Chasing the heat in an election season

This week in health: the heat and health conundrum, WHO’s pandemic treaty and how AI can help in navigating mental health.

Updated - April 03, 2024 10:35 am IST

Published - April 02, 2024 04:06 pm IST

Image for representational purpose only. File

Image for representational purpose only. File | Photo Credit: Moorthy M.

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This is undeniably the hottest news this season, quite literally. The India Meteorological Department (IMD) predicted extreme heat in April-June in Central-western-peninsular parts. The IMD on April 1 warned of “above normal” heatwave conditions during these months over most of India. It also turns out to be the exact time when temperatures are any way soaring in the country in a no literal sense as the fiercest battle is on in the subcontinent to elect the next government. Arguably, this could be among the grimmer battles fought. In light of this, advisories have been issued to the Election Commission of India (ECI) as well as the different States to take adequate precautions. Notably, this is not a ‘mild’ increase: Gujarat, Maharashtra, Andhra Pradesh, north Karnataka, Odisha, and western Madhya Pradesh, which on average see one to three heatwave days during April and May, are likely to experience two to eight heatwave days, the advisory from the IMD said. Heatwave days occur when day temperatures in a place are at least 4.5 degrees Centigrade above normal, or greater than 45 degrees Centigrade, on two consecutive days. While these States are particularly vulnerable, above normal temperatures are likely over all of the country barring Kerala, Jammu and Kashmir, Himachal Pradesh, Uttarakhand, and most of the northeastern States. For more information on what precautions to take while going to the polls, please hit the link above. 

For more information on what this heat phenomenon is about and the seriousness with which one should approach this, do read Purvi Patel’s explainer: As India’s summer begins, understanding the heat and health conundrum. Anthropogenic climate change is turning ambient heat, a relatively banal manifestation of the sun, into an inevitable environmental hazard. In 2023, with the atmospheric carbon dioxide level reaching new heights of 425 ppm, we witnessed the warmest decade on record spanning from 2014 to 2023. Until a few decades ago, hazards of high heat largely existed in confined, fire-based occupational settings or for people who exerted in hot weather for a long time, e.g. soldiers, athletes, and workers, and during occasional heatwaves, she writes. Mentions of heat stroke have been found in literature since ancient times. With rising global temperatures, dangerous high heat has begun permeating our routine indoor spaces. This gradual expansion of the realm of extreme heat is potentially the gravest consequence of climate change for India. India has observed a significant mean temperature increase of 0.15 degrees C per decade since 1950, according to a 2020 assessment by the Ministry of Earth Sciences. The observed warming is not occurring evenly across India. Warm days and warm nights have also increased at about seven and three days per decade, respectively, during the period between 1951-2015. Currently, 23 States, mainly of plain and coastal regions, are considered more vulnerable to widespread heat impact. However, that doesn’t mean hilly states are safe. Although their maximum temperatures do not reach heatwave threshold levels of 45°C, the population is experiencing higher temperatures compared to previous decades. 

And how does this affect our health? Exposure to severe or continuous heat leads to heat stress. When uncompensated, heat stress manifests as heat-related illnesses. Such illnesses range from superficial/mild and manageable (e.g. prickly heat, heat-related swelling, heat cramps, heat exhaustion) to a medical emergency (i.e. heat stroke). Heat stroke is the most severe of heat-related illnesses: it presents with impaired brain function (i.e. stroke) due to uncontrolled body heating. It is a time-critical condition that often turns fatal if there is a delay or failure in reducing body temperature by rapid, active cooling. Besides neurological impairment, high core body temperature (at least 40 degrees C), or hot, dry skin are other heat stroke symptoms. These may be confused with fever. Clinically, a diagnosis of heat stroke poses a unique challenge as it requires the elimination of other causes of stroke, history of infection, and medication overdose.

Back on to the non-communicable diseases bandwagon, Vasudevan Mukunth reports on a study that finds one-way statins can cause diabetes, and a solution to the crisis as well. Administering ursodeoxycholic acid (UDCA) can stave off the tendency of statins to induce glucose intolerance and diabetes, a study by a group of researchers in China has found. Statins are prescribed to people with a high risk of cardiovascular disease. They work by blocking the activity of an enzyme involved in the metabolic pathway that produces LDL, or “bad”, cholesterol. Statins are on the World Health Organisation’s list of essential medicines and among the most sold drugs worldwide.

