Good evening, friends. It's a pleasure to welcome you to Summerville College this evening.
I was very briefly at the conference yesterday. And one thing I didn't say at the time, which I think I should have said at the time,
is that the whole ethos of Somerville College is including the excluded.
And I think that people who have suffered from mental health problems have for far too long been excluded.
So you are absolutely right. Place this evening to have a lecture about mental health.
But I'm not going to introduce our principal speaker this evening.
I'm going to ask, Go, I'm going to ask New Foundation Fellow and we are so delighted that Gopal Surinamese,
who, as you all know, is the former solicitor general for in India.
I'm going to ask him to to introduce this to cash out as a juror because I think it's so important this lecture and go for is just to say welcome.
Some of this is the first time you have welcomed somebody to your college to come.
What a pleasure. Thank you. Thank you, John.
It's absolutely marvellous to be present here. Mr Kissel this restroom is a very distinguished civil servant.
I had an opportunity to work with one of his predecessors, Sujata Rao.
And in my capacity as solicitor general, I realised how important was policy and particularly in the context of public health.
And more significantly, in the context of mental health.
I had some role to play. In the. Downsizing of the 1987 Mental Health Act, when as a commissioner, I submitted the report,
which led to the reconstruction of a mental health hospital in northeast called Taste Poor.
Having said that, the importance I think of mental health is so fundamental to our existence,
and it is not a surprise that England's chief medical officer in the 2013 annual report
identified various groups of young people at risk of developing mental health problems.
Children living at a socioeconomic disadvantage.
Children with parents who themselves had mental health or substance misuse problems.
Children who experienced personal abuse or witnessed domestic violence, or those who were excluded from school.
Teen parents. Young offenders. And young lesbian.
Gay, bisexual or transgender people. And, of course, ethnic minorities.
What is important is that poverty produces an environment which is extremely harmful to individuals, families,
communities and mental health, and the impacts of poverty are present throughout the life course before bed and into a ditch.
And I do believe that there is something called cumulative impact on mental health, which needs to be addressed.
I admire Mr Kirsch of disruption, although I have met him only this evening.
The reason why I admire him is he is one of the very few civil servants who
has been able to address what I call as cognitive dissonance in policymaking.
He has been aware of it, and particularly how important it is that public health is not merely a project or a magic incantation,
but is a real deliverable which adds to the quality of people's lives.
Mental health problems are indeed the largest single source of disability in the United Kingdom.
They account at the moment for over 23 percent of the total burden of disease.
I want all of you to appreciate that there are no signposts all of us can
suffer at some point of time in our own lives or in the lives of our dear ones.
Mental health problems. They are indeed very significant, and they must be addressed.
They must be addressed. I think not only in terms of education awareness, but most importantly, destigmatize issue.
And I also believe that apart from these stigmatisation,
there is so much of scope for new therapeutic curriculum, which should be introduced in schools.
A lot of the work in India, particularly in the public health sector and in the public space,
which Mr This Raj has written about is indeed available in the public domain.
But what he has crafted out are actually ground level experiments and the ground level experiments,
which are translated into real deliverables, make his work extremely significant.
I said on behalf of Somerville College and the principal, extend you a very special welcome.
And having had the privilege of worked with very distinguished civil servants in the government who have
contributed so much to society and to thought and who are not merely the last levels of Whitehall's,
I'm sure we are all looking forward to an evening of stunning disclosures.
Thank you. Barrenness, royal friends.
I'm delighted and honoured to be asked to give this lecture.
Several people have made this possible. And I'm grateful to Dr. Pamela Webster.
Dr. Facilitated and Ajani Dr. Annika Koestler, Dr. David Geller.
For their kind invitation to meet. I'm particularly grateful to Mr. Gore possible venue for this very, very kind words of introduction.
It is a very great honour. In calling the stock issues in public health in India, my intention is quite simply,
just to identify those issues which have a bearing on the health and welfare of a very large population.
There are many complications in this and regional variations.
I will say something about this weather and disease burden. Health infrastructure.
Health. Human resources. And there are also many, many implications in India, given India's federal structure,
where the primary constitutional responsibility for health care is that of the states.
