Monday, November 23, 2009


Serious environmental health problems affect millions of people who suffer from respiratory and
other diseases caused or exacerbated by biological and chemical agents, both indoors and outdoors. Millions are exposed to unnecessary chemical and physical hazards in their home, workplace, or wider environment.

Concern about the health effects of the high levels of air pollution observed in many mega cities is growing; moreover, it is likely that this problem will continue to grow because countries are trapped in the trade-offs of economic growth and environmental protection. Population in urban areas are at risk of suffering adverse health effects due to rising problems of severe air and water pollution.

Cooking and heating with solid fuels on open fires or traditional stoves results in high levels of indoor air pollution. Indoor smoke contains a range of health-damaging pollutants, such as small particles and carbon monoxide.

Indian women spend nearly 60% of their reproductive life in either pregnancy or breast-feeding.
Most of the women keep their children in the kitchen when they are cooking, thereby exposing the children to the pollutants too. This, combined with malnutrition may retard growth and lead to smaller lungs and a greater prevalence of chronic bronchitis. There is an urgent need for the implementation of control programs to reduce levels of particulate and other pollutant emissions. To be effective, these programs should include the participation of the different stakeholders
and initiate activities to identify and characterize air pollution problems, as well to estimate
potential health impacts. A full understanding of the problem and its potential consequences for the local setting is essential for effectively targeting interventions to reduce the harmful impacts of air pollution.

Monitoring of air and water quality is crucial for devising programmes and policies related to pollution management. Establishing a reasonably adequate monitoring network with contemporary technology will be given priority. Ways of linking treatment of sewage and industrial effluents to the urban and industrial development planning need to be worked out. The goal should be to ensure that by the end of the Eleventh Plan no untreated sewage or effluent flows into rivers from cities and towns.


Exposure to chemicals, biological agents, physical factors and adverse ergonomic conditions,
allergens, safety risks, and psychological factors often afflict working population of all ages. People also suffer from injuries, hearing loss, respiratory, musculoskeletal, cardiovascular, reproductive, neurotoxic, dermatological, and psychological effects. Such risks are often preventable. The illness resulting from such exposures is not identified properly due to lack of
adequate expertise. The work up of the cases by physicians lacking skills to identify such illness leads to unnecessary use and waste of scarce medical resources as well as their own time. Freedom from occupational illness is essential in today’s competitive world where workers’ productivity is an important determinant of growth and development.

The objectives of occupational health initiative during the Eleventh Five Year Plan will be to promote and maintain highest degree of physical, mental, and social well-being of workers in all occupations; identify and prevent occupational risks of old as well as newer technologies such as Information and Nano technology; build capacity for prevention, that is, early identification of occupational illness; create an occupational health cell under NRHM in each district headquarter, well-equipped to be able to promote primary, secondary, as well as tertiary prevention; and establish occupational health services in agriculture, health and other key sectors for placement of workers in suitable work and propagating adaptation of work to humans.

During the Eleventh Five Year Plan, following strategies will be implemented to reduce occupational health problems:

• Creating awareness among policymakers on the cost of occupational ill health including injuries
• Ensuring use of technologies that are safe and free from risks to health of the workers
• Sensitizing employers as well as workers’ organizations for their right to safety and the implication of injuries in their lives
• Instituting legislation and ensuring proper enforcement for prevention and control of occupational ill health and compensating those who suffer intractable illness due to work
• Building a national data base of occupational illness and injuries
• Monitoring and evaluating programmes and policies related to pollution prevention and control
• Establishing surveillance and research on occupational injuries and building capacity in health
sector to be able to participate in preventing work related illness and injuries
• Enforcing safety regulations and standards
• Introducing no-fault insurance schemes for all workers in the formal and informal sectors

Cancer & Public Sector Spending: 11th Plan

Cancer has become an important public health problem in India with an estimated 7 to 9 lakh cases
occurring every year. At any point of time, it is estimated that there are nearly 25 lakh cases in the country. The strategy under the National Cancer Control Programme (NCCP) was revised in 1984–85 and further in 2004 with stress on primary prevention and early detection of cancer cases. In India, tobacco related cancers account for about half the total cancers among men and 20% among women. About one million tobacco related deaths occur each year, making tobacco related health issues a major public health concern.


