Monday, 30 July 2012

What We Can Learn From Third-World Health Care

Lord Crisp, Former Head of UK NHS, talking about sharing lessons across rich and poor countries regarding healthcare.

New York Times, Original Link Here

JULY 26, 2012, 12:01 AM

What We Can Learn From Third-World Health Care

The young doctor had just returned from a month working in a country in Africa, familiar to the rest of us only through pictures of its impoverished population and news reports of recurring natural disasters and political upheavals. "You must feel exhausted but great," a senior colleague commented. "You went in there and you really helped those people."
But my younger colleague felt neither exhausted nor relieved to be back home, she confided when the older doctor had left the room. She had cared for dozens of patients with abscesses and broken bones, tumors and arrow wounds, relying on nothing more than a single rickety X-ray machine, a handful of battered surgical instruments and the aid of one well-connected local nurse.
"We could get so much done with so little over there," she said. "It's like we're not doing something right over here."
Put another way, the American health care system has become the great international paradox, spending more but getting less.
With all the most advanced technology and equipment, spending far more on health care than any other nation - a whopping $2.6 trillion annually, or over 17 percent of our gross domestic product - the United States consistently underperforms on some of the most important health indicators. Our infant mortality rates, for example, are worse than those in countries like Hungary, Cuba and Slovenia. Our life expectancy rates are not much better; in global rankings, we sit within spitting distance of Cuba, Chile and Libya.
This quality conundrum dogs us, even as our best and brightest have tried to imagine a more cost-efficient system. Some have pursued the carrot-and-stick route, linking quality measures to reimbursement. Others have attempted to reduce quality to its most basic parts, creating checklists and to-do lists. And still others have rearranged networks of hospitals, clinics, physician practices and payments, conjuring up a breathtaking array of combinations, permutations and bundles of care in order to create more cost-efficient systems.
But, according to an essay published this summer in The Stanford Social Innovation Review, we might have saved ourselves the huge effort, the expenses and the disappointments of only marginally successful initiatives, if we had first looked to countries traditionally viewed as needing our aid and learned from their successes in facing challenges similar to our own.
In the essay, Rebecca D. Onie, a founder and the chief executive of Health Leads, a domestic health care organization; Dr. Paul Farmer, a founder of Partners in Health, a Boston-based medical nonprofit group; and Dr. Heidi Behforouz, medical and executive director of the Prevention and Access to Care and Treatment project, a community-based health care initiative in the United States that is part of Partners in Health, argue eloquently for "reverse innovation." They contend that for decades, several nongovernmental and nonprofit medical organizations have delivered high-quality care in some of the most challenging circumstances possible. Applying the solutions these medical organizations have already discovered could allow us to bypass or at least foreshorten what has become an interminable trial-and-error search for the answers to our country's health care woes.
Their own organizations offer several models of success. For nearly three decades, Partners in Health, for example, has delivered consistently high-quality care to more than 2.5 million people in a dozen countries like Haiti, Rwanda and Peru, places with widespread poverty, scarce numbers of providers and no health care infrastructure. But they have managed to achieve, among other successes, the highest rate of cure of multidrug-resistant tuberculosis in the world and better rates of adherence to treatment regimens and follow-up than in much of the United States.
The key to their success is an unabashed disregard for some of our most cherished assumptions about what constitutes good care. Instead of providing antibiotics, CT scans and high-tech interventions, Partners in Health considers basic necessities like food and housing as critical components of the group's medical work. Instead of asking patients to travel miles to the only clinic and see only the doctor or nurse, they train cadres of community health workers who can monitor, administer and advise in the heart of local villages and in people's homes.
Applied to organizations in the United States, this approach has proved startlingly effective, as the Prevention and Access to Care and Treatment, or PACT, program has demonstrated. PACT targets some of the poorest and sickest patients with H.I.V. and other chronic illnesses in the greater Boston area. Just like Partners in Health, PACT relies extensively on community health workers who are trained in tasks like helping patients take their medications and make it to clinic appointments as well as reviewing their pantries and teaching them to prepare healthy meals. Applying these broad definitions of care, PACT has significantly decreased the number of emergency room visits and life-threatening opportunistic infections, cut hospitalization rates by 60 percent and yielded a 16 percent savings for Medicaid.
Health Leads has stretched these definitions even further, giving the terms "provider" and "care" a millennial twist. Each year, Health Leads trains a selected group of technology-savvy and tenacious college students to staff "resource desks" in primary care and prenatal clinics in cities like New York, Baltimore, Boston and Chicago. With these Health Leads volunteers in place, doctors can, for example, "prescribe" housing assistance for a family whose child's severe asthma has been exacerbated by a cockroach infestation, healthy foods and nutrition resources for a man suffering from obesity, or transportation to a drugstore for an elderly woman who needs diabetes medications. At the resource desk, a Health Leads volunteer then "fills" these prescriptions by finding the best solutions for the problems at hand, whether that means tracking down the appropriate agency, navigating complicated online application processes or providing support as the patient makes the calls. In clinics where a single social worker may be responsible for as many as 25,000 patients, Health Leads volunteers have more than doubled the services provided.
The successes of PACT and Health Leads are no secret. But what does remain mysterious as our health care system threatens to implode is why more of us haven't done the same and rushed to apply the lessons learned and proved elsewhere.
"We keep trying to reinvent the wheel," Ms. Onie observed. "The humbling reality is that we are trying to recreate innovations that have been robustly developed in the developing world."
In other words, we have yet to deploy what could prove to be the most powerful weapon in the fight to contain costs and improve the quality of health care: our own humility.