Even if a not insignificant share of public spending on health care is by the central government or.
By state governments using funds of the central government. And clearly, these issues will need to be addressed in a sensible and coherent way.
Inefficient health systems ought to be built. Now, this talk comes at the end of a very interesting two day conference.
On mental illness and mental health. But while there are very many critical issues.
At the heart of a mental health policy or programme.
It is essential that these issues are understood within the context of the health of the people, the public health context.
There can be no mental health without public health. This would apply to other areas of discussion.
It's very easy to go into silos and talk about malaria as the only thing that happened,
what drove what you were closest, as though that was the only thing to address. But but that cannot be so.
And so, as I said, there can be no mental health without public.
Now, a good place to start is to look at what has gone wrong in a recent piece entitled Archives of Failures in Global Health.
Professor Medical Pie of the McGill University looks not at the dramatic successes with which we're all familiar,
but at failures areas where the global health community and individual governments have been either unable or unwilling to make a difference.
And several of these failures identified by him relate specifically to India.
These include India's failure to invest in Health India's premature declaration in 2005,
leprosy elimination and India's failure to address child malnutrition and stunting.
There are also situations where India is not alone, but where there is recognised shortcomings,
such as the failure to deliver on the promises of the Alma-Ata Declaration of 1978,
the failure of the Global Malaria Eradication Programme, the failure to achieve the Millennium development goal on maternal deaths.
The failure to address the non-communicable diseases epidemic.
The weakening of the campaign to end AIDS by by 2030 and the failure to address global mental health.
So there are areas which are specific to India and areas where India is part of the community of nations.
But the overall team being a failure at this very sorry list gives a good outline of the range of India's public health issues.
One very striking feature is the continued prevalence of communicable disease,
along with the rapid increase in the spread of non-communicable diseases in a country where maternal and infant mortality are still unacceptably high.
I mean, there are people here from many disciplines. All of you will recognise if you work on India,
that India is forever in a stage of transition and this is more true of public health as it is with other areas.
Several developed countries have reduced maternal and infant mortality and also brought communicable disease under control.
This allows them the resources, the space to address the threat of non-communicable disease.
India does not have this luxury if we have successfully eliminated smallpox and polio.
We are still fighting malaria, tuberculosis, leprosy, aids and a string of water rather sadly called neglected tropical diseases.
This is actually is a recognised W.H. Attempt. None of this is actually new alma mater,
the Conference on Primary Health Care 1978 urged that governments have a responsibility for the health of their people,
which can be fulfilled only by the provision of adequate health and social measures.
This was 40 years ago.
I don't know how to recognise the importance of promoting preventive curative and rehabilitative services of nutrition and safe drinking water,
public health, education, access to drugs, immunisation, family planning, maternal and child health.
Most importantly, it recognised the need for health, human resources and went into some detail.
Health workers, including physicians, nurses, midwives,
auxiliaries and community workers as applicable, as well as traditional 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.
So we've people we've known this for a while, and I think it's important to remember that this has always we know that.
Now, I've been talking about communicable disease, the bird disease burden.
I would like to say here the public health policy and practise in India has traditionally been driven by communal communicable disease.
The very early developments in the public health policy related to drainage hygiene sanitation.
Basically, the attempt being to control the spread of communicable disease.
And there have been very significant achievements in the past and most recently in the case of polio,
where it's now been over seven years that we have not had an incidence of the wild polio virus now.
India's polio campaign was a combination of financial resources, superior technology, dedicated manpower.
But we have not had comparable results in routine immunisation where you India figure average is still only 62 percent of approximately 20,
somewhere between 27 and 28 million babies are born every year in India.
On 62 percent of them, get the full round of nine shots in the first nine months or double digits, so this is right.
It's it's better than what it was like so much else in India, but it's still not good enough.
So. Malaria and other vector borne diseases as dinghy still a major public health challenge.
We have seen a reduction in the number of cases, but 94 percent of Indians one point to five Britons are still at a risk of malaria.
And our government has set a target of elimination of malaria by 2030.
It's a similar situation in tuberculosis, where India still contributes 25 percent of the global burden,
with an estimated 2.8 million new cases, new cases, two point eight million new cases in 2018.
Off this about.
