The Indian past has never been more political. This newsletter questions the traditional (male, Hindu, dominant-caste, ‘secular’) orthodoxies presented in Indian schools’ history curricula. We investigate historical narratives by consulting sources and perspectives outside established media, and we review some of the most interesting academic books and articles currently languishing behind university paywalls.
There are no definitive answers here because we want to invite as many people as possible to an alternative conversation — on what it means ‘to do history’. If nothing else, we hope to convey that history matters, and to spark our readers’ interest in undertaking historical enquiries of their own.
Write to us with your thoughts and feelings at indianparallelcampaign@gmail.com!
Content-warning: the following piece discusses themes (illness, death) that some readers may find distressing.
Hello again, friends —
Welcome to the last installment in our public health trilogy!
Last week, we discussed how early Indian nationalists framed the legitimacy of the independent Indian state in terms of public health. They promised to do better by their compatriots, and to give Indians’ bodies the respect and care they had been denied under colonialism.
But while the value of public health had been clearly established, what that truly meant was far from straightforward. In the decades following independence — as the Indian state grappled with economic and military anxieties and a desire to centralise its power — public health policy increasingly limited itself to narrow disease-management programmes and population control, which were deemed necessary for the sake of loftier national goals.
Over time, these means came to be seen as ends in themselves, and the fundamental importance of health became so obscured as to be forgotten — condemning us to a present that is often indistinguishable from our past.
Brave new world?
Some of the earliest discussions on health policy in India occurred within the Congress Party’s National Planning Committee (NPC) — a body constituted in 1938 to prepare for Independence. Sunil Amrith, in an excellent open-access paper, argues that the NPC’s work encapsulates many of the contradictory tensions that have animated India’s approach to public health ever since.
The NPC advocated thinking about healthcare “not as a matter for the affected individual to obtain for himself, or even as a matter of spasmodic charity...but as a matter of right”. Criticising colonialism for leaving public health to a small network of voluntary organisations, it proposed a state-run health service — inspired by the welfare schemes of continental Europe and New Zealand, as well as the planned health policy of the Soviet Union (obvs).
Given that none of these exemplar countries were ‘tropical’, this was an important rejection of colonial notions of ‘tropical medicine’, which had held disease as somehow innate to, and inevitable in, India’s climate. Instead, the NPC was declaring that the needs of the Indian people were not any different from the needs of people in ‘temperate’, developed, countries.
Rather, it was poverty — a direct result of the colonial drain of India’s wealth — that was responsible for India’s poor health conditions. “The root cause of disease, debility, low vitality and short span of life is to be found in the poverty — almost destitution — of the people.”
In such statements, we can see a democratic belief in equality and the intrinsic value of health as an end in itself, as well as welfarist concerns about poverty and its public health implications.
But on the other hand, the NPC’s work also frequently betrayed a colonial view of health as an instrument — in this case, as a means to achieve the self-reliance and economic progress that was considered necessary to reduce poverty in the first place.
This contradiction is a critical chicken-and-egg problem in the early thinking on public health. What needed to be addressed first — poverty to ensure better health, or better health to reduce poverty?
The answer to that depended on whether you viewed health as having intrinsic or instrumental value. Was health an end, or merely a means? Was it possible for health policy to think of it as both — and could such a vision ever make sense?
The NPC. Source: Twitter / History of Congress
Born this way
As we’ve discussed before, Indians — especially the elites — had lived in and with certain colonial ideas for so long that those ideas had come to feel self-evident and natural. Giving ground to elitist truisms about ‘degeneration’ and population control, the NPC also blamed poor public health on the “appalling ignorance of the masses”, and the “social customs and institutions of the people”. Drawing on the widespread concern with marriage reform in late-19th and early-20th century India, the planners reserved particular ire for premature marriages and Indians’ lack of awareness of ‘marriage hygiene’.
Such statements sat uncomfortably close to then-prevalent beliefs about eugenics, as Sarah Hodges has demonstrated. The NPC spoke approvingly of the potential of “careful scientific breeding of the human race” — and though it worried about overpopulation, it held that “the cultivation of the race would have to be approached from an entirely different angle than from that concerning mere numbers”.
The radical nationalist imagination of that time justified this as a democratic eugenics, because it was intent on paying “more attention...to improving the calibre of the race as a whole, and not only to particular classes or strata within it”.
