27th Ramanadham Memorial Meeting: Public Health, Inequality and Democratic Rights


The late sixties marked the first major crisis of independent India at all levels of its
economy and polity. This crisis gave birth to radical movements. Among these
were the tribal and peasant struggles led by Marxist Leninist parties. Brutal state
repression was launched on these movements. Regional civil rights
organisations arose as a response to the various illegal modes of repression. Thus in
1974 Andhra Pradesh Civil Liberties Committee [APCLC] was founded in
Andhra Pradesh.

Those were the times when A. Ramanadham, a medical doctor by profession,
founded one of the district units of APCLC in Warangal town.
Born in Mustikuntla, a small village in Khamman district in 1933, he started his
career as a government doctor. Dissatisfied with the unethical medical practices, he
left his job and set up his own Children’s Clinic in 1968 in Warangal. That year
marked the beginning of his involvement in various social issues. The clinic was to
become, perhaps, the only democratic centre in the entire town.
In June 1975, Emergency was imposed institutionalising the ongoing repression. Dr.
Ramanadham, along with other activists, were arrested. After lifting of
Emergency APCLC was able to function again. Dr. Ramanadham became its
Vice President.
Civil rights organisations that had earlier been confined to their own regions and
histories, began to share information and experiences. Joint investigations into
repression on worker and peasant struggles and joint campaigns on repressive
laws. In this process of building fraternal relations PUDR came to know the work of
Dr. Ramanadham. And to appreciate his gentle friendliness and modesty

Dr. Ramanadham’s involvement with civil liberties was inseparable from his
professional role as a doctor. In fact, his professional role helped the civil rights
movement which, in turn, made him a better doctor. It helped him to understand
the social origins of the diseases of his patients He did not confine himself to
giving medicines but tried to spread a scientific outlook. Out of this came his
famous book in Telugu, Medical Guide which was addressed to the people and not
to health workers.
Dr. Ramanadham tried to create a space for democratic values wherever he went
and in whatever he did. Struggling against corrupt medical practices in a health
centre in Husnabad, helping friends to bring out a revolutionary literary journal in
Warangal, helping a young girl and conducting her marriage against the will of her
influential parents, organising a people’s clinic with the help of doctors on strike in
front of Warangal -Government Hospital, are examples of Dr. Ramanadliam’s
involvement and initiative in democratic concerns

In the late seventies peasant struggles for higher agricultural wages and against
landlord repression spread in Warangal and other districts Police was given extensive illegal powersto repress these struggles. Governments kept changing  but state violence continued. With APCLC, Dr. Ramanadham was actively involved in investigating fake encounters, custodial torture and deaths. This earned  them the wrath of the police

On 2nd September 1985, at Kazipet railway station, SI Yadagiri Reddy was shot
dead by unidentified assailants, believed to be naxalites. Next morning his body
was carried in a funeral procession in which a number of armed policemen
participated. The procession was led by the district Superintendent and the Deputy
General of Police. When it neared the Children’s Clinic, a group of policemen
broke into the clinic. They ransacked the clinic and assaulted the compounder and
waiting patients. Then they went into the neighbouring shop, Kalpana Opticals,
where they found Dr. Ramanadham and shot him at point blank range.
Immediately after, a neighbouring doctor took him to Mahatama Gandhi Memorial
Hospital, about two kilometres away. Soon after he was declared dead. With his
death the Warangal unit of APCLC” ceased to function
Four days after his death, police filed a second FIR in the Yadagiri Reddy murder
case, the first murder case to be registered under TADA in Warangal. Dr
Ramanadham was named as accused. However, in the case of the murder of Dr.
Ramanadham, no accused were named. Police maintained that naxalites were
responsible and they had used snatched police revolvers. Two policemen were
suspended for dereliction of duty as their revolvers had been snatched
Barely a year later J. Laxmareddy, President of the Karmmagar unit of APCLC
was killed by police on 7 November 1986. The Warangal unit was revived with
the efforts of N. Prabhakar Reddy who became its convenor. A lawyer by
profession, he was instrumental in obtaining bail for hundreds of rural youth
charged under TADA. On 7 December 1991, police came to his house and shot
him dead.
The murders of civil rights activists are not random acts of violence by a few
deviant policemen. These are part of a larger political policy of the government
against the people. Perhaps the only meaningful way of remembering Dr
Ramanadham is by committing oneself to the movement for democratic rights
and affirming our faith in people’s struggles to implement and extend these
rights.

