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Malaria in Mumbai: drug resistance and a weak health system

Maharashtra has seen a severe outbreak of malaria this year, and Mumbai is the worst affected by the disease. Of the 47,200 cases reported in Maharashtra between April and July this year, Mumbai accounted for 29,531 cases.

Malaria has always been a major silent killer in India, with about 1.5 million laboratory-confirmed cases reported annually. About 50% of these cases are due to the more serious falciparum strain which is increasingly resistant to chloroquine, one of the most commonly prescribed drugs for malaria. The latest guidelines under the National Drug Policy issued by the union government have recommended that the falciparum strain of malaria be henceforth treated using Artesunate combination therapy (ACT).

V D Khanande, joint director (malaria), health, has promised speedy implementation of the guidelines once the drug is made available to the state. An order has been placed with the union government for these drugs. However, until the drugs are provided, patients with falciparum malaria will continue to be treated with chloroquine though it is considered to be inadequate. Resistance to chloroquine has been a major cause for worry for Mumbai doctors

The outbreak also exposes the inability of the public health system to cope with the disease. Both public and private hospitals are filled with patients. The health system needs strengthening if lives are really to be saved.

The BMC claims that malaria is now on the decline. And officially, the monsoon-related death toll is lower than last year’s. But doctors are taking BMC statistics with a pinch of salt.

Umesh Isalkar, Falciparum malaria to be treated with ACT. The Times of India, September 2, 2010. Pratibha Masand, Malaria threat not over: Medics. The Times of India, August 28, 2010. Times News Network, Malaria bites city harder this year. The Times of India, September 1, 2010.

Floods in Pakistan: trying times for health agencies and the State

The floods in Pakistan have been trying for both Pakistan and the international health agencies. The United Nations has stated that 800,000 people have been marooned, rendered unreachable except by air, due to the massive infrastructural damage caused by the floods. “Entire settlements of mud brick houses are reported to have been swept away, major bridges have collapsed, and some major provincial cities have been totally cut off, after road and rail links were severed,” said a spokesperson for the International Federation of the Red Cross.

The United Nations has 18 helicopters ferrying health workers and aid to the worst-hit areas. However, there is an urgent need for an additional 40 helicopters to serve these areas better.

The situation is made worse by the spread of waterborne diseases, skin diseases, respiratory infections and malnutrition-related diseases in flooded areas. The United Kingdom has announced a grant worth £5 million for water and sanitation equipment through UNICEF.

Prime Minister Yousuf Raza Gilani, in a meeting discussing health issues arising out of the floods, has said: ”As human misery continues to mount, we are seriously concerned with the spread of epidemic diseases.” He noted that the health system was crippled by the floods: more than 200 health facilities are damaged and about one-third of all women health workers of the country are displaced. President Asif Ali Zardari has estimated that it will take at least three years for the country to recover from the floods.

As in any other natural calamity, the most vulnerable are also the most marginalised. There have been reports of denial of aid and relief to flood affected persons who belong to religious minorities. In the southern Punjab, 500 Ahmedi families staying in makeshift houses were reportedly denied access to relief aid, apparently on the directives of local mullahs. “The Punjab government has a very specific history of greater tolerance towards Sunni extremists… In the current context what that does is, that it places Shi’ites, Ahmedis and Christians at a very high level of risk,” said Ali Dayan Hasan, a senior researcher at Human Rights Watch. Internal divisions can prove to be a hurdle in already trying times.

Anonymous, UN says 800,000 cut off by Pakistan floods. Dawn, August 25, 2010. Peter Moszynski, Agencies act to avert “public health catastrophe” after floods in Pakistan. BMJ August 7, 2010. Omar Waraich, Religious minorities suffering worst in Pakistan floods. Time, September 2, 2010,8599,2015849,00.html

WHO Western Pacific Region to pull up its socks to battle TB

The Stop TB Technical Advisory Group has called for increased financial and technical support in order to retain the gains in tuberculosis control in the Western Pacific Region. The World Health Organisation (WHO) has said that countries will need to strengthen programmes for early detection and give their people easy access to treatment.

Dr Shin Young-soo, WHO Regional Director for the Western Pacific region, highlighted the complexities of dealing with TB. “The TB epidemic tends to concentrate in vulnerable and marginalized populations who have limited access to health care and are difficult to reach.”

