The first 20 years after Independ ence were the golden decades of health services development in India. This period saw many bold ventures in the field of public health, resulting in considerable improvement in the health status of the Indian population. Unfortunately, the situation has changed over the last two decades. The situation regarding the control of communicable diseases is precarious, and the condition of public health - moribund. The nation continues to repeatedly experience malaria epidemics, even after 40 years of implementation of the National Malaria Control and Eradication Programme - a high priority programme. Epidemics of cholera and gastro-enteritis occur even in Delhi, our national capital, which spends huge amounts of money on its development. Various parts of the country regularly experience epidemics of viral encephalitis, meningitis, kala-azar, infectious hepatitis, typhoid fever and food poisoning. Tuberculosis, our major public health problem, continues unabated even after 35 years of implementation of the National Tuberculosis Control Programme. The situation is the same regarding the control of sexually transmitted diseases. In such a situation, how can we talk about the control of cancer and coronary health disease - assignments needing greater determination and inputs than those required for the prevention and control of infections. It is paradoxical that while we claim that our resources are inadequate to provide safe drinking water to the people, we have huge funds to spend on AIDS control. AIDS is not a top public health priority in India.

In a Delicate Bind
The re-emergence of ‘plague’ after 35 years is another example of the failure of the public health (surveillance) system in our country. However, some public health experts and micro-biologists differ from the National Commission, saying that they have evidences that points against the diagnosis of plague.
The 1996 epidemic of dengue in Delhi is another example of gross technical and administrative failure to anticipate, prevent and control an epidemic. With the country facing such frequent epidemics, it can be seen that the public health system has completely failed to provide even basic health care to the people of India.

Protecting the people against epidemics is one of the primary duties of any government. It is amply clear that the National and State Directorate of Health Services have failed to do so. Frequent epidemics and high mortality have failed to generate the right concern. Epidemics die out naturally but they recur again and again for want of sustained and long-term control measures.

The nation has failed to protect its citizens against epidemics. When the poor are affected, it fails to cause much alarm, the media are not vocal. Another weakness of the public health system is that priorities are often determined by international agencies. This is an indication of the poor plight and neglect of the public health system in India.

Misplaced Public Health Priorities
In public health, what is important is not what has been achieved, but what remains to be done. With the integration of public health medical services, a treatment-oriented clinician, with no formal education in public health or training in epidemiology, often holds the post of the Director of Health Services. Such a person usually believes that expansion and strengthening medical care facilities automatically improves health care services (Journal of Public Health Policy 1990).
In Western and other developed countries, water is potable, sanitary disposal and excreta is universal, food is in plenty and unadulterated, homes and workplaces are habitable and safe, harmful pests and insects are controlled. Unfortunately, this is not the case in India. We have to concentrate on environmental sanitation, hygiene, and social services. We, in India, cannot do away with the fundamental elements of public health and follow the West blindly. In the control of diseases, important elements are epidemiology, participation of the community, preventive measures and raising the standard of living, rather than pure medical care.
While there is little doubt that the focus of the public health system must turn to comprehensive health care, the poor quality of curative services provided at health centres, must clearly be rectified by all-round strengthening of facilities (Chatterjee 1993).

Basic Public Health Measures required for the Control of Diseases are the following:-

1. Good Environmental Sanitation

• Adequate supply of safe drinking water.
• Sanitary disposal of human excreta and prevention of pollution of drinking water sources.
• Sanitary disposal of refuse, animal excreta, and other liquid, solid and gaseous wastes - domestic and industrial.
• Effective control of vectors such as mosquitoes, house flies and sand flies, and of animals such as stray dogs and rodents.
• Housing that is well ventilated, well lit, pollution free, safe from accidents and less crowded.

2. Promotion of Healthy Lifestyles

• Information Education and Communication (IEC) on health and related matters to enable and empower the people to look after personal and community health. Individually and collectively, people should feel responsible for their own health and that of their communities.
• Promoting health through social action by voluntary organisations and local communication organisations.
• Improving nutrition, especially of adolescent girls, pregnant women and children below five years of age.
• Ensuring optimum use of available health and medical services.

