India slammed for jailing health activist

Just two weeks after Human Rights Day on December 10, the Indian government has sentenced a leading health and human rights activist to life in jail amidst fierce protest from noted academics and health professionals. Binayak Sen, an Indian public health expert and pro-poor advocate, was jailed last week after being accused of helping Maoist rebels.

Human rights groups such as Amnesty International say that the Indian government has unjustly sentenced Sen to an extraordinarily harsh and undeserved life sentence on the basis of dubious evidence. India has openly declared that left-wing ideologies are a threat to its economic growth - which it continues to pursue as aggressively as ever - and Sen's supporters say that in its desperate bid to quash growing Maoist insurgency, India is also ignoring basic human rights.

Sen has been globally lauded for his work to improve rural healthcare in India, and was awarded the 2008 Jonathan Mann award for Global Health and Human Rights. Respected intellectuals such as Amartya Sen and Noam Chomsky have petitioned against his life sentence.

Sen's various imprisonments (in 2007 too, he was held without trial for several months) expose serious weaknesses in India's judicial and political system. The government is growing politically more conservative while paradoxically trying to push for a more open and liberal economy. Yet Sen's jailing is also disastrous news for the country's public health. Sen has for decades fought for the health of marginalised people, such as India's vast and neglected tribal populations, which the government has virtually ignored.

Government schemes to improve healthcare in rural areas often fail through a lack of resources and corruption. For instance, a policy advisor at one of India's major health institutes told me that doctors who are recruited to work in remote villages often bribe a local to fake records for them while they themselves remain in the city. Thus, on paper it looks as though these populations are receiving healthcare when in fact, they never even see a doctor.

It is this broken health system that health professionals like Sen are struggling against. For India to jail one its few true champions of the poor is nothing short of a travesty.

How to fix mental health in poor countries

In developing countries, depression and anxiety are widespread, but the requisite healthcare to treat them rarely is. There are several reasons why mental health is woefully neglected in poor countries.

Often, such illnesses are harder to identify. Doctors and nurses are not always trained enough to spot these disorders in patients they see, nor is the population always educated enough to seek treatment themselves. Not only that, there is an extreme shortage of skilled mental health professionals even in relatively wealthy developing nations.

As a study published by The Lancet today shows, in these situations, lay health counsellors could provide vital support for mental health programmes in poor countries.

The use of lay health workers is highly controversial, and there are ferocious debates over how much responsibility they should be given, and what tasks can be delegated to them. These arguments are entirely valid - doctors are trained not just in medical knowledge but also in ethics. How much can a training course, however rigorous, compensate for years of experience? Still, while countries are trying hard to recruit health professionals, and trying even harder to stop them flying off to more prosperous countries, the shortage of staff is impossible to ignore.

Vikram Patel, a mental health expert at the London School of Hygiene and Tropical Medicine, UK, also runs a clinic in Goa, India. Patel has for some years argued that for countries like India, people with mental illness will continue to be neglected unless less formally trained healthcare workers are incorporated into the health system.

Now, Patel and his colleagues have found that adding a lay health counsellor to a team of a primary care physician and visiting psychiatrist meant that after 6 months, patients were much more likely to recover from mental illnesses such as depression.

The lay health workers effectively oversaw the patients' care from educating them about mental health issues, and advising them on ways to communicate their illness to family members, to coordinating non-drug treatments with the physician or psychiatrist.

Essentially, these health workers are the driving force behind ensuring that patients turn up to appointments, and that their care is well-coordinated - which can be difficult in remote areas. In patients treated privately, lay workers made no difference, which is perhaps understandable since private care is likely to be more personalised and have a better ratio of doctors to patients.

If properly trained and supervised, there doesn't seem to be any reason why health workers shouldn't have some role in delivering healthcare. After all, without them, some patients have no healthcare at all.

Should India refuse foreign aid?

With an economy that is continuing to gallop ahead, should India still receive overseas aid from countries like the UK? That's what Andrew Mitchell, the UK’s secretary of state for International Development, and Pranab Mukherjee, India's finance minister, met to discuss last week.

India has for some time struggled with an identity crisis. It is battling to reconcile its image of emerging superpower, that has itself given millions in aid to countries like Sri Lanka and Pakistan in times of crisis, with the reality of being a nation that is still home to a large proportion of the world's poor.

India's rich are getting even richer, and this wealth is starting to manifest in startlingly crass extravagances. Witness, for instance, the billion-dollar, 27-floor monstrosity of a house recently built by the Ambanis, one of the wealthy Indian business dynasties.

