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The
Concept of "Forgotten People"
The Voluntary Health Association of India has
rendered a singular service to the voiceless people of
the country by taking up in 1995 the health concerns of
what it had aptly termed as ‘those who live on the
other side of the moon’. For this purpose they also
drew attention to the sharp decline in the quality of the
public health services of the country to an extent of
having an outbreak of a virtual ‘epidemic of
epidemics’. A very sharp deterioration of the key
public health institutions of the country was identified
as a collateral consequence of the neglect of this vital
area by the political leadership of the country. As this
initiative of VHAI was in line with my lifelong pursuit
of relating medical technology to the people of the
country, I readily agreed to accept VHAI’s
suggestion to undertake this venturesome project of
studying the three aspects and use the analysis to offer
‘a prescription for the malady’.Mythical Poverty Line
The Planning Commission has now accepted the
estimates of the Lakadawala Committee which consisted of
some of the most respected scholars of the country. This
has put the percentage of the population living below the
poverty line to be substantially higher than the earlier
estimate of about 33 percent. These, certainly,
constitute the ‘forgotten people’ of the
country. In addition, there are those who live barely
above the mythical poverty line, but having no elements
of nourishment in their diets; or not having a living
space of 25 square metres, including a kitchen and a
toilet for a family of not less than five persons; with
no protected water supply or environmental sanitation.
The conditions under which they are forced to work to
earn a living to have the privilege of living above the
poverty line, are more often similar, if not worse. If
this number is added, more than two-thirds of the
population of the country falls in the category of the
forgotten people.
The present day economic and socio-cultural compulsions
of the people are the consequences of the existing
political power relations: a water thin segment of the
population, forming less than 5 percent which control the
political and economic power. This is the ruling class.
They form the other pole of the highly polarized society.
They use various devious means to ‘forget’ the
very existence of the forgotten people. I have very
approvingly used a saying from the Czech writer, Milan
Kundera, which says that ‘the struggle between the
oppressed and their oppressors is a struggle between
memory and forgetfulness’, to underline the process
of forgetfulness and the struggle involved in resisting
this. In order to further increase profits and political
power, the ruling class has employed most sophisticated
means of education, motivational manipulation and
Goebelesian methods of information control to bring about
what I have called ‘selective cerebral
decortication’ among the remaining 10-20 percent
people who constitute the now notorious ‘burgeoning
Indian middle class’, who are conditioned to consume
products belched out by the industry, so that they
contribute to the increase in the gross domestic product.
These faithful followers of the market have been made to
join the ranks of Marie Antoinettes of the world to cry
out to the wretched of the earth: ‘why don’t
people eat cake if they cannot buy bread?’. I have
called this the ‘Marie Antoinette Syndrome’.
Profile of the
Forgotten People
The Directive Principles for the State Policy of
the Constitution of India have enjoined upon the State
‘to protect and promote the health and nutrition of
the people of the country’. Even fifty years after
India attained Independence, the country remains far
behind in conforming to that Directive. Indeed, the
country does not have a reliable civil registration of
births and deaths, what to speak of record of the
notifiable diseases, and epidemiological data on the
major public health problems. I have contended that this
is not entirely unintentional. This is one of the
mechanisms used by the ruling class to ‘forget’
about the vast masses of the suffering people of the
country. Nevertheless, the living conditions of the
forgotten people are so deplorable that it is still
possible to reconstruct their disease profile -
undernutrition and malnutrition; widespread prevalence of
water-borne diseases; tuberculosis; leprosy; blindness;
AIDS; diseases specific to mothers and children and so
on.
Health Care
Assessibility
Health problems cause a great deal of suffering
to a very large number of the forgotten people. Contrary
to the conventional wisdom, that was widely shared by
medical anthropologists and medical sociologists,
nation-wide data are now available on the utilization of
medical services from the Forty-second Round of the
National Sample Survey and a smaller scale survey on the
same subject conducted by the National Council of Applied
Economic Research to show that, motivated by their
‘felt needs’, people in very large numbers seek
medical help from institutions, mostly of allopathic
system of medicine. Only a negligible proportion among
them go to the primary health centres and dispensaries.
Government and private hospitals account for most of the
visits, both in the cities and in the villages, as
in-patients as well as out-patients. They have to spend
substantial amounts of money to gain access to services
from both the sectors. Expenses incurred in obtaining
treatment for illness has now become the second most
important cause of rural indebtedness (next only to
dowry). Poor patients have to spend more than the better
off ones for obtaining the same services. Even this
information is sufficient to underline the predicament of
the people of the country, particularly the forgotten
people, in finding ways of alleviating their sufferings.
