Dr. Sylvia Karpagam
Public health is an art and a science -a fine thread that links social determinants of health with long term health outcomes, prevents disease before it occurs, anticipates epidemics and protects not just the rich and famous, but the poorest and most vulnerable. It draws threads between individuals, communities, states and countries. It anticipates, plans and budgets. Importantly, it doesn’t discriminate and, most certainly, doesn’t profit out of sickness.
Under the ambit of comprehensive public health care comes health promotion, preventive, curative and rehabilitative services. It requires not just policies, but action, measured by robust systems of evaluation and enforced by accountable processes of regulation.
In the context of the Covid19 pandemic, some questions need to be asked. Was India prepared for the pandemic? Is India able to deal with the current crisis? Are there lessons to be learnt?
To the first question, the answer is NO. India was neither prepared for Covid19 nor any otherdisaster (man-made or natural) or pandemic. In spite of India’s claims of being a socialist democracy, it is, in reality, sprinting towards a dangerous capitalist and commercial model of healthcare, that places the large, curative (read lucrative) super-speciality hospital as a panacea for the country’s numerous health problems. While Bangalore may boast of some of the largest (and most expensive) hospitals in the country, these unfortunately doesn’t automatically transform into better health outcomes. The recent Covid 19 experience is a stark reminder of how little the city is equipped for any kind of public health crisis.
It is important to note that large scale privatisation happens by actively breaking down public health structures- by the kind of policies, who the ‘policy makers’ are and who are considered as the important ‘stakeholders’
Doctors in public hospitals are some of the most experienced. Strict protocols and standard practice guidelines means they are much more likely to follow rational or evidence based medicine. They may not also stand to gain from expensive prescriptions though they do find ways to make some quick bucks by cuts and commissions with labs and diagnostic centres.Poaching of extremely skilled doctors from government and charitable hospitals is an open secret. It is not at all uncommon to find agents coming and speaking to doctors during duty hours and offering them lucrative packages to shift practice to the private sector. While one may say this is healthy competition, it is actually unfair competition. A visit to some of the tertiary public hospitals in cities will show how woefully inadequate they are brought on by a combination of under-funding and disinvestment in human resources. Public private partnerships and health insurance schemes are no more than a smokescreen to deliberately route tax payers money to schemes that largely benefit private corporates and multinationals.
Central and state health insurance schemes force more and more patients from remote rural areas to access centralised healthcare services. All of us would surely know that the closer healthcare is to where one lives, the better it is for a variety of reasons, out of pocket expenditure being just one of them. Health care schemes are often only for a few ‘packages’ thus making healthcare very fragmented. For instance, a person with cataract and symptoms of liver failure may be operated for cataract but asked to pay for the liver condition. In the context of Covid 19, one can see that centralised healthcare leads to patients being forced to travel long distances widening the geographic spread of the virus. If a patient who is positive for Covid 19 in Manvi taluk is managed locally, instead of traveling all the way to Bangalore for a confirmatory test, the spread of disease would have been contained better.
To the second question about whether India is able to deal with the current crisis, the answer is NO. The only reason this pandemic may pass without a high fatality is because of immunity that has come from years of exposure to different strains of bacteria/viruses and sub-clinical infections. A day of curfew with clanging of pots and pans has no known record of being of any consequence in a pandemic.
It’s important that lessons are learnt for the future.
One possible lesson is for even the middle class and well off to start availing publichealthcare institutions even though these facilities will not magically transform overnight.Bureaucrats have to be held accountable as should those making major decisions. While it is convenient to target the frontline health care provider, one has to understand that they often have the least power, are overworked, underpaid, bullied and who often do long hours, compromising their personal lives. One has to understand that systems and structures operate over and above any individual healthcare provider. It is important that the public health system is held accountable to deliver comprehensive, ethical, non-discriminatory care forpatients.
The language of blaming sick people or their families for their illness should stop. The culture of abusing patients or infantilising them for the single reason that they are poor or sick or worse both, should stop. Patients are not always ignorant. There are several systemic and structural barriers to access healthcare that shouldn’t be placed at the doorstep of any one individual. Stereotyping patients is common practice, with little attempt to give patients social, psychological or emotional support. A diagnosis, even of a stigmatising disease or a life threatening one, is thrown at the patient without even a pause to consider the devastating consequences.
Shortage of drugs and poor supply of even basics like lab reagents, swabs, glucose testing kits etc. if not addressed seriously can be the death knell for public hospitals. The number of pharma shops and diagnostic services around what is an essentially free public health centeror hospital gives a good idea of the quality of these services within the hospital..
Another important lesson to be learnt is that preventive care has to be an important part of the healthcare system. The Nipah virus could only be controlled in Kerala because of a responsive public health system. This responsibility cannot be placed on the private sector because they have a conflict of interest. It is a sad fact that private hospitals benefit more from disease than from the prevention of it.
Often social determinants of health are completely ignored by the healthcare system which operates on a curative model. A simple advice to a patient with high blood sugar, to cut down on carbohydrates and sugar can drastically reduce their need for life long medicines but this is often not even part of the advice. Animal foods play an important role for children, adolescents, pregnant women and mostly everyone. If a woman is diagnosed with anemia, she may be asked to consume iron tablets and green leafy vegetables but never told about the benefits of animal foods, especially liver. This comes from the intrinsic caste prejudices that doctors are susceptible to, with personal prejudices guiding medical advice more than science!!
Disease of public health importance such as dengue, chikungunya, malaria, typhoid, HIV, tuberculosis, sexually transmitted diseases, and now Covid 19, can only be addressed with a good and functioning public health system.Only by learning from the Covid 19 experience can we be more prepared for future disasters.
The writer is a public health doctor and researcher based in Karnataka.