Wednesday, 25 July 2012

Casebook on Ethical Issues in International Health Research

Ethics Casebook

Publication details

EditorsRichard Cash, Daniel Wikler, Abha Saxena, Alexander Capron
Number of pages209
Publication date2009


This publication is the outcome of a project of the Secretariat of the Research Ethics Review Committee of the World Health Organization in partnership with the University of Geneva, and with the support of the Réseau universitaire international de Genève/Geneva International Academic Network (RUIG/GIAN).
This casebook collects 64 case studies, each of which raises an important and difficult ethical issue connected with planning, reviewing, or conducting health-related research. The book’s purpose is to contribute to thoughtful analysis of these issues by researchers and members of research ethics committees (RECs, known in some places as ethical review committees or institutional review boards), particularly those involved with studies that are conducted or sponsored internationally.
This collection is envisioned principally as a tool to aid educational programmes, from short workshops on research ethics to in-service learning for scientists and REC members, to formal degree or certificate courses. In such settings, instructors will typically select a number of case studies that will be distributed to the participants to provoke and focus discussion. (To assist those using these case studies in their classrooms and workshops, a teaching guide has been included.) Individuals who want to stimulate their own thinking about research ethics or to become more familiar with a range of real-world dilemmas in international health research, especially in developing countries, may also benefit from perusing this book, either on topics of special interest to them or as a whole.

The human right to pain relief in the context of the international fight against illicit drugs

The human right to pain relief in the context of the international fight against illicit drugs

In over 150 countries proper pain and palliative care treatment is the exception rather than the rule. Hence over 80 per cent of the world's population has either no or poor access to pain relief services, including the prescription of morphine and other opioids.

As part of her education at the Utrecht University School of Law in the Netherlands, Marie Elske Gispen wrote an LL.M. Thesis about this issue, which she now has adapted at the request of IFHHRO.
Her report focuses on the Single Convention on Narcotic Drugs (SCND) of 1961 in relation to the realisation of the right of patients to adequate pain relief. Gispen states that pain relief could be easily attained if morphine, the key medicine used in effective pain treatment, were dispensed according to the WHO's standards on pain management. The SCND clearly leaves room for the use of opioids for medical purposes, however, many states are either unwilling or poorly equipped to offer such services to their citizens - due in part to the SCND's highly burdensome control mechanisms. As a result, opioid availability is limited in most developing countries.

The predicament that underlies the current poor access to pain relief is opium's dual character of being both an essential medicine as well as an illicit drug. This dual character has led to strict and harsh international regulatory schemes, which practically disallow states to fulfil their human rights obligations. This strict approach - currently contested by multiple actors in the field including IFHHRO - motivates, among others, the present public health deficit of poor pain treatment services. The author argues that the human rights framework "proves to be a valuable tool to combat this deficit; for denial of pain treatment effectively translates into a human right to pain relief as part of the effective realisation of the right to health and, as increasingly argued, the freedom from inhuman and degrading treatment."