People’s Union for Democratic Rights (PUDR), Delhi

Invites you to attend

27th Ramanadham Memorial Meeting

Public Health, Inequality and

Democratic Rights

Speakers:

Dr. Yogesh Jain

Jan Swasthya Sahyog

Topic: Social Inequality and Public Health

Dr. Jacob Puliyal

St. Stephens Hospital, Delhi

Topic: Immunization Programmes and Public Health

Dr. Amit Sen Gupta

People’s Health Movement

Topic: Drug Policy, Pricing and Public Health

Chair

Dr. Ritu Priya Mehrotra

Centre for Social Medicine & Community Health, JNU

8th September, 2012

5 pm – 8pm

Conference Hall

Indian Law Institute

Opp Supreme Court

Bhagwan Das Road

New Delhi

False Promises- Dr Mohan Rao


A basket weaver at work with her baby at her side, in Tamil Nadu. The infant mortality rate is very high for working women, particularly those in the primary sector, a large proportion of whom are labourers.

The claim that the Unique Identification project will facilitate the delivery of basic health services is dishonest

AMONG the many reasons cited for India to proceed with the Unique Identification (UID) project – that it will facilitate delivery of basic services, that it will plug leakages in public expenditure, that it will speed up achievement of targets in social sector schemes, and so on – the most specious is perhaps the claim that it will help India reach its public health Millennium Development Goals (MDGs).

Despite impressive economic growth in the country, the huge load of preventable and communicable diseases remains substantially unchanged, in addition to starvation deaths. Although life expectancy has increased and infant and child mortality rates have declined, these declines have been relatively modest. Infant and child mortality take an unconscionable toll – 2.2 million children every year. We are yet to achieve the National Health Policy (NHP), 1983, target of reducing the infant mortality rate (IMR) to less than 60 per 1,000 live births in all the States. More serious is the fact that the rate of decline in the IMR has been decelerating, from 27 per cent in the 1980s to only 10 per cent in the 1990s. The same is true for the rate of decline in the mortality rate of children under five from 35 per cent in the 1980s to 15 per cent in the 1990s. It is clear that India will not reach the Millennium Development Goals of reducing IMR, U5MR and the maternal mortality rate (MMR).

India has higher maternal deaths than any other country. The NHP target for 2000 was to reduce the MMR to less than 200 per 100,000 live births. However, in 2000, between 115,000 and 170,000 women died in childbirth, accounting for about one-quarter of all maternal deaths worldwide. Far from declining over the 1990s, maternal and neo-natal morbidity and mortality rates in India have, at best, plateaued. High and unconscionable as these levels of maternal mortality are, it is nevertheless critical to bear in mind that they represent just a fraction of the morbidity and mortality load borne by women in the country. Thus, for instance, deaths caused by anaemia among women who are not pregnant are twice as many as among those who are. Similarly, communicable diseases take a much higher toll than that due to pregnancy and childbirth.

The reasons are complex and stem, above all, from the lack of political and financial commitment to build a public health system that can meet the challenges. As the National Health Policy (NHP) 2002 admitted, this is, at 0.9 per cent of the gross domestic product (GDP), the fifth lowest public expenditure on health in the world. The decline in public investments over the years was matched with growing subsidies to the private sector in health care in a variety of ways. Thus we have the largest, and one of the least regulated, private health care industry in the world. Evidence from across the country indicates that access to health care has declined sharply over the last two decades. As the government admits, the policy of levying user fees has impacted negatively upon access to public health facilities, especially for poor and marginalised communities and women.

High private medical expenditure

It is to be remembered that along with poor public financing, India has one of the highest private medical expenditures in the world: out-of-pocket expenditure accounts for 83 per cent of the total health expenditure in the country. It is thus not surprising that, as the NHP 2002 notes, medical expenditure has emerged as one of the leading causes of indebtedness. At the same time, the proportion of people not availing themselves of any type of medical care for financial reasons increased between 1986-87 and 1995-96 from 10 to 21 per cent in urban areas, and from 15 to 24 per cent in rural areas. It is not just the poor; even the middle classes – the upper echelons of which welcomed globalisation – are finding it increasingly difficult to meet medical care costs.

The short UID Working Paper on Public Health astonishingly sees the UID as helping create “demand” for public health in the country. If people are voting with their feet for the private sector, which they do not and cannot trust, it is precisely because the public sector does not offer them quality care. Nor, indeed, is whatever care offered free of cost. Why then go to a crumbling system that offers little other than immunisation and family planning? Indeed, there is a huge unmet demand. In other words, the critical shortfall in supply of quality comprehensive services. How does the UID help with that? The UID Working Paper on public health sets out what it calls “killer application” to provide citizens an incentive to obtain a UID card in order to meet health needs. This unfortunate language apart, the fact that we have not built a health care system for the population is hardly fortuitous.

