03 Jul,2019

NUCLEAR WEAPONS ABOLITION – TIME IS NOW TO ACT

NUCLEAR WEAPONS ABOLITION – TIME IS NOW TO ACT

 

7th July is a historic day when the UN General Assembly passed Treaty Prohibiting Nuclear Weapons in 2017. The treaty is an opportunity which the global community must utilize to make the world free of nuclear weapons. An opportunity lost may never be regained.

 

World has never been in such uncertain situation in the last several decades as it is now. The ongoing conflicts in several hot spots in the world if not cooled down urgently, may escalate into larger wars. A last minute decision by the US President Trump to not attack Iran has only saved time. The tension still persists. The situation in Syria has been one of the worst scenarios in the recent times.  Iraq and Afghanistan are not yet stabilized.  Internal strife in Somalia, Rawanda and Yemen are other grave scenarios. Our own region, the South Asia is equally volatile. The events following Pulwama terrorist violence which martyred 49 CRPF personnel had almost pushed India and Pakistan to the brink of war. Threat of use of nuclear weapons gave dreadful shiver to the people on both sides. The jingoists on either side of the border took no time calling for destruction of the other. Any use of nuclear weapons would have been catastrophic not only for India and Pakistan, but the whole world. 

 

Ira Helfand, Co-President International Physicians for the Prevention of Nuclear War (IPPNW) and Allan Robock & colleagues from Department of Environmental Sciences School of Environmental and Biological Sciences Rutgers University, New Jersey, USA conducted a study on the Climatic Consequences of limited Nuclear Conflict between India and Pakistan using 100 Hiroshima size nuclear bombs. The study proved with evidence that over 2 billion people would be put to risk globally as an aftermath of nuclear famine which would ensue under such situation. Any nuclear conflict between the major nuclear powers could be end of modern civilization. Such situation is not a utopia. We have already seen unprecedented damage after the atomic bombing of Hiroshima and Nagasaki where over 200000 people were killed. The after effects of radiations are seen even today.  

 

South Asia is one of the poorest regions in the world. The human development ranking for India and Pakistan is at 130 and 150 respectively. Hunger index of India is at 103 and Pakistan at 106 out of 119 countries. About 40% of the world’s stunted children and 53% of all wasted children live in South Asia. Around 34% of the population has no access to sanitation. Investments in health and education remain less than 4% and 3% of respective GDPs. Yet successive governments and military establishments have escalated military spending in India and Pakistan to US$ 64 billion and US$ 11 billion annually in 2017, respectively. India’s defense expenditure is 1.62 % of its GDP, while its central health budget is 0.26 of GDP, six times less than its arms budget. Pakistan’s spending on arms is equivalent with budgetary allocation 8.9 billion USD. With Pakistan worth 300 billion USD economy its defense expenditure comes to 2.9% of the GDP. 

 

As per the latest report of Stockholm International Peace Research Institute (SIPRI) the annual global defense expenditure is US$ 1699 billion (2.2 % of the global GDP). The US tops the defense spending at 611 billion USD. China’s defense expenditure is 215 billion USD, while India is the 5th largest military spender with an outlay of 55.9 billion USD (Rs.363350 crore).  

 

Increase in spending on arms race causes serious resource crunch on health, education and development. The developing countries and poor in these countries are worst affected.

 

It is time, steps are taken for complete nuclear disarmament and end to arms race. On 7th July 2017 historic Treaty Prohibiting Nuclear Weapons (TPNW) passed by the UN General Assembly with 122 votes in favour and only one against. This is a moral victory for the peace movement globally. The Treaty on the Prohibition of Nuclear Weapons opened for signature at United Nations headquarters in New York on 20 September 2017 and will remain open indefinitely. Once 50 nations have ratified or acceded to it, it will enter into force. Already 70 countries have signed it and 23 have ratified.

 

It is a big opportunity for complete nuclear disarmament and save the world from nuclear catastrophe. It is time the nuclear armed states realize this and join the treaty without any ifs and buts. India should take lead.

 

 

29 Jun,2019

Dilution of ESI scheme will compromise with workers health and productivity

Dilution of ESI scheme will compromise with workers health and productivity

 

India has a work force of about 54 crore people. Despite that they are engaged in the productivity and development of the nation, they remain marginalized. Since most of them are in unorganized sectors they are devoid of any social security benefits. Those in the government departments and public sector enterprises, who are covered under social security, are only about 3%. Among the rest work force small number are in formal economy and vast majority, 93%, are in the informal economy. Other than Government and public sector employees, only about 11% of the total work force is covered under the social security schemes.  

The Employees’ State Insurance Scheme (ESIS) is a multidimensional social security scheme meant to provide Socio-economic protection to the employees in the organized sector against the events of sickness, maternity, disablement & death due to employment injury and to provide medical care to the insured employees and their families. The scheme provides full medical care to the employees registered under the ESI Act, 1948 during the period of his incapacity, restoration of his health and working capacity. It provides financial assistance to compensate the loss of his/her wages during the period of his/her abstention from work due to sickness, maternity and employment injury. The scheme also provides medical care to his/her family members. 

 

The ESI scheme is different from any insurance scheme as it covers medical benefit, retirement benefit, sickness benefit, disablement benefit, dependent benefit, maternity benefit, confinement expenses, funeral expenses, unemployment allowance, vocational rehabilitation allowance. It covers from OPD care to in patient care to the post hospitalization expenses. No insurance scheme gives so much coverage. The ESIC could be a guiding scheme where the government directly imparts healthcare at various levels.

It is unfortunate that the Union Government has been initiating ill-advised ‘reforms’ in the ESI Scheme without differentiating between ‘health insurance’ and ‘social security’.

The ESIS is based on contributions by the employers to the amount of 4.75% of the wages and the workers to the amount of 1.75% of their wages. With effect from 1st July 2019, the rates of contributions to ESI Scheme will be reduced from 4.75% to 3.25% of wages for the employers and from 1.75% to 0.75% of wages for the workers, as decided by the Ministry of Labour and Employment. 

The logic given by the government behind this reduction in contribution is that they have accumulated huge reserves out of this scheme. This needs to be studied on the basis of facts. During the period  from 2014 to 2019, ‘non-earmarked reserves’ grew from Rs.15,650 crore in March 2013 to Rs.68,292 crore in March 2019. The reserves have accumulated because of the increase in the income ceiling for coverage under ESIC from Rs.15,000/- to Rs.21,000/- per month in January 2017. This added to the number of workers covered under the scheme, so the contribution amount. The other reason for increase in the reserves is that the government has in fact reduced its spending on the workers. In the year 2014, a lot of changes were effected in the ESI Scheme. These curtailed a majority of benefits under the ESI Scheme, especially the super specialty treatment. This resulted in a huge reduction in the expenditure of the ESI.  The eligibility criteria to get super specialty treatment which was three months of joining the scheme was changed to two year of service. The workers and their families could not avail the facilities during that period. 

Another fact is that while the number of employees covered under the ESI increased from 1.95 crore to 3.11 crore i.e 59.5% during the period from 2014 to 2018, the number of dispensaries increased only marginally from 1418 to 1500 ie. 5.7% only. This has led to further underutilization of funds collected. There are only 44 model hospitals in the whole country, which is too low a number. The condition of the whole system is far from satisfactory as even many of the model hospitals do not have up to date facilities. The infrastructure in terms of modern diagnostics, super specialty care and number of doctors and paramedical staff is not as per the requirement. There is huge rush of patients in each hospital which the unmatched number of doctors find difficult to cope with. Patients’ complaint invariably is that the availability of medicines too is not sufficient.  Many a times the patients are out sourced for diagnostics and treatment. There is need to develop own infrastructure to cater to the needs of the patients effectively.

If proper medical care are extended to all the employees covered under the ESI scheme, as per calculations based on the expenditure towards medical care incurred by the ESIC Delhi, the expenditure on medical care alone may amount to Rs.18400/- crore per annum. (In Delhi, where the primary, secondary and tertiary medical care – all are administered by ESIC directly per capita medical expenditure is Rs.5,555/- in 2017-18). The income from contribution of ESIC in the year 2017-18 is Rs.20077/- crore. Meaning thereby, that the ESI will not save more than Rs.1677/- crore which in fact may not be sufficient to meet the other social security benefits to the employees. Thus the Labour Ministry through its decision, has been instrumental in piling up of huge reserves, without properly utilizing the same for providing social security to the employees and their family members. 

There is need to differentiate between ‘health insurance’ and ‘social security’.

Social security is non-negotiable, as it is enshrined in articles 39(e), 41 and 42 of the Directive Principles of the Constitution of India.   Besides, social security is one of the fundamental principles of the International Labour Organisation (ILO), of which India is also a founding member.   As per the established principles, social security, which is supplementary to the Fundamental Rights of citizens of the country, are mandatory and not something which could be left to the option of either the employees or employers.  Extension of Medical Care, sickness benefit, maternity benefit, employment injury benefit disablement benefit and dependent benefit (family benefit) are mandatory provisions as per internationally accepted social security standards.  Leaving even one of these benefits out of the social security net, would be nothing but working in a manner contrary to the Directive Principles of the State Policy of our Constitution. It has to be clearly understood by the decision makers that productivity of a person depends on his health. Any step to dilute the health scheme will affect productivity and thus development of the nation.

 

25 Jun,2019

Healthcare Education Policy Will undermine the basic essence of medical education

 

Healthcare Education Policy

Will undermine the basic essence of medical education

 

The draft of National Education Policy 2019 is in public domain. This means people across the country can give their inputs on this draft before it is discussed in the standing committee followed by debate in the parliament for formal adoption. The document dwells on various aspects and different sectors of the education. Medical education is generally debated along with the national health policy document where general guidelines about the approach are presented.  But the present National Education Policy document too has given space to it as ‘Healthcare Education’ in the Clause number 16.8. The initial part of the document recognizes “that Healthcare Education must ensure that skilled doctors, nurses, and paramedics are trained in a scheme that appreciates pluralistic health education perspectives alongside specific disciplinary foci. Reforms in medical education must necessarily have a profound impact on the quality of healthcare delivery. The goals and standards for medical education must be derived from the vision of ‘state of the art, quality, and affordable healthcare for all’. Reforms in healthcare education must aim to improve the quality of infrastructure for primary and secondary healthcare, particularly in rural areas. Improving access to healthcare education for rural students, and lowering the cost of education is key to achieving this goal”.

The sub clause 16.8.1 deals with the basics of MBBS training and lays stress on regular assessment of the students. This is important step. It stresses on introducing rotatory internship. The rotatory internship already exists; without a certificate of having done this one does not get the degree. It is another matter that because of pressure of entrance into post graduate courses, the students do not spend much time in it. However for training a basic MBBS doctor for general practice it is important that the young doctors spend stipulated time in the hospital during the internship seriously.

Next clause suggests introducing the basic course for first 1-2 years. After this they will be free to join MBBS, BDS or Nursing etc. It is not clear in this how this will be done. The document leaves the issue to be discussed with the National Medical Commission (NMC). Bridging of courses, that is lateral entry of students from nursing and other disciplines to join is another point taken up in this clause. How this will be integrated is again not clear in the draft.

 

The clause 16.8.3 deals with the exit examination for the MBBS graduates. The document has outlined that the students will appear in the examination after 4thyear. Selection to the post graduate courses will also be made on the basis of this exit examination so that the students do not have to appear in the examination for PG courses again. But what is not clear is the status of the students who are not able to get minimum qualifying marks. These students have already appeared in the final year examination in different subjects. Those who have passed in the regular exam will not get the degree until they get minimum qualifying marks in the exit exam. The students from medical colleges which are better equipped are likely to clear the exit exam. But since the exit exams are in the MCQ format, the result may not be as expected. This is an extra stress on the students. In fact the logic behind it is to discourage the students from getting admission to the substandard colleges. This amounts to in fact running away by the government from the responsibility to ensure quality education in all the colleges. The NEET exam is already under lot of debate. Some states like Tamil Nadu are opposed to it and they lay stress on rules for the medical education to be state specific also. There are also issues of language in the examination.

The WHO recommends one doctor per one thousand of population. Replying to a question, the Minister of State for Health, Smt. Krishna Patel had told in the Lok Sabha that on 31st March 2018 that 1022859 doctors of modern medicine are registered with various state medical councils. She further said that around 8 lakh doctors are actively available at one time. This means that the doctor population ratio in India is 0.62 doctors per one thousand populations. While nearly 70% of India’s population lives in rural areas, the rural India has 1/4th the doctors as compared to urban areas.  This is a huge gap to be fulfilled. Thus we need more doctors for our population. For this the government plans to open more colleges. To fulfill the health requirements of our people we have to have medical colleges which impart relevant training to the students and orient them to the needs of our society and encourage them to work in areas so far neglected.

 

A review of the medical education scenario shows that admission to the medical colleges has been a contentious issue for quite some time. Initially most of the medical colleges were in state sector. Going by the information from the website of Medical Council of India, at the time of independence, there were 20 colleges out which only one was in private sector. Most of new additions were in the state sector till late eighties. But after the shift in economic policies and neo liberal model of development the whole scenario changed. Between the periods 1990 to 2017 number of colleges opened in private sector was 238 while only 115 were opened in state sector. Many of these were made as deemed universities which could have their own examinations, admission system and fee structure.  

 

Many of these were charging under hand money as capitation fee. Merit was completely ignored and money became supreme. Seats are reserved under the management quota where they can charge at their will. For example in the state of Punjab the tuition fee in the government colleges is Rs.13.4 lakh  for the full course of MBBS for 4.5 years. In the private colleges in the seats under the management and the NRI quota it varies from Rs.35 lakh for the full course to Rs.63.9 lakhs. Astonishingly telephonic enquiry from the Era’s Medical College Lucknow revealed the tuition to be 17 lakh per annum which with 10% increase every year comes out to be nearly Rs.91.34 Lakh for MBBS course. The PG seats tuition fee in this college is up to Rs.49 lakhs per year. That means for MBBS and MS/MD both from this college, one will have to pay nearly 2.5 crore rupees and an additional charges for books, travel etc. This means the student has to spend nearly 3 lakh rupees per month or Rs.10000/- per day.

 

This is a cruel joke. In our country where vast majority of population is devoid of even basic needs, it is literally impossible for them to imagine to send their wards to the medical college even when they are on merit. There was hope that after introduction of NEET, capitation fee will end. But what has happened is to the contrary. The private colleges increased their tuition fee and are now earning legally in white money. This will simply undermine the quality of medical education and not fulfill the needs of society we are striving to achieve. Going by the track record it appears that the advice to the MCI to regulate the fee structure can turn out to be an eye wash.

 

The proposal to upgrade 600 district hospitals to teaching ones sounds good. This again would require lot of funds. Similar is the case of post graduate courses in which seats are proposed to be increased. The national medical commission in its outlines has said that the private players will be allowed to open medical colleges where only up to 40% seats fee will be governed while the rest will be free for the institutions to charge the tuition fee.  

 

The situation of the allied branches and paramedical branches is worse. Most of such colleges in private sector that are imparting nursing training, laboratory training and other courses do not fulfill the requirements. Many of these do not have any hospital attachment. The proposals in this document that  these training programmes will be hospital-based, at those hospitals that have adequate facilities, including state-of-the-art simulation facilities, and adequate student-patient ratio and that these courses will be made accessible and affordable to students from rural backgrounds. Focus will also be given to priority areas like physiotherapy, hospital management, medical engineering and technology etc. All this has to be watched. For this we need to increase funds in the public sector. 

 

The proposal to upgrade Ayush is welcome. There is need to make them evidence based and more scientific. 

State must recognize its responsibility to health and education if it really wants to serve the people. Health and medical education cannot be left to market economy mechanism, they should be taken as social responsibility. The governing bodies for the purpose need to be democratic. The structure of NMC has 25 members, all of whom will be nominated by the central or the state government/UT. This makes the regulatory body totally undemocratic with only bureaucratic control and no involvement of various stake holders.

 

 

20 Jun,2019

Cry of the children – who is to care?

Dr Arun Mitra

 

It is time to remember Elizabeth Barrett Browning for her poem ‘The Cry of the Children’ dedicated to the condition of children in England who were made to clean chimneys and work in hazardous industry. As a result many would catch serious diseases and eventually die an early death. The poem examines children's manual labor forced upon them by their exploiters. It was published in August 1843 in Blackwood's Magazine. But since then England has moved far ahead. All the children go to school, get proper nutrition and healthcare required of them. But where do we stand today ! 