Yet India is still ranked 119th among 169 countries in the latest edition of the Human Development Index (HDI) published last month. This means India is well below similar emerging economies such as China (ranked 89) and even behind poorer neighbours such as Sri Lanka (ranked 91).

The HDI ranks countries on measures of well-being such as life expectancy, education, and standards of living. Under the shiny visage of India's economy, indicators such as the HDI are particularly telling, revealing the extent to which the government still neglects much of its population. India's social development lags so far behind its economic development that it is a scandalous betrayal of its poor.

December 1 was World AIDS day, and India has a staggering 2.5 million people with HIV. Understandably, many Indians feel frustrated that their country's image in the West is too often one of dirt and disease.

There's much more to India than that, it's true. But though India might want to feel that it has moved beyond the dependency of foreign aid - and countries like the UK might wonder why they are still giving millions to a country that is rich enough to have a competitive space programme - until the government honours its duty to all of its citizens, not just the wealthy and privileged, it is too early for aid donors to give up their commitments.

Reaching out to India's untouchables

Just under the gleam of India's shining economy - which barely skipped a beat even in the world recession - lies the uncomfortable truth that millions still barely survive each day, so deprived are they of nutrition, shelter and healthcare.

Some of these people are rural farmers struggling to eke out an agrarian living in an increasingly industrialised world. Others are slumdwellers in urban hubs like Mumbai. As neglected as these groups often are, there is a slice of the population that is even more ignored - the dalits or 'untouchables', as they used to be known. India's 160 million Dalits make up nearly one-sixth of the country's population, yet you would never guess this from the utter lack of representation in much of Indian society.

In an attempt to make these invisible people visible to the rest of the world, photographer Marcus Perkins is showing a series of portraits of Dalits called Being Untouchable at HOST Gallery in East London, between 18th and 23rd October (the image above is part of the exhibition). The exploitation, injustice, and oppression that the series documents resonate with the plight of vulnerable and marginalised worldwide.

In theory, the Indian government isn't totally turning a blind eye, and has for years made concessions in healthcare and education. But the insidious caste system - still very much present in India, no matter what anyone claims - continues to shun Dalits from society. This means that they are often denied access to public places such as hospitals, schools, and places of worship. Land-owners often refuse to sell to them, and employers find weak excuses not to employ them.

This blatant exclusion inevitably has disastrous results on Dalits' health. According to the Community Health Cell, an Indian civil society organisation, infant mortality rates in Dalits are higher than in non-Dalits. In Dalit communities, 91 babies die per 1000 live births, compared to a national average of 72 per 1000. In Nepal, Dalits have a life expectancy of just 42 compared with (admittedly still appalling) 58 years.

Healthcare experts and human rights activists in India confirm anecdotally that Dalits are discriminated on a daily basis, and local newspapers do report on the issues they face, but Dalits' virtual lack of access to healthcare is largely ignored by the global health community too.

You would be hard pressed to find much in the way of research published in reputable medical journals, and this is partly where the problem lies. Without the weight of evidence to shame governments into action, the healthcare of marginalised communities will always stay neglected.

Will India finally quit smoking?

If you're an Indian aged between 30 and 70, you are more likely to die from smoking than you are of anything else - including AIDS, malaria, TB, or traffic accidents. India's nicotine addiction kills a staggering 1 million people every year. In India though, cigarette smoking is not the only problem - tobacco is voraciously chewed, sniffed, and even used as toothpaste.

The Indian government's response to this crisis has been dangerously sluggish. Under increasing pressure from the global health community, it has finally stepped up its anti-smoking efforts. But these efforts have been seriously undermined by feeble policymaking.

For instance, the government agreed this summer that, as in other countries, cigarette packets should feature even more gory pictorial warnings to freak out potential smokers - after all, a picture of someone's jaw dropping off from mouth cancer is probably more likely to give a smoker second thoughts than the current blurry image of diseased lungs. But, inexplicably, although Pakistan has already made these new images mandatory, India has decided to wait until this December before enforcing the policy.

In 2005, the government banned smoking on screen in Bollywood movies. Given the numbers of Indians who flock to movie theatres to watch Bollywood films, this sent a strong public health message that smoking isn't glamorous. But then last year, the Delhi high court overturned the ban because it "violated the fundamental right of film-makers".

The government does seem to be slowly waking up to problem, shamed in part by the fact that NGOs and foreign aid agencies are more active (this year saw a high-profile US$5 million dollar donation by the Gates Foundation to boost anti-tobacco campaigns).

