By the year 2000 three quarters of the world's population residing in developing countries with poor health has come to realise the oft-repeated slogan 'Health for all by 2000 ' is a cruel joke perpetrated by rulers. It is unfortunate that India is in the third position from the bottom with respect to per capita medical expenditure, the other two countries being Bangladesh and Mozambique as per WHO 1993 report.
It is axiomatic that communicable diseases take a heavy toll in terms of morbidity and mortality. The rural areas in India, even after five decades of development are not still having the basic hygienic necessities like toilet facilities and potable water. Coupled with illiteracy, abject poverty , malnutrition and a large number of AIDS victims, it presents a pathetic scenario.
Development from Indian view point appears something that is big like huge dams, big international airports, tube trains, big steel plants, five star hotels and five star hospitals and high tech culture. But what see today is teeming millions with abysmal poverty disease matrix which creates a deep lacerated wound in the mind.
Health should not be considered as a disease or disorder free state but also includes a state of physical and mental well being when an individual carries out his day today activities.
In developing countries ,disease state is a matrix with poverty and illiteracy where poverty is reckoned as not having sufficient purchasing power to purchase the needed nutritious food. The disease - illiteracy - poverty matrix perpetuate a vicious cycle. This vicious matrix further gets complicated by the absence of potable water, toilets and hygiene. Thus the present plan to tackle disease poverty illiteracy separately and individually is not likely to yield the defined results.
A massive parallel processing of these three inter-connected components of matrix have to be dealt simultaneously. To plan such a strategy, we need an information matrix about the rural India. This information matrix can be designed and action initiated. It needs a dynamic vision and political leadership with commitment, who can understand the reality.
Reality is what we take to be true. What we take to be true is what we believe. What we believe is based on our perception. What we perceive depends on what we look for. What we look for depends on what we think. What we think depends on what we perceive. What we perceive determines what we believe. What we believe determines what we take to be true. What we take to be true is our reality. What we see today is the distortion of reality with closed mind and insulated thoughts, leading to distorted images and self deception.
Ill health unfortunately is believed and considered hither to as a biomedical problem exclusively which is not a reality. It is realized now that social economic and behavioural sciences have a major role in combating the diseases in the poor. These are the new ingredients that have to integrated into the health strategy.
To prevent communicable taking further heavy toll, the disease portfolio has to be upgraded owing to the emergence of new diseases and their patterns. This needs creation of new tools. For example tuberculosis (though TB is well controlled in developed countries), malaria and AIDS- these three diseases are to be given top priority in India.
Evaluation and monitoring have to be season - based with geographical poverty matrix made free. New strategy for TB Leprosy therapy with multi drug complex have to be augmented and monitored with a health system designed to take care all the deficiencies.
New tools for disease prevention have to be thought of like impregnated mosquito nets etc for malarial control and this has to be given some priority. Malaria can be controlled only when the environment or dwelling is hygienic . With the existing unhygienic rural areas without toilets or drainage facilities, it is not possible to control malaria. This is a universal fact. Therapy is always costlier than prevention but governments normally do not act till a calamity takes place.
Along with environmental development, the other major thrust is to have self reliance by having village - level health workers with short training programmes who can take care of the diseases like TB, Malaria, H1V/AIDS, leprosy. A strategy has to be developed to take fast decisions. By taking longer time for decisions, people would be dead. The most important decisions are for rolling back malaria, stopping TB and preventing AIDS that are taking a heavy toll.
The bad news about the diseases is that dynamics of disease are more complex than we think. The old enemies have developed new weapons for defending and new enemies have emerged . The process in fighting a disease is non-linear and the progress cannot be expected to be on our side always.
Disease and poverty are intensively linked inextricably. There is an immediate need to combat poverty through better and more targeted health interventions. This requires a re-focusing of the areas of work which would make a large difference to the poor.
One important consideration is that the acceleration of AIDS warrants us for immediate action and intervention. A hospital in each state to treat exclusively the affected is essential. It will stem the tide of acceleration or at least the spread from pregnant mothers to new born infants. The treatment for AIDS pregnant mothers now has become cheaper due to the new drug — Nevirapine developed by Boehringer Ingelheim, Germany. About 50 per cent of treated AIDS infected pregnant women did not pass on the virus to the child. New born babies are given syrup medication two hours after birth.
Economics of therapy dictate the use of this drug. World Bank is funding such programmes in Africa and India. The problem is proper utilisation. Another aspect is vaccination. The major disease geographical areas are to be demarcated wherever possible. This activities include special economic and behavioural sciences, cost- benefit, cost -effective strategies involving vector control surveillance systems with communication from and to all centres.
Medical sector has to concentrate on the new diagnostic technologies using recombinant antigens, use of live clones to construct chimeric viruses and subunit vaccines, DNA vaccines that can be administered on the mucosal areas. Genetic engineering has to be resorted to develop vaccines.
Except for Hepatitis B, we do not have any genetically engineered vaccine. If we do not have, we have to purchase the technology and produce vaccines. Information technology has been given prominence because of the big names and players involved in it. There is no doubt that IT can be used to gather information, analyse and plan on scientific lines. We need to apply the appropriate technology (Indian or foreign) to increase productivity in various fields of human endeavour, but IT becomes inoperative in the absence of relevant new technology. Thus IT cannot create wealth by itself. It is only a means to identify and focus areas of interest. In developing countries this reality is not realized since they believe in high tech culture. Thus IT as such cannot contribute to rural affluence. What the rural people need today is quality of life free from disease and poverty.
The other area is disease forecasting. When a disease spectrum operates by seasons, we expect this situation like the brain fever in AP which took over 100 lives. This happened due to callous negligence and as the necessary precautions was not taken by the concerned persons. Our culture has become calamity culture . Unless there is death, no one recognizes the situation and we show knee jerk reaction only after death occurs.
Now there are several genetically engineered vaccines either being developed or under the process of development. With all the institutional expertise and high density scientific research , we could produce only one vaccine against Hepatitis B. The Hyderabad -based Indian Immunologicals of NDDB has taken the right step to produce vaccine for rabies to be used in humans. It is an excellent idea that has been translated. There is no industry link to produce new drugs. A state of the art health management system has to be conceived.
Vaccination for the established diseases like whooping cough etc has to be taken to monitor the outbreak spectrum varying with geography. Vaccination has to be organised for all ages and times according to patterns shown by illnesses. Scientifically- based mission oriented, time targeted approach is essential to control diseases.
The author is founder, former Director of Institute of Genetics, Hospital for Genetic Diseases,Osmania University