article: Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do?

This is an open access article published in the Indian Journal f Medical Ethics.  Original source can be found Here.

Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do? SUBRATA CHATTOPADHYAY1 PDF Abstract Corruption, an undeniable reality in the health sector, is arguably the most serious ethical crisis in medicine today. However, it remains poorly addressed in scholarly journals and by professional associations of physicians and bioethicists. This article provides an overview of the forms and dynamics of corruption in healthcare as well as its,implications in health and medicine. Corruption traps millions of people in poverty, perpetuates the existing inequalities in income and health, drains the available resources undermines people's access to healthcare, increases the costs of patient care and, by setting up a vicious cycle, contributes to ill health and suffering. No public health programme can succeed in a setting in which scarce resources are siphoned off, depriving the disadvantaged and poor of essential healthcare. Quality care cannot be provided by a healthcare delivery system in which kickbacks and bribery are a part of life. The medical profession, historically considered a noble one, and the bioethics community cannot evade their moral responsibility in the face of this sordid reality. There is a need to engage in public discussions and take a stand - against unethical and corrupt practices in healthcare and medicine - for the sake of the individual's well-being as well as for social good. Introduction Corruption is, to say the least, a complex phenomenon and a difficult problem. It is complex because of its deep roots in the social, cultural, economic, political, legal, and ethical value systems of individuals, communities, cultures, and countries. It is a difficult problem because it defies easy answers and resists any single-track, copy-book model of solutions. There was a period in the not-so-distant past when corruption was considered, at best, merely an issue of development and, at worst, a socioeconomic issue beyond the world of scientific medicine. In the recent past, however, corruption in the health sector has raised serious concern and received global attention among researchers and policy-makers (1-4). In October 2003, the UN General Assembly adopted the United Nations Convention against Corruption, which came into force in 2005. Other UN agencies have also undertaken anti-corruption measures in health. For example, the Good Governance for Medicines programme, launched as part of the World Health Organisation Medicines Strategy, 2004-2007, incorporated corruption as a priority issue. Further, having recognised the relationship between child mortality and corruption, the United Nations Children's Fund linked its promotion of child rights to good governance (5). Undermining the moral vision-and nobility-of the art of healing, corruption is arguably the most serious ethical crisis in medicine today. Thus, understanding corruption, its varied nature and its adverse effects on health outcomes is absolutely necessary for healthcare professionals in the 21st century, not only to steer clear of fraud, but also to devise effective strategies to tackle the menace and safeguard the moral vision of medicine (6, 7). What is corruption? Corruption has been defined as "the abuse of public office for private gain" (8). This definition appears to be narrow as it does not cover areas other than "public office." Transparency International, a global anti-corruption watchdog, defines corruption as "the abuse of entrusted power for private gain" (3). Questions may arise about how terms such as "private" (or "public") are defined and whether it would be ethically justifiable to abuse entrusted power for shared collective gain. Private gain may also be either actual (or immediately available) or potential (to be realised in the future), and financial or even political. It is thus extremely difficult, if not impossible, to provide a definition of corruption which is applicable to all its forms, types and degrees across various cultures to the satisfaction of all stakeholders. In the absence of such an allinclusive and precise definition, "the abuse of entrusted power for private gain" may serve as a 'working definition' as it could cover, in general, most of the unethical and corrupt practices in the health sector. Corruption is pervasive across cultures and endemic in countries, be they small or large, poor or rich, capitalist or socialist or in the North or South (3). Newspapers generally capture only startling instances of large-scale corruption. Petty corruption, however, has long been a part of, or rather a way of, 'normal' life in many parts of the globe. Furthermore, those who take or give bribes in a particular setting (eg an office or the residence of an official) may claim in another setting (e.g. a court) that these were 'gifts'. Thus, cultural interpretations and legal implications of what is perceived of as corruption may also vary from one context to another. What are the forms of corruption in healthcare and medicine? The problem of corruption in healthcare is of a multidimensional nature. Corruption may be involved, for example, in construction of health centres/hospitals, purchase of instruments, supply of medicines and goods, overbilling in insurance claims and even appointment of healthcare professionals. Another aspect of the problem is the involvement of multiple parties, e.g. policy-makers, ministers, economists, engineers, contractors, suppliers, and doctors. All this may give rise to innumerable clandestine transactions of a corrupt nature among various stakeholders. Forms of corruption in healthcare and medicine may include, but not be limited to, the following (1,3,5): Bribes and kickbacks Characterised as hallmarks of corruption, bribes and kickbacks can be paid by individuals and firms to (i) procure government contracts, leases or licences for the construction of healthcare facilities, and for the supply of medicines, goods and services, as well as ensure the terms of their contracts; (ii) prefix and 'rig' the bidding process; (iii) manipulate and falsify records, and modify 'evidence' to give the appearance of its being in compliance with the norms of regulatory agencies; (iv) speed up the procedure of permission to carry out legal activities, eg obtaining institutional affiliation, company registration or construction permits; and (v) influence or change legal outcomes so as to avoid punishment for wrong-doing (3,5). Theft and embezzlement This may occur as theft of public assets and goods, such as instruments and medicines, by individuals for sale, personal use or use in for-profit private clinics. The theft of government revenues, such as patient registration fees, and the payment of salary to deceased or "ghost" workers are other forms of corruption (3, 5). Intentional damage to public goods for private gain1 Public assets and instruments in government hospitals may also be intentionally damaged so as to make them unavailable to patients, with the ultimate aim of ordering the services from private clinics in return for financial incentives or "commission." Absenteeism Perceived somewhat less often as a form of corruption, absenteeism (not attending work but claiming salary) in the health sector has been a major concern in some developing countries (5). Informal payments In some countries, patients commonly make informal payments to healthcare professionals for better services. The imposition of such a "tax" on "free" healthcare services has a negative impact on access to health services (5). Use of human subjects for financial gain Clinical researchers get paid by the biomedical industry for the recruitment of poor and illiterate, ie vulnerable, human subjects for clinical trials (9). Another way in which hospitals and physicians use patients is by charging uninsured patients and patients with other health plans far more than the actual costs involved and what the health insurers pay. Institutionalised potential corruption In some for-profit hospitals, physicians have contractual obligations to admit a fixed number of patients to allotted beds and prescribe a number of laboratory investigations (even if unnecessary) to generate revenues. Whatever the form, corruption has far-reaching consequences on patient care, clinical research and medical education, as outlined in Table 1. Case studies: windows into how corruption affects health sector Published reports on the exploitation of human subjects in clinical trials and the scam in the National Rural Health Mission (NRHM) in Uttar Pradesh (UP), India, give us a window into how unethical and corrupt practices can mar clinical research and public health programmes, turning them, quite literally, into "killing fields". 1. Clinical trials Illiterate persons not to be used for clinical trials (9) Hyderabad: Reeling under allegations of using poor and illiterate people as guinea pigs for clinical trials [emphasis added], five of the 12 registered clinical research organisations in the state...claimed to have even decided against using illiterate volunteers for trials (emphasis added). The Times of India, Hyderabad, September 7, 2011 Only 45 of 2868 clinical trial deaths [in India] compensated since 2005 (10) Business Standard, New Delhi, March 5, 2013 Few would disagree that clinical trials hold the promise of making a positive difference in the lives of people. However, there is no room for such a pleasant illusion in the face of the unethical and corrupt practices in health research. Nearly 2900 people died in India during clinical trials of drugs conducted by various pharmaceutical companies from 2005-12, and compensation was paid in only 45 cases (10). This news came after an earlier news report that victims of the 1984 Bhopal gas tragedy were also enrolled, without their knowledge or consent, in clinical trials sponsored by certain pharmaceutical companies (11). Further, as revealed in 2008, 49 babies had died during clinical trials for new drugs at the All India Institute of Medical Sciences, India's premier medical institution, over a period of two-and-a-half years (12). Table 1 Primary areas Specific aspects under primary areas Types of unethical and corrupt practices Implications Patient care Construction of healthcare facilities Bribes and kickbacks for procuring contracts, speeding up procedure High cost, low-quality construction work and facilities that do not fulfil needs, resulting in inequity in access Purchase and supply of medicines, goods and services Bribes, kickbacks to fix winner of bids in advance Unethical marketing and sales of medicines Suppliers not held accountable for failing to deliver High-cost, sub-standard or