Low-Hanging Fruits
We must recognise that even our limited resources need to pay a little more attention to investments in health. Otherwise, we are going to see our development stalled. And even our ability to progress on the path of overall equitable development is going to be hurt if we do not invest in health. As we have seen in COVID-19 and even otherwise, economic development and social stability slip on the banana skins of public health failures. So we have to invest in health. So I believe it’s important that we do also prioritise where we invest in, so that we get the best returns for health.
There, I would place a lot of emphasis on primary health care. It is absolutely important for us to recognise that that is where most diseases can be addressed, right from prevention and positive health promotion to early detection, effective care, referral as needed, so that you do not allow diseases to develop to a state of severity, where people will have to go to hospitals at a considerable distance and a considerable expense. And that will actually burden people as well as the health and financial systems of the country. So investments in health are absolutely necessary.
And primary health care offers the best opportunity because it provides not only essential care for the maximum number of conditions to virtually everybody, every human being, every Indian citizen or every Indian resident will need primary care sometime or other in life, whether it is vaccination right at the beginning, or some degree of rehabilitative care, treatment for blood pressure and diabetes later in life. So primary care systems are absolutely important. And we need to invest in that.
Recognising that some level of advanced care is also required. We do need to invest in our district and medical college hospitals and make sure that secondary care is available and some elements of essential tertiary care are available. And we need to build in connectivity between primary care and secondary care in a bidirectional manner. And fortunately, we now have digital technologies which we can use for that kind of a connectivity and even tele consultations. But some emergency transport systems also need to be invested in. If we do this, we’ll be able to spend our resources with the maximum amount of health gains across the spectrum and across the age spectrum as well across the life course, because everybody from birth or even preconception to terminal care has to be ultimately managed in primary care. So that is where I think we must invest and ensure that we get the maximum returns for health.
Public Healthcare Versus Private Healthcare
Well, I think ignoring primary healthcare has been a big mistake and we have recognised it even during the COVID-19 period and even earlier. Repeatedly, we have had these lessons, but COVID-19 brought it out very starkly. If you look at it, maximum amount of care had to be given in primary care settings in urban and rural areas, whether it is early detection and advising people to isolate themselves at home, testing and referral for care if required to facilities of isolation and entire vaccination program. All that had to be done through the primary health care teams.
And we also saw that pure reliance on private sector didn’t help. All the hospital facilities didn’t function very well in terms of accepting the people who needed care. We even saw oxygen shortages there. And equally importantly, we also saw when vaccination programme was handed over not only to public sector, but also to the private sector, most private sector entities couldn’t go beyond the metros. They couldn’t go into two-tier and three-tier cities because they didn’t have the accreditation. They didn’t qualify for accreditation.
So the weakness of the private sector in serving primary care, in serving even secondary care in some of the areas like the two-tier and three-tier cities became very apparent during COVID-19. I’m not saying private sector is unnecessary. We need to use it optimally. But we do need to strengthen our public sector primary care services, both in rural and in urban areas and bring in the private sector as per need and opportunity. But the private public sector has to set the terms and monitor whatever the performance is.
Individual Actions
Well, Global warming will result in a number of health problems. And we know that firstly, extreme heat is going to be the biggest challenge and we are seeing it right now. Heat waves across the world, including in India, people are wilting in that heat and getting very sick or even dying from heat. We also know that global warming and Climate change will result in a number of vector-borne diseases, especially mosquito-borne diseases, right from malaria to chikungunya to dengue. And now Zika. We’ll see all of them happening with much greater frequency. We also will see waterborne diseases because of extreme weather events resulting in floods, water contamination or extreme heat resulting in droughts and water scarcity. And people will be drinking even unclean water because clean water may not be available. And we also recognise there will be a number of other health problems, whether it is strokes or heart attacks or mental health problems, renal failure. All of these are likely to happen as well. And we also know that it’s likely to affect agriculture and food systems, resulting in nutrition insecurity.
So what I would say is, first of all, in terms of facing up to the challenge of extreme heat, make sure that people do not expose themselves to extreme heat for long hours. And if they have to, for whatever reason, occupational reasons, then they’ll have to protect themselves by wearing caps, wearing eyeglass protection, wearing loose cotton, comfortable clothes, which allow ventilation. Try and move around in well-ventilated areas and take plenty of clean water. That’s the most important because hydration is going to be absolutely critical. So some of these things are going to be important. But even in our house, we must ensure that there is adequate ventilation so that we will be able to get relief from the free flow of air. So these are some of the precautions that people will have to take. And basically, in terms of ensuring that they also are conscious of the fact that extreme heat can result in strokes and heart attacks, they ought to not only drink enough water, but make sure that their blood pressure is also under good control.
