"Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control".

Article 25, Universal Declaration of Human Rights

Despite several advances in the healthcare sector, large areas of India continue to cry out for attention. It's estimated that nearly 40 per cent of the population live below the poverty line, going without essential nutrient, vitamin and mineral inputs and eating less than one square meal a day. This renders them susceptible to a large number of diseases and remains the main reason why most of the preventable diseases are still rampant in the subcontinent.

Protection from all the conditions discussed below, and access to the services to deal with them, is an internationally-agreed RIGHT, endorsed by the Government of India.

MALNUTRITION

Poverty is the principal cause of the poor health and low nutritional status of people in India. Lack of regular meals and of the proper intake of the necessary food components are common factors in the life of the lower economic groups. Malnutrition in the young leads to chronic health problems later in life.

Though not on the scale of Somalia or Ethiopia at their most newsworthy, the tell-tale signs of malnutrition - the protuberant belly and skinny limbs - can be seen in most parts of the country, in villages, towns, slums, cities and metropolises alike. Extreme malnutrition leads almost inevitably to stunted physical growth and mental retardation.

Malnutrition mostly takes these forms:

Protein Deficiency

Many families in India rarely consume natural proteins as part of a whole meal. The Integrated Child Services Development Scheme (ICDS) programme (see under the chapter Children) aims to overcome this problem by providing children up to six years of age with the required protein content, including eggs. The government has realised the vast potential of ICDS to achieve the major national nutritional health goals.

In 1975, ICDS was operational in only 33 blocks in the country. By the end of the century, there were 4,200 operational ICDS projects and an additional 461 blocks under the World Bank Assisted ICDS III. Funding increased accordingly. Between 1975 and 1992, the total expenditure on ICDS was Rs 1,190.21 crores. In the year 1999-2000 alone, the budget outlay for ICDS reached Rs 855.76 crores.

A National Nutrition Surveillance Model has been developed in collaboration with the National Institute of Nutrition, Hyderabad, and the government of Andhra Pradesh, to bring down malnutrition.

The World Food Programme, operational since March 1976, extends food aid for supplementary nutrition to children below six years of age, and expectant and nursing mothers.

Iron Deficiency

Anaemia is a common problem among female children across all economic groups in society. Severe anaemia is bound to reduce efficiency and could also be the reason for low immunity against disease. It has been identified as the cause of a high maternal mortality rate. Oral doses of iron and folic acid and intake of certain food items are the only solutions to combat severe anaemia. The government aims to provide the required doses of iron to the target group through its "adolescent girls programme", in addition to teaching them about personal hygiene and safe motherhood practices. Complaints have come in from different parts of India, however, about the uneven and irregular distribution of these essential health inputs. Unless the system is tightened and it is ensured that the tablets reach the adolescent girls in time, the ambitious programme will merely be a loud howl in the dark.

Iodine Deficiency

Iodine deficiency is estimated to affect 200 million of India's children, causing foetal death, goitre and cretinism as well as stunted growth.

Seventy per cent of households in India consume iodised salt, thanks mainly to the government's efforts in making consumption of fortified salt compulsory.

The decision of the government to introduce non-iodised salt in the market has raised a clamour. Some grassroots level workers feel it will undo all the good achieved hitherto, and set the battle against iodine deficiency back by several years. They have urged the government to retain the old policy in the interests of the nation.

Vitamin Deficiency

Large numbers of people in India suffer from vitamin deficiency, leading to a number of problems among children.

Vitamin A deficiency is the leading cause of preventable childhood blindness, and can lead to death, yet the solution is, in principle, simple. The promotion and consumption of foods rich in Vitamin A or supplementation of children's diets with just two Vitamin A capsules a year. Only one in four of India's under fives receive supplements, in the form of vitamin A doses supplied with the medical kits that reach PHCs and Anganwadis or nutrition feeding centres of the ICDS project.

Breast Feeding

Health experts advocate breast feeding of children up to four-six months of age. All the evidence shows that it prevents malnutrition, keeping the child far ahead of bottle-fed children in terms of physical and mental fitness. And it is by far the cheapest form of feeding babies. A breast-fed child is not only healthier, but is also less susceptible to bacterial infections, has less chance of contracting childhood cancers and diabetes and is less prone to food allergies.

