Providing healthcare to its citizens in 21st century has become the most daunting task for all nations. Hardly had we scored success in dealing with old and established diseases that we are now confronted with a very complex set of diseases due to changing life styles and environmental factors. According to the W.H.O. constitution "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." What is health? The governments as well as many among us do not work towards keeping health issues high on our agenda as health is taken for granted. ? All religious personalities and leading lights have spoken on health emphasizing its value. Thomas Jefferson once said "There is only one wealth and that is health". Gandhi Ji always reminded his audience of the value of health and he himself vigorously pursued a disciplined life in pursuit of health. His life is an example that depicts how one could stay healthy by observing simple rules enunciated by our sages. Understanding the factors that undermine health and anticipating the outcomes that would follow given lack of commitment to the health, is an emerging new concept. Our ancestors figured out that physical health can only be reinforced by strengthening psychological and spiritual health. Controlling the mind by sanitizing the thoughts can help us maintain physical body in a healthy state. Healthcare systems in many parts of the world today are in turmoil as concluded by the World Health Organization (W.H.O.) Emulating American model the governments in many parts of the world are on a privatization spree making healthcare a luxury for vast segments of society. Also, the Governments in developed and developing countries alike are finding it difficult to help attain the goal of 'Health for all'.
Despite repeated assertions and tall claims about our achievements in the field of health such as a raise in life expectancy (current figure for male is 64 years, and for female 68 years) and elimination of small pox, polio myelitis and so on, the fact is that the health scenario in India continues to remain grim. This is a direct consequence of ignoring health and education ever since independence. The World Health Organization (WHO) admitted in the beginning of 21st Century that healthcare systems in most countries lay in shambles. Widespread poverty and illiteracy (India's current literacy is pegged at 62% for adults) makes the goal of providing universal healthcare extremely challenging. An educated and literate populace is easy to deal with in matters of health, education and advancing preventive healthcare, which results in higher prevalence of safe motherhood, lower infant mortality and lower birth rate. The characteristics of this poor state of the health of the nation can also be attributed to a poor allocation for health (3.3 per cent in first five years plan, 3 per cent in second plan, and currently it is about 4.1 % of GDP. New Zealand spends 10.1% of its GDP, OECD 9.5% and Nepal 5.5%) despite the ruling government's acceptance of Bhore Committee report which advocated a 10 per cent allocation for health. The low allocation coupled with neglect of our own indigenous system of medicine as well as preventive, promotional, rehabilitative, and public health and a disproportionate stress on curative and tertiary healthcare, has today left our healthcare system in a blind alley.
Our planners consistently ignored the ancient wisdom which laid enormous stress on hygiene, cleanliness and sanitation. The foundations and principles of modern day healthcare are well enshrined in our scriptures. Thousands of years ago our sages expanded and propagated a holistic vision of health enunciating a concept of health well beyond physical, mental and social wellbeing to embody emotional and spiritual wellbeing. Modern scientists have failed to appreciate that our noble fore-fathers with far less material possessions could generate energy and vitality to protect their physical and mental health by practicing spirituality whereas the people of developed and rich countries today remain highly stressed and in poor health despite much affluence and wealth. This phenomenon of stress has recorded unprecedented growth in last few years in consequence to switch over to a market based economy, which has caused widespread joblessness, reduced social security and an ever-impending fear of securing meaningful employment. I think alleviation of stress is one of the most formidable tasks confronting the healers today and modern medicine's purely technical and mundane approach will be of little help in this regard.
