The twentieth and the twenty-first centuries have been marked by a remarkable improvement in human health led by a greater understanding of disease causing pathogens, hygiene, diet and sanitary precautions as well as a epistemological changes in the governing sections of the society that led to the incorporation of health into the legislative and administrative reforms. There is a vast amount of literature today that pertains to public health awareness, prevention and control of communicable diseases. These diseases by their nature are not localized on single individuals but are targeted on larger populations. As such, they must also be addressed on a regional level and it appropriately becomes the function of the government to take adequate measures to control the outbreak of infectious diseases. The utility of such integrated approached have been demonstrated many time before. The reduction of typhoid incidences in nineteenth century France have been attributed to improved sanitation facilities(Woods, 2003), and the prolonged vector breeding and parasite transmission reduction programs have been responsible for the remarkable reduction of malaria in South America, Central America and many Asian countries. Johansson and Mosk (1997) have detailed the impact of public health interventions on adult mortality rates in Japan.
India as a Case Study
The choice of India for the evaluation of it's communicate disease and emergency control facilities is justified both by the size of her population as well as the emerging role that she is destined to play in the socio political activities of the future. India is endowed with immense resources - mineral, natural, cultural as well as in terms of trained and untrained manpower. The administrative capacity of Indian Government is considerable. Within a span of fifty years from her Independence, the nation has exponentiated its agricultural production, dampened surging growth rates and successfully withstood massive famines. The reach of the bureaucracy spans the entire subcontinent from where it effectively collects revenues, conducts the largest democratic elections in the world and through periodic census creates an immense pool of statistical data. Indian pharmacology, medicine and information processing skills have already attracted the attention of the world. . Its basic public health infrastructure (laboratories, clinics etc) has been successful at carrying out complicated development programs requiring a high level of coordination and outreach-such as increasing agricultural production and reducing fertility-to a vast population over much of its history(Gupta, Khaleghian, & Sarwal, July 2003).
The demographic and geographic distribution of this immense spread of humanity, climatic conditions, illiteracy, poor social conditions, insufficient sanitation, unbalanced industrial growth, diverse terrain and other facilities in some parts of the nation make India particularly prone to communicable diseases, environmental health hazards and natural calamities. It must however be made clear that despite its major shortcomings, health care facilities in India are not archaic. Primary health centres exist throughout the country and provide basic curative services in a reasonably equitable fashion. Numerous vertical health programs have been carried out successfully, namely the famous Indian family planning and polio eradication programs. Most outbreaks are brought to control with relative promptness and efficiency. Outbreaks of Cholera and Plague stand out among these (Arnold, 1989). The analysis of the strengths and weaknesses of India's communicable diseases prevention is addresses in detail in the following discussion.
Through its periodic census carried out every decade since 1872, India has demonstrated her ability to carry out complicated tasks that require a sharp delineation of tasks, judicious distribution of resources and flexible decentralization of authority. According to the Indian Constitution, public health and sanitation are the responsibility of state governments. Despite this, the central government is capable and does exercise remarkable control over health care issues. One reason for this is that preventing the spread of contagious diseases from one state to the other falls in the "concurrent list of responsibilities" which is shared by both the state and the centre. Here too, the centre's decision will override that of the state government should an argument arise. Further the authority to sanction port quarantine, research and training facilities lies with the centre government alone. Thus, nationally sponsored programs such as the drive for prevention of tuberculosis derive their mandate through their position on the concurrent list. But the major source of power for the central government is the greater monetary resources at its control. Through capital resources and fiscal policy, the central government exercises more than a subtle influence on the health and hygiene of the nation.
While largely beneficial, this has led to a more or less vertical mode of decision making, despite the decentralization drive that characterized post independence India. The immense numbers of workers at the district and panchayat (rural) level play no part in the decision making process and largely serve to simply implement orders from above. This is unfortunate as it is these health care workers who operate at the grass root level that have the actual knowledge of the working conditions and deficiencies within the system. Various reports cite the inflexibility and lack of autonomy in health spending. Officials have continually lamented their absence of flexibility to decide which expenditures should be cut, or to seek to raise additional resources themselves. They were also concerned about uncertainties in the amount and timing of allocations and transfers from the state, and remarked on the consequent difficulties in paying staff and purchasing supplies reliably (Gupta, Khaleghian, & Sarwal, July 2003). There is an urgent need to innovate in delivering programs, managing budgets and allocating resources. Further, some room must be allowed for experimentation with regard to new approaches to budget preparation, financial management and personnel management to improve performance.
