Abstract
The disease burden in South Asia is complex and multifaceted: old, new, re-emerging and newly recognised conditions all coexist and interact in ways that we have yet to fully understand. The characteristics of COVID-19 have stressed these comorbidities. A discussion on longevity and the theory of epidemiological transition is followed by an analysis of the Indian experience with infectious and non-infectious diseases, injuries and inflammatory conditions, as an illustration of what has been happening in South Asia more generally. These conditions are not hermetically sealed from each other with comorbidities frequently the cause of death even if the official data does not reveal this. In the final part of this essay, the significance of the research findings in the other five papers that comprise this collection are discussed: these deal with the role of hospitals, new diagnostic and drug technologies and the question of ‘elite capture’ as an explanation for the high cost of medical care for the poor. The collection presents case studies from India, Pakistan and Bangladesh. Our collective approach has been to see the disease burden and health-care responses through a political economy of death and disease, and to link that with insights from ethnographic research and case studies.
Introduction
James Douglas, writing of the short lives of Europeans in Bombay (now Mumbai) in the early nineteenth century, repeated the popular saying that ‘two monsoons do not now measure the life of a man’.Footnote1 Since then, four big events have impacted in dramatic ways on the health of South Asia, two catastrophes offset by two positive changes: the Spanish flu pandemic of 1918–20 and the current COVID-19 pandemic on the one hand, and the post-1921 population explosion and the dramatic increases in longevity since then on the other. By 2019, the whole of South Asia had experienced an increase in life expectancy at birth of more than twenty years since 1960; Sri Lanka was the exception because longevity was already very high there (). While it is too soon to calculate the impact of COVID-19, the history of South Asia since 1950 has been one in which population growth and increases in life expectancy have overridden the impact of catastrophic events in the long run, including wars and famines.
Table 1. Life expectancy at birth in South Asia, 1960 and 2019, ranked from highest to lowest in 2019.
To begin with, it is important to establish some conceptual clarity by asking why I prefer to speak of the modernisation of South Asia’s disease burden rather than its ‘epidemiological transition’. The theory of epidemiological transition sits parallel to the theory of demographic transition by seeking to explain the changing relationship between death rates and structural changes in the economy. The pre-industrial period is called Stage 1 of the epidemiological transition when crisis mortality was high because of epidemic infections and famines: hence the ‘Age of Pestilence and Famine’.Footnote2 During Stage 2, death rates started to fall, epidemics receded, population growth began to accelerate and longevity increased: the ‘Age of Receding Pandemics’. This gave way to Stage 3, called the ‘Age of Degenerative and Man-Made Diseases’, when death rates continued to fall, longevity increased to about fifty years and fertility levels also began to decline. From the viewpoint of the history of diseases, the dramatic change in the epidemiological transition of any country is the shift from infectious to degenerative or non-communicable diseases (NCDs) and what determines that shift.
These three stages of epidemiological transition are sometimes articulated as four stages, but what remains a constant problematic is that the theory oversimplifies reality by not recognising that the boundaries between these stages (irrespective of their number) are blurred because of the overlapping and interrelated nature of many diseases. Zuckerman and Armelagos, for example, stress ‘the chronic nature of some infectious diseases, such as tuberculosis, as well as increasing recognition of the role of infectious disease and inflammatory processes in many chronic conditions (e.g. HPV and cervical cancer)’.Footnote3
In the case of South Asia, new evidence points to extensive levels of asthma, a chronic inflammatory-autoimmune condition that remains largely underdiagnosed, undertreated and hidden because having a persistent cough gives rise to shame and social stigma. In India, for example, 6 percent of children and 2 percent of adults have asthma.Footnote4 More generally, the Indian government has started to prioritise tuberculosis (TB) comorbidities, which include HIV, diabetes and smoking tobacco.Footnote5 The last three conditions are generally regarded as ‘life style diseases’ (belonging to NCDs), but they interact with infectious TB with terrible consequences. Mental health and how it relates to an individual’s susceptibility to infectious, non-infectious and autoimmune diseases is another example of the blurriness between different disease groups, and therefore the rigidity of epidemiological transition theory.
The interplay between microorganisms in the human gut and the brain is now being analysed, further deepening our understanding of the connection between the physical and emotional aspects of illness.Footnote6 The COVID-19 pandemic has thrown light on these interconnections in new ways: the hitherto unknown pathogen, SARS-CoV-2, has been identified as triggering a cytokine storm syndrome in severely ill patients who risk death due to multi-organ inflammation, damage or failure because their bodies have overreacted to the presence of the virus. This ‘maladaptive immune response’ has been treated by medicines designed to reduce the body’s immune reactions, a practice that is counter-intuitive to what is normally recommended for the treatment of a viral disease.Footnote7 More generally, the high mortality rates associated with COVID-19 have been sheeted home to comorbidities including infections and non-infectious and undiagnosed conditions. For all the above reasons, while describing the changing health and mortality scenarios in South Asia, it is advisable to think of these as part of a complex process that is better described as the modernisation of the region’s disease burden rather than an ‘epidemiological transition’. Despite these reservations, the distinction between infectious or communicable diseases and non-infectious or non-communicable diseases has formed an important part of any discussion of mortality and morbidity in South Asia since 1950.
This collection addresses a number of considerations that underpin the paradox of South Asia’s ongoing development, set against the formidable health problems the region faces. In this introductory essay, I describe some of the sweeping changes that have occurred in South Asia’s disease burden and how these are connected with health interventions by governments and societies. I cite the Indian case as a way of defining the broad contours in the region’s disease burden because India accounts for 78 percent of all the people living in South Asia (1.38 billion out of 1.86 billion in 2020).Footnote8 While this focus cannot claim to be comprehensive, it is supplemented by two other essays in this collection about Bangladesh and Pakistan, the next most populous countries. Together, Bangladesh and Pakistan account for populations of 165 million and 221 million, respectively. These two papers and the other three that follow this introductory essay provide deeper insights into the social, economic and political conditions that are driving disease and death in South Asia. Solomon’s study of the treatment of traumatic brain injuries (TBIs) in a Mumbai public hospital reminds us that South Asia faces a triple rather than a double disease burden—unintentional and intentional injuries kill more people in India than respiratory diseases and TB (, Row 8). Injuries, however, do not play a big role in epidemiological transition theory—another weakness of the concept. Solomon’s contribution is complemented by a paper by Vicziany and Hardikar on the role of hospitals and new blood technologies in rural India, again based on the state of Maharashtra. In the poor district of Wardha, hospitals are the first port of call for people with serious conditions and injuries. Both papers straddle the conventional division between infectious and non-infectious diseases because the deeper causes for injuries may be hidden—for example, an accident may occur because of a pre-existing health condition. The genetic blood conditions reported for Wardha also lie beyond the simplistic communicable/non-communicable diseases divide. The next two papers in this collection deal with the rise of innovative domestic generic drug manufacturing companies in India and Bangladesh—with a particular focus on the political economy of creating these new industries that now find themselves confronted by the need to comply with the World Trade Organization’s (WTO’s) intellectual property provisions. The availability of cheap, domestically produced generic drugs has been a very important factor in South Asia’s response to many types of diseases and comorbidities. The final paper on Pakistan takes a broader view of the health of people in South Asia by explaining the processes by which the health-care sector has become the subject of ‘elite capture’. The affordability of treatment and medicines (also discussed by Vicziany and Hardikar, Plahe and McArthur, and Sarkar and Plahe in this collection) emerges as an important consideration, with Out-of-Pocket (OoP) expenditures acting as a major constraint on the average Pakistani’s capacity to remedy the illnesses and conditions that prevent them from enjoying life.
