Many thanks for this invitation. I am pleased and honoured to be among you on this very special day, a day in which you start a new phase in your lives.
I would like to pay a special tribute to late Padma Shri Dr. Vitthalrao Vikhe Patil, Founder, Pravara Institute of Medical Sciences. It is thanks to his vision and generosity that we are all gathered here today.
I would also like to express my thanks to:
1. Padma Bhushan Shri Balasaheb Vikhe Patil, Managing Trustee, Pravara Medical Trust;
2. Dr. Vijay Kelkar, Chancellor, Pravara Institute of Medical Sciences. Dr Kelkar has been a source of professional and personal inspiration not only to me, but to a whole generation of economists; and
3. Dr. MG Takwale, Vice Chancellor, Pravara Institute of Medical Sciences.
Medical doctors have long had a humanistic view of the world. Some were brilliant writers. Conan Doyle, Somerset Maugham, A.J. Cronin, and more recently Abraham Verghese--are some examples I know. Leonardo da Vinci is another humanist whose many interests included medicine. Other medical doctors tried to understand the social system in which they lived. Quesnay, a French medical doctor who lived in the 18th century, put forward the concept of the income flow cycle--the spending of one person in the economy is the income of another--an insight whose full significance came to be understood several centuries later. My knowledge of Indian, Chinese, Arabic and other old cultures is too limited to know for certain, but I am persuaded that similar examples of medical doctors taking an interest and making a contribution beyond their immediate field exist in non-European cultures.
The Pravara University itself is a humanistic endeavor by its origins, its history, and its philosophy. Dr Vitthalrao Vikhe Pattil was born in an ordinary peasant family, and was deeply moved by the conditions of the rural masses and the immense human potential among the rural masses. This is what led him to build a hospital and medical facilities in rural areas from which this university ultimately was born. Helping human beings achieve their full potential was part of his objective, and also is the underlying theme of this address.
The National Rural Health Mission is another more recent program that also builds on the realization that much of India's human capital formation --and hence much of the country's future--is taking place in rural areas. Whereas in the next 3 decades we should expect India's urban population to increase by 300 million people at least, to 50--60 percent of the population, India is still 70 percent rural. This is where India's next generation is being prepared. The National Rural Health Mission builds on this realization and covers the whole of India, with special focus on 18 states. The mission goals are to reduce the infant mortality rate, reduce mortality rate in the country, and to reduce the total fertility rate. The Mission also aims at population stabilization and gender and demographic balance.
What I would like to do today is to say a few words on economic development, put health in that perspective, and conclude with the role and importance of health and, particularly, public health in building a prosperous and fair society.
Let's start with what is the problem of development.
Two centuries that changed the course of humanity
Human beings have been on earth for 4 million years, a very long time. But during these 4 million years very little changed in their material conditions of life: infant mortality has been very high for most of this 4 million years, life expectancy was low, below 30 years of age, and malnutrition endemic. These conditions changed very slowly over thousands of years. Some modest improvements in the material conditions of life took place in some civilizations for which we have some records --basically in the last 4-5 thousand years.
A dramatic turn started with the industrial revolution in 1750. Scientific discoveries applied to production expanded the range of products that could meet human needs (and human fancy) and brought huge productivity improvements. Some calculations suggest the number of hours needed to create one hour of light dropped from several hundred hours to a few minutes--when all is accounted for, that is when account is taken of the hours of work embedded in the power plant, in the transmission and distribution system, in the hours that it takes to produce a bulb, etc. Between 2 or 3 BC and the Industrial Revolution, the number of hours to produce a ton of wheat declined from several hundreds to 275 in 1830 to 2 hours at present. Similar calculations have been made for example for the number of hours needed to weave cloth--and again that number declined from several hundred hours to minutes. In short, labor productivity increased enormously. Increases in the productivity of labor are at the heart of modern forms of production and the basis of modern societies.
The Industrial Revolution started in England, gradually spread to other European Nations, and the US in the 19 century and to Japan and other countries of East Asia in the 20th century. The highest living standards in the world are no longer in England. They are in the US, Singapore, and Japan and others that caught up with the West. The living standards in these countries are 40 times higher than those in India, or 8 times those in China. "Catch up" growth comes from the fact that it is easier to learn than to invent, and hence India and China can adopt technologies and organizational innovations that increase productivity. This is what we are seeing now in many parts of the developing world in East and South Asia, and in Latin America. Recall that China and India in 1750 accounted for one half of the World economy. This declined to less than one percent 200 hundred years later. We now expect that your generation will see a redistribution of global economic power closer to what it was at the time of the industrial revolution.