The Working Paper highlights the fact that we lack good-quality health data or indeed even vital statistics. It is equally true that this should come from integrated routine health system and not ad hoc surveys. But how is the UID to rectify this? People are avoiding the public health system for a variety of reasons: lack of drugs, lack of doctors, having to pay for services, inconvenient hours, rude personnel, and so on. Unless these issues are attended to, data quality cannot be improved. The UID is no magic bullet.

Thus the UID is not designed to meet the public health challenges in the country and should not pretend to do so. On the contrary, given that many diseases continue to bear a stigma in this country, the UID scheme has the unique potential of increasing stigma by breaching the anonymity of health data collected. It thus violates the heart of the medical encounter, namely confidentiality. By making this information potentially available to employers and insurance companies, the scheme bodes further gross violations of health rights. It is this reason above all that persuaded many countries in Europe not to accept such schemes.

his maternity unit near the primary health centre at Sellamanthadi village near Dindigul in Tamil Nadu is not in use. Evidence over the past two decades shows that access to public health care has dwindled, spawning one of the world's largest private health care industries.

The justification that the launch of the Rashtriya Swasthya Bima Yojana provides a “killer” opportunity for the UID scheme to free ride is equally moot; an evaluation of the RSBY scheme in Kerala, a State with extremely good health indicators, shows a number of problems, in particular an inability to reach marginal groups (Narayana D., “Review of Rashtriya Swasthya Bima Yojana”, Economic and Political Weekly, vol.xlv, No.29, July 17, 2010). Anecdotal evidence from Kerala also indicates a huge increase in costs because of what are politely called “moral hazard” problems. Simply put, doctors in the private sector are subjecting patients to unnecessary tests and treatment now that they are assured of payments. In short, this creates an “effective demand” for the private sector in a segment of the population hitherto not availing itself of this because of poverty. It is for these reasons that the High Level Expert Group of the Planning Commission rejected recently such a model of health care universalisation.

The biometric health insurance cards issued to Delhi slum-dwellers under the State government’s “Mission Convergence” scheme requires card-holders to identify themselves with a fingerprint before they can avail themselves of free hospital treatment. Non-governmental organisations (NGOs) involved in the scheme say that they are inundated with complaints about malfunctioning fingerprint readers, which fail to authenticate even after multiple swipes. Since the scheme is tied up with private health providers, users in need of emergency treatment often end up paying inflated fees for services that they could get at a lower cost, if not free, at a government hospital.

One area where the UID card would be extremely beneficial has, of course, to do with clinical trials. As is well known, since 2005, India has opened up as a market for clinical trials of drugs, and that this is a huge industry, with MNCs now rushing in. It is equally a well-known secret that the trials that are being conducted are not good trials that the MNCs want. These good wishes are being vitiated by the trial subjects, the poor guinea pigs. Again, the evidence is of necessity anecdotal, but given the poverty levels, one way of getting quick cash – or indeed cellphones – is to enlist in several trials simultaneously. We all know this is happening and this is one area where the UID would be useful. That is to say, the guinea pigs can be carefully monitored not to enlist on more than one trial. Will it help in identifying side effects? In obtaining compensation for side effects or death? Of course not: the card cannot help here.

While there are systemic problems for low health access and outreach (such as low – and falling – immunisation coverage), to pretend that the UID scheme offers a solution to the problem is dissembling at best, and dishonest at worst. The UID scheme has thus little to offer for improvement in the public health situation in the country. On the other hand, the UIDAI has much to gain from a link-up with the public health system.

As the UIDAI Working Paper on public health puts it, in amazingly bad language: “The demand pull for this needs to be created de novo or fostered on existing platforms by the respective ministries. Helping various ministries visualise key applications that leverage existing government entitlement schemes such as the NREGA and PDS will get their buy-in into the project …. and will also build excitement and material support from the ministries for the UID project even as it gets off the ground.”

Given the significant potential for misuse of data, human rights violations and breach of confidentiality of health information, one hopes that the Ministry of Health will restrain its “excitement” and undertake a rigorous analysis of the costs and risks of the scheme before providing “material support” to the UID project. Or is this expecting too much from a Ministry that routinely betrays people?

Dr Mohan Rao is Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.

FRONTLINE- Volume 28 – Issue 24 :: Nov. 19-Dec. 02, 2011

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