Increased cooperation is essential for the successfully combating communicable diseases, national emergencies and environmental hazards. Surveillance, for example, cannot be carried out by a single in isolation: There is a need for collaboration between administrators, government health workers, community leaders, private providers, school teachers and anyone else who might detect the subtle changes in disease incidence that surveillance system are designed to monitor(Gupta, Khaleghian, & Sarwal, July 2003). Vector control is another area that requires improved collaboration. Location of stagnant water and spraying, draining away etc of waste water calls for collaboration between health staff, community members and drainage officials, and are seldom effectively carried out by one group alone. Collaboration is the most significant part of any communicable disease outbreak prevention. All sections of the society such as the Police, local governments, community leaders, healers, school teachers, and every other member of the community have a part to play, and it is frequently the job of public health officials to make sure they play it an effective, coordinated and timely way (Medicine, 2002b).
The major onus of any outbreak control is to increase the awareness of the public regarding the modes of disease expansion, prevention and hygiene factors. Many successful disease prevention campaigns have relied on public input to complement its decision making and to channel resources when required in the direct direction. Further in India, the public is largely unaware of the parameters that decide the quality of service delivery and are not in general aware of the methods to direct their grievances.
It has been suggested that having a separate cadre of trained staff in the field of public health-as distinct from the medically trained staff who currently occupy the more senior positions-would revitalize public health services and improve health outcomes (Karnataka, 2001). The circumstances that the administrative service personnel are required to work under points to the need for such a special medical cadre. Interdepartmental transfers are very common among these officers so that their ability to build the necessary skills as to well retain a working knowledge of the department is restricted. Also, frequent dislocations reduce their personal interest in the problems of a locality as a necessary emotional attachment is very often missing.The fact remains that the administrative service officials are the true decision makers whose work it is in the end that is responsible for disease control and prevention. The staff on the technical rolls of the health department are well qualified and perform a range of public health services. They are vastly experienced as they have served in the respective departments all through their lives. The administrative staff (public health) reportedly face discrimination as they stand low in the administrative hierarchy and many basic infrastructural facilities are lacking such as a proper office and transport systems. More worrying is the fact that they often do not have the autonomy to practice their own knowledge and skills acquired through years of experience. "Creating a separate cadre of public health staff alone, without addressing the systemic issues that impede staff functioning, may not improve the health department's performance significantly. Despite the fact that there is a secure and well-paid public sector employment, there are serious obstacles to public health service delivery such as worker-supervisor relations, managerial autonomy and staff incentives, including opportunities for promotion or recognition for good performance" (Gupta, Khaleghian, & Sarwal, July 2003).
Major Health Threats to India
Any public health threat, just cannot be determined by the number of causalities but also from the life lived with disability. So, although one of the foremost risks, malnutrition and micronutrient deficiency (WHO), does not cause as many deaths as some other risks examined, its overall health impact puts it in the top five health threats in context to India. The five major health threats are as follows.
For communicable disease control under emergency conditions, a rapid assessment is needed to identify the main communicable disease threats. The next step, which comes, is to prevent the communicable diseases by maintaining a healthy physical environment. Next is the establishment of disease surveillance system to ensure early reporting of each cases and proper monitoring of the disease trends. And, outbreak of the disease can prevented through adequate preparedness and rapid response like quarantining the existing cases. Next comes in the appropriate treatment.
The environmental hazards can be controlled by a coordinated effort between government and society. Government needs to invest more for providing proper sanitation, hygiene and potable drinking water to each of the individual and after that it is society which needs to take up the responsibility of maintenance.
Conclusion
India in on its rapid path of progress towards being one of the powerhouses of the twenty first century. However, in her thirst to be an industrial and technical giant, she should not forget the necessary precautions and directions that must be taken to protect her citizens from the scourge of infectious diseases. Such a move is necessary not only to protect the health and life of her citizens but also to prevent the massive damage to the economy and society that can stem from it. BY implementing decentralized systems of public health administration that judiciously combines public input and convenience of governance, the nation can progress towards health autonomy, awareness and progress.
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