Public Health

Public Health (janoswasthya) a non-government health sector of the pre-British period. The Vaidyas, the only health workers during the Hindu period, practiced Ayurvedic methods of treatment. Unani (Hekimi) methods were added to Ayurvedic system during the Muslim period. However, folk treatment was also prevalent along with these two methods. The east india company who brought western treatment established the Indian Medical Service (IMS) in 1764 to look after European health in British India. Medical Colleges were established in the three Presidency towns between 1835 and 1845 to train subordinate medical staff. Till 1860, Indian Medical Service practice largely remained confined within the orbit of curative medicine. A sanitary perspective was however introduced for the first time in 1835 by James Ronald Martin, presidency surgeon of Bengal.

With the assumption of control by the Crown from the East India Company in 1857, the army in India came to constitute the largest single concentration of British troops outside the United Kingdom, one-third of all British forces. High rates of illness and death from epidemic diseases threatened the security of this force and prompted health measures across the subcontinent. By mid-19th century Britain was entering the era of sanitary reorganisation. Of the total number of British deaths in the army in the first half of the nineteenth century, only 6 per cent were due to military conflict. The rest were caused by four major diseases-fevers, causing 40 per cent of all deaths and three-quarters of all hospital admissions; dysentery and diarrhoea; liver diseases; and cholera, the greatest killer, particularly when the troops were on the march. The diseases which killed British soldiers were endemic to the country.

Florence Nightingale's campaign for a sanitary commission for bringing medical reforms among the European troops in India was rewarded in May 1859 when a Royal Commission was appointed to investigate the sanitary state of the army in India. The Military Cantonments Act of 1864 provided for a system of overall sanitary policing under the charge of military medical officers. New army barracks were constructed for providing more ventilation. The Cantonments Act also made provision for the medical inspection and regulation of brothels to mitigate the danger of venereal diseases among British soldiers.

Between 1866 and 1867, a sanitary commission was appointed to each of the presidencies of Bengal, Bombay and Madras to investigate the conditions of the general population and its interface with the army. In 1868 came the Contagious Diseases Act, which was the first direct state intervention into Indian women's health. It was designed to protect the health of the soldiers and regulated the treatment and quarantine of prostitutes and soldiers in hospitals to mitigate the evil of venereal diseases.

The establishment of charitable dispensaries from the 1830s has been regarded as one of the earliest attempts to extend western medical care to the Indians. They became centres for vaccination against smallpox and for spreading western ideas about hygiene and sanitation. From 1870 the colonial administration distanced itself from the financial responsibility of running these dispensaries and they were left to raise their own resources. In Bengal, the total number of dispensaries rose from 61 in 1867 to over 500 in 1900. The Government of Bengal, from time to time, drew up schemes for employing the native, male kaviraj to popularize western medicine (alongside the use of indigenous drugs) at the village level. There were about ten to fifteen tikadars (inoculators) who practised in 1830. Their number rose to 30 in 1844 and to 68 by 1850. In 1907, the Director General of the IMS agreed to the proposals of giving Commissioners of different districts all over India a free hand to permit municipal and local boards to choose and employ vaids and hakeems.

The Compulsory Vaccination Act of 1880 empowered provincial Governments to introduce compulsory vaccination for children over 6 months old. Apart from this kind of feeble medical intervention on the part of the imperial Government the actual responsibility for public health was left to the initiative of the local administrative units like municipalities in the larger towns (set up between 1871 and 1874) and District Boards were being set up in the rural and semi-urban areas since 1881. They were required to raise their own resources and provide for drainage, water supply, general sanitation, maintenance of hospitals and dispensaries, etc in addition to other developmental activities. Municipalities generally employed untrained Sanitary Inspectors and the District Local Boards employed ill-paid and poorly educated vaccinators. Between 1888 and 1893, a Sanitary Board was set up in each province, composed of administrative and public works officers apart from the Sanitary Commissioner and the Inspector General of Civil Hospitals. The main function of these Boards was to give technical advice to the local bodies on sanitary works, which would be backed by financial contributions of the provincial Government.

