“I feel that keeping the human experience of deprivation and provisioning at the centre, we need to think what does it do to human life.”- Harsh Mander

Team Kitaab is in conversation with social justice and human rights activist, Harsh Mander where we spoke to him about his latest book, A Matter of Life and Death: The Unfinished Journey to Secure Healthcare for All (Speaking Tiger, 2026)

Harsh Mander is one of India’s most trusted and courageous social justice and human rights activists. He is also the author of several acclaimed books on contemporary India, among them, Looking Away: Inequality, Prejudice and Indifference in New India; Ash in the Belly: India’s Unfinished Battle Against Hunger; Burning Pyres, Mass Graves: India’s Covid Tragedy; This Land Is Mine, I Am Not of This Land: CAA–NRC and the Manufacture of Statelessness.

About the Book

In this book—easily among the most important for India and the world today—the acclaimed social and human rights activist Harsh Mander shows us how active neglect and deliberate anti-poor policies have denied adequate healthcare to over half the world’s population. As he writes, ‘Approximately 4.5 billion people lack full access to essential health services. Two billion face financial hardship… Approximately 4.8 million children under 5 died in 2023, mostly from preventable causes. These include neonatal complications, pneumonia, diarrhoea, malaria and malnutrition-related illness. Around 50% of these deaths were preventable with existing low-cost interventions.’

The problem, Mander points out, is not just the absence of healthcare services. A total of 1.4 million people die annually from unsafe water, inadequate sanitation and hygiene, and air pollution. The problem is most acute in developing econ¬omies—in India, for instance, over 2 million people die every year because of malnutrition and morbidity. In today’s world, with its scientific wherewithal and financial resources, almost all these deaths are preventable. The reason they are not, is deep and structured inequality, at the base of which are neo-liberal and discriminatory politics; capture of the world’s resources by big capital; rampant privatization; and the retreat of the upper and middle classes from the larger society in pursuit of affluence.

Having shown us the magnitude of the failure of both policy and conscience, Mander argues for the right to health as a fundamental human right. Universal basic healthcare, he insists, is achievable, and shows not only how it can be enforced legally, but also how it can be funded.

Team Kitaab: In A Matter of Life and Death, you argue that healthcare failures are fundamentally political rather than technical. What, in your view, is the single biggest political myth that sustains inequality in healthcare today?

Harsh Mander (HM): Inequality is a policy choice. It is not a chance outcome of the human convention. I think that’s centrally something to understand. India and much of the world was very unequal in colonial times. In the first few decades, up to about 80s our inequality reduced because there was a certain imagination of the good state. In multiple ways, Gandhiji talked about wiping tears of every eye, of the last vulnerable person in your design of any kind of public policy. The constitutional position again of rights took us exactly at a place where the whole idea of human rights is that every person is equal.

Now, we might say any random set of people together are not equal. Some people might have brighter brain, somebody may have stronger body, somebody might cook well, some great minds, some can produce babies, some cannot. We are of course inequal, but I think we are equal in human worth and human dignity. If you take that premise as a starting point, then it is possible to imagine a world that gives people equal chances.

Equal chances do not literally mean equal, because if you are starting from a point of greater disadvantage, then you need more than the next person. Equal chances, equal dignity, equal worth, equal rights – in that spectrum I would explain how we can imagine a healthcare system that is founded on these principles. Also, on last person first.It is very different imagination of healthcare system compared to what we see, even in large parts of the world.

Team Kitaab: You write with equal force about policy, morality and lived suffering. How do you balance rigorous structural critique with the need to keep individual human stories at the centre of the narrative?

HM: Thank you for noting that because in a sense my book is on public health. But it is different from the large majority of books you read on public health. Not because it is less rigorous, not because it is not developing an argument or because it is not empirical. But because not just in how I write but how I believe we must engage with issues of public policy. We must remember the human being and the human cost of the policy choices we are making.

And I think, dramatically, not just talking about Covid pandemic time,there is a Professor Akash Gupta in UCLA who had asked, how many people die in India out of preventable causes? People who need not have died had theyhad access to food, nutrition, clean water, and healthcare. Conservatively he came back with a figure of about two million. If you look back, the last famine that India saw the Great Bengal famine, the number of people who died were around three million. So, what we are saying is that we are seeing something like the Great Bengal famine happening around us every day every year all the time and we don’t even notice it, far from acknowledging it.

