INDIAN INSTITUTE OF PUBLIC HEALTH GANDHINAGAR

MASTER IN PUBLIC HEALTH (MPH)

2022-24

INTRODUCTION TO PUBLIC HEALTH

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Compilation of reading resources

 COURSE OUTLINE
__________________________________________________________
Course Name : Introduction to Public Health
Credit : 1 (16 hours)
Course coordinator for 2022: Mayur Trivedi
Course instructors for 2022: Mayur Trivedi
_____________________________________________________________________________________

Course Overview: This course will be offered to students of Master in Public Health. This foundation
course will provide clarity of fundamentals of health, healthcare, and public health, in general, and in the
time of pandemic, in particular. This course will appraise the participants to the definition and concept of
health, determinants and dimensions of health, healthcare, and public health. Participant will get a
detailed account of public health objectives and functions. It will enable them to appreciate
multidisciplinary, multisector nature of the subject. The course will provide details of global and Indian
evolution of public health. It will also provide avenues to discuss health systems in the world and in India.
From a macro perspective of health and public health, the course would provide insights into public health
measures in the time of pandemic with specific emphasis to COVID 19.

Learning Objectives: The objective of this course is to enhance the ability of participants in appreciating
the breadth and complexities in the area of public health. Specifically, it will enable the participants

• To understand fundamentals of health, public health, and healthcare system in Indian and global
context
• To appreciate the concept, evolution, approaches, functions, and stakeholders of public health
• To appraise the participants with the importance of public health measures in the context of
pandemics
Evaluation Pattern:
ACTIVITIES MARKS
Group discussion and case study presentation 25
Module Exam (MCQ) 20
Total Internal (15) 45 (to be converted into 15)
Semester –end examination 20
 Class Plan for the Course:

No Lecture Topics Reading resources

1 Introduction to the course
Huber M Knottnerus JA Green L , et al. How should we define health? BMJ 2011; 343 : d4163
2 Introduction to Health
What is health? The ability to adapt. Editorial . Lancet 2009 ; 373 : 781
Determinants of Health Source: https://www.who.int/news-room/q-a-detail/determinants-of-health
National Academies of Sciences, Engineering, and Medicine 2019. Global Health
Determinants of Health Transitions and Sustainable Solutions: The Role of Partnerships: Proceedings of
3-4
and Health transitions a Workshop. Washington, DC: The National Academies Press.
https://doi.org/10.17226/25276.

Jambroes, Nederland et al; Implications of health as ‘the ability to adapt and self-manage’ for public
health policy: a qualitative study, European Journal of Public Health, Volume 26, Issue 3, 1 June 2016,
5 Health and health care Pages 412–416, https://doi.org/10.1093/eurpub/ckv206

Alma Ata declaration. http://www.who.int/publications/almaata_declaration_en.pdf?ua=1

Health, Public, and Public Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century (2003)
6
Health
Public health approach and Ten Essential Public Health Services and How They Can Include Addressing Social Determinants of
7-8
functions Health Inequities. Available at
9 Stakeholders in PH https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/Ten_Essential_Services_and_SDOH.pdf
World Health Organization. (2007). Everybody's business -- strengthening health systems to improve
Healthcare system – Global
10-11 health outcomes : WHO's framework for action. World Health Organization.
and Indian perspective
https://apps.who.int/iris/handle/10665/43918
“Das Gupta, Monica. 2005. Public Health in India : An Overview. Policy Research Working Paper; No.
12-13 History of PH in India 3787. World Bank, Washington, DC. © World Bank.
https://openknowledge.worldbank.org/handle/10986/8541
COVID19 Playbook Source: https://preventepidemics.org/covid19/resources/playbook/#key-principles-
Public health and
14-15 and-high-yield-tools
pandemics
16 Recap and evaluation
Reference Material:

A course pack containing various reading resources will be shared with the participants.

In addition, participants are advised to refer to the following resources.

1. WHO constitution http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf

2. Chapters 1, 2, 21, 22, 23 from K. Park, Park's Textbook of preventive and social medicine.
Latest edition
3. Winslow CEA. The untilled field of public health. Mod Med 1920;2:183–91.
4. Robert Beaglehole and Ruth Bonita. 1997. Public health at the crossroads: achievements and
prospects. Cambridge: Cambridge University Press.
5. High level Expert Group report on Universal Health Coverage in India. Available online:
http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf
6. Online Public Health course Centers for Disease Control and Prevention (CDC). Introduction
to Public Health. In: Public Health 101 Series. Atlanta, GA: U.S. Department of Health and
Human Services, CDC; 2014. Available at: https://www.cdc.gov/publichealth101/public-
health.html.
7. Institute of Medicine 2003. Who Will Keep the Public Healthy?: Educating Public Health
Professionals for the 21st Century. Washington, DC: The National Academies Press.
https://doi.org/10.17226/10542.
8. How Public Health Took Part in Its Own Downfall? Ed Yong.
https://www.theatlantic.com/health/archive/2021/10/how-public-health-took-part-its-own-
downfall/620457/
9. White F. Primary health care and public health: foundations of universal health

systems. Med Princ Pract. 2015;24(2):103-16. doi: 10.1159/000370197. Epub 2015 Jan
9. PMID: 25591411; PMCID: PMC5588212.
 TABLE OF CONTENTS

Page
No. Particulars
No.

1 What is health? The ability to adapt. Editorial. Lancet 2009 ; 373 : 781 1

Huber M Knottnerus JA Green L, et al. How should we define health? BMJ 2011; 343 : d4163
2 2-4

Determinants of Health
3 https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health 5-9

Alma Ata declaration. 1978

4 10-12
http://www.who.int/publications/almaata_declaration_en.pdf?ua=1

5 What is public health? – Prof. Mayur Trivedi 13-18

Public health orientation: from disease-centric provider outlook to wellbeing-focused community

6 19-22
perspective – Prof. Mayur Trivedi

Ten Essential Public Health Services and How They Can Include Addressing Social Determinants of
7 Health Inequities. 23-24
https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/Ten_Essential_Services_and_SDOH.pdf

8 What do public health people do? – Prof. Mayur Trivedi 25-29

9 Significance of Public Health in the time of coronavirus - Prof. - Mayur Trivedi 30 -34

10 Case studies 35-47

 Editorial

What is health? The ability to adapt

Health is not a “state of complete physical, mental, and for a more realistic understanding of what it means to
social well-being”. And nor is it “merely the absence of be healthy. The fact is that one cannot be healthy in an
disease or infirmity”. The first part of this formulation unhealthy society.
is enshrined in WHO’s famous founding constitution, Health certainly has to encompass these complex deter-
adopted in 1946. It was supposed to provide a minants of illness. But to say this can induce a feeling
transformative vision of “health for all”, one that went of fatigue, even defeat. The obstacles to a minimum
beyond the prevailing negative conception of health quantity of health seem so huge and so complex that
based on an “absence” of pathology. But neither definition it is almost impossible for a single doctor to have any

Zone Books
will do in an era marked by new understandings of disease influence on their effects. But if we take a more modest
at molecular, individual, and societal levels. Given that we view of what health means, perhaps we may be able to
See Series page 837
now know the important influence of the genome in transcend the complexities of disease and offer a very
disease, even the most optimistic health advocate surely practical mission for modern medicine.
has to accept the impossibility of risk-free wellbeing. That mission was set out most clearly by a French
That said, the conjunction of the physical, psychological, physician, Georges Canguilhem, in his 1943 book,
and social remains powerfully relevant to this day. Indeed, The Normal and the Pathological. Canguilhem rejected the
this framework should be extended in two further idea that there were normal or abnormal states of health.
dimensions. First, human health cannot be separated He saw health not as something defined statistically
from the health of our total planetary biodiversity. or mechanistically. Rather, he saw health as the ability
Human beings do not exist in a biological vacuum. We to adapt to one’s environment. Health is not a fixed
live in an interdependent existence with the totality of entity. It varies for every individual, depending on their
the living world. The second dimension is in the realm circumstances. Health is defined not by the doctor, but
of the inanimate. The living world depends upon a by the person, according to his or her functional needs.
healthy interaction with the inanimate world. Thanks to The role of the doctor is to help the individual adapt to
the science of climate change, we now understand only their unique prevailing conditions. This should be the
too well how contingent our human wellbeing is on the meaning of “personalised medicine”.
“health” of the Earth’s systems of energy exchange. The beauty of Canguilhem’s definition of health—of
Science has contributed to our understanding of normality—is that it includes the animate and inanimate
wellbeing through an ingenious apparatus of techniques environment, as well as the physical, mental, and
that reveal not only the causal pathways of ill health but social dimensions of human life. It puts the individual
also evidence for their amelioration. But the language patient, not the doctor, in a position of self-determining
of science can be inhibitory. For example, the notion of authority to define his or her health needs. The doctor
suffering is no longer fashionable. It is not a scientific becomes a partner in delivering those needs.
word; it seems vague and old-fashioned, harking back to For a scientific journal too, Canguilhem’s definition is
a time of clinical impotence, when patients had to endure liberating. By using adaptability as the test of health, a
and tolerate pain without respite or relief. Science aims journal can evolve to address the changing circumstances
to deliver the means to eliminate much of what once of disease. Adaptability frees us to be agile in the face of
passed for human suffering. shifting forces that shape the wellbeing of individuals and
But as the opening article in our Series on health in the populations. Canguilhem’s definition also allows us to
occupied Palestinian territory shows, dimensions of suf- respond to disease globally, taking account of the context
fering, especially at the community level, are measurable of conditions in a particular place, as well as time.
and often severe. Science has not eradicated suffering, Health is an elusive as well as a motivating idea. By
despite its enormous power to deliver technologies to replacing perfection with adaptation, we get closer to
improve health. Being more humble about the experience a more compassionate, comforting, and creative pro-
of individuals, rather than simply drawing up reductive gramme for medicine—one to which we can all con-
report cards of their health status, opens up the possibility tribute. ■ The Lancet

1
www.thelancet.com Vol 373 March 7, 2009 781
BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 1 of 3

Analysis

ANALYSIS

How should we define health?

The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of
chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the
ability to adapt and self manage in the face of social, physical, and emotional challenges

Machteld Huber senior researcher 1, J André Knottnerus president, Scientific Council for Government
Policy 2, Lawrence Green editor in chief, Oxford Bibliographies Online—public health 3, Henriëtte
van der Horst head 4, Alejandro R Jadad professor 5, Daan Kromhout vice president, Health Council
of the Netherlands 6, Brian Leonard professor 7, Kate Lorig professor 8, Maria Isabel Loureiro
coordinator for health promotion and protection 9, Jos W M van der Meer professor 10, Paul Schnabel
director 11, Richard Smith director 12, Chris van Weel head 13, Henk Smid director 14

1
Louis Bolk Institute, Department of Healthcare and Nutrition, Hoofdstraat 24, NL-3972 LA Driebergen, Netherlands; 2Department of General Practice,
Maastricht University, Scientific Council for Government Policy, Postbus 20004, NL-2500 EA The Hague, Netherlands; 3Department of Epidemiology
and Biostatistics, School of Medicine, University of California at San Francisco, USA; 4Department of General Practice, VU Medical Center,
Amsterdam, Netherlands; 5Centre for Global eHealth Innovation, Toronto General Hospital, Toronto, Canada; 6Department of Public Health Research,
Wageningen University, The Hague, Netherlands; 7Pharmacology Department, National University of Ireland, Galway, Ireland; 8Stanford Patient
Education Research Center, Palo Alto, CA, USA; 9National School of Public Health/New University of Lisbon, Portugal; 10General Internal Medicine,
Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands; 11Netherlands Institute for Social Research, The Hague, Netherlands;
12
UnitedHealth Chronic Disease Initiative, London, UK; 13Department of Primary and Community Care, Radboud University Nijmegen Medical
Centre; 14Netherlands Organisation for Health Research and Development, The Hague, Netherlands

