Panel No. 28

Panel Title: Public Health in South Asia

Convenor: Prof Zulfiqar Bhutta, Dept. of Paediatrics, Agha Khan University, Karachi, Pakistan

    Thursday 8 July, 13–18

Panel Abstract: Almost fifty six years beyond independence most of the states in South Asia (with the notable exception of Sri Lanka and the Maldives) have some of the lowest health indicators in Asia. A recent review of global under-5 child mortality places the rates in the region among the highest in the world with almost 40% of the total global burden of deaths occurring in four countries of South Asia alone. It is also estimated that almost 70% of the entire global burden of low birth weight occurs in South Asia and enormous inequities exist in the provision of health care and services. These issues of high burden of maternal and child mortality are also associated with the rising burden of diseases of development such as diabetes, cardiovascular diseases and urban obesity. The region has also experienced much tumult and conflict. While countries such as Afghanistan have seen large scale social upheaval and war, other countries have also experienced incessant low-grade conflict for an extended period of time.
All these issues must be viewed in the backdrop of enormous developments in many fields and the rapid growth of enterprise. India leads most of the world in information technology, both Pakistan and India boast nuclear weapons and sophisticated missile delivery systems and have been on the brink of nuclear conflict on several occasions. These incongruities and misplaced priorities lie at the heart of the South Asian dilemma, where overt developments in technology and industrialization have failed to bridge the urban rural divide and remove pervasive poverty and social inequity. In particular the status of women in south Asia, especially among its rural populations, is of great concern. This is especially true in the Northwest tribal belt and Afghanistan where gender discrimination has been systematically practiced as a state or social policy for decades.
Poverty and gender inequity are not the only social issues that impact health in South Asia. The rapid growth of religious intolerance and feuds in the subcontinent in recent years, have all brought much focus to bear on the determinants of such change. The genesis of such upheaval has many dimensions including macroeconomic policies that fail to benefit the poor and lack of investments in human development. The recent growth of religious intolerance and obscurantism in the region has enormous implications on the physical and mental health of its population.
Amidst all these worrying developments are many promising signs of vibrant people and remarkable initiatives in South Asia. The case of Sri Lanka is a stark reminder that investments in education and sound public health policies can yield dividends that can even withstand a crippling civil war. The examples of the Grameen Bank and microfinance initiatives have led to several rural development programs targeting women in the region. There are also many examples of philanthropic initiatives to provide public sector services in seemingly impossible areas such as urology and transplantation and cancer treatment. All such success stories indicate that not only is humanity alive in South Asia but the region has the potential to emerge as a bastion of peace, health and well being.
This panel will hope to bring together outstanding individuals from the public health and social science domains in South Asia and discuss ways of promoting dialogue and action. Presentations will be planned to cover all major aspects of interest and lead to a broad discussion on future strategies and interventions involving academia, researchers, public health professionals and civic society.

Papers accepted for presentation in the panel:

Paper Giver 1: Prof. Zulfiqar Bhutta, Department of Paediatrics, The Aga Khan University Hospital, Karachi, Pakistan

Paper 1 Title: Maternal and child health in South Asia: a public health and development enigma

Paper Abstract: South Asia poses enormous incongruities and challenges to health and development specialists. It possesses a remarkably advanced and qualified work force, leads the world in information technology, is making ground breaking advances in pharmaceutical and biotechnology and also is home to two nuclear states. However, its development indicators and human development indices rank among the lowest in the world and have been fairly resilient to change.
We undertook a comprehensive review of available data on the burden and major causes of maternal, infant and child mortality in the countries of South Asia and their major determinants in order to suggest a framework for interventions. All available recent available information on maternal and child health (MCH) from the region was reviewed and compared with data from the WHO, UNICEF, World Bank and the Bellagio Child Survival group. Information and evidence relevant to interventions that could potentially impact on MCH in the region were also reviewed.
Our review indicated that despite relatively better socioeconomic conditions, South Asia ranks poorly for all indicators. Maternal mortality ratios range from 60-830 per 100,000 births, infant mortality rates range from 15-176 per 1000 live births and neonatal deaths account from 45-55% of all infant deaths. Maternal and child malnutrition rates remain among the highest in the world, with low birth weight infants accounting for 13-33% of all births. Most of the child deaths are related to potentially preventable disorders such as birth asphyxia, diarrhea, acute respiratory infections and sepsis. The underlying determinants of MCH include health system dysfunction in providing services to poor and rural populations, widespread poverty as well as systematic gender inequity in access to health care and education.
Our review indicates that if South Asia is to meet its millennium development targets, it must invest actively in supporting improvement in MCH at grass root level. These efforts should be evidence-based and serve to provide basic preventive and curative services at primary care level. This will require substantial reduction in current levels of non-developmental and defence-related expenditures, deliberate investments and targeting of interventions to poor populations and especially women and children.

