Health Care for All

Former Prime Minister I.K. Gujrat, in his address to the 1998 Science Congress at Hyderabad, made a revealing remark on the state of our basic amenities. ‘I see before me the bottled water kept for the dignitaries on the dais. It reminds me of three classes of Indians: one who can afford bottled water; others who manage to get some water in their taps or in a nearby tap or a pump irrespective of its quality or regularity of supply; the third set of Indians are those for whom drinking water is a daily problem and who will be ready to drink any polluted water.’ For such a situation to persist after fifty years of independence was a national shame, he added. Unfortunately, if we do not do enough on this front, and the related one of health care, ten years down the road we might still be saying the same thing.

In the ultimate analysis, any society will be judged by its ability to provide universal health care for its people. This does not merely entail the ability to treat diseases and ailments but also to prevent their onset by means of suitable systems and measures. We are aware that not all diseases are entirely preventable. For example, we do not fully know what causes cancer, or diabetics. We do not have cures for many genetic disorders. Permanent cures may not be possible even for many allergies and respiratory problems such as asthma. However, through regular medication and precautionary measures, most patient can lead normal lives.

Disease Prevention

Most communicable diseases, however, can be prevented by suitable sanitation systems, control of disease –spreading materials (such as foul water) or vectors (like mosquitoes), and by immunization programmes carried out on a large scale. A number of diseases can be controlled by paying adequate attention to nutrition and dietary supplements. For example, the use of iodized salt can prevent goiter, which is rampant in many part of the country. The intake of vitamin a can prevent blindness. Globally, 25 per cent of blind and visually handicapped persons are in India! And, or course, among people who can afford it, a balanced food  intake and physical exercise can help prevent several forms of heart disease.

The rich at least have access to information about health-related issues in many ways: through journals and magazines, discussions with others an visits to doctors and medical specialists. That is not the case with may lower-income groups and poorer people. There is a total absence of health income education among these sections. And even if they want of them cannot afford a visit to a doctor, or afford regular medication` when it is urgently required. More often that not, they end up relying on quacks. Barring a small percentage, most primary health care (PHC) centers do not provide any tangible health care to people. There are many reasons for this: irregular and limited supply of medicines, not enough doctors or paramedical staff, and callous and apathetic medical staff, the leverage of influential local individuals, the excessively bureaucratic operation of the system. Despite all this it is creditable that the death rate in India has come down 9 (per thousand) in 1995 as compared to 14.9 in 1971.

Sanitation

Proper drainage of dirty water, disposal of garbage, sewage and human and industrial wastes are crucial for a clean microenvironment, which is a prerequisite for preventive health care. We have simply to visit the slums of Mumbai or Delhi to witness the urgency of such measures. Even in rural India, most women have to wait until it is dark so that they can relieve themselves in the open. The fifth in these places renders them rife with diseases.

My co-author Y.S. Rajan narrates his experience with a Department of Science and Technology project at Mumbai for setting up a big plant for garbage processing and installation of simple latrines in slums. The latrines had about ten modules built around a central pillar. To decide on their location, Rajan visited many slums in Mumbai. An incredible amount of putrid water collected and stood for days around the huts even when it was not raining. Added to this dirty water and excreta were various other forms of garbage thrown out by the slum dwellers. How could they and their children be expected of their attitude towards keeping general public conveniences like latrines clean? Many poverty removal schemes are not applicable to the Mumbai slums because the earnings of the people who live there are above the poverty line! They may earn more than they would back in the village. They have better clothes and more food. But the appalling sanitary conditions negate all other aspects of progress. A similar situation exists in most big cities. The response of elite Indians is to remove the slums from view and send the occupants many kilometers away. Or simply to ignore them by building high walls to block these dirty areas from sight!