Table 2. Top 10 Causes of Death in India (all ages) 2010–2013.
The simultaneous decline, persistence and rise of infectious diseases
summarises India’s modern disease burden by ranking the top ten causes of death. The first three are all non-communicable diseases: cardiovascular (25 percent of all deaths), respiratory (7.8 percent) and malignancies (5.8 percent). Together, these accounted for almost 39 percent of total Indian mortality in 2013 and each outstripped the three main infectious diseases recorded by the official statistics: diarrhoeal diseases (5.1 percent), respiratory infections (3.9 percent) and TB (3.7 percent). I stress ‘official statistics’ because the on-the-ground reality suggests that infectious diseases are far more prevalent and serious than indicates (see discussion below).
The missing factors in the ‘top ten’ are the great scourges of the past: plague,Footnote9 smallpox,Footnote10 guinea worm,Footnote11 yawsFootnote12 and polio.Footnote13 The last cases of these were reported in 1966, 1975, 1996, 2003 and 1999–2011, respectively. Success in eradication was often driven by draconian levels of state intervention, as exemplified by Prime Minister Indira Gandhi’s surveillance campaign to rid the country of smallpox.Footnote14 The Bihar Military Police, for example, were used to protect the health workers who were tasked with locating and isolating smallpox victims whose families did everything possible to hide them from detection. The polio campaign also required state intervention, but in this case, the backing of civil society groups, including Muslim religious leaders, proved invaluable. The experience of Pakistan on polio eradication has been very different—polio remains a problem and the support of religious leaders has been wanting (see Mohsin Ali and Rais in this collection).
Many other familiar infectious diseases persist in India but have been greatly reduced in virulence and impact. Immunisation against ‘childhood diseases’ such as measles, diphtheria, pertussis (whooping cough) and tetanus have reduced the mortality of children under five years of age. Mortality from different kinds of acute diarrhoeal diseases has been greatly reduced with better access to safe drinking water: access went up from only 4.5 percent of the population in 1947 to about 80 percent in 1997.Footnote15 Since then, not much has improved with about one in four Indian homes lacking clean water.Footnote16 The number of annual malaria cases has come down from 75 million in the 1950s to some two million in the 1990s despite the many difficulties that have characterised the unsuccessful attempt to eradicate it.Footnote17 Even TB, perhaps the most intractable of all communicable diseases because of its complex nature and ability to hide, has seen a reduction in annual reported cases by almost half from five million to 2.74 million between 1997 and 2011.Footnote18
These achievements are significant, yet many infectious diseases persist in South Asia and contribute in significant ways to the world’s disease burden. Malaria provides a dramatic example of the global importance of India, where cases between 2000 and 2019 fell from twenty million to six million.Footnote19 Of the eleven countries that currently contribute to 70 percent of the global burden of malaria, India is the only non-African countryFootnote20—this is surprising given India’s relatively high levels of economic development. Malaria is not only severely debilitating but also a major killer, accounting for 7.7 percent of deaths in children aged 5–14 years.Footnote21
A similar story applies to TB in India—despite falling case numbers, India’s 2.74 million new cases in 2018 was the highest globally, followed by China with one million cases.Footnote22 India’s share of known global TB cases is about 26 percent.Footnote23 The data, however, is highly unreliable for as the minister for health noted in 2019, ‘at least 30 percent of…India’s population is infected with tuberculosis’,Footnote24 including children whose condition is rarely understood or reported.Footnote25 In addition to the considerable emotional strain on families caused by avoidable death, TB is especially costly for the economy given that it accounts for 8.3 percent of deaths amongst India’s most productive people aged between 30 and 44.Footnote26 If the treatment for TB is successful, it nevertheless takes seven years for people who had the disease to climb out of poverty.Footnote27 More importantly, the very drugs that have been used to contain TB are now the source of drug resistance. With almost 27,000 known cases of MDR (multi-drug resistant) TB, India has emerged as the centre of the global epidemic of drug-resistant TB.Footnote28 In short, TB has modernised: it exists in both old and new forms and has become one of the world’s important comorbidities. The privatisation of health care in India has contributed to that modernisation because two-thirds of the sufferers are treated in an unregulated environment.Footnote29 The private health sector is not motivated to keep good records about patient health, preferring to focus on measuring the size of drug sales.Footnote30 The negative impact of the privatisation of health-care services has also been dramatic in the case of Pakistan.
On the other end of the spectrum of India’s disease burden stands the formidable stunting of children which prevents individuals’ physical and intellectual abilities from reaching their full potential. Indian stunting has been a long-familiar, slow and silent killer and a debilitating agent that now accounts for one-third of the world’s cases of malnourished children at a time when the proportion of open defecation in India has risen to 60 percent of the global total.Footnote31 Again, as many poorer countries successfully tackle stunting, India’s global prominence in this old disease was noted by the Ministry of Drinking Water and Sanitation in 2017:
…close to four out of ten children (39%) are stunted…the highest number of stunted children in the world…. In fact, statistically, in terms of proportion of total stunted children, we are worldwide amongst the top four countries, lagging only Yemen (47%), Pakistan (45%) and the Democratic Republic of Congo (43%)—a situation which is highly deplorable.Footnote32
Citing the work of Chambers and Von Medeazza on the need to address the ‘correlation between sanitation and nutrition’, the Jal Shakti ministryFootnote33 has continued to promote the 2014 Swachh Bharat Abhiyan (Clean India Mission) programme to eliminate this policy ‘blindspot’.Footnote34 Unfortunately, the Fifth National Family Health Survey, 2019–20, showed that the problem has increased since the Fourth Survey five years earlier: the percentage of children under five years of age ‘suffering from stunted growth has gone up substantially in 11 states, severe wasting in 14 and anaemia in 17 out of the 18 states’.Footnote35 Twenty percent of children in India remain underweight.Footnote36 The iceberg of diseases generated by fecally transmitted infections (FTIs)Footnote37 and infections by parasitic zoonosesFootnote38 will take time to address because they typically persist at sub-clinical and asymptomatic levels.
