Struggle for Health: Which is the Way Ahead?

February 24, 2013

By Punyabrata Gun [Translated by Debarshi Das]

[This is part of a continuing series of articles on the People’s Health Movement by Dr. Punyabrata Gun. Previous articles in this series include Peoples’ Health Movement in India: Looking Back at Dalli Rajahara – Achievements and Problems, The Journey of Shramajibi Swasthya Udyog (Working Class Health Project) and The day junior doctors took to the streets in demand for public health. These articles have been translated from Hindi or Bengali. – Editors]

As public health sinks deep in a state of crisis due to assault of globalisation, there is a need for people’s movement for attaining right to health. In India the movement for public health is about thirty years old. In this article an attempt has been made to discuss different strands of the movement, the pro-people character of different strands, role of forces of social change in shaping health movement.

Health does not mean absence of disease. According to WHO, it is a state of physical, mental, social and spiritual wellbeing. To remain healthy one needs rights to work, food, clothing, housing, education and health care. In order to attain optimum health, the socio-economic condition needs to be changed. Historically speaking the working class is supposed to give leadership to the struggle for change, the advanced detachment of the working class is supposed to indicate the direction for change.

In our country the role of this advanced detachment is really inadequate. Yet a number of doctors and medical students have dedicated themselves to the communist movement. From the biography of Bengali poet Sukanta Bhattacharjee, we learn during the mid-40s the Communist Party used to run a hospital – ‘Red Aid Cure Home’. During the time of Bengal Famine ‘People’s Relief Committee’ was formed to stand by the needy. Many doctors and health workers participated in this mission. Among those who stood by the struggling people of the Tebhaga Movement, we know of Dr. Purnendu Ghosh and Dr. Shatrajit Dasgupta. In the ’50s doctors like Dr. Pashupati Nath Chatterjee left their career and went abroad to bear the responsibilities of the international left students’ movement. In 1952 under the leadership of Dr. Arun Sen, a team of leftist doctors formed ‘Students’ Health Home’ in order to provide health insurance to students. Dr. Bijay Kumar Basu, who was a member of the Indian Medical Mission to China, was involved throughout his life in spreading the Chinese health method of acupuncture. On the Vietnam Day of 1947 Dhira Ranjan Sen of the Calcutta Medical College was martyred. In the seventies Dr. Bhaskar Rao was martyred during the Naxal movement. During the same movement scores of students quit the medical colleges to go to the villages, some of them could come back to join the profession, many could not.

Even today there are many doctors who are members or supporters of revolutionary communist groups in India. Many of them are whole timers. Two groups I can recall have doctors at state or at central leadership. However when the author wanted to work in the health movement along with his medical practice after obtaining the medical degree in the mid-eighties, he could not find such opportunity in his state.

The situation has not changed much in the last 25 years. It may sound harsh, but the attitude of the political groups towards doctors could be summed up as: either the doctors would quit their profession to become whole time political activists, or like other doctors they would continue with their practice and simply pay fat levy to the groups, they would treat the occasional patients sent by the group for free, and run medical camps under the banner of the organisation. To organise the doctors and health workers for right to health does not figure in the agenda of revolutionary groups.

In the absence of their initiative the health movement is run by hundreds of NGOs. The money to provide health facilities come from different funding agencies of home and abroad. Many young men and women who want to change the society join these NGOs. In the end instead of changing the system they themselves change. The system co-opts them.

Why people’s health movement?
Any programme of development either benefits public health or causes harms to it. There is a need to understand the mechanism. In the sectors and places where so called development takes place, per capita income rises, food intake per head rises, conditions of work and housing improve, medical facilities improve. Overall, risks of diseases due to malnutrition and infectious diseases decline, life expectancy rises. On the other hand, hazards due to the process of industrialisation also rise, such as accidents, pollution induced diseases, work pressure induced mental disease, addiction, heart ailments etc.

The pattern of industrialisation that we have experienced in our country has entailed massive displacement and loss of livelihood. As a result the poor working people are not freed from diseases that have roots in malnutrition or infection. In addition, they are being afflicted with diseases, which are part of modernisation.

