ISSN (Online) - 2349-8846
-A A +A

Poverty, Health, and Wealth in India

Karen M McNamara (kotokaj@gmail.com) is a postdoctoral fellow at the Asia Research Institute of the National University of Singapore.

Public Health and Private Wealth: Stem Cells, Surrogates, and Other Strategic Bodies edited by Sarah Hodges and Mohan Rao,New Delhi: Oxford University Press, 2016; pp xv + 283, ₹850.

The relationship between poverty and health has historical and contemporary dimensions that concern academics, medical practitioners, activists, and the public at large. In order to understand contemporary dimensions of poverty, we must dig deeper to uncover the historical roots of these problems and the various ways in which the question of poverty has been addressed in specific locales. Across the world, empires have used colonies as sites of experimentation for medical, scientific, and technological projects in the name of reducing poverty. Many development and nation-making projects continue in the paths of earlier technocratic poverty amelioration methods, often with little improvement.

Public Health and Private Wealth: Stem Cells, Surrogates, and Other StrategicBodies, edited by Sarah Hodges and Mohan Rao, critically addresses the techno-scientific methods deployed to reduce poverty and improve health in India. The title of the book, however, is somewhat misleading, since the majority of the chapters focus on historical cases, not on stem cells and surrogacy. Poverty is the main concern of this book—the use of the concept, the work it does, the expert discourse it entails, who or what it empowers, and what it obscures (p 2). The editors note that academic studies have hardly focused solely on these aspects of poverty, except for the limited amount of quantitative data that have been generated by economists and statisticians. One of the aims of the book is to bring in other disciplinary frameworks for studying and understanding poverty. This volume explores how issues of poverty are interlinked with scientific projects that sought to tackle the problem in various ways across different periods in India, from colonial times to the post-liberalisation era. The editors question why current policymakers in India are not as concerned with the question of poverty as they were in the past. Today, many projects meant to improve healthcare in India have fed into the commercialisation and privatisation of the healthcare system. There has been little increase in government spending on public healthcare, while the private healthcare industry is one of the fastest growing segments of the Indian economy.

This volume seeks to problematise the relationship between poverty and science in contemporary India by tracing it historically from the British colonial period. The edited book is divided chronologically into three parts, each with three chapters. The three parts explore the role of science in the quest for poverty reduction in late colonial and early independent India; the role of hospitals in improving everyday health in independent India; and the role of the poor in the development of official science policy, biotechnology, and the private healthcare industry. The range of issues across a vast period of time is an important, if ambitious, project to attempt. The chapters are written by historians and social scientists, most of whom are affiliated with the Centre of Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi. Many of the chapters provide detailed policy analyses that make for an interesting, if sometimes dry, read. In some chapters, the arguments get lost in the reporting of case studies, policy minutiae, and acronyms. The chapters that use more narrative or ethnographic approaches stand out in refreshing relief.

Colonialist Origins of Poverty Studies

David Arnold starts off the volume with a fascinating analysis of official policies from the 1850s through the 1950s to show how and why governments in India became concerned with poverty. He clearly describes how the link between health and poverty emerged in the early part of the 20th century with the advent of nutrition studies. Before this, poverty was not a main issue of concern for colonial administrators, who naturalised poverty as a cultural feature of India or the result of economic and natural disasters, such as famines or epidemics. These views prevented a focus on poverty’s connection to public health; in other words, how poverty itself caused poor health. The colonial state and the medical establishment put most of their efforts into medical and biological understandings of disease and health, instead of trying to eliminate poverty. Popular explanations for famine, poverty, and poor health at that time drew on Malthusian notions of overpopulation. The new focus on nutrition studies in the 1920s brought poverty into discussions of ill health. Even so, the lack of economic resources to acquire food was commonly eclipsed by social and cultural explanations for poor nutrition.

Other chapters in the first part continue this line of thought by examining the use of techno-scientific rationales to address questions of health in India. These measures included surveillance techniques to control tuberculosis, monitor health status, and implement family planning. State agencies, international health experts, and even academic researchers used these techniques. Rebecca Williams’ case study on Harvard’s “Khanna Study” in the 1950s in Punjab makes a convincing argument that the language of “health equity” was used in this research as an apolitical way to mask the root cause of poverty—socio-economic injustice. Instead the poor became objects of medical knowledge and management, and “their poor health was converted from a symptom of poverty to a set of indices to be improved through rational medical management” (p 81).

Commercialisation of Healthcare

In the second section on the role of hospitals in India, the first two chapters provide useful background on the commercialisation of healthcare in post-independence India. Ramila Bisht and Altaf Virani describe how the Indian state called for public–private partnerships (PPPs) as a solution to meet the needs of the poor. They argue that the state did not act alone but was influenced by international organisations such as the World Bank and broader global and economic forces. One feature of this policy shift was the increasing privatisation and corporatisation of Indian hospitals in the 1990s. Through a case study of a hospital in Mumbai, they show how the PPP of this particular hospital has created more marginalisation and exclusion of the poor, evidence that market solutions fail to fulfil the responsibilities of the state to provide healthcare for its citizens. Rama Baru makes the critical point that commercialisation of healthcare can happen without privatisation because it also occurs in public and non-profit sectors. He ends his chapter with a note on the changing values of the middle class in India and how this has influenced the culture of medical practice for both practitioners and patients. This is an important intervention that takes the analysis momentarily away from policy studies to think about wider social changes happening in India.