inappropriate drugs and goods and equipment Health inequity Distribution and use of medicines Sale of "free" drugs or supplies Theft of drugs/supplies at storage and distribution points_ Undue "tax" on free drugs and supplies Lack of access to essential medicines for poor patients Interruption of or incomplete treatment of patients Access to healthcare, admission into hospital Bribes and informal payments Lack of access to basic healthcare for poor patients Health inequity Monitoring and regulation of quality in products, services Bribes for approval of registration and quality of drugs Bribes or political considerations influencing results of inspections or suppressing findings Circulation of counterfeit or fake drugs in market Spread of infectious and communicable diseases Death of patients from improper treatment or inadequate services Biomedical research Clinical trials Recruitment of human subjects for drug research for financial incentives Absence of adequate compensation policy for participants in trials in case of injury or death Exploitation of "guinea pigs in human form" in unethical trials Death of trial participants without compensation Students' research Bribes or informal payments for "supervising" students' research projects Fraud and misconduct in research and publication Medical education* Admission Bribes to gain entry into medical education Political influence, nepotism in selection of students Entry of incompetent healthcare professionals into medicine Loss of faith, cynicism and frustration with an unfair system Ethically compromised professionals who perpetuate the vicious cycle of unethical and corrupt practices Examination Bribes to pass qualifying examinations or top merit list Appointment of physicians and medical teachers Nepotism, favouritism, political influence in selection of healthcare professionals Note: *The head of the Medical Council of India, removed from his post for allegedly taking bribes to grant permission for the establishment of private medical colleges, was president-elect of the World Medical Association (WMA). Perhaps this is the price for putting economics before ethics. In 2005, as a policy pursuant to economic liberalisation, the Government of India amended Schedule Y of the Drugs and Cosmetics Act to permit concurrent phase II and phase III trials in India (13). A myriad of factors, such as substantial reduction in time and cost in conducting clinical trials, diverse population, English-speaking healthcare professionals and less stringent regulatory mechanisms, made India one of the most attractive locations of clinical trials. Not surprisingly, there was a substantial growth in the number of clinical trials held in India from 2005. In 2000, the Indian Council of Medical Research (ICMR) had issued ethical guidelines for biomedical research on human subjects (modified in 2006) and the registration of clinical trials was made mandatory by the Drugs Controller General of India (DGCI) in 2009. However, the ICMR guidelines are not legally binding, while the DCGI is understaffed and illequipped to monitor and regulate research effectively. Thus, blatant unethical practices, such as providing lucrative financial incentives for the recruitment of human subjects, obtaining "informed-but-not-understood-consent" from poor illiterate "volunteers," and failing to provide compensation for the death of participants in trials, have become a part of the booming industry of clinical trials in India (14-17). Part of the threat that the industry of clinical trials poses to India stems from the fact that these trials, conducted mostly by the contract research organisations (CROs) hired by pharmaceutical companies, are essentially commercial ventures in the garb of benevolent medical research. The question arises as to whether the drugs tested in India will actually benefit or be affordable for needy patients. The crisis is further compounded by the dampening "ethical climate" of the Indian institutions that are related to the conduct of clinical drug trials. India ranks 94th in the list of 178 countries in the corruption perception index (18). In a country where corruption is undeniably an all-pervasive part of life, including healthcare and medicine, it is hard to imagine that if at some point, provisions are made for ethical oversight of all clinical research, such oversight will be of the highest standards and that "guinea pigs in human form" will get high-quality care in keeping with ethical standards. Questions thus arise whether it is ethically justifiable to allow the conduct of clinical trials to begin with, in the absence of ethical oversight, effective regulatory mechanisms and an appropriate compensation policy for the participants, especially in countries plagued by corruption. 2. National Rural Health Mission, Uttar Pradesh Half a dozen babies are born in the clinic daily, but the water tank is broken, so deliveries are performed without running water. The centre has an ambulance, but it, too, is broken. Repairs would cost only about $30, but there is no cash to pay for it. Crucial medical supplies, like oral rehydration salts for children with diarrhoea, have been out of stock for months. Mr Tiwari [centre's vaccination officer] said that the money to fuel the generator ran out, leaving workers scrambling to keep vaccines cold (19). In 2005, India launched a centrally-funded country-wide health programme, the NRHM, in order to revamp rural health. The Government of India allocated the state of Uttar Pradesh (UP), which can rival sub-Saharan Africa in terms of infant mortality and child malnutrition, "the largest sum of money of all states" to improve the abysmal status of its health services (19--22). What went wrong with the NRHM in this state? According to the report of India's Comptroller and Auditor General (CAG), the UP State Health Mission failed to fulfil its mandate and was responsible for an unaccounted loss of Rs 5754 crore out of the total amount of Rs 8657 crore (20). "[I]n the case of NRHM in Uttar Pradesh, it was organised looting of government funds." (21) According to the Central Bureau of Investigation (CBI), "Large-scale bungling took place in the implementation of NRHM. The modus operandi for siphoning off state wealth included overpricing, fake supply of medicines and hospital equipment by fictitious firms as well as huge kickbacks in construction activity to improve health services in government-run primary health centres in rural areas. The CBI also discovered how some persons acted as middlemen between contractors and influential bureaucrats and ministers to supply medicines and equipment under the programme" (20). How did people suffer when the NRHM was beset by corruption? Subhadra Chaurasia developed cataract in her right eye four years ago. In the past one year, visibility in her left eye has also faded. If the 75-year-old doesn't receive medical attention soon, she will go completely blind. She has two sons, both married, who barely make a living from the 2.5 bighas [of land] they own in Raipur village, 10 km away from Lucknow. The yield from this landholding is just enough to save the family from starvation. With no money to buy even basic necessities of everyday life, Subhadra can't dream of having an eye operation, something that would cost more than Rs 15,000. But if you go by official records, Subhadra has already been operated upon and cured (22). NGOs, private nursing homes and doctors have siphoned off crores of taxpayers' money intended for eye operations for the rural poor in the state over the past five years (22). Tehelka [investigative journalists' team] visited more than half a dozen villages in and around Lucknow and found that the women, children and men who should have been the beneficiaries of the NRHM funds are living without the most basic health services. The funds meant for them have been siphoned off by the politician-bureaucrat-private contractor nexus (22). NRHM's Mothers Protection Scheme, known as Janani Suraksha Yojana, was launched in 2005 to provide conditional cash transfers to pregnant women for facilities like transportation to encourage them to give birth in health facilities. But civil society organisations find pregnant rural women didn't receive quality maternal health services, especially if they were from lower income groups... (23). Quality of care in UP is poor, according to nongovernmental organisations, and may have worsened due to the corruption (23). Crores of rupees were thus spent on the construction of nonexistent healthcare facilities, and on the acquisition of goods and services which never reached the intended beneficiaries. This scam not only perpetuated ill health and suffering among the rural poor, but also cost six lives. Among the six persons who died are top-ranking medical officers, murdered presumably as part of a cover-up operation to hush up the wrongdoing. What is fearsome is that it is only the tip of the iceberg which is visible; the bottom of the "iceberg" of corruption is almost untraceable. Sadly, the art of healing has turned into a science of stealing and the conspiracy to cover up has introduced criminality into medicine. What is scandalous is that doctors are not only among the victims of corruption; they are also beneficiaries and perpetrators, together with the others involved in the larger nexus that is threatening to undermine the very foundation of medicine. The question arises as to what physicians and bioethicists should do to tackle the menace of corruption and to answer this, one must be clear on why they should do something in the first place. Medical corruption: why should physicians and bioethicists care? There are a number of good reasons why physicians and bioethicists should care about corruption, discuss the problems that corruption creates and perpetuates in healthcare and medicine, explore possible remedial measures to tackle the menace, and take a stand against unethical and corrupt practices in the health sector. The first is, to put it simply, corruption kills. The difference between life and death, good health and suffering is often determined by corruption. Not surprisingly, the poor suffer the most. Three of the UN's eight Millennium Development Goals, which are intended to reduce poverty by half by 2015, relate directly to health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases. Corruption in the healthcare system has been revealed as one of the factors responsible for the failure to fulfil these goals by the target date (3). Corruption also exacerbates the harm caused by natural disasters. For example, the death toll in the earthquake in Haiti was directly related to corruption. Buildings certified as earthquake-resistant had not been constructed properly because the system was plagued by corruption and thus, there