Understanding the notions of Risk and Uncertainty: Critical Insights from the Indian Health Sector

Purendra Prasad - Department of Sociology, School of Social Sciences, University of Hyderabad


The title that I gave is “Understanding the Notions of Risk and Uncertainty-Critical Insights from the Indian Health Sector”. What I try to do is, I take few observations from the Indian Health Sector and throw up certain issues for discussions.

The moment we talk about the Indian Health Sector I think two models of health care are always referred in the literature.  One is the Canadian model of health care, which is Public Private Partnership which is what I think in the post 1990s aggressively Indian Health Sector is being actually urged to move towards.

The second kind of a model that they always fall back outside the capitalist systems is the Chinese model, where they always say that public health sector in India has lot more to learn from the Chinese system and they go back to the barefoot doctors concept to that of everything that’s so well and working very well in that Chinese tradition.

But what we don’t try to look at is what the context in which Indian Health Sector evolved. I think that’s very important to locate before you say whether we tread the path of Chinese Model or tread the path of Canadian Model.  

And in that sense I think when you try to look at the, say for instance Chinese Model of Health Care System where you have three units working, the Chinese Medicine, the Allopathic Medicine, as well as the Integrated Medicine which is the combination of both the Chinese and the Allopathic..  And if you look at the Indian systems of the Medicine where of course today I think after the NDA (National Democratic Alliance) government came (to power) they talk about the Indian system of medicines where they are also taking about the Unani, Homeopathy Siddha Medicine and other Natural systems of medicines, as unified Indian Systems of Medicines. It’s a different story whey Indian systems of medicines has been brought into the picture starting from say 98, 99 onwards. But before going into any of those details, I think what I am trying to look at is India is always actually valorized in terms of Pluralistic Medical traditions, where (there is) co-existence of different systems of medicines. But actually what is being undermined or what is not being highlighted is about the kind of co-existence that other systems of medicines has with the Allopathic systems of knowledge.

So, there is lot of hegemony, dominance, power relations that exist between these systems of medicine which is normally not highlighted.  And when you look at the dominant technological reductionist model that has been adopted in India right from the independence period, where in the Indian National Science Congress, where Nehru was present when the entire council wanted to debate on the Indian systems of medicine, without even discussion the one system of knowledge has been approved which has become the only system of the medicine in the Indian context which has been patronized, which has been legitimized and hence you find the other systems as “alternative systems”.  

So all that I am trying to see here is a kind of dichotomous model which did not emerge as a process, but it was imposed. So, in that sense I am not going to look in to the details about what led to the decline of Indigenous Knowledge System and how it negotiated with the other systems of knowledge.  I don’t think I am trying to look at some of those issues.  

All that I am trying to bring forward here is, the way certain knowledge system has been institutionalized, text based medical knowledge systems have been institutionalized, including Ayurveda, Unani and other Indian systems of medicine. So, to the extent that these systems of knowledge can be commoditized these systems of knowledge can be commercialized there is no problem with those knowledge systems.  So that’s something that the institutionalization of the  medical systems the way it has taken place and when you look at what is the purpose of these institutionalized medical knowledge systems is that to provide access to the scientific knowledge systems for the large majority of the population. So, in a way the way British had the way the British has the Civilizing Mission, the Indian ruling class in the post Independent period had what is called as the “Modernization Mission”, catching up with the modernity. So that’s where these texts based institutionalized medical systems have been justified that they provide better access to the large majority or probably to all the citizens of this country free of cost.  

When you go by Bhore Committee (Set up by the Government of India in 1943 to investigate and recommend improvements to the Indian Public Health system) recommendations it says that the objectives of the Indian Health Policies is providing health care at the door step of every citizen in the nook and corner of the country. So, looking at some of these dimensions, what you find to , it boils down to couple of things.

One, all qualified doctors, text based medical systems have been concentrated in urban and semi-urban settings and very systematically public health care system which has been located in the rural, semi-urban, urban areas has been systematically discredited over a period of time.  And since market is expected to self-regulate and the kind of enormous confidence in the market also made the Indian policy makers that private sector is totally unregulated in this country. There is no accountability for the private sector except milk the kind of infrastructure that’s made available by the government.  So, in that process if we look at in the post 1990s after the economic reforms obviously this process has been much more intensified, where the state has been less supportive of the public health sector domain, corporatization and privatization of health sector has been glorified, in fact they talk about Hyderabad today being one of the major destinations in terms of medical tourism. Because, the medical competency of the Indian health sector is comparable with North-American and European, so the way government as well as the private sector is promoting that you can visit that Golconda, Charminar Hi-tech city (places of tourist interest) and Apollo, Global and other (top class) hospitals.  

So, this has been one of the major promotional (campaign) kind of a thing that we are no less competent than the western kind of a hospital and health care systems.  So, we have reached, we have arrived at the global levels, global standards.  So, this is one of the major kind of a point that, I think you find in the recent kind of debates where super specialties, technological modernity, curative medicine has actually taken over. But if you look at the other dimension the way that some of the speakers were talking about the Hi-tech spaces.  Similarly if you look at the other side of it, you find completely in the rural sector no qualified practitioner actually or very minimum number of qualified practitioners exist in the rural areas and most of the practitioners are actually legally not recognized, so they may be community healers, they may be healers from different medical systems, but not recognized legally.  

So, in that sense what has been created for the large majority of the population here is, they have been alienated from accessing the modern health services, and whenever they try to utilize the services of the locally available knowledge systems they are always blamed as irrational, superstitious, inward looking and people who do not have right choice.  So in this sort of an uncertainty that has been created, today we are talking about the “choices” that people make and largely the communities are blamed for not making a “rational choice”.

In that sense when these masses wanted to actually embrace modernity, the social and physical distance is too large.  The kind of a dominant upper class, upper cost models that has crept into the institutionalization process has distanced the poor.
So, what you find here is the questions that are being raised since the morning between the power and the powerlessness is something that comes quite often in the Indian health sector.

And more specifically if you look at the kind of epidemics and the kind of disease burden that is growing in India, because I don’t have to reel out some of the statistics that has come out in the light of food crisis, in light of economic crisis and other kind of things that where Punjab (state) which is supposed to be the very successful Green Revolution Belt, ranks in terms of hunger in terms of mortality much lower than Honduras and Vietnam.  And you have a large majority of women who are anemic, children who are under nourished and malnourished.  So, what people are talking today in terms of nutritional emergency etc. if you look at the dismal picture that is emerging, there seems to be one small minority who have appropriated certain knowledge systems and arrived as global kind of competent players. At another level you find large masses have actually got alienated.

Then in terms of State interventions, today the State tries to classify people as risk-groups and risk-zones. In the context of Tuberculosis, in the context of HIV/AIDS, you find certain social groups and marginalized groups labeled as risk-groups - truckers, migrants, sex-workers. They get segregated, isolated, classified, labeled and they are all supposed to be amenable for intervention because (supposedly) others are actually very-very safe. One will find that the distinction between the safe-zones and unsafe-zones, the distinction between the risk-groups and not so risky groups is being defined by the interest of certain kind of knowledge systems.

Risk is all pervasive, whether you talk about Giddens or Ulrich Beck or others’ kinds of notion of risk.  But the way the State and certain kinds of interest groups define risk is more in terms of segregation, classification and labeling processes.  I think this is where one could find that the social power of the ruling class and the articulated upper class, upper caste sections actually where the dominant technological models and knowledge systems seem to be more scientific, more justified, more rational.  All other knowledge systems seem to be not so rational.  So this is what I thought I would leave it at that, if there are questions, we could always discuss. Thank you.