Who is responsible for people’s health?

Dr Giridhara R Babu
Are you healthy? Hold on to your answer till we unravel what health means. Being in impeccable health means that you don’t suffer from any physical illness in any form and, you have flawless state of mental and societal contentment. Now, are you healthy?

If your answer is no, don’t be surprised, as you are among the majority. Momentarily, it might appear that being healthy might be a utopian resolve, rarely ever attainable by any individual in their lifespan. Luckily, it may not be that hard too, if concerted actions are taken by individual and few departments.

To understand these concerted actions, it is important to understand factors regulating health. Dahlgren and Whitehead in 1991 described numerous factors at multiple levels ranging from societal to individuals. The first layer of health determinants comprise of modifiable factors including personal behaviour and lifestyle that can promote or rescind health. For example, smoking is modifiable behaviour that can be stopped to promote health at individual level.

The next layer comprises of social and community factors, which can either support or upset the health. For example, smoking behaviour can be either started or stopped by the kind of friends one has or due to the family or community norms. The final level contains essential factors such as agricultural production, education, work environment, living and working conditions, unemployment, water and sanitation, health care services and housing. Using same analogy, smoking policies about tobacco production and consumption affect overall smoking prevalence.

Let us examine another example. In order to walk and be disease-free, at individual level, you have to have a resolve, decide and start walking by attempting every day. At the community level, it helps to have friends who motivate walking and family which has adopted walking as a habit. Structural level factors include whether you are able to cross the road without fear of being knocked down by rash drivers, how accessible are walking lanes, parks or gyms in order to continue your walking routine.

So, whose responsibility is to fix the health of India’s citizens? Undeniably, the first set of actions is at the individual level. These can be achieved through constant education and awareness among the masses. The effort in promoting yoga by Prime Minister Narendra Modi is a best first step forward. The awareness needs expansion with several collaborative actions embracing religious and local cultural beliefs, enhancing healthy traditions, incorporating promotion of healthy behaviour through school curriculum and involving women’s self help groups as change agents.

Fixing responsibility
However, the biggest problem is that several programmes are evasive in fixing responsibility for health only at individual level with inertia at other levels of determinants. To redress the longstanding inaction, laudable effort of the current administration is the Swachh Bharat Abhiyan (SBA) aiming to tackle sanitation menace. However, barring these two initiatives, no other department either at Centre or local levels has addressed any other determinant at any other level.

One would understand from the discussion so far that department of health per se has limited control over your health. At the most, it provides sickness relief and some health promotion activities such as immunization. Yet, it has become an unfair tradition and custom to blame the health department for all the woes the country has. The way forward for healthy India should involve several other departments and community actions. For India’s health to improve, all determinants of health should be addressed at every level. The government can create an overarching mission to address all the health determinants.

A simplistic tool such as ranking the blocks/districts based on the level of accomplishments in social determinants can guide future course of action. Simple yet effective solutions such as rewarding the local bodies through extra grants and recognition can imbibe pride in the villages and can ensue healthy competition. The progress can be monitored as performance indicators of administrators at block and district level. The chief minister can spearhead the mission with the accountability set at the level of development commissioner.

(The writer is Additional Professor, IIPH Bengaluru, a unit of Public Health Foundation of India)


May is here, prevent dengue

By Giridhara R Babu, May 12, 2015
Bollywood has a great influence in India. As an example, actor Salman Khan is in news steering the nation to debate on road safe-ty issues. As a bizarre exception, Yash Chopra, a great director, died of dengue and yet it did not have lasting impact on the way this major public health issue is addressed in this country.

Most people thought it was very unfortunate and even policy makers did not see it as an opportunity to initiate public health reforms in the country. So, does bad luck or being unfortunate causes dengue?

No, clearly not. Dengue is caused by dengue viruses and is transmitted by mosquito named Aedesaegypti and Aedesalbopictus. Hence, the real misfortune is that we use the asylum of “bad luck” whenever there is a real public health crisis.

The number of dengue infections in India amounts to 24–44 million contributing to 34 per cent million infections of the global total. To prevent dengue outbreaks, the initial set of solutions is to get rid of mosquito breeding areas. Is this possible? Yes, it would definitely be possible when Prime Minister’s Swatch Bharat Abhiyan (SBA) is implemented in full spirit in every area. Given this ambitious programme may take some time to provide results, some immediate mosquito control measures are immediately needed.

They include minimal engineering approaches such as filling, levelling and drainage of mosquito breeding areas. Generally known as “source reduction”, the principle is to drain off any artificial pools of water such as water containers, empty pots, discarded tins, broken bottles and coconut shells. There are also chemical methods available such as sprays but the effect is only temporary.

Most importantly, personal protection measures will have to be followed such as using mosquito net, screening the buildings with copper or bronze meshes and using repellents. Despite of all these, mosquitoes can breed and we might still be exposed. Hence, we need stronger surveillance for dengue to prevent outbreaks.

Surveillance involves controlling outbreaks, preventing their spread and thereby creating a healthy community. A stronger surveillance network is essential not only to maintain health of communities but also to counter threat of biological weapons.
Dengue deaths would be minimised if the engineering department functions well, awareness is spread so that individuals own up responsibility of personal protection and communities strive for mosquito free areas.

