Public Health in India: Dangerous Neglect
Public health services, which reduce a population’s exposure to disease through such measures as sanitation and vector control, are an essential part of a country’s development infrastructure. In India, policies have focused largely on medical services. Public health services, and even implementation of basic public health regulations, have been neglected. Various organisational issues also militate against the rational deployment of personnel and funds for disease control. There is strong capacity for dealing with outbreaks when they occur, but not to prevent them from occurring. Impressive capacity also exists for conducting intensive campaigns, but not for sustaining these gains on a continuing basis afterwards. This is illustrated by the near-eradication of malaria through highly-organised efforts in the 1950s, and its resurgence when attention shifted to other priorities such as family planning. This paper reviews the fundamental obstacles to effective disease control in India, which need to be dealt with on an urgent basis. MONICA DAS GUPTA
Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running. (paraphrased from Laurie Garrett, Betrayal of Trust). When I arrived in Berlin, I heard the words ‘sanitary’ and ‘health’ everywhere, but I really did not understand those words. What I eventually came to understand was that these words …referred to an entire administrative system that was organised to protect the public’s health…. and to improve the nation’s welfare. (Nagayo Sensai, architect of the Japanese public health system, c 1871).1
What Is Public Health, and Why Invest in It?
ublic health services are conceptually distinct from medical services. They have as a key goal reducing a population’s exposure to disease – for example through assuring food safety and other health regulations; vector control; monitoring waste disposal and water systems; and health education to improve Economic and Political Weekly
personal health behaviours and build citizen demand for better public health outcomes. Thus they involve such disparate activities as improving slaughterhouse hygiene and cattle-keeping practices, cleaning irrigation canals to discourage vector breeding, and applying public health regulations. These services are largely invisible to the public – typically, the public only becomes aware of the need for them when a problem develops (e g, an epidemic occurs).2 Yet unlike most medical services – which focus on the needs of individual patients – these services are of high priority for assuring good health for a population as a whole. When public health systems falter people pay a high price in terms of illness, debility and death, and if full-fledged outbreaks occur the economic costs can be very large. Public health services produce “public goods” of incalculable benefit for facilitating economic growth and poverty reduction. Consider, for example, the long-term growth possibilities generated by draining the malarial swamps of Washington DC. And conversely, consider the global
economic costs imposed by the avian flu and SARS epidemics, emanating from poor poultry-keeping and other public health practices in a few east Asian localities. In India, the 1994 plague epidemic following poor municipal sanitation in Surat is estimated by the WHO (1999) to have resulted in losses totalling $1.7 billion. Poor public health conditions take economic tolls in various ways, including reduced attraction for investors and tourists; continued expenditures on combating diseases which should have become history; and foregone labour productivity. The poor pay a high price in terms of debility, reduced earning capacity, health expenditures, and death. The rich suffer little mortality from communicable diseases, but nevertheless suffer repeated episodes of morbidity...