The current WHO definition of health, formulated in 1948, system. New screening technologies detect abnormalities at
describes health as “a state of complete physical, mental and levels that might never cause illness and pharmaceutical
social well-being and not merely the absence of disease or companies produce drugs for “conditions” not previously
infirmity.”1 At that time this formulation was groundbreaking defined as health problems. Thresholds for intervention tend to
because of its breadth and ambition. It overcame the negative be lowered—for example, with blood pressure, lipids, and sugar.
definition of health as absence of disease and included the The persistent emphasis on complete physical wellbeing could
physical, mental, and social domains. Although the definition lead to large groups of people becoming eligible for screening
has been criticised over the past 60 years, it has never been or for expensive interventions even when only one person might
adapted. Criticism is now intensifying,2-5 and as populations age benefit, and it might result in higher levels of medical
and the pattern of illnesses changes the definition may even be dependency and risk.
counterproductive. The paper summarises the limitations of the The second problem is that since 1948 the demography of
WHO definition and describes the proposals for making it more populations and the nature of disease have changed considerably.
useful that were developed at a conference of international health In 1948 acute diseases presented the main burden of illness and
experts held in the Netherlands.6 chronic diseases led to early death. In that context WHO
Limitations of WHO definition articulated a helpful ambition. Disease patterns have changed,
with public health measures such as improved nutrition, hygiene,
Most criticism of the WHO definition concerns the absoluteness and sanitation and more powerful healthcare interventions. The
of the word “complete” in relation to wellbeing. The first number of people living with chronic diseases for decades is
problem is that it unintentionally contributes to the increasing worldwide; even in the slums of India the mortality
medicalisation of society. The requirement for complete health pattern is increasingly burdened by chronic diseases.7
“would leave most of us unhealthy most of the time.”4 It
Ageing with chronic illnesses has become the norm, and chronic
therefore supports the tendencies of the medical technology and
diseases account for most of the expenditures of the healthcare
drug industries, in association with professional organisations,
system, putting pressure on its sustainability. In this context the
to redefine diseases, expanding the scope of the healthcare

Correspondence to: M Huber [email protected]

2

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ANALYSIS

WHO definition becomes counterproductive as it declares people post-traumatic stress disorders.12 13 The sense of coherence
with chronic diseases and disabilities definitively ill. It includes the subjective faculties enhancing the
minimises the role of the human capacity to cope autonomously comprehensibility, manageability, and meaningfulness of a
with life’s ever changing physical, emotional, and social difficult situation. A strengthened capability to adapt and to
challenges and to function with fulfilment and a feeling of manage yourself often improves subjective wellbeing and may
wellbeing with a chronic disease or disability. result in a positive interaction between mind and body—for
The third problem is the operationalisation of the definition. example, patients with chronic fatigue syndrome treated with
WHO has developed several systems to classify diseases and cognitive behavioural therapy reported positive effects on
describe aspects of health, disability, functioning, and quality symptoms and wellbeing. This was accompanied by an increase
of life. Yet because of the reference to a complete state, the in brain grey matter volume, although the causal relation and
definition remains “impracticable, because ‘complete’ is neither direction of this association are still unclear.14
operational nor measurable.”3 4
Social health
Need for reformulation Several dimensions of health can be identified in the social
domain, including people’s capacity to fulfil their potential and
Various proposals have been made for adapting the definition obligations, the ability to manage their life with some degree
of health. The best known is the Ottawa Charter,8 which of independence despite a medical condition, and the ability to
emphasises social and personal resources as well as physical participate in social activities including work. Health in this
capacity. However, WHO has taken up none of these proposals. domain can be regarded as a dynamic balance between
Nevertheless, the limitations of the current definition are opportunities and limitations, shifting through life and affected
increasingly affecting health policy. For example, in prevention by external conditions such as social and environmental
programmes and healthcare the definition of health determines challenges. By successfully adapting to an illness, people are
the outcome measures: health gain in survival years may be less able to work or to participate in social activities and feel healthy
relevant than societal participation, and an increase in coping despite limitations. This is shown in evaluations of the Stanford
capacity may be more relevant and realistic than complete chronic disease self management programme: extensively
recovery. monitored patients with chronic illnesses, who learnt to manage
Redefining health is an ambitious and complex goal; many their life better and to cope with their disease, reported improved
aspects need to be considered, many stakeholders consulted, self rated health, less distress, less fatigue, more energy, and
and many cultures reflected, and it must also take into account fewer perceived disabilities and limitations in social activities
future scientific and technological advances. The discussion of after the training. Healthcare costs also fell.15 16
experts at the Dutch conference, however, led to broad support If people are able to develop successful strategies for coping,
for moving from the present static formulation towards a more (age related) impaired functioning does not strongly change the
dynamic one based on the resilience or capacity to cope and perceived quality of life, a phenomenon known as the disability
maintain and restore one’s integrity, equilibrium, and sense of paradox.17
wellbeing.6 The preferred view on health was “the ability to
adapt and to self manage.” Measuring health
Participants questioned whether a new formulation should be
called a definition, because this implied set boundaries and The general concept of health is useful for management and
trying to arrive at a precise meaning. They preferred that the policies, and it can also support doctors in their daily
definition should be replaced by a concept or conceptual communication with patients because it focuses on
framework of health. A general concept, according to sociologist empowerment of the patient (for example, by changing a
Blumer,9 represents a characterisation of a generally agreed lifestyle), which the doctor can explain instead of just removing
direction in which to look, as reference. But operational symptoms by a drug. However, operational definitions are
definitions are also needed for practical life such as measurement needed for measurement purposes, research, and evaluating
purposes. interventions.
The first step towards using the concept of “health, as the ability Measurement might be helped by constructing health frames
to adapt and to self manage” is to identify and characterise it that systematise different operational needs—for example,
for the three domains of health: physical, mental, and social. differentiating between the health status of individuals and
The following examples attempt to illustrate this. populations and between objective and subjective indicators of
health. The measurement instruments should relate to health as
the ability to adapt and to self manage. Good first operational
Physical health
tools include the existing methods for assessing functional status
In the physical domain a healthy organism is capable of and measuring quality of life and sense of wellbeing. WHO has
“allostasis”—the maintenance of physiological homoeostasis developed several classification systems measuring gradations
through changing circumstances.10 When confronted with of health.18 These assess aspects like disability, functioning, and
physiological stress, a healthy organism is able to mount a perceived quality of life and wellbeing.
protective response, to reduce the potential for harm, and restore
In primary care, the Dartmouth Cooperative Group
an (adapted) equilibrium. If this physiological coping strategy
(COOP)/Wonca (the world organisation of family doctors)
is not successful, damage (or “allostatic load”) remains, which
assessment of functional status, validated for different social
may finally result in illness.11
and cultural settings, has been developed to obtain insight into
the perceived health of individuals. The COOP/Wonca
Mental health Functional Health Assessment Charts present six different
In the mental domain Antonovsky describes the “sense of dimensions of health, each supported by cartoon-like
coherence” as a factor that contributes to a successful capacity drawings.19 20 Each measures the ability to perform daily life
to cope, recover from strong psychological stress, and prevent 3 activities on a 1 to 5 scale.

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BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 3 of 3

ANALYSIS

Such instruments offer valuable information about a variety of Provenance and peer review: Not commissioned; externally peer
aspects, from functioning to the experienced quality of life. Yet reviewed.
there are few instruments for measuring aspects of health like
the individual’s capacity to cope and to adapt, or to measure the 1 WHO. Constitution of the World Health Organization. 2006. www.who.int/governance/eb/
who_constitution_en.pdf.
strength of a person’s physiological resilience. A new 2 What is health? The ability to adapt [editorial]. Lancet 2009;373:781.
formulation about health could stimulate research on this. 3 Jadad AR, O’Grady L. How should health be defined. BMJ 2008;337;a2900.
4 Smith R. The end of disease and the beginning of health. BMJ Group Blogs 2008. http:/
/blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-
Conclusion 5
health/.
Larson JS. The conceptualization of health. Med Care Res Rev 1999;56;123-36.
6 Health Council of the Netherlands. Publication A10/04. www.gezondheidsraad.nl/sites/
Just as environmental scientists describe the health of the earth default/files/bijlage%20A1004_1.pdf.
as the capacity of a complex system to maintain a stable 7 Kanungo S, Tsuzuki A, Deen JL, Lopez AL, Rajendran K, Manna B, et al. Use of verbal

environment within a relatively narrow range,21 we propose the autopsy to determine mortality patterns in an urban slum in Kolkate, India. Bull World
Health Organ 2010;88:667-74.
formulation of health as the ability to adapt and to self manage. 8 Ottawa Charter for Health Promotion. www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf.
This could be a starting point for a similarly fresh, 21st century 9
10
Blumer H. Symbolic interactionism: perspective and method. Prentice Hall, 1969.
Schulkin J. Allostasis, homeostasis, and the costs of physiological adaptation. Cambridge
way of conceptualising human health with a set of dynamic University Press, 2004.
features and dimensions that can be measured. Discussion about 11 McEwen BS. Interacting mediators of allostasis and allostatic load: towards an
understanding of resilience in aging. Metabolism 2003;52(suppl 2):10-6.
this should continue and involve other stakeholders, including 12 Antonovsky A. Health, stress and coping. Jossey-Bass, 1979.
patients and lay members of the public. 13 Antonovsky A. The sense of coherence as a determinant of health. In: Matarazzo J, ed.
Behavioural health: a handbook of health enhancement and disease prevention. John
Wiley, 1984:114–29.
We thank Jennie Popay, Atie Schipaanboord, Eert Schoten, and Rudy 14 De Lange FP, Koers A, Kalkman JS, Bleijenberg G, Hagoort P, Van der Meer JWM, et
al. Increase in prefrontal cortical volume following cognitive behavioural therapy in patients
Westendorp for their thoughts.
with chronic fatigue syndrome. Brain 2008;131:2172-80.
Contributors and sources: This paper builds on a two day invitational 15 Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence
suggesting that a chronic disease self management program can improve health status
conference in the Netherlands on defining health, organised by the while reducing utilization and costs: a randomized trial. Med Care 1999;37:5-14.
Health Council of the Netherlands (Gezondheidsraad) and the 16 Lorig KR, Ritter PL, González VM. Hispanic chronic disease self management: a
randomized community-based outcome trial. Nurs Res 2003;52:361-9.
Netherlands Organisation for Health Research and Development 17 Von Faber M, Bootsma-van der Wiel A, van Exel E, Gussekloo J, Lagaay AM, van Dongen
(ZonMw). At the conference a multidisciplinary group of 38 international E, et al. Successful aging in the oldest old: who can be characterized as successfully
aged? Arch Intern Med 2001;161:2694-700.
experts discussed the topic and were guided by a review of the literature.
18 WHO. WHO family of international classifications.www.who.int/classifications.
MH organised the conference and drafted the report and this article. 19 Van Weel C, König-Zahn C, Touw-Otten FWMM, van Duijn NP, Meyboom-de Jong B.
LG, HvdH, ARJ, DK, BL, KL, MIL, JvdM, PS, RS, and CvW contributed Measuring functional health status with the COOP/Wonca charts. Northern Centre for
Health Care Research, University of Groningen, 1995. www.globalfamilydoctor.com/
as speakers. HS hosted the conference with JAK, who chaired it. All research/research.asp?refurl=r#R4.
authors contributed to the article. JAK is guarantor. 20 Nelson E, Wasson J, Kirk J, Keller A, Clark D, Dittrich A, et al. Assessment of function in
routine clinical practice: description of the COOP Chart method and preliminary findings.
Competing interests: All authors have completed the ICJME unified J Chron Dis 1987;40(suppl 1):55S-63S.
disclosure form at www.icmje.org/coi_disclosure.pdf (available on 21 Rockström J, Steffen W, Noone K, Persson Å, Chapin AS, Lambin EF, et al. A safe
operating space for humanity. Nature 2009;461:472-5.
request from the corresponding author) and declare no support from
any organisation for the submitted work; no financial relationships with Accepted: 15 June 2011
any organisation that might have an interest in the submitted work in
the previous three years; and no other relationships or activities that Cite this as: BMJ 2011;343:d4163
could appear to have influenced the submitted work.

