Hepatitis B : Lurking in HIV's Shadow

The story of the hepatitis B outbreak in Gujarat has not received the attention it deserves. More so because Hepatitis B is not the typical jaundice that comes around in the monsoon season every year and then trails off as the rains dry up. This variety of Hepatitis is chronic in nature; has no cure and is potentially more dangerous than HIV and AIDS, the mode of transmission for both being the same.

At last count thirty four people had been felled by the virus and this piece of news need not be the last word on the subject as The Gujarat health department says that this death toll could raise, as about 50 persons are still being treated in different hospitals. It has now been established that unsafe syringes and injection needles has caused the spread of hepatitis B in the Gujarat town, what is now being seen as one of the biggest hepatitis B outbreaks in the country.

Following the inevitable knee jerk reaction, the government has clamped down on many doctors and chemists claiming medical negligence. Doctors have apparently been using unsterilized and used recyclable syringes meant for single use but it is quite likely to be a case of too little action and too late. Although the cases of hepatitis B have thus far been found in Modasa taluka of the Sabarkantha district, it is quirt possible that the virus may be spreading in neighbouring districts also as the use of unboiled syringes and disposable syringes being recycled is not likely to be confined to just one location. The hepatitis B virus is transmitted through contact with the bodily fluids of an infected person. The virus can be transmitted via unprotected sex or sharing of contaminated needles. Pregnant mothers also tend to pass it on to their babies.

Chronic carriers have an increased risk of developing liver disease such as cirrhosis or liver cancer, because the hepatitis B virus steadily attacks the liver. Considering that these are exactly the methods by which HIV spreads, Hepatitis-B virus (HBV) remains a major public health problem with an estimated 350 million carriers worldwide, out of which 40 million are in India. HBV is more infectious than Hepatitis-C or the Human Immunodeficiency Virus (HIV) and chronically infected individuals readily infect unvaccinated members and sexual partners. Hepatitis B is a disease more lethal than AIDS, claiming more lives in a day than the latter does in a year.

The whole episode highlights at least three things. Firstly, the depths to which the medical profession continues to sink: doctors, let alone contribute to any cure or healing are now actively contributing to patient deaths, breaching the sine qua non of the medical profession of doing no harm. Secondly, the need for blood safety and prevention of transfusion associated infections in the country has come to the fore and though because of the spotlight has been there for long on the blood banks to screen blood, not just to rule out Hepatitis B but also HIV, a lot still remains to be done.

Thirdly Hepatitis B is an expensive disease to treat and the results are not usually so encouraging, with an efficacy of only 30-40 percent. However, a relatively affordable vaccine is available to prevent it and Hepatitis-B vaccination has now become the part of the primary immunization of infants in many countries and is being administered in many parts of India in the National Immunization Program. But this is not generally known and widely administered in India, which is why the people in Sabarkantha fell victim to it in the first place. May be the deaths occurring in Gujarat and the international attention it is drawing, will make a difference in the numbers of people queuing up for the vaccine and the government making it available at far more cheaper rates than presently available.

Vignettes from time

1) I love the very old song “Those were the days. It brings back so many happy memories...

2) I have had some of the most wonderful friends in the world. Some of them, it seems, I have known half my life... or is it more?

3) I miss my father who died in my arms twenty years ago every day. Not a day goes by when I don’t think of him, in spite of all those years….

4) I also remember Mr. P.K. Madan, my principal at the Mother’s International School, New Delhi when I was studying there. He saw hope in me when no one else did, even I didn’t and showed me what a teacher is meant to be.

5) Remembering all these people and writing about them is making me cry and it is nice that it is ok for men to cry these days.

6) I am a very shy person, there is so much that I want to say; but I don’t know how to make up the words.

7) I don’t have a very healthy sense of self esteem these days; perhaps never did have one.

8) People find it hard to believe that I used to be an Air Force doctor once.

9) Some works of art like the Sistine Chapel just have to be inspired by God alone.

10) I wish that magic really existed; that you just waved a wand and things became better and different.

11) I love history ; it would be nice if time travel became possible and I could see all those historical events that you only read about in history books

12) Every time you want to really cry, just read “ The Little Prince”

13) Shakespaeare had some of the most amazing insights into human nature.

14) If I were an old style maharajah, with lots of money and nothing to do, I would travel around exploring the world.

15) Bach’s Sleeper’s Awake is a divinely inspired piece of music. You can actually feel the resurrection that will happen when the Lord Jesus comes again.

16) I don’t like greetings like “Happy Birthday”, “Happy New Year “and the like. Que Sera Sera. What will be, will be.

17) I don’t like ice cream so much. I love the sweet curd that they sell in baked clay pots from creaky, old refrigerators in Kolkata.

18) it is nice to speak many languages; I know so few.

19) Some day I want to visit the pyramids of Egypt.

