New Delhi: One might believe that the appalling conditions documented by Friedrich Engels in nineteenth-century Manchester belong firmly to the pages of history. Yet, as Ramani Atkuri demonstrates in her searing new work, ‘Staying Alive: Dispatches from the Margins’, published by Pan Macmillan India, millions in twenty-first-century India continue to inhabit a reality that would be disturbingly recognisable to the Victorian reformer.
Atkuri undertakes a similar exercise to Engels, though her prism is not political economy but public health, and her subjects are not the factory workers of industrial England but the migrant labourers, tribal communities, and rural poor of contemporary India.
The book, spanning 296 pages, draws on over three decades of frontline experience. A graduate of the Christian Medical College in Vellore with a specialisation in Community Medicine, Atkuri has worked in the rural and tribal areas of Madhya Pradesh, Odisha and Chhattisgarh since 1991, managing patients and training field-level health workers.
Her decade-long stint with UNICEF, followed by a return to grassroots work with non-profit organisations, lends her observations a weight detached academic analysis could never achieve. She writes not as a visitor to these landscapes but as someone who has lived and worked among the people whose stories she recounts.
Atkuri’s method is deceptively simple. Each chapter opens with a case study, a patient whose suffering becomes a lens through which larger systemic failures come into focus. There is the 35-year-old woman with leprosy at a Jan Swasthya Sahyog clinic; the pregnant woman in a remote settlement wrongly administered oxytocin, leading to the deaths of both mother and child; the man presumed by his wife to be heavily intoxicated but later diagnosed with a snakebite; the author’s own battle with malaria contracted while on duty.
These dispatches paint a healthcare system in which disease is understood not as a biological event but as the manifestation of accumulated social disadvantage.
Atkuri refuses to attribute delays in seeking medical care to ignorance or superstition, the easy explanations favoured by urban elites. Instead, she examines the complex interplay of poverty, distance, transport costs, loss of wages, gender norms and fragile health systems that lead patients to postpone treatment until the disease has advanced.
The rural household, she notes, spends a larger share of its monthly expenditure on healthcare than its urban counterpart, and catastrophic health expenditure remains a devastating reality for millions.
The book’s treatment of tuberculosis exemplifies its broader argument. While acknowledging India’s progress in increasing domestic spending and investing in newer diagnostic tools, Atkuri reminds readers that over 800 Indians still die of TB every day, a staggering toll for a disease for which India has had a cure for over sixty years.
She argues that this is “arguably the most important public health problem in the country today”, and her accounts of patients with body mass indices as low as 11 underscore the devastating interaction between disease, undernutrition, poverty and delayed access to care. Moreover, the book gives snakebite and animal bite management the attention these neglected conditions deserve.
Atkuri critically examines the persistence of ineffective traditional remedies, including snake stones and magnets, and documents how delays caused by these practices, compounded by shortages of anti-venom and adequately equipped facilities, often prove fatal.
Her reminder that nearly one-third of the world’s rabies deaths occur in India, and that official estimates substantially underestimate the true burden, exposes how profoundly these conditions remain neglected.
The book also addresses a troubling paradox arising from the Protection of Children from Sexual Offences Act. The author highlights how a minor girl who marries and becomes pregnant finds herself virtually unable to access proper antenatal care, as healthcare providers are legally mandated to report such cases to the police, leading to the arrest of her husband and the parents of both parties. The law offers no easy solution.
While the Indian media fixates on the rise of overweight and obesity, Atkuri reminds readers that undernutrition remains widespread and severe, documenting persistent childhood undernutrition that the digitisation of public health programmes has exacerbated.
Her account of Anganwadi workers struggling with the Poshan Tracker app offers a devastating indictment of well-intentioned but poorly executed policy. In one village, the Anganwadi worker could enrol only 10 of 21 eligible children because the registration process was time-consuming and technologically demanding.
Children without Aadhaar cards or mothers without mobile phones were systematically excluded from nutrition programmes. One worker, Santoshi Yadav, told Atkuri that the demands of data entry meant she “never gets to see the children in the Anganwadi Centre.” This is policy failure in its most intimate and consequential form.
One of the book’s achievements lies in what it does to the urban reader’s imagination. For those accustomed to healthcare being available on demand, Atkuri’s dispatches expose how profoundly geography and privilege determine health outcomes.
The perks of calling an ambulance, consulting a specialist, or buying medicines within minutes seem fortuitous when set against the challenges of disadvantaged communities that must weigh the cost of treatment against the loss of a day’s wages. This discomfort is productive, however, and the book never becomes accusatory. It refuses to search for miracle solutions, instead harping on strengthening primary healthcare, improving nutrition, investing in frontline workers and recognising what Atkuri calls the “structural violence” embedded in India’s health system.
Atkuri’s writing carries the confidence of someone who has walked difficult terrain, worked alongside frontline health workers, and listened patiently to people whose lives rarely enter policy debates.
Her commitment to social justice is evident in every chapter, and the book powerfully reminds us that the right to health is not a luxury for the few but the right of every citizen, regardless of where they live.