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From Healthy People.gov

Source: https://www.healthypeople.gov/2020/about/foundation-health-
measures/Determinants-of-Health

Determinants of Health

What makes some people healthy and others unhealthy?

How can we create a society in which everyone has a chance to live a long, healthy life?

Healthy People 2020 is exploring these questions by:

Developing objectives that address the relationship between health status and biology,
individual behavior, health services, social factors, and policies.
Emphasizing an ecological approach to disease prevention and health promotion. An
ecological approach focuses on both individual-level and population-level determinants of
health and interventions.

About Determinants of Health

The range of personal, social, economic, and environmental factors that influence health status are
known as determinants of health.

Determinants of health fall under several broad categories:

Policymaking
Social factors
Health services
Individual behavior
Biology and genetics

It is the interrelationships among these factors that determine individual and population health.
Because of this, interventions that target multiple determinants of health are most likely to be
effective. Determinants of health reach beyond the boundaries of traditional health care and public
health sectors; sectors such as education, housing, transportation, agriculture, and environment can
be important allies in improving population health.

Policymaking

Policies at the local, state, and federal level affect individual and population health. Increasing taxes
on tobacco sales, for example, can improve population health by reducing the number of people using
tobacco products.

5
Some policies affect entire populations over extended periods of time while simultaneously helping to
change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and
Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor
vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which
in turn reduced rates of injuries and deaths from motor vehicle accidents. 1

Social Factors

Social determinants of health reflect the social factors and physical conditions of the environment in
which people are born, live, learn, play, work, and age. Also known as social and physical
determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes.

Don’t miss the Social Determinants of Health topic area and objectives.

Examples of social determinants include:

Availability of resources to meet daily needs, such as educational and job opportunities, living
wages, or healthful foods
Social norms and attitudes, such as discrimination
Exposure to crime, violence, and social disorder, such as the presence of trash
Social support and social interactions
Exposure to mass media and emerging technologies, such as the Internet or cell phones
Socioeconomic conditions, such as concentrated poverty
Quality schools
Transportation options
Public safety
Residential segregation

Examples of physical determinants include:

Natural environment, such as plants, weather, or climate change

Built environment, such as buildings or transportation
Worksites, schools, and recreational settings
Housing, homes, and neighborhoods
Exposure to toxic substances and other physical hazards
Physical barriers, especially for people with disabilities
Aesthetic elements, such as good lighting, trees, or benches

Poor health outcomes are often made worse by the interaction between individuals and their social
and physical environment.

For example, millions of people in the United States live in places that have unhealthy levels of ozone
or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of
asthma in both adults and children compared with state and national averages. Poor air quality can
worsen asthma symptoms, especially in children.2

Health Services

6
Both access to health services and the quality of health services can impact health. Healthy People
2020 directly addresses access to health services as a topic area and incorporates quality of health
services throughout a number of topic areas.

Lack of access, or limited access, to health services greatly impacts an individual’s health status. For
example, when individuals do not have health insurance, they are less likely to participate in
preventive care and are more likely to delay medical treatment.3

Don’t miss the Access to Health Services topic area and objectives.

Barriers to accessing health services include:

Lack of availability
High cost
Lack of insurance coverage
Limited language access

These barriers to accessing health services lead to:

Unmet health needs

Delays in receiving appropriate care
Inability to get preventive services
Hospitalizations that could have been prevented

Individual Behavior

Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking,
his or her risk of developing heart disease is greatly reduced.

Many public health and health care interventions focus on changing individual behaviors such as
substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the
rates of chronic disease in this country.

Examples of individual behavior determinants of health include:

Diet
Physical activity
Alcohol, cigarette, and other drug use
Hand washing

Biology and Genetics

Some biological and genetic factors affect specific populations more than others. For example, older
adults are biologically prone to being in poorer health than adolescents due to the physical and
cognitive effects of aging.

7
Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition
that people inherit when both parents carry the gene for sickle cell. The gene is most common in
people with ancestors from West African countries, Mediterranean countries, South or Central
American countries, Caribbean islands, India, and Saudi Arabia.

Examples of biological and genetic social determinants of health include:

Age
Sex
HIV status
Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis
Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer
Family history of heart disease

References

Centers for Disease Control and Prevention. Achievements in public health, 1900–1999 motor-
1

vehicle safety: A 20th century public health achievement [Internet]. MMWR Weekly. 1999 May
14;48(18);369–74 [cited 2010 August 27]. Available
from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm.

2State of the Air [Internet]. Washington, DC: American Lung Association. Available
from: http://www.stateoftheair.org .

Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report, 2008.
3

Rockville (MD): U.S. Department of Health and Human Services, AHRQ; 2009 Mar. Pub no. 09-002.
Available from: http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf [PDF – 2.6 MB].

Additional Resources

Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through
action on the social determinants of health [Internet]. Geneva: World Health Organization; 2008 [cited
2010 May 10]. Available from: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf [PDF
– 4.3 MB] .

Harris K, Holden C, Chen M. Background information on national indicators for social determinants of
health. Paper presented to the Secretary’s Advisory Committee on National Health Promotion and
Disease Prevention Objectives for 2020, National Opinion Research Center; January 5, 2010.

Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health.
Washington, DC: National Academies Press; 2003.

U.S. Department of Health and Human Services. Draft report of the Secretary’s Advisory Committee
on National Health Promotion and Disease Prevention Objectives for 2020 on Social Determinants;
revised 2009 Sep 9.

8
Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts [Internet]. 2nd ed.
Copenhagen: World Health Organization; 2003 [cited 2010 May 26]. Available
from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf [PDF – 470 KB] .

9
 Declaration of Alma-Ata

International Conference on Primary Health Care, Alma-Ata, USSR, 6-12

September 1978

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth
day of September in the year Nineteen hundred and seventy-eight, expressing the need
for urgent action by all governments, all health and development workers, and the world
community to protect and promote the health of all the people of the world, hereby makes
the following

Declaration:

I
The Conference strongly reaffirms that health, which is a state of complete physical,
mental and social wellbeing, and not merely the absence of disease or infirmity, is a
fundamental human right and that the attainment of the highest possible level of health is
a most important world-wide social goal whose realization requires the action of many
other social and economic sectors in addition to the health sector.

II
The existing gross inequality in the health status of the people particularly between
developed and developing countries as well as within countries is politically, socially and
economically unacceptable and is, therefore, of common concern to all countries.

III
Economic and social development, based on a New International Economic Order, is of
basic importance to the fullest attainment of health for all and to the reduction of the gap
between the health status of the developing and developed countries. The promotion and
protection of the health of the people is essential to sustained economic and social
development and contributes to a better quality of life and to world peace. IV The people
have the right and duty to participate individually and collectively in the planning and
implementation of their health care.

V
Governments have a responsibility for the health of their people which can be fulfilled
only by the provision of adequate health and social measures. A main social target of
governments, international organizations and the whole world community in the coming
decades should be the attainment by all peoples of the world by the year 2000 of a level
of health that will permit them to lead a socially and economically productive life.
Primary health care is the key to attaining this target as part of development in the spirit
of social justice.

VI
Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals

10
and families in the community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their development in the
spirit of selfreliance and self-determination. It forms an integral part both of the country's
health system, of which it is the central function and main focus, and of the overall social
and economic development of the community. It is the first level of contact of individuals,
the family and community with the national health system bringing health care as close as
possible to where people live and work, and constitutes the first element of a continuing
health care process.

VII
Primary health care:

1. reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country and its communities and is based on the application
of the relevant results of social, biomedical and health services research and
public health experience;

2. addresses the main health problems in the community, providing promotive,

preventive, curative and rehabilitative services accordingly;

3. includes at least: education concerning prevailing health problems and the

methods of preventing and controlling them; promotion of food supply and proper
nutrition; an adequate supply of safe water and basic sanitation; maternal and
child health care, including family planning; immunization against the major
infectious diseases; prevention and control of locally endemic diseases;
appropriate treatment of common diseases and injuries; and provision of essential
drugs;

4. involves, in addition to the health sector, all related sectors and aspects of national
and community development, in particular agriculture, animal husbandry, food,
industry, education, housing, public works, communications and other sectors;
and demands the coordinated efforts of all those sectors;

5. requires and promotes maximum community and individual self-reliance and

participation in the planning, organization, operation and control of primary
health care, making fullest use of local, national and other available resources;
and to this end develops through appropriate education the ability of communities
to participate;

6. should be sustained by integrated, functional and mutually supportive referral

systems, leading to the progressive improvement of comprehensive health care for
all, and giving priority to those most in need;

7. relies, at local and referral levels, on health workers, including physicians, nurses,
midwives, auxiliaries and community workers as applicable, as well as traditional

11
 practitioners as needed, suitably trained socially and technically to work as a
health team and to respond to the expressed health needs of the community.

VIII
All governments should formulate national policies, strategies and plans of action to
launch and sustain primary health care as part of a comprehensive national health system
and in coordination with other sectors. To this end, it will be necessary to exercise
political will, to mobilize the country's resources and to use available external resources
rationally.

IX
All countries should cooperate in a spirit of partnership and service to ensure primary
health care for all people since the attainment of health by people in any one country
directly concerns and benefits every other country. In this context the joint
WHO/UNICEF report on primary health care constitutes a solid basis for the further
development and operation of primary health care throughout the world.

X
An acceptable level of health for all the people of the world by the year 2000 can be
attained through a fuller and better use of the world's resources, a considerable part of
which is now spent on armaments and military conflicts. A genuine policy of
independence, peace, détente and disarmament could and should release additional
resources that could well be devoted to peaceful aims and in particular to the acceleration
of social and economic development of which primary health care, as an essential part,
should be allotted its proper share.

The International Conference on Primary Health Care calls for urgent and effective
national and international action to develop and implement primary health care
throughout the world and particularly in developing countries in a spirit of technical
cooperation and in keeping with a New International Economic Order. It urges
governments, WHO and UNICEF, and other international organizations, as well as
multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all
health workers and the whole world community to support national and international
commitment to primary health care and to channel increased technical and financial
support to it, particularly in developing countries. The Conference calls on all the
aforementioned to collaborate in introducing, developing and maintaining primary health
care in accordance with the spirit and content of this Declaration.

12
 What is Public Health?
- Mayur Trivedi
________________________________________________________

Scenario A: Prof. X is the director of a famous public health school in India. He is a trained

medical doctor with higher education in public health from a world-famous university in the

USA. He has more than three decades of experience in the health sector. However, in these

thirty years, he has not seen patients at a clinic or in a hospital. Despite not serving as a

treating doctor or a surgeon, he is a renowned health sector expert in India. Having studied

medicine, he has not treated patients, and yet, he is a well-known health expert.

Scenario B: Prof. Y has done her bachelors in Pharmacy, and has been working in the health

sector for two decades. However, despite being a pharmacist, she has not worked in the

pharmaceutical industry; she has neither developed, manufactured nor sold medicines. She

does not even teach at a pharmacy college. Instead, being a faculty in India’s first public health

university, she has been teaching health and related subjects. Despite not being a doctor,

many like her are involved in teaching, training, and research around health issues.

These two scenarios are possible because health is a broad subject, of which clinical medicine

is an important part along with many other non-clinical specialties. To understand public

health, one needs to understand both the terms i.e. - ‘public ‘and ‘health’ – carefully. Health

has a lot of meaning and definitions, with a broad understanding as wellbeing and lack of

illness or injuries. All the actions that are aimed at attaining this state of wellbeing and

freedom from illness or injuries are healthcare actions. These actions could be seen as a)

individual or collective actions, and b) targeted at wellbeing i.e. preventive and promotive

actions or targeted at restoring health i.e. treatment or curative actions.

