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How Kerala is fighting TB, and winning

In 2016, 435,000 people in the country died of TB. Patients often incur financial distress due to catastrophic health expenses.

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Kollam, Oct 8 : Agathi mandiram (poor people’s home) in Kollam city was built to provide shelter to beggars. Today, its 123 residents are mostly homeless people with mental or physical disabilities, brought here when found wandering the streets.

In May 2018, the Tuberculosis (TB) Centre of Kollam district decided to screen every one of agathi mandiram’s inmates. Ordinarily, their in-house doctor, Shreekumar D., would identify those with TB-like symptoms and send their sputum samples for analysis to the state TB Cell a few times a year, leading to the identification of two or three cases each year.

For the first time this year, the centre sent a pulmonologist to examine every person in the home, as part of the Kerala TB Elimination Mission launched in March 2018 with the aim of reducing the number of TB cases to 2020 by the year 2020, and eliminating TB-related deaths altogether.

“It was challenging because the inmates often could not explain their symptoms nor give their sputum sample,” said P. Anish, a consultant chest physician who screened all the inmates. Deploying techniques not normally used to detect TB, such as the CT-Scan, he detected 22 cases.

This exercise was replicated across the state from April to June in an effort to screen every person in Kerala, after the state set its sights on eliminating TB, displaying confidence in its robust health system which has already delivered enviable indicators.

This confidence is why, for Kerala, eliminating TB is “low-hanging fruit”, as the state’s Health Secretary, Rajeev Sadanandan, puts it. “We are about the only state [that] is capable of eliminating this disease,” he told IndiaSpend.

Kerala’s strategy has implications for all of India, which has the world’s largest TB burden — 2.74 million or 27 per cent of the global total. Further, nearly 300,000 Indians fall through the surveillance system or do not complete their course of medication, prompting the rise of more virulent, drug-resistant strains. In 2016, 435,000 people in the country died of TB. Patients often incur financial distress due to catastrophic health expenses.

This is what makes TB a public health imperative that must be dealt with through early diagnosis, complete treatment and improved quality of care. And Kerala’s example is instructive.

“The reduction of TB cases in Kerala is dramatic,” said K.P. Aravindan, a retired professor from Kozhikode Medical College. “From a disease that was extremely common, it is now a rare disease.”

And what has helped is the state’s thorough implementation of the “active case-finding” strategy to test every resident and map vulnerable populations so as to regularly monitor, test and treat them.

Active case-finding involves health workers proactively screening people for TB, as opposed to people coming to health institutions with TB-like symptoms and getting screened, which has been the mainstay of the Revised National Tuberculosis Control Programme (RNTCP) for more than 15 years.

The Central TB Division, which works under the central health ministry and is responsible for implementing RNTCP, requires all state TB units to conduct an active case-finding exercise thrice a year among populations identified as vulnerable, such as those living in slums and labour camps, mine workers, tea garden workers and the homeless. This is typically done in an ad-hoc fashion and there is no consistent follow-up, mostly because the number of TB cases is high and resources are stretched thin.

Kerala, however, has improved an already robust healthcare system and a motivated workforce to implement active case-finding so thoroughly that each resident will be screened this year, with health workers going door-to-door to find cases. The persons identified as vulnerable will be followed-up on every three months.

These activities have increased the number of symptomatic patients tested per 100,000 from about 700 — close to the all-India figure — to nearly 1,250, according to the Kerala State TB Cell.

TB affects mostly young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the State TB Cell show. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10 per cent.

This suggested a link between chronic diseases such as diabetes, which affect older people more, and TB.

This led to a change in policy — first within the state starting 2012 and since 2017 across India — so that TB patients are as a rule tested for diabetes and vice-versa. Following Kerala’s example, all TB patients registered under RNTCP are supposed to be referred for screening for diabetes. Referral is the responsibility of the health institution where TB treatment is initiated.

In addition to increased surveillance, the state has deployed more diagnostic tools such as the Cartridge-based Nucleic Acid Amplification Test (that can detect TB bacilli in very small amounts of sputum), X-Ray and CT-scan during active case-finding, as at agathi mandiram in Kollam.

“We have reached a saturation point in detecting TB using sputum microscopy,” said Kumar, referring to the technique in which the laboratory technician looks for TB bacilli in sputum — a mixture of saliva and mucus a subject has coughed up — using a microscope. “It is now time to use other techniques.”

Complementary programmes underway in some other districts engage with treatment support groups and with the private sector to increase reporting of cases (private-sector cases are typically under-reported, so that official TB statistics reflect mostly incidence, prevalence, treatment and cure figures reported by the public sector). From January to July 25, 2018, there have been 2,672 notifications from the private sector and 10,200 from the public sector, Balakrishnan said.