During the Tenth Five Year Plan, a taskforce comprising experts from across the country was
constituted. Based on recommendations from the national taskforce a comprehensive NCCP will be
implemented during the Plan. The main activities during the Plan will be:
• Establishing new Regional Cancer Centres
• Upgradation of the existing Regional Cancer Centres based on their performance and linkages with
other cancer organizations in the region.
• Creating skilled human resources for quality cancer care services
• Training health care providers for early detection of cancers at primary and secondary level
• Increasing accessibility and availability of cancer care services
• Providing behavioural change communication along with provision of cost effective screening
techniques and early detection services at the door step of community
• Propagating self-screening of common cancers (oral, breast)
• Upgrading Oncology Wings in government medical colleges
• Creating and upgrading Cancer detection and Surgical and Medical Treatment facilities in District Hospitals/Charitable/NGO/Private Hospitals
• Promoting research on effective strategies of prevention, community-based screening, early
diagnosis, environmental, and behavioural factors associated with cancers and development of cost
effective vaccines
• Creating Palliative Care and Rehabilitation Centres
• Monitoring, Evaluation, and Surveillance

As per NSSO 60th Round, during 2004, 24% of the episodes of ailments among the poor were
untreated in rural areas and 22% in urban areas. Lack of finances was cited as a reason by 28% of persons with untreated episodes in rural areas and 20% in urban areas. It is also notable that 12% cited lack of medical facility as the cause of not receiving treatment in rural areas.

Public spending on health in India is amongst the lowest in the world (about 1% of GDP), whereas
its proportion of private spending on health is one of the highest. Households in India spend about 5–6% of their consumption expenditure on health (NSSO). The cost of services in the private sector makes it unaffordable for the poor and the underprivileged.

The cost of health care in the private sector is much higher than the public sector. Many small
providers have poor knowledge base and tend to follow irrational, ineffective, and sometimes even harmful practices for treating minor ailments. Bulk of the qualified medical practitioners and nurses are subject to self-regulation by their respective State Medical Councils under central legislation. In practice, however, regulation of these professionals is weak and close
to non-existent.

We have a huge working population of about 400 million. Almost 93% of this work force is in the
unorganized sector. There are numerous occupational groups in economic activities, passed on from generation to generation, scattered all over the country with differing employer–employee relationship. Those in the organized sector of the economy, whether in the public or private sector, have access to some form of health service coverage. The unorganized sector workers have no access. The National Commission for Enterprises in the Unorganized Sector (NCEUS) has recommended a specific scheme for health in incidences of illness and hospitalization for workers
and their families.

The Eleventh Five Year Plan will introduce a new scheme based on cashless transaction with the
objective of improving access to health care and protecting the individual and her family from exorbitant out-of-pocket expenses. Under the scheme, coverage will be given to the beneficiary and her family of five members. Providers will be both public and private.

Time-Bound Goals for the Eleventh Five Year Plan

• Reducing Maternal Mortality Ratio (MMR) to 1 per 1000 live births.

• Reducing Infant Mortality Rate (IMR) to 28 per 1000 live births.

• Reducing Total Fertility Rate (TFR) to 2.1.

• Providing clean drinking water for all by 2009 and ensuring no slip-backs.

• Reducing malnutrition among children of age group 0–3 to half its present level.

• Reducing anaemia among women and girls by 50%.

• Raising the sex ratio for age group 0–6 to 935 by 2011–12 and 950 by 2016–17.

Eleventh Plan and health care

Eleventh Five-Year Plan: There is a shortage of 5,801 doctors in PHCs and a shortfall of 4,681 specialists in Community Health Centres (CHCs).

