India ranks the lowest in the world on several health indicators and a large part of the country’s population has little or no access to quality healthcare
Providing proper healthcare to citizens in the 21st century has become the most daunting task for all nations. Hardly have we registered success in dealing with old and entrenched diseases that we stand confronted with a very complex set of diseases attributable to changing lifestyle and environmental factors. According to the WHO constitution, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Governments as well as many among us do not work towards keeping health issues high on our agenda and health is taken for granted. Gandhiji always reminded his audience of the value of health and led a very disciplined life in pursuit of optimum health. His life provides an example of how we can stay healthy by adhering to some simple rules enunciated by our sages. Understanding the factors that undermine health and anticipating the consequences of a lack of commitment to health is an emerging new concept. Our ancestors figured out that physical health can only be reinforced by strengthening psychological and spiritual health. Controlling the mind by sanitising the thoughts can help us maintain the body in a healthy state.
India ranks the lowest in the world on several health indicators and a large part of the country’s population has little or no access to quality healthcare
Despite all claims about our achievements in the field of health, such as a rise in life expectancy (68.3 years) and elimination of smallpox and polio, the fact remains that the health scenario in India continues to remain grim. This is a direct consequence of ignoring health and education ever since independence. WHO admitted towards the beginning of the 21st century that healthcare systems in most countries were in a shambles. Widespread poverty and illiteracy (currently pegged at 26% of the population) makes the goal of providing universal healthcare extremely challenging. The poor state of the health of the nation can also be partly attributed to low fund allocations for health (currently only about 1.2 % of GDP, says the Economic Survey, February 1, 2017). This low level of funding comes despite the acceptance of the Bhore Committee report, which advocated a 10 per cent allocation of funds for health. The low allocation, coupled with neglect of our own indigenous systems of medicine as well as preventive, promotional, rehabilitative and public health and a disproportionate stress on curative and tertiary healthcare, has left our healthcare system in a blind alley today.
Government hospitals are bursting at the seams with patients lined up in corridors
Our planners consistently ignored our ancient wisdom, which laid enormous stress on hygiene, cleanliness and sanitation. The foundations and principles of modern-day healthcare are well enshrined in our scriptures. Thousands of years ago our sages propagated a holistic vision of health, enunciating a concept of health well beyond physical, mental and social well-being to embody emotional and spiritual well-being. Modern scientists have failed to appreciate that our noble forefathers could protect their physical and mental health by practising spirituality. People in developed and rich countries today remain highly stressed and in poor health despite great affluence and wealth. This phenomenon of stress has recorded unprecedented growth in the last few years due to the switch-over to a market-based economy, which has led to widespread joblessness as well as a lack of meaningful employment. I think alleviation of stress is one of the most formidable tasks confronting healers today and modern medicine’s purely technical approach will be of little help in this regard.
Our health planners, over the years, have overlooked age-old Indian wisdom and have instead promoted borrowed ideas and advocated only one system of medicine, the so-called ‘modern medicine’, which has failed to ensure availability of healthcare to everyone in even the most affluent nations despite a whopping increase in health sector spending. In the new millennium, however, there has been a paradigm shift in developed countries and a new approach adopted that underscores a holistic system of medicine.
Due to misplaced priorities in the health sector in India, while a small minority can claim access to world-class health facilities, millions of Indians do not have any access to healthcare, let alone primary healthcare. It may look strange and paradoxical to point out here but the fact remains that the responsibility for ensuring health for everyone depends not only on the Health Ministry, but the policies and action initiated by other ministries too. Availability of safe drinking water must be ensured by the civic authorities as also safe disposal of human excreta and hazardous waste. Provision of proper sanitation facilities is a must.
Mantris of various ‘Bhavans’ need to put their heads and resources together to ensure better health outcomes
The Food and Agriculture Ministry needs to ensure affordable foodgrains for all, especially the vulnerable population, ensuring that its basic nutritional needs are met. The Urban Transport Ministry needs to provide adequate and safe public transport to reduce levels of air pollution as well as injuries and accidents, which account for substantial morbidity and mortality in all developed and newly industrialising countries.