was a lack of oversight (24). If physicians are really opposed to serving the machinery of death, oiled by corrupt practices in medicine, they need to address the issue, discuss it and take a stand against it. The second is that corruption fosters ill health and prolongs suffering. On the other hand, good governance (reduced corruption) is associated with better health outcomes. A transnational study found that the quality of governance was positively associated with higher life expectancy, lower mortality rates for children and mothers, and higher levels of subjective feelings of health (25). By taking a stand against corruption and in favour of appropriate anti-corruption measures, healthcare professionals may create opportunities for good governance and consequently, better health outcomes for the population. Thirdly, corruption undermines the patient's trust in the physician and healthcare delivery system. Trust lies at the core of the doctor-patient relationship in medicine. "Trust is critical to patients' willingness to seek care, reveal sensitive information, submit to treatment, and follow physicians' recommendations." (26). Patients would not like to see a doctor they do not trust and would be loath to accept such a doctor's advice. By taking a stand on corruption, physicians and bioethicists can start rebuilding the trust of patients and the people at large. The fourth is that corruption destroys the moral vision of medicine. Ethics lies at the heart of medicine-it is difficult to imagine a good but corrupt physician. Few would disagree that medicine sans morality turns this praxis into one of stealing, killing and criminality. Those who have embraced a noble profession like medicine cannot afford the luxury of "doing nothing" when its ethical foundation is being endangered by unethical and corrupt practices (27). Towards a new beginning: what should physicians and bioethicists do to tackle the menace of corruption? Corruption in the health sector is not just an issue of development, or a legal issue pertaining to fraud and abuse, but also an issue concerning ethics. As darkness is characterised by lack of light, corruption is characterised by a lack of moral values. Regrettably, the word "corruption" is conspicuous by its near absence in the agenda and vocabulary of academic medicine. At most, mention is made of "professional misconduct." Worse still is the deafening silence of the medical profession when the cause of ethics in medicine is at stake. Furthermore, bioethicists, who are the modern-day custodians of morality in medicine, have little, if any, interest in addressing this "dull" social problem. Unlike esoteric ethical puzzles such as determining the moral status of a part-human part-animal embryo, this problem does not trigger enough hair-splitting debates to satisfy their philosophical minds. The initiation of proactive measures to counter corruption in all its manifestations is long overdue. A number of anti-corruption measures that could provide a starting point are outlined below. 1. Zero tolerance for unethical and corrupt practices in health Physicians, professional medical associations of diverse disciplines and the bioethics community should discuss possible anti-corruption measures and implement a publicly declared policy of zero tolerance for unethical and corrupt practices in the care of patients, clinical research and medical education. This entails, among other things, taking appropriate measures to counter unnecessary investigations and overbilling, censuring members with questionable integrity, developing mechanisms to handle allegations of misconduct, and promoting transparency and accountability in diverse aspects of medicine. 2. Whole-hearted support for anti-corruption measures Physicians and bioethicists should support, whole-heartedly and without reservation, the anti-corruption initiatives undertaken by the other sections of society and state, such as civil society, patient rights groups, voluntary health associations, nongovernmental organisations (NGOs), the judiciary, and the media. This would help build good governance and a just society. 3. Protection of whistle-blowers Physicians and bioethicists should provide moral support and legal help to members of their profession or discipline who have dared to expose serious wrong doing in any aspect of healthcare and medicine. This is necessary because whistleblowers run the risk of facing harassment, if not harm, by vested interests. (27) 4. Legislation Physicians and bioethicists should play a more proactive role in pressing for the enactment and implementation of legislation and regulations for good governance, transparency and accountability in healthcare and medicine. Anti-corruption laws are frequently breached because of inadequate regulation and monitoring, or the absence of effective penalties. One solution could be to set up an office of ombudsman to deal with corruption (eg Lokpal) in every district, province and state capital. The ombudsman should be equipped with adequate resources, infrastructure and real powers. 5. Education The importance of (continuing) education can hardly be overemphasised. It is hard to believe that all young men and women join medicine only to make money out of people's illness. Education in ethics through the use of positive role models may reinforce moral values. It would help present and future healthcare professionals not only to steer clear of fraud and abuse, but also to create a favourable ethical climate within the profession (27). Conclusion It is time to acknowledge that corruption in healthcare entails crimes against humanity. There is no room for complacency- history will not forgive physicians and bioethicists if they fail in their moral duty to safeguard the cause of ethics in medicine when it is necessary. 1Note: This author witnessed an incident in which a delegation of doctors were complaining that intentional damage had been done to the only laparoscope in the department of surgery in a government medical college in India. The laparoscopic surgeon kept the instrument out of order intentionally, and then referred the patients to the nursing home where he had a private practice. Acknowledgements This paper is dedicated to Sri Ramakrishna and Sri Sri Thakur Anukulachandra for their teachings against unethical and corrupt practices in medicine. *Disclaimer: This author works as Head of the Department of Physiology at the College of Medicine and JNM Hospital, West Bengal University of Health Sciences, India. The views and opinions expressed here are those of the author and do not reflect the view of the College or University or any of its offices. References Vian T. Review of corruption in the health sector: theory, methods and interventions. Health Policy Plan. 2008 Mar;23(2):83-94. doi: 10.1093/ heapol/czm048. Epub 2008 Feb 14. Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ. 2001; 79(10): 954-62. Shastri SS, Mittra I, Mishra G, Gupta S, Dikshit R, Badwe RA; Tata Memorial Centre, Mumbai, India. Effect of visual inspection with acetic acid (VIA) screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India. [Internet]. Presentation, American Society for Clinical Oncology annual meeting 2013[cited 2013 Jun 15]. Available from: http://meetinglibrary.asco.org/content/112133-132 Ortega R. Ethics of 2 cancer studies questioned. The Arizona Republic [Internet]. 2013 Feb 15 [cited 2013 Jun 3]. Available from: www.azcentral.com/ news/articles/20130313ethics-cancer-studies-india-questioned.html Lurie P, Wolfe SM. Unethical trials to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Engl J Med. 1997 Sep 18; 337(12): 853-6. World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects. Last revised 2008 Oct. [cited 2013 Jul 4]. Available from: http://www.wma.net/en/30publications/10policies/b3/17c.pdf Indian Council of Medical Research. Ethical guidelines for biomedical research on human participants. New Delhi: ICMR; 2006. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R, Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA. HPV screening for cervical cancer in rural India. N Engl J Med. 2009 Apr 2;360(14):1385-94. Sankaranarayanan R, Esmy PO, Rajkumar R, Muwonge R, Swaminathan R, Shanthakumari S, Fayette R, Cherian J. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet. 2007 Aug 4;370(9585):398-406. Rathod SD. Commentary on HPV screening for cervical cancer in rural India. Indian J Med Ethics. 2011Jul-Sep;8(3):180-2. discussion 182-3. Mudur G. Indian study of women with cervical lesions called unethical. BMJ. 1997 Apr 12; 314(7087):1065. Srinivasan S. Research on public health interventions in poor countries. Issues Med Ethics. 2001 Oct-Dec;9(4):118-9. Srinivasan S, Loff B. Medical research in India. Lancet. 2006 Jun 17;367(9527):1962-4. Sengupta A. Fatal trials: clinical trials are killing people. Indian J Med Ethics. 2009 Jul-Sep;6(3):118-9. Nundy S, Gulhati CM. A new colonialism?--Conducting clinical trials in India. N Engl J Med. 2005 Apr 21;352(16):1633-6. Yee A. Regulation failing to keep up with India's trials boom. Lancet. 2012 Feb 4;379(9814):397-8. Chattopadhyay S. Guinea pigs in human form: clinical trials in unethical settings. Lancet. 2012 May 26;379(9830):e53. Transparency International India. New Delhi: Transparency International India; c2013[cited 2013 Jul 4]. Available from: http://www.transparency. org/country#IND Polgreen L. Health officials at risk as India's graft thrives. Gainesville.com[Internet]. 2011 Sep 17[cited 2013 Jun 4]. Available from: http://www. gainesville.com/article/20110917/ZNYT04/109173020 Bhalla A. How they made the NRHM sick. Tehelka.com [Internet]. 2012 Mar 17[cited 2013 Jun 4];9(11). Available from: http://archive.tehelka. com/story_main52.asp?filename=Ne170312HOW.asp Chatterjee P. How free healthcare became mired in corruption and murder in a key Indian state. BMJ. 2012 Feb 6;344:e453 doi: 10.1136/ bmj.e453 Khetan A. Where did Rs 8,500 cr of UP's health funds go? Tehelka.com [Internet]. 2011 Aug 20[cited 2013 Jun 4];8(33). Available from: http:// new.tehelka.com/story_main50.asp?filename=Ne200811COVERSTORY. asp Shukla S. India probes corruption in flagship health programme. Lancet. 2012 Feb 25;379(9817):698. Ambraseys N, Bilham R. Corruption kills. Nature. 2011Jan13;469(7329):153-5. Holmberg S, Rothstein B. Dying of corruption. Health Econ Policy Law. 2011 Oct;6(4):529-47. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Serv Res. 2002 Oct; 37(5):1419-39. Campbell AV. Can virtue prevail? Safeguarding integrity in medicine and science Indian J Med Ethics. 2013 Jan-Mar;10(1):11-13. Professor, Department of Physiology, College of Medicine and JNM Hospital, West Bengal University of Health Sciences*, Kalyani, Nadia 741 235, West Bengal, INDIA email: linkdrsc@yahoo.com, linkdrsc@gmail.com

