Health and South Asia
Harvard South Asia Institute's inaugural publication about health. Released January 2014.
Health SOUTH ASIA Harvard South Asia Institute southasiainstitute.harvard.edu 1730 Cambridge Street, Fourth Floor Cambridge, Massachusetts 02138 United States of America Authors featured in this publication reserve all rights to their essays. Health and South Asia Harvard South Asia Institute Cambridge, Massachusetts 2013 CONTENTS From the Director 2 Contributors 4 Challenges More Money, More Health? An Indian Tale Peter Berman 7 Will the Gender Violence Just Continue? Jacqueline Bhabha 13 The Graying of South Asia David Bloom 19 Indian Patent Law and the Novartis Case: An Interview with Feroz Ali Khader Madhav Khosla 23 Urban Communities and Health in South Asia Maria A. May and Richard A. Cash 29 Health Care Financing in India Nachiket Mor 35 Heath and Inequality in South Asia S. (Subu) V. Subramanian and Malavika Subramanyam 41 CONTENTS Innovations Leapfrog Technology and Epidemiology at the Worldâ€™s Largest Human Gathering Satchit Balsari 45 Graphic Violence and Trauma in Sri Lanka Benjamin Dix 51 Water Pollution and Public Health in India: The Potential for a Market-Friendly Approach Michael Greenstone, Raahil Madhok, Rohini Pande, and Hardik Shah 61 TraumaLink: Helping People Survive Traffic Accidents in Bangladesh Jon Moussally, Eric Dunipace, and Ryan Fu 67 The Pharmacy of the Developing World Achal Prabhala 71 Emergency Care in Karachi Erum Sattar 79 Health by Design: A Conversation with Rahul Mehrotra Sharmila Sen 85 Project Prakash: Merging Science and Service Pawan Sinha 89 Medical Innovation for Low-Resource Global Markets Conor Walsh 93 Coda 96 FROM THE DIRECTOR Courtesy of Ricardo A. Palleres and Raoul A. Goff. Of the approximately seven billion people living in the world today, nearly two billion reside in South Asia. Though the population of South Asia is largely young, the number of people above the age of sixty is expected to double by the year 2040. The nations in this region—Afghanistan, Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal, Pakistan, and Sri Lanka—thus face their own health-related challenges as their populations age and grow. South Asia comprises a high percentage of young children who suffer from malnutrition or who are underweight. Limited access to clean water and adequate shelter compound these health issues. And health care financing is far from ideal. Indeed, every major health-related issue being debated in the world today has a relevant case study that can be found in this region. South Asia is a place where some of the most acute health problems are aggregated, as well as a site where some of the most innovative solutions, for both this region and the world, can be found. With all this in mind, we chose health as the topic for our inaugural publication. We invite you to think of health as broadly, humanely, and ethically as possible. Health is a bundle of complex factors. Consequently, solutions to health-related challenges can be found only when we take a cross-disciplinary approach. In the pages that follow, you will see a range of professional and disciplinary perspectives—from lawyers and physicians, philanthropists and entrepreneurs, scientists and epidemiologists, policy advocates and economists, designers and graphic novelists, and journalists and open access advocates. These various experts have come together to present a rich array of solutions to health dilemmas. The publication you hold in your hands (or are reading onscreen) is not exhaustive. Instead, we aim to present a wide representation of the important, and oc2 Health and South Asia casionally surprising, ways in which people find solutions to public health problems in South Asia. Our contributors are seasoned professionals in the region, highly regarded professors who have tackled these issues for decades, younger faculty who represent the next generation of thinkers, and graduate students who are in the formative stages of their professional development. The Harvard South Asia Institute aspires to develop interfaculty relationships between the different departments and schools at Harvard and to introduce Harvard faculty to their colleagues at other universities; to foster student-teacher relationships; to connect professionals working in South Asia with the Harvard community; and to cultivate cross-region collaboration in South Asia. In these pages you will encounter a young woman from Karachi writing about improvements to the city’s ambulances and emergency-response systems; an American physician working to help road-accident victims in Bangladesh; a humanitarian aid worker creating a graphic novel about survivors of war-torn Sri Lanka, and in turn becoming inspired to document the plight of Somali migrants and Syrian refugees; an MIT professor working to restore sight to blind children in India; a writer in Bangalore analyzing the effects of Indian medical patent law on South Africa and Brazil; an Indian-born New York physician grappling with real-time epidemiology at the world’s largest human gathering—the Kumbh Mela in Allahabad; and others writing about ideas and initiatives ranging from health care financing to low-tech design to gender-violence prevention. In the final section of this publication, you will experience a little shift in perspective—a look at the notion of suffering and disease according to the Buddha; a literary vision of healing and sovereignty; and a wry, fictional depiction of medicine and the body politic. The coda flips the focus to the longue durée of the South Asian past. The nation states in this region are young, the population even younger, but the civilizational memory is as old as anywhere in the world. Here, we look forward to the future of health in South Asia through the eyes of what the past has seen and understood. A small section for taking notes is included in the print volume. It is our hope that you will actively read these essays, feel free to comment and develop your own ideas, and connect with the pieces, places, and people you find in these pages. Regards, Tarun Khanna Jorge Paulo Lemann Professor, Harvard Business School Director, Harvard South Asia Institute Harvard South Asia Institute 3 CONTRIBUTORS Satchit Balsari is fellow with the Harvard Humanitarian Initiative as well as an emergency physician at NewYork-Presbyterian Hospital/Weill Cornell Medical College. Peter Berman is professor of the practice of global health systems and economics and director of GHP Educational Initiatives at the Harvard School of Public Health. Jacqueline Bhabha is the FXB Director of Research, professor of the practice of health and human rights at the Harvard School of Public Health, the Jeremiah Smith Jr. Lecturer in Law at Harvard Law School, and adjunct lecturer in public policy at the Harvard Kennedy School. David Bloom is the Clarence James Gamble Professor of Economics and Demography in the Department of Global Health and Population, Harvard School of Public Health. Richard A. Cash is senior lecturer on global health at the Harvard School of Public Health and visiting professor at the Public Health Foundation of India in Delhi. Benjamin Dix is director of PositiveNegatives and author of The Vanni. Eric Dunipace is a Harvard School of Public Health graduate student in global health and population and founder and VP of Operations at TraumaLink. Ryan Fu is a Harvard School of Public Health graduate student in global health and population and founder and VP of Finance at TraumaLink. Michael Greenstone is the 3M Professor of Environmental Economics in the Department of Economics at MIT. Feroz Ali Khader is a member of the faculty at the the Indian Institute of Technology, Madras, where he holds the Ministry of Human Resources Development chair. Madhav Khosla is a doctoral candidate in the Department of Government (Political Science) at Harvard University. Raahil Madhok is research associate at the Abdul Latif Jameel Poverty Action Lab in Chennai, India. 