 

Death of over 125 children in Muzaffarpur due to Acute Encephalitis is very shocking. At this tender age many of these children would not even know what is happening to them. A timely action could have prevented many deaths and such a big catastrophe. These children come from low income group families and are poorly nourished. Even though exact cause of this disease is not clear but one thing is certain that a malnourished child does not have enough resistance to fight any disease. For the last about 25 years such epidemics occur in the area off and on, but no specific measures have been taken till date.  It is to be noted with deep anguish that the announcements made in 2014 about improving the infrastructure in health facilities in the district have still not been met with even after 5 years. There is serious lack of infrastructure. The number of doctors is less than 25% of the required. Similar is the situation of the paramedical staff. The technical facilities are in extreme shortage. There is need for immediate measures to save the lives of all those who are still alive but ill and also to prevent healthy children from falling sick. The situation should be declared as a calamity and emergency situation. The central government should send immediate financial/medical aid for speedy action. 

Such events are a reflection of total apathy on the part of central and state governments towards the poor people of the region which is known for such epidemics. Only 2 years back similar incident happened in Gorakhpur where 125 children died due to lack of oxygen. That also drew lot of media attention and promises. Good nutrition forms the primary basis of good health. It is even more important at the tender age of first five years of life. But we are one among the worst performers as far as nutrition is concerned. Our hunger index is 103 among 118 countries. It is even worse than some of our neighbors.

Despite economic growth the nutritional status of our children is alarmingly below required standards. In India 44% of children under the age of 5 are underweight. 72% of infants and 52% of married women have anemia. Research has conclusively shown that malnutrition during pregnancy causes the child to have increased risk of future diseases, physical retardation, and reduced cognitive abilities. Malnutrition in our country is both lack of calories as well as lack of intake of nutrients in proper proportion.

All these issues have to be sorted out through a comprehensive healthcare policy with budgeting enough to meet the needs of the people. To ensure good health of our children we have to:

  • Ensure proper nutrition to all the children.
  • Healthy nutrition to all women in reproductive age group.
  • Compulsory regular health checkup and basic investigations of children in the school to know about their health status.
  • Health education to children in schools and to prospective mothers. 
  • To meet the above ensure universal compulsory education.
  • Raise family income by ensuring sufficient remuneration to meet their nutritional needs.
  • Provide healthy environment, proper housing, clean drinking water supply and sewerage facilities.
  • Strengthen midday meal scheme.  
  • Economic measures have to be taken for inclusive growth.

These are the minimum measures needed to be taken to prevent such happenings in future. Public health spending has to be increased immediately to 3% and subsequently to 6% of the GDP in the coming years.

 

18 Jun,2019

Healers, not Predators

Dr Arun Mitra

 

This is not for first time that violence has taken place against the doctors. Maximum of such incidents have occurred in Maharashtra. The violent incidents in Bengal got so much highlighted because the political atmosphere was already surcharged and the approach of the Chief Minster to the whole incident was rather precarious. A few words of sympathy and an assurance of inquiry into the whole incident were needed. No one can work in the atmosphere of uncertainty, particularly so when it comes to treating a person which requires lot of concentration, care and empathy. Persistent resistance by the medical fraternity and the support of senior doctors to the junior colleagues made the chief Minister realize that she was on wrong path. Situation is now defused and doctors are back to work. But this has left several questions which need deep introspection.

What are the reasons for such repeated acts of violence, what are the immediate measures required to prevent such acts and  what are the long term solutions to ameliorate the situation?

When death of a near and dear occurs there can be an emotional outburst. This does not in any way mean that persons should resort to violence. There are several ways to redress the grievances. One must realize that the state hospitals lack infrastructure and good governance. In most of the state run hospitals the young doctors are over worked. Sometimes they have to work continuously for up to 36 hours or more. This puts them under lot of stress and strain.  These young doctors do not have time to explain the seriousness of the condition of the patient to the attendants in details. In the absence of a senior colleague there is a trust deficit which becomes an irritating point for the attendants. Whatever the reason, the society has to understand that those giving treatment are trained to heal, not to kill. As medical students they are taught to be modest and sympathetic. Error is human.  Barring a few black sheep negligence is not a rule but an exception. As negligence cannot be condoned, neither is the violence as a reaction to it justified.

 A national level law against violence on doctors can be a strong deterrent. But many a times those perpetrating violence are ignorant of laws. Such a law may reduce the number of incidents but will not put an end to it completely. Despite such a law, the state of Maharashtra has been witnessing such violent attacks. For violence to come down substantially there is need to strengthen the doctor patient relationship. It is a very pious one based on faith on each other. The society has to realize that there are limitations for doctors. Our health care facilities in state sector lack required infrastructure. With a meager 1.1% of the GDP spending on health in the public sector, the working conditions are not going to improve. Such issues must be shared by the doctors with the public. This will   integrate them with the society. Many doctors live in a shell without mixing with the common man. The doctors  must react to the patients’ concerns. Unfortunately not many medical bodies have reacted to deaths in Muzaffarpur, nor did they do at the time of deaths in Gorakhur. Such preventable deaths are a slur oonour healthcare delivery system. Such issues should be our primary concerns. Medicos should be in the front rows to help the needy in the event of natural calamities. Such gestures help to remove negative feelings in the society about medical professionals.

Medicine is a passion and service. Not denying the fact that a doctor has to earn, the medical profession cannot be made ruthless profit making commercial business as it has become after the entry of corporate sector which view it as a means to reap huge profits. This is failure of the state. Vast majority of our population cannot afford treatment in private sector and have therefore to depend on state sector only.

Because of poor spending on health by the government the patients have to shelve money from their pockets. Nearly 40% of the patients have to borrow for their treatment. No wonder 6.3 crore people of our country are pushed below poverty line because of out of pocket expenditure on healthcare. High cost of treatment in the private sector, particularly in the corporate hospitals has even started affecting the middle classes. There is urgent need to make an inclusive healthcare policy.

Somehow violence is becoming a culture in our country. Calling ourselves followers of Buddha, Guru Nanak and Gandhi we have seen violence to the extreme in 1984, 2002 and now in the form of vigilantes and mob lynching. Some of the law makers have been issuing very irresponsible statements in past and rewarding those involved in mob lynching. Those at the helms of affairs should show more responsible behavior. If violence is eulogized then it becomes a part of psyche which does not spare anyone, even the perpetrators.

 

07 Jun,2019

Health as National Agenda

Dr Arun Mitra

The recently concluded general elections lacked talk on healthcare for the people, even though health and education form basis for development of any society. Unfortunately both of these have been given back seat in the election campaign which has been essentially centered on emotive issues. This is a very sad reflection of our political scenario. Even the representatives of most marginalized sections of the society, who are worst affected due to poor state support on these two core issues, have failed to highlight these points.

In the last about two decades our country has moved ahead in terms of advanced healthcare. But much of it has developed in private sector because of which access is limited to only high income group of our population. Focus on health tourism in healthcare provides opportunities to rich and affluent from abroad to avail advanced healthcare in India at a lower cost of what it is in their countries. These policies however leave vast majority of our population devoid of access to quality healthcare.

The inequalities in health care are a global issue, but they are worse in the developing countries. In 2017 nearly 50% of the world’s total population did not have access to quality essential services to protect and promote health. Around 800 million people were spending 10% of their household budget on out of pocket health expenses. As a result 100 million people were being pushed into extreme poverty every year (1). In our country out-of-pocket expenditure by the households constitutes 63% of Total Health Expenditure (THE). Due to this 6.3 Crore people are pushed below the poverty line every year (2). The share of Out of Pocket Expenditure on health care as a proportion of total household monthly per capita spending is 6.9% in rural areas and 5.5% in urban areas(3). This is considered to be catastrophic expenditure.

According to the National Sample Survey Office’s (NSSO) 71st  round report on ‘Health in India’ (4), India accounts for a relatively large share of the world’s disease burden. Lack of access to food, education, safe drinking water, sanitation, shelter, declining control over land and its resources by the already marginalized sections and falling opportunities for employment further adds to disease burden. There is an epidemiological transition from the communicable diseases to non-communicable diseases.  

Public spending on health in our country is only around 1.1% of its GDP (2015-16). As high as 86% of rural population and 82% of urban population are not covered under any scheme of health expenditure support. The Ayushman Bharat gives coverage only for indoor care whereas about 70% expenditure is incurred on outpatient care. The scheme excludes major part of the low income group population out of it. Rural households primarily depended on their ‘household income/savings’ (68%) and on ‘borrowings’ (25%), the urban households relied much more on their ‘income/saving’ (75%) for financing expenditure on hospitalization, than on ‘borrowings’ (only 18%) (5). About 60% people took treatment without any medical advice. This was primarily attributed to ‘financial constraints’ (57% in rural, 68% in urban). Out of the total medical expenditure, around 72% in rural and 68% in urban areas was made for purchasing ‘medicine’ for non-hospitalized treatment (6).

Recently released National Health Accounts (NHA) Estimate for 2014-15, shows that the Government Health Expenditure (GHE) per person per year is just Rs. 1108. According to NHA, Total Health Expenditure (THE) for the same period worked out to Rs 3,286 per person. Of this, out-of-pocket expenditure was Rs. 2,394 constituting 63% of Total Health Expenditure (7). The Centre:State share in total public expenditure on health was 31:69 in 2015-16. The share of Central government in total public expenditure on health has been declining steadily over the years.

 

India is one among 193 countries who have signed the  Agenda for Sustainable Development Goals (SDGs) launched by a UN Summit in New York on 25-27 September 2015. The Goal No 3 of the SDGs solely focuses on health. It comprises of 13 targets which include, No Poverty, Zero Hunger, Good Health and Well-Being for people, Quality Education, Gender Equality, Clean Water and Sanitation etc. Some of the important targets to be achieved by 2030 include maternal mortality ratio to less than 70 per 100,000 live births, end preventable deaths of new-born and children under 5 years of age, reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. It also envisions to end the epidemics of AIDS, Tuberculosis, Malaria and neglected tropical diseases and combat Hepatitis, water-borne diseases and other communicable diseases. This demands national strategies and programmes to achieve universal healthcare and access to safe, effective, quality and affordable essential medicines and vaccines for all. This requires 5% - 6% of the public spending of GDP. Since our public health spending is around 1.1% only, it sounds difficult to meet these targets. According to SDG Index and Dashboards Report 2018 India’s ranking in SDG is 112. In comparison other South Asian countries barring Pakistan are better in their performance. Their rankings are Pakistan 126, Sri Lanka 89, Nepal 102, Bangladesh 111, Bhutan 83, China 54. In SDG on health India ranks at 143 out of 188 countries(8). 

The NITI Ayog has been given the task to take steps to achieve SDG targets. There is need to involve various stake holders for implementing these. Health is state subject in India, but the health policy decisions are guided by the Central Government. Therefore the government should come out with all details on the steps taken till date. The NSSO data 2018 should be made public. The Ayushman Bharat is based on involving insurance sector. The global experience shows that better results are achieved by state’s direct spending on health. There is need to immediately increase the public health spending to 3% of GDP and increase it to 5% to be able to meet the SDG requirements on health. 

In a Multi-country consultative workshop to assess the progress on implementation of health and health-related sustainable development goals, held at Dubai, 29-30 May 2019, it was observed that the Low and Medium Income countries (LMIC) need special assistance to meet these goals. It is to be ensured that these goals should not meet the fate of Alma Ata declaration signed in 1978. The Alma Ata declaration had envisioned health for all by the year 2000. India too was a signatory to that. But the targets were never achieved. We cannot loose time; effective measures need to be taken for not only the points mentioned in the target 3 on health of the SDGs but the other related targets need to be equally fulfilled if desired results are to be achieved. Special focus has to be laid on gender equality as women are by and large sufferers in the pursuit for better health. Maternal and child healthcare have to be given priority.

Since out of pocket expenditure on health is one of the major causes of impoverishment, families send their children for labor to support day today needs of the family. There are reports that some families mortgage their children to meet healthcare needs. Income disparities have to be reduced. Steps have to be taken for economic reforms targeted at working people’s needs for appropriate remuneration. Ensure job security and food security and. Prices of essential commodities have to be curtailed to make them within reach of low income groups. Growth has to be made inclusive so as to translate its gains to the deprived sections. Goal no.4 stresses on the quality education. This can be fulfilled only through an education policy with increase in public spending on education. Right to Education should apply to all the levels of education. Steps need to be taken for the promotion of good climate.

Goal no.16 is emphatic on peace  and justice. Conflicts are leading to reversals in SDG progress. (9). The countries that are facing armed conflicts and civil wars, more so those in the category of low-income countries are finding it difficult to meet the health objectives. India is the second biggest buyer of arms. Our spending on the defense is adversely effecting the spending on health and education. To reverse this trend it is pertinent to hold mutual dialogue with the neighbors to sort out pending issues. Peace is the most essential to have healthy living.

It is time people come forward to demand the effective implementation of the SDG target on health. Health has to be made a national agenda by the society and force the Indian polity to be serious on health.

References:

  1. World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses, 13 December 2017 

    News Release  Tokyo  https://www.who.int/news-room/detail/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses.
  2. National Health Policy 2017:  http://cdsco.nic.in/writereaddata/national-health-policy.pdf.
  3. Situation Analysis Backdrop to National Health Policy 2017: https://mohfw.gov.in/sites/default/files/71275472221489753307.pdf
  4. Health in India NSS 71st Round Report : http://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdfhttp://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdf
  5. Ministry of Health and Family Welfare - Cabinet approves Ayushman Bharat - http://pib.nic.in/PressReleaseIframePage.aspx?PRID=1525684.
  6. https://www.livemint.com/Politics/30z97MDZDMewkJHsfM5D6I/Medicine-costs-form-bulk-of-outofpocket-health-expenses-N.html
     
  7. National Health Accounts- Estimates for India - 2014-15 - https://mohfw.gov.in/sites/default/files/National%20Health%20Accounts%20Estimates%20Report%202014-15.pdf.
  8. The 2018 SDG Index and Dashboard reporthttps://www.sdgindex.org/assets/files/2018/01%20SDGS%20GLOBAL%20EDITION%20WEB%20V9%20180718.pdf#page=22.
  9. The 2018 SDG Index and Dashboard reporthttps://www.sdgindex.org/assets/files/2018/01%20SDGS%20GLOBAL%20EDITION%20WEB%20V9%20180718.pdf#page=22

06 Jun,2019

Health as nodal point for a lasting peace in South Asia

Dr Arun Mitra

 

With the elections over, it is time to think beyond nuclear rhetoric, surgical strikes, threats of hitting inside the territory and waging war. Such slogans sound good for short term gains, but in the long run these can be catastrophic with serious impact on the life of people.  There is lack of trust among nations in South Asia, particularly in respect to the relationship between India and Pakistan. This mistrust becomes an alibi for the military industrial complex on either side to justify huge military spending. This is done on the pretext of threats, some of them existential and some imaginary. It is therefore important to be realistic in defining and propagating such threats as this concerns our lives.

Global arms expenditure is a cause of serious concern. The US defense budget is about three times as large as China’s. China’s military spending was three times more than India in 2017.  But China’s percentage of GDP spent on defense was less than India’s. The Stockholm International Peace Research Institute (SIPRI) database, estimated that even though China’s military expenditure was USD 228 billion in 2017 while India spent 64 billion, India’s expenditure in terms of GDP was 2.5% of its GDP while China spent 1.9% of the GDP. India’s defense spending increased by around 7 per cent from the previous fiscal year and Pakistan increased its defense budget by around 20% for 2018-19. However, Pakistan being a small country, its defense budget is five times lower. The ‘Military Balance 2018’ report by the International Institute for Strategic Studies (IISS) estimates India overtook the UK as the fifth-largest defense spender in the world in 2017. According to SIPRI, with talk about increasing Military spending towards 3% of GDP, India is likely to be at world number three military spending level. By 2025-2027, India will likely double its military spending.

 In a “The BMJ South Asia collection 2020 Authors’ Consultation”, organized by the British Medical Journal (BMJ) on May 29th 2019’ at Dubai, the issue was seriously debated. Participants from India, Pakistan, Sri Lanka, Bangladesh and Nepal reached a consensus that the South Asian countries have similar health problems and thus common solutions. While there is abundance of Communicable Disease burden, there has been observed that non communicable diseases have shown an increase in the last few years. It is therefore essential that a collective effort is put in to sort out the health related issues. As health indicators of the region are very dismal this becomes even more important. All these countries should increase public spending on health and education and other social needs.