13
 Doctors help people recovering from sickness; but, anyone can help

prevent illness

Most individual healthcare is medical or clinical care at the time of illness or injury. When a

person feels uneasy beyond home remedies, he/she approaches a healthcare provider, gets

diagnosis done, gets and consumes medicines, and ensures precaution and care, as

prescribed. This may result in a cure or healing. This journey from the onset of illness to cure

or healing is a story of medical or clinical care. Such clinical or medical care involves the

services of medical and para-medical staff. Illness and treatment being technical matters,

medical and clinical expertise is needed to cure a patient. A team of doctor, nurse, laboratory

technician, radiologist, and pharmacist provides individual care to a patient and help in the

process of recovery from illness or injury. This is an example of individual medical care.

Health, on the other hand, is a subject of humanities. Appreciation of human health requires

a much wider and deeper understanding of a range of issues, in addition to and beyond

medical care. Why are some communities healthier and live longer than others? Why do

some sections of the same society have better health than others? These are some questions

that can be answered by such a wider understanding of health. The determinants of health,

therefore, are different from the determinants of illness. In addition to the individual’s

genetic predisposition, the health is determined by individual actions – practice and

behaviour, household environment, educational status, cultural beliefs, social norms and

traditions, food habits, occupation, environment, law and order, medicines, and a lot of other

socio-economic factors. These factors can range from cellular level factors to the societal

14
level. They could be natural factors or they could be cultural factors. Many of these are under

individual control but a lot of it is for public actions.

That brings us to the word ‘Public’. This involves collective efforts for people and not

individuals. The group of people could be at the community level, state level, national level,

or global level. These may include sick people and healthy people. The actions - medical and

non-medical care - that are aimed at people at large, beyond individual medical care, are

called public health interventions. Such public health interventions are aimed at improving

health, increasing life, and ensuring a better quality of life of people through organized efforts

of society or government. Public health professionals are interested in a deeper

understanding of the determinants of health and illness. The public health efforts are

community-oriented efforts taken at the public level aiming at a mass, and not individuals.

They are aimed at keeping healthy people healthy by contributing to the reduction of illness

and injuries.

15
Let us understand public health with an illustration. Suppose you reach home and see that
all the houses on the street or in the society are flooded. Water from somewhere has flown
all over the houses. As soon as you reach your home, you realize that rooms and kitchens
are also wet with flowing water. Now, what would you do to get your house back to
normal?

According to a common understanding, you will say, 'we will take out the water with the
help of tumblers and buckets, and then we will mop the floor clean’! Your neighbours will
also start cleaning their houses. All the people will start cleaning the houses in ways that
are easy and less laborious, as per their understanding. They may also help each other as
much as possible. Now, looking at the flooded houses, one may pause to think of where
the water came from, why is it continue to pour and how can one solve it. That person may
find an open tap and close it to prevent further flow of water. Someone else would look for
clogged drainage that is not allowing the free flow of water.

Thus, to clean the houses in society, some people start mopping the floor, while others start
closing the open taps and cleaning the drains filled with garbage. The people who are
mopping the floor in the front room will be visible and the effects of their work will be felt
immediately. At the same time, people who went inside the house to turn off the taps and
clean the drains will not be seen, and therefore the effects of their work will not be felt
immediately.

This flooded homes and society is our world, and the flowing water can be seen as sickness
and injuries. Buckets and tumblers and mops are all the ingredients used in the treatment.
Taps and drains are various factors affecting health. People who are constantly mopping
the floor, and therefore, who are constantly in front of the eye, are medical and clinical
professionals, including a doctor. The public health professionals are the ones who find the
cause of the house getting wet, turn off the taps, and clean the drains. They are not visible
all the time, like someone bringing the house back to shape like moppers, but play a very
important role in ensuring that the house does not flood!

16
To further understand, let’s take an example of mosquito-related illnesses like Malaria,

Dengue, and Chikungunya. When someone develops a fever that does not get cured with

home remedies the patient is provided with medicine like Chloroquine, based on blood

investigations. The fever is reduced and eventually the patient gets cured. This is individual

clinical care.

However, the healthcare services are much more than mere medical or clinical care and are

not only for the patients but for people in general. Such medical and non-medical care that is

aimed at people at large, beyond individual care, are called public health interventions. Such

public health interventions are aimed at improving health, increasing life, and ensuring a

better quality of life of people through organized efforts of society or government.

When a household uses mosquito repellent or coils to protect the family members from a

mosquito bite, this could be seen as individual preventive healthcare. However, when efforts

are done to protect the population from the menace of mosquitoes, these could be public

health efforts. These include a) identification and elimination of mosquito breeding sites

inside and outside homes, b) fumigation and spraying in vulnerable areas and distribution of

mosquito nets to vulnerable people, and c) proactive screening and preventive treatment in

endemic areas. Malaria control activities may also include awareness generation activities in

the form of improving the knowledge that leads to changes in the behaviour of people. It may

also include efforts to ensure the mass treatment of infected individuals in such a way that it

doesn’t affect the finances of the family of infected individuals. This is done through equitable

health financing efforts in the form of health insurance coverage and fully or partially

subsidized treatment for vulnerable groups. All these efforts are beyond individual treatment

and are done for the entire community through organized efforts.

17
Illness and treatment being technical matters, medical and clinical expertise is needed to cure

a patient. A team of doctor, nurse, laboratory technician, radiologist, and pharmacist provides

individual care to a patient and help in the process of recovery from illness or injury. This is

an example of personalized medical care. Health, on the other hand, is also a subject of

humanities. Appreciation of human health requires a much wider and deeper understanding

of a range of determinants of health, i.e. what affects the health of people, in addition to and

beyond medical care. These determinants include a) individual behaviour, b) family and

cultural practice, c) food and other habits, d) occupation, e) environment, f) socio-economic

realities, and g) policy and legislation. While clinicians and para-clinicians cure and care, the

public health professionals study and work on such a range of determinants of health. The

efforts of public health professionals ensure that healthy people remain healthy, do not fall

sick or get injured, and remain physically, financially, and socially fit after the illness. The

public health efforts are organized efforts by many people for many people, unlike the

treatment of a sick individual.

Treatment as medical care and health interventions as public health efforts are thus different.

Medical care is indeed very important to get rid of illness and injuries. However, public health

efforts are also equally important to ensure that people remain healthy, remain protected

from injury and illness and if illness occurs, get treated without having to face financial

burden.

18
 Public health orientation: from disease-centric provider outlook to

wellbeing-focused community perspective

- Mayur Trivedi
________________________________________________________

Public health education and research involve a lot of learning, unlearning, and re-learning for

graduates of various disciplines. This is particularly relevant for medical and paramedical

graduates who receive four-five years of training in looking at the health and illness from the

cellular level. Medical education is depth-oriented; a medical professional would strive to zoom

in deeper inside the body – all the way down at cellular level –to understand and explore deeper

causes of illness operating in that particular individual and identify an effective treatment for the

same. On the other hand, for an effective public health perspective, one needs to learn to zoom

out to understand the breadth and width of context in which individuals live, operate, and

prosper – all the way up to societal level – to appreciate the wide range of social, economic,

environmental, and occupational issues that affects one’s life decisions and identify acceptable

solutions to such issues thereby impacting whole communities. This journey from individual

treatment-centeredness to the public health perspective involves the expansion of the cellular

perspective to a social perspective.

The decision of treatment of an individual involves the exploration of symptoms and

measurement of parameters. The treatment in itself involves either passing on instructions about

medicines and precautions, or technical actions on human bodies ranging from a simple dressing

19
of wounds to complicated surgery. Thus, clinicians and para-clinicians are generally trained to

believe that once the diagnosis is correct, the curative actions are certain and under control

through medicines and/or use of technology. The patients are expected to either surrender for

the intervention with the use of technology i.e. surgery etc. or follow the prescription of

medicines and precautions i.e. non-surgical medical care.

Now, there is a price involved in such decisions; price of actions as well inaction. The price of

action is monetary in terms of the direct and indirect cost of treatment. The price of inaction,

i.e. not following the advice of the doctor, could be monetary or non-monetary on patients

particularly in life threatening conditions. The opportunity cost i.e. monetary and non-monetary

price for not following the prescription or surgery is huge on patients and their families. And

thus, most of the patients would follow the instructions through. They would beg, borrow, or

steal to pay for the treatment in the private sector or go to public hospitals to receive free but

perceivably poor quality of care. The patients who cannot afford to do either of these are left

alone. The healthcare providers do not bother about them beyond a sense of sorry.

The healthcare providers are excellent in handling technical skills, information, and tools of

treatments i.e. medicines, equipment, reagents, and instruments. They are not trained to focus

on the economic, social, or occupational dimensions of human health while diagnosing and

treating ailments. However, for overall wellbeing, people need to be handled beyond illness,

injuries, and treatment. The healthcare providers are not inclined to understand the constraints

and enablers that patients may have in following the prescriptions.

20
This is where the prevention and promotion based public health approach would differ from

treatment based individual health approach. While clinical education deals with the questions

of ‘how’ illness and injury occur. It revolves around host and agent and establishes the

connections thereof. Such inquiry falls short of probing ‘why’ illness and injury occur? Why do

they occur more among a certain section of society?

When clinicians and para-clinicians enter public health, they need to unlearn the habit of

prescribing. They also need to unlearn their exploration for prescription in terms of the inquiry

that is meant to generate just a prescription. In a typical clinical world, the provider would seek

information on symptoms on one hand and provide information on treatment on the other. A

clinician’s inquiry expands neither to include an individual’s vulnerability towards the causes of

illness nor to the financial ability to pay for the treatment beyond consultation charges. They

neither seek details about their living environment in which the precautions would unfold.

The provider’s contact with patients starts with symptoms and ends with the provision of

information (i.e. consultation and prescription) and surgical inputs, if and as needed. The public

health professionals would need to go beyond this limited patient-provider transaction. A public

health professional would need to strive to understand the reasons for unwillingness and

unaffordability to act meaningfully before and after the event and interactions, to plan the

community level actions to avoid illnesses and injuries as well as their socio-economic impact in

future. In fact, a public health professional would most of the time need to begin actions with

the unwillingness of the individuals or community.

21
The role of a provider would cease to exist if a patient is either unwilling or unable to follow the

prescriptions. A clinician’s role would end with a ‘no’ from a patient, while the public health

professional’s role will start with such refutation. The Public health inquiry starts when decisions

around treatment end. Public health professionals need to develop the art of this style of inquiry

to understand and appreciate the context, empathize with the vulnerable and generate

information about conditions that affect the lives of people, in general, and their decisions that

result into a perpetual cycle of illness, injuries, and the mother of it all, poverty.

This can be done by reducing patient-provider power imbalance and by realigning the focus of

inquiry from ‘how’ to ‘why’, more often with a wide range of community members each time and

every time one interacts with them.

22
 Ten Essential Public Health Services and How They Can
Include Addressing Social Determinants of Health Inequities
Public health departments and their partners need to consider how conditions in the places where people live,
learn, work, and play affect a wide range of health risks and outcomes. These social determinants of health
(SDOH), and actions to address the resulting health inequities, can be incorporated throughout all aspects of
public health work. Through broader awareness of how the key public health practices can better incorporate
consideration of SDOH, public health practitioners can transform and strengthen their capacity and impact to
advance health equity.

