The health transition

Progress on non-communicable diseases should not be benchmarked against sustainable development goals.

In the last week of September, India’s health ministry received the prestigious UN Inter-Agency Task Force Award for “outstanding contribution to the achievement of NCD (Non-Communicable Diseases) related SDG targets”. At the same time, a Lancet paper by the monitoring group, NCD Countdown 2030, contended that India will fall short of the NCD targets pertaining to SDGS. NCDs are the leading cause of mortality, globally and in India, and are dominated by cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. So what is true?

The target set for all countries is to achieve one-third reduction in NCD related mortality between the ages of 30 and 70 by 2030, relative to 2015. The Lancet study reports that high income countries and several upper middle income countries are on course to achieve this target. Lower middle income countries, like India, will need to accelerate the rate of decline to reach the target. Many low income countries are unlikely to reach the target by 2030.

The Lancet paper examines global trends in NCD mortality, using three rates: Mortality between 30-70 years, mortality under 70 years and mortality under 80 years. The first is the indicator linked to the SDGs. The second also measures NCD mortality below 30 years of age, which represents a considerable burden in regions like sub-Saharan Africa. The third regards most NCD deaths before 80 as preventable and premature. The authors rightly argue that the arbitrary selection of the 30-70 year age range limits consideration of, and action against, NCD deaths in the younger and older age groups outside that age band.

These arguments make perfect sense when pleading for broader multi-sectoral policy commitment and extended health system action against NCDs, whose challenge demands a life course perspective — one that is not limited to middle age. Further, the challenge of NCDs will not cease in 2030. As the epidemics mature, the 70-80 age group will pose challenges in many parts of the world. Therefore, the current response should not be a short-term staccato response but one which anticipates and mitigates preventable NCD mortality across the entire 0-80 age range even after 2030.

Use of the three indicators simultaneously to judge progress towards 2030 ignores the varying stages of developmental and epidemiological transition that different countries are traversing. As countries advance along this path, life expectancy progressively rises and the median age of NCD-related mortality will move to a higher age at each subsequent stage. Even within countries, groups with relatively lower NCD mortality in the 30-70 age group (most often women and persons in underdeveloped regions) are likely to move to higher levels of mortality in that age group.

As countries in early health transition (such as sub-Saharan Africa) advance to the next stage by 2030, they will see reduced levels of NCD mortality under 30 but will see NCD mortality rising in the 30-70 age group. A substantial reduction in NCD mortality in the 30-70 age group, by 2030, is not an appropriate performance measure of progress in such populations. Similarly, countries like India which have advanced to the next stage of transition will experience the gender effect of more women facing the risk of dying from NCDs between 30-70 years, even as men will see some NCD deaths shift to the 70-80 year age group. The under-developed states of India will behave like sub-Saharan Africa, transferring under-30 NCD deaths to the 30-70 age group. Inability of these countries to fully meet the 30-70 age SDG target, or reduce the under-80 NCD mortality by a third by 2030, should not be projected as a failure. Much of the impact of current efforts, on reducing the under-80 NCD mortality in India, will come after 2030 even though substantial progress would have been achieved in reducing deaths under 70 by that year. Reducing the 30-70 or under-70 or under-80 NCD mortality should not, therefore, be regarded as an acid test of performance in all countries.

However, age limits should not become a barrier to the provision of NCD care under a Universal Health Coverage (UHC) programme — another major SDG target. Countries keen on achieving the specified 30-70 age related mortality target may tend to focus their resources on preferential care for that group, especially in the provision of life saving clinical services, neglecting other age groups. This militates against equity and undermines the principle of universality. For this reason, reduction of under-80 mortality would be a better measure to judge the overall health impact of UHC.

Therefore, reduction in 0-70 mortality would be a reasonable indicator for tracking India’s progress on NCDs while progress in under-80 mortality would be a good indicator for assessing progress on UHC. It is essential that the government, civil society, academia and media recognise these nuances of health transition which shape the sweep of NCD epidemics as they evolve.

