Health

Tobacco epidemic in India

Context: ‘World No Tobacco Day’ is observed annually on May 31. India ranks first globally in male cancer incidence and mortality rates. India tops the global list in tobacco-related lip and oral cancers, followed by lung cancer. Along with the health burden, tobacco use imposed an economic cost of ₹1.77 lakh crore (1.04% of India’s GDP) in FY18. 
Tobacco prices remain low in India, thus tobacco affordability undermines WHO’s MPOWER framework and fuels the cancer epidemic in India.

Relevance of the Topic:Mains: Tobacco Epidemic in India: Government Initiatives.

About tobacco

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  • It is the common name of several plants in the genus Nicotiana, and the general term for any product prepared from the cured leaves of these plants.
  • Dried tobacco leaves are mainly used for smoking in cigarettes and cigars, as well as pipes and hookahs. They can also be consumed as snuff, chewing tobacco and  dipping tobacco. 
  • It contains the highly addictive stimulant alkaloid nicotine as well as harmala alkaloids.
  • It is grown in warm climates with well-drained soil. Major tobacco-growing countries include China, India, Brazil, and the United States.
  • It causes a wide range of diseases , including heart disease, stroke, respiratory diseases, and various cancers (especially lung cancer) and affects those consuming it as well as those cultivating it. 

Problems with tobacco cultivation: 

  • It is a highly erosive crop that rapidly depletes soil nutrients. This requires more fertilizers to be used which further worsens soil quality. 
  • The plant is also a major contributor to deforestation. Up to 5.4 kg of wood is required to process 1 kg of tobacco. 
  • The production and consumption of tobacco generates nearly 1.7 lakh tonnes of waste every year in India. 
  • A 2021 study estimated that the country incurred a loss exceeding ₹1.7 lakh crore as a result of tobacco’s effects on the health of its consumers in the fiscal year 2017-2018. 

Status of tobacco use in India: 

  • After China, India has the world’s highest number of tobacco consumers nearly 26 crore, according to an estimate in 2016-2017. 
  • Also, the health of more than 60 lakh people employed in the tobacco industry is also placed at risk because of the absorption of tobacco through the skin, which can cause various diseases.
  • Tobacco use has gone down in the population and tobacco use in women, which went up by 2.1% between 2015-2016 (NFHS). 
  • Tobacco use is also the cause for nearly 3,500 deaths in India every day, which impacts human capital and GDP growth in a negative way.

Government initiatives to curb tobacco epidemic in India: 

  • WHO’s Framework Convention on Tobacco Control (FCTC), 2005: India is one of the 168 signatories, to reduce tobacco usage worldwide by helping countries develop demand and supply reduction strategies. 
  • Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA) 2003: Includes provisions for prohibiting smoking in public places, banning tobacco advertising, and mandating pictorial health warnings on tobacco products.
  • National Tobacco Control Program (NTCP) in 2007: To improve the implementation of COTPA and FCTC, improve awareness about the harms of tobacco use, and help people quit it. 
  • Tobacco taxation:  A globally accepted method to effectively control tobacco use is also applied in India. Tobacco, except for tobacco leaves, is placed in the highest tax slab of 28% under GST, and also subject to a heavy burden of cess, given that the commodity is seen as a sin good.
  • Promulgation of the Prohibition of Electronic Cigarettes Ordinance, 2019 : Prohibits Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement of e-Cigarettes.
  • National Tobacco Quitline Services (NTQLS): To provide telephone-based information, advice, support, and referrals for tobacco cessation.

Challenges in addressing the tobacco epidemic in India: 

  • High prevalence of tobacco use: Due cultural acceptance and availability of wide variety of products including bidis, cigarettes, and smokeless tobacco, complicate efforts to regulate and control usage.
  • Issue with tobacco taxation: The GST system in India relies more on ad valorem taxes than the pre-GST system, which primarily used specific excise taxes. Many countries with a GST or value-added tax (VAT) also apply an excise tax on tobacco products. 
    • In India, the share of central excise duty in total tobacco taxes decreased substantially from pre-GST to post-GST for cigarettes (54% to 8%), bidis (17% to 1%), and smokeless tobacco (59% to 11%). 
    • A large part of the compensation cess as well as the National Calamity Contingent Duty, or NCCD currently applied on tobacco products is specific.
    • Bidis and smokeless tobacco have low taxes, encouraging consumption. 
    • Smokeless tobacco products in India are taxed ineffectively due to their small retail pack size (often 1/2 gram or less) which keeps the price low.
    • Cigarettes are taxed based on their length, and the presence of filters, creating multiple categories with varying tax implications creates opportunities for cigarette companies to avoid taxes legally.
  • Weak enforcement of tobacco control laws: 
    • Smokeless tobacco products (SLTs) such as gutka, khaini have predominantly been non-compliant with COTPA packaging guidelines. 
    • The fines for violating COTPA regulations have not been updated since 2003. For instance, a tobacco company is fined a maximum of only ₹5,000 for violating packaging restrictions for the first time.
    • COTPA bans direct advertisements of tobacco but is unclear on indirect ads, allowing surrogate advertisements using proxy products like elaichi to promote tobacco brands. 
      • During the ICC Men’s Cricket World Cup 2023, surrogate ads for at least two tobacco brands, endorsed by famous cricketers, were displayed. These ads indirectly promote tobacco use.
    • NTCP is ineffectively implemented due to insufficient staffing, resource allocation, utilization, and lack of effective monitoring mechanisms.
  • Economic dependence on the tobacco industry: The industry provides employment and livelihoods to millions of people especially in rural areas, ana also it contributes significantly to government revenues through taxes, creating a conflict of interest in implementing stringent control measures.
  • Healthcare burden: The high prevalence of tobacco-related diseases puts a strain on the healthcare system, which is already burdened with other public health issues.
  • Access to cessation services: There is limited access to effective cessation programs and support services, particularly in rural and underserved areas.

