RESUMEN

India's ruling class, in association with international agencies, bureaucrats, and business interests, has formed a powerful syndicate that has been imposing its will on the country to the detriment of public health. After gaining independence, India developed a body of knowledge suited to its social, cultural, economic, and epidemiological conditions. This led to an alternative approach to public health education, practice, and research that foreshadowed the Alma Ata Declaration on Primary Health Care of 1978. In the early 1980s, global power shifts undermined national and international commitment to the Declaration. Wealthy countries' response to the declaration of self-reliance by economically disadvantaged countries was swift: an effort to suppress the Declaration's ideals in favor of an unscientific, market-driven agenda. As a result, public health practice in India virtually disappeared. Responding to growing restiveness among a population in need, political leaders have launched the foredoomed National Rural Health Mission and pursued an American brand of public health through the Public Health Foundation of India. Reconstructing the damaged public health system will require pressure on the syndicate to ensure India's public health heritage will be used to effectively transfer "People's health in people's hands" according to the guidelines set down at Alma Ata.

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Two major research studies carried out in India fundamentally affected tuberculosis treatment practices worldwide. One study demonstrated that home treatment of the disease is as efficacious as sanatorium treatment. The other showed that BCG vaccination is of little protective value from a public health viewpoint. India had brought together an interdisciplinary team at the National Tuberculosis Institute (NTI) with a mandate to formulate a nationally applicable, socially acceptable, and epidemiologically sound National Tuberculosis Programme (NTP). Work at the NTI laid the foundation for developing an operational research approach to dealing with tuberculosis as a public health problem. The starting point for this was not operational research as enunciated by experts in this field; rather, the NTI achieved operational research by starting from the people. This approach was enthusiastically welcomed by the World Health Organization's Expert Committee on Tuberculosis of 1964. The NTP was designed to "sink or sail with the general health services of the country." The program was dealt a major blow when, starting in 1967, a virtual hysteria was worked up to mobilize most of the health services for imposing birth control on the people. Another blow to the general health services occurred when the WHO joined the rich countries in instituting a number of vertical programs called "Global Initiatives". An ill-conceived, ill-designed, and ill-managed Global Programme for Tuberculosis was one outcome. The WHO has shown rank public health incompetence in taking a very casual approach to operational research and has been downright quixotic in its thinking on controlling tuberculosis worldwide.

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In India, by the second century B.C., Ayurvedic medicine had already taken the momentous step of becoming rational therapeutics. Physicians created a methodology based on the supreme importance of direct observation of natural phenomena and the technique of rational processing of empirical data. However, over the long history of the country, Ayurvedic medicine underwent severe erosion of its knowledge and practice because of profound political, cultural, social, and economic changes. Nevertheless, it was used by the poor because access to Western medicine was denied by the ruling classes. Alarm bells started to ring with the declaration of self-reliance and self-determination by the poor at Alma-Ata in 1978. A syndicate of the rich countries, with active support of India's ruling elite, mobilized the enormous influence and resources of organizations such as the International Monetary Fund, World Health Organization, UNICEF, and World Bank to promote their unconcealed agenda of promoting the private health sector and further decimating the public sector.

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The Commission on Social Determinants of Health (CSDH) is the latest effort by the World Health Organization to improve health and narrow health inequalities through action on social determinants. The CSDH does not note that much work has already been done in this direction, does not make a sufficient attempt to analyze why earlier efforts failed to yield the desired results, and does not seem to have devised approaches to ensure that it will be more successful this time. The CSDH intends to complement the work of the earlier WHO Commission on Macroeconomics and Health, which has not had the desired impact, and it is unclear how the CSDH can complement work that suffers from such serious infirmities. Inadequacies of both commissions reflect a crisis in the practice of international health at the WHO, stemming from a combination of unsatisfactory administrative practices and lack of technical competence to provide insights into the problems afflicting the most needy countries. Often the WHO has ended up distorting the rudimentary health systems of the poor countries, by pressuring them into accepting health policies, plans, and programs that lack sound scientific bases. The WHO no longer seems to take into account historical and political factors when it sets out to improve the health situation in low-income countries--which is supposed to be the focus of the CSDH. An alternative approach is suggested.

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India's political leadership has chosen personnel from the Indian Administrative Service cadre of generalist administrators and from the clinician-dominated cadre of the Central Health Services to run the country's health service system. The personnel's inadequate or distorted understanding of some of the basic principles of public health practice--such as developing an epidemiological approach to solving community health problems, choice of appropriate technology, and optimization of health service systems--has had a very deleterious effect on the health service system. These administrators have become vulnerable to manipulation by personnel from international agencies, who also have questionable public health credentials, to create space for imposition of their technocentric, ill-conceived, and ill-designed agenda. To rationalize adoption of such an obviously faulty agenda, they have to be ahistorical, apolitical, and atheoretical and indulge in misinformation, disinformation, and suppression and manipulation of information. This amounts to what Navarro has termed "intellectual fascism."

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The setting up of the National Rural Health Mission is yet another political move by the present government of India to make yet another promise to the long-suffering rural populations to improve their health status. As has happened so often in the past, it is based on questionable premises. It adopts a simplistic approach to a highly complex problem. The Union Ministry of Health and Family Welfare and its advisors, because of ignorance or otherwise, have doggedly refused to learn from the many experiences of the past, either the earlier, somewhat sincere efforts to develop endogenous mechanisms to offer access to health services or the devastating impact on the painstakingly built rural health services of the imposition of prefabricated, ill-conceived, ill-formulated, technocentric vertical programs on the people of India. They also ignore some of the basic postulates of public health practice in a country such as India. That they did not substantiate the bases of some of their contentions with scientific data from health systems research reveals that they are not serious about their promise to rural populations. This is yet another instance of what Romesh Thaper called "Baba Log playing government government."

