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engagement, there is a very real chance that private universities may end up mimicking the culture of public universities which led to their failure, leaving us educationally as well as nancially poorer.
Note
1 See Patterns of Deception, a project of Annenberg Public Policy Center of the University

of Pennsylvania, http://www.ackcheck.org/ patterns-of-deception/false-logic/, accessed on 30 October 2013 for use of false logic in especially analysing political rhetoric.

References
Hodges, Sarah (2013): It All Changed after Apollo: Healthcare Myths and Their Making in Contemporary India, Indian Journal of Medical Ethics, Vol X No 4, October-December, pp 242-49. Pathak, Binay Kumar (2014): Critical Look at the

Narayana Murthy Recommendations on Higher Education, Economic & Political Weekly, Vol XLIX, No 3, 18 January, pp 72-74. Patnaik, Prabhat (2010): A Left Approach to Development. Economic & Political Weekly, Vol XLV No 30, 24 July, pp 33-37. Rapport, Nigel and Joanna Overing (2010): Social and Cultural Anthropology: The Key Concepts (London and New York: Routledge). Tilak, Jandhyala B G (2013): Higher Education in India: In Search of Equality, Quality and Quantity (New Delhi: Orient Blackswan).

Political Accountability for Outbreaks of Communicable Diseases

Debabar Banerji

The political and bureaucratic leadership of Indias public health services and programmes, unqualied and untrained for this role, has allowed foreign and international agencies to set the countrys health agenda. In the process, while massive amounts are being pumped into health programmes, the health services have deteriorated and the poor continue to suffer.

Debabar Banerji (banerjinucleus@gmail.com) is Professor Emeritus, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.
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he outbreak of the cholera epidemic in New Delhi in 1984 dramatically exposed the extent of the breakdown of the public health system in the country (Banerji 1984). This deterioration has been going on ever since the political leadership with the support of foreign powers launched the ill-fated family planning programme in 1967. Assuming that the Indian Administrative Service (IAS) ofcers who inherited the anti-people attitude of the British trained Indian Civil Service (ICS) would be better suited to perform the hatchet job of forcing the poor to submit to sterilisation, the politicians handed over this task to them. The union ministry of health was broken up to form a separate and well-funded department of family planning. By 1984, when the cholera epidemic broke out in Delhi, the bureaucrats had considerably increased their power and extended their tentacles into wide areas of public health. However, they had neither the required qualications nor experience and nor could they be held accountable due to frequent transfers. For example, how could a health secretary, who has spent most of his service life outside the ministry and who has a college education, say, in English literature, negotiate with international agencies about acceptance of the latters patently faulted International Initiatives for India? How can he take key decisions on areas of cadre structure, health manpower development or hospital