4 Health and South Asia CONTRIBUTORS Maria A. May is the Harvard South Asia Initiative’s program consultant in Dhaka, Bangladesh, and the program manager for BRAC’s Social Innovation Lab. Rahul Mehrotra is professor of urban design and planning at Harvard’s Graduate School of Design and founder principal of RMA Architects. Nachiket Mor is chair of CARE India, an organization that focuses on ending poverty and social injustice. Jon Moussally is an attending emergency physician and founder and president of TraumaLink. Rohini Pande is the Mohammed Kamal Professor of Public Policy, area chair for political and economic development, codirector of Evidence for Policy Design, and director of the Governance Innovations for Sustainable Development Group at Harvard’s Kennedy School of Government. Achal Prabhala is an Indian researcher, activist, and writer based in Bangalore and works on intellectual property rights in relation to medicine and knowledge. Erum Sattar is a doctoral candidate at Harvard Law School, editor in chief of the Harvard Asia Quarterly, and president of the Harvard Pakistan Student Group. Sharmila Sen is executive editor-at-large at Harvard University Press. Hardik Shah is a Giorgio Ruffolo Research Fellow in the Sustainability Science Program at the Harvard Kennedy School of Government. Pawan Sinha is professor of vision and computational neuroscience in the Department of Brain and Cognitive Sciences at MIT. S. (Subu) V. Subramanian is professor of population health and geography in the Department of Society, Human Development, and Health at the Harvard School of Public Health. Malavika Subramanyam is a social epidemiologist at the University of Michigan. Conor Walsh is assistant professor of mechanical and biomedical engineering at the Harvard School of Engineering and Applied Sciences and a core faculty member at the Wyss Institute for Biologically Inspired Engineering at Harvard. Harvard South Asia Institute 5 6 Health and South Asia Courtesy of Gates Foundation. More Money, More Health? An Indian Tale Peter Berman1 In 2009, a prestigious global task force proposed specific steps to improve the funding of health systems in lower-income countries. The slogan it adopted for its report was “more money for health, more health for the money.” As best I can tell, this slogan originated from Professor Ramalingaswami of India, a distinguished public health leader, several decades earlier. It describes well the dual challenge facing South Asian countries which underspend on health but also squander limited funds on poorly performing systems. According to the global database maintained by the World Health Organization, health spending in the South Asian nations of Bangladesh, India, Nepal, Pakistan, and Sri Lanka ranges 3–5% of gross domestic product (GDP). This is well below average for all developing countries and is even in the range of lower-income countries. The share of government spending out of total expenditure on health care ranges 27–45%, showing the relatively modest roles played by governments in these health systems. Nonetheless, governments are often the main providers of important public health services, such as immunizations or disease-control interventions, which can account for a large share of total health gain over time. Getting more government money for health and more health for government money could make a difference in overall health in South Asian countries. While living in New Delhi as lead economist for health, nutrition, and population with the World Bank, I was delighted in 2005 to hear strong public statements by India’s finance minister and prime minister that they intended to double or triple government health spending over the next five years. (Actually, their statement was even more ambitious, proposing to raise government health spending from about 1% of GDP to 2–3% of GDP, during a period Harvard South Asia Institute 7 of rapidly rising GDP.) When the health minister calls for such increases, one might be forgiven for a tempered reaction. But when the leading finance authorities in government get out in front, there is reason for optimism, even enthusiasm! With my colleague Rajeev Ahuja, I decided to follow the money in the ensuing years. And therein lies a tale with lessons for nations in South Asia and elsewhere. The plan that took shape in 2005 was promising. India was in a period of unprecedented economic growth, with real increases in GDP of over 8% between 2004 and 2008, and again in 2009–10 and 2010–11. Government revenues were buoyant. The union government announced a major new initiative, the National Rural Health Mission (NRHM), and promised to increase its allocations to the scheme by 30–40% each year in the eleventh plan period. NRHM included a number of technically sound public health interventions to improve maternal and child health and control communicable diseases. It proposed that states, which accounted for about three-quarters of all government health spending, should also gradually increase their spending on NRHM, to accelerate increases in total spending. The scheme consolidated and expanded the government’s channeling of funds through “societies,” government-affiliated agencies with less bureaucratic spending rules, to reduce red tape. (Not an idle goal, Indian government departments actually still wrap their files in real red tape!) It channeled a sizable share of new spending through cash-transfer block grants to districts, subdistricts, and individual health facilities; and cash grants to expectant mothers to encourage them to seek prebirth services and deliver their babies in health facilities. In 2005, India, still a low-income country, had the political will, the economic means, and the strategy to dramatically increase financing for essential health care. We have tracked the progress of increasing government health spending three times since 2005, most recently in early 2013, to try to capture progress through the conclusion of the initial seven-year period of the NRHM. What happened, and what can we learn from that experience? Overall, recent data (see fig. 1) confirm that India has significantly increased its government health spending from 0.93% of GDP in 2004–5 to almost 1.1% of GDP in 2011–12. In real per capita terms, the amount has increased by 83% (from INR 254 to INR 465). The goal of doubling government spending as a percent of GDP has