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Mainstream, Vol XLVI No 33

Threat to State Security : Incarceration of a Public Health Practitioner

Saturday 2 August 2008, by K B Saxena


[(Book Review)]

Indian Doctor in Jail: The Story of Binayak Sen—A Report to the Nation by Doctors in Defence of Dr Binayak Sen; Publishers: Doctors in Defence of Dr Binayak Sen, Promila & CoPublishers in association with Bibliophile South Asia, New Delhi and Chicago; pages 112; price : Rs 250.

Democracies are considered the world over as a superior form of polity when compared to authoritarian regimes due to their ability and confidence to face multiple and complex challenges particularly in a culturally diverse and socially unequal society. This is on account of the former’s institutional structures of participation, accountable governance, resolution of conflict through dialogue and accommodation and commitment to universally recognised rights and freedoms. But how would a democracy be described when it demonstrates its incapability to understand, much less to deal with, political violence from its disenchanted and alienated social groups, turns to extraordinary laws curbing civil liberties, acquiesces in unaccountable governance for enforcing security, despises advocacy of human rights and legitimises matching counter-violence to meet this challenges? The history of modern political theory has come to describe such a State as fascist which, while retaining the democratic institutional arrangements, descends into authoritarian practices through both legal and extra-legal practices in dealing with its citizens. The book under review, which revolves around the detention and continued incarceration of Dr Binayak Sen, brings out the typical features of such a State when it finds the work of this public health professional providing health care services to Adivasis in a remote block a threat to its security.

Indian Doctor in Jail: The Story of Binayak Sen, is a report to the nation in his defence compiled by a group of doctors who have known him and his work and followed his thoughts and actions from a medical student to a public health practitioner to a critic of health policy and a human rights activist. The book has been written specifically because the campaign for his release has overwhelmingly focused on human rights issues. The Chhattisgarh Police has disputed that he is a genuine doctor since no medical equipment was found during the search in his house. Under the façade of healing people, he has been accused of carrying out illegal activities. The book, therefore, showcases his work in public health and his engagement with the Chhattisgarh State in this field. It is essentially an effort to show that his work as a civil rights activist was really an extension of his work as a public health specialist. The book has eight chapters interspersed with extracts from his writings. The first chapter is an introduction by Nandita Haksar who raises the intriguing question: when does a doctor threaten the security of the country? The next four chapters illustrate when and why Dr Sen’s views and activities rattled the State. Chapter 7 chronicles the behaviour of Chhattisgarh Police while the last chapter contains an appeal to fellow citizens to join the campaign for the release of Dr Sen.

The traces of Dr Sen’s critic of public health policy and the dominant perception of public health were evident in his student days at the CMC, Vellore. He conceptualised the role of a public health specialist as one who not only examines the individual patient he comes in contact with but is also concerned with the health of the community and works for improving their physical and social conditions. He posited illness in its social setting, that is, the physical and socio-economic conditions which brought about its existence, the underlying causes which created these conditions and strove for improving them to reduce its incidence. This view at once transforms the role of a doctor from a specialist dispensing medicine to a social activist who is changing the overall conditions of life and their development deficits. It enlarges the ambit of intervention from merely treating the disease but also its social determinants such as hunger, malnutrition, lack of access to safe drinking water, insanitary conditions, stress arising from uncertainty of securing work and low wages etc. Dr Sen saw this approach to public health not merely as an ideological conviction but a strategic choice as well because interventions at the level of the community can drastically reduce the incidence of disease and action on forging its social determinants can prevent its recurrence. Through his own work he demonstrated that this strategy was pragmatic too since it achieves optimum results from the least efforts and resources and is, therefore, eminently suited in the conditions of the country. This conviction in him could be observed even while he was in the Christian Medical College at Vellore as the Registrar, Child Health. In an essay written by him on medical education for a competition and for which he won the first prize, he was critical of its curricula, mode of training as well as the system of selection for entrants to the course which were responsible for the medical brain-drain and concentration of doctors in urban areas while rural health facilities were languishing due to their unwillingness to work there. The selection process, which is weighted in favour of public school education, puts premium on academic success to the neglect of attitudes, values and motives. Even its utility to test the cognitive domain is questionable. It certainly did not facilitate entry into the profession of those willing to work in rural areas. The curricula is exclusively hospital-based and patient-oriented which make them unsuited for rural health work. He showed remarkable insight when he commented that, in the rural situation, the analytical approach from symptoms to physical examination to laboratory examination and treatment is an unaffordable luxury and a pragmatic approach of clinical assessment with limited diagnostic aids and range of therapy has to be adopted taking into account both the deficiencies of infrastructure as well as the social conditions of the patient. The doctor is required not merely to teach the patient but also the community of which he is a part as well as his team of health workers. Sadly, the government has failed to reform medical education along these lines which has not only alienated the doctors from the conditions of people’s health in rural areas but increasingly turned them commercially driven with heavy reliance on diagnostic aids. He rightly contextualised that a doctor in the rural setting is virtually a manager who has to sort out manpower problems, attend to environmental health programmes, maximise the use of existing facilities and manpower resources and at the same time acquire proficiency in research methodology to be able to use the information flowing from patients and analyse them for corrective interventions. This is a message which needs to be driven home to the undergraduates who, after getting their degree, produce the self-serving alibi of lack of facilities and environment for their reluctance to serve in the rural areas despite getting the benefit of education at the taxpayer’s expense.

