02 May,2019


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.









24 Apr,2019





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.       


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


16 Apr,2019






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




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


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


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.  






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.  



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.





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





Tubers of starchy vegetables

Potatoes and cassava

50 (0-100)





All vegetables

300 (200-600)





All Fruits

200 (100-300)




Dairy Foods

Whole milk or equivalents

250 (0-500)




Protein Sources

Beef, Lamb and pork

Chicken and other  poultry





14 (0-28)

29 (0-58)

13 (0-25)

28 (0-100)

75 (0-100)

50 (0-75)














Added fats

Unsaturated oils

Saturated oils

40 (20-80)

11.8 (0-11.8)






Added Sugar

All sugar

31 (0-31)



















26 Jan,2019


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.



  • 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


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.







29 Dec,2018


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.



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)




(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.         








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.



Govt. Society






1947 – 1950







1961 – 1970




1971 – 1980




Total A




1981 – 1990




1991 – 2000




2001 – 2010




2011 – 2017




Total B




Total A + B




(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/-


From 20-50 Rupees


Above 50 rupees



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


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


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


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.