2.8 billion with the new cases in 2018, the total number of persons living with tuberculosis was 28 million incidents and almost 28 million,
about 1.4 1.5 million almost are afflicted with drug resistant tuberculosis.
The situation,
which has arisen almost entirely because of unregulated treatment by private providers and if India is to achieve elimination of tuberculosis by 2025.
Which is a much publicised objective. Very much more needs to be done.
We must also recognise the major threat of non-communicable diseases, diabetes, cardiovascular disease, cancers.
For many years, India, with the rest of the world,
believed the non-communicable diseases such as hypertension and diabetes would result in inappropriate diets in high income countries,
and we now all know that this is not so.
We now know more realistically the diabetes and hypertension, as also cancers and mental illness have comparatively little to do with incomes.
Much more to do with the known risk factors of tobacco.
The uncontrolled use of alcohol, the lack of exercise and poor diets.
India, which moved the global mental health resolution of the World Health Assembly in 2012,
has consistently called for a recognition of the fact that mental illness must be regarded as one of the major non-communicable diseases.
W.H.O. has now agreed to this, but this is a very recent admission.
Approximately five percent of India's population is believed to have common mental disorder with a further 1.5 percent with severe mental disorder.
This translates into about 80 million persons, which is a staggering number by by any account.
In particular, while all continue, all noncommunicable ailments need continuous and regular treatment over the life course.
The stigma surrounding mental illness makes it all the more difficult for appropriate measures to be taken.
India's Mental Health Policy of 2014 and the Mental Health Care Act of 2017 laid down very salutary principles which placed the interests
of persons with the illness of before and not necessarily the interests of families or guardians or of treating psychiatrists.
It is a legislation that recognises the rights of persons with the illness to appropriate treatment,
which I believe was a very major move in a country where the rights to health care itself is not properly understood.
Other diseases, whether communicable and non-communicable may affect smaller number of persons,
but in a country of India's size is still add to the burden of disease.
These include rheumatic heart disease, leprosy, thalassaemia, sickle cell anaemia,
congenital disorders and accidental deaths, especially road traffic deaths.
So the numbers add up very substantially.
Now, having spoken about communicable and non-communicable diseases, we need to look also at maternal and infant mortality,
and while numbers do not tell us everything, we must still know what they are and.
Despite its magnificent efforts, largely driven by government, maternal mortality nationwide is still at 142 deaths per 100000 births.
We were not successful in reaching the Millennium Development Goal target, 209 deaths by 2015.
Now the sustainable development goal of this disease now requires us by 2030 to
reduce global maternal mortality ratio to less than 70 per 100000 live births.
As I said, we had 142. We need to get to 70 now.
Interestingly, many states and India have already achieved this care of 61 modest 68 promenades of 79.
But there is also Rajasthan, a 244 interpretation 285.
And assignment three. So whether at the national level, we will achieve the sustainable development goal.
It's great it's out there at this point of time. Now let me also say infant mortality.
Infant mortality requires us by 2030. Sustainable Development Goals require us to reduce by 2013 infant mortality to 12 deaths, 1000 live births.
We are currently at thirty nine and we have 10 11 years to get from thirty nine to 12.
As I said, we. The last published figures with 41 in 2015 is believed to be around 39 now.
Here again, Canada is already at Rhode Island after 23 and Delhi is at 26.
But with what is 66 by reputation, 69 and asylum at 73.
It's it's a very, very wide variation. The chances that we will meet our targets.
Again, it's very hard to say, you know. Now, these numbers indicate the size of the challenge, but what they conceal are the details.
It is true more women and infants are surviving the trauma of childbirth.
But not much else is changing in their lives. Women continue to be underweight, anaemic,
married too early or becoming mothers too early and now giving and are giving birth to underweight babies at the risk of wasting and stunting.
The Lancet has recently called attention to the fact the malnutrition was the predominant
risk factor for death in children under five in every state of India in 2017,
accounting for 69 68 percent of under-five total under-five deaths.
There are. The additional details are grim. The prevalence of low birth weight in India,
twenty one point twenty one point four percent of all births and I said so somewhere between 27 and 28 million births every year.