Dr Sen’s social commitment did not emerge from a priori ideological premise but from experience. While treating TB patients at Rasulia Clinic, he clearly saw the failure of the National TB Programme in controlling its incidence due to its focus on the immediate causes of the disease and not in the social determinants of the disease. The technocratic approach neglected malnutrition as a central causal factor and concentrated on the individual patient rather than the community. He addressed both these shortcomings in the third destination of his professional journey at Bagrumnala Clinic from where his non-governmental organisation, ‘Rupantar’, serviced 26 villages of Gond and Kamar tribes in a very backward block of Dantewada district. He relied on cheaper and more effective sputum smear examination (rather than X-Ray based diagnosis), trained community health workers for quick laboratory investigation, adopted short treatment regimens ensuring free of charge, uninterrupted drug supply and trusted community surveillance for ensuring continuity of treatment. For effective preventive strategy, he resorted to the screening of family members for early diagnosis. The success he achieved with this low cost approach would be the envy of the DOTS Programme, introduced six years later by the government with foreign funding, a horde of consultants and top- heavy vertically-managed structure of implementation. He, thus, translated the insights shown in the essay he had written during his stay in the college into an achievable and satisfying course of action. He is reported to have achieved similar success in reducing mortality from the falciparum variety of Malaria so endemic in the forest areas in his community health programme with the health workers taking blood smears, getting the slides examined in a peripheral clinic and furnishing the report in a couple of hours for prescribing accurate treatment. The externally aided National Anti-Malaria Programme (now National Vector Borne Diseases Control Programme) has yet to achieve this success. While the results of the community-oriented approach were significant in respect of these two major disease control programmes, they were no less important in attending to the several local health problems which remain untreated by our public health units. This case is, however, not unique as similar models of community health at low cost are being implemented by non-governmental initiatives elsewhere in the country.

Dr Sen not only rendered health care through his clinic and outreach programme but also enthusiastically cooperated with the Chhattisgarh Government in improving public health services. This demonstrated his constructive approach. He attributed the constraints of the existing public health programmes to the increasing distance between people and health services due to the complexity of the system and sought to bridge this gap by training 869 women community health workers (Mitanins) of two blocks as ‘barefoot doctors’. He was deeply involved in other social welfare measures of the State. The State Government acknowledged his contribution to the preparation of a State drug formulary (2002) in the standard treatment guidelines for medical officers. The Mitanin programme has been favourably commented upon and appreciated by the State Government. Dr Sen’s contribution was not confined to the public health initiatives but extended to the problem of malnutrition and hunger which was the underlying cause of numerous health disorders. He addressed this by propagation of local varieties of rice in cultivation which were resistant to insects, pests and disease, set up seed and grain banks which were also replicated by the State in some blocks. He and his wife, Ilina, are associated with the official Advisory Committees for health, education and population programmes and have always been keen to assist in promoting better policies.

