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.
Monday, November 23, 2009
OCCUPATIONAL HEALTH IN 11TH PLAN
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
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.
NATIONAL CANCER CONTROL PROGRAMME (NCCP)
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.
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.
NATIONAL CANCER CONTROL PROGRAMME (NCCP)
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.
• 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: psappu@hotmail.com)
The Hindu, 23 Nov. 2009
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: psappu@hotmail.com)
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: mohanrao2008@gmail.com
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: mohanrao2008@gmail.com
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.
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.
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
NATIONAL RURAL HEALTH MISSION TO BE IMPLEMENTED IN LETTER AND SPIRIT
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.
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
| Population: | 1,168,714,600 |
| Children-under-5 mortality rate: | 79 per 1000 |
| Vitamin A deficiency, in children 6 to 59 months old: | 57% |
| Iodine deficiency: | 33% |
| Prevalence of anemia, in children 6 to 59 months old: | 69% |
| Prevalence of anemia, in women: | 62% |
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.
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.
Sunday, November 23, 2008
Green Hospitals
Critics say hospital buildings and food are enough to make you sick. Today there's a growing movement in health care to get hospitals to green their facilities and, as host Bruce Gellerman reports, it's transforming the medical community.
GELLERMAN: About a dozen years ago, the U. S. Environmental Protection Agency reported that medical waste incinerators in hospitals were the largest source of deadly dioxins in the country. The disclosure shook the medical community and led to the creation of an organization that takes its name from the doctor's Hippocratic Oath. Gary Cohen is the executive director of Health Care Without Harm.
COHEN: And we thought how ironic that is that hospitals whose mission is to heal people are contributing to environmentally related disease in this society and we said we need to redefine what that "first, do no harm" ethic means and it means clean up your act.
GELLERMAN: The hospitals quickly cleaned up their act. The number of medical waste incinerators went from 5600 to fewer than 70 still operating today and Health Care Without Harm has become a worldwide coalition of nearly 500 organizations in more than 50 countries. The mission: hospitals, heal thyself, go green. The group led the effort to safely rid medical facilities of toxic mercury found in thermometers and blood pressure devices. But Cohen says there are still things in hospitals that can make you sick:
COHEN: And in the case of patients, if you're getting your IV drip with a PVC medical device it is dripping a reproductive toxin into your veins. Nobody's telling you that but that's the facts, and so our challenge to the hospitals has been look, can't we build cancer centers without carcinogens? Can't we build pediatric units without chemicals linked to birth defects and asthma? This is what health care needs to do. They haven't looked at, except for the last number of years they haven't looked at their environmental health impacts of their operations and their buildings and the stuff they buy.
GELLERMA: From bedpans and surgical gloves to operating rooms and MRI machines, hospitals are enormously expensive to build, equip and operate. And when it comes to making life saving decisions, administrators aren't about to worry about buying energy-saving devices. Still, medicine is starting to use the power of the purse to go green. Architect Robin Guenther is co-author of the book "Sustainable Health Care Architecture."
GUENTHER: Health care is 17 percent of the gross domestic product so health care purchasing represents a huge market leverage around any goods and services a hospital may buy.
LEVY: This is not brain surgery to save energy and water in a hospital. This is common sense kind of stuff.
GELLERMAN: Paul Levy is CEO and president of Beth Israel Deaconess Medical Center. It's a teaching hospital - one of three in Boston's Longwood Medical area. It has three million square feet of space, seven thousand employees, and a 1.2 billion dollar budget. Levy's first priority is patient care; his second is green - as in money, not green as in the environment.
LEVY: Much of the energy work and environmental work in hospitals is driven more by cost issues than by a desire to make the world cleaner and reduce carbon emissions and the like, but that's okay because they end up being the same program anyway.
GELLERMAN: Cutting costs and emissions in hospitals requires a healthy dose of technology. The prescription calls for using automated devices that control lights and temperature, the flow of air and water. Most of these devices are hidden in walls and out of sight.
[WALKING DOWN HALLWAY]
GELLERMAN: But at Beth Israel Deaconess some sensors can see you.
LEVY: It's your traditional vending machine, it's got a picture on the front that's brightly light. It has a refrigerator built to keep things cool, and on top of the machine is a little sensor to keep...
GELLERMAN: Oh, look at that. I wouldn't have noticed it...
LEVY: ...to track of how many people walking by it, and when it detects that the traffic has dropped, it powers down the machine the same way your computer would go into rest mode.
[SOUND OF MAKING A PURCHASE AT A VENDING MACHINE]
GELLERMAN: Vending machines are energy vampires, so hospital utility manager Mark Lukitsch has installed automatic detection devices to curb their appetite. He says small change can add up.
LUKITSCH: We're able to save probably, with the 26 units we installed over the next 10 years, somewhere in the 70, 000 dollar range, just for a simple device that has a payback of less than a year.
GELLERMAN: Again, hospital CEO Paul Levy.
LEVY: The thing is about hospital buildings, because they're so big, and because they're so energy intensive, you can make a minor modification in the operation of building and actually result in a fairly substantial savings.
[WALKING DOWN HALLWAY]
GELLERMAN: Down the street from Boston's Beth Israel is Brigham and Women's Hospital. It has nearly twice as many employees, 13,000.
MOMBOURQUETTE: It's a big business, it's a big business. About 9,000 babies are born here every year. It's the biggest in New England, and one of the biggest in the country actually.
GELLERMAN: Art Mombourquette is vice president of support services at Brigham and Woman's. The hospital is a city unto itself. A hallway a quarter of a mile long - called the pike - connects buildings.
MOMBOURQUETTE: We're walking on one of our green initiatives – this corridor is in the process of being replaced. It's an old vinyl composition tile that we're ripping out and replacing it with a renewable product, it's a rubber product. Not only is it a renewable product, it also doesn't require any floor finishes, which means it doesn't need any harsh chemicals to clean it off when it yellows. So it's much better for the people who need to clean it. It's also softer, to walk on, it's a nice product.
GELLERMAN: It's quiet.
MOMBOURQUETTE: It's very quiet.
GELLERMAN: The long hallway leads to Brigham's newest building, the Shapiro Cardiovascular Center, 300,000 square feet of highly specialized space. It's certified silver LEED – it was designed green from the get go. No new parking spaces were added. Instead, employees were given mass transit passes. Houses that once stood on the property were moved - recycled, in a sense - to preserve the community. And inside the building's soaring atrium, special glazing was used on glass to reduce heating and cooling needs. And every patient's room has floor-to-ceiling windows.
MOMBOURQUETTE: The patient rooms actually slope up at the window, so literally funneling light into the room.
GELLERMAN: This is a hospital. Can the things that you've changed, letting in more light, using environmentally sound cleaning materials, can that help save people's lives or improve their health?
MOMBOURQUETTE: I think there's beginning to be evidence that that's a true statement, and so while it's a little difficult to quantify, there is beginning to be evidence that natural light helps healing.
GELLERMAN: Studies show hospital patients with an outside view suffer fewer complications, need less pain medication and are discharged sooner. Similar benefits have been found in hospitals where family members can stay overnight. And many hospitals are starting to build green roofs to bring nature closer to patients. And they're improving the food they serve, buying organic and locally grown.
It's all part of what's called "evidence based design." It's a concept that architect Robin Guenther says expands the definition of what constitutes health care.
GUENTHER: Buildings ultimately are the clothing that we put on our institutions. Buildings embody all our values, so when you inhabit a green building, it changes how you think about who you are and what you're doing.
GELLERMAN: At Boston's Beth Israel Deaconess, changes in architecture are changing attitudes. Community director Jane Matlaw founded "Healthy Work/Healthy Home," a program encouraging employees to bring new green ideas to the hospital.
MATLAW: And now I have people calling me frequently, saying, "Why aren't we doing this? Could we be doing this? How do we do that? and How do we make it better?" So, it's really gone from, you're a lunatic out there doing your thing, to something people really have embraced.
GELLERMAN: The benefits from going green, says Bill Ravanesi, Boston Director of Health Care Without Harm will pay for themselves - in more ways than money.
RAVANESI: There's a big transformation. We have a green tsunami around us right now, and what we're seeing is a transformation in thinking in health care, going from a mindset that says "let's build an institution," into a different kind of vision, and this vision is a healing environment.
GELLERMAN: The green wave has gone mainstream - and hospitals, their workers, their patients, and communities are the better for it.
Source: http://www.loe.org/shows/segments.htm?programID=08-P13-00047&segmentID=7
GELLERMAN: About a dozen years ago, the U. S. Environmental Protection Agency reported that medical waste incinerators in hospitals were the largest source of deadly dioxins in the country. The disclosure shook the medical community and led to the creation of an organization that takes its name from the doctor's Hippocratic Oath. Gary Cohen is the executive director of Health Care Without Harm.
COHEN: And we thought how ironic that is that hospitals whose mission is to heal people are contributing to environmentally related disease in this society and we said we need to redefine what that "first, do no harm" ethic means and it means clean up your act.
GELLERMAN: The hospitals quickly cleaned up their act. The number of medical waste incinerators went from 5600 to fewer than 70 still operating today and Health Care Without Harm has become a worldwide coalition of nearly 500 organizations in more than 50 countries. The mission: hospitals, heal thyself, go green. The group led the effort to safely rid medical facilities of toxic mercury found in thermometers and blood pressure devices. But Cohen says there are still things in hospitals that can make you sick:
COHEN: And in the case of patients, if you're getting your IV drip with a PVC medical device it is dripping a reproductive toxin into your veins. Nobody's telling you that but that's the facts, and so our challenge to the hospitals has been look, can't we build cancer centers without carcinogens? Can't we build pediatric units without chemicals linked to birth defects and asthma? This is what health care needs to do. They haven't looked at, except for the last number of years they haven't looked at their environmental health impacts of their operations and their buildings and the stuff they buy.
