Casteism in a medical college: A reminiscence

The Indian Medical Association has expressed doubts about whether casteism exists in the medical profession. I would like to report what I witnessed as a medical student at the Government Medical College (GMC), Nagpur, where I studied from 1982 to 1987. There was much to be proud of in this college which was, and is, dear to me; but what I relate here is a part of its dark underbelly that I had no idea even existed before that. It is a college whose alumni include several eminent practitioners who might reflect on whether such practices existed in the years before I joined.

DHR-ICMR Guidelines for diagnosis & management of Rickettsial diseases in India.

Rickettsial diseases, caused by a variety of obligate intracellular, gram-negative bacteria from the genera Rickettsia, Orientia, Ehrlichia, Neorickettsia, Neoehrlichia, and Anaplasma, belonging to the Alphaproteobacteria, are considered some of the most covert emerging and re-emerging diseases and are being increasingly recognized. Among the major groups of rickettsioses, commonly reported diseases in India are scrub typhus, murine flea-borne typhus, Indian tick typhus and Q fever. Rickettsial infections are generally incapacitating and difficult to diagnose; untreated cases have case fatality rates as high as 30-45 per cent with multiple organ dysfunction, if not promptly diagnosed and appropriately treated. The vast variability and non-specific presentation of this infection have often made it difficult to diagnose clinically. Prompt antibiotic therapy shortens the course of the disease, lowers the risk of complications and in turn reduces morbidity and mortality due to rickettsial diseases. There is a distinct need for physicians and health care workers at all levels of care in India to be aware of the clinical features, available diagnostic tests and their interpretation, and the therapy of these infections. Therefore, a Task Force was constituted by the Indian Council of Medical Research (ICMR) to formulate guidelines for diagnosis and management of rickettsial diseases. These guidelines include presenting manifestations, case definition, laboratory criteria (specific and supportive investigations) and treatment.

Undernutrition and the incidence of tuberculosis in India: National and subnational estimates of the population-attributable fraction related to undernutrition.

Background. India has the largest global burden of tuberculosis (TB)-related morbidity and mortality as well as undernutrition. Undernutrition impairs cell-mediated immunity, is a risk factor for the development of TB, and has the largest potential impact on the incidence of TB in countries with a high burden of TB. Methods. We refined the national estimate of the population-attributable fraction (PAF) for undernutrition in India to report the first subnational estimates, and stratified these further for age, gender, residence, caste and socioeconomic status. We also compared the PAF related to undernutrition in India with that in 15 other countries with a high burden of TB. We used data on body mass index (BMI) from the National Family Health Survey-3 (NFHS-3), as well as risk estimates for a low BMI from a recently published population-based study which had controlled for several confounders. Results. The overall prevalence of undernutrition in the age group of 15–49 years was 35.6% among women and 34.2% among men. About half (55.4%; 95% CI 27.4– 75.9) of all cases of active TB among women and 54.4% (95% CI 26.5–75.2) of all cases among men were attributable to undernutrition. In the age group of 15–19 years, the PAFs for undernutrition were 62% and 67% among women and men, respectively. The PAF of undernutrition was higher in rural areas, in scheduled castes, scheduled tribes and other backward classes, and in the lower quintiles of the wealth index. The PAF of undernutrition exceeded 50% in most states, and the largest PAFs were seen among women of scheduled tribes in central India. Among countries with a high burden of TB, India had the highest PAF related to undernutrition. Conclusion. Addressing the problem of endemic undernutrition among adolescents and adults in India could complement the current TB control strategy based on case management, and help reduce the incidence of TB in India in line with global targets.

The crisis in access to essential medicines in India: key issues which call for action.

The government is planning to introduce free generic and essential medicines in public health facilities. Most people in India buy healthcare from the private sector, a compulsion that accounts for a high proportion of healthcare-related expenditure. To reduce the burden of healthcare costs, the government must improve availability and affordability of generic and essential medicines in the market. It can do so because India's large pharmaceutical industry is a major source of generic medicines.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

Chikungunya fever, falciparum malaria, dengue fever, Japanese encephalitis... are we listening to the warning signs for public health in India?

The 2005-epidemic of Chikungunya fever highlights the weaknesses of public health in India. The failure to control mosquitoes, and the illnesses transmitted by them, has resulted in recurrent outbreaks all over the country. This is inevitable given the larger scenario: neglect of the basic requirements of health; poor political support for health; a weak public health capacity; centralised programmes for control based on selective interventions, and poorly-planned development projects which have created conditions ideal for the outbreak of disease. All these issues are concerns for public health ethics and must be addressed to tackle the problems posed by mosquito-borne as well as other communicable diseases.