Four years ago, this author had scrutinised Gujarat’s health and found it in a sorry state. At the time, its sitting Chief Minister had left no stone unturned in projecting Gujarat as a model for the rest of India to follow – a prosperous state populated by uncomplaining, hard-working people, backed by an able, hands-on administration, scaling heights the other states could only dream of. The Gujarat model appealed to the rest of India and soon the Chief Minister of Gujarat became the Prime Minister of India. His attention was now on India and not Gujarat; his successes and his failures to be measured hereon by an altogether different, and longer, laundry list.

Three years have sped past and the jury, doubtless twitchy and restless, is still out. The Economy is not in a good state; neither are Education, Health, Disinvestment, and many other domains that were promised a touch of the Gujarat wand back in 2014.

The frog is yet to be kissed, its croaks yet to be heard.

Meanwhile, what of the state orphaned by the man who was its face in every which way? It goes to elections shortly and all the pundits are of the opinion that a BJP victory is certain. The baby seldom forgets the hand that rocks the cradle.

Amid the election fanfare and rhetoric, one question begs to be asked: How has Gujarat fared, away from the constant limelight that shone on her for a good part of a decade? And one metric that consistently fails to awaken the electorate is Health. Economy, Jobs, Corruption, Governance, Subsidies, Agriculture, yes, but never Health. This is deeply tragic as the state of health of an electorate has a direct bearing on the state of all of the above-mentioned issues.

To compare how Gujarat has fared on Health indicators, it is necessary to not just list out its performance but, rather, to match its performance with six other states, namely: Kerala, Maharashtra, Andhra Pradesh, Tamil Nadu, Punjab, and Karnataka. The reasons are manifold, and have been explained earlier by this author. Briefly, first, if Gujarat is to be judged, it is to be judged against the best; little point in asking for votes claiming you are better than the holders of the wooden spoon. Second, the GDP per capita of all seven states is high across the board (Bihar: Rs 34,168; UP: Rs 48,520)

Data from: Economic Survey, 2016. Population projection data from https://nrhm-mis.nic.in/SitePages/Home.aspx and http://www.indiaenvironmentportal.org.in/files/file/NHP_2017-1.pdf

Because these seven states are the powerhouses of the nation’s economy, there is money to be made, and correspondingly money to be spent on Health. A state that fares poorly on the Economy front has a readymade excuse for faring poorly on the Health front. Third, all these states spend roughly the same on Health as a proportion of their GDP, dispelling another notion that states at the top among this bunch spend a much larger chunk of their GDP on Health. Fourth, these states have substantial rural, tribal, and migrant population, as well as a sizeable slum population, to dispel another caveat, of inaccessibility of health services or of them being burdened by migrant or slum population. Maharashtra has more tribals, migrants, and slums than Gujarat. Finally, all these states have been under stable majority government rule for long periods, resulting in a deeper understanding of, and correspondingly resource availability for, systemic problems.

Rural and tribal population figures are from Census, 2011. Migrant population data is from Economic survey, 2016-17. Health spend and slum population data is from National Health Profile, 2017.

Let us now compare Gujarat with the rest of the seven states, starting with metrics that have a direct bearing on Health. An astonishing 48.1 per cent of rural households in Gujarat contribute to open defecation. For Kerala, the figure is 5.3 per cent; for Punjab, it is 8.6 per cent. This is especially embarrassing given the emphasis of Narendra Modi, the erstwhile Chief Minister of Gujarat, on Swachh Bharat and ending open defecation. Open defecation is strongly correlated with the prevalence and spread of numerous vector-borne and pathogenic diseases, and to have a state with a GDP per capita comparable to Kerala and Punjab showing such abysmal numbers is nothing short of failure.

Data from 2016

The well-being of a population is judged by the well-being of its children and women, especially in a developing country like ours. Gujarat fares abysmally in this regard. 9.5 per cent of its children under five are severely wasted (weight-for-height); 38.5 per cent are stunted – the worst among the seven states. But what is truly unforgivable, is that 49.6 per cent of Gujarati children below two years are not fully immunised, again the worst among the seven states.