GELLERMA: From bedpans and surgical gloves to operating rooms and MRI machines, hospitals are enormously expensive to build, equip and operate. And when it comes to making life saving decisions, administrators aren't about to worry about buying energy-saving devices. Still, medicine is starting to use the power of the purse to go green. Architect Robin Guenther is co-author of the book "Sustainable Health Care Architecture."
GUENTHER: Health care is 17 percent of the gross domestic product so health care purchasing represents a huge market leverage around any goods and services a hospital may buy.
LEVY: This is not brain surgery to save energy and water in a hospital. This is common sense kind of stuff.
GELLERMAN: Paul Levy is CEO and president of Beth Israel Deaconess Medical Center. It's a teaching hospital - one of three in Boston's Longwood Medical area. It has three million square feet of space, seven thousand employees, and a 1.2 billion dollar budget. Levy's first priority is patient care; his second is green - as in money, not green as in the environment.
LEVY: Much of the energy work and environmental work in hospitals is driven more by cost issues than by a desire to make the world cleaner and reduce carbon emissions and the like, but that's okay because they end up being the same program anyway.
GELLERMAN: Cutting costs and emissions in hospitals requires a healthy dose of technology. The prescription calls for using automated devices that control lights and temperature, the flow of air and water. Most of these devices are hidden in walls and out of sight.
[WALKING DOWN HALLWAY]
GELLERMAN: But at Beth Israel Deaconess some sensors can see you.
LEVY: It's your traditional vending machine, it's got a picture on the front that's brightly light. It has a refrigerator built to keep things cool, and on top of the machine is a little sensor to keep...
GELLERMAN: Oh, look at that. I wouldn't have noticed it...
LEVY: ...to track of how many people walking by it, and when it detects that the traffic has dropped, it powers down the machine the same way your computer would go into rest mode.
[SOUND OF MAKING A PURCHASE AT A VENDING MACHINE]
GELLERMAN: Vending machines are energy vampires, so hospital utility manager Mark Lukitsch has installed automatic detection devices to curb their appetite. He says small change can add up.
LUKITSCH: We're able to save probably, with the 26 units we installed over the next 10 years, somewhere in the 70, 000 dollar range, just for a simple device that has a payback of less than a year.
GELLERMAN: Again, hospital CEO Paul Levy.
LEVY: The thing is about hospital buildings, because they're so big, and because they're so energy intensive, you can make a minor modification in the operation of building and actually result in a fairly substantial savings.
[WALKING DOWN HALLWAY]
GELLERMAN: Down the street from Boston's Beth Israel is Brigham and Women's Hospital. It has nearly twice as many employees, 13,000.
MOMBOURQUETTE: It's a big business, it's a big business. About 9,000 babies are born here every year. It's the biggest in New England, and one of the biggest in the country actually.
GELLERMAN: Art Mombourquette is vice president of support services at Brigham and Woman's. The hospital is a city unto itself. A hallway a quarter of a mile long - called the pike - connects buildings.
MOMBOURQUETTE: We're walking on one of our green initiatives – this corridor is in the process of being replaced. It's an old vinyl composition tile that we're ripping out and replacing it with a renewable product, it's a rubber product. Not only is it a renewable product, it also doesn't require any floor finishes, which means it doesn't need any harsh chemicals to clean it off when it yellows. So it's much better for the people who need to clean it. It's also softer, to walk on, it's a nice product.
GELLERMAN: It's quiet.
MOMBOURQUETTE: It's very quiet.
GELLERMAN: The long hallway leads to Brigham's newest building, the Shapiro Cardiovascular Center, 300,000 square feet of highly specialized space. It's certified silver LEED – it was designed green from the get go. No new parking spaces were added. Instead, employees were given mass transit passes. Houses that once stood on the property were moved - recycled, in a sense - to preserve the community. And inside the building's soaring atrium, special glazing was used on glass to reduce heating and cooling needs. And every patient's room has floor-to-ceiling windows.
MOMBOURQUETTE: The patient rooms actually slope up at the window, so literally funneling light into the room.
GELLERMAN: This is a hospital. Can the things that you've changed, letting in more light, using environmentally sound cleaning materials, can that help save people's lives or improve their health?
MOMBOURQUETTE: I think there's beginning to be evidence that that's a true statement, and so while it's a little difficult to quantify, there is beginning to be evidence that natural light helps healing.
GELLERMAN: Studies show hospital patients with an outside view suffer fewer complications, need less pain medication and are discharged sooner. Similar benefits have been found in hospitals where family members can stay overnight. And many hospitals are starting to build green roofs to bring nature closer to patients. And they're improving the food they serve, buying organic and locally grown.
It's all part of what's called "evidence based design." It's a concept that architect Robin Guenther says expands the definition of what constitutes health care.
GUENTHER: Buildings ultimately are the clothing that we put on our institutions. Buildings embody all our values, so when you inhabit a green building, it changes how you think about who you are and what you're doing.
GELLERMAN: At Boston's Beth Israel Deaconess, changes in architecture are changing attitudes. Community director Jane Matlaw founded "Healthy Work/Healthy Home," a program encouraging employees to bring new green ideas to the hospital.
MATLAW: And now I have people calling me frequently, saying, "Why aren't we doing this? Could we be doing this? How do we do that? and How do we make it better?" So, it's really gone from, you're a lunatic out there doing your thing, to something people really have embraced.
GELLERMAN: The benefits from going green, says Bill Ravanesi, Boston Director of Health Care Without Harm will pay for themselves - in more ways than money.
RAVANESI: There's a big transformation. We have a green tsunami around us right now, and what we're seeing is a transformation in thinking in health care, going from a mindset that says "let's build an institution," into a different kind of vision, and this vision is a healing environment.
GELLERMAN: The green wave has gone mainstream - and hospitals, their workers, their patients, and communities are the better for it.
Source: http://www.loe.org/shows/segments.htm?programID=08-P13-00047&segmentID=7
Saturday, October 11, 2008
Will There Be Another Alma-Ata?
What of the declaration from 1978 promising “Health for All”?
Thirty years have gone by since the “Alma-Ata Declaration” – adopted on September 12, 1978 at the end of an international conference on primary healthcare at Alma-Ata in the then Soviet Union (now, Almaty in Kazakhstan) – set the goal of “Health for All” by the year 2000, to be realised through universal, comprehensive primary healthcare.
The declaration, non-binding on the member-states of the United Nations, came at a time when the first and the second worlds were contending among themselves for advancing their respective power and influence in the World Health Organisation
(WHO), and the third world was pushing for a “new international economic order”. The world has since changed so very dramatically that one wonders if one should at all look at Alma-Ata 30 years on. Hardly had the dust in the aftermath of the declaration
settled down when neo-liberalism as an ideology and as an agenda began its hegemonic ascent. So what of Alma-Ata?
Alma-Ata happened five years after the democratically-elected Popular Unity government in Chile was overthrown in the coup d’état organised by Washington, in which president Salvador Allende was assassinated. Allende was a medical doctor who understood the social origins of disease and ill-health, just like Che Guevara, also a medical practitioner, did. Both of them saw “politics as medicine on a grand scale”.
Allende knew from his practice since the 1930s that a solution to the ill-health of the Chilean people lay not merely in the provision of healthcare but in bringing
about better conditions of work, housing, sanitation, nutrition, and so on. On its part, Cuba, a third world country that practised universal, comprehensive primary healthcare has attained health indicators corresponding to those of the developed world. Closer home, in our part of the world, Alma-Ata came at a time when the Maoist model of development in China – which had incorporated universal, comprehensive primary healthcare, among other things, as an integral part of a long-term programme – was being sought to be discarded following the third plenum of the 11th central committee of the Chinese Communist Party that announced the decision to launch “market reforms”.
The prospects of fulfilling Alma-Ata dimmed even further when conservative, right-wing governments in the United States and the United Kingdom headed by Ronald Reagan and Margaret Thatcher, respectively, took office. After all, Alma-Ata was informed by a
Weltanschauung that was wholly at odds with that of neoliberalism.
In the declaration, health “is a fundamental human right” whose attainment requires a multi pronged attack on the social determinants of ill-health and disease. Existing “gross inequality in the health status of the people is politically, socially, and economically unacceptable”. While the state is held responsible for the health of
the people, the latter “have a right and duty to participate...in the planning and implementation of their healthcare”. And, the conception and practice of primary healthcare should be informed by the understanding that social and economic relations and conditions profoundly influence health, disease and medicine (Paras VI
and VII of the declaration).
Sadly, on the ground, what was practised was selective primary healthcare, for instance, “targeting” children under age five with immunisation and oral rehydration salts (ORS), technical fixes that are useful but cannot go a long way in dealing with health problems whose roots are to be found in exploitation and oppression.
With World Bank-imposed structural adjustment programmes (SAPs) in the 1980s and the slashing of public health expenditure, poor families in the third world landed up at times spending a third of their daily earnings to buy the ORS packets that were being
promoted via “social marketing”. The SAPs adversely affected not only health expenditures, but also those related to education, food subsidy, public transport, etc, pruning a whole gamut of social welfare activity undertaken by states. User-fees, basically cost recovery measures, and the privatisation of health service functions
became the order of the day under the World Bank-mandated SAPs, even as the United Nations Children’s Fund (UNICEF) pleaded for undertaking them “with a human face”.
Whatever happened to healthcare as a “fundamental human right”?
The World Bank’s World Development Report 1993: Investing in Health, as David Werner wrote in an article in this journal 13 years ago (January 21, 1995), “put the last nail in the coffin of the Alma-Ata Declaration”. The World Bank has since pushed the
WHO into second place as the global agency influencing health policy, with a three-fold impact on the ground.
First, the responsibility for the coverage of health costs is a huge burden the poor have to bear more than ever before. Second, primary healthcare has become even more narrow and selective than it was in the 1980s. And, third, the private sector, including the insurance industry, has boomed in the “business” of healthcare. Yes, the business of healthcare – patients are now “clients” and clinical services are “product lines”.
