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  • Antimicrobial resistance

    The article highlights the challenges posed by anti-microbial resistance (AMR) and suggests ways to deal with it.

    Understanding the severity of challenges posed by AMR

    • Antimicrobial resistance (AMR) is the phenomenon by which bacteria and fungi evolve and become resistant to presently available medical treatment.
    • AMR represents an existential threat to modern medicine.
    • Without functional antimicrobials to treat bacterial and fungal infections, even the most common surgical procedures, as well as cancer chemotherapy, will become fraught with risk from untreatable infections.
    • Neonatal and maternal mortality will increase.

    How AMR will affect low and middle-income countries

    • All these effects will be felt globally, but the scenario in the low- and middle-income countries (LMICs) of Asia and Africa is even more serious.
    • LMICs have significantly driven down mortality using cheap and easily available antimicrobials.
    • In the absence of new therapies, health systems in these countries are at severe risk of being overrun by untreatable infectious diseases.

    Factors contributing to AMR

    • Drug resistance in microbes emerges for several reasons.
    • These include the misuse of antimicrobials in medicine, inappropriate use in agriculture, and contamination around pharmaceutical manufacturing sites where untreated waste releases large amounts of active antimicrobials into the environment.

    Stagnant antibiotics discovery

    •  The Challenge of AMR is compounded by fact that no new classes of antibiotics have made it to the market in the last three decades.
    • This has happened on account of inadequate incentives for their development and production.
    • A recent report from the non-profit PEW Trusts found that over 95% of antibiotics in development today are from small companies, 75% of which have no products currently in the market.
    • Major pharmaceutical companies have largely abandoned innovation in this space.

    Measures to deal with the challenge of AMR

    •  In addition to developing new antimicrobials, infection-control measures can reduce antibiotic use.
    • A mix of incentives and sanctions would encourage appropriate clinical use.
    • To track the spread of resistance in microbes, surveillance measures to identify these organisms need to expand beyond hospitals and encompass livestock, wastewater and farm run-offs.
    • Finally, since microbes will inevitably continue to evolve and become resistant even to new antimicrobials, we need sustained investments and global coordination to detect and combat new resistant strains on an ongoing basis.

    Way forward

    •  A multi-sectoral $1 billion AMR Action Fund was launched in 2020 to support the development of new antibiotics.
    • The U.K. is trialling a subscription-based model for paying for new antimicrobials towards ensuring their commercial viability.
    • Other initiatives focused on the appropriate use of antibiotics include Peru’s efforts on patient education to reduce unnecessary antibiotic prescriptions.
    • Australian regulatory reforms to influence prescriber behaviour, and initiatives to increase the use of point-of-care diagnostics, such as the EU-supported VALUE-Dx programme.
    • Denmark’s reforms to prevent the use of antibiotics in livestock have led to a significant reduction in the prevalence of resistant microbes in animals and improved the efficiency of farming.
    • Finally, given the critical role of manufacturing and environmental contamination in spreading AMR there is a need to curb the amount of active antibiotics released in pharmaceutical waste.
    • Regulating clinician prescription of antimicrobials alone would do little in settings where patient demand is high and antimicrobials are freely available over-the-counter in practice, as is the case in many LMICs.
    • Efforts to control prescription through provider incentives should be accompanied by efforts to educate consumers to reduce inappropriate demand, issue standard treatment guidelines.
    • Solutions in clinical medicine must be integrated with improved surveillance of AMR in agriculture, animal health and the environment.
    • AMR must no longer be the remit solely of the health sector, but needs engagement from a wide range of stakeholders, representing agriculture, trade and the environment with solutions that balance their often-competing interests.
    •  International alignment and coordination are paramount in both policymaking and its implementation.

    Consider the question “Anti-microbial resistance (AMR) represents an existential threat to modern medicine. What are the factors contributing to AMR? Suggest the measures to deal with it.”

    Conclusion

    With viral diseases such as COVID-19, outbreaks and pandemics may be harder to predict; however, given what we know about the “silent pandemic” that is AMR, there is no excuse for delaying action.

  • How IPR served as barrier to the right to access healthcare

    Request for waiver

    •  Last year, India and South Africa requested WTO for a temporary suspension of rules under the 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS).
    • A waiver was sought to the extent that the protections offered by TRIPS impinged on the containment and treatment of COVID-19. 
    • The request for a waiver has, since, found support from more than 100 nations.
    • But a small group of states — the U.S., the European Union, the U.K. and Canada among them — continues to block the move.
    • These countries have already secured the majority of available vaccines.
    • But for the rest of the world mass immunisation is a distant dream.

