When I got a Facebook notification related to the inauguration of Patanjali’s Coronil in the presence of two central Ministers, I was surprised. This is because last year, Ramdev claimed that his company has been able to find a medication for Covid 19 after much ‘research’ and ‘testing’ on the patients. But later the Ministry of Ayush in the month of June, declined to give him permission to claim it had a vaccine for Corona.

According to a report published in The Hindu, Ramdev says that the daily demand for Coronil is 10 lakh packs a day, but Patanjali is unable to fulfil that as it can only supply one lakh packs a day. Now the question is how can such a product be allowed to be sold in the market?

We all know that Ramdev is using religion and yoga to promote the dubious business, and this government has been more than happy to promote him. Basically, they compliment each other. While one can ignore the other things related to Patanjali which makes tall claims, it is criminal to ignore, promote or encourage senseless or fake claims related to cure of Corona when scientists world over are grappling with it and when the world is fighting against one of the most lethal diseases which threatens humanity.

The shameless and thuggish way that he claimed, in the presence of two ministers, that Coronil has got approval and clearance from the World Health Organisation shocked me! I felt that this government might have used its influence on WHO and probably that is why these Ministers are here. It was shocking to hear and what was a blunder was the presence of the Health Minister who did not utter a word that Coronil is not a treatment or medication to cure Covid 19. Ramdev claiming things in the presence of two ministers and their approval to what he said, suggested that politicians are ready to lose international credibility for the sake of domestic constituencies.

The two ministers, Nitin Gadkari and Harsh Vardhan, became party to a fraud by Patanjali which shamelessly dragged the name of World Health Organisation. Ramdev and his company have flouted rules and regulations without any fear as they know that the ruling party is more than happy to promote and encourage him. This is the best example of how crony capitalism functions and what is the outcome when capitalism and religion mix together.

The Hindutva propaganda media was more than eager to jump on the fallacy of Ramdev Covid vaccination claim. These rogues actually are endangering the lives of millions of people by actively participating in fake news. For their fake nationalism, they are ready to use the fake news without ever checking its credentials. Unfortunately, when the Union Health Minister participates in it then it is seriously the issue of propriety and ethics. Both the Ministers must explain what prompted them to go to participate in the programme launched by Ramdev and why they allowed themselves to be used by him.

Ramdev’s fake claims have been rejected by the World Health Organisation. It is surprising for all as to why WHO should give authorisation or certification, but WHO today has become what NASA used to be once upon a time. We must not ignore that once a boy from Balia was congratulated in the UP Assembly in the year 2005 for topping ‘International scientist Discovery’ conducted by NASA which later found out to be fake news. It is important to know how and why these fake news look ‘real’ and the answer lies in our ‘attempt’ to look the ‘best’ and ‘most outstanding’. I know we all love to be famed people, achievable and omnipresent and omnipotent yet there are realities whether we really deserve it without working harder.

It is good that the World Health Organisation issued a clarification that it has not given any certification to Patanjali research. Actually, all the TV channels who have been imposing the thuggish Patanjali on us need to explain their conduct. The shouting brigade of Sharmas, Chaudhries, Chaurasias, Dubeys, Tripathis, Devgans must be asked to explain their shameless behavior and being party to defame our country and dupe the people for buying a fake vaccine.

Indian Medical Association has sought clarification from Union Health Minister Dr Harshvardhan. IMA is rightly shocked and we are happy that it showed some spine at the moment when the Minister who himself is a well known doctor is seen in promoting a product which is neither certified nor scientific. IMA said, “Being the Health Minister of the country, how justified is it to release such falsely fabricated unscientific products to people of the whole country…can you clarify the time frame, timeline for the so-called clinical trial of this said anti-corona product?”

“The country needs an explanation from the minister. The Indian Medical Association will also write to National Medical Commission seeking suo moto explanation for his blatant disrespect to the code of conduct of Medical Council of India,” the IMA said.

We demand a ban on Patanjali products for persistently spreading fake and malicious propaganda regarding its product and violating all the business and medical ethics. The government must investigate the Patanjali products as well as its commercial practices to find whether or not they violate norms and ethics? The two ministers M/s Nitin Gadakari and Dr Harshvardhan must explain their presence at the ceremony and should completely dissociate themselves with such unethical behaviour. Let us see whether the two ministers have the courage and conviction to do so?

Related:

IMA questions Health Minister’s support to Ramdev’s Coronil

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India, one of the fastest developing countries of today, is still stuck in a time-wrap, when it comes to social advancements and mental health. Social stigma still remains an obstacle to help Indians cope with mental illness. The attitude toward mental health in India is very different from the one in the West. It’s ‘something is wrong with you and it’s your fault,’ instead of ‘this is a medical problem and can be treated’. There’s little awareness that it’s a real illness. There’s still a very deep stigma.

With a population of 1.3 billion people, India (in 2014) had 4,500 psychiatrists, compared to 50,000 in the U.S., about 4,500 in California alone. In India, about 100 million people were believed to suffer common mental disorders and millions more have more severe illnesses at that time. Ironically it is only in urban areas where medication and psychiatrists are available, but in rural areas medication is not available nor are psychiatrists. 1 

Most general physicians fail to diagnose psychiatric illness. A mentally ill patient displays symptoms, which superstitious people believe are paranormal. With the medical system in a mess and awareness about mental disorders lacking, faith healers and quacks are making hay. In rural areas of India, many villagers still believe that evil spirits cause mental illness. So-called therapy, conducted by witch doctors or family members, can include chaining up the mentally ill, chanting spells, poking them with pins, or beating them “to force the spirits out.”

According to WHO countries like India devote less than 1% of their health budget to mental health compared to 10%, 12%, and 18% in other countries. But in recent years, the Indian government has increased budgets for psychiatric education and mental health awareness, seeking to curb a sharply rising suicide rate.2  Suicide is now the second-highest cause of death in India among those between the ages of 15 and 29, according to a recent study in the medical journal Lancet. The national suicide rate was about 16 per 100,000 people in 2010, compared to 12.4 per 100,000 in the United States, according to the national Centers for Disease Control and Prevention.3   

When it comes to matters of mental health, culture counts! Cultural perceptions about mental illness and treatment can vary. Some people in India perceive mental illness to be a curse caused by the evil eye or demonic spirits, others believe it is a sign of weakness, and yet others believe they are neuro-biological disorders. In America, most people believe that mental illnesses are neuro-biological disorders, while some believe it’s a sign of weakness. However, it is important to remember that America is a melting pot of immigrants whose perceptions about mental illness are shaped by their cultural legacies, while some cultures have their misperceptions of mental illness which can deter people from seeking lifesaving treatment and support.

“There’s a big myth that everything psychiatrists do is so sophisticated and complicated. It scares a lot of people off. Demystifying mental health is important for the social acceptance of this medical help,” said K. Srinath Reddy, president of the Public Health Foundation of India, an organisation working to improve education, research, training and policy in public health. Unfortunately, society still stigmatizes those who suffer from routine psychiatric problems, so their treatment is either delayed or denied by their families or by themselves.  

In America, it is common for ads to be placed on a school notice board about free therapy or some brief psychotherapy research program or help groups saying “Are you Feeling Overwhelmed? “ or “vent with us, come in and talk to us about your experience”. These things make it so easy, so normal, for a student or an adolescent to deal with their ongoing stress or at the least relate to it. People’s minds are trained to seek help, and are taught to believe that it’s a problem and they can get help. Whereas in India there’s a gradual increase in awareness that mental illness is a health problem, not a social or personal problem, but it’s very gradual.

My reason for this quest, for wanting to be involved in a movement for change, is my personal experience with mental health in India. My memory goes back to a perfectly fine Sunday afternoon, after lunch with my family, while I was lying on my bed when a melancholy set in and I pressed my face against the pillow and wished I would stop breathing. I tried to suffocate myself and failed, struggling to breath, tried yet again and gave up. I just wanted to end my life and didn’t know why. I felt very unusual and later I felt guilty for feeling that way.  I had a very close-knit family and was absolutely happy in all sense. I began experiencing similar melancholy a couple of other times too. A cloud began to form in my mind, which saddened me all the time. When I was crossing the road all I wanted was for a truck to come hit me and end my life. Sometimes when I was on the beach, I wished I would disappear into the ocean. I tried to brush these thoughts away, but they kept troubling me all the time. Death was a kind of fantasy. As a child, I couldn’t express this to anyone. Then as years passed my condition got worse.  

