More Indians than ever before live healthy, productive lives: Bill Gates
Bill Gates believes India is winning the fight against poverty. In an interview with Swagato Ganguly, Gates, co-chair and trustee, Bill and Melinda Gates Foundation, explained points from his annual newsetter, including why the eternal poverty of poor nations is a 'harmful' myth, how there'll be almost no poor countries by 2035 — and huge milestones for India:
How do you see poverty reduction in India?
The proportion of poor in India fluctuated widely in the past, but overall the trend is downward. The government and its partners across sectors have done a great job with a number of programmes aimed at alleviating poverty and its impacts, including subsidising food and other necessities, increased access to loans, improving agricultural techniques and price supports, and promoting education and skill development.
These measures have helped eliminate famines, reduce malnutrition and illiteracy and cut absolute poverty levels sharply — more Indians than ever before have the chance to live a healthy and productive life.
This is phenomenal progress.
But why does India remain a poverty hotspot?
While the number of those in extreme poverty around the world has declined significantly, including here, India now has a greater share of the world's poorest than 30 years ago — one in three of the world's poorest people live here.
But solutions are within reach. India can ensure all children have access to basic healthcare interventions that help reduce preventable conditions, such as diarrhoea and pneumonia, which will lead to great progress in reducing numbers of children under the age of five who die each year.
All women should also be supported through motherhood, in planning families and enjoying healthy pregnancy and childbirth. This will allow India to further reduce maternal mortality rates.
What are some significant successes among projects funded by your foundation in India?
We have worked with the government of India and other partners in a number of areas where we have seen significant progress. In the last decade, India has seen a reduction of HIV AIDS cases by 56%. Most recently, India has just reached the remarkable milestone of having no new case of polio in three years — this is a great example to the world of what's possible.
With every milestone reached, India also makes strides in strengthening delivery systems that will take on other challenges in the future.
You call the idea that the world is deteriorating a myth — but it's widely believed by many. Why so?
The belief that the world is getting worse, that we can't solve extreme poverty and disease, isn't just mistaken — it is harmful. It can stall progress. It makes efforts to solve these problems seem pointless.
When people ask us why our foundation works on some of the world's most intractable problems, Melinda and i describe ourselves as "impatient optimists". We think that with a sense of urgency and hope, innovation and collaboration can achieve even the most difficult challenges.
And there is definitely good reason to be optimistic. As we mention in our Annual Letter, we think that with our current trajectory, by 2035, there will be almost no poor countries left in the world and we will have made significant progress in meeting the Millennium Development Goals.
Bill Gates believes India is winning the fight against poverty. In an interview with Swagato Ganguly, Gates, co-chair and trustee, Bill and Melinda Gates Foundation, explained points from his annual newsetter, including why the eternal poverty of poor nations is a 'harmful' myth, how there'll be almost no poor countries by 2035 — and huge milestones for India:
How do you see poverty reduction in India?
The proportion of poor in India fluctuated widely in the past, but overall the trend is downward. The government and its partners across sectors have done a great job with a number of programmes aimed at alleviating poverty and its impacts, including subsidising food and other necessities, increased access to loans, improving agricultural techniques and price supports, and promoting education and skill development.
These measures have helped eliminate famines, reduce malnutrition and illiteracy and cut absolute poverty levels sharply — more Indians than ever before have the chance to live a healthy and productive life.
This is phenomenal progress.
But why does India remain a poverty hotspot?
While the number of those in extreme poverty around the world has declined significantly, including here, India now has a greater share of the world's poorest than 30 years ago — one in three of the world's poorest people live here.
But solutions are within reach. India can ensure all children have access to basic healthcare interventions that help reduce preventable conditions, such as diarrhoea and pneumonia, which will lead to great progress in reducing numbers of children under the age of five who die each year.
All women should also be supported through motherhood, in planning families and enjoying healthy pregnancy and childbirth. This will allow India to further reduce maternal mortality rates.
What are some significant successes among projects funded by your foundation in India?
We have worked with the government of India and other partners in a number of areas where we have seen significant progress. In the last decade, India has seen a reduction of HIV AIDS cases by 56%. Most recently, India has just reached the remarkable milestone of having no new case of polio in three years — this is a great example to the world of what's possible.
With every milestone reached, India also makes strides in strengthening delivery systems that will take on other challenges in the future.
You call the idea that the world is deteriorating a myth — but it's widely believed by many. Why so?
The belief that the world is getting worse, that we can't solve extreme poverty and disease, isn't just mistaken — it is harmful. It can stall progress. It makes efforts to solve these problems seem pointless.
When people ask us why our foundation works on some of the world's most intractable problems, Melinda and i describe ourselves as "impatient optimists". We think that with a sense of urgency and hope, innovation and collaboration can achieve even the most difficult challenges.
And there is definitely good reason to be optimistic. As we mention in our Annual Letter, we think that with our current trajectory, by 2035, there will be almost no poor countries left in the world and we will have made significant progress in meeting the Millennium Development Goals.
Antibodies themselves can cause diseases
What happens when antibodies, a class of proteins generated by the immune system to neutralise foreign bacteria and viruses, attach themselves to the membrane protein of a human cell and try to destroy it?
Autoimmune diseases are the result. It was these auto-antibodies that were the subject of the 34th T.S. Srinivasan Endowment Oration, delivered here on Saturday by Professor Angela Vincent, Emeritus Professor of Neuro immunology at Oxford University.
“Some brain diseases caused by antibodies come on quite quickly and can become severe quickly. But they can be treated, and the patient gets better. Sometimes, the disease burns itself out and the patient can even go off treatment,” she said.
Speaking about myasthenia gravis, marked by weakness of select muscles, she said that in this disease antibodies bind themselves to acetylcholine receptors, which lead to reduced signalling between nerves and muscles. “Patients have mobility problems, sometimes they can’t keep their eyes open, in some cases they can’t swallow or drink.” But with treatment, under which the patient’s blood is removed through a centrifuge and put back minus the plasma containing the antibodies, there can be a remarkable improvement in just two days.
Sometimes, such diseases appear and disappear quite suddenly. Why does this happen though? While in some patients tumours, a preceding infection or a preceding allergic reaction is thought to have led to the disease, this may not always be the case. “It may just be bad luck if you make one of these particular antibodies,” she said.
In India, probably 10 patients per million per year could be diagnosed with diseases caused by antibodies. The earlier the disease is diagnosed and treated, the better the chances for the patient are, she said.
One interesting question researchers are now looking into is how frequently antibodies are the cause of common diseases such as epilepsy or dementia, she said.
Venu Srinivasan, chairman, TVS Motor Company, delivered the presidential address. Timothy A. Pedley, president, American Academy of Neurology; and E.S. Krishnamoorthy and Krishnamoorthy Srinivas, both of The Institute of Neurological Sciences, VHS in Chennai, spoke.
680 million Indians lack the means to meet their essential needs: report
680 million Indians lack the means to meet their essential needs: report
Proposing a new “empowerment line” that aims to measure the minimum economic cost for a household to fulfil eight most basic needs, a global research organisation has estimated that 680 million Indians, or 56 per cent of the population, lacks the means to meet their essential needs.
Health care, drinking water and sanitation between them account for nearly 40 per cent of the gap between their current status and the ‘empowerment line.’
In a new research report released on Wednesday, McKinsey Global Institute (MGI), the research arm of the consulting firm, created the new line by estimating the economic cost per capita to meet a minimum requirement of consumption of eight basic services — food, health care, education, sanitation, water, housing, fuel, and social security — and “others’ that included entertainment and clothing.
Using sector-specific norms for each parameter, this worked out to an average Rs. 1,544 per capita per month. MGI then estimated the value of government services reaching the household at Rs. 208 per capita per month. Adjusting for the State-delivered goods and services, the ‘empowerment line’ was set at Rs. 1,336 per month. In 2011-12, this left 56 per cent of the country below this line, nearly 1.5 times the number of people that India’s official poverty line classifies as poor.
The line was set 38 per cent higher for urban India than for rural India. Based on this benchmark, 171 million urban residents (or 44 per cent of the urban population) were below the line, compared with 509 million rural residents (or 61 per cent of the rural population), the report said.
“Every poverty line has its problems, and we are aware that there will be problems with this line too, Shirish Sankhe, director at McKinsey and co-author of the report, told The Hindu .
The additional consumption required to bring these 680 million above the line worked out to 4 per cent of GDP, the report said.
Deprivation score
Using census data, MGI also estimated the availability of basic services at the district level by compiling an Access Deprivation Score. Bihar had the highest level of deprivation with an ADS score of 62 per cent (the average resident lacked access to 62 per cent of services) followed by Uttar Pradesh, Jharkhand, Madhya Pradesh and Assam. Himachal Pradesh had the lowest access deprivation at 28 per cent followed by Punjab, Uttarakhand, Kerala and Tamil Nadu among the big States.
Country faces acute shortage of doctors and nurses, says Azad
Accepting that India is faced with an acute shortage of doctors and nurses, Union Minister for Health and Family Welfare Ghulam Nabi Azad on Friday said the government has made necessary interventions to increase human resource in the health sector in the country.
“India creates human resource for the whole world. There are around 80,000 Indian doctors in the USA and 75,000 in the UK. But there is acute shortage of doctors and nurses in India,” he said at the foundation stone laying function of a Super Speciality and Emergency Block at the Safdarjung Hospital here.
The Minister said the Government has changed the MCI and Nursing Council rules to increase the human resource within the country.
Super Speciality block
The Super Specialty block will have 807 beds while the Emergency Block will have 500 beds and both are expected to be completed in one year. Spread over 111,905 sq m, the Super Specialty Block, which is likely to cost Rs.444.70 crore.
The Emergency block will have a proposed area for construction of 41,450 sq m. with proposed construction cost of Rs.196.73 crores.
The addition aims at providing state-of-the-art tertiary medical services to patients from across the country.
Dr. Azad also spoke about the new medical infrastructure which has been created in the country in the past decade.
“Six new AIIMS and 19 Super Specialty Medical Colleges have been established in the country. As many as 71 new Cancer Institutes, including 50 tertiary cancer institutes, have also been approved by the Cabinet last year,” he said.
In Delhi itself, he said, there has been huge capacity expansion with new surgery, mother and child, OPD, teaching and hostel blocks being added to the main campus at AIIMS; a 300-bed state-of-the-art emergency centre being constructed at RML Hospital; and a 1,100-bed new OPD, IPD, Emergency and Hostel Block facility coming up at Lady Hardinge Hospital, he added.
The Health Minister said MBBS seats have also been increased by 55 per cent and PG seats by 75 per cent and doctors from the USA, Canada, the UK, Australia and New Zealand have been allowed by Centre to be faculty members in the country,
He said the Centre has also made new interventions in maternal and child healthcare.
New Delhi MP Ajay Maken said AIIMS, RML, Lady Hardinge and Safdarjung Hospitals have shown tremendous development in the recent past and that during the Commonwealth Games 2010, one of the best Sports Injury Centre was set up at the Safdarjung Hospital.
ICMR issues Code of Conduct for researchers
The Indian Council of Medical Research (ICMR) has issued a mandatory Code of Conduct for research scientists engaged in the field of life sciences. This has been done with a view to prevent the use of scientific research for bioterrorism and bio-warfare.