The rights of the pharmaceutical corporations to their intellectual property precede the “fundamental right to healthcare”, which is anyway “non-binding”.
What then of Alma-Ata?
What goes around comes around. If disease is socially derived, then ill-health and disease are an indictment of the social, economic and political order. There will be many a “Sicko” (the title of the film on healthcare in the US by Michael Moore), and, sooner rather than later, the counter-movement against the market mechanism will generate its own Alma-Ata. The struggle for healthcare as a fundamental human right goes on.
Thirty years have gone by since the “Alma-Ata Declaration” – adopted on September 12, 1978 at the end of an international conference on primary healthcare at Alma-Ata in the then Soviet Union (now, Almaty in Kazakhstan) – set the goal of “Health for All” by the year 2000, to be realised through universal, comprehensive primary healthcare.
The declaration, non-binding on the member-states of the United Nations, came at a time when the first and the second worlds were contending among themselves for advancing their respective power and influence in the World Health Organisation
(WHO), and the third world was pushing for a “new international economic order”. The world has since changed so very dramatically that one wonders if one should at all look at Alma-Ata 30 years on. Hardly had the dust in the aftermath of the declaration
settled down when neo-liberalism as an ideology and as an agenda began its hegemonic ascent. So what of Alma-Ata?
Alma-Ata happened five years after the democratically-elected Popular Unity government in Chile was overthrown in the coup d’état organised by Washington, in which president Salvador Allende was assassinated. Allende was a medical doctor who understood the social origins of disease and ill-health, just like Che Guevara, also a medical practitioner, did. Both of them saw “politics as medicine on a grand scale”.
Allende knew from his practice since the 1930s that a solution to the ill-health of the Chilean people lay not merely in the provision of healthcare but in bringing
about better conditions of work, housing, sanitation, nutrition, and so on. On its part, Cuba, a third world country that practised universal, comprehensive primary healthcare has attained health indicators corresponding to those of the developed world. Closer home, in our part of the world, Alma-Ata came at a time when the Maoist model of development in China – which had incorporated universal, comprehensive primary healthcare, among other things, as an integral part of a long-term programme – was being sought to be discarded following the third plenum of the 11th central committee of the Chinese Communist Party that announced the decision to launch “market reforms”.
The prospects of fulfilling Alma-Ata dimmed even further when conservative, right-wing governments in the United States and the United Kingdom headed by Ronald Reagan and Margaret Thatcher, respectively, took office. After all, Alma-Ata was informed by a
Weltanschauung that was wholly at odds with that of neoliberalism.
In the declaration, health “is a fundamental human right” whose attainment requires a multi pronged attack on the social determinants of ill-health and disease. Existing “gross inequality in the health status of the people is politically, socially, and economically unacceptable”. While the state is held responsible for the health of
the people, the latter “have a right and duty to participate...in the planning and implementation of their healthcare”. And, the conception and practice of primary healthcare should be informed by the understanding that social and economic relations and conditions profoundly influence health, disease and medicine (Paras VI
and VII of the declaration).
Sadly, on the ground, what was practised was selective primary healthcare, for instance, “targeting” children under age five with immunisation and oral rehydration salts (ORS), technical fixes that are useful but cannot go a long way in dealing with health problems whose roots are to be found in exploitation and oppression.
With World Bank-imposed structural adjustment programmes (SAPs) in the 1980s and the slashing of public health expenditure, poor families in the third world landed up at times spending a third of their daily earnings to buy the ORS packets that were being
promoted via “social marketing”. The SAPs adversely affected not only health expenditures, but also those related to education, food subsidy, public transport, etc, pruning a whole gamut of social welfare activity undertaken by states. User-fees, basically cost recovery measures, and the privatisation of health service functions
became the order of the day under the World Bank-mandated SAPs, even as the United Nations Children’s Fund (UNICEF) pleaded for undertaking them “with a human face”.
Whatever happened to healthcare as a “fundamental human right”?
The World Bank’s World Development Report 1993: Investing in Health, as David Werner wrote in an article in this journal 13 years ago (January 21, 1995), “put the last nail in the coffin of the Alma-Ata Declaration”. The World Bank has since pushed the
WHO into second place as the global agency influencing health policy, with a three-fold impact on the ground.
First, the responsibility for the coverage of health costs is a huge burden the poor have to bear more than ever before. Second, primary healthcare has become even more narrow and selective than it was in the 1980s. And, third, the private sector, including the insurance industry, has boomed in the “business” of healthcare. Yes, the business of healthcare – patients are now “clients” and clinical services are “product lines”.
The rights of the pharmaceutical corporations to their intellectual property precede the “fundamental right to healthcare”, which is anyway “non-binding”.
What then of Alma-Ata?
What goes around comes around. If disease is socially derived, then ill-health and disease are an indictment of the social, economic and political order. There will be many a “Sicko” (the title of the film on healthcare in the US by Michael Moore), and, sooner rather than later, the counter-movement against the market mechanism will generate its own Alma-Ata. The struggle for healthcare as a fundamental human right goes on.
Playing God: The Global Population Control Movement
Playing God: The Global Population Control Movement
Book Review, The Economic & Political Weekly, October 4, 2008
Fatal Misconception: The Struggle to Control World Population by Matthew Connelly; Harvard University Press, Cambridge, Massachusetts, 2008
by
Mohan Rao
This is a truly extraordinary book that I cannot recommend too
highly, not just to the small community of historians working in the area of health and population, but for public health workers, demographers, scholars in gender studies, feminist and health
activists and, indeed, even the occasional policymaker who reads.
The book has been reviewed favourably in extremely unlikely places, including the New York Times and the Economist. Both point out
that the author is born in a Catholic family, with many children, implying this would explain the critique of the global population control movement that this book is. Both reviews did not point out
that some of the harshest criticism in the book is reserved for the Catholic church’s stand on contraception and abortion.
Reviewers in both places seem to think ideas underlying population control is a thing of the past, like political incorrectness.
And here, they have some misguided support from the author himself, but more on this later.
Here is a scholar who had infamously written in the Atlantic Monthly, with that Cold Warrior Paul Kennedy, that population
growth in the third world, along with growing economic inequalities and migration, portended nothing less than a clash of civilisations, in a familiar replay of neo-Malthusian tropes. Here he is several years later, with extensive research under his belt, prepared not
only to critique his own earlier position, but examine what factors lead to that position itself. This self-questioning, selfdoubt,
is truly catholic – with a small c –and indeed a conversion.
Hopefully, reading this book will take others through the same journey of discovery. Being politically correct, influential
people in policymaking circles in the first world no longer talk of the yellow peril, or use phrases such as population explosion,
or metaphors like the population bomb. Nevertheless, neo-Malthusian thinking –that population growth is the cause of a host of problems, of hunger and poverty, or indeed famines, and today, genocide
and global warming – frames other policy discourses, that on immigration and the environment being prominent ones. “Most
Americans Want Immigration Drastically Reduced” reads a full-page advertisement in Harper’s, put forth by Negative Population
Growth. It goes on to argue about the “catastrophic effect of overpopulation on our environment, resources and standard
of living” (Harper’s 2004:19).1 Neo-Malthusian underpinnings are evident in some of the security discourses on refugees.
The ghastly Rwandan tragedy was seen as an inevitable consequence of
p opulation growth, not the politics of g enocide (Mamdani 2001).2 Hum do hamare do, who paanch, unke pachees (“The two of us have two, the five of them have 25”), was a slogan that won an infamous election in Gujarat after the genocide of Muslims in 2002 (Rao 2007).3 We only need to remember that as soon as the last elections
were announced in the UK, immigration became an issue, not just for the Conservatives but for the New Labour of Tony Blair as well. Both Italy and France have recently elected right wing presidents on an explicit anti-immigration platform.
Fundamentalism
At the same time, a sub-discipline of “strategic demography” has emerged, that seeks to locate the growth of slamic “fundamentalism”4 in the “youth bulge theory”. This fanciful theory argues that population growth in Islamic countries, characterised by a high proportion of youth, leads to the growth of Islamic funda mentalism, spelling political d anger, not just to democracy in these co untries but to the so-called free world (Hendrixson 2004).5 This search for biological metaphors to political and economic problems does not, for instance, explain the rise to political dominance of Protestant fundamentalism in the United States, which has of course no youth bulge, nor indeed significant po pulation growth. But such matters of truth or rigour rarely troubled demographic discourses in the past, and obviously do not, today. In other words, the population growth argument remains compelling, and truly protean, explaining just about everything, and thus of course
explaining nothing.
Here is a remarkable book, of solid scholarship (although rather overburdened with more than a 100 pages of notes and references. Another quick paperback edition is called for without this, cheaper, and thus accessible to more people). Along with a host of secondary
materials, the author has extensively tracked government and UN reports, and, most extraordinarily, been granted permission
to go through the records of organisations such as the Rockefeller
Foundation, the Population Council and so on – the prime players, or villains, in the population drama. Does this mean they have come to terms with their pasts? Or does it mean they do not really care?
Whatever it is, we must salute these organisations for the unusual courage they have displayed.
Fatal Misconception abjures rhetoric and conspiracy theories, indicating the concatenation of ideas, institutions and the
contingencies of global politics to, to use current jargon, deconstruct neo- Malthusian assumptions that lie at the heart of
population policies. It shows with meticulous attention to details of ideas, personalities and funding, how the global population
control movement was created, tracing the extraordinary unfolding of
population policies under the guidance of this movement, in India and China in particular. However, for a book that claims
to be “the first global history of population control” (p 10), the book does not give enough attention to events in Africa, Peru
(forced sterilisation of indigenous people), or indeed the US itself, with its history of eugenic sterilisations.