I feel that keeping the human experience of deprivation and provisioning at the centre, we need to think what does it do to human life. I, in many capacities engaged directly in public policy design. I was a civil servant. I was also a part of the national advisory council appointed by the last government. And I was a part of drafting some of the important social legislatures like security act, etc. Even discussing it at the highest level, as a part of the food security act, I would first talk about what does it mean to live with involuntary hunger? What does it mean if with all of your best efforts you cannot feed your children? I remember bazaar women speaking to me that the most painful lesson to teach your children is how to sleep hungry. When they spoke this, I was thinking if this is the lesson I had to teach my daughter, what would life look like to me.

By bringing the human narrative to the centre, the whole conversation becomes very different. We can talk about hunger and malnutrition in very technical terms. Is it so many calories? What is the economic burden? What are the economic costs? etc. Those are relevant conversations to a certain degree. But I feel that we centrally these are not utilitarian or economic arguments for the social rights or the right to health that I want to make a centre stage. I want to place centrally the moral argument of what is a good society. A good society is one where we take care of each other. I start my book with what Margaret Mead is fabled to have said when she was asked when did human civilization start. She is said to have picked up a femur bone from a 15000-year-old skeleton which was healed, and said that, “This reveals that somebody took care of another person who was injured. Protected them from wild animals, brought them food and took care of them. That is the beginning of human civilisation.”

In that sense I would say kindness and care are markers of human civilization. And therefore, I refuse to talk about public policy without going back to the human being, who should be at centre of the imagination of public policy.

The whole idea that we are all every human being is of equal birth and equal dignity is a difficult idea even when we begin to think about it.

Harsh Mander

Team Kitaab: The book is sharply critical of privatized healthcare models. Do you think India has already crossed a point where healthcare is seen more as a commodity than a public good?

HM: India shockingly is among the most privatized healthcare systems in the world. As you might have seen in the book, I was badly staggered with the data that the privileged Indian who enters public medical schools, a large majority of them go abroad. And of those who are left behind, eight out of ten works for private healthcare systems. Only two works for public hospitals and very less work for public hospitals like AIIMS. So, who is left to serve millions of working people and the people in distant rural areas? Even in cities, slums are very badly served.

I argue by quoting Dr. Norman Bethune, a very progressive health practitioner, who has said, “We have to learn how to take profit out of care.” And I found that to be a very powerful articulation. How do we take profit out or care? That’s a challenge. We are living in a moment where we have gone so far down a different path that this begins to sound unfeasible. Cuba is one of the best examples and then of course, we have Scandinavian countries. Even in the British National Health Scheme (NHS) before Margaret Thatcher, the schemes were based primarily on a principle that you should receive the healthcare based not on how much money you have in your pocket, but on what is your need. That seems to be such an elementary moral and professional position of medicine, but we seem to have lost it completely.

I was a former civil servant. My father was also an IAS officer. Throughout my childhood, I don’t remember going to a private hospital. We always went to a government dispensary and sat outside like other people waiting for our turn. Now, that is completely gone. It hit me during the pandemic that whenever a Chief minister or union minister got Covid, they would promptly check themselves into the most expensive private hospitals. Even Delhi’s health minister, when he got Covid, he checked into Medanta Hospital.  When asked why, he said, “My wife was really worried I will die in a government hospital.” I was so angry on hearing this, as you have said you don’t have any faith whatsoever in the systems and as we see, any senior minister or civil servants are sending their kids abroad for studies because our universities are not good enough. But then they are not good enough because you have not made them good enough. We have sort of escaped from them and found our own exits.

That is why, during the pandemic I made a rash promise that if I get Covid I will only go to a government hospital and that also to a general ward of a government hospital, which I did, and it almost killed me. But that’s another story!

In course of writing this book, I argue that how it is an entirely feasible idea. In very simple terms, we should have a public provision health care system where everybody gets the same quality of healthcare based on what they need. And how will it be funded? We fund it through progressive taxing. Tax the rich. Let people pay into their public health care fund based on how much they can afford to do it. The treatment they should get should be based on what they need.

