The Two Faces of
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
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