There are times when I wonder if the point of travel is not to broaden one’s horizons as much as narrow them down. Not to teach us to embrace all differences, but to observe the gulf between us and them and to burn with the contrast.

Narrow dusty roads and endless azure umbrellas of unstable sky down to a sharp point of intense experience, a tipping moment of clarity that upsets all wide, lolling assumptions that have been playing stowaway inside the oversized red-blue backpack with the non-adjustable straps. For instance, this stowaway thought that Punjab is a place of plenty. Plenty of food. Plenty of milk. Plenty of health and humor. But as I watched her walk up the slight incline to the main road, I had to wonder.

She trudged, head gleaming in the sun, up a hundred yards, a turn to the left, a few more steps, the dirt track, the hospital. Her thin, dry, fingers clutching a wallet the size of my palm, covered by a hanky. Very red lipstick. A black suit. Punjabi suit, not the suit of corporations. And my first thought was that she had the proportions of an adolescent baby. A large head, big eyes, narrow shoulders, skinny limbs, definite breasts, pudgy hands. Like she hadn’t had a proper chance to settle into the contours of one growth phase before she was pushed into the next.

I am always taken aback when I see women outside of cities. I had grown used to being described as small and fragile all my life. In Delhi, I feel small. So many of the women I know are taller, built sturdier. They are more voluptuous, if not thinner. They are sexier, if thinner. I was just sort of small, in contrast. But whenever I travelled to smaller towns and villages, I would end up feeling like a well-fed pet cat, even if I hadn’t eaten all day. It just has something to do with the bodies of the women I meet over there.

Very few are large. Some are neither large nor small. They just appear to have been sucked in and slung out of shape by the usual vicissitudes of children, domestic chores, fetching water, so that bits of them are thin and bits are fleshily loose. Most of them, however, are really small creatures. All face and eyes and cheekbones, and thin all over, from their bony shoulders to brittle wrists.

To see such small, brittle women in Punjab was even more surprising. People in Delhi like to say that Punjabi girls run to fat almost as soon as they get married. In the villages, with that ever-flowing myth of ghee and lassi, one sort of expects all married Punjabi women to be nicely rounded. Plump in a comforting, happy way.

But there was always someone like Kulwinder Singh, queuing up outside a Primary Health Centre (PHC), with her shiny wallet and her hanky and her big eyes. She had been diagnosed with anaemia yet again. Twice, she had miscarried, and doctors said it was because she had ‘only 5 grams of blood’.

I understood that she was talking about her hemoglobin count, which should be at least 12. She knew she needn’t have lost the babies if she ate better. Or even if she could have been checked by a health worker, or ANM (auxiliary nurse mid-wife) as they were formerly known, at the start of her pregnancy. There might have been time to build her strength, feed her more supplements. But Kulwinder had never seen a health worker in her own village.

I did ask her about what she ate, having foolishly assumed that she didn’t know how to include minerals and vitamins in her diet. But as it turned out, there wasn’t enough money to buy a great diversity of food. People just didn’t grow that much of a diversity any more. There was a buffalo at home but at the mention of milk, she looked like she was going to throw up. “How much milk can one drink?”

“It is good that we have this small hospital here,” she said. “I can walk to it if I need to. But we get only a few cheap medicines at the PHC. Most of the prescriptions have to bought from private (medical) stores.”

It was practically an echo of what I’d been hearing at nearly all the public health institutions I visited in Punjab, ranging from a bustling civil hospital where heart surgeries are successfully performed, to tiny ayurvedic dispensaries: plenty of patients, a few overworked doctors, almost no medical supplies.

I had once met an avuncular Sikh gentleman on a train, on my way back from Punjab, who initiated a hesitant conversation about the state of the state, so to speak. I knew enough about Punjab by then to see through the peaches-and-cream complexion of our collectively imagined Punjab, but I had also seen far worse. Yet, the gentleman was complaining. The state couldn’t be called a ‘developed’ state, he said. It did not compare to developed nations. Their stuff was world-class, he said.

Now this business of ‘world-class’ really gets my goat. Administrators and governors and businessmen all gibbering on about building world-class hospitals, world-class airports, world-class cities, world-class sporting facilities. What class of world are they talking about? Which part of the world? Sub-Saharan Africa is the world, and so am I. And refugees are the world, and so are multinationals selling garbage in the name of food. Who decides what model is worth emulating? Who decided that Shanghai is more beautiful than Satpura? Who wants malls glassed up to the eyeteeth and crammed with brands in which bored people with money can waste time? What a rubbishy term: ‘world-class’!

