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BMI and risk of death

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That obesity is a causal factor for many lifestyle diseases such as cardiovascular disease, anddiabetes, which in turn increases the risk of death, has been well established in the developed

world. Similarly, being underweight increases the risk of death. A study published online in TheNew England Journal of Medicine(NEJM) (Association between body-mass index and risk of

death in more than 1 million Asians by Wei Zheng et al.,) finds a strong correlation betweenunderweight and increased risk of death in all Asians. The study is an analysis of published datainvolving 1.1 million people living in Asian countries, including 287,000 Indians and

Bangladeshis. The risk of death in the case of East Asians was high for those with a high bodymass index (BMI), but not in the case of Indians and Bangladeshis. Indians and Bangladeshis

were more prone to death when they were underweight. It is a fact that severely underweightpeople are malnourished, and hence very unhealthy. Low immunity levels seen in such peoplemake them highly prone to several infections. Large-scale studies done in India, which has a

huge malnourished population, are more likely to show a large percentage of deaths associatedwith lower BMI than higher BMI. Several small studies done in India have shown the risk of

mortality increasing with higher BMIs.

The study reported in NEJM has several limitations. Being underweight increases the risk ofinfections but a person can become underweight as a result of an underlying infection. Theresearchers were not able to exclude, at the time of enrolment, underweight people already

suffering from some infection, and hence at a higher risk. That many people were reported to bedying soon after enrolment suggests they may have had some underlying infection or disease at

the time of enrolment. Waist-to-hip ratio or waist circumference is a better marker than BMI toknow fat distribution in the body. Indians, even those who are thin, tend to accumulate fat in

their waist. Abdominal adiposity is a causal factor for hypertension and diseases such as diabetesand cardiovascular disease. Those with a BMI between 22.6 and 25 with less central adiposityhave the greatest chances of living free of any infections and lifestyle-related diseases. With

more urban children becoming obese, public health messages should address the increasingchances of health complications when the BMI is lower or higher than the normal range. Theyshould also stress the need to reduce abdominal adiposity even when the BMI is within the

normal range.

Illusory tax concessions


Except for senior citizens, the Union budget has very few major initiatives on the personaltaxation front. The Direct Tax Code (DTC), which aims to revamp the existing direct tax

structure, will come into effect on April 1, 2012. In a limited way, the budget proposals aim atbringing about a transition to the DTC. The exemption limit for the general category of taxpayers

has been raised from Rs.1,60,000 to Rs.1,80,000, providing a relief of a little over Rs.2,000. Butby far the most significant initiative has little to do with tax rates or slabs. It is an administrative
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decision to reduce the qualifying age for senior citizens from 65 years to 60. With the exemptionlimit raised to Rs.2,50,000 from Rs.2,40,000, this new segment of senior citizens will get over

Rs.9,200 as relief. The Finance Minister has also created a new category of Very SeniorCitizens', 80 years and above, who will qualify for a higher exemption limit of Rs.5,00,000. This

category can save on taxes up to Rs.26,780.

The tax saving for senior citizens may look significant. For many, however, it will be illusory.For one thing, one must have an income stream that is large enough to qualify for savings. Notmany in the salaried class are likely to have a taxable income of more than Rs.2,50,000, after

retirement. It is even less likely that there will be many taxpayers in the 80-plus age group withan annual income of Rs.5,00,000. Even more contrived is the logic that senior citizens can plan

their taxes better by investing in tax-saving instruments up to Rs.1,20,000. Such instruments areessentially long-dated and even if senior citizens have enough income they would be ill-advisedto lock their money in these. The Finance Minister is absolutely right when he says that senior

citizens deserve special attention. Today's senior citizens depend on limited fixed incomes anddid not have many opportunities to save and plan for their retirement during their working years.

For instance, access to home loans and life insurance was minimal until not too long ago. Thathas made them extremely vulnerable after retirement. Government support to them ought to gowell beyond tax reliefs and address the concerns of the aged in a holistic manner.

Keywords:Union Budget, personal taxation, Income Tax, tax ememption

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Comments:

It is the responsibility of the Government to tend to the citizens in their twilight years. Pranabda'ssymbolic gestures of easing the 'tax' burden of senior citizens are basically cosmetic in natureand have no real meaning. Some suggestions for the 'holistic' approach sought in the editorial - i)

Health Insurance at a nominal premium of Rs. 600-1000 per year to cover all illnesses andtreatment including surgeries in all hospitals , ii) 66-75% concessions in travel by train, air and

bus within limits, iii) door delivery mechanisms for PDS related entitlements like rice, wheat,
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sugar etc., + 25-33% concessional rates, iv) specified special darshan quotas facilities in templesand other places of worship, v) special counters in all major government offices from Tahsils and

upwards to deal with and take spot decisions to redress their grievances, vi) old age pensions forthe unemployed - not the current Rs 300-400 BUT say a minimum of 2500-3000 etc., There are

many more useful steps - yes, it will cost over Rs. 45,000-50,000 crores/year BUT governments

spend and waste 100,000's of crores every year apart from the loss due to scams. Also tighten upthe defence procurements - you will save about Rs. 30,000 crores NOW. So, financial crunch

cannot be allowed to be cited as a reason. Minor tinkering with the income tax rates when suchlevels of income do not exist for nearly 80-90% of the 80+ citizens may get headlines from the

chatterati media but it is a pure cosmetic exercise.

from: R Rajagopal

Yes, but what led to the 'error'?


It took a nudge from Sushma Swaraj, the Leader of the Opposition, for Pr ime Minister

Manmohan Singh to admit in Parliament that he had made an error of judgment in appointingP.J. Thomas as Central Vigilance Commissioner. Although Dr. Singh can be given credit forallowing himself to be coaxed into reiterating his acceptance of full responsibility for the

appointment, which was set aside by a censorious Supreme Court, his statement throws nofurther light on the shameful episode. How did it come about that a senior civil servant charge-

sheeted in a corruption case was chosen as the country's top anti-corruption watchdog? Were thePrime Minister and the Home Minister, who were part of the three-member selection committeethat appointed Mr. Thomas, really unaware of this? Why did they not apply their minds to the

objections raised by Ms. Swaraj who, as the third member of the committee, specifically raisedthe issue of the pending charges against Mr. Thomas in the palmolein import case? Was there

pressure from any quarter to make Mr. Thomas CVC? Answering these questions is vital toinstitutional integrity.

