Health Inequalities in South Asia at the Launch of Sustainable Development Goals: Exclusions in Health in Kerala, India Need Political Interventions.

Despite substantial progress in social development during the post-colonial period, health inequalities in the South Asian countries were staggering, with reduced life expectancy, higher maternal and child mortality, and gender discrimination. Notably, even with the rapid economic growth during the neoliberal period, India fares below most of the South Asian countries in several health indicators. The Indian state of Kerala stands out with social sector gains; nevertheless, evidence indicates widening health inequalities, restricted public arenas, and undemocratic practices in health, particularly in the context of increasing market logic in the health and social arenas shaping health. The caste, class, gender, and ethnic ideologies and patriarchal power structure interwoven in the sociopolitical, cultural, moral, and health discourses similar to the South Asian context raise serious inequalities for health. At the launch of the United Nations' Sustainable Development Goals, the populations with lingering privations and forbidden freedoms for gaining better health in Kerala, similar to South Asia, were largely the dalits, ethnic and religious minorities, and women. This necessitates greater political interventions, recognizing the interacting effects of history, culture, social factors, politics, and policies on health. And public health research needs to underscore this approach.

Rising private sector and falling 'good health at low cost': health challenges in China, Sri Lanka, and Indian state of Kerala.

Despite having a captivating history of outstanding health achievements during the second half of the 20th century, China, Sri Lanka, and the Indian state of Kerala face several health challenges, particularly in the context of a shift in financing health care from a predominantly public-sector to a market-oriented provision. Over the 1990s, these "good health at low cost" (GHLC) regions faced widening health inequities and adverse health outcomes in relation to social, economic, and geographical marginalization, compared to another GHLC country, Costa Rica, and to Cuba, which have a similar history of health and economic profile. While the historical process of health development in China, Sri Lanka, and Kerala is closely entangled with the interrelated policies on health and allied social sectors with an abiding public-sector support, the retreat of the state and resultant increase in private-sector medical care and out-of-pocket spending resulted in widening inequities and medical impoverishment. Investigating the public health challenges and associated medical care-induced impoverishment, this article argues that the fundamental root causes of health challenges in these regions are often neglected in policy and in practice and that policymakers, planners, and researchers should make it a priority to address health inequities.

Towards the next generation of public health research in India: a call for a health equity lens.

BACKGROUND: Public health research is at a cross road in India. Despite a high level of health needs and new public health challenges arising in the context of rapid economic growth and social change, public health research is not keeping up with the needs of Indian society. There are, however, new initiatives creating opportunities to increase public health research, thereby raising debates about public health research priorities. OBJECTIVE: In this paper, the authors offer their own view on an agenda for the next generation of public health research in India. FINDINGS: The authors first outline the main reasons why they believe that public health research has been sidelined in India. Then, the authors argue that health equity should be the overarching principle guiding a public health research agenda. The authors suggest how to integrate equity-oriented strategies into the public health research agenda and propose some key research questions that require urgent attention from their respective disciplines.

Smoking cessation and diabetes control in Kerala, India: an urgent need for health education.

This study documented the tobacco use among male diabetes patients in a clinic-based population of urban India, patient reports of physician cessation messages and patients' perception of tobacco use as a risk factor for diabetes complications. All the 444 male diabetes patients who attended three public sector hospitals in Thiruvananthapuram district, Kerala, were surveyed to ascertain their tobacco use as well as the frequency and content of quit messages received from health staff. A significant proportion (59%) of diabetes patients were tobacco users prior to diagnosis and more than half of them continued to use tobacco, many daily, even after diagnosis. Of the 100 current smokers, 75% were asked about their tobacco use at the time of diagnosis; of those, 52% were advised to quit. However, a lack of patient awareness existed regarding the linkages of smoking and diabetes complications. Notably, 52% of patients did not associate smoking with diabetes complications. Given the magnitude of tobacco use among diabetics, there is clearly a need for more proactive cessation efforts. The times of illness diagnosis, illness flare-ups and emerging illness complications are teachable moments when patients are primed to change their behavior and more motivated to quit tobacco.

Tobacco use & social status in Kerala.

Health indicators of Kerala State such as infant mortality rate (14/ 1000 live births) and life expectancy at birth (71 yr for men and 76 yr for women) are far ahead of the Indian averages (IMR 58, life expectancy men 62 and women 63) and closer to the developed countries. However, tobacco use prevalence is similar to the national average. Smoking is the commonest form of tobacco usage among men in the State whereas chewing tobacco is more common among women and children. Tobacco chewing among men is increasing in Kerala probably due to the smoking ban and industry strategy to focus on smokeless tobacco. Tobacco use is significantly more among the low socio-economic (SE) groups compared to the high SE group. Mortality and morbidity attributed to tobacco is higher among the poorest people in the State. Age adjusted cancer rate of oral cavity and lung cancer has been increasing in the State in recent years. Heart diseases among the young people are increasing in the State. Cancer and heart diseases are chronic illnesses which may pull the individual and the entire family below the poverty line. Tobacco control therefore should be a top priority not only as a health issue but as a poverty reduction issue. Poverty alleviation is one of the major goals of developing economies. No poverty alleviation programme can ignore the potential impoverishment associated with tobacco use. Kerala with a very strong decentralized government has a very good opportunity to address tobacco control as a priority at the grass root level and reduce the impoverishment due to tobacco use.

Tobacco use among medical professionals in Kerala, India: the need for enhanced tobacco cessation and control efforts.

In developing nations where reductions in tobacco use have not been realized, it is critical that health professionals be encouraged to abstain from tobacco use. Data on tobacco use among health professionals in India are limited. We conducted cross-sectional surveys among 110 male medical school faculty (MSF), 229 physicians (67% male), 1130 medical students (46% male), and 73 female nursing students. Information on tobacco use and quit attempts was collected using structured questionnaires. Among the male respondents, current smokers were 15.1% of MSF, 13.1% of physicians, and 14.1% of medical students. Among current smokers, 42% of MSF and physicians and 51% of medical students had not attempted quitting in the last year. However, one third of MSF and physicians and 16% of medical students had attempted to quit at least 4 times. This is one of the first studies among health care professionals in India. Our findings show that a substantial proportion of physicians and medical students in Kerala continue to smoke. Smoking cessation programs are warranted in medical schools in Kerala. An initiative is presently underway by the authors to incorporate tobacco education into the medical school curriculum.