This article presents my thoughts on the general situation of health care in India. A focus on HIV is used as a means to drawing attention to the inadequate state of health care sevices and facilities, and the growing severity of pandemics. The article discusses six topics:
The article arose in response to my querry whether HIV alone was the major health care disaster in South East Asia(SEA), or whether it along with Hepatitis B and B, TB, and malaria, were simultaneously occuring pandemics that needed to be addressed within an overall cohesive framework. The overall message is -- HIV/AIDS, Hepatitis B and C, malaria, and TB are all major problems in most of SEA irrespective of the "official" government statements. Also, there exists frustration amongst health care workers dealing with diseases other than HIV/AIDS because resources for their work are non-existent. Each reply to my posting on discussion form confirmed my fears of a SEA wide tragedy driven by not one but many simultaneous pandemics -- and there is no significant infrastructure in place to deal with any of them!
The intent of this article is not to pit the care/control of one disease versus another. It is to raise awareness with respect to a wide-spread and multifaced tragedy -- an inadequate and corrupt health care system, tremendous environmental degradation, and the lack of social and political will to overcome these problems. My hope is to put HIV/AIDS in the context of this much larger problem. To make progress on any front we will need to understand the wider set of issues as they are intimately related, and learn to deal with the realities and not the rhetoric. I would, therefore, like to address some of the issues. Most of my discussion is limited to the situation in India and its contrast with that in the US as I am most familiar with these, however, I believe that situation in India applies to most of SEA. To make the discussion more complete, and thus more useful, it would, therefore, be very useful to have feedback from as many readers as possible.
There are a number of crisis in India today. Each one is claiming millions of lives, so to argue about one versus the other is counter-productive. A rough tabulation of the numbers and the source of information I have used is listed below.
| HIV/AIDS | 3.5 Million (HIV is a death sentence in India) (Source: NACO, November 1999) | |
| TB | 600 million with primary infections -- 2 million active cases/year (source: WHO) | |
| Hepatitis B | 20-80 million cases (source: WHO) | |
| Hepatitis C | 10-25 million (source: WHO) | |
| S.T.D.'s | 100 million new cases/year of the 4 curable bacterial STD Chlamydia, Trichomoniasis, Gonorrhea, Syphilis (source: WHO) The rise in cervical cancer and the number of people with other long term complications like PID are astounding. (source: doctors in India) | |
| S.T.D.'s | Viral STD's -- herpes simplex (HSV) and human Pappiloma virus (HPV) are now almost as common as bacterial STD's. (source: doctors in India) | |
| Malaria | 1 Million cases / year (source: WHO) | |
| Diarrheal | millions (could not find surveillance reports with data) | |
| Respiratory | millions (could not find surveillance reports with data) | |
| Environment | Air pollution, water pollution and impending scarcity of water (source: CSE Delhi, IWMI Sri Lanka) | |
| Lead Poisoning | recent studies by the George Foundation (http://www.tgfworld.org/) and others estimate that 100 million children in cities may have elevated lead levels causing retardation and health complications) | |
| Population | 1 billion and growing -- chewing up all the gains made. Facing huge shortages in housing, clean water, jobs, education. | |
| Poverty | ~200 million below poverty line. Increasing disparity between the rich and the poor. |
The first tragedy is that the government has NOT allocated sufficient resources to deal with ANY of these problems, or followed long term sustainable polices. In my mind the bigger tragedy is that the educated, well to do individuals have not, in sufficient numbers, protested and formed a voice of reason, or come together to deal with these problems.
