Intrinsic Capacity of Rural Elderly in Thar Desert using World Health Organization Integrated Care for Older Persons Screening Tool: A Pilot Study

Integrated Care for Older Persons (ICOPE) screening tool helps to address declines in physical and mental capacities in older people. In India, majority of the older population resides in rural areas and there is a paucity of studies that demonstrates the utility of the ICOPE screening tool in India. Thus, a cross-sectional study was conducted to demonstrate the feasibility of using the World Health Organization ICOPE screening tool in a rural population. Comprehensive geriatric assessment of intrinsic capacity revealed cognitive decline in 31.5% (n = 142) participants, diminished mobility 52.1% (n = 235) participants, eye problems in 49.4% (n = 223) participants, and hearing loss in 68.3% (n = 308) participants. Gender difference was statistically significant with mobility limitation (P = 0.005; ?2 = 7.95) and feeling of pain (P = 0.001; ?2 = 15.64), being more in females than males. This tool seems suitable in identifying the intrinsic capacity of the rural elderly.

Ethical qualms while treating diabetes in low-resource areas

Diabetes care in low-resource rural areas is often compromised by access and finance barriers, leading to ethical dilemmas for physicians in diagnosis and treatment. Rural health workers should be educated on how poverty, disproportionate rural health infrastructure, and illiteracy impact diabetes care to facilitate a paradigm shift from blaming patients for poor adherence to improving health systems in order to address underlying structural care seeking barriers of cost, distance and social stigma. With these barriers urban, high resource protocols cannot be implemented and there is need for separate evidence-based protocols for rural, low resource populations. Having such set protocols coupled with continuous training and use of mobile/telemedicine technology could help shifting tasks to nurses and peripheral health workers. The National Programme For Prevention And Control Of Cancer, Diabetes, Cardiovascular Diseases & Stroke may benefit from this communitising care model by setting up PHC-level NCD clinics run by trained nurses and health workers with physician backup using technology as needed. This way of utilizing non-physician health workers to treat uncomplicated diabetes patients may not only allow physicians quality time and more resources to treat complicated diabetes patients but also provide good quality, accessible care within everyone’s reach.

Morbidity profile and nutritional status of tribal under five children attending the phulwaris in rural Chhattisgarh

Background: According to UNICEF report, 19.8% children under-five years in India are wasted, 48% are stunted and 42.8% are underweight. Multisectoral initiatives by the national and state governments are yet to reduce the burden of malnutrition. Jan Swasthya Sahyog (JSS) Health Centre in Chhattisgarh, plays a vital role in improving nutritional status of tribal under- three children attending the phulwaris (or creches). Objectives of this study were to assess the nutritional status of under-five children attending the phulwaris located under Bamhni sub center and to identify the common morbidities among these children.Methods: The researchers conducted health check-up for 357 children in the 19 phulwaris of Bamhni sub center spread over 16 villages.Results: Mean age of children attending the phulwaris was found to be 29±12.5 months. Among the 357 children, 128 (35.9%) were underweight; 53 (14.8%) were severely underweight; 35 (9.8%) were wasted; 18 (5%) were severely wasted; 58 (16.2%) stunted and 16 (4.5%) severely stunted according to WHO growth charts for weight for age, weight for height and height for age respectively. Point prevalence of morbidity was 142 (39.7%), which included respiratory tract infection (24.6%); scabies (8.4%); otitis media (3.1%); pyoderma (2.2%); developmental delay (2.2%); worm infestation (2.2%); sickle cell anemia (0.6%) and (0.3%) had epilepsy.Conclusions: Under nutrition was still prevalent among the children attending the phulwaris and upper respiratory tract infection was the most common morbidity.