Way forward: 

  • Implement the proposed amendments to COTPA in 2015 and 2020: 
    • Regulations on surrogate advertisements, inclusion of films and video games in the definition of ‘advertisement’, and increasing the fines for violation of advertisement norms by a factor of 10. 
    • Made licensing necessary for the production, supply, and distribution of tobacco products. 
  • Inflation adjustment: Mandatory inflation indexing should be applied to specific tax rates on tobacco products to maintain their value and effectiveness in controlling consumption.
  • Uniform tax: All products that are exclusively used for tobacco making are brought under the uniform 28% GST slab, will generate the right public health message that all tobacco products are bad and their consumption needs to be discouraged.
    • To standardise and increase the retail price, mandatory standardised packing should be implemented for smokeless tobacco pouches (at least 50 g-100 g). This will also make it easier to implement graphic health warnings on the packaging.
    • The tiered system should be eliminated or reduced to two tiers, which can then be phased out over time to have a single tier.
  • Implement COTPA, PECA, and NTCP more stringently.
  • Support for tobacco farmers to switch to alternate crops, avoiding loss of livelihood.
  • There is also a need for up-to-date data to understand trends in tobacco use to tackle the tobacco industry, which modifies its sales strategies based on readily available sales trends. 

Uniform Code for Pharmaceutical Marketing Practices – 2024

Context: Ministry of Chemicals and Fertilizers has notified the Uniform Code for Pharmaceutical Marketing Practices, 2024 to curb unethical marketing of drugs and ban medical representatives from using inducements to access healthcare professionals. Before this, pharmaceutical industry was following UCPMP 2015 which was voluntary in nature. However, the new UCPMP 2024 is quasi-judicial in nature.

SALIENT FEATURES OF UNIFORM CODE FOR PHARMACEUTICAL MARKETING PRACTICES 2024

  • According to 'Ethical Criteria for Medicinal Drug Promotion, 1988' of WHO, 'Promotion' refers to all informational and persuasive activities by manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase and/or use of drugs.
  • Promotion of a drug must be consistent with the terms of its marketing approval and a drug must not be promoted prior

Medical Representatives

  • Medical Representatives are sales representatives and other company representatives who call on healthcare professionals, pharmacies, hospitals or healthcare facilities in connection with promotion of drugs.
  • Medical representatives must not employ any inducement or subterfuge to gain an interview. They must not pay, under any guise, for access to a healthcare professional.
  • Companies are responsible for the activities of their employees, including the medical representatives, for ensuring compliance of this Code.

Brand Reminders

Brand Reminders are permitted in two categories

  • Informational and education items including books, calendars, diaries, journals (including digital), dummy device models and clinical treatment guidelines for professionals used in healthcare settings value of which does not exceed Rs 1000 (One thousand) per item. Such items should not have an independent commercial value for healthcare professionals
  • Free samples provided by the companies to medical professionals:
    • Free samples of drugs shall not be supplied or directly handled to a who is not qualified to prescribe such a product.
    • Such samples should be provided only for creating awareness about treatment options and for acquiring experience in dealing with the product.
    • Such samples should be limited to prescribed dosage for not more than three patients for the required course of treatment.
    • Each sample should be marked 'free medical sample not for sale' or bear another legend of analogous meaning.
    • Each sample should not be larger than the smallest pack present in the market.
    • Sample of a drug which is hypnotic, sedative or a tranquilizer should not be given.
    • Each company should maintain details such as product name, doctor name, quantity of samples, date of supply of free samples to healthcare professionals etc.
    • Monetary value of samples distributed should not exceed 2% of domestic sales of the company per year.

Continuing Medical Education

  • Engagement of pharmaceutical industry with healthcare professionals for Continuing Medical Education (CME), Continuing Professional Development (CPD) or otherwise for conference, seminar, workshop etc. should only be allowed through a well-defined, transparent and verifiable set of guidelines.
  • Conduct of such activities in foreign locations is prohibited.
  • All pharmaceutical companies should share details of such activities on their website and may be subject to independent, random or risk-based audit.

Support for Research

Pharmaceutical companies can provide rational support and encouragement to research and innovation through industry-academia linkage subject to following conditions:

  • The research study should have requisite approval from competent authority (ICMR, DCGI, Ethics Committee, Institutional Authority, NMC etc.) and is conducted at a recognised site or location.
  • Engagement of healthcare professionals in consultant-advisory capacity shall be for bonfide research services, under a consultancy agreement involving a consultancy fee or an honorarium-based payment.
  • Expenditure on research by pharmaceutical companies is an allowable expenditure subject to provisions of Income Tax Act, 1961.

Relationship with Healthcare Professionals

  • No gifts should be offered or provided or promised for personal benefit of any healthcare professional or family members by any pharmaceutical company or its agents.
  • No travel facilities inside or outside the country should be extended to healthcare professionals or their family members by pharma companies or their representatives except the person is a speaker for a CME or a CPD program.
  • No hospitality like hotel-stay, expensive cuisine, resort accommodation etc. should be extended to healthcare professionals or their family members by pharma companies and their representatives except when the person is a speaker for a CME or a CPD program.
  • No cash or monetary grant should be extended to any healthcare professional or their family members under any pretext.

