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The Architecture of Dying: What India's Healthcare System Refuses to Learn

In a world that worships longevity but fears the decay that precedes it, we have forgotten how to die. BJ Miller, a palliative care physician who lost three limbs to an electrical accident, reminds us that dying is not just a medical event — it is a design problem. His TED talk, a quiet manifesto for reimagining the end of life, lands with the force of a snowball in a burn unit: cold, startling, and strangely beautiful.

But what happens when you transplant Miller’s insights into the brutal, underfunded, and often indifferent healthcare machinery of India? The answer is a mirror held up to a government that has systematically designed suffering into the lives of the poor, while exporting a fantasy of "Ayushman Bharat" as universal care. This is not about the absence of empathy among individuals — most doctors and nurses, as Miller notes, mean well. It is about a system, and the political class that architects it, that places disease at the center and pushes human dignity to the periphery. Let us walk through Miller’s three design cues, and see how the Modi government has inverted every one of them.

The First Cue: Tease Out Unnecessary Suffering

Miller distinguishes between necessary suffering — the existential pain that comes with loss, the "cosmic right-sizing" — and unnecessary suffering: the kind "invented" by bad design. In India, unnecessary suffering is not an accident; it is a policy outcome. Over 70% of healthcare expenditure is out-of-pocket, pushing an estimated 55 million Indians into poverty every year (Lancet, 2018). When a terminal cancer patient in a district hospital is told there is no morphine because the Narcotic Drugs and Psychotropic Substances Act deters even legitimate pain relief, that is invented suffering. When a family sells its land to pay for ICU care that will only prolong agony, that is a design failure.

The government’s response has been a raft of insurance schemes that funnel public money into private players. Ayushman Bharat, with its grandiose promises, covers only hospitalisation — it does not reimburse outpatient care, medicines, or diagnostics. For the dying, who often need palliation, not intervention, the scheme offers a loud silence. As Miller says, "Justice for acute trauma and treatable illness. They’re no place to live and die." Our public hospitals, starved of funds and staff, have become triage centres that can only offer numbness — or death in a corridor.

The Paradox of Indian Healthcare Spending

Consider a comparison. India’s public health expenditure hovers around 1.28% of GDP (Economic Survey 2022-23), against a global average of 6%. The government’s own National Health Policy 2017 had promised 2.5% by 2025; the pandemic was used as an excuse to abandon even that modest target. The table below shows just how miserly India’s spending is, and how little reaches the most vulnerable:

Public Health Expenditure as % of GDP and Palliative Care Access

Country	Public Health Expenditure (% GDP, latest)	Palliative Care Integration (0-100 scale, WHO)	Morphine Consumption per Cancer Death (mg, 2019)
United Kingdom	8.0%	93	68,000
Canada	7.5%	90	58,000
India	1.28%	1.5	1.2
Bangladesh	0.8%	2.0	0.8

The numbers are an indictment. India, a nation that prides itself on being a pharmacy to the world, leaves its dying in agony because the drug control regime, driven by a punitive mindset, treats even terminally ill patients as potential addicts. The Narcotics Drugs and Psychotropic Substances (NDPS) Act amendments in 2014 were supposed to ease access to opioids for medical use. Yet, implementation has been patchy — states like Uttar Pradesh and Bihar have virtually no palliative care infrastructure. Unnecessary suffering is not just tolerated; it is legislated.

The Second Cue: Dignity through the Senses

Miller’s second design cue is about tending to dignity "by way of the senses, by way of the body, the aesthetic realm." He speaks of a snowball brought into a burn unit, the smell of cookies in a hospice kitchen, a woman with ALS who wants to smoke French cigarettes again. These are not indulgences — they are reclamations of humanity. In India’s healthcare landscape, where the public system often treats patients as bodies to be processed, such sensory grace is an unimaginable luxury.

The government’s obsession with "smart cities" and "digital health" betrays a conviction that technology alone will solve systemic rot. The National Digital Health Mission envisions electronic records for all, while primary health centres lack running water and basic analgesics. The aesthetic dimension — natural light, gardens, spaces for families, the ritual of parting — is dismissed as Western frippery, when in fact it is rooted in India’s own traditions of care. Where is the government’s investment in community-based palliative care, in training panchayats to support the dying? It is non-existent. The Ayush revolution the state promotes — yoga, Ayurveda — is about branding, not about integrating holistic, patient-centred approaches into the mainstream.

Miller’s Zen Hospice Project sprinkles flower petals on the dead as they are wheeled out, a small ritual to "usher in grief with warmth rather than repugnance." In India, bodies are often handed over in corridors, with families scrambling for ambulances. Dead bodies of COVID victims were treated as biohazards, not as beloved human beings. The government’s guidelines for disposal during the pandemic were a masterclass in dehumanisation — no touch, no ritual, no time. The aesthetic, in the truest sense, is the opposite of anaesthetic. But a system that equates efficiency with speed can only offer the latter.

The Kitchen as the Centre of Care

Miller finds the most poignant room in the Zen Hospice to be the kitchen, where cookies are baked even for those who can barely eat. In India, the notion that a government facility would allow a kitchen for families, let alone bake cookies, sounds like science fiction. Hospital kitchens, where they exist, are notorious for corruption and neglect — the infamous "rat in the mid-day meal" stories are just the tip. The Public Distribution System ensures that even the grain meant for the poorest is often adulterated or stolen. When the state cannot provide the basic grammar of sustenance, can we speak of a caring society?