The book documents admirably this movement’s command over resources,
financial, and intellectual, and the strategies adopted to win friends and influence people – that is so overwhelming even
today.6 And how, in the process, was established a pattern of domination, and a network of institutions, that continues to be
effective in areas as diverse as HIV/AIDS policy and indeed reproductive health policy. Yet, it is not a simple, or simplistic,
first world – imperialism story, which it fundamentally is, but a nuanced, multilayered one. The book is above all rich in
tracing the ideas that influenced such a motley, and huge, group of people. Yes, imperialism is central to the population control movement, but there is also the element of individual freedom and rights it promises, especially to women. Yes, it was hugely racist – and sexist – and this was of course at the heart of the science of
eugenics, which saw its apogee in the Holocaust, but this was not unique to G ermany.7 Indeed the Scandinavian countries and Canada had eugenic sterilisation laws long after the Nuremburg trials discredited them. Yes, cold war politics – communism will spread because of population growth – dictated many of the urges of the movement in the hopeful post- second world war years. Yes, too, that the things done were terrible, but above all that there was consent, approval and indeed active participation from a host of
third world elites. This was a joint global elite project, using different threads of arguments at various times. The movement
felt it could decide who could be allowed to be born and where, and who could be allowed to die.
At times the arguments were eugenic: that the worst were breeding whilst the best were not. This argument seemed to find particular resonance in India with all the leading population control people,
predominantly upper caste Hindus (and indeed a few upper caste Muslims), being particularly suspicious, and fearful of
lower caste and Muslim reproduction. This argument was what led to the sterilisation laws in a host of states in the US, and indeed the US’ immigration policies early in the 20th century. Eugenics is of course currently being reinvented as n eo-eugenics in the wake of advances in biotechnology: parents can now “freely” decide, if they can afford it, what genetic characteristics they do not want in
their child.
Women’s Rights
At other places, the arguments were about women’s rights, as is the case today. It is indeed a case for women’s and men’s rights – but the problem was that this was used instrumentally. Margaret
Sanger, who made this argument forcefully, was also a eugenist, causing profound embarrassment to her erstwhile socialist colleagues. Matthew Connelly is inexplicably rather sweet on Sanger. I would suggest he quickly read Sarah Hodges (2006)8 and Sanjam Ahluwalia (2008)9 before the quick new edition of this book. A question Connelly does not raise is why Sanger, during her tour of
India influencing people to the population control cause,10 did not make overtures to Periyar or Ambedkar, both fierce proponents of birth control. The reason is of course very simple: for Sanger contraception was for eugenic purposes; for Periyar and Ambedkar, it was a quest for gender justice and a blow against
patriarchy and caste.
Above all, the arguments were about economics and development. Population growth in third world countries was seen as the primary reason for their horrible poverty. Colonialism, or indeed the continuing drain of resources from these countries, did not figure. Economic growth could only take place if population was
controlled, it was argued, if necessary with force. I was astonished to discover in this book that Kingsley Davis, the guru of
demographers, who gave testimony in the US senate as to why population control is necessary to combat communism, gave
approval to Sanjay Gandhi’s fearful policies of coercive sterilisations during the Emergency in India (p 320).
The many-headed, hydra-like beast that was created, acting globally, accountable to no one but themselves – which is unfortunately characteristic of most non-governmental organisations (NGOs) – comprised a network of organisations including the Population Council, the Rockefeller Foundation, the For Foundation, the
International Planned Parenthood Federation (with its clutch of poodle national family planning associations) and so on.
They obtained funding from organisations such as the World Bank, the USAID and the UNFPA, and in turn funded a whole range of activist NGOs. As the book documents, during the 20th century more money has
been poured into this movement by first world governments, and others, than any other cause. Linked through funds and people were the leading academic departments at Harvard, Princeton and so on,
and think tanks that increasingly influenced foreign policy. Significantly, all the major demographic journals were funded
by the same institutions and were thus largely responsible for the scientific sheen demography carried. The interconnection between these that Connelly demonstrates is both mind-boggling and
frighteningly impressive.
Revealing Facts
Connelly also shows us how these ideas were used to push the population control agenda globally. Utterly revealing was the
fact that leading donors knew what the Emergency was doing to family planning in India and welcomed it (pp 322-23). Similarly,
I was shocked to discover that donors knew that ultrasounds were
d istorting child sex ratios in China – but that, in their anxiety to control population, encouraged China to import ultrasounds
with aid funds (p 347), and indeed, that the World Bank used structural adjustment loans to push population control policies (p 349).
Connelly does not note the irony that it is precisely these groups and organisations that are involved with reproductive
health and rights today. He seems to believe, inexplicably, that population control is a thing of the past. Thus we have
some paeans to the idea of reproductive health and rights that came to centrestage at the International Conference on Population
and Development at Cairo in 1994. There is such a wealth of literature on the troubled relationship between this evocation of women and reproductive rights – and the wrongs that accompanied it. He misses the significant point that what was being pushed through as the Cairo consensus was the agenda of US feminists. It has been described as white, western and quintessentially bourgeoise.
From Angela Davis onwards, a whole lot of people have written about this. I have described this as an outcome of the marriage
of multinational feminisms with international debt. Surely it is significant that the Cairo consensus not only had the imprimatur of the World Bank, but was silent on what the Bank’s policies had
unleashed on women and their rights and entitlements globally through structural adjustment programmes. Indeed, the Cairo consensus came in for scathing criticism by the leading women’s groups in India on precisely this ground. There is also a movement for reproductive justice, which rejects this concept of
reproductive rights.
Birth rates are declining across the globe, although it is not clear if this is linked in any significant manner with population control programmes. Yet, as we have seen, ideas associated with this
movement have a way of resurfacing in inexplicable ways. Today, warns Connelly, we may already be witnessing something no
less pernicious: the privatisation of population control. It is governmentality without government, in which people police themselves, unconsciously reproducing and reinforcing
inequality with every generation.…
Parents increasingly experience genetic counselling and solicitous concern for foetal health as social pressure to have perfect children, even if standards for perfection are constantly changing. In everyday conversation, people ascribe a whole range of
behaviours to good or bad genes, faithfully reciting a eugenic catechism without the faintest idea of where it comes from or where
it can lead (p 382).
Email: mohanrao2008@gmail.com
Notes
1 Harper’s (2004), Vol 309, No 1853, October.
2 Mahmood Mamdani (2001), When Victims Become
Killers: Colonialism, Nativism and the Genocide in
Rwanda, Princeton University Press, Princeton.
3 Mohan Rao (2007), ‘Saffron Demography: So
Dangerous, Yet So Appealing’, Different Takes,
No 48, Spring 2007, Amherst, Mass, Reprinted in
Babies, Burdens and Threats: Current Faces of
P opulation Control, Hampshire College, Mass.
4 The untroubled use of this word, as of the phrase
“Hindu nationalism”, to describe Hindu fascist
groups indicates the reach and dominance of
crude western thinking, repeated unquestioningly
in India and elsewhere. The word fundamentalism
of course derives very specifically from
the history of Protestant groups in the US, wishing
to reach into the fundamentals of their version
of Christianity to guide their politics and
everyday lives. There are enormous problems
with this characterisation of the Sangh parivar as
Hindu fundamentalist or Hindu nationalist. In
the first place, they do not represent Hindus, and
indeed seem to be deeply ashamed of Hinduism,
wishing to transform it into a more semitic, “masculine”
religion, like Christianity or Islam. There
are of course no fundamentals in Hinduism. Their
claim to be nationalistic is equally moot since
they played an extremely marginal role in India’s
freedom struggle. Indeed, the assassin of
Mahatma Gandhi, a good and proper Hindu, was
a member of the Sangh parivar as it then existed.
5 Anne Hendrixson (2004), Angry Young Men,
Veiled Young Women: Constructing a New Population
Threat, Cornerhouse Briefing No 34, December,
Dorset.
6 As I write the review I see a news item in the
Times of India (‘In Kerala, Having a 3rd Kid May
Invite Penalty’, July 30, 2008) that Kerala seeks
to introduce a two-child norm, with a number of
penalising disincentives. The Kerala Law
C ommission that has mooted this, under the
leadership of the progressive justice Krishna Iyer,
does not seem to know that Kerala has long completed
her demographic transition. In other
words, that even for purely instrumental reasons,
the move is entirely unnecessary, and equally
entirely foolish.
7 Indeed, many doctors and scientists involved in
eugenic sterilisation, and worse, in Nazi G ermany,
got away at the Nuremberg trials where it was
pointed out that the German laws were modelled
on ones current in the US and in many other countries.
Indeed, the US Supreme Court had found
these laws constitutionally valid and thus acceptable.
See Harry Brunius (2006), Better for All the
World: The Secret History of Forced Sterilisations
and America’s Quest for Racial Purity, Alfred
A Knopf, NY.
8 Sarah Hodges (2006), Reproductive Health in
India: History, Politics, Controversies, Orient
Longman, New Delhi.
9 Sanjam Ahluwalia (2008), Reproductive
Restraints: Birth Control in India, 1877-1947,
P ermanent Black, Ranikhet.
10 This, incidentally has been famously rebuffed by
Gandhi. Gandhi rejected contraception sometimes
arguing that contraception would lead to sin and
the weakening of individuals and nations; he sometimes
also rejected contraception on the grounds
that neo-Malthusianism was fundamentally flawed;
at all times arguing that celibacy was the solution
where women, and indeed men, were concerned.
Book Review, The Economic & Political Weekly, October 4, 2008
Fatal Misconception: The Struggle to Control World Population by Matthew Connelly; Harvard University Press, Cambridge, Massachusetts, 2008
by
Mohan Rao
This is a truly extraordinary book that I cannot recommend too
highly, not just to the small community of historians working in the area of health and population, but for public health workers, demographers, scholars in gender studies, feminist and health
activists and, indeed, even the occasional policymaker who reads.
The book has been reviewed favourably in extremely unlikely places, including the New York Times and the Economist. Both point out
that the author is born in a Catholic family, with many children, implying this would explain the critique of the global population control movement that this book is. Both reviews did not point out
that some of the harshest criticism in the book is reserved for the Catholic church’s stand on contraception and abortion.
Reviewers in both places seem to think ideas underlying population control is a thing of the past, like political incorrectness.