Coca-Cola investment in India on track

The original source of this article can be found here.  LIVEMINT(India) Wall Street Journal

Coca-Cola investment in India on track

World’s largest beverage maker to spend $5 billion in India over eight years, setting aside concerns that a slowing economy will affect its investments

Suneera Tandon 

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First Published: Fri, Aug 23 2013. 12 18 AM IST

The company could, after evaluating demand and volume growth, even increase investments if required, Ahmet C. Bozer, executive vice-president of Coca-Cola, said. Photo: Bloomberg

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New Delhi: Coca-Cola Co., the world’s largest beverage maker, is on track to spend $5 billion in India over eight years, setting aside concerns that a slowing Indian economy would affect the company’s investments.

“Our investments in India are on track as we build scale, manufacturing capacity, distribution capability and a robust product portfolio to realize our business goals in India,” said Ahmet C. Bozer, executive vice-president of Coca-Cola. The company is anticipating that India will be among the top five markets globally in the near future, up two positions from its current rank, said Bozer. who was in Delhi on Thursday to celebrate 20 years of Coca-Cola’s operations in India and to inaugurate a bottling plant in Greater Noida.

The company could, after evaluating demand and volume growth, even increase investments if required, he said.

In June 2012, company chief executive Muhtar Kent had announced the $5 billion investment in its India business to expand capacity and improve its distribution network in Asia’s third largest economy. The company has 57 bottling plants in India, including the new one that’s owned and operated by franchise Moon Beverages, which has invested more than Rs.140 crore to build the plant.

The new plant will allow the company to make beverages including value-added water and sports drinks, expanding the beverage maker’s existing product portfolio in India.

Bozer said the company’s vision was to double system’s (franchise bottling plants) revenue in India in this decade. “Our ongoing investment in the country is focused on delivering innovation, partnerships and a beverage portfolio that enhances the consumer experience...” he said.

To be sure, India volume growth for the owner of beverage brands including Coca-Cola, Fanta, Spriteand Minute Maid was a feeble 1% in the second quarter of fiscal year 2013 on account of a heavier-than-normal monsoon.

Although foreign investors are holding back on their investments amid concerns over India’s slowing economic growth, Bozer clarified that there would be no slowdown in the execution of the company’s investments in India. “There will be economic ups and downs and that will not affect our investments,” he said.

To be sure, the per-capita consumption of Coca-Cola in India is relatively low at 14 compared with a world average of 94. Per capita consumption is defined by the company as the number of servings of 8 fluid ounces consumed by a person in a year.

Globally, the company sells 3,000 products. “Our portfolio will expand over time,” said Atul Singh, deputy president, Pacific Group, Coca-Cola.

Pinakiranjan Mishra, a partner and national leader, business and risk advisory services, at consulting firm EY, said carbonated beverages are still not the regular thirst-quenchers used by consumers in India unlike in the West. As a category, packaged beverages are under-consumed and under-penetrated.