Twenty one percent of these low birth weight 39 percent stunting 15 percent, wasting 59 percent anaemia in children.
Now.
And many of you would know very recently, the 2019 Global Hunger Index places India to rank of 102 out of 117 countries, 102 the worst in South Asia,
the worst in our neighbourhood Bangladesh, Pakistan, Nepal, Sri Lanka, Myanmar are all ahead of India on this list of global hunger.
So these are these are very, very. These are very significant and important figures.
And I can't leave the subject of disease burden without saying something about population size,
the relationship between health policy and population policy has always been very contentious.
And for too long. Population policy has been seen as a question of population control and is only
relatively recently that more voices have been heard primarily from civil society,
calling for a population policy that addresses the questions of women's health, nutritional status,
the ability of women within families and communities to take decisions relating to themselves.
Women's literacy in education awareness amongst both men and women.
Of the options for family planning available to them.
And the recognition that higher standards of primary care can impact significantly on the health of women and children.
This also raises necessary to recognise that whatever efforts are made by India today, howsoever Heatherwick and howsoever well-funded.
The impact will not really be felt for the next 15 or 20 years.
India's population today stands at approximately 1.3 billion.
And in population growth, as in communicable diseases, significant variation across the states.
Many states have achieved replacement fertility. Fertility rate of 2.1, but many other states, which are Pradesh, Bihar,
Jharkhand just have not reached and that do not appear likely to reach this anytime soon.
More positively, it's not. In the 70 odd years since independence,
life expectancy has increased significantly from twenty six at independence to seventy point three for women and sixty six point nine for men today.
So it is, it is. It is an achievement that we must we must recognise.
There's another there's another caveat to be made here, which is that in a country of our size, there's a real danger.
That not just about size, but with a population that has such unequal access to resources.
There is a real danger that we concentrate only on the diseases of the urban population or the relatively better off
sections of the population or persons who can have access to care or persons who are in a position to pay for care.
It is possible that the diseases of those persons who were unable to access
health care or falling outside the area of interest of health policy makers.
Now, Professor Fine's list of failures significantly also highlights India's failure to invest in health care.
Most discussions on the subject will tell will cite this fact that as against the ultimate objective of three percent of the GDP to health care,
India has never gone beyond one point one percent.
Now, there are several important writers. Expenditure as a percentage of GDP is both by the centre and by the states do traditionally,
as I said earlier this evening, it is simply a government that has made substantial contributions.
Now this expenditure includes the cost of maintaining hospitals, the salaries of doctors and nurses,
and expenditures borne almost entirely by the states, who do not generally find it easier to generate significant resources of their own.
The ability of state governments to generate resources through taxation is somewhat limited.
It's also necessary to look again to look at the details, it's not enough to say so much percent of GDP.
How are these public expenditures divided across infrastructure, human resources, hospital care, public health, medical education, medical research?
Each of these would require a formidable level of investment,
and the tendency has been both for the government of India and for the states to look for low hanging fruit,
such as the construction of hospital buildings or the purchase of expensive equipment,
rather than the more time consuming efforts involved in investing in the education of nurses or public health workers,
or on clinical and health research. Now, most of the issues health care financing are quite well known,
but I would like to say something about India's current policy as reflected in the scheme known as the Iceman part,
predominantly General George or the Prime Minister's Healthy India programme.
This there is there is a huge, widely publicised, social media driven campaign promoting this broken.
But it is necessary not to be diverted by the by the glitz and to look at actual and projected achievements.
Now, this scheme, the PMG White, has two components.
The first is an insurance based hospital care scheme,
persons enrolled under the PM G-A-Y are entitled to seek treatment with empanelled government and private hospitals.
The payment for which up to a maximum of five hundred thousand rupees five lakh rupees
per year for any one of 1350 packages for which rates have been negotiated with the BMJ.
Why people? Now, this is the broad principle on which many health insurance schemes function, including the rest,
she has lost the Bima Yojana, which India launched in 2008 and is now, for all practical purposes, abandoned.
Now, but under BMG BMJ, which, as I said, five blacks per year.
Thirteen hundred and fifty packages with rates of negotiated.
The latest figures are that four point forty six million persons have received cashless treatment in over eighteen thousand hospitals.