Further inquiry in this vein would bring a more nuanced understanding of how individuals involved in medical care perceive and navigate their worlds, which we see in the chapter based on interviews with Apollo hospital doctors in Chennai by Sarah Hodges. She analyses myths about Apollo hospitals and the history of corporate hospitals in India. Her innovative analysis disrupts the linear narrative of private hospital growth and shows how easy it is to be drawn into the myths about private hospitals that the media, the state, and hospitals create. In this case, she counters four myths about the story of the significance of Apollo to show how they are created through the image management of Apollo as a “success story.”

Techno-science and Poverty

The third section focuses on the role of techno-science in India today. These chapters discuss how biotechnology has become the new “technological fix” for issues of poverty and social inequality. These fixes include a push for India to be at the forefront of global research on stem cell treatments and the development of the biotech industry. Priya Ranjan argues that neo-liberal reforms have driven the creation of policies in which “the poor/poverty in India thus appear both as [a] reason for India’s expected rise in the global biotechnology sector and as the beneficiaries of the new technology” (p 221). These contradictions are laid out most clearly in Mohan Rao’s captivating chapter on the surrogacy industry in India. He traces the genealogy of Malthusian notions of population control in India to reveal how these ideas laid the foundation for the thriving surrogacy industry. The state and other organisations have targeted poor Indian women with many public health programmes to curb their reproduction. The surrogacy industry is the newest twist in these developments where “these women now turn waste to gold” (p 168) by producing a certain kind of babies, ones that are now valued because of the profit they bring.

The afterword makes a compelling argument for mainstreaming indigenous knowledge as an alternative model for sustainable development in India, but seems a bit tacked on and does not clearly connect to the arguments and positions laid out in the bulk of the book. The editors say that this afterword is included to protect against a reading of the book as solely a critique of the West. It is doubtful if most readers would read the book in this way, as the projects of science and health analysed in the chapters were not solely Western projects, but included those taken up by Indians as well as those that were propelled by the growth of capitalism around the world. It would have been more engaging to have an afterword which addressed the many timely questions and concerns about poverty raised in the book, discussed ways to move forward, or even mentioned projects or movements in India that use innovative approaches to improve poverty and health.

This edited volume gives us a thought-provoking framework that is not an economic model in order “to advance a different set of questions to guide the study of science and poverty in modern India” (p 14). Considering that many of the authors are part of a department of community health at a public Indian university, it is surprising that there is no discussion of how to use this interdisciplinary knowledge in the field of health or for policy. This is despite the fact that the book seems to be concerned with bringing back the issue of poverty to policymakers. Most of the case studies give a bleak picture of how science is used unsuccessfully to improve health and poverty. Where can we find models that work or are more promising? The problems of poverty examined in the volume are vast and complicated, and easy solutions are not to be expected; but a discussion of other possible techno-scientific futures, perhaps, would have been useful. Hodges articulately states this concern earlier in the book when she emphasises that “attending to our assumptions about the past matters, because our understanding of the past grounds our ability to imagine a different future” (p 140).

Conclusions

The connections made between historical problems of poverty and contemporary situations contribute to valuable longue durée understandings of poverty. Sometimes the thread of poverty and science gets lost in the wide range of multifaceted case studies, many of which have a predominant focus on health and medicine. It would have been interesting to include broader comparative analyses that connect these shared historical pasts to contemporary situations across South Asia, instead of focusing exclusively on India. The goal of the volume is to bring in other disciplinary frameworks, but most analyses are historical and policy-focused with top-down approaches to poverty. Additional case studies or analysis of policies on the ground would bring a more nuanced view of how policies unfold in everyday life to affect health and well-being.

Overall, this book is a welcome addition to studies on science and technology, the history of medicine, and public health in South Asia. The questions raised and problems exposed by the volume are not relevant to India alone, but have resonances in the practice of science and medicine across the world. We can see how techno-scientific projects and the movement of capital have created similar trends that unfold in specific ways within particular localities. It would be productive to read this book comparatively, with works that address similar issues in other parts of the world. The links between poverty and science are often invisible and naturalised. This volume sheds light on these complicated relationships and gives us nuanced views of the historical precedents and transformations of contemporary forms of poverty in India.

 

Updated On : 19th Sep, 2017

Comments

(-) Hide

EPW looks forward to your comments. Please note that comments are moderated as per our comments policy. They may take some time to appear. A comment, if suitable, may be selected for publication in the Letters pages of EPW.

Back to Top