Thursday, January 1, 2015

A year of man-made health crises

Over the past year, several significant public health crises have unfolded in India and globally. As this year hurtles to an end, it becomes important to examine these events, if only momentarily, to understand the lessons they hold.
On closer examination, it becomes apparent that many of these crises were man-made — either because of continued neglect, a lack of focus on prevention and insufficient investment in health, or a focus on addressing diseases but not their root causes, i.e., the social determinants of health.
Early in the year, the war in Gaza and the blockade exacerbated a health crisis caused by continued international neglect of the people of Gaza. At the last count, the four-week conflict left 10,000 homes annihilated and displaced 4,50,000 people. The real public health crisis was the lack of electricity, clean drinking water and safe homes. Overcrowding and the lack of water and sanitation facilities led to a rise in the incidence of water-related diseases. As time passes, this destruction will expectedly result in multiple health crises that will affect the physical and mental well-being of hundreds of thousands of people.
Yet nothing made more news than the Ebola crisis in West Africa, where over 7,000 people have died. In the poorest and perhaps most politically unstable part of the continent where this crisis unfolded, the biggest areas of neglect were health systems, infrastructure, funding, trained human resources and little community education. Ebola has been endemic to the West Africa region for almost two decades. Yet, the ability of this region to address this disease, or any other, remains severely limited. Ebola wasn’t a global priority either, because it was centred in a poor region. International agencies bickered and took their time to respond while people died. When the first case emerged in the U.S., Ebola finally qualified as an important disease, and new experimental drugs, vaccines and preparedness soon followed. As always, it seemed too little, too late.
Health care in India
Let’s turn homeward. As India marched towards acche din , it also marched towards global leadership in many diseases. This year witnessed repetitive crises in malaria and dengue. Diabetes and heart disease continued to confound us. Earlier this year, we had a shocking stock-out of HIV testing kits and later of HIV drugs that, ironically, we produce and supply globally. Even as thousands were deprived of drugs in the public health sector, the government defended itself saying the situation was not “too bad.” India’s drug-resistant TB crisis too came out of the closet with over a 1,00,000 cases. We also finally admitted on national television that TB is the country’s time bomb.
However, the highlight was the sterilisation tragedy in Chhattisgarh. Over 10 of the 83 women who underwent sterilisation surgeries in the State died, while many others were hospitalised in a critical condition. The incident revealed the patriarchal mindset of successive governments who focus on female surgical sterilisation as a cornerstone of family planning. It also revealed the ongoing nexus between government officials and petty manufacturers, as the antibiotics given to patients were suspected of containing rat poison. Unfortunately, no politician or government official has been tried for culpable homicide. These deaths remain unpunished.
On a broader level, the quality of health services in urban and rural India, in both the public and private sectors, continued to be abysmal, as millions of patients travelled to access health services elsewhere. Over 60 per cent of all Indians continued to access healthcare in the private sector (many from quacks) at exorbitant costs and were often exploited with inappropriate tests and treatment. India’s epidemic of micro bacterial resistance also continued unabated as pharmacies sold antibiotics over the counter without sufficient control from the government. The biggest blow came at the end of the year as news leaked that the new government would cut health spending by around 20 per cent. For a country whose spending on health is among the lowest in the world, this was a terrible way to wrap up the year.
Lessons for the next year
What can we learn for 2015? Governments in India and elsewhere that promise development, growth and human well-being must recognise this: all this is not possible without investments in health and health systems. We need to invest in improving preventive and primary health care, sanitation, waste management and health education. Finally, if our long history of continuing disease and recent crises teach us anything, it is that the fundamentals of health remain critically important in disease control — sufficient nutrition, safe habitation, better air quality, sanitation, health-seeking behaviours, safety, and reduced conflict. All of these are deeply linked, not just to health but social and economic policy. Reducing spending on health will make things worse, not better, in India and elsewhere. Acche din will not arrive either next year or the decade after unless India integrates these lessons with its public policy.

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