'Nayana' - a unique mobile Eye Care initiative for people with diabetes

'Nayana' - a unique mobile Eye Care initiative for people with diabetes

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Nayana (which means 'eye') - a diabetes retinopathy prevention and treatment van - is a venture funded by the World Diabetes Foundation (WDF) in Karnataka state and is indeed a great boon for the rural people living with diabetes retinopathy. Three year ago when the van was first introduced in this area retinopathy treatment was only been available at certain urban hospitals. This means traveling 200-300 Km to access such care, resulting in huge barrier for people who live in rural areas and semi-urban areas. However, now Karnataka has achieved impressive results after introducing a unique to bring the treatment out the patients.

Every month the van visits 23 locations across 13 districts catering to the needs of 18.31 million people. These locations consist Of 8 Eye Hospitals/Eye Departments Of larger hospitals, 3 Government hospitals and 11 other clinics.

"We have completed 375 field days. We see an average of 33-34 patients per location. This is the only van in India which is providing these kinds of facilities for the prevention and treatment of diabetes retinopathy,' said Dr. Shivaram, a senior ophthalmologist and coordinator of this mobile eye care van, based in Yalundar, Karnataka. He further said, 'After the introduction of this van, 80 per cent of the people living with diabetes in rural areas have started getting treatment of retinopathy.'

People living with diabetes in this area have made a Diabetes Forum. This forum organizes periodical meetings to address the problem of diabetes. Mr. Mahadev Appa, a patient of diabetes retinopathy and retired government employee, said, 'I had been suffering from diabetes for the last 20 years. However, I had no idea about diabetes retinopathy till 2 years back when this van came to my village, B.R. Hills. Then I got myself checked and was diagnosed with diabetes retinopathy. I immediately started taking treatment and today my retinopathy problem is gone." His 24 years old daughter Gayatri feels that her father has got a new lease of life.

The increasing number of diabetes mellitus cases pose major health care challenges in India. According to the WDF, diabetes is the leading cause of blindness worldwide. In India it is estimated that one in five people who have had diabetes for more than 10 years will develop diabetic retinopathy.

The main stages of diabetic retinopathy are:

(i) non-proliferative - background diabetic retinopathy, characterized by the development of occasional small blisters (microaneurysms) caused by enlarged capillaries and small haemorrhages on the surface of the retina. Moderately severe to very severe non-proliferative diabetic retinopathy is also known as pre-proliferative diabetic retinopathy.

(ii) proliferative - symptoms of which include: blurred or double vision; reduced vision; and dark or floating spots.

In the non-proliferative stages, abnormal blood vessel permeability results in the leakage of water, blood cells, proteins and fats into the surrounding retinal tissue. At this stage, diabetic retinopathy usually shows no symptoms unless accompanied by diabetic macular edema.

People progress from pre-proliferative to proliferative diabetic retinopathy when new blood vessels grow from, and across the retina in response to lack of oxygen delivered by the original vessels. This is called neovascularisation. However, these new vessels are very weak and are even more likely to break and bleed into the clear gel (the vitreous) that fills the back cavity of the eye, blocking vision. Scar tissues may also form near the retina, detaching it from the back of the eye and resulting in blindness.


Diabetic macular edema

This is a common complication associated with diabetic retinopathy. It corresponds to a swelling in the macula, one of the areas of the retina. When some of the small blood vessels in the retina are blocked, the surrounding ones dilate to compensate for this. The dilated vessels are generally leaky and fluid builds up in the macula, which in turn causes the macula to swell and cease to function. It is the most common cause of visual impairment in patients with non-proliferative retinopathy. Loss of vision can occur suddenly and treatment is not very successful.

Treatment

'There is no pharmaceutical therapy available at present that stops the progression of diabetic retinopathy. However, lasers are widely used in treating diabetic retinopathy.. Laser is an intense and highly energetic beam of light that emerges from a light source and is focused on the retina' said Dr. Shivaram.

Nayana is thus actually rekindling the light in many eyes, which would otherwise have become sightless.

Amit Dwivedi

(The author is a Special Correspondent, Citizen News Service (CNS). Email: amit@citizen-news.org, website: www.citizen-news.org)

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'Diabetes doctor is at your doorstep' in Chunampet villages

'Diabetes doctor is at your doorstep' in Chunampet villages

The phrase 'the doctor at your doorstep' sounds incredible! But it is true. This is what the ‘MDRF-WDF Chunampet Rural Diabetes Prevention Project’ is about.

Recent studies have proved that diabetes has reached a pandemic stage, not only in urban India , but its prevalence rate in rural areas is also increasing rapidly. As of now, an estimated number of more than 20 million people with diabetes live in rural areas. According to Dr Viswanathan Mohan, a renowned diabetologist, ‘the incidence of diabetes in rural Kerala is more than in its urban areas. This could be due to eating of more rice (which is a staple food of south India), changing life styles leading to a more sedentary existence, and the genetic Indian disposition towards diabetes.’

Yet, virtually all diabetes efforts in India are currently focused in the cities.

With this in view, the above project was launched in March 2006 by the Madras Diabetes Research Foundation (MDRF), with the support of World Diabetes Foundation (WDF), Denmark. The project, which is of 4 years duration, led by Dr S.Ravikumar and his team, is being conducted in cluster villages at Chunampet, which is about 100km from Chennai.

In the words of Dr Mohan, one of the principal investigators of the project and President of MDRF, "This project aims to implement the four A test i.e. make diabetes health care available, accessible, affordable and acceptable in rural areas. It aims at addressing prevention of diabetes at all the three levels - primary, secondary and tertiary."


The highlight of the project is the use of a fully equipped Tele-medicine Van as a novel tool to make diabetes health care, including treatment of its complications, accessible to the rural population. With its help, 23449 people (above 20 years of age) from 42 villages have been screened for diabetes and its related complications, especially eye and foot complications. Thus 87.7% of the total population of these villages has been screened within a period of one and a half years. Just for the sake of figures, 970 people had known diabetes and 1114 persons were diagnosed for the first time. 1061 retinal examinations have been done in the telemedicine van. Those identified to have sight threatening diabetic retinopathy are treated free of cost at the main centre. Medicines are not provided free, except in very special cases of type 1 diabetes. But tests and specialized treatments are free. Thus effective strategies in community based diabetic screening programmes in a rural setting have been evolved by involving ophthalmologists of urban areas via telemedicine.