The broad spectrum of FTIs goes well beyond diarrhoeal diseases which are visible, easier to manage and therefore recorded in the official data (as noted in ). FTIs are transmitted via ingestion, respiration and absorption through the skin; an environment that tolerates defecation in public places facilitates infections. In India, the stunting of children because of repeated infection was 25 percent amongst the wealthiest households compared with 28 percent amongst the poorest households in Sri Lanka.Footnote39 Amongst the poorest households in India, it was about 60 percent, which was 14 percent higher than in the poorest countries of Latin America.Footnote40 The large roundworm Ascaris lumbricoides can alone steal up to one-third of a child’s food intake.Footnote41 The Government of India’s Swachh Bharat programme has sought to reduce the fecal transmission of infection by ending open defecation and funding toilet construction for homes; however, the October 2019 declaration that rural India was now Open Defecation Free (ODF) was perhaps premature. The latest government report shows that only 27.3 percent of rural toilets are twin pits,Footnote42 the preferred system because of their long life, lower use of water compared to flush toilets (one-third) and ability to convert excrement into manure.Footnote43 Many problems have hindered the programme including poor or incomplete construction, the lack of proper maintenanceFootnote44 and a focus on building toilets rather than persuading people to use them.Footnote45 For the other 70 percent of rural toilets, the absence of a system to manage the sludge has given rise to concerns about large-scale pollution of groundwater’.Footnote46
More fundamentally, the problem of water scarcity remains in the arid parts of India, areas vulnerable to monsoon failure, and other regions where water is lost because of inadequate capture. All rural toilets need water for flushing away waste, and this competes with essential human and animal needs and agriculture. The result is that despite positive changes, open defecation in rural India still occurs in at least 22 percent of households,Footnote47 and in many areas up to 50 percent or more of households.Footnote48 The Government of India programme does represent a break from the privatisation of public health services, but a considerable distance has yet to be covered to eliminate the multiple risks of fecal infection.Footnote49 The importance of continuing with this new policy initiative, however, is undeniable given that inadequate sanitation costs India about 1 percent of its GDP each year because of productivity losses and treatment costs.Footnote50 It would be hard for any government to handle all of these problems simultaneously in the short term because on-the-ground pollution is matched by an unclean sky, with one study estimating that one out of eight Indian deaths ‘can be attributed to air pollution’.Footnote51
In short, official records showing India’s changing disease burden greatly understate the severity of the old, new, persistent and re-emerging infectious diseases. If there was better data for rural areas, where more than 60 percent of Indians live, the data gaps would turn out to be even greater. As it happens, only between 20 percent and 45 percent of Indian death certificates provide a medically certified cause of death (MCCD)—and these records pertain to events that occur mainly in urban hospitals.Footnote52 The situation is worse in Pakistan: ‘Few hospitals maintain systematic records and government health authorities lack rigorous data monitoring resources’.Footnote53 In the whole of South Asia, only Sri Lanka and the Maldives have achieved 100 percent reportage of MCCD.Footnote54 suggests that as a result, the high official death rates from COVID-19 in Sri Lanka and the Maldives probably reflect a better system of civil registration. Taken together, the cause of death data problems, hidden infections and infections that lead to the deterioration of human organs all suggest that it is too soon to dismiss the contribution that communicable diseases make to South Asia’s disease burden.
Table 3. COVID-19 in South Asian countries ranked by total deaths per 100,000 compared with Peru (no. 1), the USA and the UK on 6 October 2021.
The emergence of non-infectious diseases
Non-communicable diseases are part of the complex story of South Asia’s modernisation of morbidity. The speed of change for particular conditions varies between the different countries of the region, and within them, there are great inter-provincial variations and differences by age, gender and socio-economic groupings. In the case of India, shows that between 1990 and 2016, deaths from cardiovascular, pulmonary and diabetic conditions increased for all three by about 30 percent at the national level. The implications are dire: the three non-infectious conditions listed in reflect an annual death toll of four million Indians, the majority between thirty and seventy years old. These are ‘premature’ deaths and ‘represent some of the world’s largest health losses’.Footnote55 These ‘new’ diseases are much harder to control through state action because they need to address the negative impacts of new lifestyles which people ‘choose’. As the WHO has noted, some tax, marketing and health interventions by governments can help,Footnote56 but ultimately it is up to individuals to change their behaviour despite the many stresses of modern living (both urban and rural) that compel people to eat too much sugar, salt, fat and fast foods, smoke cigarettes and live sedentary lives in their efforts to increase income and the chances of promotion.
Table 4. Percentage increase in total mortality from three main groups of non-communicable diseases (NCDs) in India from 1990 to 2016 (national level data).
also identifies South India’s states as having high levels of the rapidly-growing diabetes epidemic. But state-based differences hide many complexities in the modernisation of Indian diseases. For instance, 7.3 percent of Indians in the fifteen states surveyed by a 2017 study suffered from diabetes, but in the poor state of Bihar, the incidence was only 4.3 percent compared with 10 percent in the richer state of Punjab.Footnote57 The incidence of diabetes in urban areas is also double that of rural India: 11.2 percent relative to 5.2 percent. The same study reported that the prevalence of pre-diabetes in the fifteen states was 10.3 percent. Urban living and more wealth, it seems, correlate positively with a higher incidence of diabetes and, ultimately, higher death rates. However, at a deeper level, socio-economic differences within rural and urban India turn out to be significant. In rural areas, better-off socio-economic groups have a higher incidence of diabetes, but the opposite is true of urban areas where lower socio-economic groups suffer more from this condition. These differences point to the importance of changing human behaviour driven by complex factors including location, dislocation and aspirations. Living in a village appears to provide poorer Indians with some protection against diabetes, but when poor villagers migrate to urban areas, they become caught up in lifestyle changes that contribute to higher levels of diabetes. Relocation to urban areas and the pressures, uncertainties, instabilities and ‘rowdiness’ of urban living are extreme (see Solomon in this collection), contributing to bad habits and bad health. Despite these changes, India still lags behind the non-communicable disease patterns of more developed economies, though it is rapidly catching up: for example, Australia’s mortality rate from non-communicable diseases accounts for 89 percent of total deaths compared with India’s 63 percent, but the risk of premature mortality amongst thirty to seventy-year olds in 2016 was 9 percent and 23 percent, respectively.Footnote58
The raw mortality figures hide the loss of many years of healthy living owing to the disabilities created by all these conditions. Disabilities are included in the estimate of disability-adjusted life years (DALYs) that ‘represents the loss of the equivalent of one year of full health. DALYs for a disease or health condition are the sum of the years of life lost due to premature mortality (YLLs) and the years lived with a disability (YLDs) due to prevalent cases of the disease or health condition in a population’.Footnote59 DALYs greatly outstrip annual deaths: for instance, in 2017, some 9.7 million Indians died, but there were 486 million DALYs.Footnote60 My focus on mortality data, while an oversimplification, is however justified by the fact that DALYs mirror deaths in their incidence and disease character: ‘About three quarters of deaths and DALYs occurred in rural areas….[and] the top 15 conditions that accounted for the most DALYs were mostly those causing mortality’.Footnote61 The top cause of DALYs in India in 2017 was coronary heart/artery disease (ischemic heart disease).Footnote62 However, Menon et al. ranked ‘nutritional deficiencies’ as the third top cause of DALYs and ‘diarrhoea’ as the sixth.Footnote63 These two factors reflect the devastating impact of the stunting of children in India.