What happened to health?
First a quick word on how to measure health.
The truth is that there are no satisfactory measures to capture the health of a nation. The World Health Organization has grappled with the issue and concludes that health is simply "absence of illness". Whereas incomes can be measured in rupees or US$, education can be indexed by years of schooling, and road building by kilometers, the aggregate health of a nation is not easy to measure. Therefore, we normally resort to a variety of indicators, all imperfect, that capture one or the other facet of the health of the nation: infant mortality, life expectancy, or the incidence of specific illnesses such as hook-worm, HIV-AIDs, or diabetes.
By any measure, the health of the world population has improved spectacularly over the last two centuries. This is largely because of improved agriculture, which has increased the quantity of food available, and a better understanding of disease transmission, which has guided public efforts to stem infectious diseases. Together, these factors have helped lower infant mortality, reduce morbidity, and extend life expectancy, allowing many more people to enjoy and even outlive seventy years of age. Until the late eighteen century, even the world's richer countries suffered from inadequate food production and high malnutrition. Increases in agricultural productivity account for almost half of the increase in life expectancy according to research by Robert Fogel, a Nobel prize-winning economic historian.
There were other forces at play as well. First, in the nineteenth century, pioneers of epidemiology discovered the transmission paths of disease. This prompted the draining of swamps to destroy mosquito breeding grounds, thereby curbing malaria and yellow fever. It also demonstrated the need to separate water and sewerage, which controlled cholera epidemics. London, Paris and New York were all able to grow out of cholera epidemics thanks to investments in water, sewerage and sanitation. Such public health interventions had dramatic effects on disease incidence, mortality, and the quality of life. Second, and more recently, since the 1940s, progress has continued with the discovery of streptomycin, which was effective against tuberculosis. Between 1940 and 1950, the major bacterial killers became treatable and, in most cases, curable. Diseases that became curable included pneumonia, dysentery, cholera and venereal diseases. Also important during the same period was the development of new vaccines, for example against yellow fever. And equally important, DDT allowed a breakthrough to control malaria. Extensive use of inexpensive DDT led to the rapid eradication of malaria in several parts of the world. Last but not least, the establishment of the World Health Organization greatly facilitated the spread the medical and public health knowledge and technology to poorer countries. From the 1950s, WHO was the driving force behind the public health (such as anti-malaria) campaigns and immunization drives (e.g. against smallpox).
These developments had effects beyond the health status. They also increased the productivity of labor: a man or a woman in good health is much more productive. And they also increased incomes: a man or a woman in good health can work more days of the year, and earn higher incomes. In short, healthier people are richer than unhealthy ones because they can work longer, harder, and more consistently than others.
Health also has an effect on education: healthier children can learn better. For example, the elimination of hookworm in the South of the US led to higher school enrollment, attendance, and literacy. There are many documented instances demonstrating that healthier people can learn faster and better, and this is particularly important for children.
Children who are healthy and adequately nourished may spend more time at school and are better learners. And have higher incomes as adults. This has been amply demonstrated in micro studies. Conversely, malaria, malnutrition, TB and other diseases reduce cognitive ability, lower attendance, and reduce long term earnings.
Can Better Health Lead to Higher Growth? Or is it Growth that Leads to Better Health?
This obviously raises the question whether better health can lead to higher growth? It is obvious that better health leads to a better life for individuals--less illness, longer lives, and also less poverty. Numerous studies in India and elsewhere, actually even in the United States have shown that one of the major reasons for families to fall into poverty is illness in the family. This leads to a vicious circle of indebtedness, falling incomes, and the possibility of further illness,
Some of the early literature on the relationship between health and economic growth in the US concerned hookworm. In the South of the United States in the 1920s, hookworm was called "the germ of laziness" because the southerners were seen as lazy and their productivity low, until the hookworm was eliminated. When Nobel Prize winner economist Arthur Lewis wrote about illness and development, he spoke about hookworm as a cause of anemia and thus a drain on productivity.
An early example of this literature comes from a bauxite mine in Guyana. In 1924, Dr. Giglioli, a scientist who then lived in the Caribbean, received this letter from a manager of a mine:
"Dear Dr. Giglioli
Relative to our conversation in regards to the benefits derived from the elimination of the hookworm at Akyma, I would like to call your attention to the following facts: In the beginning of 1923, ninety six miners on the ore face were mining 342 tons of bauxite per working day, whereas on the 1st of February of 1924, 76 miners at the ore face were mining 540 tons of bauxite per working day. In September 1923 you tried the carbon-tetrachloride treatment on these miners".