“There is enough room for existing companies to grow. However, lower price points will spur demand,” he said.

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First Published: Fri, Aug 23 2013. 12 18 AM IST

Most frequent global health authors.

Global health authors.  A search on Scopus for 'global health' in article title comes up with 4,437 articles.  The earliest being in 1958.  The authors ranked according to how many of their article titles included global health are below.  Interesting.

Latin American countries crack down on junk food

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The Lancet, Volume 382, Issue 9890, Pages 385 - 386, 3 August 2013

doi:10.1016/S0140-6736(13)61657-8  (click here for original posting)

Latin American countries crack down on junk food

Barbara Fraser

While several Latin American nations have introduced healthy food laws to try to combat childhood obesity, implementation has proved trickier. Barbara Fraser reports from Lima, Peru.

Sergio Escalante got a shock at lunchtime on the first day of school this year. His school's food kiosk no longer offered the usual fare—potato crisps, cookies, sweets, soft drinks, and sandwiches dripping with creamy sauces.

“He came home and said there was nothing to eat”, his mother, Miriam González, a nurse, recalled with a chuckle. “They were selling fruit and chicken sandwiches without mayonnaise—to him, that meant ‘nothing to eat’.”

The food concession was lining up with Peru's new healthy food law, which aims to tackle the country's rising obesity rate by getting children onto a healthier diet.

Peru's law is the latest in a series of efforts by Latin American countries to tackle a public health problem that has accompanied the economic boom of the past two decades—more overweight kids and an increase in non-communicable diseases such as diabetes and cardiovascular problems.

But although several countries have passed laws, implementing regulations have lagged, and some public health experts are calling for international measures—such as the ones used to tackle cigarette sales—to counter what they say is powerful lobbying by the food and advertising industries.

Peru's law immediately drew criticism from legislators, advertisers, and even the Catholic archbishop of Lima, who said that shaping children's dietary habits was a job for parents, not the government.

But the entire country will benefit if the government can head off future health problems by reducing children's consumption of salty, sugary, and high-fat processed foods, according to Luis Fernando Leanes, who heads the Pan American Health Organization (PAHO) office in Peru.

“Being able to decrease children's exposure to these foods will mean more hospital beds free in the future to care for people with other illnesses”, he said on July 9 at a conference in Lima on public policy for promoting healthy foods.

Peru, Chile, Colombia, Costa Rica, and Brazil are among the Latin American countries with healthy food legislation. Uruguay's Senate recently approved a law and Ecuador is considering one. The Latin American Parliament, an inter-governmental group, is drafting non-binding recommendations for countries that are considering legislation.

In Latin America, efforts to redirect children's food choices have taken several approaches. Most have focused on controlling the food offered and advertised in schools. Some countries have added labelling regulations, while others have tried limiting advertising, especially on television.

In 2011, PAHO issued a series of recommendations on the regulation of marketing of food to children, in the wake of a series of studies showing that television channels in some countries bombarded children with more than a dozen ads per hour for foods high in salt, fat, and sugar.

The Peruvian law, signed by the president in May, calls for nutrition education in schools; information campaigns by the education and health ministries; a system for monitoring nutrition, overweight, and obesity among children and adolescents; healthy food in school kiosks or cafeterias; more physical activity; and controls on advertising aimed at children and adolescents younger than 16 years.

The law prohibits advertising that encourages “immoderate consumption” of food and non-alcoholic beverages that contain trans fats or high levels of sugar, salt, and saturated fat; shows “inappropriate portions”; appeals to children's naiveté or emotions; claims products are natural when they really are not; or uses testimony from real people or fictitious characters whom the children might admire. It also forbids adverts that suggest that a parent is “more intelligent or more generous” if he or she purchases a particular product.

Studies have shown the power of advertising. In São Paulo, Brazil, 85% of parents said advertising influenced their children's demands, and three-quarters said prizes or free food were strong incentives, according to a 2010 study commissioned by the Alana Institute, a Brazilian non-profit organisation that advocates for children's rights.

Full-size image (49K) Jenny Matthews/Panos Pictures

The Peruvian law will not take effect until implementing regulations, being drafted by a multi-agency commission, are approved. Those regulations will flesh out the details and ultimately determine how strong the law will be.

Chile passed a healthy foods law after a 5-year effort by consumer organisations, academics, and some sympathetic legislators, but the deadline for publishing the implementation regulations passed on July 6, said Cecilia Castillo, a paediatrician who works with a consumer group. “We're afraid the law may just die”, she says. “The regulations have been difficult because of pressure from large companies.”

Industry lobbying led Congress to remove some provisions before the law was approved in 2012, including a “traffic light” symbol on packages, indicating how healthy a food item is; banning the sale of junk food within a certain radius of schools, like a rule that applies to cigarettes; and a prohibition on the distribution of infant formula.

The law does require nutrition labelling and ingredient lists on packages of prepared food and calls for the Health Ministry to identify foods that are high in calories or salt and set per-portion limits on fats, sugars, and salt. Those foods cannot be advertised to children younger than 14 years, and advertisers cannot use toys, stickers, or other enticements.

Castillo called the law “the best legislation possible” but said there was little public participation in the drafting of the regulations, and the law's supporters do not know how strong they will be.

In Chile, as in Peru, food and advertising industry representatives argued that the industry could regulate itself with codes of conduct. The problem with such codes, which exist worldwide, is that “none of them is particularly strong”, says Corinna Hawkes, head of policy and public affairs for the London-based World Cancer Research Fund International. “What works are clear objectives and clear criteria” for substantially reducing children's exposure to advertising.

Countries should begin by gathering their own data about advertising that targets children and set clear standards for types of food, age groups, communication channels, marketing techniques, and labelling requirements, she says. They must also devise ways to monitor the rules they put in place.

Industry representatives must also play a part, not in drafting the rules, but in negotiations about how they will be implemented, said Ekaterine Karageorgiadis, a lawyer with the Alana Institute in Brazil. The institute, which also raises awareness about nutrition, has taken some food companies to court under consumer defence laws.

In Costa Rica, industry lawyers appealed to the country's Constitutional Court to overturn a law promoted by the Education Ministry, which limited the kinds of food available in schools. “People told us not to take on the big food industry” because of its political and economic clout, says Education Minister Leonardo Garnier. “And the pressure was strong, but both the public and the media played a role in support of the regulations.”

That backing, he said, stemmed from a growing realisation of the seriousness of obesity-related public health problems. When colleagues in Mexico warned Garnier that industry representatives would lobby for setting maximum levels of sugar and fats in a way that would allow them to sell the same product in a smaller package, Costa Rican officials based their calculations on energy density instead. “We were insistent that it wasn't a matter of package size”, Garnier said.

The court upheld the law and manufacturers began to adapt. A few months after the law took effect, one company invited Garnier to a press conference, which he attended with some trepidation. To his surprise, the company—which had had only five acceptable products when the law took effect—was launching 20 more products that complied with the new standards.

To ensure that the law is implemented properly, Education Ministry staff members are training school principals and food vendors, he said. Controlling advertising to children, which is not addressed in Costa Rica's law, may be a task for the future.