WITH this degree of trust, cooperation and achievement, the State’s conduct in arresting Dr Sen, thereby preventing his health programme from functioning, may seem baffling. The explanation is to be found (not overtly stated) in his activities as a human rights activist which he carried out in his capacity as the Vice-Chairman of the People’s Union for Civil Liberties (PUCL). In this role, he intervened in the cases of death and rape in police custody, strongly disapproved of Salwa Judum which had led to the relocation of 644 tribal villages in a camp with dismal conditions, recruitment of people to fight Naxalites etc. Dr Sen appealed to the human rights community to seek their intervention to stop suppression of human rights in this area. These violations of human rights have been documented by public spirited citizens and even by the National Commission on Child Health. The sensitive doctor did not fail to see that the cause of ill health arising from widespread malnutrition and hunger was embedded in the paradigm of development which dispossesses people from their land and forest causing multiple impoverishments and destroys their social support. It is not difficult to surmise that the police and political establishments were irked by the critique of their policy and the exposure of their strategy to fight Naxalites and would have decided to teach him a lesson. His valuable work in public health, therefore, would have carried little weight against the discomfiture arising from the criticism of the development policy. The hostility of the police establishment to human rights advocates is well known because they expose the widespread human rights violations and extra-legal actions of the security forces.

The arrest of Dr Sen by the police and the subsequent attempt to paint him as a dangerous terrorist, as confirmed by the charge-sheet filed against him, the overbearing police presence in the course of trial and presenting a long list of prosecution witnesses to prolong his incarceration are intended to intimidate the social and human rights activists and send a clear message to them to desist from exposing the atrocities on the hapless tribals. The charge-sheet also reveals lack of professionalism in police investigation. The detention is being built up by using the law of conspiracy on the ground that Binayak passed on some letters from Narayan Sanyal, a detainee belonging to CPI (Maoist) to Piyush Guha, another detaince and member of the CPI (Maoist) and he met Sanyal in jail several times and, thus, to incriminate him in a crime of guilt by association. The police suppressed the information that these visits were made in his capacity as the local head of the PUCL with prior official permission. The raids conducted in his clinic and farm house brought out no incriminating evidence. This failure has made them more desperate to label him as a dangerous terrorist who is a threat to the security of the State. But the comments in the charge-sheet on his work as a doctor also shows the ‘illiteracy’ of the police. This is so evident in the comment made by the police that Dr Sen is virtually a zero as a doctor since in his home no medical equipment was found to show that he was a medical practitioner. The conduct of the police does not surprise because it is no different in other cases of a similar nature. The role of the Supreme Court in declining to hear the bail application, however, is deeply disappointing for it is the institution of last resort for the defence of human rights against the excesses of the State. The political establishment of the State has used this detention to silence the widespread critique of Salwa Judum cleverly engineered to facilitate transfer of tribal land to the MNCs for setting up industries. The political interest to push acquisition of tribal land and the ‘security’-oriented approach of the police to deal with a political movement coalesce into a well-thought-out strategy which consists of abrogation of human rights through draconian laws, security operations bereft of any accountability and terrorisation of human rights advocates into silence. With such a nexus of interests, it is not difficult to see that moral protests such as those contained in the appeal of Noble Laureates and several reports of civil society groups have failed to move not only the Central and the State governments but even the mainstream political parties. The incarceration of Dr Sen may continue unless a renewed attempt is made in the Supreme Court for the release of Dr Sen on bail and a humane treatment in jail elicits a favourable response.

The book is lucidly written with appropriately sequenced narratives and sustains interest throughout so as to be finished in one reading. Its value lies not merely in mobilising the people for securing Dr Sen’s release and exposing the conduct of the Chhattisgarh Government but in providing insights into the perspective on public health. Its importance goes beyond the case of Dr Sen as a person, a doctor and a human rights activist. It should be read not merely by those interested in human rights and public health programmes but also those engaged in development administration in the tribal areas. It has particular relevance for the policy establishment in health which needs to review its existing approaches to health programmes and adopt a culturally acceptable alternative paradigm of clinical care conceptualised by Dr Sen. This model relies on the strength of the community, treats people as the subject and not the object of the healing enterprise, demystifies the medical technology, decentralises the whole operation, firmly institutionalises democratic decision-making and minimises the distinction between mental and physical labour.

The reviewer is currently a Professor at the Council for Social Development, New Delhi.

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