We have to face the challenge to meet the SDG goals on health by 2030. India is one among 193 countries who have signed the  Agenda for Sustainable Development Goals (SDGs) launched by a UN Summit in New York on 25-27 September 2015. To attain indicators of health there is urgent need for poverty eradication; bring down hunger to zero, quality education, gender equality, clean water and sanitation etc. Maternal mortality ratio has to be brought down to less than 70 per 100,000 live births, neonatal mortality to 12 per 1,000 live births and under-5 mortality to less than 25 per 1,000 live births. This requires minimum of 5% - 6% of the public spending of GDP. Since our public health spending is around 1.1% only, it sounds difficult to meet these targets. According to SDG Index and Dashboards Report 2018 India’s ranking in SDG is 112 and Pakistan 126. With ranking at Sri Lanka 89, Nepal 102, Bangladesh 111, Bhutan 83, China 54 these countries are doing better. In SDG on health India ranks at 143 out of 188 countries.

It is time to review our priorities. The civil society has to come forward in all the countries of the region to raise the issues that concern our health. A strong voice is needed to force the decision makers to cut down the arms expenditure. For this there is need for a continuous dialogue among nations and monitoring by the civil society. Health as a common goal can be the nodal point for a lasting peace in the region.

 

25 May,2019

Challenge of Healthcare for the New Government

Dr Arun Mitra

 

The elections are over and it is just a matter of procedures that the new government will take over. The people have given unprecedented mandate. Even though the basic issues were missing in the election campaign, but at the end of the day people would expect steps to be taken by the new government to improve their lot in terms of employment opportunities, job security, proper remuneration, quality healthcare and education etc. Even though unfortunately none of these were in the frontline of the agenda of the elections, however they remain core issues of life.

 

It is admitted by repeated documents of the government including the national health policy 2017 document that as a result of out of pocket expenditure on health 6.3 crore people of or country are pushed below poverty line. This is a serious issue. There is immediate need to improve this situation. There is need for several steps to be taken to ameliorate the situation.

 

Health is a basic requirement of all individuals irrespective of caste, creed, gender, religious groups or economic status. It is therefore imperative that health is recognized as a fundamental right. There is need to enact National Health Bill as Right to Health care Act that can guarantee that every citizen shall have right to comprehensive and quality healthcare at state’s expense, in a government health facility, and in case of its non-availability in a private health facility. Health should be included in the concurrent list of the Constitution and adoption of a National Health Policy legally binding on the executive.

 

To meet the above it is urgently required that public spending on health should be increased. The share of Out Of Pocket Expenditure on health care as a proportion of total household monthly per capita expenditure was 6.9% in rural area and 5.5% in urban area. This poses heavy burden on the households. More than 40 per cent of the population has to borrow or sell assets for treatment, according to the 2004 National Sample Survey Organisation. The estimated costs of Universal Health coverage range between 4 and 6 per cent of GDP. Though considerable, this financial commitment is achievable. As an immediate step the public health spending should be increased from 1% to 2.5% and then to 5% in the coming four years. Direct spending by the government has shown better results compared to the insurance based healthcare delivery system worldwide.

 

National Health Profile 2015; Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India estimates that expenditure on medicines constitutes nearly two-thirds (60%) of out of pocket expenditure, forcing them to get buried in quagmire of poverty.  There is need to implement a Rational Drug Policy that allows drugs to be sold only under their generic names. Exempt production of generics from patent rules. Ensure improved availability, accessibility and affordability of drugs including vaccines and sera in the public health system; through quality conscious pooled procurement systems and promotion of manufacture of essential medicines. There is need to adhere to policy of cost of production for ceiling of drug price.

 

In the last few decades there has been shift from opening the medical colleges in the state sector to the private sector. This process has been further speeded up in the last four years. In the year 2017 there were 214 government medical college and 253 private medical colleges. In the period between 2014-2017 the number of new medical colleges opened was 36 in government sector and 58 in the private sector. The colleges in the private sector charge exorbitant fee to the tune of rupees one crore for the MBBS course. Most of these colleges lack proper infrastructure and violate the norms and forms of medical ethics.  There is commercialization of medical education. Policy should be change to open more medical colleges in the state sector.  

 

Set up Primary Health Centre at every 30000 population, with 24-hour service, a Health Sub-Centre at every 5000 population and a fully staffed Community Health Centre with all facilities at every 100000 population. Establish round-the-clock ambulance service at every 30000 population. Post women medical and paramedical personnel in all health centres and hospitals in adequate numbers. All Government health facilities should adhere to Indian Public Health Standard (IPHS) norms.

Social determinants of health like safe drinking water, sewage facilities, clean environment, proper housing, sufficient remuneration, employment opportunities and job security must be given priority. Rules should be framed accordingly. Arrange assured safe drinking water supply through piped water in all habitations, total sanitation in all households and localities, and enforce complete safeguards against air, water and soil pollution by industries, mines and other developmental projects.

Eliminate Malnutrition by implementing National Food Security Act 2013 which aims to provide subsidised food grains to approximately two thirds of India’s people and ensures Maternity entitlements to all pregnant women. Set up Nutrition Rehabilitation Centre at each block to address the issue of severely malnourished children.

 

Whereas our spending on health is very low, we are spending huge amount on arms race including the nuclear weapon system. Presently India is the second biggest buyer of arms in the world and also aspires to become an arms exporting country. We have to play a leading role in initiating mutual dialogue with neighbours to strengthen peace and divert money towards health, education and development. 

 

 

24 May,2019

NUCLEAR RHETORIC BY SHRI NARINDRA MODI A DANGEROUS CONNOTATION

Dr Arun Mitra

 

Nuclear rhetoric by the prime minister in his election speech at Barmer on 21st April that India does not have nuclear weapons for Diwali is irresponsible, dangerous and provocative. Counter statement by Mehbooba Mufti that Pakistan does not have these weapons for Eid have brought to the fore how vulnerable situation in our region could be. Prime Minister’s statement may fetch him some votes and applaud from innocent followers and admirers, but it shows complete lack of statesmanship that his utterances could have far flung impact.

 

The events following Pulwama terrorist violence which martyred 49 CRPF personnel had nearly pushed India and Pakistan to the brink of war. Threat of use of nuclear weapons gave dreadful shiver to the people on both sides. The jingoists on either side of the border took no time calling for destruction of the other. But for the timely release of Wing Commander Abhinandan and public opinion of the saner elements in the civil society situation could have taken ugly turn leading to catastrophic collateral damage and mutually assured destruction since both India and Pakistan are nuclear weapons possessing countries. 

 

Ira Helfand, Co-President International Physicians for the Prevention of Nuclear War (IPPNW) and Allan Robock  & colleagues from Department of Environmental Sciences School of Environmental and Biological Sciences Rutgers University, New Jersey, USA conducted a study   on the Climatic Consequences of Nuclear Conflict between India and Pakistan using 100 Hiroshima size nuclear bombs. The study warns that over 2 billion people would be put to risk globally as an aftermath of nuclear famine which would ensue under such situation.  

 

South Asia is one of the poorest regions in the world. The Human Development Index ranking for India and Pakistan is at 130 and 150 respectively. Hunger index of India is at 103 and Pakistan at 106 out of 119 countries. About 40% of the world’s stunted children and 53% of all wasted children live in South Asia. Around 34% of the population has no access to sanitation. Investments in health and education remain less than 4% and 3% of respective GDPs. Yet successive governments and military establishments have escalated military spending in India and Pakistan to US$ 64 billion and US$ 11 billion annually in 2017, respectively. India’s defense expenditure is 1.62 % of its GDP, while its central health budget is 0.26 of GDP, six times less than its arms budget. Pakistan’s spending on arms is equivalent with budgetary allocation 8.9 billion USD. With Pakistan worth 300 billion USD economy its defense expenditure comes to 2.9% of the GDP.   

 

Increase in spending on arms race causes serious resource crunch on health, education and development. The developing countries and poor in these countries are worst affected.

 

It is time, steps are taken for complete nuclear disarmament and end to arms race. The Treaty Prohibiting Nuclear Weapons (TPNW) passed by the UN General Assembly on 7th July 2017 is a big opportunity for complete nuclear disarmament and save the world from nuclear catastrophe. It is time the nuclear armed states realize this and join the treaty without any ifs and buts.

   

India has been harbinger in the peace movement. India’s role under the leadership of Jawahar Lal Nehru in founding Non Aligned Movement has been path breaking. Rajiv Gandhi action plan for nuclear disarmament is still relevant. We must take initiative to join the TPNW. Let peace and disarmament become a leading factor in the region instead of jingoism for electoral benefits. Role of peace movements in India is very vital in the present context.  Absence of timely realization of this could trigger the situation to disaster as the type of rhetoric made recently is likely to be repeated any time and may not remain just in worlds next time.       

References:

  • https://www.ippnw.org/pdf/Bombay.pdf

17 May,2019

India’s Pursuit to meet Sustainable Development Goals on Health

Dr Arun Mitra

 

To ensure empowerment of vulnerable groups  women, children, young people, persons with disabilities, older persons, refugees, internally displaced persons and migrants and  to protect human rights the 2030 Agenda for Sustainable Development was launched by a UN Summit in New York on 25-27 September 2015 which has 193 countries as signatories(1). It envisages “a world of universal respect for human rights and human dignity, the rule of law, justice, equality and non-discrimination”. The Agenda has 17 Sustainable Development Goals (SDG), and 169 targets which seek to eradicate poverty, promote human rights and achieve gender equality. The agenda became effective from 1st January 2016.

 

The UNO has defined sustainable development as that meets the needs of the present without compromising the ability of future generations to meet their own needs. To achieve sustainable development it is important to have economic growth social inclusion and environmental protection.   The Sustainable Development Goals (SDGs) are not legally binding, nevertheless, countries are expected to take ownership and establish a national framework for achieving the 17 Goals. Implementation and success will rely on countries’ own sustainable development policies, plans and programmes (2).


The Goal No 3 of the Sustainable Development Goal (SDGs) solely focuses on health, which is “to ensure healthy lives and promote well-being for all age groups (3)”.

 

SDG-3 comprises 13 targets. These include No Poverty, Zero Hunger, Good Health and Well-Being for people, Quality Education, Gender Equality, Clean Water and Sanitation, Affordable and Clean Energy, Decent Work and Economic Growth, Industry, Innovation and Infrastructure, Reduced Inequalities, Sustainable Cities and Communities, Responsible Consumption and Production, Climate Action, Life below Water, Life on Land, Peace, Justice and Strong Institutions, Partnerships for the Goals.

 

Targets to be achieved by 2030 include maternal mortality ratio to less than 70 per 100,000 live births, end preventable deaths of new-borns and children under 5 years of age, reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births, end the epidemics of AIDS, Tuberculosis, Malaria and neglected tropical diseases and combat Hepatitis, water-borne diseases and other communicable diseases, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being, strengthen the prevention and treatment of substance abuse, halve the number of global deaths and injuries from road traffic accidents, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes, achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.

 

WHO has estimated cost of reaching global health targets by 2030 (4). A study conducted by the Lancet Global Health shows that investments to expand services towards universal health coverage and the other SDG health targets could prevent 97 million premature deaths globally between now and 2030, and add as much as 8.4 years of life expectancy in some countries. While most countries can afford the investments needed, the poorest 67 low- and middle-income countries that face the greatest challenges in terms of expanding health services will need assistance to reach the targets. "Universal health coverage is ultimately a political choice. It is the responsibility of every country and national government to pursue it," says  Dr Tedros Adhanom Ghebreyesus, the Director-General of WHO.

 

To meet the SDG target would require up to US$ 371 billion or US$ 58 per person by 2030. This would require health spending as a proportion of gross domestic product from an average of 5.6% to 7.5%. The global average for health spending as a proportion of GDP is 9.9%. Although higher spending does not necessarily translate to improved health, making the right investments at the right time can.

 

For India it is a big challenge to meet the SDG goals on health. Our public health spending is around 1.1% only. This is too low an expenditure on health. Our Maternal Mortality Rate is 130 per 100000 live births. To bring it down to 70 requires political will. India’s under 5 mortality rate was 43 in 2015. It has to be brought down to 25 and the Infant mortality rate has to be brought down to 12 from 34 in 2016 (5).

 

According to SDG Index and Dashboards Report 2018 India’s ranking in SDG is 112. In comparison other South Asian countries barring Pakistan are better in their performance. Their rankings are Pakistan 126, Sri Lanka 89, Nepal 102, Bangladesh 111, Bhutan 83, China 54. In SDG on health India ranks at 143 out of 188 countries (6). 

 

The government’s recently announced health scheme Aushman Bharat is based on involving insurance sector. The global experience shows that health has improved by direct spending by the state. There is need to immediately increase the public health spending to 2.5% of GDP and increase is to 5% to be able to meet the SDG requirements on health.  

 

References: 

  1. https://www.coe.int/en/web/programmes/un-2030-agenda
  2. https://www.un.org/sustainabledevelopment/development-agenda/
  3. https://www.nhp.gov.in/sustainable-development-goal-(sdg)_pg
  4. https://www.who.int/en/news-room/detail/17-07-2017-who-estimates-cost-of-reaching-global-health-targets-by-2030
  5. https://www.livemint.com/Opinion/dwStpMl7oSnvNz4sMEia5L/India-needs-a-better-report-card-to-meet-SDG-targets-on-heal.html
  6.  https://sdsnyouth.org/sdg-index-2018

 

 

16 May,2019

ABSENCE OF HEALTH DISCOURSE IN THE ELECTION PROCESS IS UNFORTUNATE

With election fever picking up, the blame game is increasing with every passing day. Issues concerning the people are not being highlighted as they should have been. The ruling party has very cleverly brought the rhetoric against Pakistan as core issue. The speeches by the first rank leadership are by and large ignoring the issues of health and education. Even though the points related to healthcare have been mentioned in the manifestos of the various parties but until and unless they are emphasized by the leadership in their public discourses time and again, these do not become part of people’s mind. A critical analysis of the manifesto of two major parties shows some differences in the approach.

The manifesto of the BJP is centered around eulogizing the Ayushman Bharat which is said to cover 50 crore people for in patient care only. It nowhere talks of how to get the rest 80 crore people in the scheme in future. Moreover it does not give any proposal of  bringing the people seeking outpatient care only in the scheme. Thus it sans any step towards universal healthcare. It talks of opening more medical colleges but does not give any information on whether they will be in the state sector or the private sector. This is important because the number of medical colleges opened in the last few years is more in the private sector. These colleges are charging exorbitant tuition fee which makes them out of reach of even the middle class families. The manifesto also does not talk of increasing public spending on healthcare which is essential for ensuring quality healthcare to the common citizens.

The manifesto of Congress  party recognizes the healthcare as a right of every citizen. It promises to increase the public spending from present 1.1% to 3% of the GDP by the year 2023-24 with step by step increase in every budget. What is needed is immediate increase to 2.5% of the GDP to be raised to 6% in the next five years. The manifesto promises to enact Right to Healthcare Act ‘that will guarantee to every citizen the right to healthcare services, including free diagnostics, out-patient care, medicines and hospitalisation through a network of public hospitals and enlisted private hospitals’. That the manifesto recognizes insurance based model not a preferred model to provide healthcare is a welcome note. It promises to implement free public hospital model to provide universal healthcare. Increasing the number of doctors by establishing more medical  colleges, providing scholarship and loans  to the medical students.

The manifesto of the left parties highlights the right to free health as a fundamental right. Increase in the public health spending to 6% of the  GDP, end to commercialization of medical education. Strengthening of public health facilities, fixing the drug prices based on their cost of production and enact patent laws favourable to our country.

However these are documents which are important in a way that the governments to come can be questioned on their performance based on the promises made in the manifesto. But what is lacking is special forceful emphasis in the public speeches by the political leaders. This reflects lack of sensitivity to the health issues to the required level even though it is admitted that nearly 6% of the population is pushed below poverty line because of catastrophic out of pocket expenditure on health. There are also reports that financial stress as a result of out of pocket healthcare expenditure is an important cause of suicide among farmers. It is time for public to act and force a pro-people healthcare discourse.

11 May,2019

SEWERMEN’S HEALTH – WHO WILL CARE?

 

SEWERMEN’S HEALTH – WHO WILL CARE?

 

One cannot help but tremble at the very thought that even today human beings go down in the gutters full of garbage to clean them manually. During the process they get submerged in the waste, which we even hate to smell. It is not unlikely that deep in the sewer where hot dirty water and soiled waste is flowing, some of it enters into the mouth and stomach leading to serious health problems. As a result many of them fall prey to several diseases of skin, eyes, oral cavity, respiratory system, gastrointestinal tract, nervous system and may develop even mental problems. In extreme situations they fall unconscious after inhaling poisonous gases which many a times proves fatal.  

 

Sewer gas is a complex mixture of toxic and nontoxic gases produced and collected in sewage systems by the decomposition of organic household or industrial wastes. Typical sewer gases include hydrogen sulfide, ammonia, methane, esters, carbon monoxide, sulfur dioxide and nitrogen oxides(1).