not been achieved. But this was in fact a very ambitious goal, given the rapid GDP growth of that period. (When GDP is growing so quickly, you have to run pretty fast just to stand still in spending as a percent of GDP.) What emerged from our research is an important story about how more than political commitment and fiscal capacity is needed to increase health spending effectively in a complex, low-income country like India. Initially, India’s national government allocated substantial new funds to NRHM according to its plans. But in the first few years of the program, evi8 Health and South Asia dence increasingly emerged that budgets and allocations were often not being translated into actual expenditures on the ground (see fig. 2). A number of significant bottlenecks at both central and state levels were impeding the flow of funding through a complex federal system and the multiple mechanisms that had been created. India’s independent comptroller and auditor general, in his 2009 audit report on NRHM, noted the difficulties in assuring disbursements and recommended that “funds flow arrangement should be rationalised to ensure minimum unspent/excess amount is left outside government accounts.” Gradually, some of these bottlenecks have been broken. In more recent years, actual reported spending in many states has in fact exceeded budgets and allocations. Our research suggests several reasons for this. First, unlike regular budgets, funding through the society mechanism can be disbursed over several years, allowing more spending in later years from the underspending in earlier ones. Second, officials have been more modest in their budgets, causing the gaps between budgets and expenditures to shrink from both the slowing of budget growth and the increasing pace of spending. Third, there have been some improvements in the mechanisms used to move money. The state governments underestimated the systems that would be needed to make millions of small payments to community health workers and expectant mothers. Despite reduced rules, society officials often still sought authorizations just to be safe, which in turn delayed spending. Although spending has improved and there is evidence that NRHM can point to many positive achievements, the overall financial result was far below what was promised. And the progress has been uneven. There are strong indications that things have worked better in the more advanced states and that progress has been slower in lagging states which were the intended beneficiaries of additional effort by NRHM. A major corruption scandal affecting the program in Uttar Pradesh, India’s most populous state, undermined support. It remains difficult even now to track the financial position of the program overall and assure accountability—funds transferred from one level of government to another or to societies can appear as spent in the accounts but still be languishing in a bank account along the way. India has reconfirmed its commitment to NRHM, now the National Health Mission, in its current twelfth five-year plan, and proposed continued, increased spending, although with somewhat less ambition. Growth has slowed and the government faces new fiscal challenges that have narrowed the large opening for financial increase that appeared in 2005. Systems are improving. What India, and other countries in South Asia, can learn from this experience is that achieving more money for health and more health for the money requires much more than rapid economic growth, political and policy commitment, and program design. It requires attention to the mundane mechanics of how government functions at many levels and good evidence to Harvard South Asia Institute 9 monitor progress and make rapid corrections. Building effective and efficient service-delivery systems is hard but valuable work that needs to begin before the window of funding opportunity opens and is sustained once it does. Figure 1: Government health expenditure in India as percent of GDP.* * Audited accounts of actual expenditure are only available through 2010 at this time. Figure 2: Growth in total NRHM allocations and their utilization. 10 Health and South Asia References: Berman, Peter, and Rajeev Ahuja. “Government Health Spending in India.” Economic and Political Weekly 43, nos. 26/27 (June 28–July 11, 2008). Berman, Peter, et al. “The Changing Government Health Financing Landscape in India.” HNP Discussion Paper. Washington, DC: World Bank, 2009. Government of India Comptroller and Auditor General. Performance Audit Report. No. 8 of 2009–10. http://www.cag.gov.in/html/reports/civil/2009_8_PA/contents.htm. Ravishankar, N., Rajeev Ahuja, and Peter Berman. “Strengthening Public Financing for Primary Healthcare Delivery in India.” Boston: Harvard School of Public Health, forthcoming. 1. Assistance from Rajeev Ahuja is gratefully acknowledged. Harvard South Asia Institute 11 12 Health and South Asia Courtesy of Radhika Jain. Will the Gender Violence Just Continue? Jacqueline Bhabha India, the birthplace of nonviolence and yoga, has recently become the poster child for gruesome gender-based violence (GBV). Global attention was first alerted to this grave and long-standing national crisis on December 16, 2012, when a twenty-three-year-old physiotherapy student was brutally gangraped on a bus in the nation’s capital and hundreds of thousands of citizens flocked to the city center to protest. It was realerted eight months later when a photojournalist was similarly brutalized in India’s commercial capital, right next to one of Mumbai’s most popular high-end malls. And a few weeks after that incident, the rape of a six-year-old village girl in Rajasthan hit the headlines, not because of the routine fact that a forty-year-old had raped a six-year-old (rural victims’ cases rarely get reported) but because the panchayat, the village-governing body, had ordered the girl’s parents to marry her to the rapist’s eight-year-old son. Will this violence just continue unchecked? For foreign observers, these recent reports further mar the India brand— they compound the gloomy economic news about growing inequality, rising unemployment, and a falling rupee. Parents may be less inclined to let their backpacking daughters travel to India; celebratory accounts of the wonders of Jaipur’s literary festival or Cochin’s Biennale are tarnished by a darker perception of the Indian public sphere. For domestic media consumers closer to Indian news, the prevalence of rape, sexual harassment, marital violence, and a host of other forms of GBV is inescapable but generally ignored. But for Indian women and girls, particularly those who rely on public transport for school or work, it is an overwhelming fact of daily life. Reliable up-to-date data is hard to come by. According to the Wall Street Journal National Crime Records Bureau, 24,206 rapes were reported in 2011, likely a fraction of occurrences Harvard South Asia Institute 13 given pervasive underreporting. Women’s and children’s rights organizations such as Majlis and Aangan argue that public awareness has finally caught up with what they have known and tried to address for decades—an epidemic of gender violence that starts before birth (India’s sex ratio is worse now than it was half a century ago) and feeds off impunity, puritanism, and radical gender and class inequality. Will this violence continue unchecked? Government response to the explosion of adverse publicity was energetic. A high-level judicial commission, the Verma Committee, set up to investigate the Nirbhaya case (as the Delhi rape came to be called) and GBV more broadly, and to make recommendations, reported with record speed, competence, and force. In line with loud public calls for punitive measures (some Congress MPs even called for castration and death penalty for all rapists!), the committee directed considerable attention to criminal law reform. It called for radical change, inter alia to speed up trials and increase convictions in rape cases, to criminalize marital rape, to eliminate chain-of-command impunity for military and police officers. The committee did not limit itself to punitive measures. It also called for a systemic engagement with preventative approaches, from adolescent and sexuality education in schools, to enhanced protections for street children and other young people brutalized by an absence of appropriate family care. Taking note of changing youth mores and growing scientific data on adolescent psycho-biological maturation, it also recommended reducing the age for consensual sexual activity from eighteen to sixteen. It wisely recognized that adolescent homelessness and sexuality are issues that need to be addressed constructively rather than punitively. In short the Verma Committee called for a dual approach to the GBV crisis—a law-enforcement overhaul to radically improve criminal law enforcement and reduce impunity, and a comprehensive set of preventive social and economic reforms to tackle gender norms and roles in schools, to enhance adolescent skills and opportunity, and to reduce caste-, class-, and gender-based discrimination. Beyond the Verma Committee report, however, little progress on the ground has been made. So, will the violence continue unchecked? On the legislative front, a new law, the 2013 Criminal Law (Amendment) Act, has only partially adopted the committee’s recommendations. Except for wives under fifteen (n.b. eighteen is the minimum legal age of marriage for a woman), marital rape has not been criminalized, apparently because bringing the law into the bedroom was not considered a good idea. And even where the committee’s recommendations have been enacted, practice has not followed the law. For example, fast-track court cases have been approved in theory, but in practice long delays continue. Just this past week, nine months after the Delhi gang rape, the court has finally convicted the men involved. On the preventative front, predictably the committee’s recommendations have had much less attention or uptake. The recommendation that consensual sexual activity be legalized at sixteen was rejected, with a rabid lobby baying for the blood of 14 Health and South Asia the juvenile, allegedly the most vicious rapist in the Delhi case. The committee’s insistence that youth opportunity, gender norms, and adolescent education be a prime target of pedagogical and social intervention has so far fallen on deaf ears. As a result, educational opportunity, the best route to female protection and social advancement we know, is still radically unavailable. Sixty-six years after Indian independence, only 50% of sixteen-year-old rural girls attend secondary school; in Rajasthan, the largest state in the country, female illiteracy runs at 66%. Despite superb work on adolescent education strategies conducted by public entities such as the National Council of Educational Research and Training and the National Commission for Protection of Child Rights, and by nonprofits such as the MV Foundation in Andhra Pradesh, the Study Hall Educational Foundation in Uttar Pradesh, and Muktangan in Maharashtra, little progress has been made in supporting teachers who want to address issues of equal access, sexuality, gender roles, and reproductive rights and health in the classroom. Meanwhile, information technology makes violent and sexually explicit imagery widely available, while consensual adolescent sexual experiences remain largely inaccessible and socially proscribed. Small wonder, perhaps, that the number of rapes committed by juveniles more than doubled in the last ten years. So, will the violence continue unchecked? We hope not. But change requires dramatic intervention in gender relations and in the balance of power between boys and girls, men and women. Prosecutions and convictions alone, critically important as they are, will not do the trick. Attitudinal shifts, incentives that validate male/female collegiality rather than predation, and much more radical equality between the sexes need to be scaled. So do alternatives to early marriage, and to female financial dependency. A set of Harvard research initiatives addresses, together with local Indian partners, some of these complex issues. The Champions Project, now in its second year, investigates the factors that enable low-caste girls from illiterate backgrounds to make it to college. How, we ask, have these “champions” become positive deviants, successfully engaged in higher education and self-improvement when most of their peers are already married and bearing children? Data from our first round of research, in Maharashtra, is depressing. It suggests that government programs have contributed very little. Scholarships are hard to access, application forms for stipends are unavailable and daunting, and transport schemes are generally coed and not regarded as safe. What really makes a difference, according to our findings, is parental mentorship (agreeing to delay a daughter’s marriage, take on her housework, scrape together resources to support her) and individual resilience (in the face of persistent harassment and abuse). The research team is launching Champions phase two in Rajasthan. Another initiative targets adolescent education. Its main goal is to figure out how high-quality sexual education and reproductive-rights curricula developed decades ago can be moved from ministerial shelves into classrooms. What political and educational incentives need to be Harvard South Asia Institute 15 in place to displace the very widespread notion that sexual education equals encouraging sex? What do teachers need to get the clout to implement radically new teaching syllabi and methodologies? What steps must be taken to enable Indian boys to demonstrate their virility and strength in collaborative, gender-respectful rather than belligerent ways? And finally, what forms of empowerment and support do young women need to turn the tables on their predators? A joint team of educators, researchers, and politicians is addressing these questions. Stay tuned. 