I am reproducing another article by Dr K S Jacob from The Hindu dated 20th June. After reading this I have to ask myself "Are doctors promoting health in the community OR Are we just merchants selling health as a commodity ?". Please read on and give your comments

Public health and the clash of cultures

K.S. Jacob

The varied disciplines involved with public health, their divergent frameworks result in different agendas. The public-private partnerships are suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by powerful private players.

Health is now a major priority on the international agenda and is an imperative for development. Despite advances in some developing countries, much still needs to be achieved in many nations.Determinants of health: The relationship between poverty and disease had long been acknowledged by public health reformers. Progressive groups within the movement advocated reform and enlisted many inputs — political, financial, social, cultural, engineering, science, educational, religious, and legal in addition to medical — to be part of efforts to improve the health of populations. The convergence of these disciplines is necessary for improvements in the health of populations. The public health perspective, thus, draws on a variety of disciplines. Consequently, it is not a discipline in the traditional sense.
The different context of public health: The public health movement in India relies on medical models with urgency-driven curative medical solutions which have always been short-term fixes and have resulted in the postponement of permanent public health solutions. The easy availability of antibiotics and medication in the developing world mean that provision of clean water, improvements in sanitation, nutrition and housing, all of which are basic public health approaches, is always on the back burner.
Varied language, framework and cultures: The complex situation has resulted in poor public health systems. The multiple disciplines with their diverse ideology, frameworks and language have muddied the waters and have made progress slow. The medical fraternity and the pharmaceutical industry advocate the biomedical model with its preference for curative treatments. Their language includes symptoms, signs, investigations, diagnosis, medicines and treatment. On the other hand, financial institutions argue for and insist on the capitalistic model, which reflect their own concerns rather than those of population health. They view issues through a different set of idioms including economics, capital, collaterals, loans, interest, repayment schedules and penalties. The social science perspectives, major determinants of health, are often not considered key issues in actual practice and are marginalized. Political leaderships, with their short-term needs, prefer an electoral languag! e and immediate gains, with their focus on retaining power and addressing specific constituencies. Civil servants concentrate on planning, budgets, targets and manpower.The West brought about improvements in population health by providing a minimum standard of living for its citizens and yet insists that India focuses on specific problems rather than in improving the general public health infrastructure. Similarly, many international banks and aid agencies focus on curative heath care and side-step the fact that even minimal improvements in the health of populations are determined by social and economic factors and prefer to support vertical health programmes for particular diseases. Nevertheless, the absence of basic public health measures will ensure the persistence and re-emergence of the very diseases targeted (e.g. malaria, polio and tuberculosis). Politics and finance trump public health every time.
Shared objectives and divergent agendas: While many disciplines have public health as a goal and share public health objectives, their diverse backgrounds and models clearly support their divergent agendas. Financial institutions support initiatives which are profitable. For example, the provision of clean water and sanitation are much less profitable for the various actors involved, compared to the provision of medicines and vaccines. Despite several recent key reports which emphasize the dramatic health (and economic) benefits that can be gained from improvements in water and sanitation, such targets receive low priority in funding. On the other hand, vaccines (e.g. Haemophilus influenza B), which target diseases with much lower prevalence and that have much less impact on the health of populations, receive generous support.
Ownership and ability to deliver: Poor public health standards are a result of major problems related to ownership of the public health goal. The rise of the biomedical viewpoint over the last century has given medicine a much larger role in improving the health of populations than to its ability to deliver. With its focus on biology and drugs, it is not in any position to bring about the public health revolution necessary to have a significant impact on population health whose main determinants are social and economic. The other disciplines necessary to achieve the public health transformation do not take the lead as they lack a sense of ownership of the public health goal. The powerful perceptions and models within the constituent disciplines make public health professionals peripheral players. Public health needs to be a socio-political mass movement if any significant degree of success is to be achieved.
Basis of public health policy: Social justice and an egalitarian society are the essence of public health. The evidence base for medicine and policy are often used selectively to support specific models and frameworks. For example, while evidence is used to defend the introduction of vaccines for disease prevention, it is not employed to argue for interventions which use clean water, sanitation and nutrition which have a much greater impact on the health of populations. Similarly, the estimation of the global burden of disease, on which much of the arguments for funding are based, is controversial and is much less valuable in for use in developing countries as it does not reflect regional priorities.
Health and public health as a human right: The poor health status of populations is related to chronic poverty working through hunger, undernutrition, illiteracy, unsafe drinking water, social discrimination, physical insecurity and political exclusion. The promotion of health, and consequently of social and economic rights of the poor in India, is the most important human rights struggle of our times. While the west continues to focus on human rights in developing countries, the developed world refuses to acknowledge that public health is also a basic right and support its fulfilment. In fact, the failure to meet the public health needs of populations has become normalised across India and on the international stage. However, governments and international agencies often prefer to confine the debate to the issue of resources for medical treatment, as a means of deflecting the debate from the true social and economic causes of ill-health. The public health vision for the 21st! century needs new policies based on a human rights perspective to address the challenges of health needs of populations.
Possible direction: There is a need to differentiate public health as a discipline, a goal, an agenda, and as practice. The abuse of power among the many public health stakeholders and actors and its relationship to their financial clout needs careful review. The current public-private partnerships in public health in developing countries are more suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by the powerful private players. The conflicts of interest and differentials in power within groups working on public health initiatives and their different ideologies, agendas and tensions should be acknowledged.Public health should be located within society and politics rather than within medicine. The majority of the priority health conditions in India require public health solutions (e.g. water, sanitation, nutrition, housing, education, employment, social protection) rather than medical and pharmaceutical interventions. However, the mainstreaming and scaling up of efforts in these areas requires political commitment for inter-sectoral dialogue, an ethical framework which views public health as a human right and resource allocation which examine issues through the public health lens.There is a need for a people’s movement which champions public health issues as basic rights. The current supply-side and top-down approach to public health needs be replaced by a bottom-up approach with community mobilisation for meaningful changes to occur. The challenge is to integrate public health goals into the diverse disciplinary frameworks and models.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. This article is based on his paper published in a recent issue of the Journal of Epidemiology and Community Health published by the BMJ group.)