The little we know officially about the circumstances that led to Mr. Thomas' appointment is a

piece of obfuscation. This is in the form of Attorney General G.E. Vahanvati's labouredsubmission in the Supreme Court that the Department of Personnel had failed to place the fullfacts about Mr. Thomas, or the relevant papers and file, before the selection committee. This

sounded like a lame attempt to absolve the Prime Minister and Home Minister of accountabilityby making out that the appointment was a result of bureaucratic inefficiency or oversight. As wehave made clear in earlier editorials, Mr. Thomas is entitled to a fair trial under the procedure

established by law and no presumption of guilt should be attached to his part in the palmoleinimport case. What is scandalous is the government's decision to shield him and ipso facto protect

itself against the fierce criticism about the highly coloured circumstances under which he wasselected for the post. After the Supreme Court quashed his appointment and indicted thegovernment for attempting to defend the indefensible, the least Dr. S ingh should have furnished

was a detailed account of how or why he was led into 'error'. An acceptance of responsibility is astep forward but insufficient. The proper course for a Prime Minister with a reputation for
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personal financial integrity would be to square with Parliament and the public on what it was thatmade him and his senior government colleague insist on, and rush through, the appointment of

Mr. Thomas in defiance of morality, the law, and common sense.

Of mercy and ending life


We could have dismissed the petition on the short ground thatthe right to life guaranteed byArticle 21 of the Constitution does not include the right to d ie, observe Justices Markandey

Katju and Gyan Sudha Misra sagely in the Aruna Shanbaug case. However, in view of theimportance of the issues involved we decided to go deeper into the merits of the case.Negotiating the grey ethical areas re lating to euthanasia in a humane, progressive, and persuasive

way, this detailed Supreme Court judgment lays down a broad legal framework for dealing witha subject that has not received the attention it deserves from the legislature. The court's decision

on the immediate matter at hand the plea that Aruna Shanbaug, the nurse who has been lyingin a vegetative state on a Mumbai hospital bed since she was brutally raped and strangulated in1973, should be allowed to die is largely based on medical evidence. The evidence furnished

by a panel of experts showed that while Ms Shanbaug may be in a permanent vegetative state(PVS), she is neither brain dead nor in a coma. The court also went into the question of who

could initiate the move to withdraw life support to a person in PVS. Its answer is that suchdecisions can be taken by parents, spouses, and close relatives or, in their absence (as in MsShanbaug's case), the next friend. Justices Katju and Misra held that her next friend was

clearly KEM Hospital staff, who have been amazingly caring for her day and night for so manylong years, and not the petitioner who urged that Aruna be allowed to die in dignity.

Upholding the distinction between active euthanasia, which involves taking specific steps such

as injecting a person with a lethal substance, and passive euthanas ia, which is withdrawingmedical treatment with the knowledge that it will cause death, the court has held that the latter is

permissible in exceptional circumstances for example, when a patient is kept alive purelymechanically and when he or she is only able to sustain involuntary functioning throughadvanced medical technology. Citing a slew of international case laws on the subject, the

Supreme Court has laid down a strict framework for the procedure to be adopted for non-voluntary passive euthanasia until suitable legislation is in place. All mercy-killing pleas should

be heard by a two-member bench of the appropriate High Court and decisions may be taken onlyafter seeking medical opinion from three empanelled doctors, who must examine the patient, hisor her medical records, and also get the views of the hospital staff. Leaving such decisions

entirely to a patient's relatives or doctors carries the risk that murders will be carried out in theguise of mercy killing. In its judgment, the court has struck a fine balance it has shown greatsensitivity in handling the heart-rending case of Aruna Shanbaug and her wonderful next friend,'

the KEM Hospital staff, taken a progressive and empathetic view about dying with dignity, butsubjected it to exacting and rigorous procedures.

Keywords:Aruna Shanbaug case, euthanasia, mercy killing
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Comments:

You are right to uphold the decision of the Supreme court in the Aruna shanbaug case.To no one

should befall such a fate and even in the most dismal of the fate for Aruna Shanbaug,a mostrelieving thing to happen is the preparedness of the KEM Hospital staff to look after her till thenatural end.As a parent my pain is endless.

from: Chidambaram Kudiarasu

Posted on: Mar 9, 2011 at 07:31 IST

Approaching the Supreme Court for a decision on euthanasia is a cruel joke on the justices.Yet

justices Katju and Misra were undaunted to take on the case and proved themselves to be secondto none of the judges of the civilised world.They redeemed themselves from this excruciating

task with a trail blazing judgement.Neither did they duck the issue nor they left a scope forsloppiness by greenhorn judges of the days to come.They should be ha iled for settling the issue

even in the absence of a specific legislation.Thirty seven years of PVS of Ms Aruna Shanbaug ismind-boggling.May God bless her soon! The incredible aspect of her case is the loving care shehas been receiving from the KEM hospital and its staff. Unabated flow of milk of mercy from

her fraternity obviates the need for mercy-killing.However the marvellous support given to MsAruna in terms of monetary and human resourses for the thirty seven long years by the KEM

hospital and its staff needs to be compensated and encouraged by awards and liberal funds fromthe government and world benefactors like Bill Gates,Ajit Premji of Wippro et al

from: G.Rajaram.
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In search of a second earth