    Grounds on which patent laws are justified

    • Patent laws are usually justified on three distinct grounds:
    • On the idea that people have something of a natural and moral right to claim control over their inventions.
    • On the utilitarian premise that exclusive licenses promote invention and therefore benefit society as a whole.
    • On the belief that individuals must be allowed to benefit from the fruits of their labour and merit.
    • These justifications have long been a matter of contest, especially in the application of claims of monopoly over pharmaceutical drugs and technologies.

    Patent laws in India

    • In 1959, a committee chaired by Justice N. Rajagopala Ayyangar objected to monopolies on pharmaceutical drugs through colonial-era patent law.
    • The committee found that foreign corporations used patents to suppress competition from Indian entities, and thus, medicines were priced at exorbitant rates.
    • The committee suggested, and Parliament put this into law through the Patents Act, 1970, that monopolies over pharmaceutical drugs be altogether removed, with protections offered only over claims to processes.
    • This change in rule allowed generic manufacturers in India to grow. 

    How TRIPS goes against the interest of developing countries

    • WTO has into its constitution a binding set of rules governing intellectual property.
    • Countries that fail to subscribe to the common laws prescribed by the WTO would be barred from entry into the global trading circuit.
    • It was believed that a threat of sanctions, to be enforced through a dispute resolution mechanism, would dissuade states from reneging on their promises.
    • With the advent in 1995 of the TRIPS agreement, this belief proved true.
    • The faults in this new world order became apparent when drugs that reduced AIDS deaths in developed nations were placed out of reach for the rest of the world.
    • It was only when Indian companies began to manufacture generic versions of these medicines as TRIPS hadn’t yet kicked in against India, that the prices came down.

     Argument in support of the patent regime

    • Two common arguments are made in response to objections against the prevailing patent regime.
    • One, that unless corporations are rewarded for their inventions, they would be unable to recoup amounts invested by them in research and development.
    • Two, without the right to monopolise production there will be no incentive to innovate.

    Issues with the argument in support of patent regime

    • Big pharma has never been forthright about the quantum of monies funnelled by it into research and development.
    • Moderna vaccine in the U.S. emanated out of basic research conducted by the National Institutes of Health, a federal government agency, and other publicly funded universities and organisations. 
    • Similarly, public money accounted for more than 97% of the funding towards the development of the Oxford/AstraZeneca vaccine.
    •  Therefore, the claim that the removal of patents would somehow invade on a company’s ability to recoup costs is simply untrue.
    • The second objection — the idea that patents are the only means available to promote innovation — has become something of a dogma.
    • The economist Joseph Stiglitz is one of many who has proposed a prize fund for medical research in place of patents.

    Consider the question “What are the issues with the patent regime under the TRIPS in the field of medicine?”

    Conclusion

    We cannot continue to persist with rules granting monopolies which place the right to access basic healthcare in a position of constant peril. In its present form, the TRIPS regime represents nothing but a new form of “feudal calculus”.

  • Understanding the Ct value in a Covid-19 test

    Recently, the Maharashtra government sought clarity from the Indian Council of Medical Research (ICMR) on the threshold Ct value to treat a person Covid-negative.

    What is Ct value

    • Short for cycle threshold, Ct is a value that emerges during RT-PCR tests.
    • In an RT-PCR test, RNA is extracted from the swab collected from the patient.
    • It is then converted into DNA, which is then amplified.
    • Amplification refers to the process of creating multiple copies of the genetic material — in this case, DNA.
    • Amplification takes place through a series of cycles — one copy becomes two, two becomes four, and so on.
    • Put simply, the Ct value refers to the number of cycles after which the virus can be detected.
    • The lower the Ct value, the higher the viral load — because the virus has been spotted after fewer cycles.

    Why Ct value is important

    • According to the ICMR, a patient is considered Covid-positive if the Ct value is below 35.
    • If the benchmark were to be lowered to 24 — the value mentioned in Maharashtra’s letter — it would mean that Ct values in the range 25-34 would not be considered positive.
    • A benchmark of 35, therefore, means that more patients would be considered positive than we would get if the benchmark were 24.
    • The ICMR has said lowering Ct threshold parameter may lead to missing several infectious persons.

    Does Ct score indicate the severity of disease

    • A small study published in the Indian Journal of Medical Microbiology in January this year found that there was no correlation between Ct values and severity of disease or mortality in patients with Covid-19 disease.
    • It found that the time since the onset of symptoms has a stronger relationship with Ct values as compared to the severity of the disease.
    • The Ct value tells us about the viral load in the throat and not in the lungs.
    • The Ct value does not correlate with severity – only with infectivity.