Ironically, their very marginalization in the economic
life of the country makes them more vulnerable to various
forms of health problems.
SICKNESS OF THE PUBLIC
HEALTH SERVICES SYSTEM
Signs
and Symptoms
- Population
Problem
The specter of rapidly rising population has
haunted the ruling class since the early sixties.
The increasing numbers, they argued rather
naively, will ‘eat away the fruits of
development’. They did not pause to ask the
logical question as to which class has been
eating away the fruits of development all these
years? It was also logical for this class to seek
to ‘solve’ this problem by making use
of the law and order machinery to make people
accept family planning. Much worse, due to the
overriding priority given to it, there has been a
crass neglect of the other aspects of the health
services. I have described the family planning
programme as the ‘darkest and the biggest
blot in the landscape of the health services of
the country’. It has been like a ferocious
bull let loose in the China shop of the health
services. After meeting ‘setback after
setbacks’ over the last three decades, the
bureaucrats
and their political masters seem to be at their
wits’ end. Some three years back a
‘high powered committee’ under the
chairmanship of
Dr. M. S. Swaminathan submitted its report. The
bureaucrats apparently did not like some of its
radical recommendations. So a few months back
they themselves have come up with a concoction of
their own which ignore the fundamental factors
which have led to the failure of the programme.
The National Family Health Survey conducted
recently presents some alarming aspects of the
state of the family planning programme as well as
some special programmes initiated by the Union
Family Planning Department to strengthen the
programme. One of the most disturbing findings is
that even during the first three months of its
existence, only a third of the infants born in
urban areas were fed exclusively with the
mother’s milk; in another third, it is
supplemented with only water, while in the
remaining third, some top feed was added as
supplements. In the rural areas too the situation
was very bad, though the percentage of infants
fed exclusively on mother’s milk was 40. It
was also found that despite all the efforts of
the past, only 30 percent of the eligible
children were protected against the six
immunizable diseases. Another disturbing finding
was that less than a fifth of the mothers of
childbearing age knew about AIDS.
- Primary Health
Centre
Considerable information was collected about the
functioning of the sheet anchor of the public
health system of the country - the Primary Health
Centre. These had to bear the main brunt of the
long neglect of the health services. In large
areas of the country, it has become virtually
non-existent. People are left by the
‘authorities’ to fend for themselves.
Even in the much adulated states of Kerala and
Tamil Nadu, it is estimated by senior health
administrators that barely one-fifth of the
doctors posted in the rural areas live in the
village where the PHC or the additional New PHC
is located. This means in four-fifths of the
cases either there are no indoor-beds or the
patients are left to their ‘fate’.
Hospitals at sub-divisional/taluk/tehsil,
district and city levels and teaching hospitals
almost universally showed signs of neglect,
decay, mismanagement and blatant apathetic
attitude of the staff. Over and above, there have
been the tell tale manifestations of acute
resource crunch. There have been numerous
instances where the allotted budget could barely
meet the salary requirements of the staff.
Non-payment of the salary for months together was
found to be the rule in one of the important
states. The moot point here is that the situation
was allowed to deteriorate to this level in a
democratic country, despite the constitutional
directives. This provides a frightening
manifestation of the degree to which the ruling
class is allowed by the political system in
neglecting literally the life and death issues of
the forgotten people. Incidentally, there was a
recent report (The Pioneer, April 22, 1997) of
the Delhi High Court summoning the Union
Secretary for Health and the Director General of
Health Services to explain how the Government
could sanction funds for medical treatment abroad
of high officials while the health services are
denied funds for their most essential activities.
- National Health
Programmes
‘National Programmes’ against the
extensively prevalent communicable diseases often
reflect certain important aspects of the history
of public health practice in the country. They
‘remind’ us of aspects of public health
organization and management of the bygone years.
There was a huge outcry against having the
National Malaria Control/Eradication Programmes
as ‘vertical’ programmes; however, it
has also been noted that the country had public
health administrators who could ensure that as
many as 56 million households were visited twice
every month by health workers, year after year,
and each of the houses were DDT sprayed twice
every year. There is an evidence to show that the
authorities in India did not come round to
realize that the researches carried out in the
country in the 1960s triggered a virtual global
revolution in dealing with tuberculosis as a
public health problem. Then there were the set
programmes against diseases such as leprosy,
trachoma and filariasis.