16 Health and South Asia Harvard South Asia Institute 17 18 Health and South Asia Courtesy of Rosie Putnam. The Graying of South Asia David Bloom South Asian populations are poised for rapid aging. The share of people aged 60 or older in South Asia—taken to include Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka—was essentially unchanged between 1970 and 2010, but is expected to double to 15% by 2040. In 2010, there were 126 million South Asians aged 60 or over, a number that is projected to reach 329 million by 2040, more than the entire current population of the United States. The aging of South Asian populations is a phenomenal achievement, reflecting a sharp decline in mortality resulting from infectious diseases and poor nutrition and a corresponding two-decade increase in life expectancy over the past half century alone. But greater longevity also creates some formidable social and economic challenges. These include the prospect of mass loneliness, frailty, and financial insecurity among burgeoning numbers of older South Asians. Especially daunting are the projected burdens of care and financial support on older people’s children, grandchildren, and communities. An equally distressing feature of population aging in South Asia is the fact that the region is likely to grow old before it becomes wealthy—a pattern distinctly different from today’s more developed regions of the world. For example, if income per capita in South Asia increases through 2040 at the same rate as it has enjoyed since 1980, it will reach $8,900 (in dollars adjusted for purchasing power parity), just half the level enjoyed by the developed regions when their elder shares crossed 15% (around 1980). Notwithstanding these concerns, there are both policy and behavioral adaptations to population aging that suggest its consequences for South Asia are not set in stone. One set of adaptations is fertility decline, which continues to Harvard South Asia Institute 19 be a salient feature of South Asian demography. In 1950, lifetime fertility for the average South Asian woman was six children; this figure has fallen to just 2.5 today and is projected to decline further in the decades ahead. Lower fertility is a partial antidote to population aging, because it signals a falling burden of youth dependency, which can free up significant social resources for use in addressing the rising burden of old-age dependency. A second set of adaptations involves the design and implementation of institutions that provide health and economic security for the elderly. Such institutions are currently in a nascent state throughout South Asia, as the lionâ€™s share of responsibility for caring for older people rests privately with families. But this pattern of support for older people is likely to be challenged. Many younger people are moving to urban areas, and although such relocation tends to lead to higher incomes, it also leaves fewer people behind to provide care and companionship for parents. Women, who are the traditional caretakers, are joining the workforce in increasing numbers. This, too, leads to higher incomes, but it means that women are less able than in the past to provide care. South Asia must get started now on developing new institutions and policies for supporting its older people. Although not easy, this task is surmountable. It raises fundamental questions as to who will create and manage these institutions, and who will pay for them. A country that is seeking to expand the availability of pensions and health care will need to decide on the level of benefits, their reach of distribution, and the public-private division of responsibility for both their provision and financing. Thorny questions always arise regarding the work disincentives that pensions can lead toâ€”a problem that will need to be addressed. Funding is particularly problematic, as neither payas-you-go pension systems nor pensions that are fully funded in advance turn out to be as reliable as their advocates assert. And of course, problems abound in ensuring that older people have access to health care, as tough decisions will be needed about the balance between prevention, treatment, and care. A final set of adaptations to the challenges posed by population aging lies in behavioral changes. For example, people who expect to live longer lives will tend to save more for longer periods of retirement. These increased savings can provide the basis for societal investments in both human and physical capital that can lead to gradually rising living standards for everyone, including older people. Population aging also creates numerous opportunities for business development related to everything from the design of housing and recreation facilities to the training of human resources for eldercare to the establishment of programs for financial literacy. As it ages, South Asia might look to industrial countries for examples of how to cope. Numerous developed-country institutions provide an important bulwark against the problems of aging populations. Social security programs provide at least a benefits floor for a large segment of the older population. Some variant of universal health insurance is available to the majority of peo20 Health and South Asia ple above a certain age. And a network of health care institutions that cater to older people, while far from universally available, provides some substantial amount of reassurance of continuing care for at least some segment of the older population. But blindly copying these institutions would not serve South Asia well, as they have some serious pitfalls. For example, most of the social security and national health systems are funded on a pay-as-you-go basis. This places them at the mercy of demographic changesâ€”as the population ages, it becomes increasingly difficult to guarantee the economic security of older people. Winston Churchill once said, â€œA pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.â€? Population aging clearly poses challenges for South Asia. But the biggest risk South Asia faces is not aging itself, but rather the possibility that it might fail to act in a timely manner. As for the rest of the world, population aging represents virgin territory for South Asia. But the absence of proven charts for navigating these waters should not be a cause for alarm. Rather, it is an opportunity for South Asian populations to show their mettle by adopting new behaviors and institutions that address the challenges of population aging in ways that are appropriate to their circumstances and that allow them to realize the benefits of longer lives. Harvard South Asia Institute 21 22 Health and South Asia Courtesy of South Asia Institute. Indian Patent Law and the Novartis Case: An Interview with Feroz Ali Khader Madhav Khosla In 1970 India enacted its first patent legislation, the Patents Act. A committee headed by a retired judge of the Indian Supreme Court (the Rajagopala Ayyangar Committee) had recommended a limited process patent over the wider product patent with respect to pharmaceutical drugs. In other words, a patentee would be able to claim monopoly only with respect to the process by which a drug was produced and not the final drug itself. The act of 1970 adopted this recommendation, leading to the domestic emergence of a robust generic-drug industry built on reverse-engineering drugs obtained from patented processes. In 1994, however, India signed the Treaty on Trade-Related Aspects of Intellectual Property Rights (TRIPS). As part of its TRIPS obligation, India was given ten years to