Reaching the unreached

The rising cost of modern healthcare systems and the expansion of proprietary science will take healthcare out of the reach of the economically underprivileged. By strengthening public research and community hospitals, medical practitioners can reach out to the excluded, says M. S. SWAMINATHAN, noted scientist.

THIS century has begun with remarkable achievements in science and technology, particularly in the area of molecular genetics. Human genome mapping has been nearly completed and more than 40 hitherto unknown disease genes, including ones responsible for epilepsy, deafness, colour blindness and muscular dystrophy, have been identified. The human genome map has also revealed that all members of the human family have in common nearly 99.99 per cent of their genetic information. Thus, there is no scientific basis for discrimination on the basis of race, colour, caste or gender. It is a matter of shame that the sex ratio continues to be unfavourable to women in our country. According to the preliminary results of the 2001 census, the sex ratio has further declined in the 0-6 age group, although there is a marginal improvement in the overall sex ratio. Unfortunately, female foeticide seems to be on the rise, particularly in several Northern States.

According to the World Health Organisation (WHO), almost 90 per cent of deaths from infectious diseases are caused by only six diseases - pneumonia, tuberculosis, malaria, diarrhoea, measles and HIV/ AIDS. The spread of infectious diseases is happening partly because of the increasing resistance of microbes to antimicrobial drugs. WHO has also chosen the following activities for priority attention:

*Roll back malaria

*Tobacco-free initiative

*Fight against tuberculosis and HIV/ AIDS

Efforts to prevent and control these diseases will make an important contribution to poverty alleviation and social and economic development.

The unravelling of the genomes of disease-causing organisms have opened up a new window of opportunity to medical graduates to make significant contributions to combating infectious diseases. For example, the recent findings on the genomic structure of Mycobacterium tuberculosis present a wonderful opportunity for young medical researchers to develop new diagnostics, drugs and vaccines. The far-sighted Biotechnology Policy Statement of the Government of Tamil Nadu has provided for the establishment of a Bioinformatics and Functional Genomics Centre near Tidal Park in Chennai and also for a biovalley along the knowledge corridor extending from Chennai to Mahabalipuram with provision of infrastructure for medical and environmental biotechnological enterprises. Already, a Women's Biotechnology Park is functioning at Kelambakkam. A biovalley for medicinal plants is also to come up in the Kodaikanal-Madurai area.

There are, thus, uncommon opportunities for medical graduates inclined to take a career in medical research and drug development, to embark on an exciting adventure to find effective and affordable cures for the important diseases affecting our children, women and men. Generic and customised biochips are being developed for disease diagnosis, monitoring of drug treatment and analysis of mutations. DNA micro arrays or genome chips have started helping in the areas of gene discovery, drug discovery and epidemiological and toxicological research. Also, nanotechnology, a molecular-precision manufacturing technology, is close to realisation. When this technology is perfected, doctors will be able to keep desktop-sized computers which contain the raw processing power of one million human brains.

While the scientific world is witnessing such extraordinary progress in medical technology, interest in research and technology development is still poor among our young scholars. Even much of the medical research in progress is not very relevant to the needs of our country, according to Prof. Subbiah Arunachalam of the M.S. Swaminathan Research Foundation, who maps scientific projects and priorities through scanning published literature. Even when outstanding research of relevance to the control of common diseases is carried out in our country, the linkage between lab to patient is poor. For example, in the area of tuberculosis control, the Chengalpet BCG trial has no parallel. However, as the Director of Tuberculosis Research Centre at Chennai, Dr. P. R. Narayanan has recently pointed out, quoting Dr. Halfdan Mahler, a former Director General of the World Health Organisation who initiated the imaginative Small Pox Eradication Programme - "all countries benefit from the fruits of India's TB research - all countries except India".

Similar is the case relating to the bio-environmental control of malaria developed by Dr. V. P. Sharma and his colleagues in India. According to WHO, the bio-environmental control of malaria developed by Dr. Sharma is emerging as a major landmark in the management of malaria in South Asia. We are yet to derive benefit from our own work. How can we end this unfortunate irony?

In my view, Medical Colleges and Universities can show the way. For this purpose, it will be useful to introduce a separate course on research methodology and on cutting-edge developments in medical research in the MBBS course. Such a course on research methodology could be linked to undertaking research projects in suitable institutions belonging to both the public and private sectors, during summer vacation. This will not only help the young medical scholars to experience the excitement of science but will also foster cross-fertilization of ideas, linking clinical problems with basic research in a symbiotic manner.

A proud achievement of independent India is the near doubling of average life expectancy since 1947. Life expectancy is now 61 years and it is higher in Kerala and Tamil Nadu. This improvement has resulted largely from improved availability and intake of food, since the benefits of advanced medical technology are available only to about 10 per cent of the population. The universal nutritious noon meal programme for school children introduced by the late Chief Minister Dr. M. G. Ramachandran 20 years ago was an important step in the upgrading of the nutritional status of children. While we have been successful in improving the nutritional status of the population during the last 50 years, success in combating low birth weight, anaemia and povety-induced endemic hunger has been only marginal.

Low birth weight children start their lives with handicaps including impaired brain development. Four major interventions are urgently called for. These are: attention to the nutrition of pregnant and nursing women, equitable distribution of available food among members of a household, better child rearing practices and prompt attention to infection. Studies in Kerala have shown that equitable distribution of food between income groups and within families, introduction of complementary food to breast-fed infants, and early diagnosis and effective management of infections in childhood, have been responsible for the better nutritional status prevailing in the State.