 

Exposure to low levels of hydrogen sulfide causes irritation of the eyes and respiratory tract. Other symptoms include nervousness, dizziness, nausea, headache and drowsiness. This gas smells like rotten eggs, even at extremely low concentrations (2). Inhalation of the combination of the two toxic gases hydrogen sulfide and carbon monoxide and the suffocating gas methane is can be fatal (3).

 

Government of India had notified Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 and Rules 2013. The act recognises that working near or in a manhole inherits potential dangers which may result in serious accidents and in some extreme cases, loss of life as well. The common accidents include falls/slips, fire or explosion, oxygen depletion, gas poisoning, heat stress, drowning, asphyxiation arising from gas, fume, vapour and entrapment by free-flowing solids. Amongst these, dangerous gases are easily overlooked or neglected, leading to serious casualties. The health and safety of personnel can be safeguarded to a great extent by use of safety equipment and by taking precautions appropriate for each hazard condition. 

 

It is ironical that despite latest scientific knowledge about the hazards involved in manual scavenging of sewers, this practice continues to exist. Central Public Health Environmental Engineering Organisation under the Ministry of Housing (CPHEEO) and Urban Affairs Govt. of India has  set Standard Operating Procedures (SOP) for cleaning of Sewers and Septic Tanks. There are several directions given in it (4).

 

These have to be followed before sending a person in the sewer, which is to be done in an extreme case, otherwise manual scavenging has to avoided. The CPHEEO has given a list of 44 equipment required for the purpose. Some of these include Protective Suits, Head lights, Air blowers, emergency medical kits, Ambulance at the cleaning site and breathing apparatus. It is mandatory for the supervisor to explain the dangers involved in going down the sewer to the person and to obtain his written consent. It is important to check gas level beforehand and to give proper time for aeration of the sewer. In case the gas level is dangerous then air as to be blown in. The scavengers have to be trained personnel for the job and their medical examination has to be done to ensure that they are in good health.

 

It is ironical that despite reports of hazards, the number of deaths is not coming down. Bezwada Wilson, founder of the Safai Karamchari Andolan says that as of now 1760 persons have died in the sewers. He contests the government’s data of only 666 deaths.

 

The issue that why till date we have not been able to check this practice, requires deep introspection. Even though the act was framed in 2013, the instructions are hardly followed. There is complete lack of monitoring system. Legal action against the defaulters is very weak.  There is need to devise and follow proper monitoring and stringent punishment to the defaulters. 

 

There is need for proper education of the workers engaged in cleaning work. Since most of them come from low education status, they have to be briefed about the health hazards. In the situation of grave unemployment such workers are likely to be exploited by the vested interests who have no care for the human beings. Even though the Hon’ble Supreme Court  had passed an order of giving 10 lakh compensation to the effected family of the deceased, it is not easy for the family to get it. There is need to strengthen the collective efforts by the unions of the Safai Karmacharis in this regards. It is ironical that the authorities do not have exact data of how many people have died cleaning sewers or received compensation(5).

 

 

References:

  1. https://en.wikipedia.org/wiki/Sewer_gas
  2. Sewer Gas | Wisconsin Department of Health Services:  https://www.dhs.wisconsin.gov/air/sewergas.htm
  3. Bad Air: Sewer Gas and Death | The Crime Fiction Writer's Blog https://writersforensicsblog.wordpress.com/2015/09/22/bad-air-sewer-gas-and-death/
  4. http://164.100.228.143:8080/sbm/content/writereaddata/AMRUT%20SOP%20Book%20Final.pdf
  5. https://thewire.in/labour/sewer-cleaning-deaths-compensation

 

02 May,2019

SPREADING THE MYTH OF COW URINE

The claim by Ms.Pragya Thakur, BJP candidate from Bhopal, that her cancer was cured by cow urine has once again brought to the fore the issue whether medical science in our country will be governed by myths or by scientific evidence based approach.  Dr.S.S Rajput, a surgeon at Ram Manohar Lohia Institute of Medical Sciences in Lucknow has confirmed that he had done three radical operations on her breasts to get her rid of cancer. The doctor’s statement has exposed the claim of Sadhvi about cow urine as a cure of her breast cancer.  

 

Benefits of cow urine for human consumption have been propagated since long. The propaganda has increased manifold after the present government came to power. Any item to be consumed by us must be proven for its usefulness and harmlessness. This is even more important for the products labeled to be used for medicinal purpose.

 

Modern scientific system of medicine enhanced the knowledge gained in the past and developed it further on the basis of new scientific innovations.  Anatomy and Physiology made us understand the basic structure and functioning of the life systems. Our body has an elaborate system to utilize whatever is needed and to excrete those materials which are either not required or are harmful. It is a common knowledge that part of the food which we consume is digested and rest is excreted through the gastrointestinal track. After the food has been metabolized in the body, the waste products are excreted in urine. The chemical composition of urine of mammals is essentially the same. That cow urine is different from human urine sans evidence. 

 

Urine is a liquid produced by the kidneys to remove waste products from the bloodstream.  Basic composition of cow/human urine are Water, Urea, Sodium, Chloride, Sulfate, Potassium, Phosphate, Creatinine, Ammonia, Uric Acid, Calcium, Magnesium etc. Since the composition of human and cow urine are similar, it is difficult to believe that with similar composition how only the cow urine is useful for human body?

 

To get scientific information of the utility of the cow urine and cow dung for the human consumption, information under RTI was obtained from the Department of Animal Husbandry, Dairying and Fisheries, government of India. They replied that “the information is not maintained by this CPIO of cattle Division”. Simultaneously same information was sought from the Guru Angad Dev Veterinary and Animal Sciences University (GADVASU), Ludhiana. The information received from 22 departments of the GADVASU denied any such information with them. It is worth mentioning here that GADVASU, Ludhiana, has been ranked first among the 14 state veterinary universities in the country, as per the ranking of agricultural universities and research institutes conducted by the Indian Council of Agricultural Research (ICAR), New Delhi, for 2016-17.

 

Thus there is no scientific information available about the usefulness of cow urine for human health at the highest level of academics in the veterinary. On the contrary some studies have reported toxic effects of cow urine concoction. Moreover cow urine consumed in crude form could be infectious and may lead to serious health problems.

 

 

Many scientists have already exposed the claims by Baba Ramdev and others that the cow urine destroys the ‘poison like Betadine’. They show in their experiment that the pure water discoloured by adding Betadine to it is again purified by adding cow urine into it. This occurs with any urine because of the chemical reaction of Sodium Thiosulphate present in the urine which reacts with Tri-Iodide ion present in Betadine. When the two react there is formation of Sodium Iodide which is a colourless solution and this reaction is same with any urine.  

 

According to veteran historian D N Jha, the cow and its products (milk, curd, clarified butter, dung and urine) or their mixture called Panchagavya assumed a purificatory  role during the medieval period. But here too several Dharmasastra forbid its use by women and the lower castes because if a Shudra drinks cow urine he goes to hell.

 

Therefore one has to be to be skeptical about the role of cow urine for human health. The evidence does not hold true on that. It is more of a  belief system than science. The propaganda about the benefits of the cow urine in the recent days seems to be connected to the Hindutva Agenda of the RSS and its outfits. It is part of their strategy to push the society back to the medieval times.

 

It is high time that the Ministry of Pharmaceuticals as well as the Ministry of Health intervene to stop this propaganda. It is for the election commission to see whether spreading of such obscurantist unscientific ideas meets the requirement to cancel her nomination.

 

 

 

References:

https://www.ncbi.nlm.nih.gov/pubmed/6314793

http://servecows.org/chemical-composition-of-distilled-cow-urine/

https://www.thoughtco.com/the-chemical-composition-of-urine-603883 

https://www.youtube.com/watch?v=rjMbE9flUhQ

24 Apr,2019

NUCLEAR RHETORIC BY SHRI NARINDRA MODI A DANGEROUS CONNOTATION

NUCLEAR RHETORIC BY SHRI NARINDRA MODI

A DANGEROUS CONNOTATION

 

Nuclear rhetoric by the prime minister in his election speech at Barmer on 21st April that India does not have nuclear weapons for Diwali is irresponsible, dangerous and provocative. Counter statement by Mehbooba Mufti that Pakistan does not have these weapons for Eid have brought to the fore how vulnerable situation in our region could be. Prime Minister’s statement may fetch him some votes and applaud from innocent followers and admirers, but it shows complete lack of statesmanship that his utterances could have far flung impact.

 

The events following Pulwama terrorist violence which martyred 49 CRPF personnel had nearly pushed India and Pakistan to the brink of war. Threat of use of nuclear weapons gave dreadful shiver to the people on both sides. The jingoists on either side of the border took no time calling for destruction of the other. But for the timely release of Wing Commander Abhinandan and public opinion of the saner elements in the civil society situation could have taken ugly turn leading to catastrophic collateral damage and mutually assured destruction since both India and Pakistan are nuclear weapons possessing countries. 

 

Ira Helfand, Co-President International Physicians for the Prevention of Nuclear War (IPPNW) and Allan Robock  & colleagues from Department of Environmental Sciences School of Environmental and Biological Sciences Rutgers University, New Jersey, USA conducted a study   on the Climatic Consequences of Nuclear Conflict between India and Pakistan using 100 Hiroshima size nuclear bombs. The study warns that over 2 billion people would be put to risk globally as an aftermath of nuclear famine which would ensue under such situation.  

 

South Asia is one of the poorest regions in the world. The Human Development Index ranking for India and Pakistan is at 130 and 150 respectively. Hunger index of India is at 103 and Pakistan at 106 out of 119 countries. About 40% of the world’s stunted children and 53% of all wasted children live in South Asia. Around 34% of the population has no access to sanitation. Investments in health and education remain less than 4% and 3% of respective GDPs. Yet successive governments and military establishments have escalated military spending in India and Pakistan to US$ 64 billion and US$ 11 billion annually in 2017, respectively. India’s defense expenditure is 1.62 % of its GDP, while its central health budget is 0.26 of GDP, six times less than its arms budget. Pakistan’s spending on arms is equivalent with budgetary allocation 8.9 billion USD. With Pakistan worth 300 billion USD economy its defense expenditure comes to 2.9% of the GDP.   

 

Increase in spending on arms race causes serious resource crunch on health, education and development. The developing countries and poor in these countries are worst affected.

 

It is time, steps are taken for complete nuclear disarmament and end to arms race. The Treaty Prohibiting Nuclear Weapons (TPNW) passed by the UN General Assembly on 7th July 2017 is a big opportunity for complete nuclear disarmament and save the world from nuclear catastrophe. It is time the nuclear armed states realize this and join the treaty without any ifs and buts.

   

India has been harbinger in the peace movement. India’s role under the leadership of Jawahar Lal Nehru in founding Non Aligned Movement has been path breaking. Rajiv Gandhi action plan for nuclear disarmament is still relevant. We must take initiative to join the TPNW. Let peace and disarmament become a leading factor in the region instead of jingoism for electoral benefits. Role of peace movements in India is very vital in the present context.  Absence of timely realization of this could trigger the situation to disaster as the type of rhetoric made recently is likely to be repeated any time and may not remain just in worlds next time.       

References:

  • https://www.ippnw.org/pdf/Bombay.pdf

 

16 Apr,2019

ABSENCE OF HEALTH DISCOURSE IN THE ELECTION PROCESS IS UNFORTUNATE

16.04.2019

 

ABSENCE OF HEALTH DISCOURSE IN THE ELECTION PROCESS

IS UNFORTUNATE

With election fever picking up, the blame game is increasing with every passing day. Issues concerning the people are not being highlighted as they should have been. The ruling party has very cleverly brought the rhetoric against Pakistan as core issue. The speeches by the first rank leadership are by and large ignoring the issues of health and education. Even though the points related to healthcare have been mentioned in the manifestos of the various parties but until and unless they are emphasized by the leadership in their public discourses time and again, these do not become part of people’s mind. A critical analysis of the manifesto of two major parties shows some differences in the approach.

The manifesto of the BJP is centered around eulogizing the Ayushman Bharat which is said to cover 50 crore people for in patient care only. It nowhere talks of how to get the rest 80 crore people in the scheme in future. Moreover it does not give any proposal of  bringing the people seeking outpatient care only in the scheme. Thus it sans any step towards universal healthcare. It talks of opening more medical colleges but does not give any information on whether they will be in the state sector or the private sector. This is important because the number of medical colleges opened in the last few years is more in the private sector. These colleges are charging exorbitant tuition fee which makes them out of reach of even the middle class families. The manifesto also does not talk of increasing public spending on healthcare which is essential for ensuring quality healthcare to the common citizens.

The manifesto of Congress  party recognizes the healthcare as a right of every citizen. It promises to increase the public spending from present 1.1% to 3% of the GDP by the year 2023-24 with step by step increase in every budget. What is needed is immediate increase to 2.5% of the GDP to be raised to 6% in the next five years. The manifesto promises to enact Right to Healthcare Act ‘that will guarantee to every citizen the right to healthcare services, including free diagnostics, out-patient care, medicines and hospitalisation through a network of public hospitals and enlisted private hospitals’. That the manifesto recognizes insurance based model not a preferred model to provide healthcare is a welcome note. It promises to implement free public hospital model to provide universal healthcare. Increasing the number of doctors by establishing more medical  colleges, providing scholarship and loans  to the medical students.

The manifesto of the left parties highlights the right to free health as a fundamental right. Increase in the public health spending to 6% of the  GDP, end to commercialization of medical education. Strengthening of public health facilities, fixing the drug prices based on their cost of production and enact patent laws favourable to our country.

However these are documents which are important in a way that the governments to come can be questioned on their performance based on the promises made in the manifesto. But what is lacking is special forceful emphasis in the public speeches by the political leaders. This reflects lack of sensitivity to the health issues to the required level even though it is admitted that nearly 6% of the population is pushed below poverty line because of catastrophic out of pocket expenditure on health. There are also reports that financial stress as a result of out of pocket healthcare expenditure is an important cause of suicide among farmers. It is time for public to act and force a pro-people healthcare discourse.

 

06 Apr,2019

WORLD HEALTH DAY PLEDGE

WORLD HEALTH DAY PLEDGE

 

Since the year 1950 the 7th of April is observed as world health day all over the world. The decision to observe this day was taken by the world health assembly in 1948 at Geneva. It is an important day to highlight the plight of people’s health and thence plan strategy to take steps to ameliorate the related problems. The objective is to increase public awareness of various causes and prevention of different diseases and also to provide knowledge how to prevent their complications. It is important to impart knowledge to the people about how to take self-care.  It is also time to ask governments to provide healthy environment.

 It is a matter of concern that health still remains a pipe dream for large number of population.  In 2017 nearly 50% of the global population did not have access to quality essential services to protect and promote health. Around 800 million people were spending 10% of their house hold budget on out of pocket health expenses. As a result 100 million people were being pushed into extreme poverty. Situation in the poor countries is more pathetic.

 

In our country despite advances in healthcare there persist gross inequalities in access to it. The low socio economic groups have difficulty in getting modern healthcare.  Inequalities persist in terms of geography, caste, religion and gender as well. Rising cost of health care adds to these inequalities. Out-of-pocket expenditure by the patient constitutes 63% of Total Health Expenditure. The share of Out of Pocket Expenditure on health care as a proportion of total household monthly per capita expenditure is 6.9% in rural areas and 5.5% in urban areas.

The communicable diseases have been the major cause of illness in our country. Many of these can be prevented by simple measures through health awareness in the public. The air borne diseases like the influenza can be prevented if the persons take precautions like covering their face with mask and to maintain distance from the patient. Tuberculosis is another illness which can be prevented by avoiding contact with the patient. Many vector borne diseases can be prevented by taking care of the vector. The Dengue, Chikungunya and Malaria can be prevented by avoiding the mosquito bite and checking reproduction of mosquitoes. For this people be encouraged to remove stagnant water from the area, to use mosquito nets and mosquito repellents. Many water borne diseases like the jaundice and other abdominal infections can be prevented by using clean drinking water and boiled water. Simple measures like washing hands before eating, washing vegetables in running water, not to eat uncovered food products, to avoid preserved food, to do exercise regularly, to take balanced diet can prevent many diseases. Since the non-communicable diseases are increasing in the society, there is need to inculcate basic knowledge about their prevention. Senior citizens and children who are more prone to be taken ill need more attention through awareness among their families. There is also need to give knowledge about the methods of waste management. Such above said measures do not incur huge cost. What is needed is change in habits, life style and some medical tips.  