If we look at the state of medical treatment along with the rise of diseases, we find that government medical services are shrinking by the day. Services which used to be provided for free and were of good quality are to be purchased with increasing price from ’90s onwards. The quality has also deteriorated. The private services are expensive and are not of right quality.
From the data one finds,
• In India the second most important cause of indebtedness is medical expenses.
• Every year one crore people go below the poverty line to meet hospital expenses.
• One-third of those who get admitted to hospitals, take loans or sell property to meet the hospital bills.

Thus, like the other necessities of life, health and especially medical treatment are important issues, issues important enough to have a place on the agenda of people’s movement, of revolutionary movements.

In India health services have long been part of social services – charity hospitals and dispensaries, medical treatment of the poor etc. The idea that health is not charity, that it is a right to be achieved through struggle, started giving birth to movements in different parts of the country from the start of the 1980s. Yet most of the people’s movement and revolutionary movements has remained indifferent to building up movements with the demand of right to health. Like right to land, water or livelihood, right to health is critical for life. Not only living a healthy life, it sometimes makes a difference between life and death. But unlike the other issues lack of medical facilities does not affect people all the time. Only when they do not get treatment or cannot buy it or get harmed due to callousness or cheating by doctors or medical institutions they suddenly become conscious, they erupt in spontaneous protests. Most of the time such protests are misled. Hospitals get ransacked, doctors and health workers are beaten up. The main reasons that are responsible remain out of the target. This is where the task of the organisers of people’s movement lies: to sensitise people regarding the social conditions which affect health, to consolidate people on the demand for development of medical services.

It is hard to enlist the support of a particular class in a movement which tries to achieve the demand of a different class. But health movement has the strength to attract majority of people in a society – the middle class, the poor, urban and rural people, women, and men. However there is a risk that agenda of urban influential elite groups would get priority.

People’s health movement is for using science and technology for the improvement of health conditions. However the movement is against the notion that,
• Social problems can be solved through technology alone,
• Only the specialists can decide on behalf of people, that what is good and what is bad for them,
• People are not the driving force of the medical system but are to be used by medical institutions as fodder.

What is people’s health movement?
Success in the movement for improvement in socioeconomic conditions (such as movement for raising wages, farmers’ movement for economic demands) leads to upliftment of people’s health. But such movements are not called people’s health movement. In this article we shall call those movements as people’s health movement that are aimed at improving health or development of medical system. Part of environmental movement can be part of the health movement, such as occupational health movement. Moreover movements which are launched for the purpose of protecting public health such as movement for public distribution system, for public sanitation, anti-addiction movement are parts of health movement.

Let us remind ourselves of some facts:
India is one of the topmost countries as far as privatisation of medical services is concerned.
• 80% of the medical expenses are borne by patients as out of pocket expenses.
• More than 80% of doctors in India are private practitioners.
If we examine other countries, in the erstwhile USSR and People’s Republic of China all health related responsibility of people was with the state. In the UK less than 5% of the medical expenses are borne by patients. Among the developed countries USA tops on the share of expenses on patients; but compared to India it’s much less at 60%. In India in 1990, 10% of patients could not get medical treatment due to poverty. After the economic restructuring the number rose to 20% in 2003. If the government takes the responsibility of providing health services instead of making people pay out of pocket, expense in public health by the government would go up from 1% to 5% of the GDP.

Control on private medical services is almost non-existent.
What will be the quality of treatment, whether it is justified, what will be the price of treatment – every decision has been left to the market. There is no control on the pharma industry or the medical equipments industry. As a result the market is flooded with unnecessary and harmful medicines, these medicines are expensive, patients are forced to undergo costly and superfluous tests. Teaching of medicine is passing into private hands; medical colleges and nursing colleges are profitable businesses. In private colleges only the rich people can send their children as it costs lakhs of rupees to get admitted there. After getting their degree the graduates from such colleges are naturally treating the profession as a pure business.

