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Subject: Social Justice

  • One country, two viruses

    Context

    China’s handling of coronavirus, in contrast to SARS, has been effective, should be a template for others.

    Why lockdown of Wuhan is a big deal?

    • A move without precedent: China’s lockdown of roughly 60 million people in Wuhan and other cities in Hubei province for more than a month now is without precedent in the history of public health.
    • Best way to stop the virus from spreading: The best way to stop a virus from spreading from person to person, is to give it no place to spread to.
      • This is achieved by isolating those who are infected and quarantining those who might be infected.
    • Cordon sanitaire: In China, though, the control has moved beyond traditional quarantine to a cordon sanitaire-an exclusion zone people cannot travel into or get out of.
      • In most countries, this simply would not work for a period this long and a population that large.
    • Inconceivable move in other places: Wuhan is a city of 11 million people, slightly larger than Chennai or Bengaluru. It would be inconceivable to think of cutting off transportation in and out of these cities or asking people to stay at home for even a day, let alone a month.
      • No political control nor administrative mechanism: Like India, most countries in the world have neither the political control to impose their will on people this way nor the administrative mechanism to enforce this degree of control.

    Human cost and ethic of the lockdown

    • The human cost: The human cost of such a strategy is immense.
      • Feeling of being unable to escape: The fear induced by being unable to escape from a place where a new virus is circulating is immense.
      • The worries and stresses of everyday life multiply one hundred-fold when everything from shopping for food to occupying children stuck at home becomes a challenge.
      • The slightest cough, cold or fever can trigger panic.
    • Ethics involved in the move: The ethics of the cordon sanitaire in Wuhan, as well as the quarantining by Japanese authorities of the cruise ship Diamond Princess, will be debated for years after this particular outbreak is over.
    • Slowing the spread: But whatever its human and financial cost, China’s actions in the first month of the outbreak helped to slow the spread of the virus within the country as well as internationally.

    How China’s response this time is different from the SARS

    • On December 31, the Chinese government informed the WHO, and the world, of the existence of a form of pneumonia of unknown cause
      • It also told the people of Wuhan to wear masks if they had symptoms and seek medical attention.
    • Virus identification: For the world, the big breakthrough from China came on January 7, when researchers in Wuhan identified the virus as a new coronavirus.
    • Sharing of the genetic sequence of the virus: Two days later, China shared its genetic sequence with the world.
      • How genetic sequence helped? The sharing of the genetic sequence allowed labs all over the world to develop testing kits to detect the disease.
      • It also put countries on the alert for travellers with the disease, without which the new coronavirus would have spread much quicker and farther than it has so far.
    • China’s response to SARS: The Chinese response to SARS in 2003, in contrast to this, was a cover-up.
      • The disease circulated for nearly three months, enabled by government secrecy and censorship.
      • Spread of disease without warning: When travellers from China brought the disease first to Hong Kong and from there to other cities across the globe, there was no warning.
      • It was only after the disease spread in Hong Kong, that scientists and public health experts began to decipher this new virus.
      • Lessons learned: China, fortunately, learned the lessons for SARS and put together systems to identify and respond to this new disease quickly.

    What India can learn from China

    • Infrastructure with speed: Public health officials all over the world, including in India, should study the speed with which China put together an infrastructure to deal with this new disease.
      • Modern, well-equipped hospitals dedicated to coronavirus patients were constructed in weeks.
    • Centralised information and logistic system: Centralised information and logistics systems and systems to ensure coordination between multiple levels of government -from the central government to provincial and municipal governments, were put into place.
      • All the systems seem to have worked reasonably smoothly, given the chaotic and complex atmosphere of a disease outbreak.
    • Unique approach: The way China has tackled this disease has been an “all of government, all of the society approach”, in the words of Bruce Aylward, the leader of the WHO team that recently spent two weeks in the country.
      • It was, as he described it, “a very old-fashioned approach”, but one that had “prevented at least tens of thousands, but probably hundreds of thousands of cases.”

    Conclusion

    • In all probability, it is only a matter of time before India sees new cases. The Indian health system, as in China, is multi-layered. Some states like Kerala have strong public health infrastructure and a strong response capability. Many other states like Uttar Pradesh and Bihar do not have strong public health systems. They will find it difficult to respond and will learn that diseases, like the revolution, can be brutal.

  • Youth can be a clear advantage for India

    Context

    The demographic dividend is close to five-decade-long demographic opportunities that can be leveraged only with suitable policies and programmes

     The youngest population in the world

    • Median age at 28 years: By 2022, the median age in India will be 28 years.
      • In comparison, it will be 37 in China and the United States.
      • 45 in western Europe, and 49 in Japan.
    • The demographic dividend
      • The working-age population more than non-working: India’s working-age population has numerically outstripped its non-working age population.
      • An extraordinary opportunity: A demographic dividend, said to have commenced around 2004-05, is available for close to five decades.