Actions to curb tobacco and alcohol consumption will help reduce future risk of NCD in the under-30 age group, while reducing mortality at all ages, and help create a healthier society which will yield inter-generational benefits well beyond 2030. Actions related to reduction of blood pressure, control of diabetes and provision of competent primary care supplemented by cost-effective specialist clinical care for treatable NCDs will benefit all age groups, with the highest benefits in the 30-80 age group. Energetic implementation of public health policies and NCD-inclusive health services under UHC are what the country needs. India’s efforts in these areas certainly merit the UN commendation. The indicators used to track progress are helpful to further stimulate these actions even if they are not perfect for measuring progress across the broad spectrum of health transition in the relatively short run up to 2030.

Source: Indian Express, 12/10/2018

Why Sex is So Important

Our life is in a turmoil, it is a constant struggle, with nothing original, nothing creative — I am using the word ‘creative’ very carefully. The painter, the architect, the woodcarver, he may say he is creative. The one who bakes bread in the kitchen is said to be creative. And sex, they say, is also creative. So what is it to be creative? You are seeing the expression of creativeness in a painting, in a poem, in prose, in a statue, in music. We have accepted all that as creative because it brings fame, money, position. But is that creativity? Can there be creation, in the most profound sense of that word, so long as there is egotism, so long as there is the demand for success, money and recognition — supplying the market? I say there is a state where there is creation in which there is no shadow of self. Perhaps sex is felt to be creative and has become important because everything around us is circumscribed, the job, the office, going to the church, following some philosopher, some guru. All that has deprived us of freedom and, further, we are not free from our own knowledge; it is always with us, the past. So where there is no freedom, either outwardly or inwardly, specially inwardly, we have only one thing left, and that is called sex. Why do we give it importance? Because that is the easiest thing to handle; other things can only come when you are free. So, we have given this thing (sex) tremendous importance in life. And when you give something, which is only one part of life, tremendous importance, you are destroying yourself.

Source: Economic Times, 12/10/2018

Augmenting life — on Nobel Prize 2018

This year’s science Nobels compel us to relook at evolution, and also at gender parity

The Nobel Prize for Chemistry this year is a tribute to the power of evolution. The laureates harnessed evolution and used it in the laboratory with amazing results. Frances H. Arnold, an American who was given one-half of the prize, used ‘directed evolution’ to synthesise variants of naturally occurring enzymes that could be used to manufacture biofuels and pharmaceuticals. The other half went to George P. Smith, also of the U.S., and Sir Gregory P. Winter, from the U.K., who evolved antibodies to combat autoimmune diseases and even metastatic cancer through a process called phage display. The prizes reaffirm the importance of the concept of evolution in our understanding of life as among the most profound of forces we are exposed to. The Physiology and Medicine prize has gone to the American James P. Allison and Tasuku Honjo, from Japan, for showing how different strategies can inhibit the metaphorical ‘brakes’ acting on the immune system and thereby unleash the system’s power on cancer cells to curb their proliferation. These immunologists have enhanced the power of the body’s immune system to go beyond its natural capacity.

Arthur Ashkin, from the U.S., has been awarded one-half of the Physics prize, for enabling us to individually hold, study and manipulate tiny bacteria and viruses using ‘optical tweezers’. In many laboratories, optical tweezers are used to study and manipulate subcellular structures such as DNA and little molecular motors. Optical holography, wherein thousands of such optical tweezers can operate together on, say, blood, to separate damaged blood cells from healthy ones could be a treatment process for malaria. The parallel is clearly in how this work has, individually, enabled us to reach out beyond what is permitted by our sensory and physiological capabilities. Gérard Mourou, from France, and Donna Strickland, from Canada, who share the other half of the Physics prize, have been honoured for their methods to generate ultra-short pulses of laser light. The work, published in 1985, went into Ms. Strickland’s PhD thesis and soon revolutionised the field. Among its uses are in Lasik surgery in ophthalmology, and in making surgical stents. More recently, attosecond lasers have even made it possible to observe individual electrons. In sum, the prize-winners have drawn upon the fundamental forces in science and reached out beyond human physical limitations. However, the world of science can do with some introspection. For, two of the six laureates – Donna Strickland and Frances Arnold – are women. They are only the third and fifth women Nobel laureates in Physics and Chemistry, respectively, since the inception of the Nobel prizes. Along with the celebrations, this statistic gives reason for the community of scientists to introspect over what makes an enabling environment for women to practise science in.