What is even more shameful, is that Bihar, with a GDP per capita one-fourth that of Gujarat has an immunisation rate (61.7 per cent) better than Gujarat. What is going on? Does Gujarat care? Does it realise that these are the stunted, wasted, unimmunised children who, when they grow up, would take in their hands the reins of Gujarat’s economy, education, health, politics, prosperity?

Data: National Family Health Survey, 2015-16

The Gujarat Chief Minister recently lauded Gujaratis for creating a world record for standing up and singing in the largest number ever the national anthem. With 49.6 per cent children not fully immunised, not administered “3 doses each of polio and DPT”, standing up to repeat this feat in the future could be problematic. But then, setting priorities has never been a priority for our politicians.

If the health of Gujarati children is a cause for concern, the health of its infants is a cause for alarm. Gujarat has the worst sex ratio next only to Punjab; it has the worst Infant Mortality Rate next only to Andhra Pradesh; and it has the worst Under-five Mortality Rate among the seven states. Kerala, on the other hand, has reached levels that are the envy of many European states; its IMR is now lower than nine European countries.

Data: National Family Health Survey, 2015-16

When it comes to Women, Gujarat’s indices are shocking. Gujarati women have the lowest BMI among the seven states; the least antenatal care availed of; and the least informed about condom use and HIV. These are women who would give birth to children who would in-turn carry the burden of those abysmal wasted, stunted, and unimmunised numbers. The catastrophic cycle completes.

Data: National Family Health Survey, 2015-16

Misery refuses to take a breather. The three most prevalent pathogenic and debilitating diseases in the Indian context, away from the seasonal viral outbreaks, are malaria, tuberculosis, and to a lesser extent leprosy. Gujarat fares worst next only to Maharashtra (that has a four-fold higher slum population) in Leprosy; it fares the worst in Tuberculosis and Malaria among all the seven states. These numbers aren’t affected by seasons or viral outbreaks as can be the case with Dengue or H1N1. These are diseases that afflict those who live in unsanitary, poor, cramped conditions, where health infrastructure has more or less failed. For Gujarat, that has one the highest GDP per capita among all states, to show such numbers speaks of a malaise either left unidentified or, worse, ignored.

Data: 2016 (provisional), National Health Profile, 2017

One must then ask: Can the situation improve? A comparison of Gujarat’s Health infrastructure with the other six states provides the sorry answer. Gujarat has the least number of medical colleges, the least number of blood banks and, most worryingly, the least number of registered doctors per million population. It fares better than Maharashtra, Punjab, and Andhra Pradesh so far as availability of a government hospital bed is concerned, but then again, yet again, there is Kerala to beat.

Data: 2016, National Health Profile, 2017

For a state nurtured by the current Prime Minister for more than a decade, these are damning statistics. And it is not that their damning nature is anything new – the state of Gujarat’s Health under Narendra Modi was as woeful. At the time, many charitable economists had suggested that the health indices would pick up once Gujarat had blazed the trail on economic prosperity – the so-called Stage I, Stage II hypothesis. Well, Gujarat has been shining economically for more than a decade, but the light is yet to fall on its Health. On the contrary, it has gotten worse since Narendra Modi abandoned Gandhi Nagar for New Delhi.

What, then, is the solution? There isn’t one, or at least there isn’t one that is out of the box. If Kerala can do it, why can’t Gujarat? Or is it that prosperity is to be locked up in a Godrej for it makes the inheritor appear wealthy, even if he is stunted and wasted and hobbling on crutches and burying his dead infant and defecating in the open and piggy-backing his underweight wife and shivering from malaria and coughing from tuberculosis and hunting for a blood bank and running to find a doctor?

The BJP will almost certainly win Gujarat come December and once again these abysmal indices would be forgotten. Once again the politicians will ask us to grin and bear it. But they forget, and sadly we forget, too, that they are the ones grinning and we are the ones bearing it.

This article first appeared in newslaundry on Oct. 23, 2017.