MAN’s capacity for industrial production had multiplied manifold during the Industrial Revolution of the last century, and now the Scientific Revolution we have embarked upon promises to take it to unimaginable heights. Inexhaustible sources of energy are at our disposal: we can obtain the raw materials we desire in almost unlimited quantities and even make them; and automation, besides enhancing man’s capacity, lightens his toil and releases him from the tyranny of monotonous labour. Agricultural production also is capable of tremendous increase.

All this knowledge is there. We can share it and add to it if we will. Our government has taken up the task of developing our resources under the five year plans of development. Today, there is no reason for our people to remain poor, miserable and backward. In fact, if they remain so, they cannot put to use the new scientific knowledge, since the development of resources is achieved by the labour of man, all men for the benefit of man, and all men.

Man is the central figure of all our efforts. Thus the health of our people becomes a factor of prime importance, both to enable them to contribute their best to the common effort of development and a enjoy the fruits of that labour.

These are the demands of the situation, but the health of our people is far from satisfactory. The death rate is 14 per thousand, almost double that of advanced countries. Infant mortality is 108¹ per thousand live births, which is almost five times the figure for developed countries. Nearly 40 per cent of the children die before they attain the age of ten. Maternal mortality, though it has dropped considerably in urban areas, is still over 150,000 a year.

Expectation of life, which is a good measure of the state of the health of a people, is 32 years, i.e., less than half the expectation of life in advanced countries. Worse still, even this short span of life is crippled by ill health.

This high toll of life and ill health is largely due to infectious diseases which are in the main controllable and have been controlled elsewhere. The incidence of gastro-intestinal diseases and respiratory infections cause an enormous number of deaths among children. Malaria used to sicken one hundred million individuals of all ages and kill about two million a year. Fortunately, the anti-malarial campaign conducted by the government has proved effective and brought down this figure to less than one-tenth. A still further improvement is expected.

 

Tuberculosis is another killer; about half a million to one million die of it every year, and it is variously estimated that two and a half to ten millions suffer from this disease. Filaria, leprosy, venereal diseases and trachoma cause prolonged ill health. Cholera flares up now and then, somewhere or other, and even though better controlled, it still takes a heavy toll of life. Small pox, which should have disappeared by now, is still a factor to be reckoned with. Plague, a controllable disease, is quiescent at present, but can flare up again unless we take proper preventive steps.

These infectious diseases have a high incidence in our country largely because the body resistance of our people is at a very low level owing to defective and inadequate nutrition. This matter requires our immediate and most urgent attention if we are successfully to meet our health problem. One cannot help recalling the old axiom ‘eat good food even if you have to live in filth.’

We are all aware of the fact that we have not managed to produce even sufficient quantities of cereals of meet the energy requirements of 2,700 calories per man per day; at the moment our people on an average get less than 2,000 calories. But, of course, the problem is much bigger than merely providing energy requirements. Diet, to be able to raise the resistance of the body against disease and to maintain optimal physical well-being, must be well-balanced. It must provide adequate quantities of body-building proteins, minerals and protective substances such as vitamins, besides meeting the necessary energy requirements. This demands a large increase in the production of milk, vegetables, eggs and fruit.

Most of our people live in lamentably unsanitary conditions surrounded by filth of dirt and plagued by disease-carrying germs and insects. They lack supplies of clean drinking water. Thus environmental hygiene assumes a very high place in our efforts to solve the health problem of our people. Reasonably accurate surveys of living conditions, both in rural and urban areas, should be conducted and targets fixed for improving conditions.

 

Given adequate nutrition and reasonably sanitary environments, control of infectious diseases which take such a toll of life in our country becomes a comparatively easy matter. Medicine has made great advances during the last 80 years, particularly so during the last 25 years, and has placed man in a position to conquer infectious diseases of all types. This has been largely achieved by the discovery of antibiotics, specific drugs and insecticides. We only need a suitable organization and the material means to put these to use.

As regards organization, the most important factor is medical personnel and adequate facilities for its work everywhere. Our country is hopelessly short of trained physicians. It is estimated that we had 70,000 doctors at the beginning of our second five year plan, and that we would train, during the plan period, another 12,500 doctors, making a total of 82,500 doctors, that is one doctor for about 5,000 of our population. These figures, however, can be misleading because all the qualified doctors are not engaged by the state. The majority of them are free to settle wherever they choose. The result is that 85 per cent of them practice in urban areas where only 18 per cent of the population resides.