This seems to be a unique example of private public partnership, with the doctors ‘reaching out to the unreached’, and following a structured care recall programme by going back to the people frequently for follow up action.

Of course, the WDF did fund and initiate the project at the behest of MDRF. But then Mr. C. Ramakrishna donated his land, the National Agro Foundation lent its support, the Indian Space Research Institute provided the satellite communication for the telemedicine van, and Dr S. Ravikumar, project director, along with his dedicated team are managing the work with exemplary zeal. Apart from taking state of art medical care virtually to the people’s doorsteps, they regularly organize public awareness camps and nutrition workshops. I saw one such workshop where a cookery session of simple and healthy recipes was in progress and another one where the importance of diabetes care was being spread through a puppet show.

All these efforts have resulted in a perceptible reduction of glycated haemoglobin (HbA1c) by nearly 2%, which can lead to a risk reduction of 76% in retinopathy and 34% in albuminuria in persons living with diabetes. This would obviously lead to tremendous economic savings.

Apart from this, the project has empowered the local people, especially women and youth to become educators and catalytic spokespersons, spreading the message of better eating habits and healthier living. Surely it can be replicated in other parts of the country.

Shobha Shukla

The author teaches Physics at India's Loreto Convent and has been writing extensively in English and Hindi media. She serves as Editor of Citizen News Service (CNS).

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WDF transforming health policy through DIPAP

WDF transforming health policy through DIPAP

Diabetes in Pregnancy—Awareness and Prevention (DIPAP) - a success story of World Diabetes Foundation (WDF)


Prevalence of diabetes is increasing globally and this includes pregnant women with gestational diabetes mellitus (GDM).

GDM is defined as a transient abnormality of carbohydrate/ glucose intolerance of variable intensity - a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. Women with this condition are at an increased risk of diabetes in future, as are their children and the following subsequent generations.

Thus an important public health priority in the prevention of diabetes is to address maternal health during ante and post partum period. Primary prevention will most likely reverse or halt the trend of increasing diabetes cases. Keeping this in mind, the World Diabetes Foundation (WDF) has been funding the project Diabetes in Pregnancy - Awareness and Prevention (DIPAP), run by diabetologists at Dr V Seshiah’s Diabetes Care and Research Institute at Chennai, working with the Tamil Nadu government in India.

There is no current national data regarding GDM. But on the basis of a community based study carried out in the Government Maternity Hospital , Chennai, it was found that the prevalence of GDM in urban, semi urban and rural areas was 17.8%, 13.8% and 9.9% respectively. Greater incidence in urban areas could be attributed to a more mechanized and sedentary life style coupled with increased maternal age.

The morning of 27th November 2008 was bleak indeed, what with the terrorists indulging in inhuman and senseless killings in Mumbai and cyclone Nisha playing havoc with normal life in Chennai. But somehow we managed to reach the government hospital of Chennai Municipal Corporation at Saidapet. This is one of the several hospitals where the DIPAP project has been running successfully since 2004.


It really lifted my low spirits to see about 20 women who had braved the inclement weather to be there for screening/ follow up action for GDM. The two lab technicians, Vimala and Radhi, appointed by the project managers, were busy taking the blood samples for glucose monitoring.

Uma Bhaskar, a 29 year old mother of two kids was all praises for the project team. She was a high risk patient due to her obesity and was diagnosed with GDM during her first pregnancy, 4 years ago in a private clinic. But did not follow it up, till she came to this hospital two years ago during her 2nd pregnancy. She had to be administered insulin during pregnancy and is still on oral medication, along with diet control. She comes for regular checkups and feels that likes of her have benefited immensely from this programme.

21 year old Gayatri, mother of a one year old daughter, travels 21 km. to reach this hospital. She was referred to this hospital for an ultra sound scan and diagnosed with GDM during routine screening. However, she was able to control her condition through diet control and regular walking, and did not require medication. She remarked with a grin that now she was eating less sweets and felt better equipped to manage her condition, thanks to DIPAP.

Dr Madhuri Balaji, who is closely associated with this project, spoke of the main problems faced during implementation of the project:

(i) lack of awareness in pregnant women about GDM;

(ii) failure of the women to follow up with subsequent check ups (the first checkup should be done around 12 weeks of gestation, with follow up screenings during 24th and 30th weeks). This may happen due to relocation of the woman to her mother’s house for delivering her first child, as is customary. Or, if it is her second pregnancy, then she cannot afford the long wait at the hospital with a small child in tow;

(iii) diet and other controls may not be followed once the pregnancy period is over. The woman has other things to care about now and her well being comes last in the family.

The medical officer in charge of this hospital Dr Shanthi Viveka, was all praises was this laudable effort of WDF, as were the other nursing staff. They felt that the project has benefited everyone. But they were a little wary as to what would happen once WDF disassociated itself with the project. She cited shortage of hospital staff as well as poor infrastructure, as possible impediments in continuing with the mandatory screening of pregnant women all over the state.

WDF has thus successfully implemented a system which screens and controls gestational diabetes. It has been able to initiate a change in health policies in the region to the extent that it has now become mandatory to screen all pregnant women for GDM in Tamilnadu. But it remains to be seen how well the government will implement it through its own resources all over the state. Also,this example is worth emulating in other parts of the country too.

Shobha Shukla

The author teaches Physics at India's Loreto Convent and has been writing extensively in English and Hindi media. She serves as Editor of Citizen News Service (CNS).

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Activists decry India's deferment of pictorial health warnings on tobacco products

Activists decry India's deferment of pictorial health warnings on tobacco products

Civil society in India has strongly condemned the recent decision of the Group of Ministers (GOM) in India to defer the implementation of pictorial health warnings on tobacco product packages which was to come in to effect from November 30, 2008. The pictorial warnings have been deferred, again, till at least end of May 2009.

This decision of GOM is very unfortunate and has appalled the public health community across the country, said members of Advocacy Forum for Tobacco Control (AFTC). By repeatedly postponing the implementation of pack warnings on tobacco packages, the government is failing from performing its important duty to provide essential information to make Indian consumers aware of the effects of tobacco, particularly to the vulnerable poor and the illiterate, further said AFTC members.