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Most of the WHO's vertical programs, because they were ill-conceived, ill-designed, and defectively implemented, have fallen far short of expectations. These limitations have been doggedly ignored by the WHO, although the authorities in India have now realized that such vertical programs are expensive and not sustainable. Launching of Communication for Behavioral Impact (COMBI) appears to mark a desperate effort to revive their performance. It represents yet another deviation from the mandate given to the WHO. In 1983, the then director general warned against motivational manipulation of people to sell health ideas, but the WHO has now brazenly come forward to look for help from the private sector. COMBI uses the jargon and language of the market place to "market" health programs; it calls this "cause-related marketing." The WHO has been most a historical in conceptualizing COMBI, as it has not learned from the failure of UNICEF's earlier venture to market child survival by employing experts in social marketing to bring about "community mobilization." The WHO should have reviewed the large body of literature on work in the health social sciences, health education, and the many programs based on the concept of "information, education, and communication." The pointed neglect of such key issues raises serious moral, ethical, and human rights questions. The COMBI approach amounts to be a breach of trust--a threat to human dignity.

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Health is politics, and politics is health as if people matter--this has been a refrain of such scholars as Rudolf Virchow, Halfdan Mahler, and B.C. Roy. Many seeds of hope for health were generated during India's struggle against colonial rule. After Independence, with the changes in power relations, these seeds could not find the appropriate soil to nurture them. Power relations influence health service development, which is a sociocultural, economic, political, organizational, and managerial process with epidemiological and sociological dimensions. Even within the power structure, however, a carry-over of the democratic process of the pre-Independence era has created a pro-people ambience. Despite considerable difficulties and shortcomings, India has developed an endogenous, alternative body of knowledge more suited to the prevailing social, cultural, economic, and epidemiological conditions. This has formed the content of alternative approaches to education, practice, and research in public health--strikingly similar to the Alma-Ata Declaration. The response to this declaration of self-reliance by the world's poor, together with the earlier specter of population explosion, brought together the political leadership of all hues, the bureaucrats, and foreign agencies to impose prefabricated programs on the people. The result was a decimation and decay of the health service system, causing considerable suffering to the poor. The remedy is a return to the heritage of the alternative approaches that emerged during the early years of Independence.

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In India, health programs have often been imposed on the deprived poor by a syndicate of foreign agencies and the local ruling class. During the first two decades after Independence, the political setting was somewhat conducive to scientific debates on the development of health services for India's people. The scenario changed radically during the next three and a half decades, when the country's ruling class became more oppressive and foreign agencies exerted increasing pressure to impose a prefabricated and scientifically suspect agenda of health services that were even more unequal and iniquitous to the interests of the deprived. With the help of themes from some of his major works, the author reflects on his experiences of the last half-century to make a case for using scientific critiques as an instrument for resisting foreign domination.

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The Alma-Ata Declaration on Primary Health Care of 1978-based on the World Health Assembly's resolution of 1977 on Health for All by the Year 2000--was a watershed in the concepts and practices of public health as a scientific discipline; it was endorsed by every country in the world, rich and poor. According to the Declaration, health is a fundamental right, to be guaranteed by the state; people should be the prime movers in shaping their health services, using and enlarging upon the capacities developed in their societies; health services should operate as an integral whole, with promotive, preventive, curative, and rehabilitative components; and any western medical technology used in non-western societies must conform to the cultural, social, economic, and epidemiological conditions of the individual countries. Since Alma-Ata, a syndicate of the rich countries and the ruling elites of the poor countries, aided by the WHO, World Bank, World Trade Organization, and other international institutions, has done much to overturn the Declaration's primary health care initiatives. The WHO's recent attempt to regain some credibility, its Commission on Macroeconomics and Health, ignored the primary health care principles of the Alma-Ata Declaration. A struggle for these principles will have to be part of the larger struggle, by like-minded individuals working in individual countries, for a just world order.

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The World Health Organization has been able to interest some of the world's top economists in joining the Commission on Macroeconomics and Health, to study macroeconomics of health services for the poor peoples of the world. The commission has been ahistorical, apolitical, and atheoretical. It has adopted a selective approach to conform to a preconceived ideology. It has ignored earlier work done in this field. And it has pointedly ignored such major developments in the health services as the Alma-Ata Declaration. These failings have brought the quality of the scholastic work to an almost rock-bottom level. The commission's tunnel vision in its recommendations on so important a subject is not surprising. Its emphatic recommendations for perpetuating vertical programs against major communicable diseases (tuberculosis, AIDS, and malaria) on the grounds that such programs have proved convenient to "donors" reveals the real motivations for an almost openly ideology-driven agenda. This is a serious danger signal for scholars who wish to take a scientific attitude toward program formulations for the poor that provide maximum returns from limited resources. The concept of DALYs (disability adjusted life years) is bristling with gross infirmities. The WHO-generated data used for DALY calculations, converted into dollar terms, are patently invalid, unreliable, and not comparable between and even within countries.

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