Death as Infrastructure: Why Building Hospitals Alone Cannot Determine Survivability

The treatment that offers my mother the best chance of living longer costs Rs 5 lakh for a single cycle. If it works, she will continue receiving it until the cancer becomes resistant or the side effects become intolerable. The uncertainty is no longer whether medicine is the solution – it is whether we can afford it.

In March 2025, my mother was diagnosed with ovarian cancer. She responded well to her first line of treatment and remained in remission. Four months later, the cancer returned. Her oncologist recommended molecular testing to determine whether she qualified for a targeted therapy. The result was positive: she was eligible. What should have been reassuring instead exposed another reality. The treatment came with a price tag of Rs 5 lakh per cycle, while her annual insurance cover is capped at Rs 10 lakh.

It was not only a medical journey but an economic one too. Each clinical decision became inseparable from a financial calculation. The question quietly shifted from "What treatment offers the best chance of survival?" to "What treatment can we afford before our resources run out?" Ours is not an exceptional story. Across Assam – and across much of India – it is becoming an increasingly familiar one.

The situation unfolds when Assam is witnessing significant investments in healthcare infrastructure. The state government has expanded medical colleges, strengthened district hospitals, and increased investments in diagnostics and specialised services. The Assam Cancer Care Foundation – a collaboration with Tata Trusts – has begun distributing cancer care facilities across districts, so that patients no longer have to travel to Guwahati or beyond for chemotherapy and radiation. These are significant achievements. They reflect an important political commitment – that geography should no longer determine whether someone can receive cancer care.

Yet, hospitals are only one layer of healthcare infrastructure. The ability to survive increasingly depends on the affordability of targeted therapies, and immunotherapy infusions capable of extending life. For families in Assam, these costs are amplified by geography. Advanced molecular diagnostics are available only through a handful of laboratories outside the state’s routine public health system. Patients often travel repeatedly between Guwahati, Mumbai, Bengaluru or Delhi for consultations, testing and treatment. Accommodation, transport, lost wages and caregiving accumulate alongside medical bills. 

The National Cancer Registry Programme estimates continue to show Assam among the states with the country’s highest cancer burden, making this challenge particularly urgent. Across the northeast, the disease burden from cancer runs to over 2,100 disability-adjusted life years per 100,000 population – the second highest of any region in India. 

Cancer is often described as a biological disease. Yet for millions of people today, what determines survival is not only the biology of the tumour but the architecture of the health system surrounding it. A patient may receive an early diagnosis in a state-of-the-art facility, undergo sophisticated imaging, and consult highly trained oncologists – and still face death, not because medicine failed, but because the recommended treatment was unaffordable. 

The hospital exists; survival does not necessarily follow. Essentially, that is death as infrastructure. 

We usually think of infrastructure as something that enables life – roads, bridges, hospitals, electricity. Yet infrastructure also allocates life. It determines who reaches treatment, who can afford diagnostics, who qualifies for new medicines, and who survives long enough to benefit from scientific innovation. When those systems consistently distribute survival according to purchasing power, death itself becomes infrastructural. To speak of death as infrastructure is therefore to move beyond narratives of individual misfortune. It asks how policy, pharmaceutical pricing, public investment, insurance design, and global inequalities become woven into the biology of disease. The tumour may grow within the body, but the conditions that permit its progression are often produced outside it. Many deaths attributed to cancer are also deaths produced by an infrastructure that prices survival beyond reach.

The architecture of cancer care has changed faster than India’s health policy has. Increasingly, treatment decisions depend on sophisticated molecular diagnostics rather than conventional pathology alone. For ovarian cancer, tests such as Next Generation Sequencing (NGS), Homologous Recombination Deficiency (HRD) profiling, and Folate Receptor Alpha (FRα) testing determine whether patients qualify for targeted therapies capable of extending survival by months or even years. Yet they remain prohibitively expensive and largely unavailable within India's public health system. Precision medicine has therefore created a new frontier of inequality. Access is no longer determined simply by whether a patient reaches a hospital. It is determined by whether they can afford the test that unlocks treatment.

Twenty years ago, the central challenge in cancer care was physical access. Patients travelled hundreds of kilometres to reach specialist hospitals, often arriving too late for treatment. Today many patients overcome that barrier. They reach modern cancer centres, receive sophisticated diagnoses, and consult highly trained oncologists. Yet they encounter a different obstacle. Medicine increasingly knows what can prolong life. The question is whether patients can pay for it. The geography of exclusion has shifted from distance to affordability.

We often speak of access to healthcare, but access itself is infrastructural. It is shaped by insurance coverage, the availability of public hospitals, the price of diagnostics, intellectual property regimes, pharmaceutical markets, transportation, caregiving and household savings. A diagnosis of cancer, therefore, marks not only the beginning of medical treatment but entry into an economic system that continually asks whether life can be afforded.

As The Lancet has increasingly argued, financial toxicity has become a clinical consequence of cancer itself, accelerating physical decline while exhausting emotional and social reserves. Pharmaceutical innovations extend survival while remaining inaccessible to those who need them most. The health system does not explicitly sentence people to death; rather, it creates conditions in which survival is contingent upon purchasing power. The infrastructure does not fail – it functions exactly as it has been designed, distributing the possibility of survival unevenly.

Recognising this gap does not diminish Assam's achievements. On the contrary, it identifies the next frontier of health policy. If the first generation of investment focused on building hospitals, the second must focus on making contemporary cancer care financially accessible. That requires expanding insurance coverage to reflect advances in precision medicine, negotiating lower prices for targeted therapies, investing in publicly funded molecular diagnostics, and strengthening patient assistance mechanisms. Infrastructure should not end where the prescription begins.

The measure of a health system is not only how many hospitals it builds, but how many people are able to complete the treatment those hospitals recommend. The true infrastructure of healthcare is the infrastructure of survival. When affordability becomes integral to policy – not an afterthought – public investment translates into longer lives, greater equity, and deeper public trust. Until then, for many families, death will continue to be shaped not only by the biology of cancer, but by the economics of care.

When my mother's oncologist explained which medicine could help her, the uncertainty was no longer medical. It was financial. This distinction haunts me every day. Modern medicine increasingly knows how to prolong life. Public policy has yet to ensure that those possibilities are available beyond those who can pay for them. We often celebrate hospitals as symbols of development. Perhaps the more difficult question is whether we are willing to build the economic infrastructure that allows people to survive after they walk through their doors. 

Until we do, many deaths will be more than biological tragedies – they will be infrastructural ones.

Abantee Dutta is co-founder and director of Studio Nilima: Collaborative Network for Research and Capacity Building, based in Assam. She writes from the perspective of a caregiver.

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