And here, they have some misguided support from the author himself, but more on this later.
Here is a scholar who had infamously written in the Atlantic Monthly, with that Cold Warrior Paul Kennedy, that population
growth in the third world, along with growing economic inequalities and migration, portended nothing less than a clash of civilisations, in a familiar replay of neo-Malthusian tropes. Here he is several years later, with extensive research under his belt, prepared not
only to critique his own earlier position, but examine what factors lead to that position itself. This self-questioning, selfdoubt,
is truly catholic – with a small c –and indeed a conversion.
Hopefully, reading this book will take others through the same journey of discovery. Being politically correct, influential
people in policymaking circles in the first world no longer talk of the yellow peril, or use phrases such as population explosion,
or metaphors like the population bomb. Nevertheless, neo-Malthusian thinking –that population growth is the cause of a host of problems, of hunger and poverty, or indeed famines, and today, genocide
and global warming – frames other policy discourses, that on immigration and the environment being prominent ones. “Most
Americans Want Immigration Drastically Reduced” reads a full-page advertisement in Harper’s, put forth by Negative Population
Growth. It goes on to argue about the “catastrophic effect of overpopulation on our environment, resources and standard
of living” (Harper’s 2004:19).1 Neo-Malthusian underpinnings are evident in some of the security discourses on refugees.
The ghastly Rwandan tragedy was seen as an inevitable consequence of
p opulation growth, not the politics of g enocide (Mamdani 2001).2 Hum do hamare do, who paanch, unke pachees (“The two of us have two, the five of them have 25”), was a slogan that won an infamous election in Gujarat after the genocide of Muslims in 2002 (Rao 2007).3 We only need to remember that as soon as the last elections
were announced in the UK, immigration became an issue, not just for the Conservatives but for the New Labour of Tony Blair as well. Both Italy and France have recently elected right wing presidents on an explicit anti-immigration platform.
Fundamentalism
At the same time, a sub-discipline of “strategic demography” has emerged, that seeks to locate the growth of slamic “fundamentalism”4 in the “youth bulge theory”. This fanciful theory argues that population growth in Islamic countries, characterised by a high proportion of youth, leads to the growth of Islamic funda mentalism, spelling political d anger, not just to democracy in these co untries but to the so-called free world (Hendrixson 2004).5 This search for biological metaphors to political and economic problems does not, for instance, explain the rise to political dominance of Protestant fundamentalism in the United States, which has of course no youth bulge, nor indeed significant po pulation growth. But such matters of truth or rigour rarely troubled demographic discourses in the past, and obviously do not, today. In other words, the population growth argument remains compelling, and truly protean, explaining just about everything, and thus of course
explaining nothing.
Here is a remarkable book, of solid scholarship (although rather overburdened with more than a 100 pages of notes and references. Another quick paperback edition is called for without this, cheaper, and thus accessible to more people). Along with a host of secondary
materials, the author has extensively tracked government and UN reports, and, most extraordinarily, been granted permission
to go through the records of organisations such as the Rockefeller
Foundation, the Population Council and so on – the prime players, or villains, in the population drama. Does this mean they have come to terms with their pasts? Or does it mean they do not really care?
Whatever it is, we must salute these organisations for the unusual courage they have displayed.
Fatal Misconception abjures rhetoric and conspiracy theories, indicating the concatenation of ideas, institutions and the
contingencies of global politics to, to use current jargon, deconstruct neo- Malthusian assumptions that lie at the heart of
population policies. It shows with meticulous attention to details of ideas, personalities and funding, how the global population
control movement was created, tracing the extraordinary unfolding of
population policies under the guidance of this movement, in India and China in particular. However, for a book that claims
to be “the first global history of population control” (p 10), the book does not give enough attention to events in Africa, Peru
(forced sterilisation of indigenous people), or indeed the US itself, with its history of eugenic sterilisations.
The book documents admirably this movement’s command over resources,
financial, and intellectual, and the strategies adopted to win friends and influence people – that is so overwhelming even
today.6 And how, in the process, was established a pattern of domination, and a network of institutions, that continues to be
effective in areas as diverse as HIV/AIDS policy and indeed reproductive health policy. Yet, it is not a simple, or simplistic,
first world – imperialism story, which it fundamentally is, but a nuanced, multilayered one. The book is above all rich in
tracing the ideas that influenced such a motley, and huge, group of people. Yes, imperialism is central to the population control movement, but there is also the element of individual freedom and rights it promises, especially to women. Yes, it was hugely racist – and sexist – and this was of course at the heart of the science of
eugenics, which saw its apogee in the Holocaust, but this was not unique to G ermany.7 Indeed the Scandinavian countries and Canada had eugenic sterilisation laws long after the Nuremburg trials discredited them. Yes, cold war politics – communism will spread because of population growth – dictated many of the urges of the movement in the hopeful post- second world war years. Yes, too, that the things done were terrible, but above all that there was consent, approval and indeed active participation from a host of
third world elites. This was a joint global elite project, using different threads of arguments at various times. The movement
felt it could decide who could be allowed to be born and where, and who could be allowed to die.
At times the arguments were eugenic: that the worst were breeding whilst the best were not. This argument seemed to find particular resonance in India with all the leading population control people,
predominantly upper caste Hindus (and indeed a few upper caste Muslims), being particularly suspicious, and fearful of
lower caste and Muslim reproduction. This argument was what led to the sterilisation laws in a host of states in the US, and indeed the US’ immigration policies early in the 20th century. Eugenics is of course currently being reinvented as n eo-eugenics in the wake of advances in biotechnology: parents can now “freely” decide, if they can afford it, what genetic characteristics they do not want in
their child.
Women’s Rights
At other places, the arguments were about women’s rights, as is the case today. It is indeed a case for women’s and men’s rights – but the problem was that this was used instrumentally. Margaret
Sanger, who made this argument forcefully, was also a eugenist, causing profound embarrassment to her erstwhile socialist colleagues. Matthew Connelly is inexplicably rather sweet on Sanger. I would suggest he quickly read Sarah Hodges (2006)8 and Sanjam Ahluwalia (2008)9 before the quick new edition of this book. A question Connelly does not raise is why Sanger, during her tour of
India influencing people to the population control cause,10 did not make overtures to Periyar or Ambedkar, both fierce proponents of birth control. The reason is of course very simple: for Sanger contraception was for eugenic purposes; for Periyar and Ambedkar, it was a quest for gender justice and a blow against
patriarchy and caste.
Above all, the arguments were about economics and development. Population growth in third world countries was seen as the primary reason for their horrible poverty. Colonialism, or indeed the continuing drain of resources from these countries, did not figure. Economic growth could only take place if population was
controlled, it was argued, if necessary with force. I was astonished to discover in this book that Kingsley Davis, the guru of
demographers, who gave testimony in the US senate as to why population control is necessary to combat communism, gave
approval to Sanjay Gandhi’s fearful policies of coercive sterilisations during the Emergency in India (p 320).
The many-headed, hydra-like beast that was created, acting globally, accountable to no one but themselves – which is unfortunately characteristic of most non-governmental organisations (NGOs) – comprised a network of organisations including the Population Council, the Rockefeller Foundation, the For Foundation, the
International Planned Parenthood Federation (with its clutch of poodle national family planning associations) and so on.
They obtained funding from organisations such as the World Bank, the USAID and the UNFPA, and in turn funded a whole range of activist NGOs. As the book documents, during the 20th century more money has
been poured into this movement by first world governments, and others, than any other cause. Linked through funds and people were the leading academic departments at Harvard, Princeton and so on,
and think tanks that increasingly influenced foreign policy. Significantly, all the major demographic journals were funded
by the same institutions and were thus largely responsible for the scientific sheen demography carried. The interconnection between these that Connelly demonstrates is both mind-boggling and
frighteningly impressive.
Revealing Facts
Connelly also shows us how these ideas were used to push the population control agenda globally. Utterly revealing was the
fact that leading donors knew what the Emergency was doing to family planning in India and welcomed it (pp 322-23). Similarly,
I was shocked to discover that donors knew that ultrasounds were
d istorting child sex ratios in China – but that, in their anxiety to control population, encouraged China to import ultrasounds
with aid funds (p 347), and indeed, that the World Bank used structural adjustment loans to push population control policies (p 349).
Connelly does not note the irony that it is precisely these groups and organisations that are involved with reproductive
health and rights today. He seems to believe, inexplicably, that population control is a thing of the past. Thus we have
some paeans to the idea of reproductive health and rights that came to centrestage at the International Conference on Population
and Development at Cairo in 1994. There is such a wealth of literature on the troubled relationship between this evocation of women and reproductive rights – and the wrongs that accompanied it. He misses the significant point that what was being pushed through as the Cairo consensus was the agenda of US feminists. It has been described as white, western and quintessentially bourgeoise.
From Angela Davis onwards, a whole lot of people have written about this. I have described this as an outcome of the marriage
of multinational feminisms with international debt. Surely it is significant that the Cairo consensus not only had the imprimatur of the World Bank, but was silent on what the Bank’s policies had
unleashed on women and their rights and entitlements globally through structural adjustment programmes. Indeed, the Cairo consensus came in for scathing criticism by the leading women’s groups in India on precisely this ground. There is also a movement for reproductive justice, which rejects this concept of
reproductive rights.
Birth rates are declining across the globe, although it is not clear if this is linked in any significant manner with population control programmes. Yet, as we have seen, ideas associated with this
movement have a way of resurfacing in inexplicable ways. Today, warns Connelly, we may already be witnessing something no
less pernicious: the privatisation of population control. It is governmentality without government, in which people police themselves, unconsciously reproducing and reinforcing
inequality with every generation.…
Parents increasingly experience genetic counselling and solicitous concern for foetal health as social pressure to have perfect children, even if standards for perfection are constantly changing. In everyday conversation, people ascribe a whole range of
behaviours to good or bad genes, faithfully reciting a eugenic catechism without the faintest idea of where it comes from or where
it can lead (p 382).