The aim is to ensure that all research activities, involving microbial or other biological agents, or toxins, whatever their origin or method of production, are only of types and in quantities that have justification for prophylactic, protective or other peaceful purposes.
Ethical considerations in this Code of Conduct would be binding on all laboratory scientists involved in scientific research concerning dangerous organisms and toxic weapons against any living being or environment.
Bioethics has emerged as a new discipline over the past couple of decades and is poised to become a multidisciplinary specialty. Institutional review boards/Institutional ethics committees have evolved as conscience keepers of professionals with the view to safeguard the welfare of members of society against any possible harm from scientific advances.
Advances in laboratory technologies have created new and complex ethical dilemmas. Laboratory services are an integral part of disease diagnosis, treatment, response monitoring, surveillance programmes and research.
Therefore, personnel working in clinical and/or research laboratories should be aware of their ethical responsibilities. It is necessary to comply with the ethical code of conduct prescribed by national and international organisations, and address the emerging ethical, legal and social concerns in the field of biological and biomedical sciences.
Pointing out that modern biology and biotechnology offer novel ways of manipulating basic life processes, the Code of Conduct says that purposefully or unintentionally, genetic modification of micro organisms could be used to create organisms that are more virulent, are antibiotic-resistant, or have greater stability in the environment.
The scientists engaged in such research activities should be aware of the potential risks and concerns relating to science and its wider applications and the ethical responsibilities they shoulder. They should not only be aware of but comply with the requirements of international conventions and treaties relevant to their research work, the Code of Conduct says.
Junk food high in fat, sugar and salt: panel
An expert group has suggested restricting the availability and consumption of junk food or food high in fat, sugar and salt in schools and in a 50 metre radius around them. It has also called for increasing the availability of wholesome food to schoolchildren across the country.
The committee has identified chips, fried foods, sugar-sweetened carbonated beverages, sugar-sweetened non-carbonated beverages, ready-to-eat noodles, pizzas, burgers, potato fries and confectionery items as the common foods containing fat, sugar and salt in high quantities.
It gave this suggestion in draft guidelines for making available quality and safe foods in schools. A copy of the guidelines was on Wednesday submitted to the Delhi High Court.
The Court has been hearing a petition by non-government organisation Uday Foundation in the matter. The Food Safety and Standards Authority of India had set up the expert committee on a direction by the Court to advise the Central Advisory Committee to develop guidelines for making available quality and safe food in schools.
The guidelines further state that steps should be initiated to develop a nationwide programme for identification of more foods based on the criterion and inform the schools accordingly.
Another category of concern is the non-standardised deep fried foods such as samosa, chana-bhatura, etc that are available in school canteens and nearby areas. The guidelines state that the school managements must ensure regulation of such foods through canteen policies that promote consumption of healthy, wholesome and nutritious foods alone.
Canteen in schools should not be treated as commercial outlets; they carry a social responsibility towards inculcating healthy eating behaviour, the guidelines noted. The canteens can be used to motivate children to consume healthy and hygienic food.
The guidelines also stress the need to regulate `the exposure and power of advertisements and promotional activities’ that are targeted at children.
``It is recommended that the government may advise the Advertising Standards Council of India or any other relevant body to consider developing such a framework for (1) regulating advertisements for foods high in fat, sugar and salt (2) limiting reach of such advertisements in the electronic media where the school children are the key audience (3) restricting celebrity endorsements for such foods and (4) regulating promotional activities of such foods targeted at the children,’’ the guidelines pointed out.
It has also been stated that FSSAI should ensure that the labels on all food packets should carry information on the type and quantity of various nutrients and how much the serving size contributes to the total daily requirement.
For an all-party manifesto on health
As the countdown to the next general election begins, political parties are making multiple promises to pull in votes. All the party leaders are committing to transforming the lives of people. But health, ironically, does not feature high on their priority list, even though it is the central pillar of a nation’s development and productivity and the key to happiness for individuals, families and societies. Perhaps it is time to remind all parties that are seeking to govern the country that India’s health challenges are perhaps the greatest for any single nation in the world.
We continue to face the unrelenting burden of the old and new threats of communicable diseases. The discussion on maternal and child health care, and nutrition, is far from being complete. We have also emerged as the world’s epicentre of chronic diseases such as diabetes, hypertension, heart ailments and mental disorders. Nothing short of a massive transformation of the health system can address these challenges and meet the needs of citizens. People expect much more than a handful of select services under the limited ambit of the existing national programmes.
The good and bad news
The fundamentals have been laid down in the last few years as part of the National Rural Health Mission. More than 8,00,000 Accredited Social Health Activists workers, 33,000 nurses, 14,000 paramedics, 8,000 doctors and 3,000 specialists have been inducted; over 20,000 facilities have been constructed; and over 20,000 ambulances have been deployed. Medical graduate seats have increased by 55 per cent and postgraduate seats by 75 per cent. The Janani Suraksha Yojana has ensured that an additional 12 to 13 crore women are now delivering in government facilities and more than 6 lakh newborn babies are receiving care in neonatal care nurseries in district hospitals each year. Polio has been eliminated from the face of the country. The Infant mortality rate (IMR) too has declined from 68 to 42 per 1000 live births between 2000 and 2012. This is exciting, but not enough. In Brazil, the IMR is 13 and in China it is 12.
Each year, more than 40 million people, mostly in rural areas, are impoverished and run into massive debts to access healthcare. The devastating contribution of out-of-pocket medical expenses to poverty is often not fully appreciated by the media and policy-makers.
Long-term goals in healthcare transformation require a timeline that surely goes beyond the life of one Lok Sabha. The Centre and States also have to work in unison, regardless of which parties are in power. An all-party commitment to broad tenets is therefore absolutely essential to ensure focus, consistency, speed and accountability. We, therefore, call for a national manifesto on health affirmed by all parties.
On Universal Health Coverage
The Twelfth Plan strategy envisages Universal Health Coverage (UHC) as the long-term goal “that will unfold over two or three Plan periods.” The doctrine of UHC guarantees cashless access to a defined package of quality health services to all citizens. Such a system that has been in existence for long in developed countries such as Germany, the U.K., Canada, Japan, Australia, New Zealand and in Scandinavian countries, has now been embraced by middle-income countries such as Thailand, Mexico and Brazil.
Given that India has a mixed health system, both public and private sectors have to work in tandem to provide appropriate, equitable and affordable care at all levels. The High-Level Expert Group (HLEG) on UHC, constituted by the Planning Commission, envisioned a National Health System wherein a strong public sector leads the design and delivery of UHC, drawing on support from the private sector in a well-regulated framework. In this system, all citizens are entitled to a comprehensive package of primary, secondary and tertiary care services, and have access to government and accredited private facilities for obtaining services such as diagnostics, vaccines, drugs or surgeries as an entitlement, without having to pay at the point of care. It is estimated that UHC would require public spending on healthcare to the tune of 3.0 per cent of the GDP or more.
A debate on the details of how the Centre and the States will deliver UHC can be settled through democratic processes in due course. It is however time that the entire spectrum of political leadership expresses unequivocal allegiance to the high principles that embody commitment to health equity and pledge to transform the health system in a decade. And let these common principles be enshrined in the manifestoes of all the national parties.
The main priority
To begin with, parties must make healthcare a core priority for the next decade, to enable transformation of the healthcare system, while promoting pro-health policies in other sectors. We believe that the following five principles form the core national agenda on health and should be embraced by all the parties.
First, we call upon all the political parties to commit to the goal of achieving UHC in the country by the year 2025, and develop a clear roadmap thereof by mid-2015.
Second, public spending on health should be raised from a meagre 1.04 per cent of the GDP in the Eleventh Plan Plan to 3 per cent by 2020, and 4 per cent by 2025.
Third, all essential drugs, including anti-cancer agents, should be made available free to all citizens in 3-4 years.
Fourth, standards of care including clinical guidelines, applicable to both the public and the private sectors, should be developed and enforced in the next five years.
Fifth, equity must be ensured in the provision of health services across districts, communities and gender.
The next government, irrespective of its party composition, should within the first 100 days of coming to power create an enabling mechanism to plan, mentor and implement the above promises. A National Health Regulatory and Development Authority would help to effectively advance this agenda.
This election should set a benchmark and transform the landscape of healthcare in India, no matter who comes to power.
Engaging the private sector in TB control
Tuberculosis is easily one of India’s most critical public health issues, but TB prevention and control efforts face several challenges. Of these, perhaps the most significant is the effective engagement and participation of India’s vast private sector, which manages 60 per cent of all TB patients.
The private sector is highly fragmented and consists of providers of variable quality. Many TB programme managers may perceive the private sector as their main challenge and feel that engaging them would be outside the scope of their mandate. This detachment between the public and private sector is unproductive and fuels further spread of TB. Patients regularly float from one sector to the other, expending their resources and becoming more and more ill. There is also increasing evidence of a rise in the rates of drug-resistant TB — an indication that all is not well with the management of TB patients in the community.
Why does not the public programme effectively regulate or engage this sector? In many cases, managers are too preoccupied with the implementation of the DOTS programme. Other constraints to this engagement include a lack of trust on both sides, necessary skills and shortage of human resources.
Mutual distrust between public and private sectors is not new. It is fuelled by perverse market forces on the side of the private sector and antipathy on the part of the public sector. Private providers have poor compliance with the Revised National TB Control Programme’s (RNTCP) patient management strategies, with errors in diagnostics, drugs dosage and duration. Additionally, treatment adherence is a major issue — patients often stop their treatment or take medication in an irregular manner due to high costs or lack of monitoring. There is disturbing documentation on the use of inappropriate tests and prescriptions by both qualified and unqualified medical providers, leading to rising patient costs and incorrect diagnosis.
Moreover, private providers perceive TB as a clinical issue and do not always look at the community and public health perspectives of patient care, such as early diagnosis, infection control and prevention of transmission, social and psychological support and a patient-centric approach, which are necessary to achieve cure and halt transmission within the community.
India’s anti-TB programme has in the past floated public private partnership (PPP) schemes, but these have not had the necessary impact, perhaps because of insufficient benefits and incentives for the private sector.
Yet, given that the private sector treats a significant number of TB patients, its engagement is essential to achieve universal access to quality diagnosis and treatment. The sheer strength of numbers underscores the importance of an efficacious PPP model. The truth is that India’s TB burden cannot be substantially reduced unless we engage and successfully partner with the private sector.
The RNTCP is a robust public health programme, having reached over 15 million patients in the past 10 years. It has helped reduce TB prevalence and mortality, in line with the Millennium Development Goals. Similarly, there are numerous examples of clinicians in the private sector who successfully treat and cure TB patients. Yet, negative perceptions from both sides remain a major obstacle to successful partnerships.
A strategic approach to explore PPPs would include mapping the private sector in terms of core competence. Non-profit organisations such as Partnership for TB Care and Control in India (The Partnership) can provide support to State and district TB officers in the mapping exercise. Knowledge Attitude Practices (KAP) studies should explore and identify behavioural barriers within the public and private sector on PPP. The PPP strategy should include a system for accreditation of private facilities that offer the best standards of care. There will have to be stricter regulation of the sale of anti-TB drugs.
The existing PPP framework on offer from the RNTCP needs revisiting and a critical review. The concept of private providers participating through preset schemes from the RNTCP has found very few takers. There are several innovations and models of private-private and private-NGO linkages which should be fostered and scaled up. However, before a PPP model is developed, it is important to have consultations with key stakeholders including healthcare professionals, non-governmental organisations, the pharmaceutical industry for an ideal and flexible PPP system. The urgency then is for stakeholders to come together to create a strong PPP model for enhanced TB control.
