Photo: Unnikrishnan 

Endramaya (60), a migrant casual labourer carrying on his back his wife, Lakhamma (50), her broken right leg in a plaster cast. Lakhamma is also a migrant worker, and she was injured in an accident in the outskirts of Bangalore two weeks earlier. The couple came to the city from Raichur in the northern dry belt of Karnataka state, where a farm and market crisis make local people migrate in search of work elsewhere in the country. State capital Bangalore, one of the best technology hubs in the world, “the Silicon Plateau of India”, is a favorite destination for many migrants.

This photograph first appeared in The New Indian Express, Bangalore (as “Express Reader Photo”).

Bangalore, 2002.

I was on my way to the office when I spotted the couple. Endramaya had already walked for over two hours along the two-km stretch of Mahatma Gandhi Road in the heart of the city, carrying Lakhamma on his shoulder, occasionally resting on the roadside.

Endramaya made several attempts to get his wife medical treatment. His first stop was the government Primary Health Centre (PHC). But the PHC did not even have the basic facilities to take an X-ray or to put a plaster cast on the patient’s leg. Endramaya then took his wife to several private hospitals and clinics, but they would not treat her. He did not have enough money to pay.

After several days, once he was able to mobilise some money, Endramaya took Lakhamma to a private clinic for treatment. Needless to say, the couple ended up spending most of the money they had. They had just enough for the bus fare to Raichur. After treatment, they spent the night on the pavement and it was raining. Around midnight, Endramaya started walking towards the Central Bus Station located in the heart of the city.

He walked over 7 km, almost unnoticed in a city that is home to six million people, thousands of them employees of top firms, including several Fortune 500 companies. He tried several times for a free lift, waving at cars, some of the latest models, four-wheel drives, and auto-rickshaws passing by. It did not work. Perhaps after several days on a hospital trail and a sleepless night he did not look quite ‘presentable’. Endramaya would walk slowly, after every few yards letting his wife sit on the kerb, so that he could stretch his hands and try to flag down some vehicle. Moments later he would continue his journey.

It was morning peak hour. Several vehicles slowed down, those driving them staring at the couple in disbelief, but they proceeded to catch their deadlines as if nothing had happened. I was upset and angry. Running towards them, I pulled my camera out of my backpack. I paused and started clicking. Then they told me their story. I joined the duo, waving hands at vehicles. Two cars stopped, their occupants willing to help. We all pooled in some money and helped the couple get a taxi to the bus station.

That evening at the photo studio I was waiting for the prints to come. A curious clerk at the cash counter asked me about the photograph. I was still upset, so I talked a bit loud about it all. Overhearing our conversation, a gentleman patted me from behind. “It is a good shot, but you should have used a wide-angle lens,” the professional photographer said, leaving me speechless. As a medical professional, I should have told him about the ‘rigor mortis’ of private-sector health care and the numbness of citizens in general. As a humanitarian professional, I should have told him that medical expense is the second-largest contributing factor for rural indebtedness in India after dowry, an equally unacceptable social evil.

A leading national newspaper flashed my photograph of Endramaya’s journey on the front page of their city edition the following morning. The caption said how callous the city could be towards its “guests” like migrant workers. They said it was “reality and not virtual,” probably referring to the virtual reality shows at the city’s annual international IT (Information Technology) fair that concluded the previous day. It did not have space to discuss larger issues – mounting medical expenses and an insensitive health policy that denies even basic facilities to the poor.

A day after the news report, I was giving a class on humanitarian action at a leading medical college in the city. I waved the newspaper featuring Endramaya’s journey on the front page. One of the senior students said: “It is a multiple fractures of tibia and fibula.” Quite a professional remark! By that evening I had one more professional remark, from a photographer: “It is a very good picture, but we missed the story.” Sad.

