The World Health Organization(WHO) has released a special Report on Climate Change and Health propose a set of priority actions from the global health community to governments and policy makers, calling on them to act with urgency on the current climate and health crises today (11th October 2021). The report lists 10 recommendations for priority action and is available here.
Prior to the publication a public consultation was conducted by the WHO in which I provided feedback in individual capacity (acknowledged in WHO report) . The feedback revolved around the following themes(full submission available for download):
need for developing global, regional and national agendas for climate crisis preparedness, support for more interdisciplinary/transdisciplinary collaboration,
recognition of rights and dignity of health workforce in our path to climate resilience,
greater recognition of the impact of climate change on non-communicable diseases and injuries, particularly chronic kidney disease, snakebite, and cardiovascular diseases needs priority attention.
higher taxation of app-based food delivery business which has higher carbon footprint;
stop promotion of vegetarian diets which amounts to cultural imperialism by suppression of food practices of minorities, tribal, Adivasi and Indigenous populations who are being being attacked for their traditional meat-based food practices by removing words like “eating less meat” & “largely plant-based diet”;
ensure food security of vulnerable people by providing guarantee against price fluctuations through development of appropriate investment and legal mechanisms.
It is pleasing to note that the WHO has involved stakeholders meaningfully and inculcated feedback in letter and spirit. The removal of terms “eating less meat” is welcome, but more work needs to be done to prevent climate action being used as an opportunity for cultural imperialism. Continuing to work with stakeholders to understand the several issues better, as evidence evolves will be key to climate action. We have to grapple the defining issue of our generation together.
Just a few days after starting its own COVID-19 vaccination program , India provided vaccines as grant- in-aid to other countries1 . This was in sharp contrast to some high-income countries which stockpile vaccines, and block proposals to suspend intellectual property rights in World Trade Organisation2. India now is in the midst of a humanitarian crisis 3 but its vaccination rates continue to fall. While it is not possible to go back in time and make amends to ensure availability for all, revising the current vaccination strategy (which is riddled with equity issues) can save lives , prevent health systems burdening and ensuring a functioning ecosystem during the pandemic .
Equity enables maximizing benefits from scarce resources
India’s original vaccination strategy was to sequentially vaccinate priority groups healthcare workers, frontline workers, people more than 50 years. of age and younger people with associated comorbid conditions (diabetes, hypertension, cancer, lung diseases) 4. In principle this invoked equity – prioritising those at highest risk. However, the Indian government continually changed its strategy – announcing more inclusive eligibility criteria for vaccination every month. The last of these came suddenly in the last week of April 2021, when the Indian government announced a new “liberal policy” for vaccination5.In midst of the current crisis, while already being riddled with shortages the new policy announced that everyone above 18 years will be eligible, and effectively removed any distribution or price controls for manufacturers. This is unparalleled – no other federal democracy is making citizens pay for COVID-19 vaccines or have states competing to secure supplies. The huge demand amid all the death and despair in th current wave meant that the two Indian vaccine manufactures resorted to differential and predatory pricing. They fixed prices for state governments which are almost twice of the price paid by the union government ; it is four times for private hospital 6. An immediate consequence of this was that most state governments were not able to offer vaccines for high-risk groups , while even richer people(who can pay ₹ 1600-2400 , £ 15 to £ 25) in non-priority 18-45 years age group are able to access vaccines from private hospitals 7. The “liberal policy” also perpetuates regional inequities, wherein richer state governments will be able to buy more doses for non-priority groups while poorer states (with weaker health system) will have to wait for revenues to accrue for buying vaccines for priority groups.
The realities of vaccine shortage need to first publicly acknowledged, and a pragmatic and equity-based strategy needs to be adopted. As per media reports, only 37% of frontline and health workers had been fully vaccinated by mid-April 8 .
India needs to prioritise people “who matter and are in need” over the “rich and elite”. Vaccination of non-priority people in 18-45 years of age, should be stopped until adequate coverage of priority groups is acquired. A moral, social, and human rights lens is essential for the purpose. Younger people with mental health conditions, informal sanitation and cremation workers, families of frontline workers and healthcare workers, hawkers, home-delivery workers, prisoners , homeless people, people living in slums and field journalists who are at higher risk 91011 need to be under priority groups. Some of the re-defining of priority groups has been done by states like West Bengal and Delhi – but this is not uniform across the country.
Adopting a “One Nation – One Price – One Vaccine Buyer” policy such that the Government of India buys and makes it free for all citizens of India is the need for the hour. To overcome shortage, it can issue compulsory licenses (under Section 92 of the Indian Patent Act for public health emergencies) for all COVID-19 vaccines. A single buyer and a fixed price of ₹ 150 (£ 1.5 ; current price paid by the Union government) for the entire nation would prevent pandemic profiteering.