My family began to notice that something was wrong. I was either very depressed or would get manic in my behavior. They were not able to gauge my reactions and thought about all the possibilities. Then the umpteen visits to the physicians began and I had all kinds of physical ailments due to my mental state. I still remember, at one point my mother gave up and took me to an astrologer and a faith healer. Nothing worked, and finally my family decided to take me to a psychiatrist. My condition got really bad and was diagnosed as Clinical Depression and was given medication for it. My family convinced me that it’s not my fault and that it’s an illness and that I ‘ll get better. I had relapses and was put on sedatives a couple of times.  

My family stood by me and cooperated with everything that the Psychiatrist decided, as all that they wanted was my betterment. My erratic behavior upset me and made me guilty all the time. Sometimes I began to believe if an evil spirit had got into me, because I couldn’t feel like myself, as if someone else was controlling me. I used to feel that my family didn’t deserve this pain and that I was almost like a curse to them. My condition worsened and the Psychiatrist decided to go ahead with electric convulsion therapy. There were times I used to feel so low that I used to tell my Dad that I wanted someone close to die, to justify my sorrow, and that one cannot feel so sad for no reason. Some other time I would have manic episodes where I would throw stuff or get violent. My family lived in fear, for me and kept every single thing of self-harm like a knife or any such thing away. Instead they showed me so much love and care. When I look back at my life, I feel I have gone through too much for a child of that age and my family went through even worse. But if it was not for this wonderful family that did everything for me to feel better and didn’t give up on me, I would be dead today. 

I was doing fine in school, but on and off the illness became a hindrance. I was on medications most of the time, few more ECTs, some hypnotic therapies, and one day my life changed. I was 19, walked back from school and gulped down a whole lot of painkillers and went to sleep. When my sisters came back from work I just realised what I had done and told them and was rushed to the hospital and had a stomach wash. When I was in the ICU with a tube down my nose and mouth into my stomach and saw my family through the glass door, I could see the pain in their eyes much bigger than what my illness was causing me. I wasn’t sure if I was going to live, and prayed that I should live, I wanted to be with my family. That day, I decided, I’m not going to fight this, instead embrace it and work around it. I began to live with it and made best use of my life when I was well. I did everything that I would have done if I weren’t unwell. I got through the best of schools, was into sports and other activities, got into great companies for jobs, got overseas offers for jobs and did well at work. It was only my family and very close friends who knew my condition.

When I came to the US, I visited a couple of Psychiatrists and was diagnosed with Bipolar II, or manic-depression, caused due a chemical imbalance in the brain. I realised I was not diagnosed right in India and that the medications might have not helped me. I was treated for the mood disorder and was given medication for depression as well as mood stabilisations along with occasional therapy, and a lifestyle to follow to keep it balanced. There are times when I feel so grandeur that I have an extreme sense of creativity and ability that is almost unreal. But now I understand that it is a part of my illness and tame it wherever needed and use that eccentricity to its best when needed. Some of my best works have been because of those manic periods. But there are days when I can’t get up from the bed and the sad cloud in my head pins me down, and chains me. Those days I just take it easy, slow down, because I know those days pass and I’ll see the sun again. I have my constant struggle and know that miracles don’t happen in this case and consider this as my share of struggle and I don’t let it enslave me. Whenever I have assumed that it has ended and when I have had a relapse, I have hit my lowest, because of the disappointment. I always remember my doctor’s words “It’s like Diabetes and is a part of your chemical imbalance but can be controlled with medication and a balance in lifestyle” and do exactly that. Today I understand my illness, better than anyone else and lead a perfectly fine life dealing with it occasionally.

When I look back at life and what I see of myself today, I believe there is ‘hope’ for people like me, provided they have help and a family willing to help at the right time, before it gets too late. I was fortunate to have a family who could understand and seek help; partly because of being educated and mainly because of an attitude they had for life, which was unlike the society they lived in. I owe my life to them and to myself who developed a mind to understand things much before time and consider that as a reward for going through that mess. I know that everyone might not be fortunate enough to have someone help him or her or understand his or her problem. Moreover if I was diagnosed right, my condition wouldn’t be as bad as it was, and this was despite seeking mental health. What I see as a difference in the medical help in psychiatry back in India is the exposure. I can understand why this billion populated country has just less than 5000 professionals in this field. Partly because they don’t have enough people seeking that professional help. It is the attitude of the society. There might be a million other stories like mine who might not seek professional help due to the stigma of mental illness or even have known that they need help.   

I wish no other thirteen year old would go through what I went through and could get better much before I did, just by right diagnosis and an attitude to seek help. A whole lot of mental illnesses are treatable and can be under control, if we accept them and deal with it. If people like me share our stories to people who need help, we could help change attitudes. Mental illness, from what we see in Indian cinema since we were kids, was some crazy guy chained in some hospital which looked like a prison with crazy unkempt hair and looks as if he could harm anyone if the chains were off. That was an imprint of someone with a problem. If people see a problem they associate it with such imaginations. Things have changed quite a lot since then, but have a lot to improve yet. Only the elite, who are influenced by the west, go for psychotherapy, as it’s expensive for a common man.

Introducing mental health adaptations of the western society can help change the society in India as the society there is influenced by the west in so many other ways. This shouldn’t be difficult for the urban life there. Connecting socio-research groups and mental health associations could bring about a revolutionised change in adolescents and youth. Issues related to stress, anxiety and other disorders can be helped at a school-college level with their wellness departments specially addressing such issues, like how it is in America.  

For rural areas, there can be different approaches. Lack of education makes their approach to such ideas very difficult, and we can’t change this overnight. But we can always form an association of community health service, trained by psychotherapists and connect them to psychiatrists who could prescribe medication if needed.  

Acute problems like schizophrenia need extreme care and observation. A weekly visit to community centers could keep a check of such problems. While I researched about community health in rural India, I learnt that while I’m still thinking, someone is already doing it. My salute to people who take that plunge and make the change. One such non-profit organization is ‘The Mind foundation’. Their purpose is to provide high quality, cost-effective mental health care to every corner of rural India.4   They work on community education along with counseling and treatment via community mental healthcare workers. This just proves that people do have similar intentions for the society, but few really go ahead and do what they intended. I hope I have the strength to be one of them.

Just like how the west has embraced yoga and other forms of spiritual healing techniques originated from India, the western researched science and its medical techniques can facilitate this change to the society in India. Sometimes one doesn’t value what we have. It’s an irony that Yoga is embraced now by the youth in India as a fitness regime after the west adapted it. Till then, it was just an age-old technique adapted only by few. A therapy with a combination of such relaxation techniques along with medications that deal with chemical imbalance and psychotherapy, for the cognitive approach would be an ideal holistic approach for a general well being. I intend to raise funds in the United States for retreats or rehabilitation center which has no mental stigma attached to it (like some crazy prison where someone is chained and sedated), which facilitates a combination of psychiatric and psychotherapy along with age old spiritual and relaxation techniques like yoga and Ayurvedic massages.

 As a global community, it is time we help dispel myths about the prejudices related to this form of medical help and misperceptions about mental illness, and harness the healing power of holistic wellness. I believe there is a reason for everything, and may be my reason for what I went through is to empathize the pain of some others with similar under-recognized issues and help make a difference.

1http://www.pbs.org/newshour/bb/treating-mental-illness-medicine-religion-india/

2http://timesofindia.indiatimes.com/city/goa/1-in-5-persons-suffer-mental-illness/articleshow/23940462.cms

3 http://www.mindsfoundation.org/

*The author is a designer, and had written this piece as part of her classroom exercise in Parsons School of Design in NY. 

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SSR’s tragic death: Are we missing the wood for the trees?
Not fair to label those with mental illness as ‘weak’
Media, right-wing spew venom over Sushant Singh Rajput’s death

The post Mental health awareness in India appeared first on SabrangIndia.

On May 29, US President Donald Trump made a shocking announcement, terminating the relationship with the World Health Organisation. Addressing the media from the White House lawn Trump said, “Because they have failed to make the requested and greatly needed reforms, we will be today terminating our relationship with the World Health Organisation and redirecting those funds to other worldwide and deserving, urgent, noble public health needs.”

The US President alleged that the WHO had been pressured by China to cover-up the Coronavirus crisis when it first originated in China. Trump said, “Chinese officials ignored their reporting obligations to the World Health Organisation and pressured the World Health Organisation to mislead the world when the virus was first discovered by the Chinese authorities.” He added, “China has total control over the World Health Organisation despite only paying USD 40 million per year, compared to what the United States has been paying which is approximately USD 450 million a year.”

Accusing China for the global crisis caused by the Covid-19 pandemic, Trump said, “The world is now suffering due to the maleficence of the Chinese government. China’s cover-up of the Wuhan virus allowed the disease to spread all over the world instigating a global pandemic that has cost more than one hundred thousand American lives and over a million lives worldwide.” Trump said, “The world needs answers from China. We must have transparency. Why is it that China shut off infected people from Wuhan to all other parts of China? It went nowhere else. I didn’t go to Beijing. It went nowhere else, but they allowed them to freely travel throughout the world including Europe and the United States.”

