A macro view of the fiscal health of States
In India, the States mobilise altogether more than a third of total revenue, spend 60% of combined government expenditure, and have a share in government borrowing that is around 40%. Given the size of the fiscal operation of States, an up-to-date understanding of their finances is critical in order to draw evidence-based inferences on the fiscal situation of the country — in short, an analysis of the emerging fiscal situation of States by examining key data on State finances from individual State budgets for 2023-24.
Fiscal imbalance and consolidation
As we complete the first quarter of the fiscal year 2023-24, it is becoming evident that the increase in general government deficit and debt that occurred during the COVID-19 pandemic has begun to recede. There have been significant post-pandemic fiscal corrections at the Union and State levels. At the Union level, the fiscal deficit declined from 9.1% of GDP in 2020-21 to 5.9% in 2023-24 (BE). All State fiscal deficit was 4.1% of GDP in 2020-21. It declined to 3.24% of GDP in 2022-23 (RE). For the major States, for the year 2023-24 (BE), it is expected to be 2.9% of GDP.
This sharp reduction in fiscal deficit suggests that we cannot have an impressionistic view of the fiscal situation of the country, especially on the finances of States. Due to the absence of aggregation of individual State Budget data, a consolidated view of general government finances is not readily available. Every year, this data become available only after the publication of the Reserve Bank of India’s (RBI) Annual Study on State Finances. Aggregating fiscal data from individual State Budgets is rigorous and time consuming. Hence, the timeline of this publication by the RBI is during the second half of the fiscal year.
The analysis here is based on the data collated from the individual Budgets of 17 major States. These States are responsible for more than 90% of the combined spending of all States. Thus, fiscal issues emerging out of their Budgets are representative of the State finances in India. The analysis shows that these States together have managed to contain their fiscal deficits. This fiscal consolidation is significant in many ways. First, States in aggregate managed to be fiscally prudent despite a significant contraction in revenues even during the peak of COVID-19. Second, emergency provision for health spending and livelihood during the COVID-19 pandemic was not easy and required Union-State fiscal coordination. Third, States were able to reprioritise expenditure and quickly contain the fiscal deficit. Fourth, the reduction in fiscal deficit is a combination of expenditure-side adjustments, improved Goods and Services Tax (GST) collection and higher tax devolution due to buoyant central revenues. Fifth, non-GST revenues are also showing signs of recovery after the pandemic in most States.
However, there are significant fiscal challenges that need correction in the short to medium time frame — the most critical being containing the revenue deficit of States. The reduction in fiscal deficit has not been accompanied by a corresponding reduction in revenue deficit. As in 2023-24 (BE), out of 17 major States, 13 States have deficit in the revenue account. Out of 13 States, fiscal deficits in seven States are primarily driven by revenue deficits; the States being Andhra Pradesh, Haryana, Kerala, Punjab, Rajasthan, Tamil Nadu, and West Bengal. They also have large debt to GSDP ratios.
It is true that the mere presence of a revenue deficit cannot be considered as a sign of fiscal profligacy. It is also true that pressure on revenue expenditure was high during the COVID-19 pandemic. A more detailed and careful analysis of the rise in revenue deficit of States is also necessary. However, increasing revenue deficit driving the fiscal imbalance has long-run fiscal implications and there is a need to correct this imbalance in the revenue account.
For these seven States, their specific shares of revenue deficit in fiscal deficit for 2023-24 are: Andhra Pradesh (40.9%), Haryana (50.9%), Kerala (60.4%), Punjab (70.7%), Rajasthan (39.7%), Tamil Nadu (40.8%), and West Bengal (47%). The all-State share of revenue deficit in fiscal deficit for the same year is expected to be 27%.
An assessment of successive Finance Commissions since the Twelfth Finance Commission identified three States, i.e., Kerala, Punjab and West Bengal, as fiscally stressed States. The number of States that are now fiscally stressed has increased to seven (measured in terms of the level of revenue deficit).
What does it mean for general government macroeconomic stability? A sense of this can be made when the following fiscal numbers are considered: the combined fiscal deficit of these States is 3.71% of GSDP when the all-State average for the same is 2.9%; their combined revenue deficit is 2.15 % of GSDP, when the all-State revenue deficit is 0.78%; their combined debt ratio is higher than the Finance Commission recommended debt ratio for all States for the year 2023-24. These States together contribute around 40% to India’s GDP. In this context, to ensure higher State-specific growth, the fiscal stability of State finances is critical. Some of these States have also been big drivers of public capital expenditures and favoured investment destinations of private investors.