However, many studies have found statins could increase the risk of developing diabetes. In the study, published in the February edition of Cell Metabolism, the researchers reported one mechanism through which statins could increase glucose intolerance, involving UDCA, a bile acid. The team recruited 30 people with atorvastatin and 10 without and tracked their metabolism for four months. They reported that the faeces of those taking atorvastatin had a reduced abundance of bacteria of the genus Clostridium. Also, they said, “the decreased Clostridium-rich microbiota might influence bile acid synthesis and excretion and impair glucose metabolism” in a 12-week study of mice. To check the role of UDCA, they recruited five participants on statins and administered 10-13 mg/kg (of body weight) of UDCA per day. After two months, they found the individuals’ HbA1C levels, among others, were “substantially decreased”.

Bindu Shajan Perappadan writes that ICMR is set to bring in evidence-based norms for the prevention, screening, diagnosis, and management of lung cancer. This falls in the category of bizarre but true. Currently, evidence-based guidelines do not exist with respect to prevention, screening, diagnosis, management, and palliation of lung cancer in India, despite the fact that lung cancer is one of the commonest cancers in India accounting for 10% of total cancer deaths in the country. To address this lacuna: The Indian Council of Medical Research (ICMR) is now all set to launch a systematic review and meta-analyses which, it notes, will play a crucial role in synthesising existing evidence to inform decision-making in the management of lung cancer to guide clinical practice and improve patient outcomes. It has launched an expression of interest (EoI) from researchers who are interested in conducting systematic reviews and meta-analyses. “Prospective applicants will be tasked to conduct systematic reviews/meta-analysis pertaining to the identified review questions (PICOs) and assessing the quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool,’’the ICMR has said.

Sarojini Nadimpally, Gargi Mishra and Keertana K. Tella remark on how subpar treatment options allow sickle cell disease to persist. As per the 2023 ‘Guidelines for National Programme for Prevention and Management of Sickle Cell Disease’, of the 1.13 crore persons screened in different states, about 8.75% (9.96 lakh) tested positive. It is also one of the 21 “specified” disabilities listed in the Schedule of the Rights of Persons with Disabilities Act 2016. SCD is an inherited haemoglobin disorder in which red blood cells become crescent- or sickle-shaped due to a genetic mutation. These RBCs are rigid and impair circulation, often leading to anaemia, organ damage, severe and episodic pain, and premature death. India has the third highest number of SCD births, after Nigeria and the Democratic Republic of the Congo. Regional studies suggest approximately 15,000-25,000 babies with SCD are born in India every year, mostly in tribal communities. Treatment and care for SCD remains grossly inadequate and inaccessible. States with a high prevalence of SCD, particularly among their most marginalised populations, are falling behind in their efforts to reach out and provide basic care to those affected. 

The (un)availability of the drug hydroxyurea, limited availability of blood transfusion and the lack of access to bone marrow transplantation are cited as issues hampering normalcy for patients with SCD in the country.

Playing out the gender perspective again, the WHO has called for greater attention to violence against women with disabilities, and older women. Older women, and women with disabilities, are subjected to intimate partner and sexual violence, but also face specific risks and additional forms of abuse, sometimes at the hands of caregivers or healthcare professionals, the WHO said on Tuesday, adding that this includes coercive and controlling behaviours such as withholding of medicines and assistive devices or other aspects of care, and financial abuse. Calling for better research across countries that will help ensure these women are counted, and that their specific needs are understood and addressed, the health agency maintained that older women, and women with disabilities face particular risk of abuse, yet their situation is largely hidden in most global and national violence-related data. Among women aged 60 years and older, a review conducted by the WHO found that physical and/or sexual intimate partner violence remained the most frequently experienced forms of abuse. However, as partners aged, some women reported a shift from predominantly physical and/or sexual violence to psychological violence, including threats of abandonment and other controlling behaviours. Older women and women with disabilities can be extremely isolated when violence occurs, making it more difficult for them to escape and report the abuse. Stigma and discrimination can further reduce access to services or information, or result in their accounts of violence being dismissed by responders. For more on the subject, click on the link above.