Trump also continued his tirade against China blaming it for the failure of the American economy. Trump said, “China’s pattern of misconduct is well known. For decades they have ripped off the United States like no one has ever done before. Hundreds of billions of dollars were lost dealing with China, especially over the years during the prior administration.” He added, “China raided our factories, offshored our jobs, gutted our industries, stole our intellectual property, and violated their commitments under the World Trade Organisation. To make matters worse, they are considered a developing nation, getting all sorts of benefits that others including the United States are not entitled to.”

But Trump did not stop at merely blaming China for the pandemic or economic collapse. He also accused them of industrial espionage and said, “Today I will issue a proclamation to better secure our universities’ vital research and to suspend the entry of certain foreign nationals from China who we have identified as potential security risks.”

This open targeting of China by a person holding an office as powerful as that of the President of the United States could have implications for not just international relations between US and China, and the economies of both countries, but could also pose a potential threat to Chinese Americans and people of Chinese or East Asian origin, living, working in or vising the United States who could now be accused of being spies!

Racial tensions are already high in the United States in wake of the killing of George Floyd, an African American man, by a Derek Chauvin, a Minneapolis policeman, with protests, rioting and looting being reported from across the country. Already media persons including CNN’s reporter Omar Jiminez as well as his crew were arrested live on national television by the police while covering the unrest and protests in Minneapolis. Meanwhile, Wave 3 news reporter Kaitlin Rust and her camera person were shot at with rubber bullets, once again live on TV while covering the civil unrest in Louisville.

Meanwhile, officer Derek Chauvin, who was seen in a viral video pressing his knee on the neck of Floyd who was lying helplessly on the ground before he died, has now been arrested. His wife has also reportedly filed for divorce.

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According to a new WHO-UNICEF-Lancet Commission report called ‘A future for the world’s children?’ India ranks 131st among 180 countries in the category of child survival.

The report states that no country in the world is adequately protecting children’s health, their environment and their futures. It also stated that the health and future of every child is under “immediate threat” from ecological degradation, climate change and exploitative marketing practices that push heavily processed fast food, sugary drinks, alcohol and tobacco at children.

The report also says that children must be put at the centre of every country’s Sustainable Development Goals (SDGs). However, even though it has been five years since these goals were adopted, “few countries have recorded much progress towards achieving them”.

Health Issues India states that though the country has improved on many counts – it recorded a 30 percent decrease in newborn mortality rates – it still continues to face an evident socioeconomic crisis. While the report states that there are positive examples of how policy changes have worked and how change can be driven through citizen action, India still has a long way to go.

The infant mortality rate in India currently stands at 33 per 1,000 live births, meaning nearly 800,000 to 850,000 infants die every year in India, the average daily number standing at 2,350. Speaking to IE, Lu Gram, India Index developer at the Institute for Global Health, UCL, said, “In terms of basic survival, one-fifth of Indian households still live in extreme poverty, nearly half do not have access to improved sanitation, and over a quarter do not have access to a skilled birth attendant. The government has launched initiatives such as Swachh Bharat, Janani Suraksha Yojana and MNREGA, etc. to deal with these issues, but it remains to be seen whether they will successfully tackle them or not. In terms of children’s ability to thrive, India displays some of the worst indicators on child nutrition in the world, as 28 per cent of children are low birth weight and 42 per cent are stunted. It also has some of the highest rates of intimate partner violence, with 39 per cent of women having experienced IPV in the past (compared to 11-15 per cent seen in high-income countries). Another issue is the high youth suicide rate, as suicide is the most common cause of death for the 15-29 age group.”

India is also riddled with problems of malnutrition, 69 percent of deaths of children below the age of five were caused due to it. Not just this, a contradictory issue of obesity is also on the rise among Indian youth. By 2030, the country is set to be home to 27 million obese children, becoming a major driver of childhood obesity.

The report highlights how children have been adversely hit by marketing, especially through internet and mobile targeting. A public survey conducted between September 2018 and December 2018 showed that 88.8 percent of youth started drinking before the legal drinking age and could procure alcohol without any age check.

A report by the Tobacco Atlas stated that 625,000 children in India ranging from 10 – 14 years of age continue to use tobacco each day. It states that though 0.64 percent boys – a number fewer than other countries smoke tobacco in India each day, the number is still pegged at more than 429,500 boys making the issue a dire public health threat.

Even climate change and environmental pollution – challenge that the country’s government has pledged to overcome still stands to daunt it today.

The report reads, “Children and young people are full of energy, ideas and hope for the future. They are also angry about the state of the world.”

India deals with vast amounts of air and water pollution. In the past, India stood 177th out of 180 countries which were ranked for their environmental performance. Air pollution, the report stated, caused 1.1 million deaths in the country each year and more than 5 cities in India stood in the top 10 list of the world’s most polluted cities.

Anthony Costello, a co-author of the Lancet report said that India faced manifold challenges related to climate change in the near future. “We don’t want to bequeath our children an unsafe world, with increasing heatwaves, proliferation of diseases like malaria and dengue, water shortages, population migration and malnutrition. India faces all of these challenges in the near future,” he told Health Issues India, adding that “the Indian government should recognise that every effort to tackle climate change will be good for the health of children and all families: clean air, clean water, better play areas, safer roads, better nutrition, and population stability.”

Citing a National Rural Health Mission (NHRM) case study from India, the WHO-UNICEF-Lancet Commission report states that state officials and communities have increased public awareness of their rights and empowerment to demand these rights. However it says that more focus needs to be given to data collection as the use of data can effectively contribute to monitoring and planning health policies and programmes, including those relevant to children’s health and wellbeing, and their potential for wider scale-up.

It is the duty of Prime Ministers and cabinets to think across all ministries about the impact on the health of the children and their future, Costello says. The report too emphasizes – “Since threats to child health and wellbeing originate in all sectors, a deliberately multi-sectoral approach is needed to ensure children and adolescents survive and thrive form the ages of 0-18 years, today and in the future. Citizen participation and more importantly, soliciting the inputs of children and adolescents themselves, apart from the contribution of the government is imperative to grant the children the future they deserve.

Related:

India ranks first in child deaths under 5 years of age: UNICEF report               
Children living in extreme poverty are most vulnerable to effects of climate change
Our children’s future

The post India 131st out of 180 countries on child survival rankings: WHO-UNICEF-Lancet report appeared first on SabrangIndia.

Stunting is caused by malnutrition and both rich and poor children in India are eating badly for different reasons, said experts. “Awareness about healthy diets is low in India, even among the economically well-off segment,” said Shweta Khandelwal, additional professor and head of nutrition research at the Public Health Foundation of India.

India also has the world’s third worst (after Djibouti and South Sudan) wasting rate: 21% of its children are underweight for their height, according to the SOWC report.

Low weight and height in early childhood are a consequence of undernutrition, and their effects may be irreversible: Children who eat insufficient food lacking in the required nutrients fall sick more often and earn less as adults, effectively keeping them trapped in poverty.

India was ranked 102 on the Global Hunger Index 2019 (GHI), below Pakistan (94), Bangladesh (88) and Nepal (73). The index is a weighted average of stunting and wasting rate, and the GHI estimates that the percentage of wasted children in India increased from 16.5% to 20.8% between 2008-12 and 2014-18.

Inadequate food intake in first 1,000 days of life
Poor nutrition in early life leads to stunting and loss of IQ, which has consequences for the economy, said Mumbai-based pediatrician Rupal Dalal, adjunct professor at the Centre for Technology Alternatives for Rural Areas at Indian Institute of Technology, Bombay, and director of health at the Shrimati Malati Dahanukar Trust.

Stunting and impaired brain development are common among those who received inadequate food in the first 1,000 days of their life, said Khandelwal. “The adverse effects are difficult to reverse,” she added.

Early childhood malnutrition increases the risk of developing non-communicable diseases such as hypertension, diabetes and heart disease in adult life, the experts concurred. In addition, stunted mothers face complications during pregnancy and this affects their children as well.

Children who were stunted in the first two years of their life go on to spend less time in school and earn up to $1,440 (equivalent to Rs 1 lakh) less over their life than their peers of average height, said the SOWC report.

Poor children do not get enough protein: Study
The role of income is most apparent in the consumption of protein-rich foods such as milk products and eggs, according to the Comprehensive National Nutrition Survey (CNNS). While 82.7% of children from the richest households aged 2-4 years consume dairy products, half that number (41.3%) from poorest households do. Similarly, 8.2% of children from the poorest households ate eggs compared to 20% from the richest households.

