Girl Rag Pickers: Struggle for Survival

By M H Ahssan

The process of industrialization in India brought about fundamental changes in the mode of production and in the relationship of productive factors. The mechanization made agriculture capital intensive. Those with small and non-viable land holdings had to give up their lands and work for the richer farmers in the village or migrate to cities for their survival. The industries could not absorb the whole displaced labour, unemployment and poverty compelled the whole family, including the children to work. The profit motivated to traders and businessmen began to look for cheap labour. Child labour was found to be cheaper and easily available. Thus began the exploitation of child labour market, not only in India, but also in most of the developing countries.

The children engaged in the survival battle and that too, for a virtually subhuman existence, especially in unorganized sector. In this sector children have very limited occupational mobility, because of lack of education, skills, training and guidance, and have no occupational choice.

Their day begins with uncertainties and their work is irregular, some time it's depend upon season. The job they do show a wide range depending on availability of work- carrying load, vending, shoe shining, cleaning cars, and rag picking which require hardly any skills. It is one of the most common occupation in which thousand of children are engaged. It is estimated that six out of every ten children involve in this work to eke out their living. Motivations for the children to pick up this work for economic support is easy availability of rags in and around the towns without spending money and this work does not involved employers for employment.

Therefore, their work is either controlled by their own interest or by their family. They are called as such though they pick anything but rags. They collect scraps from streets, market places, garbage bins and waste dumps, picking up material such as paper cardboard, plastic, iron scrap, tin containers, and broken glass, in fact anything thrown away by households, shops, workshops, or other establishment that can be sold to dealer who buy these for the recycling industry.

Undoubtedly, the present work expose them to the several types of health hazards like infection form coming into contact with foe cal contaminants, dead animals and hook worm, gastrointestinal infections and danger of accidents; injuries and disease through contacts with sharp material and poisonous substance as they scrounge with bare hands and sometime even bare feet. Such kind of situations become worst in the case of “girl child”, when they are exposed to the risk of sexual harassment and physical exploitation by the people of outside world. Because of which their moral and psychological development is at stake.

The participation of children in economic activities reflects the socio economic status of the nation. The poorer the nation, there is likelihood the large number of its children are found more in work places rather than in schools. Children are required to work supplement their family income or acquire skills to become self employed or independent persons. While child labour is a product of poverty, illiteracy and ignorance of parents, girl child labour is the result of many complex issues. There is discrimination amongst male and female starting from their conception. Most of the female fetuses are brutally killed even in their embryonic life.

The misery does not end there, even if they survive some how, they are discriminated at home, school, social places and place of work. As soon as the girl child starts walking and is able to understand language, work is entrusted to her as a routine affair. The girl child has to understand a variety of tasks in and outside the house. There is a strong sex typing of roles as regard to the work that female and male children do. The burden of household duties falls largely upon the female child. At the same time female children are also faced to work and earn for the family.

Without realizing the consequences the girl children are made to shoulder many responsibilities. They are groomed to behave in a different way from the boys. By the time they are 11 or 12, they generally become docile, obey the order of elders in the family and are destined to do whatever is entrusted to them. Girl child labour is not only deprived of their education and recreation, but their overall development also gets affected. A study shows that the female child labour in rural areas is 6.9 million and in urban areas is 7.94 million. In fact in many places of work, they out number their male counterpart (Jawa, 2000). These female child workers earn less wages and work for more hours, both at home and at work place.

Girls are the most unprotected among street children and are more vulnerable to physical and sexual abuse, especially those who have crossed puberty. They have no guidance on the changes that take place with puberty and on sexual matters. While engaging in rag picking they come into contact with several types of health hazards like skin infections, cuts, T.B, malaria and develop other social evils such as gambling , drug abuse, prostitution and different kind of exploitation-physical, sexual which effects their over all development.

It is a matter of great concern that majority of girls (69%) start rag picking at the age of 6 years and work continuously for long hours without any rest. Thus they are deprived of opportunity for any active and organized play, which could provide some leisure and psychological satisfaction to them. Because of their dirty and shabby appearance they are not allowed to use recreational parks and other places, hence they find satisfaction in seeking excitement by way of indulging in addiction and other social evils. It has been reported that 80% of girls are addicted to one or other type of drug, in which tobacco chewing is the most common drug i.e., 60%. It is evident form this that the children between the age group of 13-16 years and above are most vulnerable to addiction of one or the other and need focused intervention.

As far as concern about duration of working hours, the children working in the “informal sector” are not governed by any regulation. It is ironical that, while the society has not accepted children to work, no such body of rules for those working in the informal sector has been constituted. Nor is there any supervision by the government of the kind of “informal sector” in which the children are engaged. The consequence of which is that majority of girls 63% work 11-12 hours a day and some works more than 12 hours a day, which is more than the working hours prescribed under the factories Act and that too is for adults. A study(bose,2001) reported that 70% girls faced problem of eve teasing, physical abuse and also sexual abuse by the outside people which include watch men, guard, , shop keepers, tea shop and other general public.

Health is one of the basic human needs and access to health services is right of everyone. Health has a broader meaning referring to “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity”. In other words, health encompasses psycho-socio-somatic development in medical science and improvement in provision of health services, but this has not occurred every where and benefits have not percolated to everyone. The rag picker children constituted that section of population who has not benefited form these advancement and services. The social conditions in which these children live have often precluded them from actual enjoyment of the right to have access to health facilities at per with other sections of the society. The situation turns out to be further worse due to neglect towards the health of the girl child in our society. In addition, shortage of health facilities and functionaries in the localities where they live adds to the neglect of their health needs. Added to this is the greater degree of malnutrition due to poverty. All these handicaps on health front combine together to affect the health of the rag picker girls. It is an important point to note that rag picker girls did not get regular meals or got only one meal in a day. It is unfortunate that they worked long hours and walked 10-15 miles each day virtually on empty stomach. The major circumstances responsible for malnutrition and addiction are “environment” in which they work and live. Most of the girls have cuts, injuries, joint pain, skin infections, stomach pain, body pain and the possibility of STD, AIDS and other infectious disease are also prevalent among this group(Khan, 2006).

Undoubtedly, numerous effects have been made by the government with the help of voluntary welfare agencies to promote general health status of women and children. But, by and large, the health status of women and children, especially girl children, remains unchanged among the rural poor, urban slums and tribal areas.

A matter of great concern is that with the urbanization, and the increase in volume of throwaway packing and waste material, the numbers of such children are growing. The present work exposes the children to health hazards and they also develop social evils and different kind of problems, which affect their overall future development. Moreover rag picking has not even been recognized as an occupation by the census. Since most of the children draw their livelihood out of rag picking work and it has got all the components of an occupations defined by Webster’s encyclopedia unabridged Dictionary of English language, which says that “occupation is an activity in which one regular devotes oneself, especially one’s regular work, or means of getting a living,” therefore it should be considers as an occupation so that plight of all those who are involved could be improved.. The future holds no promises for them. They are thus who are denied the joys of childhood, a favorable living environment, and opportunities for stable adult life.

Chhattisgarh's 'Blooming Health Business': Where The Doctors 'Getting Rich' At The Cost Of 'Women Uterus'

Since the state of Chhatisgarh was carved out of Madhya Pradesh in 2000, Chhattisgarh has descended on its poor women with a spate of public-health messages: Have fewer children, don’t deliver babies at home, and only trust health professionals, not your age-old beliefs, for decisions about well-being. From the remote villages in the rural grain bowl of the north to urbanised extensions of the capital city Raipur, women are listening.

In 2014, more than 124,000 women received tubectomies, a sterilisation procedure that accounts for 92% of all family-planning methods, according to the National Health Mission.

Are Doctors Asked To Treat Rape Victims With Suspicion?

By Siddharth Pal (Guest Writer)

FEATURE CEHAT (Centre for Enquiry Into Health and Allied Themes), the research centre of Anusandhan Trust, that is involved in research, training, service and advocacy on health, released a series of documents after the second season of TV show Satyamev Jayate aired last Sunday. Some guests invited to the first episode of the second season had alleged that doctors are trained very early on to treat rape victims with suspicion.

The allegation undoubtedly caused uproar in the medical community. The newest episode of the show hosted by Bollywood superstar Aamir Khan questioned the role doctors played in exacerbating the trauma of a rape survivor by putting them through the ignominy of undergoing harrowing medical examination. Added to the mental trauma, often the physical examination is painful and traumatic. In extreme cases, it was alleged that doctors do not administer painkillers to victims before examining their bruised private parts.

