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Rapid Responses: Rapid Responses published:
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Uncomparable figures.
- Chandra M. Gulhati (3 April 2004)
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Can't wait for similar treatment for Health in Africa
- Joseph Ana (3 April 2004)
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Traffic injuries neglected
- Rashid Jooma (4 April 2004)
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Any valid reference??
- Javed A. Arain (5 April 2004)
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Target oriented programs are needed
- JP Dadhich (6 April 2004)
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Obvious contrasting health patterns between the rich and poor
- Sudhir Kumar (6 April 2004)
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Why financing not in screen?
- Godwin S.K (7 April 2004)
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global social contract partinent indeed; but what is it?
- Anthony Lwegaba (8 April 2004)
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What if Mental Health is included ?
- A.A.W. Amarasinghe (29 April 2004)
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No Need for New Global social contract
- Rajeshkumar Balasubramanian, Dr Vadivelu Saravanan, Registrar In Rheumatology, Newcastle,Olaiyur@blueyonder.co.uk (9 May 2004)
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Chandra M. Gulhati, Editor, MIMS INDIA New Delhi 110019.
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May I submit that comparing the financial outlay in US $ terms in any field of activity in various countries does not give the true picture. For instance US$ 4 in India buy far more than an equivalent amount in the United States. Therefore all figures should be corrected based on their Purchasing Power Parity. As per my information US$ 1 in India equals US$ 5.3 in the United States. Besides the cost of medicines in India is not even one-tenth of US. Secondly, the article states that Indian Government spends US$ 4 per year per person. The corresponding figure of the United States should be the state's allocation, not overall expenditure. It is not clear as to who spends US$ 4,000 per year per person? Is it the Government? If not the comparison is not appropriate. In India 80 per cent of the health costs are borne by individuals. Competing interests: None declared. |
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Joseph Ana, managing editor BMJ West Africa edition, UK Office, 65 Warden Hill road, Luton, LU2 7AE
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The BMJ is to be congratulated for a beautiful theme issue on 'Health in South Asia'. International journals with such clout and wide readership across the globe can only help to bring to light, to a larger world audience, the poor health of fellow humans in the developing world. This, I believe is one of the roles of a general medical journal. (BMJ 2004;328:591) As I read through this week's editors choice , BMJ 3 April 2004, I stopped and reminded myself that I was actually reading about South Asia not West Africa including Nigeria, Ghana and the rest, because it was like de ja vu. It was really strange because I had a similar experience about the vegetation, climate and people when we drove in a bus from the airport to the private medical school in Manipal, Kartanaka, India in 1999 to attend that year's BMJ's LEAP ( local editors and publishers )conference. Be it communicable diseases, non communicable diseases, maternal and infant mortality, the catastrophy of HIV / AIDS or the paltry allocation to the health sector by governments,the picture is very similar ( probably worse) as BMJ will expose when it visits Africa( see Richard Smith's promise). Similarly the effects of rapid urbanisation to the detriment of rural development, where most Africans live, can be seen in the rise of fatal vehicular accidents, congestion and overcrowding, stress, depression and anxiety states. Factors such as prevailing illiteracy which feeds ignorance, poverty, superstition, voodoo and black magic compound the awful statistics of morbidity and mortality across all ages and both sexes in Africa. In most of these countries hard data will be difficult to colect but the lamentable state of health in the continent is there for all who live there (or visit) to see. One further similarity is that south Asia and Africa are emerging from centuries of colonisation and plunder by their colonising masters. Some will say it is harsh to judge their poor performance or make comparisons with the colonising countries, only 50 years after independence, whereas the colonisers have enjoyed centuries of uninterrupted development and growth. I don't know the answer, but whatever the case I can't wait for BMJ to throw its search light on 'Health in Africa' to reveal all, warts and all!. Competing interests: Joseph Ana is managing editor of BMJ West Africa edition and Trustee- Director of The NMF ( Nigerian Medical Forum,a UK registered charity)both of which have keen interest in seeing to improvements in health care planning and delivery in West Africa since 1991. Neither position attracts a salary but his travel expenses are often partially refunded. |
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Rashid Jooma, Professor of Neurosurgery Jinnah Postgraduate Medical Centre, Rafiqui Shaheed Road , Karachi 75510, Pakistan
