Js Thakur

Protecting Health from Climate Change

Climate change is one of the most important global environmental challenges facing humanity with implications for food production, natural ecosystem, freshwater supply, health, etc. During the last 100 years, human activities related to the burning of fossil fuels, deforestation, and agriculture have led to a 35% increase in the carbon dioxide (CO2) levels in the atmosphere, causing increased trapping of heat and warming of the earths atmosphere. The Fourth Assessment Report (AR-4) of the Intergovernmental Panel on Climate Change (IPCC) states that most of the observed increase in the global temperatures since the mid-20th century was very likely due to the increase in concentration of anthropogenic greenhouse gases (GHGs).(1) Of the six CHGs, CO2 accounted for 63%, methane 24%, nitrous oxide 10%, and other gases the remaining 3% of the carbon equivalent emissions in 2000.(2) High accuracy measurements of atmospheric CO2 concentration initiated by Charles Davis Keeling in 1958, constituted the master time series with formal international coordination of meteorological observation from ships commenced in 1853. The IPCC also reports that the global average sea level rose at an average rate of 1.8 mm/year from 1961 to 2003. The total rise in the sea level during the 20th century was estimated to be 0.17 m. The global surface warming projections will vary between 1.1 and 6.4°C and mean sea level is projected to rise by 30-60 cm by the year 2100. India is a large developing country with nearly 700 million rural population directly depending on climate-sensitive sectors (agriculture, forests, and fisheries) and natural resources (such as water, biodiversity, mangroves, coastal zones and grasslands) for their subsistence and livelihoods. The contribution of India to the cumulative global CO2 emissions from 1980 to 2003 is only 3.11%. Thus, historically and at present, Indias share in the carbon stock in the atmosphere is relatively very small when compared with the population. Indias carbon emissions per person are 20th of those of the US and a 10th of most Western Europe and Japan. Climate change is likely to impact all the natural ecosystems as well as socioeconomic systems as shown by the National Communications Report of India to the UN Framework Convention on Climate Change (UNFCCC).(2) The latest high-resolution climate change scenarios and projections for India, based on Regional Climate Modeling (RCM) system, known as PRECIS developed by Hadley Center and applied for India using IPCC scenarios A2 and B2 shows an annual mean surface temperature rise by the end of century, ranging from 3 to 5°C under A2 scenario and 2.5 to 4°C under B2 scenario, with warming more pronounced in the northern parts of India.(2) A 20% rise in all India summer monsoon rainfall and further rise in rainfall is projected over all states except Punjab, Rajasthan, and Tamil Nadu, which show a slight decrease. Extremes in maximum and minimum temperatures are also expected to increase and similarly extreme precipitation also shows substantial increases, particularly over the west coast of India and west central India. Glaciers in Himalaya are melting and may lead to glacier lake outburst floods as occurred in Himachal Pradesh. As glaciers are the source of drinking and irrigation water in mountains and Indo-Gangetic region in India, the long-term reduction in annual snowmelt is expected to result in water insecurity and more interstate conflicts in these region.(3) Most of the states in North, including Punjab, Haryana, Rajasthan, Uttar Pradesh, Madhya Pradesh, and North East, are dependent upon river water with origin in Himalayas. Urban cities in developing countries, including India, will be more affected due to fast pace of development, industrialization and increasing vehicular traffic.(4) These climatic changes will cause disruption of the ecosystems services to support human health and livelihood, and will impact health systems.(5) The IPCC projects an increase in malnutrition and consequent disorders, with implications for child growth and development. The disruption in rainfall patterns can be expected to lead to an increased burden of diarrhoeal disease and vector-borne diseases. WHO estimates that the modest climate change that has occurred since 1970, claims 150,000 lives annually. WHO has rightly chosen this issue as theme of World Health Day, 2008. The current and emerging climate change-related health risks in Asia, including India, include heat stress, water, and foodborne diseases (e.g., cholera and other diarrhoeal diseases) associated with extreme weather events (e.g., heat waves, storms, floods and flash floods, and droughts); vector-borne diseases (e.g., dengue and malaria); respiratory diseases due to air pollution; airborne allergens, food, and water security issues; malnutrition; and psychosocial concerns from displacement.(5) These risks and diseases are not new, and the health sector is already tackling these problems. However, the capacity to cope with potentially increasing levels of these risks and diseases is limited, particularly in developing countries. Since early 1990s, international efforts have created the climate change regime, the center piece of which is the UNFCCC and its instruments, the Kyoto Protocol, and Marrakesh Accords, which details rules for its implementations. These currently existing multilateral instruments themselves are not adequate to meet the twin challenges of mitigation and adaptation. They do, however, provide a basis for development of the multilateral regimes. The three Kyoto mechanisms are joint implementation (JI), clean development mechanism (CDM), and emission trading (ET).(2) Only CDM is relevant to developing countries such as India. Developing countries could view CDM as an opportunity not only to attract capital investment and environmentally sustainable technologies (ESTs), but also to implement innovative technical, institutional, and financial interventions to promote energy efficiency, renewable energy, and forestry activities that contribute to sustainable development. Most national governments have signed and ratified the Kyoto Protocol, aimed at reducing GHG emissions, but its first commitment period ends in 2012. Regional framework devised at Bali could also be the guiding force.(6) There is an urgent need to incorporate health concerns into the decisions and actions of different sector-wise approaches to mitigate and adapt to climate change. India has completed four nationally coordinated assessments of climate change projections, impacts, and mitigation. Recently, National Action Plan on Climate Change (NAPCC) has also been released with many good initiatives including a proposal for a National Solar Mission. Key Ministries of Government of India, such as Environment and Forest, Water Resources and Health and that of states, should devise urgent policy initiatives and implementation of NAPCC to mitigate the effect of climate change in country. Green technology, projects, and industries must be encouraged and promoted by instituting awards and others must be taxed. It must be supplemented by individual efforts leading to collective efforts for saving energy. There is need to promote the use of non-motorized transport systems (e.g., bicycles), mass rapid transport system, and fewer private vehicles by taxing more than one or two vehicles per family for reducing GHG emissions, improving air quality, and making more people physically active. Such an approach would also help in reducing the emerging epidemic of non-communicable diseases including road-traffic accidents. Public health associations in India such as Indian Public Health Association and Indian Association of Preventive and Social Medicine must take lead by organizing thematic seminar and special sessions in conferences. Thus, India has a significant stake in scientific advancement as well as an international understanding to promote mitigation and adaptation. This requires improved scientific understanding, capacity building, networking, and broad consultation processes. Let us join hands to save planet earth and secure our survival and of future generations.

A study of health problems and loneliness among the elderly in Chandigarh

Research Question: What are the health-related problems of the aged and why do they feel lonely? Objective: To study the health-related problems and loneliness among the elderly in different micro-environment groups. Participants: Aged persons of age 65 years and above. Setting: Urban and rural area of Chandigarh. Design: Cross-sectional. Statistical Analysis: t-test and Z test. Results: During the study, it was found that out of the total 361 aged persons of Chandigarh, 311 (86.1%) persons reported one or more health-related complaints, with an average of two illnesses. The illness was higher among the females (59.5%) as compared to males (40.5%). The main health-related problems were disorders of the circulatory system (51.2%), musculoskeletal system and connective tissue (45.7%). It was also found that loneliness was prevalent more in females (72.8%) as compared to males (65.6%). Loneliness was more prevalent among persons who lived alone (92.2%) as compared to those who lived with their spouse (58.9%) or when husband and wife lived with the family (61.4%). It was higher among the widows (85.2%) and widowers (75.8%) who lived with the family as compared to the aged who lived with the spouse (58.9%) and the aged husband and wife who lived with the family (61.4%). Conclusion: Special geriatric services should be started in the hospitals as the majority of the aged have one or more health-related problems. The aged persons should be involved in social activities to avoid loneliness among them.

Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes

Objectives To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. Design We conducted a nationally representative mortality survey where at least two physicians coded each non-medical field staffs verbal autopsy reports. RTI mechanism data were extracted from the narrative section of these reports. Setting 1.1 million homes in India. Participants Over 122 000 deaths at all ages from 2001 to 2003. Primary and secondary outcome measures Age-specific and sex-specific mortality rates, place and timing of death, modes of transportation and injuries sustained. Results The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or about 2% of all deaths in 2005 nationally, of which 65% occurred in men between the ages 15 and 59 years. The age-adjusted mortality rate was greater in men than in women, in urban than in rural areas, and was notably higher than that estimated from the national police records. Pedestrians (68 000), motorcyclists (36 000) and other vulnerable road users (20 000) constituted 68% of RTI deaths (124 000) nationally. Among the study sample, the majority of all RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non-pedestrian RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and living in poorer neighbourhoods. Conclusions In India, RTIs cause a substantial number of deaths, particularly among pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce injuries might address over half of the RTI deaths. Improved prehospital transport and hospital trauma care might address just over a third of the RTI deaths.

Biomass fuel and risk of tuberculosis: a case–control study from Northern India

Background Although a known risk factor for several respiratory diseases, the relationship between cooking smoke and tuberculosis has not been conclusively established. Hence, a case–control study was conducted among adult women of Chandigarh Union Territory in India. Methods Physician-diagnosed cases of sputum positive pulmonary tuberculosis (n=126) and age- and residence area-matched controls (n=252) were enrolled from clinics in urban, rural and slum areas. Interviews were conducted in the clinic using a pretested questionnaire to collect information on type of cooking fuel, education, occupation, socio-economic status, smoking, overcrowding and type of kitchen, etc. The conditional logistic regression model was used for control of confounding. Results The study population was predominantly in the 20–29-year-old age group (58%) and lived in urban areas (67%). The majority were illiterate (52%) and housewives (93%), and nearly half (46%) had an income of no more than Rs 25 000. Among the cases, 20.6%, 27% and 52.4% used biomass fuel, kerosene and liquid petroleum gas (LPG), respectively, whereas among controls, the respective figures were: 12.3%, 26.2% and 61.5%. The unadjusted OR for biomass fuel compared with LPG was 2.33 (95% CI 1.18 to 4.59, p 0.01). Adjustment for confounding factors (education, type of kitchen, smoking tobacco and TB in a family member) and interaction between cooking fuel and smoker in family revealed an OR of 3.14 (95% CI 1.15 to 8.56, p=0.02) for biomass fuel in comparison with LPG. Conclusions Cooking with biomass fuel increases the risk for pulmonary tuberculosis.

Adverse Reproductive and child health outcomes among people living near highly toxic waste water drains in Punjab, India

Background Environmental influence plays a major role in determining health status of individuals. Punjab has been reported as having a high degree of water pollution due to heavy metals from untreated industrial effluent discharge and high pesticide consumption in agriculture. The present study ascertained the association of heavy metal and pesticide exposure on reproductive and child health outcomes in Punjab, India. Methods A cross-sectional community-based survey was conducted in which 1904 women in reproductive age group and 1762 children below 12 years of age from 35 villages in three districts of Punjab were interviewed on a semistructured schedule for systemic and general health morbidities. Medical doctors conducted a clinical examination and review of records where relevant. Out of 35 study villages, 25 served as target (exposed) and 10 as non-target (less exposed or reference). Effluent, ground and surface water, fodder, vegetables and milk (bovine and human) samples were tested for chemical composition, heavy metals and pesticides. Results Spontaneous abortion (20.6 per 1000 live births) and premature births (6.7 per 1000 live births) were significantly higher in area affected by heavy metal and pesticide pollution (p<0.05). Stillbirths were about five times higher as compared with a meta-analysis for South Asian countries. A larger proportion of children in target area were reported to have delayed milestones, language delay, blue line in the gums, mottling of teeth and gastrointestinal morbidities (p<0.05). Mercury was found in more than permissible limits (MPL) in 84.4% samples from the target area. Heptachlor, chlorpyriphos, β-endosulfan, dimethoate and aldrin were found to be more than MPL in 23.9%, 21.7%, 19.6%, 6.5% and 6.5% ground water samples respectively. Conclusion Although no direct association could be established in this study, heavy metal and pesticide exposure may be potential risk factors for adverse reproductive and child health outcomes.

Socioeconomic Inequality in the Prevalence of Smoking and Smokeless Tobacco use in India

BACKGROUND Tobacco consumption has been identified as the single biggest cause of inequality in morbidity and mortality. Understanding pattern of socioeconomic equalities in tobacco consumption in India will help in designing targeted public health control measures. MATERIALS AND METHODS Nationally representative data from the India Global Adult Tobacco Survey (GATS) conducted in 2009-2010 was analyzed. The survey provided information on 69,030 respondents aged 15 years and above. Data were analyzed according to regions for estimating prevalence of current tobacco consumption (both smoking and smokeless) across wealth quintiles. Multiple logistic regression analysis predicted the impact of socioeconomic determinants on both forms of current tobacco consumption adjusting for other socio-demographic variables. RESULTS Trends of smoking and smokeless tobacco consumption across wealth quintiles were significant in different regions of India. Higher prevalence of smoking and smokeless tobacco consumption was observed in the medium wealth quintiles. Risk of tobacco consumption among the poorest compared to the richest quintile was 1.6 times higher for smoking and 3.1 times higher for smokeless forms. Declining odds ratios of both forms of tobacco consumption with rising education were visible across regions. Poverty was a strong predictor in north and south Indian region for smoking and in all regions for smokeless tobacco use. CONCLUSIONS Poverty and poor education are strong risk factors for both forms of tobacco consumption in India. Public health policies, therefore, need to be targeted towards the poor and uneducated.

Childhood and adult mortality from unintentional falls in India

OBJECTIVE To estimate fall-related mortality by type of fall in India. METHODS The authors analysed unintentional injury data from the ongoing Million Death Study from 2001-2003 using verbal autopsy and coding of all deaths in accordance with the International statistical classification of diseases and related health problems, tenth revision, in a nationally representative sample of 1.1 million homes throughout the country. FINDINGS Falls accounted for 25% (2003/8023) of all deaths from unintentional injury and were the second leading cause of such deaths. An estimated 160,000 fall-related deaths occurred in India in 2005; of these, nearly 20,000 were in children aged 0-14 years. The unintentional-fall-related mortality rate (MR) per 100,000 population was 14.5 (99% confidence interval, CI: 13.7-15.4). Rates were similar for males and females at 14.9 (99% CI: 13.7-16.0) and 14.2 (99% CI: 13.1-15.4) per 100,000 population, respectively. People aged 70 years or older had the highest mortality rate from unintentional falls (MR: 271.2; 99% CI: 249.0-293.5), and the rate was higher among women (MR: 281; 99% CI: 249.7-311.3). Falls on the same level were the most common among older adults, whereas falls from heights were more common in younger age groups. CONCLUSION In India, unintentional falls are a major public health problem that disproportionately affects older women and children. The contexts in which these falls occur and the resulting morbidity and disability need to be better understood. In India there is an urgent need to develop, test and implement interventions aimed at preventing falls.

Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis

BACKGROUND Few population-based studies quantify mortality from surgical conditions and relate mortality to access to surgical care in low-income and middle-income countries. METHODS We linked deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million households in India to nationally representative facility data. We calculated total and age-standardised death rates for acute abdominal conditions. Using 4064 postal codes, we undertook a spatial clustering analysis to compare geographical access to well-resourced government district hospitals (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology) in high-mortality or low-mortality clusters from acute abdominal conditions. FINDINGS 923 (1·1%) of 86,806 study deaths at ages 0-69 years were identified as deaths from acute abdominal conditions, corresponding to 72,000 deaths nationally in 2010 in India. Most deaths occurred at home (71%) and in rural areas (87%). Compared with 567 low-mortality geographical clusters, the 393 high-mortality clusters had a nine times higher age-standardised acute abdominal mortality rate and significantly greater distance to a well-resourced hospital. The odds ratio (OR) of being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 [95% CI 7·9-32·8] for >100 km). No such relation was seen for deaths from non-acute surgical conditions (ie, oral, breast, and uterine cancer). INTERPRETATION Improvements in human and physical resources at existing government hospitals are needed to reduce deaths from acute abdominal conditions in India. Full access to well-resourced hospitals within 50 km by all of Indias population could have avoided about 50,000 deaths from acute abdominal conditions, and probably more from other emergency surgical conditions. FUNDING Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, Canadian Institute of Health Research.

Socioeconomic factors and use of secondary preventive therapies for cardiovascular diseases in South Asia: The PURE study

Objective The purpose of this study was to determine the association of socioeconomic factors on use of cardioprotective medicines in known coronary heart disease (CHD) or stroke in South Asia. Methods We enrolled 33,423 subjects aged 35–70 years (women 56%, rural 53%, low education 51%, low household wealth 25%) in 150 communities in India, Pakistan and Bangladesh during 2003–2009. Information regarding socioeconomic status, disease conditions and treatments was recorded. We studied influence of rural location, educational status and household wealth on use of drug therapies. Odds ratios (ORs) and 95% confidence intervals were calculated. Results CHD was reported in 683 (2.0%), stroke 316 (0.9%), and CHD/stroke in 970 (2.9%). Median duration since diagnosis was four years. Participants with CHD/stroke were older with greater prevalence of smoking, overweight, hypertension and diabetes (p < 0.01). In patients with CHD, stroke and CHD/stroke, respectively, use (%) of antiplatelets was 11.6, 3.8 and 9.3, beta-blockers 11.9, 7.0 and 10.4, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 6.4, 1.9 and 5.3 and statins 4.8, 0.6 and 3.5. In CHD/stroke patients any one of these drugs was used in 18.1%, any two in 7.2%, any three in 2.8% and none in 81.5%. Details of drug dose were not available. Use of drugs was significantly lower in rural low education and low wealth index participants (all p < 0.01). Low wealth index participants had the lowest use of these therapies with no attenuation after multiple adjustments. Conclusion The use of secondary preventive drug therapies in patients with known CHD or stroke in South Asia is low with over 80% receiving none of the effective drug treatments. Low household wealth is the most important determinant.

Pilot testing of WHO Child Growth Standards in Chandigarh : implications for India's child health programmes

OBJECTIVE To compare the prevalence of underweight as calculated from Indian Academy of Paediatrics (IAP) growth curves (based on the Harvard scale) and the new WHO Child Growth Standards. METHODS We randomly selected 806 children under 6 years of age from 45 primary anganwadi (childcare) centres in Chandigarh, Punjab, India, that were chosen through multistage stratified random sampling. Children were weighed, and their weight for age was calculated using IAP curves and WHO growth references. Nutritional status according to the WHO Child Growth Standards was analysed using WHO Anthro statistical software (beta version, 17 February 2006). The chi2 test was used to determine statistical significance at the 0.05 significance level. FINDINGS The prevalence of underweight (Z score less than -2) in the first 6 months of life was nearly 1.6 times higher when calculated in accordance with the new WHO standards rather than IAP growth curves. For all ages combined, the estimated prevalence of underweight was 1.4 times higher when IAP standards instead of the new WHO standards were used. Similarly, the prevalence of underweight in both sexes combined was 14.5% higher when IAP standards rather than the new WHO growth standards were applied (P < 0.001). By contrast, severe malnutrition estimated for both sexes were 3.8 times higher when the new WHO standards were used in place of IAP standards (P < 0.001). CONCLUSION The new WHO growth standards will project a lower prevalence of overall underweight children and provide superior growth tracking than IAP standards, especially in the first 6 months of life and among severely malnourished children.