Rethinking health priorities in a world out of balance
Item
- Title
- Rethinking health priorities in a world out of balance
- Creator
- Madhukar Pai
- Date
- 1998
- extracted text
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Rethinking health priorities in a world out of balance
Dr Madhukar Pai
Department of Communitv Medicine,
Sundaram Medical Foundation Community Hospital, Chennai
" If you see a baby drowning you jump in to save it; and if you see a second and a third you do the
same. Soon you are busy saving drowning babies you never look up to see there is someone there
throwing these babies in the river.”
Wayne Eltwood
India, as one author very bluntly put it 'is slowly becoming an enormous lavatory which
breeds not just disease but despair1.1 In addition to being labeled the global capital of AIDS we
have, over the last, few years, witnessed outbreaks of plague, cerebral malana, dengue,
leptospirosis and drug resistant tuberculosis and typhoid.2 Infectious diseases that had been
controlled in the past have re-emerged in a big way.2 To add to our woes, we are being warned
about emerging infections (like Ebola, Hanta, etc.) even as the World Health Organization
observed the 1997 World Health theme: Emerging Infectious Diseases - Global alert, Global
response.3
There has been a widespread perception that the frequent occurrence of public health
emergencies like outbreaks are merely reflective of the declining standards of public health in
several parts of the country. This phenomenon has been called the 'urban decay.' Pollution,
overcrowding, poor drinking water quality, inadequate sanitation, poor garbage disposal and
nonexistent vector control are vignettes of this decay. Alarmed by these concerns the Indian
Government appointed an Expert Committee on Public Health System in 1995." The
recommendations of this Committee, needless to say, have gone unheeded. Nothing worth the
name has been done about the public health crisis.
What ails public health in our country today? What priority does public health receive in
out country? This article is an attempt to discuss these issues. Though sarcasm has been liberally
used, I have not entirely given up on our ability to respond to common concerns!
Public health - a governmental obligation
Have you heard of the A,B,C,D, & E strategy used commonly by government
functionaries in our country? It is probably the only strategy everyone in the governmental
hierarchy uses uniformly, from the Central bureaucrats to the Municipal Sanitary Inspector. This
strategy, perfected by generations of government staff, is used to accomplish the goal of not to
accomplish anything! A stands for Abandon, B for By pass, C for Confuse, D for Deny and E for
Escape. These are methods by which the government succeeds in not doing their basic duty to
preserve health and safeguard the interests of the citizens. When reports of malarial deaths came
pouring in from Rajasthan (during the 1994 outbreak), the government was busy denying it5
(strategy D in action); when plague was suspected in Surat, the government did precious little to
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find out whether it was indeed plague - the government officials were busy appearing on the TV
to announce that there was enough tetracycline in stock6 (strategy C)! Cholera outbreaks have
become a part of out lives but our government machinery, you guessed it, always calls them as
outbreaks of’gastroenteritis.' It may also be worth mentioning that, cholera or no cholera, even
chlorination of water is not being done regularly in most towns and cities in our country. We
have even had rodent-borne infections (leptospirosis outbreaks) in Chennai.7
Equally worrying is the fact that Chennai City is fast emerging as a major centre for
urban malaria in India. Chennai city alone accounts for more than 50% to 70% of all malaria
cases reported in the whole state.8 According to the National Malaria Eradication Programme,
Chennai is considered a high risk area for malaria.9 A high risk area is a place which is
epidemic-prone, or where malaria deaths and falciparum malaria occur. What, one may well ask,
has our Chennai Corporation done other than 'oversee' this phenomenal increase in malaria, and,
of course, mosquitoes? These days, it has almost become a cliche to say that local bodies do not
have the resources to perform their basic civic duty. Incidentally, this is the city where crores are
spent on wedding(s)!
.What is the role of the government in ensuring basic public health for its citizens? By
basic public health, I refer to things like garbage disposal, water treatment and purification,
adequate sanitation, mosquito and rodent control, etc. According to the Indian Constitution,
public health and sanitation are State subjects; a Constitutional obligation. On paper, it is the
duty' of every' civic authority' to provide basic amenities to its citizens and create a healthy
environment to live in.