Apollo Hospitals' Suneeta Reddy: 'Medical Tourism Is a Huge Market'

Medical tourism -- the phenomenon in which hospitals in emerging markets offer "sun, sand and surgery" at low prices to patients from North America and Europe -- is gaining in popularity. While India lags behind countries like Thailand as a result of airport infrastructure and other bottlenecks, health care providers such as Apollo Hospitals are expanding at 10% a year. In an interview with HNN chief M H Ahssan, Suneeta Reddy, Apollo's executive director of finance, discussed the company's opportunities and challenges in this fast-growing market.

An edited transcript of the conversation follows:

How has medical tourism grown over the years?
Reddy: It has grown...I wouldn't say substantially, but it's grown by 10%. Ten years ago, Apollo started focusing on patients outside India. It didn't happen as a result of marketing; it was more of a pull of customers towards good quality medicine, rather than our pushing them through advertising and marketing. The reason it happened was that all over Southeast Asia, people began to see a value proposition -- which was high value in terms of clinical outcomes and high-quality care -- at one-fifth of what they would traditionally pay in the U.S., and probably a third of what they would pay in a country like Singapore. As a result, we started attracting patients from all over Southeast Asia.

As it progressed, people began to realize that the India story, where health care was concerned, was improving dramatically. Just two years ago, we got the JCI [Joint Commission International] accreditation which puts us on par with hospitals in the rest of the world. We are now shoulder to shoulder with the Mayo Clinic and the Cleveland Clinic. And with that we started getting patients from the West as well. Most of them use the Internet as the medium through which they schedule their appointments and arrange consultations with doctors. But again, it's this value proposition that is really driving consumers. I would say that currently 10% of our total revenues come from medical tourism. That is not really a large amount, and it has grown by 2% to 3%.

There are obstacles in the way of what is happening. One is our airport facilities. If you look at the hospitals that are really doing well, they are connected to international airports that have around maybe 50 to 60 flights a day. Compare us with Thailand, which has 260 international flights flying into Bangkok every day -- that makes it very easy for patients to go to Bangkok for medical tourism. If you compare that with the Chennai Airport, where our largest hospital is, there are about 15 flights. So, I think that you have to look at the airport infrastructure.

Secondly, the case mix of most of the work that comes to India is tertiary care and acute care. It's not the plastic surgeries that you see in Bangkok. It's high-end orthopedic work, it's cardiology, and some of it is oncology. Patients come to us for really high-end work. To do that, because we are recognized for that sort of work, it is quite uncomfortable for patients to make this journey. We need to smoothen out that process -- so that our patients don't have to spend 12 to 14 hours in Immigration and Customs -- and we are working on that. We now have people to facilitate and assist these patients as they come across.

Finally, I would like to say that there is a huge opportunity here. If you look at the U.S. alone, there are 40 million people in the country who are not insured. If you look at the U.K., there are about 250,000 Asians who are in the waiting line at NHS [National Health Service]. Medical tourism is a huge market. I believe the way to address it is to create a package that will enable these people to use Indian facilities. We tried talking to governments and asking, "Why don't you send patients who have no treatment options to India?" Then again, we've spoken to benefits companies, etc. The only single hurdle facing the U.S. and foreign patients coming here is legal liability and the fact that they cannot address their concerns through a legal forum in the United States. They could, of course, use the Indian legal system, but it's become a way of life; people want the legal system to back them up in case there is a problem.

Now, the incidence of problems is not even 0.01% so far, because the success rates are very good and clinical outcomes are so good -- we are JCI accredited -- and patients have the same rights in India as they would in the U.S., so they are protected. But I think that it's just a hurdle that we need to overcome. Once we have done this, we will be tying up with insurance companies and benefits companies to see how we can assist people who need that type of health care.

Have you seen a discernable increase in your Western clientele over the past few years? I know the story has been out for a while now. I was curious to know if you've seen an increase.
Reddy: Yes, we have. There has been a rise of about 5%.

What do you attribute that to, if it's difficult to access these people through insurance programs or through the government? Is it direct advertising?
Reddy: It's not advertising at all. It's the fact that people are so confident that the clinical outcomes will be good. And it's testimony from patients who have been through the whole process. As I said, it's pullingpatients to the system. This is because we don't market. I mean you don't see advertisements. But, we are now working with CII, the Confederation of Indian Industry, which is doing the branding in India. There is a branding foundation in India, and they have a campaign called "Incredible India." We work with them, and we are now doing a promotion around, "Experience Indian Health Care." It was just launched and hopefully we will see a lot of results from that.

Your program combines elements of both Western care and also Eastern medicine. I noticed that in a lot of your materials, you advertise the point that there are centuries of Eastern medical practice that you rely on as well. Can you talk specifically about what some of those elements are?
Reddy: We believe in an integrated health care package. In that sense, we talk about allopathic medicine for the actual treatment, in terms of surgery, diagnosis, etc., but where rehab and wellbeing are concerned, we've tried to integrate the systems of ayurveda [traditional Indian medicine] and yoga. This has helped because when patients go back [after their surgery] they need to readjust to a lifestyle that emphasizes continuous wellbeing. The key here is that there's a lot of value that they will get from ayurveda and yoga.

It is certainly a big market in the U.S., or at least a growing market, correct?
Reddy: It is. It's strange, but when Patanjali introduced Yoga thousands of years ago, there were very few Indians practicing it. And now, 6% of the world practices yoga. It has become famous because the movie stars in the West and people all over America are doing it. Now it has come back to India, and people are now saying, "Okay, this should become a way of life." Ayurveda is the science of life.

You are one of the largest health care systems in India, correct?
Reddy: Yes, we are.

How are you reaching out to poorer populations? Can you tell us a little bit about SACH and maybe some of your other community initiatives as well? The acronym stands for: Save a Child's Heart.
Reddy: I will start with SACH. SACH is Save a Child's Heart; it also means "the truth" in Hindi. The reason we started SACH is that we came across so many children who had heart disease. We believe that if there is an intervention at that stage, when the child is young, it will given them a more productive future. So, we said let's do something for children and make them productive adults, because that is what India really needs.

We started this foundation where the hospital does everything free of cost. The money for the consumables comes from donations, and people have donated in a large way. So far, we have completed 500 free surgeries and our target [this year] is to do 1,000. We would like to do 1,000 surgeries a year. The surgeon does not charge and the hospital does not charge. It's just 50,000 rupees for the consumables which comes as a donation. People have found it to be not so difficult to give a check for 50,000 rupees [$1,170] -- especially when you know that you are saving a child's life and you're assuring him or her of a good future.

The second thing we do is outreach at the village level, where health care is not available. We wanted to create a sustainable model and not really do it as charity, but to create something that was sustainable for the future. In fact, Bill Clinton, when he was the U.S. President, inaugurated this initiative in a village called Aragonda, a small town in the Chittoor district of Andhra Pradesh. We set up a small hospital, which was a primary care facility. We connected it through tele-medicine to our tertiary care facility.

Then we created an insurance product which was 1 rupee (0.02 cents) a day, which allowed people access into the primary care facility. If they fell ill, they would be treated here. They wouldn't have to pay anything, except for the 1 rupee a day or 325 rupees a year [$7.60 a year]. And, if they needed some tertiary care work, they would be connected by telemedicine to our specialists in the main hospital. They would only have to travel to the city when they needed acute care. I think that is an excellent model. Currently, we have 64 telemedicine centers that connect us to many centers in India. We are going to work on this model and set up more primary care initiatives.

The third activity we do is to organize medical camps. We go into the villages and screen people for cancer. You know, India is the only country where cervical cancer still exists. The numbers are growing exponentially, and we believe that early intervention and screening is one of the ways to check the growth and mortality from cancer. There are many camps that we do work with from each of our hospitals that have to do with cancer screening.

The fourth activity has to do with wellness, because preventive health care is a big aspect of health care. It will be a $1 trillion industry in the next five years. Without looking at it from an industrial viewpoint, health care education is important; Apollo tries to do that through its preventive health care schemes and our outreach programs, where we do these check-ups in villages.