Source: The Hindu, 11/10/2018

The power of non-alignment

There is space to resurrect the old movement as a soft balancing mechanism against powerful states

The Non-Aligned Movement (NAM) and its precursor, the Bandung Afro-Asian conference in 1955, were examples of soft balancing by weaker states towards great powers engaged in intense rivalry and conflict. As they had little material ability to constrain superpower conflict and arms build-ups, the newly emerging states under the leadership of India’s Jawaharlal Nehru, Egypt’s Gamal Abdel Nasser and Indonesia’s Sukarno, and later joined by Yugoslavia’s Josip Broz Tito, adopted a soft balancing strategy aimed at challenging the superpower excesses in a normative manner, hoping for preventing the global order from sliding into war.

The founders of the NAM, if alive today, could have taken solace in the fact that in the long run some of their goals were achieved due to a radical change in the policies of the Soviet Union under Mikhail Gorbachev.

Understanding a movement

The NAM is often not given credit for what it deserves, because by the 1970s, some of the key players, including India, began to lose interest in the movement as they formed coalitions with one or the other superpower to wage their conflicts with their neighbours. It is also not theorised by scholars properly. The Western countries often portrayed non-alignment as pro-Soviet or ineffective and the general intellectual opposition was the result of the Western scholarly bias against a coalitional move by the weaker states of the international system. This is very similar to how upper classes or castes respond to protest movements by subaltern groups in highly unequal and hierarchical societies.

The international system is hierarchical and the expectation is that the weaker states should simply abide by the dictates of the stronger ones. It is often forgotten that when the Bandung meeting took place, the world was witnessing an intense nuclear arms race, in particular, atmospheric nuclear testing. The fear of a third world war was real. Many crises were going on in Europe and East Asia, with the fear of escalation lurking. More importantly, the vestiges of colonialism were still present.

Despite all its blemishes, the NAM and the Afro-Asian grouping acted as a limited soft balancing mechanism by attempting to delegitimise the threatening behaviour of the superpowers, particularly through their activism at the UN and other forums such as the Eighteen Nation Committee on Disarmament, as well as through resolutions.

“Naming” and “shaming” were their operational tools. They worked as norm entrepreneurs in the areas of nuclear arms control and disarmament. They definitely deserve partial credit for ending colonialism as it was practised, especially in the 1950s and 1960s in Africa, parts of Asia and the Caribbean through their activism at the UN General Assembly which declared decolonisation as a key objective in 1960.

Impact on N-tests

The non-aligned declarations on nuclear testing and nuclear non-proliferation especially helped to concretise the 1963 Partial Test Ban Treaty. They also helped create several nuclear weapon free zones as well as formulate the Nuclear Non-proliferation Treaty. The tradition of ‘non-use of nuclear weapons’, or the ‘nuclear taboo’, was strengthened partially due to activism by the non-aligned countries’ at the UN. The non-aligned could find solace that it took a few more decades for a leader like Mr. Gorbachev to emerge in one of the contending superpowers, and that many of their policy positions were adopted by him, and later partially by the U.S.