Policymakers and Healthcare
Well, I think most people have now begun to realise the reality of climate change. There was a denial in policymakers across the world, then a bit of apathy and neglect because they started prioritising other things and said, okay, climate change can wait. It’s mostly the concern of the environmentalists. Let’s focus on immediate needs of industrial development and urbanisation and maybe some social sector programs. So they went about with turning their blind eye to environment.
Now in the last decade, it’s become very clear that environment is going to be one of the biggest challenges now and in the future, and is going to really upset the apple cart of any developmental programme that is being planned. So we do need to ensure that environment is given absolutely top class priority. But I believe that it’s not something that is either or priority because we recognise that much of what we need to do in terms of environmental protection, in terms of climate resilient and climate smart, food and agriculture systems, climate resilient and climate smart, healthcare systems, climate smart and climate resilient, urban development and transport systems.
All of these are part of the general development programme of any country. So only we need to make sure that we are also bringing in the climate smart and climate resilient element into it. So there is a convergence. They’re not actually conflicting. We are not competing for different resources. We are actually bringing them together and seeing how best it can be done. And even going back to primary care, which we talked about a little while ago, it’s one of the biggest generators of employment. When now we recognise that many sectors, industry and agriculture are not able to offer the amount of employment because of mechanisation. It is the health sector, particularly in primary care, which can offer a huge amount of employment and build up a health workforce. Both in India and globally, we have an opportunity to provide employment to a large number of young people, especially women. So our climate response and our developmental imperatives are very closely enmeshed together.
Healthcare and Other Development Indicators
We should not counterpose development versus climate change response. Both have to go together. Because if we neglect climate change response, our developmental efforts will be stalled or hurt. So, I mean, you can’t have urban development when you are having floods and extreme weather events. You cannot have nutrition security when you have food and agriculture systems compromised by climate change. So I think what we must recognise is that both these are very much closely tied together and invest in both in a smart manner.
And therefore, I believe that this kind of positioning that both are different elements of development and both are sometimes conflicting because of resource requirements is an incorrect positioning because there’s a tremendous amount of convergence between our other developmental efforts and our climate change response. So we ought to invest in both of them together. Like, for example, if we are saying that we are going to be building healthcare infrastructure now in response to our pandemic preparation and trying to improve our healthcare infrastructure, let’s make it climate resilient as well as climate smart so that the energy requirements are much less and the ability to withstand extreme weather events is much better.
Healthcare & ESG
We recognise that even the healthcare sector is a victim of climate change because of extreme weather events, destroying infrastructure, compromising transport systems, stranding healthcare personnel who cannot reach the hospitals or healthcare facilities. All of those are the effects of climate change on the healthcare system. At the same time the healthcare system itself generates a large number of greenhouse gases.
And in fact, globally, it is said that about 5.4% of all greenhouse gas emissions come from the healthcare sector. About 30% from the healthcare infrastructure in terms of energy utilisation. About 70% from the supply chain. And therefore, if you can actually reduce the energy consumption in the actual healthcare premises, healthcare facility premises, but at the same time influence down the line procurement practices and resort to green procurement, you’ll be able to actually help reduce the overall greenhouse gas emissions from the healthcare sector itself. So I think the healthcare sector must be very proactive and we are seeing initiatives happening.
We are seeing in India itself, the Public Health Foundation of India helped to set up initiative in which we actually bring in a large number of hospitals together. And we have a health and environment leadership platform called Health, in which we have brought in a number of hospitals together. And we also have at the global level, a big networking of hospitals being now coordinated by the World Health Organization. So I think many healthcare facilities are responding to this challenge now. Both by reducing their own consumption of energy and release of greenhouse gases. At the same time, resorting to more climate resilient infrastructure.
SDGs and Healthcare
See, as far as the SDGs are concerned, we must recognise that the entire SDG agenda is a mixed bag. First of all, it carried over the Millennium Development Goals, which were incompletely delivered. So from 2000 to 2015, maternal and child health and infectious diseases, which were prioritised, were not adequately delivered in most parts of the world. And then in 2015, in the Sustainable Development Goals (SDGs), we added on non-communicable diseases, mental health, substance abuse, road traffic accidents, and other health problems. So we really expanded, which was necessary, which is absolutely necessary. So when we look at our own performance, we realise that having started work on the MDGs and having steered our National Rural Health Mission and later on the National Health Mission towards those prioritised areas of maternal and child health, some infectious diseases, and some nutritional problems, we did achieve some success.