Private providers should be encouraged to disseminate best practices, Standards of TB Care in India (recently brought out by the government), and encourage strict compliance with the Government of India’s ban on serology and mandatory notification of cases. The crisis of partnership in private sector engagement and monitoring of TB control can be addressed only through a participatory dialogue between private and public providers as equal and true partners. Standards of care offered to the patient should be the paramount consideration in the dialogue and the concept of “patients first” and “zero TB deaths” the common goal.
A million missing patients
Until activists and patients question approaches to prevention, diagnosis and treatment, TB will continue to plague us
Tuberculosis in India is big: 2.3 million cases, 30,000 deaths, a million missing patients. These terrifying numbers remind us of a continuing crisis — when every TB death is preventable. Behind these numbers are innumerable unheard stories of human suffering — of misdiagnosis, inappropriate treatment and lack of access to care resulting in chronic illness and death. Why are these stories not heard? Because TB patients remain silent, disenfranchised, and find no platform to voice their issues. And they don’t have champions for their cause.
A complex interplay
Tuberculosis is not just a clinical issue. Its management requires the interplay of clinical medicine, social sciences, factors of equity and right to health. Ironically, this complex interplay is what prevents patients from accessing care early, which is vital to preventing deaths.
The patient-centred approach is supposed to be the hallmark of the DOTS system of delivery under the Revised National TB Control Programme, RNTCP, where the caregiver becomes entirely responsible for ensuring that the patient takes drugs regularly and completes the treatment. However, the programme has not factored in and adequately addressed a critical issue — a patient’s right to choose the provider. Closely linked to this is the issue of confidentiality, given the stigmatisation of TB patients in the community and by health providers themselves. In addition, the public health system has not taken into account the need for social and nutritional support. There are structural issues of delivery as well. TB control services are delivered through a vertical mechanism that is not integrated into primary health care delivery, which is the first point of care in public health services. This is why despite the RNTCP offering free diagnosis and treatment everywhere, patients prefer private providers.
More than 60 per cent of patients choose a provider from the private sector, most often the point of first contact. But here they have no protection against inaccurate testing or irrational prescriptions. Poor administration of drugs along with irrational prescriptions and unregulated sale of anti-TB drugs fuel the transmission of drug-resistant TB. Yet, the government seems disinclined to regulate the private sector.
The silence around these challenges is deafening. It is disturbing that even with such catastrophic impact, few TB patients and activists are empowered enough to question the quality of preventive and curative services that exist. However, until tough questions are asked both in the public and private sector, TB will continue to plague us.
There is an urgent need for activists and patients to speak up and question approaches to prevention, diagnosis and treatment. We need to question the purely clinical approaches. Within the public health system we also need to demand the inclusion of civil society in the planning and review of the anti-TB programme at the national, State and district levels. However, for all this, patients and activists need funding to build empowered communities.
From the private sector, activists must seek accountability in the areas of diagnosis and treatment. Also, serology-based testing for TB should be banned and mandatory notification of TB cases made compulsory.
There is a need to strengthen community engagement to ensure open participation, empower the patient, family and community with information and knowledge to speak out for their rights and for public health safety.
There are learnings from experiences in the fight against HIV/AIDS. Not only were patients empowered enough to question the credibility of health systems but they were an integral part of decision-making processes.
TB could affect anyone, irrespective of social or economic status as it spreads through the air we breathe. We need opinion leaders, concerned citizens and public figures to become champions in the fight against TB.
As a society and a community we are failing not only these patients but also ourselves by not demanding the rights of patients to high-quality care and management. Until everyone speaks out, and embarks on collective action to fight TB, India will continue to lose lives, and the missing million will not be accounted for.
Dengue and malaria add to poverty: WHO
Vector-borne diseases are adding to the vicious cycle of poverty and have a significant impact of socio-economic status of communities, the World Health Organisation (WHO) has said.
While countries in South-East Asia have made substantial economic progress, dengue and malaria fuel a vicious cycle of poverty and are still killing thousands of people. On World Health Day — April 7 — the WHO has impressed upon countries to prevent and control vector-borne diseases including dengue, kala-azar, lymphatic filariasis and malaria, among others.
Forty per cent of the global population at risk of malaria lives in the WHO South-East Asian region — home to a quarter of the world’s population. Malaria is endemic in 10 of the 11 countries of the region: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. Maldives is the only country that has remained free of malaria since 1984. Sri Lanka has made remarkable progress in controlling malaria by bringing cases down from 203 in 2000 to zero since November 2012.
“These are deadly but preventable diseases. The solution lies in a united and sustained effort from all of us. Ministries of Health alone cannot control them. Committed engagement from all sectors, strong political will and active community participation is needed,” said Poonam Khetrapal Singh, WHO Regional Director for South-East Asia. “This region recently defeated polio, it is time for us to show the same resolve to defeat vector-borne diseases,” she said.
It accounts for 17 per cent of the estimated global burden of all infectious diseases. Dengue is now the world’s fastest growing vector-borne disease, with a 30-fold increase in disease incidence over the past 50 years. Outbreaks of dengue have now been reported from all countries of this region, except Democratic People’s Republic of Korea.
Lymphatic filariasis, another mosquito-borne disease, is linked to poverty and creates disfiguring and social stigma. The region has 60 million infected people while 875 million people are at risk of infection. To interrupt transmission, WHO recommends an annual mass drug administration of single dose of two medicines to all eligible people in endemic areas.
In January 2012, PM Manmohan Singh declared half of India’s children were malnourished and that was a national shame. Yet since then, not a single comprehensive national survey was conducted to determine the acuteness of the problem or measure progress, if any, of steps initiated to address malnutrition. Worse, the issue figures in a token manner in the election discourse of political parties and candidates.
The 2005-06 National Family Health Survey was the last one conducted and it found 48% of children suffered chronic malnourishment — of them, 20% acute malnourishment. The survey concluded that over half the women were anaemic and 36% underweight. The Global Hunger Index, released in October 2013, placed India among a group of countries with ‘alarming’ levels of hunger, figuring at the bottom of the heap, below China, Sri Lanka, Pakistan and several in sub-Saharan Africa.
Key interventions to boost nutrition levels include the targeted public distribution system (TPDS), Integrated Child Development Services (ICDS) and the school midday meal scheme (MDMS).
Despite increased food production and procurement for TDPS, food insecurity persists and is a chronic problem linked to poor delivery. The large number of ineligible or fake ration cards issued — a serious problem in some states, usually those that need TPDS the most — has caused huge leakages. The TPDS has glaring exclusion errors. About 20% of the estimated 90 crore eligible benefi ciariesare denied subsidized grain as they have no ration card, while 20% of the not-poor do. TPDS remains restricted to wheat and rice that would alleviate hunger, but not address malnutrition. No recommendation to include pulses, oil and nutritious millets
has been implemented. Even the food security Act — that UPA counts among its mega achievements — focuses on rice and wheat. Had the Act included higher procurement of millets, pulses, fruits and vegetables, it would have incentivized production of these, instead of just rice and wheat that are water-intensive crops.
ICDS was meant to counter malnutrition in children between 0 and 6 years and pregnant women. Government allocation, including states’ share, increased from over Rs 5,200 crore in 2007-08 to Rs 13,700 crore in 2013-14 and the number of anganwadi centres (AWCs) has increased from 10.1 lakh to 13.1 lakh in 2012-13.
Though almost 90% anganwadis are operational, the ICDS scheme reaches about 47% of eligible children, reported a CAG audit. Coverage in states varies from about 75% in Odisha to 18% in Bihar. Most AWCs lack infrastructure. In 2011-12, only 57% had drinking water on the premises, 47% had toilets and only 25% had a kitchen.
ICDS is meant to provide supplementary nutrition 300 days a year, or 25 days a month. But the number of days the programme worked ranged from 180-250, a CAG audit found. The audit revealed irregularities such as insuffi cient monitoring, suspected misappropriation of supplies, badly-trained anganwadi workers and shortfall in expenditure on supplementary nutrition, which meant lower per benefi ciary expenditure. For a fl agship programme that addresses a “national shame” the ICDS programme leaves much to be desired.
Allocation for the midday meal scheme is up from Rs 6,700cr to over Rs 10,300cr between 2007-08 and 2011-12. But many states aren’t meeting yearly targets of number of meals served. The scheme’s plagued by reports of children falling ill from eating poor quality or spoiled food. Many states are yet to achieve standards set to run it: constructing a kitchen shed, timely lifting of grains, proper food storage. Women employed as midday meal cooks remain underpaid.
While proportion of malnourished children has fallen since 2005-06, not only has the decline been slow, from 46% malnourished to about 33% by 2013, it’s been uneven with a few states and districts getting worse. But with poor tracking of the schemes’ implementation, or of the population’s nutritional status, no one seems sure if the situation has become any better or worse. And that’s the national shame.
HUNGER POLITICS | Aug 2012 | Modi quoted in interview blaming malnutrition in Gujarat on its “by and large vegetarian diet”. Because it’s a middle-class state, Gujarat is “more beauty conscious than health conscious”
Media reports laid bare the bluff: His contentions didn’t square with data whichever way it was spliced. Haryana, even more vegetarian than Gujarat, has better nutritional figures
NSSO data (2009-2010) showed poverty behind state’s poor nutritional indices
SERVED DEATH | Scams plague the mid-day meal scheme. Last July 27 village children died in Bihar’s Chapra after having the meal. Nitish Kumar cried conspiracy – that they were poisoned. Fact was, there was no monitoring, and the principal ran a racket, serving kids substandard fare
Resistance to antibiotics was on Wednesday declared a “major global threat” to public health by the World Health Organization in a first-ever global surveillance report that collated data from 114 countries.
It said some superbugs have evolved so much that up to 50% of the affected patients don’t get cured by drugs commonly used against them. Common microbes such as E coli, for instance, are posing a major emergency in intensive care units across the world.
“Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era in which common infections and minor injuries which have been treatable for decades can once again kill,” said WHO’s Dr Keiji Fukuda while releasing the report.
The report had a special warning for India. “The infectious disease burden in India is among the highest in the world and the inappropriate, irrational use of antimicrobial agents against these diseases has led to an increasing trend in development of antimicrobial resistance,” it said. The report — Antimicrobial Resistance: Global Report on Surveillance — studied antibiotic resistance in nine different bacteria responsible for common diseases such as sepsis, diarrhoea, pneumonia, urinary tract infections and gonorrhoea.
Failure of the last resort of treatment for gonorrhoea — third generation cephalosporins — has been confirmed in Austria, Australia, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the UK. Over 1 million people are infected with gonorrhoea around the world every day.
Said an intensivist in a south Mumbai hospital, “An increasing number of patients who reach the ICU with urinary tract infection are resistant to normally prescribed medicines.” The doctor said the medical fraternity couldn’t depend on one antibiotic alone. “We are using drugs in combinations most of the time.”
The WHO report found half the patients treated for sepsis caused by K pneumoniae don’t respond to carbapenem antibiotics. It also noted that fluoroquinolones used for urinary tract infections caused by E coli, don’t work in 50% cases. “In the 1980s, when fluoroquinolones were introduced, resistance was virtually zero. Today, there are countries where this treatment is ineffective in more than half of patients,’’ the report noted.
