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Thursday, January 27, 2022

Tackling a public health challenge is a team effort

🔴 Anand Krishnan writes: Technical, bureaucratic and political efforts must come together

Written by Anand Krishnan |
Updated: December 27, 2021 9:02:53 am
Scientists should realise that they need politicians and administrators to achieve public health gains and should learn to give them due respect. (Illustration by C R Sasikumar)

All major public health problems need combined technical, bureaucratic and political efforts to effectively address them with an understanding and respect for each other’s role. Technical people or people of science are characterised by training and expertise in a specific area which they are expected to regularly update and provide advice on based on evidence. Policymakers or elected representatives are the ones who choose the final set of interventions and arrange for the resources to implement them. Bureaucrats, or those engaged in administration, work through a hierarchical system to implement these interventions or programmes to achieve a given result. While technical people derive their power from their knowledge and expertise, bureaucrats exert their power due to their position in the hierarchy, and politicians derive their power and legitimacy directly from the people. All are expected to work to maximise the public good without any personal agenda.

In simpler terms, technical people identify possible solutions and their characteristics, politicians choose the intervention mix, provide resources and the bureaucrats implement them. Let’s take the example of routine vaccination. Sequential actions and decisions are related to the generation of evidence on the disease burden and effectiveness of a vaccine, recommendations by the National Technical Advisory Group on Immunisation (NTAGI), acceptance of these recommendations by policymakers and allocation of sufficient resources and finally, implementation in terms of arranging logistics and ensuring supply by administrators. The field level implementation would again be carried out by technical implementers, usually monitored by a lower-level bureaucrat.

However, we know that in real life all this does not happen sequentially, and overstepping of boundaries, knowingly or unknowingly, occurs by all three sets of people. During the current pandemic, many scientists have openly taken positions on different pandemic response options including lockdowns or school closures, which involve issues way beyond science. The use of mathematical models to justify a particular political point of view was noted. The choice of people in NTAGI (National Technical Advisory Group on Immunisation) may have political overtones. Many high-level technical people are also known to use their personal influence over policymakers to facilitate the process of policy development, or at least in setting the agenda.

A typical bureaucratisation of a response is that the process becomes more important than the end. The best example of such a tendency is when targets are fixed for everything and they become the end in itself. Often, such target setting is politically driven. However, we have enough experience — from sterilisation drives to reporting of cholera and malaria — to know that fixing targets creates problems such as fake entries or non-entries. The practice of thermal testing and collecting phone numbers outside malls and offices when the pandemic is at a low-ebb is clearly a massive exercise in futility. The restriction of basic public benefits to those who are unvaccinated is an exercise of power in the worst possible sense and has no scientific basis.

Both administrators and politicians want to be seen as doing something even if these are not scientifically appropriate. Is this acceptable if it helps governments gain trust and if there is better adherence to other interventions? Scientists will not agree. Lack of a clear-cut technical definition of community transmission enabled politicians to have a particular “narrative”. In addition, commercial interests, say of drug or vaccine manufacturers, are known to influence decisions through any of these three groups of people.

A former DG of ICMR is once said to have remarked that there are no technical people at ICMR headquarters and that all the “scientists” have become bureaucrats. Even the WHO has been struggling to define the right combination of technical and bureaucratic staff. Does the WHO do science or manage science? Most knowledgeable people would say that it manages science, and gets others to “do” the science part. Is the WHO’s work technical or more political, especially as it navigates inter-country issues, especially during a pandemic. Quite evidently, the WHO’s oversight is political in nature.

This problem is not restricted to health and sciences. Such things are also seen in defence, finance, economic, and agriculture ministries, to name a few. Most of these ministries have a running feud between the technical and bureaucratic wings. These fault lines have always existed but become critical in an emergency — for defence in a war-like situation, for the finance ministry in an economic crisis and for health in a pandemic.

In general, whenever such a debate on crossing boundaries arises, the narrative is always that science is right or has the right answers whereas politicians and bureaucrats are somehow lower in the pecking order. Is this viewpoint valid? Knowledge is useless if it is not applied for public benefit. It is politicians and administrators who enable this to happen. While one can have a clear boundary in pure sciences like mathematics or physics, this is not true for applied sciences like medicine and definitely not applicable to public health. The 19th century German physician and thinker Rudolf Virchow once said “Medicine is a social science and politics is nothing else but medicine on a large scale”. He meant that while public health has to identify solutions, its implementation is in the hands of politicians.

I believe that rather than calling for doing away with turf wars, we work towards defining clearer boundaries between these three wings, so that one wing hands over the driver’s seat to the next with a well-defined endpoint. There is also a need to put in place better dialogue mechanisms to sort out fractious issues. After all, technical issues will impact implementation and vice versa. Clearer boundaries also help in ensuring accountability, something that we need to have in this pandemic, at some point of time.

While, our preparedness to deal with future pandemics requires all these three wings to review their role and approach, I will restrict my advice to scientists. For that, I cannot do better than to paraphrase the advice of Alfred Sommers: Be balanced, objective and credible. Wait till the evidence is solid; if the data are wanting, accept that you may not have all the answers but in an emergency don’t hesitate to give a guarded opinion. Perspectives other than science are also valuable as health policy involves issues other than what epidemiologists and other scientists know or care about, so do not go beyond your area of expertise.

Scientists should realise that they need politicians and administrators to achieve public health gains and should learn to give them due respect. This problem of overstepping boundaries can only be minimised by aligning public health, administrative and political goals by mutual dialogue.

This column first appeared in the print edition on December 27, 2021 under the title ‘In crisis, it takes three’. The writer is Professor at Centre for Community Medicine at the All India Institute of Medical Sciences, New Delhi. Views are personal

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