The NPC studied in detail the fertility patterns of various social groups in the country, recommended the sterilisation of those suffering from epilepsy and ‘insanity’, and suggested placing legal restrictions on the marriage of those suffering from leprosy — because thinking about the ‘quality’ of India’s population was seen as necessary to achieving the improved economic productivity that would in turn trigger social transformation.
But as Amrith points out, there’s no ignoring how much such thinking has in common with far older dominant-caste anxieties about the reproduction of the ‘wrong sorts’. The NPC itself had no qualms about pointing out that “caste has created the outcastes and contributes to make the problems of eradication of the defective types probably easier than in the west”. Ick.
Government underreach
In 1946, a committee constituted under the civil servant Joseph Bhore submitted its Health Survey and Development Report — a blueprint for completely remodelling the country’s health services (available to view for free here). The core principles of this report: a health system must be close to the people, provide care regardless of people’s ability to pay, actively promote preventative health measures, and recognise the role that economic, social, and environmental factors played in ill health.
It was influenced by the famous Beveridge Report, envisioning for India an ambitious new system resembling the National Health Service that Britain itself was about to establish. And like the NPC, the Bhore Committee also emphasised the link between poverty and public health, highlighting “inadequate nutrition, unsatisfactory housing and clothing and lack of proper medical care during periods of illness”.
Its insightful critique of the bureaucracy rings true even today, even beyond public health: “there is a too widespread attitude of apathy of defeatism: (i) because the problems are so vast; (ii) because the political situation is so difficult and uncertain; and (iii) because of the frequently reiterated lament that 'India is a poor country’”.
Yet, as former Union Health Secretary K. Sujatha Rao points out, the Bhore Committee’s ambitions were ultimately tempered because of this exact awareness of the meagreness of India’s resources. In 1946, a conference of provincial ministers endorsed the Committee’s major recommendations but watered them down tenfold, changing, for instance, the proposed one hospital bed for every 550 people to one for every 6,500 people.
These ambitions were curtailed further still by Partition, which convinced the Indian state that it needed to focus on consolidating its hold over territory — investing in a new public health system was judged not nearly as important as the military, or industrialisation. In 1946, the Indian state had spent only 4 percent of its budget on health, and sticking to that figure rendered any chance of building a satisfactory health system — as a piece in the Indian Medical Journal that year put it — “fore-doomed”.
The Constituent Assembly debates (which you can listen to for free on YouTube!) illustrate these competing priorities. Some members pointed out that the new republic should put its money where its mouth was, providing concrete guarantees for funding public health — between 15 and 30 percent of overall expenditure. But these suggestions were rejected, and ultimately, improving public health was relegated to being a Directive Principle of State Policy — something to get to once authority had been secured at the centre and the political and economic situation was more stable.
There is a prevailing narrative in modern India about the overreach of the early independent Indian state, that the ‘high Nehruvianism’ of this time was overly optimistic about the role that the government could, and should, play in every aspect of modern life. If only.
On matters of public health, in both aspiration and practice, the country chose to stick to the very colonial template it had initially promised to reject.
Planners’ obsessive focus on industrial development and technology was seen as necessary to overcome backwardness, as India’s ticket out of the waiting room of history. For the planned economy to deliver a better standard of living, a mixed approach would be required: the ‘coordinated action’ of socialism, but alongside an explicitly capitalist sense of self-discipline and self-regulation. Indians’ bodies, subject to the worst tendencies of both ideologies, came to be seen as instruments of progress — for the time being, needing only to be healthy enough to deliver growth.
A contemporary Mithila-style painting by Kundan Roy, depicting a coronavirus vaccination. Source: Twitter
Keep calm and carry on
Independent India therefore limited itself to putting out only the most raging fires, aiming to reduce the toll of infectious diseases through stand-alone, single-issue, ‘vertical’ disease programmes. Malaria, which was estimated to affect over three-quarters of the population and was possibly the leading cause of mortality at the time, was Public Enemy No. 1.
At its height, between 1959 and 1963, India’s malaria eradication programme took up nearly 70 per cent of its budget for communicable disease control. In addition to this, in Amrith’s words, “Nehru drew on deeply-rooted Western fears of India as a source of contagion, as an epidemiological heart of darkness” — winning substantial external funding and foreign aid in the process.