recognize product patenting in the pharmaceutical sector. This transition invited some degree of concern, and several lawmakers and members of civil society were eager to check the evergreening of patenting. Under this practice, common in the pharmaceutical industry, new forms of patented drugs providentially get discovered close to the date of expiry of the original patent, and the patentee, in turn, files a fresh patent application for the new form. Section 3(d) of the 1970 act, introduced through an amendment in 2005, finds its objective in this fear. The provision renders patent-ineligible new forms of a known substance, unless such forms lead to enhanced efficacy. In 1998, Novartis AG, a Swiss pharmaceutical giant born out of the 1996 merger of Ciba-Geigy and Sandoz Laboratories, sought an Indian patent for the beta-crystalline form of its blockbuster drug, Glivec. Novartis markets the drug under the name Gleevec in the US and as Glivec elsewhere. Chemically known as imatinib, Glivec is a tyrosine-kinase inhibitor used in the treatment Harvard South Asia Institute 23 of multiple cancers, most notably Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia. Novartis’s case was that the beta-crystalline form of this molecule exhibits greater stability and bioavailability than the alpha polymorph. In response, the Indian Patent Office resorted to Section 3(d) of the Indian Patents Act of 1970, to deny patent protection on the ground that Novartis’s application covered “new form of a known substance,” with no proven enhancement of efficacy. After an unsuccessful challenge to the constitutional vires of Section 3(d) before the Madras High Court, Novartis had chosen to defend the eligibility of its product on the merits. The patent controller’s order was unsuccessfully appealed before the Intellectual Property Appellate Board, and Novartis chose to approach the Supreme Court. After considering a lengthy set of arguments involving diverse stakeholders, the Supreme Court pronounced its verdict on April 1, 2013, and dismissed Novartis’s appeal. A new form of a known pharmaceutical substance must, the court held, necessarily pave the way for enhanced therapeutic efficacy in order to attain patent eligibility. This decision, domestically and globally regarded as one of India’s most significant intellectual-property verdicts, has profound public health implications. It has also engendered a fierce debate on the appropriate incentives that a patent regime must provide and on the nature of freedom that TRIPS grants member countries to structure their individual patent regimes. In this interview, I speak with Feroz Ali Khader to learn more about the decision and its implications. Feroz Ali Khader holds the Ministry of Human Resources Development chair at the Indian Institute of Technology, Madras. His book, The Law of Patents, was published by LexisNexis in 2007. What is the standard for patent eligibility of new forms of a known substance that the Novartis decision advocates, in the context of the pharmaceutical industry? Is the decision clear in its articulation of the requisite standard, and are there any possible gaps in such articulation that the court may have to clarify in the days to come? In referring to threshold qualification, the Indian patent law uses the phrase “what are not inventions” over “patent eligibility.” Section 3(d) of the Indian Patents Act allows patents for new forms of known substances if there is an enhancement of efficacy. The act does not describe what “efficacy” is or how it is to be gauged with regard to pharmaceutical substances. The seminal contribution of the decision to patent law is its upholding of the interpretation of efficacy for pharmaceutical substances as “therapeutic efficacy,” which was developed by the Madras High Court. The decision clearly states that for a medicine, the test of efficacy can only be therapeutic efficacy. In the context of the case, the Supreme Court held that beneficial properties such as more beneficial flow properties, better thermodynamic stability, and lower hygroscopicity are irrelevant if such properties do not directly relate to efficacy (para. 180). 24 Health and South Asia Though there is room for defining more clearly what amounts to â€œtherapeutic efficacy,â€? the Supreme Court declined to go beyond the facts and requirements of the case (para. 186). This is a strategic move which gives freedom for the Patent Office and the Appellate Board to flush out the details of the standards on a case-by-case basis. The court makes it clear that the subject patent application covering the beta-crystalline form of imatinib mesylate does not qualify the test of section 3(d). It clarifies that it does not mean that section 3(d) bars patent protection for all incremental inventions of pharmaceutical substances. What is the impact of the Novartis judgment on the generic-drug industry in India in the light of the prescribed standard for patent eligibility? We have a highly diversified, layered generic industry here. Section 3(d) has been used by the generic companies not only to challenge patents held by multinational pharmaceutical companies, but also to challenge some applications filed by Indian generics. The judgment did not establish anything new. It confirmed the decisions of the Patent Office, the High Court of Madras, and the Intellectual Property Appellate Board over the last decade. Does the TRIPS permit varying standards for patent eligibility across jurisdictions? If so, what is the underlying philosophical basis for such authorization of varying standards? Countries have never been in agreement as to what the exclusions to patentability should be. This disagreement can also be seen in the TRIPS too. As the decision notes, when India introduced the Patents (Amendment) Act, 2002, it noted in its statement of objects and reasons that modifying section 3 of the act to include exclusions is permitted by the TRIPS Agreement. Given that member countries were polarized during the Uruguay Round on the intellectual property mandate under the GATT/WTO regime, one would be at a loss trying to decipher the philosophical basis of the provisions of the TRIPS. The reasons for varying standards are more often political than philosophical. What is the extent to which Section 3(d), and its interpretation in the Novartis decision, could be treated as divergent from TRIPS? I see more disagreement than agreement in the TRIPS. Constructive ambiguity was built into the TRIPS Agreement to accommodate divergent views that came from the negotiating members. Except for few provisions on which the members agree (e.g., extending the term of patent to 20 years), there are a host of provisions where the language of the agreement opens itself for multiple interpretations. Hence nothing can be treated as divergent from TRIPS, as there is no agreed view of what the TRIPS stands for. Section 3(d) has stood the test of time. Novartis, through a member country, had the option of questioning its compliance with TRIPS years ago when its patent was rejected citing, among others, this provision. It did raise the issue of noncompliance at Harvard South Asia Institute 25 the Madras High Court which