What would you identify as the biggest challenges facing the industry?
Reddy: I think there are two challenges; the main one is skilled manpower. The fact that the government has not allowed the corporatization of colleges means that they still function at a trust level. This means that people pay capitation fees, and the number of seats is limited by state governments. Health is a state subject, so there is a dichotomy there; I believe there should be a Central government policy on health care. It's not a fundamental right that people get health care; in each state there is a separate policy.

The need for health care education is tremendous. First, people should learn about health care, and second, we need to get skilled manpower. That is a huge challenge because our nurses and doctors are migrating to the U.S.; in the past, they went to the U.K. The U.S. has at least 40,000 doctors who were trained in India at subsidized rates. These hospitals are run by trusts, so the doctors really don't pay that much for their education and training. But we need to double the capacity in terms of training colleges. This is because if you are going to create the 80,000 beds that are required for us to meet the World Health Organization's norms, then we need to staff those 80,000 beds.

Yet another challenge has to do with the high cost of real estate -- to set up a hospital, you need real estate, you need land. Property prices have almost doubled. Traditionally real estate was 40% of project cost and now it has increased to 65%. We may need to set up a health care real estate investment trust (REIT)like you have in the U.S. to overcome this hurdle.

Where Are India's Heat Hotspots?

Heat waves across the world have killed tens of thousands of people since the turn of the century. In the U.S., more people die from deaths related to heat than all other natural phenomena combined. Parts of West Asia are expected to become inhospitable to human life by the end of this century. 

And in recent years, India and neighboring regions have experienced several devastating heat waves, causing the country to increasingly focus on a growing global concern—rising temperatures as a public health threat.

By 2022 India’s population is projected to exceed China’s, making it home to one-fifth of the world’s population. As a developing country located in the tropics, India suffers from factors that make it vulnerable to heat waves: persistent poverty, poor sanitation, a precarious water and electricity supply and low rate of access to health care.

Spurring the market for high-tech home health care

By M H Ahssan

A daunting array of financial and operational barriers is holding back growth. What can be done?

On the surface, technology-enabled home health care should be thriving in the United States. The country’s aging population and the transformation of acute illnesses such as heart failure into chronic diseases mean that the number of patients is growing. In addition, new medical-technology devices could help keep patients at home rather than in costly institutions, such as assisted-living facilities or nursing homes—leading to potentially big savings for the health care system.

Instead, the full potential of the technology-enabled home health care market remains to be tapped. In the United States, home care accounts for about 3 percent ($68 billion a year) of national health spending. The market is increasing by about 9 percent annually,¹ solid but hardly booming growth, especially since labor (mainly nurses and aides) accounts for about two-thirds² of the expenditure and home-monitoring technology represents a small fraction of it. What’s holding the market back? We observe a daunting array of financial and operational barriers, including the misalignment of incentives between payers and providers, the need to demonstrate a strong clinical value proposition, and the problem of designing attractive, easy-to-use products that facilitate adoption by patients.
Technology holds a central role in expanding the market for home health care. Historically, most of its infrastructure and equipment consisted of durable medical products: walkers, wheelchairs, wall rungs, safety rugs, and the like. That infrastructure enabled basic home care but could not substitute for the more sophisticated capabilities of specialized care settings, such as on-call nursing in long-term-care facilities. In recent years, however, new home care technologies—Internet-enabled home monitors, apps for mobile health, and telemedicine—are bringing aspects of advanced care into patients’ homes. These technologies are finding a place in all parts of the globe.
Expanded technology-enabled home care offers a promising pathway to bend the cost curve for ever-growing health care expenditures. Independent of the economic benefit, the moral value of enabling older members of society to live in grace and dignity in their own homes, with a ripple effect on their caregivers, is arguably the most important—if unquantifiable—benefit of home care. It will move ahead, however, only if stakeholders develop more equitable reimbursement models that create greater incentives to participate in the technology-enabled home health market. In addition, medical-device makers must focus on technologies that are easier to use, have a real impact on patients’ conditions, and make it possible to measure results.
An understanding of these issues is important for all stakeholders: medical-device manufacturers, insurers, doctors, hospitals, and government regulators seeking to optimize investments in home health care. With the market growing, and expansion opportunities available both domestically and internationally, this is a promising time to be in the business of home care technology.

Where technology-enabled home care can help

The goal of technology-enabled home care—the delivery of health diagnostics or therapeutics in a patient’s home—is to prevent or reduce the need for institutional care, alleviating the financial and emotional burden upon society and individuals. Its central thesis is that some chronic illnesses can be treated through monitoring and interventions in a patient’s home rather than in higher-cost institutional settings.

Of course, the 65-and-over age segment forms the bulk of the home care population and fuels the market’s growth. These men and women experience care primarily in four settings: their homes, assisted-living facilities, acute-care facilities (hospitals), and long-term-care institutions, such as nursing homes or skilled-nursing facilities. Clinical or economic factors propel patients from one care setting to another. The shift from homes to assisted-living facilities is typically driven by a gradual decline in cognition or physical capacity, from homes or assisted-living facilities to acute-care facilities by events such as fractures or heart attacks, and from homes, assisted-living facilities, or acute-care institutions to long-term-care institutions by movement across a financial or clinical breaking point (for example, bankruptcy or a diagnosis of dementia or other chronic illness).

The most important value offered by technology-enabled home care is preventing or delaying the shift of patients to acute- or long-term-care settings. Technologies used in home care cannot address all the potential factors underlying such shifts—for example, trauma from a car accident lies beyond their reach. The medical conditions that can be addressed successfully by technology-enabled home care meet three criteria:

• They are chronic—persisting for years rather than days or months.
• They can be prevented or addressed by protocols—repeatable and standardized step-by-step instructions executed by nonphysicians.
• They are nonintensive—there is no requirement for round-the-clock attention or human monitoring.

Diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and fracture prevention³ are high-prevalence medical conditions that satisfy these criteria. They are important disease targets for current and future technological advances in home care.

Choosing the right business model

To date, technology-enabled home care in the United States has succeeded in only a few settings: most notably, integrated payers and providers such as Kaiser Permanente (through its KP OnCall subsidiary) and US Department of Veterans Affairs (VA) medical centers (through the VA’s Care Coordination/Home Telehealth program). There is increasing evidence of the value of such programs. A 2008 study of Telehealth found that hospital admissions dropped by close to one-fifth, while its cost was up to two orders of magnitude lower than that of alternatives.
Given the potential savings, why do home care technologies have such low penetration? We find that eight key success factors, falling into three categories, must be satisfied simultaneously for a model to be commercially viable. Entrants into the home care technology market should cast a critical eye upon their offerings to verify that all eight success factors have been satisfied. Failure to meet even one can cripple an otherwise-promising business model.

Financial factors

1. Alignment between payers and providers. Episodic hospitalization reimbursements for congestive-heart-failure patients, for example, are misaligned with hospital-based technology-enabled home care programs: every patient successfully kept at home means less revenue for a hospital. A critical reason for the success of integrated payer–providers (such as the VA) in technology-enabled home care is their capitated reimbursement models—by patient per year, so each patient who avoids hospitalization represents a boost to the bottom line.
Stakeholders, particularly payers and providers, must cooperate to ensure that incentives for relevant technologies are aligned. That means either creating new reimbursement models, such as direct payments for the use of home care technologies, or adapting existing models, such as bundled reimbursements that cover a comprehensive set of clinical activities across care settings.
2. Remunerative. A home care technology’s return on investment must be clear to patients and, where different, to purchasers. Personal-health-record software aimed at individual patients, for example, remains unpopular because each user must enter a great deal of information manually in return for ambiguous benefits. On the other hand, at-home glucometers, which measure the concentration of blood sugar, have succeeded because the value to patients is simple, clear, and immediate.

Effectiveness factors

3. Having significant impact. A home care technology must affect a patient’s clinical course of care; conversely, if it merely provides information that cannot change the course of disease progression or treatment, its value is negligible. Monitoring the weight of a patient with congestive heart failure, for example, effectively alerts clinicians to an imminent worsening of that condition. The at-home interpretation of new chest pain experienced by recovering heart attack patients is not useful, because the appropriate course of action is to go to the hospital—no matter what.