Digital health driven inequity
Vaccination in India require pre-registration through a centralized online digital system called Co-WIN. With only 20% of Indians using internet12 the implementation strategy is not in touch with ground realities. The “digital divide” is even greater in rural areas, particularly in women, tribal/Adivasi people, and the urban poor13 who remain clueless about the system. Urban youth are travelling to rural areas to get vaccines14 –potentially transmitting COVID-19 to villages. Micro-planning 15 and participatory community engagement16 is crucial for successful implementation. India has in the past used them successfully without any digital tools. The Co-WIN based registration and tracking system needs to be stop and time-tested walk-in and community outreach (for disabled, homeless, very old people and other equity groups) needs to be adopted.
Instead of investing in digital health, government needs to invest in employing more vaccinators and vaccination officers. The current strategy of drawing into existing human resources has led to disruptions in routine service delivery 17 18 .
The way forward
Mahatma Gandhi’s maxim that a “nation’s greatness is measured by how it treats its weakest members” should guide the overhauling of the COVID-19 vaccination policy. Getting the vaccination program right in India is crucial for the pandemic endgame too. There is not a moment to waste.
About the Author
Dr Soumyadeep Bhaumik is a medical doctor and international public health specialist working in The George Institute for Global Health India. He is also associate editor of BMJ Global Health. Views are personal and not necessarily reflective of employer or the BMJ Global Health. He tweets at @DrSoumyadeepB
Competing interests: I have read the BMJ Group Conflict of Interests and declare no competing interests.
Funding : None
Acknowledgment : Dr Sambit Dash from Melaka Manipal Medical College, India with whom author had a discussion.
Ministry of External Affairs. Made-in-India COVID19 vaccine supplies so far (In lakhs): Ministry of External Affairs, Government of India; 2021 [Available from: https://www.mea.gov.in/vaccine-supply.htm accessed 02 May 2021.
Sachs JD, Karim SA, Aknin L, et al. Priorities for the COVID-19 pandemic at the start of 2021: statement of the Lancet COVID-19 Commission. The Lancet 2021
Thiagarajan K. Why is India having a covid-19 surge? BMJ 2021;373:n1124. doi: 10.1136/bmj.n1124
Nemani K, Li C, Olfson M, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry 2021;78(4):380-86. doi: 10.1001/jamapsychiatry.2020.4442 [published Online First: 2021/01/28]
Akiyama MJ, Spaulding AC, Rich JD. Flattening the Curve for Incarcerated Populations – Covid-19 in Jails and Prisons. N Engl J Med 2020;382(22):2075-77. doi: 10.1056/NEJMp2005687 [published Online First: 2020/04/03]
Tan LF, Chua JW. Protecting the Homeless During the COVID-19 Pandemic. Chest 2020;158(4):1341-42. doi: 10.1016/j.chest.2020.05.577 [published Online First: 2020/06/13]
Mallik S, Mandal PK, Ghosh P, et al. Mass Measles Vaccination Campaign in Aila Cyclone-Affected Areas of West Bengal, India: An In-depth Analysis and Experiences. Iran J Med Sci 2011;36(4):300-5. [published Online First: 2012/11/02]
Burgess RA, Osborne RH, Yongabi KA, et al. The COVID-19 vaccines rush: participatory community engagement matters more than ever. Lancet 2021;397(10268):8-10. doi: 10.1016/s0140-6736(20)32642-8 [published Online First: 2020/12/15]
On 22nd April 2021 in the midst of a crumbling health system the AIIMS/ ICMR-COVID-19 National Task Force/Joint Monitoring Group , Ministry of Health & Family Welfare has finally issued a revised “Clinical Guidance for Management of Adult COVID-19 patients” (* see post-publication note in end). In essence, it is not much of a guideline but a flowchart (much like the previous one). It does not adhering to any standards of a guideline, does not present any evidence (not even citations!), nor does it communicate anything around risk-benefits for any of the drugs. As such, it is impossible to understand how the guideline was developed and why some drugs were chosen and why it was not.
The article however focusses only on one aspect of the guidelines- the recommendation for hydroxychloroquine being recommended as a “may do” . However, this recommendation for hydroxychloroquine is contrary to data from randomized controlled trial. Between July 2020 (when the last guideline was issued) and now, there is a lot of trials that has been completed and we now have reasonable evidence to inform decision making. Evidence from randomized controlled trial shows that hydroxychloroquine does do not have any effect on mortality (based on data from 10859 patients ; 29 studies) in COVID=19 patients . In fact patients given hydroxychloroquine may have significantly more diarrhea , nausea and vomiting compared to those not given so. Diarrhoea and vomiting are known to increase the risk of hypovolaemia, hypotension and acute kidney injury, additional health systems burdens which one should avoided at all costs in this phase of the pandemic.
