To be healthy, wealthy and wise...
IT IS a matter of great concern that India lacksa health policy worth the name. Nearly abillion people have no assured access to healthcare and the benefits of modern science. Andwhat's worsethere is little pressure on thegovernment to prepare such a policy for thepeople. Unless there are health activists likethere are environmental activiststhe government will never take a decision either.
Traditional diseases like malarial filariasisdiarrhoea and various gastrointestinal disorders continue todominate the morbidity and mortality rates of India.Simultaneouslymodern diseasesbecause of changinglifestyles and deteriorating environmental conditionsare alsoaffecting the humanity. Apart from cancer and cardiovasculardisordersAIDS is growing menacingly. This doubleor rathertripleburden of diseases is a very serious challenge. Of theseveral factors responsible for a slipshod health care systemlack of money is one. Resource shortage will continue tobedevil developing countries. Thereforeunless these countries decide to restrict themselves to health care services for therich and neglect their poor majoritywhich many countriesare in factwilly nilly doingthey will have to search for lowcost health service measures.
Lack of respect for local traditions has proved to be amajor bane. Most developing countries have adopted modemscience as the panacea. Health workers in the developingworld will totally fail to meet challenges if they do not respectthe traditions of the developing world and integrate the best inthem with that of modern medicine. In most developingcountrieslack of understanding and concern for environmental conditions is leading to rapid environmentaldeterioration. From standard air and water pollutants to allkinds of highly toxic substancesthe air that we breathe andthe water that we drinkare becoming increasingly poisonousand unhealthy.
Like all science and technology professionals in Indiahealth scientists and public health engineers are pushingWestern ideas and practices as the only solutions to the problems. But developing countrieswhich have a heavily stressedenvironment and limited financial resourcescan respondonly to innovative solutions. One is reminded of the Mexicanphilosopher Ivan Illich who was quite correctin his diatribe against modern professionals- how they distort issues and disempowerpeople - particularly the medicos.
People's disempowerment is a seriousissue as our not-very-democratic political sysT tem often lacks a political will to counter theproblems. Moreoverwe ourselves haveadopted natural resource managementbureaucracieslaws and systems left behind byour colonial rulerswhich have left the poordisemplowered as always. In factkeeping thepeople disempowered in terms of knowledge can be the worstform of disempowerrhent in a modern-day society whenchanges are taking Olace at a bewildering paceshowingequally bewildering consequences. This may cause womenand children in developing countries to suffer several diseasesand health problems not only due to their ecological and economic conditionsbut also cultural conditions.
Prevention is always better The challenge before us today is: how do we develop low costsolutions to deal with our health problems? The two majoropportunities to reduce costs arepreventive health programmesand traditional curative care. Both the areasdemand educationpeople's campaigns and action. There isenough worldwide data to show that it is far cheaper to reducethe health impacts of smoking through preventive programmes than to allow a smoking epidemic and then cure theresulting diseases. The same holds for the AIDS epidemic orcardiovascular diseases.
Traditional medicine can also play a very important role inproviding low cost service. During its war with the usNorthVietnamwhich had little financial resource to tackle its healthproblems and a very small drug manufacturing baseneededenormous foreign exchange to import its medicinal requirements. Its supporters like China and the then Soviet Uniontoowere unable to supply such vast quantities of pharmaceuticals. And aid to Vietnam in those days was anathema.' for allWestern donors except for Sweden. Vietnamthereforedecided to make the best of its traditional resources.Standardised herbal gardens to treat common diseases weredevelopedproviding succour to the public as the first line ofpharmaceutical defence. Unfortunatelyas few efforts in traditional medicine have been appreciated by modern practitionersthey have been little studied and statistically analysed.
There is nowhowevera revival of interest in traditionalmedicine even in rich countries. People will turn to herbsbecause they believe they have fewer side effects; or they willturn to acupuncture to cure arthritisor to yoga to reducestress because modern medicine has no magic pills for theseproblems. Even that arch centre of modern medicine in the us- the National Institutes of Health - has set up an Office ofAlternative Medicine to evaluate traditional curative systemsof the world. By giving yoga a secular formMaharishi MaheshYogi was able to popularise it in the us and other Westerncountries. But it is a shame that in India itselfnothing muchhas been achieved.