Brazil took a different approach to promoting healthy food in schools, not only setting nutrition standards, but also requiring that schools purchase locally grown or manufactured products, supporting small farmers and stimulating the local economy, according to Fabio Gomes, a nutritionist at the Health Ministry's National Cancer Institute.

Unlike Europe or the USA, where processed foods make up more than half the diet, about two-thirds of the average Brazilian diet still consists of traditional, unprocessed foods, he said. The Brazilian law reinforces that, requiring that 70% of the food served to children in school meal programmes be unprocessed—rice, beans, meat, fish, fruits, or vegetables—and 30% be locally sourced.

Health experts and children's rights advocates in Brazil have tried to win controls on advertising, but so far the efforts have been unsuccessful. “As neighbouring countries approve [regulation of advertising], it gives us hope that one day one of those measures will be approved here”, says Gomes.

For the complete Lancet Series on Maternal and Child Nutrition see http://www.thelancet.com/series/maternal-and-child-nutrition

When growth is another word for violence

The original source of this article can be found here.

SOCIAL EQUITY 
When growth is another word for violence 
The single-track hawkish focus on reforms-driven growth with utter disregard for the environment, equity and indigenous livelihoods is not only futile, but almost an assault by a few against the majority at the grassroots, writes Ashish Kothari. 
 
28 July 2013 - We need faster growth, more investments, more reforms. This is the mantra being chanted by politicians and industrialists, economists and other experts, in an ever-increasing crescendo. We hear it at seminars and workshops, cabinet meetings, business award ceremonies, television and print media, and every other influential forum possible. Almost always, the justification given is that this is the only way to lift Indians out of poverty and deprivation. Interestingly, at none of these forums does one actually see the poor; images from a recent business newspaper’s award functions showed almost every one of the participants wearing crisp three-piece suits. All black, as if in mourning for the loss of a couple of percentage points of economic growth.

If the poor were at these forums, they might have asked some uncomfortable questions.

Why, for instance, are anything between 35 to 55% of India’s citizens still poor, and why does the government accept atrociously low survival criteria to determine poverty?

Can the Planning Commission’s Members live at Rs. 29 per day in Delhi, since they seem to think this is enough to pip the poverty line?

Why, despite 80% investment going into the formal economic sectors, has there been no net growth in employment in them?

Or why is India still stuck amongst the worst-performing countries on UNDP’s Human Development Index, or on the Global Hunger Index of the International Food Policy Research Institute?

Why, despite rip-roaring growth (amongst the fastest in the world), has Gujarat hardly moved in improving the condition of its children (44% were stunted in 1992, 42% in 2005-06)?

Why have upwards of 2 lakh farmers committed suicide, including many in the heart of the Green Revolution?

Why do 10% of rich Indians own over 50% of its wealth; is this where most of the new wealth generated by globalisation is siphoned off to?

Why, as Rural Development Minister Jairam Ramesh recently admitted, has the public health system collapsed, leading to over 70% of health expenditure being private, and forcing a huge chunk of the poor’s meager earnings to go towards paying doctors?

Can all this be due to inadequate reforms, or might it actually be because of the nature of these reforms?

Water harvesting near Bikaner supported by URMUL Setu. Pic: Ashish Kothari

Factor in the issue of ecological sustainability, and the doubts become louder. If the problems were not clear enough already, the recent Uttarakhand tragedy should have made them. Globally, the model of development is the same as in India; it has already degraded over 60 per cent of the ecosystems on which we all depend for our lives, and several of the planetary ecological limits we all are subject to, have been crossed. We are still altering the earth’s climate, with catastrophic results already unfolding.

A 2008 report by the Ecological Footprint Network co-published, interestingly enough, by the Confederation of Indian Industries, estimated that in India we were using twice the biological capacity that could sustain human activity, and we had already halved this capacity in the last few decades. The period of reforms has seen an acceleration of diversion of forest land (2 lakh hectares in just the last 5 years), mining operations, fishery exploitation, and damaging development along the coasts; for the first time in history, parts of the Indian Ocean are showing signs of depletion! We are already firmly on the path of unsustainability, rapidly reducing the chances of next generations to enjoy healthy, fulfilling lives. Not to mention the thousands of species of plants and animals, which are sliding towards oblivion. Even as the Ministry of Environment and Forests named the river dolphin the national aquatic animal a couple of years back, it was clearing dams and industries, effectively sealing its fate.

Handlooms promoted by Jharcraft, Jharkhand. Pic: Ashish Kothari

To add to the mismatch between statements regarding ‘sustainable development’ and actual actions, is the government’s latest decision to set up a Cabinet Subcommittee on Investment. Anyone willing to shell out Rs. 1000 crore is now getting priority treatment, including overruling of ministries (such as Environment and Forests, or Tribal Affairs) if they object to such investments. This is yet another way by which rational and democratic decision-making is being bypassed. Another way in which concerns will be bulldozed to allow construction in the most fragile areas, as was done in Uttarakhand’s chardham areas, with catastrophic results that we can all see now.

Today’s development model is one in which economic growth, which should be a means, has become an end in itself. A ritualized mantra intoned so often by our development high priests that the rest of us have even blindly started believing in it.

Resistance and Alternatives

Not everyone, though, has been hypnotized by the growth mantra. Across the country there are resistance and protest movements from adivasis and farmers, fisherfolk and the urban poor, unwilling to ‘sacrifice’ for a notional ‘national good’ that has only done them bad. They are facing repression and bullets, arrests and vilification (‘anti-national’ being a common label), but not backing down. Attempts to break them by bribing their leaders, or splitting communities with money, are succeeding in some places; in others they are being repulsed by collective action refusing to be lured by cash.

As farmers in Raigarh of Maharashtra told one of India’s most powerful businessmen, who wanted to acquire their area for a Special Economic Zone, ‘land is our mother, we won’t sell it; would you sell yours?’ Or as those to be displaced by the Jaitapur atomic power plant are saying, if you want to feed a power-guzzling Mumbai, build the plant on Malabar Hill or Chowpatty. No longer are many communities willing to be the ‘eggs’ that have to be broken to make an ‘omelette’ (to use a colourful phrase a Sardar Sarovar Project engineer once uttered to me, in justifying the project’s displacement of 100,000 people).

Equally important, there are growing voices showing that human well-being and happiness can be achieved in very different ways, more sustainable and equitable. If food security is a goal, Messrs Singh, Chidambaram and Ahluwalia would do well to look at how Dalit women farmers in 70 villages of Medak district (AP) have achieved it through collective governance of farm resources, organic cultivation of dozens of traditional varieties of millets, and creation of an alternative Public Distribution System fed by local produce.

Narmada demonstration (20th anniversary). Pic: Ashish Kothari

Villages and some urban wards in the driest parts of India, like Kachchh, have demonstrated how water security can be achieved through localized harvesting and sound management, putting a humungous question mark on the justification offered for mega dams like Sardar Sarovar. Communities in Bihar are showing how decentralised renewable sources can quickly provide energy security, not having to wait for unreliable power grid connections from super- polluting super-thermal power stations. So much so that Chief Minister Nitish Kumar wants to commit substantial funding to such sources.