Access to pain relief was one of the three themes of the Open Society Foundations campaign 'Stop Torture in Health Care', in which IFHHRO had been a partner. In this campaign, IFHHRO focused on raising broad awareness among health workers on the topic of pain relief.

About the author:
Marie Elske Gispen is a PhD Candidate at the Netherlands Institute of Human Rights (SIM) and Ethics Institute of Utrecht University in the Netherlands. She is also attached to the London-based International Centre on Human Rights and Drug Policy as a Research Associate.

Tuesday, 24 July 2012

Systematic Review of national health insurance for the poor and informal sector in LMICs

Systematic Review:   Impact of national health insurance for the poor and the informal sector in low- and middle-income countries.

Full Report here.


What do we want to know?

Moving away from out-of-pocket (OOP) payments for healthcare at the time of use
to prepayment through health insurance (HI) is an important step towards averting
financial hardships associated with paying for health services. Social health
insurance (SHI) is mandated for those employed in many developed countries
where employment and wage rates are high; this service is extended to those
unemployed through subsidy. In low- and middle-income countries (LMICs) some
version of SHI has been offered to those in the informal labour sector, who may
well comprise the majority of the workforce. We carried out a systematic review of
studies reporting on the impact of health insurance schemes that are intended to
benefit the poor, mostly employed in the informal sector, in LMICs at a national
level, or have the potential to be scaled up to be delivered to a large population.

Who wants to know and why?

Our findings will help policy makers to learn what lessons the implementation of
such insurance suggests in terms of welfare enhancement to those who currently
undertake out-of-pocket health expenditure, which often exacerbates their already
meagre material living conditions. The information in this document will help
reshape existing programmes, and assess the need for expanding and introducing HI
programmes for the poor and those in the informal sector. We further aim to
influence future effort in examining the impact of health insurance by detailing
appropriate methods that have succeeded in identifying the impact of insurance,
given the mechanism through which schemes were offered.

What did we find?

Our systematic review showed inconclusive evidence. Low enrolment is commonly
observed in many of the insurance schemes we examined. Many health system
factors may play a role in explaining low enrolment; studies did not explore supply
factors. We do not observe a pattern regarding enrolment and outcome: for
example, high enrolment is not correlated with better outcomes. There is some
evidence that health insurance may prevent high levels of expenditure. From those
studies reporting on whether or not the impact on the subgroup of insured that
were poorer was more noticeable, we find that the impact was smaller for the
poorer population. That is, the insured poor may be undertaking higher OOP
expenditure than those who are not insured.

What are the implications?

Greater effort needs to be undertaken to study the health-seeking behaviour of
those insured and those uninsured in LMICs.

How did we get these results?

We give results from 34 studies that report the impact of health insurance for the
poor using quantitative methods. We found no qualitative studies. We emphasise
the results from those studies that made a significant effort to use statistical
methods currently prevalent in the economics literature on impact evaluation.

Friday, 20 July 2012

USAID Chief trying to break links with for-profit contractors

From Foreign Policy magazine.  Original here.

Hired Gun Fight

Obama's aid chief takes on the development-industrial complex.