Handle with Care
Environmental problems are still more difficult to deal with.In many countriespopulation and consumption are increasing faster than the increase in the waste management infrastructureleading to an increase in contaminated waterairand toxic chemicals. Improved irrigation systems has lead tothe spread of schistosomiasis (a disease caused by infectionwith blood flukes). Development of water supply systemswithout adequate drainage facilities have helped spread filariasis. Construction of overhead water supply tanks in citieshave led the urban mosquito - A aegypti and the dengue epidemic to proliferate. Extensive paddy cultivations havespurred Japanese encephalitis.
Felling of tropical forests have generated diseases like therecent Ebola virus epidemic in Zaire and some years agotheKyasanur Forest Disease in Karnataka. Due to the mismanagement of the subimalayan flood plainsdrainage congestionand constant waterlogging appear to have revived kala azar inBihar. Cancer incidence has much to do with environmentalcarcinogensdietary and lifestyle changes. Undoubtedlyweare getting exposed to numerous little known chemicals.
Delhi's citizens have the highest concentration Of DDT intheir body fat in the worldbecause of the pesticide's widespread use. There is also very little concern in India abouttoxic waste disposal. Because of the Indians' love for filmmusic but restricted coverage of the electricity gridbattery-based transistor radios have become extremely popular. Butno thought has been given to the disposal of the batteries containing highly toxic substances. This is just one instance. Goodenvironmental management will play a critical role in keepingmany diseases at bay. But changes call for massive educationalcampaigns for creating mass awareness and alternative consumption patterns and governance systems; interventions inthe market to ensure more environment- friendly investmentin industrial processes and products; reworking of nationalbudgetary and pricing policies so that people pay the fullecological costs of their consumption; and of courselegalexercises to bring to book environmental criminals.
Over the yearsNGOS worldwide have played a major rolein doing three things: a) making people aware of environmental issues; b) fighting against disastrous projectsand c)developing participatory systems of resource management.Excellent efforts have been made by various Indian researchinstitutes to show that mosquito-borne diseases can be controlled by eradicating breeding sites - an environmentalmanagement that simply requires a very high order of people'sparticipation. The work of the Vector Control ResearchCentre in Pondicherry and the work of the Malaria ResearchCentre in the various villages of India are outstanding examples ofstrategies that need to be replicated worldwide. Similarlythework of the Orangi Pilot Projectan NGOin the slums ofKarachi in Pakistanwhere people themselves - once madeaware of the health costs of bad sanitation - have investedmillions to construct a sewage-based waste disposal systemwithout any State intervention. But few governments learnone lesson: environmental management is not possible without participatory systems of governance.
Success: a different mindgame
TO identify low cost and environment- friendly tecnologicalsystems requires great skills in first identifying the needsandin developing the necessary technologies. In the last century orsothe world overpeople have built sewage-based waste disposal systems which have innumerable inherent problems.Firstlyin poor countriesthey prove so expensive that only afraction of the population can afford them. Secondlythesesystems demand enormous quantities of water which have tobe supplied by building large dams; and thennearly a quarteris flushed down the drain to carry away a few grammes of solidwaste to the nearest waterbodythereby polluting and messingup innumerable waterbodies and rivers. Despite their highcostmore and more sewage systems and dams continue to bebuiltwhich is a wastage of public money.
Surelythere must be alternative ways to deodorise anddepathogenise human waste and turn them in to excellentcompost so that the nutrients can go back to the very mediumfrom which they came to farm soils. All over southeast andnortheast Asiarecycli@g of human excreta has been a common practiceand even todaymany Japanese cities do not use sewage-based disposal systems. Yetthe total funding in thisarea of research is probably not more than us $5 million. Whatdoes this mindset show? A total lack of concern about thegood uses of the environment? Our sanitary engineers havelearnt sewage systems from the European schools of engineeringand that is all that they think of now. Andsince mostsanitary engineers serve wasteful systemsthey could care less.