Our health planners overlooked the age-old Indian wisdom to promote borrowed ideas and promoted only one system of medicine, the so-called modern medicine, which itself has failed to ensure availability of healthcare to everyone in most affluent nations despite a whopping increase in health sector spending. In the new millennium, there is a paradigm shift in developed countries and a new approach that underscores integration of holistic approach and lays more stress on family medicine, is being promoted. Due to misplaced priorities in health sector in India, while a handful minority can claim to have world-class healthcare, millions of Indians do not have access to any healthcare at all let alone primary healthcare. It may look strange and paradoxical but the fact remains that the role and responsibility for ensuring health for everyone is more dependent on what action and policies other ministries adopt than the health ministry alone. Availability of safe drinking water must be ensured by civic authorities as also safe disposal of human excreta, and hazardous wastes and provision of sanitation is a must. Food and agriculture ministry should guarantee affordable food grains meeting the nutritional requirements. Urban transport ministry can provide means of safe public transport to reduce levels of air pollution as well as injuries and accidents, which account for substantial morbidity and mortality in all developed and newly industrializing countries. The environment ministry should ensure a safe and healthy environment by preventing and controlling pollution of air, water and soil by formulating standards and their proper enforcement. The housing ministry should make available dwellings for all. The role of health ministry should largely be focused on ensuring highest standards of public health and preventing diseases as nearly 80 percent ailments are amenable to prevention. Promoting healthy lifestyle and healthy behaviors should be encouraged. Community participation and involvement remains the backbone of any good healthcare system. The emerging challenge of Non Communicable Diseases has to be met head on with focus on creating healthy work places.
The successive governments at the centre never recognized health as a means to achieve human development but treated it as a minor government department that needed some allocation simply because it was there. Policy makers, planners, healthcare providers today have to make good for past misses. Serious challenges lie ahead as on one hand expectations of people continue to rise due to technological breakthroughs and availability of new modalities for diagnosis and cure, and on the other prohibitive cost makes these inaccessible for much of the population even in developed countries. Hopes were raised by World Health Organization by formulating a strategy of 'Health for All' by year 2000. Now that the year 2014 has come, the goal remains elusive with new threats emerging such as AIDS, Tobacco-related illnesses, drug abuse, resurgence of old infectious diseases and above all work related and environmental illnesses. However, the intervening period gave us time to analyze the constraints and impediments to achieving this goal. In my own assessment the goal of health for all is laudable and the approach of attaining it goes through 'primary healthcare route'. We need to have a broader, more comprehensive and integrated approach which should recognize and make use of our age old wisdom, practices and societal beliefs. Ancient Indians were known to enjoy long and healthy lives when no technologies existed. Whatever they said or thought has proved to be correct no matter, which scientific scale one uses. That eating less is associated with a longer life was a fact known to them (Alp Bhuktam Bahu Bhuktam - one who eats less enjoys food for a long time).
Their biggest observation was that vegetarian food consumption is associated with a longer life and lesser affliction by degenerative diseases. This fact is now universally accepted and even scientists approve this fact. The recent data indicating that red meat consumption is associated with higher incidence of heart disease and cancer goes to support their observation.
Let us first see where do we stand today and what are our achievements? After Independence the life expectancy of an Indian (life expectancy denotes the average number of years a new-born child is expected to live under current mortality conditions) has risen from 32 years at that time to 65 years. ; the maternal mortality at present is 178 /100,000 live births (2011-2012) which is still too high; the death rate from 27.4/1000 population has dropped to 8/1000 population (2012) in last decade and infant mortality rate has declined from 146/1000 live birth at the time of independence to 42/1000 (2012) live births in last decade. An interesting fact is that though these figures represent the national averages there is a wide inter-state variability and some states like Kerala are way ahead whereas states like Bihar and Madhya Pradesh which lag behind. Again, though infant mortality has registered a drop; problem of malnutrition has not been solved and remains a matter of grave concern. India, has one of the highest incidence of low birth weight, nearly 7.5 million low-birth weight babies annually â€“ the highest for any country. It is now universally acknowledged that poverty is harbinger of poor health and without a reasonable socio-economic development health for all cannot be achieved. Yet the 'human development report, published in the last decade' places the overall prevalence of poverty in India at 38 per cent, i.e., about 350 million, which is an unacceptably high figure. "As per NSSO report based on the survey conducted by it in July 2004-June 2005, the average per capita calorie in-take at all India level in rural areas is 2,047 kilo calories as compared to 2,153 kilo calories based on the results of similar survey undertaken during July 1993-June 1994," More alarmingly, the poor nutritional state resulting from this insufficient calories intake is far more prevalent in pre-school children, which might have serious effect on their physical and mental development. In women, prevalence of anemia during pregnancy is as high as 87.5 percent with 13 percent recording severe anemia, which has profound implications for the health of new-born. Similarly potable water, disposal of waste, sewerage system and clean toilets are available to few. Besides, there are other distortions like three doctors to one nurse whereas there should be three nurses for one doctor, lack of adequate numbers of public health specialists, epidemiologists, pathologists and radiologists. Above all the world's first nation to launch a family planning programme way back in 1952 has miserably failed in meeting the targets thanks to the corruption perpetrated by the governments in power.