And thus annoyed, I began to argue. In Punjab, there was so much to be proud of, I said to the gentleman. Look at the beautiful miles of mustard and emerald rice. Why, look at the development indices, if you like. People weren’t starving to death here. And even for the poor and homeless, there was always a langar at the nearest gurudwara, or a prasada at some dera. The roads are quite decent, and few villages were so remote that it might take days to reach a doctor.

This avuncular gentleman, who turned out to be breeder of race-horses in Pune, kept shaking his head, insisting that whatever was accomplished was accomplished by a generation that had long ceased to have any control over anything. ‘Decades ago,’ he stressed. Since the late sixties, nothing had changed for the better in infrastructural terms. Punjab, he said, had been overdrawing its natural and social savings account for far too long.

Now, I was just back from reporting about serious stuff like the spurt of cancer in the bread basket, sinking water tables, and bonded labor sprinkling the emerald fields. In my heart, I knew the gentlemen on the train was spot on with his overdraft analogy, but it upset me that the criticism came from him – a rich fellow probably, and he didn’t even live in Punjab. Besides, I like winning arguments and it was upsetting me to have to lose this one. I went back to my detective novel and did not make any further attempts to engage in a discussion about overdrawn social accounts.

But here, now, I was watching Kulwinder Singh who had had two miscarriages because she had ‘only 5 grams of blood’. Like anything else, health too is an investment. You have to put good things into your body. And unless you grow every single thing your body needs, you have to have money to buy health. And if you cannot afford to… well, then what happens?

I went on to do a story on the public health system in the state and the current crisis and changes it was struggling with. Take a look at some of the figures from Punjab’s budget for the financial year 2006-07. The state allocated Rs. 2761.77 crore for education, sports, arts and culture; Rs. 909.78 crore on health and family welfare; Rs. 964.80 crore on social welfare and nutrition; and Rs. 232.64 crore on water supply, sanitation, housing and urban development. Only Rs 232.64 crore were needed, according to those who rule the state, to ensure a decent water supply, sanitation service, along with housing and urban development. When I look at these figures, I cannot help wondering how much a new airport costs. Or how much it costs to just run and maintain a ‘world-class’ airport for a year. I wonder if it is more than Rs. 232.64 crore.

Meanwhile, take a look at another set of figures:

In 1980-81, health spending comprised 5.49 % of the state budget; by way of comparison, Police and Administration got 8.28%. In 1990-91, health got 4.61% of the budget while Police and Admin got 20.83%, although perhaps that could be attributed to the very troubled decade of insurgency. However, the trend continued much after the insurgency was controlled. In 2003-04, health got only 3.86%, while Police and Administration got 23.18%. In the 10th five-year plan (2002-07), state spending on health came down to just 2.28% of the budget.

Inexplicably, even these funds were not used up. A substantial portion of the state budget for health and family welfare remained unspent. The ratio of total expenditure to total outlay has gone down from 0.83 in the 4^th five-year plan, to 0.74 in 9^th plan.

And once again, I wondered, what happens to world-class when it comes to spending? Which model from which country do the finance guys in parliament look at when they make these plans? There is absolutely nothing ‘world-class’ about a measly 2.28% set aside to ensure the state’s health.

These figures might have improved marginally over the last couple of years. India as a whole certainly has improved, having notched up its health score to 3.4% of the total government spending (according to World Health Organization statistics in 2009). But we are nowhere near world-class even now. Canada puts aside at least 17.8% of its expense account for public health. So does Botswana. Norway, Germany and Japan do 17.9% and Switzerland does 18.5%. And Haiti does 29.8%. China does 9.9%. Malawi, Macedonia, Zambia, Turkmenistan, Guatemala, Peru, Sweden, Bosnia, Iran, Thailand, Cuba, Qatar, Nepal, Nigeria – you name it. They are all doing better than us. None of them are crowing about being superpowers or more urbanized or globalised or more ‘open’. If it is any consolation to us, Pakistan is below us on the health merit list. Figures for Somalia are not available but I would be very curious to see how much of a difference there is between the way that government spends its money, and the way we do.

These are all just numbers, of course. Dollars, crores, percentages, ratios. It is hard to derive meaning from a pie-chart or a five-year plan. It is hard to imagine that what these numbers mean is a lack of medical supplies, a shortage of doctors and even a misplaced emphasis on treatment, rather than the prevention of disease. It is hard to see that the numbers translate into a young Kulwinder Kaur of Kartarpur village, standing in the sun at the local PHC, with her yellowing skin, hollow eyes, sad smile and a matter-of-fact narrative about having given birth to a stillborn, because she has got ‘only five grams of blood’.