Huge gap between rural and urban areas.
In the towns the number of doctors per one lakh population is about six times than in the villages. In the towns the number of beds is twenty times the beds in villages. Medical expenditure in villages is less than half than in the towns. Besides there are discrimination based on class, caste and gender.

The medical system is hospital-centric, doctor-centric.
Role of community health workers and other medical workers is not defined. Many minor diseases can be treated without the help of doctors, yet these are referred to doctors. As a result places where doctors are severely required do without them.

Both quality and quantity of government medical facilities are inadequate.
The conditions are deteriorating even further with the start of massive privatisation drive from the beginning of 1990s. Only 10-15% of the patients avail of medical services provided by the government. Less than 3% of the total expenditure on medicine is spent on the services provided by the government. In government hospitals and health centres there is a perennial shortage of medicines, even lack of essential life saving drugs. National Rural Health Mission which was started in 2005 has failed to show any positive results so far.

It is useful to remember the information given above to understand people’s health movement.

Different strands of people’s health movement

People’s Science Movement
Under the initiative of people’s science movement in different parts of the country people’s science club and similar organisations have brought many issues of health under focus, in order to make science easy to understand and popular. Of these organizations, one can name Kerala Shastra Sahitya Parishad (KSSP) of Kerala and Lok Vidyan Sanghathana of Maharashtra. KSSP has initiated campaigns in order to spread health consciousness in the state. Lok Vidyan Sanghathana has tried to make medical science popular and demystified in Maharashtra. Among their campaign themes following are prominent: exploitation of the patient through injection or saline drip, use of ORS in diarrhoea, health problems of women relating to child birth, tobacco de-addiction etc. These organisations have conducted signature campaigns in the respective states for rational pro-people drug policy.

In 1993 in a small town called Shirur located near Pune in Maharashtra, in a government hospital, uteri of mentally challenged women used to be surgically removed. The purpose was to free the challenged women from lack of hygiene during menstruation and risk of pregnancy. Lok Vidyan Sanghathana sensitised the people and forced the government to stop such hysterectomy.

In the beginning of ’80s many science organisations of India formed the All India People’s Science Network (AIPSN). Through preparing slide shows and poster exhibitions numbering 500, a campaign named ‘Bharat Jan Vijnan Jattha’ was launched which toured different areas showing these materials. Subsequently ‘Bharat Jnan Vijnan Samiti’ was formed.

During the end of ’70s and beginning of ’80s numerous science organisations were formed in West Bengal also. Mainly people of progressive and revolutionary politics led these. They brought many health themes into focus. Two magazines, ‘Utsa Manush’ and ‘Bijnan o Bijnankarmi’ played crucial role These organization formed a co-ordination—Ganabijnan Samanway Kendra, WB.

After these organisation became weak, the entire stage was captured by ‘Paschimbanga Bijnan Mancha’ which is a frontal organisation of the then-main ruling party CPI-M. Through the help of ABTA which is a teachers’ organisation influenced by the party, they recruited scores of students in the organisation from many schools. In AIPSN. since the organisations influenced by the CPI-M were dominating the scene, Ganabijnan Samanway Kendra, WB did not become a part of it.

Campaign on drug policy
In 1980 All India Drug Action Network (AIDAN) was formed comprising of many science organisations, health groups, consumer groups, NGOs. At the same time Bangladesh banned unnecessary and harmful drugs. A climate was being created to take a holistic view on medicine, to think over the issues in a new way. At that time in West Bengal Drug Action Forum (DAF) was formed. A publication booklet of DAF ‘Medicines for the People or the People for the Medicines’ was distributed in thousands of copies all over the state. It was translated in Hindi for distribution in Bihar. DAF used to publish English newsletter ‘Drug, Disease, Doctor’ for doctors and students. Many young doctors joined the movement for rational, pro-people therapy due to the influence of the newsletter.

The member organisations of AIDAN conducted a campaign against the high dose combination of estrogen and progesterone, and forced the Indian drug controller to ban the medicine.

AIDAN filed many Public Interest Litigations to remove banned and bannable drugs from the market. The drug controller was forced to ban more than 70 irrational and harmful drugs (but many more irrational medicines have come to the market since).

