Prevention is still better than cure

By Zubeida Mustafa
Source: Dawn

The message carried year after year by WHO’s World Health Reports is that “progress in health depends largely on viable national and local health systems”. The 2003 report speaks of the need for “effective health promotion and disease prevention services” to give people a chance to lead a long and healthy life. The 2002 report focused on the reduction of risks to health and held this to be the primary responsibility of the government.

Of course, it is generally recognized that the people themselves and the health professionals should also be involved in the task of preventing diseases and reducing the risk factors. But it is the government, in its capacity as the policymaker and the one controlling the purse strings, which is expected to play the leading role.

In Pakistan this basic fact has not been sufficiently recognized. Where the push has come from outside agencies and success has depended on vaccination campaigns or distributing medicines, some progress has been made. That would explain why polio may well be eradicated in the near future.

But other preventive medicine and public health measures have carried little weight with our policymakers. The political will seems to be lacking. In other societies, programmes such as those for potable water, sanitation, immunization, malaria eradication, etc receive priority as they are known to improve the health and the quality of life of the people. Economists and medical professionals have even devised methods to calculate the economic value of health.

Now we are not being told only about life expectancy at birth. Every country has a figure called DALYs which calculates the disability adjusted life years – which stands for the number of years a person will lose because of illness. Life expectancy at birth is not given so much importance.

It is HALE (healthy life expectancy) that matters. The life expectancy for a Pakistani at birth is said to be 61.3 years but HALE is only 51.3 years with nearly 10 years being lost on account of illness.

The moot question is why doesn’t the government want to spend on measures which could avert a lot of agony caused by disease? It would also save it the expenditure incurred on the treatment of disease and the economic losses resulting from illness and absenteeism.

The WHO report for 2002 lists some risk factors, which are controllable to a great extent. The major ones that are most relevant to our conditions are childhood malnutrition, lack of potable water and sanitation, tobacco, overweight and air pollution.

The illogic of negligence and failure to address these factors are not easy to explain, especially when we know that these lead to the high prevalence of diabetes, cardiovascular diseases, kidney problems, infectious diseases, cancer, malaria and tuberculosis – just to name a few.

According to cardiologists, nearly 10 per cent of the adult population in Pakistan and 50 per cent of those above 50 years suffer from hypertension. Nearly 12 million adult Pakistanis are diabetic or have impaired glucose tolerance.

Twenty million suffer from one renal disease or the other with 10,000 dying every year because of end-stage renal failure. Tuberculosis kills 60,000 people every year.

It is well known that all these diseases are preventable to quite an extent. But that calls for behavioural changes in the people, with the idea of effecting modifications in their lifestyle.

For instance, it has been proved that diet and exercise have a direct impact on the prevalence of many diseases such as diabetes and cardiovascular disorders. The quality of drinking water and cigarette consumption are related to kidney problems, diarrhoeal diseases and many types of cancers.

Behavioural changes in people can be brought about basically through education. Although health education is imparted primarily by the health professionals when patients visit them, the government also has a role to play in facilitating this education.

By launching public campaigns through the mass media, the authorities can play a key role in imparting information to the people which is the essential first step to persuade them to change their behaviour.

Health education should start from childhood and the government has the capacity to determine what is taught to the children and ensure that every school has a playground and the children have compulsory PT periods.

The government can also help by providing information and education to physicians, who are the first point of contact for the people seeking medical assistance for their health problems.

With new technologies and research-based knowledge emerging by the day, health professionals are also in need of continuing education. Many professional bodies of medical specialists are undertaking this with a sense of commitment. But it is important that the government also play a bigger role in the process of disease prevention.

There are significant areas of public health and preventive medicine where the government’s intervention can make a vital difference. This intervention may take the form of legislation, imposing taxes on items to be discouraged, executive action or policy measures.

For instance, laws can be adopted to regulate the sale and publicity of cigarettes, encourage breast feeding by banning advertising and free distribution in maternity clinics of infant formula, control environmental pollution caused by traffic and industries, and institute safety measures in work places and on the roads and highways.

The government has adopted a number of legislative measures on all the above-mentioned issues, but it is a pity that many of these laws are not being implemented.

Take the smokers’ and the cigarette manufacturers’ lobby which has managed to bypass many of the new restrictions imposed by the Anti-Smoking and Protection of Non-Smokers Ordinance and nearly 37 per cent (a third of men and four per cent of women) are habitual smokers in Pakistan. As a result 100,000 people die annually of cigarette-related ailments (cancer and cardiac and respiratory diseases)

Environmental pollution has the same sorry story to tell. The laws have remained unimplemented. Measures to get autorickshaws to have silencers fitted and the move to penalize drivers of smoke-emitting vehicles on the road have met with open defiance. According to WHO, nearly eight per cent of deaths in a Third World country are attributable to air pollution.

Policy measures that have a direct bearing on the health of the people are those pertaining to water supply, sewerage, sanitation and garbage accumulation. These are under the direct control of the municipal authorities but they have not acted effectively because of resource constraints and lack of commitment. Unsafe water and sanitation lead to 3.1 per cent of deaths.

One wonders why the government does not feel the compulsion of adopting such measures which, in the long run, prove to be more cost-effective. After all, preventive measures are cheaper than the cost of treating patients suffering from cancer, tuberculosis, renal failure, etc.

It is probably because the government is gradually withdrawing from the health sector. According to the Human Development Report 2003, the Pakistan government spends 0.9 per cent of its GDP on health while the private expenditure on health care amounts to 3.2 per cent of GDP.

What is more, the government’s health expenditure has not registered a substantial increase over the years in terms of percentage of GDP. Hence the growing burden of ill-health has to be borne by the people.

In the absence of any feasible and widely accepted health insurance plan, in a preponderance of cases it is the patient who pays for his own treatment.

Another problem is that we have no precedent of successful litigation by people for compensation when they have suffered because of the negligence of the authorities or any party responsible for causing pollution or creating a public health hazard. The need of the hour is for greater emphasis on prevention than on cure as is at present the trend.