This public health machinery remained structurally weak in both the investigative and executive aspects. In the districts, the Civil Surgeon, an Indian Medical Service Officer was expected to advise the municipalities on sanitation in addition to performing regular medical duties. He lacked experience or formal training in sanitation. In 1881, the Superintendent of Vaccination was made the Deputy Sanitary Commissioner of each province and had to supervise general sanitation as well as vaccination and vital statistics of several districts. Epidemics were handled by the district revenue subordinate officials. The agency employed to collect the vital statistics at the village level were the village chaukidars.

The Bengal Births and Deaths Registration Acts passed in 1873 was at first in force in a few towns but in 1897 it was extended to all municipal towns. The Epidemic Diseases Act passed in 1897 to control plague empowered the provincial Governments to make provisions for the inspection of corpses and the compulsory notification of all cases of deaths from plague. The Indian plague Commission also recommended that more municipal health officers be employed, and that one of their principal duties should be to supervise the registration of births and deaths. The outbreak of plague epidemic in 1896 revealed the defects of the existing health organisation. The Plague Commission report (1904) recommended improvement of the Sanitary Department for dealing with plague and other diseases and establishment of adequate laboratory accommodations for research, teaching, serum and vaccine production.

Lord Curzon's Government took steps to reorganise the Sanitary Department. Sanitary Commissioner with the Government of India was to advise the Government on sanitary and bacteriological questions and also to organise and direct medical research throughout India. This system was modified in 1912. The establishment of a provincial public health service for Bengal was mooted by the Resolution of 1912.

By the Montague-Chelmsford Reforms of 1919, Central Legislature became responsible only for legislation relating to infectious and contagious diseases, for census and statistics, sanitary control of ports and India's international health relations. Thereafter, reorganisation of public health departments became a marked feature in different provinces. Trained public health staff were recruited in rural and urban areas in most provinces. While in some provinces the health staffs were deputed by the local governments to serve under the local bodies in Bengal they were servants of the district boards and municipalities. The Bengal Village Self-Government Act of 1919, provided for Union Boards which established a network of self-governing units, could be utilised for decentralisation of public health measures in rural areas.

Another step towards decentralisation was made in 1925, when a scheme for public health organisation was formulated for rural areas. This scheme was introduced in 1927. Under it the district boards opened public health centres, one in each rural thana of a district, under supervision of a Sanitary Inspector or Assistant Health Officer. The cost of the scheme was borne by the Government, while the units were under the control of the District Board through the agency of the District Health Officer. The function of these units was to obtain information regarding the health conditions in the areas and to take measures of prevention against the spread of epidemic diseases. By 1930, 517 units were opened in 517 rural thanas out of a total of 574 in the whole province. Public Health Committees were also formed in many thanas. It was thought that these committees would operate for the decentralisation of public health work in matters of local interests and also serve as a' co-ordinating agency for the work of Union Boards in measures extending over a large area.

In 1930 a Rural Public Health Committee was appointed by the Government to consider what reassures were necessary to improve local public health organisation. It pointed out in the first place that the status of the health committee of the district board as a quasi independent authority should be emphasised and the committee should be strengthened by the co-option of members interested in public health.

As regards the staff of local organisation, the Committee recommended the amendment of the local Self-Government Act so as to give rural sanitary inspector a quasi-statutory position. District Boards should be authorised to employ more than one assistant to each Sanitary Inspector. Union Board on the otherhand should be authorised to employ a health officer as assistant to the Sanitary Inspector. It also recommended that the Village Self-government Act should be amended so as to make the President of a Union Board legally responsible for notification of epidemic diseases.

