The central government's policies have inadvertently de-emphasised environmental health and other preventive public health services in India since the 1950s. Diseases resulting from insanitary conditions impose high costs even among the more affluent, and rapid urbanisation increases the potential for disease spread. We analyse the central government's policies and then describe Tamil Nadu's public health system, which offers basic principles for strengthening public health within the administrative and fiscal resources available to most states. We suggest establishing a public health focal point in the health ministry, and revitalising the states' public health managerial and grassroots cadres. There needs to be phased progress in four areas: (1) enactment of public health acts to provide the basic legislative underpinning for public health action; (2) establishment of separate public health directorates with their own budgets and staff; (3) revitalisation of public health cadre; and (4) health department engagement in ensuring municipal public health.