Rajiv Shah, President Barack Obama's U.S. Agency for International Development administrator, is waging a high-stakes battle to make U.S. foreign aid programs less dependent on American for-profit contractors. At the same time, he's aiming to roughly double the amount of assistance that flows directly to governments and local organizations in the developing world.
Shah's initiative reflects Obama's broader desire to clean up government contracting announced early in his term, as well as the thrust of a White House review of development policy and the State Department's first-ever Quadrennial Diplomacy and Development Review. Although Shah's plan hasn't gotten much public attention, it represents a seismic shift in how American foreign aid programs are conducted and will require both wrenching institutional change and a very tough political battle if it is to become a reality.
Given the degree to which USAID works with contractors, some of Shah's language has been delightfully undiplomatic. In a 2011 speech, he drew parallels between the agency's reliance on for-profit firms and Eisenhower's warnings about the emergence of a military-industrial complex. Saying that USAID was "no longer satisfied with writing big checks to big contractors and calling it development," Shah argued that development firms were more interested in keeping themselves in business than seeing countries graduate from the need for aid. "There is always another high-priced consultant that must take another flight to attend another conference or lead another training," he complained.
Shah's fiery rhetoric quickly set off alarm bells among USAID's many for-profit contractors, particularly since it came hot on the heels of the agency's December 2010 decision to suspend a huge non-profit, the Academy for Educational Development, or AED, from receiving new government contracts because of abuses in two of its Pakistan projects and what USAID argued was "serious corporate misconduct, mismanagement and a lack of internal controls." AED was one of USAID's larger partners, managing about $500 million annually in grants and contracts, and the suspension led AED to go belly up just month later in the spring of 2011. AED insiders complained bitterly that USAID overreacted; USAID insiders countered that AED would have survived had it not tried to downplay and conceal the problems when they were first discovered. Eventually, AED paid $5 million to the U.S. government in a Justice Department settlement for the Pakistan projects in question.

Top 10 USAID Contractors for FY 2011
Obligated Program Funds

Chemonics International, Inc.
Partnership for Supply Chain Management
John Snow, Inc.
Development Alternatives, Inc.
The Louis Berger Group, Inc.
ABT Associates Inc.
Management Sciences for Health
Research Triangle Institute
ARD, Inc.
Creative Associates International, Inc.
A bit of history is important in explaining why the Obama administration remains convinced that too much foreign aid flows through firms around the Beltway. Much of the current struggle has its roots in a bitter battle between the Clinton administration and Senator Jesse Helms during the mid-1990s, during which Helms and his allies attempted to abolish USAID and fold its functions into the State Department. USAID managed to fend off Helms, but ended up weathering steep cuts to its operating expenses, which forced it to dramatically reduce staff size through layoffs and attrition. Even when funding for foreign aid rebounded after Sept. 11, USAID was a shell of its former self, having lost much of its staff and expertise in key development areas like agriculture. A 2003 Government Accountability Office report captured the dilemma: "Since 1992, the number of USAID U.S. direct hire staff declined by 37 percent, but the number of countries with USAID programs almost doubled, and, over the last two years, program funding increased by more than 50 percent." In short, USAID had gone from being a development agency to being a large, poorly organized contracting agency. Incredible pressure to push money out the door in Afghanistan, Iraq, and Pakistan only exacerbated these trends.
Because USAID remains laden with bureaucratic restrictions, it also tends to rely on large umbrella contracts that favor a handful of well-connected Beltway firms. The 10 largest USAID contractors received more than $3.19 billion in 2011, and more than 27 percent of the agency's overall funding was directed to American for-profit firms last year. To put this in perspective, if the for-profit contractor Chemonics were a country, it would have been the third-largest recipient of USAID funding in the world in 2011, behind only Afghanistan and Haiti.