It was a strategy that proved especially effective given the context of the Cold War — the US, for instance, contributed nearly 40 percent of the cost of the programme between 1959 and 1961. The Indian anti-malaria campaign was one of the most extensive anywhere, and the country quickly became the world’s largest market for the pesticide DDT.
But above all else, malaria was targeted by both the Indian state and international organisations for economic reasons — malaria control would increase agricultural productivity. The onus for action — and with it both the responsibility and the liability — was on citizens, who must put on a patriotic show of national and personal discipline and spray DDT as told.
A 1960s poster from India’s malaria eradication programme. Source: The Atlantic
Kavita Sivaramakrishnan has shown how this approach became ever more evident during the 1957 influenza pandemic. The previous pandemic in 1918 had primarily affected young, working-age people, especially in key industries like coal plants and mills. This time around, therefore — as cases rose and entire communities were incapacitated by fever, exhaustion, and pneumonia — anxieties focused on absenteeism in the country’s labour force, and how a slowing in the rate of industrial production would affect the country’s ability to stick to its Second Five Year Plan.
But beyond that, there was no real national public health response. Responsibility was left to the states, which used it primarily to reenact the old colonial tactic of treating public health as a law and order issue — policing and criminalizing the vulnerable. The government rained down pamphlets full of paternalistic instructions about ‘hygiene’ upon its citizens — all of which, of course, assumed that people had access to places with warmth and good ventilation, the ability to avoid work and crowded places, and the means to consult and pay doctors (and could read).
But the instructions were also about citizen sensibilities: be resilient, be cooperative, be self-sufficient.
Rather than acknowledging the role of poverty in preventing citizens from being any of these things, “the Indian state increasingly made out that controlling influenza...was within the immediate reach of individual agency and initiative…public health crises needed citizens to act, cooperate, and share risks and vulnerabilities, even though a majority of them had reaped few, if any, benefits from [independent India’s] development projects”.
Quite simply, in Sivaramakrishanan’s words, “the Indian public, physicians, and health workers needed to acquire traits that were viewed as necessary for India”: the government, by giving out the necessary instructions, had already done its duty, and needed to discharge no further responsibilities.
Long before the ‘liberalisation’ reforms of the 1990s, then, we can see the state hollowing out its own capacity as it did its promises — stressing self-reliance and individualism, and limiting its own role in national welfare.
But as a sociologist at the National Tuberculosis Institute in Bangalore, whom Amrith quotes, pointed out: “the Indian villager does not need to be told in words about the tuberculosis problem, but needs a service to deal with a problem which... is only far too well known to him”. It’s a quote that we think applies far beyond TB.
By 1961, India had established barely 2,600 primary healthcare units, devoting most of its resources to constructing big hospitals in urban areas (such as the prestigious All India Institute of Medical Science). This was motivated by the reasoning that rural areas had ‘less of a demand’ for medical care than urban ones — fragmenting the system along older divides of caste- and class- privilege and access.
In situations where it could no longer ignore the failures of such an approach, India came to rely on various international agencies. In Rao’s words, this “techno-managerial approach to disease control” was not just unsustainable: it meant that the Indian state itself never had to learn lessons or keep records about what worked best in the country’s context, and limited itself to ad hoc interventions.
Ultimately, this lack of local health infrastructure and embedded knowledge meant that it was not possible to consolidate even the progress that had been made using the vertical disease management programmes. Even malaria, which had almost disappeared in the 1950s, resurged in the 1960s (though, to be fair, never again at the levels of the 1940s).
Malthusian madness
The agrarian crisis of the 1960s made it apparent to the Indian state that malaria control had not achieved its desired end of improving agricultural productivity. It chose, then, to shift its focus to a public health intervention it deemed more cost-effective: ‘family planning’.
This shift represented the culmination of the state’s instrumental vision of human life: much of the field of public health, especially in rural India, came to be defined by the single, narrow, overarching goal of controlling India’s population numbers. The old question of whether health was dependent on poverty or vice versa was transformed into an unchallengeable truism into which health itself completely disappeared: development required population control.
The growing demand for healthcare in rural areas was answered by expanding access to contraceptives — and not very much else. The central government funded population control activities in the states, even though it refused to cover the costs of building up their public health networks. From 1966 onward, family planning was a separate ministerial responsibility, with almost as much funding as the entire public health service of India. The ominous shadow of 1938’s ‘democratic eugenics’ had never loomed larger over Indian public health.