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EDITOR-A notable omission in your excellent Health in South Asia theme issue is the absence of any reference to the public health problem posed by accidental injuries, particularly the burgeoning road traffic injuries and fatalities. The region is subject to an unprecedented expansion of economic growth, urbanisation and motorisation occurring in tandem. Data from Pakistan have demonstrated a disturbing parallelism between the growth of vehicles on the road and the incidence of fatal crashes.1 The Jinnah Postgraduate Medical Centre is the major trauma receiving facility in Karachi and we had 3008 head injured patients reporting to our Casualty Department in 2003. By comparison the same Centre recorded 600 head injuries in 1970 and in both these periods, 32 years apart, the majority of serious injuries were sustained on the roads.2 Our data also shows that most of the head injured in serious crashes were pedestrians and riders of motorcycles unprotected by crash helmets. Commercial vehicles were disproportionately involved in fatal crashes and the victims were often young, economically active male bread-earners. Health professionals involved with trauma care in all parts of the South Asian region would immediately recognise this information as their own and this commonality of increasing incidence, chaotic road usage with poor adherence to traffic regulations and a preponderance of pedestrians and public transport users amongst the injured and killed should be a strong imperative for a co-operative approach to the solutions. The South Asian nations urgently need to collaborate to enhance road safety research in their academic centres and in particular to study the dynamics and behaviour of our vulnerable road users, with a view to evolving programmes of traffic engineering germane to our conditions. Industrial scientists of the region should be encouraged to work together to design motorcycle crash helmets more likely to find favour with riders in the prevalent hot and humid conditions. Most important, we need to be able to learn from each other to bring more effective programmes to bear. An example is the excellent pre-hospital care scheme developed in Bangalore where a Comprehensive Trauma Consortium has established a network of radio-controlled, position-sensed ambulances manned by specifically trained paramedical personnel.3 They have for the first time demonstrated in South Asia that the timely deployment of trained pre- hospital care providers at the crash site improves the survival of accident victims4 and their experience could well be replicated in other urban centres of the region to save lives and maximise the potential of recovery of those injured on the roads. 1. Hyder AA, Ghaffar A, Masood TI. Motor vehicle crashes in Pakistan: the emerging epidemic. Injury Prevention 2000;6:199-202 2. Jooma R, Zarden AM. Comparison of two surveys 32 years apart of head injured patients presenting to an urban medical centre during a calendar year. J Pak Med Assoc. Submitted for publication. 3. Comprehensive Trauma Consortium. www.roadaccidents.com/rd/ctc_detail.html (accessed 3 Apr 2004) 4. Venkataraman NK. Presented at 5th Asian Conference of Neurological Surgeons. Djakarta. Feb 2004 Competing interests: None declared |
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Javed A. Arain, Specialist Surgeon Sharjah, United Arab Emirates
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Wat is the reference for author's statement in 2nd paragraph " a third Pakistanis above 45 suffer from hypertension" ?? I really doubt this high figure as I have been practicing medicine in Pakistan for alomost 15 yrs, till 2 yrs back. Competing interests: None declared |
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JP Dadhich, consultant neonatologist SL Jain Hospital New Delhi 110052
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In India, two-third Infant Mortality is contributed by Neonatal Mortality. The causes of deaths among the neonates are well documented both in community as well as institutions. The required interventions have also been identified. Still, every year 1.2 million neonates are dying each year. Causes like birth asphyxia, hypothermia, and sepsis are preventable and treatable with simple interventions. Till now, newborn health has been attached to some other health program. This has not resulted in a significant drop in the neonatal morbidity and mortality. Also, the donor driven programs are terminated in the middle with the change of agenda of these agencies. The need is to have a target oriented specific program addressed to neonates. Local populace and local governments at village level may be involved in the desgining and implementation of such programs. Competing interests: None declared |
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Sudhir Kumar, Consultant Neurologist Christian Medical College, Vellore, Tamilnadu, India
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Dr. Smith has nicely outlined the major areas of concern for South Asia, mainly India. Most of the facts tell their own story, but the reality is more worrying. As pointed out, people are dying of easily treatable conditions, which are not very expensive to treat. If a child dies due to lack of BMT for leukemia/lack of IVIG for GBS, it may be excusable to a certain extent on account of financial difficulties; but how can we accept children dying of infectious diseases (diarrhoea, ARTI, etc). Importantly, India cannot afford to ape the West nor can it afford to conduct research in their fields of interests. Our needs are different, we need more GPs, family physicians and simply more doctors, rather than more superspecialists at this stage. We need to conduct research in areas such as infections, malnutrition, etc, rather than newer therapies for Alzheimer's disease at this stage! Competing interests: None declared |
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Godwin S.K, Researcher Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India-695 011