Drinking Water

A recent event demonstrated how technology can assist in meeting drinking water needs. One of the DRDO laboratories at Jodhur has developed an electrohydrolysis or desalination process that is used to convert salty brackish water into potable water. Many districts of Rajasthan have brackish water. A similar situation prevails ins several  districts of Tamil Nadu and Gujarat. The technology developed by DRDO labs was promoted by the Department of Rural Development (DRD) and the Government of Rajasthan. Two desalination plants of 20000 and 40000 litres respectively have been installed and production has commenced. More than 100 villages now have potable water. I found the villagers jubilant when I went to inaugurate one of the desalination plants. This example is replicable in many parts of the country.

Health for all

Better sanitary conditions and an improved micro-environment in the habitat or workplace are the most important requirements for health. In the coming years we also need to pay attention to the working conditions within factors as well as open workplaces, be they coalmines, quarries or roads. Removing health hazards to which our people are exposed is a crucial national mission. It is not enough to consider ‘global quality levels’ of living or working places only for the well-to-do. Ordinary Indians too deserve and have a right to live and to work in a good environment.

After a good and clean environment comes the need for better nutrition, with necessary food supplements. Preventive healthcare systems- inoculation, vaccination, immunization, periodic health checks and medical treatment are the next steps. These should be made available and affordable to all Indians. Employers, Central, state and local governments should bear the responsibility to assure people of this health security cover. But how is this to be implemented?

It is true that public health services are under severe strain. There is also a tendency towards the commercialization of medical services, which by itself is not bad if there are countervailing insurance or social security covers that make them affordable for most. Nevertheless, there are also a number of bright spots. Many medical professionals who run expensive medical care systems to cater to the needs and fancies of the affluent, also subsidize the weaker sections by providing them with good services. The authors have seen such philanthropy being practiced at the L.V. Prasad eye Institute at Hyderabad. Those who are well off pay for their treatment while those who register themselves under the category ‘not affordable’ receive free treatment. Some of these private initiatives ar every efficient and humane. There are also many NGOs and a number of local initiatives that work well. Even the doctors and the staff in many government run medical centers have a number of local initiatives that work well. Even the doctors and the staff in ideas to make the existing systems functional and service oriented. There are also a number of systems using alternate and holistic medicine which are promoted by well-trained specialists; some of these can bring down the costs of running the general health care system. Given all this, we do not believe that India cannot take up the challenge of ‘health for all’. We  can make the systems work; we can change them to help people, despite the growth of the population and multiple challenges in the task of removing poverty and accelerating economic growth

It is with this firma and considered  belief that we describe some facts about the projected scenario of diseases and disabilities and describe how to combat the problems.

Towards the vision: the two Indias

Soon we will have one billion Indians. A few tests of millions of them have lifestyles equivalent to or even more luxurious than the upper strate of the developed world. They enjoy the material wealth and the facilities offered by the modern technologies, and simultaneously enjoy the benefits of cheap labour. Another 200- to 300 million Indians, the so-called middle cast, have a varied lifestyle, often aspiring to copy the developed world but having only limited resources. They face the stress of modern life but often do not have the facilities for good living. The rest of the population is engaged in jobs which leave it confronted with constant insecurity about making ends meet. This majority does not have economic surplus and has just enough for covering its bare necessities. Investment in health care is an impossible luxury.

A TIFAC survey of the future scenario of Indian epidemiology as perceived by medical practitioners reflects this reality. India would have the diseases of the developing world many communicable and infectious diseases –as well as the diseases of the developed world!.

Among the infectious, maternal, perinatal and nutritional diseases, tuberculosis (TB) is perceived as the one requiring top priority in the short term till the turn of the century; followed by AIDS, vector borne diseases, and diarrhoea. Then come nutritional diseases, hepatitis, diseases related to pregnancy and childbirth, diseases preventable by vaccination, acute respiratory infections, prenatal disorders, leprosy and sexually transmitted diseases.

Experts also indicate that the application of new developments in technologies could substantially reduce the incidence of these diseases by the year 2020. even by 2010, we can substantially reduce the ‘diseases of the developing country’, except for AIDS, provided we act immediately.

Non-communicable diseases such as ischaemic heart diseases, strokes and female cancers are perceived to be of major concern in the short run, while these are likely to decline considerably by 2020. the decline is expected to be much faster for female cancers, which is particularly good news for a country which still has an adverse sex ration for females. However, experts also envisage an increase in suicides and homicides, as also psychiatric disorders and accidents, making these areas of high priority.