It stressed that antibiotic resistance was causing people to be sicker for a longer time and increasing the risk of death. “People with MRSA (methicillin-resistant Staphylococcus aureus) are 64% more likely to die than people with a non-resistant form of the infection,’’ it said.
In India, the emergence of extremely drug resistant TB drove home the extent of antibiotic resistance. Mumbai’s doctors had in 2011-2012 highlighted TB cases that were resistant to all the known antibiotics usually used to treat it. WHO, in 2011, estimated that there are 6.3 lakh cases of multi-drug resistant tuberculosis (MDRTB) among the world’s 12 million cases of TB.
The WHO report blamed poor regulation in the medical sector, with respect to prescription, in India.
For the full report, log on to www.timesofindia.com
STATE OF NATION
Hungry for votes, but no neta to fix malnutrition problem
Politicians Call It A ‘Shame’, But Do Little To Cure Ills That Plague System
Rema Nagarajan | TIG
In January 2012, PM Manmohan Singh declared half of India’s children were malnourished and that was a national shame. Yet since then, not a single comprehensive national survey was conducted to determine the acuteness of the problem or measure progress, if any, of steps initiated to address malnutrition. Worse, the issue figures in a token manner in the election discourse of political parties and candidates.
The 2005-06 National Family Health Survey was the last one conducted and it found 48% of children suffered chronic malnourishment — of them, 20% acute malnourishment. The survey concluded that over half the women were anaemic and 36% underweight. The Global Hunger Index, released in October 2013, placed India among a group of countries with ‘alarming’ levels of hunger, figuring at the bottom of the heap, below China, Sri Lanka, Pakistan and several in sub-Saharan Africa.
Key interventions to boost nutrition levels include the targeted public distribution system (TPDS), Integrated Child Development Services (ICDS) and the school midday meal scheme (MDMS).
Despite increased food production and procurement for TDPS, food insecurity persists and is a chronic problem linked to poor delivery. The large number of ineligible or fake ration cards issued — a serious problem in some states, usually those that need TPDS the most — has caused huge leakages. The TPDS has glaring exclusion errors. About 20% of the estimated 90 crore eligible benefi ciariesare denied subsidized grain as they have no ration card, while 20% of the not-poor do. TPDS remains restricted to wheat and rice that would alleviate hunger, but not address malnutrition. No recommendation to include pulses, oil and nutritious millets
has been implemented. Even the food security Act — that UPA counts among its mega achievements — focuses on rice and wheat. Had the Act included higher procurement of millets, pulses, fruits and vegetables, it would have incentivized production of these, instead of just rice and wheat that are water-intensive crops.
ICDS was meant to counter malnutrition in children between 0 and 6 years and pregnant women. Government allocation, including states’ share, increased from over Rs 5,200 crore in 2007-08 to Rs 13,700 crore in 2013-14 and the number of anganwadi centres (AWCs) has increased from 10.1 lakh to 13.1 lakh in 2012-13.
Though almost 90% anganwadis are operational, the ICDS scheme reaches about 47% of eligible children, reported a CAG audit. Coverage in states varies from about 75% in Odisha to 18% in Bihar. Most AWCs lack infrastructure. In 2011-12, only 57% had drinking water on the premises, 47% had toilets and only 25% had a kitchen.
ICDS is meant to provide supplementary nutrition 300 days a year, or 25 days a month. But the number of days the programme worked ranged from 180-250, a CAG audit found. The audit revealed irregularities such as insuffi cient monitoring, suspected misappropriation of supplies, badly-trained anganwadi workers and shortfall in expenditure on supplementary nutrition, which meant lower per benefi ciary expenditure. For a fl agship programme that addresses a “national shame” the ICDS programme leaves much to be desired.
Allocation for the midday meal scheme is up from Rs 6,700cr to over Rs 10,300cr between 2007-08 and 2011-12. But many states aren’t meeting yearly targets of number of meals served. The scheme’s plagued by reports of children falling ill from eating poor quality or spoiled food. Many states are yet to achieve standards set to run it: constructing a kitchen shed, timely lifting of grains, proper food storage. Women employed as midday meal cooks remain underpaid.
While proportion of malnourished children has fallen since 2005-06, not only has the decline been slow, from 46% malnourished to about 33% by 2013, it’s been uneven with a few states and districts getting worse. But with poor tracking of the schemes’ implementation, or of the population’s nutritional status, no one seems sure if the situation has become any better or worse. And that’s the national shame.
HUNGER POLITICS | Aug 2012 | Modi quoted in interview blaming malnutrition in Gujarat on its “by and large vegetarian diet”. Because it’s a middle-class state, Gujarat is “more beauty conscious than health conscious”
Media reports laid bare the bluff: His contentions didn’t square with data whichever way it was spliced. Haryana, even more vegetarian than Gujarat, has better nutritional figures
NSSO data (2009-2010) showed poverty behind state’s poor nutritional indices
SERVED DEATH | Scams plague the mid-day meal scheme. Last July 27 village children died in Bihar’s Chapra after having the meal. Nitish Kumar cried conspiracy – that they were poisoned. Fact was, there was no monitoring, and the principal ran a racket, serving kids substandard fare
Antibiotic resistance a global threat, says WHO
TIMES NEWS NETWORK
Resistance to antibiotics was on Wednesday declared a “major global threat” to public health by the World Health Organization in a first-ever global surveillance report that collated data from 114 countries.
It said some superbugs have evolved so much that up to 50% of the affected patients don’t get cured by drugs commonly used against them. Common microbes such as E coli, for instance, are posing a major emergency in intensive care units across the world.
“Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era in which common infections and minor injuries which have been treatable for decades can once again kill,” said WHO’s Dr Keiji Fukuda while releasing the report.
The report had a special warning for India. “The infectious disease burden in India is among the highest in the world and the inappropriate, irrational use of antimicrobial agents against these diseases has led to an increasing trend in development of antimicrobial resistance,” it said. The report — Antimicrobial Resistance: Global Report on Surveillance — studied antibiotic resistance in nine different bacteria responsible for common diseases such as sepsis, diarrhoea, pneumonia, urinary tract infections and gonorrhoea.
Failure of the last resort of treatment for gonorrhoea — third generation cephalosporins — has been confirmed in Austria, Australia, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the UK. Over 1 million people are infected with gonorrhoea around the world every day.
Said an intensivist in a south Mumbai hospital, “An increasing number of patients who reach the ICU with urinary tract infection are resistant to normally prescribed medicines.” The doctor said the medical fraternity couldn’t depend on one antibiotic alone. “We are using drugs in combinations most of the time.”
The WHO report found half the patients treated for sepsis caused by K pneumoniae don’t respond to carbapenem antibiotics. It also noted that fluoroquinolones used for urinary tract infections caused by E coli, don’t work in 50% cases. “In the 1980s, when fluoroquinolones were introduced, resistance was virtually zero. Today, there are countries where this treatment is ineffective in more than half of patients,’’ the report noted.
It stressed that antibiotic resistance was causing people to be sicker for a longer time and increasing the risk of death. “People with MRSA (methicillin-resistant Staphylococcus aureus) are 64% more likely to die than people with a non-resistant form of the infection,’’ it said.
In India, the emergence of extremely drug resistant TB drove home the extent of antibiotic resistance. Mumbai’s doctors had in 2011-2012 highlighted TB cases that were resistant to all the known antibiotics usually used to treat it. WHO, in 2011, estimated that there are 6.3 lakh cases of multi-drug resistant tuberculosis (MDRTB) among the world’s 12 million cases of TB.
The WHO report blamed poor regulation in the medical sector, with respect to prescription, in India.
For the full report, log on to www.timesofindia.com
Loo and behold, India’s dirty secret is out in the open
With as many as 597 million people practising open defecation, India still has the largest number of people defecating in open in the world, according to a new UN report.
The report — ‘Progress on Drinking Water and Sanitation (2014 update) — released on Friday says 82 per cent of the one billion people practising open defection in the world live in just 10 countries.
Worse, despite having some of the highest numbers of open defecators, India does not feature among the countries making great strides in reducing open defecation, the report jointly prepared by the WHO and the UNICEF says.
Neighbours do better
In contrast, India’s immediate neighbour Bangladesh and Vietnam, are among the top 10 countries that have achieved the highest reduction in open defecation since 1990. Vietnam, Bangladesh and Peru have reduced open defecation prevalence to single digits, according to the report.
According to the UN, countries where open defecation is most widely practised have the highest number of deaths of children under the age of five, as well as high levels of under-nutrition, high levels of poverty and large disparities between the rich and poor.
There are also strong gender impacts: lack of safe, private toilets makes women and girls vulnerable to violence and is an impediment to girls’ education, it says.
Since 1990, almost two billion people globally have gained access to improved sanitation, and 2.3 billion have gained access to drinking water from improved sources. Some 1.6 billion of these people have piped water connections in their homes or compounds.
More than half of the global population lives in cities, and urban areas are still better supplied with improved water and sanitation than rural ones. But, the gap is decreasing. In 1990, more than 76 per cent people living in urban areas had access to improved sanitation as opposed to only 28 per cent in rural ones. By 2012, 80 per cent urban dwellers and 47 per cent rural ones had access to better sanitation.
In 1990, 95 per cent people in urban areas could drink improved water, compared with 62 per cent people in rural ones. By 2012, 96 per cent people living in towns and 82 per cent of those in rural areas had access to improved water.
Disease risk
Poor sanitation and contaminated water are linked to transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, and typhoid. In addition, inadequate or absent water and sanitation services in health care facilities put already vulnerable patients at additional risk of infection and disease.
The report presents estimates for 1990-2012 and is based on data from nationally representative household surveys and censuses for the same period.
It reveals that by 2012, 116 countries had met the Millennium Development Goal (MDG) target for drinking water, 77 had met the MDG target for sanitation and 56 countries had met both targets. MDG 7.C aims to halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.
Fight Medical Apartheid
Kiran Mazumdar-Shaw
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While Indian pharma keeps drugs affordable, western MNCs can be blatantly discriminatory
Marijn Dekkers, chief executive officer of Bayer, shocked advo cates of afforda ble healthcare by candidly stating that “We did not develop this medicine for Indians, we developed it for western patients who can afford it.“ He was referring to a new cancer drug developed by his company.Dekkers' words are by far the most honest admission of the business model that seeks to alienate a section of patients by discriminating against them on the basis of nationality, race and economic status. Rather than wanting to save lives around the world, what Bayer is interested in is maximising profits by selling expensive drugs to “western patients who can afford it“. And those who cannot, well, it is a dead end for them as they have to do without Bayer's lifesaving drugs.
Some might say that it's a perfectly reasonable position after all, Bayer and other pharmaceutical companies are forprofit institutions. But never in the past were they so dismissive of humanitarian concerns.
Here is what George Merck, who became the president of his father's eponymous chemical manufacturing company Merck & Co in 1929, had to say on the subject: “We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have re membered it, the larger they have been.“ It is a reminder to pharma industries of their responsibility towards non-wealthy patients.
The question is: Should a drug be described as “blockbuster“ by a billion dollar label or a billion patients' label? If drugs are developed only for those who can afford them, but not for those who need them, isn't it unethical? It is, after all, a violation of the right to health enshrined in the World Health Organisation's constitution which states that the highest attainable standard of health is a fundamental right of every human being.
