Imrana Qadeer

Critical perspectives on the NIMH initiative “Grand Challenges to Global Mental Health”.

Fleischhacker WW; and the EUFEST Study Group. Sexual dysfunction in first-episode schizophrenia patients: results from European First Episode Schizophrenia Trial. J Clin Psychopharmacol 2011 Jun;31(3):274-80. 4. Juruena MR, de Sena EP, de Oliveira IR. Safety and tolerability of antipsychotics: focus on amisulpride. Drug Healthc Patient Saf 2010;2:20511. 5. Balon R. SSRI-associated sexual dysfunction. Am J Psychiatry 2006 Sep;163(9):1504-9. 6. Stahl SM. Essential psychopharmacology. The prescriber’s guide. 1 South Asian Edition. New Delhi: Cambridge University Press; 2007. 7. American Psychological Association. Answers to your questions: For a better understanding of sexual orientation and homosexuality [Internet]. Available from http://www.apa.org/helpcenter/sexual-orientation.aspx [cited 2012 Mar 21]. 8. Kalra G. A psychiatrist’s role in “coming out” process: Context and controversies post-377. Indian J Psychiatry 2012 Jan-Mar;54; 54(1):6972.

“Antivaccine Lobby” replies to the BMJ

We are a group of paediatricians, healthcare activists, teachers in public health, and bureaucrats who have championed universal immunisation in India throughout our working lives, so we were taken aback at being called an “antivaccine lobby” in the BMJ .1 Studies funded by the World Health Organization show that the incidence of Haemophilus influenzae type b (Hib) in India is lower than projected.2 Furthermore, probe studies from Asia show that Hib vaccine does not significantly reduce the burden of disease compared with placebo.3 We discuss the anecdotal evidence and the farcical equity argument used to recommend the pentavalent vaccine (diphtheria, pertussis, tetanus, Hib, hepatitis B) in India4 in our rapid response,5 and concentrate here on the safety issue. Meta-analysis shows that the combined vaccine is not as effective as single vaccines administered separately6; therefore it is not used widely in the West, where reporting of adverse events is reliable. Pentavalent vaccine was withdrawn in Sri …

Medical tourism in India: perceptions of physicians in tertiary care hospitals.

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.