Framework of revenue deficit consolidation
On the question of revenue deficit, a long-run view is also necessary. If we examine data from the last 20 years, revenue deficit had almost disappeared from State Budgets before COVID-19. States, in aggregate, were generating revenue surpluses almost all the years during this period. However, the re-emergence of revenue deficit in recent years should take the focus back on the management of revenue deficit by creating an incentive compatible framework. The following measures can be considered.
Going forward, interest-free loans to the States by the Union Government, if continued, may be linked to a reduction in revenue deficit. This will help eliminate the possibility of a substitution of States’ own capital spending and also prevent the diversion of borrowed resources to finance revenue expenditure. A defined time path for revenue deficit reduction with a credible fiscal adjustment plan would help restore fiscal balance and improve quality of expenditure.
A forward-looking performance incentive grants could also be considered for a reduction of revenue deficit. In this context, different approaches provided by earlier Finance Commissions can be considered to decide the framework of the incentive structure.
In conclusion, we need to get the focus back on the management of revenue deficit. For this, a macro view is essential.
A comprehensive revenue deficit reduction framework is essential to improve the fiscal health of States.
Facts about the News
– Revenue Deficit is the excess of its total revenue expenditure to its total revenue receipts. Revenue Deficit is only related to revenue expenditure and revenue receipts of the government.
– The difference between total revenue expenditure to the total revenue receipts is Revenue Deficit.
- Revenue Deficit: Total revenue receipts – Total revenue expenditure.
- Revenue deficit = Total Revenue expenditure – (Tax Revenue + Non Tax Revenue)
- The excess of total expenditure over total receipts excluding borrowings is called Fiscal Deficit. In other words, the Fiscal Deficit gives the amount needed by the government to meet its expenses. Thus a large Fiscal Deficit means a large amount of borrowings.
fiscal Deficit = Total expenditure — Total receipts excluding borrowings
- Fiscal deficit indicates the additional number of financial resources needed to meet government expenditure.
- it is an indicator of the increase in future liabilities of the government on interest payment and loan repayment. The government has to pay back the borrowed amount with interest in future. Consequently, the government has to either borrow more from the people or tax people more in future to pay interest and loan amount
- NOTE- Various policies undertaken by the government at national as well as sub-national levels to reduce the accumulation of debts and reduce deficits is known as fiscal consolidation.
- Fiscal consolidation can be achieved by increasing revenue and decreasing expenditure.
Antibiotics with promise — a lifeline India awaits
In the relentless battle against highly drug-resistant infections, a team of doctors recently witnessed a glimmer of hope amid the challenges they faced. Their extraordinary efforts and the life they saved highlight the critical need for action. This is not just a story; it is an earnest plea for Emergency Use Authorisation (EUA) for essential antibiotics that can make a profound difference between life and death.
In an intensive care room of a leading hospital in Hyderabad, an 18-year-old patient bravely fought not only his aggressive T-cell leukemia but also a formidable and resistant adversary — Extensively Drug Resistant Pseudomonas aeruginosa. This strain, known for its high resistance to multiple antibiotics, left the medical team with limited and often ineffective treatment options. Despite the administration of last-resort antibiotics, the patient’s condition deteriorated rapidly. Persisting fever spikes, and the infection’s assault on his lungs signalled a grave situation. The bacteria were literally eating up the patient’s face. Time was running out, and his life hung in the balance.
An Indian innovation
In their quest for a lifeline, the doctors turned to a promising antibiotic, cefepime/zidebactam. Developed by Indian researchers, this antibiotic combines two active components to combat drug-resistant gram-negative pathogens, including Pseudomonas aeruginosa. While still undergoing phase 3 trials internationally, this Indian innovation has shown remarkable potential. Under a compassionate use protocol, the necessary approvals were obtained, and the patient received cefepime/zidebactam. Miraculously, signs of clinical improvement began to surface. The patient’s fever subsided, blood cultures turned negative, and the need for oxygen diminished. Slowly but steadily, his strength returned, reigniting hope.
This extraordinary case underscores the urgent importance of granting EUA for antibiotics currently in phase 3 trials or licensed from other countries. The survival of this young patient serves as a poignant reminder of the need for timely access to effective antibiotics for those most in need.
