How my interest in public health happened

I graduated from St. Johns Medical college, Bengaluru, Karnataka after my MBBS and MD in Community Medicine. For a period of 6 years, I worked part-time in a Primary Care Trust in the National Health Services (NHS), UK, and was involved in developing a white paper on issues of public health relevance. I realized that most of identified public health issues in the UK (depression, sexually transmitted diseases, obesity, alcoholism etc.) were primarily related to the social determinants of health. I felt that I had an important role in addressing the social determinants of health in India, which were somewhat similar, but also vastly different.

 In India, I worked in some non-governmental organisations (NGOs), but I realized that many of these spaces were predominantly occupied by dominant caste males who were more interested in building their own careers and agenda, but not ready to address many of the issues that the community faced in reality. Subsequently, as part of the Right to Food and Right to Health campaigns, some of us from diverse backgrounds began working on issues that we felt were crucial to address. 

Public health lessons from the pandemic 

The Covid pandemic and subsequent unplanned lockdown has unmasked the deep rooted structural crisis within the country’s healthcare system. 

If the healthcare system had been universal, comprehensive, well-regulated and decentralized, its response to the Covid 19 pandemic would have been far more effective with regards to both preventive and curative aspects. However, the Indian model of healthcare, with its rapid move towards large scale privatization, corporatization, centralization is wreaking havoc on India’s poor, with most government “policies” tending to protect commercial interest more than that of its more vulnerable communities. Central and State government health insurance schemes are fragmented, ‘package’ based and continue to create out of pocket expenditure (OOPE), leaving people completely at the mercy of the unregulated private sector.  

This was very evident during the pandemic, with people being admitted for Covid 19 in private facilities and being charged almost Rs. 30,000 – 40,000 per day. When people’s livelihoods and basic needs have been shaken by the pandemic and lockdown, a hospital admission is a catastrophic experience for the family and can push their wellbeing back significantly. Shutting down of essential public transport has affected people in numerous ways. It is also important for the Government to acknowledge that the years of damage and neglect to the public health facilities is taking its toll. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) intended to cover the “bottom 40% of poor and vulnerable households”, as identified by the Socio-Economic Caste Census (2011) fails on several fronts – as evident in the 2018-2019 annual report of the National Health Authority. Although claiming to be universal, it doesn’t cover the entire population nor all morbidities. Source: Annual report (2018-19), AB-PMJAY, National Health Authority. 

The government should learn its lessons from the failure of the for-profit private sector and of the AB-PMJAY scheme to provide any meaningful response during the COVID-19 pandemic. It should stop promoting privatisation of healthcare, and instead invest in strengthening public healthcare. Annual health budgets need to increase and the Government should invest money in adding to the capacity of public healthcare facilities and infrastructure instead of giving subsidies to the private sector. This health crisis should be a turning point in India’s health policy making, and bring back the centrality of the public health system in ensuring universal health care. 

Invisibilised health workforce
While it is true that junior doctors and nurses face several problems and these need to be addressed, the idea that these are the only workers in the healthcare system needs to be dismantled. 

The pandemic has spotlighted the hazardous working conditions of the health workforce at the lower end of the caste, class and gender spectrum: cleaners, ASHA workers, Group D employees, mortuary workers, sweepers, sanitation workers, auto-tipper drivers and mortuary/ambulance drivers.

Even when equipment is provided, it is not ergonomically designed and doesn’t protect their operators from occupational hazards. Outsourcing or contracting out essential services such as those provided by these frontline workers means they fall outside the ambit of usual regulatory mechanisms, and are therefore more vulnerable to exploitation and occupation-related injuries and illnesses. The accredited social health activists, or ASHA workers, have been lauded for being the eyes, ears, arms and feet of the health system. Again, ironically, they are the most poorly paid in the health system, depending mostly on the whims of others for their ‘honorarium’. Whether it is compensating for occupational ill health, providing work-specific PPE kits, enforcing labour laws, regularising jobs, easing access to comprehensive healthcare, or providing adequate rest and holidays – it is high time the government foregrounds these frontline workers.

Adverse impact of communalisation of the pandemic
As expected during any pandemic, there will be pockets and clusters of infection and a good public health system will anticipate this and either prepare for/prevent it or respond to it in a scientific way. In India, however, the easy choice was to communalise the issue and put, specifically the Muslim community, at high risk of being discriminated, harassed and targeted on the pretext that they were spreading the virus. If anything had to be blamed, it should actually be the government’s slow response to prevent the entry of the virus into the country through international travel and the unscientific propaganda by the India media. Stigmatising, failure to protect patient confidentiality and denial of care to patients diagnosed or suspected Covid positive was a major setback in the handling of the pandemic.