Even as India would struggle to eradicate the diseases born of poor living conditions and poverty, some of the stress typical of modern developed countries is expected to increase. Is this something which can be prevented by reorienting ourselves as we make progress? Can some elements of our cultural heritage and simple living be retained to prevent or avoid some of this stress? Or, as some cynics would say, is it that our simple living and emphasis on values is only a manifestation of our poverty rather than an affirmation of a fundamental conviction in austerity?

Immediate steps for the new vision

One thing is definitely clear- halting the spread of TB, AIDS, diarrhoea, etc. must become a priority. Our vision should be to eradicate. Before or by 2020, the infectious, maternal, perinatal and nutritional diseases. The action plan can be simple and effective. Let us look at some examples.

Experts opine that the information on TB mortality is quite sketchy, despite the considerable number of epidemiological studies on the disease. There is an immense need to develop a reliable TB database.

At present, polyvalent BCG vaccine, which is vulnerable to interference caused by non tuberculosis mycobacteria, is used. An effective vaccine for the prevention of tuberculosis must become a priority. Monoclonal BCG vaccination and the identification of specific clones for development of more efficient vaccines are some of the preventive technologies that have been identified. Guidelines for identifying high-risk individuals and protocols for chemoprophylaxis also need to be developed. Health education programmed need to be undertaken for specific target groups. Many NGOs and youth organizations can be fruitfully utilized to fulfil major life-saving missions. The television and film media could also be tapped to spread the message, and there could be corporate sponsorship for such programmes. In the awareness compaign. Let us also invoke some of the fears raised by the recent ‘Surat plaque’. Let us make all Indians aware that TB is not a disease confined to the lower classes.

TB is diagnosed by screening for specific symptoms of the disease and by sputum microscopy for acid-fast bacillus. Culture facilities facilitating detection of the disease are available only at specialized institutions. The diagnostic tools of endoscopy and bronchography are available only in tertiary hospitals. Rifamycin, the mainstay in short-course chemotherapy, is produced indigenously but is quite expensive. Some of the future technological requirements for TB diagnosis and treatment are R & D investment for developing Elisa kits and cost-effective process technology for producing rifamycin, immunoassay of mycobacterial antigens, water –soluble dyes for bronchoscopy and bronchography.

Similarly AIDS another major killer, would need to be tackled frontally. Fortunately, there is a much greater awareness campaign for AIDS than for TB. To date, a vaccine to prevent HIV infection has not been found, though clinical trials have started. AZT is the only drug currently in use to inhibit the replication of HIV. It inhibits the enzyme reverse transcriptase and thereby the viral genome. However, viral mutations lead to drug resistance within twelve to eighteen months. This occurs when AZT is used in combination with other drugs.

The option available for India to contain the AIDS epidemic lies in preventive measures such as the identification of high risk individuals through screening, screening of blood used in blood transfusion, community awareness about the disease, and so on, we also need to focus on research to produce indigenous drugs based on traditional medicine.

Gastro-intestinal disorders are responsible for more than one-tenth of the disease burden in India. Much of it can be tackled by providing sanitary living conditions and good, clear drinking water to al Indians. In addition, we need to concentrate on finding simple, safe and inexpensive methods of diagnosis.

The search for such inexpensive diagnostic tools and vaccines is combined with other challenges. One is straightforward: the protection of intellectual property rights (IPR). If some body or some company has already invented a new drug and patented it in India, permission has to be obtained from the party concerned before it can be used. The party may change heavily for IPR, upsetting our cost calculations. Or a new drug not covered by such patents would have to be discovered; this may not always be easy, as research and its qualification through various regulatory tests takes considerable time.

There could also be unforeseen challenges. When a smaller company manages to invent and to produce an important vaccine, a bigger company selling vaccines may try to use underhand means to prevent its rival company from establishing itself on the market. So genuine companies trying to provide inexpensive vaccines and medicines may have problems in overcoming such illegal and immoral ‘competitive’ practices.