20) The New Testament parable of the prodigal son is one of the most timeless stories ever written.

21) Along with the parable of the Good Samaritan, the lost sheep, the lost coin. they give you hope.

22) When you meet a truly good and holy man, you just know.

23) It is great when you scan your computer and there is no virus.

24) Not many are going to read this; but still talking about you is so agonizing.

25) I am haunted by the thought of the kind of legacy I will and frightened that I won’t leave one at all.

Dead in the teens : The trauma of India's Students

One of my friends whose whereabouts are usually not traceable, because he is involved in hectic travel has grounded himself for the next month or so. He has stationed himself at home ; well not exactly at home, but like a tame pet, he goes off to the office in the morning and is safely back to home base by evening. after hearing that piece of news, I haven been given similar instructions on the home front and my wife herself has taken leave a month’s leave and has parked herself at home. In both our families, a child is going through that iconic rite of passage – the board exam….. An event talked about in awe and hushed whispers.

I do not know the number of students who sit for the Board examinations in India every year, with practically each state having its own board of secondary education apart from the grand daddy of them all, the Central Board of Secondary Education. But whatever be the number, the ides of March bring with them the news of the examination season and the country it would seem defers to the phenomenon. elections if due, are scheduled and rescheduled to ensure that the examination schedule is not trifled with ; the election commission , typically a law unto itself , defers to the board examinations – elections will never be scheduled in a way that they interfere with the examination time table.

But stress for exam going students and increasingly their families is becoming a major issue in the last decade and it is a matter of concern that young people are being exposed to stress at such an early stage of their lives when their coping mechanism is so weak. Eexamination stress pushes students to various kinds of perversions, not only affecting concentration and memory but also forcing them to adopt abnormal behavior. Stressed out children are increasingly consuming tobacco, drinking tea, coffee and taking commonly-available amphetamine drugs such as cough syrups to keep up while preparing for exams.

And then there are those who simply can’t cope and end their lives. According to government reports, over 5000 students committed suicide in 2006. The unofficial figures are even higher. It seems stress is pushing our students to the brink; many of them just in class six. Boys are more vulnerable to committing suicide than girls, because adolescent girls seek support from family and friends to deal with emotional stress during examination. But as boys are less expressive, they tend to suppress their feelings of inadequacy and fear of poor performance. This often drives them to suicide to end their frustration

What’s pushing today’s Indian students - a bright generation with a global reputation for their high intelligence quotient - to the brink? Parental and peer pressure, rising ambitions and fierce competition are brewing a deadly cocktail for these young minds. Moreover, a nation racing towards affluence, an economy on a remarkable upward growth trajectory and skyrocketing salaries are putting unprecedented pressure on youth to succeed.

Although some note has been taken of the phenomenon, the changes are till date largely cosmetic. helplines set up by the central board of secondary education and other NGOs that function in these months of the year certainly serve a useful purpose, educational reforms that will evaluate performance and learning by means other than examinations alone or an over haul of the syllabi have been slow in coming. The reform of India’s Macaulayan system of education based on rote learning and memorisation requires urgent attention.

Besides, though the UPA government has imposed a 2 percent cess on all Central taxes, decades of under-investment in education has created shocking shortages of buildings, laboratories, libraries, even drinking water and sanitation facilities in the nation’s dilapidated education sector. A national consensus has to be built on the premise that higher education outlays are vitally important investments in the nation’s future and that this outlay is needed to be accompanied by revamp of the educational system so that young lives are not snuffed out under the burden of school syllabi and examinations, which currently passes for education in India

The Lathi Charge : Police Brutality in India

The other day, Kiran Bedi, the generally respected police officer (now retired) was on a talk show on television. She was an invited guest on a program which was discussing police brutality. The context was where in U.P, the police brutality which we have now come to take for granted reached a nadir when they beat up a six or seven year old girl in Etawah. She had apparently stolen an amount of Rs 280.00 and was caught. Kiran Bedi did not of course say that the police were doing the right thing. but her statement that the police were an underpaid, over worked force who tended to get angry and then ventilate it on any one who came their way came pretty close to retelling an old story from my school days.

That story is all about how a man came back from office one evening annoyed because his boss had shouted at him. upset with his wife because his tea wasn’t waiting for him when he got home, he shouted at his wife, who turn, later in the evening yelled at their son because he was taking too long over his home work. The son bade his time and next morning kicked the family dog hard in the stomach on his way out to school. the wheel turned full circle when the husband on his way to work a couple of hours later, trod on the dog’s tail who in turn snapped and bit the man on his ankle starting off a fresh cycle of feuding.

