Every family in India with school-age children was shaken up recently by the tragedy that struck Bihar. 22 children in the village of Dharmasati Gandaman died from organophosphate insecticide poisoning after consuming a state-sponsored mid-day meal prepared at their school. Anguished parents blamed the school and the state for the disaster, saying their children would still be alive had they eaten a home-cooked lunch. Although everyone starting from the state’s chief minister downward started ducking responsibility, one thing was clear – a governmental initiative to improve public health had backfired.
“In the happiness of the subjects lies the benefit of the king and in what is beneficial to the subjects is his own benefit” – Arthashastra 1.19.34
The chief issue brought to the fore by Dharmasati Gandaman is the complex topic of what exactly the government’s role in the promotion of public health should be. Should people have the right to make their own decisions in all aspects related to their health, even if those decisions are known to lead to ill health? Should we instead support full-bore authoritarian control – the government enforcing certain healthy behaviors by taxing and banning “bad” things? Could there be a middle ground where the government uses its persuasive power through educational programs and ad campaigns to effect the change it desires?
CHANAKYA VS. THE ENLIGHTENMENT
Traditional Indian ideas of the relationship between state and society involved the Raja treating society much like a herder treated his cattle, or the way a gardener treated his plants – as property to be husbanded and cultivated for mutual benefit. The collective identity, as a member of a Jati (which in turn formed one element of the matrix of wider society), was considered primary, and individual identity came a distant second. Chanakya’s Arthashastra, a specimen par excellence of traditional Indian ideas on the relationship between Man, Society and State, seems to fall on the side of a benign paternalism. Enlightened kings were to make choices that would benefit society as whole, putting the welfare of the many over the rights of the few, or the one.
However, the British Raj, followed by the cultural supremacy of United States of America, inserted a new idea into the mindset of Indian elites – the idea of personal freedom and individual responsibility. The knee-jerk response of anyone raised on the ideals of the European Enlightenment (and its children, the French and American Revolutions) would be “Let the individual do as he chooses”.
SUCCESSFUL PATERNALISM: THE GOOD
When it comes to healthcare, however, there are a few complicating aspects to the Enlightenment paradigm – first, governments have a commitment to social stability just as much as they do to individual rights, and widespread disease can rock the foundations of society. Secondly, the massive growth of welfare states in this century means that an individual’s poor choices concerning his health do not merely cause troubles for himself, they also come back to bite the rest of the public in the form of increased health care expenditure. Thus, any government has a vested interest in maintaining the health of its citizens at the best possible level. Consequently, from Chanakya’s encouragement of the distribution of food at concessional rates after natural calamities, to the building of public latrines, gardens and fire places, all the way to modern-day TB, HIV and immunization programs, the tendency in India has been to give primacy to the efforts of the state.
Even developed societies like the US have benefited from paternalistic health policies – the most recent public health issue to garner significant attention was the decision by New York City to ban the sale of supersized soft drinks. Ostensibly, this was done because the average New Yorker was considered too stupid to realize that drinking Coke and Pepsi in massive quantities every day was a speedy route to fatness, diabetes and death. This led to significant outrage, not least because Americans have a particular hatred for government stepping into their personal lives. However, reality is probably on the side of the ban-enforcers – most people do not have the IQ or the knowledge to make wise healthcare decisions without pushes from the government.
With great power comes great responsibility.
In many health-related scenarios, only the state has the raw power needed to effect substantial change. When it comes to vaccination, say, the full benefit is often realized only when a majority of the population has been covered. Whether it is Muslim clerics in Uttar Pradesh decrying Pulse Polio as a plot to sterilize Muslim children, or hippie New Age parents in America reintroducing measles into their communities because of unfounded fears that the vaccine causes Autism, there are definite benefits to a macho alpha-male state that whips the population into line by forcing them to accept vaccinations.
When Mad Cow disease threatened the world, when Bird flu appeared poised to make a comeback, it was only the power of government that could force the culling of animal herds to ensure public safety. Several nations quarantine individuals with Multi-drug resistant tuberculosis, essentially putting them in jail-like conditions. Nothing brings out the inherent opposition between the interests of the individual and the interests of the wider society better than such cases, and a laissez-faire government can never achieve the rapidity of response that an authoritarian one can achieve.
UNSUCCESSFUL PATERNALISM: THE BAD AND THE UGLY
Certainly, none of the arguments in favor of government intervention to shore up public health is a claim that the government is an unalloyed force for good. For example, strict government regulations and high cigarette taxes have certainly resulted in lower rates of lung cancer, but lately, the missionary zeal against tobacco is morphing into totalitarianism. I recently interviewed at several hospitals for a job, and there were at least two which required me to sign a form saying that I would not smoke tobacco – not in the hospital, not at home, not anywhere, never ever. Though I do not smoke, I found it outrageous that a potential employer would have the gumption to control what I did at home in my personal life.