The discovery of six exoplanets or extra-solar planets (planets outside the Solar System) orbitinga single sun-like star, dubbed Kepler-11, at a distance of about 2,000 light-years from Earth

makes it the largest collection to be ever found. Those found earlier using ground-baseddetection methods were single exoplanets orbiting a star. The d iscovery by the Kepler spacecraft

launched in March 2009 and reported recently online in Nature(A closely packed system oflow-mass, low-density planets transiting Kepler-11 by JackJ. Lissauer et al.,) became possibleas the Kepler telescope continuously looks out for exoplanets transiting the more than 150,000

stars in a specific region of the sky in the Cygnus and Lyra constellations. A transiting planetcauses a dip in the brightness of the star. Three to four transits causing the same dip in

brightness, taking the same time to transit the star, and taking the same amount of time betweensuccessive trans its are necessary for confirmation that the object is a planet. Though severalthousand planets may be present in the region studied, the actual number that may eventually be

found will be smaller as the orbital plane of the transits must be perfectly aligned with Kepler'sline of sight. All the six exoplanets have orbits smaller than Venus's, with the orbits of the first

five being smaller than Mercury's. The innermost planet must have a dense and rocky core as ithas 4.6 times Earth's mass despite being only 1.4 times the size of the Earth. Most of the otherplanets have significant amounts of light gas.

The main objective of the Kepler mission is to find Earth-sized planets orbiting Sun-like stars

and capable of supporting life. All the six exoplanets are bigger than Earth, with the largest onescomparable with Uranus and Neptune. Like Mercury and Venus, they are too close to the star to

support life. According to the U.S. National Aeronautics and Space Administration (NASA),finding an Earth-sized planet in the habitable zone that is neither too close nor too far from thestar may take at least three years; one transit would take nearly a year and three such transits are

needed for planet confirmation. With Kepler only halfway into its mission, we cannot possiblyexpect discovery of an Earth-like planet before 2013. The Kepler finds add to our understanding

of the universe. For instance, with ground-based instruments, generally only the radius and notthe mass of the planets can be measured, and hence the density and composition would remainunknown; the size and mass of only three exoplanets smaller than Neptune used to be known.

Kepler has added five more to that list.

Keywords:exoplanets, Kepler-11, extra solar planets, NASA

Opposition in Libya struggles to form a united front

Anthony Shadid

Kareem Fahim

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A Libyan rebel who is part of the forces against Libyan leader Muammar Qadhafi holds a rocket

propelled grenade launcher as another carries spare ammunition outside the village of Bin Jawwad, west

of Ras Lanuf on March 5, 2011. Photo: AP

The question of its capabilities is likely to prove decisive to the fate of the rebellion, which

appears outmatched by government forces.

In less than three weeks, an inchoate opposition in Libya, one of the world's most isolatedcountries, has cobbled together the semblance of a transitional government, fielded a ragtag rebel

army and portrayed itself to the West and Libyans as an alternative to Col. Muammar el-Qadhafi's four decades of freakish rule.

But events this week have tested the viability of an opposition that has yet to coalesce, even as it

solicits help from abroad to topple Colonel Qadhafi.

Rebels were dealt military setbacks in Zawiyah and Ras Lanuf on March 8, part of astrengthening government counteroffens ive.

Meanwhile, the opposition council's leaders contradicted one another publicly. The opposition'scalls for foreign aid have amplified divisions over intervention. And provisional leaders warn

that a humanitarian crisis may loom as people's needs overwhelm fledgling local governments.


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I am Libya'

I amLibya, Colonel Qaddafi boasted after the uprising erupted. It was standard fare for one ofthe world's most outrageous leaders megalomania so pronounced that it sounded like parody.

It underlined, though, the greatest and perhaps fatal obstacle facing the rebels here forging a

substitute to Colonel Qadhafi in a state that he embodied.

We've found ourselves in a vacuum, Mustafa Gheriani, an acting spokesman for the

provisional leadership, said on March 8 in Benghazi, the rebel capital. Instead of worryingabout establishing a transitional government, all we worry about are the needs security, whatpeople require, where the uprising is going. Things are moving too fast.

This is all that's left, he said, lifting his cell phone, and we can only receive calls.

The question of the opposition's capabilities is likely to prove decisive to the fate of the rebellion,which appears outmatched by government forces and troubled by tribal divisions that the

government, reverting to form, has sought to exploit. Rebel forces are fired more by enthusiasmthan experience. The political leadership has virtually begged the international community torecognise it, but it has yet to marshal opposition forces abroad or impose its authority in regions

it nominally controls.

Organisers acknowledge the chaos but contend that there is no one else to talk to.

We require help'

We require support, whether it's military or otherwise, we require help, Abdel-Hafidh Ghoga,the deputy leader of the provisional leadership, told a news conference in Benghazi. The

international community has to assume its duty at this point.

While the mood remains ebullient in parts of eastern Libya, largely because few believe thatColonel Qadhafi can reconquer a region that long seethed under his rule, it is more sullen inBenghazi, a Mediterranean port and Libya's second largest city.

At the courthouse that has served as a government headquarters, bedlam reigned on March 8, asgusts of wind slammed doors shut and shattered a window. Nationalist music blared over hurriedconversations that unfolded beneath cartoons lampooning Colonel Qadhafi.

Security has begun to deteriorate, with gunfire echoing in the distance, some robberies and

assailants' throwing a grenade at a hotel housing foreign journalists.

At the front, three and a half hours away, rebels sought to recover from a government offensivethat forced them from Bin Jawwad and sent them reeling toward Ras Lanuf, a strategic refinery

town. The government also appeared to deal setbacks to the rebels in Zawiyah, a rebel-held townnear Tripoli, and Misratah, a strategic coastal city.


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With momentum seeming to shift, the rebels face the prospect of being outgunned andoutnumbered in what increasingly looks like a mismatched civil war.

They don't understand, said Sami Tujan, an officer trying, unsuccessfully, to command rebels

near a checkpoint. They're a big target.

Aging but effective weapons

The rebels won their initial battles with an assortment of aging but effective weapons, and aseemingly plentiful supply of ammunition, including some from North Korea and Russia. On the

beds of Toyota pickup trucks, many of the soldiers mounted an old Soviet heavy machine gun,which they referred to by the 14.5-millimeter rounds it fires. The guns are bundled together and

used as antiaircraft weapons, and may have been responsible for downing a governmentwarplane earlier this week near Ras Lanuf. Men holding rocket-propelled grenade launcherscomplete the patchwork rebel air-defence system.