Even if we look at health systems relevant outcomes (which are of course equally important to patients) which are of significance in the currently crumbling health system recommending the use of hydroxychloroquine does not make any sense – it increases the number of people who need mechanical ventilation(based on data from 6379 patients ;5 studies).
*As of 10th May 2021 – another version of the AIIMS/ICMR guideline is being circulated in social media without hydroxychloroquine . I could not verify the veracity of this version of guideline being genuine considering the ICMR website https://www.icmr.gov.in/ still hosts the 22nd April 2021 version
The importance of robust transport systems in promoting socioeconomic development is well understood. However, developing a transport system that considers the diverse needs of a vast country like India is beset with challenges. The existential nature of the covid-19 pandemic has fundamentally changed a lot of things, but most importantly how we think and plan. The risk of viral transmission from public transport (both real and perceived) is here to stay. This has resulted in many people preferring to opt for personal transport, leading to the use and sales of bicycles increasing substantially across India. This is similar to what has been seen in many other countries.
Could covid-19 be the proverbial “un mal pour un bien” that leads to the development of a transport system which is not only safe, affordable, and inclusive but also resilient—providing health, environmental, and economic benefits? We hope this will be the case.
With climate change high on the agenda, we should be ushering in large scale action that embraces more sustainable forms of transport. Bicycles offer a healthy, inexpensive, and environmentally friendly solution. Analysis of a new transport model in Stockholm that promotes bicycling estimated it could decrease the mean population exposure for both NOx and black carbon by about 7% in the most densely populated areas of the city, resulting in decreased mortality.
India has a considerable burden of non-communicable diseases and increasing physical activity is crucial to preventing them. A meta-analysis of 187 000 individuals found that cycling can decrease all cause mortality by 10%—this is after adjustment for other physical activity. Developing ways to increase people’s use of bicycles is therefore a sound investment from a public health perspective too as it would have health benefits at a population level.
The new economy and micromobility
It is expected to take a few years for the Indian economy to recover from the impact of the pandemic, with some commentators expressing concerns that the pandemic has widened inequities even further. People in India spend about 20% of their monthly households budget on transport. Reducing this output and providing people with more expendable money will be key to expediting India’s economic recovery. While car sales rose in India towards the end of 2020, this will increase people’s spending on transport and only the automobile and petrol industry will benefit from it. Again, bicycles have the advantage here. The Energy and Resources Institute (TERI) estimates that if we replace two and four wheelers with bicycles for short distance trips, it could result in an annual benefit of 1.8 trillion Indian rupees nationally.
The healthcare costs saved by the public health benefits of bicycling both at an individual and macro level might also be substantial. The social benefits of bicycling, including the fostering of community spirit and engagement with likeminded people, would ultimately lead to substantial economic benefits too. Modelling these should be part of sustainable development plans in the future.
The way forward
Cars are the ultimate status symbol in India. The first sign of a family doing well financially is the act of buying a car. An important part of encouraging the use of bicycles will be dispelling the notion that they are a “poor man’s transport,” and emphasising the ways in which they are “vehicles of the future.” This changed narrative is already taking root in the young urban middle class, but a greater push is needed. Social marketing campaigns that educate and encourage communities to opt for a “Green Travel Habit” are a good starting point.
India already has a very well drafted National Urban Transport Policy (NUTP), which lays out a plan for better road networks and associated facilities like road intersections, cycling tracks, secure parking spaces, and app based bicycle hiring services that provide connectivity to and from transport hubs. The NUTP also recommends that an “Urban Roads Code” should be adopted to ensure the safety of bicycle users by designing speed limits and barrier free accessibility, but little has changed on the ground. India needs to make bicycling safer by actually implementing the Urban Roads Code across the country and not just haphazardly in a few sections of selected cities. Roads should be audited for hot spots for accidents and appropriate mitigation strategies should be formulated.
Financial incentives to make the use of bicycles more attractive are also needed. A “climate change tax” (using the polluter pays principle) on personal cars and fuel for personal vehicles would be one fiscal push. This would only impact people who are well off and encourage use of more environmentally friendly forms of transport. Removing the Goods and Services tax on bicycles needs to be a parallel investment, along with providing free bicycle helmets, making their use mandatory by law, and making our transport infrastructure more bicycle friendly to prevent bicycle related injuries.