A dire situation
Infection specialists, intensivists, oncologists, and doctors treating severe infections in critically ill and immunocompromised patients are confronted with a grave reality. The scarcity of potent antibiotics to combat drug-resistant infections poses a direct threat to countless lives. It is distressing to witness patients succumb to infections just because the available antibiotics have lost their effectiveness due to rising resistance. The dire situation faced by doctors as they grapple with drug-resistant infections is a devastating reality that cannot be ignored. Each year, millions of lives are lost due to the inadequacy of available antibiotics in the face of these formidable pathogens. The relentless march of drug resistance has rendered once-effective treatments ineffective.
The challenges faced by doctors in combating drug-resistant infections are multifaceted. They must navigate through a shrinking arsenal of effective antibiotics, leaving them with limited choices and often resorting to suboptimal treatments that may have significant side-effects or offer little hope of a cure. The constant race against time, trying to stay one step ahead of the mutating bacteria, adds to the immense pressure and helplessness experienced by doctors on the front lines.
India, a nation that has demonstrated remarkable progress in granting EUA for COVID-19 vaccines, now stands at a critical juncture. We must extend the same level of urgency and commitment to saving the lives of patients who may otherwise succumb to infections resistant to all currently available antibiotics.
While it is true that several antibiotics are licensed within our country based on small clinical studies and of questionable benefit, we must recognise that what we truly need are powerful weapons to fight against drug-resistant infections. Antibiotics that have been thoroughly evaluated or proven to be effective are essential in the battle against superbugs.
Cefepime/zidebactam is a shining example of India’s scientific prowess. Currently undergoing international phase 3 trials, this antibiotic has demonstrated its potential to save lives. By recognising the importance of cefepime/zidebactam and expediting its EUA, we not only save lives within our borders but also extend a helping hand around the globe to countless individuals in desperate need of effective treatment options.
Made by Japan
Cefiderocol, a licenced antibiotic in several countries, developed by a Japanese company, has demonstrated excellent efficacy against drug-resistant infections. It is disheartening that it remains unavailable within our country. The gravity of the cases faced by patients in India demands access to this life-saving antibiotic, and we firmly believe it should be made accessible without delay. However, we must emphasise the importance of responsible and appropriate utilisation of these medications. A collective decision by a team of experienced doctors, including infectious diseases experts should be made mandatory before initiating their use. This will ensure that these powerful antibiotics are administered to patients who will benefit the most while minimising the risk of misuse or overuse.
We implore the authorities to recognise the urgent need for action and acknowledge the immense potential of these life-saving antibiotics. By granting EUA for cefepime/zidebactam, an Indian innovation, and cefiderocol, a globally recognised antibiotic, we can strengthen our arsenal against drug-resistant infections. Their inclusion in the EUA list would not only empower doctors but also instil a renewed sense of hope and confidence among patients and their families. As a nation known for its scientific achievements, we have the opportunity to make a substantial impact on the world stage.
Emergency Use Authorisation for essential antibiotics, as two examples show, can make a profound difference between life and death.
Facts about the News
- Pseudomonas aeruginosa is a common gram-negative, rod-shaped bacteria that can cause disease in plants and animals, including humans.
- It is a species of considerable medical importance, as it is a multidrug resistant pathogen recognized for its intrinsically advanced antibiotic resistance mechanisms, and its association with hospital-acquired infections such as ventilator-associated pneumonia and various sepsis syndromes.
- It is found in soil, water and most human-made environments throughout the world. It thrives not only in normal atmospheres, but also in low-oxygen atmospheres, thus has colonised many natural and artificial environments.
- Red line campaign – The Union health ministry’s Anti-Microbial Resistance awareness campaign urges people not to use medicines marked with a red vertical line, including antibiotics, without a doctor’s prescription.
- These medicines are called the ‘Medicines with the Red Line’.
- To check the irrational use of antibiotics, the ‘red line’ will help the users to differentiate them from other drugs.
- This campaign is aimed at discouraging unnecessary prescription and over-the-counter sale of antibiotics causing drug resistance for several critical diseases including TB, malaria, urinary tract infection and even HIV.
Initiatives to Prevent AMR-
- National Programme on AMR containment.
