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An interview with Dr. Debabar
Banerji, an eminent Public Health expert in the country
who spent a lifetime for the development of a
people-oriented medical technology, particularly for the
unserved and the underserved. This interview contains
fragments from his autobiographical episodes and some
sweeping comments on the events in the field of the
health in India, as he sees them.
Dr. Debabar
Banerji (born in 1930) became a qualified doctor in 1953
from the Medical College, Calcutta. His commitment to
people’s health took him to work as a physician in
Western Tibet and in interior Himalayan regions
(1956-59), as a sociologist at the National Tuberculosis
Institute, Bangalore (1959-64) and as a teacher at the
National Institute of the Health Administration and
Education, New Delhi (1964-71) and at the Centre of
Social Medicine and Community Health of the School of
Social Sciences, Jawaharlal Nehru University (1971-91)
New Delhi. He has been given the status of an Emeritus
Professor of the University after his retirement. He had
also been a Visiting Professor at the Institute of
Tropical Hygiene at the University of Heidelberg during
January - March, 1992. He has now set up the Nucleus for
Health Policies and Programmes in New Delhi to serve as a
forum for discussion on these wide issues.
The major fields of his interest are: Policy and
programme/issues concerning Primary Health Care, Family
Planning Programme, Nutrition and Communicable Diseases
Control/Eradication; Development of Alternative Health
Care Strategies; Application of Operational Research to
Health Fields; Social Orientation of Education and
Training of Health Workers and Health Systems Research
for Health Manpower Development and Application of Social
Sciences to Health Fields.
He has published a large number of research papers in
learned journals, both within the country and abroad. His
writings have formed chapters in some thirty separate
books. He has also brought together his long research
activities in the form of the books like Serious
Implications of the Revised National Tuberculosis Control
Programme of India (1977), India’s Forgotten People
and the Sickness of the Public Health Service System: A
Prescription for the Malady (1995). A Public Health
Approach to the Problem of AIDS in India (1992), A
Socio-cultural, Political and Administrative Analysis of
Health Policies and Programmes in India in the Eighties:
A Critical Appraisal (1991), Social Sciences and Health
Service Development in India : Sociology of Formation of
an Alternative Paradigm (1989), Health and Family
Planning Services in India: An epidemiological,
Socio-cultural and Political Analysis and a Perspective
(1985), The Making of Health Services in a Country:
Postulates of a Theory (1985), Poverty, Class and Health
Culture in India (1982), Family Planning in India: A
Critique and a Perspective (1967). He is currently
working on an important title - Landmarks in the Making
of the Health Services in the Countries of South Asia and
is preparing for a talk on "Protecting
Consumers’ Health in Developing Countries" to
be delivered in the 15th World Congress of the
Consumer’s International in November 3 - 7, 1997.
He has served as a consultant to numerous organisations
and has been invited to give orations and lectures within
the country and abroad besides being in WHO Expert
Committees and Advisory Panels. He is in the Editorial
Board of the International Journal of Health Services and
The Indian Journal of Tuberculosis.
Q: What
motivated you to take up the medical profession?
Ans:
My grandfather was among the first fully trained
physicians to practice in the city of Delhi - in 1888.
There was, thus a family tradition. Besides, I had to
decide whether I wanted to take the ‘medical
stream’ of subjects at the early age of 13. Then, my
scholastic performance was very mediocre. Only some rapid
improvement in the next four years enabled me to get
admission to the venerable Medical College of Bengal
(1835) in Calcutta, where I studied during 1948-53. There
was no medical college in Delhi for males at that time.
So, the motivation took shape with the maturity of my
thinking about what I saw around me. The great Medical
College, the Calcutta University and, above everything
else, the city of Calcutta - the ‘infamous’
city of processions - has had a profound effect in
developing my motivation during those formative years. As
early as in 1944, I had recorded in my diary that I would
like to do ‘something distinctive. It was clear to
me that I would not like to earn tons of money as a
doctor. Although I had the privilege of having some of
the outstanding clinicians of all times as my teachers,
who were particularly affectionate and helpful to me
because of my scholastic attainments. I had decided as
early as in 1950 that I would not like to be a clinician
in any of the three fields where I had excelled, namely
medicine, surgery and obstetrics and gynaecology.
Laboratory research also did not interest me and I had
dubbed most of it as ‘fourth carbon copy’ of
research which had earlier been carried out in the West.
Unwittingly, it took long stints in the Himalaya to help
me in defining what I wanted to do as a physician; I
wanted to relate medical technology to the people,
particularly to the hitherto unserved and underserved.
This has remained my guiding light for more than four
decades.
Q. What do
you say about the quality of education you received?
A.