“The decision to defer and unduly delay the mandatory placement of pictorial health warnings on tobacco products is a cynical abdication of governmental responsibility to protect people’s health by providing them much required information on the deadly effects of tobacco consumption” said Dr K Srinath Reddy, President, Public Health Foundation of India.

“The government should set up strong and transparent mechanisms at the highest levels to prevent industry interference in the implementation of tobacco control measures and policy making processes. Since the tobacco industry sells a product that kills one million people in India annually, therefore, industry’s interests will always be in conflict with the nation’s public health and economic aspirations” remarked Bhavna B Mukhopadhyay, Senior Director, Voluntary Health Association of India (VHAI).

Article 11 of the Framework Convention on Tobacco Control (FCTC) imposes a time bound obligation on each of its signatory parties, of which India is also a part, to implement pictorial health warnings on tobacco product packages within 3 years of its coming into force. The deadline for India to implement pictorial health warning was 27 February 2008. It’s a national shame that India, once considered a global leader in tobacco control has repeatedly failed to enforce this provision of pictorial health warnings. Countries across the world (who are party to FCTC) have unanimously adopted international standards for implementing the international tobacco control treaty that mandates health warning labels that cover 50 percent or more, and no less than 30 percent, of tobacco packaging and feature effective pictures of health conditions caused by tobacco.

“The news of postponement of implementation of pictorial warnings was most unfortunate. Especially because it came within a day of unanimous adaptation of guidelines for article 11 of FCTC dealing with the packaging and labeling of tobacco products by the Conference of Parties of 160 governments meeting in Durban, South Africa on November 22, 2008. The Government of India was present in that meeting and the decision was applauded by the entire global community” noted Luther Terry Awardee Dr PC Gupta, Director, Healis Sekhsaria Institute for Public Health.

The decision to defer the implementation of already diluted, delayed and long overdue pictorial health warnings on tobacco packages is nothing but retraction of India’s commitment to FCTC. By deferring the implementation of graphic warnings, the international position of India will be pushed much below from the 34th position that was accorded to India in the recent international status report adopted by Canadian Cancer Society to a much lower ranking.

"It is high time that national tobacco control policies in India are congruent to what India is obligated to do by ratifying the international global tobacco treaty - Framework Convention on Tobacco Control. Last week in the global meeting, India adopted the strong guidelines for Article 5.3, to protect health policies from tobacco industry interference” remarked Bobby Ramakant, from the Indian Society Against Smoking, Asha Parivar, who also represents Network for Accountability of Tobacco Transnationals (NATT).

Civil society organizations strongly urges to the Indian government to implement the graphic warnings without further delay. The government must act now to protect Indian citizens, especially the vulnerable children and illiterates from serious health hazards caused due to tobacco consumption.

Shobha Shukla

The author teaches Physics at India's Loreto Convent and has been writing extensively in English and Hindi media. She serves as Editor of Citizen News Service (CNS).

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Another blow to enforcement of tobacco control policies in India

Another blow to enforcement of tobacco control policies in India

Pictorial warnings on tobacco products postponed 7th time

Right after the strong and effective guidelines to stop tobacco industry interference in health policies were adopted by the government representatives of 160 countries including India, the pictorial warnings on all tobacco products that were supposed to become mandatory from 30 November 2008 in India, were, again delayed – reportedly due to hectic lobbying by the industry allies and other entities like the beedi growers’ association.

Pictorial warnings on tobacco products have been delayed, at least, seven times. Before going to the 3rd Conference of Parties (COP3) to the global tobacco treaty (Framework Convention on Tobacco Control), the Indian Ministry of Health and Family Welfare had revealed before the Central Information Commission that tobacco industry is putting "pressure" to relax the tobacco control policies (source: The Hindu, 14 November 2008).

The Article 5.3 of the global tobacco treaty, if defined broadly, recognizes “the tobacco industry's fundamental and irreconcilable conflict with public health.”

The tobacco industry interference has times and again weakened and delayed the enforcement of the public health policies - for example, more than 70 court cases were filed against tobacco control policies in Indian courts in September 2008, and due to aggressive lobbying, the consultative Group of Ministers (GoM) formed to review the pictorial warnings on tobacco products, had diluted the pictorial warnings provision and postponed the implementation of pictorial warnings on tobacco products at least six-times earlier. This is the seventh time the pictorial warnings on tobacco products have been again postponed, as reliable sources revealed, to the end of May 2009.

The industry interference in public health policies certainly needs urgent attention to save lives otherwise it will continue to threaten to reverse the great advancements made in forging public health policies and implementing them. Meantime tobacco continues to kill more than a million people in India, and 5.4 million globally, every year.

Also when these pictorial warnings were finally approved by a GoM, why did the GoM met again in an emergency meeting a week before the pictorial warnings provision was about to become mandatory? GoM including the Union External Affairs Minister - Pranab Mukherjee, the Union Information and Broadcasting Minister - PR Dasmunsi, the Minister of State for Labour and Employment - Oscar Fernandes the Union Minister for Commerce and Industry -Kamal Nath, Union Minister for Culture and Urban Development -Jaipal Reddy and Union Health and Family Welfare Minister Anbumani Ramadoss,

The GOM in an earlier meeting this year headed by India's External Affairs Minister Mr Pranab Mukherjee had agreed for two mild images of a scorpion signal depicting cancer or an x-ray plate of a man suffering from lung cancer as pictorial warning to deter people from smoking.

These pictorial warnings provide smokers with helpful information on the health effects. Most smokers want this information, and certainly want their children to have this information too. The tobacco industry is continuing its decades-long strategy of trying to minimize the effectiveness of package warnings. The tobacco industry is no friend of smokers - and ironically it's true that 'the tobacco industry kills its best customers'.

Pictorial warnings on all tobacco products are a good public health strategy because the cost of package warnings is paid for by tobacco companies, not government. Also this should not be looked upon as an isolated initiative rather has to be supported by comprehensive healthcare, legislative and education programmes to attain long-run public health gains. Pictorial warnings may also be appropriate, particularly in countries with low literacy rates or where research shows that smokers are ignoring standard warning labels.

Several nations have implemented strong health warning label requirements. Examples include:
- Canada, whose health minister recently proposed enlarging the labels from 30% of the package face to 60%;
- Thailand, which has added the message "SMOKING CAUSES IMPOTENCE" to its list of required warnings; and
- Australia, which was the first nation to require that "how to quit" information be printed on every pack.
- South Africa, Singapore and Poland also require strong warning labels.