An interesting five-year study by researchers at IIT Madras found that more women now opt for C-section deliveries. There was a rise in the number of Caesarean sections (C-section) between 2016 and 2021 in the country, despite a drop in medical complications during pregnancy. The chances of a delivery through C-section were greater if a woman gave birth in a private hospital, the study revealed. Also, overweight and older women (aged 35-49) were more likely to have C-section deliveries.

A C-section delivery, a surgical procedure, is generally recommended to save the life of the mother and the unborn infant. When not strictly necessary, however, it can cause several adverse health outcomes, lead to unnecessary expenditure, and place a strain on scarce public health resources, earlier researchers have proved.In an in-depth analysis of Tamil Nadu and Chhattisgarh, the researchers found that though pregnancy complications and high-risk fertility behaviour were more prevalent in Chhattisgarh, C-section was more prevalent in Tamil Nadu.V. R. Muraleedharan, one of the authors of the paper, said, “A key finding was that the place of delivery (whether the delivery was in a public or a private facility) had the greatest impact on whether delivery was by C-section, implying that ‘clinical need’ factors were not necessarily the reason for surgical deliveries. Across India and Chhattisgarh, the ‘non-poor’ were more likely to opt for C-sections, while in Tamil Nadu, the case was surprisingly different, as the poor were more likely to have C-sections in private hospitals.”

A key story this week, and those that follow, predictably is the rise in the prices of essential medicines beginning April 1. With the prices of 384 essential drugs and over 1,000 formulations saw a hike of over 11%, due to a sharp rise in the Wholesale Price Index, consumers have to pay more for routine and essential drugs, including painkillers, anti-infection drugs, cardiac drugs, and antibiotics. In its communication dated March 25, the National Pharmaceutical Pricing Authority said the annual change in WPI was 12.12% for the calendar year 2022. Last year, the National Pharmaceutical Pricing Authority (NPPA) announced a 10.7% change in the Wholesale Price Index (WPI). Every year, the NPPA announces a change in the Wholesale Price Index (WPI) in accordance with the Drugs (Price Control) Order, 2013, or DPCO, 2013. A senior Health Ministry official said that the price hike was to ensure that there would be no shortage of medicines in the market, and that manufacturers and consumers mutually benefit. “Manufacturers will not sell at a loss and we must ensure a steady supply of essential medicines in the country. Additionally, the prices are allowed to rise in a controlled manner,’’ he said.

Malini Aisola, co-convener of the All India Drug Action Network, a group that works to promote affordable healthcare, expressed concern that the new WPI would trigger increases in the ceiling prices under the DPCO provisions for fixing prices for scheduled formulations.“The increase is the highest seen since the DPCO 2013 came into force and this is the second year in a row that the WPI is higher than the annual permitted price hike for non-scheduled formulations (10%). Because such a drastic hike will distort the price control in place on essential medicines, the government should intervene in the interest of maintaining the affordability of these drugs. Such high back-to-back price increases are undermining the purpose of price fixation of essential medicines,’’ she added.

A spillover of the observation of World TB Day, here are a bunch of articles: Saurabh Rane and Himanshu Patel write with insight on high-quality care in TB: Rights and perspectives of affected individuals. Care that speaks to the needs and expectations of those affected, must. therefore, be defined by experts but also those who receive it. As survivors, the authors say that high-quality care is not limited to diagnosis and treatment. It goes far beyond that. They call for a renewed discussion, where patients and survivors can lead the paradigm shift, and enable the care systems to address the gaps more effectively, and inclusively. The need is to create a paradigm of care that is not just people facing, but also community and people- focussed. By filling in this gap, of missing voices from actual consumers of care, the national program, as well as the private sector can deal with the TB epidemic in a far more comprehensive manner. 

