Dismantling of Public Health
– Deadlier Sting Than Dengue!
(In the dengue and chikungunya epidemic, who is the real killer? Rather than the Aedes mosquito, the needle inexorably points to Government policy on health and social sector spending. The total insensitivity of the private sector towards saving lives also stands exposed. Below is a discussion of the issues involved, based on a conversation with Dr. Imrana Qadeer. – Ed.)
With the drastic cut in health budgets in the era of liberalisation, we have seen a decade of several epidemics - plague, malaria, severe blood dysentery – forcing the Government to backtrack slightly and increase the health budget marginally. The Structural Adjustment Policy has severely affected our public health infrastructure, which is crucial in the Indian situation, to allow health coverage to reach out to the poor. Such coverage depended on small primary health and community health centres. The investment in manpower is about 70% of the total investment in health. When you cut down the total to 1% and 1.5% and now its 0.9%, then clearly, with 70% going into maintaining personnel, the 30% remaining is negligible.
Another step caused by budget cuts is the dismantling of the monitoring systems – which means that we lost the capability to monitor and predict impending epidemics. So, the cuts are responsible for the re-emergence of diseases we had controlled – such as plague and malaria, for instance. And a new phenomenon is the emergence of a whole new range of viral diseases – encephalitis, Japanese encephalitis, bird flu, and now dengue and chikungunya.
Faced with the results of such a health policy, the Health Minister responds by protesting that what we are seeing is not an epidemic! What, then, is the definition of an epidemic? As a public health person, we all call something an epidemic when, over a very short period of time, the incidence rises steeply. And dengue and chikungunya are illnesses whose prevalence was non-existent or negligible. Now in over two weeks, we are reporting thousands of cases – how can one deny that there is an epidemic! When pushed, the Government responds by admitting it is a ‘situation'! The Minister actually asked what was the point of calling it an epidemic. This politics of face-saving is all aimed at not accepting that we're destroying our infrastructure.
Dengue has no treatment, so timely recognition of the factors which give rise to it, and prevention are life-saving. Once it occurs, then only supportive treatment is possible; a blood manufacturing system is needed that can keep up with the demand for platelets. And even if it is being done in Delhi , there is little doubt that quantities for other states are insufficient.
The other official strategy is to say that the diseases have not been proven: a diagnosis is acceptable only when the virus is located. Now where there are no facilities to diagnose, no virology labs, no facilities to take samples and do the testing, how can one diagnose? As for plague, so now for dengue: for each case that they report, there are probably at least five cases that are going unreported.
The problem is being desperately denied because admitting it amounts to indicting the systematic neglect of health care, and the welfare sector at large. In the case of dengue and chikungunya, for instance, the problem can be traced to water policy: it is the scarcity and inadequate supplies of water that force people to collect water. So it's all very fine to blame people and say that they are responsible – but the real responsibility lies with the Government.
And we need to ask: why is there such a heavy load on our prime institution? Because we have done away with our peripheral institutions. The AIIMS is completely inundated. And what is very interesting is that all through the debate on reservation, the private sector was all along powering the anti-reservation stir, talking of ‘merit', and ‘quality', and ‘excellence'. Today, it is incredible that no one in the media seems to be talking of the responsibility of the private sector and private hospitals in managing the epidemic, and all the blame is being laid at the door of the public sector institution. Now any institute, however good it might be, cannot single-handedly control an epidemic. AIIMS charges Rs 50 for testing per day, and only one private lab offered to support AIIMS – and they charge Rs. 150 per day! And they are ‘generous' enough to offer to reduce their charges! But if they can reduce their prices, why are they charging so high for common people in the first place? Even more interesting was that the Ministry rejected the offer. For all its talk of ‘public-private partnership', it is clear that even for the Ministry, this phrase just means public facilitation of private greed – not private sharing of a public health crisis!
A serious intention to rid India of epidemics calls for a total turnaround in the policies of privatising the health and welfare sectors – but it seems this will not happen until Governments feel the sting of people's anger.