The advisory group voiced these concerns in its meeting held in July 2010 in Tagaytay City, Philippines, to draft the ‘Regional Strategy to Stop TB in the Western Pacific Region (2011-2015)’. The meeting assessed the progress of the TB prevention and control programme implemented by WHO and looked at emerging problems in the field. For instance, the problem of multidrug resistant TB is not being addressed adequately. Likewise the threat posed by HIV in increasing the incidence of TB needs to be tackled. “HIV still poses a major threat and has the potential to reverse the gains achieved by the TB control efforts,” warned Dr Young-soo.

The ‘Strategic Plan to Stop TB in the Western Pacific 2006-2010’ had acknowledged and identified vulnerable populations. It focused largely on migrant homeless populations, intravenous drug users and those in institutions like prisons and asylums who have little access to healthcare. This plan states: “TB is a disease of poverty that thrives on deprivation and inequality. Within countries, the distribution of TB is higher among the poor than among the non-poor.”

The draft strategy for the next plan will be finalised for endorsement at the WHO Regional Committee for the Western Pacific in October 2010.

WHO Regional Office for the Western Pacific, Strategic Plan to Stop TB in the Western Pacific 2006-2010, Manila, 2006. (Draft, 7th March 2006) Address TB challenges now or lose the fight against the disease, WHO warns. World Health Organisation, Western Pacific Region, July 27, 2010, WHO homepage

The UK government is privatising the National Health Service

The British government has been accused of increasing privatisation in the healthcare system. This reaction came in response to the government’s announcement that it was considering options for private sector investment in the state-owned National Health Services Professionals. The government’s White Paper hands over the major responsibility for healthcare to general practitioners. About £110 million of the healthcare budget will be allocated to them. This would also lead to the dissolution of 10 strategic health authorities, and of 152 management bodies known as primary care trusts. It is claimed that this move will help cut costs incurred due to expenditure on the bureaucracy.

Karen Jennings of UNISON, the UK’s largest healthcare trade union, expressed her outrage: “This is purely about promoting privatisation…regardless of the consequences on patient care. A sell-off may bring a short-term cash injection, but cost NHS Trusts vast sums in the longer term.” The curbing of health expenditure will not only have a direct impact on the situation of healthcare in the UK; it will also affect the nature of employment of healthcare workers.

The Department of Health has stated that the move towards privatisation “is in line with the government’s policy to maximize the value of assets and commercial opportunities.” The government has assured the public that the implementation of its proposals advocating privatisation will be done transparently and will involve diverse actors like healthcare professionals, local authorities and unions.

UNISON has called this “unlawful” as the government only requests feedback and comments on the implementation of the change, not on whether or not to privatise in the first place.

Kylie MacLellan, Union in legal bid to block NHS shake-up. Reuters, August 24, 2010. Anonymous, Health Union challenges NHS ‘shake-up’, BBC News. August 24, 2010. Randeep Ramesh, ‘Government accused of ‘promoting privatisation’ of NHS. Guardian, August 5, 2010.

Dental Council of India under the scanner

After Ketan Desai’s removal from his post of president of the Medical Council of India (MCI) and the subsequent dissolution of the MCI, the Dental Council of India (DCI) is next in line. The DCI has come under the scanner for corrupt practices with regard to the granting of permission for new colleges and renewing permissions for existing ones. Dr Anil Kohli, president, DCI, has been charged with corrupt and illegal practices and the union health ministry has launched a probe into this. The DCI chief has been accused of “amassing huge amounts of un-accounted money, illegal income and wealth and indulgence in self-seeking decisions as an influential functionary of DCI”. The enforcement directorate has launched an inquiry into Dr Kohli’s wealth and his financial stake in various trusts and firms. It is also investigating his family members.

An application by the Shaan Education Society to establish a dental college, the Shaan Education Society’s Guardian College of Dental Sciences and Research Centre, Thane, was rejected by the DCI because of major lacunae including the lack of faculty, of a central library and of a central store. But the college received approval barely one month after this rejection, suggesting corruption. The DCI has also been accused of demanding Rs 25 lakh for renewal of permission from Dr SM Naqvi Imam Dental College and Hospital in Darbhanga, Bihar. The government has set up another committee to probe into corrupt practices regarding granting renewal of permission to existing colleges.

Rakesh K Singh, Govt sinks teeth into dental council chief malpractices. The Pioneer, July 23, 2010.

Chemicals on your plate

Dinesh Trivedi, union minister of state for health and family welfare, expressed concern over the increasing use of chemicals and hormones in vegetables in India. In a letter to Sujatha Rao, union secretary in this department, he cautioned against the lethal effects on people’s health, of continued consumption of such hormones.