The Environment Ministry needs to ensure a safe and healthy environment by preventing and controlling air, water and soil pollution by formulating standards and ensuring proper enforcement. The Housing Ministry needs to make available habitable dwellings for all. The role of the Health Ministry should largely be focused on ensuring highest standards of public health and disease prevention. Promoting a healthy lifestyle and healthy behaviour should be encouraged. Community participation and involvement remains the backbone of any good healthcare system. The emerging challenge of non-communicable and lifestyle diseases has to be met head on with focus on creating healthy workplaces.
Community involvement remains the backbone of any good healthcare system
Successive governments at the Centre never recognised health as a means to achieving human development but treated it as a minor government department that needed a minimum of funding. Policy-makers, planners, healthcare providers today have to make good for the past apathy. Serious challenges lie ahead as, on the one hand, people’s expectations continue to rise due to technological breakthroughs and availability of new modalities for diagnosis and cure and, on the other, prohibitive costs make these inaccessible for most of the population even in developed countries. Hopes were raised when the World Health Organisation formulated the strategy of ‘Health for All’ by the year 2000. Now that 2017 is on its way out, the goal remains elusive, with new threats emerging such as tobacco-related illnesses, drug abuse, resurgence of old infectious diseases, zoonotic and vector-borne ailments and, above all, work-related and environmental illnesses.
Drug abuse as well as zoonotic and vector-borne ailments have to be tackled on a war footing
In my humble assessment, the goal of ‘health for all’ is laudable and needs to be achieved through the primary healthcare route. We need to have a broader, more comprehensive and integrated approach which recognises and makes use of our age-old wisdom, practices and societal beliefs. Ancient Indians were known to enjoy long and healthy lives when no technology existed. Whatever they said or thought or practised has proved to be correct, no matter which scientific scale one employs. That eating less is linked to longer life was a fact known to our forefathers—alp bhuktam bahu bhuktam (one who eats less enjoys food for a long time). That vegetarian food is associated with longer life and less affliction by degenerative diseases, too, was well known. These dictums are now universally accepted even by scientists.
Let us first see where we stand today as far as our achievements are concerned. Life expectancy, which stood at 32 years at the time of independence, has gone up to 68.3 years. Maternal mortality at 174 /100,000 live births (2015) is still too high; the death rate which was 27.4/1000 has dropped to 7.3/1000 (2016) and the infant mortality rate has declined from 146/1000 live births at the time of independence to 40.5/1000 (2016) live births in the last decade. An interesting fact is that though these figures represent the national averages, there is a wide inter-state variability, with some states like Kerala being way ahead in health indicators, whereas states like Bihar and Madhya Pradesh lag far behind. Again, though infant mortality has registered a drop, the problem of malnutrition has not been solved and remains a matter of grave concern. India has one of the highest incidence of low birth weight, nearly 7.5 million low-birth weight babies annually, the highest for any country. It is now universally acknowledged that poverty is the harbinger of poor health and without reasonable socio-economic development, health for all cannot be achieved. Yet, the Human Development Report, published in the last decade places the overall prevalence of poverty in India at 38 per cent, i.e., about 350 million, which is an unacceptably high figure. (The WHO 2015 report says 170 million people, or 12.4%, lived in poverty defined as $1.90 or Rs 123.50, a reduction from 29.8% in 2009). As per an NSSO report, the average per capita calorie intake at the all-India level in rural areas is 2,099 kilo calories and 2058 kilo calories in urban areas. More alarmingly, the poor nutritional state resulting from this insufficient calorie intake is far more prevalent in pre-school children, which might have a serious effect on their physical and mental development. In women, the prevalence of anaemia during pregnancy is as high as 87.5 percent (with 13 percent recording severe anaemia), which has profound implications for the health of the new-born. Similarly potable water, disposal of waste, sewerage system and clean toilets are available to only a few, though in the case of the last, much headway has been made by the Swachh Bharat Abhiyan. Besides, there are other distortions, like one nurse for three doctors, whereas there should be three nurses for one doctor. In addition, there is a lack of adequate public health specialists, epidemiologists, pathologists and radiologists. Above all, the world’s first nation to launch a family planning programme way back in 1952 has failed miserably in meeting its targets.