Over past years there were consistent efforts to water down the implementation of the tobacco control policies in India. India's Union Minister of Labour and Employment, Mr Oscar Fernandes, who is also a member of GoM, had earlier said while replying to a written querry in the Lok Sabha (parliament) on 21 April 2008: "Public health measures such as pictorial health warnings on tobacco products don't have any immediate economic impact on the industry due to the item's addictive nature and the time taken for demand reduction, according to various studies." Mr Fernandes also told the Parliament that 'his ministry was receiving representation from various organisations/central trade unions such as CITU, the Tobacco Institute of India, Federation of Farmers Association and others particularly relating to apprehension of loss of employment, arrangement of alternative jobs to the affected 'beedi' workers and adverse effect on health among others (Source: PTI, 21 April 2008).

On 15 December 2006, GK Sanghi had raised the question in Rajya Sabha about Government's response to the 'beedi' workers agitating against the proposed printing of skull and bones on 'beedi' packs. In May 2007, Gutkha (chewing tobacco) manufacturers in India were attempting to get a court injunction to delay the directive requiring all tobacco products to carry health warnings. Another interesting attempt was made in the same month (May 2007) when External Affairs Minister Pranab Mukherjee suggested in his letter that the sign will likely offend the Muslim community, who are employed in the beedi industry of Murshidabad, as they unlike Hindus bury their dead, and do not burn them. Another major move to water down the Indian Cigarette and other tobacco products Act also happened in May 2007 when Tamil Nadu Chief Minister M Karunanidhi called on the central government to defer implementation of the legislation, saying that "the move has threatened the livelihood of 1.5 million beedi workers in the State." Karunanidhi said beedi manufacturers in the State have stopped production with some tobacco industry players threatening to go on an indefinite strike from 1 June 2007 if the Act is enforced. Also in May 2007, The Karnataka Beedi Association in India said that the directive to print skull and bones on beedi packs would result in a steep decline in beedi sales adversely affecting the welfare of beedi workers. The All India Beedi Industry Federation had also written to Prime Minister Manmohan Singh that the 2 October 2008 smoking ban has made things tough for the beedi industry. Meanwhile, "we have told the Prime Minister ... that a forced printing of the pictoral (cancer) warning … will lead to a further decline in sales by 30%," had said Rajnikant Patel, president of the All India Beedi Industry Federation to the media.

As per the World Health Organization (WHO)’s MPOWER Report (2008), despite conclusive evidence, relatively few tobacco users understand the full extent of their health risk. Graphic warnings on tobacco packaging deter tobacco use, yet only 15 countries, representing 6% of the world’s population, mandate pictorial warnings (covering at least 30% of the principal surface area) and just five countries with a little over 4% of the world’s people, meet the highest standards for pack warnings.

“The bidi workers, majority of whom are bidi smokers, are in favour of pictorial health warnings on bidi packets. About 73 percent of the workers agreed that bidis are harmful to health and 79 percent felt that picture based warnings are important on bidi packets, at least to protect the younger generation,' according to the study conducted by the Voluntary Health Association of India (Source: IANS, 3 November 2008).

The fight to enforce public health policies, and put a check on industry interference, is clearly a long uphill battle indeed.

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Sustainable agriculture can be the back-bone of Indian economy

Sustainable agriculture can be the back-bone of Indian economy

"Who said agriculture is a business of loss. I am saving more than Rs 80,000/- (about USD 1,750) every year and providing bread & butter to my 11 family members who are dependent on me," said Prabhavati Devi, who lives in Sardar Nagar block of Gorakhpur district. She has one and half acres land in which she is producing more than 86 types of crops annually. Prabhavati Devi is doing organic farming, which is a very reliable method of sustainable agriculture resulting in high production at low cost.

According to her, '12 years back I too was doing chemical farming and had no idea about this model of sustainable agriculture which involves an efficient management of time and land available for farming.

However, when I came in contact with Gorakhpur Environmental Action Group, GEAG (A Eastern UP based Non-Governmental Organization), I learned how to use indigenous-technical knowledge.' She further said that, 'although my husband and other family members are not supportive of my agriculture work, I have shown them how a woman farmer can make agricultural production a sustainable and financially viable activity.' She is also the head of 'Yamuna Self Help Group' which has now become a Federation having five committees. She is also provides training to other farmers all over India. Thus Pravhavati Devi has become an ideal other women farmers.

According to Dr. Sheema Tripathi, working in GEAG, "sustainable agriculture should not be confused with organic farming as both are very different form each other. Sustainable agriculture means not only the withdrawal of synthetic chemicals, hybrid-genetically modified seeds and heavy agricultural implements, it also tries to simulate the conditions found in nature. Sustainable agriculture involves Multiculture, intercropping, use of farmyard manure and remnants, mulching and application of integrated pest management. If this is followed then there is no reason why agriculture cannot be an economically viable activity in addition to being environmentally sustainable.'

She further said that, 'Sustainable agriculture is very profitable in terms of money and soil conservation in the long run. Without doubt, it can meet the requirements of the country. GEAG tried to study this issue in eastern Uttar Pradesh and found that very few farmers follow the whole set of practices required in sustainable agriculture. However, thousands of farmers across the state use chemical pesticides.'

According to The United Nations Population Fund, (UNFPA) report India is projected to be the most populous country in the world by 2050, overtaking China. Its population, now 118.6 crores, is projected to be 165.8 crores in 2050. Increasing population growth is likely to reduce the area under agriculture. The major thrust of the agricultural development programmes in India is on efficient use of scarce natural resources like land, water and solar- energy. This can be achieved only through improved productivity in a cost-effective manner, which alone would result in the welfare of the farmers and agricultural labor. Balanced and integrated use of fertilizers, agricultural credit, institutional support, accelerated investments in agriculture, enhancing the competitiveness of agro-exports, creation of additional irrigation facilities etc. are being given encouragement through various schemes and activities of the Government of India.