The growing communalisation in India has not left the healthcare system unaffected.

Islamophobic comments and dehumanising ‘jokes’ are not at all unusual and one can hear these being bandied around in doctors’ social gatherings. This is offensive, to say the least, and actively contributes to the denial of healthcare rights to patients. An example of this communalised hatred is Dr Aarti Lalchandani, the Medical officer of the Govt Hospital (Medical College Kanpur, UP) who, at the peak of the COVID pandemic was caught on camera making derogatory and hateful comments, falsely attributing the COVID-19 pandemic to the Muslim community. A letter had to be put out by a group of 221 concerned individuals criticising the doctor’s statements. Her behaviour is not isolated. She has not taken recourse to medical knowledge on how a virus functions in a pandemic, but to her own deep-rooted prejudices.

Disastrous consequences on non-Covid patients
The response to Covid 19 was a major setback to non Covid care patients who were denied even basic, essential and emergency care. Pregnant women, cancer patients, dialysis patients, those with chronic diseases like HIV/tuberculosis/cancer/other non-communicable diseases are likely to have developed several complications due to poor access. These include multi-drug resistance, progression of illness, early death and increased morbidity. 

This phenomenon is also evident with several social determinants of health. Of particular concern is the ‘lockdown’ of essential government services such as pensions, public distribution system (PDS), Integrated Child Development Services (ICDS) Scheme, mid-day meals, education etc. The long and short terms consequences of these will have a huge impact on India’s development milestones, but it doesn’t seem like the government is either interested in documenting these or responding to them. Instead the government seems to want to use this difficult situation to further push corporate agenda and further enabling the private sector.
Further, disruption of immunisation service to prevent potentially fatal infections in children like measles, pertussis, tuberculosis, mumps etc. can see a resurgence of some of these diseases as well as aggravation of the vicious cycle of interaction between malnutrition and vaccine preventable diseases in India. 

Discriminatory practices and prejudice within the healthcare system
If healthcare providers themselves carry deep-rooted cultural, gender, caste and religious prejudices and biases, these can be damaging to the well-being of their patients as well as students and colleagues. They are incompetent to teach or practice patient care. This is quite central to how the health system responds to patients from oppressed communities. People engaged in occupations that are traditionally associated with Dalit communities and seen as unclean – such as manual scavenging, sanitation work, mortuary, handling dead bodies, etc face difficulties in accessing even basic healthcare and patient rights. One often hears patients say that they have never been touched by a doctor. During COVID times and with telemedicine, this physical distancing from a patient and relying more on tests recreates a new form of medical untouchability that sits well with the caste and class location of the doctors.

 In the context of mental health care, it should be stated at the outset that mental healthcare even for so-called privileged communities is dismal, so one can only shudder to imagine what it must be for those from non-privileged backgrounds. Many mental healthcare professionals are trained in a Western model, making them disconnected from many of the lived realities of people in India. In the absence of a cultural/religious/social/economic understanding of mental health, health care providers can become more of a problem than a solution. The potential to abuse the positions of power that doctors hold is enormous.

The religious/caste/gender divide between the healthcare provider and patient, if premised on discriminatory behaviour, can lead to immense damage to a person’s mental well-being, more so if the person is already in a vulnerable mental state. Patient rights and dignity is increasingly becoming linked to their social location. This has to change. Healthcare systems need to start introspecting on how dignity can be offered to all patients irrespective of their social location.
It is vital to have representation from vulnerable communities at all levels of the healthcare system from policymaking, administration, management, clinical work, nursing as one way of making the health system more responsive to larger social issues. The decision to have additional coaching classes, effective and functional grievance redressal mechanisms, mentorship programs, language improvement skills, common eating systems, etc. will not come from communities that see no value in these interventions.

Nutrition, Malnutrition & Forced Vegetarianism – What It Means for Children
The National Programme of Nutritional Support to Primary Education (MDM Scheme), launched in August 1995 emphasises on the provision of cooked meals with a minimum of 450 – 700 calories and 8-12 grams of proteins and was further converted by the National Food Security Act (NFSA) 2013 into a legal right upto Class 8. Over 94% of the children in government and government aided schools come from Scheduled Caste, Scheduled Tribe, Other Backward Classes and minority communities.