3. Control/Eradication Programmes Against Major Communicable Diseases.

• Strengthening National/State Disease Control Programmes.
• Providing high quality medical services to minimise morbidity, disability and mortality.
• Instituting strong epidemiological services, especially efficient and integrated disease surveillance operations.
• Securing active community participation and involvement of voluntary agencies.

4. General Requirements

• Proper organisational set-up with effective leadership. Bifurcation of public health and medical services may be necessary. Good management is imperative for success.
• Health policy to ensure trained public health manpower, infrastructure facilities and adequate finance.
• According higher priority to public health services, at least on par with the medical services.
• Decentralisation of the services, resources, authority and responsibility. Honest implementation of the Panchayati Raj system. Emphasis should be on intersectoral and integrated development. Decentralisation of delivery of health services, down to the village level. This will enable the central level to concentrate on functions that are presently given less importance, for example, regulatory functions, research etc.
• Placing people’s health in their own hands. For this, they have to be organised, trained and empowered.

The Status of Communicable Diseases Control Programmes
In 1950, there were 1,76,307 reported cases of cholera, with 86,997 deaths. Presently, the total number of cholera cases in a year range between 2000 to 10,000. Malaria deaths are on the increase due to an increase in Plasmodium falciparum cases. Prevalence of leprosy has dropped substantially; however, there is no evidence that the incidence has come down. Tuberculosis has not responded to control measures. In India, nearly 7.3 crore working man-days are lost every year owing to people falling ill due to water-borne diseases. On a conservative estimate, this amounts to a loss of nearly Rs 14,000 crores (Sharma 1993).

Diarrhoea and dysentery are not even recognised by the poor as diseases. Viral encephalitis, meningococcal meningitis and dengue fever outbreaks are common occurrences. Hydrophobia continues without any organised control measures.

The following recommendations are suggested on the basis of elementary principles of public health, mentioned earlier.

1. Strengthening the general health services.
2. A proper environmental sanitation and hygiene programme.
3. Modelling lifestyles, through an IEC drive.
4. Strengthening epidemiological services.
5. Disease-specific measures for the control of high priority infections. This step assumes much importance when the vertical programmes for the control of specific diseases will be abolished.

Control and Management of an Epidemic

• Epidemic warning system through surveillance data. This has to be backed up with electronic communication equipments.
• Early detection of outbreaks: involvement of local practitioners and private organisations, high suspicion index, quick confirmation of diagnosis, etc.
• Epidemiological investigations to find out the reasons for the epidemic, so that the most appropriate and locally effective control measures can be instituted.
• Responsibility for epidemic control measures should be separated from that for epidemiological investigations.
• Setting Priorities for the Control of Diseases. Setting priorities is important; epidemiological information will help in this regard.

Priority Health Problems
Many of the national disease control or eradication programmes, currently in operation, need to be reviewed and revamped with new strategies and programmes.

Vector-Borne Diseases
Vector-borne diseases include malaria, filariasis, viral encephalitis, dengue and chickenguina etc. Their control programmes cannot be operated in isolation as vertical programmes. They should be an integral part of a comprehensive vector (mosquito) control programme and the general health services. The use of insecticides should be restricted only to specified emergency conditions; no single method of vector control can work by itself.
Sanitary disposal of waste water and drainage are basic aspects of water management. These are essential steps in the control of breeding places of the vector. Intersectoral co-ordination and multi-disciplinary approach is needed to reduce/eliminate mosquitogenic conditions. Water management is the most crucial in the management of vector-borne diseases. Active participation of the people is vital for success. This should be encouraged through the national IEC drive for health promotion and disease prevention.
Mass single-day chemoprophy-laxis is recommended in endemic areas. An effective way of controlling epidemics is observing a ‘dry day’ every week. All containers in the houses and surrounding areas should be emptied once a week. This will result in the control of the vectors.
Voluntary organisations and private medical practitioners in endemic areas should be associated with the implementation of the programme, particularly health education and treatment.
Curative and epidemiological actions are to be integrated as part and parcel of the general health services. General health services should be strengthened to ensure that every person with symptoms of any vector-borne disease is diagnosed, appropriately attended and medically treated. Blood smears should be taken from all provisionally diagnosed cases to confirm diagnosis. This is equally applicable to private medical practitioners and hospitals.
Monitoring, evaluation and surveillance should be ensured through epidemiological services. Micro-level assessment of control measures is necessary.