This brings us to another important area. Most vaccines would require good delivery and storage mechanisms. They lose their effectiveness or potency when not stored at particular, often low, temperatures. So as with milk or fruit, we need good refrigeration or chilling systems to enables the vaccines to reach villages.

Also, how do we ensure that the vaccines have indeed been stored at proper temperatures through various phases of handling, from the factory in which they are manufactured upto the point of the consumer? Here too there are technologies to help us keep control. There are thermal sensitive paints which can change colour; a strip of such paint can be put on the medicine or vaccine cover. If the instructions regarding the exact temperature and permissible time without refrigeration are violated, the colour will change irreversibly.

Fortunately, in India there are groups working on vaccines and irreversible thermal sensitive paints. But when it comes to stable and reliable electric power supply to the rural areas and towns, enabling the operation of good chilling systems in the rural areas, one is assailed by doubts.

A reliable refrigeration system presumes a stable supply of electric power. Electric power is a vital component for operating most machines. The entire electronics industry depends on it, though modern-day systems consume less and less electric power for greater performance. It is time we as a nation learn to appreciate the important of electric power for industry. The current crisis in the power sector cannot be allowed to continue. In our march towards becoming a developed country, we need to drastically transform our electric power operations. It is not merely for agriculture or industry, but for the very health of our people. What this suggests is the importance of interlinkages. In the past few decades, many government departments, agencies and individuals have begun to function autonomously. The concept of self- reliance should be for the country as a whole, not for departments, agencies or individuals alone! But in India, many of the agencies do not see beyond their allocated areas. Some one concentrates on the purchase of a vaccine; another on development; another ‘deals work’ to protect everybody. ‘I have done my task! The representative of any department might say. Of course there are also problems in such a system for those with initiative. On the pretext of coordination, many irrelevant questions are raised and often months pass before a decision is taken. We have heard many sincere people telling us they have sent detailed proposals with specific linkages spelt out to the department concerned in Delhi or the state capital. Often Delhi has something to say even when proposals are sent to the state capital. It may take three to six years for the proposals to be cleared; often the clearance comes after the subject matter has become partially or fully obsolete.

If we want to achieve a developed India, we have to learn to get out of this pitiable state of inaction. If laws, rules and procedures have to be changed, this should be done. The rate at which technologies offer new solutions and new windows of opportunity is fortunately very high in the current phase of human development. We can make up the lost time and missed opportunities, provided we learn to move fast. Such opportunities are not waiting around for us. Others grab them. We need to think holistically and innovatively, and not in our closed compartments. And above all, we need to learn to act fast and protect those who make genuine mistakes. Failure is a part of any venture! The authors can cite from their experience of three mission-oriented organizations: the Department of Atomic Energy, the Indian Space Research Organisation and the Defence Research & Development Organisation, which have project –oriented management for time-bound achievements in high technology, and also their societal application. Defence lasers can be used surgically to treat glaucoma or cataract. Atomic energy is used for irradiating, for example, groundnut seeds for higher productivity; and space research has led to an accurate prediction of the onset of the monsoon. The unique characteristic of all these three departments is that their scientists are not afraid of taking decisions and above all are not afraid of failures. But they have indeed succeeded, thanks to visionaries like Dr Homi Bhabha, Prof Vikram Sarabhai, Prof Satish Dhawan and Dr. Nag Chaudhri.

For example, satellite remote sensing offers a medium to map out areas where mosquitoes breed or such areas from which other diseases can spread. There have been a few successful experiments over limited areas. We have our remote sensing satellite whose data is being sold commercially worldwide. We have many experts in remote sensing applications! Many entrepreneurial scientists and technologists have started small companied and provide services even to foreign clients. Why don’t we deploy these talents to benefit the country as a whole, in the big battle ahead to combat diseases? We are aware that satellite mapping alone cannot solve all problems. It can monitor, and present a quick picture and help us to develop microplans. Similarly, there are other tools. Also there may be several sources of local knowledge available with out tribal communities or village elders about the control of vectors. Why not deploy this after a quick study? DRDO had an interesting experience in the north-eastern state of Assam, where the organization has a Defence Research Laboratory especially devoted to preventing malaria and its treatment. It is a small laboratory with less than fifty members. It has been established to keep our armed forces healthy. This laboratory has done something unique in health care. It has characterized the vector of the mosquito prevalent in that region based on their own medical knowledge and the experience of the local people. The laboratory, in turn, has treated the people in the villages and helped them to be free of malaria.