Illusion and reality
There has never been a greater need than today to undertakemass education programmes - both formal and informal.Health communicators should document the health needs ofthe poor and the marginalisedand bring them to the attention of policy planners; secondlythey should understand andapply effectively the new knowledge that scientists are regularly throwing up. We know very little about the long or short-term health impacts of the dietary changes taking place worldwide. Even in Asiadietary habits which comprise cuisinesdeveloped over thousands of yearsare changing rapidly. just20years agodairy products and meat and eggs were all considered good food in the West. TodayWestern nutritionistsadvise us to have as little of these as possible if we want to utavoid a range of diseasesincluding cancer.
Traditional Indian doctors (vaids) bemoan the fact thatcow milk is no longer easily availablebeing replaced in allIndian cities by buffalo milk. What is the long-term implication of the switch to vegetable oils? In southern Europewidespread use of olive oil is apparently a key factor for the lowincidence of cadiovascular diseases in the region. But howdoes the ordinary citizen acquire that knowledge whichenables his family to adopt health-friendly dietary decisions?Third World newspapers rarely have a health correspondenton their staff. I am deeply impressed by Jean Carper's twobooks: The Food Pharmacyand Food: Your MiracleMedicine. Carper sat in theNational Medical Library inthe usand scanned nearly100papers recordingscientific analyses of foodproductsand the healthimpacts of various foods.
The Centre for Sciencein the Public InterestaRalph Nader group in the'usdoes outstanding workin monitoring resturantfood in the usso much sothat it has earned the mediaepithet of 'the food police'.The Centre regularly carriesout surveys of variousresturants and snacks likepopcorns sold in cinemahalls. These surveys are sowidely recognised andaccepted that whole restaurant chains can lose business for weeks if an adversesurvey is released. Publiccampaigns are also neededto increase medical professionalism and introduce consumerand health laws to reduce medical malpractice. There is even agreat n(kd to empower communities by teaching them to con -duct their own epidemiological surveysespecially given themoney-power of the environmental exploiter and the State'snegative role in environmental issues all the way from LoveCanal in the us to Bhopal in India.
There is no safe womb
Women and children often are the last to recieve the benefitsof health services. Wherever women live within a biomass-dependent economyenvironmental degradation has meantthat women have to spend enormous time just collecting fuel-woodfodder and water to meet household needs. In suchconditionsthe crumbling local economic -ecological baseinduces male migrationcausing the work burden on womento become heavier. While the women work in the fieldstheirchildrenespeciallly infantsare neglected. Graduallythe children @too get involved in various economic and householdactivities. While young girls are entrusted with the care of theiryounger siblingsboys take to grazing cattle. As the situationworsenseven young boys move out of the degraded ecosystem in search of workthus leading to an increase in childlabour in formal industrial and commercial sectors.
A Centre for Science and Environment study of the late'80s revealed that women worked anywhere between ninehours to 14 hours dailydepending on different seasons. Thegirl child's education Was neglected. Since the mother plays acritical role in raising the childrenany condition that arrestsfemale literacyproves detrimental for the society. In urbanareaswomen and childrenincluding the unborn foetusfacenew threats. Numerou'sw pollutants are found to pass throughthe foetus and affect the child. A recent United NationsEducational Programme@study reports that some toxins whichmay not affect the exposed mothermay affect the foetus.
Rarely - if ever -data on the exposure levels to toxicsubstances are known or made available to the public.Numerous surveys on developing countries have shown thatrural women using woodstoves in badly ventilated roomscanbe exposed to more carbon monoxide and benzopyrene thanchain smokers or people working in the most polluted cities ofthe world. But such studies are rare. A UN report preparedbefore the Rio Conference on environmental degradation andits impact on women and children noted in no uncertaintermsThere is no safe womb today.
My recommendations to overcome this stalemate are:
• There is a need to constantly inform people about opportunities and options they have in terms of health services and measures.
• There is a need for constant campaigns for mechanisms thatempower peopleespecially womenboth in terms of knowledge and legal rights to demand better health and education services and ecological conditions.
• There is a need to constantly analyse the specific environmental and economic conditions of poor developing countries and identify appropriate technological needs.
This article is the edited version of a keynote lecture by the author at the l5th annual conference of the International Union of Health Promotion and Education held recently in TokyoJapan