Insufficient calorie intake stunts the growth of children and they end up not realising their full potential
Recent research indicates that the role of lifestyle and environment in securing human health is, perhaps, more profound than was previously thought. Interestingly, our ancestors always knew the truth of this, as is evidenced by their penchant for cleanliness, environmental protection, sanitation and good food habits. The Indian system of medicine invariably recommended an alteration in diet and food habits in all cases of illness. The concept of biodiversity was propagated and one was exhorted to show compassion to all living beings, with trees even being venerated. The Isha Upanishad clearly states, Isha vasya midam sarvam yat kinch jagtyam jagat (God dwells in everything present in this universe). To promote social well-being and harmony, the ancients enunciated the concept of Vasudhaiva Kutumbukam (The world is a family). If everyone is a family member, where is the room for discord and how can there be isolation and alienation?
We now recognise that many of our present-day ailments result from an unhealthy lifestyle and many disorders are related to poor nutrition, alcohol abuse, smoking and stress. What is not frankly accepted is that many of these diseases result from a society that alienates people from itself and from one another. Modern medicine is unable to provide solutions for this. Identifying
Many present-day ailments come from unhealthy fast food and stressful lifestyles
the need for social answers to disease, therefore, is also an important part of the solution. If healing of people is to be really achieved, the spiritual dimension of care has to come in, for it is vital. A decidedly more humane and healing approach is required, which stresses the promotion of the body’s self-healing powers, as was preached and practised by our ancient systems. A serious effort is required to explain the strength of the spiritual aspect of healing to modern practitioners and calls for a new approach so that healthcare providers inculcate and adopt it.
Current trends in medicine stress on a concept of healthcare based on ‘quality of life’ and this dimension is assuming increasing importance in healthcare. This becomes particularly relevant as life expectancy increases and people start living longer. In fact, this concept was first put forth in our scriptures, which maintained that not only should we live to 100 years, but also have our vision, hearing and other sensory and motor functions intact. Prof. O. Boyle of Ireland says that illnesses, diseases and their management can significantly influence areas such as functioning, mobility, mood, life satisfaction, sexuality, cognition and ability to fulfill occupational, social and family roles. The emerging ‘quality of life’ construct may be viewed as a paradigm shift in outcome measurement, since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to ageing populations, both for the healthy elderly and for those who develop chronic diseases, where maintenance of quality of life rather than cure may be the primary goal of treatment.
During my tenure as Health Minister, we accorded high priority to the neglected public health system. Right at the outset we prioritised our activities and prepared an action plan to address the distortions that I talked about above. We encouraged community participation and involvement, beginning with the launching of the polio eradication programme and ending with its successful completion. I felt then, as I do now, that people do get motivated and enthused if they are communicated the message of health unambiguously. The Delhi Government under the BJP was the first to take the initiative for the ‘Rational Use of Essential Drugs’. The programme was so successful that it has now been adopted by many states in India. The WHO has recognised it as the ‘Delhi Model’ and this is now being propagated and implemented in many countries of the world with the guidance and support of India.
We were also very concerned about tobacco-related illnesses and, despite much opposition, a bill was passed in Delhi—The Delhi Prohibition of Smoking and Non-Smokers Health Protection Act 1996. This inspired the promulgation of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), the principal comprehensive law governing tobacco control in India. The Act was passed before India became a party to the WHO Framework Convention on Tobacco Control. In 2004, the Ministry of Health and Family Welfare exercised the powers granted to it under Section 31 of COTPA by promulgating a first set of rules with respect to smoke-free and tobacco advertising issues. With respect to general enforcement of COTPA, G.S.R. 1866(E) lists certain officers who are authorised to carry out entry, search, and seizure provisions under the Act.
