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Universal health coverage in India, economic growth, and social justice

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The Lancet, 08-14 January 2011 issue, India health coverageThe Lancet has published, in its 08-14 January 2011 issue, a series of papers on India’s path to full health coverage. Taken together, the papers and comments show that a failing health system is perhaps India’s greatest predicament. The papers (pay only, the comments are free to read) reveal the full extent of opportunities and difficulties in Indian healthcare, by examining infectious and chronic diseases, availability of treatments and doctors, and the infrastructure to bring about universal health care by 2020. This Lancet issue with the India health coverage special brings together a rapidly growing body of evidence to show that Indian health is in grave crisis. As the country with the largest democracy in the world, India is well positioned to put health high on the political agenda.

Introduction to the Lancet Series – Indian health: the path from crisis to progress – Can India’s vibrant political process and civil society create the public demand for health reform? Do Indian health institutions — the Ministry of Health and Family Welfare and the health professions, for example — have the capacity to lead reform? In India, community identity rivals individual identity in importance. How do community identities shape attitudes and policies towards health? – Richard Horton, Pam Das (The Lancet)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: the time is right – India’s record in expanding social opportunities has been uneven. The health and nutritional status of children and women remains poor, and India is routinely ranked among countries performing weakly on overall health performance. But there is good reason for hope. The country has withstood the recent global financial crisis and quickly returned to rapid economic growth. There is a refreshing openness to participation by civil society and to the power of ideas to improve performance and governance. We are enthused by India’s recent commitments to invigorate the public health-care system to address health disparities. – Vikram Patel, A K Shiva Kumar, Vinod K Paul, Krishna D Rao, K Srinath Reddy (London School of Hygiene and Tropical Medicine, London, UK and Sangath Centre, Goa, India; UNICEF India; All India Institute of Medical Sciences; Public Health Foundation of India)

Securing the right to health for all in India – The health status of people transcends the health-care sector, and the social determinants of health, such as food, water, sewerage, and shelter, still elude large numbers of the poorest citizens in India. Inequity in social determinants of health and health care in a market-based system itself becomes a pathogenic factor that drives the engine of deprivation. These inequities are set to increase even further in the near future even as major investments are being projected and planned in the health sector from 0·9% to 3·0% of the gross domestic product. The stunted public health system is hardly geared up to absorb this increased allocation; already state governments are returning allocated money because of the inability to absorb increased allocations. – Binayak Sen (Christian Medical College, Tamil Nadu, India) (The Lancet writes: “One notable absentee from the launch of the Series on Jan 11, 2011 is paediatrician and Comment author Binayak Sen. He remains in prison, an appalling situation discussed in an Editorial in the Jan 8-14 issue of The Lancet.”)

Gender equity and universal health coverage in India – The findings presented on health-care coverage in India emphasise that maternal health concerns, such as fertility and maternal mortality, continue to affect large numbers of women and girls in India. Although these concerns are diminishing, present trends indicate that India is not on target to reach national and Millennium Development Goals. Too many Indian women and girls are unnecessarily affected by gender-based violence and inequities in health-care access and use. – Anita Raj (Department of Social and Behavioral Sciences, Boston University School of Public Health)

The Lancet, 08-14 January 2011 issue, India health coverageIndia: access to affordable drugs and the right to health – Competition from generic companies is the key to affordable drugs. Generic companies in India can therefore produce drugs at prices that are among the lowest in the world. This cost advantage means more than 89% of the adult antiretroviral drugs purchased for donor-funded programmes in the developing world are supplied by companies in India. The European Union and India free-trade agreement seeks to introduce TRIPS-plus and other measures, such as patent term-extensions, data exclusivity, increased border and enforcement measures, and investment protection agreements, all of which would impede generic competition. – Anand Grover, Brian Citro (Lawyers Collective HIV/AIDS Unit, Mumbai)

Good governance in health care: the Karnataka experience – The health sector, with high public interaction and large societal impact affecting almost the entire population, was the second most corrupt sector in India. Bribes related to health care comprised the highest portion of all bribes paid in the state of Karnataka in 2008, at 40%. More than 150,000 estimated households below the poverty line paid bribes for seeking basic health care in 2005 in the state. In 2008, 64% of all bribes paid in the state for basic services was by people living below the poverty line and amounted to INR650 million. – Hanumappa Sudarshan, N S Prashanth (Karuna Trust, Karnataka, India; Institute of Public Health, Bangalore, Karnataka, India)