We will make little progress by dealing with each of these issues in isolation. Extremely limited resources generate, at times, an unhealthy competition even amongst those who wish to do something good. Our hope lies in rising above this pettiness -- rather than quibbling about funding for our pet peeves we must look at common goals. Examples of these are
I believe these tragedies are societal in their cause and eventually their solution lies with them. Many of these crisis can be averted without big government involvement, as the solutions rest with individual people. So, it is time to take stock of ourselves. How often have well informed and educated people gotten together and marched down the Rajpath in New Delhi to demand pollution control or better health care. Where has the collective voice of sanity and civil consciousness gone? Perhaps, it is as one person mentioned to me -- "we are all too busy with our own little scams (rat races) that there is neither time nor the courage to bell the cat". Similarly, the media (newspapers, TV, ...) has failed in their responsibility as the principal means of informing the people about the state of the country, forming public consciousness, and eventually precipitating responsible action. One reporter told me in November 1999 -- "we have been too busy covering the political situation for the last 9 months and will get back to you to talk about these problems when we have some time". It certainly is demoralizing when a large free press foregoes responsible investigating and reporting on issues that are taking the lives of millions of fellow country-people, and is derailed at the slightest whiff of "political" news. Unfortunately, we have to recognize that this lack of care and social responsibility is the reality. So, we have to start from the ground up, by identifying the good, able, and well-meaning people and institutions and building on them. Changes will not occur by fiat or by miracle, we have to create the foundations and then slowly build the "civil" society we want. In my opinion we have no choice in this if we wish the country to provide a decent life for a significant fraction of the next generation; the current health pandemics will also affect the elite!
Having said all this, it is worthwhile to return to the issue of HIV/AIDS and the role of the West versus the individual countries in controlling it.
But do all these reasons, and others, mean that HIV/AIDS should have special status and funding? Is the long term cost and death due to say hepatitis B any less? The answer is NO. However, in my opinion these are NOT the key questions for they are divisive rather than constructive. HIV/AIDS prevention or Hepatitis B prevention are just labels. Labels are not worth fighting over -- they represent an unnecessary tendency to protect ones turf. We need common solutions that address the many problems simultaneously and in the most cost effective way.
Why do I personally focus on HIV/AIDS? To me HIV/AIDS is a label that allows me to address all the major global health problems for which the vector of spread is blood or sex. We will not solve HIV/AIDS crisis without also impacting Hepatitis B (sex, blood, mother to child) Hepatitis C (sex?, blood, mother to child), the many STD's, and other blood borne diseases. Also, HIV/AIDS and TB are highly correlated and need to be addressed simultaneously. Nevertheless, if someone else wishes to change this label to Hepatitis and work with it as the focus, I believe the two of us will be doing exactly the same work. So in my mind there is no contention, just symbiosis.
In the debate over HIV/AIDS versus Hepatitis B what is, nevertheless, important is how much money is being devoted to prevention through education, how much to ensure clean blood supply, how much for the respective diagnostic blood tests (these three costs are common to both diseases), and finally how much to infant immunization against Hepatitis B. In developed countries the immunization is paid for by the public health system (insurance in the US), blood supply is fully screened, proper sterilization is routine, and money is made available for testing and health education. Consequently, spread is taking place only because education, for a variety of reasons, has not succeeded as much as one would hope for. What I would like to now highlight is that in developing countries like India the tragedy is that there is no significant money for any of the above!
The money we see for HIV/AIDS prevention in India has mostly come from international sources. The Phase II of NACO is 86% funded by loans, primarily from the World Bank and USAID. The 14% Indian contribution is of the same size as the foreign exchange incentives given to Indian business for hard currency trade. So, in spite of the rhetoric, as far as the indigenous government funding is concerned India is treating HIV/AIDS no different than any other disease. Also, there is no sustained awareness campaign through TV or the newspapers, or any other media. In short, the government is, to first approximation, spending nothing extra. And this, in my opinion, is why we are making so little progress in fighting and eliminating any one of the health or environmental crisis mentioned above. There just does not exist any significant collective will or desire on the part of the people with means or the government to fight these societal wars.
So, in the end, the intervention we are arguing about relies on the little that the West is offering; and if they remove that support, which no one should expect to be eternal, then there goes the whole program. So this leads me to the next topic -- why is the West seeding the effort? Are they just setting up the developing world for a fall when they pull out, or do they really care, and are they doing what is reasonable?
HIV/AIDS, along with other sexually transmitted diseases (especially Herpes Simplex and HPV), is the only significant infectious disease in the Developed world (I am ignoring influenza). In fact, one could define the developed world as countries that have controlled the spread of infectious diseases. Of these only HIV/AIDS is fatal, nevertheless, due to the growing prevalence of HSV and HPV in the US, CDC has, in 1999, launched a major campaign against them too. In the 1980's HIV/AIDS seeped into the public consciousness and they want to get rid of this scourge and the fear associated with it. The result of the public outcry was the large funding for research, education, and drug and vaccine development.
