The Unseen Enemy Within: Why Hepatitis Still Claims Lives in India
Heramba Nath
In the annals of preventable human suffering, few public health tragedies are as persistent and ironic as hepatitis in India. Despite the advent of vaccines, the availability of improved hygiene and sanitation infrastructure, and decades of awareness campaigns, viral hepatitis continues to claim lives in India with stubborn regularity. This is not merely a failure of medicine, but a lapse in systems, political will, and social equity. The contradiction is both painful and preventable: a disease whose death toll is now largely avoidable continues to reap a heavy human cost in the world’s most populous democracy.
Hepatitis, an inflammation of the liver, can be caused by various viruses—A, B, C, D, and E. In India, hepatitis A and E are primarily waterborne and associated with poor sanitation and unsafe drinking water, while hepatitis B and C are blood-borne, often linked to unsafe medical practices, unregulated injections, and mother-to-child transmission. Despite years of medical advancement and large-scale immunisation drives, millions remain infected, and many die silently without ever being diagnosed. Hepatitis B and C, in particular, continue to fester as a ticking time bomb, causing chronic liver disease, cirrhosis, and liver cancer.
India bears one of the world’s highest burdens of viral hepatitis. According to recent estimates, over 40 million people in India are chronically infected with hepatitis B and approximately 6 to 12 million with hepatitis C. The World Health Organization (WHO) ranks hepatitis as the seventh leading cause of death globally, and India contributes significantly to this mortality burden. These staggering figures reveal not only a health emergency but also the underlying socio-economic and institutional weaknesses that perpetuate it.
The tragedy lies in the contrast between possibility and reality. Hepatitis B, for instance, is vaccine-preventable. Since 2002, India has integrated the hepatitis B vaccine into its Universal Immunisation Programme (UIP), now given to infants at birth and during early months of life. The hepatitis A vaccine is also available, though not part of the UIP for all children. Yet gaps in coverage, missed doses, and logistical challenges persist. Large swathes of the population—particularly in rural and underserved areas—remain outside the protective umbrella of vaccination. Even where vaccines are available, awareness about their importance remains critically low, especially among informal sector workers and daily wage earners.
India’s fight against hepatitis is not just a medical battle, but a public infrastructure war. Hepatitis A and E thrive in environments of inadequate sanitation, contaminated water, and open defecation. Though the Swachh Bharat Abhiyan has made important strides in improving rural sanitation and building toilets, access to clean water and proper sewage systems remains a challenge in many regions. Urban slums and peri-urban clusters continue to be hotspots of hepatitis outbreaks, as public taps, leaky drainage, and unhygienic food vendors form a cocktail of exposure points.
In 2018, the Government of India launched the National Viral Hepatitis Control Programme (NVHCP) under the National Health Mission, with the aim of eliminating hepatitis C and reducing the morbidity and mortality of hepatitis B by 2030. The programme was designed to provide free diagnostics, testing, treatment, and public awareness campaigns. The strategy was robust on paper, but on-ground implementation has suffered from the usual systemic hurdles: shortage of trained personnel, erratic supply chains for drugs like tenofovir and sofosbuvir, limited decentralisation, and underutilised health infrastructure in rural areas.
A persistent concern is the absence of widespread screening. Hepatitis B and C are often asymptomatic for years, silently damaging the liver until it is too late. Without proactive testing, millions remain unaware of their infection. Unlike HIV, hepatitis does not benefit from the same level of activism, funding, or political urgency. People often do not know that routine screening is possible or necessary. In many parts of India, blood transfusions are still not screened with the utmost rigour, especially in informal medical setups, allowing the disease to spread undetected. Unsafe injection practices and poorly sterilised surgical equipment further exacerbate the risk.
The issue of stigma is another silent villain. Hepatitis patients—particularly those with hepatitis B and C—face social discrimination. Misinformation leads many to wrongly assume that hepatitis spreads through casual contact. This stigma discourages people from coming forward for testing or treatment, much like the early years of the HIV/AIDS crisis. In educational institutions and workplaces, disclosure often results in isolation or denial of opportunity. Such stigma needs urgent dismantling through mass literacy programmes that emphasise the scientific truths of transmission and treatment.
The matter of maternal transmission is equally troubling. An infected mother can pass the hepatitis B virus to her child at birth. However, timely birth dose vaccination can dramatically reduce the risk of transmission. While the UIP has introduced the hepatitis B birth dose, coverage is still far from universal. Many children—especially those born at home or in non-institutional settings—miss this critical intervention, placing them at high risk from day one of life. Health workers often face logistical difficulties in ensuring timely delivery, and mothers are rarely counselled adequately during antenatal care visits.