Research to achieve health care for all in India – Many of the leading causes of disease burden across communicable diseases, non-communicable diseases, and injuries continue to be under-represented in this published research output, indicating that even among the limited papers on public health research, a large proportion do not address public health priority conditions in India. Distinct from published papers, an analysis of public health research reports produced in India also showed that the leading chronic non-communicable diseases and injuries were under-represented between 2001 and 2008. – Lalit Dandona, V M Katoch, Rakhi Dandona (Public Health Foundation of India, New Delhi, India; Institute for Health Metrics and Evaluation, University of Washington; Department of Health Research and Indian Council of Medical Research, Ministry of Health and Family Welfare, Government of India)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: missing core determinants – India’s growing economic strength is based on an economic model that has enhanced the very disparities that the call is concerned about. Promotion of medical tourism at the cost of universal primary health care has not been accidental, but the result of a policy that places the market above people’s basic needs. All health-care reforms have to respond to this political dichotomy in the economy of health. Any health-care reforms, including the national health bill and integrated national health system suggested, have to be placed within a national effort to provide food, water, shelter, sanitation, education, and other basic needs. – Ravi Narayan (Centre for Public Health and Equity, Society for Community Health, Awareness, Research and Action, Bangalore, India)

Towards a truly universal Indian health system – The current framework of economic growth is not designed to address the concerns of very large sections of the population, for whom it has directly perpetuated the situation of ill health and inadequate health care. This position is not one of mere semantics, since any sustainable recommendation needs to be set in an honest and robust analysis of the causes of ill health in India. Little mention is made of the severe, persistent, and near ubiquitous poverty that has characterised this era of so-called economic growth, in which 77% of Indians live on less than INR20 a day. – Amit Sengupta, Vandana Prasad (People’s Health Movement-India [Jan Swasthya Abhiyan], Uttar Pradesh, India)

Please see this page on the Lancet series for longer summaries of the comments.

Sound and fury over the ‘New Delhi superbug’

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The Government of India has decided on a matter of medical research to protest what it sees as an attack on India’s pride and reputation. In the process it is ignoring entirely the public health implications of the findings concerning the ‘New Delhi metallo-beta-lactamase 1 (NDM-1) positive Enterobacteriaceae‘ which a typically hair-trigger and chronically underinformed media have promptly labelled the ‘New Delhi superbug‘.

The Lancet study on 'New Delhi metallo-beta-lactamase 1'National politicians are notoriously quick to point out and rubbish any perceived stain on Mother India’s honour – never mind that 53 million children under five are malnourished and 456 million live in poverty. And so it is with the Lancet Infectious Diseases paper whose findings ought to be treated with the seriousness they deserve, rather than be rubbished out of hand as being an attempt to scuttle India’s ambitious medical tourism industry. The problem is seen as commercial, not health, which becomes clear given the non-partisan nature of the defenders.

India’s Union Health and Family Welfare Minister Ghulam Nabi Azad directed the ministry he heads to issue a statement which said: “While such organisms may be circulating more commonly in the world due to international travel but to link this with the safety of surgery hospitals in India and citing isolated examples to show that due to presence of such organism in Indian environment, India is not a safe place to visit is wrong.” The Indian health authorities also complained to the Indian media that several authors of the Lancet study had pharmaceutical ties. “After seeing the research paper I strongly refute that hospitals in India are the source of the strain and strongly condemn naming the bacteria after New Delhi,” said Director General of Health Services RK Srivastav.

Malnourished children under 5, MDGs map, World Bank

Malnourished children under 5, MDGs map, World Bank

Politician S S Ahluwalia, who is deputy leader of opposition in the Rajya Sabha (upper house), called the study a “sinister design” of foreign multinational companies to undermine India’s burgeoning medical tourism industry. He said in the Rajya Sabha that “the timing of the article was suspicious” as it came when “India is emerging as a global power in medical tourism”. However, being in the opposition, he also asked the government to “come out with a registry that will record infections when they are detected in hospitals, and also antibiotics for their treatment”. This demand was probably prompted by a report citing an official of the Indian Council of Medical Research as having said that India currently does not have any rules or registry to record hospital-acquired infections.