As the great powers are once again launching a new round of nuclear arms race and territorial expansion and militarisation of the oceans, a renewed activism by leading global south countries may be necessary to delegitimise their imperial ventures, even if they do not succeed immediately. If these states do not act as cushioning forces, international order could deteriorate and new forms of cold and hot wars could develop. China, the U.S. and Russia need to be balanced and restrained and soft balancing by non-superpower states has a key role to play in this.

If the present trends continue, a military conflict in the South China Sea is likely and the naval competition will take another decade or so to become intense, as happened in earlier periods between Germany and the U.K. (early 1900s), and Japan and the U.S. (1920s and 1930s).

The U.S. as the reigning hegemon will find the Chinese takeover threatening and try different methods to dislodge it. The freedom of navigation activities of the U.S. are generating hostile responses from China, which is building artificial islets and military bases in the South China Sea and expanding its naval interests into the Indian Ocean. Smaller states would be the first to suffer if there is a war in the Asia-Pacific or an intense Cold War-style rivalry develops between the U.S. and China. Nuclear weapons need not prevent limited wars as we found out through the Ussuri clashes of 1969 and the Kargil conflict in 1999.

The way forward

What can the smaller states do? Can they develop a new ‘Bandung spirit’ which takes into account the new realities? They could engage in soft balancing of this nature hoping to delegitimise the aggressive behaviour of the great powers. The rise of China and India, with their own ambitious agendas, makes it difficult that either will take the lead in organising such a movement.

China’s wedge strategy and its efforts to tie Afro-Asian states through the Belt and Road Initiative have limited the choices of many developing countries. However, despite the constraints, many have been able to keep China off militarily by refusing base facilities and also smartly bargaining with India and Japan for additional economic support. They thus are already showing some elements of strategic autonomy favoured by the NAM.

More concrete initiatives may have to rest with emerging states in the Association of Southeast Asian Nations (ASEAN) grouping. Engaging China and India more intensely while restraining the U.S. and Russia from aggravating military conflict in Asia-Pacific can be the effort of the developing countries. Norm entrepreneurship has it value, even if it does not show immediate results.

The alternative is to leave it to the great powers to engage in mindless arms race and debilitating interventions, which rarely create order in the regions. Restraining the established and rising powers through institutional and normative soft balancing may emerge as an option for developing countries in the years to come. They still need a leader like Jawaharlal Nehru to bring them together.

T.V. Paul is James McGill Professor of International Relations, McGill University and a Fellow of the Royal Society of Canada

Source: The Hindu, 11/10/2018

In Conscious Company

Organisations ought to be treated as a new form of collective life along with family and society. Sri Aurobindo explained that like the individual, the nation, society (or organisation) also has a body, an organic life, a moral and aesthetic temperament, a developing mind and a soul for the sake of which it exists. Like the individual, it is a group-soul that must become more self-conscious to attain a holistic well-being. Knowledge and beliefs held at an organisational level generate a closed self-referential system where the organisation simultaneously reinforces its beliefs and creates its own environment. We use the term ‘collective consciousness’ in organisational perspective to denote the wholeness that is formed by the members of an organisation coming together. Market consciousness is the first and primary level of collective consciousness of business organisations. Socially conscious organisations are based on mutual recognition and acceptance of others like customers and other channel partners. Spiritual consciousness organisations adopt a caring attitude towards existence. A socially and spiritually conscious leadership is critically important for the organisations to evolve to the higher levels of consciousness. In a world where more than three-fourth GDP is produced by organisations and more than half of the human population spends more than a third of the waking hours in organisations, it is important to work upon enhancing organisational consciousness.

