by K.S. Jacob

The Hindu

Date:06/12/2007

URL: http://www.thehindu.com/2007/12/06/stories/2007120652391000.htm

The context of public health in India demands a different framework and different solutions from what has been achieved in the west. The great imperative is a public health movement that champions the issues of basic rights.

The majority of the people living in India have yet to reach the utopian ideal of health for all, despite many decades of planning and implementation of programmes. This article re-examines the issues. The survival of the human body is best explained by the material explanation that argues that the variation in health and longevity is related to tangible resources. The reciprocal association between poverty and disease had been recognised by public health reformers in the west, who advocated social reform on political, economic, humanitarian, and scientific grounds.

Successive governments in India have, over the past five decades, proposed and implemented many schemes for the provision of safe water, sanitation, nutrition, vaccination coverage, education, and employment. Yet millions of people do not have access to these basic needs. Malnutrition is rampant among children; vaccination coverage is inadequate; elementary education second rate; and unemployment widespread in the rural areas and among the poor. Nevertheless, most States have pursued weak policies in this area and neglected the local governments, giving them a low stake in improving infrastructure despite increased budgetary support. The size of the unfinished tasks is mind-boggling.

The social, economic, and political context during the public health revolution in the west, when public health became part of their way of life, differed markedly from the situation in the developing world. The differences include:

The antibiotic era : The public health revolutions in the west were completed before the introduction of antibiotics. They eliminated epidemics of infectious diseases through public health measures. However, the antibiotic era complicates issues in modern India. The cycle and politics of cholera is an apt example. The role of antibiotics in the prevention of diseases in populations is negligible, and they worsen the situation by providing temporary relief to the suffering and allow the underlying causes for the epidemic to go untreated.

The illusions of curative medicine: The rates of tuberculosis in the west decreased long before the advent of anti-tuberculosis medication. The provision of adequate housing, the reduction of overcrowding, and improved nutrition was the ground on which this war was won in the western world. Singular reliance on the current curative approaches (for example, Directly Observed Treatment Short-course or DOTS) to problems that require long-term public health solutions will prove ineffective with the unchecked spread of infection.

The challenge of the pharmaceutical industry: The pharmaceutical industry profits from disease and ill health. The straightforward concept of the oral re-hydration solution (ORS), easily available in each household and introduced to prevent deaths, was taken over by the industry to net huge profits. The sale of ORS by the industry disempowered the population in managing diarrhoea using techniques easily available in every home.

Vaccinations as a panacea: The eradication of small pox through vaccination was an outstanding example of disease prevention. However, not all infections follow comparable patterns. The recent resurgence of polio in India is proof. The eradication of polio will surely also involve access to safe water and sanitation, in order to prevent the spread of the virus. Likewise, the work on other vaccines being done in India plays into the hands of the pharmaceutical industry and takes away from the task of providing basic health needs for the community.

The medicalisation of public health: Many contributions — engineering, political, economic, educational, and religious, in addition to medical — were part of the effort in the west. India´s public health efforts are being based on the assumption that medicine has all the answers. India´s population control programme is an example. The programme has a solitary focus, a single solution, that is, women´s fertility and sterilisation. It does not examine the multifaceted interaction between livelihoods, social security, education, employment, and infant mortality, but continues to view sterilisation of women as the only objective.

The framework and consequently the approaches employed did not take into account the different context of independent India. The errors include:

Employing urgency-driven curative medical solutions instead of long-term public health policies: The lack of safe water and poor sanitation are the reality for the majority in India, so much so that they rarely come into public awareness. Nevertheless, every epidemic of an infectious disease makes media headlines. The government response is swift and curative. Unfortunately, the media quickly move on to the next crisis and the need for permanent public health solutions is forgotten. This is also true for the association between tuberculosis and housing or chronic malnutrition and poor nutrition.

Mistaking primary care for public health: The efforts of many of the current champions of public health are usually restricted to providing curative services, albeit at the small hospital, clinic or at the village level. There is a constant demand for better curative services. This frustrates public health efforts by treating diseases and preventing death (and reducing their impact on society and on social consciousness), which should have been prevented in the first place using public health strategies.

Reducing public health to a biomedical perspective: Public health requires the meeting of many disciplines in order to bring about the necessary revolution. Public health in India relies primarily on medicine to achieve its goals. The recently launched National Rural Health Mission continues to focus and prioritise medical input and interventions. Public health issues, though mentioned, are clearly secondary.

The different context in India mandates a different framework and different solutions. The alternatives include:

Social justice and the production of an egalitarian society: The Constitution of India clearly recognises the need for social justice and has many principles to produce a just society. The upper classes, with their financial ability to buy basic needs, do not view this as an emergency. Surely, the majority of Indians, the poor and the under-privileged, have a right to demand a significant amount of governmental resources for meeting their basic needs. However, the influential minority ensures that the elected governments do not meet the basic needs of the poor.

Water, sanitation, housing, nutrition, education, and employment as basic rights: Basic needs are human rights that, in civilised societies, should be guaranteed to all. The richer classes, who currently have the ability to buy these needs, should accept the need for a basic minimum standard for all. However, the fall of socialism and the rise of capitalistic thought have resulted in the sidestepping of such ideals.

National statistics and the evaluation of government policies and programmes: The right to health is a fundamental right and should be employed to assess the performance of elected governments. However, the government prefers to restrict the discussion related to the health of the population to the issue of resources for medical treatment as a means of deflecting the debate from the true social and economic causes of physical and mental ill health. Public health statistics (disaggregated by gender, caste, and region) should be examined to set policies and programmes to counter adverse trends in large sections of the population.

Public health as national interest: It is not in the national interest to have unmet basic needs for the majority of the population. However, many international aid agencies prefer to support specific health programmes for particular diseases. Nevertheless, the absence of basic public health needs will ensure the persistence and recurrence of the very diseases targeted (for example, malaria, polio, and tuberculosis). The west ensured a basic minimum living standard for all its citizens, and yet is adamant that the developing world focusses on specific problems rather than on developing its public health infrastructure. Similarly, many international banks focus on curative heath care and side-step the fact that even minimal changes in the health of populations are determined by socio-economic factors, rather than medical input.

Lastly, the deprivation of basic rights for large sections of the population over a long period of time leads to cynicism among the poor in the democratic process. The naxalite movement, with its philosophy of armed revolution spreading through many deprived parts of India, is a sign of such a trend.

The context of public health in India and the developing world demands a different framework and solutions. The recently launched Public Health Foundation of India aims to provide American-style education to improve public health in the country. While the results of this are awaited, the side-stepping of existing public health resources within medical colleges and governmental institutions and their completely separate operations is a cause for concern. There is a need for a public health movement that champions the issues of basic rights. The egalitarian dream for India should not die. The time for public health action is now.

(Dr. K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore. His areas of interest include culture and public health and their impact on health and disease. This article is similar to the author´s paper published as an editorial in the July 2007 issue of the BMJ group´s Journal of Epidemiology and Community Health in the U.K.)