Although nowadays we have a better hookworm treatment than carbon-tetrachloride, the thesis is still the same: eliminating infectious disease raises labor productivity. Similar studies were conducted in other places on the impact of eradication of malaria. In the late 1970s, two economists, Ram and Nobel Prize winner Theodore Schultz, showed that improvement in health led to increased output growth and that agricultural productivity was higher in those areas of India in which the prevalence of malaria was low.
By the 1940s and 1950s, it was broadly recognized that disease impairs a country's economic growth because it decreases the expectancy of a healthy life, because it has demographic effects--keeping fertility high in response to high child mortality--and because it lowers the returns to economic activity.
The 1960s saw the emergence of the human capital approach. The economist Mushskin wrote in 1962: "Health is an investment". This was the first time an economist equated investments in health to investments in more conventional assets: machinery, or buildings. At that time there was still a certain amount of debate as to whether improvement in human capital, as contributed by investment in health, was important for economic growth. But by the 1990s the effects of health on wealth had been clearly documented and there was little doubt left that better health led to higher incomes. Some economists showed that the returns to investments in health were even greater than the returns to education.
Several publications in the 1990s had a critical influence on thinking on health policy. The United Nations Development Report of 1990 conceived and coordinated by an eminent Pakistani economist, Dr Mahbub ul Haq, included health as one of the indicators of human development. Several publications of the World Bank in the early 1990s helped establish the returns of investments on health and remove any remaining ambiguity on the importance of investing in health as part of the process of economic development.
There is as much evidence indicating that better health leads to higher labor productivity, as there is indicating that higher incomes lead to better health. For example, in the case of the hookworm we just discussed: one of the primary sources of hookworm disease is walking barefoot in soils soiled by human feces. Wearing shoes prevents infection. Richer people wear shoes. So, was the decline in hookworm disease in the Southern US triggered by higher incomes which allowed people to buy shoes? Or was it caused by de-worming campaigns? Similarly, it has been demonstrated that better education leads to better health--educated people typically know better how to take care of their health.
Because people with higher incomes are healthier one can hence ask the question whether better health can lead to higher incomes. In particular, better health leads to longer lives. Hence the question has been asked whether longer lives lead to higher growth. This has attracted the attention of a number of economists and is at the origin of a number of empirical studies. The results are inconclusive. Whereas better health and longer lives are valuable in themselves, they do not seem to translate into higher incomes.
Cuba is an interesting example. Very large investments in health and education have led to a healthy and educated labor force. Life expectancy in Cuba for example, is higher than in many industrialized countries. But income levels in Cuba are apallingly low. Similarly, in the 1970s Sri Lanka had achieved high levels of health and education, but income levels stagnated and, ultimately, the economy had to abandon its socialist path.
The reason is very simple. As Nobel Prize winner Professor Solow often said: the ingredients of economic growth are well known: health, education, infrastructure, and so on. But the recipe is time and country specific, and has to be discovered. This is not an easy task, but one that is possible as the example of several East Asian countries, and now India, demonstrates.
So, at any point in time, governments have to decide whether they better intervene in areas that improve education, or that increase health, or that increase incomes. Should they build a school or hire a teacher? Should they build a road? How such decisions are made is more an art than a science, and there is no clear cut rule.
We will not get into how these decisions are made in practice, and how best to take them. But there is one area to single out as particularly important for public health policy: this is that of early childhood development.
Nutritional Health in India and Childhood Development
India sees every year 1.8 million deaths of children under 5 years of age, and 52 million children are stunted. One third of the children are born with low birth weight (less than 2.5 kilograms), 48 percent of children under five are stunted (short for their age), 43 percent are underweight (low weight for their age), and 30 percent are wasted (too thin for their height). India has higher stunting rates than some of its neighbors, including those with lower income, and rates of underweight are twice those in sub-Saharan Africa and five times those in China. "Hidden hunger", that is vitamin and mineral deficiencies, although not visible to the naked eye, are another source of ill health. 62 percent of preschool children and 16 percent of pregnant women are deficient in vitamin A and 70 percent of preschoolers and 56 percent of women are anemic. Add to this that vaccination campaigns have yet to reach the totality of the population.
How can this huge problem be addressed? The solution is not always more food, more vitamins and more minerals. For example, investments in water and sanitation infrastructure enable households to improve their hygiene and reduce diarrheas. Improving the hygiene of households, coupled with behavior change, reduce their risks of contracting communicable diseases. Investing in secondary education of girls--helping girls live, earn and learn--is another critical determinant of the next generation's child survival, health and nutrition.