At the front lines at Ras Lanuf, the opposition forces relied on more rudimentary trackingmethods to spot planes: a lanky man standing on top of a large dump truck with a pair ofbinoculars, along with hundreds of sets of ears of eager volunteers.

Even then, the government's Soviet-made planes mostly operated with impunity. Government

forces have also marshalled artillery, better tanks and helicopters that the rebels cannot match.

On March 8, as government forces gathered near Ras Lanuf, rebels strategised and argued amongthemselves, complaining that they did not have enough rocket-propelled grenades and that a spy

was among them.

Logistics, namely resupplying the front, has proved to be a challenge for the rebels. So hasleadership. Small units of men who said they belonged to specialised branches of Libya's armyjoined the fight, including members of special forces units and paratroopers. Some senior

officers are also seen at the front, but many of the rebels are bankers, policemen and theunemployed, who have formed enthusiastic but somewhat hapless brigades.

Apart from a few mechanised units in Benghazi and Tobruk, and a few armoured battalions

near Bayda, rebel-controlled areas lack any substantial hardware with which to take on the pro-Qaddafi stronghold of Tripoli, said a report on March 3 by the London-based InternationalInstitute for Strategic Studies. The pro-Qaddafi regions are also well garrisoned with artillery,

antiaircraft and mechanised formations, it added. After government authority collapsed in much

of eastern Libya, res idents set up what they ca ll local councils of varying numbers ofrepresentatives three in Darnah, six in Bayda. Theoretically, each is supposed to send arepresentative to Benghazi, where the opposition has set up a group called the ProvisionalTransitional National Council of Libya, a kind of state in waiting. Composed of 30

representatives, it is led by Mustafa Abdel-Jalil, a former Justice Minister and perhaps the solefigure who enjoys national support.


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Its authority remains tentative, a point acknowledged by those involved. We didn't have anyauthority, of course; we just gave ourselves authority, said Iman Bugaighis, a spokeswoman for

the council. Nobody has any political experience.

The council has barely begun to address the major choices the rebels need to make: whether to

support foreign intervention and whether to negotiate in any way with the government.

The council has pleaded for a no-flight zone, still being debated by the West, but rebel leaders in

Darnah warned that they would oppose any foreign interference with arms.

In his news conference, Mr. Ghoga ruled out any talks with the government, though Mr. Abdel-Jalil, theoretically his superior, told an Arabic satellite channel that if Colonel Qadhafi left in 72

hours, no one would pursue him.

How do we talk about something that hasn't been proposed? Mr. Ghoga asked.

Partition?

Opposition leaders also differ on whether to formally declare a transitional government,underlining fears that it may lay the groundwork for Libya's partition. Two of its representatives

met European officials on March 8, but the council has yet to unite with disparate, dividedopposition groups abroad, activists say.

There is no communication between opposition groups and no leadership for the opposition,said Adem Arqiq, an exiled Muslim Brotherhood member in Dublin. There are opposition

groups in Europe, in the United States and in some Arab countries, but each works for himself.There were efforts to unify them, but they failed.

For days, convoys of aid, many from Islamic relief organisations, have barrelled across the

Egyptian border, helping stanch shortages, in a remarkable show of organisation and solidarity.Mr. Gheriani estimated that Benghazi had six months of supplies, and the United Nations wassending more aid to the port. But in the hinterland, where local councils are still struggling to

reconstitute bureaucracies that collapsed last month, some worry a crisis is approaching.

No one knows how long supplies will last a week, two weeks, said Ahmed Boughrara, anengineer and organiser in Bayda. Then it's going to be a huge crisis.

Some have expressed a more lurking concern: that in a protracted fight, it may grow difficult to

maintain the unity that the opposition has sought to bridge religious and tribal divides.

The longer this conflict lasts, the more people are going to be radicalised, said Ibrahim el-Gadi, a hydrogeologist in Darnah, whose son was wounded in a fight with government forces.

We are not now, but it will be so if this conflict doesn't finish. (David D. Kirkpatrickcontributed reporting from Tripoli, Libya, and Nada Bakri from Beirut, Lebanon .) NewYork Times News Service


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Keywords:Libyan crisis. Qadhafi opponents

UAE plans to buy Australian uranium

AP

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Australia will soon begin negotiating to sell uranium to the United Arab Emirates on conditionthat it is only used for peaceful power generation, the Australian government said on March 8.

Australian Foreign Minister Kevin Rudd announced the negotiations on a bilateral uranium tradeagreement while visiting the Middle Eastern country's capital Abu Dhabi, according to a

government statement released in Australia's capital, Canberra.

Australia, which holds 40 per cent of the world's known uranium reserves, does not sell uraniumon the open market and bans nuclear power generation at home.

But it sells uranium solely for power generation under strict conditions that ban any military

applications in bilateral trade agreements with the United States, China, Taiwan, Japan, SouthKorea and several European countries. Australia refuses to consider uranium sales to India untilNew Delhi signs the Nuclear Non-proliferation Treaty. The UAE has already ratified that treaty

and is negotiating or has concluded nuclear safeguards agreements with countries including theUnited States, France, the United Kingdom and Japan, Mr. Rudd said.

Australia welcomes the UAEs efforts to establish a responsible approach to nuclear power

generation and hopes that it will serve as a model for other countries in the Middle East, he said.

The trade conditions will ban nuclear material from being transferred to any third country andfrom being used in weapons or to power warships.

The seven-state Emirates federation is building its first nuclear reactors on a sparsely populated

desert along the Persian Gulf near the border with Saudi Arabia. Although it sits atop one of theMiddle East's largest oil reserves, the OPEC member must import natural gas to fuel its existingpower plants. Blackouts occasionally occur in pockets of the country during the hot summer

months as power demand outstrips supply. The country expects its energy needs to double by theend of the decade. The federal government in Abu Dhabi awarded a South Korean consortium

the $20 billion contract to build four 1,400-megawatt reactors in late 2009.