In reality, one look at the functioning of our municipalities is enough to convince us that
the raison d'etre of their existence is to perpetuate diseases like cholera, malaria, dengue,
diarrhoea and a host of other equally horrible pestilences. By not ensuring even basic public
health measures, the government, by the error of omission, is contributing to the resurgence of
infectious diseases. Things have come to such a pass that people have had to file suits against
civic bodies for failing to perform their basic duties. Justice Krishna Iyer, in fact, called them
"mosquito-friendly municipalities".10 In his”widely acclaimed recent judgment, Justice Narayana ~
Kurup pulled up the Kochi Corporation for its 'lethargy and inaction' in curbing the mosquito
menace in the city. "A responsible local body constituted for the purpose of preserving public
health cannot run away from its duty by pleading financial inability," the judgment said.1”
Years ago, Justice Krishna Iyer had tried to clean up Ratlam municipality' by ruling that it
was the duty of the civic authority to provide basic amenities to its citizens.1 More recently,
Justice Kuldip Singh issued detailed instructions on garbage collection to deal with garbage
problem in Delhi.1 Apparently, the only force which makes our civic bodies do the work they
are supposed to is legal action. There also, judgments and rulings do not seem to lead to anv
sustained action. The judiciary in our country, after all, can only advise, it does not have the
teeth to implement.
We Indians are a tolerant lot. We actually seem to enjoy living amidst filth, squalor and
plagues. People dying of eminently preventable diseases like diarrhoea and malaria does not
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seem to raise any concern. The fact that even rodent-borne diseases like plague and leptospirosis
have come back does not seem to wake us up from our indolence and indifference! As we
approach 2000, the magical year by which countries are supposed to attain 'Health for AH', it is
well worth noting the fact that only 14% of the Indian population has access to adequate
sanitation.4
Public health - an individual's responsibility
Is our affliction plain apathy or have we completely given up on our civic authorities? Let
me illustrate with a story from Vellore. Every year Vellore experiences outbreaks of cholera
during summer. One of the worst affected areas in Vellore town as far as cholera (and malaria
and heaven knows what else!) is concerned is an underdeveloped area called Saidapet. In this
area, water shortage is a chronic problem. People fix hand pumps wherever they can and suck
out what little water they can get from the woefully inadequate water system. Needless to say,
when they suck out water, they also succeed in sucking out sewage from the sewage lines which
run crisscrossing the water lines (it is anybody's guess as to when the pipes underground were
last replaced!). "There are days when we open the tap and get raw sewage coming from it," said
one resident. What has he done about it? "What can I do, it is municipality that has to look into
it," he said with a resigned look on his face. It also goes without saying that not much has been
done about the appalling quality of drinking water in this area, despite the annual drama of
cholera outbreaks. Our municipal friends find it much easier to go around doing cholera
inoculation (knowing fully well that no vaccine works during cholera epidemics!) to people
rather than give them clean drinking water! They in fact believe that they are making a great
contribution to public health by inoculating people with a useless vaccine!
People, in general, do not like to think about unpleasant things like garbage and
sanitation. Envisage this common scenario: garbage in your street has not been cleared for more
than a week. What do you do? It is much easier to hold your breath, avert your eyes, and quickly
walk past the rotting heap of garbage at the end of your street than raise a noise about it
(individuals, apparently, are equally capable of using the A,B,C,D, & E strategy!). As days go by,
you keep hoping that the Corporation people will come and clean up the mess. When it becomes
absolutely intolerable, and if stress of living has not completely wiped out the last traces of civic
responsibility in you, you may dash off a letter to the editor of the local paper and hope that
someone will do something about your problem. What about the other residents in your street?
Do they share your concern too? Chances are many would not even admit that there is a
problem! Some will even advise you not to get involved in such issues - "what ought to be done
by the corporation, should be done by the corporation," they will say. The arm chair cynic next
door will say, "let us all stop paying our taxes, that will teach them (Corporation)!"
Quite obviously, the government alone is not to be blamed for the sad state of affairs we
find ourselves in. There are two very fundamental questions here that need answering: Why is
public health not a priority for our government? Why is it that people have become incapable of
getting involved in common concerns?