    The two caveats

    • The demographic dividend is an extraordinary opportunity. There are, however, two caveats.
    • First: Dividend available in different states at different times.
      • India’s population heterogeneity ensures that the window of demographic dividend becomes available at different times in different States.
      • Example of Kerala vs. Bihar: While Kerala’s population is already ageing, in Bihar the working-age cohort is predicted to continue increasing till 2051.
      • Decline in 11 major states by 2031: By 2031, the overall size of our vast working-age population would have declined in 11 of the 22 major States.
    • Second: Many factors that matter for harnessing the dividend
      • Factors that matter: Harnessing the demographic dividend will depend upon the-
      • Employability of the working-age population.
      • Health.
      • Education.
      • Vocational training and skill.
      • Besides appropriate land and labour policies, as well as good governance.
      • Demography is not destiny: India will gain from its demographic opportunity only if policies and programmes are aligned to this demographic shift. Demography is not destiny.

    Need for skills

    • Need for the additional jobs: The Economic Survey 2019 calls for additional jobs to keep pace with the projected annual increases in the working-age population.
    • Lack of education and skills: UNICEF 2019 reports that at least 47% of Indian youth are not on track to have the education and skills necessary for employment in 2030.
      • Possibility of demographic disaster: The projected demographic dividend would turn into a demographic disaster if an unskilled, under-utilised, and frustrated young population undermines social harmony and economic growth.
    • Poor learning outcomes: While over 95% of India’s children attend primary school, the National Family Health Surveys (completed up to 2015-16) confirm that poor infrastructure in government schools, malnutrition, and scarcity of trained teachers have ensured poor learning outcomes.

    What needs to be done?

    • Adopt a uniform school system: A coordinated incentive structure prompting States to adopt a broadly uniform public school system focusing on equity and quality will yield a knowledge society faster than privatising school education can accomplish.
    • Ensure training in line with the market demand: Most districts now have excellent broadband connectivity-
      • Let geography not trump demography: Irrespective of a rural or urban setting, the public school system must ensure that every child completes high school education, and is pushed into appropriate skilling, training and vocational education in line with market demand.
    • Invest and modernise: Modernise school curricula, systematically invest in teacher training so that they grow in their jobs to assume leadership roles while moving beyond the tyranny of the syllabus.
    • Use of technology: Deploy new technology to accelerate the pace of building human capital by putting in place virtual classrooms together with massive open online courses (MOOCS) to help prepare this huge workforce for next-generation jobs.
      • Investing in open digital universities would further help yield a higher educated workforce.

    Focus on women

    • Translating literacy into skill: Growing female literacy is not translating into relevant and marketable skills.
      • A comprehensive approach is needed to improve their prospects vis-à-vis gainful employment.
      • Need of the flexible policies: Flexible entry and exit policies for women into virtual classrooms, and into modules for open digital training, and vocational education would help them access contemporary vocations.
    • The need for equal pay: Equal pay for women will make it worth their while to stay longer in the workforce.
    • The deferred bonus: Economist Yogendra Alagh has written that the significance of this “deferred bonus” (women entering the workforce), could be higher than the immediate benefits of the dividend from shifts in population age structure.

    Health care

    • In India, population health is caught between the rising demand for health services and competition for scarce resources.
    • Impact of economy on rural health: The National Sample Survey Office data on health (75th round, 2018), shows that a deep-rooted downturn in the rural economy is making quality health-care unaffordable.
      • People are availing of private hospitals less than they used to, and are moving towards public health systems.
      • Diverting public investment from However, central budget 2020-21 lays emphasis on private provisioning of health care which will necessarily divert public investment away from public health infrastructure.
    • The Ayushman Bharat Yojana: It links demand to tertiary in-patient care.
      • This promotes earnings of under-utilised private hospitals, instead of modernising and up-grading public health systems in each district.
    • We need to assign 70% of health sector budgets to integrate and strengthen primary and integrated public health-care services and systems up to district hospital levels.
      • Include out-patient department and diagnostic services in every health insurance model adopted, and-
      • Implement in ‘mission mode’ the Report of the High-Level Group, 2019, submitted to the XV Finance Commission.
    • The elderly population in India is projected to double from 8.6% in 2011 to 16% in 2040.
      • This will sharply reduce the per capita availability of hospital beds in India across all major States unless investments in health systems address these infirmities.

    Conclusion

    The policies that we adopt and their effective implementation will ensure that our demographic dividend, a time-limited opportunity, becomes a boon for India.

     

     

     

  • Gearing up to fight the next big viral outbreak

    Context

    India is ill-prepared to deal with the new strain of coronavirus (SARS-CoV-2) that is causing worldwide panic. Policymakers must take forceful action to prevent the spread of the new virus and heed the urgent warnings of global public health professionals about new pathogens.

    No country is adequately prepared

    • Finding of the Global Health Security Index: The World Health Organization (WHO)’s Global Health Security Index finds that no country is adequately prepared.
    • It assesses 195 countries across six categories–
      • Prevention
      • Early detection.
      • Rapid response.
      • Health system quality.
      • Standards.
      • Risk environment.
    • India’s dismal rank: India is ranked 57th.
      • That the country scores around the global average is no comfort, because the global average is a low 40.2 out of 100, and India’s score is 46.5. (For the record, the U.S. is ranked first and China 51st).

    Four-point health agenda

    • The prospect of new outbreaks puts four items on the health agenda in the spotlight that require both immediate and longer-term action:
      • Early detection and prevention.
      • Better collaboration across health service providers.
      • More investment in health systems; outcomes, and education; and-
      • Better care of the environment and biodiversity, which directly affects people’s health safety.