T.V. Padma, meanwhile, writes that eradication of TB remains a distant goal as systemic challenges persist. Survivors Against TB, a community advocacy group of TB survivors, wrote a letter to the Prime Minister “on the urgent and pressing need to expand efforts to address India’s Tuberculosis (TB) crisis.” The letter mentions that despite the government’s commitment to “eliminate high-burden infectious” TB by 2025, ‘we are still far from reaching this goal’ and identifies six key challenges: TB diagnosis and access; lack of access to free, quality treatment and drugs; adequate nutrition and mental health support; stigma-free and gender-responsive care; economic support; and high-quality care. Undernutrition in adults contributes to 34–45% of all new cases annually, while undernutrition in patients with TB is a major risk factor for TB deaths, apart from increasing the risk of drug toxicity and relapse. This is the most important risk in the management of TB. Undernutrition impacts both the occurrence of TB and the outcomes of TB treatment, which include mortality, drug toxicity to patients, and relapse. The Government has recognised this need for nutritional support by launching a direct benefit transfer scheme of ₹500 since 2018, as well as a food-basket scheme under the PM TB Mukt Bharat Abhiyan. If we are to reduce TB deaths, this is one of the low-hanging fruit, experts say. This is doable. However, there is limited sensitisation among doctors including chest physicians regarding this.

The TB incidence rate in India had fallen from 237 per lakh population in 2015 to 199 per lakh population in 2022, while the mortality rate had declined from 28 per lakh population in 2015 to 23 per lakh population in 2022, according to the India TB report 2024 released by the Union Health Ministry on March 27, stating that the country has set 2025 as the target for eliminating the disease. India achieved 16% decline in new TB cases and 18% reduction in mortality since 2015. Additionally, of all the TB cases notified in 2023, nearly 32% of notifications came from the private healthcare sector which is an increase of 17% from the previous year. According to the data released in the report, while the overall notification of TB cases has improved by over 50% in the last nine years on an annual basis, Uttar Pradesh saw the highest jump in notifications (by 21% compared to the previous year) followed by Bihar (15%). The Centre added that after the COVID-19 pandemic, the National Tuberculosis Elimination Programme (NTEP) embarked on a journey towards accelerating TB elimination, guided by the National Strategic Plan (NSP) 2017–25.

Nevertheless, it is clear that with the 2025 target ahead of us, whatever improvements are merely incremental, what we need is geometrical progression, from all sides of the problem. 

Did you know it is possible to draw up a living will, in anticipation of hospitalisation at a later date? Mini Murungatheri writes to explain that a living will is to avoid the indignities of hospitalisation. On March 12, a gathering of 30 people, mostly doctors, nurses, and volunteers of the Pain and Palliative Care Society, signed ‘living wills’ in Thrissur, Kerala. A ‘living will’ is a legal document prepared in advance, detailing your preferences for medical care or for the termination of medical support in circumstances in which you are no longer able to make those decisions for yourself. “Everybody wants to die with dignity. No one wants to die in the freezing cold ICU alone, without loved ones. But people may not be in a mental or physical condition to articulate their wishes in their last days. Patients, even in the eventuality of terminal illness with no hope of recovery or irreversible coma, are often kept on life support just to delay death — perhaps under social or family pressure. These expensive treatments push many families into a huge debt trap,” says Divakaran Edasseri, Director of the Institute of Palliative Care, Thrissur. 

Chandrakant Lahariya and Amit Harshana write a very important story on a very important day in the history of response to the HIV/AIDS epidemic in India. Twenty years ago, on April 1, 2004, the Indian government launched Free Antiretroviral Therapy (ART), for Persons living with HIV (PLHIV), a decision which has proven one of the successful and a key intervention in the fight against HIV/AIDS. The decision to make free ART for any adult living with HIV was a path-breaking one. From November 2006, the free ART was made available for children as well. In two decades of free ART initiative, the facilities offering ART have expanded from less than 10 to around 700 ART centres — 1,264 Link ART centres have provided, and are providing, free ART drugs to approximately 1.8 million PLHIV on treatment.