'Most people in rural India depend directly or indirectly on farming for their livelihood.
Despite this, not enough attention has been given to agriculture to overcome poverty. The agriculture sector has a vital place in the economic development of India. However, very little interest has been shown by the policy makers to strengthen sustainable agriculture in India,' said Dr. Shiraj A. Wajih, President of Sustainable Agriculture Network (SANUP), a network of more than 200 NGOs working in agriculture sector in Uttar Pradesh. SANUP is the only network in Uttar Pradesh which is directly working with the farmers to strengthen their knowledge of sustainable agriculture growth. However, it is a matter of concern that even the government, along with the multinational companies, seems to be aggressively promoting chemical farming in order to make quick profits. This is violating the basic norms of sustainable agriculture and will be counter-productive in the long run.' He further said that, 'the biggest and most important achievement of sustainable agriculture network has been in sustainable agriculture literacy in bringing about a change in farmers thinking and perceptions.'

India is a land of agriculture and which needs to be strengthened in a sustain way. The government should make farmer-friendly policies and should encourage farmers to adopt low input cost and high production methods. In this way agriculture will become not only a means of subsistence for the poor but will also become the back-bone of Indian economy.

Amit Dwivedi

(The author is a Special Correspondent to Citizen News Service (CNS). He can be contacted at: amit@citizen-news.org, website: www.citizen-news.org)

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Expanding Access to the Female Condom

Women represent over 47 percent of those infected with HIV worldwide, and will soon make up the majority. Each day, millions of women around the world are put at risk of HIV infection from unprotected sexual intercourse. Greater focus is urgently needed on strategies that address women's disproportionate risk of infection, enable them to negotiate safe sex, and provide tools, such as female condoms, to protect themselves from infection. Women and girls remain at risk because they are economically and socially dependent on husbands or partners, are at risk of sexual coercion and violence, and have little power to negotiate safe sex.

In sub-Saharan Africa, the hardest hit region, women account for more than 55 percent of all infections. "In India, where HIV is spreading rapidly, current data from UNAIDS and India's National AIDS Control Organization reveal that women make up at least one quarter of all HIV infections," states Avni Amin, Senior Program Associate at CHANGE. The female condom is the only existing method of STI and HIV prevention that can be initiated and controlled by women. Data show that the female condom is a highly effective barrier against transmission of HIV and many other sexually transmitted infections. Consistent and correct use of the female condom reduces the risk of sexually transmitted infection (including HIV) by between 94% and 97% per act of intercourse. In addition, the female condom allows women to simultaneously protect themselves from unwanted pregnancy.

Studies from several countries indicate that with appropriate levels of education, training, and support, women find the female condom both effective and empowering, allowing them to negotiate safe sex. In Ghana, observes Alice Lamptey, National Coordinator of the Society for Women and AIDS in Africa (SWAA)-Ghana, "it is accepted that men can do what they like with their wives and girlfriends. We had to find a way to protect women, and we found the female condom." Ghana's female condom program is currently one of the most successful in the world.

Cost, lack of knowledge of the method, and provider biases are the most important impediments to increased access to the female condom worldwide. The female condom sells for roughly U.S. 55 cents per unit, which is clearly too high for sustained use in many settings. This is partly related to the lack of public sector investment in this method by governments or international donor agencies. The United States and other donor countries could dramatically reduce HIV transmission by investing in expanded access to the female condom and the programs needed to support sustained use worldwide. By investing in strategies to support expanded use of the female condom, we can start saving lives right now!

Ishdeep Kohli-CNS

Countries unite against tobacco industry interference

Countries unite against tobacco industry interference

GLOBAL TOBACCO TREATY MEETING ADOPTS STRONG GUIDELINES FOR PROTECTING AGAINST INDUSTRY ABUSE

DURBAN: Today on 22 November 2008, 160 countries agreed on strong new guidelines to block tobacco industry interference in global health policies and the implementation of the global tobacco treaty.

Since it took effect in 2005, implementation of the global tobacco treaty, formally known as the Framework Convention on Tobacco Control (FCTC), has been systematically obstructed by Big Tobacco. The abuses of corporations like Philip Morris International (PMI), British American Tobacco (BAT) and Japan Tobacco have ranged from attempting to write tobacco control laws, blocking the passage of smokefree legislation, and using so-called "corporate social responsibility" to circumvent ad bans.

Tobacco industry interference has been the number one obstacle to the treaty's implementation, and ratifying countries now see protections against this interference as the backbone of the treaty.

"The tobacco industry has long exploited every opening to perpetuate a preventable epidemic that pads their bottom line," said Kathy Mulvey, international policy director of Corporate Accountability International. "These guidelines will help advocates and public officials begin to slam the door on tobacco industry tactics, and focus on implementing the treaty's lifesaving measures."

The new guidelines are designed to give teeth to Article 5.3 of the treaty which states, "in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law."

The guidelines include the following recommendations, rooted in the principle that the tobacco industry has a fundamental and irreconcilable conflict with public health:
- governments should reject partnerships with the tobacco industry;
- conflicts of interest such as the "revolving door" between the tobacco industry and public health offices, government investments in the tobacco industry and tobacco industry representation on tobacco control bodies should be avoided;
- government interaction with the tobacco industry should be strictly limited and transparent;
- the tobacco industry should be required to be transparent about its activities, a measure which will help to counter interference by Big Tobacco's front groups and allied organizations.

"This week a diversity of countries, facing a diversity of tobacco industry offenses, arrived on a set of universal principles to strip this industry of its ability to threaten public health," said Network for Accountability of Tobacco Transnationals (NATT) spokesperson Bobby Ramakant. "An important precedent has been set that life-threatening corporate practices will not be tolerated."

Ratifying countries also approved strong guidelines for tobacco product packaging and banning tobacco advertising, promotion and sponsorship, but funding to support treaty implementation remains in question.

"In sum, these meetings have been an overwhelming victory for tobacco control," said Sam Ochieng from NATT in Kenya. "But now our work begins anew in implementing this landmark treaty. Our initiatives on the ground will require increased funding and constant vigilance against an industry whose profit-driven avarice will continue to challenge our advances, though its power to do so has been greatly reduced."

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Media for Freedom, Kathmandu, Nepal
Citizen News Service (CNS)
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Bihar and Jharkhand News Service (BJNS)

The Politics of Big Capital and the Poor in Narmada Valley

The Politics of Big Capital and the Poor in Narmada Valley
Dr Rahul Pandey

On the 5th of November I was in Khandwa, a town in central India, taking part in a rally organized by the Narmada Bachao Andolan (NBA), or Save the Narmada Movement. About 20,000 rural people, mostly landless farm labourers or small-medium farmers, many of them tribals, had traveled 50 to 400 km on tractors, trucks and buses to participate in the rally, all at their own expense. Every family carried a packet of food cooked at home to last for a day or two. The women with babies carried them along as well.