What about non-agricultural livelihoods? Kuthambakkam Village in Tamil Nadu has workshops producing a range of products, as does Prakash Amte’s Anandwan, both providing dignified employment to the poorest and most socially ostracised sections such as Dalits. Producer cooperatives and companies are helping generate decent returns for craftspersons and farmers in Andhra Pradesh, Gujarat, and other states; some even manage their own retail. Communities in Vidarbha of Maharashtra whose right to protect and manage forests has been recognized under the Forest Rights Act are combining it with NREGS and other laws or schemes to make holistic development plans for their villages, and earning substantial revenues by sustainable use of bamboo, tendu, and other forest produce.

Slum dwellers in Bhuj are showing how localized water and housing projects can empower some of the poorest families, while dealing with typical urban problems. Citizens in many urban areas are showing how local water harvesting, garbage management, biodiversity spaces, and other initiatives can reduce the footprint of the city on the countryside, and provide more decent living to city-dwellers. And increasingly many of these initiatives are linking to scale up over larger landscapes or spread to other areas. With some governmental help, as in the case of Jharcraft in Jharkhand, the initiatives can reach lakhs of families.

Farmers of Deccan Development Society, Andhra in a biodiverse field. Pic: Ashish Kothari

Growth Fetish

Though there are far more sustainable and equitable options available to take all Indians towards prosperity, our decision-makers are stuck to the growth fetish. It’s a fetish that makes them blind to anything other than profits. This is why a company listed in London with an NRI as chair, which has been hounding the Dongria Kondh adivasis in Odisha to give up their sacred forested mountain for mining, is given ‘Businessman of the Year’ award. (As an aside, I wonder if he would have been awarded if he had instead pressed for demolition of the Somnath mandir or the Taj Mahal, because there was iron ore beneath it?). No awards for excelling in economic development are given to ‘ordinary’ citizens who demonstrate that livelihood security can be achieved without displacing people and destroying the environment.

It is also a fetish that produces strange schizophrenia. So a prominent businessman writes in the Times of India that we are a “land blighted by … unemployment and sharp inequalities”; he then notes that his company’s “employee strength has been halved due to improved productivity” and outsourcing; and then he argues for more ‘reforms’ and growth completely oblivious to the ‘jobless’ nature of such growth as demonstrated by his own company.

Finally, it is a fetish that is brazenly undemocratic. This is why Telecom Minister Kapil Sibal can get away with blaming his government’s policy paralysis on some of the most important pillars of India’s democracy; at the aforesaid business newspaper’s awards ceremony, he is quoted as blaming “one, the erudition of the CAG; two, the media; and three, the court”. Such irresponsible pronouncements are fodder for state governments like Chhattisgarh who ride roughshod over basic civil liberties of people peacefully protesting forcible land acquisition. The government is even encouraging semi-autocratic governance in Special Economic Zones and private cities (e.g. Lavasa), where several democratic rights of citizens are suspended.

It is in this sense that the blind pursuit of growth is nothing short of violence on both the poor and on nature, and increasingly threatening even much of the middle class with pocket-breaking inflation and expensive private services. The sooner we as Indian citizens realize this, and press for fundamental changes to make social equity, ecological sustainability, and meaningful economic security the central pillars of decision-making, the sooner we will take the country towards true and lasting prosperity.⊕

Ashish Kothari 
28 July 2013

Ashish Kothari is with Kalpavriksh, Pune. His recent book Churning the Earth: The Making of Global India (Viking/Penguin books), with Aseem Shrivastava, deals with the above issues in more detail.

URL for this article:
http://www.indiatogether.org/2013/jul/opi-growth.htm

Amartya Sen/ Jean Dreze new book An Uncertain Glory.

Original post can be found here

Amartya Sen: India's dirty fighter

Half of Indians have no toilet. It's one of many gigantic failures that have prompted Nobel prize-winning academic Amartya Sen to write a devastating critique of India's economic boom

• 
• • Madeleine Bunting
  • The Guardian, Tuesday 16 July 2013 17.15 BST

The roses are blooming at the window in the immaculately kept gardens of Trinity College, Cambridge and Amartya Sen is comfortably ensconced in a cream armchair facing shelves of his neatly catalogued writings. There are plenty of reasons for satisfaction as he approaches his 80th birthday. Few intellectuals have combined academic respect and comparable influence on global policy. Few have garnered quite such an extensive harvest of accolades: in addition to his Nobel prize and more than 100 honorary degrees, last year he became the first non-US citizen to be awarded theNational Medal for the Humanities.

1. An Uncertain Glory: India and its Contradictions
2. by Jean Dreze, Amartya Sen
3. 

1. Tell us what you think: Star-rate and review this book

But Sen doesn't do satisfaction. He does outrage expressed in the most reasonable possible terms. What he wants to know is where more than 600 million Indians go to defecate.

"Half of all Indians have no toilet. In Delhi when you build a new condominium there are lots of planning requirements but none relating to the servants having toilets. It's a combination of class, caste and gender discrimination. It's absolutely shocking. Poor people have to use their ingenuity and for women that can mean only being able to relieve themselves after dark with all the safety issues that entails," says Sen, adding that Bangladesh is much poorer than India and yet only 8% don't have access to a toilet. "This is India's defective development."

Despite all the comfort and prestige of his status in the UK and the US – he teaches at Harvard – he hasn't forgotten the urgency of the plight of India's poor, which he first witnessed as a small child in the midst of the Bengal famine of 1943. His new book,An Uncertain Glory, co-written with his long-time colleague Jean Drèze, is a quietly excoriating critique of India's boom.

It's the 50% figure which – shockingly – keeps recurring. Fifty per cent of children are stunted, the vast majority due to undernourishment. Fifty per cent of women have anaemia for the same reason. In one survey, there was no evidence of any teaching activity in 50% of schools in seven big northern states, which explains terrible academic underachievement.

Despite considerable economic growth and increasing self-confidence as a major global player, modern India is a disaster zone in which millions of lives are wrecked by hunger and by pitiable investment in health and education services. Pockets of California amid sub-Saharan Africa, sum up Sen and Drèze.

The details are outrageous but the outlines of this story are familiar and Sen and Drèze are losing patience (they have collaborated on several previous books) and their last chapter is entitled The Need for Impatience. They want attention, particularly from the vast swath of the Indian middle classes who seem indifferent to the wretched lives of their neighbours. So they have aimed their critique at India's national amour-propre by drawing unfavourable comparisons, firstly with the great rival China but even more embarrassingly with a string of south Asian neighbours.

 An Indian boy defecates in the open in one of New Delhi's slums. Photograph: AP Photo/Kevin Frayer

"There are reasons for India to hang its head in shame. Alongside the success, there have been gigantic failures," says Sen. He is making this critique loud and clear in the media on both sides of the Atlantic ahead of the book's launch in India this week. "India will prick up its ears when comparisons with China are made, but the comparison is not just tactical. China invested in massive expansion of education and healthcare in the 70s so that by 1979, life expectancy was 68 while in India it was only 54."

Sen and Drèze's argument is that these huge social investments have proved critical to sustaining China's impressive economic growth. Without comparable foundations, India's much lauded economic growth is faltering. Furthermore, they argue that India's overriding preoccupation with economic growth makes no sense without recognising that human development depends on how that wealth is used and distributed. What's the purpose of a development model that produces luxury shopping malls rather than sanitation systems that ensure millions of healthy lives, ask Drèze and Sen, accusing India of "unaimed opulence". India is caught in the absurd paradox of people having mobile phones but no toilets.

