A look at India’s flawed public health policies through COVID-19’s prism

The term ‘public health’ has two different understandings or interpretations, which have had serious implications on how India and the world have tackled the novel coronavirus disease (COVID-19) pandemic so far.

The first understanding of public health is influenced by its definition as organised community efforts for the prevention of disease. This alludes to the activities carried out by any society to prevent problems of health arising among its citizens.

In the context of COVID-19, these include activities like contact tracing, health awareness, vaccine distribution and so on, in which health professionals are actively engaged.

The second interpretation is academic in orientation and is best defined by the term ‘population health’. It is a term that used to signify the health status of a population.

The idea of public health here is to capture and represent the health status of a population that is measured using existing indicators. This is more technical and only represents the health status, seldom offering any lead on how to change it.

‘Population health’ rarely captures diverse efforts and public health activities that are dynamic and contextual. Unfortunately, the current focus has been on it, with very little focus on the activities towards preventing disease.

This was evident in the context of COVID-19 when daily and weekly estimates and projections were mostly about the prevalence of the pandemic and deaths due to it. 

These predictions hardly suggested specific points for action to reduce the occurrence of the pandemic. The controversy surrounding the COVID-19 lockdown and its contribution to the reduction of the pandemic is still relevant for want of any convincing explanation on how exactly decline happened.

Public health, to be effective, needs to move beyond demonstrating what the state of ‘population health’ is to something that offers specific action points (organised community efforts) to prevent the occurrence of disease.

Who is in charge?

Another issue concerns the agencies responsible for implementing public health. The first definition only says organised community efforts. Technically, the private sector, people’s representatives, civil society or the government can be agencies for implementing public health.

In India, the government has emerged as the sole body responsible for implementing public health activities across the country in the past. During COVID-19, the health departments of state governments were responsible for and were in the forefront of implementing public health activities.

This is true for other disease control programmes such as TB, HIV, Malaria and non-communicable diseases too. However, the real public health work is carried out by the grassroot-level field workers.

These include the auxiliary nurses and midwives, accredited social health activists, multipurpose workers, who in some states are redesignated as junior health inspectors or public health nurses and community health volunteers.

These foot soldiers carry out actual public health work through their regular community outreach, that was utilised during COVID-19 as well. 

Not only is their ‘public health’ work unacknowledged but they also are guided by administrators or policymakers at the mid-level of the state health departments.

These administrators are neither public health professionals nor do they belong to the public health cadre. Most of them are medical professionals and are appointed as clinicians.

They are deemed to be ‘experts’ in public health policy and planning by virtue of their administrative experience — another form of jugaad or innovation in Indian public health.

No states till date have developed a strong public health cadre by appointing public health professionals for this task at the middle level or higher-level positions.

Reactive approach 

There has been a systematic failure to create and develop institutional mechanisms for maintaining public health by employing public health professionals. This has resulted in every public health response becoming a last-minute, crisis management activity.

This was apparent in the context of COVID-19. That is when state health departments roped in a range of volunteers from local self-governing bodies, political parties, the police force and others and expected them to transform public health overnight.

The image of ‘war rooms’, ‘jumbo centres’ and ‘Covid help desks’, all indicate the reactive approach during a crisis. This is also ‘boasted’ by some as organised community efforts for public health with intersectoral coordination.

States claim these short-term ad hoc approaches as an achievement during a crisis, without having any systematic analysis on the real contribution of these initiatives towards prevention.

Most of these initiatives emerge due to political clout and get legitimised by the ‘public health experts’ of the health departments. These ‘experts’ are mostly senior clinicians from the state health department who are close to power centres and seldom have expertise in public health practice.

Some states had hired public health consultants during COVID-19 and mostly followed national guidelines without taking the local context into account.

This kind of adhocism is also followed during the special drives of public health programmes regarding TB control, vaccination drives, prevention of diabetes, hypertension, cancers, etc.

There is a need to build institutions for public health practice with professional public health cadres (workers, administrators, epidemiologists, policy makers and others) with a regular mandate of maintaining public health for a designated population.

Causes, not consequences

Finally, there is the ambiguity surrounding diverse approaches in public health action. It is well-known that for any public health action to become effective, the social context must be taken into account.

It is a truism that every disease / epidemic will have fundamental social causes that need to be addressed to prevent its occurrence. This is owing to the social determinants of health approach.

Every disease will have consequences too that impact the social fabric of the society. In public heath practice, primacy should be given to the social causes of disease occurrence rather than social consequences, as the latter may not even arise if occurrence is prevented.

There is a tendency among some with a ‘generic’ understanding of public health to focus exclusively on the consequences of disease, which propagates an inherent assumption that the occurrence of the disease is inevitable.

This results in a failure to acknowledge the fundamental causes of the occurrence of the disease. During the two waves of COVID-19 in India, the social dimensions of the disease highlighted its consequences on people’s lives and livelihoods.

But hardly anything was spoken about how people’s lives (the nature of habitation, health behaviours related to physical distancing and diet and so on) contributed to the occurrence of COVID-19 in the first place.

This is true even for other chronic diseases like diabetes, hypertension and cancer, wherein the focus is more about screening, treatment and follow up, with barely any effort to identify and interpret the social causes behind its occurrence. 

In public health, this approach of focusing on the consequences of disease without addressing its causes is always critiqued with a classic statement: “Mopping the floor while keeping the tap open.”

Mathew George is Professor at the Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai

Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth  

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