Diseases like the H1N1 flu pose major challenges because of the continuing neglect of public health.
The repeated outbreaks of swine flu (H1N1) over the past decade and deaths due to the Ebola virus in Africa have focused our attention on infectious diseases and their lethal impact on people’s lives. Improved public health standards and the antibiotic revolution have resulted in the conquering of infectious disease in the Western world. The upper classes in India have enjoyed similar successes through effective (but selective) interventions in water, sanitation, nutrition, housing, vaccination and access to healthcare. However, decades after the availability of technology and solutions, the larger society in India continues to face disproportionate levels of morbidity and mortality due to infectious disease. Deaths due to malaria and tuberculosis, which seem to disproportionately infect the poor, keep mounting every year.
The situation begs the question why. The answer lies in our refusal to take into account the local reality and social determinants of health. The survival of the human body is best explained by the material explanation which argues that the variation in health and longevity is related to the access to tangible resources. The association between poverty and disease is well recognised. Yet, malnutrition is rampant among children; vaccination coverage is inadequate; housing is substandard; healthcare is unaffordable and unavailable; and elementary education is second rate in rural areas and among the urban poor.
Nevertheless, most governments at the centre and the states, despite their rhetoric, have pursued weak policies in these matters and consider health a low budgetary priority. They employ urgency-driven curative medical solutions instead of long-term public health policies. For example, cholera is endemic in India and there are periodic outbreaks of the disease. These outbreaks attract media attention and put pressure on governments to deal with the situation. The government response is swift and curative. The role of antibiotics in prevention of diseases is negligible; they often worsen the situation by providing temporary relief to the suffering, while allowing the underlying causes of the epidemic to go unaddressed. The provision of clean water, sanitation and public health measures that can prevent the cycle of transmission do not become government priorities. Unfortunately, the media quickly move on to the next crisis and the need for permanent public health solutions is forgotten.
The management of many infectious diseases is essentially symptomatic and supportive and should be available in primary care. Swine flu is essentially a self-limiting disease with a low fatality rate. However, a minority of patients, especially those who are immune-compromised or with cardiac, respiratory or liver conditions develop severe disease. The signs of serious infection (e g, persistent high-grade fever, increased respiratory rate, altered consciousness) need to be recognised and aggressively treated. The prevention of fatalities requires easy access to healthcare.
Nevertheless, while governments talk about access to healthcare and many expert committees recommend universal health coverage, the health infrastructure in the country remains sub-standard and neglected. The government primary care system is under-resourced and overburdened. Staff discipline and morale are low and they rarely, if ever, receive training to upgrade their skills to keep up with advances in medicine.
While governments advocate health as a fundamental right in their policies and suggest that its denial is justiciable, their budgets do not support upgrading of the country’s dysfunctional healthcare system. They prefer to restrict discussions on population health to the issue of resources for medical treatment and cite the healthcare system’s low absorption capacity and inefficient utilisation of funding as an excuse for not raising spending on health. They use this as a means of deflecting the debate from the true social and economic causes of physical and mental ill health.
The denial of basic rights to clean water, sanitation, nutrition, immunisation, housing and employment, on the one hand, which facilitates the spread of infections in the community, and poor access to healthcare, on the other, make a deadly cocktail which fuels epidemics of infectious diseases. The current context of health and healthcare in India remains grim and the country is a fertile ground for the spread of infectious disease. Public health in India demands a framework that not only prevents the spread of infectious diseases by breaking the cycling of transmission, but also puts in place basic healthcare infrastructure to treat and manage infections in people who contract them. Healthcare professionals and activists have long argued the need for a public health movement that champions the right to health not in isolation, but by the provision of both basic needs and access to healthcare.