Overall, few children aged 2-4 years consumed protein-rich foods, said the CNNS study: 62% consumed dairy products, 15.6% ate eggs and 31.6% ate pulses and nuts, indicating few children get the required amount of proteins regardless of household income.

Children under the age of two, breastfed or not, also do not get required nourishment irrespective of household income. Only 6.4% of children in this age group had enough intake of essential nutrients, found the CNNS.

Consumption of proteins was low among children from the poorer states in the eastern and central parts of India, the study found.

Source: Comprehensive National Nutrition Survey

“Poor diets like one having inadequate quantity and quality of carbohydrates and proteins are adversely associated with child’s growth and development and may result in stunting and/or wasting,” said Khandelwal. “Failure to provide key nutrients during the first 1,000 days, a critical period of brain development, may result in lifelong irreversible deficits in brain function.”

Growing children require nutrient-dense foods, especially proteins from eggs, milk, beans, nuts and seeds, fish and meat, and good fats, Dalal said. “Lack of protein, good fats and micronutrient-dense foods which are replaced by empty calories will cause growth failure, frequent infections, lack of concentration in school, tiredness and so on,” she said.

Rice and wheat dominate, fruits and vegetable rare
Around 55% of children aged 6-23 months who were surveyed consumed no fruit or vegetable, according to the SOWC report. But almost all children, across age groups, consumed cereals and (starch-rich) tubers such as potatoes, according to the CNNS.

Traditionally, Indian diets were rich in nutrient-rich foods such as millets and pulses. However, in a bid to ensure food security, the Indian government enacted policies that led to farmers favouring rice and wheat over fruits, vegetables and livestock products, according to Transforming Food Systems for a Rising India, a 2019 book by Cornell University researcher Prabhu Pingali.

The result is that fruits and vegetables are too expensive for many families: Only 25.4% of the poorest children aged 2-4 years ate fruits and 54% vegetables, according to the CNNS.

Children from the relatively richer households did slightly better–56.7% of the richest children ate fruits and 61% vegetables. But the low numbers indicate that nutritious food is not consumed even by children whose parents can afford it.

“Most studies say that children may be considered to have adequately diversified dietary intake if they had food items from at least four of the seven food groups,” said Khandelwal. The seven food groups, as per the WHO’s infant and young child feeding practices guidelines, are grains, roots, and tubers, legumes and nuts, dairy products, flesh foods, eggs, vitamin A rich fruits and vegetables and “other fruits and vegetables”.

Source: Comprehensive National Nutrition Survey

“Lack of (food) diversity is a serious threat gradually pushing us towards hidden hunger,” said Khandelwal. “Several micronutrients, vitamins and minerals have vanished from our diets because we have substantially cut down variety in our daily meals. Most households, due to time and resource (money, education, access, availability) paucity, are moving away from traditional local recipes, vegetables and fruits to a quicker, more accessible market version of takeaway or home-delivered meals.”

It is important to emphasise balanced healthy diets with micro- and macronutrients as a public health policy, she added.

Anaemia, obesity and stunting/wasting
As many as 38% of Indian children below four years of age, as we said, are stunted–including those belonging to the richest households. Obesity is less prevalent–2% of all children of that age are overweight or obese, according to the SOWC report. Over 40% of children aged 1-4 years are anaemic, as per the CNNS.

In addition to being stunted, children from the richest households–who can afford iron-rich vegetables, fruits and meat–also reported being anaemic. Over one-third (34.2%) of such children and just under half (46%) of the poorest children reported some form of anaemia.

This simultaneous existence of anaemia, obesity and stunting/wasting is what nutrition experts call the “triple burden of malnutrition”.

Inadequate protein and good fats in mother’s diet is also a reason for stunting, according to Dalal. A significant reason for faltering growth in the first few months of a child’s life is the lack of awareness about right breastfeeding techniques, said Dalal. Ignorance about how an infant should latch on correctly to the lower areola exists not just among mothers but also doctors, nurses and healthcare workers.

Breastfed children’s diets do not contain enough proteins and other growth micronutrients. “It is also important to include vegetables and fruits and (a) variety of whole grains like bajra, sorghum, millets and so on,” said Dalal. “They (the children) should not be exposed to junk foods like biscuits, wafers, street foods like batata-vada, bhajiya, (nutritional supplements like) Pediasure, Horlicks, high sugar/jaggery foods, sugary drinks and cakes and pastries.”

The WHO recommends that the child be introduced to solid and semi-solid foods–called complementary foods–at six months, as breast milk is no longer sufficient to meet the needs of the growing body, the CNNS report noted. However, the complementary foods fed to most children lack proteins and other micronutrients, said Dalal. “They are monotonous and watery and do not contain seeds, nuts, legumes and animal proteins,” she said.

Multi-disciplinary approach
Nutrition cannot be improved by standalone programmes and India’s attempts at tackling multiple forms of malnutrition are diluted, said Khandelwal. “Health fads, yo-yo diets, poor environmental factors, exposure to domestic violence, smoke or alcohol during the first 1,000 days also impact stunting,” said Khandelwal.

“Many issues around income, education, gender, women empowerment, poverty, social inclusion/welfare schemes, sanitation etc are related and known to have an impact on nutritional status of the masses,” she added. “All these have to be addressed under a smooth harmonised multi-sectoral strategy guided by effective leadership to have a sustained impact.”

Khandelwal emphasised the need for multidisciplinary strategies. “Right now, most programmes and policies are a bunch of single-focus top-down initiatives with no conversations between the multiple sectors who should be talking and assuming collective responsibility to advance science and translate those into public health policy/action,” she said.

A plan for improving diagnostic and tertiary care, providing trained staff and enhancing the capacity to deal with issues related to malnutrition are necessary, Khandelwal pointed out. “Let us not associate nutrition with merely how much and what to eat but all other related behaviours to have a meaningful impact on public health and nutrition,” she added

This story was first published here on Healthcheck.

(Iqbal is an intern with IndiaSpend.)

Courtesy: India Spend

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The skilled health workforce in India does not meet the minimum threshold of 22.8 skilled workers per 10,000 population recommended by the World Health Organisation, shows research published in the online journal BMJ Open.
 
The actual size of the health workforce in India is lower than the number of medical professionals registered with various councils and associations in the country. The research paper published in The BMJ Open by Dr Anup Karan, Additional Professor, Indian Institute of Public Health Delhi, (IIPHD) and his team came to this conclusion after comparing data from the National Sample Survey (NSS) and a review of published documents by the Central Bureau of Health Intelligence.
 
Despite the health sector employing five million workers in India it continues to have low density of health professionals with figures for the country being lower than those of Sri Lanka, China, Thailand, United Kingdom and Brazil, according to a World Health Organisation database. This workforce statistic has put the country into the “critical shortage of healthcare providers” category.
 
Bihar, Jharkhand, Uttar Pradesh and Rajasthan are the worst hit while Delhi, Kerala, Punjab and Gujarat compare favourably.
 
“Southeast Asia needs a 50% increase in healthcare manpower to achieve universal health coverage by 2030. India faces the problem of acute shortages and inequitable distributions of skilled health workers as have many other low- and middle-income countries,’’ said K. Srinath Reddy, president, Public Health Foundation of India.
 
Estimates of non-health workers engaged in the health sector and technically qualified health professionals who are not part of the current workforce is able to be provided in India for the first time by the study as it is based on data from two sources.
 
The authors retrieved data on the number of registered practitioners, such as doctors, nurses, physiotherapists and dentists, from published literature and websites of professional councils and organisations.
 
They also estimated the number of qualified and unqualified healthcare workers actually working in India using the 68th round (July 2011-June 2012) of National Sample Survey Organisation (NSSO) data on ‘Employment and Unemployment Situation in India’ – a household survey conducted every five years.
 
As well as registered practitioners, the health workforce in India includes many informal medical practitioners, such as traditional birth attendants, faith healers, snakebite curers, and bonesetters without formal education or training.
 
The total size of health workforce registered with different councils and associations was 5 million, but the NSSO estimated the size of the workforce to be 1.2 million fewer at 3.8 million.
 
Based on the registration data, the density of the total health workforce was estimated to be 38 per 10,000 population, but the NSSO data found it be lower at 29 per 10,000 population. In eastern and rural states total health workforce density was lower than the WHO minimum threshold of 22.8 per 10,000 population.
 
According to the registry data the density of doctors and nurses and midwives per 10,000 population across India was 26.7, whereas the NSS0 data put it at 20.6.
 
The estimates also reveal “an alarmingly large presence of unqualified health professionals,” as adjusting for adequate qualifications of health workers reduced the workforce density from 29 to 16 health workers per 10,000 population.
 
The presence of unqualified health professionals in the health system is not unique in India.
 