Some statistics from the National Family Health Survey (5th round) 2019, which should concern us
• Breastfeeding children age 6-23 months receiving an adequate diet – 11.0%
• Non breastfeeding children age 6-23 months receiving an adequate diet – 19.5%
• Total children age 6-23 months receiving an adequate diet – 12.8%
• Children under 5 who are stunted – 35.4%
• Children under 5 who are underweight – 32.9%
• Women whose body mass index is below normal (<18.%) 17.2% • Men whose body mass index is below normal – 14.3% • Women who are overweight or obese (>25) – 30.1%
• Men who are overweight or obese – 30.9%
• Children age 6-59 months who are anemic (<11 g/dl) 65.5%
• Non pregnant women age 15-49 years anemic (<12 gm/dl) – 47.8%
• Pregnant women age 15 – 49 years who are anemic (<11 g/dl) – 45.7%
• Men age 15-49 years who are anemic (<13 g/dl) – 19.6%

 For a majority (94%) of children in government schools who are from marginalised communities and malnourished, garlic, onion and eggs form an important part of their diets, limited only by the factor of affordability. Eggs have been denied to children as part of the mid-day meals in schools for several years. Described as the ‘menstrual discharge’ of the hen, eggs are labelled as ‘sinful’, ‘violent’, and agitating the senses, with egg eaters deserving to be ‘destroyed’. If, instead of this unscientific propaganda, the nutritional value of eggs had been the primary deciding factor, children would have been given eggs as part of the mid-day meal scheme on 5 days of the week. 

The idea that Dalit, Adivasi and OBC children should be grateful for whatever food is ‘given’ to them is deeply ingrained in the minds of doctors, activists, researchers, policy makers and pretty much the entire gamut of citizens in the country.

The idea that children have inviolable rights to healthy, nutritious, tasty, clean, culturally relevant food is lost on most people who claim these same rights only for themselves. This is the crux of how caste discrimination operates in India, reinforcing all the hegemonic, hierarchical imbalances that are so evident that they become invisible. An entire mafia has formed around children’s food, making it almost impossible for children to have one decent meal as legally mandated by the NFSA.

In addition, it is important to understand that a predominantly cereal based ‘vegetarian’ diet that is currently being imposed on India, is contributory to the crisis of non-communicable disease in the country. 8.7% (50 million) Indians in the age group 20 – 70 year age live with Type 2 diabetes, an attributable risk factor for several complications affecting the eyes, heart, kidney, nervous system and circulatory system. Cutting down on sugars, reducing traditional cereals, and increasing the consumption of animal source foods has the ability to drastically prevent or reduce the large-scale prevalence of Type 2 diabetes and its complications. However, in India, politics, culture, religion, caste and economics around cereals, vegetables, fruits, pulses, oils, eggs, meat etc., constantly dictate what people eat. Even a suspicion of transporting beef or a mention of its nutritional/cultural/religious value can trigger a series of events ranging from abuse, arrest, harassment and lynching. This has been used with a great degree of expertise by politicians seeking to fragment India along caste and religious lines. Anaemia in children less than 5 years is 60 per cent in India. This, with chronic hunger and other nutritional deficiencies that invariably co-exist, can lead to less than expected performance of the child in school. In a caste and class ridden society, where many government schools fail to meet even minimum educational standards, the child’s disadvantages start early in life.

Adverse impact of beef bans and anti-cow slaughter bans
The beef ban brought in by the Government of Karnataka raises several questions. Firstly, has the government even considered the lakhs of people connected to livestock who will lose their livelihood in one stroke? Has the government made any alternate arrangements for them or are they expected to just starve to death because of ‘religious sentiments’ of those whose economic welfare is well ensured? Incomes of people have dropped markedly since the unplanned lockdown by the government and it is actually the government’s duty to ensure that livelihoods are not only protected, but supported during these difficult times. Instead the government seems keen on taking away livelihoods. Most of the people whose livelihood will suffer because of the cow slaughter ban are also Dalit, Muslim and Christian. This shows the discriminatory nature of government decision-making. In the backdrop of malnutrition in the state, the lockdown has brought about a serious deterioration in peoples access to nutritious food – a lockdown of most essential services like Public Distribution System (PDS), Integrated Child Management Services (ICDS) Scheme, Mid-Day Meals (MDM) etc. To then further take away access to a nutritious and cheap food shows how the vindictive nature of the government.