Rashtriya Swasthya Bima Yojana: I have serious doubts about the benefits that will actually accrue to the rural poor from health insurance and the option to go to private hospitals.

The Eleventh Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome, bemoans the Plan document.

The role of health care in economic development has received increasing attention in recent years. There is a general agreement that economic growth is not merely a function of incremental capital-output ratio. Investment in man -- enhanced allocation for education, imparting skills and health care -- plays a significant role in fostering economic growth. It is, therefore, in the fitness of things that the Eleventh Five-Year Plan, whose central theme is ‘Inclusive Growth,’ has substantially stepped up the allocation for health. The Plan document presents a well-conceived, comprehensive programme for the sector. According to the Prime Minister, the aim is to provide broad-based health care in rural areas through the National Rural Health Mission (NRHM).

Health care in a shambles

While the proposed structure for providing health care is adequate and commendable, what is in place at present is thoroughly disappointing. The Plan document itself bemoans: “The public health care system in many States is in [a] shambles. Extreme inequalities and disparities persist both in terms of access to health care as well as health outcome.” (The Eleventh Plan: Vol. II, page 61, para 3.1.16.) The Plan deplores the critical shortage of health personnel, particularly doctors and nurses, poor working conditions and inadequate incentives, and the low utilisation of the meagre facilities in government hospitals. Government hospitals at all levels present a picture of neglect and decline.

I shall deal with two major problems: shortage of doctors for rural service; and the desperate state of medical education.

Health care after independence

Before independence, medical facilities in rural India were rudimentary. The Community Development Block pattern of rural development launched in the 1950s was the harbinger of modern health care in rural areas. According to the approved model, every block was to have a Primary Health Centre (PHC) with 10 beds at the block headquarters and three sub-centres at carefully selected locations. The sanctioned staff for a PHC consisted of two doctors, one Lady Health Visitor and two Sanitary Inspectors. One post of Auxiliary Health Worker and two posts of Auxiliary Nurse-Midwives were sanctioned for each sub-centre. A doctor was required to visit each sub-centre twice a week. I was the Collector of Darbhanga in north Bihar from mid-1958 to the end of 1960. During my tenure, out of the 44 blocks sanctioned for the district, only 37 had become operational. Some 25 blocks had one doctor each and the rest none. Most posts of Lady Health Visitors and Auxiliary Nurse Midwives were vacant.

As chance would have it, I became Bihar’s Health Secretary in July 1962 and stayed on in the post for nearly five years. The total number of blocks in Bihar was about 600. In spite of my best efforts, very few blocks had the full complement of doctors and paramedical staff. During the severe drought of 1965-66, it was only by resorting to draconian measures that we could ensure that all blocks had at least one doctor. Most doctors had an urban background and were reluctant to go to rural areas lacking in modern amenities. There has been no significant improvement in the situation during the last four decades. According to the data given in the Eleventh Plan, there is a shortage of 5,801 doctors in PHCs and a shortfall of 4,681 specialists in Community Health Centres (CHCs).

The Eleventh Plan presents a well thought-out and comprehensive structure for health care in rural areas. The important features of the set-up are:

— 1.75 lakh sub-centres each with two Auxiliary Nurse Midwives at one sub-centre for each panchayat (five or six villages).

— 30,000 PHCs at one for a group of four or five sub-centres. Each PHC will have one Lady Health Visitor and three staff nurses. There will also be an AYUSH physician. (AYUSH is acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy).

— 6500 CHCs each with 30-50 beds. The staff will include seven specialists and nine staff nurses.

— 1800 taluk or sub-divisional hospitals and 600 district hospitals will be fully equipped to provide quality health service.

When this structure is in position, and if it functions reasonably well, we can expect a significant improvement in the quality of medical care in rural India. There will, of course, be an enormous increase in the number of medical graduates, postgraduates and nurses needed to operate the system. The baffling question is how to find the number of personnel needed to fill the vacancies and new posts.