was ruled against them upholding the constitutional validity of the provision. With regard to the compliance with TRIPS, the Madras High Court indicated that it would be a matter that had to be agitated before the Dispute Settlement Body (DSB) of the WTO. Since then, we have not seen any country file a complaint stating that section 3(d) is not TRIPS-compliant, despite the steady flow of rejection of patent applications in India based on section 3(d) objections. Moreover, countries like the Philippines, Brazil, and others have considered the idea of having a section 3(d)–like provision in their patent statutes. Barring some industry voices, we do not see a challenge to this provision under the DSB. The TRIPS Agreement, being an international treaty, will be interpreted as the members practice it. Has the Novartis decision also applied new legal standards for the traditional patentability requirements of novelty and nonobviousness? The patent in issue was rejected as it failed both the tests of invention and patentability under the act (para. 195). The Supreme Court avoids the issue of categorizing section 3(d) either as a standard of patentability or as an extension of the definition of “invention” (para. 190). But it does imply that section 3(d) sets up a second tier of qualifying standards for pharmaceutical substances (para. 103). As someone who has worked on the constitutional challenge to Section 3(d) before the Madras High Court, what are your views on the possible arbitrary application of this provision to hold as patent-ineligible even innovative and patient-friendly compounds? Wherever there is discretion, there is room for arbitrariness. We have trusted our patent offices with much greater things. All decisions applying these provisions can be appealed. I see the decision as a testimony to the failure of Novartis’s patent prosecution rather than as a triumph of a unique provision in Indian patent law. Remember, the validity of the provision was not in issue before the court. What was in issue was the particular application filed by Novartis and the causes for its rejection. 26 Health and South Asia Harvard South Asia Institute 27 28 Health and South Asia Courtesy of of BRAC, Bangladesh. Urban Communities and Health in South Asia Maria A. May and Richard A. Cash Like the rest of the world, South Asia is quickly transforming from a land of villages and farms to one of megacities (see fig. 1). This migration signals economic growth and new opportunities, but also presents alarming new vulnerabilities for health. In many cases, the new health risks arise from conditions in informal and underserved urban communities. Every year, approximately 100,000 people move to Mumbai with the intention to stay there permanently.1 Across India, close to 100 million people live in slums.2 About half live in “notified slums,” which have official recognition from the government and whose residents have won certain protections. Though far from perfect, notification opened the door to greater tenurial security, enabling local residents to advocate for better provision of public services of schools, utilities, and police protection. Slums have intense internal dynamics. Katherine Boo’s highly acclaimed Behind the Beautiful Forevers gives an excellent description of the underground economy and politics of Annawadi, a large slum in Mumbai: At Annawadi, everyone had a wrong he wanted righted: the water shortage, brutal for three months now; the quashing of voter applications at the election office; the worthlessness of the government schools, the fly- by- night subcontractors who ran off with their laborers’ pay. . . . But the slum dwellers rarely got mad together—not even about the airport authority [which was responsible for the eviction of the entire community]. Instead, powerless individuals blamed other powerless individuals for what they lacked. . . . What was unfolding in Mumbai was unfolding elsewhere, too. In the age of global market capitalism, hopes and grievances were narrowly conceived, which blunted a sense of common predicament. Poor Harvard South Asia Institute 29 people didn’t unite; they competed ferociously amongst themselves for gains as slender as they were provisional. And this undercity strife created only the faintest ripple in the fabric of the society at large. . . . The poor took down one another, and the world’s great, unequal cities soldiered on in relative peace.3 In Bangladesh, the country’s 13 million slum dwellers live without any formal legitimacy from the national or municipal governments (see fig. 2). The capital, Dhaka, is thought to be the world’s fastest-growing city, receiving over 300,000 people last year.4 Roughly half of slum dwellers live on public lands and therefore can avail the Supreme Court, although to date these efforts have had limited impact. The others, who live on private land, have no protections. Consequently, slum communities are largely left to fend for themselves. In the wake of a formal authority, mastaans, or local slumlords, who often are backed by powerful political forces, step in to “maintain order,” at the price of regular extortion, plus intimidation and violence, when required. The importance to the slum dwellers of achieving political power to change their environments and circumstances has long been recognized as critical to their long-term development and survival. In the late 1980s, a small organization in Mumbai began to work with a slum threatened with eviction. It helped a group of local women gather demographic information about the community and present it to the municipal authorities. These were the people that would need resettling. The authorities reviewed it and said that there was no available land to offer. The organization helped the community obtain a list of publicly owned land that was not in use. The women visited many sites and returned to the authorities with the list, having ranked the locations in order of preference. Eventually the authorities agreed to provide a plot of land where they could build homes and stay permanently. Inspired by the success of this approach, the organization, called Society for the Promotion of Area Resource Centres (SPARC), began to spread the idea to communities across India, then across the world. It helped establish a network of local chapters, called Slum Dwellers International.5 One of the keystones of their work is to take community leaders, like those who achieved the earliest successes in Mumbai, to other communities as far as Kenya, to talk about their strategies and experiences. Over the past 25 years, SPARC has helped over 12,000 families secure resettlement in Mumbai.6 Similar to SPARC, the organization Urban Partnerships for Poverty Reduction (UPPR) in Bangladesh helps slum dwellers organize community-development committees to improve their living environments.7 It has had some impressive successes, including the establishment of the planned community for the landless veterans of Bangladesh’s War for Independence in 1971. Built by the army, the neighborhood has wide lanes, functional latrines, formal electricity connections, and an effective drainage system. These 400 families are some of the few