Even more stark is the comparison with Bangladesh. "Our hope is that India's public policymakers will be embarrassed by the comparison with Bangladesh. On a range of development indicators such as life expectancy, child immunisation and child mortality, Bangladesh has pulled ahead of India despite being poorer.'

What makes this comparison so powerful is that Bangladesh has targeted the position of women not just through government policy but also through the work of non-governmental organisations such as BRAC and the Grameen Bank. As a result, there have been astonishing successes, says Sen, such as a dramatic fall in fertility rate and girls now outnumbering boys in education. All this has been achieved despite having half the per capita income of India.

Other impoverished neighbours such as Nepal have made great strides, while even Sri Lanka has kept well ahead of India on key indicators despite a bitter civil war for much of the last 30 years. Drèze and Sen conclude in their book that India has "some of the worst human development indicators in the world" and features in the bottom 15 countries, along with Afghanistan, Yemen and Pakistan. Seven of the poorest Indian states account for the biggest concentration of deprivation on the globe.

 Street scene in Delhi's Kathputli colony, where the houses have no running water, electricity or sanitation. Photograph: Donatella Giagnori/LatinContent/Getty Images

After this blizzard of facts and figures – and the book is stuffed with them – one might fear reader despair, but the reverse is true. This is a book about what India could do – and should do. Kerala, Tamil Nadu and Himachal Pradesh are held up as good examples of how social investments from the 60s to the 80s have reaped dividends in economic growth. What holds India back is not lack of resources but lack of clear-sighted, long-term policies and the political will to implement them. Sen (still an Indian citizen) is optimistic, pointing to the political mobilisation following the rape of a young woman student on a bus in Delhi last December, which led to the rapid adoption of new measures to combat violence against women. The consciences of the Indian middle classes can be stirred, and, when they are, political action follows.

But he admits "intellectual wonder" at how it is that more people can't see that economic growth without investment in human development is unsustainable – and unethical. What underpins the book is a deep faith in human reason, the roots of which he traces to India's long argumentative tradition going as far back as the Buddha. If enough evidence and careful analysis is brought to bear on this subject then one can win the argument, and it is this faith that has sustained him through more than five decades of writing on human development. It was his work which led to the development of the much cited UN's Human Development Index.

Influential he has certainly been, but he acknowledges he still hasn't won the argument. To his dismay, there are plenty of examples where people seem set on ignoring the kind of evidence he stacks up; in passing he asks: "How can anyone believe austerity with high levels of unemployment is intelligent policy for the UK?"

He laughingly comments that colleagues say his thinking hasn't evolved much, but he dismisses the idea of being frustrated. All he will concede is the astonishing admission that he wishes someone else had written this book on India. "There are a number of problems in philosophy which I would have preferred to tackle – such as problems with objectivity. But this book had to be written. I want these issues heard."

He says that the Nobel prize and the National Medal from President Obama may be "overrated" but they give him a platform, and he unashamedly uses it – giving time to media interviews and travelling all over the world to deliver speeches. That has led to compromises on the intellectual projects he would have liked to pursue, but life has been full of compromises ever since he narrowly survived cancer as an 18-year-old: there are all kinds of food he cannot eat as a result.

He is an extraordinary academic by any account – a member of both the philosophy and the economics faculties at Harvard – and is helping to develop a new course on maths while supervising PhDs in law and public health. He has plans for several more books and no plans to slow down. Mastery of multiple academic disciplines is rare enough but it's the dogged ethical preoccupation threading through all his work that is really remarkable. None of the erudition is used to intimidate; he is always the teacher.

Some argue that Sen is the last heir to a distinguished Bengali intellectual tradition that owed as much to poets as it did to scientists, politicians and philosophers. Sen is the true inheritor of Rabindranath Tagore, the great poet and thinker of the early decades of the 20th century. A family friend, he named Sen as a baby; the only photograph in Sen's Cambridge study is that of the striking Tagore with his flowing white beard.

But on one issue Sen admits he now parts company with Tagore, and instead he quotesKazi Nazrul Islam, Bengal's other great poet who became an iconic figure for the nation of Bangladesh. Tagore was too patient; Nazrul was the rebel urging action. And he repeats a quote he uses in the book: "Patience is a minor form of despair, disguised as a virtue." He wants change and that means he is about to embark on a demanding tour of Indian cities to promote the book. The doctors have told him that if he slows down it will be irrevocable, so he's decided not to. Retirement is not an option.

Human papillomavirus (HPV) vaccine – identifying and overcoming the challenges to reaching those who need it most

See the published article here. Human papillomavirus (HPV) vaccine – identifying and overcoming the challenges to reaching those who need it most Posted: 09 Jul 2013 02:54 AM PDT by Dr Ernestina Coast Women in low and middle-income countries experience the greatest burden of cervical cancer in the world, with more than 88% of the 275,000 deaths annually taking place in these areas. The human papillomavirus (HPV) is the most common sexually transmitted infection globally and is the major cause of cervical cancer. Two preventive vaccines were licensed in 2006 and boast great potential for reducing the burden of cervical cancer.  Despite the fact that the vaccine has proven to be safe and effective against HPV, there has been a significant lag to delivering it in low and middle income countries (LMICs). Using both a literature review and interviewing experts working in the HPV vaccine field we investigated the current challenges to introducing the HPV vaccine.    We found that although early research anticipated the biggest challenge to be the sociocultural barriers including potential stigma or concerns to vaccinating girls 9-13 years against a sexually transmitted infection, this wasn’t really the case in the literature or as expressed by experts. The need to communicate and educate or ‘sensitise’ the public, policymakers and various stakeholders on the vaccine, HPV and its link to cervical cancer were important to overcoming and preventing these issues. The main challenges that were identified included those relating to the logistics and delivery of a new vaccine to a new target group – teenage girls as well as countries’ infrastructure and storage systems. Countries performing demonstration projects have proven that it is possible to reach these girls, vaccinating at schools, health centres, campaigns or often through more than one avenue and have achieved higher coverage of the HPV vaccine than in many high income countries like the United States or the Netherlands.  Financing of the HPV vaccine has been a topic of much debate worldwide as costs for the vaccine ranges from US$13 to US$100 for each dose, making it unaffordable to most LMICs. Vaccine financing through mechanisms such as the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) are improving access to LICs to vaccines through negotiating lower vaccine prices and co-financing until countries can afford the vaccines. However other costs, including start-up and on-going implementation costs to sustain programmes are still significant challenges. Finally, the third main challenges were the political barriers and facilitators to introducing the HPV vaccine. Expensive, new public health interventions, such as the HPV vaccine, demand more evidence to convince countries that it is a worthy cause in which to invest their limited resources and represents an important barrier that needs to be overcome.  Excitingly, many demonstration programmes and pilot projects are currently testing out what works and how it can be made sustainable long term. Our study helps to document not only the challenges that have been identified but how national immunization programmes, demonstration and pilot projects are overcoming and successfully implementing the HPV vaccine, so that others considering its introduction can learn and continue to build upon their experiences. Further information Wigle J, Coast E, Watson-Jones D (2013) Human Papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): health system experiences and prospects, Vaccine, Online. ISSN 0264-410X