It should be possible to recruit adequate number of doctors and persuade them to stay in the field if the three suggestions given below are adopted and strictly enforced.

— After internship, every medical graduate should be required to work for a minimum of two years in rural areas before he is granted the MBBS degree.

— Only those who have completed three years of rural service should be admitted to any postgraduate course, including the Diplomate of the National Board.

— Every postgraduate student should serve for one year as a specialist in a CHC or sub-divisional hospital before he is awarded the degree or a diploma.

These proposals are not entirely new. Assam has already made rural service compulsory for medical graduates. Some medical colleges have been encouraging fresh graduates to opt for rural service for short periods. The implementation of the proposals, of course, calls for resolute political will. The rationale for making these seemingly harsh suggestions is this. Despite the recent increase in fee, medical education is heavily subsidised by the state. It is manifestly just and fair to stipulate that those who receive medical education should serve the rural society for a short period. Incidentally, the young graduates will benefit a great deal by getting an opportunity to improve their clinical skill. There should, of course, be substantial improvement in the salary of doctors and the amenities available to them.

Shameful state

The proliferation of sub-standard, under-staffed and ill-equipped private medical colleges in recent years is an unmitigated menace. A few institutions like the CMC, Vellore; St. John’s, Bangalore; and the Kasturba Medical College, Manipal, are among the country’s best. But many private colleges lack basic facilities and are run as profit centres for garnering huge amounts as capitation fee. I hear that the present capitation fee for an MBBS seat is Rs. 35 lakh-50 lakh and for a postgraduate seat above Rs.60 lakh. For a discipline like Radiology, the amount could exceed Rs. 1 crore!

Some 15 years ago, a relative of mine had to pay only Rs. 2 lakh through a bank draft and Rs. 2 lakh in cash to get his son admitted to a postgraduate course. The Indian Medical Council has laid down arduous norms in respect of faculty, hospital beds, equipment and so on. Apparently, there is some laxity in the enforcement of the norms. I have heard that while a well-equipped college may run into difficulties, substandard institutions manage to pass muster. I have also heard of cases in which retired teachers and other doctors with postgraduate qualification are shown as visiting faculty for short periods during an inspection by Medical Council teams. No civilised country, not even a soft state like India, can allow such a scandalous state of affairs to continue. It is time the government took resolute action to stem the rot.

Some reservations

The Prime Minister in the Foreword and the Deputy Chairman of the Planning Commission in the Preface have highlighted the positive role the Rashtriya Swasthya Bima Yojana will play in providing health care to the population below the poverty line. I have serious doubts about the benefits that will actually accrue to the rural poor from health insurance and the option to go to private hospitals. As I have not personally observed the working of the scheme, I would leave it to experts familiar with field conditions to evaluate the Yojana.

Another controversial matter is Public Private Partnership (PPP) in providing health care. I do not share the optimism expressed in the Plan document about the role of private institutions in providing health care in rural India. Nor do I agree with the Commission’s enthusiasm about the role of corporate health care and the benefits flowing from the expansion of medical tourism. These issues deserve to be dealt with by more knowledgeable persons.

I shall conclude reiterating that health care in rural India and school education throughout the country should squarely be the concern of the government. Private initiative can certainly supplement the government’s efforts in these fields, but that will benefit only the affluent.

(P.S. Appu is a former Chief Secretary of Bihar and former Director of the Lal Bahadur Shastri National Academy of Administration, Mussoorie. He can be reached at:

The Hindu, 23 Nov. 2009

Friday, November 20, 2009

JNU’s Centre for Community Health Warns Against Bt Brinjal Hazards

Press Release

New Delhi, 20/11/2009: Responding to the introduction of Bt Brinjal in the country for public discussion by Jairam Ramesh, the Union Environment Minister, the Centre of Social Medicine and Community Health (CSMCH), Jawaharlal Nehru University has sent a letter to the Union Minister saying, “We believe that there are serious issues of safety that are not yet addressed through long term studies. There is some data that these crops could be allergy- inducing, and indeed that they might be mutagenic. It is for these reasons that in the European Union but major countries have a restrictive regulatory regime. Countries in EU have a precautionary approach towards GM crops and major countries like Germany, France, Hungary, Greece etc has a ban on their cultivation.”