Yet, the Indian cultural memory is rich with caregiving traditions — the langar in gurudwaras, the community kitchens in temples, the haldi-doodh brought to a sick neighbour. The government has systematically dismantled community solidarity through divisive politics and centralisation, then wonders why families dump their elderly in overburdened city hospitals. The kitchen of care is not a building; it is a social fabric. That fabric is in tatters.

The Third Cue: Play, Adaptation, and a Life More Wonderful

Miller’s final cue is radical: we must set our sights on wellbeing, not just the absence of horror. He calls it "play" — the creative, generative impulse that turns the need for cover into architecture, the march of time into music, and the fact of death into something we design towards. This is the hardest lesson for a government that thinks in terms of schemes, targets, and electoral cycles. Palliative care, in its true form, is about helping a person say, like Frank, "I want to raft down the Colorado River," and then enabling that, even if it carries risk. It is about Kate wanting to feel her dog’s cold muzzle against her dry skin instead of more chemotherapy.

In India, the discourse on health has been captured by two extremes: cure or abandon. The government’s fit-india, eat-millet, do-yoga campaigns are a moralistic drumbeat that blames the individual for systemic failures. If you get cancer after surviving on a polluted diet in a smog-choked city, you are told to crowdfund your treatment. The state does not ask what would make your remaining life meaningful, only whether you can be saved or not. The Ayushman Bharat cards become a lottery ticket for the lucky few; for the rest, death is a bureaucratic process. The National Programme for Palliative Care, launched in 2012, remains a ghost — barely funded, unknown to most district officials. The government’s refusal to integrate palliative care into medical education ensures that generations of doctors will continue to see death as failure, not as a stage of life requiring its own art.

What Would a “Designed” Indian Death Look Like?

To design for death is to design for life — to ensure that every person, regardless of wealth, can die with dignity, in the presence of loved ones, free of pain, and with a sense of having mattered. Miller’s talk offers a blueprint: distinguish necessary from unnecessary suffering, soothe with the senses, and make room for play. What would that look like here? It would mean a national health policy that allocates at least 3% of GDP to public health, with a dedicated stream for palliative and geriatric care. It would mean a complete overhaul of the NDPS Act to treat morphine as essential medicine, and training thousands of community nurses to deliver pain relief at home. It would mean hospitals with windows, gardens, and spaces for ritual — not just “spiritual centres” inaugurated by ministers in corporate chains. It would mean a government that stops building statues and starts building hospices.

None of this is imminent, because the current dispensation is not interested in designing a society of care. It is interested in projecting power. The prime minister’s photo on vaccine certificates, on ration bags, on everything — that is the aesthetic of a regime that has no room for the intimate, vulnerable space of dying. The digital health ID is a tool of surveillance, not of comfort. The import of "wonderment" cannot be measured in GDP, so it has no place in the New India narrative of bullet trains and unicorns.

Criticisms

• A health budget of 1.28% of GDP is consistently maintained, while corporate tax cuts and billionaire bailouts are prioritised.
• The Ayushman Bharat scheme is promoted as universal healthcare, though it excludes 70% of the population from cashless outpatient care, medicines, and palliation.
• The NDPS Act is kept so restrictive that terminally ill patients are denied morphine, while state governments are not held accountable for non-implementation of the 2014 amendments.
• Palliative care is largely ignored in medical curricula, and the National Programme for Palliative Care is left unfunded and unmonitored.
• Primary health centres are starved of resources, while large sums are diverted to private hospitals through public insurance models, enriching corporate interests.
• During the COVID-19 crisis, guidelines for handling dead bodies were framed in a manner that stripped families of necessary rituals, under the garb of safety.
• Sensitive caregiving traditions are eroded by communal polarisation and the systematic dismantling of community bonds, with healthcare being reduced to a transactional, state-centric model.
• The government’s wellness campaigns are used to burden individuals with responsibility for illnesses caused by environmental degradation and policy failures.
• Aesthetics, dignity, and sensory care are treated as irrelevant in public hospitals, which remain overcrowded, windowless, and dehumanising.
• The National Digital Health Mission is advanced as a solution while basic infrastructure like water, electricity, and painkillers is still missing from rural health facilities.

Miller ends his talk with a line that should echo in every planning commission chamber: "Let death be what takes us, not lack of imagination." India’s healthcare tragedy is, at its core, a failure of imagination — a failure to see suffering as something that can be redesigned. The cure is not just more money, though money is essential. It is a shift, a thousand small shifts, away from the edifice of a boastful state and towards the quiet, persistent work of making life, and death, more wonderful. The snowball is melting, as it always does. The question is whether we will learn to hold its coldness and be transformed, or whether we will simply let it drip away, blaming fate and the unfortunate poor.

Original talk by BJ Miller at TED, "What really matters at the end of life," March 2015.
Data: WHO Global Atlas of Palliative Care, 2020; Lancet Commission on Palliative Care and Pain Relief, 2018; National Health Accounts, India, 2020-21.