-Dr. Vijay Yeldandi

Introduction

The traditional approach to health policy has been a top-down approach, often criticized as being paternalistic, condescending, often male chauvinist, non-contextual, and therefore inherently flawed. Such policies are prescriptive and inflexible, and use rigid evaluation frameworks of “desired” outcomes based on “a –priori” assumptions. Health is a complex adaptive system¹ and policies that are reductionist in design and implementation have been less than satisfactory.²

Health policy design and implementation need to be participatory and adaptive, with iterative policy improvements factoring in emerging outcomes being an inherent part of the process.^3,4 Here we discuss an example of control of Rabies in India in a “One Health” framework. We also propose that strategies of participatory action that are adaptive are key to community engagement. Such engagement lays the foundation for sustainability which is imperative for building resilience in health systems. A combination of a bottom-up approach rooted in the community defining the goal and the metrics being used, linked to adaptive external support through public health systems and non-governmental entities is essential. A key component of such a system is substantial ownership of the community in financial planning as well as governance. 

Engaging the community

 All too often engaging the community is a one-time activity that may provide a “feel good” glow to the principal activists but does not necessarily lead to sustainability once the intervention has ceased. Resilience requires both ownership and sustainability for which resources, both tangible and intangible, are required. Let us consider a couple of examples from history:

1. The story of raw milk:

In 1892 Lina Straus and her husband Nathan Straus (a Jewish immigrant from Germany whose family migrated to USA in 1854) founded the Nathan Straus Pasteurized Milk Laboratory to provide pasteurized milk to children. Straus was convinced that milk from infected cows was a source of tuberculosis in children. His own cow had died and autopsy demonstrated pulmonary tuberculosis, later his son died of pneumonia and pericarditis (possibly tuberculosis). It is estimated that the Nathan Straus Pasteurized Milk Laboratory supplied free pasteurized milk to 297 milk stations in 36 cities. This initiative saved 445,800 vulnerable children. Nevertheless, despite incontrovertible evidence of the benefit of pasteurizing milk, the first city to require pasteurization of milk was Chicago in 1908.^5,6,7,8 Even today in California it is legal to sell unpasteurized raw milk (a warning on the package is required). This practice of consuming unpasteurized milk in the USA has been linked to multiple outbreaks of serious infections and mortality in the last 20 years.⁹

1. The story of toilets:

In the last two decades, India has focused greater attention on the provision of toilets as an essential measure of improving public health through sanitation. Even as investments in building toilets ramped up, a change in behavior and cessation of the practice of open defecation emerged as a challenge.¹⁰   A campaign to have community buy-in became imperative.^11,12,13 Despite all of the progress made and the report of the Government of India that 95.4% of households have and use toilets,¹⁴ toilets in India remain quantitatively and qualitatively far from desirable, in public toilets on roads; public hospitals, and railways. Could we have had greater success through better design? Should public toilets be merely functional? Is a beautiful toilet a mere luxury? Consider the experience of Laura Orlando in 2007 working with Grupo Ecológico Zayab-Ha, with some support from RILES, building more than 60 beautiful compost toilets called Nahi Xix in Chemax, Mexico in a poor Mayan community.

Not only did the toilets become a source of pride for the women, there was also a completely unplanned outcome. The NGO Zayab-Ha (members of the community) through their ongoing engagement with the community established a new NGO Kiimac Koolel Ool managed by women in the community. Eventually with the support of the government a women’s center and shelter “Tumben Kuxtal” was created ultimately contributing positively to the social fabric in many ways. ¹⁵

Rabies control: An example of the “One Health” approach

Rabies in India

Rabies, an acute progressive viral encephalomyelitis with a severe case fatality ratio, is one of the most significant infectious diseases. This zoonosis, due to viruses in the genus Lyssavirus that perpetuate among mammals (predominantly from the Carnivora and Chiroptera orders) worldwide, causes >55,000 human deaths, tens of millions of human exposures, and substantial animal losses annually. Most cases occur in Asia (~55%) and Africa (~45%), where canine rabies is enzootic. Costs for prevention and control activities are prohibitively high for developing countries. The Ministries of Health and Family Welfare (MoHFW) and Agriculture and Farmer’s Welfare (MoAFW) indicate that major rabies reservoirs are dogs, with greater than 90% of cases diagnosed in this species. Over 90% of human rabies post-exposure prophylaxis (PEP) cases are attributable to dog bites. Other animals constitute a smaller proportion of cases, all secondary to rabid dogs. Clearly, this is a problem of non-reporting (as are the human rabies cases). A majority of cases are diagnosed based on clinical signs only.¹⁶