In 2012, USFDA approved 39 drugs. Of the 12 for cancer, 11 cost $1,00,000 a year. Most recently, a breakthrough Hepatitis C pill won approval with a $1,000-a-day price tag. Yes, drug innovation is expensive and the inordinately long-drawn-out approval process must be compensated through market mechanisms to allow pharma companies to recoup such investments. But the question is how much should this return on investment be? And how quick should it be? By putting a very high price on a drug, we are putting a price on life. And what we see in the price of many drugs is that life and, by extension, health is therefore unaffordable to most people in the world.
Generic producers in India have brought down the prices of lifesaving drugs used to treat diseases such as HIV , TB and cancer by as much as 90%. In the 1990s, HIV/AIDS drugs cost $12,000 per patient a year which saved patients in the US but not in Africa. The world seemed to accept the unacceptable until in 2001 an Indian pharma company produced a three-in-one HIV/ AIDS treatment for $1 a day.
Today , most antiretroviral medicines purchased by the US's global AIDS programme come from India and more than 80% of HIV drugs that Medecins Sans Frontieres, Unicef and Clinton Foundation use are generics from India. UNAIDS executive director Michel Sidibe best summed up India's `human' role in global healthcare when he said: “Millions will die if India cannot produce new HIV/AIDS medicines in the future it is a matter of life and death.“
India is a vital producer of affordable medicines and the world's largest producer of generic drugs. The Indian pharma industry accounts for 20% of the world's pharma industry in value terms and constitutes a significant 80% in volume terms.
Indian generics account for a 30% share of the US market and are critical to President Barack Obama's affordable healthcare programme. Data from the 2013 Generic Drug Savings in the US report shows that generic pharmaceuticals saved the American health system and patients $217 billion in 2012 and a staggering $1.3 trillion in the most recent decade.
India's contribution to affordable healthcare goes much beyond being a pharmacy to the world. It extends to affordable innovation which goes to the core of ensuring a global right to healthcare. Helped by a significantly lower cost base and a large talent pool of scientists and engineers, India's research engine is now driving a new model of innovation that focusses on quality and affordability.
With returns on investment plummeting to unsustainable levels in the West, companies are now rapidly leveraging India's `affordable innovation' platform through outsourcing, risk-sharing, and co-development partnerships. And it is not just the country's drug makers, many remarkable Indians like cardiac surgeon Devi Shetty are striving to make access to quality healthcare non-discriminatory. He has successfully leveraged technology and economies of scale to make medical care accessible and affordable to the masses. His hospital in Bangalore offers heart surgery at a fraction of the cost in developed countries and is a medical Mecca for patients from Africa, South and Southeast Asia and Middle East.
I truly believe that it is sustainable for pharma companies to innovate without the need for exorbitant pricing. Affordable healthcare is possible today thanks to technology and globalisation.
Some might say that it's a perfectly reasonable position after all, Bayer and other pharmaceutical companies are forprofit institutions. But never in the past were they so dismissive of humanitarian concerns.
Here is what George Merck, who became the president of his father's eponymous chemical manufacturing company Merck & Co in 1929, had to say on the subject: “We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have re membered it, the larger they have been.“ It is a reminder to pharma industries of their responsibility towards non-wealthy patients.
The question is: Should a drug be described as “blockbuster“ by a billion dollar label or a billion patients' label? If drugs are developed only for those who can afford them, but not for those who need them, isn't it unethical? It is, after all, a violation of the right to health enshrined in the World Health Organisation's constitution which states that the highest attainable standard of health is a fundamental right of every human being.
In 2012, USFDA approved 39 drugs. Of the 12 for cancer, 11 cost $1,00,000 a year. Most recently, a breakthrough Hepatitis C pill won approval with a $1,000-a-day price tag. Yes, drug innovation is expensive and the inordinately long-drawn-out approval process must be compensated through market mechanisms to allow pharma companies to recoup such investments. But the question is how much should this return on investment be? And how quick should it be? By putting a very high price on a drug, we are putting a price on life. And what we see in the price of many drugs is that life and, by extension, health is therefore unaffordable to most people in the world.
Generic producers in India have brought down the prices of lifesaving drugs used to treat diseases such as HIV , TB and cancer by as much as 90%. In the 1990s, HIV/AIDS drugs cost $12,000 per patient a year which saved patients in the US but not in Africa. The world seemed to accept the unacceptable until in 2001 an Indian pharma company produced a three-in-one HIV/ AIDS treatment for $1 a day.
Today , most antiretroviral medicines purchased by the US's global AIDS programme come from India and more than 80% of HIV drugs that Medecins Sans Frontieres, Unicef and Clinton Foundation use are generics from India. UNAIDS executive director Michel Sidibe best summed up India's `human' role in global healthcare when he said: “Millions will die if India cannot produce new HIV/AIDS medicines in the future it is a matter of life and death.“
India is a vital producer of affordable medicines and the world's largest producer of generic drugs. The Indian pharma industry accounts for 20% of the world's pharma industry in value terms and constitutes a significant 80% in volume terms.
Indian generics account for a 30% share of the US market and are critical to President Barack Obama's affordable healthcare programme. Data from the 2013 Generic Drug Savings in the US report shows that generic pharmaceuticals saved the American health system and patients $217 billion in 2012 and a staggering $1.3 trillion in the most recent decade.
India's contribution to affordable healthcare goes much beyond being a pharmacy to the world. It extends to affordable innovation which goes to the core of ensuring a global right to healthcare. Helped by a significantly lower cost base and a large talent pool of scientists and engineers, India's research engine is now driving a new model of innovation that focusses on quality and affordability.
With returns on investment plummeting to unsustainable levels in the West, companies are now rapidly leveraging India's `affordable innovation' platform through outsourcing, risk-sharing, and co-development partnerships. And it is not just the country's drug makers, many remarkable Indians like cardiac surgeon Devi Shetty are striving to make access to quality healthcare non-discriminatory. He has successfully leveraged technology and economies of scale to make medical care accessible and affordable to the masses. His hospital in Bangalore offers heart surgery at a fraction of the cost in developed countries and is a medical Mecca for patients from Africa, South and Southeast Asia and Middle East.
I truly believe that it is sustainable for pharma companies to innovate without the need for exorbitant pricing. Affordable healthcare is possible today thanks to technology and globalisation.
Harsh Vardhan favours higher tax on tobacco products
Union Health Minister Harsh Vardhan said on Tuesday that he supported higher taxes on cigarettes and tobacco products.
Having seen the impact of tobacco on patients he had treated as a doctor, Dr. Harsh Vardhan said he was particularly sensitive to the issue.
He was speaking at the release of a report on the ‘Economic Burden of Tobacco-related Diseases in India’ based on research conducted by the Public Health Foundation of India, and supported by the Health Ministry and the World Health Organisation.
Nata Menabde, WHO Representative to India, estimated that an increase in tax would raise the price of tobacco products by 10%, which in turn would reduce tobacco consumption by 4-5%.
Massive cost
The cost incurred for treating diseases caused by just tobacco use was an estimated Rs 16,800 crore in 2011, but if one were to take into account the associated indirect morbidity and premature mortality, the amount touches a staggering Rs. 1.04 lakh crore, the report said.
According to the report, while the expenditure on associated indirect morbidity stood at Rs. 14,700 crore, the notional loss caused by premature mortality through diseases due to tobacco use was a massive Rs. 73,000 crore.
“The total economic costs attributable to tobacco use from all diseases in India in 2011 was a staggering Rs. 1,04,500 crore,” health ministry said in a statement based on the report. The figure of 1.04 lakh crore is more than the combined expenditure incurred in 2011 by the Central and state governments on healthcare, it said.
The report estimated that the economic costs attributable to tobacco use from all diseases in India in 2011 for people aged 35-69 at over Rs. 1 lakh crore, or 1.16% of the Gross Domestic Product. Cardiovascular disease was the biggest contributor (Rs. 3,600 crore) followed by respiratory diseases, tuberculosis and cancer. Among the 13 States which were part of the study, Uttar Pradesh faced the highest healthcare burden followed by West Bengal and Andhra Pradesh. Men contributed to 91% of the total economic burden, the study found. The report estimates direct and indirect costs from all diseases caused due to tobacco use and four specific ones; respiratory diseases, tuberculosis, cardiovascular diseases and cancers.
Time to Act Is Now
The latest World Health Organisation’s (WHO) report on the resistance to the use of antibiotics, Antimicrobial Resistance: Global Report on Surveillance,is a horror story. Resistance to crucial drugs – when microorganisms like viruses, bacteria and parasites mutate and make medication ineffective to cure infections – has become so common that illnesses which were treatable for decades are now threatening to kill again. These are not rare diseases that are difficult to treat. Doctors worldwide are seeing resistance to antibiotics used to treat illnesses like gastroenteritis, malaria and typhoid. They are therefore being forced to fall back upon older drugs which had been set aside years ago because of their side-effects.
All this spells bad news for medical advances like stem cell transplants and bone marrow transplantation and also for patients of chronic illnesses who are prone to infections that could otherwise have been treated. The situation is worse in India. One, the country already has a battle on its hands with multi-drug resistant tuberculosis (TB). Two, the health system services are hardly equipped to deal even half-way with the grim scenario painted by the WHO. Three, to compound matters, drug resistance is high in hospital-acquired infections. However, there is no reliable national data as to the extent of antimicrobial resistance in India.
The WHO report finds rampant resistance to carbapenem antibiotics, considered to be the last-resort treatment for life-threatening infections due to a common intestinal bacteria, klebsiella pneumonia. It is a huge source of hospital-acquired infections like pneumonia, bloodstream infections, and infections in newborns and intensive care unit patients. There is also high resistance to third-generation cephalosporins and fluoroquinolones, the two essential anti-bacterial drugs used to treat E coli. The resistance has become a major cause of bacterial diarrhoea and nontyphoidal salmonella. The tendency of Indians to self-medicate with over-the-counter antibiotics is made worse by doctors tending to “over-prescribe” these drugs.
The controversy a few years ago that followed the discovery of the New Delhi Metallo beta lactamase-1 or NDM-1 “superbug” – the result of antibiotics resistance – led to demands for a policy on antibiotics use. In 2013, the union government placed 24 antibiotics under the new Schedule H1 category. These drugs cannot be sold without a doctor’s prescription and invite penalties on chemists for non-compliance. Individual state governments too have issued notifications bringing various antibiotics, anti-TB and psychotropic drugs under this category. Much will depend on the stringency of the inspections by the drugs inspectorate, never a strong point of state government administration. As in many other areas, it is the regulatory mechanism that is the weak link. However, there are concerns that such regulations could adversely affect the sick in rural areas where there are few doctors and people at times depend on chemists for drug advice. Important antibiotics could be driven into the grey market, thus burdening the patient further. While strengthening the regulatory mechanism to prevent the sale of over-the-counter antibiotics without prescriptions, the issues arising from the lack of an adequate number of medical practitioners in rural and remote areas to write these prescriptions will have to be dealt with.