Team Kitaab: You repeatedly insist that mass suffering persists because societies choose indifference and not because solutions are unavailable. Why do you think preventable deaths fail to produce moral urgency among political and economic elites?

HM: The whole idea that we are all every human being is of equal birth and equal dignity is a difficult idea even when we begin to think about it. When I speak to young people, all of us who live in a city would have seen a homeless woman is severely psychotic. She doesn’t know who she is, does know her name, and is covered in her excreta. Can we actually look at her and say, “Wow, she has the same dignity as my mother. If my life had treated her differently, she would have been where my mother is. And if life had treated my mother differently, she could have been here.”

This journey to recognise equal worth of every human being has to be the starting point where we then develop policies and systems that treats every human being with equal worth. In India, the moral frame of caste is actually the absolute reverse, which is the idea that the accident of your birth legitimately determines the rest of your life chances. Your birth both, into a caste and a gender and that we have lived with without significant resistance. There has been resistance throughout, but the system has endured for 2000 years.

And then we have this neoliberal idea, I grew up in fortunately idealistic times. For a decade or two after independence, there was a sense of nation building, about your responsibility to others. That also we have abandoned with neoliberalism, which to my mind, is less importantly an economic model and more importantly a model framework that greed is good. That you don’t owe anything to anybody. And I think it is this combination of the ideas of caste and the neoliberal model frame that makes the Indian rich and middle class among the most uncaring people in the world. And I say that very carefully, but strongly.

Team Kitaab: Much of your work confronts the retreat of the middle classes from public systems. Can universal healthcare become politically possible without the middle-class reinvesting faith in public institutions?

HM: See it is a bit of a situation like which comes first- egg and chicken. Arundhati Roy is very evocative with her words and somewhere she said that there has been only one successful secession movement in this country. And that is the secession of the middle-class from the rest of India.

So, if law and order is bad, we will have our own gated colonies, our own security guards. If electricity is not there, we will have our own electricity. If air is impure, we will have our own. Hospitals we already have fancy private options available. We have airconditioned schools and we send our kids abroad. It is this secession that I have seen within my lifetime. In my parents’ time everyone went to the government schools. By my time, government schools had already begun to be a place where people wanted to exit from. But health systems still were systems we contributed to.

Because I was in the IAS, I am part of the CGHS health system. It entitles me actually to be treated at the most expensive private hospital at public expense. This was unthinkable when I was a civil servant some 20 years ago. At that time, I had this clarity that if I fell sick, I would have to go to the same government hospital. It cannot be as hellish as they have made it today. It has become a huge political thing to treat everyone equal footing founded on the notions of equality, equal worth and equal dignity of all human beings.

Firstly, the government subsidizes corporate private hospitals with land and tax benefits that should end completely. The government also makes them viable. When people are talking about providing health care in India, you are actually talking about paying premium to private insurance companies which mostly referring you to a private hospital. The very small amounts that India is spending on public health is also going into private sector. So, I feel it has to be a very conscious decision that all public spending has to be on public health systems. If you are running a private hospital for profit, you must then be treated as a profit institution and not a care-giving institution in terms of how you are taxed, without state engagement or state subsidization.

If a government minister or an IAS officer still wants to access private hospitals, let them pay market rates. Even Scandinavian countries pay for excellent health care services by very high tax rates, which people very willingly pay. Even there they do allow private hospitals to function. But you don’t go to them because you don’t have good public health care system of high quality. 5 or 10% of the very rich still access private health care, but that is not because they don’t have an option.

Team Kitaab: The book links health to hospitals, hunger, sanitation, housing and labour conditions. Has modern policymaking become too fragmented to address suffering in a genuinely holistic way?

HM: Excellent question as all the questions that you have asked!