It is also important to rid the society of myths about diseases particularly in the low socio economic and less literate section of the society. Even today large number of our population is swayed away by myths. They visit the faith healers in the pursuit of better health. Some of the common diseases they look for remedy from such faith healers are Mumps, Chicken Pox, Bell’s Palsy, epilepsy, sexual problems, infertility etc. Many a times such beliefs cause delay in treatment and worsening of illness. Preaching to produce ‘customised babies through garbh vigyan sanskar’ by the the “Arogya Bharti” is pushing the society to medieval times. But when such practices are patronized by those at the helms of power it is a very serious issue. Not too long back two ministers of the Gujarat government felicitated the ‘tantriks’ in one of their conferences.

Unfortunately health care is not a major issue in the public discourse. There is need to make debate on healthcare a day-to-day agenda of the public. The medical organizations have to play vital role for this.  Medical professionals along with Anganwadi & Asha workers and local level social  activists have to come forward. Health committees should be formed  at the Mohalla and the Village level which should discuss the health concerns of the area as well as policy matters pertaining to health in general. Written information through pamphlets, group meetings and interactive sessions can pay real long term dividend.

 

30 Mar,2019

With ASAT would we be really secure?

With ASAT would we be really secure?

Not long ago when on 11th May 1998 India conducted nuclear test, there was lot of jubilation by the government and the workers of the ruling party. People were made to believe that with this India will become a powerful country to reckon with. Those who raised skepticism about the whole programme were dubbed not standing with national interest. In response, the Pakistan government conducted nuclear tests just after 17 days on 28th May. Whereas India had done 6 explosions, Pakistan did seven. The whole talk of powerful nation with nuclear weapons got subdued. With this, we got into nuclear arms race, spending huge amount on nuclear weapons programme. At present both countries spend exorbitant amount on arms race in comparison to the expenditure on the social needs.  

Now that Indian government has developed Anti Satellite missile (ASAT), it would be naïve to believe that our neighbouring country will not react to it. Even though the Anti-Satellite missiles are not directed towards Pakistan because they do not have any satellite, yet Pakistan would not tolerate the macho image of India. China too has satellites. However it is not possible to target them.

Pakistan reaction will be seen in due course of time. But the situation has become murkier. The whole campaign against the weaponisaiton of outer space may be weakened. Many technologically developed countries have not jointed this star wars programme because there is a general agreement that outer space should be left without any such waste.

ISRO is a respectable organisation which has to its credit developing satellites for communication and other purposes. This apparent move during election days is not only undesirable but dangerous. We cannot afford to waste our resources in such competition and develop programmes with a desire to create a sham image nationally and internationally. Statements by the Finance and Defence minister that the test firing is India's bid to prepare for "tomorrow's war" is unwarranted and too ominous.

At this time when the electioneering is its peak, the Prime Minister should lay more emphasis on health, education and social indices. It is risky to justify the achievements of scientific community by statements like “My aim is to make every Indian feel secured. I have great belief in the countrymen’s capabilities, commitment, dedication and ability to craft unitedly a nation which is strong, prosperous and secure. I envision such a Bharat where people can imagine such futuristic projects and garner the courage to go forward.”

India is signatory to the Outer Space Treaty reached in January 1967. International treaty is binding on the parties to use outer space only for peaceful purposes.

We must plan our strategies based on priority needs of our people. India ranks at 140 in human development index and Pakistan at 150. Our hunger index is 103 out of 118 countries and Pakistan’s is 106.  While the government admits below poverty line people to be 20% of our population, the unofficial figures may be much higher. India’s happiness index fell from 133 to 140 last year out of 156 countries as per the survey by the Sustainable Development solutions network under the UN. Investments in health and education remain less than 4% and 3% of respective gross domestic product (GDP) in the region. These are serious issues which to be addressed.

We should develop new strategies to combat terrorism in south Asia. Rhetoric against each other has not paid till date. We are a big country with immense diversity. It is time to take initiatives for a sustainable peace and development.

 

09 Mar,2019

DIFFERENTLY ABLED NEED CARE - NOT MOCKING

Disability is an unfortunate part of human life which affects the natural way of living. It becomes a cause of misery and dejection. It becomes the cause of disadvantage and restriction of activities. In our country persons with disabilities do not get attention which is due to them. They become subjects of mercy and pity. Even though such people have several rights under various Indian laws as well as UN conventions that are followed in India, but there is by and large apathy towards them. This apathy adds to the feeling of despair among such people who have physical, sensory or mental impairments. We must realize that such persons need special care if we have to get best out of them. They may not be able to perform several functions which other people can do, but they can do well in many fields. That is why they are called as differently abled persons. What these people need is their rightful place in the society. They need special rights from the society and the government not pity from any one. 

In the Hindu mythology when Rishi Ashtawakra, who had several deformities on his body, entered the ‘sabha’ of Raja Janak, the ministers sitting there started laughing at him. In response he too started laughing. He was asked that people sitting in the sabha were laughing at his disfigured body, but why did he laugh? He replied that he had thought that this sabha is a gathering of wise men. But I am sorry to say, he said that there is hardly any intellect in this gathering. Their insensitivity and poverty of intellect is reflected from their behavior that they judge a person by his appearance not by the qualities he possesses. This story can be compared to the episode at IIT Kharagpur in which the Prime Minister addressed the meeting of engineering students where a young lady was explaining about an app developed to help the dyslexics.  Suddenly, to the astonishment ofevery one the Prime Minister interrupted and said, “Will this help  40- or 50-year-old persons?” Then after a pause he continued “That will make their mother happy!”  The IIT should have been wise enough to invite someone who could meet their expectations on science instead of the Prime Minister Narendra Modi because science is not his domain. It is well known that he is poor in knowledge and lacks sensitivities. He has grandiose & megalomaniac behaviour. His mocking at the function has brought to the fore the poverty of thinking specifically in respect to the differently abled persons.  

Dyslexia is a learning disorder which can cause problem with reading, writing and spelling. A dyslexic person is not in intellect. He has difficulty in decoding single words like b may be read as d ordoes may be confused with goes. He makes errors in reading and writing. Because of inconsistencies such persons develop complex in facing new situation and develop anxious behaviour. There are special training facilities for the persons with disabilities which can help to bring them to the main stream of society.

Our society attributes many disabilities to the god’s will or a result of Karmas of the previous life. The term ‘Divyang’ is an outcome of this thinking. This is escaping  responsibility to care such persons because once it is will of god we cannot do much about it and be satisfied with it. It is because of this insensitivity which is inherent part of thinking of many of us that the students of IIT who are supposed to be cream of the society clapped when Narendra Modi made fun of dyslexia by making remarks on his political opponent.  They only know whether their response was after they understood the intention of the prime Minister or it was a part of behavior that everyone must laugh when the king laughs. But whatever the reason, it showed lack of scientific temper among the students of that level and lack of courage to question the wrong. Making mockery of the disabled person is ethically & morally wrong and socially inappropriate; more so when it comes from the mouth of a person who is custodian of the nation.

Such a behavior from the person of the level of the Prime Minister should have been widely condemned. But barring a few activists and organizations most of the social and medical organization have kept themselves aloof from the issue. Even the medical organizations, the IMA or the organizations involved in caring for such children have not come out in open in large number in protest. This is a worrisome issue reflecting inertia in the society. Disability can befall on any individual or family. So far we do not have any such mechanism to study the genetic structure of the parents and counsel them about parenting to prevent disabilities in the offspring. Even Thalassemia   which can be prevented by genetic counseling and advice about marriage is not any issue in our country. Instead we believe in myths and take the advice of horoscopes when it comes to matrimonial matters. There is need for social awareness on such issues. However, in no case, making disability as an issue in election campaign can be condoned.

 

Dr Arun Mitra

 

02 Mar,2019

HEALTH IN WAR TIMES

Dr Arun Mitra

 

War is the one of the most serious threat to public health with catastrophic effects on infrastructure & environment and accounts for more deaths and disability than many major diseases combined. It destroys families, communities and sometimes-whole cultures. It channels limited resources away from health and other social needs. 

 

The escalation of tension between India and Pakistan has to be viewed in that context. When the tension persists there is always an imminent danger of its entering into larger war. Warning about such situations, Maj. Gen. (Retd.) Vinod Saighal in a letter to the Prime Minister in 1990 had written “another war between India and Pakistan could result in physical suicide for Pakistan, economic suicide for India and a catastrophe for the subcontinent". It holds true now as well, even more so. Events in the last few days are witness to it. In wars, wellbeing of people is the chief concern; their livelihood, health, nutrition and other needs all become uncertain. 

 

The issue in the present context is of much more seriousness as both India and Pakistan are one of the most deprived in the world. The priorities in the two countries have to be to correct the abysmally poor human development index of 130 and 150 in India and Pakistan respectively. Hunger index of India at 103 and Pakistan at 106 out of 119 countries is a matter of grave concern. War will mean destruction and further deprivation, hunger, disease, mental problems and unprecedented loss of life.

 

Health effects during war times range from displacements, injuries, incapacitation, mental stress, lack of food, under nutrition, starvation and death. During the two world wars around 9 crore people are reported to have died.  In 1965 Indo-Pak war which lasted for 17 days the Indian army suffered 11,479 casualties with 2862 killed and 8617 wounded and according to Indian records 5800 Pakistanis were killed. Inter-communal violence between Hindus, Sikhs and Muslims at the time of partition had resulted in between 500,000 and 1 million casualties.

 

During war times there occur large number of displacements from near the border areas and people have to live in the refugee camps. There were 21.3 million refugees worldwide in 2015. The health indicators of refugee population are poorer than the communities from which they come. They are more prone to diarrheal diseases, measles, acute respiratory infections, malaria, malnutrition and other infectious diseases. The incidence of Sexually Transmitted Diseases and HIV transmission are high in refugee camps due to engagement with sex workers, rape, and insufficient access to reproductive health services.

 

Refugee camps are generally away from the main population and poorly accessible by road, and lack basic amenities like clean drinking water supply, proper sewerage system and have a limited power supply. The high mobility of the refugee setting, with the constant inflow and outflow of people, presents a unique challenge because it is difficult to provide sustained care over a period of time.

 

Loss of family life, death of near and dears, uncertainty of the future leads to extreme mental stress; the children are more likely to be affected. They are likely to develop Post Traumatic Stress Disorder (PTSD). Women and children are worst sufferers as they are more vulnerable to be abused. All this affects their behavior even after the things get settled down and they return to their native places.

 

The International Physicians for the Prevention of Nuclear War (IPPNW) in its Aiming for Prevention - International Initiatives on small arms had carried out One Bullet Stories by its IPPNW-Kenya affiliate. The One Bullet Story (OBS) is about the people, their stories, and the injuries caused by the guns and bullets. It was done with the aim to infuse the human face into the campaign against armed violence by highlighting the plight of the victims through their experiences and powerful testimony. Health professionals are in the front lines as the primary witnesses of the horrific impact of firearm violence.


The Ottawa Process that led to the Mine Ban Treaty achieved its high level of success largely through the exposure of the plight of the victims and survivors of the mine explosions. It is the gruesome photos of the innocent and unsuspecting civilians injured by the Antipersonnel Mines (APMs) that created the public outcry and attracted high profile personalities like the late Princess Diana to the campaign. The initiators of this outcry were the International Committee of the Red Cross (ICRC) field surgeons such as Robin Coupland MD who brought the focus of the international community to bear on the indiscriminate and horrific nature of landmine injuries. 

 

Nuclear weapons have totally changed the war scenario. Testimonies by the Hibakusha (Atomic Bomb Survivors of Hiroshima and Nagasaki) would move any one. It is of utmost urgency that tension between India and Pakistan has to be deescalated. Present day bombs are much more deadly compared to those dropped at Hiroshima and Nagasaki. Even a limited nuclear war would put over 2 billion people at risk. It is through highlighting the Humanitarian Impact of Nuclear Weapons that the IPPNW and the International Campaign to abolish nuclear weapons (ICAN) played a vital role in getting the Treaty Prohibiting Nuclear Weapons (TPNW) passed in the UN General Assembly in July 2017 and won the organization Nobel Peace Prize that year.

 

There is no place for Jingoism in such situation. Any talk of war today means mutually assured destruction. Nothing is more precious than a healthy life of our children.  



References:

http://www.uniteforsight.org/refugee-health/module1

https://emergency.unhcr.org/entry/111814/health-in-camps

https://www.unhcr.org/health.html
//economictimes.indiatimes.com/articleshow/49032326.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

 

23 Feb,2019

Malnutrition in India – Who will take care?

Arun Mitra

 

The report published in the Drug Today Medical Times on 19thFebruary 2019 by Shri B S Rawat  that  244 malnutrition deaths occurred in Delhi hospitals in 4 years is highly alarming. This report is based on the information received on an RTI information provided by Deputy Director of Delhi based State Family Welfare Bureau Shri C K Dutta to Shri Raj Hans Bansal.  It is an extremely serious matter because Delhi is capital of the country and  despite its serious pollution problems it is a dream city for millions of Indians who come here for education and in search of jobs besides tourism. Large number of workforce come to Delhi from different states to work in factories, dhabas, households and other places. Many of them live in shanty areas without proper water supply, hygiene or housing.

Quoting Health Minister Deepak Sawant the PTI had reported on 22nd July 2018 that as many as 19,799 children died in Maharashtra between April 2017 and March 2018 due to various reasons, including poor weight and respiratory illnesses. The main reasons of death during the period were poor weight at the time of birth, premature delivery, contagious diseases, congenital respiratory illnesses and deformities, besides others.  The Minister said this in a written reply during the Monsoon Session of the Legislative Council in Nagpur.

Despite the claims of substantial growth in the GDP our country is unable to provide sufficient food to feed its population; it is unable to provide access to food to a large number of people,  especially women and children. According to Food and agriculture Organisation (FAO) estimates in ‘The State of Food Security and Nutrition in the World, 2018” report, 195.9 million people are undernourished in India. By this measure 14.8% of the population or 1 in 4 children is undernourished in our country. Also, 51.4% of women in reproductive age between 15 to 49 years are anaemic. Further according to the report 38.4% of the children aged under five in India are stunted (too short for their age), while 21% suffer from wasting, meaning their weight is too low for their height. Malnourished children have a higher risk of death from common childhood illnesses such as diarrhea, pneumonia, and malaria. The Global Hunger Index 2018 ranks India at 103 out of 119 countries on the basis of three leading indicators -- prevalence of wasting and stunting in children under 5 years, under 5 child mortality rate, and the proportion of undernourished in the population.

The Malnutrition is caused due to lack of balanced diet. India's malnutrition problem results not from calorie intake but from dependence on a carbohydrate based diet low in protein and fat. Another factor triggering malnutrition is inadequate sanitation, which triggers an increase in infection-borne deficiencies in nutrients.  

There are two major types of malnutrition:

  • Protein-energy malnutrition - resulting from deficiencies in any or all nutrients.
  • Micronutrient deficiency diseases - resulting from a deficiency of specific micronutrients.

     

According to the reports up to 40 per cent of the food produced in India is bound to get wasted. About 21 million tonnes of India's entire wheat produce are wasted and 50 per cent of all the food across the world meets the same fate.  India Wastes As Much Food As United Kingdom Consumes.

Child malnutrition impacts on economic productivity. The mental impairment caused by iodine deficiency is permanent and directly linked to productivity loss. Maternal malnutrition increases the risk of poor pregnancy outcomes including obstructed labour, premature or low-birth-weight babies and postpartum haemorrhage.

 

Animal studies have shown that malnutrition can cause decrease in brain volume, number of neurons, synapses, dendrites and reactive zones. ... The greatest effect of malnutrition on brain development is experienced during the time of rapid brain growth which is first three years of life. This is the period during which the brain is vulnerable.

To prevent malnutrition one needs plenty of fruit and vegetables, plenty of bread, rice, potatoes and other starchy foods, some milk and dairy foods, some meat, fish, eggs, beans and other non-dairy sources of protein.

The Lancet, one of the most authentic medical journals has come out with daily dietary recommendation for 2500 calories from various food items fulfilling caloric requirements, as well as ingredients essential for growth of different body parts and mental faculties. An estimation of the cost of this daily diet based on the present day price of the food items comes out to be approximately Rs.130 per person per day. For a family of 5 members this comes out to be Rs.650 per day or Rs.19500 per month. This is impossible to be met with in present day economic structure of our country.

The minimum wage in India as recommended by the expert Committee, in the name of national minimum wage, amounts ranging from Rs 8892 to Rs 11,622 per month meant for unskilled worker. This is far below the level of minimum wage recommended by 7thPay Commission. The trade unions have been demanding minimum wage to be Rs.18000/- even though this also does not meet the nutritional requirements. The major work force in our country is in the unorganized sector where these acts are hardly implemented. The agriculture labour and the marginal farmer is worst affected.