Across India, about 20 per cent of the total reported cases were in the private sector, while in Kerala, the figure was 36 per cent.

For two decades now, children living with infected adults have been given preventive drugs and are monitored as part of a protocol called chemoprophylaxis. Now, the state has decided to give infection-control kits to TB-positive patients, said Kumar, consisting of masks, disposable spittoons and disinfectant solution to protect TB from spreading to family members.

The department has found just 352 new cases of TB all over the state — in a population of 38 million — during the active case-finding and vulnerability mapping exercise so far, Balakrishnan said.

Kerala’s TB incidence is estimated to be 67 cases per 100,000, less than half the 138 per 100,000 pan-India. Since 2009, when Kerala began active case-finding, the TB notification rate in the state’s public sector has been falling by about three per cent every year. This is despite the fact that the number of people being tested for TB has remained constant, Balakrishnan said.

The proportion of TB in children under 15 years has consistently fallen in Kerala. In 2016, 6.3 per cent of TB cases were among children (under 14 years), down from 8.7 per cent in 2008.

Fewer children are being affected because primary transmission has gone down, state TB officer Sunil Kumar told IndiaSpend. This could mean that direct transmission of the disease from the environment or from other TB patients has reduced.

The biggest lesson Kerala holds for the rest of the country lies in the basic implementation of the programme — treating the TB patient who comes to the hospital appropriately, said Yogesh Jain, a founder member of Jan Swasthya Sahyog, a community hospital in Bilaspur.

The importance of following the “old-fashioned” guidelines from RNTCP related to early diagnosis, completion of treatment and other protocols cannot be overstated. “There are no magic bullets here. Kerala is showing a mirror to the rest of the country that we have to do what we are supposed to do well,” he said.

While Kerala’s example may not be entirely replicable across India — given the vast population, paucity of resources, and lack of infrastructure, capability and preparedness — much can be done with the existing resources too.

Aravindan pointed out that even in low-resource states such as Odisha and Chhattisgarh, some programmes work. “It is political will that makes programmes work,” said Aravindan.

(In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform. Menaka Rao is a an independent journalist based in Delhi. The views expressed are those of IndiaSpend. Feedback at [email protected])

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Women, Sabarimala temple and right to equality

The Sabarimala issue is not just about entry right to the women but now has become Religion Vs Fundamental Rights. In India, there are numbers of such issues which are still keeping the females deprived of rights.

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Ages back the women folks were exploited and the same is happening in modern times. Hinduism abolished Sati — a female was forced to be burnt alive in the pyre of her husband. Raja Ram Mohan Roy started a campaign against it and it came to an end. But has this changed brought much change in the lives of the women folk in the present times!

Sabarimala temple is Ayyappa temple situated in the Sabarimal region in Kerala. Here the females of age 10 to 50 are not allowed to enter due to the menstruation problem. There has been a lot of hues and cry over this issue.

Legal battle:

In 1991, this boycott to temple section for ladies was tested under the steady gaze of the Kerala High Court in S. Mahendran Vs The Secretary, Travancore case. Kerala High court decided for the preclusion of ladies entering the temple and asserted that these confinements have existed since time immemorial and not unfair to the Constitution. This request of the High Court was executed and pursued for the following 15 years. In 2006, the boycott was tested by the Public Interest Litigation recorded by the Young Lawyers Association with the Supreme Court, asserting that rule 3(b) of Kerala Hindu places of Public worship (Authorisation of entry) Rules 1965 that states, “women who are not by custom and usage allowed to enter a place of public worship shall not be entitled to enter or offer worship in any place of public worship” is infringement of established standards of equality, non-discrimination and religious opportunity. On April 25, 2016, the representative lawyer of the Devaswom, K.K Venugopal stated: “There is a sensible grouping by which certain classes of women are excluded”. Supreme Court was concerned regarding the statement if menstruation was associated with purity of women. The case was then assigned to the Constitution Bench by the Supreme Court.

In 2018, Justice Dipak Misra, The Chief Justice of India, while addressing to the PIL, put a query to the temple’s management over denying passage to women. The case was heard by a constitution bench headed by Justice Misra alongside Justices Rohinton Nariman, Justice AM Khanwilkar, Justice DY Chandrachud and Justice Indu Malhotra. The court held that Sabarimala pilgrims couldn’t be a different group or religious division. The traditions are subjected to sacred legitimacy and preclusion of ladies passage to temple infringing upon the Fundamental Rights. Justice Chandrachud claimed, “Your entitlement to implore as a lady isn’t subject to any law, it is a constitutional right”. He additionally included that notice issued under the standards recommending the age restrictions on ladies entry as “discretionary on its essence”.

