Modern Healthcare versus Public Opinion

My neighbors in a village in North Goa, on the west coast of India, where I now live, told me that over twenty-five years ago (around 1987), the Health Department of the State introduced little black fish (guppies?) into the open rainwater drains that ran parallel to the newly made tarred roads. The local teacher (respectfully called ‘Master’) explained that the fish were meant “to eat the malaria causing mosquito larvae”.

Apparently, the larvivores did their job, grew plump and multiplied rapidly. The poor who lived near the drain swished nets through the water and transferred whichever unlucky creatures got trapped into wicker baskets. These (creatures, not baskets) were then fried or curried for the next meal. True or not, the story is probable.

Malaria, whether once imported through migrant labour or tourists, continues to flourish.

A nurse in the hospital where I worked believed that ‘enemies’ of India were pasting “mosquito-attracting chemicals” on bus-stops to bring down the population through malarial deaths. There were many who believed her, who thought this ‘nonsense’ about stagnant water was political propaganda. They also believed papaya-leaves worked wonders, medicines didn’t. In times of epidemic, superstition reigns.

People say there was not so much typhoid/tuberculosis/diabetes until the ‘others’ came to settle. The increase in garbage, unmanaged sewage, pollution of water-bodies, change in food habits and poor hygiene is not considered of consequence. Because primary level education hasn’t been effective. Public healthcare and literacy are linked through posters and textbook morals, but active, personal involvement of the public is nil.

A large number of Indians still believe sickness happens due to bad luck or past-life ‘karma’: natural pregnancies are successful or aborted god-willing. Ironically, IVF and ‘surrogate pregnancies’ are flourishing; maybe one of our many, many gods planted that technology on the planet to help the childless to experience parenthood and gynecologists to experience entrepreneurship.

Few doctors and patients begin a treatment without the breaking of a coconut, bowing to a deity or chanting an auspicious prayer. Getting science into mainstream lifestyles is difficult. Developing a scientific temper, building a curious attitude, using commonsense, is more difficult. That diseases in certain homes/villages/districts/states are preventable is an idea that needs aggressive ‘marketing’ to all stakeholders.

Across the Arabian Sea, neighbouring Pakistan has a problem dealing with polio; there is a sect of Muslims there who believes giving polio-drops is anti-religion. Dialogue, therefore, is as important as statistics if public health policies are to be enforced.

In a Navhind Times’ 21 Oct, 2014, news report, Goa’s Health Department said that when the Annual Parasitic Incidence (API) drops below 1 case per 1000 persons, it can be considered a preelimination stage. In 2013, the API had hovered around 1.8. Three years later, in spite of larvicidal methods being used around the state, the statistics haven’t changed much. It’s hard to believe statistics, too, because, in spite of regular government-sponsored advertisements on radio/television telling people to take fevers seriously (for tuberculosis, dengue and malaria), people don’t always do. “It’s only a fever” doesn’t get reported. Quite often, even the causes of deaths-at-home are not known. Only cases that are recorded in hospitals are counted. Responsible private hospitals sincerely inform the government agencies as they’re meant to when they get a patient with a communicable disease like leptospiroris. A large number of hospitals aren’t responsible.

It might be a good idea to bring into the loop priests who conduct death ceremonies, for they have the ear of the populace. But, though they can easily access information on death due to disease, which makes them an important resource, they’re not included in any healthrelated projects.

Ancient medical literature has mentioned many ‘public health’ diseases in the Atharva Veda and the Charaka Samhita. Malaria is one example, leprosy, tuberculosis and diabetes being others.

At the time of Independence in 1947, of India’s approximately 330 million people, 75 million were estimated to be infected with malaria annually. In 1953, the Govt. of India launched the National Malaria Control Programme. By 1958, the malaria cases dropped to 2 million and by 1961 to a little less than 50,000, with no recorded deaths. In the ‘70s, there was an upsurge. The National Malaria Eradication Programme recorded 6.45 million cases in 1976. The Urban Malaria Scheme was implemented in 1971-’72. The Modified Plan of Operation in 1977 improved the situation for half a decade. But the impact was on vivax malaria. Then came the P. falciparum Containment Program. Successive five year plans couldn’t slow the malarias down: forest malaria, urban malaria, rural malaria, industrial, and border and migration malaria. Vectors became immune to insecticides. And people stopped trusting drugs.

In India, alongside allopathy, people try other streams of medicine, like homeopathy, Ayurveda and unani.

Diseases like small-pox, chicken-pox and measles are believed to be acquired because someone in the family displeased certain goddesses. Temples dedicated to these goddesses flourish, especially in the neighborhoods of obstetric/pediatric hospitals. Or maybe the hospitals were built there because those temples were good catchment spots. If public healthcare programs are to work in conjunction with modern medical methods, local ‘quacks’ who have the trust of the community must be roped in to contribute in some way. Like the midwives who are now trained by the government, these can have a role to play.

Then we have the major embarrassments: leprosy and tuberculosis still carry stigma. A patient is considered untouchable. The disease is considered a punishment for some ‘paap’ (sin) committed in a past life. The person is expected to suffer to ‘erase’ it, to atone for whatever crime he’d committed in another life. They are also considered to be income-related ailments: only the poor get them, the rich hide their distress well. Distribution of free medicines doesn’t rid the community of beliefs. Observing people recover, spreading the word of their recovery, getting moral reinforcement from mothers-in-law and other elders of the village/family… that is important. Again, no public health program includes them.

In old civilizations that are today impoverished, a sense of honour, a clinging to tradition is important. To shake it, to challenge it, results in defiance. Many public health programs fail when the people targeted don’t co-operate. But sustained education works. Small-pox inoculation was compulsory for three or four generations. Polio- Sundays are carefully and systematically followed all over India. MMR vaccines are easily and cheaply available. Drugs for the treatments of HIV and HCV are distributed and counseling given alongside. Slowly, the word about how ‘the needle’ helps curb illness has spread, and today, the unschooled woman who works as a maid in my house tells me that the nature-cures are a waste of money, it’s better to save and invest in ‘proper’ medicines bought from a chemist. And yet, when someone came around the other day talking about oral/dental hygiene, she balked. She said: “He thinks he knows too much.” Her family refused to even try his products. The man displaying the virtues of the toothpaste could have learned his marketing lessons from the plastictoys seller at the bus-stand: be heard, be interesting, hold the audience’s attention and make sure you’re accessible even after your little drama is over. Reach out multiple times. Then wait and let the people come to you. Crowds attract crowds. Get some of your friends to stand around. Get them to voice their opinions.

Marketing tactics work beautifully in public health programs. The government needs to realize that by forcing ideas down people’s throats, public health programs flop. By cajoling and convincing, they work beautifully. Maybe it could do a pilot project for an existing program: the anti-rabies’ one or the one on being a responsible driver on Indian roads. Que sera, sera.