Unqualified health professionals are usually the first point of contact for rural and poor population in many low-income and middle-income countries.
 
Government medical colleges in the country produce 50 per cent of all doctors in India every year, but nearly 80 per cent of them work in the private sector.
 
The data also showed that approximately 25% of currently working health professionals do not have the required qualifications as laid down by professional councils, and that 20% of adequately qualified doctors are not in the current workforce. More than 80% of doctors and 70% of nurses and midwives were employed in the private sector.
 
Despite 71 per cent of the country being predominantly rural, the proportion of doctors and nurses in rural areas are 34 per cent and 33 per cent, respectively, it showed.
 
The density of health workers, including allopath and AYUSH doctors, nurses and midwives, in India is 20.6 per 10,000 population. Most central and eastern Indian states have a low density of health workers, ranging from approximately 23 per 10,000 population in Bihar and Northeastern states other than Assam, to as low as 7 per 10,000 population in Jharkhand.
 
The only South Indian state reflecting lower density than the all-India average is Andhra Pradesh (25), and the only eastern state having a higher density than the all-India average is West Bengal (36).
 
The highest concentration of health workers is in Delhi (67), followed by Kerala (66) and Punjab (52.)
 
Delhi has the highest density of doctors (34), but the density of nurse and midwife is the highest (38) in Kerala.
 
The researchers point to several limitations of their study, including the registration data being inadequately updated and likely to include deceased, unemployed and professionals who have migrated overseas, and the survey data being self- and also outdated reported.
 
Nevertheless the authors were able to conclude: “Distribution and qualification of health professionals are serious problems in India when compared with the overall size of health workers. The policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce.”
 
The health workforce in India comprises broadly eight categories, namely: doctors (allopathic, alternative medicine); nursing and midwifery professionals; public health professionals (medical, non-medical); pharmacists; dentists; paramedical workers (allied health professionals); grass-root workers (frontline workers); and support staff.
 

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Prime Minister Narendra Modi’s Lok Sabha constituency Varanasi (above) is one of the world’s most polluted cities when measured for PM 2.5. Many gases and particulate matter that cause air pollution also have greenhouse properties, exacerbating climate change.

Soon, your skin feels the coarse particles that make up this dust. There is enough of it here, according to 2018 World Health Organization (WHO) data, to classify Prime Minister Narendra Modi’s parliamentary constituency as one of the cities with the most polluted air on the planet.

Home to 1.2 million people, Varanasi, sprawled along the banks of India’s holiest river, the Ganga, has since 2016 frequently overtaken India’s national capital New Delhi in terms of air pollution, according to WHO data.

Varanasi is not alone. Home to over 600 million, the Gangetic plain hosts four other cities–Kanpur, Faridabad, Gaya and Patna–that occupy the top five slots in the 2018 WHO list of the world’s most polluted cities, measured for particles that are 2.5 micron in diameter (PM 2.5) or less.

These particles are 1/25th the diameter of a human hair. They are known to cause cardiovascular and respiratory diseases, even cancers. India’s cities also occupy 11 of 15 of the slots in WHO’s list of most polluted cities in the world when a larger pollutant–PM 10–is considered.

The impact of this air pollution doesn’t just stop at human health. Several of the gases that cause air pollution also have greenhouse properties–they trap the sun’s heat and push up the earth’s temperature, and the latest research implicates these pollutants as changing local and global climate by means still being studied. It does seem, experts said, that temperatures are rising on the Gangetic plain, and the monsoon is becoming more uncertain.

“Air pollutants, a lot of them, also have an effect on the climate,” said Erika von Schneidemesser who studies the links between air pollution and climate change at Institute of Advanced Sustainability Studies (IASS) Potsdam, a German research institute. “If the particulate matter released in the air has a high amount of black carbon (or soot), then it will absorb more sunlight and contribute to warming and thereby climate change.”

While several gases–such as carbon dioxide (CO2), methane and nitrous oxide–were known to cause warming, it was earlier believed that particulate matter in the air reflects sunlight, causing a cooling effect.

Emerging research now indicates otherwise. While some particulates have a cooling effect, others cause an increase in temperature, studies suggest.

The year 2018 was the warmest on record for the planet since record keeping began in 1880, according to an assessment by US National Oceanic and Atmospheric Administration (NOAA), the largest repository of climate data in the world.

As temperature fluctuations become the new normal, people are paying less attention to weather, said a 2019 February study based on twitter interactions. People tend to remember weather events only for as long as two to eight years, and if unusual weather continues for longer, they will no longer find it unusual or be able to tell the difference, the study said.

This is the fifth story in our series on India’s climate-change hotspots (you can read the first story here, the second here, the third here and the fourth here). The series combines ground reporting with the latest scientific research and explores how people are adapting–or trying–to the changing climate.

The human cost of air pollution

Boatman Ravi Sahani, 24, scans the Assi ghat, or steps–one of the most popular in Varanasi along the Ganga–for tourists, whom he will offer a 30-minute ride. It is 2 pm. He has been here since 4 am and will remain here till 8 pm, pleading with tourists to take a ride in the boat.

But few are interested.

The river water is dark and the air smoggy. Tourists complain that the polluted air makes them cough and causes their skin to itch. For Sahani this means reduced income.

“We have done this work for generations. The money I make is barely enough to survive,” he said. “If I had money to start something else, I would, but I don’t have it.”

Ravi Sahani, a boatman in Varanasi, Uttar Pradesh, said fewer people are interested in a boat ride on the Ganga, affecting his only source of income. The river water is dark and the air smoggy. Tourists complain the air makes them cough and causes their skin to itch.

Varanasi had no good air day in all of 2015, according to a 2016 report called Varanasi Chokes by the Centre for Environment and Energy Development (CEED), IndiaSpend and Care4Air. “One of the reasons why we chose to study Varanasi was to make a point that the problem of air pollution is not limited to Delhi alone. The need was to take it beyond the national capital,” said Aishwarya Madineni, Bengaluru-based researcher and report’s author.

While air quality in high-income countries is improving, nearly 97% of those living in cities–with a population of more than 100,000–in low and middle-income countries are now breathing polluted air.

In 2016, the WHO attributed 7 million deaths–comparable to the population of Hyderabad–to indoor and outdoor pollution. Of these, the highest number of deaths, 2.4 million, were in south-east Asia alone. As air quality declines, more people will be at risk of stroke, heart disease, lung cancer as well as chronic and acute respiratory disease, according to the WHO.

Cities in Asia, including India, have some of the world’s most polluted air. The darker shades represent higher levels of PM 2.5 (particulate matter less than 2.5 µm diameter) in the map above, updated regularly by the WHO.
Source: World Health Organization

These cities will also be drivers of climate change, experts said.

Air pollution is affecting temperature, rainfall

Air pollution can cause a net rise or fall in temperatures and change rainfall patterns, experts said.

When something burns, the chemical process of combustion leads to the release of either a gas or particulate matter like soot. In most instances, gases and particulate matter are released together. Scientists said they have a “fair understanding” of the nature of both most gases and particulate matter.

“But there are blind spots in our knowledge,” said Schneidemesser of IASS-Potsdam, and it is difficult to say how these chemicals will interact with each other.

If the particles and gases causing warming dominate the mix, the net result would be a rise in temperature. Particles such as those of dust, sea salt and ash suspended in the air are known as an aerosol. Some aerosols absorb more heat from the sun, others have reflective properties, causing temperatures to drop.

“Aerosols can make significant changes to cloud properties,” said Sachchida Nand Tripathi, professor and head, department of civil engineering, Indian Institute of Technology (IIT), Kanpur. He has, for years, studied how air pollution caused changes in local and regional environment.

In the clouds, water condenses around particulate matter to form droplets, which then come down as rainfall. Aerosols can weaken rainfall. Here’s how it works: while the water available in the clouds is the same, it is now redistributed among the large number of particles available.

As a result, two patterns are emerging. “One, it shows the increasing aerosols in the atmosphere are slightly weakening the Indian monsoon,” said Tripathi. “And two, over a short time scale, it can redistribute the rainfall.”

But the impact of aerosol pollution on rainfall is a complex mechanism, which depends on moisture availability, amount of pollution and altitude, among other factors.

At the local level, this could mean that rainfall might vary greatly within a city. For instance, a highly polluted city centre might receive a sudden, short burst of rainfall that can even lead to flash floods, as Nagpur reported in August 2016. Aerosol pollution can interfere with cloud formation and cause hailstorms, similar to the one reported from Delhi in February 2019.

Of the world’s 15 most polluted cities–measured for PM 2.5–13 are Indian. All 13 are in the Indo-Gangetic plain, which stretches from Pakistan in the west to Bangladesh in the east.