The socio-economic costs of antibiotic resistance can be gauged from the fact that patients remain ill for longer and there is even a greater risk of death. The longer stays in hospital with the accompanying higher expenditure put a heavier burden on scarce resources. Many medical practitioners in India place some of the responsibility for the overuse of antibiotics on patients who demand “strong” medicines so that they can get well quickly and blame them for prolonging treatment with “mild” medication. There is also the aggressive marketing by pharmaceutical companies which leads to superfluous prescription of antibiotics. An insistence on hospital authorities overseeing and auditing their stocks of antibiotics is seen as one solution. The education of patients must also run parallel since it is a well-known fact that discontinuation of the regimen with even a modest improvement of symptoms is common across socio-economic strata. As has been demonstrated beyond doubt in the case of TB, this is a dangerous and fatal practice. The WHO report shows that there is no time to lose and that urgent action is imperative.
A huge health burden
That over 27 per cent of tobacco consumers in India fall in the 15-24 year age bracket amply demonstrates how successful the tobacco companies have been in continually enticing the vulnerable sections of the population into the suicidal practice. The addition of new customers every year even as thousands of patrons die annually ensures that the tobacco companies’ customer base remains wide and tall. If the global tobacco-related mortality is about 5.5 million people annually, India’s burden alone is nearly one million. With nearly 35 per cent of the adult population in the country addicted to the dangerous substance rolled in paper or leaf or packed in plastic sachets, India is the second largest consumer of tobacco products in the world. Besides the high levels of mortality and morbidity, there is a huge economic cost involved in treating people with diseases caused directly or indirectly by tobacco use. As a result, the out-of-pocket expenditure on medical treatment results in “higher poverty rates.” A recently released Health Ministry report estimates that 9.3 lakh people in India are affected by the health costs of tobacco. According to the report, the total health expenditure burden of tobacco in the year 2011 was a little over Rs.100,000 crore. To put it in perspective, the amount was “12 per cent more than the combined State and central government expenditure on health in 2011-12.” The revenue earned through excise duty in the same year was a paltry 17 per cent of the health burden of tobacco. The “benefit” argument of revenue generation through sales therefore stands completely negated.
It is for these reasons that the Central government, which considers health to be one of the priority areas, should simultaneously implement multiple strategies to prevent people, particularly children as young as 15 years, from getting addicted to nicotine and help the existing users to quit smoking and/or chewing tobacco. If the government is indeed serious about reducing the prevalence by 15 per cent by 2020 and 30 per cent by 2025, the most effective way of achieving it is by raising taxes. It is indeed heartening that the new Union Health Minister “supports” higher taxes on cigarettes and tobacco products; raising tax on tobacco is the WHO’s theme this year. But for any tax increase to become effective, the price difference between various brands and different tobacco products must be minimal. But India follows a bizarre, producer-friendly excise duty structure for cigarettes, beedis and chewing tobacco that makes a mockery of taxation. Hence, a complete overhaul of the taxation system is warranted to achieve the desired benefits. It is time the tobacco issue was addressed with greater seriousness.
Fighting for survival
In what is not a surprise any longer, India leads a group of high-burden countries with respect to one more health indicator — neonatal (0-27 days of age) deaths. Of the three million neonatal deaths globally in 2012, some 779,000 were in India. Nigeria comes second with about one-third of India’s figure. Also, globally there were 2.6 million stillbirths in the same year, of which 600,000 were in India. Since about half of all stillbirths occur close to delivery and could potentially be prevented, the story becomes even more poignant. The first 24 hours after birth represent the most critical period for the survival of a neonate. Of the one million newborns dying globally on the first day of birth, nearly one-third are in India. That 56 per cent of all under-five deaths in India happen during the neonatal period reveals how vulnerable the neonatal period is. Besides bearing the ignominy of being the highest neonatal burden country, for India what is worrying is its inability to achieve death toll reduction. The country, which had a neonatal mortality rate of 29 per 1,000 live births in 2012, recorded an average annual rate of reduction of just 2.6 per cent during 1990-2012. According to papers published recently in The Lancet, India, Nigeria and Pakistan registered the “slowest rates of progress” in reducing neonatal mortality.
According to a 2012 WHO report, India is one of the 10 countries with an estimated 100,000 to 250,000 preterm births, as in 2010. The high number of preterm births is one of the reasons for the very high numbers of newborn deaths in the country — preterm births cause about 50 per cent of neonatal mortality. Though very little is known about what causes preterm births, poverty, adolescent pregnancy, inadequate spacing of deliveries, and lack of medical care are some of the risk factors. Starting 2006, over 500 special-care newborn units have been set up in district hospitals, and about 600,000 admissions take place a year. Thanks to initiatives such as cash transfer, institutional deliveries have increased since 2006. Yet, a concomitant reduction in infant mortality has not been achieved; many deliveries still take place at home, especially in the States of Uttar Pradesh and Bihar. Hence, there is a dire need to increase the number of well-trained birth attendants. Also, the lack of well-trained healthcare workers and well-equipped healthcare centres has proved to be a “barrier” to improving newborn survival. There is, hence, an urgent need to improve the quality of care. What must be borne in mind is that many of the initiatives taken to save neonates’ lives would also help in reducing maternal mortality. With 50,000 deaths, India has the highest maternal mortality in the world.
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Dhanya Sanal*
A small bite by a seemingly trifling organism can really turn your life upside down. Can you believe the fact that Vector borne diseases cause more than one million deaths each year? Yes, the number of deaths from vector born diseases is increasing alarmingly. Under tropical conditions of excessive heat and high humidity, man is subject to serious physical and mental handicaps. He perspires profusely and loses vigor and energy and exposes himself to such dangers as sun stroke and diseases. Tropical conditions are ideal for survival of germs and bacteria and also encourage the spread of insects and pests. On this World Health Day, WHO is drawing attention to a group of diseases that are spread by insects and other vectors, the heavy health and economic burden they impose and what needs to be done to reduce these burdens. Many people who survive infection are left permanently debilitated, disfigured, maimed or blind.
The tag line of this year's World Health Day 'Small Bite Big Threat', compel to turn the attention towards the alarming occurrence of vector borne diseases, and it substantiate and
 recommends the governments, local authorities, community groups and individuals to work together to prevent vector borne diseases. "Mosquitoes, flies, tick and bugs may be a threat to your health-and that of your family-at home and when travelling", is the message of this year's World Health Day.
Epidemiology Vectors are organisms that transmit pathogens and parasites from one infected person (or animal) to another. Vector borne diseases are illnesses caused by these pathogens and parasites in human population and account for 17% of the estimated global burden of all infectious diseases. Although, the disease most commonly found in tropical areas where 40% of the population is at risk, globalization, climate change and urbanisation have affected transmission of vector borne diseases and causing their appearance in countries where they were previously unknown.
Major Vector Borne Diseases
Prevention and control
Time has come to utilize the full potential for vector control for reducing vector-borne disease. Back in 1940's, the discovery of synthetic insecticides was a major breakthrough and the massive use of insecticides in 1940's and 1950's successfully brought many important vector-borne diseases under control. But, with in the past two decades, many important vector-borne diseases have re-emerged or spread to new parts of the world. Alongside this alarming spread of vectors there is a serious concern of increasing insecticide resistance. At the same time, the world is facing an extreme shortage of entomologists and vector control experts who promote 'integrated vector management' as the best approach to strengthen vector control. This approach uses a range of interventions, from indoor residual spraying to the use of natural insect predators, in combination and in a value added way. Integrated management makes sense as many vector borne diseases overlap geographically.
Key elements in the prevention and control of vector borne diseases include the following:
· Long-lasting insecticidal nets.
· Indoor residual spraying
· Outdoor spraying
· Addition of chemicals to water
· Insect repellents like coils, vaporizing mats.
· Reducing breeding habit of the vector.
· Biological control of vectors through the introduction of parasites, predators or other living organisms.
· Genetic control strategies.
· Waste management.
· Housing modification
· Personal protection against the vector
· Medication for travelers
· Prophylaxis and preventive therapies.
· Mass treatment for lymphatic filariasis, sotistosomiasis, onchocerciasrs.
· Vaccines for Japanese encephalitis, Tick-borne encephalitis, and yellow fever.
· Blood and body fluid safety in the case of Chagas disease and crimean-congo haemonhage fever.
· Food safety in case of Chagas disease and Tick borne encephalitis.
Key challenges in the control of vector-borne diseases include.
Ø Emerging insecticide resistance.
Ø Lack of expertise in vector control.
Ø Surveillance of vectors and their diseases.
Ø Sanitation and access to safe drinking water.
Ø Pesticide safety and poisoning
Ø Climate and environmental change.
The poorest segment of of the society and least developed countries are most affected by vector born diseases. illness and disability prevent people from working and supporting themselves and their family causing further hardship and impeding economic development.
World Health Day is celebrated on 7 April every year to mark the anniversary of the founding of WHO in 1948. Each year a theme is selected that high lights a priority area of public health. The Day provides an opportunity for individuals in every community to get involved in activities that can lead to better health. In recent years, renewed commitments from ministries of health, regional and global health initiatives, with the support of NGO's, the private sector and the scientific community, have helped to lower the incidence and death rates from some vector-borne diseases.
As vector borne diseases begin to spread beyond their traditional boundaries, action needs to be expanded beyond the countries where these diseases currently thrive. WHO resolved to provide communities with information and aims to raise awareness about the threat posed by vectors and vector-borne disease, and to stimulate families and communities to take action to protect themselves from the perennial bane.
Lifestyle Disease Education and Awareness Programme (LEAP)
A survey conducted recently by School Health Programme (an initiative of NRHM) among students in Kerala found that about 2.7 per cent of the 10 lakh children in Government schools are overweight and 0.8 per cent obese. The survey pointed its fingers to the life style diseases among youth, a threat our country needs to tackle in the coming decades. Lifestyle diseases like diabetes and cardio vascular diseases have now spread from urban regions to even rural and tribal areas of the country. Kerala which is known for its advances in health indicators, take no time to roll out a comprehensive programme to prevent life style diseases among school children in the State. Thus born the Lifestyle Disease Education and Awareness Programme (LEAP).
A Giant ‘LEAP’ for Mankind
Union Minister for Health & Family Welfare Shri Ghulam Nabi Azad inaugurated LEAP in the State which aims to control and prevent occurrence and prevalence of lifestyle diseases in school children through health education, life style modification and regular screening. The Programme is a joint initiative of the National Rural Health Mission and the State Departments of Health and Education. The new initiative will complement a peer programme titled ‘Amrutham, Arogyam’ for adults in the State. About 70 lakh adults were screened as a part of ‘Amrutham, Arogyam’ programme.
Changing Lifestyle and its Multiple Effects
The World Health Assembly organized by World Health Organisation(WHO) in 2010 at Geneva cautioned in its report that non communicable diseases -mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, kill nearly 35 million people per year. The report also says that almost 90% of fatalities before the age of 60 occur in developing countries and are largely preventable. (Courtesy: WHO website)
Unhealthy diet, lack of exercise, stress and excess use of junk food are the main causes that lead to lifestyle diseases at an early age. The cut-throat competition in academics forces students to distance themselves from sporting activities in and outside the school premises. India with its majority young population is more vulnerable to such non-communicable diseases.
LEAP- An Introduction
The LEAP initiative will help educate teachers and students on lifestyle diseases. Continuous awareness campaigns will be conducted across the schools as a part of this programme. Medical Officers, dietitians and other health workers will lead the classes which lay emphasis on healthy diet, exercise and good eating habits.
Main Objectives of LEAP:
· Awareness classes for students and teachers on regular exercise and healthy diet.
· Facilities for exercise at schools.
