Health         Do we take care?     

Yup…you have guessed correctly. Both these scenes are being staged in our very own India. Our land of contrasts and contradictions!!

     scene    ₁

A tiny room in a village. The worn out walls are lined with racks, half filled with dusty, grimy bottles. An old man is sleeping on the floor, curled up beside a broken table. Now he is shaken out of his siesta by a group of four people. The 70-year old Jishnu Singh and his twenty year old daughter-in-law, Shanta bai. They are carrying a bawling toddler and an infant who looks too weary even to open her eyes.

“Has the new doctor saab arrived yet?” asks Jishnu. “Nah…may be after a week, or a month,” replies the old man. “Ohhh! Is the nurse madam around then?,” says the desperate Jishnu. No. She has gone to the town….will be back after a couple of days.

Can the old man please help them? Jishnu’s two-year old grand son has high fever and a racking cough; and the baby is suffering from diarrhoea. Sorry, no luck!

The public health clinic — the only one in the village — has run out of its stock of medicines… even cough syrups, and the cheap oral rehydration salts!! Jishnu has no options now. He will have to go to the village
quack.

Alush green campus in the outskirts of a city. A helicopter has just landed there, carrying Omar Ali—a resident of Malaysia—and his wife. As he steps out of the craft he looks around with pleasure—at the gymnasium, the yoga centre and the picturesque pebble walk.

No, he has not come to a luxury spa, but to a private hospital to undergo heart surgery.

He is met by a team of medics and nurses, and taken to his room—a large airy space, fitted with swish electronic gadgets. Of course, the hospital offers the best and the most technically advanced health equipment available in Asia and employs world-class medical practitioners.

Ali nods in approval…he has made the right choice. Even if he is paying a fortune for it!

    Healthy... are we?    

Its not all been downhill, of course. The overall health status of the country has certainly improved through the years. Life expectancy has gone up, infant mortality rate has reduced. Small pox has been eradicated and the goal to eradicate leprosy by 2005 looks achievable. But these statistics seem fine only when you look at them in isolation. Compare these with the rest of the world and they pale into insignificance.

You then realise that our country continues to account for 23 per cent of total child deaths, 20 per cent of maternal deaths, 30 per cent of tuberculosis cases and 68 per cent of leprosy cases in the world.

In fact, health-wise we are way down the ladder—jostling at the bottom with some of the most underdeveloped countries of the world!

    ‘Communicating’ with killers    

Now let us take stock of the two of the most deadly menaces that haunt the Indian people. Malaria and tuberculosis –both falling in the category of communicable diseases. These are not new, unknown evils—that have suddenly descended upon us. Neither are they incurable. In fact, a large part of the world population— today—has successfully gotten rid of them altogether. But not us, Indians.

    In Andhra Pradesh, for instance, almost 75% of total malarial deaths in the tribal population are because of Pf malaria.

    Malaria... spreading poison   

In the 1960s a well organised battle was waged against malaria. And the total number of malaria cases were brought down from 75 million to one hundred thousand. But this victory was short-lived. The disease returned with a vengeance, and in 1976, 6.47 million cases were reported. The alarming feature is that the proportion of Pf malaria (the most dangerous strain of malaria) has been rising.

Why was there a resurgence of malaria? Because sometime during the last 20 years the malarial parasite became resistant to drugs and the mosquitoes (malarial vector) became resistant to pesticides.

Programmes to counter malaria, like the National Anti- Malarial  Programme (NAMP) are hampered by acute fund shortage. And poor health service systems.

    TB…still going strong!   

India accounts for one-third of all the TB cases reported in the world. About fifteen million Indians have TB and 2.2 million more are infected every year.Experts predict that TB deaths may go up to as many as four million in the coming years. The National TB Control Programme (NTCP) languishes for want of funds and lack of proper strategy and implementation. Even though a revised programme has been started with the help of the World Health Organisation—its reach to the people who are most affected is still very limited.

    Nutrition… or lack of it!   

The diseases spread like wildfire among a huge portion of India’s people, because they are too weak to fight them! Why? They either don’t get enough to eat, or their daily meals fail to provide the basic nutrients that are required to build up a strong immune system! Women and children are particularly vulnerable to nutritional deficiencies. About 74 per cent of the children in India, suffer from anaemia. Malnutrition accounts for more than 50 per cent of child deaths.

    Who takes care of healthcare?   

This is only the tip of the iceberg. Like the TB, malaria and nutrition programmes, most other public health initiatives, too, have fallen far short of their set targets.

Why? You can find the answer yourself. If you just glance back at the last page, you will realise that the term ’fund shortage’ has cropped up more than once. Yes. The Indian government spends too little on essential health services. Again, basic figures prove this fact. In our country, out of the total amount spent on health, only 18 per cent comes from the government treasury. This service is provided free of cost to people around the country. But this ridiculously small amount accounts for a miniscule 0.9 per cent of India’s Gross Domestic Product.