The Public Health organisation in Bengal, as it evolved before the famine of 1943 was insufficient to meet even the normal needs of the population and the level of efficiency was very low. The Department of Public Health and Local self-government under the charge of a Minister, was responsible for public health of the entire province. There were four Assistant Directors of Public Health in each of the four divisions namely, Burdwan, Presidency, Rajshahi and the combined divisions of Dacca and Chittagong. The supervision of the Assistant Directors of Public Health was very ineffective; one of the biggest snags being that they were supposed to supervise officers who were really not under them, since a District Health Officer was an employee of the District Board. In the Malaria section there were an engineer, an entomologist and a qualified assistant. Other officers in the provincial health department included the Director of the Public Health Laboratory (for cholera vaccine), officers of the Bengal Vaccine Institute (for small-pox vaccine), maternity and child welfare, and vital statistics, and an Inspector of Septic Tank Installations.

Public Health work in the districts was the responsibility of the District Boards. Each of the twenty six districts had a whole time District Health Officer. In each health circle in the district there were three subordinate health workers; a Sanitary Inspector, a health assistant and a medicine carrier. In addition some 100 vaccinators were appointed temporarily for about 6 months in the year. All these subordinate health workers in the districts were servants of the local body.

This Public Health Organisation which existed in Bengal in the 1940s suffered from a number of limitations which impaired the efficiency of the public health services. The income of District Boards had not increased to cope with the increasing demand for expenditure on roads, water supply, public health services, hospitals, etc. Their power of taxation was limited and they had to depend on grants from the provincial revenues. The provincial Government themselves suffered severely from financial stringency and was not able to provide adequate funds.

Thus the Public Health Department did little more than touch the surface of the life of the people in general and rural population in particular. This public health organisation entirely broke down during the famine of 1943 and could not be restored to normalcy even in the post famine era in Bengal. [Sujata Mukherjee]

Public health during Pakistan period Before the arrival of the British to the Indian subcontinent, basically the Ayurvedic and Unani methods of treatments were prevalent to this region. During the World War II when the public health services declined considerably, a committee named 'Health Survey and Development Committee' was formed under the leadership of Joseph Bhore in 1943 to recommend appropriate measures for the improvement of public health sector. This committee, popularly known as Bhore Committee, included physicians, public health experts, bureaucrats, engineers, and legal practitioners. The committee formulated a set of important recommendations and action plans for the overall improvement of public health of the country. Before the recommendations of the Bhore Committee were implemented, the subcontinent was divided into two independent countries, India and Pakistan. The committee report, however, undoubtedly played significant role in both of the new nations in improving the public health situations.

Soon after independence, the First All Pakistan Health Conference was held in Lahore in 1947. Based largely on Bhore Committee report, a set of action plan was identified for the improvement of administration and activities of the Ministry of Health Services. In 1949, all administrative power and responsibilities, other than international health, quarantine, and regulations and researches related to health and hygiene, were vested on the provincial governments.

The Second All Pakistan Health Conference was held in Dhaka in 1951. The conference approved a six-year plan for the health sector. Among others the plans included increase of the number of beds in hospitals; increase of the number of village dispensaries; transformation of medical schools to medical colleges; establishment of Institute of Hygiene and Preventive Medicine, Medical Research Institute, and Drug Testing Laboratory, one for each of the provinces; coordinators of the preventive and curative medicines; and establishment of malaria eradication centres. After that the health ministry of the government of East Pakistan undertook a five-year plan for development of health administration and public health sector in general. Under this programme provision was made to establish a Rural Health Centre and three subcentres in each thana. Besides, decision was also taken to launch eradication programmes for malaria and smallpox, BCG vaccination for tuberculosis control, etc. For supervision and implementation of public health activities the District Board used to appoint in each district a District Health Officer (DHO). His responsibilities and assignments mostly remained confined in programmes for the prevention of diseases. The activities of the DHO used to be under the dual control of District Board and the Director of Public Health. In fact, there was no coordination in the management system of curative medicare among the Surgeon General and the Director of Public Health. As a result the two were brought under the hood of the same administrative control in 1958 and the post of head of health administration was designated as the Director of Health Services.

Like other sectors of administration, compared to West Pakistan, the health sector of East Pakistan also remained neglected. In 1952 four medical colleges including one for women only were established in West Pakistan, whereas in East Pakistan the second medical college was established at Chittagong 5 years later in 1957. The only institute of the country, Institute of Hygiene and Preventive Medicine was established in Lahore. In all aspects of government's activities in health sector, East Pakistan was grossly deprived. During long 23 years no satisfactory infrastructure was built in this part of the country to develop skilled manpower in the health sector and striking disparity always existed between the two wings.