CSMCH took cognizance of the reports suggesting that the Genetic Engineering Approval Committee (GEAC) has decided to approve the environmental release of Bt Brinjal from Monsanto/Mahyco in India which would for all purposes permit the use of transgenic and Genetically Modified Organisms (GMOs) and products for edible purposes.

The letter notes that CSMCH is seriously troubled with this move. The letter says, “ First of all, this is entirely unnecessary from a public health perspective, indeed undesirable. The argument that Bt brinjal would not require pesticides is dissembling. There are other, better, pest management methods like non pesticidal management that we need to utilize.”

It refers to “serious methodological flaws in the studies that have been carried out, not to mention ethical ones.”

It takes note of the “profound conflict of interest issues involved in the studies carried out in India. The companies that stand to gain by the introduction of these crops into the market were the sponsors of the studies. This is entirely unacceptable.”

The Prof Mohan Rao, Chairperson, CSMCH says, “There has not been adequate assessment of the ecological consequences of the introduction of this food crop. These concerns regarding the health and environmental risks associated with GM crops are too serious to be disregarded. Given our retailing structure, labeling is impossible in India and contamination is inevitable. Introduction of GM crops would kill the choice of the consumer."

The letter concludes saying that “this policy move is entirely unnecessary, has not been transparent and is potentially injurious to public health. We believe there should be a moratorium on such technologies till their safety both to human beings and the environment is proven.”

PublichealthWatch is a collective of public health researchers.

For Details Contact: Prof. Mohan Rao, Chairperson, CSMCH, JNU Ph: 26704420, 26717676, E-mail:

Thursday, August 13, 2009

Management of A(H1N1) epidemic: greater clarity needed

*Dr. Mohan Rao, Prof. Rama Baru, Dr. Rajib Dasgupta, Prof. Sanghmitra Acharya, Prof. K.R. Nayar, Prof. Ramila Bisht, and Dr. Ritu Priya of the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi write: *

As public health workers, we are concerned with the reaction in various quarters to the A(H1N1) (swine flu) epidemic. The hysteria created by the media and the knee-jerk reaction from the Ministry of Health and Family Welfare, are not conducive to rational and well-informed management of the situation.

Swine flu is not more lethal, for instance, than ordinary flu and dengue. There is thus no need for the panic response. It can be treated like any ordinary flu unless there are complications that require hospitalisation. There needs to be greater clarity in the management and treatment of A(H1N1) so that the public is informed regarding the aetiology, treatment and management of swine flu.

Secondary and tertiary levels should be used for confirmation and treatment alone and not for screening, as is being done at present. Screening should be done at the primary level — whether public or private. These have to be given guidelines for screening and testing. The Indian Medical Association will need to play a proactive role in professionally and ethically sensitising its members. Treatment should, at least in the current phase, be limited to designated public hospitals. The government needs to explicitly come out with guidelines regarding the stage of the epidemic at which presumptive cases and not just (laboratory) confirmed cases will be treated with specific antivirals.

Equally, there is no need for the government to open up testing and treatment in the private sector. As public health workers, we know that the private sector is diverse in quality and competence. The situation therefore is ripe for unnecessary — and expensive — testing for swine flu and unnecessary over-diagnosis and treatment. This will not only lead to resistance to the only drugs we have but widespread exploitation of people wrongly diagnosed to have swine flu. The response to this epidemic must be coordinated by institutions such as the National Institute of Communicable Diseases, Indian Council for Medical Research and the National Institute of Virology and not be guided by clinicians alone.

The swine flu epidemic must not be used as an opportunity for quick money making but must be used to strengthen the capacities of the public health infrastructure, including systems for surveillance and monitoring.