4. Actionable. Merely observing or flagging an event is not enough; a home care technology must be accompanied by some way to take action—through a device, a nurse, or the patient—when an intervention is required. A nursing intervention prompted by alarming weight gain in a congestive-heart-failure patient is an effective action; displaying a stand-alone Web page with a chart of recent weight gain by a patient, leaving it up to him or her whether and how to do anything, is an ineffective one.

5. Timely. The home care technology must be sufficiently rapid and reliable to be useful in guiding decisions or initiating interventions. An always-on accelerometer, for instance, quickly detects a fall. A daily automated phone call to check on a patient at home to see if a fall occurred does not.
6. Closed loop. A technology must contain a “closed feedback loop” to measure progress against goals and to verify whether effective actions or treatments actually occurred. Without such a loop, a technology’s value cannot be proved, measured, or optimized. A technology that enters a patient’s after-treatment physical-activity levels directly into a provider’s electronic medical records through a wearable device has a closed feedback loop. A technology that enters a patient’s physical-activity levels into a stand-alone system requiring a separate provider login has an open one. Without seamless processes, feedback data may be overlooked or ignored. To fulfill a closed loop, a home care technology must be tightly coupled with processes and tools to ensure that measurements reach their intended recipients in a timely and easily viewed way.

Accessibility factors
7. Usable. Technologies must be available and understandable to the right users at the right place and time; poor user interfaces or immobile physical locations can doom business models. A wireless blood pressure cuff at home is easily usable, for example; a fixed blood pressure kiosk in a retail pharmacy is significantly less so. Further, if a technology has been tested only with tailored populations or under special conditions (such as clinical trials) it is important to verify that it will be scalable to larger populations and real-world conditions.
8. Repeatable. A technology must be used frequently—typically, at least daily—over the course of a chronic disease. Infrequently used technologies do not generate good habits among home care consumers and are eventually forgotten or ignored. The daily measurement of body weight on an electronic scale by congestive-heart-failure patients is repeatable. On the other hand, a device that performs an annual eye exam for diabetic patients works too intermittently to be compelling for home use.

What the future holds

The environment for home care technology is likely to change in the coming years. Greater adoption has two key drivers.

Health care reform

At a time of general fiscal stress and specific concern about billing fraud, public or private payers are unlikely to increase funding or coverage for home care. The Congressional Budget Office estimated that the 2010 Affordable Care Act, for example, will pare a cumulative $39.7 billion from federal home-health-care reimbursements over the next decade.⁶ Payers are more likely to pursue various forms of capitation (payment per person rather than, say, per service) and shared-risk models, in an attempt to give providers an incentive to subsidize home care technologies and services.

Misalignment between buyers and beneficiaries is an important brake on the penetration of home care technologies. They are likely to benefit if reform efforts successfully accelerate the alignment of incentives—for example, through the creation of Accountable Care Organizations (groups of coordinated health care providers) or bundled payments between payers and providers.⁷ Indeed, the spread of home care technology has an especially strong potential to accelerate under such a scenario because care pathways that rely on skilled labor—pharmacists, nurses, and doctors—are most vulnerable to labor shortages and to eventual augmentation by technology-driven approaches.

Increasing the evidence base

As multiple technology-enabled home care pilots, at public and private organizations alike, have rolled out over the past decade, data accumulated on both sides of the ledger for clinical value and returns on investment. In some cases, technology-enabled home care pilots have produced compelling successes; in others, they have done less well.

Fraud remains a looming concern in home care; the US Government Accountability Office reported “estimated improper payments for Medicare of almost $48 billion for fiscal year 2010,” including expenditures for home oxygen and other home health claims.⁸ To qualify for coverage from payers or to generate incentives within insurance for individuals, home care technologies may also offer new avenues to address home care fraud, in addition to improving patients’ health and quality of life and saving money.
We see substantial growth potential in technology-enabled home health care. An aging population and an increasing chronic-disease burden point to a large and growing market. But home care stakeholders must get the reimbursement models right and ensure that the technologies coming to market truly make a difference for patients and the bottom line alike.

Vaccine-Derived Polio Found In Hyderabad Sewage Is An Outcome Of India’s immunisation Strategy

By NEWSCOP | INNLIVE

Public health experts expect to find vaccine-derived polio virus in the environment for at least the next year.

On Wednesday, Telangana health authorities announced a polio vaccination drive because a strain of polio had been found in the Amberpet Nala in Hyderabad. The announcement triggered alarm that polio had resurfaced in India, a country that the World Health Organisation had declared polio-free in 2012. However, the presence of vaccine-derived polio viruses is expected in sewage systems across the country for at least the next six to 12 months, say public health experts, reiterating the government’s position that there is no cause for alarm.

World 'No Tobacco' Day 2009

By Suman Ranganathan

The World Health Organization selects "Tobacco Health Warnings" as the theme for the 20th World No Tobacco Day, which will take place on 31 May 2009. Tobacco health warnings appear on packs of cigarettes and are among the strongest defences against the global epidemic of tobacco. WHO particularly approves of warnings that contain both pictures and words because they are the most effective at convincing people to quit.

Tobacco health warnings appear on packs of cigarettes and are among the strongest defences against the global epidemic of tobacco.

WHO particularly approves of tobacco health warnings that contain both pictures and words because they are the most effective at convincing people to quit. Such pictorial warnings appear in more than a dozen countries.

On World No Tobacco Day 2009, and throughout the following year, WHO will encourage governments to adopt tobacco health warnings that meet all the criteria for maximal effectiveness, including that they cover more than half of the pack, appear on both the front and back of the pack and contain pictures.

The WHO Framework Convention on Tobacco Control obligates its more than 160 countries parties to require "health warnings describing the harmful effects of tobacco use" on packs of tobacco and their outside packaging and recommends that the warnings contain pictures. WHO works through its Tobacco Free Initiative department to help the parties to meet their obligation, providing technical and other assistance.

As WHO Director General Margaret Chan says, "We hold in our hands the solution to the global tobacco epidemic that threatens the lives of one billion men, women and children during this century."

Tobacco health warnings are a big part of the solution about which Dr Chan speaks.

Please return soon to this website for a richer explanation of why the World Health Organization chose "Tobacco Health Warnings" as the theme for World No Tobacco Day 2009 and about what the warnings -- pictorial ones in particular -- can do to fight tobacco.

A Possible Remedy for Poor Health Care in India

By M H Ahssan

India wants to be a preferred destination for medical tourism, but its health care offering for its own citizens is lacking. The doctor-to-population ratio for the country is 6:10000, compared to a global ratio of 14:10000. It is estimated that over the next two decades, India will need twice as many doctors, three times as many nurses and four times as many paramedics it has at present.

With 60% of the hospitals and 80% of the doctors belonging to the private sector, and 70% of the health care resources in India concentrated in the top 20 cities, rural India is hit the hardest.
To address this problem, the Medical Council of India (MCI) has proposed a truncated medical course for practitioners in rural areas. Called the Bachelor of Rural Medicine and Surgery (BRMS), it is a three-and-a-half-year course aimed specifically for students from rural India to take care of the basic health care needs of the target population.

The proposal for the BRMS, initiated by the MCI a couple of years ago, has recently received the backing of the country’s Planning Commission. A report released by an expert group within the Commission notes that the course should focus on “high quality of competence in preventive, promotive and rehabilitative services required for the rural population with a focus on primary health care.” It also recommends that by 2020, India should have BRMS colleges in all districts with a population of over 500,000. The report clarifies that this is not a shortened version of a traditional medical degree (MBBS) course, but a unique initiative to address the country’s rural health care issues.

Not everyone is convinced of the efficacy of the BRMS course. In an address on the website of the Indian Medical Association, its president, Vinay Aggarwal, points out that the course is akin to “promoting and legalizing quackery.” He adds: “While modern medicine is experiencing a knowledge explosion, and a five-and-a-half-year MBBS course is insufficient to provide basic information to would-be doctors … how can reducing the duration of training be the remedy to the maladies plaguing rural health? Compromised education, and training in institutions where infrastructure and faculties have been compromised, will compromise the health of villagers …. An army of half-baked doctors for villagers with a three-and-a-half-year curriculum is a gross injustice.”

Rana Mehta, executive director, PricewaterhouseCoopers, India, disagrees. “I see it as a positive step,” he says. “In one way it is a compromise, because you don’t do the [traditional-length] course, but given the huge shortage of doctors in India, this is a very good and innovative move.” The only caution that Mehta adds is that BRMS practitioners “need to keep within the paradigm of the knowledge that they have.”

