Asia-Pacific Network of International Forum for Social Science and Health

ASIA-PACIFIC NETWORK OF INTERNATIONAL FORUM FOR SOCIAL SCIENCE AND HEALTH

NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE, New Delhi

NATIONAL CONFERENCE

ON

HEALTH REFORMS AND SOCIAL SCIENCES

New Delhi, 16-18 March 2006

KEYNOTE ADDRESS

Yogesh Atal Ph.D., D.Sc.(Hons.)

Former Principal Director of Social and Human Sciences, UNESCO

This is indeed a singular honour for me to address this gathering of health specialists and the social scientists. Coming together of the specialists from the two distinct fields – that have apparently no clear-cut linkage in the eyes of the common man – is indeed of great significance. It is recognition of the need for developing an interaction between the social sciences and the health-related disciplines. Of course, the social scientists cannot play the role of a doctor; and the doctors may also feel ill at ease to wear the mantle of a social scientist. But this fact should not deter them from interlocution. The field of health is bigger than medicine and the treatment of the ill. It invites involvement of other specialists, including, of course, the social scientists.

As an indicator of social development, health ought to be seen in a wider perspective, and health reforms should go beyond improving the medical services and hospital administration.

One can say that compared to the medical sciences, social sciences are relatively recent entrants to the academe. Ever since Man – the Homo sapiens – arrived on this earth, his health concerns also came along. Unlike other species, a human child is a hopelessly dependent biological brute. And it is the mother and the immediate family that has the responsibility to prevent it from the diseases, and to cure it when it falls prey to them. There is no human society in the world – howsoever primitive and backward – that does not have its own pharmacopoeia, and its own medicine men to treat the diseased and the sickly. It is a different matter whether the treatment proffered is in the form of some herbs or animal products, or magic or witchcraft, or is based on some other kind of experience. In such practices, the rudimentaries of a medical science can be seen; invocation of the supernatural, and attributing the cause of disease to such powers is part of psychological healing.

But the need for social sciences was perhaps not felt that early. Little communities of people leading a simple life posed few problems of management of interpersonal relations. Scientific understanding of the societies did not concern the ordinary man, particularly the primitive man. Of course, some societies, even the primitive ones, did have ‘thinkers’ and ‘philosophers’ who prescribed or justified certain social phenomena, but they cannot be put in the category of social scientists. Neither social thinkers, nor social reformers qualify as social scientists.

To an extent, this observation would also hold true for the quacks, magicians, and other traditional healers, who cannot be regarded as Medicine men in the current sense of the term. But their craft has implications for alternative systems of medicine.

Sociology entered the field much later. Psychiatry – as a branch of psychology -- arrived earlier, and focussed on the problem of mental illness.

When sociology arrived on the scene, health was not on its agenda of priorities.

It can be said that anthropologists working in the remote tribal areas of the non-Western world -- where no other specialists ever reached --were the first to document traditions and practices relative to the treatment of the diseased and disposal of the dead. They contributed to the field of medical anthropology and to eschatology. Their ethnographic descriptions brought home the point that there are different ways of handling human pathologies. Concepts of purity and pollution, of clean and unclean, and etiologies of diseases have variously been defined by different cultures. It is this knowledge that became important in the training of doctors and clinicians who were despatched to the colonies to improve the health situation and treat the patients. It was then discovered that while the non-Western societies adhered to their beliefs in regard to the causation of a particular disease, they were not averse to accepting new medicines brought by the outsiders. In our own country, small pox, to take just one example, is still regarded as an expression of wrath by the goddess of Small pox – Shitala Mata—which is appeased by the family of the patient; but at the same time, the patient is not denied medical attention. When WHO launched the massive programme for the eradication of small pox from India, it is this knowledge that came handy to the medical doctors. I heard from my brother -- who is now an established surgeon – who was then working on that project -- some fascinating accounts of people’s reactions in the villages of Bihar. In fact, I prodded him to pen down his experiences in a book form, for which I offered my services to edit. And the title I proposed for that project was Goodbye Goddess. He began the work enthusiastically, but later abandoned, thinking perhaps that it was out of his jurisdiction. I mention this instance to suggest how a man of medicine could have made a significant social scientific contribution. It is a pity that no social scientist from Bihar took interest in doing research on this campaign.