In 2017, nearly 7% of global carbon emissions came from India, up from 6% in 2016 according to a December 2018 report from the Global Carbon Project, a collaborative effort between several research institutes to quantify global greenhouse-gas emissions.

Currently, India is the world’s fourth largest emitter of CO2, behind China, US and the European Union (EU). While US and EU emissions are falling, Indian and Chinese are rising. The US continues to have the highest per capita carbon emissions in the world.

These emissions come from the burning of fossil fuels or even changes in land-use patterns. Large scale deforestation could lead to a net rise in carbon emissions from a country.

Countries With World’s Highest CO2 Emissions

Carbon emissions from India and China continue to rise, while those of the US and the EU are declining. The US has the world’s highest per capita carbon emissions.
Source: Global Carbon Budget Report 2018

A majority of Indian cities in the top 20 most polluted cities in the world are in the Indo-Gangetic plain.

What makes this region, that stretches from Pakistan in the west to Bangladesh in the east, so polluted?

“Apart from being densely populated the region also has a unique topography,” said Tripathi. “To the north of the Indo-Gangetic plain are the Himalayas, and to the south is the Deccan plateau. This creates a valley effect and causes the air to stagnate.”

Northwesterly winds that blow across the region spread polluted air across the Indo-Gangetic plain. Winds can also spread pollution from Central Asia and Pakistan all the way to parts of Punjab, said Tripathi.

The Indo-Gangetic plain is a “global aerosol hotspot”, causing the ice in the Himalayas to melt faster, said a 2011 NASA study. The aerosol is also causing rainfall variability during the summer monsoon, another 2015 study said.

But it is not just cities in the Indo-Gangetic plain that are polluted.

“There is high pollution around both Mumbai and Hyderabad as well. In the case of Mumbai, due to the topography, the pollution gets carried by the winds to the oceans,” said Sagnik Dey, associate professor at the Centre for Atmospheric Sciences, IIT-Delhi. Dey has studied the distribution of aerosols over India using satellite imagery and found that the distribution changes every season, varying even between neighbourhoods.

This image from NASA, taken on August 23, 2018, shows aerosol pollution–a mix of particulate matter and gases–over India. The red over the Indo-Gangetic plain in north India indicates aerosol pollution caused by soot, the purple haze over Rajasthan indicates aerosol pollution due to dust from the Thar desert, while the blue specks over northern Gujarat are from aerosol pollution caused by the presence of sea salt in the air.
Credit: Earth Observatory, National Aeronautical and Space Agency, USA

Dey highlights another gap: the lack of air-quality sensors.

“We have just over 130 continuous automatic air monitoring systems, of which 40 are in the NCR [National Capital Region],” said Dey. “Nearly 500 districts in India don’t have a single monitoring system, whether automatic or manual. To put it simply, we have no idea how polluted many of India’s tier-2 and -3 cities are because we are not measuring the pollution levels there at all.”

Back in the Indo-Gangetic plain, the effects of India’s inaction are plainly evident.

A lifetime of changes

Baijnath Majhi is 87. He has never gone to school. Like his father, he is a boatman, as are his children and grandchildren. Over his lifetime, Majhi has watched the Ganga’s water get visibly polluted and the air quality in Varanasi deteriorate.

“We can earn money only when people come,” said Majhi, “I have been sitting here since morning but there hasn’t been a single customer yet.”

Baijnath Majhi said he has seen air and water quality in Varanasi deteriorate over his lifetime. These are changes that should, normally, take hundreds of years, according to experts.

For those like Majhi, the polluted air means a worsening quality of life and a cycle of poverty he hasn’t been able to escape. Majhi accepts whatever a tourist is willing to pay. The alternative is day long idleness.

Many changes that Majhi has seen over his lifetime tend to play out over a timescale of hundreds of years, said experts. But the sheer quantity of air pollution has meant that those like Majhi are able to notice a perceptible difference.

The amount of CO2 in the atmosphere has almost doubled since the pre-industrial age till now, according to the Global Carbon Budget report released in December 2018. Between 1960 and 2017 alone, the amount of CO2 in the atmosphere has gone from 310 ppm (parts per million) to 410 ppm–a rise of over 32%.

Level Of CO2 In The Air Since 1950s

Source: Global Carbon Budget 2018 report

A lot of this pollution does not come from vehicles in India. “Household pollution in rural India is a big contributor mostly caused when solid fuels like coal or wood is used for cooking,” said Dey. This is a feature common to most developing countries, he added.

Improving monitoring

In Delhi in January 2019, unprecedented air pollution and public pressure led the government to launch the National Clean Air Programme (NCAP)–a five-year plan that focused on improving air quality across 102 cities in India.

A key component of this plan is increasing the monitoring of data using low-cost air monitoring devices. “For real change, different departments have to work together; the pollution control board alone will not be able to make much of an impact,” said a senior official at the Ministry of Environment, Forests and Climate Change (MoEFCC), speaking on condition of anonymity since he was not authorised to talk to the media.

The NCAP has its flaws: it lacks legal mandate, does not have clear timelines for its action plan, and does not fix accountability. It also ignores air quality in rural India, as IndiaSpend reported in February 2019.

Solutions to tackle air pollution exist, but state government officials must lead the way, said the MoEFCC official. “An increase in public pressure is needed to drive change,” he added.

Coordination between government departments to address air pollution is another requirement. In Varanasi, for instance, the civic body in charge of making regulations rarely consults the pollution control board.

Dey of IIT-Delhi believes that while the NCAP is “heading in the right direction”, it is not enough. “We need to invest a lot more in measuring the data,” he said.

Measuring air pollution and climate-change impacts is difficult, said IASS-Potsdam’s Schneidemesser, because “there are so many interactions and feedback mechanisms” between air, land and ocean systems.

But on the bright side, “if regulations are put in place, it is possible to see improvements in air quality on the timescale of weeks and at times even days”, she said, citing the example of Beijing–a city where the minimum temperature falls to -8 deg C– where air pollution was brought down by 35% over five years to 2017.

Beijing’s transformation was possible because the government had a plan, various departments enforced the plan and the laws and helped millions of households switch from coal to natural gas for winter indoor heating. In Varanasi, it would be a start if government officials started talking to their colleagues.

This is the fifth of a series on India’s climate change hotspots. You can read the first part here, the second here, the third here and the fourth here.

(Disha Shetty is a Columbia Journalism School-IndiaSpend reporting fellow covering climate change.)

Courtesy: India Spend

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Children are especially vulnerable to micronutrient deficiencies. Lack of zinc in childhood leads to poor growth and stunting, vitamin A deficiency can cause night blindness and poor immunity, while iron deficiency leads to poor mental and physical development.

Nutritional supplements are one solution, but these are expensive. It would cost ‘US$5.9 billion (Rs 41,764 lakh crore) a year to deliver 14 essential nutrition interventions at full coverage across India’, says this 2016 study in the Maternal Child & Nutrition journal. Compliance is another challenge. Despite a National Nutritional Anaemia Prophylaxis Programme addressing anaemia through supplementation over the past 50 years, more than half of India’s children under five (58.6%) and women (53.1%) were anaemic in 2016, according to the ministry of health and family welfare’s National Family Health Survey, 2015-16.

Why can’t people get required nutrients from food itself, asked American economist Howarth ‘Howdy’ Bouis in the 1990s. Bouis came up with the idea of breeding seed varieties naturally high in micronutrients with high-yielding seed varieties, a concept later termed ‘biofortification’.

Bouis founded the agricultural research non-profit HarvestPlus at the International Food and Policy Research Institute (IFPRI) in Washington D.C. in 2003, which developed high-yielding seed varieties of staple crops including maize, rice, millets and wheat biofortified with vitamin A, zinc and iron.
In face of initial skepticism from public health experts and scientists, Bouis worked tirelessly over decades to develop and then popularise biofortification as a solution for hidden hunger–raising funds, working with breeders to develop seed varieties, conducting research to prove efficacy and convincing governments to invest in the technology.

Each $1 invested in biofortification gives a country a return of $17, showed a 2017 review of HarvestPlus evidence from 2003 through 2016, co-authored by Bouis. Today, biofortified foods are being used by over 30 million farmers across the world, especially in Africa and Asia.

The Indian Council for Agricultural Research (ICAR), run by the ministry of agriculture and farmers welfare, has also developed over a dozen biofortified varieties of cereals, pulses, oilseeds, vegetables and fruit, said this 2017 bulletin.

ICAR also established minimum levels of iron and zinc to be bred into varieties of pearl millet (bajra, kambu), making India the first country to have such standards for millet varieties. Biofortified pearl millet, introduced into the diet of Indian adolescents, led to reduced iron deficiency and improved learning skills and mental ability, IndiaSpend reported in September 2018.