There have been other innovations in India’s health care sector. At Devi Shetty’s cardiac care hospital, Narayana Hrudayalaya, for instance, patients are treated for heart ailments at a fraction of what it would cost elsewhere across the globe. Shetty attributes this to “process innovation.” And at the Indian arm of GE Healthcare, the goal is to innovate and make affordable and accessible health care products to meet the specific needs of the Indian population.
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It now remains to be seen whether the BRMS ranks among these and other innovations from India — or whether it will prove the skeptics right.

U S AUTOMOBILE INDUSTRY - The Jurassic auto and idea park

By M H Ahssan

The U.S. auto giants are an example of how things work in the age of unbridled corporate power. Of how the collapse of restraint on that power fractures economy and society.

It is unfair to call the United States auto industry dinosaurs, as some now do. It is certainly unfair to the dinosaurs. The 'Terrible Lizards' did not lay the basis for their own extinction or that of myriad other species. The U.S. automobile companies did - and will take large numbers of jobs, workers and businesses with them.

It is more like the asteroid hit on the earth which is presumed to have fried the dinosaurs. But that's unfair to the asteroid. The U.S. auto giants General Motors, Ford and Chrysler are more a fine example of how things work in the age of unbridled corporate power. Of how the collapse of restraint on that power must fracture economy and society. They also set the very standards that the Indian elite lusts to emulate.

Metal lizards
The original dinosaurs (which scientists now tell us were neither all that terrible nor lizards) were great examples of success and adaptation. Good enough to rule the planet for 150 million years. The U.S. auto industry is the opposite. It's not just that the Terrible Metal Lizards opposed fuel efficiency standards. Of course, they did. They also promoted gas-guzzling SUVs as a lifestyle must. They cranked out cars many did not want to buy. They wielded heavy clout in Congress. And were able to sponge off public funds in the name of saving jobs as they have yet again. Having received $25 billion earlier, their hats are in their outstretched hands again.

But that's the easy part. There's a lot more they did, as a major sector of industry - and as part of the larger corporate world of the U.S. Over decades, they destroyed both existing and potential public transport. The 'American Dream' so far as the automobile went was an imposed nightmare. In Detroit itself, you can see the skeletons of a once alive transport system. All across the country, for decades from the 1920s, they bought up public transport systems and shut them down. Trains were shifted from electric to diesel engines. Sometimes, they were simply done away with and replaced by buses and then cars. Together with Big Oil, Big Auto converted electric transit systems to fuel-based bus systems. In one estimate: In 1935, electric train engines outnumbered diesel train engines 7 to 1. "By 1970, diesel train engines outnumbered electric ones 100 to 1. And GM made 60 per cent of the diesel locomotives." The electric rail system in and around Los Angeles was almost erased.

Fostering the cult
Fostering the cult of the individual-owned automobile was a major goal. By 2001, that goal was achieved beyond belief. Some 90 per cent of Americans drove to work by that year. The findings of the 2001 National Household Travel Survey are striking. Only 8 per cent households reported not having a vehicle available for regular use. The survey showed that "daily travel in the United States totalled about 4 trillion miles, which works out to an average of 14,500 miles per person over a full year." Trips by transit and by school bus each made up just 2 per cent of daily trips taken in 2001.

Not just a cult but a culture grew around the Metal Lizards and fossil fuels. Even an economy that goes to war to deal with perceived threats to oil. (As Robert Fisk often asks: would there have been a war in Iraq if Iraq's national product had been asparagus?) Again together with Big Oil, Big Auto for decades crushed all serious moves towards cleaner energy sources.

Almost everything grew dependent on it. From agriculture to aviation, individual to national needs. When oil prices rose (before their present crash) thanks to heavy speculation, countless households in the U.S. were paralysed. Hundreds of little family trucking businesses went kaput. People in outlying places who drive many miles to fetch things like bottled water and provisions found their budgets burning. An average American family in 2004 spent up to a fifth of its income on transportation. That's against 13 per cent on food. In "automobile dependent neighbourhoods," according to the Bureau of Labour Statistics, that could go up to 25 per cent. In bigger cities, the traffic only gets worse, never better. There were over 135 million passenger cars in 2006. Overall, registered vehicles clocked in at more than 250 million.

Imagine the centrality of oil, autos and private vehicles to just about everything. This is the very model our own Indian elite seeks to transplant. Private automobiles at the cost of public transport. Never mind the latter is a lot cleaner and creates large numbers of jobs. And so we add thousands of such vehicles to the roads each week.

But back to the Metal Dinosaurs of Detroit. Their asteroid hit will impact on far more than the nearly quarter of a million workers directly stranded on their turf. There are also more than a million retirees and dependents in trouble. The retirees now watch their health benefits vanish. That's not nice in a country where health costs are the largest single cause of bankruptcies. At age 75 or 80, it is misery. Then there are millions of other workers in associated sectors. In part-makers, supplier companies, in dealerships.

The health issue is also vital. With all its wealth, the U.S. has no decent public health system. The corporate world as a whole has never allowed that to emerge. The health insurance mob, Big Pharma, huge corporations in the medical field, and so on. Take the loss of jobs in the automobile sector to Canada. One reason is simply because Canada has a much better public health system. Even GM (which also exists there) has lobbied in the past in that country to see that Canada's universal health plan was not scuttled! It has saved GM countless dollars.

Each car that GM puts out carries a healthcare cost of around $1600. For Chrysler, that's $1500. But for Toyota, that cost is under $300 per car. Japan has a far superior public health system. In the corporate-media of the U.S., this does not lead to calls for a good health system. Or for making health access cheaper. It leads to calls for doing away with the union contracts that guaranteed auto workers health benefits for life. For retirees, the pullback has already begun.

India even now has one of the most highly privatised health sectors in the world. Yet it exults in emulating the worst of the U.S. model. The Indian elite boasts of India as one of the hottest destinations in 'medical tourism.' Sure, Americans might fly to India to get their surgeries done (which would cost them an arm and a leg in their own country). But close to 200 million Indians have given up seeking any kind of medical attention at all - simply because they cannot afford it.

'Too big to fail'
Meanwhile, the logic of "too big to fail" keeps Big Auto and others of its ilk going. There is never any debate in the U.S. on whether they should have been allowed to get as big as they did. President-elect Barack Obama says he will aid the auto oligarchs who he calls "the backbone of American manufacturing." Sure, with that many jobs at stake, any government must worry about the consequences of letting them sink. No question about it. It's on the basis of that very fear that the Terrible Metal Lizards are able to bargain for handouts from public money. This economy has lost close to a quarter of a million jobs in the month of October alone. So the thought of many more simply vanishing is scary. The U.S. has already lost over 1.2 million jobs this year. Close to half of those in the past three months alone.

So there is a good chance that more public money will be thrown at the auto giants. And that, without larger strategic shifts being imposed on them. Yet, everyone knows this does not mean an industry saved. They could be back soon with demands for still more. At which time, with things being even worse (quite likely) the pressure to save jobs by pouring in public money will be still greater. This is the United States.

The money given out in the bailout so far has delighted the Tuxedo dinosaurs - CEOs and senior executives. As The New York Times notes ruefully in a lead editorial: "Just weeks after the Treasury Department gave nine of the nation's top banks $125 billion in taxpayer dollars to save them from unprecedented calamity, bank executives are salting money away in billionaire bonus pools to reward themselves for their performance." Other bailout bandits have held meetings at resorts costing hundreds of thousands of dollars.

Remember the 'debate' over CEO compensation in India? The media shouted down their favourite Prime Minister when he made a few meek sounds of protest over inflated CEO pay. Well, there too, we were and are on the very track that has helped the U.S. land itself in the mess it now is in. Welcome to the Jurassic Auto & Idea Park.

Medical Corruption: Who will lead the anti-corruption agenda in the health sector?

The conduct of election of members to the Medical Council of India in 2013 and its subsequent actions over the past year have underlined the brazen corruption in the regulatory body. Developments in the health ministry raise doubts over whether these issues will be tackled at all.

The removal of Dr Harshvardhan from the helm of the health ministry may merely be to give him more room to focus on the Delhi assembly election campaign for the BJP, but there appears to be an apprehension in several quarters that the shift, whether intentionally or otherwise, will be a setback to the attempts to free the medical sector from corruption.