The day long rally and mass gathering looked like a sea of people - women in colourful saris and men in white dhoti-kurta - united by common peril and anger. The peril of them and their children becoming pauperized. The anger at being taken for a ride. These people represented more than 100,000 families, or over half a million citizens, who have been displaced because their original villages and lands are either submerged or about to be submerged by the reservoirs of six big dams built on the river Narmada. The dams are Indira Sagar, Onkareshwar, Maheshwar, Maan, Upper Veda, and Bargi. The people in the rally narrated their woes and demanded land for the lost land that is guaranteed by the government's own resettlement and rehabilitation (R&R) policy but denied to them.

The experience of these people from the Narmada valley is the story of how the poor always get a raw deal by the politics of the market driven economic paradigm. It is the story of how inequality and poverty are reinforced by the current system. Broad contours of this story are the same all over the globe wherever the profit and growth objectives of big money come in conflict with the basic livelihood rights of the economically weak - landless labourers, small farmers and artisans in villages, tribals in forests, fishing communities in coastal regions, and city based vendors and workers living in slums and other low income areas.

Here is what has happened to the people in the Narmada valley. Some time back a team of five persons from academic institutes, including myself, carried out an independent survey of 429 families displaced due to Indira Sagar dam, to understand how their living conditions have changed after displacement. At the time of the survey these families had been already displaced for 3-5 years and living either privately or on government resettlement sites. We visited eleven such sites. Most of resettlement sites lacked basic amenities like access to markets and employment opportunities, proximity to affordable and cultivable land, trees, clean water, grazing land for cattle, and drainage.


Although no family received any land as mandated by the R&R policy, the government provided them some cash compensation against the fixed property lost in submergence. This compensation was grossly insufficient to help families make productive investments. We did not find a single family that could rebuild its lost livelihood even after 3-5 years of displacement. Most farmers lost substantial farmland to submergence but could purchase at best a small fraction as the cash compensation for land was much below the market rate. Small farmers became either landless labourers or more dependent on farm labour work to supplement insufficient income from farming. The landless farm labourers were pushed further to the brink of precarious survival. Their income fell sharply and became more uncertain as both farm labour demand and wage rates were squeezed in the areas in the vicinity of submergence.

As economic hardship deepened and common grazing land was no longer available, almost all families were forced to sell all or part of their cattle. Several children were withdrawn from schools. Health problems like physical illness and psychological depression had increased. With earning opportunities shrinking locally, seasonal migrations had become common and some families were contemplating longer-term migration. The irony was that people were not sure which would be a good place to migrate and whether their economic condition would improve after that. In retrospect, almost everyone we met felt they should have been given land for land.

When people, whose main skill base is in agriculture and local resources, are suddenly uprooted, there are only two ways to rebuild lost livelihoods. Either they get back good quality agricultural assets (i.e. cultivable lands along with support systems) and other natural resources which they can harness with the skill and knowledge they already possess. Or they are provided with alternate productive assets with potentially attractive markets and granted sufficient material support and cushion of time to acquire new skill base required to operate new assets economically, source new inputs, market new outputs, and begin lives afresh.

The people who came for the NBA rally were the ones for whom sparing a day from farm work and traveling up to Khandwa was not easily affordable. But they came because they are convinced that the only hope to gain their right is to come together and make their voices heard. They also have faith in NBA activists like Chittaroopa Palit, Alok Agarwal and others who have stood behind them like a rock and have patiently pursued countless court cases on their behalf.

Though justice has been repeatedly repudiated, persistent struggle has also brought some successes like the recent High Court judgment that land for land with a minimum of 2 hectare be allotted to each displaced family. However, the State Government, as always, wants to reject this demand and has challenged it in the Supreme Court. So yet another tiresome phase of court hearings lies ahead. Every flicker of hope has been followed by long spell of despair. The disciplined march and gathering of 20,000 people, all carrying in their heart such memories of years of frustration and struggle, yet displaying remarkable resolve and calmness, resonated in such a way that it felt like emanating spiritual energy of 20,000 individuals meditating together.

A friend of mine who was shocked at listening to this story, asked, "How could the Government subject half a million citizens to such cruelty?" The answer is: our political structures are not democratic enough to empower the ordinary people. On the contrary, such people are constantly denied their right to livelihood when they come in the way of commercial projects that demand large scale acquisition of land, water, minerals, forests and other natural resources. The state has almost always sided with the big business. This is how the free capital driven markets work. They strip the poor of whatever capital they have and pass it to those who are already overloaded with it. In case of Narmada dams, for instance, the State Government has granted several concessions to the corporations owning the dams. As for the displaced families, it says there is no land available in the state. At the same time it has doled out more than 100,000 acres for biodiesel crop plantations and thousands of acres for industrial parks and special economic zones.

Interestingly, the GDP of the nation may often rise in the process as most of lost wealth of the poor was not accounted in the formal markets whereas most of new wealth acquired by the rich is. Hence the process of pauperization of the poor does not raise hackles of those policy makers, economists and intellectuals who are worried mainly about economic growth and capital investments. It also does not bother many politicians as their funds come from supporting the rich and votes from dividing the vulnerable poor. Thus the poor like those living in the Narmada valley remain perpetually caught in a recessionary spiral. The recent global financial recession is no news to them.

So, what can be done when years of chasing court cases and appealing to the governments have not yielded much? The only non-violent way is for the people to reorganize with greater vigour and numbers and make the system accountable. The people's movements like the NBA do not oppose industrialization. They oppose the process that unilaterally takes away resources from the displaced communities and makes their living conditions worse, and channels most of the benefits of industrial projects to the affluent. As an alternative, they demand a much more democratic way of deciding who will give up what resources, how the displaced will be rehabilitated, and how the benefits of projects will be shared.

