The missing public

Where is the public in public health policy?

Years ago, when this author studied policy making in public health at Johns Hopkins School of Public Health in Baltimore, his teachers harped regularly on one point. They said public health is 90 per cent about people and just 10 per cent about drugs and other medical paraphernalia. The truism seems to have been overturned today.

Public health is today all about the business of medicines, drugs, vaccines. Patents and profits are the over-riding mantras. Consider research on hiv/aids. N early 25 million people have died of the disease since it was discovered in 1981. Thirty million are living with the disease. Most health research institutions including the Bill Gates Foundation accept that a vaccine on aids is beyond the capacities of a single country, a single team of scientists or a single institution.Yet funding encourages individual research, not concerted efforts.

At the same time, drug majors like Glaxo SmithKline and Merck have discovered vaccines for cervical cancer and market it aggressively in Europe and usa. Merck has marketed Gardasil aggressively, while Glaxo SmithKline has also been bellicose about Cervarix. Millions of girls have already been vaccinated in the US and Europe. And these vaccines have supporters among European and American doctors, even legislators.

Diane Harper, professor of medicine at Dartmouth Medical School in the US says, "Merck lobbied a variety of opinion makers, women's groups, medical professionals and created a sense of panic". In the US, hundreds of doctors were hired and trained to speak on Gardasil. They were paid US $4,500 for a single talk session. Harper who is an authority on vaccines said that the efficacy of these vaccines is still not proven. She said that the vaccine does not protect after three years in some cases.

Public health policy makers must ask "Has the investment on cervical cancer vaccine been worth it?" The US Food and Drug Administration took just six months to approve the vaccine. The agency usually takes three or four years to approve a vaccine. Once the patent period is over, there will be generic versions of this vaccine in Africa and South Asia--cervical cancer is not a lifestyle disease in most of the developing world. And it is quite likely that the already moribund primary health care system in the developing world will be forced to adopt the vaccine.

In recent years, there has been lot of scare in the US media on the measles vaccines. Papers like The New York Times have carried reports that many kids would turn autistic if vaccinated with the measles vaccine. One of the reports noted, "Most people had measles infection in the first seven months of this year than during any comparable period since 1996. In Britain, Switzerland, Israel, Italy, measles outbreaks have soared."

Global agencies like who and Unicef have been zealous advocates of measles vaccines as part of their child survival programmes. Now African or South Asian mothers are told "Beware of the measles vaccines. Your child might turn autistic". What is the credibility of our medical fraternity? What about the "public" in public health.

There are now question marks over the other vaccines, most notably the Rubella and Varicella vaccines. The Congenital Rubella Syndrome (crs) is now the latest scare babies in the womb can go blind, turn deaf or have mental impairment. Mothers in the US are told that crs cannot be detected by ultrasound, and the defects cannot be noted before the child is born. Is it not incumbent on public health professionals to get to the root of the matter?

It will be too much to expect drug companies to focus on the public. They, after all, are guided by profit. But then what about public health professionals? Is it too much to expect them not be swayed by the companies.

Manu N Kulakrni is at the Institute of Social Sciences, New Delhi

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