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A world out of balance
To me, the apathy - at the governmental and the individual level - to public health is
merely a reflection of the general malaise within the system. Its roots go very deep. We are
beginning to see this, if we care to look for it, in many places, in many different ways. We see
this when we notice industries poisoning our land, water and air for immediate financial gains,
without any concern for our own future; when we see sky scrapers surrounded by squalid slums:
when the rich exploit the poor without realising that the poor too have a right to survive and
there is enough for everyone; we see this when our rulers act with absolute self-interest with no
concern for the country or the people; we see this when we stockpile more and more arms when
our children are malnourished and starving; when our elected representatives would rather invest
money in fancy cutouts than provide people with drinking water; when government officials
deny the occurrence of outbreaks than help in investigating and controlling them; when doctors
would rather wait for cholera victims to come to them (and make money) than protest against the
poor water and sanitation conditions in the community where they work; when municipalities
plead lack of funds while money meant for public health is siphoned off by corrupt officials:
when yet another scam comes to surface and people say "so tell us something new!"
All this leads me to think that humans are slowly losing the ability to think beyond
themselves. Us and Ours is giving way to Me and Mine. The obsession with material progress is
threatening to wipe out feelings of sympathy and compassion in all of us. Social problems and
common concerns rarely figure in our personal agendas. Those of us who try' to discuss these
issues (say someone who talks about protecting the environment) are called 'crackpots.' Those of
us who feel uncomfortable with aggrandizing wealth are considered 'misfits' in today's savagely
competitive world.
What is to be done?
There is very little doubt in my mind that if we have to get out of the mess we are in, we
need to go back to basics! More money, resources and attention should be focused on basic
issues like water, sanitation, garbage disposal, pest control, and civic amenities. Unless these
basic needs are met with there can be very little progress in the health of our country. These
issues are bare necessities for living, they are not a luxury. Every Indian citizen has a right to
these basic services. Is is too much to ask for these basic needs when several crores of rupees get
siphoned off by corrupt politicians? When one politician can walk away with nearly 1000 crores
(enough to provide water and sanitation to many million people!), where is equity and justice in
this country?
What has been the response of the health sector to this crisis in public health? By and
large, the response has been one of building more and more tertiary, high tech, centres of'disease
care' which few in our country can afford. The emphasis has always been on high-tech,
expensive modalities of therapy used for the rich and elite, never on simple, low-cost health
measures for the masses. Almost nothing has been done to address the underlying issues.
Needless to say, health professionals (doctors in particular) have rarely taken disease prevention
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seriously. When making money is ail important, preventing diseases is akin to killing the golden
goose!
We also need to realise that we all are a part of one ecosystem, sharing one small blue
planet, as it were. None of us are immune to any problem that concerns humans. A dengue
outbreak in a tribal area in Orissa can easily reach New Delhi. A cholera outbreak in a slum can
easily affect those living in five star hotels. A gas leak in an industrial area can easily spread to
the whole of the city. Ultimately, we breath the same air, drink the same water, and live on the
same soil. Pollution and diseases know no barriers (can one think of polluted air staying put in
one place?!) - what affects a poor, slum dweller today can easily affect you and me tomorrow!
Those who live in duplex condos are as susceptible to pollution and lung cancer as the auto
driver on the streets! Issues of public concern are everybody's business. It cannot be left to
doctors or the government alone. No one can claim to be unconcerned. And not doing anything
is no answer.
To be able to work together for a healthier tomorrow, we need to start caring for those
around us. The ability' to think beyond oneself and respond to common concerns will be the most
crucial next step in human evolution. It may just ensure our survival.
References
1. Dhavan, Rajeev. Dung, dengue and death. The Hindu, 8 November 1996.
2. John, T J. Emerging & re-emerging bacterial pathogens in India. Indian J Med Res
1996;103:4-18.
3. World Health Organization. Emerging Infectious Diseases. WHO 1997, Geneva.
4. Government of India. Report of the Expert Committee on Public Health System 1996.
Ministry' of Health & Family Welfare, New Delhi.
5. Mankodi, Kashyap. Political and Economic Roots of Disease. Malaria in Rajasthan.
Economic & Political Weekly, January 27, 1996.
.
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6. Anonymous. Surat disease toll put at 27. The Hindu, 24 September 1994.
7. Ratnam, S. Leptospirosis: an Indian perspective. Indian J Med Microbiol 1994;
12(4):228-239.
8. Malaria Research Centre. Seven Point Action Plan for Malaria Control in Madras City.
MRC, Delhi.
9. Government of India. Operation Manual for Malaria Action Programme 1995. National
Malaria Eradication Programme. Ministry of Health & Family Welfare, New Delhi.
10. Krishna Iyer, V R. Mosquitoes and men. The Hindu, 4 5 February, 1997.
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