Exceedingly hard work, done with intense rigour along
highly alert senses and intellectual capacity to quickly
integrate the information received were the hallmarks of
our education. The main justification given was that
people would literally entrust their lives and limbs to
the practitioners of the profession. The Calcutta
University carried it much too far: in our batch only 15
per cent of the hand-picked students were allowed to get
through in the ‘first chance’. If I assign 100
points to our quality, I would give less than 30 to more
than 90 per cent of the present day recognised colleges;
the capitation fee colleges will get 5, at the most.
Q. What were
the health problems when you were a medical graduate and
how effective were the control measures taken by
different agencies?
A. Apart from the horrendously high infant and
maternal morbidity, undernutrition and malnutrition and
the numerous forms of water and air-borne diseases were
the major problems of that time. We were taught to
consider ALL fever cases as malaria and ALL chronic
non-fever cases as tertiary syphilis, unless proved
otherwise! Bacterial infections affecting almost any part
of the body and influencing results of surgery and
childbirth, was then a great bugbear. Tuberculosis of the
lung and other organs was quite prevalent, with
adolescents as the main ‘target’. In the
eastern region Kala-azar was also a major health menace.
When I started to work: Tibet, AIIMS, Himachal, NTI,
Bangalore, NIHAE and the Centre of Social Medicine and
Community Health of JNU, I had the privilege to closely
observe, if not actively participate in some of the most
exhilarating community health initiatives taken during
the first two decades after Independence. I had called
these two decades as the ‘Golden Decades’ of
public health in India. Significantly, these were all
endogenous efforts, though we had always kept the windows
wide open to allow fresh breeze from outside to come in
to give new perspectives to the endogenously developed
ideas. We, however, refused to be swept off our feet by
the breeze, as has happened so often later on when
prefabricated ‘Global Programmes’ were allowed
by our political leaders, bureaucrats, medical
professionals and planners to be thrust on the country on
considerations which were certainly not scientific.
Setting up of the PHCs, malaria control/eradication
programmes, social orientation of education and training
of health physicians and other health workers and the
making of Managerial Physicians immediately come to my
mind as the most imaginative health management
strategies.
Q.
Were
there any voluntary agencies active at that time?
A.
There was a qualitative difference in the voluntary work
in the health fields those days. Public figures, from
Gandhi ‘downwards’, literally went about
begging for contributions for a wide variety of voluntary
agencies started by them. These were the very antithesis
of most of the present day CAPART or World Bank and other
foreign or the rare Indian donor-driven NGOs which have
given such a bad name to voluntary work. The famous
Carmichel (later R G Kar) Medical College at Calcutta was
one among the chain of voluntarily supported medical
colleges that were set up as counterpoises to the ones
controlled by the British colonialists. There were so
many big hospitals run by voluntary agencies, like the
Jadavpur (later K S Ray) Tuberculosis Hospital in
Calcutta, all over the country. The New Delhi
Tuberculosis Centre of the Tuberculosis Association of
India did pioneering work in the programme. There was the
Hind Kushth Nivaran Sangh, again founded by Gandhi. To
the Jesuit priest, Father Tong goes the credit of
initiating the nondenominational Coordinating Agency for
Health Planning which in due course evolved as the
Voluntary Health Association of India. There were,
besides, church controlled medical education (Vellore and
Ludhiana) and hospital services which were open to all.
The Christian Missionaries were the pace makers for
building the nursing profession in the country.
Q.
How
will you rate the health management of the present day,
as compared to the early days of Independence?
A.
Perhaps by far the most important feature of health
administration of the ‘Golden Decades’ has been
the capacity of the administrators to run very complex
and very big programmes, which covered diverse regions
and conditions of this country of ours. Even in my early
thirties, when I was occupying lowly government
positions, I had written very strongly about certain
aspects of the programmes (e.g. the ‘vertical
programmes’). However, the way the personnel of the
Indian Medical Service (IMS), which was the
‘steel-frame’ of the health services, ran the
National Malaria Eradication Programme was truly
astounding - getting 56 million houses visited twice
every month, identifying the fever cases, providing the
presumptive treatment, taking blood slides of fever
cases, and administrating radical treatment if a slide
was found to be positive. Over and above, each of the 56
million houses was sprayed with DDT twice every year. In
contrast to the handling of a programme of such gigantic
proportion then, the way the administration responded to
the recent epidemic of plague puts in clear perspective
the extent of decay and degeneration that had taken place
in the subsequent three decades. The health
administrators did not even have an information system.
