In India, one’s economic status determines life and death.

During my childhood, many like me in the middle classes went to public hospitals when they were sick, and the services they offered were completely free. Today every Indian city is dotted with expensive super-speciality private hospitals, which closely resemble five-star hotels, complete with a turbaned, often elaborately moustachioed, bellboy who opens your car door. The quality of services in public hospitals has declined since people of influence no longer have any stake in their effective functioning, but even more gravely for the poor, care in the public hospital may be cheaper than in the private sector — but it is no longer free.

The average per hospitalisation costs in a public hospital is estimated to be as high as Rs. 3,000, and over 70 per cent of the charges are due to drugs and diagnostics that are prescribed but not supplied. Many pharmacies and laboratories have mushroomed around public hospitals and there is a nexus that encourages government doctors to prescribe more drugs and diagnostics for outside purchase rather than provide them free within the hospital.

I spent early years of my working life as a civil servant in remote rural and tribal districts of Chhattisgarh and Madhya Pradesh. I observed how often large numbers of tribal and other villagers in rural hinterlands would die in multitudes in localised epidemics of gastroenteritis or malaria which would be barely reported even in the state media. These areas were meagrely served with any kind of primary health services. The major concern of most of the scant public health staff that was deployed was to find ‘cases’ for family planning, preferably terminal methods. Child health was reduced to polio drops, not comprehensive health care, sanitation, nutrition and clean drinking water; and maternal health to contraceptives.

After returning to Delhi, over the last decade, I began working with urban homeless people and found to my initial surprise that the urban poor were almost as poorly served by primary public health services. The urban homeless find it nearly impossible to find admission in urban tertiary care hospitals, stigmatised as they are by public authorities as illegal, illegitimate, unsanitary burdens on the city and its infrastructure, including hospitals.

Most cities have virtually no public primary health care services, except a few maternity clinics again focussed mostly on family planning. The few that exist have virtually no allocations for drugs and diagnostics. In many cities, slum dwellers spoke of the disrespect with which they were treated by the health personnel: doctors will not even touch them for a physical examination because they find them unclean, and often taunt them for producing too many babies. Public doctors demand that they buy not just most drugs, but even consumables like plastic gloves, before they can be treated. They wait long hours in queues, mostly in the mornings; therefore visiting a public health clinic meant sacrificing a day’s wages. They therefore find it more economical to go to a private practitioner, often unqualified, who also charges them money but then treats them more respectfully. Sadly the treatment they offer is frequently irrational and inappropriate. Those who cannot afford the private practitioners’ fees go instead directly to the pharmacist and take whatever drugs he suggests. Others just lived with their ailments, enfeebled and ultimately die.

The last four years, my ageing parents — both in their eighties — were in very frail health, with many life-threatening conditions. My mother recently passed away. We were in and out of an array of expensive private hospitals, each of which was staggeringly expensive. But they were always crowded: there was clearly no shortage of people who could afford their astronomical fees. My mother had 24-hour-nursing at home for the last three years. I realised soberly that if we were less privileged — like the majority of Indians are — my parents would not have been alive. Should only one’s relative wealth determine the possibilities of continuing life?

The runaway costs of health emergencies can have catastrophic outcomes for families. Some years back, I saw a television report which continues to haunt me, of a man in Uttar Pradesh who unsuccessfully tried to drown his nine-year-old daughter in a river. His daughter was devastated and bewildered, because she knew her father to be a loving and responsible parent. The broken man explained that his daughter’s kidneys had given way, and for the past two years he had spent all his savings and sold all his belongings for her treatment. As a result, his other children were pauperised, struggling even for their basic needs like food. He felt he had no option, except to drown his beloved sick child.

In our work with homeless children, we sometimes find that parents abandon their children if they have grave health problems like cancer and heart disorders. We take them to public hospitals, and even there unless you have a large sum of money you cannot admit them.

To be poor in India is a crime. To be poor and also gravely ill is a crime deserving nothing less than the death penalty.