Recent research indicates that role of lifestyle and environment is perhaps more profound in securing human health than was previously thought. Interestingly, our ancestors always knew this secret as is evidenced by their great penchant for cleanliness, environmental sanitation and food hygiene. Indian system of medicine invariably recommended alteration in diet and food habits in all cases of illness. The concept of biodiversity was propagated and one was exhorted to show compassion to all living beings and even trees. Isa Upnishad clearly states ' Isa Vasya Midam Sarvam Yat Kinch Jagtyam Jagat ('God dwells in all and everything whatever is present in this universe'. To promote social wellbeing and harmony they enunciated the concept of ' Vashudhev Kutumbukam' The world is a family. If everyone is a family member where is the room for discord and how can there be isolation and alienation?
We now recognize that many ailments result due to an unhealthy lifestyle and many disorders are related to poor nutrition, alcohol abuse, smoking and the stress. What is not frankly accepted is that many of these diseases are the results of a society that alienates people from themselves and each other. Modern medicine is unable to provide solutions to this. Identifying the need for social answers to disease is also an important part of the solution. If healing of people is to be really achieved, spiritual dimension of care is basically important. A decidedly more humane and healing approach is required which stresses promotion of body's self-healing powers as was preached and practiced by our ancient systems. A serious effort is required to explain the strength of spiritual aspects of healing to modern practitioners and it calls for a new approach so that healthcare providers inculcate and adopt this.
Current trends in medicine are stressing a concept of healthcare based on 'quality of life' and this dimension is assuming increasing importance in healthcare. This becomes particularly relevant as the life expectancy increases and people start living longer. In fact, this concept was first put forth in our scriptures, which maintained that not only we live to 100 years, but also have our vision; hearing and other sensory and motor functions intact. Prof. O. Boyle of Ireland says that illnesses, diseases and their management can significantly influence areas such as functioning, mobility, mood, life satisfaction, sexuality, cognition and ability to fulfill occupational, social and family roles. The emerging quality of life construct may be viewed as paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to aging populations both for healthy elderly and for those who develop chronic diseases where maintenance of quality of life rather than cure may be the primary goal of treatment.
During my tenure as health minister, my ministry accorded high priority to the neglected public health system. Right at the outset we prioritized our activities, prepared an action plan to address the distortions that I talked about above. We encouraged community participation and involvement beginning from the launching of 'polio eradication programme' and continued till end. I felt people do get motivated and enthused if they are communicated the message of health unambiguously.
The Delhi government was the first one to take an initiative for the 'Rational Use of Essential Drugs'. The programme was so successful that it has now been adopted by dozen states in India. The WHO has recognized it as 'Delhi Model' and is being propagated and implemented in many countries of the world with the guidance and support of India WHO programme for Rational Use of Essential drugs. We were very concerned about ' tobacco related illness' and despite much opposition a bill was passed in Delhi as ' the Delhi prohibition of smoking and non-smokers health protection Act 1996'. This inspired the promulgation of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), the principal comprehensive law governing tobacco control in India. The Act was passed before India became a party to the WHO Framework Convention on Tobacco Control. In 2004, the Ministry of Health and Family Welfare exercised the powers granted to it in Section 31 of COTPA by promulgating a first set of rules, which, with respect to smoke free and tobacco advertising issues, have been stayed by court order or superseded. With respect to general enforcement of COTPA, G.S.R. 1866(E) lists certain officers who are authorized to carry out the entry, search, and seizure provisions of the Act.