Bouis was awarded the World Food Prize in 2016 for his work in reducing hidden hunger.

“You have to persevere and keep repeating yourself,” Bouis told IndiaSpend in an interview at the ‘Accelerating the End of Hunger and Malnutrition’ conference in Bangkok, Thailand in November, 2018, jointly organised by IFPRI and the United Nations’ Food and Agriculture Organisation (FAO).

Edited excerpts.

What gave you the idea to develop biofortified crops?

I was attending nutrition meetings where nutritionists were saying supplements and fortified foods were needed to address vitamin A deficiency. They said taking one vitamin A capsule daily for six months would reduce child mortality by 23%. A vitamin A capsule costs a dollar. To provide 500 million tablets each year over a decade would cost $5 trillion. But people were already getting vitamin A through food, so I thought why not breed these vitamins into crops so that diet will provide enough nutrition?

I then spoke to scientists and asked if it was possible to develop both high nutrient and high yield crops. But they said no, it would be a trade-off between high yields and high nutrients.

Then I met another group of scientists who said there needn’t be such a trade-off, that it was good for plants to contain more minerals because it would be good for the plants’ own nutrition. So it [developing both high nutrition, high yield varieties] wasn’t a trade-off but was actually complementary.

If we had done that in the 1960s, we would not have all these [micronutrient] deficiencies. Back then knowledge of these deficiencies was poor.

Do you see biofortification as a support to supplementation efforts, such as India’s iron and folic acid tablet distribution programme to address anaemia? Or can biofortification replace supplementation?

It really depends on the situation. About 40% of the daily requirement of iron is being added through biofortification. If 60% of iron requirement is met through diet, then [biofortification] can take this to 100%. But if only 20% of iron requirement is met through diet, [biofortification] will take this up to 60%, in which case supplements will still be needed.

A key difference [between biofortification and supplementation] is cost. You need to invest once in breeding [to get biofortified crops]. Subsequently, you don’t have any cost. With biofortification, the cost would be the same year after year. But supplements are very expensive.

Are nutrients like iron better absorbed through food?

A lot of things determine how much iron gets absorbed by the body. The main factor is an individual’s nutrition levels. If very deficient in iron, they would absorb a lot more iron compared to an individual with adequate iron levels.

How much do you work with the Indian government and how open are they to biofortification?

We focused on trying to get three governments–China, India and Brazil–to invest in biofortification independent of HarvestPlus, and we have managed to do that now. All three governments now independently fund research on biofortified crops. It didn’t happen right away, it took many interactions, but now the Indian government has its own independently-funded biofortified research on crops. So they are enthusiastic about the potential.

Can only one nutrient per crop be fortified at a time? In future, could more than one nutrient be fortified per crop?

We didn’t want to do two nutrients at a time because it is a complicated process and it takes up to 10 years of breeding to fortify seeds with one nutrient. We had to do it one nutrient at a time.

A good example is maize. We chose vitamin A to begin with and fortified maize in 10 years. Now we have 10 years to add zinc. Latin America eats a lot of maize, but while Vitamin A deficiency is not a big problem there, zinc deficiency is. So we are developing maize varieties for Latin America that are high in zinc. What we accomplished with vitamin A biofortification for maize in Africa, we are starting to develop for Latin America.  

How many farmers are growing biofortified crops?

There are 170,000 wheat farmers growing biofortified crops in India. It is a drop in an ocean [India has 127 million cultivators], but you have to start somewhere. The mission is that 20 years from now, most wheat varieties currently being grown are biofortified and capture 75% of the market.

Are biofortified crops high in minerals yield after yield, or do farmers have to purchase biofortified seeds after every harvest?

[Biofortified seeds] are not hybrids, so can be planted from previous crops each year. This, however, can’t be done for too many years. They should be purchased every three years, as is the case with regular varieties.

In Africa, you have chosen maize for biofortification because that’s their staple crop, while in India it is rice and wheat. As diets change, will we change which foods are biofortified?

It is not so much the food staple which changes with changing dietary habits, it is other things added to the diet, if you look at what poor and rich people eat. In South India, poor and rich people alike eat rice, but they could add other things [like fruits, nuts or meat].

There is an Indian company Nirmal Seeds which is a biofortification success story. The pearl millet market differs from rice and wheat because of two things–it is not part of the food subsidy programme [Karnataka included millets in its public distribution system in 2012] and most of it is grown from hybrid seeds sold by private seed companies.

Nirmal had a particular variety which was biofortified with iron and also had a 10% higher yield. They told all of their 100,000 customers to buy this variety as it had a higher yield, and placed a logo on it showing it was high in iron. Within one or two years, 100,000 farmers were growing a high yield variety of biofortified pearl millet.

What can the Indian government do to accelerate biofortification?

Our discussions with Indian government started in 2004-05. At that time, there wasn’t much enthusiasm among scientists but we kept going year after year.

India now has a new policy that all varieties of millet have to meet a certain level of nutrition before being released in India. In many countries, you can’t release a seed variety unless it is first tested by the government for disease resistance, drought resistance and iron density above a certain level. So even a high-yielding variety with low iron levels can’t be released. India is the first country to have such standards for millets.

We want them to give highest priority to biofortification. Government needs to give an incentive [to farmers] in public interest, and they can attract the market by including biofortified produce in the food subsidy programme.

Are you satisfied with the progress that biofortification has made?

No, not at all. The mission is to capture 90% of crops grown in a country. There are now 10 million farmers using biofortified crops across the world and we want this to be 200 million farmers by 2030.

But releasing biofortified varieties in the market takes time. It takes 10 years to breed a high nutrient seed variety and 20 years to get it into the market. You have to create a pipeline of varieties year after year till it becomes the norm.

The modern seed varieties developed in the 1970s made a huge difference to yield, so farmers switched to them. But if any new seed [including biofortified varieties] offers just a 3% higher yield, it may not lead to a farmer switching. So it takes time.

It is a matter of sticking it out. You have to do that for a long time. I began raising funds in 1993 and HarvestPlus began operations in 2003. It took 10 years to get a little bit of funding for the first 10 years, but it was only enough to do experiments, not for breeding programmes. There were no private programmes. Now of course you have the hybrids in the private sector. So we work with the private seed companies. You have to have some money to get centres to try new ideas. Now we are at the point when they want to do it and donors are interested [in biofortification].

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

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In the age group of 5-14 years, indoor air pollution caused 4,700 deaths of children in India in 2016–the base year of the study–9% more than 4,300 deaths caused by outdoor air pollution in children of the same age group , according to the WHO study, released on October 29, 2018.

These findings come at a time when north India is again gripped by polluted air as winter approaches. Air quality in the country’s capital Delhi plunged to the season’s worst levels on October 25, 2018, The Wire reported on October 25, 2018.

The 24-hour average level of particulate matter (PM) 2.5–airborne particles 30 times finer than a human hair that can sicken or kill people by entering their lungs–was recorded at 168 microgram per cubic metre of air  (µg/m3) in Delhi on October 25, 2018, about seven times the WHO prescribed 24-hour safe level of 25 µg/m3.

PM 10–about seven times finer than human hair–was recorded at 369 µg/m3 in Delhi on October 25, 2018, about seven times the WHO’s 24-hour safe level of 50 µg/m3.

Indoor polluted air bigger killer of under-5 globally than outdoor air
Globally, indoor air pollution caused 3.8 million premature deaths in 2016–a toll greater than that due to malaria, tuberculosis and HIV/AIDS combined–including over 400,000 deaths of under-five children.

In the same year, outdoor air pollution was responsible for about 4 million premature deaths; of these, almost 300,000 were children under five years of age, according to the study.

“Breathing clean air at home is essential for children’s healthy development but widespread dependence on solid fuels and kerosene for cooking, heating and lighting results in far too many children living in terribly polluted home environments,” said the study.

About 3 billion people worldwide still depend on polluting fuels and devices for cooking and heating, as per the WHO study. In India, nearly half of the household population use solid fuel for cooking.

“Women and children spend most of their time around the hearth, exposed to smoke from cooking fires, resulting in indoor concentrations of some pollutants that are five or six times the levels in outdoor air,” the WHO study said.

To assess the levels of air pollution, the study looked at the exposure of children globally to PM 2.5 and its effect on their health during various stages of their physical development. In 2016, children in India were exposed to an outdoor PM 2.5 level of 65 µg/m3. This is more than six times the WHO annual safe level of 10 µg/m3.

A health emergency for children
In India, more than 98% under-five children lived in areas where PM 2.5 exceeded the WHO standard in 2016.

About 93% children and about 630 million under-five children in the world were exposed to levels of PM 2.5 higher than the WHO prescribed safe level of 10 µg/m3.