Email: mohanrao2008@gmail.com
Notes
1 Harper’s (2004), Vol 309, No 1853, October.
2 Mahmood Mamdani (2001), When Victims Become
Killers: Colonialism, Nativism and the Genocide in
Rwanda, Princeton University Press, Princeton.
3 Mohan Rao (2007), ‘Saffron Demography: So
Dangerous, Yet So Appealing’, Different Takes,
No 48, Spring 2007, Amherst, Mass, Reprinted in
Babies, Burdens and Threats: Current Faces of
P opulation Control, Hampshire College, Mass.
4 The untroubled use of this word, as of the phrase
“Hindu nationalism”, to describe Hindu fascist
groups indicates the reach and dominance of
crude western thinking, repeated unquestioningly
in India and elsewhere. The word fundamentalism
of course derives very specifically from
the history of Protestant groups in the US, wishing
to reach into the fundamentals of their version
of Christianity to guide their politics and
everyday lives. There are enormous problems
with this characterisation of the Sangh parivar as
Hindu fundamentalist or Hindu nationalist. In
the first place, they do not represent Hindus, and
indeed seem to be deeply ashamed of Hinduism,
wishing to transform it into a more semitic, “masculine”
religion, like Christianity or Islam. There
are of course no fundamentals in Hinduism. Their
claim to be nationalistic is equally moot since
they played an extremely marginal role in India’s
freedom struggle. Indeed, the assassin of
Mahatma Gandhi, a good and proper Hindu, was
a member of the Sangh parivar as it then existed.
5 Anne Hendrixson (2004), Angry Young Men,
Veiled Young Women: Constructing a New Population
Threat, Cornerhouse Briefing No 34, December,
Dorset.
6 As I write the review I see a news item in the
Times of India (‘In Kerala, Having a 3rd Kid May
Invite Penalty’, July 30, 2008) that Kerala seeks
to introduce a two-child norm, with a number of
penalising disincentives. The Kerala Law
C ommission that has mooted this, under the
leadership of the progressive justice Krishna Iyer,
does not seem to know that Kerala has long completed
her demographic transition. In other
words, that even for purely instrumental reasons,
the move is entirely unnecessary, and equally
entirely foolish.
7 Indeed, many doctors and scientists involved in
eugenic sterilisation, and worse, in Nazi G ermany,
got away at the Nuremberg trials where it was
pointed out that the German laws were modelled
on ones current in the US and in many other countries.
Indeed, the US Supreme Court had found
these laws constitutionally valid and thus acceptable.
See Harry Brunius (2006), Better for All the
World: The Secret History of Forced Sterilisations
and America’s Quest for Racial Purity, Alfred
A Knopf, NY.
8 Sarah Hodges (2006), Reproductive Health in
India: History, Politics, Controversies, Orient
Longman, New Delhi.
9 Sanjam Ahluwalia (2008), Reproductive
Restraints: Birth Control in India, 1877-1947,
P ermanent Black, Ranikhet.
10 This, incidentally has been famously rebuffed by
Gandhi. Gandhi rejected contraception sometimes
arguing that contraception would lead to sin and
the weakening of individuals and nations; he sometimes
also rejected contraception on the grounds
that neo-Malthusianism was fundamentally flawed;
at all times arguing that celibacy was the solution
where women, and indeed men, were concerned.
Health care costs: A market-based view
If health care costs continue to rise at current rates, they could amount to 20 percent or more of the GDP of many developed countries. To understand how to manage—or influence—this expenditure, decision makers should look at the factors that influence the supply and demand of health care services.
* Throughout the world, leaders of government health agencies, heads of health care companies, and even patients—collectively, the shapers of the modern health care system—behold the growth of health care spending with alarm. For almost 50 years, spending has grown by 2 percentage points in excess of GDP growth across all Organisation for Economic Co-operation and Development (OECD) countries. As a result, health care has become a much bigger part of most of these economies.
* If current trends persist to 2050, most OECD countries will spend more than a fifth of GDP on health care. By 2080 Switzerland and the United States will devote more than half of GDP to it—and by 2100 most other OECD countries will reach this level of spending.
* Health care leaders fervently hope that the projections are off the mark. What will have to change to prevent health care from devouring half of a national economy?
This article contains the following exhibits:
* Exhibit 1: In the health-care market, the line between supply and demand is sometimes blurred.
* Exhibit 2: Per capita spending on health care strongly correlates with national GDP.
* Exhibit 3: The median increase in health-care spending in member countries of the Organisation for Economic Co-operation and Development (OECD) has been two percentage points above GDP for nearly 50 years.
* Exhibit 4: At the historic growth rate, health care will consume an ever-growing proportion of developed nations' wealth.
* Exhibit 5: In many countries, the tax-financed part of health care represents a massive transfer from young taxpayers to older health care users.
The McKinsey Quarterly
* Throughout the world, leaders of government health agencies, heads of health care companies, and even patients—collectively, the shapers of the modern health care system—behold the growth of health care spending with alarm. For almost 50 years, spending has grown by 2 percentage points in excess of GDP growth across all Organisation for Economic Co-operation and Development (OECD) countries. As a result, health care has become a much bigger part of most of these economies.
* If current trends persist to 2050, most OECD countries will spend more than a fifth of GDP on health care. By 2080 Switzerland and the United States will devote more than half of GDP to it—and by 2100 most other OECD countries will reach this level of spending.
* Health care leaders fervently hope that the projections are off the mark. What will have to change to prevent health care from devouring half of a national economy?
This article contains the following exhibits:
* Exhibit 1: In the health-care market, the line between supply and demand is sometimes blurred.
* Exhibit 2: Per capita spending on health care strongly correlates with national GDP.
* Exhibit 3: The median increase in health-care spending in member countries of the Organisation for Economic Co-operation and Development (OECD) has been two percentage points above GDP for nearly 50 years.
* Exhibit 4: At the historic growth rate, health care will consume an ever-growing proportion of developed nations' wealth.
* Exhibit 5: In many countries, the tax-financed part of health care represents a massive transfer from young taxpayers to older health care users.
The McKinsey Quarterly
The Corner House on Health
Who Owns the Knowledge Economy? Political Organising Behind TRIPS
by Peter Drahos with John Braithwaite
When TRIPS was signed in 1994, the United States, Europe and Japan dominated the world's software, pharmaceutical, chemical and entertainment industries. The rest of the world had little to gain by agreeing to these terms of trade for intellectual property. They did so because a failure of democratic processes nationally and internationally enabled a small group of men within the United States to capture the US trade-agenda-setting process, to draft intellectual property principles that became the blueprint for TRIPS and to crush resistance through US trade power.
A Decade After Cairo Women's Health in a Free Market Economy
by Sumati Nair and Preeti Kirbat with Sarah Sexton
This briefing evaluates the 1994 UN International Conference on Population and Development. It assesses several processes that affect women's reproductive and sexual rights and health: the decline and collapse in health services; neo-liberal economic policies and religious fundamentalisms; and development policies underpinned by neo-Malthusianism.
GATS, Privatisation and Health
by Sarah Sexton
The World Trade Organisation's General Agreement on Trade in Services (GATS) could have a significant effect on human health, and health care services.
Trading Health Care Away? GATS, Public Services and Privatisation
by Sarah Sexton
If Cloning is the Answer, What was the Question? Power and Decision-Making in the Geneticisation of Health
by Sarah Sexton
Most discussions about human embryo cloning focus on ethics and potential health benefits. In the process, the many social, economic and environmental aspects of health and disease are increasingly hidden, while issues such as how the potential benefits of biotech would be obtained and distributed are sidelined. It has therefore become hard to raise key questions about the increased geneticisation of our lives and societies.
by Peter Drahos with John Braithwaite
When TRIPS was signed in 1994, the United States, Europe and Japan dominated the world's software, pharmaceutical, chemical and entertainment industries. The rest of the world had little to gain by agreeing to these terms of trade for intellectual property. They did so because a failure of democratic processes nationally and internationally enabled a small group of men within the United States to capture the US trade-agenda-setting process, to draft intellectual property principles that became the blueprint for TRIPS and to crush resistance through US trade power.
A Decade After Cairo Women's Health in a Free Market Economy
by Sumati Nair and Preeti Kirbat with Sarah Sexton
This briefing evaluates the 1994 UN International Conference on Population and Development. It assesses several processes that affect women's reproductive and sexual rights and health: the decline and collapse in health services; neo-liberal economic policies and religious fundamentalisms; and development policies underpinned by neo-Malthusianism.
GATS, Privatisation and Health
by Sarah Sexton
The World Trade Organisation's General Agreement on Trade in Services (GATS) could have a significant effect on human health, and health care services.
Trading Health Care Away? GATS, Public Services and Privatisation
by Sarah Sexton
If Cloning is the Answer, What was the Question? Power and Decision-Making in the Geneticisation of Health
by Sarah Sexton
Most discussions about human embryo cloning focus on ethics and potential health benefits. In the process, the many social, economic and environmental aspects of health and disease are increasingly hidden, while issues such as how the potential benefits of biotech would be obtained and distributed are sidelined. It has therefore become hard to raise key questions about the increased geneticisation of our lives and societies.
Saturday, September 20, 2008
Contaminated milk kills Babies
China is once again rocked by a baby milk formula scandal. Four babies have died and at least six thousand are suffering from kidney stones, which has led to acute kidney failure in many of the sick children. Originally, only the San Lu brand was thought to be contaminated, but it has since transpired that twenty other brands have been tested positive for melamine. The World Health Organisation has called on the Chinese authorities to explain how the scandal was allowed to develop.
Baby milk inspection in ChinaAnd while hospital waiting rooms across China are filling up with worried parents and babies with kidney stones, TV commercials promoting baby formula are still on air:
"This is a TV commercial for formula. A special ingredient makes this formula easier to digest - specially designed for your baby's delicate digestive system. Nestle Grow Formula Number 3 - for babies growing the healthy way."