Compliance of UCPMP 2024 by Pharmaceutical Associations

  • All complaints related to an activity of breach of the Code should be made within six months of the alleged of the breach of the Code, with an additional delay of 6 months. Complainant should identify himself, the pharma company and details of breach of the Code.
  • A non-refundable amount of Rs 1,000 is to be deposited by the complainant along with complaint.
  • All Indian Pharmaceutical Associations will form a committee for handling complaints as 'Ethics Committee for Pharma Marketing Practices (ECPMP), in each Association to be chaired by its Chief Executive Officer. The Committee will have 3-5 members and its composition will be approved by the Board of Association.
  • ECPMP will conduct enquiry and decisions of the committee should be taken by majority
  • Penalties: Once it is established that a breach of UCPMP 2024 has taken place by an entity, the ECPMP can propose one of the following against the erring entity:
    • Suspend or expel the entity from the Association
    • Reprimand the entity and publish full details of such reprimand.
    • Require the entity to issue a corrective statement in the same or other suitable media.
    • Ask the entity to recover money or items, given in violation of Code from the concerned person/s.
    • In cases where disciplinary, penal or remedial action lies within the domain of any agency or authority of Government in accordance with statute, the ECPMP may send its recommendations to such agency or authority through the Department of Pharmaceuticals.
    • Appeal against UCPMP 2024
      • If a party to the complaint is dissatisfied with the decision of ECPMP, it may file an appeal before the Apex Committee for Pharma Marketing Practices (ACPMP) to be headed by Secretary, Department of Pharmaceuticals, having a Joint Secretary and a Finance Officer as its members.
      • Appeals against the order of ECPMP must be ordinarily filed within 15 days with an additional 15 days of reasonable time delay permitted for reasons to be recorded in writing

Menstrual Hygiene Day

Context: Menstrual Hygiene Day, observed on May 28th, highlights the critical importance of proper menstrual hygiene management. The health, happiness, and empowerment of women and girls all suffer as a result of improper management of menstrual hygiene.

Insufficient knowledge and poor hygiene during menstruation can result in various health issues. On this day, it is crucial to shed light on the consequences of improper menstrual hygiene management and its impact on women's health.

What is Mensuration?

  • Menstruation is the process in which the uterus sheds blood and tissue through the vagina. This is a natural and healthy process for girls and women of reproductive age. In Western communities, this is often called “the period.” It typically lasts 2 to 5 days, but this varies by individual.
  • Menstruation is a natural and normal process experienced by females, yet societal taboos, cultural beliefs, and limited access to resources often lead to inadequate practices.

According to 5th NHFS (2019-2021): 

  • Women aged 15-24 years who use a hygienic method of protection during their menstrual cycle is 78%. Among these women, 64% use sanitary napkins, 50% use cloth, and 15% use locally prepared napkins. 
  • Only 73% of rural women while 90% of urban women use a hygienic method of menstrual protection respectively.
  • However, a few States continue to have lower than average access to use of a hygienic method of menstrual protection by women and girls.  

Important consequences of improper menstrual hygiene management:

  • Health Implications: Poor menstrual hygiene can lead to various infections, such as urinary tract infections (UTIs), bacterial vaginosis, and yeast infections.
    • Further, there is a correlation between poor menstrual hygiene and an increased risk of cervical cancer. A study by the World Health Organization (WHO) highlights that inadequate menstrual hygiene management can contribute to the development of human papillomavirus (HPV), a leading cause of cervical cancer.
  • Psychological Impact: Lack of access to proper menstrual hygiene products and facilities can cause significant stress, anxiety, and embarrassment among women and girls. A report by UNICEF reveals that the stigma and shame associated with menstruation can negatively affect mental health, leading to feelings of low self-esteem and social isolation.
  • Social Consequences
    • Educational Disruption: Girls who lack access to menstrual hygiene products often miss school during their periods. UNESCO estimates that one in ten girls in Sub-Saharan Africa misses school during their menstrual cycle, which can accumulate to 20% of the school year. This absenteeism can hinder their academic performance and limit their future opportunities.
    • Poor menstrual health can significantly impact the sexual and reproductive health. It can lead to being pushed into child marriage, and facing a higher risk of domestic violence, malnourishment etc.
    • Workplace Challenges: Inadequate menstrual hygiene can also impact women's participation in the workforce. It is found that women in low-income settings often miss work during their periods due to a lack of access to proper sanitation facilities. This can affect their income and career advancement opportunities.
  • Environmental Impact: Improper disposal of menstrual hygiene products, such as throwing them in open areas or water bodies, can lead to environmental pollution, affecting both human health and ecosystems.
  • Economic Consequences: The health complications arising from poor menstrual hygiene can lead to increased healthcare costs for individuals and communities. Treating infections and diseases caused by inadequate hygiene can strain both personal finances and public health resources.
    • Loss of Productivity: The absenteeism from school and work due to menstrual hygiene issues results in a loss of productivity. According to a study by the International Labor Organization (ILO), this loss of productivity has broader economic implications, affecting the overall economic growth and development of a country.
  • Human Rights Issues: Poor menstrual hygiene management is a significant barrier to achieving gender equality. Women and girls who lack access to menstrual hygiene products and facilities are often unable to participate fully in social, educational, and economic activities. The United Nations Population Fund (UNFPA) emphasizes that menstrual hygiene is a critical aspect of women's rights and gender equality. Further, the stigma and discrimination associated with menstruation can lead to social exclusion and discrimination against women and girls. This can prevent them from accessing essential services and participating in community activities, further entrenching gender disparities.