In the year 2012, a similar campaign like that of Sabarimala temple was launched by the Bharatiya Muslim Mahila Andolan (BMMA) & Bhumata Brigade to offer prayers at the Haji Ali Dargah. It is the resting place of Sayyed Peer Haji Ali Shah Bukhari on the islet of Mumbai coast. This shrine is 585 years old. The Haji Ali Dargah is administered by the Haji Ali Dargah Trust a public charitable trust enrolled under the Maharashtra Public Trust Act. The trustees of the Dargah had chosen to deny ladies access to the grave area in 2011, calling the un-Islamic. It had expressed that it was redressing it’s earlier misstep of enabling ladies to touch the actual grave. The argument by the petitioner was that the Muslims deprive their women to equal rights, they keep them suppressed and the women folks don’t have a right to raise their voice in Islam.

On 26 August 2016, Bombay High Court decided that women to be allowed to enter the sanctum sanctorum. Even the Supreme Court sealed the verdict of Bombay High Court and the women were allowed to enter the shrine sacred area on 29 November 2016. This was welcomed by all the people across India. It was stated that now the Muslim women have got their rights which were deprived of them since the advent of Islam.

Similarly, the Supreme Court has ordered that the women should be allowed in the Sabarimala temple and the old practice should be done away with.

In the case of Sabarimala temple, various Hindu groups are not accepting the decision of the Supreme Court and want a revision of the judgment. The present day’s ruling party Bharatiya Janta Party (BJP) is backing the agitation against the judgment.

Are the women not suppressed now by going against their right to enter the temple? It is not an insult to the highest court of law in India? The law of the land is above the ruling class or any religion but the BJP and other Hindu organizations are adamant for rather they are trying to show strength through mass gathering against the judgment.

Is this the respect to the law of the land?

Declaimer: The views are the sole discretion of the author...
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Climate change will worsen disparities, may increase support for Naxals: Report

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Bengaluru, Oct 16 : As the effects of climate change on livelihoods become more pronounced, especially for people involved in agriculture and fishing in South and South-East Asia, support for rebel groups and the Naxalite movement is likely to shoot up, according to a new report.

There is evidence that climate change will worsen socio-economic and political disparity in the region as those in power will get to decide who gets the limited resources and how much, the report, co-authored by researchers Pernilla Nordqvist and Florian Krampe while working for the Stockholm International Peace Research Institute (SIPRI), has said.

“The climate-conflict linkage primarily plays out in contexts that are already vulnerable to climate change and violence, and where income is highly dependent on agriculture and fishing,” Nordqvist told IndiaSpend in an email.

Human activities have already caused warming of 1 degree Celsius as compared to pre-industrial times, according to the latest report of the United Nations’ Intergovernmental Panel on Climate Change (IPCC). By 2030, or latest by mid-century, global warming is likely to reach 1.5 degrees Celsius.

Close to 2.5 billion people live in South and South-East Asia, where poverty rates have been declining substantially, thanks to years of strong economic growth in countries such as India. However, the region is also prone to the fallouts of climate change, with glaciers in the Himalayas melting and several island-countries facing rising sea levels. Floods, cyclones, heat waves and droughts are now a frequent occurrence and are expected to intensify in the coming years.

“The region is highly vulnerable to the impact of climate change and also has a recent history of political violence,” Krampe told IndiaSpend.

Nordqvist and Krame examined 2,000 peer-reviewed studies on the relationship between climate change and conflict and narrowed down on 21 of the most authoritative works for their report, which was published in September 2018.

Their findings from India show that rebel groups and government forces both find recruitment easier when drought is around the corner.

The IPCC report also adds that climate-related risks to livelihoods, food security, health, water supply and human security are projected to increase as the planet warms by 1.5 degrees. With a 2-degree rise, the risks will intensify.

In some areas affected by the Naxalite conflict, the worsening of livelihood conditions has been related to the increased intensity of ongoing civil conflicts. During a drought, or a potential drought, there is an increased risk that rebels and government actors recruit or cooperate with civilians in exchange for livelihood and provision of food.

Naxalites could use climate-related events to gain power in an ongoing conflict, and rebel groups more generally could increase their use of violence against civilians to ensure their groups’ food security, according to the report.

“They violently remove local farmers from their land to ensure enough cropland and agricultural supplies for their own use. The risk of violence seems especially high in rural areas, where government control is scarce and the local population is dependent on the support or protection of rebels or other armed actors,” Nordqvist said.