How COVID-19 will affect assessments of India’s modernisation of diseases, premature deaths and disabilities will be revealed in the coming years. In the meantime, the extent of its devastation was revealed in the May 2021 report by the Institute for Health Metrics and Evaluation, which showed that in the preceding week, COVID-19 had already become India’s leading cause of death, outstripping heart/artery disease (the previous leading cause of mortality) by more than 2.5 times.Footnote64
The papers in this collection
The five papers in this collection following this one include three on India, one on Bangladesh and one on Pakistan. How this new research contributes to our understanding of the modernisation of diseases in South Asia is discussed next.
First, Solomon’s article on traumatic brain injury (TBI) provides an account of the familiar horrors of living in the pressure-cooker urban environment that Mumbai has become. above shows the high number of deaths from injury in India; more detailed information shows that for men aged 15–39, road injuries were the leading cause of death in India in 2017.Footnote65 Solomon’s case studies go beyond simple data about road and rail accidents by dealing with the behaviour of young men who perform ‘stunts’ and engage in ‘rowdy’, anti-social antics. Unlike infectious or non-infectious diseases, TBIs are not gradual or silent killers that merely emerge from changing lifestyles. Rather, urban accidents provide dramatic examples of the new values and romantic dreams that have come to define everyday life in Indian cities. These imaginings are daily undermined by the stresses, frustrations and disappointments of urban living that routinely drive young adults onto collision courses with the ever-expanding steel and concrete infrastructure that encases their lives. Solomon’s critique of epidemiological transition is simultaneously a critique of the delusional and misguided ambitions of urban developers who want Indian cities to emulate Shanghai. This compelling study signals a new research focus by Solomon, building on his incisive work on urban kitchens and diets in Mumbai.Footnote66 When talking about injuries or food, he describes how the human body in urban India absorbs, metabolises or fails to metabolise the shocks to which it is subjected. In this paper, as with his unique monograph, his portraits capture the emotional impact of daily living and dying.
The second article by Vicziany and Hardikar adds further qualifications to the epidemiological transition theory by compelling us to re-evaluate the extent to which urban aspirations diverge from rural ones. Interviews with villagers in Wardha district (Maharashtra, India) showed that the urban–rural divide is being slowly erased by the twin forces of cultural relevance and hospitalisation for critical conditions. In the former case, the ongoing veneration of the ‘devis (goddesses) of contagion’ remains as important to urban as to rural dwellers, in particular the goddess of smallpox and most recently the Corona devi. With the blessing of village goddesses, hospitalisation is driving a health revolution in which villagers bypass the second-rate, government-funded Primary Health Centres and sub-centres and head straight for the largely urban-based hospitals for complex procedures including liver transplants. And it is not only the family’s primary breadwinner who is receiving critical care, but also children born with genetic blood disorders and other conditions. Aiding the erasure of the urban–rural divide is a new group of politicians who seek to help rural voters by providing timely, private referrals to such hospitals in which these politicians have made large financial investments. The villagers’ aspirations to live longer and healthier lives are only held back by the high costs of hospital treatment. New medical diagnostic technologies have the potential to reduce the costs and monitoring of allopathic (Western medical) interventions if they are introduced to villagers at their doorsteps. Bioactive paper, already being used for typing the primary blood groups ABO and RhD, makes that possible.Footnote67 Such point-of-care technology can reduce diagnostic delays and costs: ‘Development of simple, rapid, and reliable assays (tests) for blood grouping would be of great value for bedside compatibility checks and quick blood grouping in emergency scenarios and in situations where there is no access to laboratory facilities such as in rural areas, military facilities, and in developing countries’.Footnote68 In Wardha district, the majority of interviewees would welcome such technologies which complement the veneration of life-saving goddesses.
The hospitals that are central to the papers by Solomon as well as Vicziany and Hardikar are also users of the new drugs that are being developed by domestic pharmaceutical-manufacturing companies in South Asia. The growth of the new generic drugs industry in India and Bangladesh is the subject of two articles in this collection. They remind us that the modernisation of South Asia’s disease burden is a process that takes place within global power structures, and inter-country and inter-company rivalry. They describe how decolonisation after British rule ended led to the flight of the powerful multinational corporations (MNCs) that had created artificially high prices for drugs as part of their profit-maximising strategies. Laws and other safeguards were put into place to encourage the growth of domestic drug manufacturing capacity, leading to the emergence of India and Bangladesh as globally significant producers of generic pharmaceuticals. In contrast to the drugs of old produced by midwives, soothsayers or religious specialists who all played an integral role in the societies to which they belonged, modern drugs are industrial products manufactured by large pharmaceutical companies. As disembodied industrial outputs, the quality of these drugs needs to be strictly controlled. The achievements of India and Bangladesh as new global drug producers and exporters can be gauged by their ability to meet the US Food and Drug Administration (USFDA) definition of a generic drug as a medicine that:
…works in the same way and provides the same clinical benefit as its brand-name version. This standard applies to all FDA-approved generic medicines. A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used. [They also] use the same active ingredients as brand-name medicines and work the same way, so they have the same risks and benefits as the brand-name medicines.Footnote69
However, these achievements have been challenged by the WTO’s regime on intellectual property rights (IPRs). Both India and Bangladesh must comply with WTO rules as members of that organisation. This has required both countries to respond in different ways, reflecting their levels of economic development. In the case of India, Plahe and McArthur analyse what happened to India after it became fully compliant with the WTO’s 1994 Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement; with Bangladesh, Sarkar and Plahe ask how Bangladesh might prepare for the post-TRIPS environment that the country must adhere to in 2029. The decolonisation of pharmaceutical production in South Asia up to the TRIPS regime wrought dramatic changes. By 2019, India’s drug exports accounted for 2.6 percent of the value of international trade in pharmaceuticals, while the quantity of output was the third largest after China and Italy.Footnote70 The transformation of Bangladesh was not only dramatic but also technologically significant. Unlike garments manufacturing, which remains at the bottom end of the technology scale, pharmaceuticals have taken Bangladesh to the upper end while also emerging as the largest employer of white-collar workers in the country.Footnote71 These successes, however, have hidden systemic weaknesses that are now creating difficulties for the sustainability of the industry in both countries. Import dependency on active pharmaceutical ingredients (APIs) from China has become critical due to rising import prices, while the inability of the poorest citizen to afford even these cheap, locally-manufactured drugs acts as a major constraint on reducing death rates from all causes.