    Thailand’s outstanding example

    • Sixth rank on Health Security Index: That Thailand is ranked sixth in the Health Security Index- the highest ranking for an Asian country.
      • The rank says a great deal about the country’s track record in disease prevention, early detection, and rapid response linked to investments in its public health system.
      • When the deadly Middle East Respiratory Syndrome (MERS), also caused by a coronavirus, broke out in 2015, Thailand quickly notified the WHO of its first confirmed case and acted transparently to arrest the spread.
      • This is in stark contrast to delayed notification by China’s officials of the recent outbreak.

    India’s record in past outbreaks

    • Underscoring inadequacies: The influenza A (H1N1) outbreaks since 2009 in Rajasthan, Maharashtra, Tamil Nadu and other States have acutely underscored the need for better detection, awareness of symptoms and quarantining.
    • Protocols for surveillance: Clearer protocols for all three types of surveillance are needed in all States.
      • And these protocols need to be communicated to health professionals at all levels and the public in local languages.

    Conducting stress tests on health system

    • Countries need to do the stress tests for their preparedness to deal with health emergencies.
    • Exposing the crucial gap: Each State in India should do this to expose crucial gaps in areas such as-
      • Adequacy and supply of diagnostic equipment.
      • Health facilities.
      • Hygienic practices, and-
      • Prevention and treatment protocols.
    • Ensuring strong supply chains: Queues of desperate shoppers trying to buy hand sanitizer, face masks and other protective products in Hong Kong and China highlight the need for strong supply chains for products that people need during health emergencies.

    The partnership between countries and with the private sector

    • Partnership to ensure supply chains: Partnerships between private and public sectors, and between countries– that can sustain supply chains and bolster the medical capacity of countries struggling to cope.
      • Collaborative approach in Asia: In Asia, collaborative approaches exist, for example, for combating tuberculosis, AIDS and malaria.
    • Need to do more: More is needed to tackle health emergencies on the scale of recent outbreak, particularly on funding.
      • Emergency loan option: There could be an emergency loan facility, with a “deferred drawdown option” as the World Bank uses for disasters, natural or health.
      • The loan option can help augment own resources in times of a public health catastrophe.
    • Investment is the best defence: But the best defence of all is to invest more, and more efficiently, in health and education to prepare populations and strengthen health services.
      • Low health expenditure: Health expenditure by the government in India is less than 5% of Gross Domestic Product, which is low for a middle-income country.
      • Spending at that level limits, among other things, the availability of health professionals during crises.
      • According to WHO, India has only 80 doctors per 1,00,000 people.

    Investment in health, education

    • Kerala’s experience: Kerala’s experience in 2018 with the deadly Nipah virus showed the value of investing in education and health over the long term.
    • What measures were taken in Kerala? The availability of equipment for-
      • Quick diagnosis.
      • Measures to prevent diseases from spreading and-
      • Public information campaigns- all helped to keep the mortality rate from the Nipah virus relatively low.
      • Having capable public health professionals helped in the information exchange with WHO and other international bodies.

    The relation between environmental degradation and health

    • A new dimension of new pathogens: One of the many dimensions of new pathogens that is getting increased attention is the link with environmental degradation.
    • The relation between pollution and viral respiratory infection: The interaction between particulate matter from pollution and viral respiratory tract infections, especially in the young and the elderly, as well as the malnourished, has been increasingly noted in epidemiological studies.
      • Many of the highest air pollution readings are being recorded in Indian cities.
    • Most vulnerable country: An HSBC study of 67 countries ranks India as the most climate-vulnerable one because of the impact of severe temperature increases and declines in rainfalls.
      • Reasons for vulnerability: The effects of such occurrences are magnified by the high density of the country’s population, the sheer number of people in harm’s way, and the high incidence of poverty.
      • Research is increasingly connecting global warming to vector-borne viruses.

    Conclusion

    The dangerous trend for disease spillovers from animals to humans can be traced to increased human encroachment on wildlife territory; land-use changes that increase the rate of human-wildlife and wildlife-livestock interactions; and climate change. Protecting the precious biodiversity should be a priority.

     

     

     

     

     

     

     

  • Assisted Reproductive Technology Regulation Bill, 2020

     

    The Union Cabinet has approved the Assisted Reproductive Technology Regulation Bill, 2020 to monitor medical procedures used to assist people to achieve pregnancy.

    What is ART?

    • Assisted reproductive technology (ART) is used to treat infertility.
    • Assisted reproductive technology includes medical procedures used primarily to address infertility.
    • This subject involves procedures such as in vitro fertilization, intracytoplasmic sperm injection, cryopreservation of gametes or embryos, and/or the use of fertility medication.

    Highlights of the bill

    • National Board: The Bill provides for a national Board which will lay down a code of conduct to be observed by those operating clinics.
    • Standardization: It will also formulate minimum standards for laboratory and diagnostic equipment and practices to be followed by human resources employed by clinics and banks.
    • National registry: Under the proposed law, a national registry and registration authority will maintain a database to assist the national Board to perform its functions.
    • Confidentiality clause: The Bill will also ensure confidentiality of intending couples and protect the rights of the child.

