For more than 30 years now, Kerala, a state on the Malabar coast of south-west India, has been held up as a model of ‘good health at low cost’ and seen as an example of how to promote greater health equity. The situation in the past few years, however, is somewhat at odds with that perception. Emerging diseases like Chikungunya have taken on epidemic proportions; dengue is spreading; traffic accidents are increasing; and generally lifestyle diseases have begun to take a heavier toll.
The legendary health of Kerala seems to have begun to fray at the edges.
In most countries the extent to which public health is a clearly identified, organised entity is limited. More often it entails the workings of several interrelated institutions. While ideally it needs to be a social institution, the involvement of society in public health is normally severely constrained.1 Any concerted effort on addressing people's health requires some form of political intervention. This is best done through deliberative democracy. It is of note that, despite having evolved a democratic local government system with deliberative space for citizen participation, Kerala currently fares rather poorly in addressing its public health challenges.
Certainly Kerala's achievements in health are great. For example, a comparison in 2008 of infant mortality rates shows a figure of 12 per 1,000 for Kerala and 53 for India as a whole. The lower IMRs in Kerala have a lot to do with the ‘support led’ strategy of the governments in the state over a long period. The resultant higher educational and health status of women in the state are also important. In India as a whole, nearly 50% of women marry under the age of 18, while in Kerala the proportion is around 15%. The proportion of married and pregnant women who are anaemic is also significantly lower in Kerala. While child malnutrition in India is one of the highest in the world, in Kerala the proportion of children under the age of three who are underweight is little more than half the 40.4% nationally.
These achievements are worthy of greater study. In a series concerned with health equity there is much to be learned from Kerala. Looking ahead, however, there is reason for caution. First, over one-fifth of Keralan children under the age of three are underweight; close to half are anaemic. Second, the persistence of a small proportion of malnourished women along with an increasing proportion of obese women suggests increasing inequality in the society. The marginalised in Keralan society are not benefiting from the equitable provision of services. Kerala is failing to build a healthy living environment for its poor. This is a failure of public health.
Public health must be more active. In this, Kerala might learn from the UK in the nineteenth century. Towards the middle of the 18th century in the UK, the life expectancy at birth of the upper classes first began to rise but the poor remained mired in their misery. Progressive Enlightenment thought, and the dual revolutions of republican liberty and expanding commerce in Europe and America introduced a rationalist and democratic agenda. It became increasingly assumed that the desirable goal of protection from disease should apply equally to all citizens. Yet the industrial revolution was turning the towns into overcrowded ghettos with high death rates.
Birth and death registration became the single most powerful weapon in the hands of public health activists everywhere in the West. Without it neither Mills in the city of Lawrence, Massachusetts nor Reincke in Hamburg, could have shown the reduction in the general death rate resulting from the supply of pure water. So too, without the ability to compare the death rates across several cities, Hazen's theorem – each death from typhoid fever avoided by the use of better water meant two or three more saved from other causes – could not have been developed.2 It was the systems built to address the problem of differential death rates that stood the West in good stead to face its public health challenges.
In Kerala the civil registration system is a colonial legacy but it has not become part of the democratic deliberations at the level of local government. It remains an appendage to the large central bureaucracy. The literate population has not been sensitised to civil registration as a rich source of data for measuring vital statistics at the local level. Were this to happen it would spawn some systematic public initiatives to face the challenges of both communicable and non-communicable diseases.
This is a lost opportunity for strengthening both local democracy and the public health response to face the challenge of health in Kerala. The message for other countries from Kerala on health equity is not only in what we have done, of which we are justifiably proud, but also in what we are now failing to do. There is a need in both developing and developed countries for more emphasis on public health, since it is the failure to implement these policies that works against the improvement of the health of the poor. In developing countries good data born of civil registration can provide the spur that it did in the wake of the industrial revolution in the west.