The greatest responsibility is, therefore, with the urban/rural local bodies to keep the sanitation tidy and healthy. Yet, every year, during dengue outbreak, one would read in the media that the minister suspended the doctor or the government announces a new hospital or a new health scheme.

Knee-jerk reactions
Tactlessly, the blame is put often on the health department, comprising of the only professionals who might be doing something to mitigate the suffering. These tranquil knee-jerk reactions readily available to policy makers are akin to blaming the firemen for doing their best to defuse the fire.

In addition, public health training and application of skills needs to be integrated into practice of routine practitioners throughout the country to prevent and mitigate outbreaks such as Dengue. Public health cadre comprising of trained and professionally skilled manpower should be functional in all the states.

It is a fallacy of terming dengue deaths as unfortunate and system continues the eternal neglect of public health. The public too would remember for some time and then there is lull till next outbreak. Dengue as an infectious disease is only an index of many dreaded diseases and poor public health system in India. Like every year, dengue fever will be on the rise this year too. The month of May marks the precursor season for the rise of dengue cases.

This is the perfect month to analyse whether deaths due to dengue are unfortunate and therefore, nothing can be done about them or could the government do anything to prevent them.

This year too, we have choices: One is to call the deaths as unfortunate, second is to place the injudicious blame on the health department or finally, is to address the real public health issues. Let us hope that only the wise choice is made ahead of the dreaded dengue season in India.

(The writer is Additional Professor, Public Health Foundation of India, Bengaluru)


Visiting private clinic for immunisation?

Dr Giridhara R Babu, April 08, 2015, DHNS:

I am trained as a medical doctor. Few years ago, I was out of town when my wife had to take our elder daughter, who had developed a fever, to a paediatrician.After examining her and prescribing medicine, the paediatrician, in this case a private practitioner, casually inquired with my wife, if she would like to postpone the onset of puberty for the daughter. He went on to describe the efficiency of an injectable drug, which postpones the onset of puberty. He said, “As a mother, you wouldn’t want to see the changes a girl has to go through at a young age”.When I returned home, my wife asked me, annoyed “Tell me, you are also a doctor. Why would a doctor want me to do this to my daughter? Is it wrong to go through natural stages in life?” I had no answer but was amazed and shell-shocked. That said, I was not surprised; as a doctor trained in public health, we are aware of the dangers of rapid commercialisation of health care in an unregulated environment such as the Indian healthcare scenario. The resulting disregard of patients’ healthcare choices bothered me.I was also suddenly aware of the vulnerability of the parents, even the educated and the middle-class ones, let alone those who are poor and illiterate. There is a certain powerlessness in healthcare encounters as opposed to an empowerment that one usually expects; heeding to the advice of healthcare professionals is not always questioned unless one has access and interest in finding out more about the various therapeutic tools being offered to patients.However, there are “good” and empowering technological tools too. One of the wonders that modern technology has offered is that anyone can know whether vaccines are maintained in cold chain or not just by glancing on a square in comparison to circle. This is called as vaccine vial monitor (VVM), and is widely used in most vaccines supplied in the government health systems. Vaccines lose their efficacy if a certain temperature is not maintained right from their production to their use.

The World Health Organisation has mandated the governments to use VVM to indicate the status of cold chain maintenance. In the absence of cold chain, vaccines might be impotent and administering them can vaccinate your children but they may not be immunised. To be immunised, the vaccine has to be potent and initiate an antigen-antibody response in the immune system. I consider that, it is the duty of every parent (as well as their intention!) to know whether their children are immunised or not (not just vaccinated).

Several years back, during my previous work in the WHO, I had interacted with many paediatricians about the importance of cold chain maintenance of vaccines. Little did I know about the implementation of these best practices till we had second child recently.

Oral polio vaccine

Don’t be surprised to know that a lot of vaccines used in the private sector do not have vaccine vial monitors. I asked a learned paediatrician about how many vaccines have VVM and he answered, “Hmm, well sometimes we do see for oral polio vaccine, but we recommend killed vaccine (an injectable), so pretty much all others don’t have it”. That was a harsh welcome to reality for me! You might be shelling a bomb for vaccines at private facilities but in my opinion, their efficacy needs to be monitored.

The real question, however, is how do we ensure good quality vaccines irrespective of whether it is provided by the public or private sector. In the public sector, one can be sure of the use of VVM, but in the private sector, I am not so sure. As illustrated in the above example, why would the private practitioner adopt a technology? One argument is that modern medicines and technology as tools get promoted probably because they provide some financial incentives to the persons who prescribe them.

In the case of VVM, there is no added incentive and it increases the work for manufacturers. Often, several people endlessly criticise the government health system whenever there are debates concerning the quality or access. At least, the vaccine cold chain maintenance in the government is immaculate.

But, I wonder, as responsible partners, why not private system decree the manufacturers that they don’t accept the vaccines without VVM? If self-regulation among the medical profession is to work, then this is a great step in that direction. Until then, it might be worth asking whether going to private clinic for immunisation may be beneficial for your kid or not. If not, what choices do we really have?

(The writer is Associate Professor, Indian Institute of Public Health, Public Health Foundation of India, Bengaluru)


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