Before that deal was signed, the UAE reached an agreement with the United States to import, notproduce, fuel for its nuclear reactors. The Emirates committed not to enrich uranium or reprocessspent nuclear fuel into plutonium, which is used in nuclear bombs.

Washington has promoted its plan to help the UAE develop peaceful nuclear power as a model

of the kind of cooperation it would like to achieve with nearby Iran. The U.S. and its alliessuspect Tehran is using a civilian program as a cover to develop an atomic weapons capability.
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Keywords:UAE, Australia, uranium

Antibiotic challenges, dilemmas, policies

K.S. Jacob


India was recently in the news for the wrong reasons. The serious threat posed by the newlydiscovered microbe, NDM-1 (New Delhi metallo--lactamase-1), resistant to many antibiotics,

triggered alarm and panic. Predictions that the country will not meet the millenniumdevelopment goal for child mortality caused dismay. They highlighted the nation's paradox. The

country faces two conflicting challenges. The urban rich with their easy access to medicaltreatments often receive inappropriate antibiotic therapy. On the other hand, the rural poor, withtheir lack of basic medical facilities, find it difficult to obtain such medication. The former

results in microbial resistance, while the latter in preventable deaths. The official reactions toboth these problems and their implications were denials. However, after the short-lived

indignation and outrage, it is back to business as usual, the old inertia with its deceptive calm.

Microbial resistance

Resistance of microbes to standard antibiotics is well known. Hospital-acquired infections, incircumstances where the use of antibiotics is high, are common. The development of bacterial

resistance to antibiotics is natural and occurs due to adaptation to hostile environments.However, the rapidity of its development and increased prevalence of such resistancedocumented in many tertiary hospitals reflect a serious problem. In addition, the life-threatening

nature of many infections, a limited availability of existing antibiotics and the absence of newones in the drug development pipeline are causes for alarm. This is true for many bacteria,

including those causing tuberculosis. It indicates the emergence of new and lethal dimensions forold diseases, which had effective and affordable cures. The increase in antibiotic resistance incommunity-acquired infections compounds the problem. It suggests that resistant microbes,

usually found in hospital environments, are now prevalent in the community.

The misuse and abuse of antibiotics by physicians is serious. Inadequacy of training inprescribing rational antibiotic therapy is a major lacuna. Prescribing antibiotics for simple viral

infections to prevent possible secondary bacterial infections is common practice amongphysicians, despite good clinical trials showing no value of such prophylaxis. Absence ofsentinel surveillance and regular guidance for prescribing also makes practice diff icult.

Indiscriminate prescription of newer antibiotic medication while allowing for recovery in

individual patients, risks development of microbial resistance.

The generally safe profile of antibiotics, their minimal side effects and short duration of the

course of medication are factors that lend themselves to abuse. The pharmaceutical industrycontributes to the problem by promoting the sale of antibiotics independent of patient need.Pharmacists readily dispense antibiotics without a doctor's prescription. A widely prevalent

belief among the general population that all infections respond to antibiotics also perpetuates
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inappropriate use. Many fail to realise that the majority of fevers are due to viral infections,which do not respond to antibiotic therapy.

Poor access

The lack of surveillance of microbial resistance at primary and secondary hospitals and theabsence of guidance in prescribing encourages the use of newer broad-spectrum drugs insituations were older medication would have sufficed. The poor state of the public health care

system, the private sector with its focus on profits and deficiencies in the regulation and sale ofantibiotics also muddy the waters.

While NDM-1 grabs the headlines, the true magnitude of the problem of antimicrobial resistance

to common antibiotics remains unknown. Widespread multi-drug resistance essentially implies areturn to the pre-antibiotic era and represents a major crisis in health. On the other hand, the lackof affordable access to basic medical facilities for the poor in Bharat complicates the issues.

Pneumonia, an acute respiratory infection, is the leading cause of child deaths in the world and a

common cause of under-five mortality in India. The World Health Organisation (WHO)estimates that less than a quarter of children with pneumonias receive antibiotics, resulting insignificant mortality. Similarly, mortality in adults with bacterial infections is also a majorconcern. The absence of adequate and timely antibiotic therapy due to a lack of access to

affordable medical care (for the vast majority of the rural population in the country due to theurban-centric nature of our health care delivery system) contributes to preventable deaths.

The way forward

Urban and rich India, with its inappropriate use of a ntibiotics, requires strict practice guidelines,

tighter regulation and an audit of antibiotic utilisation. On the other hand, poor and rural India

needs improved access to antibiotics and affordable health care.

Rational antibiotic therapy prevents the development of resistant micro-organisms, superbugs

and untreatable infections. Rational use will also result in a massive reduction in the cost ofhealth care. High- income countries have managed to decrease the rate of antimicrobial resistancethrough a multi-pronged approach. Their well-regulated health-care systems allow for

monitor ing of antibiotic consumption and resistance, prescriber and consumer education andregulation of use.

Fighting antibiotic resistance in India with its inadequate public health care infrastructure,

unenforced regulation and poor health education is a major challenge. Continuing physician

education, guidance on prescribing and monitoring practice is necessary. Regulating the sale ofantibiotics and microbial surveillance are mandatory.

India should start sustainable action to contain antibiotic resistance. It should raise awareness

using the mass media. Hand washing routines, to prevent the spread of infection within hospitals,are observed more in the breach in most health facilities. These need to be made mandatory.

Antibiotic sensitivity patterns, minimum inhibitory concentrations and a strategy of de-escalation


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of an antibiotic regimen should guide therapy in tertiary hospitals. The latter mandates a changeto an appropriate older antibiotic rather than continuation of a newer broad-spectrum drug,

after obtaining information on microbial sensitivity.

The formation and functioning of hospital infection control committees are obligatory. They

should monitor hospital-acquired infections at surgical sites and secondary to the use ofintravenous access, urinary catheters and ventilators. The committee should compile sensitivitypatterns, recommend prescribing guidelines, audit practice and educate health professionals.Specialist hospitals should have consultants in infectious diseases who should advice in making

rational choices for complex clinical situations. Modern technology allows for support inprescribing, tracking of antibiotic use and in containing the spread of resistance. In fact, it should

be mandatory for hospitals to make public their rates of hospital-acquired infections andmicrobial sensitivity patterns, to allow for informed choice for patients.

