During the devastating pandemic New England Journal of Medicine (NEJM, Oct. 15, 2020) published a somewhat reflective article, titled“Covid-19 and the Mandate to Redefine Preventive Care”. The article reminded us – “A large-scale shift to a population-based prevention strategy is long overdue. The Covid-19 pandemic is delaying life-saving preventive screening for millions of patients, and our health system will struggle to catch up. Perhaps this crisis will be the impetus for change.” This kind of introspection is quite important in a country like US where healthcare budget is among the highest in the world as well as where healthcare is primarily hi-tech, corporate-controlled sector. In a more recent article (24.06.21) in the same esteemed journal it is urged that “Missing the Point — How Primary Care Can Overcome Covid-19 Vaccine “Hesitancy” In another article in NEJM (8.10.20), it is clearly stated – “To control Covid-19 and prevent unnecessary suffering and economic damage from future pandemics, the United States will need to improve its capacity for collective action to protect the public’s health.” Hence we can see that the two things – public health and primary care – are stressed time and again in the time of the current pandemic. Also, implicit here is the question of social security.
In his widely read and famous book The Health Gap Sir Michael Marmot asked, “Why treat people and send them back to the conditions that made them sick?” He further added, ‘As doctors we are trained to treat the sick. Of course; but if behaviour, and health, are linked to people’s social conditions, I asked myself whose job it should be to improve social conditions. Shouldn’t the doctor, or at least this doctor, be involved?’ (The Health Gap, p. 4) Here comes the question of social determinants of health. It is internationally accepted, practicsed and applicable. These basic questions of public health are completely forgotten or pushed to the margin in this situation of pandemic.
An article in Lancet (5.05.21), while discussing about India’s primary care situation during this unusual time, clearly states that (“Has COVID-19 subverted global health?”) – Not surprisingly, there have been dramatic reductions in essential public health and clinical interventions; data from India’s National Health Mission indicate that there was a 69% reduction in measles, mumps, and rubella vaccination in children, a 21% reduction in institutional deliveries, a 50% reduction in clinic attendance for acute cardiac events and, surprisingly, a 32% fall in inpatient care for pulmonary conditions in March, 2020, compared with March, 2019. Similar reports are emerging from other countries, including disruptions to insecticide-treated net campaigns, access to antimalarial medicines, and suspension of polio vaccination.
Going against “one-size-fits-all” message during strict lockdown imposed on Indian population last year, it was cautioned in Lancet (“COVID-19 care in India: the course to self-reliance”, 24.08.20)) – The directive for self-reliance must leverage India’s societal fabric and collective sense of purpose to empower communities to say where they would like to quarantine and isolate. Local jurisdictions should be provided with more data, as disaster responses are most effective when locally contextualised. Community-centred guidelines for people to self-organise and self-care must be vigorously disseminated. Health agencies should work with civil society organisations to regain trust. Women’s empowerment groups in Kerala, for example, were marshalled to map where older people live to ensure they had access to medicine and food while self-quarantining—an acceptable, workable, and scalable solution in the Indian context. Moreover, “In summary, what is needed is a plethora of low-tech solutions (especially facial coverings), adherence to science, and societal participation in caring for vulnerable people. There is not always an app for that. But there are the people of India.”
Against this perspective, we can retrospect the forgotten days of our health system, when preventive medicine, primary healthcare and public health were discussed with due importance.
I believe that human cost and depravation of dignity is more tragic than the Holocaust, but never taught in world history. My contention is not partition or human tragedy per se. I want to focus on medicine and health sustaining the impact of partition.
Before partition public health system in India was aghast and subsequent disruption by partition further contributed to the near breakdown of health services. The Bhore Committee presented a “Beveridge-style blueprint that no colonial government of India would ever have put into practice.” (Arnold David, “The rise of western medicine in India”, Lancet 1996; 348: 1075-78.)
As a result, Western medicine was never so powerful in India when it shed its colonial identity. The Bhore Committee had a very good panel of international experts including Weldon Darlymple-Champneys, Henry Sigerist (the doyen of history of medicine), John Ryle, Janet Vaughan, John Cumpston and others. Cumpston suggested a one-year pre-medical, two-year para-clinical and two-and-a-half-years of clinical training, which lasted for more than 50 years. (Pratima Murthy, Aloke Sarin and Sanjeev Jain, “International Advisers to the Bhore Committee: Perceptions and Visions for Healthcare”, Economic and Political Weekly 2013; 10: 71-77.)
