Health is a development issue

Delhi is in the grip of Dengue outbreak again. To date, over 800 cases and 2 deaths have been reported this year. People panic. The blame games do the rounds. Monsoon passes. Winter sets in to dry up the mosquito breeding sites. Cases come down. And it is forgotten. Come next year and the story repeats itself. 

Aren’t all seasonal diseases supposed to be that way? The worrying part is that Dengue and vector borne diseases like Malaria, Japanese Encephalitis, and Chikungunya (the sister diseases caused by the bite of mosquitoes) are preventable. Other seasonal diseases like Typhoid, Acute Diarrheal Diseases, and Influenza are also easily preventable diseases. Yet season after season, year after year, we are caught off guard. To a large extent, we ‘let nature take its course’ and we do too little to stop the cycle. 

Diagnostic facilities have become more refined, medicines have become better, and hospitals have become more equipped to handle complicated cases. But the result of improved health services has not resulted in a clear cut fall of prevalence and incidence of these diseases. The history of malaria control program in India is not a straight forward success story. The interesting thing about malaria is that this is a disease where cure was discovered before the cause. But in spite of the facts that the disease is thousands of years old, its pathology well understood, preventive measures are well known, diagnostic facility and treatment are freely and widely made available; yet it continues to be a major cause of morbidity and mortality. This is a very important observation for the main point of this article drawn below. Dengue follows urbanization, unplanned urbanization in particular. The Delhi experience illustrates that well. The posh colonies have pockets of slums where mosquitoes breed and the disease is spread to the surroundings. Construction sites, open ditches and water tanks, potholes, clogged drains, and other stagnant water bodies are the favorite breeding sites. Dengue vector mosquitoes breed in/near places where humans reside and therefore its preponderance to unplanned and overcrowded urban habitation. Japanese Encephalitis (JE) has more danger of going rural and affecting huge geographical areas like wet paddy fields. Also because of its attack on the nervous system and danger of permanent nervous system damage, the issues of timely diagnosis and management of complications are major concerns for JE. In all the three diseases, prevention measures are very similar and there is a good chance to control them that they cease to be a public health problem.

The problem of communicable diseases like malaria, dengue, and JE is not purely a medical problem. Medical technicalities of these diseases like pathogenesis, diagnosis, treatment, etc are not even the primary issues. In many of the developed countries, these diseases are not a public health problem; not because they have better medical facilities, but because the diseases are simply not common. There is no substantial number of cases or deaths. It is also not because the western people have developed immunity to these diseases because of their genetic make-up. The differences in prevalence and incidence are therefore not primarily medical. We have the disadvantage of living in the tropics where the climate suits the breeding of vectors. Other important differences are that we have little/no town planning whereas they have got it, our development roadmap is chaotic whereas they have fine blueprint; they have more civic sense and awareness than us, their health seeking behaviors are different from ours, and so on. 

Cliff Analogy. Source: internet

Prevention is better than cure. This is over-said but hardly done. Let’s make the line more dramatic with an analogy used in public health circles called the ‘cliff analogy’. There’s a spot from where people accidentally fall off the cliff. It is a common occurrence. So, what did the people do? They put an ambulance at the bottom of the cliff to pick those who fall so they can be brought to the hospital. That saved many lives but people continue to fall off and some people even lost their lives. To cut the analogy short, then it was decided to build a fence around the spot. This fence prevented the people from falling off the cliff. Building of the fence is symbolic of prevention of diseases before they occur (fell). One may go a step further to move people away from the spot at the edge of the cliff (which signify addressing social determinants of health). Preventive measures as you can see from the analogy are easier, cheaper, and more effective than the management of diseases after they occur. 

And so must prevention of diseases be an important component of development planning. While constructing buildings, roads, canals, dams, and drainage, whatever; health concerns must be a priority right from the planning process. In agriculture, economics, housing, etc. health concerns such as food security, poverty alleviation, healthy living conditions, etc must be taken into consideration. If health is a given priority in all of the development processes, many of our public health problems will be solved on their own. Health is a development issue. Medical service is only one of the many components necessary for good health.