Big Brother and Overreach: Extrapolating from the anti-tobacco crusade, will there someday be a tax on fatty foods as well? Maybe cheese will be banned. Maybe not going to the gym five days a week will get you arrested. Giving power to the government is a never-ending process – a government is much like the ever-growing fish in the Puranic story of the Matsya avatara, which repeatedly became too big for its bowl, until only the vast ocean could contain it. Your life will be hemmed in by all sorts of restrictive rules and regulations, all of which will be claimed to be “in the interest of your health”.
Who will watch the Watchmen? It is a superficial and dangerous illusion that the government is more reliable than “evil corporations”. Recently, a scandal erupted over whether the head of an Indian Government panel investigating the safety of the anti-diabetic drug Pioglitazone had recommended banning it because he had financial interests in a company that made a competing drug. While none of these charges have been substantiated, it is a sobering reminder that blind trust cannot be placed in any office or authority.
Iatrogenics: Another underappreciated aspect of governmental standardization of public health is that it makes populations vulnerable to catastrophic errors caused by the governmental intervention itself, something doctors call “Iatrogenics”. In the past, each of the 22 kids in Bihar would have brought their food from home, and even if contamination had occurred, it would have affected only one of them. But centralization of the cooking process homogenized their food intake, making more of them vulnerable to a single catastrophic error.
Death panels: Finally, even if the government did have the power to control your life to make you healthy, there are some peculiar conflicts of interest which would make its job more complicated than it seems on first glance. While cutting back on fatty food and not smoking might reduce the risk of a sudden death from heart attack at age 60, it does little to prevent a long, slow decline from Alzheimer’s disease after age 80. Already, the majority of health expenditure in the US is on chronic diseases of the elderly, which cost a lot to manage. Knowing that, would Finance ministers prod Health ministers to adopt public health policies that maximized quick painless deaths after people had outlived their economic usefulness?
THE WAR ON DRUGS: FRONTLINE BETWEEN THE INDIVIDUAL AND GOVERNMENT
“The root of material well-being is activity, of material disaster its reverse. In the absence of activity, there is certain destruction of what is obtained and of what is not yet received.”
Arthashastra, 1.19.35
Given that governments spend considerable energy on ensuring the safety and security of their citizens, it is only natural for them to expect their citizens remain active and productive, instead of lying around taking cocaine all day. This is in head-on conflict with an addict’s primary desire – to take his next hit of cocaine.
Governments have agonized over this issue for centuries. Statistics show that US governmental agencies spend around 40 billion dollars annually preventing their people from having access to drugs. The “Opium Wars” that resulted in Imperial Britannia opening up Imperial China to trade were triggered by Chinese elites’ alarm at the social decay that was resulting from widespread use of Indian opium by the Chinese masses. Closer to home, we see sporadic reports in the papers about ghost villages in Punjab where essentially all the young men are hooked to opium – resulting in a slow death of their communities. As the strongest entity in a society, the government must enforce some restrictions for the promotion of the general good, to ensure that the trains keep running and the shops are open.
One’s perspective on drugs does change when we consider the other side of the equation, though. In India, ganja smoking is banned. However, Hindu sadhus have been smoking ganja and charas for millennia, treating it as a divine gift from Shiva. You cannot travel to any of the Himalayan hill stations without seeing a sky-high sadhu smoking away on his chillum. It would be pretty outrageous if policemen started rounding up every other sadhu in sight for drug abuse – the modern Indian state, for all its might, is a mere wisp in the historical tapestry of the Indian subcontinent, while the sadhu and his predecessors are part of a rich and proud tradition that has been intimately associated with the land since before the beginning of recorded history. It is his birthright to do as his gurus have taught him to, as long as he isn’t hurting anyone else in the process. If some farmer sees some poppy plants growing on his land and decides to eat some sap, is it justifiable to toss him in jail for that?
CONCLUSION
All things considered, some amount of paternalism is absolutely essential for optimal public health – there is no way the average Kumar or Manish can know what is best for him, given the burgeoning complexity of the health sciences. India, with its massive poverty and illiteracy issues, may particularly benefit from a strong-willed state that follows a blood-and-iron policy with regard to public health. At the same time, giving one group of people unwarranted power over the decisions made by others has never really worked out well in the past. India’s traditional attitudes of respect for authority and communitarianism may make it particularly prone to abuses of power. Therefore, universal principles on whether to allow full individual autonomy or full governmental paternalism on health care issues are difficult to formulate. We can only do the best on a case-by-case basis given our limited knowledge, and pray that disasters such as the Bihar poisoning don’t happen again.