And a whopping 82 per cent of the total spend on health is accounted for by the private sector—which, of course, charges fees for services rendered. In other words, the Indian people— rich, middle-income, poor, very poor—are largely left to fend for themselves on the healthcare front…

Because going by the statistics available, government spends less than Rs. 200 per person’s health. In India, in fact, the proportion of population paying for its own health-related costs is higher than anywhere in the world.

    Government services … ailing   

There are 22,975 Public Health Centres (PHCs) spread across the country. Not a small number, right? If all these centres were functioning to their optimal capacity, then certainly the healthcare scenario would not have been as dismal as it is today. In reality, almost all the centres are plagued by a variety of problems. Here are some examples:. .

• Only 38 per cent of the PHCs have the required number of doctors.
   
• Only 31 per cent of the PHCs have sufficient stock of medicines..
   
• None of the villagers are involved in the process running these units. Outsiders, who have very little idea about the real needs  of the local community, implement the schemes. Result: people never get what they really require.

This faulty public health system has led to huge disparities in healthcare.

    Urban and rural… stand divided    

Health facilities in rural and urban areas vary widely. Seventy per cent of India’s population lives in rural areas and only 30 per cent in urban (the number is growing rapidly), but urban areas hog the lion’s share of facilities. As far as hospitals are concerned there are only 0.36 hospitals for every one lakh people in rural areas. While the urban areas have 3.6 hospitals for the same number of people. The PHCs in rural areas do not offer even X-rays or blood testing facilities, which for a city dweller constitutes basic healthcare.

In the rural areas, the percentage of people who have no access to proper care has risen from 15 in 1986 to 24 now.

    Doctors… do a disappearing act!    

Of what use is a mammoth healthcare system without doctors? But that is a fact. Villagers have no access to any specialised medical care like paediatrics, gynaecology, anaesthesia and obstetrics. Even though 165 recognised medical colleges churn out 12,000 medical graduates every year, the shortage of doctors in the rural areas persists. While one-fifth of them leave the country for greener pastures, most others opt for the private sector. As a result the number of physicians per 1000 individuals is a measly 0.2 in the public health sector.

    Private healers    

While the public health sector has failed to deliver the goods the private sector has grown by leaps and bounds. It includes a wide range of health care — from the plush corporate hospitals with state-of-the-art equipment, which cater to the medical tourists, to the local quacks. The average cost of treatment in the private system is 2.1 times higher for rural patients when compared to public health care.

And even after that, they are not guaranteed proper treatment! You see,the private sector operates in a completely unregulated fashion. Some private medics are not even registered doctors!

    Why are we lagging behind… healthwise?    

Oh, we can find excuses galore for ourselves! After all, don’t we have a mammoth population? And a thousand other related problems that prevent our government from providing us the kind of health services that a citizen of, say, the UK expects…

Sorry, not a valid excuse anymore. Because as per the WHO sources, a developing nation like Cuba or even China — which also has a huge population burden — appear to have done far better than us.

Judge for yourself. Again as per WHO figures, the life expectancy at birth in China is 70.3 per cent, as compared to 60 per cent in India. Also, while China bears only 18.1 per cent of the world’s burden of communicable diseases, India has a crippling load of 30.3 per cent!

So what did the Chinese do that we did not?

1. They stressed on training local people — Barefoot doctors — to take care of the primary health care centres.
2. They integrated traditional medicine practitioners with the mainstream system.
3. The Chinese vaccination drive for diphtheria, measles and polio reached 85 per cent of the population by 1990.

In 1959, Cuba had only 6000 doctors. Today it has one doctor for every 200 persons. It has an infant mortality rate of 7.9 and life expectancy rate of 76 years, which compare with the UK and the USA. The Cubans have adopted preventive medicine in a big way and this has given a boost to the immunisation programmes. They have eradicated cholera, polio and measles. The Cubans have integrated different branches of medicine — like herbal medicine and acupuncture therapy — into mainstream health system.

    Way to go?   

Lets take stock again. Currently, there are two types of health services operating in India — public and private. There is also a third category — practitioners of alternative medicines. Did you know that nearly 70 per cent of the Indian population use indigenous herbal medicines as a means of primary health?

     The Indian way...    

The Indian Systems of Medicine (ISM) includes six systems: Ayurveda, siddha, unani, yoga, naturopathy and homeopathy. At present there are 3004 ISM hospitals, 23,028 dispensaries and as many as 611,431 registered practitioners in India. But little has been done to set up a framework, to standardise education or to promote research. ISM has huge potential and can solve a large part of our health care problems because they are effective, safe and inexpensive.

Now all these systems are working parallelly. They will probably be far more effective if they worked together. For instance, the cheaper ISM remedies can be promoted through the public health care units. After all, this strategy has worked wonders in Cuba.

But the key phrase is ‘community participation’ — that is — getting the people trained and involved, at least in primary healthcare. And this method is being used in some parts of our country already. Let me give you an example. Some years ago, a group of village women in Parinche Valley in Pune district were trained in human and veterinary health by an NGO. Today these resourceful tais run the public health centres in 13 gram panchayats in the valley. Successfully.

Should we build an army of such tais to take care of the poor—who cannot afford the services of the thousands of medical graduates who pass out of our medical colleges every year? Or is there some other way? What do you think?