1)INFUSING PUBLIC HEALTH INTO INDIAN MEDICAL EDUCATION
WHAT’S THE MATTER
The country has witnessed the menace of two COVID19 waves and stares at a third.
While COVID19 has been presented as an overarching public health calamity, the influence of medical doctors in the health policy response to COVID19 has been particularly profound.
This is symptomatic of our longstanding tendency to confound medicine with public health which permeates even the highest policymaking echelons.
If anything, both the scope and consequence of medicine in the overall health of the population is significantly limited.
COVID19 entails that this fact leaves the libraries and academia, and manifests as tangible policy measures that help consolidate public health in the country.
BACKGROUND
Distinct specialty, stagnation In the 1950s, a global consensus and a concomitant national consensus on the importance of sociallyoriented physicians in population health resulted in the establishment of community medicine as a distinct medical specialty, both at the undergraduate and postgraduate levels.
Vast swathes of the community medicine curriculum are devoted to tackling major public health challenges through a plethora of vertical disease control programmes which have always driven the national public health discourse.
The larger medical curriculum has remained more or less stagnant since postIndependence.
Similarly, hardly any attempt has been made to reform the community medicine curriculum, from one that primarily provides technical inputs to technocratic health programmes to one which can also take on the larger questions related to health policy and health systems, and inculcate critical thinking along lines that are divergent from clinical medicine.
INTERNATIONAL EXAMPLE
Countries such as Cuba demonstrate how a medical curriculum attuned to public health can strongly influence the whole philosophy of healthcare provision in a country.
The Cuban example However, none of these confers the competencies necessary to critically assess the larger public health and health systems landscape of the country.
Despite the considerable overlap between them, the nonsubstitutability of community medicine and public health cannot be ignored, at least in the current Indian context.
CHALLENGES
Community medicine, while frequently equated with public health, fails to embrace multiple facets of the multidisciplinary assemblage of competencies that is public health.
Juxtapose the community medicine curriculum with that of any of the few bastions of sociallyoriented public health courses, and the distinction becomes readily apparent.
But proponents of community medicine have not been in denial of this essential distinction — eventually, community medicine is a medical specialty while public health is a multidisciplinary science.
Since public health is a multidisciplinary science, why do we emphasize instilling public health competencies in medicine, and not so much for other allied fields such as engineering or anthropology?
The pragmatic answer is that medical doctors, de facto, are likely to continue to be the most influential players in public health policy at least in the foreseeable future.
This makes it imperative that medical doctors imbibe multi-disciplinary public health thinking right since their formative days.
CONCLUSION
Multidisciplinary science some experts have advocated the establishment of public health departments in medical schools, inspired by the COVID19 pandemic.
Recent medical curricular reforms in India have laid a stress on inculcating clinical empathy, early clinical exposure, and at least ritualistically, on greater community exposure.
For a medical curriculum to be steeped in clinical medicine and not inculcate a broader public health orientation is least desirable where health policy is largely shaped by doctors.
At the postgraduate level, reemphasising multidisciplinary public health principles would be equally important to ensure that we create not just community medicine technocrats but also wellrounded advocates of health system reform.
While healthcare reform is a complex process with numerous interacting elements, the role of formative medical education in it is quite often underrated.
Community medicine will always defend its exclusivity as being a fundamentally medical specialty meant only for doctors, and public health courses will rightfully need to be open to students from diverse backgrounds.
Looking ahead A middle ground can be struck by upgrading community medicine to ‘community medicine and public health’ both at the undergraduate and postgraduate levels.
This will involve revamping the community medicine curriculum through incorporation of or emphasising those areas of public health which are presently left out or underemphasised, such as social health, health policy and health systems.
At the same time, representation of experts other than doctors and from fields allied to public health will be essential in the refurbished ‘community medicine and public health departments.
2) REFLECTIONS ON THE ‘QUASIFEDERL’ DEMOCRACY
WHAT’S THE MATTER
Despite a basic structure, Indian federalism needs institutional amendment to be democratically federal.
Events coinciding with the jubilee of India’s Independence draw attention to the federal structure of India’s Constitution, which is a democratic imperative of multicultural India, where the constituent units of the sovereign state are based on language, against competing identities such as caste, tribe or religion.
This builtin structural potential for conflict within and among the units, and that between them and the sovereign state, need imaginative federal craftsmanship and sensitive political management.
The ability of the Indian Constitution to keep its wideranging diversity within one sovereign state, with a formal democratic framework is noteworthy.
Possibly, with universal adult suffrage and free institutions of justice and governance it is nearly impossible to polarize its wideranging diversity within any single divisive identity, even Hindutva; so that, despite its operational flaws, the democratic structure and national integrity are dialectically interlinked.
But its operational fault lines are increasingly denting liberal institutions, undermining the federal democratic structure as recent events have underscored.
SOME FAULT LINES
First, the tempestuous Parliament session, where the Rajya Sabha Chairperson broke down (in August 2021), unable to conduct proceedings despite the use of marshals; yet, the House passed a record number of Bills amidst a record number of adjournments.
Second, crossborder police firing by one constituent State against another, inflicting fatalities, which also resulted in retaliatory action in the form of an embargo on goods trade and travel links with its landlocked neighbour.
Such unfamiliar events of federal democracy are recurrent in India, except their present manifest intensity.
Legislative disruption was described by a Union Law Minister (while in Opposition) as a ‘legitimate democratic right, and duty’.