  • Growth of ARCs not in line with NPA trends

    Key takeaways from the RBI report

    • The RBI report states that notwithstanding the rise in the number of Asset Reconstruction Companys (ARCs), the growth in their assets under management (AUM) has been largely trendless except for a major spurt in FY14.
    • The growth of the ARC industry has not been consistent over time and not always been synchronous with the trends in non-performing assets (NPAs) of banks and non-banking financial companies (NBFCs).
    • During 2019-20, asset sales by banks to ARCs declined, which could probably be due to banks opting for other resolution channels such as IBC and SARFAESI.
    • The acquisition cost of ARCs as a proportion to the book value of assets declined, suggesting lower realisable value of the assets.

    Overview of ARCs in India

    • The ARC industry began with the establishment of the Asset Reconstruction Company India Ltd (ARCIL) in 2003.
    • Of the total AUM, about 62 per cent and 76 per cent was held by the top-three and top-five ARCs in March 2020, respectively.
    • After remaining subdued in the initial years of their inception, a jump was seen in the number of ARCs in 2008, and then in 2016.
    • Although the number of ARCs has risen over time, their business has remained highly concentrated.

    Role of the government

    • Indian ARCs have been private sector entities registered with the Reserve Bank.
    • Public sector AMCs in other countries have often enjoyed easy access to government funding or government-backed.
    • By contrast, capital constraints have often been highlighted as an area of concern for ARCs in India.

    Scope for new ARC supported by the government

    • The ARC proposed in the Budget will be set up by state-owned and private sector banks, and there will be no equity contribution from the Centre.
    • The RBI report supported the government’s proposal for a new ARC, saying that “such an entity will strengthen the asset resolution mechanism further.”
    • Introduction of a new asset reconstruction company for addressing the NPAs of public sector banks may also shape the operations of the existing ARCs, it added. 
    • The ARC, which will have an Asset Management Company (AMC) to manage and sell bad assets, will look to resolve stressed assets of Rs 2-2.5 lakh crore that remain unresolved in around 70 large accounts.

  • Undermining vaccination for all

    The article highlights the issues with the new vaccine strategy adopted by the government.

    Revamped vaccine strategy

    • With the second Covid-19 wave reaching catastrophic proportions, the Government of India has acted by unveiling a completely revamped vaccine strategy.
    • Two key elements are the hallmark of this new strategy, which will be implemented from May 1.
    • First, the vaccination drive has now been extended to the entire adult population, namely, to those above 18 years.
    • Second, vaccine manufacturers have been given the freedom to sell 50% of their vaccine production to State governments and private hospitals.
    •  A third element of the vaccine strategy, which was not announced formally, is a grant of ₹45 billion to the two vaccine manufacturers, the Serum Institute of India (SII) and Bharat Biotech, to boost their capacities.

    Issues with the new vaccine strategy

    1) Control over the market for vaccine

    • The central government has given up its control over the market for vaccines, a key feature of the vaccine roll-out plans thus far.
    • This issue assumes further significance since the Government of India is well aware about the significance of vaccinating every citizen in the country; “none of us will be safe until everyone is safe”.
    •  It is, therefore, vitally important that public health authorities in the country take an objective view of the realities of the country before adopting strategies for vaccine availability.

    2) Vaccine export

    • The phased roll-out of the government’s ambitious vaccination drive, beginning with health-care and frontline workers in January was in sync with the availability of vaccines in the country.
    •  But, given that India too saw a degree of “vaccine-scepticism”, the Government of India found itself in a situation where it could promise exports of vaccines to 95 countries, mostly in Africa and Asia.
    • As of April 26, these countries have received more than 66.4 million doses of vaccines from India.
    • Until now, nearly 142 million vaccine doses have been administered in the country, the third highest in the world.
    • However, in terms of population share, less than 2% has received both vaccine doses, while less than 9% has received one dose.
    • But there is one worrying facet, which is that a demand-supply mismatch has begun to appear as the coverage of the vaccine-eligible population expanded.
    • The largest supplier, SII, gave two explanations for its inability to meet its commitments.
    • The first was that the United States Government had restricted exports of vaccine culture and other essential materials.
    • Second, the company complained that it lacked the financial capacity to expand its production, requesting a grant of ₹30 billion from the government.