INDIA'S 'MOST CORRUPT, UNHEALTHY' HEALTH SECTOR

By M H Ahssan / Hyderabad

All is surely not well with the Health Administration of the country. The other day two shocking revelations were made in the press. One of them related to detection of serious irregularities by the Parliamentary Standing Committee on health and family welfare in respect of advices and letters of recommendations from some experts submitted to the Drug Controller General of India (DCGI) regarding several drugs. These recommendations, apparently, read the same, word-for-word, as those submitted by the drug companies concerned. 

Taking India's Pulse: The State of Health Care

By M H Ahssan

Much has been made of India's rapid rise in the pharmaceutical and biotechnology arena. The country is now one of the world's largest producers of generic drugs and vaccines. Companies like Ranbaxy and Dr. Reddy's Laboratories are becoming well known around the world.

But with the most recent national election - in which the incumbent party was ousted largely due to its failure to address the needs of the impoverished masses - interest is growing in the Indian health care industry's domestic agenda. How India plans to leverage its reputation on the global pharmaceutical stage to address the needs of its own people was the focus of a panel and keynote address at the Wharton India Economic Forum held recently in Philadelphia. The speakers, who represented a variety of sectors, agreed that the problem was serious, but they were optimistic that Indian health care could improve if both government and industry took some key steps.

Broken System
No matter how you look at it, the Indian health care system is in poor shape, noted Ajay Dhankar, a principal in McKinsey and Company's Asia-Pacific health care practice. Many people who need care can't afford it -- and thus aren't receiving the drugs and treatments they require. Most health care in the country is paid for by individual patients, explained Dhankar. "Some 66% of it is paid out of pocket at the time of the incident, and 80% of the money is spent by those who can't afford it. So the entire payer system is broken. Two-thirds of what the government spends on health care goes to secondary and tertiary care [instead of basic services]."

The insurance industry, a key player in health care, is far from mature in India. Dhankar explained that India has a mix of private, social, and community insurance: "Private insurance is overregulated - international insurance companies were formerly not allowed to own more than a certain percentage of firms in the Indian market. Now those regulations have been relaxed a bit, but it's still hard for them to make money in India. Social insurance is run by the government - but the same agency that collects the money also sets up the hospitals. So there's no logic to it. In the community insurance space, a lot of innovative things are being done, and it has shown a lot of potential. But these schemes tend to go bankrupt if there's a big event - say, an earthquake."

Taken as a whole, the situation in India can seem daunting. Siddharth Dube, scholar-in-residence at the Center for Interdisciplinary Research on AIDS at Yale University, painted a sobering picture of the country's AIDS epidemic. "By some indicators, it's as bad as sub-Saharan Africa," he said. "It's far more serious than people have been led to believe. By the government's own estimate, 5 million Indians are already affected - but some say it's closer to 8 million. About 1,200 people were infected each day in 2003 - and 325,000 died that year."

In some areas, said Dube, up to 5% of all adults are infected. "India's capacity to check the epidemic is defeated; there's still no political commitment around AIDS. The epidemic will only get worse in the next five to ten years."

Basic services - which can often stem the development and spread of disease -- are sorely lacking in many areas, added Preetha Reddy, managing director of Apollo Hospitals Enterprise. The gap between rich and poor is very visible: while world-class treatments are available at many facilities, many rural residents still don't have safe drinking water. "There's been no concentrated effort to handle this problem," said Reddy.

Chance for Change
The dismal picture, however, also represents a tremendous opportunity. "We see no systemic barriers to fixing the problem - they are just 'stroke of the pen' barriers," Dhankar said. "We just need well-thought-through policies and innovative solutions. While the core elements are being fixed, and growth and development are indeed taking place, health care can't grow without government support," he said.

Quality standards at hospitals are not only rising, but they are being certified and benchmarked against their global counterparts, said Reddy. "A lot of institutions are working to achieve international standards for quality." The benefit? "We can then get patients from other countries to come here," Reddy explained. Since many patients in the U.S. and the U.K. are on long waiting lists for treatment, it makes sense for India to position itself as an alternative location for care. Such a program, popularly called "health tourism," can be used as a base from which to build other parts of the system. India could potentially target some 10% of the world health care market, Reddy noted, but the infrastructure isn't in place yet. As long as the system is kept in balance, tertiary health care tourism can be used to subsidize basic services.

Hospitals are also considering the issue of affordability, said Reddy, noting that many groups were pooling their purchasing in order to negotiate lower prices from drug companies - thus reducing the cost to the end user. Keynote speaker Kiran Mazumdar-Shaw, chairperson and managing director of Biocon, said that the biotechnology sector was also addressing that problem. "The hepatitis B vaccine price has come down to a fraction of the original - from $5 to $10 per dose to just $0.25. This is having a huge impact on immunization programs."

Big Picture Strategy
Raman Kapur, ex-president of worldwide genetics at Schering-Plough, suggested that government could play a key role in improving health care. "Perhaps it could provide the basic needs; on the pharmaceutical side, it can provide infrastructure and be a catalyst. Generics have been a success; within five years the two dominant generics producers will likely be India and China. India is now starting to develop infrastructure for clinical trials," he said. "Continuous, inexpensive electricity and other inputs at international prices would go a long way toward leveling the playing field."

One way Indian industry could differentiate itself, says Kapur, is to emphasize areas of research that the G8 countries aren't focusing on - namely, non-temperate region diseases like malaria and tuberculosis. Diabetes is also a key disease for research, since it is possible that more than 10% of the world's diabetics may be in India over the next decade, he said.

Like Kapur, Mazumdar-Shaw urged companies to focus on neglected diseases. "We need innovation and aggressive programs, directing research on AIDS, leprosy, rotavirus - why are those vaccines not being developed in India?" she asked. "We have lots of innovative capability in India but a weak research engine when it comes to academic institutions providing us with ideas as they do elsewhere. This needs to change."

Strategic Partnerships
In 1994, noted Mazumdar-Shaw, four of the top 10 pharmaceutical companies in India were Indian. Today that figure has risen; nine out of the top 10 are Indian. India ranks third in its region in the number of biotechnology companies; only Australia and China are ahead of it. India has strong capabilities in product manufacturing, product development, and product discovery, and the sector has grown with very little venture capital funding, she noted. "Its vaccine capacity is among the world's largest, and it's poised to be a global hub for clinical development. For drug discovery, its analytical costs are among the lowest."

India's disease sector is larger than that of the U.S. and Europe combined, she added. On the flip side, "the large and diverse disease pools also provide speed of enrollment and a rich resource for research activity," said Mazumdar-Shaw. "Many international venture capitalists see having an 'India strategy' as a powerful way to decrease risk. Risk capital is drying up in the West. Funding probability increases with the progress of drug development - the farther along a drug is, the more likely someone is to fund it."

Since venture capital commitment is greater after proof of concept, she said, "valuations increase exponentially along the development curve." Partnering with India, many companies find, is a powerful and cost effective way to climb the valuation chain. Mazumdar-Shaw's own company, Biocon, has been successful in partnering with small biotech startups: "Such partnerships allow Indian companies to integrate backward into discovery research and external companies to pursue forward integration strategies."

Fine ideas all - but whether these global partnerships and world-class development initiatives will filter down to the rural farmer suffering from AIDS still remains to be seen.

Obesity: An Overblown Epidemic?

By Sarah Williams

A growing number of dissenting researchers accuse government and medical authorities--as well as the media--of misleading the public about the health consequences of rising body weights.

Could it be that excess fat is not, by itself, a serious health risk for the vast majority of people who are overweight or obese--categories that in the U.S. include about six of every 10 adults? Is it possible that urging the overweight or mildly obese to cut calories and lose weight may actually do more harm than good?
Such notions defy conventional wisdom that excess adiposity kills more than 300,000 Americans a year and that the gradual fattening of nations since the 1980s presages coming epidemics of diabetes, cardiovascular disease, cancer and a host of other medical consequences.

Indeed, just this past March the New England Journal of Medicine presented a "Special Report," by S. Jay Olshansky, David B. Allison and others that seemed to confirm such fears. The authors asserted that because of the obesity epidemic, "the steady rise in life expectancy during the past two centuries may soon come to an end." Articles about the special report by the New York Times, the Washington Post and many other news outlets emphasized its forecast that obesity may shave up to five years off average life spans in coming decades.

