Editorial
India—a tale of one country, but stories of many states
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
www.thelancet.com Vol 390 December 2, 2017 2413
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,
Christian Als/Panos
with communicable, maternal, neonatal, and nutritional
diseases still high in many states and NCDs and injuries
increasing in every state, highlighting major health
inequalities. Published Online
November 14, 2017
Earlier this year, a study published in The Lancet analysed http://dx.doi.org/10.1016/
access to and quality of health care among and within S0140-6736(17)32867-2
countries using a new metric, the Healthcare Access See World Report page 2427
See Perspectives page 2428
and Quality (HAQ) index. Despite India’s HAQ index
See Articles page 2437
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 Prime Minister 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. n The Lancet