengthened to 66 and 70 years. Our maternal mortality remains a matter of shame: around 200 then, still 130 now.
Every second death in India was ascribed to ‘fever’. The reporting system of births, deaths and infectious diseases was so primitive that in rural areas, the village watchman was responsible for notifying authorities!
From 1932-41, seventy thousand Indians succumbed to smallpox every year. But by the time India was thirty years old, it had been eradicated. Crippling guinea-worm disease was endemic in vast tracts of the country; in 2000, the WHO declared India free of the scourge.
Seven decades ago, 1 in 5 Indians died before the age of 1. That this is no longer the case is because of our ambitious, far-reaching and successful universal immunisation program for children. Bombay Presidency, which first adopted vaccination, could inoculate a measly (no pun intended) 5% of its kids. Today, this figure is almost cent percent.
But read this passage from the Bhore report: ‘It must be remembered that a disease like ___ is perhaps more easily prevented than most other infectious diseases and should have been prevented long ago. India continues to be the largest reservoir of ___ infection, although vaccination against it was (one of) the first preventive measure(s) introduced into the country and has been practised on a large scale for the past seventy or eighty years.’
In the Bhore Committee report, the blank was smallpox. Today, we can replace it with diphtheria, and it would all still be true.
The Committee found that British India had just one doctor for every 6500 Indians; independent India now has one for every 1500 or so. An epidemic in British India would have expected a single nurse to minister to 43,000 people, who would have competed to swallow medicines formulated by one of just 75 pharmacists in the entire country.
When these figures are broken down, they appear even more alarming. The entire state of Orissa was served by less than 130 doctors. Any set of 14,500 citizens of the Central Provinces (now in Madhya Pradesh) had to rely on just one doctor. Then, as now, doctors congregated in cities; the urban areas of Sind (now in Pakistan) were home to 49 times as many doctors as the rural ones. The Committee noted that ‘it seems fairly certain that an appreciable proportion of those living in rural areas may, throughout their lives, receive no medical aid from either a hospital or a dispensary’.
‘During our tours in the provinces’, the 1946 report continued, ‘we noticed that in most dispensaries and out-patient departments of hospitals, the time devoted to patients was so short as to make it perfectly obvious that no adequate medical service was given to the people. For instance, in one dispensary the average number of cases seen in an hour was 75. The time given to a patient, therefore, averaged 48 seconds’. Any visitor to a public hospital in 2019 will aver that not much has changed.
In many ways, the committee didn’t just document the present, it also predicted the future. At a time when India still spends less than 2% of its GDP on healthcare, the report’s advice - that ‘plans based on the assumption that unlimited funds will be available for recurring expenditure will have little practical value’ - is still valid. Speaking about the funding of public hospitals, it revealed that ‘the financial resources of these bodies are, in the majority of cases, insufficient to maintain adequate services staffed with well-qualified personnel’ - also true. Finally, it foresaw that no government would adhere to world standards in health institutions ‘in the absence of a public opinion sufficiently strong to demand such enforcement in the interests of the community’.
Like India, its public health system is a senior citizen with aches and pains, complaints and consolations. Neglected, unseen and taken for granted - but with a desperate will to survive. Because for India to live on, Indians need to live.