It is interesting to note that when theorising began in sociology, its impetus came from biology. Darwin influenced social theorists who propounded theories of social evolution. Those who devoted themselves to conceptualisation of the social phenomena began comparing human societies with organism and borrowed the concepts of structure and function from biological sciences. Even the concepts of growth and decay were borrowed from them. Those focussing on social disorganization talked of social pathology. The concept of homeostasis was employed to understand the process of equilibrium, which corrected deviance and brought back normalcy in human group situations. Perhaps it is known that Talcott Parsons, who revolutionized sociological theory by introducing a systems approach, came to the discipline via medicine. No wonder, he presented an excellent introduction to “sociology of sickness” in his book on the Social System.

Using the concepts borrowed from biological sciences, “Sociology arose in an effort to describe human functioning, but as this occurs in the social group rather than in the individual organism.”

The journey of Sociology in the field of medicine began when it was used to orientate the medical clinician. Initial studies in Sociology of medicine attempted to relate specific social factors and processes to particular states of health and disease. Some studies explored patterned social relationships in the field of medicine. Over the years, sociological studies in this field have contributed to the understanding of varied types of social phenomena in medicine, such as growing place of medicine and medical practice in the social system of the Western world; different attitudes and values which various segments of the population have toward health, illness, and medical care; social organization of health personnel; social structure and functioning of hospitals; and social roles played by patients and health personnel as they interact in different settings; social processes through which health personnel acquire the outlook, standards, and competence for providing satisfactory professional service; social and psychological factors concerning different kinds of disease. Studies have also been made of medical students, nurses and doctors. There are studies of what medical personnel expect of patients, and on the types of behaviour that patients expect of medical personnel.

A review of work in the field of sociology of medicine suggests that studies in this area were carried out as part of Sociology of occupations/ professions, Sociology of Work, and Sociology of formal organizations. There have also been specific studies relative to medical practice and the intricacies of doctor-patient relationships.

To this we may also add those social researches which have used methodology of social science research but which have not been done with social science orientation. Such studies would include, among others,

Epidemiological investigations which statistically correlate findings on the prevalence of particular diseases with selected personal, social and economic characteristics of a population; surveys of attitudes of patients or of the public towards medical personnel and health services; and economics of health.

Such surveys quite often provide interesting and useful facts to public health officers, hospital administrators, and health related NGOs. However, they contribute little to the growth of systematic sociological knowledge unless, they are recast in sociological terms and set in a theoretical perspective.

This quick survey of the field of sociology suggests that not much has been done in this field; in case of India, the situation is far worse. But what is encouraging is the fact that social scientists – not only sociologists but also other specialists, particularly psychologists, social workers, demographers, and economists – are now being engaged in various capacities in the health field as well. When I was the Research Director with the Indian Council of Social Science Research in the early seventies, the ICSSR collaborated with the Indian Council of Medical Research and the Indian Council of Agricultural Research in setting up a Study Team to review teaching of social sciences in professional education, i.e. Medicine, Agriculture, and Engineering. The setting up of such a Team was an indication that social sciences have been granted a visa to enter the portals of professional education. The subject of Preventive and Social Medicine taught to the medical graduates opens one window on the social sciences. At least some exposure to social sciences is given to all medical graduates. And to those who specialise in this specialty, such training brings them closer to the social sciences; these medical graduates prefer statistical tools to a stethoscope!! Some of my students whom I taught sociology or social work have also been appointed as medical social workers in hospitals.

But all these are instances of applications of social science. Basic social scientific research in medicine is a different cup of tea. In the 1960s, when I first visited the United States, I enquired about the status of sociology of medicine. Interestingly, the doctors regarded sociology of medicine as an applied science as distinct from basic research. In their worldview, basic research was confined to laboratory work. Since social scientists did not work from a laboratory, the doctors regarded all social science research as applied, having no theoretical potential! And as applied social science, they expected it to contribute to the cure of the patient, and not to engage in esoteric theorization.

I am sure such image must have changed by now. But I still feel that whenever the issue of cooperation between social sciences and medicine is raised the other party always wishes to know what is it that social sciences can do for them. There is also the general feeling that a social scientist is a social critic, and that his role is seen as a critic of the prevailing medical practice. Many in the medical profession oppose the intrusion of social science on the ground that medicine is a highly technical field and the social scientist is not trained to comment on it. With increasing court cases against doctors and hospitals for negligence and malpractice, rising criticism of the over-commercialization of medical profession, and deteriorating services of the government-run hospitals the doctors are also assuming a defensive posture to protect themselves against public censure.