Barriers to Menstrual Hygiene

  • Socio-Cultural Barriers: Cultural taboos and societal stigma around menstruation can prevent open discussions and proper education on menstrual hygiene. Menstruating women and girls may face social exclusion and discriminatory practices, limiting their participation in daily activities.
  • Educational Barriers: Inadequate education on menstrual health and hygiene leads to misconceptions and misinformation. Many girls miss school during their periods due to lack of proper facilities or support, affecting their education and future opportunities.
  • Economic Barriers: High cost of sanitary products can be prohibitive, especially for low-income families. Further, Limited availability of affordable menstrual hygiene products in many regions.
  • Infrastructure Barriers: Lack of clean and private toilets in schools and public places makes it difficult for women and girls to manage their periods. Also, Insufficient access to clean water for washing and maintaining hygiene.
  • Health System Barriers: Poor access to healthcare services for menstrual-related issues and reproductive health. Shortage of healthcare providers trained in menstrual health education and management.
  • Policy and Legal Barriers: Insufficient government policies and regulations to support menstrual health and hygiene. As was evident in the recent debate over proposals of menstrual leave, which clearly highlighted lack of consensus.

By addressing these barriers, we can improve menstrual hygiene management and support the overall well-being of women and girls.

Constitutional Provisions: 

  • Article 42, Constitution of India: The State shall make provision for securing just and humane conditions of work and for maternity relief. 

Draft Menstrual Hygiene Policy-2023· 

  • Ministry of Health and Family Welfare (MoHFW) is the Nodal Ministry for the Menstrual hygiene policy.
  • The policy recognizes menstruation as a natural bodily process for all who menstruate including girls and women of reproductive age and addresses the long-standing challenges associated with menstruation in our country. 
  • The policy will serve as a catalyst to raise awareness, challenge societal norms and foster a society that embraces menstrual hygiene as a natural and normal part of life.

Policy strategy·  

  • Ensure access to affordable and safe menstrual hygiene products: To ensure affordable and accessible menstrual products such as disposable or reusable sanitary pads, menstrual cups, tampons or reusable cloth pads, etc are available to all who menstruate, especially those in low-income communities and marginalized groups.
  • Promote quality standards and regulatory framework: Develop and implement comprehensive quality standards for different types of menstrual hygiene products available in the market to ensure their safety, efficacy and reliability.  
  • Availability of clean and dignified menstrual hygiene facilities: Promote the development and improvement of menstrual-friendly infrastructure in homes, educational institutions, workplaces and public spaces to include safe, clean and private toilets, proper waste disposal systems and handwashing facilities with soap and clean water.  
  • Promotion of education and awareness on menstrual hygiene: Awareness campaigns targeting menstruators to provide accurate information including options of products available, debunk myths and misconceptions and address social and gender-related challenges associated with menstruation.  
  • Collaboration with Non-government sector/engagement with private sector: Support research and development initiatives that explore new technologies, materials and product designs which improve menstrual hygiene management, while considering accessibility, ease of use, affordability and environmental sustainability.  
  • Foster research and innovation in menstrual hygiene management: Encourage research institutes and academia to contribute to evidence-based policymaking, promote innovation and improve the overall understanding and implementation of menstrual hygiene practices. 

Pre-eclampsia

Context: May 22 is commemorated as Pre-eclampsia Day to prioritize proactive measures for safe motherhood and childbirth, as preeclampsia significantly raises the risk of heart failure, coronary heart disease, stroke, and cardiovascular mortality for mothers.

About pre-eclampsia: 

  • It is a serious pregnancy complication that typically develops after 20 weeks of pregnancy in women with previously normal blood pressure. It can also develop shortly after childbirth.
  • It is characterized by high blood pressure and signs of damage to other organ systems, most often the kidneys.

Symptoms: 

  • High blood pressure, protein in the urine (proteinuria), severe headache, nausea or vomiting, vision problems (including light sensitivity, blurred vision, or seeing spots), upper right abdominal pain and rapid weight gain,.

Causes: 

  • The exact cause is unknown. 

Risk factors: 

  • History of high blood pressure, a family history of pre-eclampsia, multiple pregnancies (twins, triplets, etc.), diabetes, obesity, autoimmune diseases and in vitro fertilization (IVF).

Complications: 

  • If left untreated, it can lead to serious complications for both mother and baby. For the mother, complications can include eclampsia (seizures), stroke, bleeding problems, kidney failure, and heart attack. For the baby, complications can include premature birth, low birth weight, and growth problems.

Prevention

  • The prevention is the use of low-dose aspirin. 

Addressing India's Nutrition Challenges: Comprehensive Guidelines for a Healthier Future

Introduction to Nutritional Concerns in India

  • India faces a dual burden of undernutrition and overnutrition, contributing to a significant rise in noncommunicable diseases (NCDs) such as cardiovascular diseases, cancers, and diabetes, affecting not just adults but also adolescents and children.
  • In response, the National Institute of Nutrition (NIN) under the Indian Council of Medical Research has issued robust dietary guidelines targeting vulnerable groups including pregnant and lactating women, children, and the elderly.

The Burden of Unhealthy Diets

  • According to the NIN, an unhealthy diet is responsible for approximately 56.4% of India’s total disease burden.
  • Emphasizing that a healthy diet combined with physical activity could prevent up to 80% of Type 2 diabetes cases and significantly reduce the incidences of heart disease and high blood pressure, these guidelines are timely and critical.

Need to Focus on Mothers and Children

  • Optimal nutrition from conception to the age of 2 years is crucial for proper growth and development, preventing undernutrition, micronutrient deficiencies, and obesity.
  • The 2019 Comprehensive National Nutrition Survey highlighted the concerning prevalence of lifestyle diseases among children and adolescents, with findings such as:
  • About 5% of children aged 5-9 and 6% of adolescents are overweight or obese.
  • Prevalence of diabetes and pre-diabetes in young populations.
  • High levels of bad cholesterol (LDL and triglycerides) in 37.3% of children ages 5-9, and 19.9% of pre-teens and teens ages 10-19. Levels of good cholesterol were low in a fourth of all children and adolescents.