Source: Economic Times, 11/10/2018

‘2 of 5 women don’t report sexual assault’

Perpetrators Known In Most Cases: Study

One in four of those reporting non-marital sexual violence are adolescents in the 15-19 age group, pointing to higher vulnerability of minors who are also less likely to report such instances to police as compared to adult women, a study on the lack of disclosure of such crimes has found. Overall, two in five female survivors do not inform anyone of sexual violence suffered. The findings on the lack of disclosure are part of an analysis of the national family health survey – 4 (2015-16) that show of 4.4 lakh adolescent girls who were victims of sexual violence in the year preceding the survey, 35% neither sought help or told anyone. Only 0.1% girls reported the violence to police. The data analysis for the 15-49 year age group shows that 14 lakh women experienced sexual violence from someone outside their marriage. Here too, 42% neither sought help nor told anyone. Only 1.9% reported the violence to police. The analysis on non-marital sexual violence in India is led by Dr Anita Raj, director of the Centre for Gender Equity and Health, University of California, in collaboration with the Mumbai-based International Institute for Population Sciences. The study concludes nonmarital sexual violence is a “pervasive concern” affecting far greater number of women and adolescent girls than reported cases suggest. “More than 2 in 5 never tell anyone of this abuse. Adolescent girls 15-19 years are disproportionately affected and even less likely to report the crime to police. Most assailants of this violence are known to their victims, as partners, family members or friends. Stranger-perpetrated sexual violence against women and adolescents is less common,” the analysis found. The study suggest only 5% adolescents reported the perpetrator to be a stranger. The study suggests that since in most cases the perpetrator is a known person, prevention strategies need to focus on “potential perpetrators”. It is emphasised that mobility restrictions on girls out of fear of strangers will not work as a preventive measure. The study recommends reduction in stigmatisation and improved police response can facilitate victims’ disclosure. “This prevalence was calculated for the population of all women aged 15-49 years, and by age category,” Dr Raj said.

Source: Times of India, 11/10/2018

Natural disasters cost India $80bn in 20 yrs: UN report

Climate change is making development highly risky, particularly in lower-middle income countries like India. A study released by the UN office for Disaster Risk Reduction (UNISDR) on Wednesday said India suffered economic losses of $80 billion during the 20-year period of 1998 to 2017. India has been ranked among world’s top five countries in absolute economic losses. Globally, disaster losses during this period have been estimated at $3 trillion. These losses have increased by more than 120% in the last 20 years compared to the preceding two decades (1978-1997). And if we just account for climate related disaster losses, they have gone up by more than 151%. Mami Mizutori, head of UNISDR, said: “The report makes it clear that economic losses from extreme weather events are unsustainable and a major brake on eradicating poverty in hazard exposed parts of the world.” She emphasised on the need for countries to capture economic losses which can help in disaster mitigation, saving lives and livelihoods. “In the period 1998-2017, disaster-hit countries reported direct economic losses of $2,908 billion of which climate-related disasters accounted for $2,245 billion or 77% of the total. This compares with total reported losses for the period 1978-1997 of $1,313 billion of which climate-related disasters accounted for $895 billion or 68%,” the UNISDR said. “It is also clear that the economic losses suffered by low and lower-middle income countries have crippling consequences for their future development and undermine our efforts to achieve the 17 Sustainable Development Goals, in particular the eradication of poverty,” the UNISDR said. The study was jointly conducted by UNIDR and Centre for Research on the Epidemiology of Disasters (CRED) and released before October 13, the International Day for Disaster Reduction. In the last 20 years, climate-related disasters killed 1.3 million people and left 4.4 billion injured and homeless. India is worst sufferer of disaster-related deaths and economic losses. Thousands of human lives are lost and hundreds of crores worth of properties destroyed every year, though not all of them are reported, a fact authenticated by the UN report that said loss data is not available for 87% of disasters in low income countries. “While the majority of fatalities were due to geophysical events, mostly earthquakes and tsunamis, 91% of all disasters were caused by floods, storms, droughts, heat waves and other extreme weather events,” the report said. Storms, floods and earthquakes are not just common to India. In fact, three European countries are in the top 10 nations having suffered maximum economic losses on account of these climate change disasters — France ($48 billion), Germany ($58 billion) and Italy ($57 billion).

Source: Times of India, 11/10/2018