Prof K S Jacob
Indian reality calls for regional research, local solutions and national perspectives rather than subservience to international approaches, which do not prioritise India’s needs.
Improved public health standards and the antibiotic revolution resulted in the conquering of infectious disease in the western world. Although the HIV/AIDS epidemic did dent human confidence in our ability to tackle infections, its control though education, public health strategies and development of new treatments re-focussed attention and efforts at controlling non communicable diseases in developed countries. The conquest of infections among the upper classes in India through effective interventions of clean water, sanitation, nutrition, housing, vaccination and easy access to health care has made Indian decision makers also take on the challenge of non communicable diseases. Yet, decades after the availability of technology and solutions, India continues to face disproportionate morbidity and mortality from infectious disease.
The situation begs the question why. The answer lies in our refusal to take into account the local reality, our reduced emphasis on national priorities, our submission to international recommendations and our failure to set our own health agenda.
The polio paralysis: The west eradicated polio by the use of clean water, improved sanitation and the oral polio vaccine. India adopted the use of the oral polio vaccine, sans clean water and sanitation. Many arguments were used to support the use of the oral vaccine over its injectable cousin. The policy pursued for over forty years has not made India polio-free. The voices within the Indian research community that had been arguing for the use of the injectable vaccine were sidelined; the Indian administration listened to the World Health Organisation (WHO) and continued the use of the oral vaccine. The recent re-emergence of polio including the incidence of vaccine-associated polio in many parts of the country has resulted in a rethink of the policy. It is now fashionable to list the merits of the injectable polio vaccine, both in India and within the international research fraternity. Clean water and sanitation, despite their significant contribution to population health, are still not part of India’s battle against polio and infectious diseases.
The all-persuasive argument for the use of vaccinations as a panacea to prevent diseases is an example of the medicalisation of public health. The elimination of small pox through vaccination was an outstanding example of disease prevention. However, not all infections are similar. The presence of asymptomatic carriers and feco-oral transmission make the polio virus a completely different cup of tea. The eradication of polio will surely also involve the provision of safe water and sanitation in order to prevent the spread of the virus. The fact that different departments at the WHO and at the Government of India handle water, sanitation and vaccines means a compartmentalisation of the holistic view required to take on the challenge of polio.
The swine flu fiasco: The much-hyped swine flu pandemic, predicted by the WHO and fanned by national and international media, never materialised. More people probably died of seasonal flu than from the “pandemic.” It, however, resulted in public panic and the possible re-direction of massive resources to procure medication, masks and vaccines. One suspects that many pharmaceutical companies laughed all the way to the bank. The WHO failed to revise its prediction, after the initial hysteria and despite mounting evidence of the low level of intensity of the infection, resulting in massive financial losses to many governments.
International health agencies faced similar situations when the predicted avian flu epidemic also failed to appear. However, the panic resulted in huge economic losses with the culling of millions of birds and the restrictions on travel and tourism across many regions and countries.
Typhus tales: The past decade had seen the emergence of acute and debilitating fevers with high mortality rates in India. These patients were negative for the standard aetiologies of typhoid and malaria, common in the country. A systematic investigation into such presentations resulted in the documentation of the re-emergence of scrub typhus and rickettsial infections. Investigations from several districts and states documented the wide prevalence of such fevers. These fevers did not generally respond to the newer antibiotics but showed dramatic improvement with the older but currently infrequently prescribed medication (such as doxycycline). Typhus is localised to India and Asia and falls below the radar of global health agencies, resulting in a lack of international guidelines. Diligent Indian researchers identified the re-emergent typhus and solved the mystery infection.
Vacuous new vaccines: Financial institutions and the pharmaceutical industry support vaccines, which are profitable, for the prevention of disease over provision of clean water and sanitation.
Despite several recent key reports, which emphasise the dramatic health and economic benefits gained from improvements in water and sanitation, such solutions receive low priority in funding. On the other hand, vaccines, which target diseases with much lower prevalence and that have much less impact on the health of populations, receive generous support. Many lobbies are now arguing for newer vaccines (E.g. vaccines against Haemophilus influenza type b and Streptococcus pneumoniae), developed and used in the west, in India. However, these vaccines target rare conditions in India and play into the hands of the pharmaceutical industry. They take away resources from the task of providing basic public health needs for the country. A cost benefit analysis taking into account the effectiveness against the risks is mandatory for countries with limited health budgets and in resource poor settings.
WHO is to advise? : The WHO was set up to promote and coordinate efforts at improving the health of populations across nations. It is responsible for the analysis of causes of ill-health and for recommending solutions to improve the health of populations. It is actively involved in developing international guidelines for the control and eradication of disease. However, the organisation by its very nature, takes an international perspective on issues. While its advice may be technically correct, the diversity of health contexts across nations may make its recommendations less appropriate to country-specific situations. Developed nations rarely follow its advice and set their own health agenda. Some countries like China study its recommendations but employ their own solutions by tailoring the suggested proposals to their local reality.
The World Health Organisation, by its composition and funding, is controlled by international and western expertise. Its advice is tailored to a broad context of low and middle-income countries. However, its ability to mobilise resources are limited. Nevertheless, its advice is followed by western and international donor agencies that use their funding schemes to control the health care agenda in low and middle-income countries. Yet, such solutions may not exactly fit the Indian context. While India does provide know-how to the WHO, such expertise seems to be subservient to the overall goals of the international health and financial communities.
The way forward
Despite over 60 years of independence, India continues to be colonised by the west, but in subtler form. We seek and receive advice from international agencies, which do not fully understand our different context nor acknowledge our priorities. Indian problems require Indian solutions. India needs to highlight its own health priorities and formulate its own health policies. While international advice from the WHO and from donor agencies should be considered seriously, we need to make our own decisions suited to the Indian context. We need to encourage independent thought and local expertise, which provides advice to national authorities and which are accountable for the nation’s health. International advice tailored to meet the needs across national borders may not be suitable for India. Following international advice and recommendations also means throwing one’s hands up in despair, when the suggested solutions fail to deliver.
There is a need to set up statutory bodies composed of experts with a genuine track record of research and policy making. Decisions should be based on good evidence, honest discourse and intelligent policymaking. The experts will need to evaluate the health problems of the country, study its context and be involved in decision and policymaking. They should be accountable for their impact on the health of populations. A regular review of strategies, the identification of policies and plans that fail and course corrections or a different approach and direction are mandatory.
India has such expertise in health. It needs to be empowered to assess local reality, suggest solutions, make decisions, set the national health agenda for the health of its people. Unless India decides to take the destiny of the health of its people in its own hands, we will not be able to tailor solutions for the Indian context, improve the health of our population and empower our people.
Prof. K.S Jacob is on the faculty of the Christian Medical College, Vellore. The views expressed are those of the author and do not reflect the position of any institution or organisation.)
An open letter published in Hindu Daily
Courtesy : www.thehindu.co.in