For example, our neonatal mortality rate, which was not really coming down, has come down, and our maternal mortality rate and infant mortality rate, under five mortality rate, are well in the range of reaching the SDG targets by 2030, though we’ll have to do a little more on neonatal mortality rate. But we also have started having a little more success in tuberculosis and other infectious diseases. Malaria, certainly in some parts of the country, especially Odisha, very good control has been achieved. But we need to do more in order to reach the 2030 targets.
But my concern is not so much about the national aggregate indicator. It is about the disparity between states. There are huge disparities between states. There are states which are performing very well, as expected, particularly the southern states and some western Indian states. But even the NITI Aayog has listed states which are not performing well on composite SDG indicators, especially health, like Bihar, Jharkhand, Arunachal Pradesh, Meghalaya, Uttar Pradesh, and Assam.
So now we have to make sure that these gaps are bridged. Otherwise, our national indicators will also slip down. But more importantly, we just can’t take pride that Kerala and Tamil Nadu are doing well and Jharkhand and Chhattisgarh are not doing well. And we have to really make sure that everywhere we perform well in terms of our SDG indicators. And the other element, of course, is what I mentioned is we have added on non-communicable diseases, mental health, and other areas. We haven’t really started off very well on that. We need to pay much more attention to that. Otherwise, we’ll slip up on those additional indicators. The carryover effect of our MDG efforts will be there for some part of the SDG indicators. But they add on elements like non-communicable diseases, cardiovascular disease, cancer, respiratory diseases, and also mental health. They are not going to perform very well as expected because we haven’t really framed a very strong program to be delivered for these.
Planetary Overshoot
Firstly, when we talk about the environment and we talk about planetary health, we talk in a vague manner saying that we must protect the planet. When people say, what do you mean by protecting the planet? We say, okay, let’s avoid deforestation. We must avoid air and water pollution. And we must ensure that there is adequate biodiversity.
But is there a measure? Interestingly, there is something called Planetary Overshoot Day in which the composite resources of the earth, the planet, and the ability to regenerate its resources every year are measured. Now, we do consume some of the natural resources every year. And even by natural process of decay, some of the resources like plant life, they perish, animal life, they perish. But the nature has the capacity to regenerate most of it over the course of the year, provided we don’t interfere and then start draining away a lot of those resources or placing barriers like deforestation, like excessive water consumption, and so on, or a tremendous amount of pollution.
Now, the planetary overshoot day, when it was estimated in 1970, it was the 30th of December. That means our budgetary deficit for the environment was only one day. But now, in 2023, it was the 2nd of August. That means our budgetary deficit, I mean, we are functioning on an environmental deficit. And that deficit has grown. And if the entire planet, if all of us had lived like Luxembourg, it would have been the 10th of February. If we had all lived like Qatar, it would have been the 14th of February.
So, the worry is that each year, the planetary overshoot day is receding. The planet’s capacity to regenerate its own resources is now disappearing or diminishing. So, what are we leaving for the future generation? Very little. So, I’m very much worried, and my book is entirely geared towards a duty towards the future generation. We have to protect ourselves, certainly. But we have a moral obligation to make sure that we leave the planet in a healthy state for the future generation. And that’s my first point.
The second point is, we are all connected. We are connected to each other. All our body systems are connected within the body, and they function with excellent coordination, unless we do something silly, like eating the wrong kind of food and smoking. But similarly, human beings are all connected to each other. We are connected to nature. By not recognising this connectivity, we are also causing a tremendous harm to the planet and to ourselves. John Muir, who was an American, Scottish-American naturalist, said, if you target anything in nature, you will find it connected to everything else. And Martin Luther King said it even more beautifully. He said, basically, all men are caught in an inescapable network of mutuality tied in a single garment of destiny. He called this connectivity between all of us a single garment of destiny. And he said, whatever affects one directly affects all others indirectly. So, I think it’s absolutely necessary for us to recognise this harmony within our bodies, within our society, within our global community, and work together. And that we need to do, particularly not only to protect the current generation, but as a duty towards the future generation.