Continuing with our mission to prevent diseases due to environment and occupation and protect environment a centre for occupational and environmental Health in Lok Nayak Hospital and Maulana Azad Medical College was set up which came to be acknowledged internationally. We launched campaigns on 'Matri Surksha Programme (safe motherhood)' to strengthen reproductive health, ' Cancer Control Programme', 'Cataract Free Delhi Programme' and 'Shravan-Shakti Abhiyan '(for deafness affecting old and rehabilitation of elderly deaf). We were able to enact ' Delhi Physiotherapy and Occupational Therapy Bill' and ' Delhi Artificial Insemination Act'. To promote holistic vision of medicine 100 acres of land was earmarked for setting up in half area a hospital based on Naturopathy and drugless therapy. In the remaining half, an Ayurvedic Medical College along with a hospital and research center was to be established. Medicinal herbs were to be grown in this area.
A 'Healthy City Project' was also started in trans-Yamuna locality, ' Hepatitis B Immunization Programme' was taken up and we established a 'Delhi Research Center for Modernized Promotion of Ayurvedic (the Indian system of medicine)'. To strengthen health education we carried over the concept of health to schools and introduced ' Compulsory Yoga and Positive Health Education' in schools and also initiated a value based calendar to promote and inculcate moral values among children at a tender age.
However, I have to honestly admit that much remains to be accomplished. I am for promoting the 'Human Face' of medicine and considerable effort is needed to inculcate these virtues among our budding physicians. They need to be reminded what our ancient sages propagated 'na atmartham napi kamartham atha bhuta-dayam prati | vartate yah cikitsayam sa sarvam ativartate ' The translation means 'A physician should not offer his services motivated by commercial considerations, but should do so out of his inherent, unadulterated love for humanity.
The Hippocratic Oath has lost meaning today as a significant number of physicians are becoming bereft of compassion and remain preoccupied with the pursuit of material possessions. I strongly feel this to be the biggest challenge as to how we change the mind-set of our healers so that poor and needy do not feel unwanted.
A major and the most important task in my view remains educating the politicians, decision makers and those who to enable them to grasp the importance of health. A restructuring and reorganization of health ministry has become a compelling indispensability. For the reasons enumerated above, sub-departments of health may have to be contrived in all ministries for better inter sect oral coordination and for emphasizing on them the exigency to initiate appropriate actions to aid health ministry. They should become equal partners in health promotion movement and preventing illness. Secondly, the allocation for health should be augmented from present levels to more realistic levels. Let health be a concern of one and all.
A new and integrated holistic system of medicine is the need of the hour, which should incorporate the best of all systems including Ayurveda, Siddha, Yoga, Naturopathy, Homeopathy and our other ancient systems. These systems and their practitioners have served and healed the mankind for millennia and they cannot be ignored and dumped as unscientific and irrational. Integration of these systems may help contain fast rising cost of medicine. Students can pursue postgraduate medical qualification in any system such as Homeopathy, modern medicine or Ayurveda and should be able to practice the way they like.
In the medical curriculum for first few years all systems such as Ayurveda, Homeopathy and Naturopathy may be taught and at the end of this term students can choose whichever option they like. We cannot afford to ignore the wisdom and sayings of our great ancestors who selflessly served the mankind and handed down to us a code of conduct on nutrition, daily habits, spirituality and strengthening the moral values to delay and forestall onset of ageing and illness.
