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| The mosquito is a great leveller | | |
- By Jayati Ghosh
For a while now, the notion of the "public" has gradually receded from the consciousness of the elites in India. Not only are private solutions found for most conditions, but even the very idea that there are still spaces (and indeed, places) that are universally accessible and have universal impact is barely recognised any more.
It is true that the ruling classes are still affected by some of the most obviously public goods, such as road infrastructure. This is why the most common middle class complaints in urban India relate to the state of the roads, since this is one area where they cannot simply opt out by accessing their own exclusive roads.
But for many other goods with high externalities, the rich in India have found ways of avoiding, bypassing or simply transcending the need for responding to external conditions or accessing public services. Atmospheric pollution, for example, has become the problem of the poor. Increasingly, those who can afford it travel in air-conditioned vehicles and live and work in equally protected environments, and go for walks in parks of colonies where there are no "polluting units."
Safe drinking water is no longer considered something that must be provided by civic authorities. Instead, the rich buy commercially bottled water or install special water filters in their home and offices, while the poor are left to fend for themselves as best they can with the inadequate and mostly polluted water available in public taps or through tube wells.
Similarly, health care services are now characterised by the most extreme duality, with the rich opting for deluxe institutions with "world class" infrastructure (although not necessarily better medical attention). The poor are forced to avail of either very overcrowded public facilities or access medical shops where they are routinely exploited and often provided with inadequate care.
In all this, the concept of public health has been somehow forgotten. So, among the rich in India, there is now little recognition that health conditions of a community affect each member of it, that there must therefore be cooperative and communitarian solutions to health problems and common approaches to dealing with the basic conditions affecting health.
It takes something like an epidemic which affects rich and poor alike, to bring home the essential publicness of health to this country’s elites. The current outbreak of dengue in Delhi and some other major cities (at the time of writing it had still not been declared to be an epidemic, apparently because doing so would adversely affect tourism), is one such instance. Dengue — as we all now know only too well — is a viral disease spread by the Aedes mosquito which breeds in clean stagnant water and bites humans in the daytime.
Even as dengue spread and more and more cases crowded public hospitals, it was still common to hear in upper class drawing rooms that this was because of the lack of adequate sanitation, cleanliness and proper precautions in the slums and residences of the lower middle classes. There was still an implicit notion that "it can’t happen to us." Only when the media publicised the fact that even members of the Prime Minister’s household were suspected of having contracted the disease, did it strike some of our more privileged citizens that such diseases do not always respect the social distinctions so ingrained in ourselves.
If this does actually bring back the attention of policymakers and the general public to the need to focus on community health and conditions of nutrition, sanitation and the like, then even this current outbreak will turn out to have a silver lining. For the past two decades have been characterised by an unfortunate, and even alarming, reduction of interest and public expenditure on the essentials required to maintain good public health.
The role of public intervention is obvious for communicable diseases which are passed either directly among humans or indirectly through the physical environment. Clearly, ensuring clean, safe water and immunisation against communicable diseases, for example, generate direct health benefits for all of society, through reduced rates of disease and reduced probability of any individual being affected.
Despite this being so obvious, it emerges that both Central and state governments have become increasingly remiss about ensuring such minimal expenditure and such basic precaution. Even in the mid-Eighties, health expenditure of Central and state governments taken together was more than 1 per cent of GDP, but now it is only around 0.9 per cent. Central government expenditures on health alone have been completely flat at only 0.1 per cent of GDP, which is one of the lowest ratios in the developing world.
While the pattern obviously varies across states, a number of state governments have actually shown declines — sometimes significant — in per capita health expenditures, especially on public health such as immunisation. And this is now showing in the most worrying changes in basic indicators such as immunisation rates of small children.
The most recent National Family Health Survey has just released results for five states. The results are absolutely shocking for anyone even minimally aware of the importance of containing infectious diseases that can be prevented through vaccination. In three of the richest states of India — Maharashtra, Punjab and Gujarat — per capita public spending on health has declined in constant prices terms after 2000. And the NFHS results indicate that in these three states, immunisation rates of children in the age group 12-36 months have actually fallen in 2004-2005 compared to 1998-1999.
In some cases the decline is dramatic — from 78 per cent to only 59 per cent in Maharashtra, for example. This may be of only academic concern today. But it can turn into a future public health disaster, with the possible re-emergence and spread of diseases such as polio, tetanus, diphtheria, and so on — all of which are now so easy to prevent. We should not have to wait for one of these diseases to affect the families of the powerful before taking public action on an emergency footing on this.
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