The surveillance of microbial resistance should not be restricted to ter tiary hospitals, as currently

practiced. It should also involve primary and secondary care centres to identify local and

regional patterns. The people of Bharat need a different surveillance network and practiceguidelines tailored to meet their specific needs. Sentinel centres in primary and secondary care

hospitals, with regional coordinating facilities, should be set up to help smaller hospitals.National and regional databases and advisory councils are mandatory. The implementation of

such systems is the challenge facing the country.

The solution to improve access to basic health care for poor and rural constituencies may lie in adifferent set of practice guidelines. Regulation of antibiotic use for this sector must be balancedby adequate availability and access to such treatments. Antibiotic policies should factor in

different microbial resistance profiles. Simplified antibiotic prescribing protocols for use byhighly trained paramedical workers and nurse practitioners have been found to be useful in many

low-income countries. Such strategies merit consideration for increas ing access and availabilityin rural and remote parts of the country.

Another cause for concern is the use of antibiotics in the agriculture-food industry (e.g. poultry,pig, fish farming and in honeybee hives) where these drugs are used as growth promoters.

Policies for rational use in this sector are also urgently required.

A decade has passed since the flagging-up of concerns about antibiotic resistance and increasedmortality due to untreated infections. The divergent and complex demands of the different

segments of the country have resulted in inertia and inaction. There is an urgent need to put inplace suitable policies and mechanisms for reductions in antibiotic resistance and yet provideeasy access to antibiotics in areas with poor penetration of health-care services. The challenges

for India and for Bharat are different and demand different solutions. The country is yet to have acomprehensive antibiotic policy. Implementation plans remain on paper. The country needs

carefully tailored strategies to meet the dissimilar challenges of its diverse contexts.

( Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)


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India faces the challenge of inappropriate use of antibiotics while Bharat copes with poor

access to treatment, resulting in a policy conundrum and inaction.

French diplomacy f alls from grace

Vaiju Naravane


Stung by criticism both within the country and abroad at France's slow response to the Tunisian

and Egyptian revolutions and the subsequent developments in Libya, President Nicolas Sarkozyhas taken the bull by the horns, jettisoning his discredited Foreign Minister Michle Alliot-Marie

and appointing a seasoned politician, the former Prime Minister, Alain Juppe, to re-shapeFrance's foreign policy.

Mr. Juppe, who held the post of Defence Minister at the time of the Cabinet reshuffle onFebruary 27 (the fourth within the space of one year), has served as Foreign Minister before, and

commands universal respect in France. He bargained hard and obtained the departure from Mr.Sarkozy's side at the Elysee Palace of Claude Gueant, a tough right-winger wide ly considered to

be Mr. Sarkozy's Grey Eminence on foreign policy, who has now been named Minister for theInterior and Immigration, although the President's diplomatic Sherpa, Jean-David Levitte,remains in place.

Naming Mr. Juppe to the post became a hard yet inevitable choice for Mr. Sarkozy, given therebellion within French diplomatic ranks. On February 22 a group of serving and ret ireddiplomats calling themselves the Marly group published what can only be described as a

diatribe against the President's foreign policy, saying it was amateurish, impulsive andpreoccupied by media considerations.

The writers of the article said that despite loudly trumpeted announcements, Europe remains

powerless, Africa escapes us, the Mediterranean snubs us, China dominates us and Washingtonignores us. More seriously, the voice of France has disappeared from the world and ourfollowing of the United States perturbs many of our partners. Today, aligned with the U.S., we

are of interest no one since we have lost our visibility and our capacity for diplomaticmanoeuvre

Trouble in Tunisia

The revolt of the diplomats was a consequence of a series of diplomatic incidents and gaffes

including the sacking of the Ambassador to Tunisia, Pierre Menat, who was blamed for notanticipating the country's social unrest. After sacking Mr. Menat, the President named BorisBoillon, a 41-year-old Arabist, to the post in Tunis. But the new Ambassador, whose experience

as the head of a French mission abroad was limited to Iraq, had a violent altercation with theTunisian press corps for which he was forced to apologise on Tunisian national television.
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Quick on the heels of this, came revelations that Foreign Minister Ms Alliot-Marie had offeredousted Tunisian strongman French expertise in riot control measures and had vacationed in

Tunisia after the unrest began, using planes belonging to close Ben Ali aides. Worse, Ms Alliot-Marie issued a series of half truths to cover up her ties to the Ben Ali coterie and her family's

business deals there. Such was the anger against France in Tunisia that the Minister who

supported Ms Alliot-Marie was also forced out of office. It turned out that just weeks earlier,Prime Minister Francois Fillon, too, had accepted the hospitality of Hosni Mubarak during a

family Christmas holiday in Egypt.

Damaged image

For weeks, French diplomacy was seen to be faltering in what is considered to be its sphere ofinfluence, the North African Maghreb region of Tunisia, Algeria, Morocco and Libya and the

Machreq or the Levant. Opinion polls indicated that 72 per cent of the French felt France's publicimage had been irretrievably damaged abroad. With his popularity ratings consistently low at 30

per cent, Mr. Sarkozy, who has been counting on foreign policy initiatives such as his presidency

of the G20 to bolster his image at home in view of the 2012 elections, realised that urgent actionwas needed. Ms Alliot-Marie had to go with French diplomacy passing into more experienced

and more capable hands.

Several of Mr. Sarkozy's foreign policy initiatives have gone wrong. In 2007, he announced thecreation of a Union for the Mediterranean, an attempt to bind the 17 nations around the

Mediterranean with the European Union through a series of specific projects and initiatives bothcultural and economic. The objective was twofold to give a sop to the Turks who had to bekept out of the European Union at all costs and to increase French influence amongst the

Mediterranean rim countries while increasing controls on illegal immigration into countries suchas Greece, France, Spain or Italy. However, the project never really got off the ground because of

a lack of consultations with other EU partners and the revolutions in Tunisia, Egypt and Libyahave severely compromised what remains.