    Strict punishment:

    • India has one of the highest growths in the number of ART centres and ART cycles performed every year.
    • India has become one of the major centres of this global fertility industry, with reproductive medical tourism becoming a significant activity.
    • This has also introduced a plethora of legal, ethical and social issues; yet, there is no standardisation of protocols and reporting is still very inadequate.
    • The Bill thus proposes stringent punishment for those who practise sex selection; indulge in sale of human embryos or gametes and those who operate rackets.

    Other such Bills

    Taken together, theses proposed legislations create an environment of safeguards for women’s reproductive rights, addressing changing social contexts and technological advances.

    Surrogacy Regulation Bill 2020

    • The Surrogacy (Regulation) Bill, 2020 proposes to regulate surrogacy in India by establishing National Board at the central level and State Boards and Appropriate Authorities in the States and Union Territories.
    • The major benefit of the Act would be that it will regulate the surrogacy services in the country.
    • While commercial surrogacy will be prohibited including sale and purchase of human embryos and gametes, ethical surrogacy to the Indian Married couple, Indian Origin Married Couple and Indian Single Woman (only widow or Divorcee) will be allowed on fulfillment of certain conditions.
    • As such, it will control the unethical practices in surrogacy, prevent commercialization of surrogacy and will prohibit potential exploitation of surrogate mothers and children born through surrogacy.

    Medical Termination Pregnancy Amendment Bill 2020

    • The Medical Termination of Pregnancy Act, 1971 (34 of 1971) was enacted to provide for the termination of certain pregnancies by registered medical practitioners and for matters connected therewith or incidental thereto.
    • The said Act recognised the importance of safe, affordable, accessible abortion services to women who need to terminate pregnancy under certain specified conditions.
    • Besides this, several Writ Petitions have been filed before the Supreme Court and various High Courts seeking permission for aborting pregnancies at gestational age beyond the present permissible limit on the grounds of foetal abnormalities or pregnancies due to sexual violence faced by women.

  • Powering the health-care engine with innovation

    Context

    India needs to tap the potential of the health-care start-ups in India and make the necessary provision to deal with the problems in the adoption of innovations in health-care.

    Expanding the supply side

    • Need to increase the hospital empanelled: As the scale of this scheme grows, a key area of focus is-
      • To expand the secondary and tertiary hospitals empanelled under PM-JAY and
      • To ensure their quality and capacity while keeping the costs down.
    • The ratio of doctors and beds: At present, there is one government bed for every 1,844 patients and one doctor for every 11,082 patients.
    • 3% hospitalisation under the scheme: In the coming years, considering 3% hospitalisation of PM-JAY-covered beneficiaries, the scheme is likely to provide treatment to 1.5 crore patients annually.
      • This means physical and human infrastructure capacity would need to be augmented vastly.
    • Need for more beds: Conservative estimates suggest that we would need more than 150,000 additional beds, especially in Tier-2 and -3 cities.
    • Long-term strategy: While a comprehensive long-term strategy will focus on expanding hospital and human resources infrastructure, an effective near-term approach is needed to improve efficiencies and bridge gaps within the existing supply and likely demand.
    • Mainstreaming innovation: A strong, yet under-tapped lever for accelerating health system efficiency and bridging these gaps is mainstreaming innovation in the Indian health system.

    Transformative solutions

    • India’s burgeoning entrepreneurial spirit combined with a systematic push for the development of a start-up ecosystem has led to a plethora of innovations in health care.
    • It is estimated that there are more than 4,000 health-care technology start-ups in India.
    • How do start-ups help? Today, start-ups are working to bring-
      • Innovative technologies and business models that leapfrog infrastructure.
      • Human resources.
      • Cost-effectiveness and efficiency challenges in Tier-2 and -3 cities.
    • How other innovations could help?
      • Artificial Intelligence platforms that aid in rapid radiology diagnoses in low resource settings.
      • Tele-ICU platforms to bridge the gap in high-skilled critical care personnel.
      • Centralised drone delivery of blood, medicines and vaccines to reach remote locations cost-effectively and reliably are all no longer just theoretical ideas.
    • Time to implement transformative solutions: It is high time for transformative solutions to make their way into our hospitals, especially in Tier-2 and -3 cities, to turbocharge the way health care is delivered at scale.

    Challenges in mainstreaming healthcare innovations

    • Lack of uniform regulatory standards: One challenge is non-uniform regulatory and validation standards.
      • Regulations evolving in India: Regulatory requirements, specifically for biomedical start-ups, are still evolving in India.
      • As a result, hospitals often rely on foreign regulatory certifications such as FDA and CE, especially for riskier devices and instruments.
      • Government to overhaul standards: The government is now pushing ahead to overhaul Indian med-tech regulatory standards and product standards which will help bridge this trust-deficit.
    • Difficulty in the promotion of start-ups: Another problem in promoting start-ups is the operational liquidity crunch due to a long gestation period.
      • Health-care start-ups spend long periods of time in the early development of their product, especially where potential clinical risks are concerned.
      • Long gestation period: The process of testing the idea and working prototype, receiving certifications, performing clinical and commercial validations, and raising funds, in a low-trust and unstructured environment makes the gestational period unusually long thereby limiting the operational liquidity of the start-up.
    • Lack of framework to adopt innovation: Another hurdle is the lack of incentives and adequate frameworks to grade and adopt innovations.
      • Health-care providers and clinicians, given limited bandwidth, often lack the incentives, operational capacity, and frameworks necessary to consider and adopt innovations.
      • This leads to limited traction for start-ups promoting innovative solutions.
    • Procurement challenges: Start-ups also face procurement challenges in both public and private procurement.
      • They lack the financial capacity to deal with lengthy tenders and the roundabout process of price discovery.
      • Private procurement is complicated by the presence of a fragmented customer base and limited systematic channels for distribution.