Bold socio-economic initiatives coupled with public movements are needed to ameliorate the situation if we really want to care for our children and make them physically and mentally strong and to a strong nation. Midday meal is a good scheme. It needs to be implemented effectively. But ultimately it is the increase in purchasing capacity of the people which can sort out the issue of mal nutrition.  

References:

 

16 Feb,2019

Collective effort needed to save life and health

Arun Mitra

 

Terrorist violence in Pulwama which killed our brave young soldiers fighting to save the sovereignty of the country has shaken the whole nation. Each citizen is aghast at this violent act. There is natural wide spread anger and feeling of revenge. Life is the most sacred thing on earth. It is beyond imagination how can one think of destroying this beautiful gift of nature. Medical profession has through the history worked to save life and promote good health. Doctors around the world work day and night for preserving life and preventing disease so that we do not fall sick. In the event of being taken ill medics put forth all their efforts to get the person rid of illness and put him/her back to work. Every year millions are spent globally on doing research to invent new methods of treatment so that the generations to come can lead a healthy life. Death is the end of life which doctors try their best to prevent. This is why it is important to oppose violence of all kinds.

 

It is unfortunate that our region which is one among the most deprived in the world is suffering the heat of violence constantly in one form or the other leading to further deprivation of our resources away from our basic needs to wasteful expenditure on arms race. Terrorist violence has killed large number of people both in India and Pakistan.

 

As per a report by National Consortium for the Study of Terrorism and Responses to Terrorism, A Department of Homeland Security Science and Technology Center of Excellence, Based at the University of Maryland published in September 2018 number of terrorist attacks globally in 2017 was 8584 which caused death of 18753 people and injured 19461 persons.

 

During the same year there were 574 terrorist attacks in Pakistan causing death of 851 persons. In India there occurred 860 attacks leading to death of 380 persons including the incidents in Chhattisgarh and North East. Both the countries have witnessed serious terrorist violence incidents like the attack on Indian Parliament in 2001 and Mumbai in 2008. In Pakistan the worst incident has been the terrorist attack on school children in Lahore.

 

Such violence leaves behind a long tale of unforgettable events and misery. Those injured in such violence have to suffer all their life due to the loss of limbs, eyes or other organs besides the mental disorders including Post Traumatic Stress Disorder (PTSD). Children lose their school education and worst is the loss of love and affection and care of parents.

Such events create a natural hatred against the perpetrator and demands for a similar response and stringent action.  But such situations have to be tackled with much seriousness and statesmanship. Rhetoric may yield catastrophic results.

War is the one of the most serious threat to public health with catastrophic effects on infrastructure & environment and accounts for more deaths and disability than many major diseases combined. It destroys families, communities and sometimes-whole cultures. It channels limited resources away from health and other social needs.

In the present situation any talk of aggression could be of serious consequences as both countries are nuclear weapons possessing countries. The use of these weapons in the event of a war cannot be ruled out. The death of over 200,000 people killed by atomic bombing of Hiroshima and Nagasaki and the effects of radiation fallout are still not forgotten. Present day nuclear weapons are much more deadly. Even a limited use of 100 nuclear weapons could put 2 billion people at risk.  

 

It is time to work collectively to curb the menace of terrorism which is totally inhuman and dastardly act. Whereas it is important to defend the sovereignty of the nation, it is imperative to wage ideological struggle  against terrorism through civil society actions against fundamentalism, conservatism and also creation of more avenues for education and job opportunities.

 

Reference:

https://www.state.gov/documents/organization/283097.pdf

 

07 Feb,2019

Health Care - What the political parties must promise

Dr Arun Mitra

Despite advances in health care there persist gross inequalities as far as access to it is concerned. Even today the low socio economic groups have difficulty in getting modern healthcare.  Inequalities also persist in terms of geography, caste, religion and gender. High out-of- pocket expenditures, with the rising financial burden of health care adds to these inequalities. Out-of-pocket expenditure by the patient constitutes 63% of Total Health Expenditure. As a result every year 6.3 Crore people are pushed below the poverty line in India due to health care costs. The share of Out of Pocket Expenditure on health care as a proportion of total household monthly per capita expenditure is 6.9% in rural area and 5.5% in urban area. This led to an increasing number of households facing catastrophic expenditure due to health costs. A large proportion of the population still lacks access to food, education, safe drinking water, sanitation, shelter, land and its resources, employment and health care services. It affects both the occurrence of disease and access to health care.

The recently launched National Health Protection Scheme (NHPS) reduces universal health care to health insurance coverage, and that too for only 50 Crore population while the rest 80 Crores are left out. Moreover it covers only inpatient care even though more than 60% of healthcare cost incurred by the patient is on outpatient treatment. The private health insurance companies and health care providers are already expecting huge windfalls from NHPS. With significant involvement of the private sector, the scheme is clearly indication of a shift from public provisioning of health towards privatization. These would have far reaching implications especially in the area of healthcare.

Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill-health and the deaths of poor and marginalised people. Health for all means that powerful interests have to be challenged. That globalisation has to be opposed, and that political and economic priorities have to be drastically changed.

It is in this context that the political parties should come forward with promises on healthcare in the coming elections to the Lok Sabha.

Political parties have to agree to that the attainment of the highest possible level of health and well-being is a fundamental human right, regardless of a person's socio-economic and ethnic background, religion, gender, age, abilities, sexual orientation, class or caste. The principles of universal, comprehensive Primary Health Care, envisioned in the 1978 Alma Ata Declaration, should be the basis for formulating policies related to health.  

Therefore the parties should promise to:

Enact National Health Bill  as Right to Health care Act that can guarantee that every citizen shall have right to comprehensive and quality healthcare at state’s expense, in a government health facility, and in case of its non-availability in some cases in a private health facility.

Include health in the concurrent list of the Constitution. Adopt a National Health Policy legally binding on the executive.

Promise to take positive steps so that governments promote, finance and provide comprehensive Primary Health Care as the most effective way of addressing health problems and organising public health services so as to ensure free and universal access.

Enhance public spending on health to 4 per cent of GDP .

Set up a standing National Commission of Health with judicial powers to which the bureaucracy would be answerable followed by such commissions at state level.

Put an end to privatisation of public health services and ensure effective regulation of the private medical sector, including charitable and NGO medical services.

Set up Primary Health Centre at every 30000 population, with 24-hour service, a Health Sub-Centre at every 5000 population and a fully staffed Community Health Centre equipped with all modern facilities at every 100000 population. Establish round-the-clock ambulance service at every 30000 population. Post women medical and paramedical personnel in all health centres and hospitals in adequate numbers. All Government health facilities should adhere to Indian Public Health Standard (IPHS) norms.

Arrange assured safe drinking water supply through piped water in all habitations, total sanitation in all households and localities, and enforce complete safeguards against air, water and soil pollution by industries, mines and other developmental projects.

Eliminate Malnutrition by implementing National Food Security Act 2013 which aims to provide subsidised food grains to approximately two thirds of India’s people. Set up Nutrition Rehabilitation Centre at each block to address the issue of severely malnourished children.

Promote people’s spending power by ensuring sufficient wages so as to meet their nutritional needs.

Expenditure on medicines constitutes nearly two-thirds (60%) of out of pocket expenditure. There is need to implement a Rational Drug Policy that allows drugs to be sold only under their generic names. Exempt production of generics from patent rules.

Ensure improved availability, accessibility and affordability of drugs including vaccines and sera in the public health system; through quality conscious pooled procurement systems and promotion of manufacture of essential medicines.

Strengthen Public Sector Units to make cheap bulk drugs.

Adhere to policy of cost of production for ceiling of drug price with no more than 30% trade margin.

Establish a regularly updated Indian National Formulary on the lines of British National Formulary to provide unbiased prescribing information and rational guidelines for use of drugs.

The estimated costs of Universal Health coverage ranges between 4 and 6 per cent of GDP. This financial commitment is achievable. What is required is political will for this if we want to build healthy India.

 

02 Feb,2019

Combating Malnutrition Bold socio economic initiatives needed

Arun Mitra

 

The Lancet, one of the most credible medical journals took up the challenge to study the dietary patterns around the world and then come up with recommendations for a healthy diet. It formed an EAT Lancet Commission for the purpose which had 37 members on it. From our country, a renowned Cardiologist and President of Public Health Foundation of India, Dr.K.Srinath Reddy and Ms.Sunita Narayan- Director General, Centre for Science and Environment  and  editor of the Down to Earth were the part of this team. The commission’s exercise was done with focus on how to maintain good health of a person in regard to dietary intake and the impact of present day dietary patterns on environment. The commission studied and need to develop such dietary habits which are sustainable and ensure availability of sufficient food in times to come. The recommendations also highlight need for intake of micro nutrients required for physical and mental growth. Thus they have come out with recommendations about diet which is essential, healthy and also environmental friendly. Its basic recommendations include less intake of red meat & sugar and increase the intake of vegetables.  

The recommendations also take into concern the report of Food and Agriculture Organization of UNO which points out that emissions from the global livestock account for 14.5% of the green-house gases emission as a result of the human activity.

Despite economic growth the nutritional status of our children is alarmingly below required standards. Roughly 40% of children under five are stunted and 21% of children under five are severely wasted or undernourished. Needless to say that a well-nourished child is likely to have better immunity and has more chances to remain healthy and grow well. Most of the undernourished children come from poor socio economic groups. 

In India 44% of children under the age of 5 are underweight. 72% of infants and52% of married women have anemia. Research has conclusively shown that malnutrition during pregnancy causes the child to have increased risk of future diseases, physical retardation, and reduced cognitive abilities.

Malnutrition in our country is both lack of calories as well as lack of intake of nutrients in proper proportion.

 

The Lancet diet chart has given a deep insight into daily requirements of balanced food, fulfilling caloric requirements, as well as ingredients essential for growth of different body parts and mental faculties. Question however is now to fulfill these in the socio economic structure of our society?   

The average approximate cost of this diet was found to be around Rs.130 per person per day. For a family of 5 members this comes out to be Rs.650 per day or Rs. 19500 per month. This is impossible to be met with in present day economic structure of our country. According to the World Bank data 27 crores people in our country are poor who cannot afford two square meals per day. With the economic reforms undertaken by the government there is constant onslaught on the poor strata of people. Jobs are being constantly contractorized and outsourced. Wages of workers are falling every day. The social security benefits are being withdrawn. For these people it is a nightmarish job to feed themselves with a balanced diet. There is thus need for very strong economic reforms for job security of workers, fixing minimum wages based on persons daily food intake and his/her other needs of family including clothing, housing, education, recreation etc.  For this we need a powerful public movement if we have to feed our children and develop a healthy nation.

Lancet Diet Chart:

Food Item

Recommended intake per day in grams

Caloric intake per day

 

Cost in Rupees February 2019

Whole grain

Rice, Wheat, Corn and others

232

811

 

   7

Tubers of starchy vegetables

Potatoes and cassava

50 (0-100)

39

 

  2

Vegetables

All vegetables

300 (200-600)

78

 

  10

Fruits

All Fruits

200 (100-300)

126

 

  20

Dairy Foods

Whole milk or equivalents

250 (0-500)

153

 

 15

Protein Sources

Beef, Lamb and pork

Chicken and other  poultry

Eggs

Fish

Legumes

Nuts

14 (0-28)

29 (0-58)

13 (0-25)

28 (0-100)

75 (0-100)

50 (0-75)

30

62

19

40

284

291

 

  7

  7

  5

 12

  7

25

Added fats

Unsaturated oils

Saturated oils

40 (20-80)

11.8 (0-11.8)

354

96

 

 5

 5

Added Sugar

All sugar

31 (0-31)

120

 

2

   

TOTAL

 

129

 

Reference:

https://www.google.com/search?q=malnutrition+india+2018&oq=malnutritinin+indi&aqs=chrome.2.69i57j0l5.7784j0j8&sourceid=chrome&ie=UTF-8

 

https://www.weforum.org/agenda/2019/01/why-we-all-need-to-go-on-the-planetary-health-diet-to-save-the-world/

 

https://doctor.ndtv.com/nutrition/national-nutrition-week-2018-status-of-malnutrition-in-india-1910586

 

https://www.savethechildren.in/articles/malnutrition-in-india-statistics-state-wise

 

 

26 Jan,2019

HANDING OVER GOVERNMENT HOSPITALS TO THE PRIVATE SECTOR WOULD PUSH ALREADY MARGINALIZED SECTIONS TO FURTHER IMPOVERISHMENT

The Punjab government through a public notice given in the newspapers has invited expression of interest from the private NGOs, doctors or others for providing services in the Government Hospitals and running of health institutions situated in difficult areas.  This has drawn sharp reaction from various sections in the state including medical organizations, civil society groups and political parties. Such a decision of Punjab government to hand over hospitals under its care to the private sector will have serious detrimental impact on health services in the state. It will escalate the cost of treatment and increase the out of pocket expenditure on health. Public health spending by the government in the state is already very low. The state has more of a curative oriented healthcare. Public spending on preventive healthcare is only around 8% compared to the recommendation of National health policy document  2017, which says that more than two-third of the resources should be allocated for primary care. Therefore because of obvious reasons of lack of proper nutrition, lack of clean drinking water supply and sewerage facilities and absence of proper housing poor households have to bear the catastrophic expenditure on healthcare. 

 

 

The research papers titled ‘Health-care utilization and expenditure patterns in the rural areas of Punjab, India’ published in  J Family Med Prim Care   and ‘Sub-national health accounts: Experience from Punjab State in India’  have brought forward some relevant points and made recommendations to improve the healthcare in the state. The total health expenditure of Punjab is around 4.11% of Gross State Domestic Product (GSDP). Share of public health expenditure is less than one-fourth of this. The Out of Pocket Expenditure by the patients is more than 76%. People have to shelve from their pocket to get healthcare the cost of which has gone high after increase in the non-communicable diseases for which they go to private sector.

 

 

More than 10% of the household expenditure on health is considered as catastrophic. In the above studies it was found that Catastrophic expenditure was incurred by 7% of the households while seeking outpatient care and by 53% while seeking inpatient care. Catastrophic expenditure was more often borne by households in poorer quintiles. About, 23.3% of outpatient and 59% of the inpatient health-care expenditures were financed through borrowings or from other sources such as sale of assets suggesting financial hardship in meeting health expenses. Need to borrow even for outpatient health care was higher in the poorer household expenditure quintiles. In rural Punjab, 67% of increases in poverty were estimated to be due to Out of Pocket expenditure.

 

 

Global experience has shown that dependence on the curative care does not sort out our healthcare problems. It is therefore needed to spend more on preventive aspect. The strengthening of primary health care is the only way to have Universal Health Care. The public health spending thus has to be increased to minimum of 2.5% immediately followed by raising it to 4% in subsequent years. Availability of medicines in public healthcare facilities should be ensured as major chunk of expenses is incurred on purchasing medicines.

 

 

 

The retraction by the Health Minister after public outcry that there is no such plan to handover government hospitals to the private sector is to be viewed with skepticism. He has said that this was to strengthen the public health system by inviting private specialists to give healthcare in the government hospitals and that this could be a trial in few selected hospitals. The excuse that government has dearth of doctors and therefore need for Public Private Partnership is not a correct understanding. It is because of lack facilities and infrastructure in the state hospitals that many doctors trained in various specialties do not opt for state services. After all they want to utilize their talent to the best of their ability. This is just an alibi to handover public sector facilities to the private sector. Handing over state sector hospitals for better services  has already been experimented and failed in the state of Bihar. Medical education forms the basis of training of doctors. Due to exorbitant fees in the private medical colleges in the state many deserving students cannot get admission in the medical course. Last year when some Private Medical colleges increased tuition fees arbitrarily the Minister stood with them and supported their increase in fees. This has already put much burden on the medical students and their families. Expensive medical education coupled with expensive healthcare delivery system under the PPP mode will make healthcare even more expensive.

 

It is important to control the corruption in the healthcare system rather than handing over the government hospitals to the private sector. The corporate sector would jump into this and will further enhance the atmosphere to a unaffordable health care. The statutory & regulatory bodies should be strengthened to control the unfair happenings in the healthcare and check the prices of drugs and medical devices. 

 

It is the duty of the government to provide healthcare to its citizens. India is signatory to the Alma Ata declaration for universal healthcare and is thus bound by this international treaty. However successive governments have failed to keep their promises. But by handing over its own hospitals the state government has completely washed off its hands from its responsibility.