And while figures are frequently released on the numbers of claims settled with hospitals,
information is not necessarily forthcoming on improved health outcomes even.
Now, there are many, many difficulties in this insurance based model where it is the government's
intention to negotiate the lowest possible rates for the prescribed treatments.
It is the endeavour of private hospitals to increase these as much as they can.
And while it's clear that even where negotiated rates have been announced,
private hospitals will render only as much treatment as they believe they can afford to within the negotiated rates.
They are not about to start losing money for the sake of my health.
Another very serious problem with PM G-A-Y is that it only supports cases of hospital admission,
ignoring the fact that a substantial number of cases could conveniently be dealt with in the outpatient wards.
Indeed. In these cases, hospitalisation probably brings on a range of unrelated additional costs.
Loss of wage for the for the family member who is accompanying the patient and stuff like this.
And these are costs that insurance will not cover.
The costs of food being eaten by the attendance of the patient, all or none of these are people covered by insurance.
And there is also the issue of useless hospitalisation and useless surgeries being performed only in return for the insurance,
which is available on such procedures.
Now, all this leads to the suspicion that the scheme has been designed primarily to make use of unused capacity in private hospitals.
Interestingly, a recent article authored by the two senior most civil servants in the health establishment relates with some pride that more than half
the hospitals empanelled under the scheme are private and that private hospitals have witnessed a 20 percent increase in footfall.
And these persons thought that this was something that needed to be publicised, and, as I said, with great pride.
Now I said there were two parts to the NGO. I said this insurance based hospital treatment is one part.
The other part is the establishment of health and wellness centres.
This really appears to be a programme for upgrading and strengthening existing sub centres and primary health centres.
12 services have been identified, which these wellness centres are expected to provide over.
I mean, I'm like somewhat limited range of services currently provided. Now, in an ideal situation,
this this part of the programme would have an address based on your understanding of the bulk
of people's health concerns would have been taken care of within the umbrella of primary care,
with only more complicated cases being referred to a second judicial level where, if necessary, costs could be covered by insurance.
However, it's being done in the reverse.
So the whole focus is on insurance base hospital treatment and less of the focus is on creating of these new health and wellness centres.
And there's also very little information about how these wellness centres are doing.
We know that there are over 24000 primary health centres that are lacking 56000 sub centres.
But the only information I was able to find is that more than 20000 wellness centres have been established now.
It is also not clear whether.
How these wellness centres, even the ones that are supposed to been established, have addressed the problems of inadequate human resources,
the limited availability of drugs, disposables, generally poor maintenance,
the ecosystem in which the wellness centres are to function remains the same.
And it is not clear that renaming them has effectively solved anything.
There is also the more fundamental question of who should pay for health care.
Having an insurance system still requires substantial amounts of government funds to be paid out as insurance premium for on population cover.
There is no sign in any of the annual budgets since the scheme was launched of the increased funding that would be necessary to make the scheme work.
Even the chief executive of The BMJ, why one of the two people who was talking about increased footfall in a much publicised interview admitted
that he hoped India's investment in health care would reach two point five percent of GDP by 2025,
of which only a small amount would come to PM's. You know, if government has not budgeted for the insurance claims,
which would be received if it is not budgeted for the operation of the wellness centres.
It is not at all clear how this is expected to function.
It is also not clear why if the government has the resources or plans to have the resources to pay the insurance companies,
why these funds could not be used to strengthen existing systems or to better equip
them to function or to ensure the reliable presence at all times of trained health,
human resources and public facilities. So these are all big and up to now unanswered questions.
Human resources and the availability of well-trained and suitably motivated human resources remains.
One of the most challenging issues in public health in India, the requirement is huge weather of doctors with the first degree.
So for specialists, doctors with both parties. Qualifications.
Nurses, allied health professionals, public health workers and each of these categories is a crisis situation in itself.
As for the most recent information, the Medical Council of India, of which more or none has approved the award of MBBS,
the first degree eight thousand three hundred twelve seats every year,
of which slightly over 50 percent are in government colleges, the remainder being in private colleges.