The case is worse, if things can be any worse at all, in
the cases of epidemics of heamorrhagic dengue fever and
earlier that of cholera right in the national capital
city of Delhi. Bihar has been having uncontrolled
outbreaks of Kala-azar from the early seventies; there
are serious outbreaks of epidemics of cholera, malaria,
infective hepatitis, Japanese encephalitis, and other
such diseases only a few of which get bare mentions in
newspapers as there is no effective official information
system and, expectedly, there is little response from the
administration.
Q.
What
are the possible reason for the deterioration of the
standards of public health services?
A.
I would mention only a few of the very complicated
aspects of the question. One is that, unlike the ICS,
which was replaced by the IAS, there is no such
replacement when the IMS was abolished. The field was
thus left free for those who had no health administrative
competence to grab the key public health posts that were
earlier held by the IMS personnel. The political
leadership is to be held squarely responsible for this
scandal. For most of them the Ministry became a position
for enjoying perquisites of various kinds and for
bestowing patronage, often at a price. An almost
pathological preoccupation with the family planning
programme for three decades, which had a devastative
effect on the health services, is another cause. I have
called the family planning as a ferocious bull in the
China shop of the health services of the country. When
conditions of political and economic subjugation of the
country, in the form of following the dictates of the
World Bank, the IMF, the WTO and other such Western
dominated agencies, are added to the already tottering
conditions, it does not need much imagination to expect
abject surrender of the government to the dictates from
the Western countries to impose on the country their
ill-conceived global initiatives in the fields of AIDS,
immunisation and tuberculosis. This further aggravated
the already serious sickness of the health service
system.
Q.
What
are the biggest hurdles in providing effective health
services at present?
A.
By far the greatest hurdle is political. Political
leaders in health have nonchalantly ignored their
responsibility towards the people. They have recklessly
interfered with vital elements of the health service
system for their narrow, often purely personal, gains and
interests. In this they are joined by some bureaucrats
and physicians, who too have some vested interests. I
consider this nexus as the key hurdle. As they have
already inflicted considerable damage to almost all the
facets of the system, reconstruction of the health
services will need considerable effort.
Q.
What
future do you foresee for the public health services of
India?
A.
From what we have been able to achieve when the setting
was somewhat congenial during the ‘Golden
Decades’, I will be quite optimistic about the
future of the health services of the country. The
institutional framework is there. Given the commitment
that is bound to be generated as a response to popular
pressure, the nexus will be impelled to act to rejuvenate
these vital institutions and start a chain reaction for
building an effective, people-oriented system.
Q.
Has
the health status of the people of the country changed,
for better or worse, over the time?
A.
If we take into account the widely accepted criteria,
such as infant mortality rate, crude death rate, life
expectancy and the sex differential in life expectancy,
we have almost conclusive evidence that the health status
of people has improved everywhere in the country. There
are, however, two vital questions in this regard. What is
the correlation between access to health services and
improvement in the health status? Secondly, with an acute
problem of human ecology caused due to expansion of the
population from 350 million in 1951 to the estimate of
950 million at present, with acute problems of access to
housing, sanitation, protected water, food, employment,
etc., to what extent can we use the very encouraging
vital rates to claim improvement of the health status of
the people?
Q.
What
message do you have for the new medical graduates of the
country?
A.
It may be kept in mind that the medical graduates of the
country almost exclusively come from the upper three per
cent of the English knowing richer sections of the
population. I belong to this thin stratum. Among them, my
message is confined only to those young medical graduates
who are:
- prepared to go by the
guidelines of the Hippocratic Oath;
- are reasonably
ethical in their behaviour;
- do not betray the
trust of the patients/community;
- who are in the health
services of the country.
To the
brightest among them, who have deep social commitment and
who are prepared to work very hard, my advice will be
that they form a critical mass, along with similarly
motivated persons from other related disciplines (like
nursing) to get the privilege of bringing about the
inevitable changes that shouldtake place in the present
tottering system. They have to be essentially
self-generating, but they must lookout actively for
allies who can contribute to their sacred task.
Inevitably too, there would be betrayers who will need to
be weeded out before they do too much of harm. For the
rest, my advice will be that they too can get a deep
sense of fulfillment by being effective medical personnel
as:-
- teachers in medical
colleges and other institutes;
- as clinicians in
various institutions for medical care;
- as health
administrators who have to run the entire system
and its myriad components;
- as public health
specialists dealing with special areas, such as
microbiology and chemical analysis.
Having
closely observed the making of an IAS in JNU and given
numerous seminars for the mid-level IAS Officers and
taking the existing unjust social and administrative
order as a given constraint, I would strongly advise the
health service doctors to actively agitate for getting a
substantial percentage among them the same status,
promotional avenues and salaries as the corresponding IAS
officers, who are intellectually inferior or, at most
equal, to the bright boys and girls who have entered
medical colleges in a free, all-India competition.
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