PUCL Bulletin, June 2001

The Two Faces of Public Health
By Ritu Priya

Public Policy debates have voiced concern about the content of education and pedagogic methods, but little is being debated about the approach to public health interventions.

Recent violent protests in the country's capital, triggered by the execution of a Supreme Court judgement ordering the removal of all small-scale industries and polluting units from residential areas have raised issues roofed in the perceptions of "how" to improve the health of populations. On the one hand is the increasing environmental pollution by industrial units within residential areas, on the other is the fact that a large number of families are dependent for their livelihoods on these factories. The present debate on Delhi's small-scale industries has got couched in terms of pollution control versus lives of the poor. This deserves serious consideration, as the approach to "de-polluting" tried out in Delhi to be replicated throughout the country.

Air and water quality are of course important for the health of all. But of equal significance for health are diets, work, and social relationships. A sudden guillotine of livelihoods will destroy the fabric of life of over 10 lakh workers and 1.25 lakh lower middle class owners of small-scale units who, together with their families, constitute over one-third of the city's population (by the most conservative estimates). While the workers' existing conditions are deplorable, they will be forced into even poorer conditions of work, be buffeted from place to place, and pass through periods of hunger.

Consequently, their families will experience an increase in childhood as well as old age mortality. Frustration and ill health will escalate among the young adults and the middle aged. The middle class and the elite may feel happy for a while at "having dealt with pollution" but will soon recognise the marginal impact created by the factory removal, as pollution increases with increasing private vehicles. In addition will be the experience of escalating conflict and violence amidst its own members and from the poorer sections, thereby increasing stress and anxiety-related diseases. The net impact can only mean a worsening of health and social indices for the city as a whole.

Thus, while the public health argument for the removal of the factories reflects one perspective within the discipline, a different public health perspective questions the utility of this measure for improving the health of the city's citizens. This is just one illustration of the urgency of the debate on approaches to public health problems. Approaches to tuberculosis, malaria, AIDS, malnutrition, and alcoholism are among those that also demand urgent consideration.

Public health has an inherent democratizing potential, its concerns having been one impetus for improving the quality of life of the deprived. However, it also has the potential for legitimizing large-scale coercive action in the name of 'public good'. Public health arose in Europe as a specialised sphere of activity in the industrialised cities of the mid-19th century, with the realisation that the health of one section of society was closely bound to that of the other and that of each section was determined by its conditions of life. Improving the abysmal living and working conditions of the poor was undertaken, realising that these led to rampant malnutrition and communicable disease and also posed a threat to the health of the better-off through epidemics and social delinquency.
The Bhore Committee Report of 1946 (setting the tone for health services development in post-independence India) insisted that "the tiller of the soil be at the centre of all planning" and "health care be available to all irrespective of the ability to pay."

The Alma Ata Declaration of 1976 (which pledged 'Health for All') was another reminder that all spheres of life impinge upon health and therefore inter-sectoral planning for health with a focus on the deprived is necessary. In the past decade, highlighting of women's health and moves for 'gender sensitisation' of public health has proved another democratizing thrust.

However, public health also provided rationales for Nazi acts of genocide (as eugenics) and barbaric experimentation on human subjects (as 'scientific knowledge to help humanity'). It accepted the frank coercion of forced sterilization during the internal Emergency of 1975-77.

It has incessantly initiated the soft coercion of victim-blaming and behavioral manipulation of patients and specific social groups 'for their own good'.
The difference between these two kinds of initiatives - the democratising and the coercive - has been that the former gave prime importance to conditions of life of a person or group as determinants of health, thereby proposing measures to improve conditions so that people are able to do what they want to remain healthy. The latter focused on the person or group's internal factors (whether genetic and racial, or the 'negative cultural traits' of the colonized 'natives'/the poor/the women/the tribal etc.) thereby targeting people without improving their conditions in any significant way.

Public health experience has also shown that simplistic single- pronged, technology-driven programmes have never fulfilled their promise. Smallpox got eradicated only when the local context and people's life conditions were given due consideration in application of immunization. Enlarging of the Family Planning Programme beyond contraceptive services in the 1990s by adopting the Reproductive and Child Health (RCH) approach was a result of this realisation.

Improving the health and life conditions of the slum-dwellers was among the various reasons given for the slum demolition drive of the Emergency period under the leadership of the erstwhile Vice-Chairman, D.D.A., Shri Jag Mohan (and present Minister of Urban Development). The failure on this count became evident when a cholera epidemic broke out in the city in 1988, affecting almost exclusively the residents of Shri Jag Mohan's resettlement colonies! Thus history teaches us that techno centric and bureaucratic solutions to public health problems do not work if they fail to consider people's suffering and the local context.

The closure of factories in Delhi illustrates the use of legal and administrative measures to regulate environments and behaviours without adequate attention to preventing the violation of official pro-people plans or rehabilitation of workers displayed by the action.

The holistic approach, known to both public and town planning (but often lacking in practice), would first look at Delhi's sources of air pollution - 67 percent from vehicles of which two-third comes from two-wheelers, 13 percent from thermal power plants, 12 percent from industrial units and 8 percent from domestic combustion. Obviously the first needs priority attention. A less disruptive procedure for maximum health benefit requires a realistic assessment of each case on its merit, flexibility, and local innovativeness for solutions. A judicious choice of pollutions control mechanisms, alternative production, substitute products, etc. would reduce the need for relocation.

Relocating the remaining small number to where waste can be released
without harming local inhabitants would then be possible. Bureaucracy and local people working together could possibly implement such approaches, especially with socially sensitive technical inputs, if there is transparency in the process. This calls for a major effort, and a reorientation of bureaucratic culture. However, a democratic state which has been negligent in the past, but which is an organ of the people, working with them and for their benefit, will be required to undertake such an effort. A simplistic and coercive approach may decrease environmental pollution but will not improve the city's health.

-- Ritu Priya is an Assistant Professor, Centre of Social Medicine and Community Health, JNU

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