Paper Giver 2: Dr. Bo Lindblad, IHCAR, Karolinska Institutet, Stockholm, Sweden
Paper 2 Title: Maternal and fetal malnutrition in South Asia
Paper Abstract: To be published

Paper Giver 3: Dr. Tej Purewal, University of Manchester, UK

Paper 3 Title: Beyond Consensus: NGOs Doing Reproductive Health in Delhi

Paper Abstract: In 1994 the International Conference on Population and Development (ICDP) that took place in Cairo was seen as a watershed for population activities internationally. Two of the most significant points emerging out of the ICPD were 1) an emphasis upon NGO involvement in the delivery of reproductive health services and 2) a view of reproductive health as an issue of rights. This was a particularly poignant shift, given India’s history of target-driven population policies. The adaptation to the post-ICPD rhetoric has shown some interesting interpretations of it in India. This paper will draw upon fieldwork done in Delhi with two NGOs delivering reproductive health services to specified communities. In doing so, the paper will analyse some of the contours of the supposed decentralization of reproductive health services and the manner in which the new ‘consensus’ is being embodied or even challenged by local NGO activities ten years on.

Paper Giver 4: Dr. Projit Mukharji, SOAS, London, UK

Paper 4 Title: Reproductive Health as a Metaphor for Division

Paper Abstract: By the middle of the 1830s the triumph of the Anglicists in India House had meant that the hitherto ambivalent attitude of the colonial state towards native medicine was reversed in favour of a more pronounced patronage to Western Allopathic Medicine. Of the eight branches of classical Ayurveda, faculties were founded at the newly formed Calcutta Medical College for six. The only two that were ignored were the ones dealing with venereal diseases and infertility. The incorporation of these into the Medical College as full faculties was not until as late as a hundred years later in the 1930s.
Medicine dealing with, reproductive health was therefore largely left to the Vaids and Hakims. By the second half of the century though, the inordinately large incidence of venereal disease in the British Indian Army was forcing the Government to take sexual medicine and disease more seriously. The 1860s saw a spate of Contagious Disease Acts, but in these Acts, the matter was treated more as a police matter and prostitutes were sought to be registered rather than view it as a medical problem. The flip side of this attitude of treating sexuality and sexually transmitted diseases as a police matter than a medical problem was that in 1868, when a one man committee was set up to look into the problem, he clearly states in his report that, it was a problem that was predominant among the ‘lower classes’, native or European. Further when a circular is sent out four years later to gather the opinion of District Magistrates on the issue of control of venereal diseases through the control of prostitutes, we meet with a number of elite Hindu District Magistrates, including the redoubtable Bankim Chandra Chatterjee, the doyen of Bengali literature and the author of India’s national song ‘Vande Mataram’, arguing that such practices did not affect the elite Bhadralok in general and the high caste Hindus, in particular. But by the end of the first decade of the 20th Century, when Lord Curzon’s Partition of Bengal had evoked large scale protests from the Bengali elite, we find the Imperial Gazetteer, arguing that factors that affected reproductive health adversely were more prevalent among caste Hindus than the sub-altern classes and ‘muslims’.
Once again the native Hindu elite, like most comprador colonial elites, seem to have internalised this trope of colonial de-legitimation. A spate of literary texts critical of the sexual mores of the high caste Hindus are paralleled by an inordinately large number of advertisements for sexual medicines in the daily press, sometimes reaching as far as 70 per cent of the total advertisements.
By the 1920s the issue of ‘obscene’ advertisements is important enough to draw comment from Gandhi himself. Even in the 1930s when sexual complaints and reproductive health is ‘medicalised’, it hardly ceases to be a metaphor for division and otherisation. The sub-committee on Population under the National Planning Committee established by the Jawaharlal Nehru, clearly states that India’s problem is not population explosion per se but ‘mis-population’, it goes on to clarify the term further to mean, that the ‘wrong sections’ of the population are growing.
Within the discourse on venereal diseases, population, not to mention the nebulous category of ‘diseases of women’ , in this time my paper shall attempt to show that ‘reproductive health’ and ‘sexual ailments’ came to be viewed as a metaphor for otherisation. The medical, administrative and the elite discourses and attitudes on the issue all reflect this proclivity, though albeit the story will probably not be as neatly chronological as this schematic abstract may suggest.