The challenge of building rural health services

The challenge of building rural health services, States responsibility in providing these and training paramedical personnel to carry out limited curative and preventive responsibilities were part of Indias development thinking before and after independence. The Sub-Committee on Health of the National Planning Committee of the Indian National Congress set up in 19381, the Gandhian Plan2, the Bombay Plan3, and the Peoples Plan4 of 1944 despite major differences in addressing the issue of economic growth and poverty, unanimously agreed on building rural health services. The Bhore Committee Report5 called for an integrated 3-tier health infrastructure to provide basic services for the rural areas. Reviewing past achievements, the Mudaliar Committee Report6 in 1962 offered financial options for building health services. Indias mixed economy attempted to accommodate a welfare policy that led to expansion of health service infrastructure, manpower and public sector drugs and instruments production units. The training of paramedics was a key activity through nursing, ANM and Basic Health Workers and Health Assistants training schools. After the Third Plan this emphasis got diluted. Investments in health services continuously declined and urban hospital based services got priority over the rural 3-tier system proposed by Bhore Committee. To contain the emerging dissatisfaction in rural areas, the State introduced the Minimum Needs Programme in the Fifth Five Year Plan (1974)7, the Community Health Workers Scheme in 1979, and expanded and restructured primary health Centre network adding Community Health Centres in the Sixth Five year Plan (1981)8. The acceptance of Alma Ata declaration of Comprehensive Primary Health Care in 19789, the National Rural Health Mission (NRHM) of 2005, training Accredited Social Health Activists (ASHAs) and now the proposal for a shorter training for rural practitioners, all were meant to strengthen rural infrastructure. The para-medics, however, remained neglected as a variety of male and female health workers were integrated into multi-purpose workers of both sexes in 197310 without much attention to improving the number and quality of training schools. Instead of an effective integrated manpower, capable of responding to the needs of rural areas the State created an army of ASHAs with limited skills to apparently provide full coverage. Absence of an effective infrastructure in rural areas and a medical education based on colonial vision of medicine that divided clinical medicine and public health failed to inspire doctors to work in PHCs though their numbers continued to rise as private medical schools expanded and further undermined public health component of medical education. Concentration in cities and out migration characterized this set of personnel. This paucity of personnel in rural areas created a huge gap between needs and availability of public sector providers. People depended upon private providers from different systems of healing such as AYUSH and folk medicine, and the fastest growing among these were the informal allopathic practitioners. This trend was more in the well off areas as compared to other relatively poor areas where profits are difficult in private practice. Was it wrong then to believe that adequate primary health care for all is possible? Or, did the system fail because the steps required by the policy for building rural health services were scuttled? The answer to this question lies not within the health service system, but in the larger developmental process. Since 1970s, the ongoing global collapse of the welfare States made them forego their political promises. They opted for structural adjustments that called for withdrawal of State investments in welfare, and its centrality in provisioning of welfare services. The Indian State too succumbed to this pressure informally over 1980s and formally in 1992. The State itself accepted its institutional inefficiency and inability to deliver services; corruption within and lack of managerial proficiency was assumed as incurable and all these were used to cover up the structural distortions introduced over the years. Private sector as an alternative became the State favourite at its own cost, leading to significant shifts of subsidies from public to private sector. The evidence often showed their anti-poor inclination such as failure of olymeriza private tertiary care institutions to provide free care to the poor in 10 per cent of their indoor beds and 25 per cent of the OPD patients11. Health Sector Reforms further transformed this sector into an industry which is expanding at 12 per cent CGPA (cumulative growth per annum) since 2008 and its market is poised to gross Rs.1.3 trillion in revenue by 202012. According to investment Commission of India, the Confederation of India and the consultant firm Mc Kinsey, the main sources of this growth are hospitals, nursing homes, medical equipments, laboratories and upcoming specialities such as aesthetics and weight loss, health insurance, medical tourism and expanding private medical education13. In the process, the very nature of definitions of primary health care and public health changed. From ‘comprehensive’ primary health care the policy makers moved to ‘selective′, and then ‘primary level’ and latter ‘essential’ care thus, fragmenting content and delinking levels. The tertiary institutions were absolved of the responsibility to support the secondary institutions and were free to become a part of the global health market. Market forces and availability of technology and not epidemiological priorities regulated them. This led to a schism in services, urban hi-tech curative, and rural ill staffed, ill equipped institutions dependent on ASHAs and AWWs for community work. The focus of rural services narrowed down to population control, maternal and child health and a few disease control programmes14 while the medical market penetrated it through first referral private institutions for curative care, private practice by government personnel and other forms of public private partnerships. Today, the rural health service is characterized by its inadequacy and poor utilization. The NRHM, that was to change this reality, apart from provisioning of materials and finances, has actually delinked primary from the tertiary level, focused on private partners for first level and secondary referrals and use of contract workers15 rather than developing manpower specially paramedics. The new cadre of ASHAs in absence of this support remains necessary but not sufficient as is evident from the current Annual Health Survey of the Office of the Registrar General of India16. ASHA under the “Janani Suraksha Yojana” can take the woman to the PHC but cannot impact maternal and infant mortality in majority of the high priority States. The rural elite are moving to urban medical markets and 65 per cent of rural population uses Indian systems of medicine17. An empiricist, a-historical analysis of the situation can at best show us the present pattern of preferences but it does not show us why these preferences are as they are. If people use private services because, these are ‘close at hand, better or cheap for basic needs’ then, should we be pragmatic and use their actions to accept the status quo or should we explore it further? This is the dilemma for Gautham et al18 in this issue. There are problems with their choice. Public health teaches us to olymeri death and suffering not only as an end in itself but also as one of its various tools, that when used judiciously, changes the epidemiological history of diseases and becomes the experiential basis for olymeriza peoples participation in disease control strategies. A balanced curative and preventive strategy is then its essence and not only basic clinical services. Should it not be possible for trained paramedics, part of the public health team, to provide that basic care which the informal private practitioners are providing- many of whom are from the government health services? The notion of ‘basic diseases of the poor’ too needs to be shed off as they bear the brunt of common and uncommon diseases and their complications due to the delays in treatment and neglect and therefore, deserve more attention! One, therefore, needs to ask where do local practitioners send their patients when they cannot handle them? The solution to the challenge of handling rural health needs lies in strengthening the public sector rural infrastructure as a whole including primary, secondary and tertiary referral facilities and integrating national disease control programmes and not in accepting the informal practitioners as permanent solution or equipping primary rural institutions without adequate support from secondary and tertiary levels. This calls for restructuring NRHM. To use peoples health olymeri as justification of status quo in a context ridden with constraints, promotes the interests of the medical market ignoring the needs of the rural population. If the people in rural areas are not impressed by the NRHM and yet seek modern medicine in private sector then, is it not our professional responsibility to search for the cause of this contradiction and examine the constraints of their context rather than accept the obvious structural and functional flaws? In building a comprehensive rural health service, linking up private providers with primary institutions may be the first step in the alternative strategy but that strategy must evolve out of an analysis of the subverted policies and not pragmatism that overlooks the undermining of the principles of public health planning.

Universal health care in India: Panacea for whom?