Recently the number of drugs whose prices are under control of the central government has been reduced from 74 to 25 by a government notification. Because of PIL filed by AIDAN and other organisations the government has been compelled to put the order under abeyance. Government officials have sent a proposal to the central ministry so that all essential drugs are kept under price control.

In the first phase of AIDAN in parallel with PILs there were attempts to sensitise the doctors and common people. After it became weaker AIDAN’s activities have been limited to only filing PILs and petitioning to government offices.

When Novartis tried to patent a drug of leukaemia, AIDAN launched a campaign among the doctors to boycott all products of Novartis (Novartis is the manufacturer of popular drug for pain relief, Voveran).

LOCOST which is a member organisation of AIDAN has been manufacturing 60 essential drug in the generic category and has been supplying them to non-profit organisations. Price of LOCOST medicines is half to one-fifths of branded medicines. From the operation of LOCOST it is clear that besides the profits of pharma companies there is no other reason for prices of drugs to be so high.

Health campaign by feminist movements
Stree Shakti Sangathan of Hyderabad, Saheli of Delhi and other organisations ran campaign against contraceptives such as Depo-Provera, NET-EN, Nor-plant. As a result the government desisted from using these contraceptives in its family planning programmes. In such campaigns, issues such as demystifying reproductive health of women, campaigning against domestic violence, female foeticide have figured. However most of these organisations are funded-NGOs and are restricted to small pockets.

Bhopal Gas Episode and health movement of the gas victims
Health movement of Bhopal gas victims was truly a people’s movement for health. On 2nd and 3rd December, 1984 gas started leaking out from the Union Carbide factory of Bhopal. The gas victims started the movement to get proper information about the components of the leaked gas, what were the ill effects on health, which are their antidotes. Zahrili Gas Kand Sangharsh Morcha (ZGKSM) was formed. In March 1985 Medico Friends Circle (MFC) conducted a survey on effects of poison gas on victims. On 3rd June, 1985 ZGKSM set up a health centre Jan Swasthya Kendra in the Union Carbide premises with the help of Nagarik Rahat aur Punarvas Committee (NRPC), Trade Union Relief Fund (TURF) of Bombay, Union Carbide Karmachari Sangh (UCKS). In the meanwhile, facing relentless campaign and people’s movement the government was forced to distribute sodium thiosalphate (NaTS). In JSK. sodium thiosulphate was administered intravenously to the gas victims and the changes in their symptoms were monitored and documented. Documentary evidence against Union Carbide was piling up. On 24th June the government launched an assault on the centre and 31 health workers, including doctors, were arrested. But this did not stop the work. From the last week of August to the beginning of 1986 a clinic ran from the slums of victims with the help of junior doctors of West Bengal, MFC and Shaheed Hospital.

Although JSK was short lived, struggle of gas victims demanding for proper medical treatment, for all relevant information on gas, for compensation had not stopped. Their militant organisation ZGKSM was captured by the SUCI. Volunteers from the neighbouring districts who came together to organise ZGKSM activities were sidelined. Finally by supporting the opportunist agreement of the Indian government with Union Carbide the ZGKSM forfeited the faith of gas victims. After this ‘Gas Pidit Mahila Udyog Sanghathan’ came forward to lead the movement of gas victims. A section of the intellectuals who were supporting the ZGKSM formed ‘Bhopal Group for Information and Action’, and then ‘Sambhavna Trust’.

Sambhavna Trust is combining allopathy, Ayurved, Yoga to treat the gas victims! Scientific basis of such treatment is not known to us. Secondly, although the trust does not accept money from funding agencies, it is almost fully dependent on donations (usually from foreigner friends).