Tamiflu & H1N1 flu (Swine flu)

The US Centers for Disease Control and Prevention (CDC) recommends Tamiflu for prevention and treatment of swine flu. Tamiflu is the first neuraminidase inhibitor tablet for the treatment and prevention of influenza A and B. Tamiflu was approved by the US FDA for the treatment of influenza in October 1999 and for influenza prevention in November 2000.

The product, which was developed by Gilead Sciences, a US biopharmaceutical company (that discovers, develops and manufactures therapies for viral diseases and infectious diseases) is commercialized globally by Hoffmann-La Roche, a Swiss global health-care company that operates worldwide.

Notably, Donald Rumsfeld was chairman of the board of directors of Gilead company from 1997 until 2001, when he was appointed U.S. Secretary of Defense but he retained a huge shareholding.

The CDC website states, "CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses."

Researchers conducted a review of numerous studies of of anti-viral medications, which was then published in the prestigious medical journal Lancet on Jan. 19, 2006. As per this review of 51 randomized controlled trials, Tamiflu was useless against the avian flu and many other flus. Contrary to the CDC, their recommendation was not to use Tamiflu.

According to Roche Laboratories, the pharmaceutical company which owns exclusive distribution rights to the drug, Tamiflu has a shelf life of 48 months.

Stock prices of both the companies Roche and Gilead Sciences soared once the drug was recommended by the government as the best treatment. Gilead earns healthy royalties on every pack of Tamiflu.

Indeed what is lacking in the overall discussion about pandemic flu is disagreement, criticism, and skepticism from researchers willing to question and test the data on the efficacy of Tamiflu.

Sunday, June 07, 2009

Ghulam Nabi Azad takes over as Health Minister


Ghulam Nabi Azad, took over as Union Minister of Health & Family Welfare May 29, 2009. Terming his new assignment as an opportunity to serve even the most deprived section of society, Azad emphasized implementation of National Rural Health Mission (NRHM)‘in letter and spirit’ as his first priority. He said that UPA Government has undertaken many major programmes which were long awaited by the people of India such as NREGA, Rural Road Connectivity, Highways and Jawaharlal Nehru Urban Renewal Mission. National Rural Health Mission is one such programme, which is playing a major role in improving the health status of over one billion people in India. This has addressed a long-standing grievance of non-existing rural health infrastructure. ‘It is not possible to implement NRHM just by sitting in the Ministry, therefore I have decided to take a half yearly review of the programme with all the State Governments so that Mission is implemented fully,’ Azad said.

The new Health Minister said that National Urban Health Mission will be vigorously pursued and will be soon implemented after approval by the Cabinet. Underlining the importance of the Mission, Azad said that urban population is increasing very fast and urban health care infrastructure is not able to cope with growing demand.

The Minister also pointed out the initiative of strengthening six new AIIMS and up-gradation of 13 state medical institutions under the first phase of PMSSY. Two more AIIMS like institutes and upgradation of six state medical institutions will be taken up in the phase II. Referring to the new diseases, which have emerged in the recent times, Azad said that production of new vaccines will be a priority area. India needs to be independent in this crucial sector as these new diseases are a major danger in the light of large population and paucity of health infrastructure, the Minister said.

The Minister also counted early detection of non-communicable diseases, establishment of a drug authority, promotion of ayurveda, AIDS prevention and strengthening of health research as his chief priorities.

On a question regarding AIIMS the Minister said that supremacy of institutions is sacrosanct in the authority of institutions will not be allowed to be diluted.

Minister of State in the Ministry of Health & Family Welfare, Dinesh Trivedi also took over the charge. Both the Ministers were later briefed by the senior officers of the Ministry.

Saturday, May 23, 2009

Central Reserve Police Force (CRPF) fights diseases

Central Reserve Police Force (CRPF) fights diseases

Among the many fights it has been engaged in, the Central Reserve Police Force (CRPF) is waging one against its own ailments. A large proportion of this fighting force—about 25 per cent—is suffering from serious diseases.