And yet an increasing number of scholars have begun accusing obesity experts, public health officials and the media of exaggerating the health effects of the epidemic of overweight and obesity. The charges appear in a recent flurry of scholarly books, including The Obesity Myth, by Paul F. Campos (Gotham Books, 2004); The Obesity Epidemic: Science, Morality and Ideology, by Michael Gard and Jan Wright (Routledge, 2005); Obesity: The Making of an American Epidemic , by J. Eric Oliver (Oxford University Press, August 2005); and a book on popular misconceptions about diet and weight gain by Barry Glassner (to be published in 2006 by HarperCollins).

These critics, all academic researchers outside the medical community, do not dispute surveys that find the obese fraction of the population to have roughly doubled in the U.S. and many parts of Europe since 1980. And they acknowledge that obesity, especially in its extreme forms, does seem to be a factor in some illnesses and premature deaths.

They allege, however, that experts are blowing hot air when they warn that overweight and obesity are causing a massive, and worsening, health crisis. They scoff, for example, at the 2003 assertion by Julie L. Gerberding, director of the Centers for Disease Control and Prevention, that "if you looked at any epidemic--whether it's influenza or plague from the Middle Ages--they are not as serious as the epidemic of obesity in terms of the health impact on our country and our society." (An epidemic of influenza killed 40 million people worldwide between 1918 and 1919, including 675,000 in the U.S.)

What is really going on, asserts Oliver, a political scientist at the University of Chicago, is that "a relatively small group of scientists and doctors, many directly funded by the weight-loss industry, have created an arbitrary and unscientific definition of overweight and obesity. They have inflated claims and distorted statistics on the consequences of our growing weights, and they have largely ignored the complicated health realities associated with being fat."

One of those complicated realities, concurs Campos, a professor of law at the University of Colorado at Boulder, is the widely accepted evidence that genetic differences account for 50 to 80 percent of the variation in fatness within a population. Because no safe and widely practical methods have been shown to induce long-term loss of more than about 5 percent of body weight, Campos says, "health authorities are giving people advice--maintain a body mass index in the 'healthy weight' range--that is literally impossible for many of them to follow." Body mass index, or BMI, is a weight-to-height ratio.

By exaggerating the risks of fat and the feasibility of weight loss, Campos and Oliver claim, the CDC, the U.S. Department of Health and Human Services and the World Health Organization inadvertently perpetuate stigma, encourage unbalanced diets and, perhaps, even exacerbate weight gain. "The most perverse irony is that we may be creating a disease simply by labeling it as such," Campos states.

A Body to Die For
On first hearing, these dissenting arguments may sound like nonsense. "If you really look at the medical literature and think obesity isn't bad, I don't know what planet you are on," says James O. Hill, an obesity researcher at the University of Colorado Health Sciences Center. New dietary guidelines issued by the DHHS and the U.S. Department of Agriculture in January state confidently that "a high prevalence of overweight and obesity is of great public health concern because excess body fat leads to a higher risk for premature death, type 2 diabetes, hypertension, dyslipidemia [high cholesterol], cardiovascular disease, stroke, gall bladder disease, respiratory dysfunction, gout, osteoarthritis, and certain kinds of cancers." The clear implication is that any degree of overweight is dangerous and that a high BMI is not merely a marker of high risk but a cause.

"These supposed adverse health consequences of being 'overweight' are not only exaggerated but for the most part are simply fabricated," Campos alleges. Surprisingly, a careful look at recent epidemiological studies and clinical trials suggests that the critics, though perhaps overstating some of their accusations, may be onto something.

Oliver points to a new and unusually thorough analysis of three large, nationally representative surveys, for example, that found only a very slight--and statistically insignificant--increase in mortality among mildly obese people, as compared with those in the "healthy weight" category, after subtracting the effects of age, race, sex, smoking and alcohol consumption. The three surveys--medical measurements collected in the early 1970s, late 1970s and early 1990s, with subjects matched against death registries nine to 19 years later--indicate that it is much more likely that U.S. adults who fall in the overweight category have a lower risk of premature death than do those of so-called healthy weight. The overweight segment of the "epidemic of overweight and obesity" is more likely reducing death rates than boosting them. "The majority of Americans who weigh too much are in this category," Campos notes.

Counterintuitively, "underweight, even though it occurs in only a tiny fraction of the population, is actually associated with more excess deaths than class I obesity," says Katherine M. Flegal, a senior research scientist at the CDC. Flegal led the study, which appeared in the Journal of the American Medical Association on April 20 after undergoing four months of scrutiny by internal reviewers at the CDC and the National Cancer Institute and additional peer review by the journal.
These new results contradict two previous estimates that were the basis of the oft-repeated claim that obesity cuts short 300,000 or more lives a year in the U.S.

There are good reasons to suspect, however, that both these earlier estimates were compromised by dubious assumptions, statistical errors and outdated measurements.
When Flegal and her co-workers analyzed just the most recent survey, which measured heights and weights from 1988 to 1994 and deaths up to 2000, even severe obesity failed to show up as a statistically significant mortality risk. It seems probable, Flegal speculates, that in recent decades improvements in medical care have reduced the mortality level associated with obesity. That would square, she observes, with both the unbroken rise in life expectancies and the uninterrupted fall in death rates attributed to heart disease and stroke throughout the entire 25-year spike in obesity in the U.S.

But what about the warning by Olshansky and Allison that the toll from obesity is yet to be paid, in the form of two to five years of life lost? "These are just back-of-the-envelope, plausible scenarios," Allison hedges, when pressed. "We never meant for them to be portrayed as precise." Although most media reports jumped on the "two to five years" quote, very few mentioned that the paper offered no statistical analysis to back it up.

The life expectancy costs of obesity that Olshansky and his colleagues actually calculated were based on a handful of convenient, but false, presuppositions. First, they assumed that every obese American adult currently has a BMI of 30, or alternatively of 35--the upper and lower limits of the "mild obesity" range. They then compared that simplified picture of the U.S. with an imagined nation in which no adult has a BMI of more than 24--the upper limit of "healthy weight"--and in which underweight causes zero excess deaths.

To project death rates resulting from obesity, the study used risk data that are more than a decade old rather than the newer ratios Flegal included, which better reflect dramatically improved treatments for cardiovascular disease and diabetes. The authors further assumed not only that the old mortality risks have remained constant but also that future advances in medicine will have no effect whatsoever on the health risks of obesity.

If all these simplifications are reasonable, the March paper concluded, then the estimated hit to the average life expectancy of the U.S. population from its world-leading levels of obesity is four to nine months. ("Two to five years" was simply a gloomy guess of what could happen in "coming decades" if an increase in overweight children were to fuel additional spikes in adult obesity.) The study did not attempt to determine whether, given its many uncertainties, the number of months lost was reliably different from zero. Yet in multiple television and newspaper interviews about the study, co-author David S. Ludwig evinced full confidence as he compared the effect of rising obesity rates to "a massive tsunami headed toward the United States."

Critics decry episodes such as this one as egregious examples of a general bias in the obesity research community. Medical researchers tend to cast the expansion of waistlines as an impending disaster "because it inflates their stature and allows them to get more research grants. Government health agencies wield it as a rationale for their budget allocations," Oliver writes. (The National Institutes of Health increased its funding for obesity research by 10 percent in 2005, to $440 million.) "Weight-loss companies and surgeons employ it to get their services covered by insurance," he continues. "And the pharmaceutical industry uses it to justify new drugs."

"The war on fat," Campos concurs, "is really about making some of us rich." He points to the financial support that many influential obesity researchers receive from the drug and diet industries. Allison, a professor at the University of Alabama at Birmingham, discloses payments from 148 such companies, and Hill says he has consulted with some of them as well. (Federal policies prohibit Flegal and other CDC scientists from accepting nongovernmental wages.) None of the dissenting authors cites evidence of anything more than a potential conflict of interest, however.
Those Confounded Diseases

Even the best mortality studies provide only a flawed and incomplete picture of the health consequences of the obesity epidemic, for three reasons. First, by counting all lives lost to obesity, the studies so far have ignored the fact that some diversity in human body size is normal and that every well-nourished population thus contains some obese people. The "epidemic" refers to a sudden increase in obesity, not its mere existence. A proper accounting of the epidemic's mortal cost would estimate only the number of lives cut short by whatever amount of obesity exceeds the norm.