As one of the top contenders for the title of India’s Worst Prime Minister, Indira Gandhi, put it during the peak of the Emergency’s compulsory sterilisation programme:
“We must now act decisively and bring down the birth rate. We should not hesitate to take steps which might be described as drastic. Some personal rights have to be held in abeyance for the human rights of the nation: the right to live, the right to progress.”
Amul ad from 1976. Source: John Dayal and Ajoy Bose in Scroll.
It is true that this approach also owed much to the priorities of international organisations. Until 1993, the World Bank largely restricted itself to giving India loans for family planning programmes. Elsewhere in South Asia too, Western donor priorities more or less cannibalized healthcare systems into population control programmes.
But it is also patently clear, as Amrith argues, that the reason the Indian state was so receptive to these ‘international missionaries of population control’ was because their interests coincided with “the sexual, racial and caste-based anxieties underlying the Indian nationalist movement’s discussions of health, and...its privileging of the centralised state as the prime instrument of change”.
Moreover, our fabled bureaucracy — since the days of Thomas Malthus’ work as a professor of political economy in the East India Company’s college — has had a long tradition, both British and Indian, of analysing Indian society in coldly Malthusian terms, relying on census statistics and other demographic observations to understand everything from famine to urban development.
It is difficult to grapple with the colossal toll family planning has had upon the growth of other health services in India. The government itself has admitted, in its National Health Policy for 2002, that “the rural health staff has become a vertical structure exclusively for the implementation of family welfare activities. As a result, for those public health programmes where there is no separate vertical structure, there is no identifiable service delivery system at all”. (Except for CoWIN, of course.)
In the absence of any other animating vision or inkling of political will, India periodically threw up its hands and appointed expert committees to deliver public health recommendations: about 25 of them over the last 70 years. These yielded nothing but piecemeal solutions — with scintillating suggestions such as introducing sterilisation targets, or refashioning malaria surveillance officers as multipurpose workers — rather than any kind of deep systemic analysis.
It has always been easier and cheaper to insist that people change their behaviour rather than to change the system to better serve people.
And so by 1991 — beyond which we think this story must be taken over by political scientists and policy analysts rather than historians — public health increasingly became an oxymoron, as those who could afford it retreated into the private sector.
This arguably set into motion a vicious cycle, as these relatively prosperous citizens became more unwilling to pay taxes, which in turn constrained the ability of the state to devote public funds to health (on the off chance that statues and temples ever fell out of fashion).
The state’s tendency to see health in mercenary terms has meant that the suffering of the living and the cruelty of death have often been collapsed into bare statistics. And in the face of a fragmented and incoherent system — designed in many ways to prevent birth and ignore death — the value and dignity of human life has been transformed into cynical calculations of acceptable loss.
Even now, before we have even had a chance to process the devastating levels of excess death during the pandemic, the ashes are being swept under the rug by yet another round of cruel population control legislation. The state is ready and raring to abandon even more responsibility, to move even more people into the circle of bare life.
We need to look at, and then past, the numbers — and actually see the uncomfortable truths they tell us about ourselves and our country.
The body keeps the score
“On Sunday evening Burra Bazar was the scene of some excitement, due to the strange adventure of a low class native, who had formerly been employed as a dome in the Medical College Hospital. It appears that the man, having contrived to secure a human arm and skull from the Hospital with the aid of some of his comrades, went about the streets carrying them in his hands and soliciting alms from passers-by. A crowd collected…and the man…responded by tearing [the severed arm and skull] to pieces with his teeth…”
— The Statesman, Calcutta, 1908 (quoted in David Arnold, Colonizing the Body)
One of the most striking things about the coverage of the second wave of COVID-19 in India has been the proliferation of images of corpses, graveyards and cremation pyres. Such photographs continue a tradition that has been in place ever since the camera first came to India in the 1830s — cremation, especially, came to be framed as a viscerally visual event. As David Arnold puts it in Burning the Dead, “[its] cultural meaning, political significance, and historical evolution have long been bound up with its visibility and the capacity of images to render it accessible and intelligible to others.”