The text for this commercial typifies the kind of claims made by the marketers - they emphasise the special quality attributed to their brand. Aggressive advertising campaigns like this have led to a sharp decrease in the number of women breast-feeding their babies.
And now the magic formula has been found to contain melamine, a chemical used in the manufacture of durable household products like plastic dinnerware and cutlery. Suppliers - be it the farmers or the dairies - are suspected of diluting milk to cut costs, then adding melamine to make it appear higher in protein. More protein means more money.
Kidney stones
It also means more babies - thousands of them - with kidney stones. John Foreman, an American paediatrician and kidney specialist:
"We know that melamine can form stones, and presumably that's what's happening to those children. They are getting stones in their kidneys and that's blocking the flow of urine, which is backing up in the kidneys and causing them not to function properly."
The San Lu Group knew that melamine was being added to formula for three years, but opted to remain silent. Local authorities also chose not to investigate the affair, for fear of bad press just when the spotlight was on Beijing for the Olympic Games.
The Chinese media released the information about the contaminated San Lu milk on 11 September. On 16 September, it was revealed that 21 other brands had the same problem, including Olympic Games sponsor Yili.
Confidence waning
Now the public has little or no confidence in any of the popular dairy products. In a supermarket at the Workers' Stadium, an old woman is looking up and down the shelves:
"I wouldn't dare buy [Yili] anymore. Only foreign milk; that should be alright."
Imported milk is three times more expensive, but many are prepared to pay to be safe. On an internet forum for mothers, 94 percent of those questioned have said that they will not use Chinese brands. And now, not even regular milk is an alternative. On Friday, it was announced that liquid milk from three of China's largest dairies was tainted with melamine.
The current milk crisis is the last in a series of food scandals in China. Eggs, steamed sandwiches, animal feed and prawns have all featured in the string of health scares. Three years ago, 13 babies died in the Anhui province as a result of malnutrition. They had been fed a kind of fake formula containing no nutrition.
Indeed we need to reach far beyond the actual consumers of baby milks. This is a case of Globalised Contamination.
The hue and cry around the Sanlu baby milk tragedy in China is focusing very narrowly on the quality of the milk produced by one Chinese company. This detracts from the fact that formula feeding regardless of brand and origin has inherent risks. What is also being overlooked is the large number of babies dependent on formula feeding at an age when breastfeeding should be the norm. The fact that aggressive marketing may be one key factor that is tilting the balance against breastfeeding
is also not being addressed.
China has had regulations that implement the International Code of Marketing of Breastmilk Substitutes since 1995. The regulations are incomplete and have regrettably never been fully implemented or enforced despite ICDC's past and recent efforts. Maybe this latest episode of babies dying and suffering as a result of formula feeding will get the Chinese authorities to sit up and give breastfeeding the support it deserves. They must act to protect their children. It is the least they can do. There will doubtlessly be more muck-ups with milks but the harm will be
minimised if breastfeeding is made popular and routine.
Until that time, foreign companies selling formula in China will be gloating over increased sales.
Baby milk inspection in ChinaAnd while hospital waiting rooms across China are filling up with worried parents and babies with kidney stones, TV commercials promoting baby formula are still on air:
"This is a TV commercial for formula. A special ingredient makes this formula easier to digest - specially designed for your baby's delicate digestive system. Nestle Grow Formula Number 3 - for babies growing the healthy way."
The text for this commercial typifies the kind of claims made by the marketers - they emphasise the special quality attributed to their brand. Aggressive advertising campaigns like this have led to a sharp decrease in the number of women breast-feeding their babies.
And now the magic formula has been found to contain melamine, a chemical used in the manufacture of durable household products like plastic dinnerware and cutlery. Suppliers - be it the farmers or the dairies - are suspected of diluting milk to cut costs, then adding melamine to make it appear higher in protein. More protein means more money.
Kidney stones
It also means more babies - thousands of them - with kidney stones. John Foreman, an American paediatrician and kidney specialist:
"We know that melamine can form stones, and presumably that's what's happening to those children. They are getting stones in their kidneys and that's blocking the flow of urine, which is backing up in the kidneys and causing them not to function properly."
The San Lu Group knew that melamine was being added to formula for three years, but opted to remain silent. Local authorities also chose not to investigate the affair, for fear of bad press just when the spotlight was on Beijing for the Olympic Games.
The Chinese media released the information about the contaminated San Lu milk on 11 September. On 16 September, it was revealed that 21 other brands had the same problem, including Olympic Games sponsor Yili.
Confidence waning
Now the public has little or no confidence in any of the popular dairy products. In a supermarket at the Workers' Stadium, an old woman is looking up and down the shelves:
"I wouldn't dare buy [Yili] anymore. Only foreign milk; that should be alright."
Imported milk is three times more expensive, but many are prepared to pay to be safe. On an internet forum for mothers, 94 percent of those questioned have said that they will not use Chinese brands. And now, not even regular milk is an alternative. On Friday, it was announced that liquid milk from three of China's largest dairies was tainted with melamine.
The current milk crisis is the last in a series of food scandals in China. Eggs, steamed sandwiches, animal feed and prawns have all featured in the string of health scares. Three years ago, 13 babies died in the Anhui province as a result of malnutrition. They had been fed a kind of fake formula containing no nutrition.
Indeed we need to reach far beyond the actual consumers of baby milks. This is a case of Globalised Contamination.
The hue and cry around the Sanlu baby milk tragedy in China is focusing very narrowly on the quality of the milk produced by one Chinese company. This detracts from the fact that formula feeding regardless of brand and origin has inherent risks. What is also being overlooked is the large number of babies dependent on formula feeding at an age when breastfeeding should be the norm. The fact that aggressive marketing may be one key factor that is tilting the balance against breastfeeding
is also not being addressed.
China has had regulations that implement the International Code of Marketing of Breastmilk Substitutes since 1995. The regulations are incomplete and have regrettably never been fully implemented or enforced despite ICDC's past and recent efforts. Maybe this latest episode of babies dying and suffering as a result of formula feeding will get the Chinese authorities to sit up and give breastfeeding the support it deserves. They must act to protect their children. It is the least they can do. There will doubtlessly be more muck-ups with milks but the harm will be
minimised if breastfeeding is made popular and routine.
Until that time, foreign companies selling formula in China will be gloating over increased sales.
Tuesday, March 18, 2008
No package deal
Rajib Dasgupta and Rama V. Baru
Health and education are fundamental rights of every child and it is imperative that the state and civil society ensure that these services are available, accessible and of good quality. Data from the National Nutritional Monitoring Bureau and the National Family Health Survey 3 indicate that child malnutrition continues to be a serious concern.
The government is now considering the replacement of cooked meals with packaged foods and biscuits in its Mid-Day Meal (MDM) and Integrated Child Development Services (ICDS) programmes. It is argued that this shift would improve efficiency and help overcome fiscal and managerial constraints faced in the implementation of these programmes. Reports also point to the role of the packaged food and biscuit industries that see the potential for furthering their business interests through these government programmes. The proposed policy shift has evinced concern from the academic community of senior scientists, medical professionals, educationists, nutritionists, public health experts and civil society organisations.
The objective of the mid-day meal programme was to increase enrollment and ensure better nutritional status among children. Several studies have demonstrated the positive impact of mid-day meals on school enrollment. The extent of impact on the health and nutrition of children is largely dependent on whether the meal that is provided is supplementary or a substitute for a full meal.
Several civil society alliances, professional networks like the Indian Association for Preventive and Social Medicine (IAPSM) and academics came together at a consultation that was initiated by the University School Resource Network project at Jawaharlal Nehru University. This consultation sought to review the scientific evidence that favoured cooked meals in the nutritional support programmes. Those present at this consultation unanimously opposed the idea of replacing cooked meals with packaged foods. A review of available evidence showed the value of cooked meals over dry rations or biscuits. Several studies have shown that not only is the quality variable but the nutritional impact of dry snacks is also questionable.
A fresh meal offers a better range of nutrients and is less costly in terms of per rupee nutrient yield when compared to packaged food. Calorie deficiency is by far the single most important challenge and its correction through wholesome balanced diets will go a long way in tackling micronutrient deficiencies as well. The other benefits of cooked meals are that they address ‘classroom hunger’ and also provide protection against acute hunger among children in drought affected areas.
A wholesome cooked meal makes the school attractive for the child and along with improved enrollment and attendance helps the learning process. Children learn to sit and eat together and that contributes to breaking caste and class barriers.
Despite overwhelming evidence regarding the positive contribution and demand for these schemes, these programmes are not without problems. These are related to resources, infrastructure, problems in delivery and issues of quality and quantity. Different states have different experiences related to the cooked meal programme that need to be properly studied.
The consultation was of the view that the constraints of finances and management that are faced by these programmes need to be addressed by context-specific fiscal and managerial solutions. In the context of hunger and malnutrition, the MDM and ICDS programmes have contributed significantly but they need to be strengthened further. Therefore those present at the consultation argued against any shift in policy without acknowledging the overwhelming scientific evidence regarding the value of cooked meals at feeding programmes.
In response to a public interest litigation on the right to food, the Supreme Court had in 2001 ordered that each child was entitled to a cooked meal that had 300 calories and 8-12 gm of protein per day for a minimum of 200 days a year. Malnourished children were entitled to 600 calories and 16-20 gm of protein. At present, the allocation per child does not allow for variety in the menu and therefore it is necessary to enhance financial allocation. This would ensure an increase in both quantity and nutritional quality of the food that is being served.
Instead of a supplementary feeding programme, the children would get a full meal that takes into account locally available foods with nutritional adequacy. Infrastructure in schools — water supply, toilets, kitchen area and hiring of cooks — often does not receive adequate attention. Monitoring systems to check quality and possible corruption and leakages in food grain supply need to be strengthened.
The strategy for implementation needs a decentralised approach taking into account the regional and local contexts. This would also result in greater accountability and transparency at every level of the programme.