Second, the analyses use body mass index as a convenient proxy for body fat. But BMI is not an especially reliable stand-in. And third, although everyone cares about mortality, it is not the only thing that we care about. Illness and quality of life matter a great deal, too.

All can agree that severe obesity greatly increases the risk of numerous diseases, but that form of obesity, in which BMI exceeds 40, affects only about one in 12 of the roughly 130 million American adults who set scales spinning above the "healthy" range. At issue is whether rising levels of overweight, or of mild to moderate obesity, are pulling up the national burden of heart disease, cancer and diabetes.
In the case of heart disease, the answer appears to be no--or at least not yet. U.S. health agencies do not collect annual figures on the incidence of cardiovascular disease, so researchers look instead for trends in mortality and risk factors, as measured in periodic surveys. Both have been falling.

Alongside Flegal's April paper in JAMA was another by Edward W. Gregg and his colleagues from the CDC that found that in the U.S. the prevalence of high blood pressure dropped by half between 1960 and 2000. High cholesterol followed the same trend--and both declined more steeply among the overweight and obese than among those of healthy weight. So although high blood pressure is still twice as common among the obese as it is among the lean, the paper notes that "obese persons now have better [cardiovascular disease] risk profiles than their leaner counterparts did 20 to 30 years ago."

The new findings reinforce those published in 2001 by a 10-year WHO study that examined 140,000 people in 38 cities on four continents. The investigators, led by Alun Evans of the Queen's University of Belfast, saw broad increases in BMI and equally broad declines in high blood pressure and high cholesterol. "These facts are hard to reconcile," they wrote.

It may be, Gregg suggests, that better diagnosis and treatment of high cholesterol and blood pressure have more than compensated for any increases from rising obesity. It could also be, he adds, that obese people are getting more exercise than they used to; regular physical activity is thought to be a powerful preventative against heart disease.

Oliver and Campos explore another possibility: that fatness is partially--or even merely--a visible marker of other factors that are more important but harder to perceive.

Diet composition, physical fitness, stress levels, income, family history and the location of fat within the body are just a few of 100-odd "independent" risk factors for cardiovascular disease identified in the medical literature. The observational studies that link obesity to heart disease ignore nearly all of them and in doing so effectively assign their causal roles to obesity. "By the same criteria we are blaming obesity for heart disease," Oliver writes, "we could accuse smelly clothes, yellow teeth or bad breath for lung cancer instead of cigarettes."
As for cancer, a 2003 report on a 16-year study of 900,000 American adults found significantly increased death rates for several kinds of tumors among overweight or mildly obese people. Most of these apparently obesity-related cancers are very rare, however, killing at most a few dozen people a year for every 100,000 study participants.

Among women with a high BMI, both colon cancer and postmenopausal breast cancer risks were slightly elevated; for overweight and obese men, colon and prostate cancer presented the most common increased risks. For both women and men, though, being overweight or obese seemed to confer significant protection against lung cancer, which is by far the most commonly lethal malignancy. That relation held even after the effects of smoking were subtracted.

Obesity's Catch-22
It is through type 2 diabetes that obesity seems to pose the biggest threat to public health. Doctors have found biological connections between fat, insulin, and the high blood sugar levels that define the disease. The CDC estimates that 55 percent of adult diabetics are obese, significantly more than the 31 percent prevalence of obesity in the general population. And as obesity has become more common, so, too, has diabetes, suggesting that one may cause the other.
Yet the critics dispute claims that diabetes is soaring (even among children), that obesity is the cause, and that weight loss is the solution. A 2003 analysis by the CDC found that "the prevalence of diabetes, either diagnosed or undiagnosed, and of impaired fasting glucose did not appear to increase substantially during the 1990s," despite the sharp rise in obesity.

"Undiagnosed diabetes" refers to people who have a single positive test for high blood sugar in the CDC surveys. (Two or more positive results are required for a diagnosis of diabetes.) Gregg's paper in April reiterates the oft-repeated "fact" that for every five adults diagnosed with diabetes, there are three more diabetics who are undiagnosed. "Suspected diabetes" would be a better term, however, because the single test used by the CDC may be wildly unreliable.

In 2001 a French study of 5,400 men reported that 42 percent of the men who tested positive for diabetes using the CDC method turned out to be nondiabetic when checked by a "gold standard" test 30 months later. The false negative rate--true diabetics missed by the single blood test--was just 2 percent.

But consider the growing weights of children, Hill urges. "You're getting kids at 10 to 12 years of age developing type 2 diabetes. Two generations ago you never saw a kid with it."

Anecdotal evidence often misleads, Campos responds. He notes that when CDC researchers examined 2,867 adolescents in the NHANES survey of 1988 to 1994, they identified just four that had type 2 diabetes. A more focused study in 2003 looked at 710 "grossly obese" boys and girls ages six to 18 in Italy. These kids were the heaviest of the heavy, and more than half had a family history (and thus an inherited risk) of diabetes. Yet only one of the 710 had type 2 diabetes.

Nevertheless, as many as 4 percent of U.S. adults might have diabetes because of their obesity--if fat is in fact the most important cause of the disease. "But it may be that type 2 diabetes causes fatness," Campos argues. (Weight gain is a common side effect of many diabetes drugs.) "A third factor could cause both type 2 diabetes and fatness." Or it could be some complex combination of all these, he speculates.

Large, long-term experiments are the best way to test causality, because they can alter just one variable (such as weight) while holding constant other factors that could confound the results. Obesity researchers have conducted few of these socalled randomized, controlled trials. "We don't know what happens when you turn fat people into thin people," Campos says. "That is not some oversight; there is no known way to do it"--except surgeries that carry serious risks and side effects.

"About 75 percent of American adults are trying to lose or maintain weight at any given time," reports Ali H. Mokdad, chief of the CDC's behavioral surveillance branch. A report in February by Marketdata Enterprises estimated that in 2004, 71 million Americans were actively dieting and that the nation spent about $46 billion on weight-loss products and services.

Dieting has been rampant for many years, and bariatric surgeries have soared in number from 36,700 in 2000 to roughly 140,000 in 2004, according to Marketdata. Yet when Flegal and others examined the CDC's most recent follow-up survey in search of obese senior citizens who had dropped into a lower weight category, they found that just 6 percent of nonobese, older adults had been obese a decade earlier.

Campos argues that for many people, dieting is not merely ineffective but downright counterproductive. A large study of nurses by Harvard Medical School doctors reported last year that 39 percent of the women had dropped weight only to regain it; those women later grew to be 10 pounds heavier on average than women who did not lose weight.

Weight-loss advocates point to two trials that in 2001 showed a 58 percent reduction in the incidence of type 2 diabetes among people at high risk who ate better and exercised more. Participants lost little weight: an average of 2.7 kilograms after two years in one trial, 5.6 kilograms after three years in the other.

"People often say that these trials proved that weight loss prevents diabetes. They did no such thing," comments Steven N. Blair, an obesity researcher who heads the Cooper Institute in Dallas. Because the trials had no comparison group that simply ate a balanced diet and exercised without losing weight, they cannot rule out the possibility that the small drop in subjects' weights was simply a side effect. Indeed, one of the trial groups published a follow-up study in January that concluded that "at least 2.5 hours per week of walking for exercise during follow-up seemed to decrease the risk of diabetes by 63 to 69 percent, largely independent of dietary factors and BMI."

"H. L. Mencken once said that for every complex problem there is a simple solution--and it's wrong," Blair muses. "We have got to stop shouting from the rooftops that obesity is bad for you and that fat people are evil and weak-willed and that the world would be lovely if we all lost weight. We need to take a much more comprehensive view. But I don't see much evidence that that is happening."

COAL DEATHS : IGNORING THE WEAPONS OF DESTRUCTION

By M H Ahssan / Hyderabad

Based on data collected from 92 coal power plants in India, a 2012 study that went largely unreported estimated the mortality impact of electricity generated from coal at 650 deaths per plant per year! INN analyses the key findings of the report and the remediation measures suggested. 

The Supreme Court of India recently dismissed a petition by anti-nuclear activists to stop commissioning of the nuclear power plant at Kudankulam. The petitioners argued that the plant did not meet safety standards recommended by nuclear experts, a viewpoint that the apex judicial body in the country obviously did not concur with.