In a report published in Lancet on August 23, 1947, after partition the three countries (England, India and Pakistan) would enjoy friendship and “[t]o this friendship, which is needed on both sides, medicine could contribute much.” (K. Srinath Reddy, “India’s Aspirations for Universal Health Coverage,” NEJM 373, 1 (2015): 1-5.) Thus the role of medicine was carefully written on the blood lines of partition, carnage and extreme hatred. In that report it was also rightly regretted that the Bhore Committe’s recommendations “are likely to fall into the background.” What were the actual recommendations of the Committee we are referring to? Briefly, its recommendations were – (1) Integration of preventive and curative services of all administrative levels. (2) Development of Primary Health Centres in 2 stages (a Short-term measure, and a long-term programme (also called the 3 million plan) of setting up primary health units with 75 – bedded hospitals for each 10,000 to 20,000 population and secondary units.)
In public speeches, Darlymple-Champneys spoke of NHS-like healthcare as providing a sense of ‘national’ purpose and pointed out that the provisioning of adequate healthcare, accessible to all citizens, may well be the ingredient that will ‘leaven the bread’ (make India rise). On reviewing Indian medical education in 1946, Sigerist warned us, “health education was wasted unless it is somehow combined with education in citizenship, which is impossible without history.”
We are at crossroads.
An editorial by Raman Kumar is of immense importance with respect to the present academic scenario in India. (Raman Kumar, “The tyranny of the Medical Council of India’s new (2019) MBBS curriculum: Abolition of the academic discipline of family physicians and general practitioners from the medical education system of India,” Journal of Family Medicine and Primary Care 8, 2 (2019): 323-325.) He has raised an important question, “The absence of the discipline of family medicine/general practice within the MBBS curriculum is not inadvertent. It has been deliberately blackened out.”
We can benefit by focusing briefly on historical trajectory of primary healthcare (I would like to use this particular term). Comprehensive primary health care (CPHC) was the pivotal issue of the historical Conference of Alma-Ata in 1978. As a result of sustained pressure from giant corporate and MNCs CPHC was later reduced to “selective primary healthcare”, then to GOBI and so on. The Conference enunciated, “An acceptable level of health for all the people of the world … can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share”. Logically, medical curricula would follow suit.
According to Reddy, India is “a country that’s become the global pharmacy for myriad inexpensive drugs but allows 63 million of its people (almost the population size of UK) to sink into poverty each year as a result of unaffordable health care costs. (Sanjeev Jain, Aloke Sarin (ed). The Psychological Impact of Partition of India, (India: Sage), 2018, p. 37.)
70% of health care expenditures consist of out-of-pocket spending, which is highly impoverishing. Neologisms like “medical poverty trap” and “medical tourism” are well known now. Today, the private sector provides nearly 80% of outpatient and 60% of inpatient care.
National Health Policy 2017 assures “availability of free, comprehensive primary health care services, for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable, non-communicable and occupational diseases in the population.” (National Health Policy 2017) The Policy has also noted that right to health cannot be perceived unless the basic health infrastructure spread-out across the geographical frontiers of the country. Though, right to health is not included in the fundamental rights of Indian Constitution.
In American experience too there is a need of primary care physicians – “Primary care is the foundation of effective healthcare systems … primary care physicians, patients and physicians value continuity in their primary care relationships, which can last many years.” (John Z. Ayanian and Mary Beth Harmel, “Transforming Primary Care – We Get What We Pay for,” NEJM 2016 374 (24): 2390-92.)
Moreover, the great majority of patients prefer to seek initial care from a primary care physician rather than a specialist, but their unhappiness with their primary care experience is growing. Even specialists might recognize that they would suffer if primary care deteriorates, being forced to coordinate care and confront psychosocial issues in patients with multiple acute and chronic conditions rather than focusing on diagnosing and managing specific diseases within their scope of expertise. Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.
Should we care to listen to it?