Jokes apart, Kiran Bedi’s evidence sounded pretty much like this. Sure the police are underpaid and over worked and are subject to all manner of political interference that further undermines their work. But by their manner of functioning, the police have dome nothing much to improve their image of an institution of almost uniform loathing. A police station should be a place of protection but instead it feels extremely unsafe and unwelcoming, a place most people want to avoid. Beating, torture and illegal arrests are common, so common that complaints about them are few. a NOIDA police station officer blandly told a research team from the Peoples’ Union for Civil Liberties that a suspect always needs `thukai pitai’ (sound trashing) to tell the truth. Brutality is so institutionalized that People in general have an acquired fear, however little it may be, towards the police. Children are frightened by the parents by telling that they would call the police if they do not eat food; do not obey them. The policemen are pictured as cruel people by films.

The police of course have a history of ruthless suppression of the population that they have inherited from the British regime but sadly even after so many decades after independence the police machinery has not evolved very much from the colonial police, including in the police weapon of choice – the lathi. At a time, when there is so much of terror and insecurity that is coming from the outside, one would expect the police to be an institution where one could turn to for safety, protection and comfort. that is the way it is in other countries ; that is the way of a civilized society – that you turn to the State and arguably its most visible instrument – the police for safety and security – but alas – not yet so in India. Here it would seem, one is better off, the further one is from the police.

Ode to a Mosquito

Amitabh Ghosh’s book, The Calcutta Chromosome reminds us in India of the country’s long association with Malaria. On 20 August 1897, in Secunderabad, Sir Ronald Ross, an Army doctor with the Indian medical service, in the course of experiments conducted in Kolkata’s Presidency General Hospital(PG Hospital to you and me !) and Secundrabad ,he found the malaria parasite and went on to prove the role of Anopheles mosquitoes in the transmission of malaria parasites in humans. Despite India’s historical association with malaria, (Sir Ronald Ross later went on to win the Nobel Prize for medicine), India’s tryst with malaria has far from ended. Malaria is endemic in all of India except at elevations above 1800 meters and in some coastal areas.

Two-thirds of all cases are reported from Gujarat, Karnatka, Madhya Pradesh, Orissa, Uttar Pradesh and Punjab.

- Orissa, Assam & Maharashtra account for 80 percent of all _plasmodium falciparum_ malaria which is potentially fatal

- Malaria is reported nationwide, including Delhi and Bombay; but not in Himachal Pradesh, Jammu & Sikkim, isolated coastal areas around Western Ghats, Andaman and Nicobar Islands. Transmission begins with the onset of the Monsoon season in mid-June.

- _P. vivax_ predominates until August, with _P. falciparum_ infection rising to a peak in September.

At the time of independence in 1947, there were an estimated 75 million malaria cases and 0.8 million deaths annually. National Malaria Eradication Programme was launched in 1958, based mainly on widespread DDT spraying. The number of reported cases was reduced to about 100,000 by 1965-66. After global eradication was called off in 1969, funding decreased steeply, and by 1976 reported cases peaked at 6.47 million. Malaria was nearly eradicated from India during the early 1960’s.

Malaria and poverty are intimately connected. Judged as both a root cause and a consequence of poverty, malaria is most intractable for the poorest countries in the world and it affects the health and economic growth of nations. Its epidemiology and its control are complicated by poverty as it is a dominant disease in poverty stricken societies. The economic loss due to the loss of man-days due to malaria was estimated to be at Rs. 10,000 million per year in 1935. The annual incidence of malaria was estimated at around 75 million cases in 1953 with about 8 lakhs deaths annually

The fact that malaria is fundamentally a disease of the poor has meant that malaria has received comparatively scant attention in recent times. By the early 1990s, worldwide funding on malaria research had practically dried up.

While older vaccines for diseases like mumps and measles are more widely and cheaply available, vaccines for malaria, tuberculosis and AIDS, the developing world's top killers, are so risky and costly to bring to market that little progress has been made in these areas. The malaria vaccine about to be tested has been under development for two decades -- and at one point it was nearly abandoned. Till the millennium development goals, once again put malaria on the world map, the disease was literally out of sight of the world. In recent years, the Bill and Melinda Gates foundation has been the most high profile philanthropist involved in malaria control. The Gates couple began handing out research grants for malaria in late 1998, even before they had formalized the structure of their foundation. Since then, they have poured more than $860 million into just malaria research and another $650 million into the Global Fund for fighting AIDS, tuberculosis and malaria.

The latest review of the national programme was carried out in early 2007 as an international collaborative Joint Monitoring Mission following a sample survey in households and health facilities of malaria control implementation carried out by the National Institute of Malaria Research, New Delhi. An interesting finding of the review was that the malaria burden in the country is unknown despite an elaborate surveillance system. The number of officially reported malaria deaths is about 1000 per year, but a study of medically certified deaths in the country suggest that the real figure is at least 40 times as high.

A hundred and ten years and more after Ronald Ross made his breakthrough discovery of the malarial parasite on Indian soil, there is still a lot that remains to be done in reducing malaria deaths and one can only hope that malaria will be the next disease selected for eradication after the long suffering polio.