In their conclusions, the authors address a range of options that might save these industries in the post-TRIPS era. If we think of India and Bangladesh as a two-tiered regional producer of generic drugs, we can see that the upper layer (namely India) is being wooed by MNCs eager for mergers, acquisitions and other joint arrangements as multinationals move into generic drug production. In the meantime, the second, lower layer (namely Bangladesh) could strike similar deals, not with MNCs, but rather with large Indian pharmaceutical companies across the border. Such mutually beneficial arrangements could lead to the sustainability and growth of medical pharmaceuticals production in both countries. Regrettably, if the privatisation of health care continues, the long-term viability of drug manufacturing in South Asia provides no guarantee that it will be able to meet the urgent needs of the poorest people whose financial means do not stretch to buying sufficient quantities of the cheapest drugs in the world.
The privatisation of health care is assessed in the final article in this collection by Mohsin Ali and Rais in the context of Pakistan’s health system over the last seven decades. Much of what we know about Pakistan derives from security paradigms, in particular concern about its use as a base for global terrorism, but there is little understanding of its health-care problems. This paper deepens our insight into the negative consequences of economic liberalisation in South Asia. The authors explain how ad hoc policy making, instability, patronage politics and rent-seeking have led to a maldistribution of resources, lack of oversight and inequitable access and service provision for a burgeoning population. Two consequences flow from these, both of which contribute to the further weakening of the state and civil society: first, the privatisation of health care, and second, the increased influence of the international donor community. The authors portray the Pakistani state as one that has abdicated its responsibilities and allowed those with the least capacity to carry the burden of the health sector’s costs and mistakes. They conclude that the country’s health system is hamstrung by the constraints of a political settlement in which elites with short-term horizons bargain for influence rather than concern themselves with developing an inclusive, consensus-based approach to improving governance and the delivery of better health.
Their argument compels us to consider the responsibilities of civilian leaders in Pakistan, rather than just assume that a ‘predatory military’ has forged a ‘predatory partnership’ with other dominant classes.Footnote72 By shifting attention away from a preoccupation with the Pakistani military, we can perhaps see stronger parallels between Pakistan and the other states of South Asia. This then enables us to ask whether other countries in the region have also suffered from the ‘elite capture’ that prevents the state from responding to the essential needs of its citizens. ‘Elite capture’, with or without the military, is an important issue for the whole region. Many of the problems identified by Mohsin Ali and Rais certainly have their counterparts in India, for example in the privatisation of health care and the burden of OoP medical expenses for the sick (see Vicziany and Hardikar in this issue).
Conclusion
The papers in this collection speak to the everyday problems of ill health, health care and mortality in South Asia—or rather how to acquire good health, proper care and a long and healthy life. We have addressed a number of significant issues here, but many gaps remain in terms of the countries covered and other issues that we have not explored. Each paper points to a significant problem that cries out for more attention—not at the statistical level but by collecting evidence from case studies and ethnographic accounts. In particular, we need more research about inter-country differences, and, within each country, about inter-provincial variations and differences between various social groups. We need more research to understand the consequences of some of the health paradoxes that South Asia presents—for example, the emergence of antimicrobial drug resistance because of the overuse of drugs despite a chronic shortage of drugs for some people and some conditions. Rural South Asia, in particular, needs our attention. As noted by Shafqat, despite setting up a highly effective National Control and Command Centre and the support of medical professionals and the military, Pakistan’s assessment of the impact of the COVID-19 pandemic still lacks full information about rural areas.Footnote73
In this collection we have seen that new non-communicable conditions have joined communicable diseases and led to an increase in the complexity of the region’s disease burden. Inflammatory and autoimmune diseases such as asthma have also emerged while injuries remain important considerations. It is too soon to say that non-communicable diseases have overtaken communicable ones because the statistical evidence for this is fraught with under-reporting, misunderstandings and a lack of plausible verification. Rather, new research is drawing attention to the comorbidities between non-communicable and communicable diseases and other conditions including inflammatory and autoimmune conditions. The concept of ‘epidemiological transition’ does not capture these interrelationships and so I have preferred to speak of the modernisation of the region’s disease burden. In South Asia, incomplete data has been exacerbated by the privatisation of the health sector, even though private hospitals have provided easier access to health services because government doctors avoid rural appointments or provide poor care when compelled to serve outside cities and towns. However, the private sector is not a universal ‘bad’ for another reason beyond filling in the health-care gaps tolerated by governments—it is, after all, private pharmaceutical-manufacturing companies that have reverse engineered important drugs for a wide variety of medical conditions and provided these generic drugs at prices lower than those routinely charged by multinationals. The most important recent achievement is by the Indian pharmaceutical company Cipla, which has not only received a generous licence from Merck to manufacture and sell Molnupiravir, the world’s first antiviral COVID-19 pill, in India, but which is also supplying Merck with ‘raw materials…made under contract in India’.Footnote74 Cipla is building on its reputation as the producer of some of the world’s cheapest generics (see Plahe and McArthur) via its plan to charge only US$20 for a five-day course of treatment instead of the US$700 cost in America.Footnote75 Governments are also coming around to reassessing strategies for better health care by focusing on overriding environmental problems, especially water availability and quality. Perhaps it is in these large infrastructure domains that an important role for the state can be asserted more forcefully.
Acknowledgements
I am grateful to my colleague Mark Wahlqvist, Emeritus Professor of Medicine at Monash University, for his comments on an early version of this paper. Thanks, too, to Professor Kama Maclean, editor of South Asia, for her careful reading of the manuscript and Vivien Seyler for excellent editorial assistance.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. James Douglas, Glimpses of Old Bombay and Western India (London: Sampson Law, Marston & Co. Ltd, 1900), p. 77.
