Public health isn’t about state-run hospitals
Nearly all democracies use two modalities of modern medicine to keep citizens healthy—public health and disease-care. Public health is what the state does to prevent diseases and to protect health. In contrast, disease-care includes the different types of biomedical interventions that are carried out to restore health after an individual falls ill. Therefore, disease-care is popularly called “healthcare”. Healthcare is labour-intensive, given by one worker to one client at a time. Clinics and hospitals are visible infrastructure and sought after as a felt need in times of distress.
Public health, on the other hand, is invisible infrastructure, working in society to mitigate social determinants of diseases and in the environment to mitigate environmental determinants of diseases. Usually, this is managed by a ministry of public health or at least a separate public health department under the health ministry.
For a set of complicated reasons going back to the beginning of self-government in the late 1940s and early 1950s, India abolished the public health wing of the earlier British Raj. To this day it has not been reinstated, in spite of innumerable pleas and recommendations from public health experts.
To confuse the common man, the term “public health” has been misappropriated by policy leaders and medical professionals to mean healthcare in the public sector. Healthcare is not and cannot be called public health—though the quality and cost of healthcare can be scrutinized under the public health mandate, to make sure healthcare is achieving the goal of restoring health. This is obviously a threat to the free-for-all game of healthcare.
Where public health is under government control, two sets of officers can enter any premises for inspection—the police for law, order and crime prevention, and the public health officer for health, hygiene and disease prevention.
Public health must be managed by professionals trained in public health and empowered to work for the health security of all people—urban and rural, poor and rich. Such professionals must be part of a cadre-like structure and career track. This will help attract the best brains to public health.
Not everyone realizes that medical colleges teach only disease diagnosis, treatment and individual preventive medicine, but not public health, which entails environmental and community risk factors and remedial interventions. Sure, there are departments of community medicine in medical colleges that do expose students to the potential of public health, but they do not teach the practice of public health.
Global peer pressure forced India to establish a few community-level interventions to prevent certain diseases. For example, in the absence of an overarching public health infrastructure, India created stand-alone vertical projects against tuberculosis (TB), malaria, leprosy, filariasis, childhood cluster of infectious diseases and acquired immune deficiency syndrome (AIDS). Today all of them remain silos without being integrated into the public health infrastructure.
And it is precisely for this reason that none of these individual verticals has delivered its potential in disease prevention. The most obvious is TB, which has reached a point where we are afraid it may have become uncontrollable due to rampant drug resistance. The drug resistance was man-made, a result of the lack of application of public health expertise in TB control tactics.
This is one part of the story. The other involves water- and food-related diseases like typhoid fever, cholera, viral hepatitis A and E, the ever-present influenza that kills a lot of otherwise healthy adults, scrub typhus, leptospirosis, brucellosis and many other infectious diseases. In these cases, there was no external peer pressure and hence there have been no specific programmes to control them.
In the absence of a public health framework that can supervise disease prevention, we vaccinate against Japanese encephalitis, but without controlling the disease; we vaccinate against hepatitis B, but without monitoring the benefit; meanwhile, measles continues to kill children even as we have a major measles vaccination thrust. Leprosy is being eliminated but new cases occur unabated.
Monitoring of all disease burdens can be done only by public health. Without monitoring by public health, most of our disease-control projects are flying blind.
Democracies are for the welfare of all people. Disease prevention is about equitable use of resources since the benefits are enjoyed by everyone. Healthcare can never be equitable unless we emulate Cuba and England. Diseases drain our economy in two ways—loss of productivity and expenditure for healthcare.
Non-communicable diseases are becoming epidemics—they are not easily prevented, except by huge changes in behaviour. But communicable diseases are preventable; and not preventing all preventable diseases is gross neglect of public welfare by the state. India must reinstate a functional public health infrastructure without any further loss of time. Its citizens deserve nothing less.
This article is the first in a series on public health in India.
T. Jacob John is professor emeritus at Christian Medical College, Vellore.
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