Public health in Bangladesh since independence Soonafter independence in 1971, the government took many important steps to improve public health conditions of the country. Maximum emphasis was given to certain activities such as primary health care, maternal and child health, and family planning. Along with these, due attention was also given to develop adequate manpower related to health technology and medicine. During Pakistan time and soon after independence some establishments were built in the discipline related to public health; notable among these are Institute of Postgraduate Medicine and Research (IPGMR), National Institute of Cardiovascular Diseases, National Institute of Ophthalmology, Institute of Diseases of the Chest and Hospital, Rehabilitation Institute and Hospital for the Disabled (RIHD), Bangladesh Institute of Researches in Diabetics, Endocrine and Metabolic Disorders (BIRDEM), Children Hospital, and National Institute of Preventive and Social Medicine (NIPSOM). Some of these organisations offer higher training facilities, diploma or degree courses in certain branches of medical science. In recent years the government has established a few more organisations related to medical education, specialized treatments, and public health. To ensure health for all, some non-government organisations (NGOs) have extended cooperation to this programme in various ways. Following is a summary of the various steps taken by the government in public health sector since independence:

1972	-	Formation of Bangladesh Medical Association (BMA).
	-	Conversion of Dhaka Medical School and Mitford Hospital to Sir Salimullah Medical College and Hospital.
	-	Establishment of Bangladesh College of Physicians and Surgeons.
	-	Establishment of Bangladesh Medical Research Council (BMRC).
	-	Upgrading of Rural Health Centre to Thana Health Complex.
	-	Establishment of National Health Library and Documentation Centre.
1973	-	Proclamation of Medical Council Act.
1974	-	Establishment of the Institute of Public Health Nutrition and Food Science.
	-	Amendment of Pharmacy Act, 1957
	-	Proclamation of Children Act.
	-	Amendment of Drug Act, 1940
1975	-	Formation of Bangladesh National Nutrition Council.
	-	Proclamation of Prevention of Blindness Act.
	-	Approval of Bangladesh Red Cross Society (now, Bangladesh Red Crescent Society) Order; amended in 1985.
1976	-	Establishment of Institute of Epidemiology, Disease Control and Research.
	-	Approval of the project for increase of beds in Thana Health Complexes.
	-	Proclamation of Pharmacy Ordinance.
1977	-	Enforcement of Environment Pollution Control Ordinance.
	-	Establishment of Directorate of Nursing Services.
	-	Establishment of National Institute of Population Research and Training (NIPORT).
1978	-	Signature to Alma-Ata declaration after the approval by WHO to the programme Health For All-2000 (HFA-2000).
	-	Establishment of National Institute of Ophthalmology.
	-	Formal introduction of Diploma in Public Health (DPH) and Diploma in Community Medicine (DCM) in NIPSOM.
	-	Establishment of National Institute of Cardiovascular Diseases.
1979	-	Beginning of Expanded Programme of Immunization (EPI)
1980	-	Upgrading of the post of Director of Health Services to Director General of Health Services.
1981	-	Introduction of Village Practitioner Scheme (this scheme was discontinued a few years after).
	-	Adoption of a pilot plan for upgrading primary health care services in six Upazila Health Complexes.
1982	-	Creation of post of specialized physicians for Thana Health Complex
	-	Proclamation of Drug Policy
	-	Proclamation of Drug (Control) Ordinance.
1983	-	Establishment of Bangladesh Institute of Child Health.
1986	-	Establishment of National Cancer Institute and Research Hospital.
1989	-	Establishment of Bangladesh Breastfeeding Foundation.
1990	-	Enforcement of Narcotics Control Act.
1992	-	Establishment of Institute of Child and Mother Health.
1998	-	Establishment of Bangabandhu Sheikh Mujib Medical University (BSMMU).

[ARM Saifuddin Ekram]