Thus Shah's push, under the rather benign title of "procurement reform," to channel more funds directly to institutions in the developing world: governments, entrepreneurs, educational institutions, and NGOs. The theory behind relying more on local institutions is simple and compelling: If the goal of development is to build sustainable local capacity and ownership, why not have countries play a larger role in helping help themselves? Not only is this good development policy in countries where proper management controls are in place, it also has the potential to save American taxpayers a great deal of money.
U.S. contractors, looking at losing large amounts of revenue, were not about to take this lying down.The Professional Services Council (PSC), an umbrella group of government contracting firms, quickly hired lobbyists to push back against procurement reform and helped establish the Coalition of International Development Companies, an advocacy coalition of 50 contractors touting the role of "America's most effective, efficient and innovative international development companies" in advancing the national interest. Perhaps it was a coincidence, but increased lobbying funded by the PSC directly preceded a sharply worded letter from the chairman of the House Committee on Oversight, Rep. Darrell Issa, to USAID questioning the wisdom of procurement reform. The letter hammered home one of the key arguments that contractors had been using against channeling more money directly to developing-country institutions: the threat of waste and corruption by foreigners.
That argument might be a little more persuasive if American for-profit contractors had not had their own problems in this regard. In 2010, Louis Berger Associates agreed to pay $69 million in penalties after the Justice Department found that it was intentionally overcharging taxpayers for its activities in Afghanistan. A 2009 Washington Post story revealed that managers at Chemonics encouraged employees in Afghanistan to deliberately downplay or ignore failing programs so as not to disrupt the flow of the grants.
The risk of waste, fraud, or abuse is a constant specter in American aid programs, but it should also be acknowledged that spending hundreds of millions of dollars on overhead for American firms is also a real cost, and doesn't always contribute a great deal to lasting development. To its credit, USAID seems to be taking a rigorous approach to ensure that proper systems are in place in countries where it is pushing out more money through local channels, and it has been conducting audits of public financial systems in those cases where it wants to work directly through foreign governments.
USAID's response to Issa highlighted a recent example from Senegal in its defense. In Senegal, the agency shifted from using American for-profit contactors to build schools and instead carried out the work through a partnership with the Senegalese government. Money for the schools was not disbursed until after a completed school was certified to have met agreed safety and quality standards. The cost difference was striking: It cost $425,000 per school through American contractors, but only $200,000 when built by the Senegalese government.
Things now stand at an uneasy crossroads. Contractors don't like Shah's new approach, but are nervous about too aggressively biting the hand that feeds them. USAID has committed to working with local institutions, but its spending totals in 2011 actually saw the proportion directed to American for-profits go up, not down. The agency has a huge amount of work to do if it still hopes to reach its target of 30 percent of its aid being channeled directly to governments and local organizations in the developing world by 2015. And Shah's aggressive push for a new paradigm will likely wither on the vine if the White House flips come November. For-profit contractors have always had their strongest allies on the Republican side of the fence.

Sunday, 15 July 2012

Reprint:  Orginal Link Here

Hunger: Old torments and new blunders   Amartya Sen 
  The Little Magazine.   Hunger    Vol II : issue 6
Amartya Sen

It is so old a story,/ Yet somehow always new," so said Heinrich Heine, the German poet, essayist and political activist, in Lyrisches Intermezzo. That early nineteenth century frustration of Heine (Intermezzo was published in 1823 — he went into voluntary exile in revolutionary Paris seven years later) cannot but recur in our thoughts as we observe the continued barbarity of old problems with new and added dimensions, in the distressing world in which we live. Nowhere, perhaps, is this as exasperating as in the terrible continuation of massive hunger and undernourishment in India.

It is not that nothing has been achieved in India over the half-century or more since independence in 1947. Positive things have certainly happened. First, the rapid elimination of famines in India with independence is an achievement of great importance (the last sizeable famine occurred in 1943 — four years before independence), and this is certainly an accomplishment that contrasts with the failure of many other developing countries to prevent famine. And yet this creditable record in famine prevention has not been matched by a similar success in eliminating the pervasive presence of endemic hunger that blights the lives of hundreds of millions of people in this country.

Second, the stagnating agriculture that so characterised — and plagued — pre-independence India has been firmly replaced by a massive expansion of the production possibilities in Indian agriculture, through innovative departures. The technological limits have been widely expanded. What holds up Indian food consumption today is not any operational inability to produce more food, but a far-reaching failure to bring entitlement to food within the reach of the more deprived sections of the population. Indeed, as M.S. Swaminathan has pointed out, "We have reached a stage in our agricultural evolution when our production will increase only if we can improve consumption."[1]

First enemy: Smugness and ignorance
How can things be changed? The first thing to get rid of is the astonishing smugness about India’s food record and the widespread ignorance that supports it. India has not, we must recognise unambiguously, done well in tackling the pervasive presence of persistent hunger. Not only are there persistent recurrences of severe hunger in particular regions (the fact that they don’t grow into full-fledged famines does not arrest their local brutality), but there is also a gigantic prevalence of endemic hunger across much of India. Indeed, India does much worse in this respect than even Sub-Saharan Africa.[2] Calculations of general undernourishment — what is sometimes called "protein-energy malnutrition" — is nearly twice as high in India as in Sub-Saharan Africa. It is astonishing that despite the intermittent occurrence of famine in Africa, it too manages to ensure a much higher level of regular nourishment than does India. About half of all Indian children are, it appears, chronically undernourished, and more than half of all adult women suffer from anaemia. In maternal undernourishment as well as the incidence of underweight babies, and also in the frequency of cardiovascular diseases in later life (to which adults are particularly prone if nutritionally deprived in the womb), India’s record is among the very worst in the world.