India’s anticolonial nationalists were well aware of this — through the years of the struggle for independence, the performance of last rites was transformed from a private event to a public occasion. The bodies of the celebrated dead — the martyrs, the freedom fighters — were displayed in large funeral processions, carried through packed city streets to the burning-ground. The spectacle, especially to Western eyes, was attention-grabbing, something startling and unsettling, even distressing.
Cremating the bodies of plague victims in Bombay, 1899. Source: Burning the Dead
But to other spectators, the sight was a moving experience, something imbued with patriotic capital. The naked fact of the corpse had a meaning beyond mere mourning — it demonstrated in graphic form the essential expendability of the Indian body under colonialism. Bringing out the dead can expose the sheer suffering of the living.
The searing images of the human toll of the pandemic in India do the same thing today — they demonstrate that bodies remain expendable even in independent India, in spite of the promises of those early nationalists.
It is to photojournalists such as Danish Siddiqui that we owe glimpses of uncounted pyres burning in secret behind hastily-erected walls, drone’s-eye views of that final, most unthinkable dereliction of duty: the coverup, the attempt to shroud even the shrouds — glimpses that have often vanished with earlier pandemics. These images forced us all to face the truth.
The Dom man from the passage above — his name was Paltoo — was clearly aware of the power of spectacle too. By combining his living self with carrion, by ingesting dead flesh, Paltoo was performing the truth of his own life — an abandoned, condemned, despised half-life as a member of a Criminal Tribe subject to dehumanizing work conditions — in the only way that he thought would render it visible to power and privilege: as an unsettling, graphic spectacle.
But even when forced to look, power has often refused to see — dismissing such acts as revolting, insane, criminal, ridiculous. The 19th-century French missionary Jean-Antoine Dubois called the Doms “a dissolute body”, a “class of mountebanks, buffoons, posture-masters''. And as we write this, many bhakts on Twitter are jubilantly circulating images of Siddiqui’s bullet-riddled body in the name of ‘karma’.
For the Indian state to truly be moved to action, it would have to first acknowledge that health is a right, something to which citizens are entitled under the social contract, rather than a privilege. We believe that the grim holding pattern of gruesome spectacle and public apathy will endure for as long as we see people in our society —be they essential workers or political prisoners — as expendable.
At present, the government has essentially no legally enforceable accountability to citizens for its public health failures. Rao says that even in the heyday of the Congress-UPA’s rights-based approach to primary education, information, and employment, there was apprehension about a law making health a fundamental right — because it “would only generate substantial litigation that the government would not be able to cope with”.
Ultimately, as Rao points out, the issue is not merely inadequate funds (though for what it’s worth, the total government expenditure on healthcare in the fiscal year 2020 was only 1.29% of GDP). It is the absence of the necessary will. In her words:
“The Indian health sector can get out of its present quagmire only when we begin to accord equal value to all lives — irrespective of social or economic status and sexual orientation — and when the mindset of our policymakers shifts to defining development not in terms of GDP…[we] require leadership that is committed to the...belief that health has an intrinsic value and is worthy of being pursued for its own sake”.
Until next time,
Dear Niya and Tanvi, I learnt so much reading this issue, particularly how India's work on public health spawned in the shade and service of other national goals. Thank you for dedicating three issues to helping us understand the history of public health in India. As with other issues in this newsletter, the way you lay down painstakingly researched past of public health makes the present so much clearer for me.
In addition to the above, your thoughts that refer to instrumentality are particularly striking and salient for how policy is often practiced by those outside the government. In search of relevance and attribution that is some concoction of sincerity, desperation and vanity, policy practitioners often find themselves selling the issues they work on using this instrumentality; a la "let's work on women's livelihoods because it's good for economic growth; let's support community groups because that's a good platform for public service announcements". Your observations on containing malaria for agricultural productivity, influenza and family planning are reminders that this instrumentality can, over time, erase the intrinsic value, and with it, its underlying morality of value of human life, often leaving only the goals that lend themselves to aggregate measurement as worthy of time and resources. Policy practitioners would be well advised to remember that 'history has its eyes on you'.
All this is indeed in addition to how beautiful it is how you identify and articulate the state of the world, such as our present being often indistinguishable from our past.
Your concluding observation on how health is not a fundamental right in India is particularly instructive of the choices we have made as a country, and points to a weakness that needs to be addressed, lest we continue to optimize under structural constraints that offer an illusion of hope, good enough for everyone to continue running their shop.