10 Essential Public Health Services Five Key Areas of SDOH (HP 2020)

Roles of Public Health Agency Examples of How Essential Public Health Services Can Address
(Based on 10 Essential Public SDOH Inequities
Health Services)
1. Monitor health status to identify Include SDOH measures as basis for addressing community health
and solve community health problems and inequities
problems
Ensure community health assessments (CHA) include SDOH measures and
engage communities and multi-sectoral partners in CHA efforts
2. Diagnose and investigate health Include community-level determinants of health in investigations, as well
problems and health hazards in the as policies and practices that involve other sectors to support them. For
community example
 Ensure water sources meet required standards
 Ensure brownfield sites Identify hazardous waste that might
contaminate a community
 Address deteriorating housing conditions to prevent lead
poisoning and other hazards to health
3. Inform, educate, and empower Ensure outreach and education efforts address social and structural
people about health issues determinants of health inequities

Ensure access to culturally and linguistically appropriate approaches to

community health (e.g., REACH) to help address SDOH. Approaches should
take into account such challenges as structural racism and stigma against

23
 immigrants, both of which can decrease likelihood of seeking needed
health care.

4. Mobilize community partnerships Engage and collaborate with community members and non-traditional
and action to identify and solve partners associated with SDOHs, such as
health problems  Housing authorities
 Law enforcement
 Schools
 Community organizations
5. Develop policies and plans that Leverage evidence-based policies in non-health sectors that affect SDOH
support individual and community and health outcomes, such as
health efforts  Safe and affordable housing that can reduce risk for asthma, lead
poisoning, homelessness
 Full-day kindergarten that can reduce adverse health prospects
such as teenage pregnancy

Develop and implement state/community health improvement plans that

include and address the SDOH in collaboration with community partners

6. Enforce laws and regulations that Develop strategies to ensure enforcement of existing regulations and laws
protect health and ensure safety that affect health, such as
 Housing and health codes to prevent childhood lead poisoning.
 Batterer intervention program laws to prevent violence against
women and children

7. Link people to needed personal Educate community members about their eligibility for and access to
health services and ensure the entitlement programs
provision of health care when  Medicaid, including its medical, mental health, and housing
otherwise unavailable benefits
 TANF
 SNAP

Ensure that essential health benefits and the free preventive services
provisions of the Affordable Care Act are correctly and equitably
implemented

8. Assure competent public and Support staff training and development efforts that help workforce
personal health care workforce incorporate social determinants of health inequity into their job
responsibilities

Promote hiring of workforce that reflects population being served

9. Evaluate effectiveness, accessibility, Ensure evaluation and research designs include interventions that address
and quality of personal and SDOH inequity
population-based health services
Use performance management and quality improvement methods to
explore and address more effectively the root causes of issues, which often
include SDOH

10. Research for new insights and Expand research agendas to include SDOH and related health outcomes,
innovative solutions to health especially in evaluation of natural experiments where a project is already
problems addressing SDOH but is not studying health effects (e.g., implementation of
the Essentials for Childhood Framework)

Use community-based participatory research designs

Apply evidence-based practices (e.g., The Community Guide) to address

health inequity and demonstrate improved health outcomes

Visit the CDC website to learn more about social determinants of health.
24
 What do Public health people do?

- Mayur Trivedi
________________________________________________________

What is public health and what do public health professionals do? This is a very common

question in the world full of facility-based treatment of illnesses and injuries with individual

focus. It is easy to explain the work of doctors, nurses, physiotherapists, laboratory and

radiology technicians, pharmacists, etc., but it is a little difficult to explain the work of public

health professionals.

Public Health is different from individual clinical care. Clinical science involves study of causes

of illnesses and clinical care involves treating individual patients. Public health involves the

study of factors affecting health at the population level. These kinds of works require

organized efforts carried out by the government as well as non-government entities, including

businesses.

The public health work can be broadly divided into two parts viz. public health surveillance

and research and public health interventions. The surveillance and research work involves

exploration and understanding of the known and the unknown, and the creation of newer

knowledge. On the other hand, the interventions involve action and services at the grassroots

level within facilities and outside it at the community level.

Public health surveillance and research

Public health surveillance and researches aim to know/find/understand the factors affecting

health and wellbeing, illness and injuries, and diseases and disabilities. There are three broad

25
categories of public health research viz. research on determinants of health, research of

exposures and outcomes, and research on the impact. The research on determinants of

health includes the study of the risk factors that can lead to illness and injuries, actions that

can either prevent or cure diseases and disabilities, and efforts that promote health and

wellbeing. The research on study exposures and outcomes includes measurement of the

magnitude of exposure i.e. risk factors and interventions, and magnitude of their potential

outcomes in the form of diseases and disabilities. The measurement of magnitude includes

incidence and prevalence, rates, and ratios beyond just numbers, and trends over time. It

also includes measurement of magnitude in terms of dimensions of distribution across

biological, geographical, and social categories like age, sex, geography, income, and

occupation, etc. Lastly, the impact research involves finding out what works, at what cost,

and the details of the socio-economic impact of actions and inactions. Further, such

researches can inform the policymakers and programme planners about the best and efficient

solutions to choose for better results and value for investment.

These researchers could include epidemiologists, statisticians, social scientists, economists,

management experts, nutritionists, etc. These research works are mostly done by universities

or research institutes. These researches are financially supported by the various governments

at home and abroad, multilateral organizations like the World Health Organization (WHO),

the World Bank, and UNICEF, international donors like Bill and Melinda Gates Foundation,

national donors like Tata trusts, etc.

The results of such research give rise to new insights for policymaking, programme planning,

and may also help in providing ground-level measures/services to preserve and promote

health.

26
Public health interventions

The public health actions or interventions can be divided into two parts viz. a) prevention

efforts and b) care and treatment efforts. These two subsets can further be divided into

smaller classes, as described below.

Preventive actions

The prevention interventions will include actions towards preventing onset of illnesses,

injuries, and disabilities. These could be done through two ways viz. a) efforts to promote

healthy behaviour or change in health-related behaviour, and b) systemic efforts to reduce

the individual and community exposure to health-related risks.

The behaviour change interventions include promoting or encouraging positive actions like a

nutritious diet, use of toilets, sanitation and handwashing with soap, regular exercise, etc.

The behaviour change interventions also include discouraging harmful behaviors like tobacco

and other addictions, riding a bike without a helmet, etc. can change people's thinking and

behavior. All of these are prevention measures to orient the community toward healthy

behavior. In the time of the COVID19 pandemic, the promotion of physical distancing, the

use of masks, and sanitizing hands and spaces fall under this kind of preventive public health

action.

The other set of preventive health actions include efforts to reduce exposure to various risks

that affect health. These risks are not illnesses or injuries in itself but are hazardous factors

that make individuals and communities more vulnerable than others. The risks could be

environmental, social, or structural. The preventive efforts to reduce the impact of such risk

affecting health include works aimed at a) environmental factors such as air and water

27
pollution and extreme weather conditions affecting health, b) social factors such as gender,

class, caste, religion-related discrimination and inequality. Actions like developing footpaths

and cycle tracks which can encourage physical activities like walking and cycling, and

developing an efficient drainage system for rainwater to keep mosquitoes in check during

monsoons are also preventive public health interventions. Enacting and enforcing laws

against sex determination of foetus, gender-based violence etc. can help prevent such social

risk factors influencing physical and mental health.

Care and treatment

Despite the most efficient and effective preventive actions, it is not possible to avoid all

illnesses and injuries. The second level of public health interventions ensures access to care

and treatment to minimize the physical, economic, and social effects of illnesses and injuries.

This is not about giving medicine to one or two patients from a hospital but involves efforts

towards expanding the physical, financial, and social access to better and cheaper treatment

for a large segment of the population. The access to safe and effective treatment involves a)

improvement in the government policy and programmes, b) establishment of adequate

quality infrastructure, c) provision of adequate human resources for health and materials to

ensure service delivery and d) financial and economic resources to fund the operations.

Lastly, the care and treatment interventions also include efforts towards reducing the

physical, social and economic impact of illnesses, injuries, and disabilities. This includes a

range of non-medical interventions from social and economic perspectives, including social

work and efforts towards health coverage. All these are summarized as a conceptual

framework below for ease of understanding.

28
 Public health

Surveillance and Research Interventions

(Explore and understand) (Actions and services)

Determinants Care and

Prevention
of health Treatment

Exposures and Behaviour change and Access to

health promotion Reduce exposure to risk treatment
Outcomes

Health system
Impact Promote healthy strengthening
behaviour Environment and health

Reducing physical, social and

Discourage risky behaviour Social determinant of risk economic impact of illnesses

Authors creation: Adapted from Greg Martin’s video on introduction to public health (https://www.youtube.com/watch?v=jA8uYvJ_i8Y)

29
 Significance of Public Health in the time of coronavirus

- Mayur Trivedi
________________________________________________________

The new disease at home i.e. COVID 19, caused by the novel coronavirus, has changed not only

the medical scenario of the world, but it has also affected the economy on a large scale and

changed the very way we live. It has affected the movement of people across the globe, within

countries, between cities, and now across the houses too. The lockdown to prevent the rapid

spread of the virus has affected occupations of millions and had a huge effect on the decisions of

production, distribution, and consumption of resources at societal as well as household level.

From a mere cluster of few patients in a city of China on 31 December 2019, the virus has spread

across the globe to around 200 countries or areas infecting close to 5 lac individuals and killing

around 1% of them i.e. 50,000 people in just around 3 months by March 2020. In another three

months thereafter, the pandemic created havoc; by the end of June, ten times more people i.e.

more than five lacs were dead because of the virus that infected more than 10 million people. At

the time of writing this on 18th August 2020, the spread of the virus more than doubled to 22

million in an additional one and a half months and killed additional 2.5 lac people taking the

worldwide death toll of 7.78 lacs. No disease in recent human history has travelled so quickly to

so many places and has affected so many people.

30
The medical response, in terms of screening the suspected people, diagnosing the confirmed

cases, and treating the patients, is underway massively across many countries, including India.

However, medical interventions are limited to a very small proportion of the total population

who has been affected by the overall response to the coronavirus scare. As the disease

progressed rapidly, more and more people are now being treated at home, away from medical

facilities.

What are the remaining majority of the apparently healthy population affected with? Why most

of us are advised to stay inside our homes, as far as possible? How are we contributing to the

prevention of the disease by isolating or distancing ourselves - are we saving ourselves or helping

others to save themselves? This is where public health is important in the world of individual

healthcare interventions. Public health involves people, in addition to and beyond patients.

31
 While people do take care of their own health through good food, physical activities, and warm
relationships with friends and family, the medical or clinical care at the time of illness or injury forms
the individual healthcare inputs. When a person feels uneasy beyond home remedies, he/she
approaches a healthcare provider, gets diagnosis done, consumes medicines, and ensures precaution
and care, as prescribed. This may result into cure or healing. This Individual healthcare interventions
involve the journey of medical or clinical care from the onset of illness to cure or healing with the help
of medical and para-medical staff for individual patients.

Public health, on the other hand, deals with a) improving health, b) increasing life, and c) ensuring
better quality of life of people through organized efforts of society or government. Public health
interventions are much more than mere medical or clinical care, and not only for patients but for
people in general. The public health efforts are organized efforts by many people for many people,
unlike treatment of a sick individual. The public health efforts are done to protect the population from
the possibilities of illness and injuries. It requires much wider and deeper understanding of a range
of determinants of health in addition to and beyond medical care. These determinants include a)
individual behaviour, b) family and cultural practice, c) food and other habits, d) education e)
occupation, f) environment, g) socio-economic realities, and h) policy and legislations. While clinicians
and para-clinicians cure and care, the public health professionals study and work on such range of
determinants of health. The efforts of public health professionals ensure that healthy people remain
healthy, do not fall sick or get injured, and remain physically, financially and socially fit after illness.

For most diseases that the world has seen earlier, medical care remained indeed very important.
However, public health efforts are equally important to ensure that most people remain healthy and
protected from injury and illness. While diagnosis and treatment are essential, public health actions
aimed at prevention and impact mitigation are crucial too. While doctors and paramedical
professionals are important, a range of public health professionals are also equally important.