Everything to do with the establishment of medical colleges or the conduct of the Medical Council of India needs to be looked at very carefully,
and the council itself has very recently been abolished with something called the National Medical Commission having taken its place.
Now, a very large number of medical graduates are clearly being produced every year,
but it's unclear how many of these are actually available for public service.
It's also true that there's a very wide variation in the quality of these gadgets.
Those leaving government medical colleges are generally regarded as being better
trained and while there are outstanding institutions of medical education,
the private sector such as the Christian Medical College in Vellore. Most of them do not have the same reputation.
They survive on the strength of high fee structures,
a feature which does not appear to be a deterrent given the very high status accorded to doctors in India.
The fact, however, is that a student graduated from a private college howsoever well or badly trained is not going to be
available for public service if she is to repay the debts she has incurred in acquiring a medical education.
Issues of medical curriculum and syllabus were not given adequate attention by the erstwhile Medical Council of India before its unlamented demise.
And the same is true of nursing education.
As per most recent information, the Nursing Council of India, which for some peculiar reason has not been abolished and continues to function.
There are 1630 colleges for the training of midwives,
almost three thousand colleges with the training of staff members and seventeen hundred colleges with the training of graduate nurses.
The overwhelming majority of these are privately owned and a very, very indeterminate quality.
Not enough positions have been created by state governments for nurses, many of whom look for employment opportunities abroad.
The nursing council also has regulatory control over the training of midwives and then shamefully neglected area.
Now, it's not all grim on the positive side.
There is legislation currently pending the Allied Health Care Professions Bill, the Allied and Health Care Professions voted gene,
which aims to define and regulate the conduct and training allied health professionals,
defined as an associate technician or technologist, trained to support the diagnosis and treatment of any illness, disease, etc.
The bill also lists 15 categories of professionals with 53 specific professions.
Now, this was a long overdue exercise, but it is still pending in parliament, and we have no idea where the parliament will at any stage approve this.
There's also I was also mentioned the National Medical Commission bill, which is just been passed by.
The Medical Commission exists as enliven the debates on health human resources considerably by introducing
absolutely at the last minute a provision for the creation of a category of worker called community health worker.
Now there is considerable. Anguish, really of this, because there's nothing which tells us where this person will come from,
what kind of training this person should have, what duties this government health worker will perform or any of these things.
But it just gives the government under a kind of.
Omnibus section. Actually, it could really enable government to appoint anyone they want as a as a community health worker.
So this is something to look out for now in identifying these three big areas of disease burden, financial resources and human resources.
I've still followed what might be called a hospital driven approach to health care.
How differently do we need to think? If we are talking of public health policy for India now, one of India's better known public health specialists,
You're Not Ready has recently called attention to six key elements of health system identified by W.H.O. Healthcare Infrastructure Health Workforce.
The availability of. A. I'm sorry, the availability of drugs and technologies, the level and use of health financing,
health information systems and the overall governance of health services,
and that already makes the important point that these six elements identified by W.H.O. do
not include the role of the community in driving adequate demand for adequate health care.
Now. It is still common in India for public health to be understood as basically concerned
with hygiene and sanitation and controlling the spread of communicable disease,
but. One can think of a more useful definition,
and we could more usefully understand public health or public health policy is the
establishment of a viable and functioning primary health care system serving the community,
which takes into its fold all matters relating to the health and welfare of the public, including preventive measures, appropriate nutrition,
well-functioning drinking water and sanitation systems for all members of the public, and particularly for women and children over their life course.
I made this up, this isn't from someone very grand, it is or this is not W.H.O. or anything, but this seemed to me.
A definition would take some which takes in all the essential elements of what public health ought to be covers all the relevant issues,
the prevention of communicable diseases, the treatment of non-communicable diseases over the life course, the need for government investment,
the need for qualified persons at all levels, the role of the community.
Now all this, by the way, you said in India's National Health Policy of 2017, the policy actually says more.
He talks about traditional systems of medicine,
but as in the case of much of India's policy and legislative statements and much more statements of aspiration than of commitment.
And it's also important it's not also just a question of resources.
Nothing can be done without resources, but resources without the necessary motivation.
Political will and executive ability will also not deliver satisfactory health outcomes.
I. I must, however, call attention.
To several remarkable civil society interventions.