- National Action Plan on AMR
- AMR Surveillance and Research Network (AMRSN)
- AMR Research & International Collaboration: Indian Council of Medical Research (ICMR) has taken initiatives to develop new drugs /medicines through international collaborations
– ICMR along with the Research Council of Norway (RCN) initiated a joint call for research in antimicrobial resistance in 2017.
- Antibiotic Stewardship Program
- World Antimicrobial Awareness Week (WAAW)
- The Global Antimicrobial Resistance and Use Surveillance System (GLASS)
Lessons from the fracas over foodgrains
The Karnataka government’s decision to convert the promised Anna Bhagya scheme to a direct benefit transfer temporarily has brought into focus the limits of a State government’s policy intervention on a crucial matter such as food security.
A serious problem
Under Anna Bhagya, the government had envisaged the provision of five kg of free rice per person per month to 4.42 crore beneficiaries, including 45 lakh Antyodaya Anna Yojana (AAY) cardholders, 3.58 crore Priority Household (PHH) cardholders, and 39 lakh cardholders belonging to Karnataka’s own category of PHH. This was in addition to the regular entitlements to the beneficiaries under the National Food Security Act (NFSA). The State would have required around 2.3 lakh metric tonnes of rice every month to meet this commitment. The Food Corporation of India (FCI) had agreed on June 12 to supply the quantity under the Open Market Sale Scheme-Domestic (OMSS-D) for July, but the Centre had a different plan. Anna Bhagya, which was to be launched on July 1, ran into a serious problem on June 13 when the Union Food Ministry discontinued the sale of rice and wheat under OMSS-D to all State governments, with exceptions. Karnataka had planned to utilise OMSS-D to implement the scheme, which was one of the five pre-poll guarantees of the Congress party.
Though the OMSS is meant for the sale of surplus stocks of wheat and rice at pre-determined prices through e-auctions in the open market, to improve the supply of foodgrains and control the price line, States have generally been allowed to purchase the surplus stock without e-auctions. The OMSS is now limited to accommodate small and marginal buyers and traders. The quantity that a bidder can purchase in a single bid ranges from 10-100 metric tonnes at present. The Centre’s decision took several States, especially rice-deficit ones, by surprise, since OMSS is one of the routes that they use to supplement their allocation. The suddenness of the decision especially hit Karnataka, which had begun preparations to launch the scheme in anticipation of the FCI’s help. Had there been an effective communication system in place between the Union Food and Public Distribution Department and the FCI, a statutory body under the Central government, the whole controversy could have been avoided. While suggestions were made for providing ragi and jowar, both grown in parts of Karnataka, to partially meet the proposed demand, this too would have posed supply constraints, as the quantity required was substantial.
Of course, the Centre has its own compulsions in restricting the availability of foodgrains under OMSS-D. The quarterly stock position of rice and wheat in the Central pool, as on April 1, 2023, was the lowest in the last three years, despite being much higher than the level prescribed in the foodgrains stocking norms. Uncertainty regarding the south-west monsoon and the possible impact of an adverse monsoon on the production of foodgrains are factors that the authorities must have considered before taking the decision to restrict supply. All this only justifies the need for more broad-based consultation. Besides, whether it is feasible to rely on private traders to bring down the prices for those not covered under the NFSA is a moot question.
There is one difference between the present and the immediate past: the Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY), implemented in the wake of the COVID-19 pandemic, is no longer in force. This scheme had provided five kg of free foodgrains per person per month from the central pool to AAY and PHH cardholders all over India.
The episode has delivered a key message to States that they must have their own mechanisms in place before launching any scheme. Even if there had been no row between the Central and Karnataka governments, the sustainability of Anna Bhagya was questionable as supply only through OMSS-D would not have been sufficient. On average, about 16 lakh tonnes were drawn in total by all the players in the country from 2018-19 to 2022-23. The highest quantity of about 24.6 lakh tonnes was drawn in 2020-21, the first year of COVID-19. But Karnataka would have needed about 27.5 lakh tonnes annually, about 1.5 lakh tonnes higher than the State’s allocation under the NFSA for 2023-24. Thus, the States must consider the macro picture to ascertain the practicality of their new schemes. The Centre indeed has reason to be worried if every other State promises a scheme of its own in the food sector, based on the expectation that the Central government and the FCI will come to its rescue without any regard for the emerging reality. If States do not exercise discipline and such a trend goes unchecked, the country would not have comfortable stock, let alone surplus. Also, the problem was not only of availability, but also cost. The FCI had reportedly agreed to supply grains to Karnataka at ₹36.6 per kg. Assuming that the required quantity was obtained at this cost, the monthly outgo would have been about ₹840 crore.