Health is a social fact. It is not just medicine. When we talk of health care we do not restrict it to the cure of the ailment, or the ill health of the patient. The epidemiology of the disease goes beyond biology. We need sociology to understand the occurrence of a disease and its cure so that the patient returns to normalcy and contributes to the functioning of society from his vantage point. It is now accepted that “.. the biological endowment of individuals and of populations, their physical environment, and their socio-economic milieu all shape individual responses to illness through complex interrelationships.”[1]

Talking of health is just not talking of medicine or treatment. There is now a visible shift from medical to health care. Entry into a medical complex is meant to cure ill-health. It is designed for the sick and the diseased. But those who are not sick have to ensure a good health to avoid a visit to the hospital. Hospital is for cure. An increasingly decreasing number of patients visiting the hospital should be an index of a healthy society. Such a society ensures that relatively few people go to the hospital. It means we have to create conditions for a healthy environment. And also to train people to refrain from causing man-made calamities, such as accidents, riotous killings, drug addiction, and life-style related diseases. These are not iatrogeneic diseases. They are a consequence of a malfunctioning social system.

When the 1978 WHO sponsored Alma Ata Conference gave the slogan of Health for All, it was for a much wider cause. It emphasised on the provision of basic conditions necessary to health, such as safe drinking water, better sewage, immunization, and easy reach of a clinic that could handle simple ailments, and refer serious cases to specialised centres. It was a plea for primary health care for which China’s “barefoot doctor” provided a reference model. The key message was that everyone has the right to all basic preventive and curative services, financially accessible and within easy reach of home.

The Government of India adopted a National Health Policy in 1985. It adopted a new Population policy in the year 2000. The Health Policy emphasized Health for All, and the Population policy talks of strategies for population stabilization. In both of them, hospitals and medicine are included, but only as components. In implementing the two policies, participation of other sectors of society, and of other academic specialties is essential. For one thing, these policies are an outcome of the political commitment. Health being a subsystem of the wider social system depends for its support – financial, administrative, and manpower – on other subsystems of society. It has to be seen not as a closed system that is open only to its practitioners, but as an open system with interfaces with other subsystems. For example, currently the Parliament is discussing the budget prepared by the finance ministry. The budget has an important component of health. We are told that the health sector has received the second highest hike in allocation in the budget estimates for 2006-2007. The proposed allocation is to the tune of Rs. 12,546 crore for health and family welfare, of which Rs. 8,207 crore will be spent on the National Rural Health Mission. It has also proposed reduction of customs duty on anti-AIDS and anti-cancer drugs, and on other life-saving drugs. It is interesting that out of this sum only Rs. 75 crores have been earmarked for setting up AIIMS type super-speciality hospitals. This figure is substantially smaller than Rs. 250 crores allocated last year, but only six crores were utilized. From this it can be inferred that government’s commitment to spend on Health has increased but all that money is not going for improvement of hospitals or training of doctors. Even if we had a surplus of doctors, they would not be in a position to prevent the bodily harm that is caused by social factors, for example, dowry deaths. Doctors know how to treat a patient who has suffered burns inflicted by the in-laws; but the cause of those burns are the in-laws, who behave as out-laws, that is beyond medicine.

Health is not coterminous with medicine. There is a worldwide movement to go from medicine to healthcare. And in doing so, the involvement of other stakeholders is considered vital. In raising popular awareness about health matters, India is seeking participation of our film heroes and leaders from other fields. It is Amitabh Bachchan who is exhorting people to take their children for Polio vaccines. It is Shahrukh Khan who is invited to convey the message of the rural health mission. More than the doctors, it is communicators like Big B and Shahrukh Khan that are seen as better health promoters.

We know that an internationally known social critic and a brilliant social philosopher from Latin America – Ivan Illich – took a stand against commercialisation of education and of medicine and cogently and eloquently argued a case for deschooling society and for demedicalization of society. While both the educationists and the medical practitioners showed their displeasure to Illich’s writings, decades after his publications the world is moving in the direction that he proposed in his Medical Nemesis and Deschooling Society. Swami Ramdev in India is, now doing what Illich did by way of pointing out the hidden agenda of the medical world. His de-emphasis on modern medicine, and strong plea for disease prevention through yogic exercises, and use of traditional herbal medicines is not only meant to save millions of rupees that are going to the coffers of multinational pharmaceutical companies, but also to hint at several Iatrogeneic diseases. In a short period of about five years, this small man from a poor village background has become a national icon, attracting large crowds in every part of the country. For his project, millions of rupees have already been contributed by his followers, not all of whom come from rich families. Ramdev is a new phenomenon in India; he has become a health angel. By training he is also a medicine man – but of Ayurveda – and he is preaching prophylactics so that people can live longer and healthy and remain away from the hospitals.