    3) Onus on the States

    • Central government have allowed vaccine producers to sell 50% of their production directly to State governments and private hospitals.
    • The central government would continue to support vaccination for people above 45 years, and health-care workers and frontline workers.
    • The new strategy shifts the onus onto the State governments, which have to take decisions regarding free vaccination for people above 18 years.
    • The government has not fixed the vaccine prices and has allowed the producers to pre-declare the prices they would charge from the State governments and private hospitals, a sharp departure from the extant strategy.
    • New policy fragments the market into three layers namely, central government procurement, State government procurement and the private hospitals.
    • This layering of the market would allow the producers to charge high prices from the State governments and private hospitals.
    • The new strategy would shift the burden of vaccination of the young population, namely, those between 18-44 years, entirely on the State governments.
    •  This implies that the vaccination of a significant section of the population depends on the financial health of each State government, resulting in inequitable access to vaccines across States. 

    4) Public money given for expanding production capacity

    • In view of the advance of ₹45 billion made by the Government of India to the two vaccine producers in India for expanding their production capacities decision to deregulate the vaccine market raises serious questions.
    • This question is more pertinent in India, where access to affordable vaccines is critical for ensuring “vaccination for all”.

    Way forward

    •  Rather than allowing duopoly in the vaccine market, the government should have ensured a competitive market for vaccines.
    • One positive step that the government has taken in this direction is to increase production of Bharat Biotech’s vaccine through the involvement of three public sector undertakings, including Haffkine Institute.
    • There is a need for more open licensing of this vaccine to scale up production.

    Conclusion

    There can be no alternative to vaccination for all if we want to overcome the Covid and to ensure that government needs to rethink its new strategy.

  • India third highest military spender in 2020: SIPRI

    What the SIPRI database says

    • India was the third largest military spender in the world in 2020, behind only the US and China.
    • The US accounted for 39 per cent of the money spent on military globally, China accounted for 13 per cent, and India accounted for 3.7 per cent of the globe’s share.
    • The US spent a total of $778 billion in 2020, China spent $252 billion and India’s military expenditure was $72.9 billion.
    • The United States’ military spending was 3.7 per cent of its GDP while the corresponding numbers for China and India were 1.7 per cent and 2.9 per cent respectively.
    • The other top spenders included Russia with $61.7 billion, the UK at $59.2 billion, Saudi Arabia at $57.5 billion, followed by Germany and France at just under $53 billion each.

    Increase in spending in the year of pandemic

    •  SIPRI said that the total “global military expenditure rose to $1981 billion last year, an increase of 2.6 per cent in real terms from 2019.
    • 2.6 per cent increase in world military spending came in a year” when the global GDP shrank by 4.4 per cent largely due to the economic impacts of the Covid-19 pandemic.
    • Military spending as a share of GDP—the military burden—reached a global average of 2.4 per cent in 2020, which is the biggest year-on-year rise in the military burden since the global financial and economic crisis in 2009.

  • Complexities of herd immunity

    What is herd immunity

    • The herd immunity concept is based on lowering the number of susceptible individuals.
    • If sufficient individuals in the population are immune either through vaccination or a prior exposure, then the number of susceptible individuals drops.
    • For example, if the immune population is 70%, then the susceptible population is 30%.

    Does herd immunity really protect from subsequent waves?

    • The number of daily cases depends on three factors: The number of infectious people in the population, the number of susceptible individuals, and the rate of transmission of the virus.
    • The rate of transmission is dependent on the nature of the virus and the extent of contact between individuals.
    • So, if the rate of transmission increases due to change in social behaviour and increased contact then even with a large percentage of the immune population, a significant number of daily cases can result.
    • The “herd immunity” number is not a static number but it changes depending on the rate of transmission of the virus and the extent of virus present.

    Estimating exposures in metro cities

    • Serosurveys indicated that Covid had touched 56% of population in Delhi by January; 75% in some slums Mumbai in November, and about 30% in Bengaluru in November.
    • The population touched by Covid can also be estimated by the Infection Fatality Rate (IFR).
    • This is the total number of deaths divided by the total people infected. In India, the estimate is 0.08%.
    • So this number can be used to back-calculate the number of infections based on the number of deaths in the different cities.
    • The table given below shows the number of people exposed to Covid in some metros until January 31 using the method above.

    What are the reasons behind the recent surge

    • The reasons behind the recent surge are not fully understood.
    • The one factor that is not in doubt, however, is that interaction and contact with the population has increased since February.
    • Such increased contact increased the virus in circulation and led to increased cases in the susceptible population.

  • Centre uses Disaster Management Act to restrict liquid oxygen use for non-medical purposes

    Order under Disaster Management Act 2015

    • Invoking the Disaster Management Act, the Centre ordered States that all liquid oxygen shall be made available to the government and will be used for medical purposes only.
    • The order said that under section 10(2)(I) and section 65 of the DM Act, States had to ensure that “liquid oxygen is not allowed for any non medical purpose”
    • The order was passed after the review of oxygen supply situation in the country.