Which in their motivation, work on the ground reflect the best elements of what I have defined as a public health policy.
I think here about your guest gene and his colleagues at the Johns Fosters.
A yoga instructor is good in the heart of India.
The Jazz says runs a hospital which provides a very high quality of care to a large and vulnerable population.
I am grateful to Dr. Jain for always calling my attention to what he describes as the diseases of the very poor.
I think also Dr. Vandana will pick them up and her colleagues at the Banyan in Chennai,
an organisation that has worked for 25 years now with homeless women with mental illness in India to be female,
poor and sick is to be very vulnerable indeed.
And it isn't the work of the Banyan that one sees a combination of professional excellence and compassionate imagination.
I must also mention to institutions for children with disability.
But I think our Roy Foundation and the room done by the remarkable George, Oprah and Vidyasagar in Chennai set up by Poonam Natarajan.
I was also mentioning the Cancer Institute area in Chennai run by the remarkable Doctor Santa.
Then there is my friend, Dr. Amar Rajagopal of Pallium India in Trivandrum, an organisation devoted to establishing palliative care services.
Now these institutions and many, many more that I have not mentioned are marked and are distinctive in many ways.
But most importantly, by the human and ethical quality of the individuals behind them.
And while this gives these institutions that distinction,
it also makes it ask the question of what one we expect from institutions which are not guided by a hugely charismatic figure.
Government does not believe in charisma. But yet it is government's responsibility to fund and manage health care institutions.
The best examples we have in India are in the non-profit sector and where and how are we going to bring about a meeting between these?
India's experience in tackling the AIDS epidemic stands as one possible way in which this coming
together of both the public and the private sector and their respective strengths came to the fore and.
The National AIDS Control Programme, and if you want to pay for all of them,
demonstrated how significantly community involvement can impact on the efficacy of health investments.
My distinguished friend and my one time boss, Sujata wrote in her book Do We Care?
Makes the point that India showed the capacity to respond to a situation which required not only clinical intervention,
but also changes in societal attitudes.
For possibly the first time, issues of sexuality and sexual orientation were brought into the public discourse,
with the recognition of the fact that behavioural change needed to drive India's response to controlling the epidemic,
India's national AIDS control programmes will always be remembered for their pioneering efforts.
Since 2014, however, ostensibly because the prevalence of AIDS in India has reduced and also because the government of
the day believes that abstinence is a more appropriate response to sexually transmitted diseases.
Public investment in AIDS in AIDS control has declined. And this is a very worrying situation.
But I'd like to. Sort of bring this to an end.
And. What I would like to see in conclusion, is that public health is about social justice.
The Sustainable Development Goals recognise, and in their different areas, they target inequality.
But it is also true that even with substantial progress has been made towards achieving the Sustainable Development Goals,
gaps between countries and between communities within countries continue to rise enormously.
The distinguished psychiatrist and public health practitioner, Bikram Patel, his edge and I quote from something that Kim wrote.
Inequality corrodes the fabric of a society that is crucial for all people to feel that they belong to it and have a stake in a shared future.
Social scientists refer to this connectedness as social capital.
It acts as an invisible glue that binds us all together. Both rich and poor through good times and bad.
It is this communion of hearts and minds which promotes individual and ultimately societal will be ensured.
Inequality destroys the soul of nations, of societies, of communities and ultimately of every individual's well-being.
And when Uncle Nolan, when government's aim at making quality health care accessible and affordable, when they strive in the words of Alma Typekit,
the provision of adequate health and social measures, they work towards removing inequalities that is at the core of good governance and the D.
And these noble thoughts have been read say to very recently,
even in the United Nations General Assembly high level resolution of last month, 23rd September 2019,
using almost the same words as our motto,
everything lies with national governments and the context of today's address India's government and its ability to show leadership.
And ownership in establishing effective health governs its ability to promote access to safe,
effective, quality and affordable essential medicines and vaccines.
Do you invest in adequate, sustainable resources to invest in education, recruitment and retention of a fit for purpose,
public health workforce and to address the social, environmental and economic determinants of health and health and equity?
These are monumental challenges. But they are of great importance to all who care for the future of India.
Thank you.