A striking feature of the persistence of this dreadful situation is not only that it continues to exist, but that the serious public attention it gets, when it gets any at all, is so badly divided.[3] Indeed, it is amazing to hear persistent repetition of the false belief that India has managed the challenge of hunger very well since independence. This is based on a profound confusion between famine prevention, which is a simple achievement, and the avoidance of endemic undernourishment and hunger, which is a much more complex task. India has done worse than nearly every country in the world in the latter respect. There are, of course, many different ways of shooting oneself in the foot, but smugness based on ignorance is among the most effective.

Poverty, healthcare and education
This takes us to the next question. Once we get rid of the smugness, what should we do? The old barriers to good nutrition do, of course, remain, and we have to recognise that they have not lost their bite. People have to go hungry if they do not have the means to buy enough food. Hunger is primarily a problem of general poverty, and thus overall economic growth and its distributional pattern cannot but be important in solving the hunger problem. It is particularly important to pay attention to employment opportunities, other ways of acquiring economic means, and also food prices, which influence people’s ability to buy food, and thus affect the food entitlements they effectively enjoy.[4]

Further, since undernourishment is not only a cause of ill health but can also result from it, attention has to be paid to healthcare in general and to the prevention of endemic diseases that prevent absorption of nutrients in particular. There is also plenty of evidence to indicate that lack of basic education too contributes to undernourishment, partly because knowledge and communication are important, but also because the ability to secure jobs and incomes is influenced by the level of education.

Maternal undernourishment and its far-reaching penalties
So low incomes, relatively higher prices, bad healthcare and neglect of basic education can all be influential in causing and sustaining the extraordinary level of undernutrition in India. Yet, as Siddiq Osmani has shown, even after taking note of low levels of these variables, "one would have expected a much higher level of nutritional achievement than what actually obtains" in India in particular, and in South Asia in general.[5]

So something else must be brought in. Osmani suggests — plausibly enough — the lasting influence of maternal undernourishment, working its way via underweight babies (India and South Asia lead the world in this field), who grow into children and adults more prone to illnesses of various kinds. This is in line with findings that have been identified by others, such as Ramalingaswami and his colleagues.[6] Recent medical research has brought out the long-run effects of foetal deprivation, reflected in low birth weight, which appear to cause immunological deficiencies and other health vulnerabilities. The health and nutritional adversity related to maternal undernutrition and low birth weight children is almost certainly a significant factor in explaining the terrible nutritional state of India.

Since maternal undernourishment is causally linked with gender bias against women in general in India, it appears that the penalty India pays by being unfair to women hits all Indians, boys as well as girls, and men as well as women. Even though there is ambiguous empirical evidence regarding the relative nutritional backwardness of girls vis-à-vis boys (as Svedberg discusses in his paper in this number), there is no dearth of definitive evidence of the neglect of pregnant women. For example, the proportion of pregnant women who suffer from anaemia — three quarters of all — is astoundingly higher in India than in the rest of the world. The long-run effects of underweight births not only worsen the chances of good health and nutrition of children — both boys and girls — but also immensely increase the incidence of cardiovascular diseases late in life.[7] Interestingly, since men are, in general, more susceptible to cardiovascular diseases, it also turns out that the adverse impact of the neglect of the nutrition of pregnant women is, in this respect, even greater for men than for women. What is sown in the form of unfairness to women is reaped as illfare of men, in addition to the suffering of women themselves.

The analysis so far has identified particular problems that have to be tackled if India is to overcome the massive prevalence of persistent hunger from which it suffers in many different ways. The areas of action include economic opportunities (such as growth of income and its distributional pattern), social facilities (such as basic healthcare and education), and the countering of special deprivations of women (such as maternal undernourishment). These are old problems that have not yet been overcome, unlike other fields in which success has been achieved, such as famine prevention and technological expansion of production opportunities. What, then, are the new problems?