 

References:

  • Bahuguna P, Mukhopadhyay I, Chauhan AS, Rana SK, Selvaraj S, Prinja S (2018) Sub-national health accounts: Experience from Punjab State in India. PLoS ONE 13(12): e0208298.https://doi.org/10.1371/journal.pone.0208298, it was reported that ‘In 2013–14.
  • Singh T, Bhatnagar N, Singh G, Kaur M, Kaur S, Thaware P, Kumar R. Health-care utilization and expenditure patterns in the rural areas of Punjab, India. J Family Med Prim Care [serial online] 2018 [cited 2019 Jan 21];7:39-44. Available from: http://www.jfmpc.com/text.asp?2018/7/1/39/231571)

 

Dr Arun Mitra                                            Dr G S Grewal

Member Core Committee                                         Member Core Committee

Alliance of Doctors for Ethical Healthcare                Alliance of Doctors for Ethical Healthcare

Former Chairman Ethical Committee                    Former President

Punjab Medical Council                                              Punjab Medical Council

 

10 Jan,2019

POOR OUTRAGE FROM MEDICAL AND SCIENTIFIC COMMUNITY A CAUSE OF CONCERN

Dr. Arun Mitra

 

The statement of the Vice Chancellor of the Andhra Pradesh University G Nageshwar Rao at the Indian Science Congress in Jalandhar that “we had hundreds of Kauravas from one mother because of stem cell research and test tube baby technology. It happened a few thousand years ago. This was science in this country," needs a critical review.

It is important to review this statement in the perspective of history and modern medicine. Before going into other questions of rationality it is necessary that the scientific information about stem cells is reviewed.

 

As per the information on stem cells by the National Institutes of Health (NIH), U.S Department of Health and Human Services, scientists discovered ways to derive embryonic stem cells from early mouse embryos in 1981. The detailed study of the biology of mouse stem cells led to the discovery, in 1998, of a method to derive stem cells from human embryos and grow the cells in the laboratory. These cells are called human embryonic stem cells. The embryos used in these studies were created for reproductive purposes through in vitro fertilization procedures. When they were no longer needed for that purpose, they were donated for research with the informed consent of the donor. In 2006, researchers made another breakthrough by identifying conditions that would allow some specialized adult cells to be "reprogrammed" genetically to assume a stem cell-like state.  

 

Stem cell is the basic cell from where many complex structures of the body develop. As the fertilization of egg takes place, the newly formed cell starts to proliferate and form embryo. In a 3-5 days embryo which has about 150 cells there develop embryonic stem cells. These cells are basic raw material for the body. They can either keep on growing and dividing into further stem cells or may take up specialized functions.

Stem cells are important for living organisms for many reasons. In the 3- to 5-day-old embryo, called a blastocyst, the inner cells give rise to the entire body of the organism, including all of the many specialized cell types and organs such as the heart, lungs, skin, sperm, eggs and other tissues. In some adult tissues, such as bone marrow, muscle, and brain, discrete populations of adult stem cells generate replacements for cells that are lost through normal wear and tear, injury, or disease.

 

Stem cells are distinguished from other cell types by two important characteristics. First, they are unspecialized cells capable of renewing themselves through cell division, sometimes after long periods of inactivity. Second, under certain physiologic or experimental conditions, they can be induced to become tissue or organ-specific cells with special functions. In some organs, such as the gut and bone marrow, stem cells regularly divide to repair and replace worn out or damaged tissues. In other organs, however, such as the pancreas and the heart, stem cells only divide under special conditions.

 

Thus stem cells research and its applications are a very complex issue developed only very recently. It needs lot of further research for its application to be utilized for the benefit of health of mankind.

 

We are yet to find evidence of such research and its applications anywhere in the world in the past. To talk of stem cells in the ancient India when people used to wear wooden chappals “kharawans”, ride the elephant (not even horse), used gadaas, spears and arrows as weapons, to expect them to use the highly complex advanced technology of stem cells is difficult to swallow.  Such a statement shows either bankruptcy of mind, irrationality of thinking or deceit in the effort to mix science with   mythology. This could also be to please the masters for personal benefits. Whatever the reason it has raised a serious question as to which way we are going?

 

Some time back a similar statement was given by a retired judge of Rajasthan high court in which he had said that the Peahen gives birth to the offspring when it licks the tears of Peacock. What type of judgments this man would have pronounced can easily be deduced   from this statement which crossed all limits of irrationality.

 

When Prime Minster Narendra Modi while addressing a gathering of doctors and other professionals at a hospital in Mumbai said that in ancient India Plastic surgery was so advanced that an elephant’s head could be transplanted on a human body or that “…… Karna was not born from his mother’s womb. This means that genetic science was present at that time. That is why Karna could be born outside his mother’s womb,” it was no matter to rejoice but it could be tolerated presuming that it was a gimmick by a politician to woo those who believe in such irrational ideas. Barring a few rationalists the scientific community did not speak much about this illogical utterance.

 

But when such a statement comes from the mouth of an academician it is a very serious matter. Even more serious matter of concern is that the medical and scientific community has not showed outrage over such obscurantist ideas being spread by those at the helm of affairs. It is time the medical associations come forward to condemn such irrational ideas before it is too late and country is pushed into medieval set of mind.

 

We have great respect and honour for our epics Ramayana and Mahabharta for their highlighting the cotemporary value system; but to use them for political ends must be condemned.

 

Refrences:

https://stemcells.nih.gov/info/basics/1.htm

https://www.theguardian.com/world/2014/oct/28/indian-prime-minister-genetic-science-existed-ancient-times

http://www.newindianexpress.com/states/andhra-pradesh/2019/jan/04/kauravas-born-of-test-tube-baby-technology-andhra-university-vice-chancellor%E2%80%8B-1920659.html

 

29 Dec,2018

MAKE RIGHT TO HEALTH A FUNDAMENTAL RIGHT

Dr Arun Mitra

 

Health is the basic human right. Every person has the right to live a healthy life and contribute effectively to the society’s development. As right to health is included in the directive principles, it becomes the duty of state to provide comprehensive universal healthcare to all citizens. It has to ensure prevention of disease, promotion of good health and rehabilitation of the diseased and the infirm.

 

Nutrition is the key to health. A poorly nourished person is more likely to be taken ill. Therefore prerequisites for a healthy life are safe drinking water, proper sewerage facilities, balanced nourished food with sufficient calories and other nutrients, proper housing and healthy environmental surroundings. There is need for special care for women, children and the elderly. Unfortunately we are far from meeting these requirements. Our hunger index is 103 out of 118 countries.  This is a serious matter. How do we expect children with stunted growth to build a healthy developed nation?  

 

Various studies have concluded that to ensure comprehensive primary healthcare there is need to enhance public health spending on health to minimum of 5% of the GDP. As per the National Health Accounts (NHA) Estimate for 2014-15, the Government Health Expenditure (GHE) per person per year is just Rs.1108/-. This is in contrast to the Out of Pocket Expenditure (OPE) of Rs.2394/- which comes out to be 63% of total health expenditure which is Rs.3286/- per person.  Even this expenditure is not homogenous. The spending on health varies on  socio-economic status, gender, religion, caste and geography. The average share of OPE on health care as a proportion of total household monthly per capita expenditure was 6.9% in rural area and 5.5% in urban area. This led to an increasing number of households facing catastrophic expenditure due to health costs. More than 40 per cent of the population has to borrow or sell assets for treatment. This is totally against the principles of equity and justice. Already marginalised sections, Dalits, Muslims and other socio-economically weaker groups are worst affected.  Flaws in planning and implementation of the policies have been pointed out by the Comptroller and Auditor General of India (CAG) in 2017. The audit pointed towards inadequate funding, under-spending of available financial resources, delays in transfer of funds, diversion of allocated programme funds, limited capacity to spend due to shortages in infrastructure and human resources among other issues.

 

The recently launched National Health Protection Scheme (NHPS) aims to cover almost half the population with publicly funded health insurance. The private health insurance companies and health care providers are already expecting huge dividends from NHPS. There is also proposal for Health and Wellness Centres (HWC) to deliver preventive, promotive, curative and rehabilitative services. With a low financial allocation this will not take up. There is shift from public provisioning of health towards privatisation.

 

To improve the health of the people drastic steps need to be taken at various levels. Health should be declared a fundamental rights irrespective of religion, age, sex, cast and socio economic status. The government owes its responsibility to deliver health to all by ensuring universal access to quality healthcare, education and other day to day needs. For this they should be continuous evaluation of health status of the people. Health should get proper place in the political agenda and the policy making bodies.

 

Certain steps that need urgent action is the rationalization of drug prices. Regulate drug prices in line with the rationalization of trade margins in medical devices. The ex-factory cost of the drugs should be actual cost based. Cap trade margin on drugs and medical devices to a maximum of 30%.

 

Provide free medicines and investigations in all public hospitals on the lines of Tamil Nadu, Kerala and Rajasthan. Pledge to increase the public expenditure on healthcare from 1.1% to 2.5% of GDP immediately and then increase it to 5% in subsequent five years.

 

Medical education has to be revamped and within approach of all sections. Regulate tuition fees of 100% seats in private medical colleges.

 

The Constitution guarantees six fundamental rights to Indian citizens as follows: (i) right to equality, (ii) right to freedom, (iii) right against exploitation, (iv) right to freedom of religion, (v) cultural and educational rights, and (vi) right to constitutional remedies.

 

Fundamental Rights are justiciable, as they can be enforced, whereas the directive principles are non-justiciable, in that, they are not enforceable in the court of law.  It is high time the health is included as one of the fundamental rights.

 

References:

Rs 3: Amount India Spends Every Day On Each Indian’s Health Swagata Yadavar June 21, 2018 https://www.indiaspend.com/rs-3-amount-india-spends-every-day-on-each-indians-health-53127/

 

https://www.downtoearth.org.in/news/out-of-pocket-health-spending-has-risen-in-rural-india-study-35613 (per house hold expenditure)

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5115797/ 

 

(Dnyaneshwar Chour i- Constitutional Perspective of Right to Health in India: AnAnalysisrighthttps://www.researchgate.net/signup.SignUp.html?ev=su_requestFulltext)

 

Ethical Doctor’s Manifesto – Alliance of Doctors for Ethical Healthcare

 

People’s Charter for Health - Adopted at Bihar Health Assembly – September 2018
 

22 Dec,2018

Promote Generic Drugs with Effective Quality Control

Dr Arun Mitra

The issue of cheap drugs and their quality has always been a cause of concern.  With more than 40% of our population living below poverty line, if a patient needs medicines he has to pay more than half of her/his earning. As per the Trends in catastrophic health expenditure in India: 1993 to 2014 published in the Bulletin of WHO 2018, out of pocket expenditure on health in India is catastrophic. The catastrophic health expenditure is defined as ‘out-of-pocket payments on health equaling or exceeding 10% of total household expenditure and 40% of the household’s capacity to pay’. Proportion of households experiencing catastrophic health expenditure increased in the last 20 years, and the increase was greater for the poor than the rich.

As per the National Sample Survey on healthcare in 2014, ‘medicines emerged as a principal component of total health expenses—72% in rural areas and 68% in urban areas’. It is therefore pertinent that their prices be regulated effectively and quality control ensured.

Drugs in our country are sold in two forms. The branded drugs, which are promoted by the manufacturers. They are given specific trade name by the company. Since their cost involves several promotional expenses, their price is higher.  At least 90% of the Indian domestic pharmaceutical market, of `1,00,000 crore and more, comprises drugs sold under brand names.

The concept of generic drugs was evolved to cut down this excess cost involved in packaging and other promotional means. The Indian government began encouraging more drug manufacturing by Indian companies in the early 1960s. Public Sector Pharmaceutical units played a vital role in this. A generic drug is sold under pharmaceutical/chemical name and has equal efficacy to the branded drugs. These are marketed under the chemical/pharmacological name without advertising. However here too, companies started manufacturing them under brand names. These are termed branded generic drugs which are being sold not under pharmacological name but under a different brand name even though produced by a company which is involved in manufacturing and promoting branded drugs.  

To facilitate the use of generic drugs the Government of India has set up Jan Aushadhis, which sell only generic name medicines.. There are not enough Jan Aushadhis, possibly less than 3,000 against more than eight lakh retail outlets selling branded drugs.

Through the Indian pharma’s field force numbering nearly one million medical representatives, there has developed trust among the doctors and also the patients in the companies and their brands. For similar trust to develop on the generic drugs there is need for perceptible quality assurance. Otherwise the use of generic drugs is unlikely to increase.

With value of worth US $20 billion, the Pharma sector in India is doing better than many other sectors and still continues to be major source of supply of cheap bulk drugs globally even to some of the developed countries.

But there are also reports of low quality medicines. Spurious/falsely-labeled/falsified/counterfeit (SFFC) drugs can cause treatment failure or even death. This is unacceptable. A working paper published through the U.S. National Bureau of Economic Research gave details of the results of an extensive investigation into Indian pharmaceutical quality. Around 1,500 India-made drug samples collected from 22 cities throughout Africa. It was found that ‘10 percent of the antibiotic and anti-tuberculosis samples contained insufficient levels of the key active ingredients’. Most of those drugs were not counterfeit they are legally made by the legitimate companies. They contain some therapeutic elements, but probably not enough active ingredients to actually treat disease’.

There have been cases of default by some of the leading companies. ‘Ranbaxy was found guilty in a US court in May 2013 and had to pay over half a billion dollars in fines and settlements. In 2012, Ranbaxy was forced to recall millions worth of drugs after glass particles were found mixed in with the raw ingredients used for its generic version of Lipitor. Dr. Reddy's Laboratories had to recall about 58,000 bottles of an ulcer medication because some of the pills were found to be contaminated’. According to Central Drugs Standard Control Organization (CDSCO) estimation, during 2003-2008, 6.3-7.5% of the samples were of substandard quality and 0.16-0.35% were encountered as spurious.

Such reports reduce confidence among the health providers and patients on drugs more so on generic drugs. It may be noted that there is powerful propaganda against the generic drugs by the companies selling branded drugs. This propaganda also impacts the patients who invariably ask for the branded drugs from multinational companies. This can be countered through strict quality control on all drugs particularly the generic drugs. Their trade margins have to be regulated. To enforce the regulations there should be surprise random check of the samples collected from the market. The CDSCO has to play a vital role in this. People’s confidence has to be built through public awareness and effective standardization of drug quality. More Public Sector pharmaceutical Units should be opened as it is easier to exercise quality control on them.         

References:

https://www.forbes.com/sites/theapothecary/2014/09/17/india-must-fix-its-drug-quality-problem/#145d9fd770b3

https://en.wikipedia.org/wiki/Central_Drugs_Standard_Control_Organization

https://www.pacificbridgemedical.com/regulatory-services/medical-device-pharmaceutical/quality-compliance/india

https://www.downtoearth.org.in/news/fake-drugs-constitute-25-of-domestic-medicines-market-in-india-assocham-45393

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355878/

http://www.businessworld.in/article/India-Emerges-As-Top-Five-Pharmaceuticals-Markets-Of-The-World/05-05-2018-148349/

Bulletin of the World Health Organization 2018;96:18-28.doi: http://dx.doi.org/10.2471/BLT.17.191759

 

08 Dec,2018

Healthcare must withstand market pressure to meet people’s aspirations

Dr Arun Mitra

 

A lot of debate has been generated not only in the medical circle but also the civil society whether the healthcare is a business or a profession. Anything that is termed as business is for profit only and could therefore be ruthless, apathetic and self-centered. The business has to compete in the market and follow the rules thereof which lack empathy and compassion.  About four decades back healthcare was a profession where one would earn by serving. But the scenario has undergone much change nowand medical profession too has started following the rules of market. There are several reports of overcharging and unnecessary interventions by some health providers. The infamous case of Fortis hospital charging exorbitantly from a child who had died of Dengue fever is not too old to be forgotten.

Many of these hospitals have taken land on lease from the government at throw away prices.They are thus bound to give free healthcare facilities to a stipulated number of patients from low economic group. But this hardly happens in practice.Eventhe doctors and other staff seesuch patients with contempt. This may be because of pressure from the management or apathy that they have developed in the system they have been working for long.

The process of shift in values in medical profession started by the 1980s when the policies in the South Asian countries began to be influenced significantly by the Bretton Woods institutions, specially the World Bank. The developing countries had to accept structural adjustment policies (SAP) under the corporate driven one way globalization which served the interests of the international finance capital. The governments in the developing countries changed laws in favour of multinational corporations and the local elite while denying the basic fundamental rights to the poor strata of the society.Rights to hold protests and unionize were curtailed. Subsidies to the poor taken off.Job security taken away and employment generation occurred in the form of contract labour with very low wages. This happened not only in private sector but even in public sector. The priorities in the agriculture production also shifted from the basic food to the produce that was to be used by the elite in these countries. All this further resulted into increase in the problem for the lower income groups leading to fall of health determinants.

