In the heart of India’s bustling cities and tranquil villages, there is a silent but significant fight raging on the public health front. It is not the dramatic triumphs of curative medicine that dominate this story but the quiet victories of preventing diseases such as smallpox (though eradicated, it is still under surveillance), polio, neonatal tetanus, and measles, through improved sanitation and vaccines. These are unsung wins where the absence of illness speaks volumes. Yet, in a democratic setup, leaders often chase tangible achievements and, inadvertently or otherwise, overlook these vital preventive efforts.
In particular, political leaders across the spectrum have leaned towards initiatives that promise immediate results, such as new hospitals, subsidised treatments in private hospitals, emergency response (over preventive response), and populist health policies. Many of these measures do not have much of an impact because of a lack of action beyond public announcements, which is almost always due to budgetary constraints. But even before being implemented, these schemes and the focus of our leaders on them divert attention from critical areas such as sanitation, disease surveillance, and public health education, which are important to maintain population health and prevent disease outbreaks.
The case of dengue
Consider the story of dengue, a disease that has only symptomatic treatments, and no definitive cure. When cases surge, political leaders often mobilise the State machinery to set up immediate relief camps at the expense of long-term strategies such as understanding vector bionomics or developing effective vaccines. We need both, yet, dengue stands out as a classic example of prioritising immediate response over sustainable prevention.
The focus on providing emergency relief also sidelines the availability of public attention for the root causes of dengue and its long-term prevention, and the research required in vector control, vaccine development, and improvement in public health infrastructure. As a result, the current approach fails to prevent future outbreaks and strains the health-care system.
Research and development in these areas are crucial. For example, despite its limitations and restrictions, the existing dengue vaccine underscores the need for more research. Climate change is also affecting mosquito breeding and movement patterns, and public health strategies need to adapt to these changes.
To borrow an idea from the architecture of India’s judicial setup and also the space programme, health care will benefit from being separated from political processes. Public health decisions should be based on scientific evidence and long-term goals rather than short-term political interests. This separation will ensure public health policies are driven by data and expertise, not electoral cycles.
Civil servant Joseph Bhore’s insights from 1946, into the economic and human cost of neglecting preventive health measures, still ring true. Investments in nutrition programmes, while not immediately visible, have far-reaching implications for health and productivity.
The contemporary Prime Minister’s Overarching Scheme For Holistic Nourishment (POSHAN) Abhiyan Scheme plans to reduce stunting by 2%, undernutrition by 2%, anaemia by 3%, and low birth weight by 2% every year. But the fifth National Family Health Survey found 35.5% of children under five were stunted and 32.1% were underweight in 2019-21. The prevalence of anaemic children aged 6-59 months increased from 58.6% to 67.1%, and 54.1% to 59.1% among women aged 15-19 years. This disparity between prevalence and policy targets highlights a significant gap in public health efforts.
The influence of the pharmaceutical industry in public health is undeniable. While instrumental in advancing curative medicine, its profit-driven nature often sidelines areas such as public health. For instance, despite having the same medicines to fight tuberculosis (TB), India reported 21.4 lakh TB cases in 2021, an 18% increase from 2020, translating to an incidence of 210 cases per 1,00,000 population. In contrast, the United States reported only 8,331 TB cases in 2022, about 2.5 cases per 1,00,000 persons. This disparity is not merely a matter of the availability of medical treatment but is deeply linked to socio-economic factors such as poverty, sanitation, and overcrowding (as a result of poorly organised urban housing) prevalent in India.
Some gaps
Behavioural change is key to managing public health challenges. Yet, it can be challenging in political environments influenced by populist tendencies. The absence of specialised courses such as public health engineering in India’s educational institutions points to a gap in the multidisciplinary approach required in public health management.
Public health is not just about treating diseases. It is about preventing them, requiring expertise from various fields such as environmental science, sociology, urban planning, and economics. The current physician-centric focus of India’s public health system often fails to capture this comprehensive nature.
A degree of autonomy is needed
Effective public health management should encompass preventive measures, policy formulation, community health, and environmental health, among others. In public health, adopting a separation of powers approach is essential. A fair and effective health system requires freedom from political influence, focusing on policymaking and implementation driven by scientific evidence and long-term objectives. While prioritising health decisions based on scientific evidence and overarching public health goals are crucial, there is a risk of disconnecting from the immediate health concerns of the general populace.
To address this, an ideal solution would be to place Health Ministries directly under the leadership of elected officials, such as the Chief Minister or the Prime Minister, similar to the management of the space and the atomic energy departments. This structure would not only provide a degree of autonomy but also ensure that health policies are aligned with the people’s immediate and practical needs, striking a balance between expert-driven decisions and public aspirations.
In sum, democracy is not inherently harmful to public health but the way public health is managed within democratic systems often leads to significant shortcomings. Infectious diseases, non-communicable diseases, health-care access, mental health, and misinformation pose challenges that demand a more holistic, long-term approach in public health policy. A separation of health-care decision-making from short-term political goals is crucial to develop sustainable health strategies that address both the immediate and future health needs of the population.
Dr. C. Aravinda is an Assistant Professor in the Department of Community Medicine, Thanjavur Medical College, Tamil Nadu. The views expressed are personal.