But India faces several challenges. For one thing, chewing tobacco is enormously popular and is far less socially taboo than smoking, which means that its not uncommon to see women and even children chewing paan (even worse, the tomato-red juice that paan users spit out all over India's streets is also a major hazard in spreading respiratory diseases like TB). Another issue, according to a 2004 report by the Indian ministry of health is making it easier for people to stop smoking - nicotine patches and gum are far too expensive for most people to afford.

The sheer amount of money that tobacco rakes in for the government also spells trouble. Growing tobacco is a major source of income for an agricultural country like India, putting the government in the difficult position of balancing economic growth against the health of its people. For more on this, check out a new BBC World Service documentary that explores these conflicting pressures being faced by developing countries.

Farmer suicides: Dirty White Gold vs Peepli Live

How do your cotton underpants "get from grain to groin"? Filmmaker Leah Borromeo will reveal the unhappy truth in her upcoming documentary Dirty White Gold, which shows how the pursuit of fashion drives India's cotton farmers to suicide.

So far, only tantalising snippets of the film due out next year have been made available, but it already looks set to offer a grittier, more realistic picture of farmer suicides than the much-hyped Bollywood film Peepli Live (releasing on Sept 24 in the UK).

It's a little unfair to compare a feature film designed for entertainment to a hard-hitting documentary, but Peepli Live probably owed it to India's farming population to really explore the truth behind farmer suicides.

Tehelka, an Indian weekly news magazine, recently screened Peepli Live for farmers and their families in Vidarbha, the so-called suicide belt of India, where over 7000 farmers have killed themselves since 2004. None of the villagers shown the film thought that it even came close to representing their reality. When farmers die in reality, said the rural audience, their families might not get any money at all, and unlike the film, there is zero political interest. In the meantime, desperate, debt-ridden farmers continue to take their own lives in North India.

Borromeo's film tries to unpick each part of the cotton-growing process to show us how high prices of pesticides and low yields can lead many farmers into a spiral of debt from which they can't escape. In one particularly moving interview, she speaks to a young farmer who tried to commit suicide, but survived. Check out this taster of Dirty White Gold.

Delhi under dengue siege

India's image abroad has always been that of an eccentric, though beloved, relative with an amazing past and fabulous stories to tell. Chaos is second nature to Indians, and most difficulties are borne with a fatalistic shrug of the shoulders. The mantra is that "it will all work out as it's meant to". But the problems plaguing Delhi as it gears up for the Commonwealth Games have shaken up even the most sanguine of Indians.

For a time, those of us living in India could only gaze on with horror as the games looked set to be one of the biggest sporting shambles in living memory. Shoddy construction and allegations of corruption threatened to end the games before they even began.

Then disease struck. Swine flu is making quite the comeback, with Delhi as its epicentre, and malaria is wreaking its usual havoc in the rainy season. But the biggest problem has been dengue fever. Creating mammoth pools of stagnant water in ditches and holes dug during construction for the games was like waving a red flag to dengue-carrying mosquitoes that are now terrorising the city.

Official numbers say there are about 1500 cases in the city, though non-government sources say it could be twice that. This week, thousands of healthcare staff tasked with checking homes for signs of mosquito breeding have gone on strike, which the Delhi government has not been able to end. In desperation, it is thinking of asking the Indian army to step in to help.

The frustrating thing is that none of this is a great surprise. To say that the Indian government should have seen this coming is an understatement. Dengue hits the city every year.

Earlier this summer, Indian officials were confidently reporting that they had recruited thousands of workers to check mosquito breeding sites, but they have done little to ensure the workers' loyalty. Residents groups also complained that they had seen little of these breeding checkers in Delhi neighbourhoods. Last week, in an embarrassing twist, the country's top medical institute, the All India Institute of Medical Sciences, became a dengue hotspot because it had several unchecked mosquito breeding areas on the campus.

How the epidemic will play out when thousands of athletes and visitors descend on Delhi in the coming weeks remains to be seen. But this is an infection that we can't yet prevent with vaccines or cure with drugs - controlling the spread of the Aedes aegypti mosquito that spreads is the only way. If the government seriously takes charge of mosquito control, rather than worrying about beautifying the city, they might stand a chance of avoiding a public health disaster.

A holiday with a difference

How far would you travel for an organ transplant or for a cataract operation? Growing numbers of us it turns out are travelling halfway across the globe for medical treatment in countries like India and Thailand.

I'm based in Mumbai right now, and just around the corner from me is a hospital that is advertising its top-notch medical facilities specifically to Western populations. Come to India, the message seems to be, and fix your karma and your kidneys at the same time.

But because this type of healthcare blurs national boundaries, it also means that ethical issues of who is responsible for aftercare, for instance, are desperately in need of clarification. Read my investigation of the state of India's medical tourism industry in The Lancet.