India currently prioritizes vehicles, not people, with non-vehicle users ignored in policies and development plans and infrastructure disproportionately focused on building for motorized vehicular traffic. Micromobility should be a key area that India focuses on in transport policies for the post-covid era, especially with virtual workspaces becoming more common. Bicycles are vehicles of the future and it’s time for India to invest in them.
Sucharita Panigrahi is studying for a master’s in public health degree at ICMR- Regional Medical Research Centre, India.
Soumyadeep Bhaumik is a medical doctor and international public health specialist working on policy impact and injuries at the George Institute for Global Health, India.
Disclaimer: All views in this article are personal.
“Identifying Research Priorities and Setting Research Agenda in Clinical Toxinology with a Focus on Snake Envenomation” was the theme of the round table discussion at the Toxinological Society of India Conference 2014 held at Calcutta School of Tropical Medicine on November 22 2014.
Theme lecture on Identifying Research Priorities and Setting Research Agenda was delivered by Dr. Soumyadeep Bhaumik, Cochrane Agenda and Priority Setting Methods Group, & BioMedical Genomics Centre, Kolkata, India
Health Research priority setting processes enable policy-makers, researchers, clinicians and public health professionals to effectively use available resources to collectively decide on what problems or uncertainties are worth trying to resolve/understand for maximal benefit. A transparent and evidence based priority setting process not only helps prioritization but also puts in perspective of patients and the need to improve health outcomes and reverse inequity. Snakebites, a neglected tropical condition, affects millions and kills thousands and yet there is miniscule research in this arena. The presentation focused on the basic concepts of research priority setting exercise, its utility and methods and processes for identifying research gaps and setting research agendas including question formulation, evidence assessment and prioritization process.
The Round Table discussion that followed had the following discussants
1. Professor Y K Gupta (Chair), Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi,India
2. Professor Yuri N. Utkin, Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russia
3. Professor Chittaranjan Maity, Head of the Department, Department of Biochemistry,KPC Medical College,Kolkata,India
4. Professor Antony Gomes, Laboratory of Toxinology and Experimental Pharmacodynamics, University of Calcutta, Kolkata,India
5. Professor Juan J Calvete, Laboratorio de Venomica , Estrtuctural y Funcional Instituoto de Biomedicina de Valencia, Spain
6. Dr Soumyadeep Bhaumik, Cochrane Agenda and Priority Setting Methods Group, & BioMedical Genomics Centre, Kolkata, India
7. Professor Santanu K Tripathi (Rapporteur for Toxinological Society of India). Head of the Department , Clinical & Experimental Pharmacology, Calcutta School of Tropical Medicine, Kolkata,India
The discussion focused to understand how priority setting processes can be inculcated in the field of snake envenomation and what broad domains can be considered priorities, as well as the ways to deal with challenges to development and implementation of research agenda in snake envenomation .
Please visit : http://capsmg.cochrane.org/ for more details and resources on setting research agendas and identifying research priorities.
Few would argue against the benefits of evidence informed public health and health policies. However, efforts to inform health policy in resource limited settings face particularly daunting challenges—often specific to the political complexity and resource limitations experienced uniquely in low and middle income countries (LMICs).
The Nepal Health Research Council (NHRC), a Government of Nepal body, has a long held mandate to support informed decision making by health policymakers in Nepal—an exciting but daunting role to operationalise. Informing health policy assumes that there is a base of information to communicate: in Nepal, this often isn’t available.
The 22nd Cochrane Colloquium in Hyderabad saw a special session on “Setting research agendas: balancing public health and patient level priorities” on 25th September 2014, . The session organised by the Cochrane Agenda and Priority Setting Methods Group (CAPSMG) had the following format :
Session Co-Chairs Roberto D’Amico & Damian Francis
Rebecca Armstrong: Priority setting: the CPHG experience
Robert Dellavalle & ChanteKarimkhani :On the Global Burden of Disease project and how it can help set priorities vis-a-vis public health and patient level priorities
Soumyadeep Bhaumik : Perspective of different stakeholders in a research priority setting of a public health problem in LMIC
Kevin Pottie: Priority Setting for Guidelines and Interventions
Vivian Welch: Cochrane Agenda and Priority Setting Methods Group (CAPSMG)
Discussion Session : ROLE PLAY where participants took roles as policy makers, clinicians and members of the public for deciding priority for Ebola and Sin taxes for Sugar Sweetened Beverages.