Not an instrument of politics
There is no crisis as of now on the foodgrains front. But the present situation should serve as a lesson to all political players to exercise moderation while making electoral promises, especially on matters concerning food security. Also, they should stop viewing foodgrains as an instrument of politics and begin to take an objective appraisal of programmes such as PMGKAY and Anna Bhagya.
Political parties should exercise moderation while making electoral promises, especially on matters concerning food security.
SCO calls for multipolar world order as Iran joins grouping
The formation of a “more representative” and multipolar world order is in the global interest, leaders of the Shanghai Cooperation Organisation said at a virtual summit chaired by Prime Minister Narendra Modi on Tuesday.
The grouping’s decision to induct Iran as its ninth and latest member was one of a number of agreements signed at the summit. However, India, who hosted the summit for the first time, refused to join other members on paragraphs relating to China’s Belt and Road Initiative (BRI) in the joint statement, and stayed out of a joint statement on SCO Economic Development Strategy 2030, indicating a lack of consensus in the grouping. Mr. Modi also took sharp aim at Pakistan for cross-border terrorism, and at China for connectivity projects that do not respect sovereign boundaries.
The SCO grouping now comprises China, India, Iran, Kazakhstan, Kyrgyzstan, Pakistan, Russia, Tajikistan and Uzbekistan.
The agreements signed include the New Delhi Declaration, outlining areas of cooperation between SCO countries; a joint statement on countering radicalisation; and one on digital transformation, where India offered to share expertise on digital payment interfaces. In a reference to sanctions on Russia and Iran, SCO members jointly criticised non-UN sanctions as “incompatible with the principles of international law”, which have a “negative impact” on other countries. SCO members also agreed to explore the use of “national currencies” for payments within the grouping, which would circumvent international dollar-based payments.
However, the declaration noted that only “interested member states” signed the economic strategy statement, while leaving India out of the paragraphs supporting China’s BRI. India opposes the BRI over its inclusion of projects in Pakistan-occupied Kashmir.
“Better connectivity not only enhances mutual trade but also fosters mutual trust. However, in these efforts, it is essential to uphold the basic principles of the SCO charter, particularly respecting the sovereignty and regional integrity of the Member States,” Mr. Modi said.
SCO at summit calls for multipolar world order
In his statement, Pakistan PM Shehbaz Sharif said that terrorism should not be “used as a cudgel for diplomatic point scoring”.
“Instead of cherry picking for narrow political gains, terrorism in all its forms and manifestations, including State terrorism, must be condemned… Similarly, religious minorities should never be demonised in the pursuit of domestic political agendas,” he added, in a veiled reference to Pakistan’s allegations against the Indian government on minority rights.
Meanwhile, Chinese President Xi Jinping marked the 10-year anniversary of the BRI and mentioned his new Global Security Initiative (GSI), calling for “encouraging political settlement of international and regional hotspots, so as to forge a solid security shield in our region”. He called on SCO members “to make foreign policies independently” and to be “highly vigilant against external attempts to foment a new Cold War or camp-based confrontation in our region”. Chinese officials have previously blamed the U.S. for “interference” and a “Cold War mentality”.
Quoting Rabindranath Tagore in his speech, Mr. Xi said, “The sea of danger, doubt and denial around man’s little island of certainty challenges him to dare the unknown.”
The Delhi Declaration listed a number of global challenges, including new and emerging conflicts, turbulence in the markets, supply chain instability, climate change and the COVID-19 pandemic.
“[SCO] member States confirm their commitment to formation of a more representative, democratic, just and multipolar world order based on the universally recognized principles of international law, multilateralism, equal, joint, indivisible, comprehensive and sustainable security, cultural and civilizational diversity, mutually beneficial and equal cooperation of states with a central coordinating role of the UN,” it said.
(with inputs from Ananth Krishnan)
Facts about the News
- Shanghai Cooperation Organization is a permanent intergovernmental international organization.
- Formed on 15 June 2001 in Shanghai(China)
- Before the creation of SCO in 2001 , Kazakhstan, China, Kyrgyzstan, Russia and Tajikistan were members of the Shanghai Five.
