Long shadow of public health's colonial legacy

The past is never dead.

- Ramanan Laxminarayan

It’s not even past.’ William Faulkner's words about the American South apply to India’s health system as well. Much of how the Indian State governs disease, regulates medicines, structures public health administration, and even distributes health resources is rooted in priorities shaped during British rule.Much has rightly been made of the systematic transfer of wealth from India to Britain during colonial rule. Less often discussed is the systematic underinvestment in the health of the population being ruled. That neglect depressed life expectancy at Independence but also helped create institutional hierarchies and regional disparities that persist to this day.

Consider the legal backbone of epidemic response. When Covid-19 struck, governments invoked the Epidemic Diseases Act, which was enacted after the 1896 plague epidemic in Bombay. Its sweeping powers reflected a colonial State concerned with order and control in the face of a public health emergency, rather than a public health response, which was not what the British were primarily concerned about. Similarly, the Drugs and Cosmetics Act, passed in the final decade of British rule, continues to anchor India’s pharmaceutical regulatory framework. That law too was to enable different provinces to operate independently on drug approvals with no overall concern for the ramifications for a unified country where drugs approved and manufactured in one state could be sold in another without restriction. The colonial State did not create universal health care, but it did create durable administrative frameworks that prioritised the army, port cities, and infrastructure that enabled extraction, most notably the railways. Hospitals, sanitation systems, and medical services developed first where they protected troops and trade.