Research on healthcare delivery systems has not so far received adequate attention. For example, food distribution through ICDS is not an answer to meeting the nutritional needs of infants in the age group of 6 to 12 months. The young child needs to be fed about five times, small quantities of semi-solids in addition to breast milk. Unfortunately, this age group is not reached by ICDS programmes. It would be useful to train two elected members of village Panchayats - one woman and one man - in improving child- rearing, feeding and health management practices in the community. Medical Universities can run non-degree short duration training programmes for members of such Panchayat Community Health Corps.

While dealing with nutrition, I would like to make a mention of the linkages between the nutrition and healthcare of plants and animals and human health. Recent developments in the United Kingdom and Europe with regard to infectious zoonotic conditions, namely bovine spongiform encephalopathy (BSE), popularly known as mad cow disease, which leads to variant Creutzfeldt-Jacob disease in humans, highlights the limitations of recycling food products for human consumption within the food chain. Crops grown in soils deficient in zinc, iron and other micronutrients produce grains which are deficient in such micronutrients. Consequently, hidden hunger caused by the deficiency of micronutrients in the diet is increasing.

Similarly, millions of farms, households and consumers are exposed to dangerous levels of pesticides. Pesticides with long residual toxicity like DDT are still being used in our country. A large body of experimental evidence based on in-vitro and in-vivo models suggests that many of the pesticides damage the immune system. Several organo-Chlorine, organo-phosphate, carbonate and metallic pesticides are immunotoxic. The major pesticide companies should have a responsibility to ensure that the products they sell do not pose a threat to the human immune system. Environmental pollution and carcinogens, and hospital wastes pose serious threats to human health. Lack of environmental hygiene and water pollution are major causes of the poor biological utilisation of food in the body among children as well as adults living in poverty as well as among those living under sub-human conditions in slums. More and more people are dying in urban India due to high levels of pollutants in the air. Tiny toxic particles in the air damage public health. Improving the quality of the environment and of drinking water will make substantial contributions to improving human health. We are indebted to our far-sighted judiciary for its commitment to ensuring that the basic human right of access to clean air and water is met.

It is a matter for concern that HIV positivity rate is going up in Tamil Nadu. There is need for greater awareness among the public on causes for the spread of HIV and AIDS. People should be aware of three simple precautionary steps - safe blood, safe needles and above all, safe sex. Also, medical ethics demands that there should be no discrimination against those infected with HIV or AIDS. In addition to HIV/ AIDS, there are serious outbreaks of leptospirosis, malaria, gastroenteritis, tuberculosis and jaundice. Diabetes is also gaining in intensity. We should ponder and analyse why inspite of the excellence of our Medical Universities and institutions, disease for which there are effective remedies are spreading.

In 1981, I chaired two National Committees which were set up by the Government of India to suggest strategies for eradicating leprosy and preventable blindness by the year 2000. Multi-drug therapy has helped to reduce the incidence of leprosy substantially. We are yet to take the final steps needed to achieve the goal of a leprosy-free India. Preventable blindness is also receiving much greater attention now and more community- oriented eye care centres are getting established. Medical Colleges and Universities could establish virtual colleges linking them to the Primary Healthcare Centres for attending to the preventive, curative and social dimensions of diseases of importance. Social and medical scientists should work together in helping the country to achieve the goal of health for all.

In this context, our indigenous health traditions, enshrined in the Ayurvedic, Unani and Siddha systems of health care, need greater attention. We have 6000 years of leadership in Ayurveda. The basic approach to health care in the Ayurvedic system is a holistic one, ranging from attention to diet and lifestyle to the use of plantbased drugs and therapeutic exercises. We should bring about blends of traditional health care practices and modern medicine. Without an extensive revitalisation of our time- tested health traditions, the goal of "health for all" cannot be achieved.

A disturbing trend in modern healthcare systems is the rising cost of medical help, including the price of drugs. South Africa and Kenya are taking steps to import cheaper generic drugs for AIDS treatment. With the expansion of proprietary science involving patents and other forms of intellectual property rights, orphans are likely to remain orphans in the area of health care, unless steps are taken to strengthen public good research and community hospitals. Reaching the unreached and including the excluded should be the goal of all medical practitioners. The Voluntary Health Services, established by the late Dr. K. S. Sanjivi, is striving to achieve the goal of low- cost but high quality healthcare. Similary, the Resource Group for Education and Advocacy for Community Health (REACH), Deepam Educational Society for Health (DESH) and several other community-centred organisations are doing valuable work in promoting awareness and stimulating analysis and action in the case of diseases like hepatitis, tuberculosis and HIV/ AIDS. We need a network of such organisations devoted to the health security of the underprivileged.

Mahatma Gandhi asked us to regard ourselves as trustees and not owners of our surplus wealth and of our intellectual power. Sharing the benefits of both financial and intellectual wealth with the less-privileged sections of the community should become a national ethic. Ethics should increasingly guide experimentation, whether it is human stem cell research or the production of new vaccines and drugs. Extending the benefits of advances in preventive and curative medicine to the economically and socially underprivileged sections of the population should become a fundamental part of medical ethics.

Genomics, proteomics, internet, biochips and nanotechnology can provide unique opportunities for a sustainable happy future for all, only if we apply a strong ethical push to the technological pull.

Send this article to Friends by E-Mail

Section  : Features
Previous : Earth spirituality: A new eco-social paradigm
Next     : Knowing your limits