    Dealing with the shortage

    • On April 22, Centre issued order under the DM Act, making the district magistrates and senior superintendent of police personally liable to allow unhindered inter-State movement of vehicles carrying medical oxygen.
    • Despite MHA’s orders and letters, States continued to flag shortage of oxygen supply.
    • Medical oxygen to States are being provided as per daily quota decided by an empowered group of officers in central ministries.

  • [pib] PM launches distribution of e-property cards under SWAMITVA scheme

    e-Property cards under SWAMITVA scheme

    • The Prime Minister launched the distribution of e-property cards under the SWAMITVA scheme on National Panchayati Raj Day (24 April).
    • 4.09 lakh property owners were given their e-property cards on this occasion, which also marked the rolling out of the SVAMITVA scheme for implementation across the country.
    • Under the scheme, the entire village properties are surveyed by drone and property card are distributed to the owners.
    • The Scheme has infused a new confidence in the villages  as property documents remove uncertainty and reduce the chances of property disputes while protecting the poor from exploitation and corruption.
    • This eases credit possibility also.

    About SWAMITVA Scheme

    • SVAMITVA (Survey of Villages and Mapping with Improvised Technology in Village Areas) was launched by Prime Minister on 24th April 2020.
    • It is a Central Sector Scheme to promote a socio-economically empowered and self-reliant rural India.
    • The Scheme has the potential to transform rural India using modern technical tools of mapping and surveying.
    • It paves the way for using the property as a financial asset by villagers for availing loans and other financial benefits.
    • The Scheme will cover around 6.62 Lakh villages of the entire country during 2021-2025.

  • Civil service reforms in India

    The article highlights the role bureaucracy can play in the development of the country and suggests the ways to deal with the challenges faced by the bureaucracy.

    Background of the PSU’s

    • In the 1950s and ’60s, the private sector had neither the capability to raise capital to take the country on the path of industrialisation.
    • The state had to take on the role of industrialising the country by establishing PSUs.
    • The civil services became the natural choice for establishing and managing these units.
    • They delivered substantially, if not fully.
    • Even after privatisation, the bureaucracy would be required for the transition of PSUs from the public to the private sector.

    Need for structural transformation agenda

    • The goal of making India a $5-trillion economy needs a coherent structural transformation agenda and extraordinary implementation capacity.

    1) Dealing with crony capitalisms

    • Since Independence, the political survival of Indian regimes has required pleasing a powerful land-owning class and a highly concentrated set of industrial capitalists.
    • The elites of business houses and land owners share no all-encompassing development agenda.
    • Can the present regime find a way out of this conundrum?

    2) Implementing the development agenda

    • While the agenda is an outcome of political choices, the thinking goes that market mechanisms should be used as far as possible to make economic choices.
    • This argument is at the heart of the privatisation of state assets.
    • However, markets operate well only when they are supported by other kinds of social networks, which include non-contractual elements like trust.
    • Particularly in industrial transformation, there must be an essential complementarity of state structures and market exchange.
    • Only a competent bureaucracy can provide this.
    • It is for this reason that Max Weber argued that the operation of large-scale capitalist enterprise depended upon the kind of order that only a modern bureaucratic state can provide.

    3) Removing the constraints on the bureaucracy

    • The political and permanent executives had to work as a team through mutual respect for each other’s roles as defined in the Constitution.
    • Every deviation from these ideals has lowered the capacity of the state to deliver.
    • This is the result of electoral politics where the essence of the state action is the exchange relationships between the incumbent governments and its supporters.
    • All this is achieved by undermining the impartiality of the bureaucracy in implementing rules and giving opinions frankly.
    • The power to transfer is weaponised to bring the bureaucrats to heel and it works because authority sits with the position not the person.
    • The pressure on officials to behave contrary to the ostensible purpose of the department undermines to a great extent the ability of the state to promote development.
    • If privatisation is to work, then the corruption-transfer mechanism and its effects on the bureaucracy has to go.

    4) Corporate coherence

    • Corporate coherence is the ability of the bureaucracy internally to resist the invisible hands of personal maximisation by undercutting the formal organisational structure through informal networks.
    • If this goes too far, then everything becomes open to sale and the state becomes predatory.

    Consider the question “What are the issues facing civil services in India? Suggest the ways to deal with these issues.”

    Conclusion

    We need to fight the increasing tendency to grab public resources and restore to the bureaucracy its autonomy of action as envisaged in the Constitution by de-weaponising transfers.