As I told you, I was given the responsibility of heading the working group that drafted to Food Security Act in India. What I realised is if I want to reach a situation where every person has assured access to adequate food to lead an active or healthy life, then I would ask- How does a family get assured access? They can either manufacture or purchase or receive it. If I am a food producer, my food depends on a whole range of policies connected with farmers rights. Support price and various other supports to farmers, fishing communities, forest gatherers, etc. If I have to purchase the food, then my right to food is linked to my rights as a worker. I should be paid without discrimination. Receiving is ultimately food provisioning as social security that is why you have a school meal program, or you have public distribution program, etc. In the end I realised that our laws still dealt with the third, with the provision of free food or subsidized food. But we cannot have a country which is free from hunger until we deal with farmers rights, worker and labour rights, fisher women rights, gender equality, disability rights at work, etc.

How can I achieve the highest level of health that is feasible is for me in terms of my genetics? For that, first I have the right to food which requires all of these.

So, when I look at healthcare, that’s exactly the same story. How can I achieve the highest level of health that is feasible is for me in terms of my genetics? For that, first I have the right to food which requires all of these. And then I have to healthy work environment, access to clean air, clean water and so much else. Some of us have begun to talk about the imperative of what we would call universal social rights. With this level of wealth that we have, (and I say this in the book too!) I think when the history of these times will be written, this will be seen as the cruellest periods in human history. Not that we have not seen any epidemics and famines in the past. But today we have the wealth and resources thousands of times over to ensure that no child sleeps hungry. No child dies because they lack healthcare. We choose to see other way. These are policy choices made by the elite of the world who has captured the public policy making. Who does the government consult when it makes its policies. Unless we tax the super-rich, in fact, people have calculated that just 3-4% of wealth tax from the dollar billionaires would be enough to provide all the things we need.

We were proud that we passed the right to Education law, very late, but it is now a fundamental right since 2009. Working with homeless children I realized, they were completely left out of from its imagination. Because the law says within 1-2 kms of where you live, should be a well-functioning government school. Now, imagine it is provided and it is free of charge. A homeless child who might be sleeping outside that school, will never be able to enter that school. Unless you can see that before she can enter the school, she needs protection, nutrition, roof and care. And with all of that, she can be in a position where she can enter that school.

Recognising the profound observation, the interdependence of social rights, where it is not possible to provide one without providing the others.

Team Kitaab: After documenting so much systemic failure, from malnutrition to the Covid catastrophe, what still gives you confidence that the right to healthcare can be realized in India within our lifetime?

HM: I believe that hope is a public duty in the darkest of times. If you give up hope, you don’t have to do anything. Find a solo path and lead the best life possible.

Firstly, I start from a position of hope and my politics, often friends might say, is based on a naïve optimism of human goodness prevailing. I live with that optimism because I do see a lot of goodness. I just feel that somehow, we live in times where hate and inequality, which are the two principal markers of this age, has got huge mobilization, but I don’t believe they are still the majority in this country or the world. For those of us, who believe in a good life or who care about each other, we need to organise and assert this alternative vision for the country and the world. We need to come together.

For that to happen I think we have to reclaim the moral discourse in public life. We need to talk about what is good and bad in human life, in society or state. You know today when the government threatens and buys a majority in legislatures and parliament, we should say this is absolutely appalling and immoral, but instead the discourse says how clever, they have hunger for power and they are achievers. And the ones who don’t follow this path are losers. When someone spends 6000 crores on a wedding, instead of saying how appalling in a country of this degree of deprivation and poverty, we say how glamourous.

I think we need to claim and reclaim the values of a good life and a good society. A good state can only be located in a good society. We need to build a good society before we can ever expect a good state with policies like universal health care to actually be a possibility.

Harsh Mander

Team Kitaab: Your title suggests that healthcare is ultimately a question of whose lives are valued and whose are expendable. At the end of writing this book, did you come away more hopeful about public conscience, or more alarmed by its erosion?

HM: Strangely a combination of both! Somewhere in the book, I talk about the last years of both my parents lives and how much of it was spent in hospitals. Because of the care they were able to access, my father was in the IAS and then in United nations, their lives were prolonged by many years. But I could never stop thinking that if they didn’t have that access, or this privilege, they would have gone much earlier. It is a reality we have to confront and acknowledge but not accept.

We must stir outrage and the public conscience, which is why I write what I write and do in my public life what I do. I am convinced there is a public conscience out there that has been numbed, but is still alive.

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