‘Staying Alive’: A doctor’s well-researched, authoritative critique of India’s public health system

Ramani Atkuri’s new book, Staying Alive: Dispatches from the Margins, is part memoir and part authoritative critique of India’s health system. Atkuri, a public health doctor, has worked in Central India for almost four decades. She grew up in Bokaro, Bihar (now Jharkhand) and trained as a community health physician at Christian Medical College, Vellore.

Since the early 1990s, she has worked as a health care provider, trainer, and health systems researcher-evaluator in Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, and remote parts of many other states. Drawing on meticulously documented diaries, unpublished reports, conversations with colleagues, and extensively published research, she presents a rich social perspective on India’s public health system.

The book’s central aim is to expose the health inequities that Atkuri has witnessed in her long career. She describes the morbidities and the tragedies of preventable deaths resulting from structural determinants in remote regions. She contrasts the sophisticated care available to medical tourists and the country’s elite in metropolitan cities with the absence of basic primary health care for most of India’s population. Her account conveys the magnitude of the health crises facing people in far-flung, remote corners of the country.

Personal experience

The book has 12 chapters in addition to the introduction, notes, and references. The introduction describes how the health system is structured: the facilities, human resources, health budgets, and governance undergirding the system, as well as the persistent challenges it faces.

Atkuri describes her own background and how her perspective evolved through the challenges she experienced as a public health physician in remote areas. The subsequent chapters attend to inequities in health.

Focusing on tribal lives, the chapters combine compelling stories from Atkuri’s own diaries with macro data and an analysis of state policies and programs. They trace how both infectious and non-communicable diseases in tribal and rural India shape patterns of illness among tribal populations.

Chapters on occupational health and on poisoning, snake bites, and animal bites expose urban readers to seldom-discussed realities of tribal people. Ketan Ram’s story of a possible krait bite while working in the fields at night shows that even if anti-snake venom is available at the primary health centre (which many times it is not), tertiary-level services may be required once neuroparalysis sets in. Ketan Ram was one of the fortunate few to survive a poisonous snake bite – the author recounts how he was transferred to the medical college hospital in Bilaspur and put on a ventilator, just in time.

Atkuri uses social determinants of health as a conceptual framework throughout the book, in addition to her attention to health inequities. Some determinants discussed include forced displacement and the absence of transport infrastructure.

For example, the chapter “Saving the Tiger, Moving the People” describes the health challenges faced by forest dwellers displaced from their homes in Chhattisgarh’s Achanakmar forest after it was declared a tiger reserve. She argues that such displacement reduces the Adivasis’ dietary diversity, alienates them from their traditional sources of food and income, and increases alcohol consumption among men.

This chapter also highlights the mental health effects of forced displacement: the loss of confidence, increased anxiety and fear borne from social exclusion in new environments.

The chapter “River Crossing” details the travails of accessing health care without reliable infrastructure, such as roads, transport, and bridges, and the resultant lives lost in the narrow window missed when emergency medical care can save lives.

The book also weaves an intersectional gender perspective. For example, how do sociocultural norms and stigma affect access to abortion services, legal under the Medical Termination of Pregnancy Act (1971, amended in 2021), for single women and girls below 18 years? “A Nation on the Move”, a chapter on migrants and Occupational Health, brings out the diversity of women’s health experiences through stories of women who migrate to urban areas, as well as those left behind to care for their older family members, livestock, and meagre landholdings.

Atkuri is also able to trace the development of maternal health programmes and the changing role of traditional birth attendants therein.

Contemporary problems

Atkuri succinctly discusses current debates in public health, grounding them in quantitative and qualitative evidence. She asks provocative questions about current policy: Why do Indians consume less food than they should? How does the POCSO Act affect vulnerable teenage pregnancies? What happens when the government reimburses private hospitals through health insurance schemes without regulation, and does not provide universal health care to all its citizens? Are non-physician health care providers the answer to the non-availability of medical care in rural areas?

Atkuri devotes a chapter to how the insistence on digitisation through mandatory identity documents like the Aadhaar card has adversely affected and excluded the most vulnerable from healthcare access. Stories bring out how marginalised households are compelled to pay out-of-pocket, amid rising health care costs and low government spending. Only 1.84%of GDP has been spent on health, against 2.5% committed in the National Health Policy 2017 and 6% recommended by WHO.

The author’s sensitivity and empathy are not restricted to health seekers’ experiences. She powerfully narrates the trials faced by healthcare providers in executing their duties under tough geographic and resource constraints.

“A Tablet for Everyone”, for example, focuses on frontline health workers’ perspectives on digitisation. The workers argue that digitisation has moved them away from providing care towards juggling and maintaining digital and physical records, and this, too, amid trying circumstances such as weak internet and malfunctioning devices.

The book is remarkable in its endeavours to move beyond an analysis of health inequities and critique of policies and programs towards offering plausible solutions. Some chapters present cases of on-the-ground practices that can be adapted as possible policy solutions.

The chapter “Jholawallahs” describes the contributions of many non-government health organisations that have served as pilots for scalable solutions for healthcare provision in India.

Staying Aliveisan important resource for interested health policymakers and an essential read for public health students in India and in low- and middle-income countries. Anthropologists and legal studies scholars will also find interesting insights and leads into their own disciplines. The simple, clean language and its empathetic stories make it appealing to even the general reader.

Renu Khanna is a co-founder and trustee of SAHAJ, an organistation that works to create sustainable change in the lives of marginalised communities, especially children, adolescent girls, and women.

Staying Alive: Dispatches from the Margins, Ramani Atkuri, Pan Macmillan India.

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