There occurred a policy shift that treats health as ‘techno-dependent and amenable to commodification’. The shift in concept is evident in the WHO itself when in 1996 it proposed a behaviorist model which stressed more on the individual effort for better health rather than social responsibility.The WHO started working under the influence of international monopoly corporates and took position to increase privatization and partnership with multinational companies.So the emphasis shifted to address only population control and some selected communicable diseases at the cost of its earlier broad-based approach. As a result the institution which was supposed to work for inclusive healthcare policies took lead in destroying its own agenda set at Alma Ata.

There were serious implications on medical education in our country. More medical colleges opened in private sector than in state sector affecting the very concept of social service in the medical training.

Year

Govt.

Govt. Society

Private

1947

19

 

1

1947 – 1950

7

   

1951-1960

31

 

3

1961 – 1970

34

 

6

1971 – 1980

8

 

3

Total A

99

0

13

1981 – 1990

7

 

25

1991 – 2000

12

 

31

2001 – 2010

34

 

89

2011 – 2017

62

9

93

Total B

115

9

238

Total A + B

214

9

251

(Medical colleges that opened in state and private sector)

 

This is the time when the patent laws alsochanged under the new patent regime of the WTO.The local pharmaceuticals industries suffered.  As a result, prices of newer drug increased. After lot of hue and cry from the public the government appointed a committee to go into the drug prices vis a vis trade margins, that is the difference between the price of  the drug when it comes out of the manufacturing unit and the maximum retail price i.e at what it is sold at retails. The committee pointed out startling figures of the trade margin to be the tune of even 300% - 5000% in some cases. The committee recommended capping of trade margin so that the cost of drugs to the patients is streamlined.

 

Sudhanshu Pant Committee Recommendations on Trade Margins

Product  Price  Per Unit

Trade Margin

Rs. 2/-.

No Capping

Above Rs. 2/-

50%

From 20-50 Rupees

40%

Above 50 rupees

35%

 

Committee also pointed out that in case of bonus offer the benefit should go the consumer not the retailer. For example if there is a bonus offer of 1+1 then trade margin should be halved.

The market system also pushed practices of cuts and commissions for referrals and freebies to the medical professionals by the pharmaceutical companies. This corrupted even the doctor. Time has come now to think whether health services are to be treated as business or they have to be retained as a professional service and restore its glory and nobility. 

04 Dec,2018

People Need Health and Education Rhetoric would be Catastrophic

Dr Arun Mitra


 

The Kartarpur Corridor at the Indo Pak border is not just a religious symbol, it is a hope of millions of people across the border who have been denied the opportunity to visit their nears and dears, to have a glimpse of the places they or their predecessors were born, lived and spent their childhood & part of their youth. There has been denial of strong wish to meet their newly developed friends through modern technology – Facebook and WhatsApp etc. With similar background of cultural values people of the two countries have always been having strong yearning to go to the places they have been only reading about. The Kartarpur Corridor would also be an opportunity to break myths being spread against each other. It is only when one visits Pakistan from India or vice versa one realizes how much is the love lost between the two people who not too long ago in the history lived together. The political reasons distanced them through lines but could not break the bonds of brotherhood/sisterhood. The success story of Sada-e-Sarhad bus service started in 1999 during the Vajpayee government is a glaring example. It is time and an opportunity that has come before us through Kartarpur Corridor which we should not loose.

The path however is not so simple or straight forward. Only a few days back while addressing an event to highlight the 100 day achievement of Punjab government,  Imran Khan, Prime Minister of Pakistan said that “we will show the Modi government how to treat minorities. Even in India, people are saying that minorities are not being treated as equal citizens". This was an unnecessary statement. Everyone knows that Indian constitution gives equal rights to all its citizens belonging to any religion, ethnicity, caste, creed or gender. We do not need  sermons from any outsider. Imran Khan’s statement amounted to interference in India’s internal affairs. This statement is also in total disregard to his previous utterances suggesting that the foreign ministers of India and Pakistan meet on the sidelines of the United Nations General Assembly. It is well on record that during the inauguration of the Kartarpur Corridor he had warned that a war between India and Pakistan would be catastrophic as both are nuclear weapons possessing countries. In this context his statement of teaching India about minority rights is totally unacceptable.

On the similar lines Prime Minister Narendra Modi has in an interview on 1st January 2019 said that ‘Pakistan will not learn lesson from one war.  They will take more time to mend the ways’. We have been hearing this rhetoric from both sides since long. This would lead us to nowhere. For any country to be able to wipe out the other from globe is just an imagination. We need to think beyond such statements. 

We are the nations where vast majority of people live in abject poverty. India’s hunger index is at 103 out of 118 countries and Pakistan’s is 106. We are even below our other neighbors in south Asia. Our ranking in Human Development Index is 130 while Pakistan is 150.  This is at a time when India is said to be fast growing economy. But the arms race has put a stop to our inclusive development.  People are devoid of basic needs like food, shelter, health, education. Our per capita public health spending is just 1108 rupees.

India’s defense expenditure is 1.62 % of its GDP, while its central health budget is 0.26 of GDP, six times less than its arms budget. Pakistan’s spending on arms is equivalent with budgetary allocation 8.9 billion USD. With Pakistan worth 300 billion USD economy its defense expenditure comes to 2.9% of the GDP.   Whereas Pakistan is out to purchase modern tanks, India is spending large amount on combat vehicles. This arms race is making the situation worse as it is taking resources away from social needs. The only way is to put an end to rhetoric and have dialogue and leave a better future for our next generations.

 

29 Nov,2018

HEALTH AND MEDICAL EDUCATION CANNOT BE LEFT TO MARKET ECONOMY MECHANISM

Dr Arun Mitra


 

The report that the health ministry has asked the MCI to review the tuition fees in medical colleges is a welcome step. Better late than never, it has become so essential because the fee structure in private medical colleges has gone sky high and is out of reach of not only poor people but even the middle classes are now feeling the pinch. They have to shelve their savings and even borrow to send their wards to the medical colleges. This is not only for MBBS courses, but even for the admissions to the Ayurvedic colleges. Tuition fess even in some of the Ayurvedic colleges, especially those which are deemed universities are quite high. As a result several meritorious students are left out of the medical colleges due to exorbitant charges which they are unable to pay. Such situation leads to feeling of helplessness causing serious stress in the minds of the students and the whole family. The students have worked hard to fulfill their aspirations to become doctor; Now at the stage when they have achieved merit, they are denied admission because of financial reasons, is a very sorry state of affairs.

The WHO recommends one doctor per one thousand of population. Replying to a question, the Minister of State for Health, Smt. Krishna Patel had told in the Lok Sabha that on 31st March this year 1022859 doctors of modern medicine are registered with various state medical councils. She further said that around 8 lakh doctors are actively available at one time. This means that the doctor population ratio in India is 0.62 doctors per one thousand population. While nearly 70% of India’s population lives in rural areas, the rural India has 1/4th the doctors as compared to urban areas.  This is a huge gap to be fulfilled. Thus we need more doctors for our population. For this the government plans to open more colleges. To fulfill the health requirements of our people we have to have medical colleges which impart relevant training to the students and orient them to the needs of our society and encourage them to work in areas so far neglected.

A review of the medical education scenario tells that admission to the medical colleges has been a contentious issue for quite some time. Initially most of the medical colleges were in state sector. Going by the information from the website of Medical Council of India, at the time of independence, there were 20 colleges out which only one was in private sector. Most of new additions were in the state sector till late eighties. But after the shift in economic policies and neo liberal model of development the whole scenario changed. Between the periods  1990 to 2017 number of colleges opened in private sector was 238 while only 115 were opened in state sector. Many of these were made as deemed universities which could have their own examinations, admission system and fee structure.  

 

Many of these were charging under hand money as capitation fee. Merit was completely ignored and money became supreme.

Seats are reserved under the management quota where they can charge at their will. For example in the state of Punjab the tuition fee in the government colleges is Rs.13.4 lakh  for the full course of MBBS for 4.5 years, in the seats under the management and the NRI quota it varies from Rs.35 lakh for the full course to Rs.63.9 lakhs. Astonishingly telephonic enquiry from the Era’s Medical College Lucknow revealed the tuition to be 17 lakh per annum which with 10% increase every year comes out to be nearly Rs.91.34 Lakh for MBBS course. The PG seats tuition fee in this college is up to Rs.49 lakhs per year. That means for MBBS and MS/MD both from this college, one will have to pay nearly 2.5 crore rupees and an additional charges for books, travel etc. This means the student has to spend nearly 3 lakh rupees per month or Rs.10000/- per day.

 

This is a cruel joke. In our country where vast majority of population is devoid of even basic needs, it is literally impossible for them to imagine to send their wards to the medical college even when they are on merit. There was hope that after introduction of NEET, capitation fee will end. But what has happened is to the contrary. The private colleges increased their tuition fee and are now earning legally in white money. This will simply undermine the quality of medical education and not fulfill the needs of society we are striving to achieve. Going by the track record it appears that this advice to the MCI to regulate the fee structure may not turn out to be  an eye wash. State must recognize its responsibility to health and education if really wants to serve the people. Health and medical education cannot be left to market economy mechanism, they should be taken as social responsibility.

18 Oct,2018

YOGA FOR MENTAL HEALTH – IRRATIONAL PRACTICES CAN BE HARMFUL

Dr Arun Mitra

 

Reports of medical students and young doctors committing suicides even in the premier institute AIIMS is a matter of grave concern. This issue needs serious introspection on the part of medical profession as well as the society. Depression that these young doctors and students have to pass through may have several causes, both external and internal. Stress starts in students and their parents even before the admission when the children enter into 10+1 class and are preparing to get into medical course. Many promising students remain devoid of admission to the course they have aspired for all through their schooling because of exorbitant increase in the tuition fees due to privatization of medical education. Just because one does not have money to pay as tuition fee to the tune of nearly one crore rupees for graduation, and another one crore for post-graduation they do not become doctors. They then look for other allied courses but never get reconciled to this.

 

According to Psychiatrists, the possible causes of depressive and suicidal symptomatology in medical students include stress and anxiety secondary to the competitiveness of medical school; inability to cope with the vast curriculum; repeated examinations; high expectations of the parents, teachers, and patients, and time constraints for pursuing their alternate interests etc. Weakening cohesiveness in the society is perpetuating the problem. Strong social relations were helpful in reducing the stress. Remedial measures  include restructuring of medical school curricula and student evaluations, reducing barriers to mental health services, including addressing the stigma of depression, having a dedicated psychological help clinic in the campus or having alternate means of communication through a helpline or E-mail, peer mentorship programs, consultation by psychiatrists and clinical psychologists, life skills counseling etc.

 

Interestingly the Indian Medical Association (IMA) decided to start IMA Initiative for Emotional Health & Emotional Well-Being of Medical Students and Doctors in India, ostensibly considering the increased rate of mental illness and in some cases even suicides, especially in young medicos. The Karnatka unit of IMA even organized a workshop at IMA House, Bengaluru on 8th July, 2018, comprising of presentations and orations by Isha Yoga Foundation, Banjara Academy, Laughter Yoga, and Art of Living Foundation.

 

Dr.Srinivas Kakilaya an Internal Medical Specialist at Mangaluru and a few more doctors including Psychiatrists, Neurologist and family medical practitioner challenged the approach of IMA. They called upon the IMA not to promote unproven, non-evidence based practices on such an issue of mental health which is so delicate. They pointed out that in modern medicine there are innumerable resources regarding suicidal risk, its identification and management, including emergency care. There is enough evidence regarding the effectiveness of dialectical behavioural therapy and cognitive behavioural therapy in preventing suicides. It is in fact dangerous to promote yoga and such methods for anyone with suicidal ideation, and deny the evidence based critical interventions required for such people, they pointed out. This will also send wrong message about scientific method of treating depression. Already in India, there is a treatment gap of 87.2 to 95.7 for depression in community-based studies; therefore, promotion of methods such as yoga will create further confusion and denial of care for the needy, they said.

 

The medical ethics demands of a medical practitioner to be rational and scientific in approach while treating a patient. The Indian Medical Council (Professional Conduct, Etiquette & Ethics) Regulations, 2002 says - no person other than a doctor having qualification recognised by Medical Council of India and registered with Medical Council of India/State Medical Council (s) is allowed to practice Modern system of Medicine or Surgery. A person obtaining qualification in any other system of Medicine is not allowed to practice Modern system of Medicine in any form.
 

As per the clause 1.2.1 of this the Principal objective of the medical profession is to render service to humanity with full respect for the dignity of profession and man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. Physicians should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. The physician should practice methods of healing founded on scientific basis and should not associate professionally with anyone who violates this principle. The honoured ideals of the medical profession imply that the responsibilities of the physician extend not only to individuals but also to society.

 

In our country there are already several myths and unscientific practices regarding diseases and their cure which continue to persist even among the literates.This is despite several advances in the medical science and information mechanism.

 

It is saddening that the government is not only apathetic towards many irrational ideas on health but is very subtly promoting irrational ideas. Use of Cow urine, Astrology in the hospitals with advisory to the patients to visit these astrologers, the 'Garbh Vigyan Sanskar' by Arogya Bharti advising couples to recite Shlokas at the time of mating so as to have customized  babies of their choice - the Uttam Santati. Some ministers have been seen to attend the conference of 'Tantriks' and felicitate them in Gujarat. Such acts lead to misconceptions in the minds of people and spread obscurantism. It is for the medical bodies, rationalist societies and right thinking people with scientific outlook to question rather than promoting Yoga for everything which might have only placebo effect said Dr S K Prabhakar a Psychiatrist from Ludhiana.

 

04 Oct,2018

WITHOUT RIGHT DIRECTION, DISSOLUTION OF MEDICAL COUNCIL OF INDIA WILL BE COUNTER PRODUCTIVE

Dr Arun Mitra

 

Even though dissolution of Medical Council of India (MCI) was on cards, but that it would be done so unceremoniously through an ordinance bypassing the Parliament was not expected. It is unfortunate that such exercise have become routine of the government.  Till date the MCI has been the regulatory body which decided about the admission process to the undergraduate as well as postgraduate classes; it set basic minimum standards required to open a medical college and carried out regular inspections of the colleges to check the status of education. It also maintained the registry of doctors around the country. The MCI also could derecognize any medical college which did not fulfill the required standards. It also decided the medical curriculum. Whereas the government’s nominated members were there in the MCI, it had elected members as well which gave it a partial democratic structure. Unfortunately the MCI lost its reputation as there have been allegations of corruption against some of its higher-ups particularly the past president Ketan Desai.

 

The Supreme Court of India had taken cognizance of the irregularities in the council and recommended restructuring of the system so as to make it more transparent to curb corruption and maintain high standard of medical education. The government had some time back proposed a national medical commission instead of the MCI which was put in public domain for suggestions. The structure of NMC has 25 members, all of whom will be nominated by the government. This makes the regulatory body totally undemocratic with outright bureaucratic control without involvement of various stake holders.

 

In the last few years majority of medical colleges have come up in private sector. From 1990 to 2017 medical colleges opened in private sector number 238 while only 115 in state sector. Many of these were made deemed universities with their own examination & admission system and fee structure. In the proposed NMC, the government will exercise control over the tuition fee of only up to 40% of seats which means tuition fees in 60% plus seats will be at the mercy of private managements. Thus the cost of medical education which is already very high in the private sector will further rise and will be virtually reserved for the rich classes. Since there will be no regular inspections, check on the standard of the medical education will be compromised. Already low standard of education in many medical colleges who are notoriously known to hire the faculty and patients during inspection will further go down.  

 

There will be exit exam for the undergraduate students. This is being done because difference in the standard of education in various medical colleges is glaring. Instead of meeting its responsibility to standardize education, the government is working on approach to judge ranking of the colleges by the performance of the students.  

 

There is also effort to mix the various systems of medicine and permit the AYUSH to practice modern medicine. This will further jeopardize the whole healthcare delivery process.

 

It is obvious that the medical education will become totally unregulated and go in the hands of business interests. It would be naïve to expect a person who has spent crores on getting education to have social interest and service attitude towards healthcare. The already over privatized healthcare in our country will further get expensive and out of reach of majority of citizens  who are already devoid of quality health care due to high cost of out of pocket expenditure.   

 

 

The standing committee on health headed by Shri Ram Gopal Yadav had called various stake holders to put forward their view point on the National Medical Commission (NMC). The Alliance of Doctors for Ethical Healthcare (ADEH) in its submission before the standing committee on 13th February had clearly given its view points on various issues but in the final recommendations there are hardly changes to meet the expectations.  That corruption will end in the NMC is difficult to believe. It has been observed that bureaucratic structures can be more corrupt as they are not directly answerable to the people. Time is still not lost. Government should review the final draft of the NMC otherwise worse may come out of dissolving the MCI.