administration? When the opportunistic politicians decided to set up a separate department for ayurveda, yoga, unani, siddha and homeopathy (AYUSH) in the ministry of health, they chose a bureaucrat to provide the leadership. The administrative situation is much worse in the states, despite health being a state subject. The political leadership of the ministry of health has also to be held responsible for the abolition of the Indian Medical Service (IMS) cadre after Independence and replacing it by another all-India cadre. The IMS ofcers who occupied key public health positions at the central and state levels had wide range of public health competence in the epidemiological, management and political and social elds. Hugh Leavell (1968) had aptly named them as the managerial physicians. The Central Health Ser vice (CHS) which replaced the IMS was dominated by clinicians who formed the bulk of the central government health personnel. Like the IAS bureaucrats, the CHS ofcers lled key public health positions, both at the central and state levels square pegs in round holes! Ironically, gross inadequacies among the CHS ofcials in public health served the narrow interests of the IAS bureaucrats, as they could not challenge the latters decisions. This also helped the politicians. Similarly, foreign powers and international agencies found these limitations convenient to push in their own agendas. The politicians and bureaucrats can thus be held accountable for causing great damage to the health services of the country. The 1984 cholera epidemic was merely one consequence. Due to the same reason, the capital has been regularly facing seasonal epidemics of haemorrhagic dengue fever. Those in charge of protecting the citizens health failed to discover the causes of the epidemic and devise a strategy to cope with it. The
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authorities have not even been able to set up a reasonably reliable information system for the vitally needed assessment of the size and extent of the disease. The same observations can be made about other massive communicable disease problems in the city, such as tuberculosis, malaria, gastrointestinal diseases and pollution-related health conditions. New Delhi is by far the most privileged among all the states in terms of resources. More than 66 years after Independence, India still does not have a dependable system of recording births and deaths. Efforts have been made to create a National Sample Registration Scheme, which still has problems of reliability in patches in getting some of the vital data. Decennial Censuses since 1871 are another source. As far as morbidity data are concerned, there is a huge chasm. In a recent draft document, the Indian Council of Medical Research (ICMR) frankly admits that it lacks quality data even on the main health problems in the country. What has the ICMR been doing in all these decades? This is a sad reection on the state of the top medical and public health research institution of the country. Under such circumstances, any talk of compulsory notication of communicable diseases or any public health law needing such data is meaningless, if not downright misleading. When top global public health organisations like the World Health Organisation (WHO) and the World Bank state that India is the AIDS capital of the world or India is the tuberculosis/diabetes capital of the world based on highly unreliable data one feels dejected at the level of their ethical and public health probity. Yet another cause of the breakdown of the health services is the neglect of some of the key institutions for education, training and research in public health, such as the ICMR, the All India Institute of Hygiene and Public Health (AIIHPH), the National Institute of Health Administration and Education (NIHAE) and the National Institute of Communicable Diseases (NICD). In the IMS days, a person chosen as the Directorate General of Health Services (DGHS) of the country would compulsorily spend two years as the director of AIIHPH before taking over the
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post. Similarly, in those days no ofcer could serve as a district health ofcer anywhere in the country before he/she acquired a diploma from the AIIHPH. Even the very limited account given above of the acts of omission and commission of the syndicate of political leadership and the IAS and CHS ofcers of the health ministry describes the enormous damage they caused to the health services of the country because of the lack of public health knowledge and concern for the people. It is signicant that the response of academics and health activists to such blatant sacrilege was also somewhat muted. At long last, when the inadequacies of the public health system could no longer be kept hidden, the international and national elites and the bureaucrats and business interests joined together for a public-private partnership by setting up the Public Health Foundation of India (PHFI) in 2006. The PHFI was dominated by foreign donors to improve manpower, research and consultation in the public health services in the country (PHFI 2006). The irony is that the PHFI leaned heavily on the very people who were instrumental in replacing the Alma-Ata Declaration on Primary Health Care (WHO 1978) by what they called selective primary healthcare (Walsh and Warren 1979). As expected, in the course of more than seven years, the PHFI has fallen far short of what it set out to do with so much fanfare. Heritage of Achievements Milan Kundera said that mans struggle against oppression is a struggle between memory and forgetfulness. Foreign public health experts have so effectively managed to programme the syndicate that they seem to have forgotten some of the very seminal work done in India during the two decades after Independence. Some of these forgotten works are listed here: India had the distinction of carrying out research at the Tuberculosis Chemotherapy Centre at Madras which conclusively proved that the disease can be as efcaciously treated at home as in the much more expensive sanatoria. An equally signicant research of global relevance was to provide evidence that the BCG vaccination has little protective value, at least among adults.
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Following epidemiological ndings from a national sample survey of tuberculosis in the country during 1955-58, an interdisciplinary National Tuberculosis Institute (NTI) was set up at Bangalore in 1959 to specically formulate a nationally applicable, socially acceptable and epidemiologically effective National Tuberculosis Programme (NTP) for the country within the existing nancial constraints (Banerji 1993). India had the distinction of having, for the rst time in the world, a sociologist as an equal member of the interdisciplinary team in NTI. This input enabled the team to give a social dimension to the epidemiology of the disease (Banerji and Andersen 1963). The disease was also dened in terms of the degree of felt need for services among the patients in a community. The data was also used to give a social orientation to the technology to diagnose the disease in remote rural areas in the form of smear examination of sputa by microscopy and in making tuberculosis work an integral part of the general health services of the country (Banerji 1993). India had also launched two major public health movements which prominently stood out amongst all the countries of the world. The mass BCG campaign of the early 1950s (Barua 1981) was considered to be the largest in the world. Later, the National Malaria Eradication Programme (NMEP) of 1956-64 (GOI 1958) beat Indias own BCG record of being the largest public health movement in the world. The NMEP involved fortnightly visits to 60 million houses to detect and treat malaria cases, and spraying each one of them with DDT twice a year. The incidence of malaria in the country came down by more than 99.8%. WHOs Imposition The Universal Immunisation Programme, the Global Programme for AIDS, the Global Tuberculosis Control Programme, the Global Programme for Eradication of Poliomyelitis and the Leprosy Elimination Programme, are examples of the major initiatives taken during the last three decades. Those who claim to be the inheritors of the Enlightenment suffered no pangs of conscience in substituting scientic reasoning and wellresearched conclusions for use of brute
