Speaking for Ourselves     224

Public health needs a boost, not bickering
K. SRINATH REDDY

   Because things are the way they are,
   things will not stay the way they are.
   — Bertolt Brecht
It is difficult to disagree with passionate champions of public health such as Mohan Rao and Nayar. There is also no cause to disagree when they argue, in the initial part of their viewpoint exposition, that the social determinants of health and disease need to be identified and addressed through fundamental social changes that promote equity, access and affordability as essential characteristics of the health system. There is no dispute also when they argue for the strengthening of primary healthcare and affirm that it is governments that bear the major responsibility for ensuring the availability of healthcare to all sections of the people, through appropriately structured and adequately financed public health services.
   There could be some minor differences, however, when they posit oral rehydration solution (ORS) and provision of safe water and sanitation as mutually exclusive public health programmes. While it is undoubtedly important to advocate, aim for and accomplish sustainable social promoters of health such as universal supply of safe drinking water, interventions such as ORS could still save thousands of young children who may fall victim to diarrhoea, till that salutary social objective is achieved. Obsession with technology should never drive public health polices or programmes, which need to address the determinants of health rather than merely attempt quick-fix solutions for disease. At the same time, public health should never shun appropriate use of suitable technologies to advance towards its goals.
   Similarly, prevention and amelioration of anaemia in the general population, through policies for improvement of mass nutrition and creation of hygienic conditions where parasitic diseases are avoided, is a laudable and necessary objective. Till that goal is achieved, would not special attention to the detection and correction of anaemia in an especially vulnerable group of pregnant women, who run a high risk of pregnancy-related complications and death, serve a useful public health purpose? Public health needs a broad array of interventions which can make complementary contributions to create a comprehensive response to complex health challenges. An ‘either–or’ approachcan be self-defeating and may freeze the status quo till major social changes can successfully influence all of the social determinants.
   However, my major area of discord with Mohan Rao and Nayar’s writing arises only when it strays from being a sound social critique, which it is in the initial section, to become a string of speculative comments on the role of the Public Health Foundation of India (PHFI) in the latter part of the article. The criticism of PHFI is based on assumptions that the PHFI Institutes would (i) follow an American model of education, (ii) produce public health professionals for an export market, (iii) create a cadre of elitist ‘managerial physicians’ distanced from primary healthcare, (iv) promote a technology-driven biomedical model of public health, and (v) result in neglect of existing public health training institutions.
   None of the above assumptions are valid. The PHFI will mainly draw upon Indian experience and Indian expertise, while drawing up its curriculum and developing its learning resources. Future faculty would be drawn from available expertise in India and others trained abroad, in multiple reputed centres across the world. PHFI would establish academic partnerships with public health institutions from all regions of the world and access global learnings which are robust in academic content as well as relevant to the Indian context. Connectivity with public health institutions in other developing countries would be accorded a high priority. No exclusive relationship has been established with any American school of public health and each PHFI Institute will connect with a number of Indian and international partners. In the overall context of public health education, it is useful to draw upon the strengths of international partners, including American schools where appropriate, in core disciplines such as epidemiology, health economics, biostatistics and behavioural sciences. We should remember that American universities are also home to persons such as Amartya Sen, Noam Chomsky and Joseph Stiglitz, who are respected for their independent thinking and contributions to public discourse. Similarly, American universities also house many public health teachers and researchers who are not inimical to the interests of developing countries such as India. It is for us to evolve the models of education most relevant to us and engage with those who can help us in the areas of our identified needs. Countries such as Thailand, Iran and Bangladesh have much to teach us and we will learn from them, as we will also learn from institutions in Europe, North America and Australia.
   Initially, the majority of those trained in the PHFI Institutes would be persons already employed in the State health services or health NGOs. The aim would be to add value to their role as serving functionaries in the health system. Simultaneously, efforts would be made to persuade states to create definitive positions for persons with public health expertise, so that even fresh graduates can be absorbed. The creation of a public health cadre has been recommended by several expert committees (Bhore Committee, 1946; Mudaliar Committee 1961; the Expert Committee on Public Health System 1996, constituted by the Government of India). PHFI would advocate for the creation of such a cadre, even while training existing physician and non-physician public health functionaries who are presently positioned in the health system. There would also be efforts to increase the absorption of public health professionals into the voluntary and private sectors in India. The purpose is to invigorate all components of the Indian health system with infusion of public health expertise.
   Far from creating ‘elitist physician managers’, PHFI aims to provide multidisciplinary education and training to a wide range of public health resource persons. In a situation where neither nurses nor nutritionists have a major programme for training in public health and where public health law and public health engineering are rudimentary disciplines, PHFI hopes to evolve innovative models of education. Health management too would be an important educational stream, but only as one among several that PHFI would nurture.
   In the present scenario, where are the programmes that can inform and influence sectors such as agriculture and urban planning to address public health needs? How many health economists are available in India to conduct policy-relevant studies and document the effects of distorted development on the health of the people, leave aside teach courses in this much-needed but almost non-existent discipline? At the grassroots, how many trained personnel are available for nationwide disease surveillance? Why are cause-specific mortality data not available for many common diseases? Training programmes are obviously needed at many levels and PHFI would try to facilitate them, along with other institutions.
   The fact that PHFI derives a part of its initial funding from the Gates Foundation cannot be construed as evidence that its public health education programmes would have a tubular technovision. The broad-based education that PHFI envisages will encompass a clear understanding of the multiple determinants of health and provide the skill sets for undertaking multisectoral actions to advance public health. The Gates grant is an unrestricted grant and does not bind PHFI to any particular pattern of education or research.
   PHFI is also committed to assist the growth of existing and other emerging public health training institutions in India. It would help to create a network of such institutions which can strengthen each other through sharing of technical expertise and conduct conjoint programmes in teaching and research. It must be recognized that the existing institutional strength in public health education and training is highly inadequate for developing human resources on a scale needed to transform the health services. If the present institutions were fully capable of delivering all that is required, why would the prevailing scene be so dismal both in terms of the available public health workforce and public health advocacy? Whether for advocating policy change or for implementing programmes, many more public health professionals are needed to generate and apply knowledge as relevant to public health goals.
   Finally, it is misleading to suggest that PHFI has been created to place public health in private hands. The primary objective of PHFI is to strengthen public health services. The partnership with the Central and State Governments and their participation in the governance of PHFI and its institutes will ensure that the activities of PHFI are closely aligned to the priorities identified by the government and will readily respond to the needs of public health services. A number of State Governments have already communicated their interest in establishing such a close partnership. The voice of civil society would also be heard and heeded when it provides its inputs through various advisory bodies which would soon be established. It is only when public health continues to be neglected that the health of the people will be mostly transferred to private hands, by default. The PHFI’s mandate is to protect public health, not to undermine it.
   To let the ‘status quo’ continue, because of false insecurity about new institutions or misplaced fears about hidden agendas, would be a grave disservice to the Indian people. To deliver an advance verdict of ‘guilt by suspicion’ on PHFI, even before it has started functioning, reflects neither natural justice nor scientific objectivity. A new initiative should be judged neither by the
best hopes of its friends nor the worst fears of its critics but by the reality of its activities as they unfold. It would be better for skeptics to closely monitor the activities of the PHFI, which is just born, and reserve their judgement till it opens its first Institute in 2008. It would be best, of course, if all well-meaning advocates of public health join hands and promote a sound framework for addressing India’s many health challenges.