2. I have used Omran’s explanation in this article: Abdel R. Omran, ‘The Epidemiologic Transition: A Theory of the Epidemiology of Population Change’, in The Milbank Quarterly, Vol. 83, no. 4 (2005), pp. 731–57, reprinted from The Milbank Memorial Fund Quarterly, Vol. 49, no. 4, Pt. 1 (1971), pp. 509–38 [https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1468-0009.2005.00398.x, accessed 11 Oct. 2021]; also see the excellent critique by Robert McKeown, ‘The Epidemiologic Transition: Changing Patterns of Mortality and Population Dynamics’, in American Journal of Lifestyle Medicine, Vol. 3 (1_suppl) (2009–07), pp. 19S–26S, DOI: 10.1177/1559827609335350.
3. Molly K. Zuckerman, ‘Introduction: Interdisciplinary Approaches to the Second Epidemiologic Transition’, in Molly K. Zuckerman (ed.), Modern Environments and Human Health: Revisiting the Second Epidemiological Transition (Hoboken, NJ: Wiley-Blackwell, 2014), p. 4.
4. Virendra Singh, ‘The Global Asthma Report 2018—India’ (Auckland: Global Asthma Network, 2018), p. 58 [http://globalasthmareport.org/management/india.php, accessed 13 Oct. 2021]. In two recent studies, asthma was linked to household pollution caused by burning solid fuels such as firewood: see S.K. Singh et al., ‘Socio-Economic Correlates and Spatial Heterogeneity in the Prevalence of Asthma among Young Women in India’, in BMC Pulmonary Medicine, Vol. 20, no. 190 (2020), DOI: HYPERLINK "https://doi.org/10.1186/s12890-020-1124-z" https://doi.org/10.1186/s12890-020-1124-z; and Prakash Kumar and Usha Ram, ‘Patterns, Factors Associated and Morbidity Burden of Asthma in India’, in Plos ONE, Vol. 12, no. 10 (2017), E0185938, DOI: HYPERLINK "https://doi.org/10.1371/journal.pone.0185938" https://doi.org/10.1371/journal.pone.0185938.
5. Central TB Division, India TB Report 2019 (New Delhi: Ministry of Health and Family Welfare, 2019), p. xx [https://tbcindia.gov.in/WriteReadData/India%20TB%20Report%202019.pdf, accessed 1 Jan. 2021].
6. See, for example, Emeran Mayer, The Mind–Gut Connection (New York: Harper Wave, 2018); and Emeran Mayer, The Gut–Immune Connection (New York: Harper Wave, 2021).
7. Luke Chen and Tien Quach, ‘COVID-19 Cytokine Storm Syndrome: A Threshold Concept’, in The Lancet Microbe, Vol. 2, no. 2 (Feb. 2021), p. e49, DOI: https://doi.org/10.1016/S2666-5247(20)30223-8.
8. World Bank, ‘Population, Total—South Asia’ (2019) [https://data.worldbank.org/indicator/SP.POP.TOTL?locations=8S, accessed 10 April 2021].
9. The last case confirmed as plague by laboratory analysis was found in Karnataka in 1966. In 1994, there appeared to be a resurgence in Gujarat, but there has been no scientific evidence to establish its identity as plague: see M.D. Gupte et al., ‘Epidemiological Profile of India: Historical and Contemporary Perspectives’, in Journal of Bioscience, Vol. 26, no. 4, Suppl. (Nov. 2001), pp. 437–64 [440], DOI: 10.1007/BF02704746.
10. Sanjoy Bhattacharya, ‘Uncertain Advances: A Review of the Final Phases of the Smallpox Eradication Program in India, 1960–1980’, in American Journal of Public Health, Vol. 94, no. 11 (2004), pp. 1875–83 [1877, 1881 and Table 1] [https://www.proquest.com/scholarly-journals/uncertain-advances-review-final-phases-smallpox/docview/215088223/se-2, accessed 26 Oct. 2021].
11. Aruna Rastogi, ‘Dracunculiasis (Guinea-Worm Disease)’, National Health Portal India, 2016 [https://www.nhp.gov.in/disease/communicable-disease/dracunculiasis-guinea-worm-disease, accessed 20 Jan. 2020].
12. Aruna Rastogi, ‘Yaws’, National Health Portal India, 2015 [https://www.nhp.gov.in/disease/skin/yaws, accessed 20 Jan. 2020].
13. Naveen Thacker et al., ‘Polio Eradication in India: The Lessons Learned’, in Paediatrics, Vol. 138, no. 4 (2016), p. 2.
14. Bhattacharya, ‘Uncertain Advances’, p. 1881.
15. Gupte et al., ‘Epidemiological Profile of India’, p. 440.
16. WaterAid, ‘WaterAid Launches Emergency Response to Covid-19 in India’, in WaterAid Articles (12 May 2021) [https://www.wateraid.org/us/media/india-covid-19-emergency-response, accessed 21 Oct. 2021]. As noted by V.K. Madhavan, chief executive, WaterAid India, his organisation’s focus is on the ‘basics of clean water and decent sanitation to help protect themselves (i.e. residents) from the spread of disease’: ibid.
17. Gupte et al., ‘Epidemiological Profile of India’, p. 443.
18. Ibid., p. 442.
19. WHO, World Malaria Report 2020 (Geneva: WHO, 30 Nov. 2020), p. vi [https://www.who.int/publications/i/item/9789240015791, accessed 5 Oct. 2021].
20. Ibid., p. 13.
21. Office of the Registrar General & Census Commissioner, India, Causes of Death Statistics: Presentation on Causes of Death in India, 2010–2013, Slide 24, ‘Distribution of Deaths in India: 2010-2013-Persons’ (Delhi: Ministry of Home Affairs, Government of India, n.d.) [http://censusindia.gov.in/vital_statistics/VA_2010-13_Presentation_DRG_Release.pptx, accessed 13 Sept. 2021].
22. Siddharthya Roy and Sayan Ghosh, ‘Tuberculosis: India’s Silent Epidemic’, in The Diplomat (17 April 2019) [https://thediplomat.com/2019/04/tuberculosis-indias-silent-epidemic/, accessed 29 Dec. 2019].
23. Jyoti P. Shrivastava and Alok Shrivastava, ‘Scenario of TB in India’, in Journal of Lung, Pulmonary & Respiratory Research, Vol. 8, no. 2 (2021) pp. 24–5 [25] [https://medcraveonline.com/JLPRR/JLPRR-08-00246.pdf, accessed 23 Oct. 2021].
24. Jagat Prakash Nadda, ‘India’s Leadership to End Tuberculosis’, in The Lancet, Vol. 393, no. 10178 (Mar. 2019), p. 1271, DOI: .
