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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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World Without TB

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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Universities should consult industry on designing courses to make students employable

Such initiatives hold the key to driving India’s innovative capacity forward and making the country more competitive.

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Enhancing employability

Even though the idea of globalisation has come under fire in the last few years, with increasing levels of discontentment over inequity in the distribution of gains, the benefits that the world economies have derived from it are often overlooked.

One unmistakable benefit has been the transfer of productivity-enhancing technology between nations and diffusion of innovation worldwide. The International Monetary Fund’s World Economic Outlook released in April this year also pointed out that globalisation has given a significant boost to the diffusion of knowledge and technology across the world through free trade, higher foreign direct investment and the international use of patents and copyrights.

Innovation has become the key to gaining greater market share and more and more countries are shifting their policy focus on building their innovative capacities to strengthen the competitiveness of their economies. Competitiveness is defined as “the ability of firms to compete, grow and be profitable in the long run”. Studies find an unequivocal link between innovative capacity and competitiveness of nations and regions. In fact, it is almost next to impossible for businesses to become competitive without innovating in its products and operations.

With the world innovating at breakneck speed, no country wants to be left in the lurch. Most significantly, China has laid out a plan to become an “innovative nation” by 2020 and an “international innovation leader” by 2030 in its current Five-Year Plan. Even countries like Saudi Arabia that have historically been heavily resource-dependent are making a conscious move towards higher innovation. These countries are beginning to recognise the fact that building a competitive advantage based on factor endowments (cheap labour in case of China and oil reserves for Saudi Arabia) cannot be sustained over the long run. A transition to a knowledge-based economy is imperative.

India can ill-afford to find itself lagging on the curve. The country had missed out on the first industrial revolution on account of being at the receiving end of colonial history. No other phase of innovation in history has transformed industry to such an extent. Only the digital revolution at the end of the 20th century came close. It is, therefore, a rare and opportune time for India to accelerate its development process and move into the next stage of growth by focusing on strategies to foster innovative capacity.

In recognition of the urgency to act, a roundtable on “Innovation for Prosperity” was organized by NITI Aayog and the Institute for Competitiveness last week to draw actionable policy recommendations for NITI Aayog to work upon to improve India’s innovation capacity. One of the most pertinent issues raised at the roundtable was the issue of industry-academia linkage in the Indian education system.

Around the world, universities are seen as hubs of innovation where experts from varied fields come together to share their ideas for developing new technologies, systems and processes. Such innovation originating from universities usually attracts huge demand from industry. This results in diversified products and market development, which leads to the nation gaining a competitive edge in the world markets.

Such industry-academia linkages are missing in the Indian economy. Universities are meant to play a dual role of knowledge creation and knowledge transfer. But the latter is found wanting in the Indian context. The problem resides in the abysmal quality of the country’s education system that focuses more on quantity than quality from a very early stage. For instance, the focus is always on the number of hours taught rather than the quality of education imparted in those hours.

At every level of education, students are never encouraged to think. Rote-learning is encouraged through an incessant focus on marks, which leaves no scope for thinking or innovation. Further, higher education is mostly outdated and hardly industry-oriented. Therefore, the human capital in India is barely equipped to innovate for industry. Another factor that hinders any industry-academia linkage is an utter lack of clarity on who owns the IP for collaborative innovation. Until these problems persist, any collaboration between industry and academia will be difficult to achieve.

One way to move away from the status quo is to encourage universities to consult industry while designing course curricula so that the graduates are more employable and innovative. The government can also play an enabling role in facilitating higher collaboration. It can provide tax incentives or subsidise setting up of research infrastructure in universities that can be used for industrial innovation. The government could also push for higher academic exchanges by funding the transaction costs involved in the process, which can particularly help in better understanding of what industry requires from academia.

Such initiatives hold the key to driving India’s innovative capacity forward and making the country more competitive.

(Amit Kapoor is chair, Institute for Competitiveness. The views expressed are personal. He can be contacted at [email protected] and tweets @kautiliya. Chirag Yadav, senior researcher, Institute for Competitiveness, has contributed to the article)

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‘Jallianwala Bagh massacre was preceded by reign of terror by the British’

“The massacre on 13 April was part of a policy of oppression unleashed by O’Dwyer against the frequent ‘hartals’ (strikes) or the ‘Satyagraha Movement’ (launched by Mohandas Karamchand Gandhi)

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Jallianwala Bagh Massacre
Jallianwala Bagh, 1919: The Real Story : (Flickr)

Chandigarh, Dec 11 : As the country gears up to observe the 100th anniversary of the Jallianwala Bagh massacre of innocent, unarmed Indians by ruthless British forces, the events before and after the April 13, 1919, killing of hundreds clearly indicate that the British rulers of that time were unnerved by the unrest in Punjab in general and Amritsar in particular, which led them to do something which could “teach a lesson” to the Indians.