    Way forward

    • Identify promising market-ready products: To accelerate the process of mainstreaming innovations within the hospital system in India-
      • We need to focus on identifying promising market-ready health-care innovations that are ready to be tested and deployed at scale.
    • Facilitate standard operational validation studies: There is a need to-
      • Facilitate standardised operational validation studies that are required for market adoption.
      • To help ease out the start-up procurement process such that these solutions can be adopted with confidence.
      • This, in effect, will serve the entire ecosystem of health-care innovators by opening up health-care markets for all.
    • Need to develop an interface between hospital and start-ups: A strong theme in mature health-care systems in other parts of the world is a vibrant and seamless interface between hospitals and health-care start-ups.
      • Through Ayushman Bharat, India has the unique opportunity to develop a robust ecosystem where-
      • Hospitals actively engage with health-care start-ups by providing access to testbeds, communicating their needs effectively and adopting promising innovations.
      • Start-ups as collaborators: Start-ups can be effective collaborators for the most pressing health-care delivery challenges faced by hospitals.

    Conclusion

    The dream of an accessible, affordable and high-quality health-care system for all, will be achieved when we work in alignment to complement each other and jointly undertake the mission of creating an Ayushman Bharat.

  • Battling the bug

    Context

    With multiple cities in China under a public health lockdown, global supply chains of various essential products and consumer goods are likely to be affected. This should be particularly worrisome for India, which has a roughly $93 billion total trade and about $57 billion trade imbalance with China.

    Cause of worry turned into a reality

    • Public health experts have worried most about an animal virus-
      • That gets into humans.
      • Causes human-to-human transmission.
      • Has high infectivity and a range of clinical severity.
      • With no human immunity, no diagnostic tests, drugs or vaccines.
    • An emerging virus, called the 2019 novel coronavirus (2019-nCoV), appears to be just that.
    • With the World Health Organisation declaring it a Public Health Emergency of International Concern (PHEIC), this outbreak is now a pandemic.

    What is coronavirus

    • Group of animal virus: Coronaviruses are a group of animal viruses identified by their crown-like (corona) appearance under a microscope.
    • SAARS connection: The 2019-nCoV belongs to this group of viruses, six of which, including the 2003 Severe Acute Respiratory Syndrome (SARS) and the 2012 Middle East Respiratory Syndrome (MERS) viruses, were earlier known to cause disease in humans.
      • Genetic similarity with other viruses: Genetic sequencing of the virus from five patients showed it to be 5 per cent identical to the SARS virus.
    • Bats as hosts: Since the SARS outbreak in 2003, scientists have discovered a large number of SARS-related coronaviruses from their natural hosts-bats.
      • Previous studies have shown some of these bat coronaviruses to have the potential to infect humans.
      • Genetic sequencing showed it to human coronavirus to be over 96 per cent identical to a bat coronavirus.
      • Thus, 2019-nCoV clearly originated from bats, jumped into humans either directly or through an intermediate host, and adapted itself to human-to-human transmission.
      • Bats are a particularly rich reservoir for viruses with the potential to infect humans.
      • Examples of these include viruses such as Hanta, Rabies, Nipah, Ebola and Marburg viruses, and others that have caused high levels of mortality and morbidity in humans.
      • India has 117 species and 100 sub-species of bats, but we know little about the viruses they harbour and their disease potential.

    India’s response

    • India’s response includes-
      • Surveillance of arriving passengers at airports.
      • Awareness drives in the border states.
      • Designation of hospitals with isolation wards and the availability of protective gear (e.g. masks) to health workers.
      • SOP: There are clear operating procedures for sample collection and its transport to the National Institute of Virology, Pune, which is the nodal testing centre.
      • A self-declaration mechanism is in place and a 24×7 telephone helpline has been set up.
    • Two areas of concern
      • 1. Promotion of untested medicines: There is mixed messaging promoting AYUSH products that are untested and of questionable efficacy.
      • 2. India- a hot zone of zoonotic pathogens: India has been a “hot zone” for the emergence of new zoonotic (animal-derived) pathogens for over a decade.
      • But we continue to lack the capacity to quickly identify, isolate and characterise a novel pathogen.
      • Example of China: China is a good example of how investments in research and public health will allow it to take a lead on developing diagnostic tests, vaccines and drugs for this new virus. We must do the same and prepare for the future.
    • Disruption in global supply chains and concerns for India
      • With multiple cities in China under a public health lockdown, global supply chains of various essential products and consumer goods are likely to be affected.
      • This should be particularly worrisome for India, which has a roughly $93 billion total trade and about $57 billion trade imbalance with China.
      • Disruption in medicine supply: The Indian pharmaceuticals industry imports about 85 per cent of its active pharmaceutical ingredients from China.
      • Any disruption in this supply chain would adversely affect the availability of medicines in India, which would be required in an outbreak situation.
      • Need to support local pharma. industry: India must, therefore, take steps to correct this imbalance and support the local pharmaceuticals industry in reducing its dependence on China