Oxytocin is a schedule H drug, not to be sold without the prescription of a registered healthcare practitioner. It is used during childbirth to speed up labour, and after childbirth to control bleeding and stimulate the secretion of breast milk. However, it is also widely used on vegetables: it is injected into food crops such as pumpkin, watermelon, brinjal, gourd and cucumber.

As Mr Trivedi wrote in the letter, “The even more shocking element is that the public/authorities may also be aware of this malpractice.” Colouring of fruits and vegetables with toxic chemicals like copper sulphate also came under the scanner.

However, the minister withdrew his comment when he was asked to justify his stand in Parliament. A Punjab Agricultural University study found that oxytocin had no effect on crop yield, he said in a written reply in the Rajya Sabha.

Express News Service, Minister warns about oxytocin in vegetables. Indian Express, July 28, 2010. Times News Network, Now, minister says oxytocin doesn’t cause damage. The Times of India, August 18, 2010.

State defines sanity in China

Xu Lindong walked out of the asylum after having been given electric shocks 54 times and being forced to take drugs like chlorprothixene and chlordiazepoxide over a period of six and a half years. Lindong, a farmer in Henan province, was about to file a complaint on behalf of his neighbor, a victim of abuse at the hands of local officials. Before he could do this, he was admitted to Zhumadian Psychiatric Hospital, Henan, by government officials. Lindong’s release was made possible by using the media to mount pressure on the state to release him.

China’s psychiatric hospitals are filled with people without any psychiatric conditions. They have been admitted against their will. This is a direct fallout of the growing social unrest in China, according to civil rights groups. “As social conflicts in China have intensified in recent years, the number of petitioners has increased and so has the number of normal citizens being incarcerated in psychiatric hospitals,” says Liu Feiyue, founder of Civil Rights and Livelihood Watch, a non-governmental organisation based in Wuhan. The NGO is also involved in collecting data from a variety of sources, ranging from media to other pressure groups on similar cases of incarceration.

Psychiatric hospitals in China have a symbiotic relation with the government, which pays for the treatment of patients for as long as it wants them incarcerated. However, suppressing dissent through healthcare institutions has a longer history in China. In the 1950s, China called in Soviet experts to help them set up psychiatric hospitals on the model of similar institutions in the former Soviet Union.

Jane Parry and Weiyuan Cui, China’s psychiatric hospitals help to stifle dissent, say NGOs. BMJ, July 3, 2010.

The hospital-insurer dispute: patients are the casualty

In August 2010, the cashless facility in private hospitals, including “5-star” hospitals, was stopped by the 4 public sector insurance companies, in Delhi, Mumbai, Chennai and Bengaluru. The companies claimed that customers were being overcharged for each hospitalization, across a range of treatments. They cited estimated losses of Rs 1,500 crore annually, against a yearly premium collection of Rs. 6,000 crore on mediclaim policies across the country.

The insurance companies had worked out reimbursement amounts for various treatment packages based on the hospital’s infrastructure and negotiations over these packages had been in progress for over six months. However, starting from July 1, many patients who were not part of corporate group insurance schemes were asked to pay the hospitals directly and claim reimbursements. And in August, the insurers unilaterally stopped direct payments under the scheme, leaving several insured persons in the lurch. The negative response from hospital managements forced insurers to resort to this measure, according to the CEO of Raksha TPA, the third party administrator (TPA) between the insured and the insurer.

The government later announced that cashless medical facilities for persons insured with public sector insurance companies had been restored in 449 hospitals in the four metros, after hospitals agreed to charge policy holders at par with non-insured patients. However, major hospitals such as Fortis, Apollo, Max, Hinduja, and Leelavati were still out of this network, pending agreement on standardised rates. Insured persons may, in future, have to pay higher mediclaim premiums for treatment in super-specialty hospitals and for lengthy and complicated procedures. Similarly, patients with co-morbid conditions may have to pay higher premiums for health insurance. The maximum number of hospitals which agreed to be part of the cashless network is in Delhi (163) followed by Mumbai (121), Chennai (84) and Bengaluru (81). The earlier cashless system has, however, been continuing undisturbed in the rest of the country.

Pradeep Thakur, Medical Insurers curb cashless facility, Times of India, July 10, 2010. Cashless Medical facilities restored in 449 hospitals, Agencies, Indian, Aug 17, 2010
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