In all the expressions of outrage, what is clear is that the immediate concern of the Union Health Ministry and the assortment of politicians and health officials protesting is the impact of the Lancet study on India’s medical tourism industry, which is no doubt booming, of which a substantial portion is composed of medical visitors from Britain, and which is estimated by the healthcare industry to reach USD 2.3 billion in value by 2012. Perhaps the only rational response was from the Minister of State for Science and Technology and Parliamentary Affairs, Prithviraj Chavan, who told Parliament he would provide an answer “after consulting with the health ministry and department of biotechnology”.

What actually set off the outrage in India? As Nature Blogs explains, the ‘New Delhi metallo-beta-lactamase 1 (NDM-1) positive Enterobacteriaceae’ comprise a new breed of multidrug-resistant bacterium. Germs carrying the NDM-1 gene fend off almost every known antibiotic, including the carbapenem family of drugs reserved as a last resort. One such bug claimed its first known fatality in June, when a Belgian man infected while hospitalised in Pakistan died in Brussels. The Lancet paper found the NDM-1 gene in isolates of Escherichia coli and Klebsiella pneumoniae taken from sites in the United Kingdom, India, and Pakistan. Of the 29 UK patients found with NDM-1 germs, 17 had recently traveled to India or Pakistan, and several had been hospitalised while undergoing elective surgery.

The Lancet study on 'New Delhi metallo-beta-lactamase 1'What does the Lancet study actually say? Entitled ‘Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study’, the 31 collaborating authors say that “Gram-negative Enterobacteriaceae with resistance to carbapenem conferred by New Delhi metallo-beta-lactamase 1 (NDM-1) are potentially a major global health problem“. They say this because they investigated the prevalence of NDM-1, in multidrug-resistant Enterobacteriaceae in India, Pakistan, and the UK. Enterobacteriaceae isolates were studied from two major centres in India – Chennai (south India), Haryana (north India) – and those referred to the UK’s national reference laboratory.

Here is the short statement of findings: “We identified 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan. NDM-1 was mostly found among Escherichia coli (36) and Klebsiella pneumoniae (111), which were highly resistant to all antibiotics except to tigecycline and colistin. K pneumoniae isolates from Haryana were clonal but NDM-1 producers from the UK and Chennai were clonally diverse. Most isolates carried the NDM-1 gene on plasmids: those from UK and Chennai were readily transferable whereas those from Haryana were not conjugative. Many of the UK NDM-1 positive patients had travelled to India or Pakistan within the past year, or had links with these countries.”

And this is the no-nonsense assessment: “The potential of NDM-1 to be a worldwide public health problem is great, and co-ordinated international surveillance is needed.” Who funded the research? The European Union, Wellcome Trust, and Wyeth. Does this pose conflicts of interest? According to the Indian government it does, for the Union Health Ministry has pointed out that one author “has received a travel grant from Wyeth” and another “has received
conference support from numerous pharmaceutical companies, and also holds shares in AstraZeneca, Merck, Pfizer, Dechra, and GlaxoSmithKline, and, as Enduring Attorney, manages further holdings in GlaxoSmithKline and Eco Animal Health”. However what was not mentioned is the statement that “all other authors declare that they have no conflicts of interest” which covers 29 out of 31.

The Lancet paper makes several observations which have implications for public health in India, Pakistan, Bangladesh and South Asia and these are:

Population living in poverty, MDGs map, World Bank

Population living in poverty, MDGs map, World Bank

“NDM-1-positive bacteria from Mumbai (32 isolates), Varanasi (13), and Guwahati (three) in India, and 25 isolates from eight cities in Pakistan (Charsadda, Faisalabad, Gujrat, Hafizabad, Karachi, Lahore, Rahim Yar Khan, and Sheikhupura) were also analysed in exactly the same manner but in laboratories in India and Pakistan. These isolates were from a range of infections including bacteraemia, ventilator-associated pneumonia, and community-acquired urinary tract infections.”