In the case of coronavirus, public health measures include a) identification and isolation of

suspected persons, b) minimizing the possibilities of transmission through individual and

32
collective actions, and c) proactive screening of suspected individuals and treatment of infected

individuals. Common preventive activities include a) restriction of movement (i.e. lockdown), b)

voluntary staying at home and avoiding crowded places, spaces, and events (social distancing),

c) maintaining physical distancing and using face masks during essential and unavoidable travels

and commuting, and d) frequent handwashing for all possible persons and disinfection of all

possible spaces, assuming everyone as vulnerable persons and everywhere as vulnerable spaces.

Public health activities may also include awareness generation activities in the form of improving

the knowledge that leads to changes in the behaviour of people. It may also include efforts

towards reducing the effect of preventive or curative actions on the income and finances of the

affected or infected families. Most of these efforts are non-clinical and non-pharmaceuticals in

nature. They are beyond individual treatment in clinics and hospitals and are done by non-

medical persons for the entire community through organized efforts of government and society.

Beyond epidemiological and medical aspects, the coronavirus has very interesting connections

with a) population and development in terms of migration and urbanization, b) microeconomics

in terms of loss of family income during and after the lockdown, and household level financial

implication of diagnosis and treatment, c) macroeconomics in terms of reallocation of resources

for prevention and control of the pandemic, and mitigation of the possibilities of recession due

slowdown of certain sectors, in particular, and of overall economy in general, d) social and

behavioral science in terms of socialization and social distancing as well as gender aspect of

preventive and curative actions, and e) management expertise for smooth logistical and supply

of medical and non-medical essentials, efficient human resource and organizational operations,

f) statistics to better predict the course of epidemic and plan responses thereof, g) legal and

33
governance matters for ensuring citizens to maintain emerging law and order situation, and h)

financing and insurance to ensure fair redistribution of existing resources and emerging funds to

tackle the economic impact of the disease, especially on the poor.

With climate change, the outbreak of emerging infections is becoming a common phenomenon.

Coronavirus pandemic is the latest in the series, the long-term impact of which is yet to be

ascertained. What is certain is that such a scenario will keep unfolding in one or other form. If

antibiotics and vaccines changed the course of health interventions in the twentieth century,

public health efforts will do the same and more in the rest of the twenty-first century. While the

coronavirus pandemic is an excellent opportunity to understand and appreciate public health as

an important fraternity, and respectable career opportunity, it is also a once-in-a-lifetime event

to appreciate the interdependent world that we live in. Public health corroborates the ancient

Indian wisdom of ‘Vasudhaiv Kutumbakam’ and reiterates that individual actions and benefits

are as good as collective efforts and community gains.

34
 CAST STUDY FOR INTRODUCTION TO PUBLIC HEALTH MODULE

It is important to appreciate the complexities of health, healthcare and public health interventions. It

is essential that such appreciation is contextualized away from one’s own realities.

These short cases are collections of snippets from the lives of certain marginalized communities and

providers who serve them. These are based on field experiences of public health professionals of

different kinds. They are written in different formats to appreciate the diversity of the subject and

stakeholders. The in-depth study of these scenario will help the students contextualize class-room

learning in wider perspective.

Case 1 Health issues of Agariya _ Note of Dr Puja PGDPHM10

Case 2 Functioning of primary health center _Note of Dr Sanjay Rai

Case 3 The tribal of Poshina _ Note of Dr Deepak Patel

Case 4 Issues of pregnant Maldhari of Gir _Note of Mayur Trivedi

Case 5 Health issues in slums of Ahmedabad _ Note of Dinesh Prajapati

Case 6 The tribal of Rajasthan _Note of Mayur Trivedi

Student are expected to read and appreciate complexities of health and healthcare in the lives of this

communities and connect the issues presented in the case to the learning of the classroom. Students

are also expected to discuss their individual observations in groups, and compare viewpoints. At the

same time, this may also be used for reflecting how one’s life is different than the communities

presented in the case. Students may also share similar stories from their experiences.

35
ϭ͘A quick peep into the life of Salt pan workers of the Rann of Kutchh
The salt pan workers or the ‘Agariya’ community have been inhabiting the little Rann of Kutch over
generations. They migrate to the Rann for 8 months in a year to support their only means of survival
which is ‘growing’ salt. For the rest part of the year they stay in their village. Throughout their lives
the Agariyas work tirelessly in the fields where they ‘cultivate’ salt, the technique of which has
remained unchanged over centuries. They roughly meet 75% of nation’s salt demand. The ground
water here is ten to twelve times saltier than sea water which is pumped into small fields of about
25 * 25 meters using bores. As water evaporates as a results of extreme heat from sun, usually 40
degree Celsius or more, gradually silvery white crystals of salt become visible. ( Night temperature
may be as low as 5 degree Celsius).The Agariyas harvest 10-15 tonnes of salt from each of these fields
every 15 days which is then transported to salt companies and chemical factories all over India.
I had heard about Agariyas earlier. When I received an offer to visit them, I instantly grabbed it. There
had been recently an article published in local newspaper about the marginalisation, unavailability
and inaccessibility of health and medical service in Agariya community, the timing for a medical camp
was apt and also appropriate because with nearing of monsoon they had abandoned their huts in
the Rann and had returned to their villages.

We, a team of eight doctors along with a South Korean researcher from Duke University, USA and
our mentor headed for a health check-up camp in the village Kharaghoda of Patdi taluka, District
Surendranagar. This camp was not only an effort to provide medical care to the Agariyas, It was more
intended to be a snap-shot study of ethnography and demography for us as diploma students of
Public Health Management.
Nearly 500 people attended the camp, we tried to make it multidisciplinary by setting separate tables
for General OPD, Skin, Dental, Paediatric, Obstetrics & Gynaecology along with basic laboratory
acilities such as Blood Sugar, peripheral blood smear for Malarial parasite and of course free drugs.

Close to 100 patients were examined by me. I have worked in the rural Gujrat for the entire duration
of 15 years of my career as a public health professional and have come across poverty in various
forms. The plight of the Agariyas therefore didn’t take me off guard. However our South Korean
guest, who was watching me keenly, probably got a cultural shock.
In the course of interaction, interview and examination of the beneficiaries facts about absence of
health facilities taking heavy toll on quality of their life became clear to me. The Mobile Health van
allotted for Agariyas was clearly ineffective. Not a single beneficiary or staff from the local PHC could
vouch for the regularity or usefulness of the van. The gap in health care delivery is huge.
1. Registration of pregnancy is often delayed. As a result of this antenatal care services are poor.
We came across pregnant women in 2nd trimester who had not received Inj. TT, IFA and
Calcium supplements let alone regular measurements of BP, weight, Hb% etc.
2. Immunisation sessions is irregular leaving many left outs and drop outs.
3. Malnourishment is rampant in women and children. Most women have haemoglobin levels
in single digit. We isolated one case each of Severe Acute Malnourishment and Protein Energy
Malnutrition.

36
 4. Basic amenities for survival such as housing, drinking water and food are practically non-
existent. Potato and roti is all they eat for eight months.
5. Agariyas get their skin burnt due to continuous exposure to highly saturated salt.
6. Exposure to extremes of heat and sun causes a variety of skin lesions.
7. Eye problems and blindness happens due to intense reflection of sun rays from the water
surface.
8. Complaints of burning micturition and uterovaginal prolapse is common in Agariya women.
9. Counselling or hand holding for any form of health related issue is dangerously lacking. A 22
year old 3rd time pregnant women with 2nd degree uterovaginal prolapse with 6 months
pregnancy had not gained weight since last 4 months.
10. Large family size is a norm. A woman who attended the camp had 9 living children and was
pregnant for the 10th time. Methods of family planning remains unaccepted for a variety of
reasons, superstitious belief systems, ignorance of government health system and various
social issues.
11. Incidence of tuberculosis is high.

We were informed that Agariyas don’t live beyond 50 or 60 years. Children start working young.
Because they work in salt pans, their feet absorb salt and develop sepsis. Even after death their hands
and feet are difficult to burn during cremation due to the salt content. The unburnt limbs are
collected and buried separately. The government provides eyeglasses, rubber boots and gloves to
these workers but they are insufficient, wear out quickly and are seldom replaced.

In Little Rann of Kutch, a barren brown desert which is also home for wild asses, an estimated 200,000
people live in poverty, work barefoot in extreme hardship, exposed to relentless sun and serious
occupational dangers. These people have been exploited for centuries by the money lenders, fair
price shop owners, middle men, contractors and financial institutions. They have also faced violations
of Minimum Wages Act and Contract Labour Act.
NGOs like IGSSS and VIKAS are working to make market linkages better for Agariyas, Efforts to
improve educational level is also being taken up but it’s a challenge due to perineal migration. A lot
remains to be done in the field of health care delivery system starting with regularising visits and
strengthening facilities of Mobile Medical/Health van and devising newer ways and means for health
service delivery.
The camp that we arranged for the Agariyas was just a peep into their lives, health conditions and
cultural ethos. I requested the local ASHA and FHW to follow up each of the cases and do their bit for
their betterment. I visited few houses in the community after the camp mainly of those who needed
medical help but did not turn up in the camp.
Towards the close of the day we visited a Temple in the middle of the Rann called ‘Vacchada Dada’s
place’. This place has a glorious past of bravery, valour and victory. We spent quality time on the salt
dunes climbing and sliding till most of us made it to the top. We called it a day pledging to do the
best in our capacity with the available resources for the marginalized community.

- Dr. from Gujarat Government | PGDPHM 10th Batch

37
Ϯ͘HOW INSTITUTIONAL DELIVERY WAS INCREASED FROM ANNUALLY 13 TO 430
ANNUALLY JUST IN ONE YEAR?

This is a real story of Primary Health Centre1 (PHC) AAA in ABC district of Gujarat.
When I was transferred from PHC ZZZ to PHC AAA, the PHC was in not good
condition with no staff nurses. Since it was declared as 24X7, I needed to focus on
increasing institutional deliveries. But, in absence of staff and infrastructure, the
deliveries were not increasing despite my efforts. During one review meeting, I was
literally humiliated by Chief District health Officer2 (CDHO) as he was very partial
(biased) towards me. He even took me to District Development Officer3 (DDO) and
in front of him complained that I was not working and must be punished. I was very
much depressed during that period.
Then, I started thinking about how institutional deliveries can be improved. My
Reproductive and Child health Officer (RCHO) was known to me. I asked him to help
me. As he too would be benefited from this improvement, he assured me to help.
When the appointment of staff nurses were done, I was on the recruitment board.
I hand‐picked two staff nurses, who were ready to stay at PHC. I got them
appointed and posted in my PHC with the help of RCHO sir.
Since the old PHC did not have a good infrastructure, I asked a local donor to build
a new building, to which he gracefully agreed. The donor wanted to build the
hospital, but no one was encouraging him to do that. I helped him through all
government procedure within one month, something that he was trying to do for
years.
Now we started to contact the Sarpanch of all the villages. They all agreed to
support. Then, we conducted ANC checkup camp in every villages twice a month.

1
This are government‐funded and operated rural health care facilities in India. They are essentially single‐physician
clinics usually with facilities for minor surgeries, and delivery. They are most basic medical units of the public
healthcare system in India. Apart from clinical services, they manage to offer other primary care as well.
2
In state‐governed public health system, district is a primary unit of administration dn management of health
programmes. The CDHO is the head of this branch of district panchayat. Doctors of health centers and
administrative officer are his assistant officers.
3
DDO is an administrative post in Gujarat. This officer is tasked to oversee various developmental schemes of
health, education, poverty alleviation and infrastructure creation of the state and central governments. The officer
works under overall supervision of district collector. All district officers of various braches are his assistant officers.
DDOs are generally IAS officers.