Continuing with our mission to prevent diseases due to environmental and occupational factors, a Centre for Occupational and Environmental Health was set up in Lok Nayak Hospital and Maulana Azad Medical College, which came to be acknowledged internationally. We launched campaigns on the theme of ‘Matri Surksha’ (Safe Motherhood) to strengthen reproductive health as well as a ‘Cancer Control Programme’, ‘Cataract Free Delhi Programme’ and ‘Shravan-Shakti Abhiyan’ (for deafness affecting the old and their rehabilitation). We were also able to enact the ‘Delhi Physiotherapy and Occupational Therapy Bill’ and ‘Delhi Artificial Insemination Act’. To promote holistic medicine, 100 acres of land was earmarked for setting up a hospital based on naturopathy and drugless therapy with an Ayurvedic medical college along with a research centre on the campus. In addition, a ‘Healthy City Project’ was also started in the trans-Yamuna locality of Delhi. A ‘Hepatitis B Immunisation Programme’ was taken up and we established a ‘Delhi Research Center for the Promotion of Ayurvedic Medicine’. To strengthen health education, we introduced the concept of health in schools and started compulsory yoga and positive health education classes. We also initiated a value-based calendar to promote and inculcate moral values among children at a tender age.
Dr. Harsh Vardhan was responsible for a number of health initiatives during his tenure as Health Minister in Delhi
I have to honestly admit, however, that much remains to be accomplished. I am all for promoting the ‘human face’ of medicine and considerable effort is needed to inculcate the virtue of selfless service among our budding physicians. They need to be reminded about what our ancient sages propagated: Na atmartham napi kamartham atha bhuta-dayam prati | vartate yah cikitsayam sa sarvam ativartate (A physician should not offer his services motivated by commercial considerations, but should do so out of his inherent, unadulterated love for humanity). The Hippocratic Oath has lost all meaning today as a significant number of physicians are bereft of compassion and are preoccupied only with the pursuit of material gain. I strongly feel that one of our biggest challenges lies in changing the mindset of our healers, so that the poor and needy do not feel left out.
A major and vitally important task, in my view, remains the education of politicians and decision makers to enable them to grasp the importance of health. A restructuring and reorganisation of the Health Ministry has become a compelling necessity. For the reasons enumerated above, sub-departments of health may have to be set up in all ministries for better inter-sectoral coordination and for initiating appropriate action to aid the Health Ministry. They should become equal partners in the health promotion movement and preventing illness. Secondly, the allocations for health need to be augmented from the present miserly level to more realistic levels. Let health be the concern of one and all.
A new and integrated holistic system of medicine is the need of the hour, incorporating the best of all systems, including Ayurveda, Siddha, Yoga, Naturopathy, Homeopathy and our other ancient systems. These systems and their practitioners have served and healed mankind for millennia and they cannot be ignored and dumped as ‘unscientific’ and ‘irrational’. Integration of these systems will also help contain the fast-rising cost of medicare. Students should have the freedom to pursue post-graduate medical qualifications in any system, such as Homeopathy, modern medicine or Ayurveda, and should be able to practice with a degree of flexibility, opting for the system of medicine they prefer. In the medical curriculum, all systems, such as Ayurveda, Homeopathy and Naturopathy, need to be covered and at the end of the term students should have the freedom to choose the stream they prefer. We cannot afford to ignore the wisdom of our great ancestors who selflessly served mankind and handed down to us a code of conduct on nutrition, daily habits, spirituality and strengthening of moral values to delay and forestall ageing and illness.