- Later, it include Uzbekistan and renamed with SCO
- India and Pakistan JOINED IN 2017.
- On September 2021 it was announced that Iran would become its full time member.
- Official language- Russian and Chinese.
Members- Russia, China, the Kyrgyz Republic, Kazakhstan, Tajikistan, Uzbekistan, India ,Pakistan and Iran
Observer Countries – Afghanistan, Belarus, Iran, and Mongolia
Dialogue Partners – Armenia, Azerbaijan, Cambodia, Nepal, Sri Lanka and Turkey
The SCO has been an observer in the UN General Assembly since 2005.
The irrevocable connection between anaemia and maternal health
The WOMAN-2 trial collaborators,‘Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial’,The Lancet, June 27, 2023, doi.org/10.1016/S2214-109X(23)00245-0
Of late anaemia has been in the news in India, what with the government proposing to remove a question on it from the National Family Health Survey (NFHS) and instead do a more elaborate test to determine haemoglobin levels in the blood as part of the Diet and Biomarker (DAB) survey. A paper recommending that normative values for haemoglobin must be lowered in India, based on a small study, has also come in for criticism. The WhatsApp groups of two professional sectors, where repartees have been flying hard and fast are those belonging to nutritionists and obstetricians and gynaecologists. The latter groups who have actually seen the impact of anaemia especially on maternal and infant health have been articulating their views on keeping the standards for anaemia, and to not amend them based on a statistically insignificant study. Policy makers in India must allow the results of a multi-country study published recently in The Lancet to inform their rules on measuring anaemia, handling it and making sure the interventions are sensible and far reaching.
Anaemia and pregnancy
Anaemia has a very strong link with postpartum haemorrhage (excessive vaginal bleeding after delivery), and the risk of death or near miss is very high.
As per the study, by the WOMAN (World Maternal Antifibrinolytic )-2 trial collaborators, worldwide, more than half a billion women of reproductive age are anaemic. Each year, about 70,000 women who give birth die from postpartum haemorrhage, almost all of them in low-and middle-income countries. While a known risk of anaemia or low haemoglobin levels is postpartum death, researchers decided to examine in detail the association between anaemia and the risk of postpartum haemorrhage.
This trial enrolled over 10,000 women with moderate or severe anaemia giving birth vaginally in hospitals in Pakistan, Nigeria, Tanzania, and Zambia, countries where anaemia in pregnancy was common and established by other trials. They examined the continuous association between prebirth haemoglobin and the risk of postpartum haemorrhage in a large cohort of women from low-and middle-income countries. The advantage of examining anaemia as a continuous variable, the authors argued, is that demonstration of a monotonic biological gradient is more suggestive of a causal relationship. The outcome was defined as an occurrence of postpartum haemorrhage, defined in three ways: “clinical postpartum haemorrhage (estimated blood loss ≥500 mL or any blood loss sufficient to compromise haemodynamic stability); WHO-defined postpartum haemorrhage (estimated blood loss of at least 500 mL); and calculated postpartum haemorrhage (blood loss of ≥1,000 mL).
Blood loss and shock
The mean age of the women from Pakistan, Nigeria, Tanzania and Zambia was just over 27 years. There was clear evidence from the study that lower haemoglobin values had a direct relationship with volume blood loss, and clinical postpartum haemorrhage. “We found that with decreasing maternal haemoglobin concentration, the risk of postpartum haemorrhage increases monotonically,” the authors recorded.
Anaemia reportedly reduces the oxygen-carrying capacity of blood, and therefore, women with anaemia cannot tolerate the same volume of bleeding as healthy women, and become shocked after a smaller volume blood loss, the authors reasoned. Further they added, “Given the lack of an established definition of postpartum haemorrhage in women with anaemia, before conducting this study, we examined different definitions of postpartum haemorrhage in terms of their specificity for substantial bleeding, and their association with fatigue, physical endurance, and breathlessness.” They eventually found that a clinical diagnosis of postpartum haemorrhage was highly specific for clinical signs of shock and irrevocably associated with worse maternal function.
The mean estimated blood loss post delivery was 301 mL for the 8,791 (3.2%) women with moderate anaemia and 340 mL for the 1,770 (16.8%) women with severe anaemia. 742 (7.0% of the total) women had clinical postpartum haemorrhage. The risk of clinical postpartum haemorrhage was 6.2% in women with moderate anaemia and higher, 11.2% in women with severe anaemia. Fourteen women died and 68 either died or had a near miss. Severe anaemia was associated with seven times higher odds of death or near miss than was moderate anaemia. Researchers further said that a 10 g/L reduction in prebirth haemoglobin increased the odds of clinical postpartum haemorrhage.