    Possible scenarios

    • Public health experts estimate that the epidemic will peak in three months.
    • From here on, there are a few possible scenarios, but which of these would play out is hard to guess.
    • 1st possibility: There could be very large numbers of cases and global spread of the virus with a low CFR of 0.1-0.5 per cent, like the bad flu. Or the same with increased CFR, which would lead to significant mortality.
    • 2nd possibility: It is also possible that the outbreak spiralled in China due to a combination of factors not present elsewhere, such as population density, food habits and the Chinese New Year, which sees large population movements.
      • It is also possible that the pandemic may not sustain outside China and die out like the 2003 SARS outbreak.
    • Whatever be the case, surveillance and sensible public health measures will be needed over the next few months.

    Conclusion

    India escaped the 2003 SARS and 2012 MERS outbreaks largely unscathed. This may still be the case with 2019-nCoV, but the laws of probability are likely to catch up soon. It would help to invest, build capacity and be ready.

     

     

     

     

  • Nutrition and the Budget’s fine print

    Context

    There are well-equipped schemes to address the malnutrition, plugging the policy gaps is the problem.

    Nutrition and hunger in India

    • Global Hunger Index rank 102: A few months ago, the Global Hunger Index, reported that India suffers from “serious” hunger, ranked 102 out of 117 countries.
    • Only one-tenth of children getting proper diet: Just a tenth of children between six to 23 months are fed a minimum acceptable diet.
    • Urgency reflected in the budget: The urgency around nutrition was reflected in the Union Finance Minister’s Budget speech, as she referred to the “unprecedented” scale of developments under the scheme for Holistic Nutrition, or POSHAN Abhiyaan, the National Nutrition Mission with efforts to track the status of 10 crore households.
    • The Economic Survey notes that “Food is not just an end in itself but also an essential ingredient in the growth of human capital and therefore important for national wealth creation”.
    • How malnutrition affects? Malnutrition affects cognitive ability, workforce days and health, impacting as much as 16% of GDP (World Food Programme and World Bank).

    Addressing Nutrition through Agriculture

    • Multiple dimension of malnutrition: There are multiple dimensions of malnutrition that include-
      • Calorific deficiency.
      • Protein hunger.
      • Micronutrient deficiency.
    • Addressing the issue through Agriculture: An important approach to address nutrition is through agriculture.
      • The Bharatiya Poshan Krishi Kosh which was launched in 2019 is a recent attempt to bridge this gap.
      • The krishi kosh was launched by Ministry of Women and Child Development along with Bill & Melinda Gates Foundation (BMGF).
      • Existing schemes can well address India’s malnutrition dilemma. Following is the analysis of budgetary allocation and expenditure in the previous year.

    First- Calorific deficiency

    • The Integrated Child Development Services (ICDS) scheme provides a package of services including-
      • Supplementary nutrition.
      • Nutrition and health education.
      • Health check-ups and
      • Referral services addressing children, pregnant and lactating mothers and adolescent girls, key groups to address community malnutrition, and which also tackle calorific deficiency and beyond.
      • Underutilisation of funds: For 2019-20, the allotment was ₹27,584.37 crore but revised estimates are ₹24,954.50 crore, which points to an underutilisation of resources.
      • Which area needs the emphasis: The allocation this year is marginally higher, but clearly, the emphasis needs to be on implementation.
    • Mid-Day Meal Scheme: Another pathway to address hunger is the Mid-Day Meal Scheme, to enhance the nutrition of schoolchildren.
      • Here too, the issue is not with allocation but with expenditure.
      • The 2019-20 Budget allocation was ₹11,000 crore and revised estimates are only ₹9,912 crores.

    Second-Protein Hunger

    • Contribution of pulses: Pulses are a major contributor to address protein hunger.
      • Underutilisation of funds: A scheme for State and Union Territories aims to reach pulses into welfare schemes (Mid-Day Meal, Public Distribution System, ICDS) has revised estimates standing at just ₹370 crores against ₹800 crore allocation in the 2019-20 Budget.

    Third-micronutrient deficiency

    • Horticulture Mission: The Horticulture Mission can be one of the ways to address micronutrient deficiency effectively, but here too implementation is low.
      • Revised estimates for 2019-20 stand at ₹1,583.50 crores against an allocation of ₹2,225 crores.
    • National Millet Mission: In 2018-19, the Government of India launched a national millet mission which included renaming millets as “nutri-cereals” also launching a Year of Millets in 2018-19 to promote nutritious cereals in a campaign mode across the country.
      • This could have been further emphasised in the Budget as well as in the National Food Security Mission (NFSM) which includes millets.
      • Under-utilisation of funds: The NFSM strains to implement the allocation of ₹2,000 crores during 2019-20, as revised expenditures stand at ₹1,776.90 crore.
      • Need to sustain the momentum: As millets have the potential to address micronutrient deficiencies, the momentum given to these cereals needs to be sustained.