Challenges of Micronutrient Deficiency

  • Micronutrient deficiencies (including zinc, iron, vitamins) affect between 13% to 30% of children aged 1 to 19.
  • Although severe undernutrition cases like marasmus and kwashiorkor have declined, anaemia remains prevalent, affecting significant percentages of children across different age groups.
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General Dietary Principles for the Indian Population

  • The NIN guidelines recommend diversifying diets to include at least eight food groups including vegetables, leafy vegetables, roots and tubers, dairy, nuts, and oils and reducing the staple consumption of cereals from 50-70% of total energy to 45%.
  • Increased intake of proteins (pulses, meat, poultry, fish), which should constitute 14% of daily energy intake, is advised.
  • The guidelines also focus on the importance of polyunsaturated fatty acids (PUFA) and B12, recommending sources like flax seeds, chia seeds, and walnuts for vegetarians.
  • Salt consumption should be restricted to 5g a day, and strongly recommends against consuming highly processed foods that are typically high in fats, salt, sugar.

Specific Guidelines for Different Groups

  • Pregnant Women: The guidelines suggest small, frequent meals, especially for those experiencing nausea, and emphasize foods high in iron and folate.
  • Infants and Children: Exclusive breastfeeding is recommended for the first six months, followed by the introduction of complementary foods.
  • Elderly: A diet rich in proteins, calcium, micronutrients, and fiber is advised. Elderly individuals should focus on whole grains, low-fat dairy products, nuts, oilseeds, and ample fruits and vegetables, complemented by regular exercise to maintain bone density and muscle mass.

Conclusion

India's strategic approach to combating the growing epidemic of NCDs and nutritional deficiencies through these comprehensive guidelines offers a blueprint for healthier generations. By addressing both overnutrition and undernutrition, these guidelines pave the way for a healthier future, emphasizing preventive healthcare through proper diet and lifestyle changes.

Pradhan Mantri Jan Arogya Yojana (PMJAY)

Context: Since the inception of the Pradhan Mantri Jan Arogya Yojana (PMJAY), 34.27 crore cards have been issued, and 6.5 crore beneficiaries have received treatment across 30,000 empanelled hospitals. Despite its extensive reach, the program has encountered significant challenges, including substantial payment backlogs owed to hospitals by the government.

This financial strain has led some hospitals to either refuse or limit the number of PMJAY patients they accept, raising concerns about whether the scheme needs a design overhaul to address these challenges.

About Pradhan Mantri Jan Arogya Yojana (PMJAY): 

Launched in: 2018

  • Type of scheme: Centrally sponsored scheme
  • Subsumed scheme: Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).
  • Key features: It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.
    • It offers a sum insured of Rs.5 lakh per family for secondary care and tertiary care hospitalisation to the bottom 40 per cent of the population of India.
    • It covers the cost of hospitalization, pre-hospitalization, medication, and post-hospitalization during the treatment of tertiary and secondary care procedures.
    • The Ayushman Card is like a pre-paid card worth Rs 5 lakh, which can be used to avail free treatment at more than 27,000 empanelled hospitals.
    • Every hospital must provide Pradhan Mantri Arogya Mitras (PMAMs) to assist beneficiaries.
    • The National Health Authority (NHA) has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PM-JAY in alliance with state governments.
    • The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.

Typhoid fever

About Typhoid fever 

  • Caused by Salmonella typhi and related bacteria
  • Spreads through contaminated food and water
  • Symptoms: high fever, stomach pain, weakness, nausea, vomiting, diarrhea or constipation, rash
  • Global burden: 90 lakh cases and 1.1 lakh deaths annually (WHO)

Diagnosis of typhoid fever 

  • Gold standard: isolating bacteria from blood or bone marrow and growing them in a lab
  • Limitations in smaller clinical settings: time-consuming, skill- and resource-intensive, affected by prior antibiotic treatment
  • PCR-based molecular methods: better but costly and require specialized infrastructure and personnel

Widal test:

  • Widely used in India for diagnosing typhoid
  • Rapid blood test that detects antibodies against the bacteria
  • Flaws: false positives and false negatives
  • Requires at least two serum samples taken 7-14 days apart for accurate diagnosis
  • Baseline cut-off varies in areas with high typhoid burden
  • Cross-reactivity with antibodies produced against other infections or in vaccinated individuals

Consequences of Widal test usage:

  • Obscures the actual typhoid burden in India
  • Lack of awareness and standardization of kits, poor quality control
  • Financial burden on patients: high costs for tests and antibiotic injections
  • Contributes to antimicrobial resistance (AMR) due to irrational use of antibiotics
  • AMR can be transmitted between bacterial strains and species, posing a global threat
  • Difficulty in controlling the preventable disease and additional financial strain on patients

West Nile fever

Context: The Kerala government issued an alert in the State against West Nile fever, a mosquito-borne viral infection, after one death and eight cases were reported in recent days.

About West Nile Virus: 

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  • It is a flavivirus associated to the viruses that are also responsible for causing St. Louis encephalitis, Japanese encephalitis, and yellow fever. 
  • It is a single-stranded RNA virus and is spread by the Culex species of mosquitoes.
  • It was first isolated in a woman in the West Nile district of Uganda in 1937. It was identified in birds in the Nile delta region in 1953.
  • Along all major bird migratory routes, WNV outbreak sites are found: Africa, Europe, the Middle East, North America, and West Asia.
  • No vaccine for WNV is available. Only supportive treatments can be provided to neuroinvasive WNV patients.

Transmission: 

  • Principal vector is the culex species of mosquitoes.
  • Birds act as the reservoir host of the virus.
  • Infected mosquitoes transmit WNV between and among humans and animals, including birds.
  • WNV can also get transmitted from an infected mother to her child through blood transfusion.
    • A very small proportion of human infections have occurred through organ transplant, blood transfusions and breast milk. There is one reported case of transplacental (mother-to-child) WNV transmission.
  • No instance of transmission by contact with infected humans or animals has been reported.
  • It does not spread ‘through eating infected animals, including birds.
  • According to the World Health Organization (WHO), no human-to-human transmission of WNV through casual contact has been reported till date.