25. Shrivastava and Shrivastava, ‘Scenario of TB in India’, p. 24.
26. Office of the Registrar General & Census Commissioner, India, Causes of Death Statistics: Presentation on Causes of Death in India 2010–2013, Slide 24, ‘Distribution of Deaths in India: 2010-2013-Persons’.
27. Nadda, ‘India’s Leadership to End Tuberculosis’, p. 1270.
28. Shrivastava and Shrivastava, ‘Scenario of TB in India’, p. 24. In addition to Multi-Drug Resistant Tuberculosis (MDR TB), there are two more kinds: Extensively Drug-Resistant Tuberculosis (XDR TB) and Totally Drug-Resistant Tuberculosis (TDR TB).
29. Roy and Ghosh, ‘Tuberculosis’.
30. Ada Kwan et al., ‘Variations in the Quality of Tuberculosis Care in Urban India: A Cross-Sectional, Standardized Patient Study in Two Cities’, in PLoS Medicine, Vol. 15, no. 9 (2018), e1002653, p. 2, DOI: 10.1371/journal.pmed.1002653. This invaluable study analysed the treatment of TB patients not from the viewpoint of information provided by the health practitioners, but by employing healthy adults to simulate four different stages of the disease and present themselves to a wide range of health providers.
31. In 2014, a third of undernourished children in the world were in India, where open defecation had risen to 60 percent of the world’s total: Robert Chambers and Gregor Von Medeazza, ‘Undernutrition’s Blind Spot: A Review of Fecally Transmitted Infections in India’, in Journal of Water, Sanitation, and Hygiene for Development, Vol. 4, no. 4 (2014), pp. 576–89, DOI: 10.2166/washdev.2014.027.
32. Ministry of Drinking Water and Sanitation (MoDWS), Review of Health Data in Selected ODF and Non-ODF Districts under the SBM (Report of Findings) 2017 (Delhi: MoDWS, Government of India, 2017), p. 9 [https://jalshakti-ddws.gov.in/sites/default/files/BMGF_Health_Impact_Study_final.pdf, accessed 22 Oct. 2021].
33. The Ministry of Jal Shakti was created in 2019 to bring together the Ministry of Water Resources and the Department of Drinking Water and Sanitation as a way of increasing the importance of water and sanitation policies: PTI, ‘Govt Forms “Jal Shakti” Ministry by Merging Water Resources and Drinking Water Ministries’, The Hindu Business Line (31 May 2019) [https://www.thehindubusinessline.com/news/national/govt-forms-jal-shakti-ministry-by-merging-water-resources-and-drinking-water-ministries/article27378402.ece, accessed 22 Oct. 2021].
34. Ibid.
35. Editorial, ‘Stunted Progress’, in Business Standard (Kolkata) (14/15 Dec. 2020) [https://www.business-standard.com/article/opinion/stunted-progress-120121401506_1.html, and also available at Document BSTN000020201214egcf004km FACTIVA, accessed 13 Sept. 2021]. This summary is based on the NFHG–5 2019–2020, Fact Sheets: Key Indicators, Phase 1, Ministry of Health and Family Welfare, Government of India, December 2020, IPPS, Mumbai.
36. Ibid.
37. Chambers and Von Medeazza, ‘Undernutrition’s Blind Spot’, p. 578.
38. ‘A zoonosis is any disease or infection that is naturally transmissible from vertebrate animals to humans’: WHO, ‘WHO Fact Sheet: Zoonoses’ (29 July 2020) [https://www.who.int/news-room/fact-sheets/detail/zoonoses, accessed 13 Sept. 2021].
39. Monica Das Gupta, ‘Epidemic Control in India: Re-Focusing Public Health Services for Better Outcomes’, India International Centre Webinar, chaired by T.V. Somanathan (finance secretary, Government of India), 1 Sept., Researchgate, Slide 14 [https://www.researchgate.net/publication/354167780, accessed 23 Oct. 2021]. Note that the data comes from the period 2005–08.
40. Ibid., Slide 14.
41. Chambers and Von Medeazza, ‘Undernutrition’s Blind Spot’, p. 579.
42. Ministry of Jal Shakti, National Annual Rural Sanitation Survey (NARSS) Round 3 (2019–2020) (New Delhi: Government of India, n.d.), p. 205, Table HH:15 [https://jalshakti-ddws.gov.in/sites/default/files/NARSS_Round_3_2019_20_Report.pdf, accessed 16 Oct. 2021].
43. On a steep slope, the toilet pan uses between 1.5–2 litres of water to flush out the excreta; flush toilets need some six litres of water: Astha Ahuja, ‘Swachh Bharat Abhiyan: What Are Twin Pit Toilets?’, NDTV (18 Nov. 2020 [https://swachhindia.ndtv.com/swachh-bharat-abhiyan-what-are-twin-pit-toilets-53023/, accessed 17 Oct. 2021].
44. The district of Kandhamal (Odisha), for example, had toilets in ‘various stages of decaying’ in 2021, but three years earlier, it had been one of the leading ten districts and declared a winner on ‘World Toilet Day’ by the central Ministry of Drinking Water and Sanitation: Priya Ranjan Sahu, ‘Open-Defecation-Free Kandhamal: Only If the Toilets Would Work’, in Down to Earth (16 June 2021) [https://www.downtoearth.org.in/news/governance/open-defecation-free-kandhamal-only-if-the-toilets-would-work-77489, accessed 19 Oct. 2021].
45. Kundan Pandey, ‘Building Toilets Won’t Make India Open Defecation Free: World Bank Study’, in Down to Earth (24 Dec. 2018) [https://www.downtoearth.org.in/news/waste/building-toilets-won-t-make-india-open-defecation-free-world-bank-study-62594, accessed 17 Oct. 2021]. The study reported that 40 percent of families with toilets in five villages in eastern Uttar Pradesh did not use them.
46. V.K. Madhavan, chief executive of WaterAid India, cited in Varun B. Krishnan and Priscilla Jebaraj, ‘Only 26% of Rural Toilets Use Twin-Leach Pits, Finds Survey’, The Hindu (17 Mar. 2019) [https://www.thehindu.com/news/national/only-26-of-rural-toilets-use-twin-leach-pits-finds-survey/article26562002.ece, accessed 19 Oct. 2021].
47. This figure is cited in a WHO/UNICEF report of 1 July 2021: see Shivangi Agarwal, ‘Is India Really Open-Defecation-Free? Here’s What Numbers Say’, in Down to Earth (13 July 2021) [https://www.downtoearth.org.in/news/rural-water-and-sanitation/is-india-really-open-defecation-free-here-s-what-numbers-say-77918, accessed 17 Oct. 2021]; see also Rashmi Verma, ‘Despite Toilets in Place, a Quarter of Rural Population Stuck to Open Defecation’, in Down to Earth (10 Jan. 2019) [https://www.downtoearth.org.in/news/waste/despite-toilets-in-place-a-quarter-of-rural-population-stuck-to-open-defecation-62770, accessed 17 Oct. 2021].