“In addition to the collections of isolates from Chennai and Haryana detailed above, we have confirmed by PCR alone the presence of genes encoding NDM-1 in carbapenem-resistant Enterobacteriaceae isolated from Guwahati, Mumbai, Varanasi, Bangalore, Pune, Kolkata, Hyderabad, Port Blair, and Delhi in India, eight cities (Charsadda, Faisalabad, Gujrat, Hafizabad, Karachi, Lahore, Rahim Yar Khan, and Sheikhupura) in Pakistan, and Dhaka in Bangladesh suggesting widespread dissemination.”

The concern is that there is widespread nonprescription use of antibiotics in India, leading to huge selection pressure, which led the study authors to predict that the NDM-1 problem is likely to get substantially worse in the foreseeable future. “This scenario is of great concern because there are few new anti-Gram-negative antibiotics in the pharmaceutical pipeline and none that are active against NDM-1 producers.” Even more disturbing, the authors have said, is that most of the Indian isolates from Chennai and Haryana were from community-acquired infections, suggesting that NDM-1 is widespread in the environment.

New Delhi and other India metropolises and cities have witnessed repeated surges in the incidents of dengue and, especially in monsoon months, malaria, which the city authorities of Mumbai (Bombay) are currently battling in a haphazard and quite ineffectual manner. The conclusions of the Lancet study on NDM-1 naturally also raise question about the ability of a worn out public health system to identify and respond to new threats, and it is this aspect which ought to be exercising the Union Health Ministry rather than the perceived slur on five-star medical tourism facilities. Moreover, as the affiliations of the study authors show, this is a South Asian effort concerning what ought to be viewed as a South Asian health issue, and the Indian Government’s nationalistic response ignores the regional dimension entirely (and typically).

“The introduction of NDM-1 into the UK is also very worrying and has prompted the release of a National Resistance Alert 3 notice by the Department of Health on the advice of the Health Protection Agency,” the study has said in conclusion. “Given the historical links between India and the UK, that the UK is the first western country to register the widespread presence of NDM-1-positive bacteria is unsurprising. However, it is not the only country affected. In addition to the first isolate from Sweden, a NDM-1-positive K pneumoniae isolate was recovered from a patient who was an Australian resident of Indian origin and had visited Punjab in late 2009. The isolate was highly resistant and carried NDM-1 on an incompatibility A/C type plasmid similar to those in India and the UK.”

Several of the UK source patients had undergone elective, including cosmetic, surgery while visiting India or Pakistan. India also provides cosmetic surgery for other Europeans and Americans, and NDM-1 will likely spread worldwide. It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals. The potential for wider international spread of producers and for NDM-1-encoding plasmids to become endemic worldwide, are clear and frightening.”

The authors of the Lancet study and their institutional affiliations are: Department of Microbiology, Dr ALM PG IBMS, University of Madras, Chennai, India (K K Kumarasamy MPhil, P Krishnan PhD); Department of Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, Cardiff , UK (M A Toleman PhD, Prof T R Walsh PhD, the lead author); Health Protection Agency Centre for Infections, London, UK (J Bagaria MD, R Balakrishnan MD, M Doumith PhD, S Maharjan MD, S Mushtaq MD, T Noorie MD, A Pearson PhD, C Perry PhD, R Pike PhD, B Rao MD, E Sheridan PhD, J Turton PhD, M Warner PhD, W Welfare PhD, D M Livermore PhD, N Woodford PhD); Department of Microbiology, Shaukat Khanum Cancer Hospital, Lahore, Pakistan (F Butt MD); Department of Microbiology, Pandit B D Sharma PG Institute of Medical Sciences, Haryana, India (U Chaudhary MD, M Sharma MD); Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden (C G Giske MD); Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan (S Irfan MD); Department of Microbiology, Amrita Institute of Medical Sciences, Kerala, India (A V Kumar MD); University of Queensland Centre for Clinical Research, University of Brisbane, Herston, QLD, Australia (D L Paterson MD); Department of Microbiology, Apollo Gleneagles Hospital, Kolkata, India (U Ray MD); Department of Medical Microbiology, Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK (J B Sarma MD); Department of Microbiology, Apollo Hospitals, Chennai, India (M A Thirunarayan MD); and Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India (S Upadhyay PhD).