Feral canine population in India

In the past 50 years, feral dog populations have seen a substantial increase despite control programs. ^17,18 Clearly apart from the obvious risk of human bites and rabies there is also a substantial threat to other wildlife and ecologic damage. ^19,20 In a community based study we observed co-location of feral dogs near human habitats and litter and garbage (unpublished data). Others have noted similar interactions between food sources and dog populations. ²¹

Dog bites in India

In our small study we noted a number of dog bites not related to pets. (unpublished data). A ‘One Health’ approach to the control of feral dog populations would be to ensure humane treatment of all dogs as well controlling the environmental sources of food for feral dogs. ^22,23

 First response to dog bites

First response to dog bites has to integrate wound management (washing the wound with copious amounts of soap water reduces the risk of infection substantially) and providing prompt post exposure vaccination and where indicated rabies immune globulin ²⁴ to the victim of the dog bite. Anecdotally we have seen rather ill-advised practices in the management of dog-bites as well as other animal (monkey, rat, bats) bites, this is particularly true of rural areas where animal bites have been treated with hot irons, lucky charms and other “magical spells” with advice for fasting. We await results from a recent study in which we have participated. ^25,26 

Current practice of rabies vaccination

In India there appears to be considerable variation in access to rabies immune globulin and human rabies vaccine particularly in rural areas, a considerable variation in the practice of intradermal vs intramuscular vaccines including variations in the frequency of administration is seen. A part of this maybe the significant logistical/financial burden of lower socio-economic strata in rural areas. There is a need for improvement in canine vaccination. ²⁷

Oral canine rabies vaccine

In India, in particular, vaccination of pet dogs as well feral dogs has presented numerous difficulties ranging from less than optimal adherence to vaccination of pets as well as (understandable) reluctance of municipal workers to implement traditional canine vaccination for feral dogs. For several decades now, oral rabies vaccines have been available and used extensively in North Americas and Europe. Oral rabies vaccine for dogs should be explored further in India. ^{28, 29,30}

The One Health approach to Rabies control

At multiple sites throughout the world including developing middle income countries the “One Health” approach to rabies control has demonstrated considerable success as compared to older strategies. This has included control of dog populations, vaccination of dogs and an integrated approach to the management of animal bites in humans. ^31-41 One state in India has demonstrated commendable success in adopting canine rabies vaccine integrated into a “One Health” approach to rabies control, resulting in a 92% reduction in monthly canine rabies cases. ⁴²

A systems approach integrating “One Health and One Planet” for health systems resilience

The concept of "Health" has evolved, with various existing definitions focusing primarily on the biomedical aspects. However, there is growing recognition that health is a complex interplay of multiple factors, extending beyond the absence of disease. As the examples of the story of “Raw Milk” and “Rabies Control” demonstrate, ignoring community engagement is the “Achilles Heel” of any public health policy design and implementation. Clearly, design and implementation of health policy must be a dynamic continuum that is adaptive. In our experience, an upfront investment in building meaningful relationships anchored in social justice using the paradigm of “Salutogenesis”⁵⁹and the “Meikirch model” is a prerequisite.

The Meikirch model¹ offers a comprehensive definition of health as a dynamic state of well-being that encompasses physical, mental, and social potential, enabling individuals to meet the demands of life based on their age, culture, and personal responsibility. In this model, health is not solely a physical description but also involves fulfilling the diverse demands of life through inherent and acquired potential within a social and cultural context. To simplify, individuals striving for health must address six key parameters: biologically given potential, personally acquired potential, demands of life, personal responsibility for health, age, and culture.

The healthcare sector is unique among the service industries in that it is the provider rather than the consumer who has the dominant influence over the quantity and, indeed, the quality of the product delivered. Increasingly, democratic societies demand more significant influence on the quantity and quality of services provided, and the healthcare sector is no exception. The answers may be in exploration that fosters the evolution of appropriate paradigms and eventual ownership of the goals, methodology, and metrics for advancing human health anchored in social justice. We believe that the evolution of such a system necessarily requires an intensive involvement of the community in every facet of the design of their own "Health" goals and metrics. We must develop relevant methodologies to collaborate effectively with the community and create knowledge and systems with broad applications in population health globally. In engaging with the community we believe that we must exploit newer digital technologies for improving health literacy of the community as well improve our own understanding of geographic, temporal, cultural dimensions of the community perspective of health using tools such as photovoice. ^43-58  

Finally, “Resilient Health Systems” must integrate a grass roots level ownership of all facets of health linked to a responsive resource system with sufficient reserves and a dynamic adaptive policy design and implementation laying the foundation for an autocatalytic; autopoietic system delivering a purposeful life with autonomy and dignity for all. ⁶⁰

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