South-East Asia Regional Conference on Epidemiology

Revitalizing primary health care: how can
epidemiology help?
Ravi Narayan
A recent guideline in a declaration (1) made by the Consultation on the Application of Epidemiological
Principles for Public Health Action, organized by the WHO <strong>Regional</strong> Office for <strong>South</strong>-<strong>East</strong> <strong>Asia</strong> in
February 2009, states that, “The scope and reach of epidemiology which is an integral part of public
health must be expanded to include the study of the social, cultural, economic, ecological and political
determinants of health and constitute the keystone for use of evidence for development of public
health policy.” This guideline summarizes the main point of this paper that explores the shift in the
paradigm of epidemiology which is required if this discipline has to support the revitalization and
renewal of primary health care that is taking place today.
In 1978, when the Alma Ata Declaration (2) was announced, the focus of epidemiology was on
vaccine-preventable diseases, tuberculosis, mother and child health, environmental sanitation and other
diseases, primarily communicable, often described as the diseases of poverty and underdevelopment.
Epidemiologists, in the early years of the primary health care (PHC) era, focused on communicable
diseases and maternal and child health problems, with a more orthodox approach of watching mortality
and morbidity trends of these problems, resulting in single-disease approaches and programmes. While
the Alma Ata Declaration also emphasized new concepts such as equity, appropriate technology,
intersectoral development, community participation and health as a right, the true significance of
these radical concepts was lost among public health practitioners, policy-makers, epidemiologists and
researchers in those days.
In the years that followed, noncommunicable diseases, including cardiovascular diseases, diabetes,
mental health, and occupational/environmental health problems emerged as newer priorities. These
newer, more complex challenges led epidemiologists to identify broader determinants like lifestyles,
behaviour, individual and collective risks and other such factors, that led to more broad-based health
promotion and risk amelioration strategies.
Today, the primary health care challenges at community level in a country like India include
agrarian distress exemplified by both growing childhood malnutrition and farmers’ suicides; economic
downturns that affect primary health care systems; and climate change, war and social conflicts and
other disasters that affect the broader context in which primary health care systems are developing
and need to be sustained. These require epidemiologists to be able to study factors such as poverty,
inequality, exploitation, violence and marginalization and make epidemiology relevant to the new
challenges. It will require a shift towards a new paradigm.
What is this new paradigm in epidemiology and what is the evidence required to study and
understand this new context? To answer this question, I share in this paper three short reviews that
will illustrate the challenges to epidemiology today, especially in the context of community-based
comprehensive primary health care.