The numbers are startling. In the last four years, from 2005 to 2008, almost half of its 2.6 lakh-strong workforce has suffered serious ailments.

Close to 50 per cent of these—almost 60,000 of the entire force—is suffering from diseases, which are either long-term or permanent afflictions and potentially life-threatening, like cancer, hepatitis, hypertension, heart problems, AIDS or psychiatric symptoms.

The most common problem, however, relates to the skin.

In these four years, the force has lost 1,425 men to diseases.

The number is only marginally less than the total number of casualties it has suffered in combat operations since 1946—1,659 men, including the 25 who died this year.

While there are several factors for the poor health of one of the largest para-military units of the world, one of the biggest reason is the pathetic conditions they live and operate in. Though this is a reserve force, of late it has almost permanently been deployed in troubled regions.

According to data obtained from the CRPF, more than 80 per cent of its personnel, including 6,000 officers of assistant commandant level and above, have not got a peaceful/static posting in the last 20 years.

The continuous deployment has resulted in a sharp rise in the stress levels of the soldiers, as evident from a large number of stress-related diseases like hypertension, heart ailments and psychiatric problems.

The stress factor has also led to a rise in incidents of fratricide in recent times. Since 2001, the CRPF has lost 35 men in fratricidal incidents.

Indian Express

3 May, 2009

Note: At present, CRPF has 191 Battalions. The Force remained committed to internal security and counter insurgency cum- anti-terrorist operations in various parts of the country. This is a Force with ladies contingents organised in two Mahila Battalions.

CRPF has been unable to halt the suicides among its personnel, despite introducing counselling and yoga.

Sunday, May 17, 2009

India's Profile



Children-under-5 mortality rate:

79 per 1000

Vitamin A deficiency, in children 6 to 59 months old:


Iodine deficiency:


Prevalence of anemia, in children 6 to 59 months old:


Prevalence of anemia, in women:


Thursday, May 14, 2009

Sanitation, Defecation, Gandhi, Nehru & Sulabh

Our toilets bring our civilization into discredit, they violate the rules of hygiene. A toilet must be as clean as a drawing-room, said Mahatma Gandhi reflecting on abysmal sanitary condition in India in general.

Access to public toilet, private toilet, urban toilet, rural toilet and toilet facility especially for women and girls remains quite poor in the country. This is acknowledged by the Eleventh Plan document of the Planning Commission which notes that only 36.4% of the total population has latrines within or attached to their houses as per 2001 census. Another estimate puts the sanitation coverage in the country at about 49% (as on November 2007). Clearly, open defecation remains prevalent.

On May 12, 2009, a panel discussion on `The Attitude called Sanitation' at India International Centre, New Delhi brought together Prof Amitabh Kundu of Jawaharlal Nehru University, Bindeshwar Pathak of Sulabh International, Arumugam Kalimuthu of WES-Net, Rajiv Vora, a noted Gandhian and Sudhirendar Sharma of Ecological Foundation to dwell on 'sanitation' issue that remained focussed on the issue of defecation, which is a very significant component of sanitation.

It is noteworthy that Sulabh's intervention through Sulabh Sauchalaya that started in 1973 in Ara municipality, a small town in the Bhojpur district of Bihar which is deemed a turning point remains in one of the worst unhygienic conditions imaginable. This situation prevails because a very important but micro aspect of sanitation was attended to without even attempting to alter the institutional structures that deal with the broad issue of sanitation. A fact-finding team can visit and ascertain as to why this small town still awaits and invites the intervention of Plague like crisis to liberate itself from filth.

Like Nehru who got elected as the Mayor of Allahabad by promising better sanitation but did not succeed in bringing the required change, sanitation condition of Ara in particular did not and has not improved despite the limited but potent intervention of Sulabh. Although Nehru and Sulabh moved on, the sanitation conditions in Allahabad and Ara and most of India leaves a lot to be desired in spite of purposeful interventions by likes of Sulabh. However, it must be acknowledged that Sulabh’s intervention on human waste disposal and social reforms is a remarkable. In fact the Economic and Social Council of the United Nations has granted Special Consultative Status to Sulabh in recognition of its 'outstanding service to mankind'.