    POSHAN Abhiyan and issues involved

    • 72% expenditure on technology: The National Nutrition Mission which is a major initiative to address malnutrition, had 72% of total expenditure going into “Information and Communication Technology.
      • Misplaced focus: The focus of the bulk of the funding has been on technology, whereas, actually, it is a convergence that is crucial to address nutrition.
      • Under-utilisation of funds: Only 34% of funds released by the Government of India were spent from FY 2017-18 to FY 2019-20 till November 30, 2019.
      • Limiting the possibility of an increase in the allocation: With underspending, allocations for subsequent years will also be affected, limiting the possibility of increasing budgets and the focus on nutrition schemes.

    Agriculture-nutrition link

    • The agriculture-nutrition link is another piece of the puzzle.
    • Link not explicitly mentioned: While agriculture dominated the initial Budget speech, the link between agriculture and nutrition was not explicit.
      • Why the link is important: The link is important because about three-fifths of rural households are agricultural in India (National Sample Survey Office, 70th round)
      • The malnutrition rates, particularly in rural areas are high (National Family Health Survey-4).
      • Need for greater emphasis: Agriculture-nutrition linkage schemes have the potential for greater impact and need greater emphasis.

    Way forward

    • Focus: Focus on nutrition-related interventions, beyond digitisation.
    • Bring all departments in one place: Intensify the convergence component of POSHAN Abhiyaan, using the platform to bring all departments in one place to address nutrition.
    • Nutrition based activities by farmer-producer: Direct the announcement to form 10,000 farmer producer organisations with an allocation of ₹500 crores to nutrition-based activities.
    • Youth schemes: Promotion of youth schemes to be directed to nutrition-agriculture link activities in rural areas.
    • Emphasis on fund allocation: Give explicit emphasis and fund allocation to agriculture-nutrition linked schemes.
    • Early disbursement and utilisation of funds: Ensure early disbursement of funds and optimum utilisation of schemes linked to nutrition.

    Conclusion

    Nutrition goes beyond just food, with economic, health, water sanitation, gender perspectives and social norms contributing to better nutrition. This is why the implementation of multiple schemes can contribute to better nutrition.

     

  • Medical Devices (Amendment) Rules, 2020

    The Ministry of Health and Family Welfare has notified changes in the Medical Devices Rules, 2017 to regulate medical devices on the same lines as drugs under the Drugs and Cosmetics Act, 1940.

    Medical Devices (Amendment) Rules, 2020

    • These rules are applicable to devices intended for internal or external use in the diagnosis, treatment, mitigation or prevention of disease or disorder in human beings or animals” (as notified by the ministry).
    • It requires online registration of these devices “with the Central Licensing Authority through an identified online portal established by the Central Drugs Standard Control Organisation for this purpose.
    • Among the information that the manufacturer has to upload are “name & address of the company or firm or any other entity manufacturing the medical device along with name and address of manufacturing site.
    • It also need to upload certificate of compliance with respect to ISO 13485 standard accredited by National Accreditation Board for Certification Bodies or International Accreditation Forum.
    • This would mean that every medical device, either manufactured in India or imported, will have to have quality assurance before they can be sold anywhere in the country.
    • After furnishing of the above information a registration number will be generated. Manufacturer shall mention the registration number on the label of the medical device.

    What are the items covered under the new Rules?

    • A large number of commonly used items including hypodermic syringes and needles, cardiac stents, perfusion sets, catheters, orthopaedic implants, bone cements, lenses, sutures, internal prosthetic replacements etc are covered under the new rules.
    • For some items such as sphygmomanometers (used to monitor blood pressure), glucometers (to check blood sugar), thermometers, CT scan and MRI equipment, dialysis and X-ray machines, implants etc, different deadlines for compliance have been set.
    • For example for the first three, it is January 2021, for the others it is April next year. For ultrasound equipment, it is November 2020.

    Is this a sudden move?

    • This has been in the offing for some time now.
    • In October last year, the ministry had circulated copies of the then proposed notification for public comments following recommendations of the Drugs Technical Advisory Board (DTAB), which is the highest technical body for these decisions and has experts among its members.
    • In April last year, the DTAB had recommended that all medical devices should be notified as “drugs” under the drug regulation law to ensure they maintain safety and quality standards.
    • The notification makes it clear that the government has issued it in consultation with the DTAB.

    Why was the move required?

    • For much of the last one year, the health sector has been at the centre of attention following revelations about faulty hip implants marketed by pharma major Johnson & Johnson.
    • This has caused major embarrassment to the government, too, as it exposed the lack of regulatory teeth when it came to medical devices.
    • The matter dragged on, exposing the regulatory loopholes until finally the company agreed in court to pay Rs 25 lakh each to the 67 people who had had to undergo revision surgeries because the implants were defective.
    • That is really where the discussion started about regulation of medical devices.

    What are the penal provisions under Indian law?

    • There are various penal provisions under the Drugs and Cosmetics Act, 1940 for various kinds of offences. Manufacture or sale of substandard items is punishable with imprisonment of at least 10 years, which may extend to imprisonment for life.
    • There is also a provision for fine that will “not be less than Rs 10 lakh rupees or three times value of the confiscated items”.