Dr. Soumyadeep B presentation at the session is attached and free to use under CC-BB-NY-SA (Click)
The COCHRANE METHODS SYMPOSIUM 2014 held on Sunday 21st September 2014 at Hyderbad, India was themed “” “From concepts to evidence synthesis:Towards a research agenda for methods of public health systematic reviews ”
Here is a list of some key points, quotes and slides I found interesting :
Liz Waters : Question right and match to the right evidence… Focus on evidence landscaping and realistic and narrative (but transparent) synthesis for public health reviews.
Daniel Francis: Logic Models help multi-disciplinary review teams to come together and explain relationships and improve the entire process, identify intervention components , understand rationale behind subgroup analyses and surrogate outcomes- all in a graphical manner.
James Thomas : Mixed methods meta-analyses allow to empirically understand and explain variations observed- thus allowing contextualization .. Are complementary to traditional methods.
Rebecca Armstrong : Review Advisory groups have an important role and there is need to use them better. Time for Review Advisory Group 2.0 which would include critical friends and stress on web-based technologies and include training as well as link review authors with RAG members .
Ruth Turley : Capturing all relevant evidence with lease amount of noise is difficult in a public health systematic review. This is complicated by lack of standard terminology, reviews being not restricted to RCT, not indexation of studies and evidence being locked in select databases.
Jane Noyes : New CERQual tool: will become integrated into the summary of findings tables in Cochrane reviews
Hilary Thomson: Narrative synthesis of quantitative data the Cinderella of Systematic review
Elie Akl: The most positive thing about GRADE us that it is systematic transparent and explicit but there are concerns about choice of outcomes and outcome measurements and the fact that the process is solely dependent on epidemiological data and cannot be applied to narrative synthesis and does not discriminated between different types of observational studies.
Cochrane, the global leader in evidence-informed health is for the first time in its more than 20 year history (the first Cochrane Centre opened in Oxford,UK in October 1992 ) is for the first time holding its annual colloquium in India, or for that matter in South Asia.
The 22nd Cochrane Colloquium takes place in Hyderabad, India from 21-26 September, 2014 with the theme ‘Evidence-informed public health: opportunities and challenges’. The event is landmark especially when seen in the background of the impending evidence based medicine as well as universal health coverage in South Asia.The event will see Professor Gordon Guyatt delivering the Annual Cochrane Lecture and plenaries conducted and chaired by global leaders on EBM,public health and policies with the following themes :
1. East meets West: Evidence-Informed Public Health; Concepts, Context, Opportunities, Challenges,
2.Public Health: the context, the vision, the opportunities
3.Capacity Development: Challenges and Innovations
4.Cochrane Reviews: Assuring Quality and Relevance
5.Advocating for Evidence: Improving Health Decision-Making through Advocacy, Partnerships and Better Communication
Five Special themed session which will highlight important issues on the following theme are also scnheduled and their are inumerable workshops held.There are about 88 oral presentations and more than hundred posters.
Genomic medicine is the ‘hot cake’ of current medical research. Here is my take on what should be India’s top priority areas for biomedical genomics research.
1. Research on Ethical issues in biomedical genomics . Biomedical genomic research is associated with various ethical concerns including the issue of identifiable genomic information, informed consent for data sharing of research and intellectual property issues. India has an image of championing the cause of low and middle income nation when it comes to intellectual properties and at the same time when it comes to ethics in clinical trials it has a particularly bad record. This will be one area where India should mark has #1 priority for biomedical genomics research before it ventures into other more adventurous directions .
2. Research to develop new DNA fingerprinting method for diagnosis of tuberculosis. The ICMR in its priority plan for 2012-2017 has already identified the topic as one of the important areas for research. Considering the public health issue of tuberculosis and the now imminent danger of MDR-TB this is one area India cannot ignore further.
3. Create large phenotype-genotype databases and infrastructure for data sharing
A Center for Public Health and Community Genomics, USA report advocated the need for, “ large population databases to catalog phenotypic-genotypic, demographic, socioeconomic, environmental, and behavioural data in order to explore genetic and external environmental contributions to disease…. Maintaining large databases can potentially allow scientists to examine risk across populations through segmentation, improving an understanding of why some individuals and/or populations develop disease and some remain health.”
India with a huge burden of non-communicable diseases like obesity, diabetes, heart disease, stroke, and cancer will benefit immensely if it takes the lead in this respect if this database is build. It is also important to realise that India is home to “six out of seven genetic variants of the human race “ and without involving research in Indians- genomic medicine can never grow to an adult butterfly with flying colours. India has an immense advantage in the field of information technology so database and infrastructure for data sharing should not be a major problem .
Image Courtesy :Argonne National Laboratory where it is licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.