Medico Friends Circle
The name of Medico Friends Circle (MFC) is well known due to their campaign after Dr. Binayak Sen was arrested under black laws. MFC was formed in 1974 mainly by doctors who were inspired by Jayprakash Narayan. MFC is not a regimented or a rigid organisation. It is a coordination of doctors, health workers and social activists. They exchange views through MFC Bulletin. They meet once a year to discuss burning issues of the day. Members work in different social movements or organisations, or teaching in educational institutions. They have played important role when they conducted health surveys of gas victims in 1986 and 1989. In 2002 Gujarat riots MFC teams visited relief camps, conducted medical camps there, and also analysed the role of doctors and health workers after the riots. Publications of MFC such as ‘In Search of Diagnosis – Analysis of Present System of Health Care’, ‘Health Care Which Way to Go: Examination of Issues and Alternatives’, ‘Under the Lens: Health and Medicine’, ‘Medical Education Re-Examined’ proved to be food for thought for many health activists.

Unfortunately many members of MFC who were associated with people’s movements are now heads of funded NGOs. It may be mentioned here that the author was present in the 2007 annual meeting of MFC to make a presentation on the role of doctors and health workers in the Nandigram-Singur movement. A number of MFC members work in NGOs who take funds from a trust of the Tata group. MFC members were discussing if it would be correct to depend on such funding in view of the role of the Tata group in Singur.

When mass organisations lead health movements
A notable example in this tradition is the health movement of Chhattisgarh mines workers led by the martyr labour leader Shankar Guha Niyogi and Shaheed Hospital. Inspired by the example of Shaheed Hospital workers of Indo-Japan Steel of Howrah started ‘Shramajibi Swasthya Prakalpa’ in 1984, which materialised in ‘Shramajibi Hospital’ in the 90s. In 1995 Kanoria Jute Mill workers of Chengail in Howrah formed the ‘Shramik Krishak Maitri Swasthya Kendra’. Doctors and health workers who worked around this centre formed ‘Shramajibi Swasthya Udyog’ in 1999. I shall discuss Shaheed Hospital, Belur Shramajibi Hospital and Shramajibi Swasthya Udyog somewhere else. I think that the future health movement will have to take cognizance of both positive and negative lessons of these initiatives.

From 1998 onwards a funded NGO named CEHAT has been working with mass organisations ‘Kastkari Sanghathana’ and ‘Shramik Mukti Dal’ of Maharashtra and ‘Adivasi Mukti Sangathan’ of Madhya Pradesh. The SATHI Cell of CEHAT has trained more than hundred women volunteers of these organisations as social health workers. These health workers are capable to taking primary health care to the adivasis as a bulwark against exploitation in medical services. They have been working year after year without any fees. But it is doubtful for how long it would be possible without remunerating them. These organisations have been able to improve the government health systems in their respective areas by lodging complaints about the lack of primary health care facilities and by mobilising people.

It is important to draw attention to the analysis of a CEHAT executive: ‘There have been good CHW (Community Health Worker) programmes in India undertaken by health-NGOs. They have helped to challenge the doctor-centric model of health care delivery which is especially unsuitable in villages. But these CHW programmes are dependent upon external funding and cease to function once funding is withdrawn’

The rural-based activity of these three organisations is dependent on voluntary work and local resources. Hence when the external professional help ceased, the programmes of social health workers did not stop to function.

Movement for treatment of occupational diseases and for compensation
Occupational Health and Safety Centre (OHSC) of Bombay has played a path-breaking role in organising movements for treatment of diseases which workers contract during work and for compensation. They did surveys on workers, collected data and built public opinion which created a condition so that trade unions launched movements and forced the factory owners to compensate byssinosis affected workers. A funded NGO of New Delhi PRIA is spreading awareness on occupational health by publishing books, bulletins and other campaign materials. ‘Khedut Mazdur Sangh’ of Madhya Pradesh, ‘People’s Training and Research Centre’ of Gujarat, ‘OSHAJ’ of Jharkhand, ‘PRASAR’ of Delhi have been working in the interest of lakhs of silicosis-affected labourers. The court and government are at times seen taking notice of the campaign and movements of these organisations. The late scientist Bijan Sarangi of the science magazine ‘Top Quark’ did similar work on the silicosis-afflicted workers of Chichurgeriya village near Jhargram of West Bengal. Later ‘Nagarik Mancha’ took part in this initiative. One factory was closed down due to the High Court order. The court also ordered for compensation of silicosis-affected workers.

[To be continued…]

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