I was recently invited to speak at a TEDx event organised by a school in Hyderabad. Given my research interests on health equity, I chose to build my talk around a foundational element of public health itself: what makes one healthy, is it a matter of chance (for eg. through genes), or by choice (through specific “healthy” behavioural choices, one “chooses”).
As a medical doctor, my training is in identifying causes of ill-health/disease and treat it. Further, as a scientist/researcher in public health, my journey is deeply entangled with the enterprise of doing the same for a community or a population. And as is the case with many other individual attributes that do not translate automatically into population attributes, population health too is not merely reducible to drivers of individual (ill)health. There appears to be more to it. Indeed, studying population health patterns on who (which populations) live(s) longer, who (which populations) is/are healthier, and who (which populations) die(s) younger, tells us a lot about how (ill)health is distributed in society/populations.
Let’s begin with a question that, for me, holds a lot of answers to the question of individual versus public health. Being healthy, in good health, is it a matter of chance, merely based on what kind of genes one is born with, or is it a matter of choice, meaning, is it driven by healthier lifestyle choices that some make and others don’t. What determines if a child born today is going to lead a healthy life? These are the kind of questions that public health researchers grapple with. In the talk, I share some answers to these questions of chance-choice through stories and some secondary data on health indicators from India.
India is a signatory to the Alma Ata Declaration which was a global commitment made by nearly all the countries in the world in 1978 to achieve health for all by the year 2000. It is the basis for the World Health Organization’s primary health care strategy to promote health, human dignity, and enhanced quality of life. After traversing through the MDGs the latest vision that India too has signed up for, is the United Nations’ Sustainable Development Goals.
Yet, we are not doing so well in terms of achieving these global goals. We are far away. Just take deaths due to diarrhoea for example. Children under 5 dying from diarrhoea is unacceptably high in India. Together with Nigeria, India accounts for nearly half of all deaths of children under 5 due to diarrhoea in the world. Researchers estimated that close to a lakh children under 5 die every year in India due to this.
What choice did these children have? Don’t we yet have the technology to save these children? We have doctors, nurses, hospitals. Then, why are we still having deaths due to diarrhoea among young children?
There are millions of people in India who do not have access to quality healthcare and hence are more prone to hunger, malnutrition and other forms of physical, mental or other forms of ill-health. This makes one wonder, what is the reason why some of us are healthier than others. What decides who lives to their 90s and who dies in their 50s, and worse still who shall die in their infancy or which mother shall enjoy safe maternity and which one shall die while giving birth.
Clearly, if these children (or mothers) had gotten to doctors, nurses or hospitals in time, they could have been saved. But, is that merely a matter of choice? If any mother with a child decides to walk into the nearest hospital or health centre, will they get the care needed? Unfortunately, if being healthy is all about ensuring that health services/healthcare is available, then we have a problem. We have a health system which is so variable in its quality, accessibility and availability based on where you are…and worse still, who you are!
Asha and Ramya
Asha was about 14 when I saw her in 2004. She was unconscious and had been brought to the hospital where I worked. This was a small hospital run by an NGO in a forest area in southern Karnataka. She was born into a family of an indigenous community that live in different parts of the country, often in close association with forests. She had a type of Diabetes that starts very early, even in early childhood and adolescence. Clearly, it had not been diagnosed and her sugars had shot up heavily making her unconscious. Her mother – seen in the back there – and few others from her village high up in thickly forested hills had carried her about 8 km by foot to the our hospital. We tried to convince her that she ought to be going to a higher level facility for better care. They wouldn’t listen. They said this is as far as they could come. Going to Bangalore or Mysore for healthcare was almost unheard of in their village and was out of bounds. A multitude of reasons ranging from geography to culture could be advanced, but the most hard-hitting one was of course money (or the lack of it). After a week at the hospital, with fluids and insulin, she recovered. Over the next few days, we trained her to manage her sugar levels. She was supposed to be taking regular supplies of injectable insulin for her condition. She had to undertake that 8 km on foot journey periodically to get her supplies. Meanwhile, my own life took its own trajectory, going deeper into public health research and I went back in 2015 to this hospital, this time wearing the hat of a public health researcher. I inquired how she was. I heared she was no more. Gone away. Few remembered the details of what happened. For the doctor, it was a life lost. A life of a patient with Type 1 Diabetes. Was that all, I wondered. There is a clear medical reason Asha is not here today with us. But, what really took Asha’s life is not only her “disease”. It is the lack of access to essential medicine. It is the lack of access to roads, the distance from health centres. Asha did not have to leave us so soon, I thought…and even to this day, I wonder, what resulted in such a short life for her while elsewhere people lead fluorishing and fulfilling lives with Type 1 Diabetes.