More recently, by publicly criticising the 60-year sentence meted out by a Mexican court to aFrench woman accused of k idnapping, Mr. Sarkozy prompted the writer and former Mexican

Ambassador to France Carlos Fuentes to describe Mr. Sarkozy as the dictator of a bananarepublic. This is a classic example of how the French P resident's hyperactivity and desire to be

centre stage at all times undercuts discreet diplomatic efforts to resolve tangled problems withpartners.

In France's Fifth Republic established in 1958, foreign policy has always been the specialpreserve of the President. However, successive French heads of state, from de Gaulle to Jacques

Chirac have relied heavily on precious inputs from the French foreign office and its impressivepanoply of diplomats. These close ties between career diplomats and the President's office were

vastly diminished, if not interrupted, by Mr. Sarkozy who has tended to run French foreignpolicy directly from the Elysee Palace with the help of a few close aides, bypassing successiveForeign Ministers and ignoring the advice proffered b y French envoys abroad.


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France has the second largest diplomatic service in the world after the U.S., but repeated budgetcuts have crippled the service and demoralised the men and women working to defend French

interests abroad. In July 2010, Alain Juppe and Hubert Vedrine, two of France's most respectedForeign Ministers, the first a rightist the other a socialist, jointly published an article calling for a

halt to a further reduction in force in the French diplomatic corps. The effect of constantly

trimming the Foreign Ministry budget and reducing personnel has been devastating, they said.The instrument is at breaking point and the entire world has noticed this. All our partners are

aware of it. Other great powers do not similarly destroy their diplomatic instruments.

Priorities redefined

In his first speech after taking over as France's new Foreign Minister on March 1, Mr. Jupperedefined the priorities for French diplomacy: Re-founding the Union for the Mediterranean,

increasing European integration and strengthening ties with emerging powers such as China,Brazil, India or Russia while anticipating the emergence of Africa in the 21st century. It would

be a strategic mistake to withdraw from Africa with which France has historic ties, Mr. Juppe

said. Given his past declarations on the subject, it was understood that Mr. Juppe would notallow any further trimming of the diplomatic corps.

Mr. Juppe has followed this up with strong words against the Qadhafi government and on a

recent visit to Cairo he insisted on meetings across the political spectrum, from members of theMuslim Brotherhood to the group of young computer specialists and professionals who were

instrumental in organising the uprising against President Hosni Mubarak.

But the loss of French influence in the world says Isabelle Lasserre, writer and journalist, authorof a book on French diplomacy entitled French Powerlessness, began with the fall of the BerlinWall and has continued unchecked since the only highpoint, President Chirac's threat to use

the French veto over Iraq, now definitely in the past. France has joined NATO's IntegratedCommand Structure without obtaining very much from the Americans in return. And France,

once looked up to in West Asia because of its specialist understanding of the Arab world, nowgenerates mistrust because of its new closeness to Israel.

Inevitable erosion

During the Cold War period we were able to position ourselves as an independent voice within

NATO. France handled German reunification badly, failed to grasp the importance of the 9/11World Trade Centre attacks and has been unable to deal with globalisat ion. We have seen severalforeign policy reverses, especially in Africa and the Arab world. But our increasing

marginalisation on the world stage is due also to old tropes that have dominated our world view,both historic and colonial. In a certain way, we continue to see ourselves as an imperial power

and our attitudes are shaped by that. We must come to terms with the fact that we are a secondlevel power, that the days or empire are over and we must devise a new foreign policy that is inkeeping with these new realities, by building bridges within the EY, for instance. Without which,

we shall see an inevitable erosion of French influence in the world, says Ms Lasserre.


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Whether Mr. Juppe is capable of reversing the tide and giving France its lost pride and glory isvery much a matter for conjecture, especially if foreign policy continues to be seen through the

prism of the old colonial relationship with Africa or the clientelism in West Asia. Nevertheless,in terms of the electoral timetable (France holds presidential elections in May 2012), Mr.

Sarkozy is taking a considerable risk in naming Mr. Juppe. The new Foreign Minister has a

prodigious reputation for efficiency and decisiveness. He is also respected by large numbers ofvoters from Mr. Sarkozy's own UMP party as well as from the centre and Left who admire him

for his sober personal style coupled with his forthright criticism of attempts to use issues such asnational identity or Islamophobia for electoral ends. This move by Mr. Sarkozy could lead to a

draft-Juppe movement that would be difficult for the President to counter or resist.

A series of blunders has forced President Nicolas Sarkozy to bring in a potential rival to

handle foreign affairs.

OPEN PAGE

Let's fix the problem, not the fees

Sekar Viswanathan


Even though health care is more essential to the public than education, our government does not

fix the fees to be charged by each hospital for various servicesThe same model can be

followed in the educational institutions.

The government shackles were removed and the Indian industry was freed from permit licenceraj in the early 1990s. There has been no looking back for industry ever since. The growth rate ofour economy has been phenomenal and industry has proven its prowess by becoming one of the

world leaders in the IT sector. But these winds of liberalisation have never touched our ed ucationsector.

Education still remains a highly regulated sector. The permit licence raj exists in its fullest form.

So the private players are subject to the usual government bureaucracy, delays and corruption.The fee charged by the private institutions is fixed by government-appointed committees in most

cases. On the face of it, it would appear that it is a good thing that the government controls the

fees to be collected by private institutions. But it is only when you get into the issues that youwill realise that it has harmful effects.

Let us take engineering colleges. Most State governments fix the fees to be collected from

students through fee-fixing committees. This fee is uniform for all colleges in that State. Theexpenses, both operational and capital, vary from college to college. Land price, construction

cost and staff salary are much higher for an institution in Chennai than in a college located in a
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remote village. Yet, the fee fixed is the same. The infrastructure, labs and the quality andstrength of faculty vary from college to college. Yet, the fee fixed is the same. (In Tamil Nadu,

for the NBA-accredited courses the fee is Rs.7,500 more. But the NBA accreditation has run intomany problems.)