Yet breast feeding faces tough competition from the highly commercialised bottle and tinned food industry. The government, aware of this, is stepping up its campaign to convince mothers of the importance of breast feeding as an extension of its safe motherhood practices programme. The Baby Friendly Hospitals being set up in different parts of the country cater to the same objective.

A key element is the need to keep breast-feeding mothers happy and healthy. They must have the right level of vitamin and nutrient intake, the lack of which is known to affect milk secretion.

PRIMARY HEALTH CARE SYSTEM

The primary health care system has been described as the health backbone of the nation, serving even the most neglected and backward areas. It is the responsibility of the Ministry of Health to provide well-equipped Primary Health Centres (PHCs) in every village and town, even remote hamlets. The intention is a basic system of healthcare, employing dedicated doctors and well-qualified paramedics to bear on their shoulders the well-being of a nation.

The question being raised, however, is do the PHC staffs fulfill the requirements? In most cases, unfortunately, the answer is NO.

There have been complaints of insensitivity, callousness and a lack of medicines and, after the experience of the village health nurses of Perambalur district in Tamil Nadu, sexual harassment.

But the system, which according to the government health department provides the critical interface between life saving interventions and people who need them, has undeniable potential. The latest development is the encouragement of community participation in monitoring the functioning of PHCs. If beneficiaries exhibit concern over the quality of services reaching them and make enough noise about it, the theory goes, then the services will have to improve.

Tamil Nadu has introduced a comprehensive health check-up scheme - Varumunn Kappom (Prevention is better than cure). It has proved to be a success so far, and in that there is, perhaps, a model for other states to follow.

HYGIENE AND SANITATION

The crux of India's large public health problem, scientists and commentators say, lies in improper hygiene and sanitation. It is not uncommon to see vast stretches of roads, streets and lanes in even large cities flooded after comparatively modest showers. The lack of proper storm water drainage is the primary culprit. It is not surprising, therefore, that water borne diseases are rampant in the country.

Gastroenteritis, diarrhoea, malaria and cholera are the more common of the diseases that affect India's people on a day to day basis. Access to safe, clean drinking water is the answer, but it has not been assured for a large slice of us, particularly if we live in the rural areas.

Figures once again make the picture clear:

85 per cent of the urban population has access to safe drinking water. In rural areas, the figure falls to 79 per cent. Over India as a whole, the figure is 81 per cent, which means that nearly one person in every five is drinking unsafe, contaminated water every day. Little wonder that sickness levels are so high.

(Figures from UN State of the World Report)

The situation is even worse when it comes to sanitation. Public urination, defecation and spitting are common in a country that apparently suffers from a lack of adequate public conveniences.

In urban areas, a passable 70 per cent of Indians have adequate sanitation, but in the benighted rural areas, that goes down to a scarcely believable 14 per cent, taking the overall average down to 29 per cent. Which helps explain why Indian cities continue to suffer from the devastating effects of catastrophes like the plague, when most of the western world has eliminated them.

The Surat experience - pre and post plague - can provide lessons for the rest of the country in healthcare, hygiene and sanitation management.

IMMUNISATION

India has not managed to eradicate a number of diseases which are now rarely found in much of the rest of the world despite an immunisation effort which remains our largest peacetime mobilisation. The latest weapon on the immunisation front- Pulse Polio vaccination - might not have achieved its target of a polio-free India by 2000 A.D. but the social mobilisation for the project was tremendous. NGOs, educational institutions, government doctors and social workers pooled resources and funds to conduct the multi-phased immunisation campaign. The only states that have not come close to the target are those in which the mobilisation was not cohesive or dedicated enough.

UN figures indicate that 79 per cent of Indians are fully immunised against tuberculosis, 73 per cent against D.P.T. (diptheria, pertussis and tetanus) and polio, 66 per cent against measles and 80 per cent of pregnant women against tetanus.

Rising incidences of Hepatitis B and C in the late nineties call for attention on the same level, even though the costs of vaccinating for these conditions is much higher.