Table 10.1 - Estimated and Projected Mortality Rules (per 100000) by Sex, for Major Causes of Death in India

Non – Infectious Diseases

Let us now address non-infectious diseases, some of which are considered ‘developed country’ )post-transitional) disease! Since these disease are significant in developed countries, there is also a vast knowledge base utilized to tackle them. Heart diseases are perceived to be the ones which will receive major attention for many years to come.

Urbanization and altered lifestyles are indicators of socioeconomic development and lead to risk factors for cardiovascular diseases (CVD). At present, pre-transitional diseases like rheumatic heart disease, mostly the problem of the poor, co-exist as a major cardiovascular heart disease and hypertension. In India nearly 2.4 million deaths are caused by cardiovascular disorders. Small-scale community –based studies indicate the prevalence of CVD in adults, ranging from 2-6 per cent in rural and 6-10 percent in urban areas. The health sector review of the World Bank projects that CVD mortality rates would double between 1985-2015 (table 10.1)

Studies of overseas Indians in many countries reveal excess coronary mortality in persons of Indian origin. These studies conducted in several countries and involving different generations of migrants from India/South Asia suggest a special susceptibility to CVD as persons of Indian origin face the challenges of epidemiologic  transition. When a community’s status changes from being poor to affluent, factors appear to play a role in the special vulnerability of people of a particular community, in this case of Indian origin. Other factors include the stresses due to living in a different cultural setting. Experts believe that an epidemiologic transition is therefore likely to result in a major CVD epidemic in India.

It is critically important to develop relatively inexpensive diagnostic aids for detecting coronary heart disease (CHD). These include ECG (electrocardiogram), stress ECG, nuclear cardiology, echocardiography, holter monitoring and cardiac catheterization with coronary angiography. Technologies like magnetic resonance angiography of the coronary arteries are still under investigation. ECG recorders and simple stress equipment are manufactured in India and are easily available. However, if the diagnostic facilities have to be extended to the primary care (ECG) and secondary care (Stress ECG) levels, in response to the coronary epidemic, their manufacture in larger numbers and reduced cost per unit would be necessary. Medical therapy of CHD may involve anti-anginal drugs (nitrates, calcium channel and beta blockers), anti-thrombotic agents (aspirin, heparin, etc), ACE-inhibitors, thrombolytic agents (streptokinase, urokinase, etc) and antioxidants. Primary health care centers are not presently geared to provide emergency care. Development of treatment protocols for CHD and training of appropriate manpower at primary levels needs to be taken up on a priority basis. Let us remember that CHD or CVD is not merely the problem of the very top strata, of a few tens of millions. (No doubt this strata can not only afford private treatment in India but also afford periodic check-ups and treatment in the UK and USA. It is sad to note that this strata have confidence only in foreign facilities, despite the presence of expert doctors in India and all such imported equipment with which foreign-returned Indian specialists are operating world-class facilities!)

CVD or CHD is going to become a common illness, from the lower to the upper middle class and even among many rural people. Therefore, it is not a disease of  the affluent; it is a disease which may also attack many Indians, who have just marginally escaped death from severe infectious diseases or nutritional disorders. The Kalam-Raju stent, used to prevent arteries from closing up, was one such attempt to target the treatment of this group. We need many more measures for diagnosis. Since most primary health  centers (PHCs) may not have access to excellent specialists, advances in modern communication and information technologies also would need to be deployed innovatively to provide such tele-access (that is, access at a distance). Most readings of the diagnostic equipment, ECG or others are electrical signals. These can be transmitted to the specialists in a very economical from with modern digital technologies. The opinion and advice of the specialists can be retransmitted to the PHC. We understand that many of  those who operate costly nursing homes in cities would be willing to provide such advisory services at a nominal cost as a part of their contribution to society. Let us try many such methods to reach out to people. In addition, the advice of specialists regarding dietary habits, exercises and practices for mental stress relief (including yoga) may have to be popularized in the media.