Global Packages
This has resulted in ill-conceived,
scientifically faulted, ethnocentric and technology
dominated ‘initiatives’ that have been imposed
on the country on the advice of ‘experts’ from
abroad.
UNICEF, WHO, the World Bank (WB) and some western
countries had ‘persuaded’ the concerned
authorities in the country to implement the ambitious
Universal Programme of Immunization (UPI), even though
they did not have such basic data as the incidence of the
six diseases and efficacy of the vaccines under the
epidemiological conditions prevailing in the country.
Besides, there were the enormous problems of ensuring the
potency of the vaccines at the time of inoculation and
setting up reliable systems for surveillance/monitoring
and evaluation. There must have been some very deep
rooted pathology in the minds of those who advocated such
a faulty programme.
- AIDS
Prevention
The experience with the carefully
crafted (by WHO/WB) National AIDS Control
Programme to be implemented by the National AIDS
Control Organization (NACO) (again designed in
detail by them) has been even worse. While India
was publicly denounced as the ‘AIDS capital
of the world’ by a UNDP representative in
New Delhi, five years after the launching of the
programme, the data presented by them showed
identification of less than 3100 frank cases of
the disease in a country of over 950 million
people! It has indeed been most irresponsible of
UNDP to have made such a wild allegation.
Unfortunately this is becoming a pattern. It is
now ‘discovered’ that, despite been
allocated around one-fourth of the Union Health
Budget for 1991-92, which saw a 40 percent cut in
the budget for malaria, there are very serious
flaws in the design and working of the
surveillance system of the NACO.
- Tuberculoisis
Programme
The recent (March 1977) launch of the
WB/WHO supported Revised National Tuberculosis
Control Programme (RNTCP) in the teeth of
overwhelming evidence calling into question some
of its basic presumptions is yet another example
of the utter disregard of their own commitment to
carry out scientific dialogue and discussions
with the local scholars on a subject which so
vitally concerns them. It is significant that the
Director General of the Indian Council of Medical
Research and the Director General of Health
Services who ‘sided’ with WHO/WB in
imposing the RNTCP on the country, later joined
WHO as its employees. Thus, the oppressed people
of this country will have to pay yet another
installment to their oppressors, before they are
forced to concede the flaws in the programme
suggested by them.
- Leprosy
Elimination
There was considerable enthusiasm among
the Indian leprosy workers and their counterparts
in WHO on the miraculous properties of multi-drug
therapy. This led them to make the
epidemeologically absurd claim of
‘eradicating’ leprosy from the world by
the year 2000. When some sobriety dawned on them
they invented the term, ‘leprosy
elimination’ in place of
‘eradication’. Reports of the
Comptroller of Auditor-General of India (CAG),
research and studies of Indian scholars have
questioned even the claim of ‘leprosy
elimination’ by the year 2000.
- Blindness
Control
The National Programme for Control of
Blindness and Visual Impairment has also been
shown by the CAG to suffer from major problems in
its implementation. Besides, it has been pointed
out that the focus on cataract operations takes
it away from its claimed ‘preventive’
activities.
- ICDS
There are enormous data from survey and
evaluation reports as well as reports of the CAG
to show the severity of the sickness of the
Integrated Child Development Scheme (ICDS). C.
Gopalan, however, has tried to come to its rescue
by pointing out that, despite its many flaws,
ICDS, after all, is an endogenously formulated
programme; it provides some employment to rural
women; and it ventures to reach out to the most
neglected sections of the country.
Epidemic of
Epidemics
It is not surprising that the national
programmes should also suffer from the afflictions which
affect the other components of the public health system
of the country. However, the cumulative effect of this
extensive breakdown of the public health system of the
country is the outbreak of what I have termed as ‘an
epidemic of epidemics’. The outbreak of the plague
epidemic in 1994 was the culmination of this unpardonable
neglect of their constitutional duties by the
authorities. Frequent outbreaks of kala azar, Japanese
encephalitis, cholera and gastroenteritis, malignant
malaria, hemorrhagic dengue are some of the elements
which have constituted this epidemic of epidemics. The
public health authorities do not even have an information
system to know that an epidemic has broken out, what to
speak of rushing to the affected areas to take emergency
measures to contain and control the epidemics.
....to
continue.....
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