Dr Rahul Pandey

The author is a former faculty member of Indian Institute of Technology (IIT) Bombay and Indian Institute of Management (IIM) Lucknow, and is currently a member of a start up venture that develops mathematical models for planning and policy analysis. His areas of interest include mathematical modeling, biological evolution, physics, development and environment, sustainable economics and industry, and social change. He can be contacted at rahulanjula@gmail.com

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South-East Asian Diabetes Summit to open up in India

South-East Asian Diabetes Summit to open up in India

The Diabetes Summit for South East Asia is being organized in Chennai from 28th to 30th November 2008, by the World Diabetes Foundation ( WDF) , in collaboration with the World Health Organization (WHO), South East Asia Regional office (SEARO), the International Diabetes Federation (IDF) and the World Bank.

The aim of this summit is to serve as a forum where key stakeholders, in the area of non communicable diseases (primarily diabetes), can interact with key opinion leaders, international media and WDF partners, with a view to encourage policy makers to prioritize prevention, care and treatment of diabetes in the developing world in a sustainable manner.

Diabetes is one of the fastest growing diseases in the world with over 230 million people already affected. It is the world’s leading cause of heart disease, stroke, blindness, kidney disease and lower limb amputation. The incidence of diabetes is five times higher among Asians than in white populations. An estimated 3.8 million people died in 2007, globally, because of diabetes. In India, unwittingly known as the ‘diabetes capital of the world’, an estimated 40.9 million people were living with diabetes in 2007. This figure is projected to rise to 69.9 million by 2025, making every fifth person living with diabetes to be an Indian. WHO estimates that mortality from diabetes and heart disease cost India $210 billion yearly in terms of lost productivity resulting from premature deaths. This is likely to increase to $335 billion yearly in the next 10 years..

What is diabetes?
It is a condition in which the body cannot regulate the amount of glucose in the blood. Glucose is produced by the liver from the food we eat and its level is regulated by several hormones, including insulin which is produced by the pancreas. Insulin allows glucose to move from blood to liver, muscle and fat cells where it is used as fuel/energy. People with diabetes either do not produce enough insulin (Type 1 diabetes) or cannot use insulin properly (Type 2 diabetes). Thus the glucose stays in the blood, harming other tissues/ organs as they are exposed to high glucose levels. At the same time, cells are deprived of glucose for energy. The normal fasting blood glucose level is about 100mg/dl and post lunch level is 140mg/dl.

Type- 1 diabetes: It is an auto immune disorder in which the body’s immune system attacks the cells producing insulin. Thus the body either does not produce any insulin or too little of it. The cause could be genetic or due to environmental triggers. It is typically recognized in childhood and adolescence, often in association with an illness—viral or urinary tract infection or some injury. In older persons it can occur due to destruction of pancreas by alcohol/ disease/ surgical removal/ progressive failure of pancreatic beta cells which produce insulin.

The warning signs are nausea, vomiting, dehydration, excessive thirst, frequent urination, constant hunger and unexplained weight loss, extreme tiredness, blurred vision.

Treatment of this type of diabetes entails daily insulin injections of correct dosage to be taken, generally before meals, coupled with a consistent healthy diet. As of now, its onset cannot be prevented, but it can definitely be controlled.

Type- 2 diabetes: It occurs when the body is unable to process the insulin produced by the pancreas. This is called insulin resistance. The pancreas try to overcome this by producing still more insulin, thus compounding the problem. It is typically recognized in adulthood, usually after 45years of age. But now it occurs in children also, which indeed is worrisome. The cause for this type of diabetes could be genetic. But in most cases it is due to a sedentary life style coupled with unhealthy dietary habits and obesity.

The symptoms of this type of diabetes are excessive thirst, frequent urination, lethargy, slow healing wounds, itching and skin infections, blurred vision, irritability, weight loss. It can usually be controlled with proper diet (which is high in fiber and low in saturated fats), weight control, physical exercise and oral medication. But sometimes, insulin is required to control the blood sugar levels.

Gestational diabetes: it occurs during the second half of pregnancy and typically goes away after delivery. But such women are more likely to develop Type- 2 diabetes later in life. There has been an eight-fold increase in its occurrence in the last two decades. This might be because women are having babies when they are older or because obesity (a risk factor for diabetes) is increasing. The extra stress on the body during pregnancy can also result in high glucose levels. As it is, insulin needs in pregnancy are two or three times greater than normal from about 24 weeks. Up to 16% of women develop gestational diabetes and it is usually detected with a routine glucose tolerance test between 24 and 28 weeks of pregnancy. Babies of women with gestational diabetes could have problems too. They are larger in size, putting them at risk during delivery. Also, they are more prone to developing Type-2 diabetes later in life.

Diabetes is taking a huge toll of human health and life, particularly in developing countries like India . Type 2 diabetes is assuming epic proportions and holding an entire generation to ransom. It is affecting an increasing number of children/ adolescents from all income groups. In India , there has been a tenfold increase in childhood onset of Type-2 diabetes in the last 20 years.

Diabetes in children is a global public health issue with close to 305,000 children living with diabetes world wide. In fact, Tamilnadu ( the state in which this summit is being held) is contemplating to declare those living with Type-1 diabetes as ‘metabolically challenged’, putting them at par with other disabled persons in terms of availing government benefits and schemes including reservations. This move might bring positive reinforcement into the fight against diabetes; but it may also lead to a stigmatization of those affected.

In countries like India , lack of proper health care infrastructure, rampant ignorance and absence of clear cut guidelines makes the approach to diabetes ad hoc. Lack of awareness in patients and poverty is a key factor in improper care. There is need for an integrated public health policy for screening and care of diabetes.

Drastic and immediate preventive measures are needed at the community and media level. Community action should involve improved maternal nutrition, periodical health checkup camps in schools, promoting healthy living in school, at home and at the work place.

Mass media campaigns to spread awareness about diabetes and its related complications can go a long way in educating the public. There is also the need to spread the message that diabetes can be prevented/ controlled in most cases by simply adopting healthy eating habits and an active life style.

We hope that the efforts of WDF for prevention and care of diabetes in the developing world, by acting as a catalyst to help others globally create awareness, care and relief to those impacted by the disease, will bear fruitful results.

Shobha Shukla

The author teaches Physics at India's Loreto Convent and has been writing extensively in English and Hindi media. She serves as Editor of Citizen News Service (CNS).