Symptoms:

  • Symptoms of the infection include high fever, headache, disorientation, stupor, coma, tremors, convulsions, muscle weakness, and paralysis.
  • Most of the symptoms are similar to that of Japanese encephalitis.
  • However, 80% of the patients need not show any symptoms. 
  • Severe infection may even cause neurological diseases like West Nile encephalitis or meningitis or West Nile poliomyelitis or acute flaccid paralysis.
  • There are reports of WNV-associated Guillain-Barré syndrome and radiculopathy.
  • The Flaviviridae are a family of positive, single-stranded, enveloped RNA viruses.
  • They are found in arthropods, (primarily ticks and mosquitoes), and can occasionally infect humans.
  • Members of this family belong to a single genus, Flavivirus, and cause widespread morbidity and mortality throughout the world.
  • Some of the mosquitoes-transmitted viruses include: Yellow Fever, Dengue Fever, Japanese encephalitis, West Nile viruses, and Zika virus.
  • Other Flaviviruses are transmitted by ticks and are responsible of encephalitis and haemorrhagic diseases: Kyasanur Forest Disease (KFD) and Alkhurma disease. 

Food Safety and Standards Authority of India (FSSAI) to probe allegations against Fast Moving Consumer Goods (FMCG) companies

Context: The Union Consumer Affairs Ministry has asked the Food Safety and Standards Authority of India (FSSAI) to investigate the allegations against the leading Fast Moving Consumer Goods (FMCG) companies. This follows recent claims that Nestle’s baby food products in India, as well as those in Africa and Latin America, contain excessive sugar levels.

About Fast Moving Consumer Goods (FMCG)

  • FMCGs are products that sell quickly at relatively low cost. These goods are also called consumer packaged goods.
  • They have a short shelf life because of high consumer demand such as soft drinks and confections or because they are perishable (e.g., meat, dairy products, and baked goods).
  • There are several types of FMCGs such as: 
    • Processed foods such as cheese products, cereals, and boxed pasta
    • Beverages such as bottled water, energy drinks, and juices
    • Fresh foods, frozen foods, and dry goods
    • Medicines such as aspirin, pain relievers, and other medication that can be purchased without a prescription
    • Cleaning products such as baking soda, oven cleaner, and window and glass cleaner
    • Cosmetics and toiletries such as hair care products, concealers, toothpaste, and soap
    • Office supplies such as pens, pencils, and markers
  • The FMCG sector, as India's fourth-largest industry, employs about 3 million people, making up 5% of the country's total factory employment.

About FSSAI:

  • Body: Statutory body has been established under Food Safety and Standards, 2006.It works as an independent authority and attained a special status. The FSS Act took 7 older acts into one umbrella.
    • Prevention of Food Adulteration Act, 1954. 
    • Fruit Products Order, 1955 
    • Meat Food Products Order, 1973
    • Vegetable Oil Products (Control) Order, 1947  
    • Edible Oils Packaging (Regulation) Order 1998  
    • Solvent Extracted Oil, De- Oiled Meal and Edible Flour (Control) Order, 1967  
    • Milk and Milk Products Order, 1992 
  • Nodal ministry: Ministry of Health & Family Welfare, is the Administrative Ministry for the implementation.
  • Headed by: Non-executive chairperson, appointed by the Central Government, either holding or has held the position of not below the rank of Secretary.
  • Objective: To establish a single reference point for all matters relating to food safety and standards, by moving from multi- level, multi- departmental control to a single line of command.
  • Function: 
    • Framing of regulations to lay down food safety standards
    • Laying down guidelines for accreditation of laboratories for food testing
    • Providing scientific advice and technical support to the Central Government
    • Contributing to the development of international technical standards in food
    • Collecting and collating data regarding food consumption, contamination, emerging risks, etc.
    • Disseminating information and promoting awareness about food safety and nutrition in India.

Commemorating 50 Years of Immunization Programs: A Milestone Analysis

Context: 2024 marks the 50th anniversary of the World Health Organization's Expanded Programme on Immunization (EPI), launched in 1974. This initiative, pivotal in the post-smallpox eradication era, spurred countries globally to set up national immunization programs.

India launched its program in 1978, renaming it the Universal Immunization Programme (UIP) in 1985. This year is also significant as it marks twenty years since India's last comprehensive review of the UIP, highlighting a crucial period for evaluating past progress and shaping future strategies.

About Vaccines

Vaccination effectively protects against diseases by safely using your body's natural defenses to build resistance. Vaccines train the immune system to produce antibodies, similar to natural exposure to a disease, but without causing the disease or its complications, as they contain only killed or weakened germs. 

All the ingredients of a vaccine play an important role in ensuring a vaccine is safe and effective. Some of these include:

  • The antigen. This is a killed or weakened form of a virus or bacteria, which trains our bodies to recognize and fight the disease if we encounter it in the future.
  • Adjuvants, which help to boost our immune response. This means they help vaccines to work better.
  • Preservatives, which ensure a vaccine stays effective.
  • Stabilisers, which protect the vaccine during storage and transportation.  

Global and National Vaccine Impact

  • Over the past five decades, vaccine development and coverage have dramatically improved. From vaccines for six diseases in 1974, today there are universally recommended vaccines for 13 diseases and additional vaccines for 17 more based on regional needs.
  • The coverage for the DPT vaccine, a key indicator of immunization reach, has increased from 5% in the early 1970s to 84% globally by 2022.
  • Smallpox has been eradicated, and polio nearly eliminated, showcasing significant progress in disease control through vaccination.