As climate change pushes up migration, it introduces the possibility of riots in urban areas over resources, the report said. Highlighting the case of riots in Tripura in northeastern India, it said the effects will be most felt in areas where there are already low levels of socio-political stability.

“Many of the climate change problems are trans-national. The Brahmaputra, for example, flows through three countries and is seeing frequent flooding. There is no question that countries will need to cooperate and tensions like the ones between countries India and Pakistan will make this difficult,” Krampe said.

There is some research on the relationship between climate change and conflict in countries such as India, Bangladesh and Pakistan, the report said, adding that there is little understanding of how climate change could be driving conflict in places such as Afghanistan and Myanmar.

Elsewhere in South-East Asia, in some coastal areas of Indonesia the reduced income opportunities from fishing have been linked to a rise in piracy-related activities.

But the impact does not end there.

In Pakistan, for instance, the Islamist group Jamaat-ud-Dawa (JUD) was able to increase its stronghold in Sindh province after the group participated in relief activities following extreme floods.

The IPCC report also warns that those living along coasts and populations dependent on agriculture will be the worst hit by climate change, which will push up poverty rates in coastal areas and in developing countries.

However, “Not everyone affected by climate change will join a rebel group but this also relates to the failure of the governments to respond to disasters,” Krampe said.

At the same time, not all areas will see conflict in the face of climate change. Some might even see a greater cooperation in the aftermath of a natural disaster. These regional dynamics are evolving, however, and their contours will only become clearer with time.

(In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform. Disha Shetty is a Columbia Journalism School-IndiaSpend reporting fellow. The views expressed are those of IndiaSpend. Feedback at [email protected])

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Higher food prices jack up India’s September wholesale inflation

“The prevailing market price for most kharif crops at major mandis has remained lower than the MSP, suggesting procurement hasn’t picked up.”

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wholesale inflation

New Delhi, Oct 15 : India’s inflation rate based on wholesale prices accelerated 5.13 per cent on year in September, from a 4.53 per cent increase in August, as prices of primary articles and food items rose, official data showed here on Monday.

In September last year, the WPI had stood at 3.14 per cent.

“The annual rate of inflation, based on monthly WPI, stood at 5.13 per cent (provisional) for the month of September, 2018 (over September, 2017), as compared to 4.53 per cent (provisional) for the previous month and 3.14 per cent during the corresponding month of the previous year,” the Ministry of Commerce and Industry said.

“Build up inflation rate in the financial year so far was 3.87 per cent compared to a build up rate of 1.50 per cent in the corresponding period of the previous year.”

On a sequential basis, the expenses on primary articles, which constitute 22.62 per cent of the WPI’s total weightage, rose 2.97 per cent, from a decline of 0.15 per cent in August.

Similarly, the prices of food articles rose. The category has a weightage of 15.26 per cent in the WPI index.

The cost of fuel and power, which commands a 13.15 per cent weightage, increased at a slower pace of 16.65 per cent from a growth of 17.73 per cent.

The expenses on manufactured products registered a rise of 4.22 per cent from 4.43 per cent.

On a year-on-year (YoY) basis, onion prices declined by 7.88 per cent, whereas potatoes became dearer by 68.81 per cent.

In contrast, the overall vegetable prices in September rose by 39.41 per cent, against a rise of 41.05 per cent in the same month a year ago.

Further, the data revealed that wheat became dearer by 6.09 per cent on a YoY basis while prices of pulses were up 0.74 per cent, though paddy became expensive by 2.03 per cent.

The prices of protein-based food items such as eggs, meat and fish went up marginally by 0.83 per cent.

The price of high-speed diesel rose by 11.88 per cent on a YoY basis, petrol by 10.41 per cent and LPG by 17.04 per cent.

“The WPI inflation for September 2018 revealed a negative surprise, printing 30 basis points higher than our forecast. Moreover, a lagged correction in the sub-index for crude oil is likely to result in the revised print for this month, exceeding the initial 5.1 per cent,” said Aditi Nayar, Principal economist, ICRA.

“The considerable uptick in the YoY WPI inflation in September 2018 relative to the previous month was driven by primary food and non-food items and minerals, whereas the other major indices recorded a sequential dip, partly driven by the base effect.”

According to Devendra Kumar Pant, Chief Economist and Senior Director (Public Finance), India Ratings and Research, “The prevailing market price for most kharif crops at major mandis has remained lower than the MSP, suggesting procurement hasn’t picked up.”

“The future inflation trajectory would depend on the response of mandi prices with respect of new MSP, and the movement of crude oil price and value of currency.”

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