This paper examines the current notion of universal health care (UHC) in key legal and policy documents and argues that the recommendations for UHC in these entail further abdication of the States responsibility in health care with the emphasis shifting from public provisioning of services to merely ensuring universal access to services. Acts of commission (recommendations for public private partnership [PPPs], definition and provision of an essential health package to vulnerable populations to ensure universal access to care) and omission (silence maintained on tertiary care) will eventually strengthen the private and corporate sector at the cost of the public health care services and access to care for the marginalized. Thus, the current UHC strategy uses equity as a tool for promoting the private sector in medical care rather than health for all.

Words, Ideas and Ideology in the Shifting Sand of Markets

The transformation of existing knowledge or production of new knowledge is the focus of this article. This theme is explored using women’s health, actions and perceptions, and their interpretations—within a public health perspective—as these evolve around the currently most talked about high-tech obstetric intervention—the practice of surrogacy. The interpretations of words such as production, reproduction, labour and work are central to the present understanding of surrogacy in different societies. At a point in time when social sciences are striving to understand complexities, interconnections and praxis, this article offers a possibility of judicious use of technology and a glimpse, however brief, of man’s natural essence—humanness—the cementing factor in the alternate structure of society waiting to overcome the present conflict between the global hegemonic and democratic forces. The article argues that in contemporary India, the sections where surrogates come from see surrogacy in different ways, and that has to be the starting point for analysis but not the end. Indian law-makers take advantage of this confusion about the nature of surrogacy. It buries the non-exploitative potential of procreation under the ‘compensation for agreeing’ to be a surrogate, denies her rights and undermines the value of gestational motherhood as compared to genetic identity—thus, killing several birds with one stone!

India's feeding programmes and their relevance.

Abstract In the course of any discussion on problems of food production and hunger in the Third World it is not unusual to come across a heavy emphasis on the cultural backwardness and traditional outlook of the common people. A study of the Indian situation, however, shows that the more important issues lie within the sphere of planning and policy making. It is not traditionalism but the intensive area development model and the resultant inequality which is primarily responsible for the nutrition problems of the majority of the population. The paper here examines in some detail one aspect of the nutrition policy; the nutrition distribution programmes in the context of the total developmental strategy. Indias nutrition programmes were meant to ameliorate hunger and malnutrition among the vulnerable section. But the existing socio-economic and political structure of the society has so affected the formulation and implementation of these programmes that they have practically become irrelevant. The inadequacy of resources, the inefficiency of the delivery services and the maldistribution of the available resources, weighted in favour of the richer section, combine to make ineffective all welfare programmes for the poor. Further, the herding of the heterogeneous programmes under an all-India nutrition policy deprives the national policy of a uniform conceptual basis and, therefore, undermines its rationality. In their present form the nutrition programmes lack an epidemiological perspective. They are not effectively integrated with the health services of the country. Their coverage of the vulnerable groups has no scientific basis and is most inadequate. An examination of these issues shows that any serious attempt at planning feeding programmes must take note of the available infrastructure which at present is not only inadequate but also ineffective insofar as the objective of reaching the poor is concerned. Secondly, if an integrated programme has to be offered, then nutrition programmes must find their place in the list of the health priorities and only when their impact and feasibility are. demonstrated effectively within the available infrastructure should they become a part of the package. Thirdly, it is worth keeping in mind that even if feasible nutrition programmes are evolved they can only function as temporary relief measures for a small number of people. A lasting improvement in the nutritional status of the vast majority is a function of their productive capacity and hence of their socio-economic development which must simultaneously occur and form the backbone of any nutritional policy.

Monica Das Gupta, Lincoln C. Chen and T.N. Krishnan (eds.), Women's Health in India: Risk and Vulnerability. Delhi: Oxford University Press, 1995. 320 pages. Rs. 395

This volume is based on a seminar organised by the National Council of Applied Economic Research, New Delhi, and the Centre for Population and Development Studies, Harvard. It contains 11 articles authored by researchers from various social science disciplines. Though the editors highlight the importance of social and familial pressures that constrict women within patriarchal societies, the actual exploration of this complex societal dynamic at various levels is rather uneven. This is perhaps because of the use of a perspective highly inclined towards an isolated biological view of health itself. The book attempts to explore women’s health within a life-cycle perspective. It highlights their powerlessness in patriarchal families at points when they are biologically and socially more vulnerable. Thus, early childhood, adolescence, the reproductive years and old age are treated as the critical points in the life-cycle. As a result, adverse health outcomes, especially in the area of reproductive health, mortality rates and sex differentials become the main concerns for most authors, even though the title of the book leads one to expect that the entire gamut of health issues is being addressed. A project on health conducted by social scientists could have provided deeper insights into the social dynamics of health. Instead, many of the authors have chosen to examine the much talked about demographic dimensions, reproductive health and health service scenarios without exploring adequately the social basis of these. An analysis of these larger socio-economic factors has been attempted only in a few of the contributions.