· Encourage students to reach schools either by walking or by cycling.
· Training for students in vegetable farm making and making healthy diet.
· Encourage Yoga and Sports in Schools.
· Regular screening of school students to identify lifestyle diseases.
· Awareness among students regarding lifestyle disease control.
LEAP Action Plan
Students will be screened by health workers and their details will be recorded. For every 2,500 students, a school health nurse is being appointed for this purpose. A list of students prone to lifestyle diseases will be made and special care will be availed to them. The Class teacher will keep the records of students and access the lifestyle diseases preventive measures. Each school will have a LEAP ambassador from the health club to help accelerate the activities. Model teachers have been identified from every school and they will be given training in yoga. Depending on number of students, there will be one or two in every school. Nutritional counselling will be given to the PTA by professional dieticians to create awareness.
Mercury treaty still sketchy
The Minamata Convention adopted on October 10 is a big step forward in phasing out the use of mercury—a silvery, odourless element that earned Victorian hatmakers who used it the name of mad hatters. The highly toxic element debilitates people and causes dementia and other diseases.
The international conference organised by the United Nations Environment Programme (UNEP) at Minamata city in Kumamoto, Japan, aims at curbing the health and environmental damage caused by the element. Ninety two countries signed the treaty to phase out the use of mercury and mercury-based products by 2020, and over the next five years, the signatory countries will invest in developing mercury-free solutions.
The convention also decided to set up a Global Environment Facility Trust Fund with an investment of US $10 billion for research and development.
While experts have welcomed the Minamata treaty, they believe it might not be enough to check the use of mercury.
Satish Sinha of Toxic Links, a non-profit working on hazardous wastes, says while the convention saw for the first time countries with opposing foreign policies coming together to sign a treaty, “there is a long way to go”.
No emission targets
Sinha points out that although the treaty calls for phasing out of certain products, there are no emission targets for important industries. The treaty leaves it to the signatories to fix emission targets, he says.
While it draws a timeline for phasing out a range of products, including batteries, clinical equipments, cosmetics, the treaty has not specified any date or timeline to stop the usage of mercury in artisanal and small-scale gold mining (ASGM) and coal-fired power plants, the largest emitters of mercury.
UNEP stated on October 12 this year that ASGM and coal-fired power stations are the biggest sources of mercury pollution worldwide. Miners inhale mercury during smelting and mercury that runoff contaminates fish, the food chain and people downstream. About 727 tonnes of mercury is annually emitted from ASGM operations, especially in western Africa.
Anti-hazardous chemicals campaigners such as International Plaster-of-Paris and Elimination Network (IPEN) are also unhappy with the convention’s outcome.
“Minamata-like tragedies are already taking place in areas surrounding ASGM sites, though most are hidden from public view. However, provisions to address mercury pollution through ASGM are very weak (in the convention treaty). For example, the current text allows import of unlimited quantities of mercury for use in ASGM with no phase-out date,” says Olga Speranskaya, co-chairperson at IPEN.
Close to 2,000 people died in Minamata city due to the release of methyl-mercury in the industrial wastewater by a chemical factory between 1932 and 1968. The toxic chemical bioaccumulated in shellfish and fish in Minamata Bay and the Shiranui Sea, which, when eaten by the people, resulted in mercury poisoning.
Next only to ASGM, coal burning for power and other industries contributes about 475 tonnes of mercury to the manmade emissions. According to a UNEP report this year, the mercury content of coal varies widely, introducing a high degree of uncertainty in estimating mercury emissions from coal burning.
However, the Minamata treaty only calls for the usage of best available emission-control technologies in new power plants, boilers and smelters. “For the existing and older plants, the signatories have been asked to determine emission targets,” states the treaty.
“Many countries are rapidly expanding their national electricity generating capacity, including construction of many new coal-fired power plants. The treaty’s proposed provisions will not likely result in a reduction of the number of coal-fired power plants in operation or even slow their growth,” said Speranskaya in a letter to UNEP, adding that for developing nations the treaty does not come into effect for the next 10 years.
Mercury-free devices
Days after the treaty, the World Health Organisation and Health Care Without Harm—a campaigner for mercury-free health devices— launched the Mercury Free Healthcare by 2020 campaign. The treaty calls for a ban on usage of mercury by 2020 in certain medical and monitoring devices, including barometers, thermometers, hygrometers, manometers and blood pressure monitors.
However, the treaty exempted vaccines containing thiomersal, an anti-septic and anti-fungal preservative which has mercury. While the US and Europe had phased out the vaccine preservative about 15 years ago, thiomersal was at the centre of the debate between health activists during negotiations at the Minamata Convention.
“The continued use of thiomersal is unjustifiable and phasing out its use in all products globally should be expedited. It is unethical and unjust to continue exportation of thiomersal-containing products to less developed countries from countries that no longer accept its use,” says Eric Uram, executive director at SafeMinds, a US-based health advocacy group.
UNEP has also exempted the usage of mercury for ritualistic and religious purposes after Nepal objected to the inclusion of mercury for spiritual purpose under the phase-out list. Even the Hispanic and Yoruba communities in the US and the Caribbean consume mercury for ritualistic purposes. Nepal’s representative at the convention, Govinda Prasad Kharel, undersecretary and senior environmental engineer, has told the chair of the Intergovernmental Panel for Negotiations in Geneva that strong religious beliefs are attached with mercury, so it should be allowed to be used for religious purposes.
Nevertheless, the treaty has been taken seriously by 138 nations, who approved of the convention in October. The treaty states that signatories have 10 years to phase out mercury completely, a period, Sinha believes, will be crucial as stakeholders will have to find innovations to phase out anthropogenic emissions of mercury.
Why India remains malnourished
Issue Date:
2013-11-30
Despite a fast-growing economy and the largest anti-malnutrition programme, India has the world’s worst level of child malnutrition. The government plans to pump in Rs 1,23,580 crore over the next five years to tackle the problem. Jyotsna Singh travels to highly malnourished districts in Madhya Pradesh and Rajasthan, while Kundan Pandey quizzes experts across the globe to unravel the enigma
Two-and-a-half-year-old Rabina weighs 6.5 kg. A healthy child of her age should weigh at least 8 kg. But Rabina could not escape the curse of being born in Shivpuri district of Madhya Pradesh—ill-famed as one of the highly malnourished districts of the country for the past 30 years. Rabina was not always so. At birth, she was healthy and weighed just right—a little more than 2.5 kg. But something went wrong and she did not grow at a healthy pace. At nine months, the anganwadi worker of her tribal-dominated village Udvaya declared her severely acute malnourished, a condition that could stunt her physical growth and cognitive development forever. She referred Rabina to the Nutrition Rehabilitation Centre (NRC), some 20 km away. Doctors there put her through intense nutrition supplement for a fortnight and managed to bring her out of the malnourished state. But back home, in the absence of a regular healthy diet, her condition worsened again. She is now categorised as chronically malnourished in the anganwadi worker’s register. Shivpuri has 11,392 severely acute malnourished children, show the district administration’s records of 2012. But very few—2,629 in 2012—get admitted to NRCs. Of those admitted, less than a quarter are nursed back to health. Shivpuri’s Sahariya tribals, once known for their lion-like physical strength and often made to fight wild animals in the king’s courtyard for entertainment, are now fighting a losing battle against malnutrition. “I do not remember any child from my generation or previous generations being so thin or unable to perform daily chores due to lack of energy,” says Ram Avatar, resident of Udvaya, as he wonders what ails the children of his community.
 Archana Kumari, 22, lives in a slum in South Delhi. She is pregnant for the third time in six years and is anaemic. Both her children are malnourished (Photographs: Chinky Shukla) Of the 25 million wasted children, eight million are severely wasted or suffer from severe acute malnutrition like Rabina. India is home to one-third such children. Sixty per cent of them live in six states: Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Maharashtra and Tamil Nadu.Such high prevalence of child malnutrition in India defies logic. After all, the country’s economy has doubled since 1991, when the government started counting the malnourished children. The world’s largest programme to tackle child malnutrition, the Integrated Child Development Services (ICDS), has been in force in the country since 1975, much before any country, other than the US, introduced measures to tackle the problem. All the states with a high burden of malnutrition have the public distribution system in place to ensure that the poor, even in inaccessible areas, get food grains at subsidised rates. Yet, reports regularly appear both within and outside the country, highlighting child deaths due to malnutrition. According to the Registrar General of India, in 2010, under-five mortality in India was 59 per 1,000 live births, one of the highest in the world. In 2012, British non-profit Save the Children reported that 1.83 million Indian children die every year before they turn five and pinned malnutrition as the key reason for the deaths. “The child may eventually die of a disease, but that disease was lethal because the child was unable to fight back due to malnutrition,” Victor Aguayo, chief of Child Nutrition and Development at Unicef-India, told the media in New Delhi recently. All surveys indicate that India is slipping into a vicious cycle of malnutrition. Scientists say the initial 1,000 days of an individual’s lifespan, from the day of conception till he or she turns two, is crucial for physical and cognitive development. But more than half the women of childbearing age are anaemic and 33 per cent are undernourished, according to NFHS 2006. A malnourished mother is more likely to give birth to malnourished children. The HUNGaMA (Hunger and Malnutrition) Survey across 112 rural districts in 2011 [3] by non-profit Naandi Foundation shows the impact of the world’s oldest anti-malnutrition programme. Eighty per cent of the mothers have not heard the word malnutrition in their local language, says the report. It seems India is all set to miss one of its key Millennium Development Goals: halving malnutrition by 2015. This is the reason past few months have witnessed a flurry of high-profile public statements and programme decisions to fight malnutrition. In September, Parliament passed the National Food Security Act, which aims at fighting malnutrition by tackling food insecurity. The following month, the Centre declared that NFHS will resume after a gap of seven years. It will begin in February 2014. In 2012, the 12th Five-Year Plan restructured the ICDS scheme immediately after Prime Minister Manmohan Singh termed malnutrition as a “national shame”. The scheme will provide supplementary nutrition, pre-school education, health and immunisation to children under the age of six in 200 high-burden districts by the end of the year by setting up more anganwadi centres. So far, ICDS was catering to the needs of children in the age group of three to six, leaving out the crucial under-three children. By the next year, when the scheme will be expanded to cover the entire country, its scope can be compared with the polio eradication campaign. The Centre has allocated a whopping Rs 1,23,580 crore for the scheme. This is almost thrice the budget allocated to ICDS in the previous Plan period. The government hopes this will help bring down malnutrition among under-three children by 10 per cent and among girls and women by 20 per cent. But are these measures sufficient to tackle the menace? In popular perception, poverty is synonymous with malnutrition. Reports show a major chunk of malnourished children belong to poor families and traditionally poor states. But rates of malnutrition are also significant among middle- and high-income families. As the stage is set for onslaught of malnutrition, it is time to critically look at the not-so-obvious reasons for its high prevalence in the country. Confused over measurement Analysts say WHO formula is not a standard to measure malnutrition, but a reference “Malnutrition is not the result of a single problem,” says Umesh Kapil, professor of human nutrition at the All India Institute of Medical Sciences, Delhi. “There are 15 to 20 issues (literacy level, clean drinking water and sanitation, for example) that contribute to the problem,” he adds. Consider this. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of India. According to Yogesh Jain of Jan Swasthya Sahyog, a non-profit in Chhattisgarh, close to 69 per cent of Indians earns less than US $2 a day. People in half of sub-Sahara Africa subsist with this much earning. This discrepancy has sparked a debate over WHO’s formula, which is usually has been used by countries, including India, to measure malnutrition since 2006. In May this year, a research paper published in the journal Economic and Political Weekly questioned the applicability of the WHO standard to India [4]. The paper by Arvind Panagariya, economist at Columbia University, US, argued that despite progress in other social indicators India lagged in reducing malnutrition. He attributed this to the WHO formula and called it faulty (see ‘WHO’s standard’).
