Unprepared for the future: Mumbai’s public health system remains stagnant post COVID-19

The experience of Bombay (present-day Mumbai) in dealing with the influenza pandemic of 1918 and the novel coronavirus share a remarkable continuity in the socio-economic spheres. 

Revisiting the 1918-19 influenza pandemic, the mortality figures for Bombay reflect that the caste status of the patient was fundamental to the chances of recovery. The disease, according to the Executive Health Officer, J S Turner, came “like a thief in the night, its onset rapid and insidious.” While the mortality rate amongst the upper caste Hindu population was 18.9 per cent, it was as high as 61.6 per cent for the lower caste Hindus in the city. Scholars have argued that class and caste were important determinants of spatial segregation and access to civic amenities in the city. The worst affected areas in the city were predominantly inhabited by the lower caste communities, marked by poverty, high population density, and unsanitary living conditions. The lack of adequate medical relief infrastructure in the areas occupied by the labouring poor further exacerbated the high mortality rates recorded.

A century later, particularly in the first wave of the COVID-19 pandemic, the city faced the same reality. While social prejudices in healthcare delivery have been largely overcome, economic dimensions share a noticeable continuity. Poverty, high population density, and access to basic necessities re-emerged as key determinants of the disease’s spread and recovery. The inapplicability of physical distancing in congested and unsanitary localities stands as a stark reminder of these persistent issues.

At the macro level, the experiences of Bombay with influenza and Mumbai with COVID-19 underscore the perils of inadequate state investment in health policies. The gaps in healthcare left by the colonial state were once filled by philanthropists, voluntary organisations, and local inhabitants of the city. They set up table dispensaries, removed corpses, arranged cremations, opened small hospitals, and provided blankets and medicine. 

Post-1918, the colonial government did not formulate any long-term policy to improve public health and sanitation. While the Bombay Development Directorate (BDD) was set up in 1920 to provide housing to the labouring poor, it was not a direct consequence of the influenza pandemic. Despite the recorded death toll, the cheapest materials and technology were used to construct the tenements, and basic facilities such as clean water and sewage were not accounted for in the planning process. Comprehensive urban planning remained a distant dream. While some attention was paid to the expansion of public hospitals, the financial burden was borne by the native population. Although efforts were made to expand hospital beds and construct new hospitals in the mill district, no thought was given to the maintenance costs incurred, resulting in little improvement overall. Public health in twentieth-century colonial Bombay can therefore be characterized by the prevalence of diseases, inadequate healthcare infrastructure, lack of effective planning, and financial conservatism displayed by the colonial establishment.

The recent COVID-19 pandemic and its impact on the city of Mumbai have highlighted that there is an element of the past in the present. Similarly to the 1918–19 period when Bombay recorded the highest mortality rate in comparison to other cities in the subcontinent, Mumbai was one of the worst-hit cities in India during the first wave of the COVID-19 pandemic. Furthermore, the data from 1918 reveals an inadequate availability of just 0.5 beds per 1000 people in the city for the local population. A century later, the ratio remains the same for India. For Mumbai in particular, an adequate number of hospital beds exist for the population only if public and private medical institutions are taken together. Private hospitals remain inaccessible to the lower sections of society, who form the vast majority of the population in Mumbai. There is a sharp divide between the healthcare facilities available to the upper class compared to the poor sections of the population.

According to the National Urban Health Mission and the National Building Code, it is imperative for municipal governments across the country to have at least one dispensary per 15,000 population. However, in Mumbai – the financial capital of the country – there are only 171 dispensaries for a population of approximately 12,400,000 people. This indicates that only one-fifth of the total requirement of 830 municipal dispensaries is currently provided.

It is crucial to note that the central government has not invested in a single hospital for the city since independence in 1947. Public health infrastructure has been one of the most neglected aspects of development in post-independent India. One can therefore conclude that the issues of colonial government and financing have remained perennially embedded in post-colonial India. This is due to two major reasons – lack of investment on the part of the state and the adoption of key tenets of liberalism.

The recent COVID-19 pandemic requires us to rethink our priorities and invest more in public health policies. Drawing parallels between the past and the present, it is arguable that increased political will and public-private coordination in improving public health infrastructure is extremely crucial. Short of this, an unfortunate outbreak of viruses like COVID-19 in the future could potentially leave the city staring at horrendous outcomes similar to those of the influenza pandemic of 1918–19.