Largest food mountains and worst undernourishment
The barriers to nutritional progress come not only from old dividing lines, but also from brand new ones. Sometimes the very institutions that have been designed to overcome old barriers have tended to act as reactionary influences in adding to inequity and unequal deprivation. The terrible combination that we have in India of immense food mountains on the one hand and the largest conglomeration of undernourished population in the world is one example of this.[8]

In 1998, stocks of food grains in the central government’s reserve were around 18 million tonnes — close to the official "buffer stock" norms needed to take care of possible fluctuations of production and supply. Since then, it has climbed and climbed, firmly surpassing the 50 million mark, and it appears, according to recent reports, that our stocks now amount to 62 million tonnes. To take Jean Drèze’s graphic description, if all the sacks of grain were laid up in a row, this would stretch more than a million kilometres, taking us to the moon and back. Since Jean Drèze wrote this last year (2000), the stocks have risen some more, and the sacks would now take us to the moon and back to the earth, and then back to the moon again.

It is good to hear from the Government of India that a small part of this large stock will be used for various good purposes, including one million tonnes going for relief in Afghanistan (I applaud both as a human being and as the Honorary President of OXFAM, which is much involved in providing relief in Afghanistan), but this would neither make much of a dent in the food mountain, nor stop its relentless enlargement — perhaps to 75 million tonnes soon, or even to a 100 million.[9] The Food Minister has also proposed a different way of paying subsidies to the farmers, which apparently distributes them more equitably among the regions. Instead of the government’s being obliged to buy food grains at the minimum support prices, food would now be sold at market prices and the government will pay the farmers the difference between the market prices and the minimum support prices. Farmers — even very big farmers — would no doubt be relieved to hear that their "interests", as the expression goes, "will be protected". And, of course, the stocks will keep accumulating, even though they are now approaching four times the official "buffer stock" requirements. And the public expense of the programme of subsidies (estimated not long ago at a staggering Rs 21,000 crore a year) is unlikely to spiral down. We are evidently determined to maintain, at heavy cost, India’s unenviable combination of having the worst of undernourishment in the world and the largest unused food stocks on the globe.

Policy delusions
What can be the explanation for this odd insistence on counterproductive policy? The immediate explanation is not hard to get. The accumulation of stocks results from the government’s commitment to unrealistically high minimum support prices of food grains — of wheat and rice in particular. But a regime of high prices in general (despite a gap between procurement prices and consumers’ retail prices) both expands procurement and depresses demand. The bonanza for food producers and sellers is matched by the privation of food consumers. Since the biological need for food is not the same thing as the economic entitlement to food (that is, what people can afford to buy given their economic circumstances and the prevailing prices), the large stocks procured are hard to get rid of, despite rampant undernourishment across the country. The very price system that generates a massive supply keeps the hands — and the mouths — of the poorer consumers away from food.

But does the government not remedy this problem by subsidising food prices according to the level of procurement prices — surely that should keep food prices low to consumers? Not quite. Jean Drèze and I discuss this issue more fully in our forthcoming book, India: Development and Participation, but one big part of the story is simply the fact that much of the subsidy does in fact go to pay for the cost of maintaining a massively large stock of food grains, with a mammoth and unwieldy food administration (including the Food Corporation of India). Also, since the cutting edge of the price subsidy is to pay farmers to produce more and earn more, rather than to sell existing stocks to consumers at lower prices (that too happens, but only to a limited extent and to restricted groups), the overall effect of food subsidy is more spectacular in transferring money to farmers than in transferring food to the undernourished Indian consumers.

Need for a clearer class analysis
If there were ever a case for radical class analysis, in which the Left could take the Right to the cleaners, one would have thought that this would be it. Sure enough, some public interest groups have protested and taken issues of fundamental rights to the Supreme Court. But the systematic criticism of this problem from the perspective of class inequality has been amazingly muffled and silent. The protest we hear is strangely divided, along with repetition of the mantra about keeping food prices high for the benefit of farmers and cultivators. Why is this so?

When the policy of food procurement was introduced and the case for purchasing food from farmers at high prices was established, various benefits were foreseen, and they are not altogether pointless, nor without some claim to equity. First, building up stocks to a certain point is useful for food security — even necessary for the prevention of famines. That would make it a good thing to have a large stock up to some limit — in today’s conditions, perhaps even a stock of 20 million tonnes or so. The idea that since it is good to build up stocks as needed, it must be even better to build up even more stocks, is of course a costly mistake.