38
In the Ante Natal Care (ANC) check‐up camps, we had a MBBS doctor, a laboratory
technician, a female health worker of that area, a health visitor and a staff nurse.
During these camps, we built rapport with the villagers. We invited the relatives of
pregnant women to visit our hospital and see the facilities which are being provided
to ANC mothers. Along with this, we contacted the AAA village for support for
providing tiffin to the ANC mother who came for delivery and one attendant for
three days, which the villagers gracefully accepted.
Just in three months, the deliveries started to come. Our team gracefully welcomed
every ANC mothers who came to our hospital. I also contacted my friend who was
a practicing pediatricians nearby to examine every child who was delivered in our
hospital, before relieving the newborn. We also provided the post‐natal mother a
vehicle to drop her home. On the third day after discharge from the hospital, the
hospital team visited the post‐natal mother’s home to see the health of mother
and child. In this team, the doctor and staff nurse, who were present during
delivery, were also present. This was a proud moment for the family. They were
satisfied and spread the word, which further promoted other ANC mother to visit
our hospital.
My wife used to visit every delivered child and gifted them clothes to new born,
along with protein powder to mothers.
After six months we were delivering at least one child daily. We were really proud
of our achievement. Even our commissioner of health appreciated our work and
awarded our hospital. Our DDO visited our hospital a few times, and appreciated
our work.
After analysis the work, I now realized that for doing anything, we have to be
focused, and plan accordingly. The team leader must take leadership of the work
in hand. If the people can see your clear and honest intention, they will always help
and cooperate. Before starting any work you should develop rapport with the
beneficiaries. The quality you provide must be up to the mark to retain the
customers, who are our beneficiaries in this case. In the start, we did not have
confidence in ourselves that we can pull the ANC mothers to our institute for
deliveries.
‐ Dr. from Gujarat Government | PGDPHM 10th Batch

39
ϯ͘Observations on few aspects of life of tribal in Poshina

Introduction: I have worked at Poshina (Dist: Sabarkantha) PHC during 1996 to 1999 as medical officer mobile
unit and holding charge of MOPHC. In this bordering area with Rajasthan, population consisted of local tribal
people and few other caste in 2‐3 villages. This area has very low level of literacy, high poverty, no any
industrial development, no basic infrastructure and main income source is forest products and farming. As my
first posting I was sent to so call punishment area for government employees. Their Language has so many
local terms. They have very different customs and belief. I was told by friends to change posting from this
dangerous area but somehow I managed to stay there and then liked to work by staying there in quarters for
3 years. As a medical officer in mobile unit I was supposed to visit 2 villages daily and work for whole day with
them. So I had come across many aspects of their life. Some my observations I am narrating here. As that time
I did not think in a way now after study of demography I may, I am not putting any of comments on them.

Observations: Dress: Usually one small “Langoti”. Foot ware is luxury usually a Leather ‘mojadi’ or chappal
When they come to Poshina or go out they bring Dhoti and shirt in bag and change on entry to Poshina and
take off while going home. This may be due to increase life of cloths. Always carry a big knife in waist with
occasionally sword or bow‐arrow. Bow‐arrow is still their main weapon.

Food: Maize roti, daal “chill ni bhaji” green and red chili. Sweet of wheat flour ‘Lapasi‐Lafu’ is made on festivals
and for guests. Red chilies usually grinded on stone and used in food as it is or as chatani with garlic. Local
vegetables used sometimes. Dalbati is one of frequently used food. Local fruits used. Chicken and meat is also
feast. “Mahuda” wine is used by almost 80% adults and 50 women. In field after four in afternoon you will find
most male drunk.

Housing: Small clusters of kachha huts scattered (pakka in 10%) on peaks of hill. No any developed village seen
in plains. Poshina, Delwada and Lambadiya were only so called built villages where government centers and
other people are living. Water supply is from some wells, few hand pumps and rain water collections at some
places. Few villages had tube well and stand post supply.

Occupation: Farming based on human and animals (no mechanization), Goats, cow and buffalo, collection and
sell of jungle products like “Gugal, Mahuda flowers and seeds, Honey, Woods, Baheda, mushali, Timaru” etc.
As everywhere few people involved in Loot and thieving.

Communication: Different tone and mode of beating drum sends message to clusters of home on various hills.
Death, illness, prepare to fight all expressed by drum. I was able to predict postmortem next morning by drum
sound at night.

Some interesting customs and life style:

 Youth select life partners in ‘Chitra Vichitra’ mela at Gunbhakhari village near ‘Triveni Sangam’ of Akal,
Vakal and Sabaramati River. This mela is held on 15th day after Holi. This mela itself is a paradox of Joy
and Greif. This day they cry in memory of their loving ones who have died. On other side it is full of joy
and masti. They dance, play drums, games, cart race in enthusiastic atmosphere of mela. ‘Lazim’ dance
with a cloth piece tie in wrist, singing romantic songs in their language. Ex. (‘Zeni zeni reti ma lado ladi
rame la’, Dur deshe pario pare keme Keri bhela hoye’). Many people from abroad also visit this mela.
Youths who like each other run away and if not caught them wins and becomes life partner. If caught
sometimes conflicts occur ending in fight with fatal injuries sometimes. This marriage is not complete.
They may live together, may produce kids without real marriage!!! (One of modernized world tradition)

40
 They also marry with consent of parents and arranged marriage. They officially marry when their kid
wants to marry may be at age of 35‐40.
 They use umbrella not only in monsoon but also very commonly in summer to protect them from sunlight.
Due to this kind of modern type life style some call them “ Kala Angrej”
 During marriage ceremony bride family takes their own food ‘Lapasi’ with them. In one summer this
tradition cuased an epidemic of acute gastroenteritis as it was stored in plastic wire bag for 2 days.
 Delivery usually done at home, for complication lady come in ‘zoli’ made of bamboo and cloth deliver at
PHC and went back in an hour against medical advice. If you don’t discharge all leave one by one. During
delivery at home or hospital only men attend her whether his father in law or anyone else. Lady do
accompany but don’t enter labour room or touch. “Kalla” done by men.
 For any ailment master medicine is injection and pint as local private doctors have made them used to.
Even for much prevalent worm infestation they expect injection and given by private providers. When I
give tablet with explanation they throw it out side PHC.
 Most dangerous custom is ‘VER’. For any suspicious death blame is fixed on someone sometimes we feel
foolish.(Once a person died of snake bite, the owner of farm was picked for ‘Ver’ as the snake was from
his farm). The scene on site at this time is horrible like ‘kabila’ era. Dead body lies in between both side
on hills people with weapons ready to attack with Bow and arrow, swords, ‘gofan’etc. Few leaders
negotiate for money. First for burning dead body (ZAL) amount around 50,000. Next for ‘Ver’ negotiation
starts with two lakh rupees. It may end at total of 50000 as per situation and negotiation. If this
negotiation is successful everything is over. No police case no legal interest of conviction of the culprit.
Till negotiation is on, DSP, SDM or any official cannot touch body1. Their own government is superior.
‘Raj’ (government) has nothing to with their life.
 Same way threat is on treating doctor if any patient died on treatment he may be picked for ’ver’. Once
a dead body was brought to doctor’s clinic saying ‘you keep this body give my wife back alive’. Doctor
had to pay ‘Ver’. One may feel that how they will be paying this huge amount? It is done by contribution.
The total amount is collected and distributed among all households of same family (family mean all
household in area carrying same surname. e.g. Bombadiya, Dabhi etc.)
 You have to take care not to seat on coat with red thread. It is for young couple. If any one has relation
with their daughter with bilateral willingness, no problem but if one harass wife of someone, he may be
killed.
 No incidence was noted for sexual harassment of any female health worker even if she visit alone in
forest area even when they are drunk. Sometime one may ask for 10 ‐20 rupees for ‘Mahuda’‐ it is better
to give or he may follow you until you give him. Holi is biggest festival. It’s celebration lasts for 10 days.
In these day no employee prefer to visit village. He may be entertained with treat of ‘Mahuda’ and food;
he will be set on coat and lifted till he gives some Holi money.

I stayed there for 3 years with family, and enjoyed life of forest, springs, lakes etc. Monsoon of Poshina is
worth living. These are few things that I remember but I am sure that much is left out. After 18 year scenario
may have changed.

‐ Dr. from Gujarat Government | PGDPHM 10th Batch

1
I have visited one of these kinds of scene daily for thirteen days on call from police for onsite postmortem of putrefied body found
in a well. Every day police call that today it will end but their negotiation did not end till on 13th day. And statutory process of
postmortem was performed with no subsequent interest from relatives for result or legal procedure.

41
 Case study 4: Issues in the lives of a Maldhari woman
The Gir Forest National Park and Wildlife Sanctuary is a protected area of 1412 km2 in the Saurashtra
region of Gujarat. The area is the last abode of Asiatic lions. For over a century, the Gir forest has
witnessed the co‐existence of Asiatic lions and semi‐nomadic pastoral communities (locally known as
Maldhari). They are primarily vegetarian and live a simple life in small mud houses that are scattered
within the forests. A Maldhari settlement is known as a Ness; each ness consists of 1‐20 families.
Maldharis neither own any land nor do they have any competency in farming. The forest provides
them with easy and almost free access to fodder for their cattle. The main source of their livelihood is
cattle rearing and the trading of their produce. The daily routine involves the men to go into the forests
for a day long cattle grazing trip with their buffaloes and cows, while the women tended to the calves,
the children and the chores at home.
The nesses are accessible only through rough forest trails, which are conducive only to motorbikes
or SUV’s which are tall four‐wheel‐drive (4WD) vehicles. The human settlements are away from the
nearby road that further connects them to a nearby village. The distance of a ness from the nearby
road can range anywhere from 2‐20 kms. Maldharis move out of their nesses during summer and
return only during the monsoon and the early winter periods. However, if they do not return for a
long time, their entitlement to the ness may be terminated. The forest department has mandated the
location and the movement of nesses. They are also not allowed to expand or change the size of their
dwellings. These nesses are largely deprived of electricity, running water, schools and access to
healthcare.
Primary health centers around Gir forest has the services of a mobile health unit (MHU) for Nesses.
These MHUs visit nesses that are allocated to them at regular time intervals that range from once a
week to once a month, depending on the weather and accessibility. This unit is generally staffed by an
AYUSH doctor and a driver. Once a week, when it attends to pregnant women and children to provide
immunization and ante‐natal care, the unit is accompanied by a female health worker. The van offers
emergency visits as and when required. During the monsoons, the conditions of the road deteriorates
and the dilapidated vehicle of the MHU cannot maneuver the seriously damaged forest roads. The
services of the van are thus compromised during this time period.
In the month of August, on a drizzling day, I was with a one such MHU visit. I overheard the doctor on‐
board talking to someone over her phone saying, ‘We have come to the opposite side today and will
not be able to return soon’. She also instructed the caller to arrange for a private vehicle to transfer
the patient to the nearby PHC, where the MHU was stationed, so that the on‐duty medical doctor can
attend to the patient. After the call was through, I got to know the following details about the case.
At one of the nesses, a lady, who underwent a sterilization operation recently, started bleeding from
the site of the incision. The MHU doctor suspected the rupture of the sutures as the cause for the
bleeding as the surgery was performed only five days ago. The suspicions were based on the fact that
the women was taken on a bike or a shared vehicle such as a jeep or an auto rickshaw to attend a
certain social event, few kilometers each way. When the bleeding did not stop for over two days and
the situation began to worsen, the husband walked a kilometer or so to the house of the nearest
female health worker. The call to MHU doctor was made by this FHW.
The doctor raised a few arguments: 1) why did he take her outside home on such a treacherous
journey? 2) Why wait for two days before calling for medical help? 3) If he can take his wife to a social
event, then why call or wait for MHU van; instead why not take her to nearby PHC.
The MHU continued its journey to the pre‐decided village.
‐‐‐***‐‐‐