Both, the developed and developing world, have a very poor track record in controlling sexually transmitted diseases. So the US is fully justified in pouring money into finding a cure or a vaccine for these "last" major communicable diseases. It is worth recalling that in the USA, too, there is a raging debate on why there is so much focus on HIV/AIDS and why so much money is being made available for it when more people die of cancer, etc. So it is natural that when there is a competition for resources, each one of us likes to see our pet peeves funded.
Third, the global explosion of HIV/AIDS is scary. In twenty years it has become the second largest killer after diarrheal, respiratory, malnutrition deaths that claim 10-12 million infants and the infirm every year. In Sub-Saharan Africa there are countries that have 25% of all adults waiting to die of it in the next few years. The possibility of such a tragedy within their own country is completely unimaginable to the western mind -- they would consider it akin to foreign invasion and the country would mobilize against it. Clearly, they are not willing to go to the same length to protect the citizens of the rest of the world, but what they are doing reflects their global concern. To me, it is immaterial whether they are doing it for their own selfish reasons or as a genuine feeling of compassion and global kinship. What matters is that they are doing it.
Fourth, HIV, is from a purely scientific perspective, novel, fascinating, frustrating, and diabolical. Also, there is a real hope that the focus and research on vaccine for HIV/AIDS will also lead to breakthroughs in designing vaccines for many other infectious diseases like Hepatitis C, malaria, TB, cholera, etc, which are major killers in the developing world. In the mind of the western public and their drug companies, diseases like TB and malaria have been conquered. They have little incentive to carry out long and politically sensitive vaccine trials overseas, so money for research has shrunk. Consequently, not much progress has been made in vaccines against diseases that do not pose severe health problems in the West. It is only when new diseases like HIV/AIDS, or Hepatitis C, emerge and promote more deadly forms of the known diseases, like TB with HIV, that interest in them resurfaces. In my opinion this is not an unreasonable situation. It is human nature to protect ones own interests first. So we come to the question -- what is the "moral" responsibility of the West and what should they do to help the developing countries?
Even though this is an often asked question, I believe that this is not a fair question. Do we really expect the West to shoulder the astronomical cost that intervention as an outside agency would entail? What, then, is a realistic expectation and what does the developing world need to avert the crises mentioned above? In my opinion the only sustainable items are information, awareness, drugs, and investment in vaccines. What is the West's track record in this? Take TB for example -- there are inexpensive drugs available worldwide, there is information on how to combat TB (DOTS), only the vaccine development has lagged. (BCG, known since 1922, has very low efficacy and is not sufficient to prevent many forms of TB.) On the other hand the implementation of a well proven strategy, Direct Observed Treatment Short course (DOTS), by most SEA countries has been pathetic -- most countries have essentially zero DOTS coverage. Similarly, Hepatitis B vaccine is produced indigenously, has very high efficacy in preventing infection, and yet the coverage is very low. Is the cost (Rs. 600 for the 3 courses) the only reason why there is no infant immunization program? My informal survey shows that less than 50% of health care workers and doctors have bothered to get immunized! This reflects the inability of even the elite to come to terms with the fact that over 90% of communicable diseases can be prevented by simple precautions, and that preserving good health is and should be an individual's responsibility. One has to move away from the attitude that there will be no long term harm in leading risky life-styles (sex, fatty foods, alcohol, tobacco, no exercise), and doctors or someone else will post facto take care of resulting problems with a "magic fix".
Another example. Just recently, the Bill and Melinda Gates and Turner Foundations became major partners along with UNICEF and WHO to eradicate polio globally. The every child polio immunization is finally happening. The question that troubles me in light of the many health and environmental crises that I have listed above is not whether the people of a country like India could have, on their own, put two drops of vaccine into the mouth of every child and repeated it four times, but that they did NOT! India certainly has the money, and given the "right" cause has even shown the will as demonstrated by the coming together of the nation in wake of the Kargil invasion and the magnitude of the donations for the Kargil fund!
To me these lapses in general health and environmental issues reflect the lack of a caring health and education infrastructure. In the absence of such, whatever HIV/AIDS or TB or Hepatitis intervention there is now will disappear if and when the international agencies withdraw their support.