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While considering the health problems of South Asia, it is astonishing that very little emphasis is given to the issues of financing of health care in the special issue. South Asia is considered to be a sub continent of problems and is second to Sub-Saharan Africa in terms of all human development indicators. India is one among the very few health systems having an unjustifiable degree of inefficiency and inequity in the distribution of health status, due primarily to the type of financing, organisation, management governs its health and medical care. With regard to health outcomes, it is not only a question of how much a country spends on medical care, the distribution of health care expenditure reflected through who is bearing the burden of payments is also of paramount prominence from an accessibility point of view. As the government spends less than one fifth of the total health care expenditure in India, the households are forced to spend huge amounts on health care, making each small health care seeking event a financial catastrophe. Since private out -of-pocket expenditure dominates [which is the most regressive and inefficient form of financing care], the access to care for the lower income groups is the first casualty. While WHO identified that reduction of catastrophic health care expenditure is one of the most important objectives of a health system, hospitalised Indians spent 58 per cent of thier annual household expenditure on health care and one fouth of the hospitalised population gets impoversihed due to medical expenses.1 Since curative medical expenditure is one among the large number of inputs in the household production of health, an abnormal increase in one input called medical care leaves very little for other inputs like food, education, spending on livelihood etc deteriorates not only the present health status of an individual, but the long term economic security of the individual due to the debt, or distress sales incurrred to finance medical care. The population foregoing treatment attributable to the percieved financial burden of treatment is increasing at a rapid rate as reflected by National Sample Survey data. If the public health care services is known for poor quality and inefficiency, the private medical care market is infamous for its poor standards, over prescription etc. The Indian health system needs to address two major issues with regard to financing of care: 1)reduce the existing heavy bias which favours tertiary care and urban centres (equity), but it is to be remembered that the present level of health care expenditure on hospitals by the government cannot be reduced because establishment costs are high and abandoning results in heavy sunk costs; 2)expanding the resources by the govenment in health sector to very high levels and one of the most important reasons for Sri Lankan and Kerala success stories has been the equitable and tolerably efficient spending by governments. However, Kerala's health system is in a declining phase today due to the fast decreasing public spending, increasing penetration of unregulated private medical care market, skyrocketing mediflation etc. More often allocation of funds for health care is a question of priorities as well. For the Indian government, military is more important than health care of the population because health care is never an eloctoral issue here, but war is as shown by the government statistics. So it is not fully correct to characterise resource shortage being the reason for less spending on health care. The opinion that the increased funding through global "social contract" may not work well, if history is any guide. The solutions are not easy and it requires strong political will which cannot come on its own and needs civil society's active pressure to push through the agenda of people's health in public fora. 1.Peters et al. (2002), Better health systems for India's poor, The World Bank. Competing interests: None declared |
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Anthony Lwegaba, lecturer, social and preventive medicine, school of clinical medicine and research queen elizabeth hospital, Barbados, WI
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Dear Editor, Global social contract, as a subject of your editorial was very well chosen and pertinent to health and development issues for individual and for partnerships in developing and developed countries. It contributes to the ultimate and most ambitious health vision ever, Health For All, (HFA). The comparison in a related article of what made the Kalara state in India and Syrilanka successful, clearly display a virtue of “political commitment” to the “right mix of development and services” as the cornerstone to sustainable development, of which health is integral as defined in Primary Health Care, (PHC). Between 1989 and 1999, I worked in Disaster programmes in Ethiopia, Somalia, Sudan and Uganda. In Ethiopia, my office was within the building of the UN Economic Commission for Africa; that gave me ready access to a wide database of Africa’s woes in underdevelopment. Africa’s lost decades was a familiar tune, within the conference rooms, coffee tables and corridors and certainly, it still is. Being more of a public health physician than a developmental specialist, the answers of colleagues whom I interacted with increased my bewilderment and my silent quest for the causes and remedies. For a non-economist, comparing countries that achieved different indicators of development overtime but started off with more or less similar baseline indicators looked the best option; similar to a quasi-retrospective longitudinal study. My stint in South East Asian economic tigers was perfect ground. The silent question on the “virtue” was: not why but what did they do that Africa did not? Though not all supported by hard data, these were apparent: First, a commitment to meaningful rallying vision; secondly, enforce accountability with meaningful wages against corruption; thirdly, building an enabling environment for all spheres of development; fourthly, heavy investment in human capital, and fifthly, systematic adaptation of technology for local solutions and exports. The why became redundant, when the above were in a cycle. 1. WHO Alma-Ata Declaration on PHC, 1978 2. OAU. Secretary-General's Report on Emergency Preparedness - The Action Plan for Africa in Relation to Epidemics and Natural Disasters. Conference of African Ministers of Health, Kampala. (1989) 3. UN-Economic Commission for Africa, African Alternative Framework to Structural Adjustment Programmes for Socio-Economic Recovery and Transformation (AAF-SAP); Document: E/ECA/CM.15/6 Rev.3, 1989 Competing interests: None declared |