These professional reactions are the signs of our times. The present health care system has become superefficient, and it is going fast forward, at least in terms of technology and innovation. But it has lost touch with social realities, and it is losing its human element. By the time you finish reading this note more than 15 people in India will have died of tuberculosis (TB). Every minute one person dies in India because of TB. Treating TB is no rocket science. A nutritious diet, sanitation and basic public education can cut down TB toll. This year we have even seen reports of “alleged starvation deaths” from two belts in India, a country that has a surplus of food grains. In a country where a large percentage of women are anemic, this sounds like a riddle.

Around the same time Endramaya was walking his way of the cross in Bangalore, experts were discussing the proposed new Health Policy in New Delhi. The last National Health Policy was announced in 1983. Compared with that, the new policy draft looks like a sell-out. “The new policy (draft) is more eloquent where it is silent,” says a critique. It omits the very basic concept of comprehensive and universal health care. For example, one of the salient features of the 1983 document was its commitment to the Alma Ata declaration. It said: “India is committed to attaining the goal of ‘Health for all by the year 2000 AD’ through the universal provision of primary health care services.” The new policy (draft) is silent about it.

The new policy is also silent about the role of village health workers, the frontier guards of public health, who keep the pulse of this country ticking. The new policy has just a few lines about the women’s health, without any specific plans to improve their health – a betrayal of half the population. The policy does not care about children. It does not even have a separate section for children’s health in a country where 70 out of 1000 children die prematurely.

Endramaya’s desperate walk in one of the fastest-growing cities in Asia is symptomatic of the sickness of the health systems in a large part of the developing world where they fail to cater to the needs of the poor. India’s experience of dealing with the health needs of its majority, especially the poor, has not been very impressive. In fact, the health care system has worsened in the last decade, which has seen comparatively good economic growth.

Critics argue that neo-liberal policies related to trade and commerce, as part of the World Bank- and IMF-imposed Structural Adjustment Programmes, have left a long trail of ill health. The cost of medicine, including that of essential drugs, has shot up. In the last 10 years, the price of drugs used even for killer diseases like malaria and TB have been decontrolled to boost the health of the pharmaceutical industry at the cost of human lives.

Public health investment in India is one of the lowest in the world and it fell from 1.3 percent of the GDP to 0.9 percent during the 1990s. The new policy recommends an increase to 2.0 percent by 2010. This still falls much short of the 5.0 percent benchmark demanded by the People’s Health Movement, several health and social groups and the WHO long back.

The new draft policy projects that by 2010 public expenditure will be 33 percent of the total health expenditure. But even 33 percent will be lower than the government expenditure of some of the most privatised health systems in the world. At present India spends an average of around Rs.160 (less than US $ 4) per person per annum on health care. That is roughly the price of three hamburgers, going by the standards of the new economy. No wonder that Lakhamma had to go from pillar to post before finding a place in a private clinic. In contrast to the cut in the health care sector, the defence budget has shot up. This is an insult to the people of India, where 200 million people (1/5th of the total population) do not have access to safe drinking water and 600 million who do not have access to basic sanitation. Moreover, India pays a huge amount every year to the World Bank by way of debt servicing – much more than what the country receives every year. “Our programmes are like medicine. Some of the medicine has harmful side-effects, and there are real questions about what the dosage ought to be,” says Michael Mussa, Chief Economist at the International Monetary Fund. “The best that can be hoped for is that we are prescribing more or less the right medicine in more or less the right dosage.”

The bitter pills prescribed by the World Bank have worsened health problems in many countries. For example, Bank loans for agriculture, dams, mines and power plants often cause health problems as a side effect of environmental devastation. Bank-financed dams around the world have increased the incidence of waterborne diseases like malaria and schistosomiasis because the stagnant pools of water in dam reservoirs breed vectors such as mosquitoes and snails- an additional burden on the already crippled health system. Further, structural adjustment programmes have often meant drastic cuts of social safety measures. Often poor people have ended up paying more for products and services, further cutting their limited food budget.

As a health and humanitarian worker, my attitude should be positive. I should explore the possibility of saving and rebuilding lives in disasters, wars and epidemic situations. This note may sound pessimistic. But it reflects the mood of our times.

This post and photo appeared on “Health for All NOW! Revive Alma Ata”, People’s Health Movement, Books For Change (2003)