Health care in Punjab has been mostly a private enterprise, and is a fairly successful enterprise, if one looks at the commerce aspect. It is also heavily tilted towards techno-intensive ‘tertiary’ or curative health care, with more and more emphasis on specialty or super-specialty clinics. Primary and secondary healthcare have been crumbling, because there’s no money in it. Nobody makes any money off a healthy child, after all.

Besides, any public health professional will tell you that it is pointless talking about health in isolation; it is as much about transport, roads, sanitation and water as it is about life-saving drugs. The first step to health is ensuring a safe water supply. Dr P.L. Garg, state coordinator of the Jan Swasthya Abhiyan, who was also working with the directorate, Research and Medical Education at the time, had told me that 11,849 villages in the state were classified as ‘water scarce’, but there are water supply schemes for only 8,321 villages. I asked him what happens to the rest. He shrugged.

“Nutritional standards are falling, despite the green revolution. There’s more calorie intake but protein malnutrition is rampant, since there are fewer varieties of legumes left, which were the primary source of protein here. And yet, the government has initiated no research on high-yielding legumes.”

CRIDD (Centre for Research in Rural and Industrial Development) conducted a survey in 2002, and found that 70% of the sub-centers, 67% SHCs (Subsidiary Health Centers or dispensaries), 62% PHCs (Primary Health Centers) and 51% CHCs (Community Health Centers) didn’t even have proper buildings. There are few consultations or diagnostic facilities. Not surprisingly, the report also found that only 7% of rural and 6% of urban households used public health institutions for non-hospitalized illnesses.

The state has been making its own plans to scale up public health facilities. One of the things it was trying to do (in 2007, when I was reporting on the issue) was to try and recruit more doctors through a new scheme called the ‘alternate service delivery system’. Doctors would be appointed on a three year contract and would be monitored by the zila parishad, which would be responsible for maintaining the hospital building. The contract was to be non-transferable, to ensure that doctors in rural areas do not try to wiggle out of their postings. Each doctor would get Rs. 30,000 a month, including the salaries to be paid to a pharmacist and a class-4 worker. Rs. 7,500 worth of medical supplies would be allowed each month. There were performance benchmarks too, like seeing 20-25 patients a day. The registration fee remains one rupee, which goes to the zila parishad.

The new policy came in for a shower of criticism. Researchers pointed out that panchayats don’t have the capacity to regulate educational and health institutions. Doctors agree that more flexible models are welcome, but they want the state to invest in bigger hospitals, better facilities, more doctors and more mobile units. And 2.28% of the budget is just not going to do it.

Most states in India – Punjab included – don’t even bother to develop their own health policies. Developed nations like the USA and UK spend anything between 14% and 20% of their budgets on health. Punjab, with its 2.28%, was doing slightly better than the all-India average of 1.5% but there is little comfort in knowing that one state sets aside a wee bit more than others. 2.28% just isn’t enough. Not for India and not for Punjab. Not if the only thing you can boast about is that people in the villages are not quite starving.

In retrospect, I think part of my irritation with the ‘world-class’ business was that it was constantly being referred to in the context of cities. Have you ever heard any businessman or politician attempting to create a world-class village that will have the best possible health care system and the best fruit and the cleanest water and the most ‘international’ of schools? None that I can recall.

It has taken a few years, but I am finally starting to make my peace with the term ‘world-class’. I suppose it essentially implies that there is an ideal, or at least a better life, that we aspire to, and that we ought to try and make it happen. The sad part, however, is that I am reasonably certain that not many world-class things have been created in Punjab. Golf courses maybe. I don’t know what else. It has been a couple of years since I visited Punjab last but I would be very pleasantly surprised if the new government has improved on that 2.28% figure in its annual budgets. I am certain that the predatory bird of malnourishment hasn’t been scared off the emerald rice-fields by the scarecrow of swanky new airports. And while I am hopeful that Kulwinder Kaur has more than ‘5 grams of blood’ by now, I am certain she will not be the last one queuing up at PHC counters, broken down by nutrition related tragedies.

These days, I am also seized by regret that I cut short that conversation with the avuncular Sikh gentleman on the train. I wish I had taken his phone number or card at least. I would have liked to have another bash at discussing development. Without getting defensive about who we are. Without feeling criticized simply because there is a gulf between us and the others who have done better than us. Without hostility to the notion that we have failed ourselves and need to catch up. Perhaps, then, my horizons would have broadened. Or perhaps, I could have squinted and shaken my head vigorously, like he did, and seen things in a single focused beam of wise, yellow light.