Exemplary operational research on an important public health problem

Rabies is a fatal disease once contracted, and a serious public health problem. Immunisation was unaffordable and inaccessible for most affected people in India. Omesh Bharti’s operational research allows us to reduce the unit dose needed for life saving rabies immunoglobulin (RIG) for class 3 rabid animal bites thereby raising hopes that access to this drug will improve. This study also suggests how public health research should question established guidelines that are rooted in impractical biomedicine without considering sociopolitical realities. The randomised controlled trial as a standard of research methodology is not only impractical but unnecessary. We discuss some of the challenges such as stockout of life saving medicines like RIG and suggest possible solutions. There is still a need to determine the correct RIG dose and the best technique for administering, storage and timing of this important drug.

The ethics of compulsory notification of tuberculosis

The Government of India has passed a notification making the non-reporting of tuberculosis (TB) by a clinical establishment a punishable offence. This article examines this move from an ethical standpoint. One of the main ethical concerns relates to the violation of patient confidentiality that may result from this. Also as regards improvement in patient care, there appears to be a poor cost-benefit ratio in terms of the actionable data obtained by this There may be possible adverse consequences by a limiting of access to care due to penalising of non-reporting. In terms of the bigger picture, the notification may lead to an increased tension between the private sector and Government. Moreover, it is the position of the authors that such a step distracts attention from the more important issues that plague TB care in India today.

Ultrasound in rural India: a failure of the best intentions

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a “silent observer” modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

Decoding the twisted concepts of welfare capitalism

As a public health practitioner in rural central India, issues of access to healthcare as well as cost, quality and equity issues have always interested me. Yet my day to day work has brought only a few aspects into sharper focus. This book caught my attention due to the interesting title and the promise by the editors that the book traces the role of the state and market forces in worsening health inequities. Working in a small part of the country where health inequities abound, I was curious to get a wider perspective on this. My hopes were fulfilled and I enjoyed reading this volume and learnt much from it. I would like to give the reader a quick tour of the book.

Sustaining for-profit emergency healthcare services in low resource areas

The Bawaskars in their Comment “Emergency care in rural settings: Can doctors be ethical and survive?” raise a context-specific question about the sustainability of emergency care in rural, low resource areas. This could be broadened to “What efforts are needed to sustain emergency care systems run by the private sector in rural, low resource areas without catastrophically affecting patients or healthcare providers?” There are enough constitutional, legal and ethical imperatives to state that all emergency care should be available to everyone irrespective of paying capacity. The State should be responsible for providing emergency care via the public sector or for strategically purchasing it from private providers. Even if that arrangement is not viable, private sector providers cannot expect the community to underwrite the sustainability of such services and the return on investment in their training. Finally, we suggest that the principles of ethics cannot be invoked for justifying the financial viability and sustainability of the private sector in an unequal world

Issues in access to end-of-life care in low-resource areas

Even though 1% of people require palliative and end-of-life care in low-resource situations, it remains an uncharted arena. Yet it is as important as curative care to alleviate suffering. Palliative care is not only a need in cancer and HIV disease; but is needed in a diverse group of illnesses ranging from tuberculosis, renal failures, paraplegia to chronic lung diseases. In a lower resource setting, the gaps in palliation may be the need for more technology and interventions or more healthcare professionals. Thus, palliative care will initially mean ensuring that life-prolonging treatment that most patients do not get is ensured to them. It is morally unacceptable to focus on comfort care as an alternative to advocating for patients’ rights for appropriate life-prolonging treatments. If organised well and standard protocols are developed to support health workers, appropriate care can be provided for all people. Ethical principles of autonomy, nonmaleficence and benevolence will have to guide this development. We will have to prioritise for high value care which means choosing cheaper alternatives that are just as effective as more expensive diagnostic or therapeutic modalities. There is a need to settle the priorities between palliative and disease-modifying or curative treatments. Major roadblocks that limit access of the rural poor to palliative care relate mainly to the misconceptions among policy-makers and physicians, large gaps in health worker training and cultural mindsets of care-providers. A specific example of misplaced policies and regulations is the poor availability of opiates, which can make end-of-life care so much more dignified in illnesses that have chronic pain or breathlessness. A three-tiered structure is proposed with a central palliative care unit which will oversee several physicians and specially trained nurses for noncommunicable diseases, who will oversee primary healthcare centre-based nurses, who in turn, will oversee village health workers.