The authors went on to recommend that attention should be given to the prevention and treatment of anaemia in women once they hit reproductive age.
The Indian government has a well-structured project to provide weekly iron and folic acid supplements to adolescent girls (and boys), in order to tackle the looming crisis of anaemia. The climb to a barely-acceptable haemoglobin content of 12 for women seems very steep, given the nutrition status of these children, primarily in rural areas, where quality and quantity of what they eat is less than ideal,and is only exacerbated by malabsorption, public health, experts added.
The task has already been cut out for the Indian public health programme. Health managers are aware of the risks of anaemia and know what to do to handle it. However, the rising levels of anaemia in the country is a source of concern and mandates that any project to bring down anaemia in the country must be on mission mode. The solution is not to bring down the gold standard laboratory readings literally. While the argument to detach anaemia from the NFHS is that the DAB would be undertaking a more elaborate blood draw to measure haemoglobin levels accurately, the argument against it is also that such a measure may not be feasible for a large group of people, who may say okay to a capillary blood draw (finger prick) but baulk at a venous blood drawal. Any public outreach programme must be mindful of the cultural, social realities and have a sense of the attitudes of the people they are targeting. If these factors are not sewn into a public health programme, the outcomes may be far from what was sought or planned, experts said.
Facts about the News
Definition of anaemia
– The WHO defines anaemia as a condition where the number of red blood cells or the haemoglobin concentration within them is lower than normal. This compromises immunity and impedes cognitive development.
- Cause: Anaemia, according to WHO, may be caused by several factors. The most common nutritional cause of anaemia is iron deficiency although deficiencies in folate, vitamins B12 and A are also important causes.
Understanding leptospirosis, a disease that surges during the monsoon
The disease has been called “ili jwara” in Kannada and “eli pani” in Malayalam, both meaning “rat fever”. This usage has fed a common belief that rats are the sole cause of the disease, which is not true. Leptospirosis has a spectrum of reservoir hosts, including pigs, cattle, water buffaloes, goats, dogs, horses and sheep
IRFAN SHAKEER AND ISWARYA LAKSHMI
Leptospirosis has emerged as an important infectious disease in the world today. It is a potentially fatal zoonotic bacterial disease that tends to have large outbreaks after heavy rain or flooding.
The disease is more prevalent in warm, humid countries and in both urban and rural areas.
It affects an estimated 1.03 million people every year, killing around 60,000. The burden of leptospirosis is expected to increase in the future as the urban poor population in many tropical countries increases even as sanitary infrastructure falls short.
In India, thousands of people are affected by leptospirosis every year.
However, the numbers at the global and regional levels are not exact because of misdiagnosis (its symptoms mimic those of dengue, malaria, and hepatitis), limited access to reliable diagnostics, lack of awareness among treating physicians, and lack of environmental surveillance.
Within India, studies have found that leptospirosis is more common in the south, although this could be due to the region’s better healthcare and thus better disease detection.
What causes the disease?
The disease is caused by a bacterium called Leptospira interrogans, or leptospira. It is a contagious disease in animals but is occasionally transmitted to humans in certain environmental conditions.
The carriers of the disease can be either wild or domestic animals, including rodents, cattle, pigs, and dogs.
The cycle of disease transmission begins with the shedding of leptospira, usually in the urine of infected animals.
According to the U.S. Centers for Disease Control and Prevention, infected animals can continue to excrete the bacteria into their surroundings for a few months, but sometimes up to several years.
Which people are at risk?
Humans become part of the cycle when they come in direct contact with this urine or indirectly, through soil and water that contain leptospira bacteria. A person is more likely to contract leptospirosis if they have cuts or abrasions on their skin.
The disease is also considered an occupational hazard for people working in agricultural settings, with animals, or in sanitary services that bring them into contact with contaminated water.
Recreational activities in contaminated lakes and rivers are also reported to increase the risk of leptospirosis.
What are the symptoms?
The severity of a leptospirosis infection ranges from a mild flu-like illness to being life-threatening.