Economic and Health Benefits

  • Vaccination programs are not only medically beneficial but also economically viable.
  • Studies indicate that every dollar spent on vaccination can yield a return of seven to 11 times the investment, underscoring their cost-effectiveness.
  • These programs are typically more successful in government settings, especially in countries like India where the government administers 85% to 90% of all vaccines despite a substantial private healthcare sector.

Challenges and Declines in Coverage

  • There is Persistent inequities in vaccine access by geography and socioeconomic status.
  • In early 2023, the UNICEF’s ‘The State of the World’s Children’ report revealed a concerning trend: for the first time in more than a decade, the childhood immunisation coverage had declined in 2021.
  • In 2022, globally, an estimated 14.3 million children were zero dose (did not receive any recommended vaccine) while another 6.2 million children were partially immunised.

From childhood focus to life course

  • Historically, vaccines have targeted not only children but also adults, dating back to the first smallpox vaccine in 1798. With the growing burden of vaccine-preventable diseases in adults, there is a pressing need to extend immunization to older populations.
  • Recent policies, such as the introduction of the HPV vaccine for teenage girls and pilot adult BCG vaccination campaigns, are steps toward broader immunization coverage.

Steps to be taken in this regard:

  • As vaccines are highly cost effective, once recommended by the National Technical Advisory Group on Immunization (NTAGI), vaccines for all age groups should be made available as free at the government facilities.
  • Second, the NTAGI in India, should start providing recommendations on the use of vaccines in adults and the elderly.
  • Third, the prevailing myths and misconceptions about vaccines must be proactively addressed to tackle vaccine hesitancy. The government must consider the help of professional communication agencies to dispel myths (and in a layperson’s language and with the use of social media).
  • Fourth, various professional associations of doctors — community medicine experts, family physicians and paediatricians should work to increase awareness about vaccines among adults and the elderly.
  • Fifth, medical colleges and research institutions should generate evidence on the burden of diseases in the adult population in India.

Conclusion:  

In late 2023, India launched a pilot adult BCG vaccination program to combat tuberculosis, expanding immunization efforts beyond the previous 50-year focus on children, inspired by the acceptance of COVID-19 vaccines.

The goal now is to also address vaccine inequities, target zero-dose children, and extend vaccination coverage to adults and the elderly, thereby transforming the Expanded Programme on Immunization (EPI) into ‘Essential Program on Immunization (EPI)’ that encompasses all age groups.

Impact of Rising Temperatures on Global Health

About Heat Crisis

  • Recent data confirms that 2023 marked the hottest year on record, signaling a disturbing trend of increasing global temperatures. This trend poses significant threats to urban and rural areas alike, particularly as cities expand at the cost of natural landscapes. Experts predict that for those born in 2023, it may be the coolest year of their lives, hinting at the severe climate challenges ahead.

The immediate threat posed by heat waves

  • As summer progresses across the Indian Subcontinent, the immediate threat posed by heat waves becomes more pronounced. Heat waves, characterized by unusually high temperatures and often exacerbated by increased humidity, significantly impact health. The combination of heat and humidity, referred to as "moist heat," increases the stress on the human body.
  • According to the India Meteorological Department (IMD), there has been a 30% increase in moist heat stress from 1980 to 2020, underscoring the growing impact of these climate-related events.

Health Impacts of Heat Exposure

The health ramifications of global warming are extensive and multifaceted, impacting human, animal, and plant health.

Direct consequences include:

  • Physical stress from heat: Increased body temperature can lead to dehydration, inability of the skin to cool the body through perspiration, and dilatation of blood vessels and thickening of blood with increased risk of clot formation (thrombosis).
  • Extreme weather: Events like heatwaves exacerbate public health crises by directly affecting vulnerable populations, including the elderly, infants, and those with pre-existing conditions.
    • A global study published in 2022 covering 266 studies found that heat waves are linked to a 11.7% increase in mortality.
    • The most significant risks were for stroke and coronary heart disease. As the population ages and cardiovascular risk factors such as hypertension, diabetes, and obesity become more prevalent, each 1°C increase in temperature could significantly amplify the risk of severe cardiovascular events.
  • Spread of diseases: Changes in climate affect the distribution of mosquitoes and other vectors, leading to the spread of diseases like malaria and dengue.
  • Worsening non-communicable diseases: Heat contributes to higher incidences of strokes, heart attacks, respiratory diseases, and other chronic conditions.
    • Even as of now, NCDs contribute to 65 per cent of deaths in India — a majority of them in productive mid-life. The heat effects of climate change will only exacerbate the problem.
  • Mental health: he psychological impact of climate events can lead to stress, anxiety, and depression.
  • Infrastructure strain: Health systems face increased demand not only from direct heat effects but also from the displacement of populations and damage to healthcare facilities due to extreme weather.

Environmental and Societal Consequences

  • Wildfires: triggered by excessive heat release particulate matter (PM 2.5) and toxic chemicals (ozone, carbon monoxide, polycyclic aromatic compounds and nitrogen dioxide) can cause extensive inflammation, increasing the risk of cardiovascular disease (heart attacks, strokes, heart rhythm abnormalities, pulmonary embolism, heart failure), respiratory disease, diabetes and pre-diabetes. Chemicals like benzene and formaldehyde (also present in wildfire emissions) increase the risk of cancer.
  • Agricultural impact: Heat stress combined with water scarcity reduces crop yields and nutrient quality, jeopardizing food security.
    • Countries in South Asia and sub-Saharan Africa currently grow staples (like rice and wheat) at the highest levels of heat tolerance. A further increase of 1 degree centigrade will lower their yield by 10 per cent. The crops will also be more deficient in zinc, protein and iron.
    • The Data Sciences Centre of Columbia University has estimated that if global warming continues unabated, India of 2050 will have 49 million more zinc deficient persons and 38.2 million new protein deficient persons, while 106.1 million children and 396 million women would be iron deficient.
    • Protective foods like fruit, vegetables and fish would be depleted. These foods reduce the risk of cardiovascular disease and diabetes.
    • Rising ocean temperatures will flood coastal agriculture while reducing fish yields.
  • Biodiversity loss: Rising temperatures threaten biodiversity, which is crucial for maintaining resilient food systems and access to nutritious wild foods.