Nehru said, “The day everyone in India gets a toilet to use, I shall know that our country has reached the pinnacle of progress” that day is yet to come and still political parties paid no attention to `sanitation' in the current elections.

It is now being argued that sanitation does not figure prominently in the priority of the communities. But most of the indicators of basic amenities show positive correlation with those of economic development across the states. The percentage of households with flush toilets, for example, exhibits a very strong relationship with per capita income, notes Amitabh Kundu who has authored In The Name of Urban Poor: Access to Basic Amenities. He sought to know as to why institutions like Sulabh, which emerged from a social movement, is being cited to legitimise the withdrawal of the state from sanitation and other basic sectors like health, education, housing and water-supply. Kundu referred to Bindeshwar Pathak’s book The Road to Freedom, a seminal piece of work on scavenging and the social inequity, to stress the role of community mobilisation and the need for state intervention. Kundu pointed out that while individual investment in housing, education and health has gone up the same is not true for sanitation. Consequently, he opined that the state has a significant role to play because poor don't have disposable income to invest on sanitation given the fact that over 87 % income goes into buying food.

Pathak, founder of the Sulabh Sanitation Movement and 2009 Stockholm Water Prize laureate stated that public toilet could be a place of national integration. He cited Puranas to show how there was religious order from the scriptures to keep defecation `away from the household' as opposed to the current practice of creating and promoting facility for it in the household itself. He argued that like habits `cultural change will take time. Taking the recommendations of the Planning Commission in the 10th Five Year Plan a step further with regard to allocation for subsidy for low-cost household toilets for rural families below poverty line at par with subsidy in the urban households, he argued that the rich should be `targeted' as much as the poor while raising the issue of sanitation. Dr. Pathak will formally receive the Stockholm Water Prize at a Royal Award Ceremony and Banquet during the World Water Week in Stockholm in August, 2009. This annual prize includes a $ 150,000 award. Responding to Prof Kundu’s question, Pathak, a Padma Bhushan awardee said, government does have a role but it has to be a combined effort.

Sudhirendar Sharma who chaired and moderated the discussion posed questions like why people don't adopt toilets? Why government's subsidised number game isn't effective? Has Orientalism contributed to our being what `we' are?

Kalimuthu informed that communities are not seeking sanitation. He argued that a new model is emerging wherein people will be paid for using toilet instead of they having to pay for it. Despite the rural sanitation coverage being 57 per cent, over 50 per cent of the covered households have slipped back to open defecation. Unless there is paradigm shift in our policy thrust towards sanitation, the situation may get worse.

The implementation of Nirmal Gram Puraskar, which is given to the Gram Panchayats, blocks, and districts, that achieve 100% sanitation coverage in terms of 100% sanitation coverage of individual households, 100% school sanitation coverage, making the village, block, district free from open defecation and with clean environment and organizations that have been the driving force for effecting full sanitation coverage in the respective geographical area came in for criticism.

Although sanitation also includes waste management among other things, there seemed to be a justified pre-occupation with defecation. It is estimated that about 115000 MT of municipal solid waste is generated daily in the country. This also merits serious attention.

Rajiv Vora submitted that for Gandhi, sanitation was more important than independence and by this logic most Indians are yet to gain independence. He brought forth the issue of cultural diversity in tackling sanitation. `Just toilet' may not work given the varied socio-cultural constructs of sanitation in each of the communities. Gandhi saw the state of sanitation in our trains, railway platforms and around the railway tracks as revealing the truth about sanitation in our country.

The unending discussions on defecation as part of sanitation and state’s role could not be concluded, as many questions remained unattended due to time constraint creating a necessity for an elaborate and rigorous deliberation on another occasion. One hopes that the transcript of the discussions or a perspective paper based on the discussions would be made available in the public domain at the earliest.