Children are vulnerable and susceptible to air pollution, especially during fetal development and in their earliest years, according to the study. “Their lungs, organs and brains are still maturing. They breathe faster than adults, taking in more air and, with it, more pollutants,” said the report.  

“Their bodies, and especially their lungs, are rapidly developing and therefore more vulnerable to inflammation and other damage caused by pollutants,” it said.

Acute respiratory infections caused by air pollution are the second biggest cause of death in under-five children globally, after premature birth–the leading cause–as per the study.

Under-Five Children Living In Areas Exceeding WHO Standard Of PM 2.5, By Country, 2016

Source: World Health Organization, 2018

The ravages of air pollution
Exposure to air pollution damages the health of children in numerous ways. Here are some of the evidence-based effects cited in the WHO study:

Adverse birth outcomes: Numerous studies have shown a significant association between maternal exposure to air pollution and adverse birth outcomes such as low birth weight, preterm birth and infants born small for gestational age.

“In India, infants born to women who used biomass fuels such as wood and/or dung as the primary cooking fuel in the home during pregnancy were more likely to be small for gestational age,” said the study.

Infant mortality: There is compelling evidence of an association between air pollution and infant mortality. As pollution levels increase, so too does the risk of infant mortality, particularly due to exposure to particulate matter and toxic gases.

Neuro-development: Prenatal and postnatal exposure to air pollution can negatively influence neuro-development, lead to lower cognitive test outcomes and influence the development of behavioural disorders such as autism spectrum disorders and attention deficit hyperactivity disorder.

Lung function: There is robust evidence that exposure to air pollution damages children’s lung function and impedes their lung function growth even at lower levels of exposure. Studies have found compelling evidence that prenatal exposure to air pollution is associated with impairment of lung development and lung function in childhood. Conversely, there is evidence that children experience better lung function growth in areas in which outdoor air quality has improved.

Acute lower respiratory infection, including pneumonia: Numerous studies offer compelling evidence that exposure to outdoor air pollution and indoor air pollution increases the risk of acute lower respiratory infections in children. There is robust evidence that exposure to air pollutants such as PM 2.5, nitrogen dioxide and ozone is associated with pneumonia and other respiratory infections in young children.

Asthma: There is substantial evidence that exposure to outdoor air pollution increases the risk of children developing asthma and breathing pollutants exacerbates childhood asthma. While there are fewer studies on indoor air pollution, there is suggestive evidence that exposure to indoor air pollution from use of polluting household fuels and technologies is associated with the development and exacerbation of asthma in children.

(Tripathi is a principal correspondent with IndiaSpend.)

Courtesy: India Spend
 

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A mother breastfeeding her infant. Breast milk is considered the best source of nutrition for babies. Lopolo/Shutterstock.com

As a pediatrician and a nutritionist, I have provided direct patient care to breastfeeding mothers and children and also advocated for breastfeeding policies and practices. The scientific research in support of breastfeeding is overwhelmingly clear, and most mothers in the U.S. have heard that message and learned from it. Marketing and sales of infant formula have surged in developing countries, however. That’s created a dilemma for the U.S., which has not wanted to restrict the US$70 billion infant formula business.

This comes at another price. Lack of breastfeeding worldwide is blamed for 800,000 childhood deaths a year.
 

Mother’s milk, for thousands of years

Direct breastfeeding and exclusive human milk feeding were the only sustainable infant feeding for thousands of years. Initial efforts prior to the 1800s to provide alternative animal milk sources for infant feeding resulted in greater risk of disease, often from infection, dehydration and malnutrition, as well as death.

The ability to sterilize and evaporate cow’s milk in the early 1800s allowed for preparation of alternative infant feedings, however. Throughout the rest of that century, different brands of alternate feedings, almost all based upon cow’s milk, proliferated.

The American Medical Association first called for standards for safety and quality in 1929. With more women working outside of the home during and after World War II, the use of infant formula become more common. Formula makers began to market formula as a convenience item to allow for a freer lifestyle and to replace breastfeeding. U.S. breastfeeding rates began to drop, hitting an all-time low of 24.7 percent initiation in 1971.
Medical professionals were not trained to support breastfeeding at this time, but mothers demanded to reclaim breastfeeding through a grass-roots movement. The resurgence of breastfeeding in the U.S. has been attributed in particular to efforts of founders of La Leche League International.

In 1981, the World Health Organization adopted the International Code of Marketing of Breast-milk Substitutes. All participants of the United Nations-affiliated World Health Assembly support breastfeeding and limit the marketing of alternative feedings, or infant formula, except the U.S.

The code restricts inappropriate marketing of infant formula to families and prevents formula companies from providing free formula to consumers or health care facilities. The code also calls upon all countries to enact legislation to enforce it. The code specifically does not restrict access to formula to those families who need or request to use it.

Also, the International Baby Food Action Network was formed to protect a mother’s right to breastfeed and an infant’s right to be breastfed, as well as to monitor compliance with the code. The WHO and UNICEF subsequently developed “The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding” in support of maternal and child health in 1990.

Among infants born in the U.S. in 2014, the most recent national data available, 82.5 percent were breastfed initially, but disparities existed based upon socioeconomic and demographic status.

A Lancet series on breastfeeding indicated that six- and 12-month continuation rates for breastfeeding remain low in most countries. The WHO Global Breastfeeding Scorecard also shows that no country is highly compliant on all indicators that monitor support and protection of breastfeeding.
 

Why breastfeeding matters

The benefits of breastfeeding for children and mothers are irrefutable. Initiation of skin-to-skin contact immediately after delivery, with early onset of breastfeeding within the first hour of life, supports newborn stability and provides protective immunoglobulins, especially secretory IgA, and other immune protective factors. Human milk provides human milk oligosaccharides, facilitating the colonization of the intestinal tract with probiotics and establishing a microbiome that protects against pathogenic bacteria.

In contrast, formula-fed infants face higher rates of gastrointestinal diseases, respiratory infections and a higher likelihood of sudden infant death syndrome. Longer term, they have a higher risk of obesity, type 2 diabetes, asthma and certain childhood cancers when compared to breastfed cohorts.

Also, mothers who fail to breastfeed according to current recommendations face higher risks of postpartum hemorrhage, breast cancer, ovarian cancer, obesity, type 2 diabetes and heart disease, including hypertension and myocardial infarction, or heart attack. About 20,000 cases of preventable death from maternal cases of breast cancer are attributed to lack of breastfeeding, according to the Lancet series.

Some of the poorest countries have the lowest breastfeeding initiation and duration and could gain the most in terms of health impact and economic benefit from improving breastfeeding rates.
 

What has the US done to support breastfeeding?

Partnership between governmental and nongovernmental agencies resulted in the formal designation of the United States Breastfeeding Committee in response to “The Innocenti Declaration.” The Department of Health and Human Services developed a mass media campaign in 2008 to support and promote breastfeeding.

In 2011, the U.S. Surgeon General’s Call to Action to Support Breastfeeding recognized key elements required to support breastfeeding, including health care, families, communities and employment. The Centers for Disease Control and Prevention has supported quality improvement initiatives aimed at changing maternity care practices to better support and promote breastfeeding. Breastfeeding efforts at the community level have involved obesity prevention efforts.
 

Influence of infant formula makers

Powdered infant formula must be mixed with clean water, which is often unavailable in many poor countries. Dima Sobko/Shutterstock.com

As more infants were breastfed in the U.S., formula makers turned their sights to developing countries. This contributed to a global decline in breastfeeding rates, similar to that seen in the U.S.

Infants in developing countries face the greatest risk from malnutrition, diarrhea, dehydration and death when fed formula that is contaminated by bacteria or parasites from unclean sources of water, or when bottles or nipples are not cleaned regularly in hot, soapy water. Diarrheal diseases and resultant dehydration are a leading cause of death in infants in poor countries, where breastfeeding may be lifesaving.

Good quality infant formula can be necessary and lifesaving when mother’s milk is not an option and pasteurized donor human milk is not available. However, the formula industry stands to gain the most financially when breastfeeding fails. The formula industry should not be influencing public health policy. The U.S. delegates to the World Health Assembly must lead the way in support of health policies based upon science.

As a member of the global community advocating for optimal public health and improving maternal child health outcomes, the U.S., I believe, bears responsibility to support evidence-based practices. In the area of breastfeeding support, the U.S. lags behind other resource-rich nations with a lack of universal health care, lack of paid maternity leave, and employment policies that do not provide universal support for employed mothers to continue breastfeeding.
 

Joan Y. Meek, Associate Dean of Graduate Medical Education; Professor, Clinical Sciences, Florida State University

This article was originally published on The Conversation. Read the original article.

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