Adaptive Strategies for a Warmer World

In response to these challenges, it is critical to develop comprehensive adaptation strategies that include:

  • Heat action plans: Tailored for both urban and rural settings, these plans aim to mitigate the impact of heatwaves.
  • Climate-resilient systems: Enhancements in food and healthcare systems to withstand climate changes are essential.
  • Public education and infrastructure: Educating the public and healthcare providers about heat risks and protective measures is crucial. Infrastructure improvements, such as heat-reflective building materials and increased green spaces, are also vital.
  • Personal protection measures: Wearing light-colored, loose-fitting clothes, using umbrellas or hats, and increasing water intake are practical steps individuals can take to protect themselves from heat.

As the planet faces unprecedented warming, the need for urgent action to mitigate climate change and adapt to its inevitable impacts becomes increasingly crucial. Both systemic and individual level changes are essential to safeguard global health against the rising tide of heat-related challenges.

Bring back the healthy food plate

Context: India is undergoing a major “nutrition transition” which is characterised by rapidly changing dietary patterns. There is a significant shift away from traditional diets (which were high in fibre and comprised mostly whole foods) to more western-style diets which are highly processed and high in calories. 

Factors leading to change in dietary habits: 

image 81
  • This change in dietary habits coincided with rapid economic progress and urbanisation along with a surge in the consumption of packaged and processed foods (popularly called “junk foods”). 
  • Other major factors include aggressive advertising to promote “tasty” and “affordable” comfort foods, particularly aimed at younger consumers.
    • The ultra-processed food industry in India has expanded at a compound annual growth rate of 13.37% between 2011 and 2021. India’s food processing industry is predicted to be worth $535 billion by 2025-26. 
    • According to a pan India survey conducted by the Centre for Science and Environment (CSE), 93% of children ate food that was packaged, 68% drank packaged sweetened beverages more than once a week, and 53% ate these foods at least once a day. 

Issues: 

  • Categorised as high in fats, salts and sugars (HFSS) foods, these foods are nutritionally low in vitamins, minerals, fibre but are high in calories, fats, salt, sugar, and innumerable preservatives. E.g., Cookies, cakes, chips, namkeen, instant noodles, sugary drinks, frozen meals, canned fruits, Indian sweets, and bakery products.
  • Scientific evidence shows how junk food has been medically found to weaken the body’s defences against infection, increase blood pressure, lead to a spike in blood sugar, cause weight gain, and also contribute to increased risk of cancer.
  • India is experiencing an explosion of lifestyle diseases, with unhealthy diets being one of the single largest contributing factors.
    • An Indian Council of Medical Research (ICMR) study (2023) estimates a glaringly high prevalence of metabolic disorders in India where 11% of the population has diabetes, 35% is hypertensive and almost 40% are suffering from abdominal obesity.

Regulations in India: 

  • A ruling by the Supreme Court of India in 2013 said that any food article which is hazardous or injurious to public health is a potential danger to the fundamental right to life guaranteed under Article 21 of the Constitution of India.
  • Campaigns: To protect consumers from unhealthy foods and promote their well-being, the Government of India has prioritised the promotion of healthy foods and an active lifestyle through its initiatives such as Eat Right India, the Fit India Movement, and Poshan 2.0 (Prime Minister’s Overarching Scheme for Holistic Nutrition).
  • FSSAI (Food Safety and Standards Authority of India) released the Food Safety and Standards (Safe food and balanced diets for children in school) Regulations, 2020, restricting the sale of HFSS in school canteens/mess premises/hostel kitchens, or within 50 metres of the school campus. 
  • Recently, the National Commission for Protection of Child Rights has issued notice to a health drink giant to evaluate and withdraw all misleading advertisements, packaging and labels that brand the product as a “health drink”, citing the product’s high sugar content that can adversely impact the health of children.

Way Forward:

  • Clear definition of HFSS foods: While the FSSAI has released regulations for restricting the consumption of HFSS (high in fats, salts and sugars) foods, currently, there is no way to “define” or “identify” which foods fall into the category of HFSS foods. Thus, FSSAI should define what exactly constitutes HFSS foods in the Indian context which can enable better implementation of food safety regulations. 
  • Proper list of ingredients in Front-of-Pack Labelling (FOPL): Currently, a nutrition table is printed in small print on the back of food packets which most of the population neither notices nor comprehends. There should be “warning labels” like “high in salt” or a star rating (Indian Nutrition Rating) based on the overall nutritional profile of the packaged food products, to make informed food choices. 
  • Subsidies for healthy foods: Policies can also be developed to facilitate the positive subsidies for healthy foods such as whole foods, millets, fruits and vegetables that will improve their availability, affordability, and thus greater consumption in rural and urban areas. 
  • Behavioural change campaign: Multimedia campaign targeting children and young adults should have discussions on the health impacts of junk foods; and building on “vocal for local” which promotes local and seasonal fruits and vegetables and traditional foods such as millets and balanced diets. 

Hence, through policy interventions and informed decision making, India needs a “Jan Andolan” or people’s movement to switch to healthier and nutritionally diverse diets. 

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