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: