Homeopathy: just a spoonful of sugar

World Homeopathy Awareness Week may have been last week, but figuring that it's never too late to learn about this field of 'science' that is now, with staggering audacity, claiming to be able to cure infertility, I dived head-first into the website of the World Homeopathy Awareness Organisation.

It lists ten good reasons to use homeopathy. These are: having no harmful side-effects; being gentle, holistic, inexpensive, preventative; not having been tested on animals; easy to take; involving the patient; invaluable for first aid; and - this one is quite the claim - being 'the medicine of the future. 

You don't need to be eagle-eyed to spot the missing word: effective. Nowhere in its manifesto, does the organisation feel obliged to say that the treatment actually works. Undeterred, I ploughed through a 30-page lime-green powerpoint report on why homeopathy should be used for infertility. There too, they seem breezily unconcerned about whether the remedies might actually do what they claim. Under the heading "Does homeopathy always work", they say "A lot can be achieved, but there can be circumstances that influence the treatment negatively, such as: wrong diet, environment, medication, irreversible damage." 

Sure, there are contraindications with many conventional medications too, but these are clearly laid out when a doctor prescribes them to a patient. They're not used as a get-out clause to explain why 'sugar pills with water memory' (is it just me who thinks these sound like words from Star Trek?) don't work. In a final whammy, the report says that when taking homeopathic medicine, old symptoms may return, and what's more, your symptoms may actually be aggravated. That doesn't sound much like a cure to me. 

If all of this sounds like an angry, bitter rant... it is. Homeopathy isn't harmless. Pro-homeopaths would argue that I don't have to use if I don't want to, and I should just other people do what they want. But false remedies are insidious and often become harmful very quickly. I've met people all over India who use homeopathy for illnesses ranging from diabetes to heart disease to asthma. These aren't trivial conditions and the consequences for ignoring care can be dire. 

Perhaps the most heart-rending example I heard was from a cancer surgeon in Assam, north-east India. He told me that because patients try homeopathy and other remedies first, they may not see a doctor for a lump in their breast until it's too late. When homeopathy stands between a person living or dying, homeopaths really do need to examine their conscience. Better still, governments should step in and better regulate healthcare.  

Women aren't just baby-making machines

The summer of 1984 saw a landmark conference on women’s health in Cairo, Egypt. The conference wasn’t billed as such – it was called the International Conference on Population and Development (ICPD) – but its recommendations were radical in its message: that women’s sexual and reproductive rights are central to family planning and population development.

Riding high on the waves of feminism from the 1960s and 1970s, this was a promising step in the right direction. But though it did change the way the world thought of women’s health, its promise was cut short by several factors. 

For instance, the AIDS epidemic burst onto the global health agenda at around the same time, and most health dollars were being funnelled into fighting this disease ravaging the world. And so, women’s rights slipped out of sight, and out of mind.

The past few years has seen an upsurge in interest in women’s health again, partly because maternal health got a mention on the Millennium Development Goals. But therein lies the rub. Suddenly, women’s health became all about maternal health. It’s true that pregnancy, in the developing world especially, is a time in a women’s life when her health is most vulnerable. And her poor health could also threaten the health of her baby.

But a woman isn’t just a baby-making machine. Women’s sexual and reproductive health encompasses far more than maternal health – it includes sexual rights, sexual health (in terms of avoiding sexually transmitted diseases), and the menopause. These areas outside of maternal health are badly neglected because they don’t fit with the current agenda.

Now, scientists and policymakers are starting to re-frame women’s health in an economic context. Women are the glue that holds society together, and studies show that when women’s health is focused on, the whole family, and therefore the whole nation, benefits. This seems hard to argue with, but it’s a poor reason to advocate for women’s health. Women have the right to good health for their own sake, not just because they’re a useful cog in a country’s economic wheel. The ICPD in Cairo already showed us that rights needs to be at the heart of women’s health, but we may need another revolution to remind of us that.

This post originally appeared on the website of COHRED/Global Forum for Health Research for its 2012 forum in Cape Town

Saving babies but killing women

It's hard to find a more sanctimonious bunch of people than those who call themselves pro-lifers. Their shrill anti-abortion cries are also, sickeningly, anti-women.

Just yesterday, the US House of Representatives voted (with a Republican majority) to pass a bill that would block medical care to a woman wanting to terminate her pregnancy, even in a medical emergency. Nancy Pelosi, leader of the house and a democrat, called the bill "savage". It would mean that "women can die on the [hospital] floor and healthcare providers do not have to intervene," she said.

Though the US tends to lead the way in terms of rabid anti-abortion campaigns, which has often been spearheaded by right-wing religious conservatives, the UK is fast catching up. Conservative MP Nadine Dorries tried desperately to push through legislation to strip some abortion-providers of the ability to counsel women, allowing other counsellors (some of whom are pro-life) to provide guidance instead, and her attempts gained significant political traction before being defeated.

In some instances, there's a strong medical argument for abortion. The pregnancy or labour may be threatening a woman's life. Illegal abortions can be deadly - every 10 minutes, a woman dies from a botched abortion. In poor countries, meanwhile, having pregnancies too close together can seriously affect a woman's health, and large families with small incomes can mean that kids become malnourished. Yet, as Anand Grover, UN Special Rapporteur for the right to health, says, there need only be one reason for an abortion: that the woman doesn't feel able to carry the baby. Later this month, he will put it to the UN that abortion is a woman's right.

Not everyone agrees with Grover. Cristina Odone, a columnist at UK broadsheet The Telegraph, has taken a few detours of logic and chosen to interpret the UN's bid to fight for the rights of women in poor countries as "stamping out religious freedom in poor Catholic countries". China uses abortion to kill baby girls, her reasoning goes, so abortion should be illegal; that's about as sensible as outlawing knives because some people use them to stab others.

A few NGOs are staunchly fighting for women's right to have an abortion. Women on Web, is a brilliantly feisty group that provides women who have no access to safe abortion with pills that induce an abortion. The organisation counsel the women online or over the telephone, makes them aware of medical situations for which this type of abortion isn't appropriate, and advises them to seek healthcare if in doubt. In the end, they treat women like adults, giving them the information, and leaving the decision up to them. It's about time the rest of the world did too.

Do Indian androids dream of Bollywood sheep?

India’s first-ever cocktail of Bollywood and science fiction has just won three awards in India's version of the Oscars. Robot (Endhiran) has clearly whetted Indian movie buffs' appetite, and this October will see the release of a Bollywood sci-fi superhero film called Ra.One that reworks the story of the mythological Indian demon god Ravana. Sci-fi and Bollywood are surprisingly comfortable bedfellows - after all, both genres tend to be fantastical and larger than life, and both have outlandish costumes.

Both genres are also budget-guzzlers, and Robot is Indian cinema’s most expensive creation ever, costing about US$37 million to make. The film tells the story of Dr Vasi (Rajnikanth), a robotics scientist who creates an android called Chitti that looks just like him. Vasi is in love with Sana (Aishwarya Rai), who becomes fond of Chitti. And Chitti’s loyalty is bound to Vasi by an electronic umbilical cord. For a while, the film is a rosy montage of Chitti’s benign mix of supermom (cooking and cleaning to perfection) and superman (saving people from burning buildings). But when Chitti is tweaked to become more human, he exercises his "hormone simulation upgrade" by lusting after Sana, kicking off a jealous feud between Chitti and Vasi.

Bollywood films try to appeal to 8-yr-olds and 80-yr-olds equally. This means that in its depiction of science, Robot resorts to highly clichéd conventions – scientists who are either cold and clinical or downright evil and Machiavellian. The set and costume design too tick every box in the ‘futuristic movie look’ (think shiny metallic outfits).

Robot references every sci-fi/fantasy film you can think of – The Matrix, Terminator, Predator, and Bicentennial man - and throws in tropes of vampirism and cloning for good measure. All of this is spray-painted with song-and-dance sequences that are magnificently glittery even by Bollywood standards (in one gloriously bizarre sequence, the film jump-cuts from an Indian beach to the hero and heroine serenading each other in feathered costumes atop Machhu Picchu in Peru).

The whole screenplay is so tongue-in-cheek that it is hard to know whether the filmmakers wanted to send any serious message about science or technology amidst the feather boas and spandex. It is probably best not to search too deeply for scientific significance in Robot, but if the film comments on anything, it is the threat of the ego in science. Like Dr Frankenstein’s monster, Chitti the robot is driven to turning evil and threatens to destroy its egotistical maker.

As an emerging economy, India’s scientific spending and output rises every year. Some argue that spending millions on high-profile space programmes, or on advanced science such as nanotechnology or GM agriculture, is unethical when much of the population doesn’t benefit from the country’s scientific or medical advances. Perhaps the film is hinting that India’s insistence on pushing itself as a credible global scientific presence while ignoring the suffering of millions of its people could backfire if unchecked? If nothing else, watch this Bolly/Sci-fi romp for its surreal flights of fantasy. It may clock a bum-numbing 3-hours of screen time, but it’s never boring.

Isn't sex the same in Nairobi or New York?

Sex thrusts itself into every aspect of modern life so blatantly - advertisers use it to sell us everything from cars to coffee and no Hollywood film is complete without a little light nudity - that it's easy to forget that in real life, many of us are nowhere near progressive in our sexual behaviour.

Around the planet, people have sex when they'd rather not, pretend that STDs happen to other people, and don't use condoms when they know they should.

Health experts are going to be thinking about sex and condoms a lot over the next few weeks. July 11th is World Population Day, and while fertility rates are plummeting in developed countries, populations are set to spiral in Africa and Asia. At the International AIDS Society conference in Rome this month, HIV experts are going to be talking about how to improve HIV prevention efforts. Slowing population growth and stopping HIV both rely on people using condoms more often (let's face it, abstinence is never really going to work), and figuring out how to do this is perplexing policymakers and researchers.

Many scientists study these issues in countries in Asia and Africa to figure out how to solve the conundrum, but too often the studies are predicated on the notion that people in poor countries behave or think differently in sexual relationships than they do in the West. This seems to be a major stumbling block in improving sexual and reproductive health in these countries.

Sexual and reproductive health programmes aimed at the developing world are always mindful of local cultural and social traditions – the idea being that if we import programmes designed with Western sexual attitudes in mind, they would hold little traction in conservative societies where men still tend to dominate.

Clearly, social mores affect sexual attitudes, and it would be ludicrous to take a one-size-fits-all approach to sexual health programmes irrespective of local religious beliefs or cultural approaches to sex before marriage, say. Yet cultural norms often operate at a macro, societal level; on an individual level, however, sexual relationships tend to operate similarly wherever you are in the world. Negotiating something as fundamental and intimate as sex is as delicate and complicated in Nairobi as it might be in New York.

A quick scan of research articles on increasing condom use in developing nations shows that almost all talk about how to empower women to better negotiate it. This not only puts the onus on women to take care of the sexual health of both herself and her partner, it assumes that men are not capable of taking any responsibility, and even suggests to them that they shouldn’t try to. It also ignores an obvious point: if empowering women is the answer, why doesn’t it work in the West, where many women are about as empowered as they can be?

One paper encourages women in developing countries to negotiate condom use well before they have sex. Could you really imagine even the most educated, independent, feminist woman in a city like London leaning over to their potential sexual partner over dinner, in between the main course and dessert, say, and telling them that they better stock up on condoms?

Women should always be encouraged to stand up for their sexual rights, and empowering women is a commendable goal. But if privileged women in rich countries find negotiating the balance of power in sexual relationships difficult, it seems a double standard to expect it of women in the developing world. Experts working to improve sexual health in developing countries should instead focus on bringing men into the picture. Sexual health isn’t just a woman’s problem, and it’s time we stopped pretending that men don’t also have a role to play.

Image: Condom superhero costumes at Cabbages and Condoms, Bangkok, an NGO that promotes safe sex

Photo credit: Shane R/flickr

Global campaign underway to stop rape as a weapon of war

Where armed conflict is rife, sexual violence is rarely far behind. Many of the conflicts of the past few decades, especially in Africa, have been accompanied by excruciating levels of rape and brutality against women.

These women's stories are not for the faint-hearted. Some in the Democratic Republic of Congo were gang-raped, and left so physically battered that their bodies never recover. Others, in Uganda, are turned into "bush wives", who are abducted by soldiers and forced them to live with them in the jungle.

For years, African governments have been shockingly apathetic to such violence. Now, heightened levels of awareness and pressure from NGOs and other governments seem to be changing that attitude. Kenya, for instance, has launched a serious inquiry into post-election sexual violence in 2007, and last week Luis Moreno-Ocampo, the chief prosecutor of the International Criminal Court, said he would investigate allegations of mass rape in Libya.

Women advocates have often been key drivers of this change. This week sees 100 women from around the world – activists, academics, security experts, corporate leaders, and Nobel Peace Laureates - gather at the Nobel Women's Initiative's conference in Quebec to discuss how to end sexual violence in conflict. Susannah Sirkin, deputy director of Physicians for Human Rights outlined this week ways of keeping the pressure on governments:

"We can campaign for protection measures to be more robust. We can press for peacekeepers to have clearer, stronger mandates to protect women. We can make sure more women are trained and deployed in protection forces. We can campaign for legal reforms and blacklist countries where rape is inadequately defined and covered in criminal codes. We can speak out when witnesses are intimidated or police fail to make arrests. We can support proper standards for evidence and investment in justice systems and training for prosecutors, police, judges and health professionals."

Women's health now has a higher profile than it has ever had. The World Health Organization has developed a new accountability framework for measuring progress in improving women's health, and this year also saw the launch of UN Women, intended to champion the rights of women and girls around the world.

Now is clearly the time for advocates to capitalise on this awareness, and lobby governments for action. But while governments can implement legislation and policies to crack down on sexual violence, we also need a shift in attitudes and prejudices towards sexual violence more generally.

For the most part, rape and other sexual crimes still leave a damning legacy of stigma that means that women rarely speak out. Most rapes go unreported even in developed countries, where women have the opportunity to seek justice.

The rape allegations surrounding former IMF chief Dominique Strauss-Kahn are a case in point. Last week, French philosopher Bernard-Henri Lévy launched an vociferous of his long-time friend, mocking the claims of Tristane Banon, the French writer who said she had also been previously assaulted by Strauss-Kahn:

"Sensing the golden opportunity, [Banon] whips out her old dossier and comes to flog it on television".

The allegations have yet to be proven of course, but when privileged women in developing nations face a barrage of abuse for speaking out (it's seriously hard to see what "golden opportunity" Lévy thinks is forthcoming), it is unsurprising that more vulnerable women in poorer parts of the world, with corrupt judicial systems, can see no way of seeking justice. At the very least, we owe it to women to allow them to try and tell their side of the story.

Chronic diseases to become India's top killers

India still largely tends to be associated with infectious diseases that plague the tropics - malaria, cholera or dysentery. Yet according to a report that the WHO launched last week in Moscow, more people in India die of chronic diseases such as heart disease and diabetes than of anything else.

The numbers are striking: while deaths from maternal illness and infectious diseases are set to fall by 15%, deaths from chronic diseases (especially diabetes) will rise by 18%.

India and other developing nations have known for some time about the silent killers lurking in their populations' changing lifestyle. In Indian cities especially, the metamorphosis is staggering. Young women are just as likely to drink and smoke as heavily as young men, and fast food has changed from relatively low-fat street food to burgers and pizzas. Preaching against smoking and unhealthy eating from a Western country that has already overindulged itself is tricky. But when more than 60 million are set to die in India over the next decade, not taking any action is not an option.

Earlier this year, a special series on Indian health by The Lancet called for India to boost its spending on health from 1% of its GDP to 6%. In the crowded press room in New Delhi, journalists and scientists seemed equally sceptical that India had the financial clout, or willingness, to do so, but the rallying call might have had some effect. Now, the Indian government is finally agreeing to step up the amount of money it spends on health to 2 or 3%. This is long overdue, as out-of-pocket spending on health in the private sector is skyrocketing, threatening the financial stability of many families.

Driving down chronic diseases will also have a major effect on the country's economy, because fewer people will need to take time off work or lose their jobs entirely. As the Indian government's one key imperative seems to be to grow its economy whatever the financial climate, this may be the one incentive that pushes it to fix the health of its people. The WHO says that even a 2% reduction in chronic disease deaths would mean an economic gain of US$15 billion. Can India afford not to act?

Photo credit: Selmer van Alten/flickr

Why women's health matters

Today marks the 100th anniversary of International Women's Day. Yet even as the world celebrates women everywhere, and the UN launches a special agency called UN Women to improve the lives of women worldwide, the USA seems to be paying mere lip-service to the idea.

The Republican majority of the U.S. House of Representatives has just voted to slash the budget for domestic and international programmes on family planning and reproductive health, including eliminating funding for the UNFPA (the UN Population Fund). This means that impoverished women in more than 150 countries will struggle to get any kind of help with contraception, maternal healthcare, or education.

This right-wing, abstinence-only, anti-abortion view of reproductive health is one that UNFPA suffered tremendously from during the Bush administration, and its budget was drastically cut. Obama coming to power seemed to herald a new era as he reinstated the organisation's funding to the tune of US$50 million. The outcome of this tussle over how to deal with reproductive health will have enormous implications for women worldwide.

Right now, the UNFPA is especially concerned about the health of adolescent women. These girls, hovering on the brink of adulthood, are extremely vulnerable. Many are forced into early marriage, during which they often suffer domestic violence and have babies well before they are physically ready. About 50 million girls under 18 are thought to be already married, and in the next decade it is estimated that 100 million more girls will marry before they turn 18.

Girls who marry during childhood tend not to go to school either, and the lack of education severely hampers any social development and robs them of economic autonomy. To document the grim reality of early marriage, and offer a glimpse into the life of a child bride, photographer Stephanie Sinclair is showing a series of photographs at the VII Gallery in Brooklyn, New York, until April 15. The images are also online here.

Photo credit: Stephanie Sinclair/VII

It's a miracle: the Vatican accepts that condoms stop HIV

The Vatican is set to host an HIV prevention conference on May 28, during which it will clarify its position on condom use to prevent the spread of the virus.

The catholic church's stance on the morality of health issues, especially when it comes to diseases like HIV/AIDS has always been significant, even if some scientists would prefer to ignore it, because of the large catholic populations in countries in Africa where HIV is so prevalent.

A focus on abstinence rather than contraception has in the past also heavily influenced US aid programmes for HIV. In an interview last year that was received with great excitement by UNAIDS, HIV activists and scientists, Pope Benedict XVI said that condom use by prostitutes could be seen as the "first step to moralisation", and that using a condom to prevent HIV transmission was a lesser evil than using contraception.

The Vatican is also about to update its 2008 guidelines on bioethics issues in stem cell research and reproductive technology, but whether those will be as pragmatic as the new stance on condom use remains to be seen.

The last edict had wordy explanations on the Church's position, but all it really came down to was a ban on any such technology. IVF? No. The morning-after pill? No. Gene therapy? No. The 2011 update has allegedly been sparked by a slipping of Catholic standards in hospitals.

In December 2010, an Arizona hospital had its "Catholic" status revoked because it chose to abort a baby to save the pregnant mother's life. The hospital says it is disappointed by the Church's decision but remains steadfast that it took the correct path.

In a press release, the hospital said: "Consistent with our values of dignity and justice, if we are presented with a situation in which a pregnancy threatens a woman’s life, our first priority is to save both patients. If that is not possible we will always save the life we can save".

Photo credit: loveleft/flickr

Plumbers without borders

When a disaster strikes, aid agencies tend to focus on food, shelter and healthcare. Water and sanitation is often neglected, even though the lack of clean water and decent sewage systems can wreak havoc on healthcare. In Haiti, for instance, cholera has now become the overwhelming health problem, and 3000 people are estimated to have died from a disease that is entirely treatable.

Now, the disease has spilled over into the neighbouring Dominican Republic, and this week, three cases were reported in New York (people who had attended a wedding in the Dominican Republic).

But public health experts predicted months ago that when basic infrastructure breaks down as spectacularly as it did after the earthquake a year ago, outbreaks of waterborne diseases like cholera are inevitable. Given this knowledge, how did cholera run riot?

One Haitian blogger points to the utter failure of the Haitian government to provide its people with clean water long before the earthquake hit:

"Instead of policies or plans to invest in water treatment facilities, we have been witnessing an erosion of the few water pipes we had in the capital and the other major metropolitan areas. There is not a single waste management facility in Haiti. Overall, the politics of water in Haiti has been a complete failure, and today we are paying a dear price for it."

Recently, aid agency Médecins Sans Frontières (Doctors Without Borders) made a scathing attack on the humanitarian aid response to Haiti. MSF's international president Unni Karunakara wrote in an opinion piece that agencies given funds to provide chlorinated water and improve sanitation took little action for months, which contributed enormously to the rapid spread of cholera after the initial outbreak.

Karunakara is particularly suspicious of the trend to cluster the provision of aid. In theory, this should harmonise the provision of similar types of aid. In reality, he says, it seems to mean awkwardly forcing together organisations of differing capabilities and experience.

"Instead of providing the technical support that many NGOs could benefit from," he says, "these clusters, at best, seem capable of only passing basic information and delivering few concrete results during a fast-moving emergency."

This urgently required technical knowledge could come from a new grassroots organisation called Plumbers Without Borders. The organisation, which is currently looking for expert plumbers, engineers, electricians, and carpenters, aims to provide the know-how for agencies that are trying to respond to emergencies in water and sanitation.

Should Bill Gates call the shots with polio?

Bill Gates is waging war with polio. The world has been on the verge of eradicating it for years, but stubborn pockets of disease remain in countries like India and Nigeria. Gates is now putting the might of his foundation behind eradication and is calling on governments and scientists to join him.

This latest move that has drawn fierce criticism from leading global health experts, including Donald A Henderson, the lynchpin in the smallpox eradication campaigns. The editor of The Lancet, Richard Horton, recently tweeted that global health does not depend on polio eradication.

The Gates Foundation has stirred controversy over disease eradication before. In 2007, it took the global health community by surprise when it announced a drive to eradicate malaria. Then too, malaria experts were concerned that it would divert from urgent research to control the disease through drugs and vaccines, and the jury still seems to be out on whether pushing for eradication is sensible.

Those who support Gates' polio plan argue that while eradication is more complex than it was for smallpox, aiming high can't hurt. The problem is that any move Gates makes is significant. Where Bill Gates go, the rest of global health follows. Arguably this then means that his foundation cannot ignore the judgement of the scientific community.

It is worrying then that in an article in the New York Times, Ezekiel J. Emanuel, chief bioethicist for the US National Institutes of Health says that since he had not seen enough data to form an opinion, he deferred "to people who’ve really studied the issue, like Bill Gates.”

Surely the balance has tipped the wrong way if a key figure in one of the world's most important health institutions, and who is said to be highly influential in the Obama administration, is looking to a philanthropist for advice on public health?

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.