A senior official with the Department of Health informed Down To Earth that the government plans to use the WHO formula to estimate the number of malnourished children in the latest round of NFHS, beginning 2014. But medical and community health experts are already divided over its accuracy. Some say the WHO growth chart, prepared using the formula, is just a reference and hence should not be used as a standard to measure malnutrition. “It tells us the perfect size of children from well-off background, like those born to educated parents and have access to nutritious food, sanitation and medical facilities. It shows how a child should grow in an ideal situation,” says H P S Sachdev, former national president of Indian Academy of Paediatrics. “India is a vast country with individuals belonging to many ethnic groups. In certain communities, people are of short stature. This does not mean they are malnourished,” says Kapil (see ‘WHO’s to blame’, Down To Earth, October 1-15, 2013) Use of the WHO growth chart as a standard to decide malnutrition level has led to confusion among the ground-level health workers. At the village level, an anganwadi worker is the first to identify a malnourished child. She registers every birth in her area and monitors the child’s growth at regular intervals. While the WHO formula uses three measures of physical growth—age, weight and height—to judge nutritional status of a child, anganwadi workers usually prepare the growth chart based on weight alone (see ‘Data interrupted’). If a child is detected underweight, which is a measure of malnourishment, the anganwadi worker refers him or her to NRC for intensive nutrition treatment.
An easier way to avoid these discrepancies is to follow another WHO measurement: the mid-upper arm circumference (MUAC) of a child. A child whose MUAC is less than 115 mm is considered severely acute malnourished, those with 115-125 mm of MUAC are moderately acute malnourished and those with more than 125 mm of MUAC are considered normal. However, this measurement is yet to gain momentum. Few anganwadi workers know about it and even fewer have the skill to measure MUAC properly. One has to first calculate and mark the mid-point of the arm after measuring the arm length; MUAC is determined at this mid-point. “Our anganwadi workers are not well-literate and their skill is limited. They find it is easier to keep track of a child’s growth by weighing them rather than following other measurements,” says Upasana Rai, district programme officer, Department for Women and Child Development (DWCD), Shivpuri. DWCD supervises anganwadis. .jpg) [5]With this confusion and inability to cope with measurement procedures, India’s data on malnutrition may not be accurate. ICDS records as of March 2012 show 62.8 per cent under-six children who were weighed at anganwadi centres were normal. Rest of the 37.2 per cent children were underweight or malnourished. This is almost 10 per cent dip from the estimates by NFHS 2006. The 2011 HUNGaMA report also states a reduction in malnutrition. It found that 42 per cent of under-five children are underweight and 59 per cent are stunted. But no one can say for sure whether the number of malnourished children has increased or decreased since 2006 NFHS survey. But there are arguments that favour the WHO formula. “The reference was prepared considering all kinds of people including the poor. The standard says even children in poor countries grow similar if they get similar opportunity,” says David Sanders, Emeritus Professor, School of Public Health at University of Western Cape in South Africa. He is also known as the founder of the People’s Health Movement. Arun Gupta, member of the Prime Minister’s Council on India’s Nutrition Challenges, says, “It does not matter which formula one uses to determine the number of malnourished children. We shall have to solve the problem anyway.” The debate over measurement of malnutrition ignores some of the crucial determinants of childhood health. In the 1990s, these not-so-obvious determinants had prompted V Ramalingaswami, former National Research Professor of India, to term malnutrition as “Asian enigma” (see ‘South Asia’s curse [5]’). Three decades later, none of the countries are anywhere near to solving the riddle. Sanitation, a missing link? Evidence shows malnutrition is high in areas where people defecate in the open  75% of India’s surface water is polluted by human and agricultural waste and industrial effluents. Reports say lack of sanitation is the key reason for child malnutritionOne missing piece of the malnutrition puzzle is social inequality. For example, girl children are more likely to be malnourished than boys, and low-caste children than upper-caste children. But the most important aspect is sanitation. Most children in rural areas and urban slums are constantly exposed to germs from their neighbours’ faeces. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished.  According to the Planning Commission’s evaluation report of the Total Sanitation Campaign, close to 72 per cent people in the country’s rural areas still defecate in the open (see ‘Uncomfortable facts [6]’). Every day, an estimated 100,000 tonnes of human excreta are left unguarded along river and stream banks, in open fields, on road sides and farms to contaminate water sources. According to Unicef, each gram of human excreta contains 10 million viruses, one million bacteria, 1,000 parasite cysts and 100 parasite eggs. Given the high population density in the country, this is sufficient to trigger widespread diseases. Children are more susceptible to such diseases.A visit to Dholpur district of Rajasthan shows how government efforts to provide health and nutritional care to children through ICDS and anganwadi centres have failed due to lack of sanitation. Dholpur is one of India’s highly malnourished districts. Close to 80 per cent of people here defecate in the open. In Sakhwara village of Dholpur, an open drain, carrying human faeces, passes right through the village. Children and expectant mothers cross the drain on foot to reach the anganwadi. “Diarrhoea and pneumonia have always been part of our lives,” says Bhanmati Pitaka, an elderly woman of the village. “Every monsoon at least five to six children suffer from the diseases in the village.” She claims that the village always had thin children. Lack of sanitation and clean drinking water are the reasons high levels of malnutrition persists in India despite improvement in food availability, says Joe Mediath of Gram Vikash, a non-profit that works on sanitation in India and Africa. A few recent reports also provide evidence that lack of sanitation could be the key reason for high malnutrition. A research paper published in science journal PloS One in September this year concludes that lack of sanitation is a potential contributor to stunting in India. The study was done by Dean Spears of Delhi School of Economics along with Arabinda Ghosh, an Indian Administrative Service official, and Oliver Cumming of the London School of Hygiene and Tropical Medicine. The researchers analysed recently published data on the levels of malnutrition and open defecation in 112 rural districts. They found that 10 per cent increase in open defecation resulted in 0.7 per cent increase in both stunting and severe stunting. “The early-life disease environment is poor: over 70 per cent of households defecate in the open and 71 out of every 1,000 babies born alive die before they turn one,” states the report. The researchers point out another missing piece of the malnutrition puzzle: two-thirds of all adults are literate in this region. In 1999 when the Centre launched Total Sanitation Campaign, its aim was to eradicate the practice of open defecation by 2017. Under the campaign, the government had to provide toilet facilities to schools and anganwadi centres by 2009 and to rural households by 2012. But the Planning Commission report states that the campaign is yet to achieve the targets. Today, India lags behind sub-Saharan Africa in terms of sanitation practices. About 56 per cent people defecate in the open across the country, including rural and urban areas. In sub-Saharan Africa, only 25 per cent the people defecated in the open in 2010, according to the Unicef and WHO. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent households in Nigeria, 38.3 households in Ethiopia and 12.1 per cent households in the Democratic Republic of Congo defecate in the open. “This difference in sanitation practices between India and African countries explains the difference in malnutrition rate,” says Joe. Even in India, good sanitation practices have helped curb malnutrition. Ahmednagar district of Maharashtra is one such example. In 2004 the government successfully implemented the Total Sanitation Campaign in half of the 60 villages in the district. Following this, open defecation stopped in these villages. A few years later, Spears and his fellow economist Jeff Hammer, who were monitoring the health of an experimental group in these villages, found that the average height of children had increased by about one centimetre compared to that of children in nearby 30 villages where the campaign was not introduced. The latest survey by the National Nutrition Monitoring Bureau (NNMB), which conducts surveys in rural and tribal areas to find out nutritional status of people, also brings out this aspect. NNMB found that malnutrition level among children reduced over a period of time despite less intake of food. “The improvement in nutritional status could be due to non-nutritional factors, such as improved accessibility to health care facilities, sanitation and protected water supply,” the report notes. The government should take note of such findings while implementing its anti-malnutrition programme.
Why India Eats Badly
For an aspiring global power, India suffers from shocking levels of malnutrition
The bad news is that India continues to lead most countries in several malnutrition and mortality indicators. The latest UN report places India's maternal mortality as highest in the world at 17% of global maternal mortality . The good news is that the BJP manifesto said that “extreme poverty and malnutrition will be treated as a national priority and will be addressed on mission mode“. This has to be done, because our malnutrition dimensions have now reached a situation of alarm with more than 50% suffering from some form of malnutrition or micronutrient deficiency , resulting in suboptimal cognitive and physical development, low productivity and high health costs.Malnutrition in India is not a woman and child phenomenon, but a population problem. Data of underweight/stunting of children of both sexes, low body mass index and chronic energy deficiency of adolescent girls and boys, and adults, are worrisome, and not what an aspiring world power should have. This demographic emergency should have been addressed through a national programme.
Previous governments have failed to curb this. The Budget speech of 2012 announced a multi-sectoral programme to be rolled out during 2012-13 to address maternal and child malnutrition in 200 high-burden districts. However, no implementation template was sent out to state governments, and I am informed that this is currently still the subject of discussion in states. But, wisely , the government realised that malnutrition needed more than ICDS to cure it, and initiated the policy shift towards the intersectoral strategy , something that had been recommended by the National Nutrition Policy , 1993. We must pick up from this multisectoral shift and compose a strategy that rectifies the disconnect between the causes of malnutrition and the interventions on offer. India's under-nutrition is intergenerational, and rooted not only in poverty and the lack of balance between calories, proteins and micronutrients, but also lack of information and gender inequity . The present interventions do not address structural and systemic causes of India's malnutrition; they are inadequate with poor coverage, and riddled with gaps. This is why their impact has been suboptimal. Start at the Block The unit for inter-sectoral interventions should be the block, and not the district, as the former is more compact and homogeneous, making it easier to engineer “convergence“. The minimum, basic inter-sectoral convergence requires that every targeted family must receive simultaneously benefits of calorie-proteinmicronutrient supplementation, full immunisation of children, IFA for addressing anaemia, safe drinking water and hygienic sanitation. Actual convergence must happen at the community level; its success can be tested through monitoring how many families in a village have simultaneously received these five benefits, four of which are ongoing government programmes. Gender equity and female literacy , also backed by national programmes, are indirect interventions that result in improved nutritional status, through late marriage, fewer children and better awareness. But who will ensure and monitor this convergence at the community level? Regardless of government orders and advisories from above, there must be one functionary in each village who should be given responsibility to ensure this. Presently, there is no one, and we have no data about how many households have received the complete package of their benefits. Let Private Players in We must also overcome our reservations about private sector cooperation in our campaign against malnutrition, and motivate them to assume some responsibility . Maybe companies could make available appropriate low-cost energy foods for poor and malnourished children, women, adolescent girls and boys, the sick, aged and infirm, in rural and urban markets. There is a huge market vacuum in this respect, which has been filled by forcefully advertised low-cost junk food and tobacco products. We must overcome our reservations about private sector cooperation in our campaign against malnutrition, and motivate them to do something |
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