“Though Brigadier General Reginald Dyer (who ordered his troops to fire on people who had gathered at the Jallianwala Bagh on the fateful day and killed hundreds) was blamed for the action, there is hardly any documented evidence to show how he landed in Amritsar on that day as he was posted in Jalandhar (earlier Jullundur),” author and columnist Kishwar Desai told IANS in an interview here.

Desai, who has penned a book “Jallianwala Bagh, 1919: The Real Story” recently, said that her extensive research on the happenings around the massacre revealed that the British rulers were quite unnerved by the unrest in Punjab and Amritsar.

“Prior to the killings at Jallianwala Bagh, there had been signs of increasing unrest in Punjab. These signs were being interpreted as sedition, even though causes of the unrest were varied. Indeed, it is impossible to understand what happened on 13 April 1919, without an examination of the barbarism unleashed in Punjab under the regime of the then Lieutenant Governor Sir Michael O’Dwyer to suppress the so-called rebellion,” Desai, who is the chair of The Arts and Cultural Heritage Trust that set up the world’s first Partition Museum at Amritsar’s Town Hall, points out in her book.

The author said that the idea to write this book and to bring out “some facets which had not been researched in detail so far” came after she chanced upon a photograph of the burnt-down Town Hall building of Amritsar. This happened in April 1919.

Further investigation and research, according to Desai, led to more evidence of the British atrocities on Indian subjects just before the Jallianwala Bagh incident and the violence that erupted in Amritsar on April 10 in which many people, including five Europeans, were killed. Properties, including the Town Hall, were targeted to protest against the British atrocities.

Disputing the commonly held narrative that the people who had gathered at the Bagh on the fateful day for an anti-Rowlatt Act meeting were outsiders who had come to Amritsar for the Baisakhi festival, Desai points out that the meeting was attended mostly by local residents of Amritsar and no more than 25 per cent of them were from outside.

“And it is very likely that the massacre was a carefully planned one, not spontaneous one as has been often made out. In all likelihood, no women were present,” Desai states in the book, adding that O’Dwyer, who was nearing retirement at that time, and others in power, were upset over the emerging importance of Punjab in the freedom struggle and retaliated with a reign of terror where people were whipped in public, bombed, incarcerated, forced to crawl, starved, beaten, caged and even executed.

“The massacre on 13 April was part of a policy of oppression unleashed by O’Dwyer against the frequent ‘hartals’ (strikes) or the ‘Satyagraha Movement’ (launched by Mohandas Karamchand Gandhi)… in fact, the civil administration of Punjab had already declared Amritsar a war zone (around April 11) and regarded the residents as their enemies,” Desai points out in the book.

Dyer, who had arrived in Amritsar from Jullundur on the evening of April 11, had ordered his troops to fire on the gathering inside Jallianwala Bagh on the evening of April 13, 1919. The official death figure was put at 379 while nearly 1,200 were injured. The death toll is often disputed, with claims (Indian National Congress Report) that over 1,000 innocent people were killed.

“Not a very well-known entity” when he arrived in Amritsar, Dyer had a “fairly humdrum career” till he “hit immortality as a mass murderer”, the new book says.

(Jaideep Sarin can be reached at [email protected])

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Mushirul Hasan: Man with a mission and a vision – Obituary

He had also served as the Director General of the National Archives of India and the President of the Indian History Congress. Wherever he worked, he gave it a touch of finesse and perfection – his hallmark.

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Tears welled up my eyes, when I was told by my friend, Mohammed Wajihuddin, an eminent columnist, that not a single wreath or even a flower, was laid at the grave of Prof Mushirul Hasan by Jamia Millia Islamia, the institution that the renowned historian and the educationist had nursed as his offspring.

It is shocking to note that Jamia failed to give him the little due at his last resting place – something absolutely unbearable, said, Wajihuddin. Mushir had given the prime of his life to Jamia.

Prof Azra Razzack, who had worked under Mushir in the K.R. Narayanan Center of Dalit Studies and Minorities at Jamia Millia Islamia too felt that the Indian populace didn’t give Mushir his due.