The infection can affect many organs, reflecting the systemic nature of the disease. This is also why the signs and symptoms of leptospirosis are often mistaken for other diseases.
In milder cases, patients could experience a sudden onset of fever, chills, and headache – or no symptoms at all. But in severe cases, the disease can be characterised by the dysfunction of multiple organs, including the liver, kidneys, lungs, and the brain.
Animals exhibit a variety of clinical symptoms and indications. In cattle and pigs, the disease can potentially cause reproductive failure, stillbirths, and weak calves or piglets. Dogs experience a range of symptoms, including fever, jaundice, vomiting, diarrhoea, renal failure, and even death.
What are the misconceptions?
Preventing leptospirosis requires appropriate and adequate health education, community health empowerment, and preventive habits.
The disease has been called “ili jwara” in Kannada and “eli pani” in Malayalam, both meaning “rat fever”. This usage has fed the common belief that rats are the sole cause of the disease, which is not true.
Leptospirosis has a spectrum of reservoir hosts, including pigs, cattle, water buffaloes, goats, dogs, horses, and sheep. Further, seasonal patterns such as the onset of the monsoon can also potentially facilitate the disease’s incidence and transmission.
Ambient air that is more humid can help the pathogenic leptospira survive longer in the environment, thus increasing the risk of disease exposure in the community.
The incidence of the disease is also linked to extreme weather events like floods and hurricanes, when people are exposed to contaminated water.
Similarly, poor waste management, a high density of stray animals, faulty drainage systems, and unhygienic sanitation facilities are major drivers of the disease in urban areas. In rural parts, these are contaminated paddy fields, dirty livestock shelters, and poor water-quality and sanitation.
Despite this complexity, the use of “rat fever” as a colloquial term for leptospirosis undermines a more holistic understanding of the disease’s causes.
If we are to protect people, we must use the correct terms, study the ecology of the disease and use the findings to inform healthcare policy, improve health literacy, and engage with people’s concerns.
Leptospirosis control can benefit from a ‘One Health’ approach. ‘One Health’ is an interdisciplinary approach that recognises the interconnections between the health of humans, animals, plants, and their shared environment.
People who frequently interact with animals or their urine should exercise particular caution, such as by wearing personal protective equipment like gloves and boots. The same goes for workers in flooded fields where there’s a chance of being exposed to contaminated water. They should take extra care if they have cuts or abrasions on their lower extremities.
Preventing animals from getting infected is also important to reduce the risk of leptospirosis spreading and to limit farmers’ economic losses (when the disease causes reproductive failures in pigs and cattle). This in turn requires sanitary animal-keeping conditions, which is also desirable to improve the animals’ health and to prevent the spread of many diseases. Given the spike in leptospirosis during the monsoons, it is best to take precautions, including washing one’s arms and legs with an antiseptic liquid after handling animal waste and after working in water.
In sum, with ‘One Health’ in mind, public health professionals must work closely with the animal husbandry department to familiarise people about the dangers of leptospirosis, and create countermeasures that work for the health of both people and animals.
Irfan shakeer is a Senior Research Associate and Iswarya Lakshmi is a Research Associate at Ashoka Trust for Research in Ecology and the Environment, Bengaluru where they are associated with the IndiaZooRisk+ project (India-U.K. joint initiative).
Humans become part of the cycle when they come in direct contact with urine or indirectly, through soil and water that contain leptospira bacteria. A person is more likely to contract leptospirosis if they have cuts or abrasions on their skin
Animals exhibit a variety of clinical symptoms and indications. In cattle and pigs, the disease can potentially cause reproductive failure, stillbirths, and weak calves or piglets. Dogs experience a range of symptoms, including fever, jaundice, vomiting, diarrhoea, renal failure, and even death
Preventing animals from getting infected is also important to reduce the risk of leptospirosis spreading and to limit farmers’ economic losses. This in turn requires sanitary animal-keeping conditions, which is also desirable to improve the animals’ health and to prevent the spread of many diseases
Facts about the News
- It is a bacterial disease that affects humans and animals.
- It is caused by bacteria of the genus Leptospira.
- In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases.
- Some infected persons, however, may have no symptoms at all.
- Without treatment, Leptospirosis can lead to kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, respiratory distress, and even death.
- A single dose of doxycycline 200 mg tablet is effective as a preventive medicine against leptospirosis, a bacterial infection, if given to the flood-affected within a week of the natural calamity.