Malaria
The Modified Plan of Operations has failed. The new revised Malaria Action Programme does not offer anything new; it is unlikely that it will improve the situation. There is an urgent need to have the malaria control and management strategy reviewed by a group of public health specialists, epidemiologists, malariologists and entomologists. Their recommendations should form the basis of a new programme.

• Area specific packages of anti-malaria measures based on local in-depth epidemiological studies should be implemented.
• Urban malaria mostly man-made needs to be tackled by good anti-larval measures and elimination of breeding places. Incidence of malaria in tribal and rural areas demands appropriate and locally effective interventions.
• State Health Departments should regularly disseminate information to medical practitioners regarding the diagnosis of complicated malaria and drug treatment.

Filariasis
Filariasis is endemic in 18 states in India. The population at risk has increased rom 124 million in 1971, to about 412 million in 1994. Augmentation of water supply without adequate consideration given to the disposal of waste water and sewage is the likely cause.

Viral Encephalitis
This disease has been reported in 24 states/UTs.

• Clinical and laboratory-based surveillance of viral encephalitis cases should be established in endemic areas. Surveillance is necessary to differentiate cases of viral encephalitis from other disease causing similar symptoms.
• Research is needed to determine the role of mammals and birds as reservoirs of infection. Entomological studies on the breeding and bionomics of proven and potential vectors are also required.
• It is necessary to establish surveillance for early detection of infection in piggeries in endemic areas. This will provide the earliest (about a month) warning of impending infection in human populations.

Dengue and Chickenguina
Dengue haemorrhagic fever (DHF) is a serious type of dengue infection. The patient may go into a state of shock that may prove fatal. Since 1963, epidemics of dengue have been occurring in different parts of the country.

• Surveillance of dengue cases, based on common signs and symptoms of the disease, should be established in high risk areas. This should be part of epidemiology services.

Tuberculosis
Tuberculosis is one of the leading causes of death in India, killing five to seven lakh people every year. The National Tuberculosis Control Programme was initiated in 1962. However, it has failed to make any dent in the problem.

A very large proportion of infectious tuberculosis patients visiting health centres and hospitals are being sent back with bottles of cough mixture.

Others approaching various health institutions for treatment are either not given treatment at all or are not cured (Banerji 1995). The shortage of anti-tuberculosis drugs has made it extremely difficult to ensure rational tuberculosis care.
The revised National Tuberculosis Control Programme (RNTCP) was reviewed by an Expert Committee constituted by VHAI and the Nucleus for Health Policies and Programmes (NHPP) New Delhi, in 1995. They reported that the RNTCP was both unsound and faulty; it covers only a limited population. The main question being asked is "What will happen to the programme after five years, when the RNTCP comes to an end?" The Chief of the WHO Global Programme on Tuberculosis agreed that a national tuberculosis programme must form an integral component of primary health care.

• Tuberculosis control should be accorded high priority.
• General health services need to be adequately strengthened to ensure that every person with symptoms suggestive of early tuberculosis is appropriately attended and the possibility of tuberculosis excluded. Sputum microscopy should be emphasised, overdependence on radiological diagnosis should be avoided. These measures are equally applicable to private medical practitioners also.
• Laboratory facilities for sputum microscopy should be of good quality and provided at every place of treatment.
• Every confirmed case of tuberculosis should be treated with recommended multi-drug therapy, preferably with ‘Short Course Chemotherapy’, directly supervised in the intensive phase. Regular and uninterrupted drug treatment should be assured. Multi-drug blister packs should be available for this purpose. Emphasis should be on case-holding and complete cure.
• Necessary anti-tubercular drugs should be made freely available without interruption to all PHCs, dispensaries, and private practitioners.
• Active participation of the people is vital for the success of any programme. This should be encouraged through the national IEC drive for health promotion and disease prevention.
• Monitoring, evaluation and surveillance should be ensured through epidemiological services.

There are other major problems like Acute Respiratory Infections in Children, Diarrhoeal Diseases in Children, Poliomyelitis, Infectious Hepatitis, Whooping Cough, Diphtheria, Measles, Cholera, Dysentery, STDs, Typhoid fever, Mumps, Kala-azar etc. which need to be analysed in detail. That will be attempted to in some of the future issues of this magazine.

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