Another CVD which is prevalent now in India and arises mostly due to poverty or neglect of illnesses at a young  age is rheumatic heart disease (RHD). It is a major cause of cardiovascular morbidity and mortality. The prevention of RHD requires early diagnosis and prompt treatment of streptococcal pharyngitis, especially in children aged 5-16 years. Though a streptococcal vaccine is under investigation, clinical trails are yet to take shape. A multivalent, non-cross reactive, long lasting and inexpensive vaccine would be ideal for prophylaxis with penicillin is an available technology whose compliance needs to be improved. Clinical trials on the efficacy of immuno-modulatory therapy for rheumatic fever is required. While balloon valvoplasty and surgery are presently available at most tertiary centers, the equipment and disposables are mostly imported. Indigenously developed prosthetic valves must be promoted and technologies must be developed. On all these fronts, given targets and good organization, India can easily measure up to the problem.

Other non-communicable disease such as diabetes may be a cause for concern. About 5 to 10 percent of the population in India suffers from diabetes. Preventive measures include genetic counseling and dietary and lifestyle counseling. Blood glucose detecting devices have been simplified and miniaturized. However, a high running cost and the need for changing the equipment are limiting factors. Standardized glucose measuring devices and diagnostic kits would greatly help in the management of the disease. The projected requirement of insulin for 2010, estimated at about 168 billion units annually, indicates the importance of developing indigenous technology for low cost-human recombinant and other newer forms of insulin. It may incidentally be pointed out that much of this equipment, medicines and diagnostics kits, be it for diabetes, CVDs or other diseases, can be exported. Domestic consumption alone can form a reasonably profitable business venture.

Cancer is another area that would require special attention. Amongst many high-level non-medical decision makers there is a general opinion that cancer is a disease of the rich and they can take care of it. But the facts are otherwise. Cancer is a degenerative disease influenced by age, environment, and lifestyles. Also, increased life expectancy means an increased incidence of cancer! Table 10.2 indicates the incidences of cancer in India and the future projections.

Indian incidences as per the current records appear to indicate that if we look at the common sites of cancer in the population, their proportions and trends, over 40 per cent of cancers in males and 20 per cent of females can be directly attributed to the use of tobacco. Most of these cancer cases are presented only at the late stage of the disease and very few at the early localized stage, increasing the incidence of stomach cancer in the south and gall bladder cancer in the north is observed, thus making studies on cancer etiology and epidemiology imperative. It is essential to generate information on baseline parameters for different regions of the country in order to assess the risk factors and develop measures to create awareness. Effective diagnostic and therapeutic facilities are essential all over the country. For example, endoscopes are an essential part of diagnostic services for cancer. They are available only at specialized institutions. A set of endoscopes costs about Rs. 2.5 million now. We believe that  the cost can be brought down partly by economies of scale and partly through innovative design to cater to essential needs. Often the vision of those who plan the programme is limited to procurement of the equipment in a few urban centers and in a few other areas to prove that we have it elsewhere too! This narrow vision should change.

TABLE 10.2 - Projected Number of Cancer Incidences in India

 Yet again, availability of external radiotherapy cobalt –60 units is limited to specialized units. There are only 120 unit sin the country and these are also not uniformly distributed. With the increasing incidence of cancer, it is estimated that for every one million people, at least one unit will be required. That is about 1000 units, with increasing demands in the future. With our tremendous capabilities in nuclear technologies and many other supporting Indian industries, can this problem not be solved by innovative and inexpensive design? Experts believe that it can. If there is a mission, a demand will be generated.