Effect of discrete (individual) and mixed (bulk) genomic DNA on genetic diversity estimates and population structure in Teak (Tectona grandis L. f.).

Teak (Tectona grandis L.f.), a paragon timber tree of tropical deciduous forests of Central and Peninsular India, is highly prized for its wood colour, decorative grains, durability and lightness. An experiment was carried out to compare the genetic variation detected and genetic relationships inferred in five teak populations via 10 genomic DNA samples per population each of either single seed or bulk of 3- or 5- seeds with the help of ISSR markers. The genomic DNA of single seed exhibited higher number of polymorphic loci, per cent polymorphism, nei’s genetic diversity and shannon Information Index than the bulk genomic DNA of 3- or 5- seeds. The bulking of genomic DNA of 3- and 5- seeds using Nei’s genetic distance coefficient revealed similar genetic relationships, which were at variance with those in single seed treatment. Mantel’s correlation test among the genetic distance matrices of single seed sampling, 3-seed bulk and 5-seed bulk sampling also confirmed the trend. Since the bulking of genomic DNA did not generate compatible estimates of diversity parameters and genetic relationship of five populations from its single seed sampling, we recommend strict guarding of identities of genotypes within the collected samples for obtaining precise estimates and drawing accurate conclusions about the genetic diversity and clustering of populations.

Rural blood availability: regulations must meet ethics.

Rural physicians have been practising the technique of emergency bleeding and transfusion called Unbanked Directed (to a specific recipient) Blood Transfusion (UDBT), which has been declared illegal, to meet the need for blood in rural and inaccessible areas. As a result, a crisis has emerged in the availability of blood. Is UDBT a second rate technology for the poor and the disadvantaged? And should we not rather advocate for rapid scaling up of the establishment of blood banks in all areas? We examine the ethical issues related to blood availability in the rural areas. We argue that a regulated and licensed UDBT passes muster on the ethical principles of beneficence, lack of maleficence, justice and Swaraj. Using this issue as a case in point, we further examine the idea of what constitutes appropriate or acceptable technology. While affirming that any technology has to pass muster on a litmus test of acceptability, we discuss the difference between “ideal” and “acceptable” (but less than ideal) technology. We argue there is a dynamic push and pull between the urge to regulate and restrict the use of skills by all versus the need to communitise technology. Regulated use of UDBT will allow blood to be available where it is needed most in the foreseeable future in India.

burden & pattern of illnesses among the tribal communities in central India : a report from a community health programme.

Tribals are the most marginalised social category in the country and there is little and scattered information on the actual burden and pattern of illnesses they suffer from. This study provides information on burden and pattern of diseases among tribals, and whether these can be linked to their nutritional status, especially in particularly vulnerable tribal groups (PVTG) seen at a community health programme being run in the tribal areas of chhattisgarh and Madhya Pradesh States of India. This community based programme, known as Jan Swasthya Sahyog (JSS) has been serving people in over 2500 villages in rural central India. It was found that the tribals had significantly higher proportion of all tuberculosis, sputum positive tuberculosis, severe hypertension, illnesses that require major surgery as a primary therapeutic intervention and cancers than non tribals. The proportions of people with rheumatic heart disease, sickle cell disease and epilepsy were not significantly different between different social groups. Nutritional levels of tribals were poor. Tribals in central India suffer a disproportionate burden of both communicable and non communicable diseases amidst worrisome levels of undernutrition. There is a need for universal health coverage with preferential care for the tribals, especially those belonging to the PVTG. Further, the high level of undernutrition demands a more augmented and universal Public Distribution System.