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Japan among 160 countries meeting to limit big tobacco's influence

Japan among 160 countries meeting to limit big tobacco's influence

DURBAN: Representatives from Japan are among the 160 ratifying countries meeting this week in South Africa to negotiate guidelines for a provision in the global tobacco treaty that may determine whether millions get the health protections they are now guaranteed under the treaty. And the Japanese government's 50 percent holding in Japan Tobacco International (JTI) is already threatening to slow progress in the negotiations.

The negotiations center on the implementation of Article 5.3, which protects the treaty and related public health policies from tobacco industry interference.

At stake this week is how narrowly or broadly these protections are defined. If defined broadly, ratifying countries will recognize the tobacco industry's fundamental conflict with public health, and reject collaboration with tobacco giants like JTI, Philip Morris International (PMI) and British American Tobacco (BAT). If defined narrowly, Big Tobacco could continue to gain influence with governments, and demand a seat at the table when public health policies are being developed.

"Industry interference is the number one obstacle to the implementation and enforcement of the global tobacco treaty," said Kathy Mulvey , international policy director of Corporate Accountability International. "Article 5.3 is the lynchpin of the treaty, determining whether or not countries will be able to reverse this preventable epidemic without Big Tobacco standing in their way."

The global tobacco treaty, formally called the Framework Convention on Tobacco Control (FCTC), took effect in 2005 and now protects more than 85 percent of the world's population. But efforts to implement the treaty are being systematically stymied by tobacco transnationals like JTI, reinforcing the importance of this week's third Conference of the Parties (COP) in Durban .

Mulvey's organization and its partners around the Pacific Rim are advocating for firewalls that make no special exceptions for state-owned corporations when it comes to the treaty's prohibitions on industry interference in health policy. The party from Japan has already made clear their intention to weaken any guidelines for the treaty's implementation with respect to state-owned tobacco corporations.

Since negotiations on the global tobacco treaty began in 1999, the Japanese Ministry of Finance has been heavily represented at treaty meetings, with the country often playing an obstructionist role. This has earned them multiple "Marlboro Man Awards" for actions at odds with public health and the spirit of the treaty.

"We are optimistic this time that Parties like Japan will keep the interests of our children's health closer to their heart than those of tobacco transnationals," said Network for Accountability of Tobacco Transnationals (NATT) Spokesperson Bobby Ramakant. "But we know from experience that some will act from the pocket when the circumstance demands they act from the heart."

Corporate Accountability International, with observer status at the COP, and its allies in NATT believe that the following provisions of the draft Article 5.3 guidelines must be maintained:
- Prohibitions on government partnership or collaboration with the tobacco industry.
- Protections against conflicts of interest for those involved in setting and implementing tobacco control policies.

Corporate Accountability and NATT are calling for the draft Article 5.3 guidelines to be strengthened, in order to:
- Avoid government interaction with the tobacco industry, and set strict rules of engagement for any meetings determined to be necessary.
- Ensure transparency around government interaction with the tobacco industry and around tobacco industry activities and operations.
- Emphasize the tobacco industry's fundamental conflict with public health.

"If we don't lay out clear terms now about the tobacco industry's fundamental conflict of interest when it comes to health policy making, it may cost us everything we have achieved through this treaty in turn," said Akinbode Oluwafemi of Environmental Rights Action/Friends of the Earth-Nigeria, a member of the Network for Accountability of Tobacco Transnationals (NATT). "We are dealing with an industry bent on protecting its profit interest at all human expense - an industry that has written the book on policy manipulation and interference."

Addressing HIV and IDU issues vital for TB programmes in Nepal

Addressing HIV and IDU issues vital for TB programmes in Nepal

More than 90% of the diagnosed TB patients are successfully completing treatment in Nepal today. Nepal's anti-TB programme has received appreciation in the south-east Asian region which is the result of ongoing government commitment, community support, forging wide range of partnerships, and the use of innovative ways of ensuring access to Directly Observed Treatment Shortcourse (DOTS) - especially in remote areas, says Dr Dirgh Singh Bam, Secretary, Ministry of Health, Nepal, who is also the former Vice-President of Nepal's Anti-Tuberculosis Association (NATA).

However it is due to poor programme performance of DOTS that ups the drug-resistant forms of TB including the multi drug-resistant TB (MDR TB). Up to 1.8% of new TB infections in Nepal, are of MDR-TB, informs Dr Bam.

MDR-TB is resistant to at least two of the best anti-TB drugs, isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons with TB disease. Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged. Examples include when patients do not complete their full course of treatment; when health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; when the supply of drugs is not always available; or when the drugs are of poor quality, says Dr Bam.

Nepal reports up to 29% TB-HIV co-infection, says Dr Bam. He also talks about the TB and HIV co-infection, particularly among the injecting drug users (IDU). It is difficult to reach out to the IDU community to deliver healthcare services and need to work in partnerships is clearly critical. "Without addressing HIV and IDU issues, it will be very difficult to effectively respond to TB" says Dr Bam. People who use injecting drugs, and co-infected with HIV/TB, are also at increased risk of Hepatitis C (HCV) in Nepal.

Hepatitis C is a blood-borne, infectious, viral disease that is caused by the hepatitis C virus (HCV). The infection can cause liver inflammation that is often asymptomatic, but chronic hepatitis can lead to cirrhosis (scarring of the liver) and liver cancer. HCV transmission occurs when traces of blood from an infected person enter the body of a HCV-negative person. Like HIV, HCV is spread through sharing injection equipment, through needle stick or other sharps injuries, or less frequently from infected mothers to their babies.

HCV transmission rates are higher than that of HIV, and the condition is often more severe in drug users. People who share injection equipment are vulnerable to HCV and HIV infection, says Dr Bam. In Nepal, there is a separate health programme to respond to HCV, informs Dr Bam. However TB and HIV programmes in Nepal work much more collaboratively, says he.

"Community participation is very essential for effective TB/HIV care in Nepal" emphasizes Dr Bam. Patients who have successfully completed TB treatment were leading district level TB committees to improve TB programme performance in many instances in Nepal.

The Patients' Charter for Tuberculosis Care, outlines the rights and responsibilities of people with tuberculosis. It empowers people with the disease and their communities through this knowledge. Dr Bam feels if the Patients' Charter for Tuberculosis Care can be used as a tool to empower people with TB to be aware of their rights and responsibilities, then the TB programme performance will be improved furthermore.

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