Organizations and associations like chambers of commerce and industry, Rotary and Lions International with branches all over, and numerous social and philanthropic organizations representing important groups of citizens may be roped in to building a strong movement of 'health for all'. They may be motivated to divert part of their energy and resources to take up health issues and become active partners in the endeavour of preventing illness and promotion of health. They may be urged to wholeheartedly support government initiatives on positive health and rehabilitation and care of disabled.
In my view, two other aspects which have profound impact of health and human development that require urgent consideration are involvement of students in a massive way to communicate and disseminate message of positive health among masses and encouraging every individual's participation for positive health. Students can donate some of their leisure time and vacations towards this altruistic goal of positive health. This will also enable them to acquire a health conscious attitude early in life. Individual potential may be harnessed by sensitizing him towards health. A total attitudinal transformation of people in thought, action and belief based on our ancient culture is required to make health a meaningful and purposeful concept so that everyone regards himself as guardian and defender of environment and health. Armed with healthy and hygienic habits and a positive frame of mind he can be groomed to performing one good act a day that should help in community development and acquisition of a proactive health culture, i.e., he can plant a sapling in front of his house or in neighbourhood, exhort people to work towards improving their immediate ambiance. Individuals may be encouraged to assume responsibility for their own health by shedding negative habits like tobacco, alcohol, other substance abuse and adopting a positive behaviour by 'undertaking regular physical and Yogic exercises, going to bed early and waking up early; this brings a person in contact with cosmic energy of the rising sun and may ensure restoration and proper functioning of endocrinal system.
People may be persuaded to consuming a balanced, nutritive and vegetarian diet as recommended by our ancestors (Hit Bhug, Mit Bhug, Kal Bhug; Eating what is beneficial, in small quantity and at proper time), paying attention to food and kitchen sanitation, hygiene practiced by the cook, and disposing off the wastes properly, offering leftovers to other living creatures, worshipping plants and trees, showing care and compassion to one and all as advocated in our scriptures. This only would make health a successful movement.
Before I conclude I would like to highlight certain emerging areas where urgent action is required. Food Safety, Product Safety, and Injury Prevention and Control are areas not well appreciated by health policy makers and healthcare providers. The disease burden on account of traumatic injuries whether due to traffic, or at home or at work or recreation is unacceptably high and needs urgent steps to reverse the rising trend.
The Herbal medicines, their cultivation, and export are another important area that needs to be promoted. These have provided relief to people in India for thousands of years. Such a policy of promotion would generate earnings and employment and would provide affordable alternative treatment to those who are unable to access modern healthcare facilities.
The immunizations have enabled us to get rid of the scourge of small pox, diphtheria and other communicable diseases. The time is ripe to further expand the programme to include immunization against Hepatitis B, Hemophilus influenzae, and many other vaccine preventable diseases. Such immunization initiatives require commitment of the corporate world that should come forward to play a proactive role in propagating prevention. Gates Foundation in USA has taken a lead by donating large sums for this cause in the developing world.
Strategies in existence for population control shall have to be reviewed extensively. Disincentives and incentives linked to population control and small family norm shall have to be introduced at every step and everywhere in life of an individual. Literacy programme, particularly for women shall require dynamic improvements and strengthening. Law shall have to be enacted for all elected people from panchayat to parliament to bar entry of those who disrespect small family norm. A debate must start in the country for enacting a law for the common man to restrict his family size.
Finally, the problems of health remains inseparably linked to socio-economic development. The poverty angle has to be tackled at war footing. Health for all as part of sustainable development can only materialize if poverty levels are brought down.
I may conclude by reiterating that health is a complex subject but there has been a better understanding of the factors that determine health in last few decades. Government and ministry of health alone cannot and will not succeed in achieving the goal of ' health for all' unless every single person and every organization is galvanized to become a part to this concept and idea.
To conclude: A holistic vision of health incorporating the ancient Indian wisdom with focus on spirituality is the need of the hour Author is Union Minister of Health & Family Welfare, Govt. of India and also a former Advisor to World Health Organization