The solitary reaperDr. Sanjay Rajagopalan


Sekhar, at his daily routine of cleaning up the mess of civilisation in Chennai. Photo: Special

Arrangement
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Related

TOPICS

conservationhabitat (conservation)

environmental cleanuppollution control

environmental issuesnatural resources

nature

waste

peopleaccomplishment

human interest

A solitary figure is crouched over the sands under the rays of the early morning sun on the

stretch of the beach adjoining the Adyar river estuary and the Theosophical Society in Chennai.He makes his way slowly, picking up trash, cups, cans, p lastic covers anything that he canpossibly collect in his wicker basket. I watch as he drags the wicker basket lightly over the sand,

harnessed by a knot to his gnarled and weather-beaten hand. He pauses momentarily, squinting atthe horizon as he surveys the work ahead. Sekhar, a 75-year-old appearing man, with a shy smile

(he does not know his true age) and a slight hunch, moved to Chennai about 21 years agoseeking work. He has since found gainful employment with a group of civic- minded citizenswho initially employed him with personal contributions to pick up trash nearly 20 years ago. He

is now paid a princely' sum of Rs. 500 a month, in addition to ad hoc contributions fromcharitable folk who visit this stretch of the beach.

Sekhar is literally a one-man operator who maintains some semblance o f hygiene and decorum

along these sands. He arrives everyday promptly at 6 a.m., and cleans the beach forapproximately an hour. In the evening, he typically arrives at 5.30 p.m. and again spends an hour

removing refuse. The cleanliness along this stretch is in stark contrast with the beach a milefurther south, in the residential area of Besant Nagar.

A visit to the stretch of the beach referred to as Elliott's beach these days reveals an astonishingarray of remnants originating from human civilisation (or lack thereof) that includes every

conceivable entity not suitable for human consumption or sale. There is unfortunately no Sekharhere to pick up the littler dropped with impunity by the thousands of people who visit the beacheveryday.

My mind wandered back to the period 30 years ago when these beaches were pristine, where the

shores were still strewn with shells and seaweed as opposed to the current grotesque collection of

human ingenuity. There were no Sekhars then, nor were there throngs of insensitive tourists topollute the beach. I pondered over this immense resource that we have in Chennai, miles of theotherwise pristine public beaches for one and all to enjoy and the immense impact they have hadon the lives of millions of people who call this city their home. However, the level and scale of

pollution that threatens these sands on a daily basis, together with growing helplessness andresultant apathy of its citizens, represents an existential threat to this ecosystem. How much

longer will it take before the beaches are rendered unfit for recreation and for the larger purpose
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for which beaches were meant as a beachhead against natural calamity and ecosystem for amyriad of life forms? Something needs to be done soon and it may require many Sekhars and

many civic-minded citizens who have been the happy beneficiaries of the largesse of Chennaibeaches. The intent of Wordsworth's solitary characters in many poems was to show how to be

one with nature. Perhaps, the citizens of Chennai could use Sekhar's example to rally efforts to

make the environment, at least around the beaches, a priority and allow all of us to be one withnature.

(The writer is John W. Wolfe Professor of Cardio vascular Medicine, Professor of Medicine and

Radiology, The Ohio State University School of Medicine, Columbus, U.S. His email is:

[email protected])

Moreover, many State governments consider fixing fees a populist measure which will affect

voting patterns. So there is a lot of pressure on the elected politicians to keep the fees as low as

possible regardless of the financial suffering of the education providers. The governmentsubsidises fees in its institutions like charging Rs.50,000 annually from IIT students, whereas itcosts the taxpayers Rs.2,50,000 annually to educate each student. (The only exception perhapsare the IIMs which charge an annual fee of Rs.6,00,000). But it is unfair for the government to

force the private sector to provide subsidy.

The government does not fix the price of land, cement, steel, loan rates or any other expenseincurred by the private institutions, yet it fixes the fees to be collected by them. It keeps hiking

the dearness allowance every six months. Under pressure to retain the faculty members, theprivate institutions follow suit. Yet, the fees are not increased annually in many States. It islocked for three years. The model of government committees fixing the fees has become a

failure, as it is impractical.

The institutions are under a lot of financial pressure as they have to bear the spiralling costs andpay bribe to obtain licence (known as approvals) from various government offices. Unable to

withstand the financial pressure, some institutions lower the quality of education, and someothers resort to the capitation fees or collect fees higher than fixed by the government withoutproviding a receipt. Why are we driving our own institutions to indulge in illegal activities?

What is the solution?

Let us take the health care industry as an example. Even though health care is more essential to

the public than education, our government does not fix the fees to be charged by each hospitalfor various services. For the same surgery, a reputed private hospital in the city with wonderful

infrastructure and senior doctors might charge a higher fee compared to a small private hospitalwith fewer facilities. The same surgery would be done free of charge in the government hospital.

The citizen chooses which hospital he/she wants to go to.


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The same model can be followed in the educational institutions. Each institution should have thefreedom to fix the fees, which could vary for each course, based on the expenses incurred. The

government's role will be to ensure a free and fair competition between private-private andprivate-public institutions. This competition will ensure that no institution charges an

unreasonable fee. The public will not pay high fee to an institution which provides low quality

education, especially when there are competitors who offer their services at a reasonable fee.

The government can leave accreditat ion to professional organisations (as proposed in anupcoming bill in Parliament). The accreditation agencies can visit the institution, examine the

fac ilities and faculty, interact with students, issue a grade and publish a detailed report on theirwebsite and in the government websites. This will help the public understand fully about an

educational institution. People are willing to pay more for better quality education, as it providesthe students a great career in their life. The competition will put a lot of pressure on theinstitutions to perform better. In addition, the government can provide scholarships to poor

students regardless of whether they are studying in government or private institutions.

After allowing the institutions to fix the fees, the government can monitor if they collect anyother fee without providing receipts. In India, educational institutions can be run only

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