Mushir was an institution in his own self. Having read almost all his books, Razzack said that the one which has stamped its mark on readers of history is that on Jamia Millia Islamia’s contribution in India’s freedom movement “Partners in Freedom: Jamia Millia Islamia”. A thoroughly researched book, it highlights the history of forbearance, companionship and insight within the parameters the historic Jamia Millia Islamia.

It demonstrates how personages lived for and worked towards the attainment of high morals and principles. Razzack thinks a Chair or a building in the name of Mushirul Hasan must be considered by Jamia, where he spent the prime of his life.

Having seen Mushir at close quarters for a number of years, I can state that he was a man of many lives and colours. I had known him for almost three decades. Right from my student days, I was a connoisseur of Mushirul Hasan’s books and lectures since I studied at Delhi University in the 1980s.

Not only was he a man of letters, he lived by each and every word he had written. Being a soft-spoken person, he was known never to hurt even the worst of his critics – a rare quality that Maulana Azad also possessed. Mushir might not live before us in flesh and bbody but the tremendous legacy of historicity he has left for posterity will stamp him as an immortal in the genre of writing books loaded not only with knowledge but most importantly – values and vision.

While manning Jamia Millia Islamia as its Vice Chancellor, Mushir left no stone unturned and brought it on par with the other illustrious institutions like Delhi University, BHU and Calcutta University. During his time, he turned it into a state-of- the-art university besides giving it a designer look.

He had also served as the Director General of the National Archives of India and the President of the Indian History Congress. Wherever he worked, he gave it a touch of finesse and perfection – his hallmark.

Remembering his book, “In Search of Integration and Identity – Indian Muslims since Independence”, M. Atyab Siddiqui, a Muslim thinker and Mushir’s legal advisor for a number of years, stated that he was the architect of the modern Jamia. His legacy of liberal thought and perception for the underprivileged sections of society should be carried forward. It was because of Mushir that in the comity of universities, Jamia carved its niche.

However, Siddiqui was piqued: “Mushir’s mission was to educate the beleaguered Muslim masses in the best manner possible. But it saddens me when today, I note that Jamia is in a pathetic state and requires a visionary like Mushirul Hasan to make it regain its pristine glory.”

The most noteworthy trait of Mushir’s writings was his secular credentials along with his habit of calling a spade a spade. Though the world over, he carved a niche for his books on the vivisection of India. However, his most readable book is on the Nehrus, titled, “The Nehrus – Personal Histories” – his last one.

In it, he has unquestioningly laid out the best of his feelings on Jawaharlal, Indira and Rajiv. Some of the passsages are very touching. Perhaps this seems to be a sequel of “When Stone Walls Cry: The Nehrus in Prison”. As he had a very special place for the Nehrus, he presented them as having a great capacity to gauge the pulse of the times.

Being a suave man of a few words, his magnificence was that each word he uttered had its own music and meaning that the audiences thoroughly acknowledged. Besides, wit and humour were his hallmark.

It would not be an exaggeration to say that Mushir was the son of two universities — Aligarh Muslim University (where he had studied) and Jamia Millia Islamia, that he nursed like his own child. By penning, “Aligarh’s Notre eminent contemporain-Assessing Syed Ahmad Khan’s Reformist Agenda”, Mushir paid his homage to his alma mater.

Mushir was a sensible historian. Once when he was hounded by some zealous elements for having stated that Jamia’s students were giving undue publicity to Salman Rushdie’s “Satanic Verses”, a sub-standard book, by burning it, he was attacked as he was mistaken by the motivated students. Later, he was able to impress upon them and the same people who went for his jugular became his flowers. That was Mushir’s aura and benchmark.

Today, there’s no one to match Mushir when it comes to the understanding of Islam, Muslims and Partition of India. He had told my father, Nooruddin, that the concept of a book on the 1947 Partition came to his mind when he had heard Maulana Azad state that water cannot be cut in twain egging Muslims not to vie for the so called El Dorado (Pakistan). His mammoth work, “Memories of a Fragmented Nation: Rewriting the Histories of India’s Partition” remains unmatched on the topic throughout the world.

We must continue Mushir’s vision and education for a better India.

(Firoz Bakht Ahmed is the Chancellor of Maulana Azad National Urdu University and the grandnephew of Bharat Ratna Maulana Azad. The views expressed are personal. He can be reached at [email protected])

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