Ramya’s story is very different in many ways. This is much more recent. In August 2013, when Ramya, a 4-year old girl from another village met with a road traffic accident, her foot was badly damaged. After primary care at the same hospital, she was referred to the nearest government hospital, in this case a large government medical college hospital which is supposed to have specialists and super-specialist care. In this case, my wife (also a doctor) who was at the time the doctor in the hospital atteneded to her, so we closely followed up. At the teaching hospital, there was a huge delay. Referral to essential specialists was not happening soon enough. They were already being advised that the foot may be lost. What is the consequence of a 4-year old losing her foot, we thought. More so, living in a landscape where daily wage work or venturing into forests to collect forest produce was the main occupation. Was this a decision that the doctors were arriving at after considering all possiblities? Things were moving too slow at the government hospital. Here was this girl needing immediate attention, but the system was not responding soon enough. So, some of us got together and galvanised a campaign to raise money. We identified a large private hospital in Bangalore, who was generous enough to agree to help. Finally, about 30 hours after he accident, a multi-specialist team in a reputed private hospital in Bangalore saved Ramya’s limb. Ramya is today 9 years old, walks to school, plays sports and has a smile on her face. There are two ways to read this story. One is of course to appreciate the philanthropic spirit and large-heartedness of the private sector which kicked in at the right time, and another is to of course pat our own backs and say, Wow, we helped somebody in need. But, somehow, neither of those appealed to us. We felt let down by the system. It appeared that the system was letting down “some” people among us. While those who could “buy” healthcare either through their own money or through philanthropy/social networks got one kind of care, and those who could not got another kind of care. Is this fair, we thought? What happens to those Ramyas if social networks don’t kick in…..in any case, why should the health and well-being of some people depend on the charity or philanthropy of another? Should we as a society not resolve that we ought to live in a more fair society than this? Have we not already done so when we affirmed the right to life in our Constitution? So, where is the quesiton of “choice” to be healthy for people like Ramya, if circumstances that allow choices to be made are never manifested in the first place…
Being healthy, and living long is not only a matter of seeking healthcare at the right time. Clearly, it is also a matter of where one is born, in a city or a village, what kind of household one is born into and what kind of socio-economic position one is born into, and sadly, if one is born a girl or a boy. And this is not based on my story. This is what series of nation-wide and state-wide population health surveys shows us. You pick any indicator you choose – number of women who die giving birth, or access to good quality maternal health care, access to medicines, immunisation rates etc, this pattern is repeated across decades in India. Things are improving, but clearly, they are improving faster and steadier for some, and not so for some others.
And such disadvantages are not merely about health and healthcare. They multiply and tend to perpetuate across generations. So many families in India today become impoverished merely due to out-of-pocket payments at the time of seeking healthcare. And families often cope with such impoverishment by sacrificing education, nutrition or some such vital ingredient that could potentially improve their situation. Research has shown that this kind of disadvantage tends to cluster in some regions, castes, communities and sadly can be inter-generational, hence disadvantaging some populations.
Determinants of health
If we are to ask what are then the determinants of health of populations, WHO identifies seven broad determinants of public health. And noticeably, many of them are in the domain of what is called the “social determinants of health”. It is not lack of access to cutting-edge diagnostics or the gamma-knife that is killing people, but how we have structured our societies, nations, families, governments and of course our health systems.
“This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place.”
Dr Margaret Chan, the (then) DG of the WHO, at the launch of the CSDH Final Report in Geneva 28th August 2008
So, let’s go back to the question we began with. Is health a matter of chance, or is it a matter of choice. I have come to realise, this is not a useful question at all. Because, health, to me, is to a fairly large extent determined by the social circumstances in which people live. Interestingly, this presents us with two possibilities: If health is so heavily determined socially, it need not be this way. It need not be stacked up against a few and we can together make choices to ensure fairness in the way health and healthcare is distributed in society. Sadly, social norms and social situations don’t change so easily. It needs firstly an acknowledgment. We, as a society, will never solve a problem that we don’t acknowledge exists. And to me, the major barrier to solving this problem of fairness is the denial, that this is a problem at all. Far too many arguments are made with respect to public health as if it is a matter of individual choice. As if “illiteracy” is the problem, or a mere lack of awareness, or a below poverty line status or the wrong caste. Building a fair health system and distributing healthcare fairly is not only a medical enterprise but a social (and a political) one. It also requires that our collective consciousness needs to be raised. Over the last decade, societies the world-over are witnessing an amazing level of raising of consciousness around the issue of gender…far from adequate, but it is happening. Similarly, we need to raise our consciousness about the barriers to building an inclusive society that is pervasive amongst us. We need to become champions of social inclusion in all spheres. Not out of a feeling of “doing good to the downtrodden” but rather because we ought to strive to build a society that is just and fair for all of us. And the only way we can do this, in my opinion, is to strengthen the public-oriented nature of health and healthcare, and the need to ensure that it is universal and fair and is delivered and managed in a way that is universal and fair.
We all have a role to play in this. As a public health researcher, I believe my role in this is to see how science can help us better understand the reasons for the pervasive nature of this inequity in some populations. Why and how do poor health outcomes tend to aggregate in some places and not in others? That is my quest. I believe acknowledging the unfairness within our own households, neighborhoods, towns, cities, schools, offices, parks and nations is the first step. There is a new energy in today’s youth to invest in nation’s development. What better way to show patriotism and nationalism than to acknowledge and address drivers of inequities and unfairness in our own society by raising consciousness in our own small spaces and having those dialogues and discussions so that we build a more equitable and fair society.
Sincere thanks for the invitation to speak at the event to TEDxOakridgeschoolEinstein organisers, especially Mythili Balaji, Padmavati and the entire team behind the event.