Malcolm Gladwell, the celebrated author, was posed a question by a viewer in the Munk Dialogues webcast from Canada in April 2020. He was asked what, in his view, could be the best thing to come out of the global pandemic of Covid-19. Without any hesitation, Gladwell said it would be the resurgence of public health as a widely respected discipline. He went on to say that public health was a major influence in advancing human health and well-being in the 20th century, giving the examples of many infectious diseases that have been quelled, like smallpox, poliomyelitis and HIV-AIDS. Despite these successes of public health, technological advances in illness care disproportionately captured the limelight and resources.
He could have well added the ongoing, but only partially successful, battle against tobacco and the more successful but still needed programmes to reduce maternal and child mortality. When public health is confronted by powerful commercial interests that oppose action against unhealthy foods, polluting industries, tobacco and alcohol, policymakers and sections of the public are swayed to act against public health evidence and advice. However, even in some incontrovertible areas like clean water and sanitation, services are not made universally available while economic growth is pursued zealously through lopsided models of development.
Gladwell also pointed out that the highly renowned hospitals of the US could make little impact on Covid-19 as the health system became dysfunctional due to shortages of nurses, personal protection equipment and testing kits. Top-heavy tertiary healthcare tottered when the weak legs of the health system gave way. Others have pointed out how all the smartly designed apps could not substitute for well-trained contact tracing personnel, whether in the US or UK. Doctors in highly rated hospitals in America have railed against hospital managers cutting expenses on nursing and other support staff as well as protective equipment in pursuit of the single-minded obsession to maximise profits. Lessons for India are there as our corporate hospitals are letting business managers, representing investor interests, dictate clinical practice patterns.
The former Governor of Jammu and Kashmir, N N Vohra, recently recalled that public health officers were an important part of state health services several decades ago. He was chairing a webinar on a holistic healthcare response to Covid-19 organised by the India International Centre on 8 August 2020. Drawing on his distinguished career in the Indian Administrative Service, which gave him familiarity with the organisation and functioning of the health sector, he recommended that public health competencies must be built up again in the health services as a high priority.
Public health has been marginalised in our health planning and services, both through low investment in capacity building and negligible engagement of available expertise. Tamil Nadu has had a designated public health cadre for many years. Odisha has recently followed suit. The National Health Policy of 2017 aims to establish public health management cadre in all states. However, progress has been extremely slow, due to the lack of directive from the state-level political leadership and opposition from clinicians who are concerned about losing opportunities to occupy administrative positions in district and state health services. Even the Central government has not set an example by creating a public health cadre at the national level.
Public health needs greater presence at multiple levels of public services, in the health sector and beyond. Diverse areas of expertise and a variety of functions contribute collectively to protection and promotion of public health. From virologists and entomologists to epidemiologists and health economists, and from statisticians to social scientists, the field is large. Public health nutrition, public health law and public health engineering are allied domains of public health knowledge and practice. Public health management is pivotal to the successful delivery of health programmes and improving service delivery at all levels of healthcare.
Public health nurses, community health workers, sanitary inspectors and food inspectors must lead at the frontlines. A variety of allied health professionals and AYUSH doctors too can be trained for performing public health functions at the community level. Public health professionals are better at risk communication and community mobilisation, which are much-needed skills during emergencies like the pandemic. Creating such diverse expertise and utilising them appropriately is vital to the protection of the population.
Institutional capacity must be created and supported for training public health professionals who can provide high-level expertise, as well as public health practitioners who can deliver routine services to the population and ensure success of national health programmes. Clinicians should not resent the emergence of these cadre as the efficiency of health services will improve and those who are devoted to patient care can do so without worrying about system defects that result in inadequate staff, stock-outs of drugs and equipment, and poor information systems. They will also not have to deal with an avalanche of patients whose disease could have been prevented from occurring or advancing to a severe state.
Covid-19 provides an opportunity for strengthening our public health systems. Let us not lose that opportunity, lest we have to use the mask as a fig leaf to cover our future public health failures.
K Srinath Reddy
President, Public Health Foundation of India (Views expressed are personal)
(ksrinath.reddy@phfi.org)