Rajib Dasgupta is assistant professor and Rama V. Baru is associate professor at the Centre of Social Medicine and Community Health, JNU
March 18, 2008
Indian Express
Health and education are fundamental rights of every child and it is imperative that the state and civil society ensure that these services are available, accessible and of good quality. Data from the National Nutritional Monitoring Bureau and the National Family Health Survey 3 indicate that child malnutrition continues to be a serious concern.
The government is now considering the replacement of cooked meals with packaged foods and biscuits in its Mid-Day Meal (MDM) and Integrated Child Development Services (ICDS) programmes. It is argued that this shift would improve efficiency and help overcome fiscal and managerial constraints faced in the implementation of these programmes. Reports also point to the role of the packaged food and biscuit industries that see the potential for furthering their business interests through these government programmes. The proposed policy shift has evinced concern from the academic community of senior scientists, medical professionals, educationists, nutritionists, public health experts and civil society organisations.
The objective of the mid-day meal programme was to increase enrollment and ensure better nutritional status among children. Several studies have demonstrated the positive impact of mid-day meals on school enrollment. The extent of impact on the health and nutrition of children is largely dependent on whether the meal that is provided is supplementary or a substitute for a full meal.
Several civil society alliances, professional networks like the Indian Association for Preventive and Social Medicine (IAPSM) and academics came together at a consultation that was initiated by the University School Resource Network project at Jawaharlal Nehru University. This consultation sought to review the scientific evidence that favoured cooked meals in the nutritional support programmes. Those present at this consultation unanimously opposed the idea of replacing cooked meals with packaged foods. A review of available evidence showed the value of cooked meals over dry rations or biscuits. Several studies have shown that not only is the quality variable but the nutritional impact of dry snacks is also questionable.
A fresh meal offers a better range of nutrients and is less costly in terms of per rupee nutrient yield when compared to packaged food. Calorie deficiency is by far the single most important challenge and its correction through wholesome balanced diets will go a long way in tackling micronutrient deficiencies as well. The other benefits of cooked meals are that they address ‘classroom hunger’ and also provide protection against acute hunger among children in drought affected areas.
A wholesome cooked meal makes the school attractive for the child and along with improved enrollment and attendance helps the learning process. Children learn to sit and eat together and that contributes to breaking caste and class barriers.
Despite overwhelming evidence regarding the positive contribution and demand for these schemes, these programmes are not without problems. These are related to resources, infrastructure, problems in delivery and issues of quality and quantity. Different states have different experiences related to the cooked meal programme that need to be properly studied.
The consultation was of the view that the constraints of finances and management that are faced by these programmes need to be addressed by context-specific fiscal and managerial solutions. In the context of hunger and malnutrition, the MDM and ICDS programmes have contributed significantly but they need to be strengthened further. Therefore those present at the consultation argued against any shift in policy without acknowledging the overwhelming scientific evidence regarding the value of cooked meals at feeding programmes.
In response to a public interest litigation on the right to food, the Supreme Court had in 2001 ordered that each child was entitled to a cooked meal that had 300 calories and 8-12 gm of protein per day for a minimum of 200 days a year. Malnourished children were entitled to 600 calories and 16-20 gm of protein. At present, the allocation per child does not allow for variety in the menu and therefore it is necessary to enhance financial allocation. This would ensure an increase in both quantity and nutritional quality of the food that is being served.
Instead of a supplementary feeding programme, the children would get a full meal that takes into account locally available foods with nutritional adequacy. Infrastructure in schools — water supply, toilets, kitchen area and hiring of cooks — often does not receive adequate attention. Monitoring systems to check quality and possible corruption and leakages in food grain supply need to be strengthened.
The strategy for implementation needs a decentralised approach taking into account the regional and local contexts. This would also result in greater accountability and transparency at every level of the programme.
Rajib Dasgupta is assistant professor and Rama V. Baru is associate professor at the Centre of Social Medicine and Community Health, JNU
March 18, 2008
Indian Express
Tuesday, February 19, 2008
Apology & a Bitter History of Stolen Generations
Australia's prime minister delivered an historic apology to the Aboriginal people in a gesture of reconciliation for injustices committed over two centuries of white settlement.
"We apologise for the laws and policies of successive parliaments and governments that have inflicted profound grief, suffering and loss on these our fellow Australians," Kevin Rudd told the Australian parliament.
His speech focused in particular on the suffering of what have become known as the "Stolen Generations" - mostly mixed-race children, who were taken from their families up until the 1970s in a bid to assimilate them into white society.
But Rudd's address also took in a broader apology over what he called "a great wrong" committed against Australia's indigenous peoples, repeatedly using the crucial word "sorry".
"As prime minister of Australia, I am sorry. On behalf of the government of Australia, I am sorry. On behalf of the parliament of Australia, I am sorry," Rudd said.
Use of the word "sorry" carries major symbolism for Aborigines after Australian Prime Minister Kevin Rudd's conservative predecessor, John Howard, refused to utter it when he was in power. Howard was the only one of Australia's five surviving prime ministers who was not in parliament on February 13, 2008 to hear Rudd's speech, although his Liberal party, now in opposition, backed the motion of apology.
Howard lost his parliamentary seat in last November's national elections which saw a landslide victory for Rudd's Labor party.
The full text of the speech is available at:
http://english.aljazeera.net/NR/exeres/BFA16B6A-E168-48B9-8E0A-F841361F893A.htm
A Bitter History
Aboriginal population of Australia estimated between 750,000 to two million prior to arrival of first white settlers in 1788.
Combination of disease, loss of land and violence reduced numbers by 80 per cent over the following century. Smallpox wiped out more than half the population.
Between 1900 and early 1970s estimated 100,000 Aborigines were taken from their natural parents as part of an assimilation programme, now dubbed the Stolen Generation.
Aborigines not granted vote in federal elections until 1962.
Aboriginal population was not counted in national census until 1967, prior to which Aboriginal affairs were governed under Australian flora and fauna laws.
According to 2006 census, Aboriginal and Torres Strait Islanders population stood at 455,031, out of total Australian population of 20,061,646.
Many aboriginal communities are plagued by high unemployment, juvenile delinquency, school dropouts, drugs, crime, domestic and sexual problems, and alcoholism.
Government statistics show an indigenous Australian is 11 times more likely to be in prison than a non-indigenous Australian, while indigenous Australians are twice as likely to be a victim of violence.
A 2007 study found standards of healthcare for Aborigines 100 years behind rest of Australia, with Aboriginal men having life expectancy 18 years below national average.
On 21 June 2007 then Prime Minister, John Howard, and the Minister
for Indigenous Affairs, Mal Brough announced 'national emergency
measures to protect Aboriginal children in the Northern Territory from
abuse and give them a better, safer future'. This initiative was bi-
partisan and endorsed by then opposition leader Kevin Rudd. Although the intervention is presented as a broad based social welfare initiative, it has a significant public health component.
The paper available at http://phmoz.org/wiki/index.php?title=Northern_Territory_Emergency_Response_-_Public_Health_Implications_Commentary briefly analyses the public health implications and the overall context of the intervention.
"We apologise for the laws and policies of successive parliaments and governments that have inflicted profound grief, suffering and loss on these our fellow Australians," Kevin Rudd told the Australian parliament.
His speech focused in particular on the suffering of what have become known as the "Stolen Generations" - mostly mixed-race children, who were taken from their families up until the 1970s in a bid to assimilate them into white society.
But Rudd's address also took in a broader apology over what he called "a great wrong" committed against Australia's indigenous peoples, repeatedly using the crucial word "sorry".
"As prime minister of Australia, I am sorry. On behalf of the government of Australia, I am sorry. On behalf of the parliament of Australia, I am sorry," Rudd said.
Use of the word "sorry" carries major symbolism for Aborigines after Australian Prime Minister Kevin Rudd's conservative predecessor, John Howard, refused to utter it when he was in power. Howard was the only one of Australia's five surviving prime ministers who was not in parliament on February 13, 2008 to hear Rudd's speech, although his Liberal party, now in opposition, backed the motion of apology.
Howard lost his parliamentary seat in last November's national elections which saw a landslide victory for Rudd's Labor party.
The full text of the speech is available at:
http://english.aljazeera.net/NR/exeres/BFA16B6A-E168-48B9-8E0A-F841361F893A.htm
A Bitter History
Aboriginal population of Australia estimated between 750,000 to two million prior to arrival of first white settlers in 1788.
Combination of disease, loss of land and violence reduced numbers by 80 per cent over the following century. Smallpox wiped out more than half the population.
Between 1900 and early 1970s estimated 100,000 Aborigines were taken from their natural parents as part of an assimilation programme, now dubbed the Stolen Generation.
Aborigines not granted vote in federal elections until 1962.
Aboriginal population was not counted in national census until 1967, prior to which Aboriginal affairs were governed under Australian flora and fauna laws.
According to 2006 census, Aboriginal and Torres Strait Islanders population stood at 455,031, out of total Australian population of 20,061,646.
Many aboriginal communities are plagued by high unemployment, juvenile delinquency, school dropouts, drugs, crime, domestic and sexual problems, and alcoholism.
Government statistics show an indigenous Australian is 11 times more likely to be in prison than a non-indigenous Australian, while indigenous Australians are twice as likely to be a victim of violence.
A 2007 study found standards of healthcare for Aborigines 100 years behind rest of Australia, with Aboriginal men having life expectancy 18 years below national average.
On 21 June 2007 then Prime Minister, John Howard, and the Minister
for Indigenous Affairs, Mal Brough announced 'national emergency
measures to protect Aboriginal children in the Northern Territory from
abuse and give them a better, safer future'. This initiative was bi-
partisan and endorsed by then opposition leader Kevin Rudd. Although the intervention is presented as a broad based social welfare initiative, it has a significant public health component.
The paper available at http://phmoz.org/wiki/index.php?title=Northern_Territory_Emergency_Response_-_Public_Health_Implications_Commentary briefly analyses the public health implications and the overall context of the intervention.
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