 

The rural areas with a population of 82 per cent are left with only 15 per cent of doctors, i.e. one doctor for every 25,000 people. Certain improvements have taken place due to the organization of primary health centres in development blocks, but the position is still far from satisfactory. Advanced countries like the USSR, the USA and the United Kingdom, in order to provide adequate medical facilities, have one doctor per 610 persons, 770 persons and 950 persons, respectively.

When we come to institutional facilities for rendering medical aid, the information available is as confusing. In fact, the twenty-one pages of the second five year plan devoted to ‘health’ tend to gloss over our shortcomings rather than to inform and plan. It is stated that in 1947 there was one medical institution, such as a hospital or dispensary, to cater to the needs of 30,000 to 50,000 people. In 1951, 8,600 medical institutes had 123,000 beds. During the second plan the number of institutes will increase to 12,600 with 155,000 beds.

Evidently these institutes are situated in urban areas because it is stated later ‘that the establishment of primary health units in as many development blocks as possible is a necessary step towards providing an integrated, preventive and curative medical service in rural areas.’ But it is added that ‘the population of an average development block is too large to be catered for by the proposed health unit staff.’ We are not informed how the problem will be tackled. However, 155,000 beds for 385 million people works out at four beds for 10,000 of the population.

The auxiliary medical personnel – nurses, midwives and dais, etc. – is as woefully short as doctors, and this personnel is also largely employed in urban areas.

 

Even the World Medical Association, which has fought tooth and nail for private practice, has now come to the conclusion ‘that the effective promotion of health and adequate provision of medical and material aid for the sick and their families is an essential feature of any well-ordered community. Whether this be provided by the state or by efficient private enterprise seems largely irrelevant and a matter that can be left to the inclination of each nation. The essential thing is that it should be provided.’ This is a vital issue. Can we possibly conceive that in our poor and under-developed country the medical needs of the people can be met through the sale of medical aid by private enterprise? Will the quality of medical aid be in proportion to the capacity to pay rather than to the need of the patient?

The interest of doctors must also be kept in view. They need well-planned, well-equipped and well-run institutes to work in, and a living wage. Can all these requirements be met other than by the state assuming the responsibility to provide medical aid at its best to all people as quickly as possible? We need to understand the problem, assess its size and plan with definite targets.

If the benefits of modern scientific medicine are to reach the people, urgently needed drugs must be freely available. Medicine has made phenomenal advances in therapeutics during the last forty years or so; antibiotics and a number of specific remedies have given man mastery over most diseases which are fatal to children and young adults. But all these drugs are still imported from abroad, and because of high profits and high costs of manufacture, are beyond the reach of our people, or at least of those who need them most.

Many of these health-giving drugs could be made in the country at one-tenth of their imported price, and all the rest at much lower cost than their present selling price. If the state undertook their manufacture, it might be able to supply them at cost price or even free. This issue is also intimately linked up with the provision of free medical aid by the state.

 

There is still the problem of the ayurvedic system of medicine which needs our immediate and careful attention. If it is not resolved rationally, and is allowed to be made into a political issue, it will distort our medical organizations and will harm the health of our people. It must be clearly understood that there is no ayurvedic system as distinct from any other system of medicine in the same way as there are no two systems of chemistry or any other science. There is only one science of medicine in the broadest sense of the term.

What comes to us from our past is medicine tried and tested by experience. This should now be tested by scientific methods and brought into use if found valuable. Science does not debar the use of any remedy or measure which is found to be valuable. But to deprive our people the benefit of modern wonder drugs, such as antibiotics, hormones and vitamins, would be both inhuman and tragic.

It is untrue to say that people demand ayurvedic treatment; all that they want is effective treatment which is within their means. The answer to this demand is not cheap and ineffective remedies, but cheap effective remedies. Our problem is to discuss how best these can be found.

 

* Originally titled ‘The problem’ in The Fight for Health, Seminar 12, August 1960, pp. 12-14.

 

Footnote:

1. Vital statistical figures are hard to come by because the Health Departments are behind schedule in publishing them.