‘God’s own junkyard’.

Kerala’s crisis in public health

*CR Soman (IANS) (Hindustan Times)*

February 4, 2007

Kerala is on the brink of a public health crisis. The state, which sets an
example for the rest of India and third world countries in providing primary
health care, now gropes in the dark and is fast losing the edge. The great
achievements in the fields of mortality and fertility have reached a
plateau, the near universal immunisation coverage achieved in the nineties
has fallen in most districts.

The state is regularly visited by emerging outbreaks of leptospirosis,
dengue fever and other insect borne viral fevers; the latest entrant is
chickungunya. Natural ecology has been tampered with and the once-famous
backwaters of the state are polluted and weed infested. Waste disposal in
the municipalities and corporations still remains a formidable challenge.
Conventional methods like land fill evoke furious protests from local
inhabitants. Critics have re-christened ‘God’s Own Country’ as ‘God’s own
junkyard’.

The state health department is no longer the prime mover of health
development. With less than a third of physicians, beds and institutions
under the government, the state health services department is a mute
spectator to the rapid decay of health services, particularly primary
healthcare. Many primary health centres are unmanned. Drug procurement and
distribution systems are outmoded and complaints of drug unavailability
appear frequently in the media. The state-run medical colleges have no
longer bright young academics to work for. They opt for more lucrative
placement in the burgeoning private sector instead. Many super-specialty
departments face the threat of closure in the absence of new recruitments.

There are worse problems. Recent studies suggest that Kerala has the highest
burden of coronary heart disease, stroke, hypertension, diabetes and
over-nutrition. Conservative estimates put the number of people with
diabetes at three million; people with hypertension at 4.5 million and those
with overweight and obesity at 10 million.

Every year in Kerala, between 45,000 and 50,000 people die of heart attacks,
while stroke kills over 20,000. In comparison, the annual death toll from
HIV/AIDS is just over 200. But both the government and the people perceive
HIV control as a greater priority than lifestyle interventions aimed at
curbing the epidemic of non-communicable diseases.

It is the healthcare industry that benefits from this sordid state of
affairs in Kerala. Private hospitals offering sophisticated tertiary care
are mushrooming, even in villages. By-pass surgery and coronary artery
stenting are buzzwords familiar even to the children. One would be lucky if
an MRI scan is not ordered if you reach a physician with a headache. The
doctors prescribe laboratory tests even for minor ailments.

They may argue that a variety of investigation is necessary for complete
profiling of the disease in modern medical practice. According to the Indian
Medical Association, the doctor would be in trouble if the diagnosis goes
wrong. It argues that they practise defensive medicine. But defensive
against whom? Implied in this approach is the assumption that people,
individually and collectively, are enemies of the medical profession. The
IMA cites stories of attacks against doctors and increasing trend towards
litigation against hospitals to buttress their arguments.

These are convincing arguments for the naïve. The sad truth is such
arguments are alibis offered to mislead and misinform. The over-use of
technology and drugs is driven by greed – a greed that is fuelled and
perpetuated by an unholy nexus between doctors, the drug industry and the
diagnostic sector. Huge rewards are offered to the physicians for
prescribing expensive investigations. Anywhere between Rs 2000 and 2500 is
offered as commission for an MRI scan; 40 per cent of the fee levied from
laboratory investigations reach the doctor as commission.

Private hospitals make more money through over-investigating patients in
their own laboratories than from providing care to the patient. Profit at
any cost is the watchword. Doctors in the government sector also gain
through the nexus between the industry and the profession. The government
has made no attempt to regulate the healthcare industry, and often goes out
of the way to provide them with more concessions and soaps.

Naturally, the victims are common men. Falling sick has become a reason for
one to be pushed into debts. The Kerala Sasthra Sahithya Parishad’s (KSSP’s)
studies revealed that at least 15 per cent families spend over 30 per cent
of their income on healthcare alone. While private healthcare costs exceed
Rs 55 billion per annum, the government expenditure is falling steadily. The
government’s failure in providing affordable healthcare is likely to fuel
public anger. Hospitals and doctors are likely to be targets of public
attacks. Facilities for medical education are being auctioned off to the
highest bidders.

To complete undergraduate course in a private medical college requires Rs
3-5 million. Naturally, they would expect quick returns for the investment.
Fleecing the people would be the only choice! Those who get state-funded
medical education are only too eager to fly abroad. And those who choose to
stay home prefer to work in cities and towns, leaving primary health centres
unattended.

Medical care in the state has become dehumanised and privatised.
Commodifying healthcare – increasingly driven by profit – will demolish all
that the state had achieved in the health sector during the last decades of
the 20th century.

The big question is: will the present government, keen to articulate
people’s causes but principally concerned with factional feuds ever be able
to stem the rot and usher in rays of hope?

The future looks bleak for Kerala.

*(Dr CR Soman is a leading public health expert and a former professor at
the Thiruvananthapuram Medical College and also chairman of Health Action by
People, an NGO working in the field of public health. He can be contacted at
* *crsoman <crsoman@vsnl. com>@vsnl.com <crsoman@vsnl. com>)*