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A.A.W. Amarasinghe, Consultant Psychiatrist 102 Bayberry Hills McDonough Ga USA30253 4005
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In your detailed panoramic view of health and ill health of the inhabitants of our planet, I did not encounter even a morsel of reference to mental health. If psychiatric morbidity and mortality were factored in, not only the picture painted but also the multi inferences drawn would be drastically different. Competing interests: None declared |
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Rajeshkumar Balasubramanian, Clinical fellow in Surgery West Middlesex University Hospital, TW7 6AF, Dr Vadivelu Saravanan, Registrar In Rheumatology, Newcastle,Olaiyur@blueyonder.co.uk
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We commend the ‘South Asia’ theme issue of the BMJ. The editor calls for a new global social contract for the rich to help the poor.1 Please do not weaken the poor by pretending to help. There are already social contracts namely the agreements of the World Trade Organisation (WTO), United Nations (UN), and World Bank etc. The social tenets of these institutions are wantonly broken by the rich and powerful. ‘Iniquitous decrees directed solely to private interest get passed under the name of laws’.2 Rather than a new social contract, we need to renegotiate existing international agreements to empower the third world. We list here a few reasons why the rich need not donate and the poor should not beg. Pakistan’s sick travel to India for life-saving surgery while both countries are locked in a fifty-year old war. Despite the 1948 resolution by the UN Security Council calling for a peaceful solution to the Kashmir dispute, the five permanent members of this council fuel the war by selling weapons to both sides. This global arms trade swallows up a significant proportion of GDP of many poor nations at the expense of basic needs of health, education and sanitation. Ever heard of the poor subsidising the rich? The west poaches doctors and nurses from developing countries to supply fodder for its health service. A suggestion by the UN 3 that the rich countries could recompense by repatriating a proportion of these migrants’ tax to their country of origin has fallen on deaf ears. The apathy towards this brain drain is even greater in the poor countries. The Indian government refuses to recognise the overseas experience of the doctors wanting to return home. Public health in the third world is under threat due to predatory patents. The monopolistic nature of the pharmaceutical industry is unfavourable to the poor and rich alike. Herbal extracts are being patented as new discoveries in USA and Europe, when traditional knowledge of the medicinal properties of these herbs existed in Asia over the millennia. As revenge, Indian generic drug manufacturers like Ranbaxy play Robinhood to make cheap drugs for which multinational pharmaceuticals own the patents. Come 2006, developing countries will have to abide by the WTO agreement on drug patents.4 This will not be a bad thing after all, as it will force Indian drug companies to invent their own drugs. Interestingly, the Bush administration that blocks cheap HIV drugs to Africa, was willing to bypass Bayer’s patent on Ciproflaxacin to import a cheaper version from India during the anthrax attacks on America post-September 11.5 Justice for all, eh? Many Asian and African nations are so reliant on international aid that they fail to make sufficient budgetary allocations for health spending from their own GDP. India and China vie with each other to put their man on the moon, while ignoring the HIV epidemic in their hinterlands. Neither health nor education is an issue during elections, parliamentary debates and budgets. Only a trickle of all international aid is used for the intended purpose as politicians and bureaucrats swindle the rest. International aid without good governance is counter-productive. It may seem harsh to punish the poor for the fault of their rulers but these so- called poor countries have abundant natural and human resources to lift themselves out of Dickensian despair. No more aid please. Fair trade and good governance are all we ask. Dr. Vadivelu Saravanan, Newcastle and Dr. Rajeshkumar Balasubramaniam,
London
1 Smith R. Editor's choice. Towards a global social contract. BMJ 2004;328. 2 Jean-Jacques Rousseau. The Social Contract 1762;Book IV:Chapter 1. 3 United Nations Development Programme. Human Development Report 2001;Box 4.5, page 92. Oxford University Press. 4 World Trade Organisation. TRIPS and pharmaceutical patents - Fact sheet. 2003. http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm00_e.htm accessed 2 May 2004 5 BBC News. America's anthrax patent dilemma. 2001. http://news.bbc.co.uk/1/hi/business/1613410.stm accessed 2 May 2004. Competing interests: On behalf of The Reaching the Unreached Medical Charity, Madras, India |
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