Public Health Perspective
Why people's interest in public health is less?
Whenever we think about health we usually think of three 'D' — Disease, Doctor and Drug. In other words we think of hospitals and doctors' chamber. But this perception is only half of what healthcare is all about. According to the World Health Organisation (WHO), health is a complete state of physical, mental, social and spiritual well being and not merely the absence of disease or disability.
So the disease centered perception of health is not always the right thought. It is only the clinical portion that draws people's attention. Poor access to healthcare services along with insufficient and lower quality of service provided by the public healthcare facilities for many years made this perception stronger.
People think of health whenever one gets sick, but health is a state of well being and not the state of disease only. The British Medical Journal once said in its editorial — critical scrutiny of public healthcare and medical strategy depends, among other things, on how individual states of health and illness are assessed.
One of the complications in evaluating health states arises from the fact that a person's own understanding of his or her health may not accord with the appraisal of medical experts. More generally, there is a conceptual contrast between "internal" views of health (based on the patient's own perceptions) and "external" views (based on the observations of doctors or pathologists). The external view has come under considerable criticism recently, particularly from anthropological perspectives, for taking a distanced and less sensitive view of illness and health.
It has also been argued that public health decisions are quite often inadequately responsive to the patient's own understanding of suffering and healing. Self reported morbidity is, in fact, already widely used as a part of social statistics, and a scrutiny of these statistics brings out difficulties that can thoroughly mislead public policy on healthcare and medical strategy. For example, pain is quaint essentially a matter of self perception. If you feel pain, you do have pain, and if you do not feel pain, then no external observer can sensibly reject the view that you do not have pain.
But medical practice is not concerned only with the sensory dimension of ill health. One problem with relying on the patient's own view of matters that are not entirely sensory lies in the fact that the patient's internal assessment may be seriously limited by his or her social experience. To take an extreme case, a person brought up in a community with many diseases and few medical facilities may be inclined to take certain symptoms as "normal" when they are clinically preventable.
Investment in healthcare, especially when it is driven by the interests of pharmaceutical companies, seems to produce a J-curve. For most of the curve, the more money spent, the better the health outcomes, but after a certain point, the more spending and the more emphasis on health at the expense of other areas of human activity and achievement, the worse overall health becomes.
Amartya Sen has compared people living in Bihar, Kerala, and the United States. Bihar is the poorest state in India, and Kerala is the state that has invested most heavily in education and achieved the highest rates of literacy. Predictably, life expectancy is lowest in Bihar and highest in the United States, with Kerala's falling between the two but much closer to the United States. However, the rates of self reported illness are paradoxical: low in Bihar, where the low expectations of health are disturbing, and enormously high in the United States, which is equally disturbing but for different reasons. Kerala combines the greatest longevity and the highest rate of self reported illness of all the Indian states. It seems that the more people are exposed to doctors and contemporary health care the sicker they feel.
Health has become the over-riding contemporary virtue, and the measure of healthcare in rich countries has become, to a great extent, the simple prolongation of life. The political and financial power of the multinational pharmaceutical conglomerates continues to grow, and they supply money and resources to both clinicians and researchers.
At the same time, developments in information technology drives the rigorous standardisation of the diagnosis and treatment of illness and disease so that care is increasingly directed by protocols that minimise uncertainties. Contemporary complexity science shows the lack of a linear relation between cause and effect, but doctors and healthcare systems persist in purveying a simplistic rhetoric: "If you do this, this will follow."
How many patients really understand the numbers needed to treat they are caught up in? How hard do doctors try to explain? The three trends of the industrialisation of health, the medicalisation of life, and the politicisation of medicine are intertwined and mutually reinforcing and each depends on the pretence that we know much more than we do. Only minorities of most populations are sick at any one time; the majorities are healthy. It is clearly in the interest of the pharmaceutical industry that this majority should be persuaded that they need to take action to remain healthy.
As doctors, are we simply interested in postponing death? Should we not also be interested in reducing rather than fanning the disease burden and in emphasising rather than undermining health? It is the enduring truth that we can never know what will happen tomorrow, but we are sure that the balance sheet of preventive activity of public health really offers more good than harm. Better health for a better tomorrow is nothing but better importance for public health rather than drug, disease and doctor.
The writer is a Public Health Specialist and Epidemiologist. He works as a Technical Officer at World Health Organisation, Bangladesh Country Office. The opinion of this article is personal and may not be agreeable by the organisation he serves.
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