events unfolding in Andhra Pradesh over the issue of childhood
heart disease dramatically illustrated this. Hundreds of
paediatric cardiac patients were paraded on the streets
seeking surgical treatment, and one of them died in front
of television cameras.
well-meaning media and activists are focusing on the human
drama and pathos and pressurizing the government to make
allocations. Hospitals are hard-put to cope with the patient-load.
In all this, the real issues are ignored to the detriment
of the poor. As a sage said, " God, I will deal with
my enemies on my own; but save me from my friends!"
would be worthwhile to examine the issues of public policy,
delivery and accountability in relation to childhood heart
disease and health-care. Sometimes deeper understanding
of micro-issues can give us greater insights about the management
of the economy and resource allocation than debates in ivory
few facts first. Congenital (CHD) and rheumatic heart diseases
(RHD) are the two major forms of heart disease afflicting
the young. On an average, eight children out of 1000 are
born with CHD. And the commonest causes of CHD are fully
preventable maternal infections during pregnancy, consanguineous
marriages, and childbearing by women above 30 years of age.
All these are completely avoidable - by MMR vaccination,
marriage counseling, and public education on risks of marrying
relatives and late childbearing. And yet, annually about
200,000 children are born with CHD in India. The case of
RHD is even more pathetic. It is caused by a simple streptococcal
sore throat, a common childhood infection, between the ages
of 5 and 15. While sore throat is gone in a couple of days,
the child may develop Rheumatic fever, resulting in RHD.
Even most educated middle-class parents are unaware of this.
RHD is fully preventable, and all it needs is immediate
treatment of strepthroat in children with simple, relatively
inexpensive, antibiotics. And yet, over 150,000 children
get RHD every year. There are probably 5 to 10 million Indians
suffering from CHD and RHD.
let us look at our health infrastructure and need for allocations
to meet this challenge after the disease strikes children.
In the entire country, a total of 42,000 heart surgeries
take place. A typical surgery costs Rs 100,000. 90% of the
surgeries are for coronary artery disease, and not even
10% on CHD and RHD. If today's government is willing to
make allocations to surgically treat all cases of CHD and
RHD - it will have to allocate Rs 50,000 crores to just
take care of the existing patients - and at the current
rate it will take over a 1000 years! It would cost Rs 4000
crores to just take care of the 350,000 new patients who
are added each year. Even after all that expense and effort,
about half the patients cannot be helped much and the life
span of the rest is prolonged for limited periods. And meanwhile
human misery keeps mounting as more unborn, and young children
are afflicted by these preventable diseases.
Clearly, misplaced compassion and political grandstanding
are no substitutes to sensible policy when it comes to promoting
human welfare. Poliomyelitis paralysed 500,000 children
every year not too long ago. Polio vaccines have been invented
by Salk, and later Sabin decades ago, and Salk was honoured
by the Indian government with Nehru Award long ago. Yet
millions of children fell prey to polio because of senseless
public policies, and the misplaced compassion of the many
activists to spend money on calipers for polio victims did
not improve the situation. At last, the government and civil
society got their act together, and over the past five years,
through a remarkable campaign of public-private partnership,
Polio has been almost eradicated. What we need is a similar
campaign of mass immunization (MMR), public education (consanguineous
marriages, late pregnancies and strepthroat), and immediate
treatment of strepthroat in all children in 5 - 15 age group.
Such a programme costs no more than Rs.100 crores per annum
for the whole country. We should still help the unfortunate
victims of CHD and RHD with available resources, but the
priority is clearly to prevent millions from being victims
we need the delivery system to spread health education,
administer vaccines and early treatment. Mass media must
be deployed on a grand scale in a creative manner to inform
every family. And an army of million health volunteers needs
to be raised at a low cost (about Rs. 600 crores per annum)
to be the interface between the community and primary health
centres, and they will address all the health needs, not
merely heart disease. The remarkable results of the Comprehensive
Rural Healthcare Project in Jamkhed (Maharashtra) pioneered
by Dr Raj Arole covering a population of 500,000, and many
other similar successful pilot efforts establish the efficacy
of community health workers. Finally, we need these health
workers to be owned by, and fully accountable to, the community.
There are simple mechanisms to ensure such ownership and
ailment - the childhood heart disease - thus offers invaluable
lessons in management, allocations, delivery and accountability
of our health sector. Academics and policy analysts need
to climb down from their ivory towers, and internalise these
lessons. We are lucky to live in an age when most problems
have simple, effective, relatively low-cost, high-impact
solutions. Very few of our problems are intractable. A bit
of wisdom, sensible policies, well-directed and modest allocations,
and effective delivery systems can accomplish a great deal
to promote growth and human happiness.