In the 1960s, the Troika around Lohia claimed its right to enter Parliament on the Janata’s shoulders to exit on the Marshals; posters with labels such as ‘CIA Agent’ were displayed during debates; ‘suitcases’ were transferred publicly to save the government; occasionally, “Honorable Members” emerged from debates with injuries.
This time, in the “federal chamber”, “Honorable Members” and Marshals are in physical contact — both claiming ‘casualties’ — official papers vandalized and chairpersons immobilized.
Even interState conflict has assumed a new dimension.
KEY CHANGES
Such empirical realities have led scholars to conceptualize India’s “Postcolonial democracy”, and federalism, differently from their liberal rolemodels.
Rajni Kothari’s “one party dominance” model of the “Congress system” has now been replaced by the Bharatiya Janata Party; Myrdall’s “soft state” is reincarnated in the Pegasus era with fake videos and new instruments of mass distraction and coercion.
Galbraith’s “functioning anarchy”, now has greater criminalization in India’s democracy, which includes over 30% legislators with criminal records, and courtrooms turning into gang war zones; it is now more anarchic, but still functioning, bypassing any “Dangerous Decade” or a “1984”.
Federal theorist K.C. Wheare analyses India’s “centralized state with some federal features” as “quasifederal”.
He underscores the structural fault lines of Indian federalism not simply as operational.
So, while many democratic distortions are amenable to mitigation by institutional professionalism, Indian federalism, to be democratically federal, needs institutional amendment despite being a “basic structure”. Wheare’s argument merits consideration.
STRUCTURAL CONFLICTS
The story is not different for the “all India services”, including the State cadres.
What is operationally most distorted is the role of Governors: appointed by the Centre, it is political patronage, transforming this constitutional authority of a federal “link” to one of a central “agent” in the States.
Thus, the critical instruments of national governance have been either assigned or appropriated by the Centre, with the States left with politically controversial subjects such as law and order and land reforms.
Thus, most of India’s federal conflicts are structural, reinforced by operational abuses.
Yet, there is no federal chamber to politically resolve conflicts.
The Rajya Sabha
The Rajya Sabha indirectly represents the States whose legislators elect it, but continue even after the electors are outvoted or dismissed; with no residential qualification, this House is a major source of political and financial patronage for all political parties, at the cost of the people of the State they “represent”.
Possibly, this explains its continuity.
Constituting roughly half the Lok Sabha, proportionately, it reinforces the representative deficit of Parliament, which, through the Westminster system of ‘winner-take-all’, continues to elect majority parties and governments with a minority of electoral votes.
The second chamber is not empowered to neutralize the demographic weight of the populous States with larger representation in the popular chamber; it cannot veto its legislations, unlike the U.S. Senate.
It can only delay, which explains the disruptions.
Joint sessions to resolve their differences are as predicable and comical as the “voice votes” in the Houses.
India’s bicameral legislature, without ensuring a Federal Chamber, lives up to the usual criticism: “when the second chamber agrees with the first, it is superfluous, when it disagrees, it is pernicious”.
Historically, party compositions decide when they agree or disagree.
Whenever any party with a massive majority in any state finds itself marginalized in the central legislature, it disrupts proceedings, just as popular issues not reflected in legislative proceedings provoke undemocratic expressions and reciprocal repression.
Such examples abound in India’s “quasi federal” democracy till now.
CHALLENGES
But India’s federal structure is constitutionally hamstrung by deficits on all these counts, and operationally impaired by the institutional dents in the overall democratic process.
Like popular voting behaviour, institutional preferences are based either on ethnic or kinship network, or like antiincumbency, as the perceived lesser evil, on individual role models: T.N. Seshan for the Election Commission of India, J.F. Ribeiro for the police or Justices Chandrachud or Nariman for the judiciary.
India’s federal structure, underpinned on the colonial ‘1935 Act’ which initiated ‘provincial autonomy’, attempted democratizing it by: renaming “Provinces” to autonomous “States”; transferring all “Reserved Powers” to popular governance; constitutionally dividing powers between the two tiers; inserting federalism in the Preamble, and Parts 3 and 4 containing citizens’ “Fundamental Rights” and “Directive Principles”; but nothing about States’ rights, not even their territorial boundaries.
This has enabled the Centre to unilaterally alter State boundaries and create new States.
The Indian Constitution itself has been amended 105 times in 70 years compared with 27 times in over 250 years in the United States.
With ‘nation building” as priority, the constitutional division of power and resources remains heavily skewed in favour of the Centre; along with “Residual”, “Concurrent” and “Implied” powers, it compromises on the elementary federal principle of equality among them, operationally reinforced by extraconstitutional accretion.
While the judiciary is empowered to adjudicate on their conflicts, with higher judicial appointments (an estimated 41% lying vacant), promotion and transfers becoming a central prerogative, their operations are becoming increasingly controversial.
CONCLUSION
Many deficits Democratic federalism presupposes institutions to ensure equality between and among the units and the Centre so that they coordinate with each other, and are subordinate to the sovereign constitution their disputes adjudicated by an independent judiciary with impeccable professional and moral credibility.
Empirical and scholarly evidence suggest Wheare’s prefix about federalism arguably applies to other constitutional goals (largely operationally), while the federal flaws are structural, reinforcing conflicts and violence, endemic in the distorted democratic process.
It is a threat to national security by incubating regional cultural challenges to national sovereignty, and reciprocal repression.
We might learn from the mistakes of neighbouring Sri Lanka and Pakistan rather than be condemned to relive them.
India’s national security deserves a functional democratic federal alternative to its dysfunctional “quasifederal” structure, which is neither federal nor democratic but a constitutional “basic structure”.
