Book Review: Sarah Hodges and Mohan Rao (Eds),Public Wealth and Private Wealth: Stem Cells,Surrogates and Other Strategic Bodies

At a time when the neoliberal idea of growth and development with increasing inequality is being questioned and India is cast as an emerging power globally, this co-edited book by a historian and a public health academician juxtapose public health and private investment and capitalisation of health risks, medical services and biotechnology. This book is critical of the framework of science ‘both to diagnose and treat poverty’ (p. 1). The essays set out to examine how over the last century and at the present time the priority of poverty eradication has been marginalised within the broader realm of science, technology and medical policy discourse.

Three papers in Part 1 engage with the rise of the ‘anti-politics of poverty’, that is, how from a political issue it became a technological problem during three developmental regimes (colonial, nationalist and post-Independence) in India.

David Arnold (Chapter 1) introduces the concept of the ‘medicalisation of poverty’. He examines it through the colonial government’s engagement with different aspects of public health (the disease of malaria, cholera, influenza, and sanitation and nutrition) and poverty in India over a span of 100 years. Despite provincial health officials acknowledging that large masses of people were living in poverty, it was not recognised that it caused ill health, disease and mortality. By the last decade of the 1800s medical care became more laboratory-centric resulting in ‘social understanding of poverty losing out to medical entomology and the dominance of biological expertise’ (p. 28). During the planning and developmental phase, it was established that only large-scale engineering projects could address the ‘monumental’ problem of removing poverty, not public health and medicine.

Lakshmi Kutty in Chapter 2 shows how tuberculosis (TB) that was foregrounded as a disease of poverty underwent changes in treatment through short-term drug therapy. It shows to the reader that this change in the TB control progamme was premised on a technocentric and risk-based individualised approach and cost-effectiveness. This marginalised the structural and economic issues faced by malnourished poor bodies. Interestingly, this illustrates how technological tools based on rational choice approaches and a biomedical model, are validated through the influential roles of scientific research bodies and international organisations like the WHO. Thus, the framing of TB was completely divested of the problem of poverty. Rebecca Williams in Chapter 3 unpacks the concept of equity as conceptualised by Taylor in the 1970s. It focuses on health inputs and outcomes entirely from the viewpoint of surveillance of poor populations in developing countries to produce a ‘productive workforce’ and encourage economic investment. This approach gave credence to technological and management-oriented solutions. Williams explains that the term equity was used to build a ‘surveillance approach’ as a way to stratify populations by targeting poor people and categorising them as risk groups. Poor people are largely viewed as those who need to be managed for ‘maximum impact at minimum cost’. Thus, the function of the surveillance model for equity was to identify areas of targeted ‘investment’ in health without the pursuit of equality.

In Part 2 three papers explore how public and private sector hospitals have undergone transition and commercialisation in neo-liberal times and the ways in which they impact the everyday lives of the poor.

Ramila Bisht and Altaf Virani in Chapter 4 analyse the privatisation process of the public health sector in Mumbai over the past two decades and how it has changed institutions like maternity hospitals through the Public Private Partnership (PPP) mode in terms of medical care provisioning to poor women, who were earlier its core users and beneficiaries. The chapter shows how a public multi-speciality hospital is transformed by a private partner and how services available for the poor get marginalised. The question of PPPs working for private interests is established through this study. Rama Baru (Chapter 5) explicates the triple process of commercialisation of medical care in India over the past six decades; first, through the long-lasting association between health policy and the private sector; second, the rise of entrepreneurial corporate medicine that has changed the character of the not-for-profit medical care sector and third, the commercialisation of public services through reforms. Across this transformation, Baru suggests, one has to reckon with the change in middle-class and professional medical care values in India that emphasise consumerism, the individualised approach to clinical care, and risk analysis and competition. This paper moves beyond merely describing commercialisation of medical care but argues how in this journey public sector hospitals have turned anti-poor. Sarah Hodges (Chapter 6) in her study of Apollo Hospital ventures to hold that the process of systematic image-building created certain myths that aided in its emergence as an icon for other corporate hospital entrepreneurs, economic growth and the ‘sunshine story’ post-liberalisation in India. Myths how Apollo single handedly contributed to nation building, explaining how the health care sector attained industry status with access to financial markets and made quality care synonymous with the usage of cutting-edge technologies and specialties. Peeling away these myths, the author shows that Apollo Hospital, a multi-specialty hospital, has been packaged as a glossier version of government and charitable institutions that can successfully cater to those Indians who could afford it.

Part 3 with three papers explores how biotechnology has been posited as a driver for India’s economic growth, and international recognition. It is increasingly seen as a solution to health concerns ranging from reproduction to diseases like spinal cord injuries and cerebral palsy and the poor serving as resources for medicine.

Mohan Rao (Chapter 7) maps a vast historical canvas from the mid-19th century to the early 21st century in India and discusses the issues of overpopulation, eugenics, family planning-related health services and the advent of commercial surrogacy. Interestingly, in every context women living in poverty have been the target and borne the risk of new policies and technologies. Rao explains how in the early 21st century with the opening up of the Indian economy, poor women’s reproductive bodies through surrogacy have become resources for commercial exploitation by the rich. Besides giving a detailed analysis of the emergence of India as the international hub for biotech companies, Priya Ranjan (Chapter 8) locates this against the backdrop of public investment since the 1980s in biotechnology (BT) research, creation of skilled scientific human resources, and academic tie-ups with the BT industry through PPP and commercialisation of biotechnologies. Changes through outsourcing and clinical trials in India have reinvigorated concerns related to commercial research done by global biotech companies. They are provided with a cheap skilled workforce and a huge pool of a poor population with diseases for their research. The aim of promoting biotechnology to solve problems of poverty remains mere rhetoric. In the final chapter, Rohini Kandhari analyses how the Indian state has facilitated the growth of stem cell research in anticipation of future therapeutics and has welcomed venture capital investments. Kandhari further examines how the hope for cure shapes clinicians’ practice, encouraging speculative treatment, precipitating a consideration of ethical issues such as the lack of regulation in such treatment. In this grey area, the Indian state absolves itself of ethical concerns; patients are in this context without protection from risk or promise of further treatment in case of an unsuccessful outcome and doctors are diverted from what conventional medicine can provide.

Afterword: Dhruv Raina reflects on the last quarter of the 20th century which saw the revival of indigenous knowledge (IK) and science in India when the economist-oriented discourse on development and Eurocentric knowledge met with challenges and disenchantment. The rise of indigenous groups claiming their rights within developmental projects and transnational networks played a critical role in highlighting indigenous knowledge. Dependency being an outcome of the mainstream developmental project, indigenous knowledge emerged as an accumulated body of traditional knowledge, localised in nature but which could become part of sustainable development. So, its acknowledgement by ecological science, the engagement of other disciplines with histories of knowledge and the search for solutions within the scientific community have led to the mainstreaming of indigenous knowledge.

This book is a welcome addition to the historical work on Indian public health and the anti-politics of poverty. Bringing poverty to the heart of public health, medical care and biotechnology is an urgent need in the context of finance capital, deregulation and privatisation of medical care services, and the decline of social security. This is often making the everyday lives of the poor more precarious, particularly of women, children and socially marginalised groups.