Alternative medicine should form a vital element of a holistic healthcare system
Various organisations and associations—chambers of commerce and industry, Rotary and Lions International, as well as numerous social and philanthropic organisations representing important groups of citizens should be roped in to build a strong movement of ‘health for all’. They should be motivated to divert a part of their energy and resources to take up health issues and become active partners in the mission to prevent illness and promote health. They should be urged to whole-heartedly support any government initiatives on positive health and rehabilitation and care of the disabled.
In my view, two other aspects which have a profound impact on health and human development that require urgent consideration are involvement of students in a massive way to communicate and disseminate the message of positive health among the masses and encouraging every individual’s participation for positive health. Students can donate some of their leisure time and vacations towards this altruistic goal of positive health. This will also enable them to cultivate a health-conscious sensibility early in life. A total attitudinal transformation of people in thought, action and belief based on our ancient culture is required to make health a meaningful and purposeful concept. There is a vital need for everyone to regard himself as a guardian and defender of the environment and health. Armed with healthy and hygienic habits and a positive frame of mind an individual can be groomed to perform one good act a day. This will greatly help in community development and the establishment of a proactive health culture. One can plant a sapling in front of one’s house or in the neighbourhood or exhort people to keep their environs neat and clean. Individuals need to be encouraged to assume responsibility for their own health by abandoning the use of tobacco, alcohol and drugs and by adopting a positive approach to life through a regimen of physical and yogic exercises. Going to bed early and waking up early will enable them to absorb the cosmic energy of the rising sun and ensure restoration and proper functioning of the endocrinal system. People should also be persuaded to consume a balanced, nutritive and vegetarian diet as recommended by our ancestors: hit bhug, mit bhug, kal bhug (Eating what is beneficial, in small quantities and at the proper time), paying attention to hygiene and sanitation, disposing of waste properly, offering leftovers to other living creatures, worshipping plants and trees, showing care and compassion to one and all, as advocated in our scriptures. Only this will make health a successful movement.
Proper healthcare and nutrition can help bring on the smiles to the faces of our children
Before I conclude, I would like to highlight certain emerging areas where urgent action is required. Food safety, product safety and injury prevention and control are areas not well appreciated by health policy-makers and healthcare providers. The burden on account of traumatic injuries, whether due to traffic, at home, at work or during recreation, is unacceptably high and needs urgent steps to reverse the rising trend. The cultivation, use and export of herbal medicines is another important area that needs to be addressed. These have provided relief to people in India for thousands of years. Such a promotion policy will help generate earnings and employment and will provide affordable alternative treatment to those who are unable to access modern healthcare facilities. Immunisation has enabled us to get rid of the scourge of smallpox, diphtheria and other communicable diseases. The time is now ripe to expand the programme to include immunisation against Hepatitis B, Haemophilus influenzae and many other vaccine-preventable diseases. Such immunisation initiatives require the active involvement and commitment of the corporate world, which should come forward to play a pro-active role in ensuring prevention. The Bill Gates Foundation has taken the lead by donating large sums for this cause in the developing world.
Herbal medicines have proved their utility since times immemorial
The strategies in existence for population control will have to be reviewed extensively. Disincentives and incentives linked to population control and the small family norm will have to be introduced at every step to motivate individuals to opt for small families. Literacy programmes, particularly for women, will require dynamic improvements and strengthening. Legislation will have to be enacted for all elected representatives from the Panchayat level to the Parliament level to bar entry of those who disrespect the small family norm. Simultaneously, a debate must start in the country for enacting a law for the restriction of family size. Finally, health problems remain inseparably linked to socio-economic development. Poverty has to be tackled on a war footing. Health for all as part of sustainable development can only materialise if poverty levels are brought down. I conclude by reiterating that despite health being a complex subject, a better understanding of the problems and opportunities in this field has emerged in the last few decades. The Government and the Health Ministry alone cannot and will not succeed in achieving the goal of ‘health for all’ unless every single person and every organisation is galvanised to take the movement forward to fruition.
Abject poverty like this has to be tackled before we can realise the vision of ‘health for all’