In any free society where terrible wrongs exist, some are guilty; all are responsible.” While these words of Rabbi Abraham Joshua Heschel ring true for many social and political ills that appall us, they are also a timely reminder of our collective responsibility to correct the pathetic state of public health in our country. Accepting the failures of a dysfunctional health system with passivity or being pacified by reflexive responses to any crisis, while ignoring the crying need for systemic reforms, makes us all responsible for the poor health indicators that place India behind our South Asian neighbours, other BRICS nations and, for some indicators like child immunisation, sub-Saharan Africa.
There is justified outrage at the tragic deaths of children from dengue under deplorable conditions of apathy and neglect in the capital of India. As often happens, there is an immediate search for individuals and institutions to whom the guilt could be readily apportioned. There are many who will be blamed, and will in turn point the finger at others — the state and Central governments, municipal corporations, private hospitals, public health functionaries, negligent householders and careless construction workers who let water stagnate for mosquitos to breed. Alas, all this sound and fury will abate when the virus takes a holiday in a few months, and the underlying cause — the long neglect of people’s health as a policy priority — will remain unaddressed.
The Delhi-centric national television channels have rightly vented anguish and anger over these terrible tragedies. Their gaze does not, however, extend to other tragedies that regularly visit people across India due to a health system that fails them. Buried inside a national newspaper on April 12 this year was the heartrending story of a tribal in Odisha who allegedly felt forced to sell his two-month-old son for Rs 700 to buy medicines for his sick wife. Which channel picked up that story? Each death, disability or disrupted life that could have been avoided by effective prevention or early and appropriate healthcare should be a blow against our conscience. But, alas, they do not afford us the voyeuristic excitement of a high society murder.
Back to dengue. This virus is no stranger to Delhi, or many parts of India, which are endemic (favoured residence) to it. Yet, each monsoon season, we react as though it is a stealth bomber catching us by surprise. We are familiar with all four strains. Often, viruses tend to transmit rapidly as the human host population increases in size and density. This can portend future danger for big cities. Mosquito vectors breed merrily when afforded the safe sanctuary of stagnant water from intermittent rains or careless collections in homes. Mosquito breeding will become even more intense as temperatures rise with climate change. We should be prepared to combat dengue, malaria, chikungunya and other diseases of that ilk with better design and delivery of health services.
This calls for well-coordinated prevention measures that link multiple civic services, government agencies and community organisations; efficient surveillance systems that help in forecasting and monitoring; and concerted clinical care strategies that intelligently draw upon the combined resources of public and private providers. Regulation is certainly needed, but it is not a substitute for planning and coordination. We do need to step up the speed and effectiveness of our crisis response but, even more important, we need to raise the steady state efficiency of the health system so that crises are avoided, or are minor at worst.
Thailand is a hyper-endemic country for dengue and experienced high numbers of deaths some years ago. It has now markedly reduced deaths from that disease through a combination of effective prevention measures and application of a standardised clinical management protocol. Tamil Nadu, too, is endemic for dengue but its well-organised public health services are geared to cope with the challenge. All of India should learn from these experiences and invest in creating health systems that prioritise prevention and promote competent and compassionate clinical care.
A key public health priority is the strengthening of both rural and urban primary health services. Whether it is the initial assessment and care of fevers, chronic care of high blood pressure and diabetes or ensuring adherence to tuberculosis treatment, frontline health services can provide most needed healthcare. Many patients with viral fevers do not require investigations and treatment at large hospitals — indeed, they run the risk of unnecessary investigations and inappropriate treatment if they do. Triage and referral guidelines will help primary care facilities to steer only the persons who need advanced clinical care to large hospitals.
The mohalla clinics proposed by the Delhi government are a step in the right direction. They should help prevent the recurrence of ugly scenes, like the lathi-charge of uncontrollable crowds who thronged the gates of the Ram Manohar Lohia hospital a few years ago, driven by media-stoked panic about H1N1 influenza.
That also underscores the critical importance of appropriate, timely and effective risk communication to the public. Well-informed citizens will not only be able to make the right decisions about the care they seek but can also be a collective community resource to practise and promote prevention. The media can be a useful ally in disseminating the right messages in a responsible way, even as it retains its role
as an independent monitor.
Public health systems cannot function as a motley crowd of disconnected actors ad libbing their way through an unscripted play in chaotic fashion. The different actors involved require a script, coordination, direction, and need to work as a team. It is time India got its act together to create strong, well-resourced, responsive and responsible health systems. Or else, terrible things will continue to happen to innocent children, expectant mothers, poor tribals, disabled persons — and to your family and ours. We will all be responsible when such terrible wrongs happen.
Reddy is president and Murthy is chairman, Public Health Foundation of India.
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