In this significant article, Kashish Aneja flags that the WHO’s Pandemic Agreement represents a critical step towards rebuilding trust and coordination between nations, but there are indications that it runs the risk of collapse. The WHO Pandemic Agreement aims to address the systemic failures revealed by the COVID-19 crisis, with the goal of strengthening global defences and averting future pandemics from spiralling into catastrophic human crisis. The world’s first pandemic treaty aims to “strengthen pandemic prevention, preparedness and response” with “equity as the goal and outcome”. It addresses the searing inequity witnessed during the COVID-19 pandemic including a lack of preparedness in countries and the lack of coordination at international levels. 

The most contentious aspect of the Agreement, essentially between developing countries, and others, mostly developed countries and some stakeholders, lies in the establishment of a global system for sharing pathogens and their genetic codes, while ensuring equitable access to the ‘benefits’ derived from research, including vaccines. Developing countries are hesitant to share information on pathogen spread and evolution if they perceive little in return, a situation exacerbated during the COVID-19 pandemic by “vaccine nationalism”. We will be watching this space for further details…

We have two contenders for the tailpiece section this week. 

Iti Bhargava, Manmath Goel and Namrata Rao write about whether AI can help in navigating mental health. The authors write that in mental healthcare, there is already a rapid evolution of use cases for AI with affordable access to therapy and better support for clinicians. Through text-based platforms and virtual mental health assistants, Natural Language Processing programs provide privacy and anonymity that can improve help-seeking behaviour. For users, the chatbot can support them in reframing thoughts, validating emotions and providing personalised care, especially in the absence of human support. Not only is this beneficial when a therapist is not accessible, but it also helps improve patient health outcomes just as well as in-person care.

Digital therapy assistants can help point you to resources for healthier coping in instances of distress, grief, and anxiety. Since these chatbots are scalable, cost-effective, and available 24x7, they could therefore be integrated into existing health programs. Additionally, companies building chatbots must proactively expand the scope of service delivery through partnerships and collaborations for follow-up services such as referrals, in-person treatment, or hospital care, where needed.

In the second story in this section, M. Kalyanaraman writes about how neuroscience reshapes marketing strategies in India. While Elon Musk’s neural implant may be the outlier in neuroscience, what’s common and par for the course today is mapping the brain to understand and predict human responses with data and real insight. This is being used in India to solve business problems from why life insurance buyers typically stop paying premiums after the first two years to whether an online ad can be made to ensure the consumer hits the “buy” button. Neuroscience-based market research can give reliable hard data, says an expert. Instead of questionnaires, neuroscience employs a range of instruments to directly get information on how the brain is being impacted and what decisions it will take. Do read on, at the link above.

From the Health page

If you have a few more moments, also read: 

Dr. Reddy’s to market Sanofi’s vaccine brands in India.

Zubeda Hamid’s In Focus Podcast discusses: What can microplastics do to the human body?

How do Ozempic and other weight-loss drugs work? 

IMA to engage with political leaders to put forth doctors’ demands for coming elections.

In international health news:

Thailand sounds alarm after anthrax outbreak in Laos.

Five dead and over 100 hospitalised from recalled Japanese health supplements.

Indian-origin teen first to get U.K.’s life-changing cancer treatment

Bringing up regional content from our bureaus for your perusal:

Assam

IIT-Guwahati transfers tech for first anti-swine fever vaccine.

Delhi

Delhi Government calls Assembly session to discuss healthcare facilities.

Karnataka

Shilpa Elizabeth reports that IIIT-B students develop tech to give seamless classroom experience for visually impaired.

Health Minister writes to Centre seeking urgent supply of DSTB drugs to Karnataka.

Preeti Zachariah writes: Meet the scientist who has an asteroid named after him.

Kerala

Nurses trained for creating cancer awareness among tribals in Wayanad.

Tamil Nadu

Fresh MRB notification irks doctors, they demand the recruitment of already qualified candidates.

A bereavement circle for families that have lost a child.

Psychologist, warden of de-addiction centre among five arrested in Coimbatore for death of inmate.

Telangana

Siddharth Kumar Singh reports on Telangana’s pill predicament.

As always, do put us on your radar, as we bring more health content your way. Get more of The Hindu’s health coverage here.

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