If a nuclear technologist is shown foreign equipment and asked if he or she can manufacture it in India, the answer will be yes’; he will come up with an innovative design and an estimate of the cost which may often be very high. It is a pity, but it is only very rarely that the same technologist would be faced with a project stating that our vision is to reach the whole of India. ‘Can you sit with doctors, production specialists, businessmen and others to come up with minimum essential features to create technology available at a lesser cost, on a large scale and more speedily? That is a question which is never asked. Over a period, our system has lost the capability to enthuse people, to pose challenging problems for our youth; to harness a large vision.

Let the coming fifty years be a period a expanded vision for India, faith in ourselves, a bold desire to carve new paths and create an environment for the youth to excel. Such a new developed India will inspire confidence in people of other countries as well. Let us look for a strong. Healthy and wealthy India radiating its well-being to all people.

Sight for All

Even as we speak of vision, it is depressing to acknowledge that India has one-fourth of the World’s blind or visually handicapped. About 12 million people are fully blind and 20 million suffer from various forms of serious visual handicaps, rendering them virtually ineffective.

At K.G. Hospital at Coimbatore, a well –to-do person along with a few doctors is providing eye care to many poor people, including those in nearby towns and villages. The vans go for tests and pick up cases requiring treatment. While going on a round of some of the patients I came to an elderly man and asked him in Tamil what his name was and where he was from. The man replied. ‘I have heard about you, Kalam Sir; I am happy to be near you though I cannot see you!’ I asked him how old he was. That made the elderly man tearful. He said, ‘I don’t know my age and I don’t care about it now. I have been in darkness for so many years that it appears to me that many yugas are over. Losing your own vision is such a bad thing because you own children taunt you as a kurudan (a blind man).’ Indicating his bandaged eyes he said, “These punyavans (holy souls) appear to care for me. They brought me in a van, examined my eyes and did some operations. Once they opened the bandages to do a check up’ it looked to me that I was able to see though hazily. They told me that in a couple of days my bandages would be opened and they would give me glasses. May God bless those who will save me from the miserable state of being a kurudan… Kalam Sit I am confident that I will see you with my eyes and glasses during my lifetime .. my faith in God has gone up; he comes through kind human beings …..’

The man  was obviously suffering from a cataract. Probably his children either did not care or he could not afford to go in for  an operation.

Almost 80 per cent of blindness in India is due to cataract. The other significant causes are corneal diseases, glaucoma, diabetes and other vitreoretinal disorders. Intraocular lens (IOL) implantation is an ideal method for rehabilitation of cataract patients after surgery. Extracapsular cataract surgery with IOL is one of the most cost- -effective therapies, in terms of quality of life, since vision with as good as 6/9 is possible. In India mostly intracapsular extraction is practiced. However, IOL implantation is also becoming increasingly popular. According to a survey, of the cataract operations reported in the country in 1992, 42 per cent were extracapsular and about half of these received IOLs. The projected requirements for IOLs in the country would be close to 2 million every year. This necessitates production of better quality IOLs indigenously. Another modern technique of cataract surgery employed in over 75 per cent of the cases in the USA is phacoemulsification, where surgery is performed through a 3 mm incision (5.5 mm). Alternatively, a foldable silicon IOL is implanted through a 3.5 mm incision. Phacoemulsification technology needs to be made available in India. There is also scope for development of small incision technologies such as lasers and mechanical endolenticular fragmentation.

The DRDO has made a small contribution to eye care through the development of ‘Drishti’ eye laser equipment. The DRDO has formed the Society for Biomedical Tecnology (SBMT) with the objective of creating conditions under which cost-effective, life-saving medical products can be indigenously produced and made available to the common man at affordable prices. The spin-offs of defence technology are the basic strength of SBMT. The society binds together scientists, engineers, doctors, social workers and administrators in a shared mission. In less that three years time, DRDO /SBMT, along with others, have successfully developed an external cardiac pacemaker which is one third of the cost of its imported counterpart, an automated cancer detection device for mass cancer screening, and a low cost cardiac stress test system to take this important screening toll of diagnosing coronary artery disease to small towns and community health centers. The technologies for these systems have been transferred to industry for production. The laboratory systems of Drishti and coronary catheters are under clinical validation. The Jaipur foot for polio-affected children developed by Dr. P.K. Sethi has been made ultra-light by using an advanced composite material that goes into making missile heat shields. The coronary stent is under production.