48. Personal communication from India, 21 Oct. 2021; personal communication from India, 23 Oct. 2021.
49. That still leaves the problem of India’s large dog population because their fleas and excrement carry parasitic zoonoses that infect humans: R. Sharma et al., ‘Canine Parasitic Zoonoses in India: Status and Issues’, in Revue scientifique et technique (International Office of Epizootics), Vol. 36, no. 3 (2017), p. 820, Fig. 1, DOI: 10.20506/rst.36.3.2717.
50. Das Gupta, ‘Epidemic Control in India’, slide 13.
51. Kalpana Balakrishnan et al., ‘The Impact of Air Pollution on Deaths, Disease Burden, and Life Expectancy across the States of India: The Global Burden of Disease Study 2017’, in The Lancet: Planetary Health, Vol. 3, no. 2 (Jan. 2019), pp. E26–39 [E27], DOI: 10.1016/S2542-5196(18)30261-4.
52. Office of the Registrar General & Census Commissioner, India, Causes of Death Statistics: Presentation on Causes of Death in India 2010–2013, Slide 2, Background. The WHO 2021 report gives the higher figure: see WHO, Progress Report on Covering Every Birth and Death: Improving Civil Registration and Vital Statistics in the WHO South East Asia Region 2021 (New Delhi: WHO, 2021), p. 8, Fig. 5 [https://www.who.int/publications/i/item/9789290228851, accessed 9 Oct. 2021].
53. M. Tariq et al., ‘Medical Mortality in Pakistan: Experience at a Tertiary Care Hospital’, in Postgraduate Medical Journal, Vol. 85, no. 1007 (2009), p. 470, DOI: 10.1136/pgmj.2008.074898.
54. WHO, Progress Report on Covering Every Birth and Death.
55. Perianayagam Arokiasamy, ‘India’s Escalating Burden of Noncommunicable Diseases’, in The Lancet: Global Health, Vol. 6, no. 12 (2018), E1262–3 [E1263], DOI: https://doi.org/10.1016/S2214-109X(18)30448-0.
56. WHO, Noncommunicable Diseases: Country Profiles 2018 (Geneva: WHO, 2018), pp. 12–3, Table 1 [https://www.who.int/publications/i/item/ncd-country-profiles-2018, accessed 1 Aug. 2020). The WHO has identified 16 ‘Best Buys’ government interventions that it estimated to be ‘cost-effective, affordable, feasible and scalable in all settings’ across the globe: ibid., p. 13, Table 1.
57. Anjana Ranjit Mohan et al., ‘Prevalence of Diabetes and Prediabetes in 15 States of India: Results from the ICMR–INDIAB Population-Based Cross-Sectional Study’, in The Lancet Diabetes & Endocrinology, Vol. 5, no. 8 (Aug. 2017), pp. 585–96, DOI: http://dx.doi.org/10.1016/S2213-8587(17)30174-2.
58. WHO, Noncommunicable Diseases: Country Profiles 2018 (Geneva: WHO, 2018), Australia (p. 36); India (p. 106).
59. WHO, ‘Disability-Adjusted Life Years (DALYs)’ [https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158, accessed 26 Sept. 2021].
60. Geetha R. Menon et al., ‘National Burden Estimates of Healthy Life Lost in India, 2017: An Analysis Using Direct Mortality Data and Indirect Disability Data’, in The Lancet: Global Health, Vol. 7, no. 12 (2019), pp. E1675–84 [E1675], DOI: 10.1016/S2214-109X(19)30451-6.
61. Ibid.
62. Table: ‘Burden of Disease in India Due to Major Causes in Different Age Groups, by Sex and Location, 2017’, ibid., p. E1678.
63. Ibid.
64. Institute for Health Metrics and Evaluation, COVID-19 Results Briefing: India, pp. 1, 3, Table 1 [http://www.healthdata.org/sites/default/files/files/Projects/COVID/2021/163_briefing_India_pdf, accessed 29 Sept. 2021].
65. India State-Level Disease Burden Initiative Road Injury Collaborators, ‘Mortality Due to Road Injuries in the States of India: The Global Burden of Disease Study 1990–2017’, in The Lancet: Public Health, Vol. 5, no. 2 (Feb. 2020), pp. E86–98 [E86], DOI: 10.1016/S2468-2667(19)30246-4.
66. Harris Solomon, Metabolic Living: Food, Fat, and the Absorption of Illness in India (Durham, NC: Duke University Press, 2016).
67. Miaosi Li et al., ‘Paper-Based Device for Rapid Typing of Secondary Human Blood Groups’, in Analytical and Bioanalytical Chemistry, Vol. 406, no. 3 (2014), pp. 669–77 [669], DOI: 10.1007/s00216-013-7494-9.
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69. US Food and Drug Administration, Generic Drug Facts [https://www.fda.gov/drugs/generic-drugs/generic-drug-facts, accessed 21 Sept. 2021].
70. Government of India, Economic Survey 2020–2021, Vol. 2 (Delhi: Ministry of Finance, Department of Economic Affairs, 2021), p. 97, Box 1 [https://www.indiabudget.gov.in/economicsurvey/, accessed 19 Sept. 2021].
71. Daniel Gay, ‘What LDC Graduation Will Mean for Bangladesh’s Drugs Industry’, United Nations LDC Portal, 2019 [https://www.un.org/ldcportal/what-ldc-graduation-will-mean-for-bangladeshs-drugs-industry/, accessed 8 Jan. 2020].
72. This is the argument put forward in Ayesha Siddiqa, Military Inc.: Inside Pakistan’s Military Economy (London: Pluto Press, 2nd ed., 2017), pp. 26–7.
73. Dr. Saeed Shafqat, director, Centre for Public Policy and Governance, guest speaker on ‘COVID-19 in Pakistan’, MAI Zoom Seminar, Monash University, Melbourne, 20 Oct. 2021.
74. Dr. Yusuf Hamied, CEO, Cipla, cited in Amit Roy, ‘New Covid Pill Will Be Useful for Anti-Vaxxers’, Eastern Eye (27 Oct. 2021) [https://www.easterneye.biz/new-covid-pill-will-be-useful-for-anti-vaxxers/, accessed 28 Oct. 2021]. Cipla is one of eight Indian companies that have received the licence from Merck and can charge whatever price it wants.
75. Ibid. In the long run, Cipla hopes to be able to market the antiviral pill for COVID-19 for US$1 a day, as it did for HIV and AIDS.