Colonialism leaves disfiguring scars among those who are colonised. Few countries inflicted such deep wounds as Britain did during its centuries-long colonial rule of India. Understanding the history of colonialism and its consequences is therefore essential if one is to understand the predicaments of nations today. This week, The Lancet publishes the most comprehensive assessment yet of India's present health predicaments. But India's contemporary challenges in alleviating its burden of disease must first be examined in the context of Britain's colonial legacy.
That legacy, in the words of former UN diplomat and now Indian politician Shashi Tharoor, is a “monstrous crime” (Inglorious Empire, Hurst, 2016). The East India Company, Britain's initial instrument of domination, was established in 1600 during the reign of Elizabeth I. British rule was decisively inaugurated in 1757 after the Battle of Plassey. Thereafter, as Tharoor painstakingly documents, “Britain's rise for 200 years was financed by its depredations in India”. In 1700, India made up 27% of the world economy. But Britain's tyranny, subjugation, oppression, racism, and extortion led to “the first great de-industrialisation of the modern world”. Britain systematically extracted India's wealth. Successive British Governments destroyed India's industry, trade, and shipbuilding. Britain's “colonial holocaust” led to the needless deaths of some 30–35 million Indians (which Tharoor compares to the cruelties of Mao and Stalin). The argument that Britain's enlightened despotism bestowed political unity, parliamentary democracy, rule of law, a free press, and a world-class railway system is thoroughly disproven by Tharoor, and several generations of Indian scholars. Most importantly, as one confronts today's burden of disease and disability in India, Britain showed little interest in building even the most rudimentary elements of a health or scientific research system during its period of colonial rule. The full extent of this history must be appreciated if one is to understand the health needs of the Indian people today.
In 1946, the Bhore Committee set out a proposal for a national programme of health services in India. Over the past 70 years these reforms were never implemented. For the first time, an Indian-led team of authors have now estimated disease burden and risk factor trends for all states in India covering the period 1990 to 2016. The study underscores the fact that India is undergoing a rapid epidemiological transition with a shift in burden to non-communicable diseases (NCDs) and injuries. However, huge variations in disease burden exist across states, with communicable, maternal, neonatal, and nutritional diseases still high in many states and NCDs and injuries increasing in every state, highlighting major health inequalities.
Earlier this year, a study published in The Lancet analysed access to and quality of health care among and within countries using a new metric, the Healthcare Access and Quality (HAQ) index. Despite India's HAQ index increasing from 31 in 1990 to 45 in 2015, India still ranked a woeful 154th among 195 countries. In another Lancet study, which analysed progress towards universal health coverage (UHC) as one of the Sustainable Development Goal indicators, India again underperformed relative to other countries, many of which were far less developed.
The authors note two factors that will further challenge India's health system in the coming decades: urbanisation and ageing of the population. Both of these transitions will add to and exacerbate the major risk factors for disease burden highlighted in this study, which include child and maternal malnutrition, unsafe water and sanitation, air pollution, and metabolic and behavioural risk factors for cardiovascular disease and diabetes. Targeted actions alongside broader (intersectoral) and longer-term policy responses will be required across all states.
Encouragingly, a flourishing era of innovation in the way health care is being designed and delivered is being invested in and led by the states themselves. For example, Kerala, Tamil Nadu, and the Punjab are strengthening health systems in pilot projects for UHC. However, these state level actions should not diminish the responsibility of the federal government for increasing public investment in health care. We are disappointed by the lack of ambition of President Modi's Government to invest only 2·5% of its GDP into health care by 2025, when the global average for countries is about 6%. The rise in India's economic fortunes and its aspiration to progress to the same level as its neighbour, China, is something of an embarrassment, given how improvements to health trail so far behind. Until the federal government in India takes health as seriously as many other nations do, India will not fulfil either its national or global potential.