It is important in this context to also examine a second line of reasoning in defence of high food prices, which too comes in as a good idea and then turns counterproductive. Those who suffer from low food prices include some that are not affluent — the small farmer or peasant who sells a part of the crop. The interest of this group is mixed up with those of big farmers, and this produces a lethal confounding of food politics. While the powerful lobby of privileged farmers presses for higher procurement prices and for public funds to be spent to keep them high, the interests of poorer farmers, who too benefit from the high prices, are championed by political groups that represent these non-affluent beneficiaries. Stories of the hardships of these people play a powerful part not only in the rhetoric in favour of high food prices, but also in the genuine conviction of many equity-oriented activists that this would help some very badly-off people. And so it would, but of course it would help the rich farmers much more, and cater to their pressure groups, while the interests of the much larger number of people who buy food rather than sell it would be badly sacrificed.

There is need for more explicit analysis of the effects of these policies on the different classes, and in particular on the extreme underdogs of society who, along with their other deprivations (particularly low incomes, bad healthcare, inadequate opportunities of schooling), are also remarkably underfed and undernourished. For casual labourers, slum-dwellers, poor urban employees, migrant workers, rural artisans, rural non-farm workers, even farm workers who are paid cash wages, high food prices bite into what they can eat. The overall effect of the high food prices is to hit many of the worst-off members of society extremely hard. And while it does help some of the farm-based poor, the net effect is quite regressive on distribution. There is, of course, relentless political pressure from farmers’ lobbies in the direction of high food prices, and the slightly muddied picture of some farm-based poor being benefited permits the confusion that high food prices constitute a pro-poor stance, when in overall effect it is very far from that.

It is said that a little knowledge can be a dangerous thing. So, unfortunately, is a little bit of equity when its championing coincides with massive injustice to vast numbers of underprivileged people.

A concluding remark
Not only is the persistence of widespread undernourishment in India — more than in all other regions in the world — quite extraordinary, so is the silence with which it is tolerated, not to mention the smugness with which it is sometimes dismissed. Nutritional deficiencies affect the lives of Indians at different ages but — as has been discussed — they can be closely interrelated. For example, the neglect of women’s nutrition can work through maternal undernourishment, foetal deprivation in the uterus, low birth weights, undernutrition and ill-health of children, and ultimately morbidity of adults as well. Recent research has brought out sharply the impact of early undernourishment on long-run health, and even on the development of cognitive functions and skills. The fact that India has such a massive incidence of childhood undernourishment makes this a particularly alarming consideration. Indeed, the negative effects of early undernourishment can be serious throughout one’s life, including in the propensity to suffer from cardiovascular diseases in later ages (again, higher in India, controlling for other influences, than almost anywhere else).

In battling against "so old a story" of deprivation and hunger, we also have to take note of the fact that the policy problems can take forms that are "somehow always new". In addition to addressing issues of economic growth and distribution, of healthcare and basic education, and the very old problem of gender bias and neglect of women’s health, we must also reassess public policies based on explicit scrutiny of who benefits from the respective policies, and who — most emphatically — do not. Many of the underdogs of society face not only traditional problems that have kept them back, but also new adversities arising from public policies that are meant to help the underprivileged but end up doing something rather different.

Given our democratic system, nothing is as important as a clearer understanding of the causes of deprivation and the exact effects of alleged policy remedies that can be used. Public action includes not only what is done for the public by the state, but also what is done by the public for itself. It includes what people can do by demanding remedial action and through making governments accountable. I have argued in favour of a closer scrutiny of the class-specific implications of public policies that cost the earth and yet neglect — and sometimes worsen — the opportunities and interests of the underdogs of society. The case for protesting against the continuation of old disadvantages has been strong enough for a long time, but to that has to be added the further challenge of resisting new afflictions in the form of policies that are allegedly aimed at equity and do much to undermine just that. The case for relating public policy to a close scrutiny of its actual effects is certainly very strong, but the need to protest — to rage, to holler — is not any weaker.