  • Novel Coronavirus renamed as COVID-19 by WHO

    The World Health Organization (WHO) gave an official name to the disease caused by the novel coronavirus. The death toll from the virus has now crossed 1,000 and the disease has infected tens of thousands of people, the majority of them in China.

    COVID-19

    • The disease will be called “COVID-19”; the “CO” stands for coronavirus, “VI” for virus and “D” for disease.
    • The coronavirus itself is called “nCoV-2019”.

    WHO nomenclature

    • The WHO, in consultation with the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO), has identified best practices for naming new human diseases.
    1. These best practices apply to a new disease:
    2. That is an infection, syndrome, or disease of humans;
    3. That has never been recognised before in humans;
    4. That has potential public health impact; and
    5. Where no disease name is yet established in common usage
    • Names that are assigned by the WHO may or may not be approved by the International Classification of Diseases (ICD) at a later stage.
    • The ICD, which is also managed by the WHO, provides a final standard name for each human disease according to standard guidelines that are aimed at reducing the negative impact from names while balancing science, communication and policy.

    Terms to avoid

    • The agreed best practices include advice on what the disease names should not include, such as geographic location (Middle East Respiratory Syndrome, Spanish Flu, Japanese encephalitis).
    • Disease names should not include people’s names (Creutzfeldt-Jakob disease, Chagas disease), the species or class of animal or food (swine flu, monkeypox etc.), cultural or occupational references (miners, butchers, cooks, nurses etc.) and terms that incite “undue fear” such as death, fatal and epidemic.
    • The use of names such as “swine flu” and “Middle East Respiratory Syndrome” has had “unintended negative impacts” by stigmatising certain communities and economic sectors.

    Terms to include

    • The best practices include using generic descriptive terms such as respiratory diseases, hepatitis, neurologic syndrome, watery diarrhoea.
    • They include using specific descriptive terms that may indicate the age group of the patients and the time course of the disease, such as progressive, juvenile or severe.
    • If the causative pathogen is known, it should be used as part of the disease name with additional descriptors such as the year when the disease was first reported or detected.
    • The names should also be short (rabies, malaria, polio) and should be consistent with the guidelines under the International Classification of Diseases (ICD) Content Model Reference Guide.
    • As per the WHO, “severe” should be used only for those diseases that have a very high initial case fatality rate. “Novel” can be used to indicate a new pathogen of a previously known type
    • In the case of the novel coronavirus, “recognizing that this term will become obsolete if other new pathogens of that type are identified”, the WHO has now changed its name.

  • Arsenic Contamination

    As the geography of arsenic contamination spreads, there is an urgent need for governments to reorient mitigation measures. That’s because the focus till now has only been on drinking water, but new research says arsenic has contaminated our food chain.

    Arsenic contamination of water

    • Arsenic contamination in groundwater is one of the most crippling issues in the drinking water scenario of India.
    • According to the latest report of the Central Ground Water Board (CGWB), 21 states across the country have pockets with arsenic levels higher than the BIS stipulated permissible limit of 0.01 milligram per litre (mg/l).
    • The states along the Ganga-Brahmaputra-Meghna (GBM) river basin — Uttar Pradesh, Bihar, Jharkhand, West Bengal and Assam — are the worst affected by this human-amplified geogenic occurrence.
    • In India, arsenic contamination was first officially confirmed in West Bengal in 1983.
    • Close to four decades after its detection, the scenario has worsened.
    • About 9.6 million people in West Bengal, 1.6 million in Assam, 1.2 million in Bihar, 0.5 million in Uttar Pradesh and 0.013 million in Jharkhand are at immediate risk from arsenic contamination in groundwater.

    Effects of arsenic poisoning

    • Long-term exposure to arsenic in drinking water can cause cancer in the skin, lungs, bladder and kidney. It can also cause other skin changes such as thickening and pigmentation.
    • The likelihood of effects is related to the level of exposure to arsenic and in areas where drinking water is heavily contaminated, these effects can be seen in many individuals in the population.
    • Increased risks of lung and bladder cancer and skin changes have been reported in people ingesting arsenic in drinking water at concentrations of 50 µg/litre, or even lower.

    Affecting food

    • Recent research says arsenic contamination in groundwater has penetrated the food chain.
    • It eventually causes photo-accumulation of arsenic in the food crops, especially in the leaves, can emanate from contaminated water sprayed on them.
    • Yet the focus remained on drinking water, and the affected regions became the primary stake-holder in the mitigation approach.

    Way forward

    • Mitigation measures — that are currently focused on drinking water — must have a more comprehensive approach to ensure arsenic-free water for drinking and agricultural products.
    • That means that the government must check for arsenic in water used for agricultural produce.
    • Both the Union and state governments must work toward facilitating research that can investigate the accumulation of arsenic in crops and addressing the agricultural concerns of the affected regions.
    • They must watch out for arsenic percolation in the food chain and the possibilities of biomagnification.
    • The government needs to also conduct a larger study on the arsenic contamination of our food chain and its health impacts to understand its spatial spread through the agricultural supply chain.