Mounting evidence from economics, psychology, and neuroscience indicates that early investments in young children profoundly affect their long term physical and mental health, earnings, and well being. Early experience shapes brain architecture, and early childhood development has a long reach that affects physical and mental health and well being later in life. There are sensitive periods for neurological development early in life that influence long term memory. Thus, the critical period for intervention is in the preschool years.
Similarly, Nobel Prize winner, economist James Heckman's research demonstrates the importance of non-cognitive skill in preparing children for school, adulthood, and the workplace, and his research suggests that both the cognitive and the social-emotional abilities of individuals as children explain many features of their later social and economic behaviour. Gaps in cognitive abilities are established early, and in the United States they explain much of the differential in individual educational performance across income levels. The evidence from a variety of countries over different periods of time is compelling.
Investments in individual children before the age of three produce more significant impacts than any other social or health interventions and at a much lower cost. Only investments in public health may be more important, but these tend to be complement to, rather than substitutes for, interventions targeted to young children.
To sum up, interventions affecting early childhood development produce long-term benefits for human capital and productivity. Microeconomic studies indicate that pre-natal care, food supplements for malnourished children, micronutrients, and pre-school for disadvantaged children help raise the potential for long term academic and workplace success and lifelong well being. These studies suggest that the cycle of poverty, morbidity, and early mortality can be broken by interventions in early childhood.
Unfortunately, early childhood investments have not received enough attention or resources. Developed and developing countries alike have a major opportunity to change the course of their society by turning their attention to such investments.
In India, there have been some partial initiatives in that direction. In AP, the Government has a program in which health and nutrition interventions have been layered on the livelihood platform of women’s self-help groups. A basic set of Health Institution Building activities, such as Group Health Savings and Credit, discussion of health and nutrition issues during Village Organization meetings, participation in the village fixed Nutrition and Health Day organized by the ICDS. Intensive interventions are gradually phased in and include: establishing Nutrition and Day Care Centers (NDCCs) for feeding pregnant/nursing mothers and children under 5 along with nutrition and health education; lending for feeding at the NDCC during pregnancy, income-generating activities for pregnant/nursing mothers, growth monitoring and promotion. These activities are supported by training Health activists and Community Resource Persons for nutrition and health education. Results from the project MIS seem promising – e.g., reduction of low birth weight incidence, improved weight gain during pregnancy. At the same time, one should be concerned that education is not integrated in these efforts and that borrowing is not the best instrument to provide resources to feed children.
The Community Health Care Management Initiative (CHCMI) in West Bengal, where National Rural Health Mission (NRHM) with the help of NGOs has engaged with Panchayats who have in turn partnered with women’s self-help groups to improve health and nutrition. The self-help groups play a key role in supporting village health and sanitation committees to develop village plans, conducting baseline surveys on which the village health and sanitation planning is based, monitor key health and nutrition indicators, and mobilize communities and serve as ‘agents of change’. Early results show improved utilization of services, especially by those from excluded hamlets, increased participation in village health and nutrition days by panchayats and women’s self-help groups.
And in UP, there is an initiative where Panchayats have been actively mobilized to strengthen health and ICDS system at village level. Key activities include community mobilization through campaigns for better health and nutrition called Jan Abhiyan (People’s movement) involving women’s self-help groups and Panchayats, using Gram Sabha as forum to discuss health & nutrition, participation in village nutrition and health days, establishing better linkages between AWW, Pradhan, ASHA and mother’s committee, community level monitoring.
It is time to conclude. I would like to leave you with the thought that India is experiencing rapid economic growth that holds the promise of a better life for hundreds of millions of people. Simultaneously, India is facing a silent crisis of enormous proportions related to public health, related to child development, and one in which the best of a new generation is being sacrificed to diseases that can be prevented. This crisis needs to be addressed so that an otherwise promising path to prosperity and social fairness is not threatened.
As you start your professional life, and to the spirit of Pravara, do keep in mind the higher and larger effects that your work will have on the future of the society in which we live. And in this endeavor, I wish you all a stimulating and rich path ahead.
Commission on Growth and Development. 2008. Report of the Growth Commission: “The Growth Report: Strategies for Sustained Growth and Inclusive Development”, World Bank, Washington D.C.
Spence, Michael and Maureen Lewis, Editors.2009. “Health and Growth”, by the Commission on Growth and Development, World Bank, Washington D.C.