South Asia, home to 1.97 billion people (25% of the world’s population), is no stranger to conflict and confrontation. Longstanding border disputes (such as between India and China and the decades-old standoff between India and Pakistan), the forced displacement of Myanmar Muslims to Bangladesh, and the 2021 rise of the Taliban triggering a mass exodus of professionals and educated women from Afghanistan underscore the enormous volatility and unpredictability of the region. Climate change poses a further challenge, with the real risk of interstate “water wars.” Indeed, South Asia now faces a range of threats, with real risks of these spilling over into interstate conflict. The links between longstanding conflict, insecurity, and poverty are well recognized. Abject poverty, especially when associated with disparities, underlies many of the known conflicts worldwide, unsurprisingly given the drain conflict places on social sector spending. And although lack of social inclusion and ethnic inequalities have been shown to lead to domestic terrorism, economic inequalities, and grievances are stronger drivers of rebellion and are particularly relevant in South Asia. Despite robust economic growth and progress on many technological fronts, South Asia still has the world’s largest concentrations of poverty, illiteracy, malnutrition, and preventable maternal and child deaths outside sub-Saharan Africa. Widespread poverty is closely intertwined with social disparities, marginalization on the basis of an egregious caste system, and vast inequities that perpetuate disillusionment, grassroots rebellion, and further conflict.

We have previously described the disruptive effects of conflict and insecurity on health systems, with some long-term consequences on maternal and child health outcomes. Conflict, insecurity, and uncertainty affect planning and stable investments in health systems, and the extreme distrust between India and Pakistan continues to jeopardize public health and social protection in South Asia. The two countries have fought three wars since independence in 1947, have hundreds of thousands of troops deployed on volatile borders, and dedicate 14-18% of their entire government budget to military spending, leaving little for human development and social safety nets. For example, the decades-long face-off of troops at the Siachen glacier continues to cost India and Pakistan over $600m annually, about the cost of the entire primary care and public health program in 34 provinces of Afghanistan for 2021-23. These expenditures also pale in the face of the enormous cost of maintaining nuclear arsenals and delivery systems in India and Pakistan a travesty is given that 22-28% of children in both countries don’t receive routine early immunizations.

The history of conflict and vast inequities meant the region was a sitting duck for an infectious disease outbreak that took full advantage of social vulnerability. The covid-19 pandemic has clearly exposed the extreme fragility of health systems, the limitations of emergency response capacity, inadequate early disease warning capabilities, and minuscule social support systems in the region. Consequently, South Asia has fared badly, with massive social and economic disruptions and the emergence of the delta variant leading to tremendous excess mortality across many countries in the region, including Sri Lanka, which had been less affected in the early phases of the pandemic ( Education was interrupted for an estimated 434 million children, and numbers of teenage pregnancies rose by over 450 000 as young girls were married after dropping out of school.

South Asian peoples are rooted in ancient civilizations and a deep and resilient culture. Despite the diversity of faiths, ethnicities, and geographies, they have largely lived together peacefully. In recent decades, however, exchanges between different groups, especially the youth in the region, have been minimal. Shrill, jingoistic media and unwanted acrimony in cultural and sports events have further alienated civic society. As we emerge from the pandemic, we need to promote greater exchanges between peoples of the region. Removing arcane and divisive visa arrangements would help promote peace and many of the actions outlined above. Mistrust and security challenges since independence from colonial rule have meant that too many South Asians live in fear, poverty, and ill health, with uncertain futures. Although the covid-19 pandemic has substantially set back economic progress and human development in the region, it also offers an opportunity to jump start a change in building back a fair and secure future for our children. Now, more than ever, we need to join hands to support our shared humanity and shape a new future for generations to come.