Hepatitis C, once a looming threat without a cure, is now entirely treatable with Direct Acting Antivirals (DAAs). Yet affordability, awareness, and access remain roadblocks. The high cost of treatment in private facilities, coupled with unawareness about the availability of free treatment through public health centres, means that many patients either remain untreated or fall into debt. Pharmaceutical monopolies and inconsistent procurement strategies at the state level have further delayed access to these life-saving drugs in some regions.
The tragedy of hepatitis is also interlinked with the informal medical sector. A large portion of India’s population, especially in rural areas, relies on unregistered practitioners and informal caregivers. These practitioners often reuse syringes, fail to follow sterilisation protocols, or conduct surgeries and procedures under unsanitary conditions. Regulatory oversight remains weak, and the patient’s desperation to seek affordable healthcare leads them into high-risk encounters. What begins as a tooth extraction or a minor injection can end in a lifelong infection.
Among the vulnerable populations are those marginalised by society’s structural inequities: migrants, sex workers, prisoners, injecting drug users, and tribals. The disease clusters here, often escaping the eyes of formal public health surveillance. The NVHCP rightly identifies these groups as priority populations, but implementation remains patchy. Many states still lack sufficient outreach workers or mobile testing units to penetrate these marginalised circles.
There is also a disturbing urban-rural divide in hepatitis care. In metropolitan cities, diagnostic labs, liver specialists, and public-private partnerships offer hope. In tier-two cities, these are present but costly. In rural India, hepatitis remains an invisible epidemic—undiagnosed, untreated, and unacknowledged. A villager suffering from jaundice is more likely to be prescribed herbal remedies, saline drips, or a week of rest than a proper blood test for hepatitis markers. When complications like ascites or liver failure set in, patients are referred to tertiary care hospitals miles away—often too late.
The way forward demands a multipronged strategy. Vaccination drives must be intensified, not just in infants but also in adults at risk—such as healthcare workers, prisoners, sex workers, and partners of infected individuals. The coverage of the hepatitis B birth dose must be made universal and mandatory. Innovative solutions—such as mobile vaccine vans, door-to-door immunisation in high-risk areas, and digital tracking of doses—must be deployed.
Simultaneously, public awareness must be turbocharged. Just as polio campaigns reached every household with a memorable message, hepatitis needs a flagship communication strategy. School curricula must include hepatitis education. Mid-day meal workers, school teachers, Accredited Social Health Activists (ASHAs), and anganwadi workers should be trained as foot soldiers in the war against hepatitis. Public figures, cinema actors, cricketers, and influencers must be roped in to spread the message in multiple languages and formats.
Sanitation and water safety remain the linchpin. Investments in piped water supply, sewage treatment, handwashing campaigns, and food safety inspections must be prioritised. Local bodies and municipal corporations must be held accountable for periodic water testing, drainage maintenance, and rapid response to contamination. Public eateries must face stricter hygiene audits, and street food vendors must be trained and licensed to ensure safe practices.
India also needs to address hepatitis as a human rights issue. Access to hepatitis care must be seen as a right, not a luxury. All testing—such as HBsAg, anti-HCV, and liver function tests—must be made freely available at primary healthcare centres. Follow-up treatments, antiviral drugs, and monitoring for complications should not be subject to out-of-pocket expenditures. A national hepatitis registry could help track the disease burden and ensure continuum of care. Artificial intelligence and data analytics could be employed to identify high-risk zones, optimise drug distribution, and predict outbreak patterns.
The central government must also ensure that state-level implementation does not falter due to lack of funds or training. States must be empowered and incentivised to adopt aggressive testing, tracing, and treating strategies. Just as the COVID-19 pandemic prompted mass testing and genome sequencing, India must now show similar urgency for hepatitis. Hepatitis elimination by 2030, as per WHO targets, will remain a distant dream without political commitment, financial allocation, and civil society mobilisation.
Above all, we must humanise the statistics. Behind every number lies a story—of a young child denied a vaccine, of a daily wager who lost work due to liver failure, of a pregnant woman who unknowingly passed the virus to her baby, of an elderly man denied treatment because he could not afford it. These are stories of systemic failure, but also of potential redemption. The tools for ending the hepatitis epidemic exist. The science is ready. What remains is the resolve to act.
As India strides toward becoming a global power, it cannot afford the ignominy of preventable deaths from hepatitis. If we can launch missions to the moon and deliver digital payments to the remotest corners of the country, we can surely protect our people from a disease for which the vaccine was discovered over four decades ago. The time to act was yesterday. The time to intensify action is now.