Paper Giver 5: Sylvia Sax, Department of Tropical Hygiene and Public Health, University of Hedielberg, Germany

Paper 5 Title: Turning Dinosaurs into Strategic actors

Paper Abstract: Much has been written about the need to reform bureaucratic Human Resource (HR) practices. Most Health Reform programmes include HR reform as a priority area. But what is really involved in turning around these dinosaurs that sit at the heart of many Ministry’s of Health. The Department of Health and Family Welfare, Government of West Bengal (DHFW, GoWB) has recently developed a Strategic Plan, one of immediate priorities is to restructure their HRD systems. I have been involved in helping them investigate what the immediate and long term steps are to make the dinosaur move.
Three years ago a Government if India Working Paper concluded that “Without addressing the more fundamental capacity weaknesses related to roles, structures, and systems, the attention on ‘volume capacity’ by constructing new facilities is doomed to fail. Similarly, providing more and more training without individual role capacity to use their skills is ultimately a misguided exercise in blaming the victims.” (GoI Dept. H&FW, Pp. 8 ). The previous Principle Secretary, Department of Health and Family Welfare Government of West Bengal also stressed this point in a recent speech, “Our procedures and systems have outlived their usefulness and we need to have the courage to change them if we are to implement our Strategy and realize our vision, especially HRD, accountability and links with the private sector” (SPC Meeting, 12/02/04).
But this realization is not enough; it must be turned in to action. In this paper we will examine some of the implications of health system reform for Human Resources, how policymakers can strengthen the link between Strategic (reform) objectives and the actions of the workforce and, using the example of West Bengal, how this change can be encouraged and reinforced.

Paper Giver 6: Saswata Ghosh, Council for Social Development (CSD), New Delhi, India, and P.M. Kulkarni, Centre for the Study of Regional Development, Jawaharlal Nehru University, New Delhi, India

Paper 6 Title: Do socio-economically backward sections of society lag in epidemiologic transition? An exploratory analysis for India

Paper Abstract: India has witnessed a remarkable decline in mortality since 1921 and particularly after independence. This decline is accompanied by an ‘epidemiologic transition’. Research on epidemiologic transition has recognized that the pattern of causes of death has been changing over time and it also varies across populations. Most analyses adopt an ecological approach, of relating the pattern to the national or societal level of mortality and of other characteristics such as income (see the recent work of Salomon and Murray, 2002). A natural question that arises is that does the cause pattern vary by economic classes and also by social groups ‘within a population’? It is conceivable that different socioeconomic classes of a population follow different paths of epidemiologic transition and hence at a time point during the process, are at different phases of transition. This is an issue of relevance in a country like India with a highly stratified society. Using data from the second National Family and Health Survey of India (1998-99), this paper examines whether various socioeconomic characteristics of households influence the pattern of causes of death among various age-sex groups. The results of logistic regressions reveal that social deprivation, standard of living, and education seem to be important determinants of the relative risk of death due to communicable diseases. In other words, socially and economically backward classes lag behind the more advanced sections in the transition process. There is thus a strong case for targeted health interventions.

      Full paper to be downloaded (as a pdf-file)

Paper Giver 7: SECRET

Paper Giver 8: Karin Polit, MA, Department of Anthropology, South Asia Institute, University of Heidelberg, Germany

Paper 8 Title: Social inequalities in health in Garhwal and its impact on Public health improvement

Paper Abstract: Social inequalities in health continue to be a key public health problem. Recent studies in Europe have shown that there are associations between the psycho-social environment and ill health (see e.g. Siegrist & Marmot 2004, Wilkinson 2003). Its has been shown that non-reciprocal social exchanges and low control over ones own life and decisions made in the family can contribute to ill health (Wilkinson 2001, 2003). All this seems to hold true for rural South Asia as well. The people most marginal in Garhwal, Uttaranchal are low caste rural women. I argue that women’s health and their access to medical care is influenced not only by the marginality resulting from their low caste and class status, but also their relative status within their families and villages. In this paper, I will explore the dynamics in a current Public health effort of a local NGO which focus on the education and empowerment of women, hoping to improve the overall health status in local villages. Basing my analysis on ethnographic field data and on theories of social inequality, I will explore the tools used to implement the program and evaluate their chances for success.

Closing Remarks by Dr Bo Lindblad, 17.30–18.00