Plans are afoot to enlarge these efforts, using a spin –off of defence technology for launching indigenous development of a hollow- fibre dialyser, coronary stents, drug delivery implants and microprocessor-based in canal hearing aids. The mission is enormous. The partners are medical institutions and industries. We desire that all the available technology forces and philanthropists must have come together to make it happen.

There are other solid institutions and industries in India capable of doing more. BARC is not merely devoted to nuclear devices or systems. It has the knowledge and capabilities  for many medical technologies. The Centre for Advanced Technology (CAT) at Indore has world –class capabilities in laser devices and applications. Dr. M.S. Valiathan, who led the Health Care Technology Vision 2020 studies, is an eminent scientist and technologist of India. More than three decades ago he came back from USA after his advanced studies to build an institution called Sri Chitra Tirunal Medical Centre located at Thiruvananthapuram. Operating from there against heavy  odds, he and his team have developed many biomedical devices ranging from blood fold. These devices are under commercial production in India and some of the devices are also produced abroad under successful technology export contracts. The institute has developed several unique capabilities in biomedical devices.

Similarly, the co-chairperson of the Vision 2020 exercise, the eminent nutritionist Dr. Mahtab Bamji, has extensive experience in rural areas. After retirement she spends much of her time in rural areas, contributing towards the vision. There are extremely capable medical personnel, scientists and engineers all over the country. There are many NGOs and youth in search of challenging human missions. There are many persons like Dr. V. Sudarshan of Mysore who combine modern knowledge and scientific methodologies with the inherited wisdom of our people. Also, most experts believe that many older forms of medicines and medicinal plants will have an important role to play in future medicare systems not only in India but in the world. That is the reason many foreign multinational companies invest in research and development of herbal drugs. A few of our experts opine that much of its knowledge has not been fully exploited because of the limited prevalence of Sanskrit and Indian languages. With its ancient knowledge base and excellent biodiversity, India can really become a world leader in herbal and other natural medicare systems.

Maternal and child Health

Let us end this chapter by addressing a crucial element of the health care system, that is maternal and child health. Women of child –bearing age and children under five represent the maternal and child category in any population profile. As per the 1991 census, 56 per cent of the population in India fall under this category. The projected Meternal and Child Health (MCH) population is given in table 10.3 Anaemia, chronic under-nutrition and complications during pregnancy and childbirth are the orders of priority for maternal health. In the case of children, the priorities are diarrhoeal diseases, anaemia, perinatal disorders and vitamin A deficiency. Effective antenatal care, prophylactic iron and folic acid supplements, food security, improved sanitation and drinking water facilities, universal immunization coverage are some of the measures which would reduce the problem in MCH. (see table 10.3).

In fact, none of the medicare required for maternal and child health demands breakthrough technologies. What is required is a large-scale production and distribution system. Even anemia diagnostics have become simpler, thanks to development in the technologies of advanced sensors. We require a new vision regarding our children and mothers. The very foundation of our future depends on their health.

Table 10.3 - Projected Maternal and Child Population at Different Points of Time

The Vision

The Vision for health for all Indians is realizable well before 2020. we have discussed some details with a few examples.

While one needs numbers and statistics, technical evaluation and investments, we believe that a change in thinking would lead to a miraculous transformation. The richer and more powerful sections of our society should realize that the health of their less-privileged countrymen is their problem as well. They can go to the USA or UK for a cardiac examination or surgery but they cannot escape an infectious epidemic in India very long. Enlightened self-interest should make businessmen realize that a sick worker cannot give his or her best even with the most modern equipment. High productivity requires a healthy workforce. Health administrators should learn to treat health as people’s pain and agony, not as files. Similarly, politicians at all levels should learn to look at pain removal as a part of their duty.

I would like to conclude this chapter with a quote from a convocation address I delivered at the Tamil Nadu Dr. M.G.R. Medical University, Madras, on 21 March 1996.