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Next, day I visited the ness in question and talked to the husband of the woman for whom the call was
made to the MHU doctor. The ness in question is a single‐household ness alongside a tarred road,
which connected it to the nearby village. The ness is bordered between a forest area and a revenue
area. There were 3 children at the ness, playing by themselves. The children were home alone as the
father was off grazing the cattle. Since I was a stranger, the kids did not allow me inside the ness and
I was made to wait outside till their father returned. A dog first appeared running off the road
heralding the arrival of the rest of the cattle and the grazer. Once introduced, I was allowed inside into
the first room. We sat and discussed life at Maldhari in general, and then the case of the lady, in
particular. During our discussions, the cattle went astray a couple of times to a nearby private land
and needed to be goaded. The eldest son was asked to look after the cattle for the time being. The
following information was gathered post discussions with the husband.
The couple has three children; eldest son being 12‐14 years old and the youngest son being 3‐4 years
old. While the sons live with their parents at the ness, the 8 year old daughter lives with a relative at
the nearby village and attended school there. However, she was called upon to take care of the
youngest kid in the absence of her mother. Being a single‐family ness, there was no support system
for the cattle or for the kids. The youngest kid, who was being looked after by his sister, went to sleep
and woke up hungrily. When I offered them some snacks, I was told that since their mother is not
around, these snacks would serve as their lunch for the day.
After a recent miscarriage, the couple was advised to undergo sterilization, to which they agreed upon.
The sterilization camp is conducted once a week at a CHC, approximately 30 kms away from the nearby
PHC. His wife and several other women were picked up in the morning, taken to the CHC and dropped
in the evening by the PHC vehicle.
The woman’s father passed away after 2 days of the operation. There was no way that the husband
could keep this news from her and once she learnt of it, there was no way to stop her from
participating in his last rites.
Her paternal village is about 20 kms from this village. Despite knowing that a ride on a 2‐wheeler may
not be a good idea after a recent operation, yet h arranged for a bike and took her to the funeral. The
husband returned the same day as he needed to tend to the cattle and the kids. His wife returned
home in a shared jeep after two days. She started bleeding the same night. However she waited for a
day hoping that it would heal on its own.
He managed to call the MHU the next morning. The MHU arrived at 2 pm. After checking the sutures,
the doctor advised them to go to the district hospital at Junagadh which is around 60‐70 kms away
from the ness. She was warned that she may need a blood transfusion, in addition to medical or
surgical interventions.
They called for a 108 ambulance which arrived after 40 minutes since it is stationed at a nearby CHC,
some 30 kms away. The driver of the ambulance was then instructed to take the patient to the
Junagadh district hospital. Not only did he arrive after 40 minutes, he then refused the journey as it
was beyond his allotted area of operation. The best he offered was to transfer the patient to the CHC.
The MHU staff and the driver argued for another 40 minutes while the patient was lying inside the
ambulance. The enraged husband and the MHU staff then decided to take the lady off the ambulance
and shift her to the district hospital in their own vehicle, which was risky. However, the driver of the
ambulance finally relented and agreed to go to Junagadh.
Three women ‐ two sister in‐laws and the mother in‐law ‐ accompanied the patient. They stayed at
the district hospital for two days and returned the third day on their own using public transport first
to nearby village and then a by a shared vehicle to the ness.
__________________________________________________________________________________

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5. Health issues in slums of Ahmedabad
The city health plan of Ahmedabad Municipal Corporation (AMC) puts the population estimate at 60.08 lacs in 2012, of which around 18% lives
in slums. These 9.9 lacs people live in 2.29 lacs households spread across a total of 739 slum pockets. Vector borne diseases such as Malaria,
Dengue and Chikungunya are endemic in Ahmedabad, and by now have been established as major public health concerns in the city. Studies
have indicated that poor living conditions, inadequate water supply and sewerage network facilities in slums of Ahmedabad. Thus, apart from
vector borne diseases, other major illnesses observed in the slums are Jaundice, Gastroenteritis, and Typhoid. Below are observations of a
student researcher who went as an intern to selected slums of Ahmedabad.
Health related issue Meghaninagar: Shantisagar na chapara, Kumbhaji ni chali Vasana: Mangal Talavadi, Sorai nagar
1. Source of water  Tap water  Tap water & hand pump, some of the community like
rajasthani who lives in slums are collecting water from
somebody’s nearer house.
2. Sanitation  Most of the households are having toilet & bathroom  Most of the households are having toilet & bathroom
facility. facility. Bathrooms are open.
 For DANTANI community: ‐ They have common toilet.
Majority are of them are using & some of them are also
going for open defecation.
 This toilet is prepared by government.
3. Occupation  Selling vegetables & fruits, egg & fish, Private Job worker, Auto rickshaw driver, Labor worker, Government servant in VS
HOSPITAL (housekeeping)
4. Diet pattern  Vegetarian & non vegetarian  Vegetarian & non vegetarian
5. Common diseases  TB, pneumonia, typhoid, Viral fever, Acute gastro‐enteritis, Respiratory tract infection likes cold & cough.
6. Source of  For acute condition:‐ private clinics  Private as well as government center.
treatment  For chronic condition: ‐government hospital, urban health  Urban health center
center
7. Maternal and child  In shantisagar na chapara: ‐ most of delivery are done by  Take place in government hospital & many of them having
health care aya ben (traditional birth attendant‐TBA) at her house. BPL card and takes all benefit from government. Those
Complicated pregnancy cases are treated by private as well who don’t have BPL card take treatment from private
a.) Delivery: ‐ as civil hospitals. Normally TBA charge according to hospital.
mother’s financial condition (normaly Rs.500 to 1000),
after immediate delivery she sent patient to home.

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Health related issue Meghaninagar: Shantisagar na chapara, Kumbhaji ni chali Vasana: Mangal Talavadi, Sorai nagar
Sometimes Private Doctor also visits at TBA’s delivery place
to attend complicated delivery and to check new born
baby. & if any treatment required is given by doctor.
(charges of doctor Rs. 150 to 300)
 In kubhaji ni chali:‐ private hospital as well as some are
in government hospital (civil).
a.) ANC care:‐  Mostly pregnant women visit once to the private hospital or  Almost all women are visiting to vasana urban health center
government hospital before delivery, but they visit to TBA regularly. Taking all vaccination during pregnancy.
regularly and follow instruction of her.
b.) Breastfeeding  Colostrums feeding found to be less/absent. Initiation of breastfeeding isinitiated mostly after 3‐ 5 days. Exclusive
breastfeeding is less/absent.
8. Menstruation  Most of girls are using traditional method as they don’t have enough knowledge about using sanitary pad due to illiteracy
hygiene according to private doctor.
9. Addiction  Alcohol, chewing tobacco & gutaka.  Alcohol, chewing tobacco & gutaka.
10. Family planning  Not a single family uses family planning methods and the  Not use by many couple. Some women are following
methods main reason found that male child preferences. calendar method.
 Due to religious restrictions they don’t use family planning
methods. Also because of family restriction and denial of
elder people like father‐ in ‐law & mother‐in‐law & also by
husband.
11. Dog bite cases  Dog bites are very common. Only few people take treatment for it and rest of others are not due to religious
superstition (MATA JI KI BADHA)
12. Measles cases  As religious superstition prevails over the medical treatment, majority people prefer to go to temple (Mata ki badha)
rather than hospital for treatment
13. Current cases of  Did Not find  3 cases founded each in sorainagar and Mangal talavdi.
Chicken pox  For that they keep MATAJI KI BADHA. This cases are taking
treatment from Vasana urban health center through link
worker.
14. for purification of  Purify water through linen cloth. Some of them are  Through chlorine tablet given by link worker. Some of
water not taking any precaution for water purification them are not taking any precaution for water purification.

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6. Field notes of researcher working with tribal people of south Rajasthan
During a community visit to Nalfali of Uplagarh, we met a 25-year-old, female, tuberculosis patient.
She has an undernourished child, and stays with husband and mother-in-law in a hut, on a hillock. We
went closer to her home on a motorable road, followed by motorbike ride on a wild trail, and then
climbing up the hillock for a few meters. Her dwelling was difficult to access for a local health worker.
A Garasiya tribal women, she belonged from a village near Polo forest, Vijayanagar, which is more than
100 km away. During our visit, we found out that she did not have her TB medicine for 12 days as it
was out of stock at home and she or anyone else from her home could not contact health worker. She
was found to be very weak to walk up to the mobile medical van that stops around two km away from
her house. She has received a nutritional supplement of black gram and groundnut for two months and
reported to consume it from time to time.
- An observational case study of women TB patients in tribal area of Rajasthan

During a visit to Jaidra, we came across a ruckus near the delivery point of the medical van. The
villagers got hold of a snake and beat it up almost to death. Thereafter, as the van stopped and set the
clinic up, a young intoxicated man came on a bike and ran his bike over the snake a couple of time. Then
he took and snake and whirled a few times towards villagers, and towards the VOP staff. The female
doctor overlooked his act and continued to focus on providing treatment to others. The drunkard man
also said cuss words to providers. Finally, he threw the snake and came towards the van seeking
treatment for some illnesses. The doctor patiently heard him and prescribed medicine. She also got to
check a deep wound in his legs, for which no treatment was sought. The doctor then instructed the
assistant to do him dressing and give medicine. The intoxicated man consumed 2-3 doses even as an
assistant was advising him on the therapy. He paid his contribution of Rs. 10, rode on his bike and
moved away from the scene.
- An observational case study from tribal area of Rajasthan

Raju is a 21 old male TB patient from Jaidra. He is the youngest of the three brothers, who live together.
They have lost their parents. He had stomach pain and intermittent fever for over a year. He sought care
from a private provider in Amirgadh. On the advice of this private provider, he started certain medicine. In
the meantime, he was also enrolled for DOTS therapy under GRHC intervention. He continued to have
medicines from both the sources and used to have seven tablets a day. During the interaction with him, his
medicine was checked and it was found that he was taking double doses of certain anti-TB drugs in absence
of proper counselling. The doctor then guided him with all medicines and streamlined the therapy.
- An observation during a field visit in tribal area of Rajasthan

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“……..Our job is limited to referring to them. If the patient is very ill, refer him/her. If the illness is mild,
we ask the local nurse (ANM) and get them some tablets. Otherwise, we refer and ask to take them to the
hospital. If they don’t take the patient to the hospital, it’s their headache. We do refer. Recently, a 2-3-
year-old girl was ill. She was very weak. I told her parents to take her to a government health facility as
she can be treated there. They didn’t take her there. On the third or fourth day, the child died.”
- The Anganwadi worker, a village in tribal Rajasthan

In one case, three-four different tablets, topical applications and ORS were dispensed to patients with
separate instructions for each of them. The assistant also wears masks as a precautionary measure to avoid
getting infected with infection. The patient seemed perplexed with so many medicines, and quick
instructions from a masked assistant.
- An observation from field visit in tribal area of Rajasthan

“…we work here with monkeys. The people (community) here are uneducated/uncivilized. Our work is
tricky/difficult.”
- Treating physician at NGO working in tribal area of Rajasthan
“..I have met urban people here who hate Garasias. They say we don’t board auto with them…They are
untouchables. They are treated like that”
Treating physician at NGO working in tribal area of Rajasthan
“....Seasonal ailments are prevalent here. The illnesses spread here because of the dirt. These people do not
keep clean, that also leads to diseases. Their habits are such. They don’t even bath every day. If these
people understand and get reformed, it will be better for them. What to do if they do n’t! I have told them
so many times, to no avail.”
- The Anganwadi worker, a village in tribal Rajasthan
“…For instance, Fungal infections. Mostly they get medicines from us and they get cured as well. But, it
recurs. That is due to their poor hygiene, which we can’t help. We can only educate them. We can’t do
anything beyond that, unless and until they want to.”
- Treating physician at NGO working in tribal area of Rajasthan

“….I am from Dungarpur District. I am working here for 8 years now. It took me an entire year only to
understand the local language and people. Now, I have become an expert. I can understand the local
language well. I can also speak it well and can motivate people. I even understand gossips and jokes. I
even understand their folk songs. To understand and serve the locals, I lived with them, like them. Who
am I, what am I, how educated am I - I left all that. I kept all that aside. If I want to give them services, I
will have to be like them.”
-A male nurse from a sub-centre in tribal area of Rajasthan

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