It is my belief that the resources are there -- in India at least. There are tens of millions of Indians with a lifestyle that is on par with the most conspicuous consumption of the developed countries. It has some of the best minds in all fields of human thought. There is a health and education infrastructure. What then is missing? In my opinion it is the collective will of the people, and a transparent bureaucracy and government that cares about the welfare of each and every individual? Until we generate this will and institutions, and translate them into action, it is unlikely that we will have a major impact on any one of the above mentioned problems. So the question should be -- how do we proceed to do so?
The government has to recognize that all the above mentioned problems are happening simultaneously and by reinforcing each other they may produce very non-linear effects. Under such circumstances they have the potential for devastating the country in a short time frame of a decade -- something that linear projections based on individual issues may not forecast. At the level of policy and planning it is therefore essential to look at all these issues simultaneously and comprehensively as they are intimately related. Either we will impact all or none. Due to scarcity of resources, implementation can, to some extent, be customized depending on the efficacy of given approaches. The same holds true for large foundations and organizations like WHO, UNAIDS, USAID, World Bank, etc. Without this cohesiveness we are loosing the sympathy and help of many doctors and health care workers who feel that HIV/AIDS is not their problem. So, even though I believe HIV/AIDS will pose the most severe health crisis in the coming decades, we will achieve better cooperation from a lot more people if we work on it in conjunction with other major communicable diseases, and by emphasizing common goals.
The Indian government has created NACO within the ministry of Health in response to HIV/AIDS. There is also an "AIDS cell" in the other ministries, created with the intention of maintaining dialogue and co-ordinating. While this is all very good on paper, what is the reality? My questioning showed that there has been no systematic education/enlightenment of the senior members of the ministries, nor of the career bureaucrats, and nor of the employees at either the central or state level on HIV/AIDS or its impact on the country. As a result most bureaucrats throughout India have a very superficial knowledge, and sometimes even wrong knowledge and ideas. To me it is a puzzle as to how the government thinks it can control the spread of HIV when it has not even carried out an education and awareness campaign for those who govern and can affect change!
It is important to highlight the common goals and methodologies rather than dividing the effort into small isolated agencies, thus promoting turf battles. The biggest scarcity facing successful implementation is having a large enough force of trained people who can sustain the effort for the period of decades as will be necessary. To meet this challenge we have to start nationwide programs in training all school and college teachers in issues of health and environment and have regular classes on these subjects for all students. India has over 300 million people under the age of 15, so reaching them and through them their parents provides, perhaps, the fastest sustainable way.
Develop and implement a curriculum on health, environment, and sexuality for schools and colleges across the country. It can begin with very simple things like proper hygiene in class one and work its way up so that by high school all children have the proper knowledge and understanding of the consequences of risky behavior, and know that ultimately they alone are responsible for preserving their health and the environment. We have to reach the next generation while they are still in school -- it is the most effective way and may turn out to be the only way for issues involving behavior change. Literacy and awareness is the key without which we cannot succeed. The basic messages of hygiene and prevention have to be simultaneously and constantly reinforced by the media, especially the TV, and in very simple ways that the common person can identify with and implement.
Encourage the development of NGO's and charitable foundations to reach the marginalized. They should be an independent force that care for and analyze societal issues and sustain the public's interest in them by providing knowledge and awareness.
Mobilize the industry, big and small, to understand that their workers are their biggest asset. To recognize that as the economies become more global, the competitive edge depends on a healthy and productive work force. We have to convince the owners to accept responsibility for educating the workers, providing them and their families with health care which includes full immunization for children. The government should facilitate this by providing significant tax incentives. The owners of industry, small or big, have the most influence on their workers and thus can affect changes. However, since some of these problems involve lifestyle issues, it is essential that the owners/management be trained first.
The intellectuals and the journalists (newspapers and TV) have to work together to ensure that the public is kept informed of the state of the country. To provide an independent voice of reason and vision that forms the "civil" framework to help, complement, and promote the government's actions towards eliminating these many societal problems. There has to be a clear understanding from the outset that such an effort has to be sustained for decades under what will surely be very trying circumstances until we succeed in making lasting changes.
None of these suggestions are new. They have been voiced time and again by the government and NGO's. Why then is the requisite and timely intervention NOT being mounted? Perhaps, I am not in sync with the realities and aspirations of the people. Therefore, let me step into the new millennium by posing the question once again to all: What is missing -- the resources, the will, or the collective drive to make it happen? And how do we go about generating them?
Rajan Gupta
e-mail: rajan@lanl.gov