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political power. The promotion of this defective agenda provides an aweinspiring demonstration of the power of the rich to impose their will on the poor. WHO and other international organisations and scholars of international health in public health schools in western countries missed the very obvious fact of sharp differences among the worlds countries. Even if comparison is conned to the lowest fourth of the poor countries, one can easily discern very wide differences among them in terms of such critical issues as epidemiological situation, history of public health practice, political conditions, geographical conditions, racial characteristics, religious factors, and so on. It is therefore not surprising that each one of these uniformly designed programmes was also shown to be seriously awed in terms of policy formulation and programme content. Despite massive investment in these programmes on a global scale, running into billions of dollars, they have fallen far short of the forecasts of achievements at the time of their launching (Banerji 1999). In fact, they inicted further damage to the already battered general health services of the member states, particularly those of the very poor countries. The fate of the much heralded Universal Immunisation Programme is an example. This multi-billion dollar global initiative, launched in 1985 was meant to control the six diseases by 1990. It was given an unceremonious burial without a shred of epidemiological analysis to measure the extent of control or what went wrong with it (Banerji 1990). It took 20 years for the Indian government to admit in the bureaucracy-driven National Health Policy of 2002 (GOI 2002) that the WHO -promoted vertical health programmes were not cost effective, were unsustainable and damaged the growth and development of the general health services. Replacement of the NTP by WHOs Global Programme of Tuberculosis (GPT) was by far the most damaging action among WHOs International Initiatives (Banerji 2012). As has been pointed out earlier, by all accounts, the NTP was an outstanding public health contribution to the entire world. NTP was designed to
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sink or sail with the general health services of the country. The programme was dealt a major blow when starting in 1967, a virtual mass hysteria was worked up to mobilise most of the health services for imposing birth control on the people. Another blow to the general health services was struck when WHO joined the rich countries in instituting a number of vertical programmes in the form of International Initiatives. An ill-conceived, illdesigned and ill-managed GPT was one outcome. In contrast with the NTP, virtually no research was conducted to dene the basic premises of the suggested alternative a specialised programme with its own budget, costing many times that of the NTP; declaring tuberculosis a global emergency; mandating 75% coverage and 90% cure; using expensive second line drugs in short course chemotherapy; and making the outrageous assumption that even when appropriate diagnostic and treatment facilities are made available to patients, they will default even if it meant death and so they must be administered the days dose directly under the observation of the physician. This last was the so-called directly observed treatment short-course (DOTS) regime. India meekly submitted to the dictates and converted the NTP into the RNTCP Revised National Tuberculosis Programme. Many Indian physicians were given well paid jobs to implement the ill-fated RNTCP. It was ill-fated because, as in many other countries, there was no baseline data on the prevalence, so where was the question of controlling the disease? A recent report (TOI , 5 November 2013) on the World Conference of the International Union against Tuberculosis and Lung Diseases, held at Paris, said Indians booed at global meet for genocide of TB patients apparently referring to the failure to offer drugs to new patients from June 2013 because of logistic aws in the supply of drugs. The additional secretary of health ministry, who led the Indian delegation, was dumbfounded. The breakdown of the public health system has mortally broken down the programmes for malaria and AIDS. While the polio eradication programme is dragging to its end at colossal cost and huge time overrun, the Lok Sabha has been
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informed that for the last 32 years, 1,000-10,000 wretched children have been dying of Japanese Encephalitis, with a minuscule fraction managing to travel to Gorakhpur to get the attention of a doctor. While the deputy chairman of the Planning Commission spends Rs 30 lakh in renovating two toilets in his ofce, the political class is yet to full the innumerable promises made over the past 67 years to provide potable water, sanitary latrines and proper environmental sanitation to the long suffering rural population as protection against waterborne diseases. Conclusions Indias public health heritage shows that the country can reconstruct the badly damaged public health system. It will have to retrieve the spirit of the AlmaAta Declaration on Primary Health Care (WHO 1978) and that in turn will require a long, grinding political struggle.
References
Banerji, D (1984): Breakdown of the Public Health Services in India, Economic & Political Weekly, pp 881-82. (1990): Crash of the Immunisation Programme: Consequences of a Totalitarian Approach, International Journal of Health Services, 20: 301-10. (1993): A Social Science Approach to Strengthening Indias National Tuberculosis Programme, Indian Journal of Tuberculosis, Vol 40, pp 61-82. (1999): A Fundamental Shift in the Approach to International Health by WHO, UNICEF and The World Bank: Instances of the Practice of Intellectual Fascism and Totalitarianism in Some Asian Countries, International Journal of Health Services, 27: 227-59. (2012): WHO and Public Health Research in Tuberculosis in India, International Journal of Health Services, 2: 341-57. Banerji, D and S Andersen (1963): A Sociological Study of Awareness of Symptom Suggestive of Pulmonary Tuberculosis, Bulletin of the World Health Organisation, 29: 665-83. Barua, B N M (1981): BCG Vaccination in K N Rao (ed.), Textbook of Tuberculosis (New Delhi: Tuberculosis Association of India). GOI (1958): Manual of Malaria Eradication Operation, Government of India (New Delhi: DGHS). (2002): National Health Policy (New Delhi: Ministry of Health and Family Planning). Leavell, H R (1968): Health Administrator in the Making, NIHAE Bulletin, Vol 1, 15-19. PHFI (2006): Charter of PHFI (New Delhi: Public Health Foundation of India). Walsh, J A and K A Warren (1979): Selective Primary Health Care: An Interim Strategy for Disease Control for Developing Countries, New England Journal of Medicine, Vol 301, pp 967-74. WHO (1978): Primary Health Care, Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, World Health Organisation, Geneva.

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