slum dwellers in Bangladesh that can live without fear of 30 Health and South Asia eviction. SPARC and the UPPR program have achieved something rare: they managed to convince an urban community to mobilize collectively. This is a powerful strategy for change, but quite difficult in the complex social context of slums. One of the most urgent health issues to tackle is that of sanitation and hygiene within the slums. There is rarely a system of waste management; trash is everywhere. Many communities lack any sort of hygienic toilet and are forced to resort to open defecation. Hepatitis E, linked to fecal contamination of drinking water, is common in Dhaka slums and is linked to a significant proportion of maternal deaths.8 Organizations like SPARC are tackling sanitation on a small scale, supporting communities to establish and manage private toilets. The Support Programme for Urban Reforms (SPUR) in Bihar is helping slum committees mobilize to more effectively demand basic services from the somewhat sluggish municipal governments.9 Sanitation is almost every communityâ€™s first priority. There are robust efforts to facilitate safe pregnancy and delivery for women in urban Bangladesh, notably BRACâ€™s Manoshi program that covered over six million people in urban slums last year; however, gains will be limited unless slum conditions become more hygienic.10 Health risks of slums are not limited to waterborne diseases. The close living quarters also facilitate the spread of airborne diseases, such as tuberculosis and pneumonia. Over a third of child deaths in Dhaka result from acute respiratory infections.11 Several Indian cities have discovered growing incidence of drug-resistant tuberculosis, the result of poor patient support for daily medication adherence and dense populations. These problems are unlikely to stay contained to the slums. Slum dwellers are incredibly mobile, often working in the homes of the wealthy, preparing food and tea for pedestrians, and moving between slums and returning frequently to their villages. In many South Asian cities, the majority of residents lives in slums and work in the informal sector.12 Yet their representation and voice are largely absent from the political dialogue. In a few instances, slum dwellers have mobilized in powerful ways. Inclusive policies for urban growth can help individuals and nations capitalize on economic opportunities, while removing the underlying causes of disease and vulnerability facing the urban poor. Harvard South Asia Institute 31 1. 2. Doug Saunders, Arrival City: How the Largest Migration in History Is Reshaping Our World (New York: Vintage, 2012). Amantha Perera, “‘Slum Cities’ in South Asia Need Better Planning,” April 10, 2012, http://www.theguardian.com/global-development/2012/apr/10/slum-cities-south-asiaplanning. Katherine Boo, Behind the Beautiful Forevers: Life, Death, and Hope in a Mumbai Undercity (New York: Random House, 2012). Building to Last: Creating a Platform to Tackle Urban Poverty (Dhaka: BRAC Social Innovation Lab, August 2012), http://www.brac.net/sites/default/files/Building%20to%20Last%20 (print%20friendly).pdf (accessed September 15, 2013). SPARC, “Resettlement and Rehabilitation (R&R) Projects,” http://www.sparcindia.org/ resettlement.aspx (accessed September 15, 2013). 3. 4. 5. 6. Ibid. 7. 8. Urban Partnerships for Poverty Reduction–Bangladesh, http://www.upprbd.org (accessed September 10, 2013). Fatema Khatun et al., “Causes of Neonatal and Maternal Deaths in Dhaka Slums: Implications for Service Delivery,” BMC Public Health (January 26, 2012), http://www.biomedcentral.com/1471-2458/12/84. Department for International Development, Government of the United Kingdom, “Support Programme for Urban Reforms in Bihar,” http://projects.dfid.gov.uk/project. aspx?Project=114040 (accessed September 10, 2013). 9. 10. “BRAC at a Glance,” December 2012 issue, http://www.brac.net/content/stay-informedbrac-glance#.Ujb3bNKmh60 (accessed September 15, 2013). 11. A. K. Halder et al. “Causes of Early Childhood Deaths in Urban Dhaka, Bangladesh,” PLOS ONE 4, no. 12 (2009): e8145, http://www.plosone.org/article/ info%3Adoi%2F10.1371%2Fjournal.pone.0008145. 12. Johannes P. Jütting and Juan R. de Laiglesia, eds., Is Informal Normal? Towards More and Better Jobs in Developing Countries (Paris: OECD, 2009). 32 Health and South Asia Figure 1 : Population of selected cities in South Asia and the United States, in millions Figure 2: India and Bangladeshâ€™s population distribution, in millions Harvard South Asia Institute 33 34 Health and South Asia Courtesy of South Asia Institute. Health Care Financing in India Nachiket Mor There are two key health-financing questions for India: (a) where should the money to pay for health care come from; and (b) how should it be spent? Health care is a service with some peculiar characteristics that need to inform the search for answers to these two questions. There are three characteristics in particular that are very important and which any good health-financing design would need to address. 1. The presence of large health shocks: While a great deal of health care expenditure at an individual or a household level has a regular, repeated character, in the lives of most individuals there are sudden, unexpected health shocks that can cost a great deal of money. The only way to manage this is to ensure that there is good pooling across a large group of households. However, for a variety of reasons, this does not happen naturally even if people have the money or are given it to enter such pools through the voluntary purchase of health insurance. Some form of a regulatory mandate is essential to ensure that this happens. 2. Poor health-seeking behavior: This is linked closely to the understanding that individuals have about their own health status and what is best needed for their own good health, which often tends to be very poor and incomplete. This results in very high price elasticity for primary/preventive health care, but very low elasticity for higher levels of health care, which leads to highly distorted consumption patterns. There is limited evidence that improved health literacy has any impact on this. What is needed instead is a strong sense of direction and regulation of health care which would require and incentivize individuals Harvard South Asia Institute 35 and health care providers to act in accordance with the best scientific evidence even if it is not always in complete agreement with their own personal preferences or prior beliefs. 3. Nonpostponable character: Health care expenditures, even routine ones, have this character and therefore need to be immediately financed. However, there is poor health-related savings behavior that leads to financial distress, even to meet routine health care expenditures and even among middle-income households. In environments with poor access to savings and credit instruments such as India, this problem is further exacerbated. The only way to address this is to ensure that at the precise time at which health care is needed, it will be available entirely free of cost to every individual. While there is much debate worldwide on whether the government should be a provider of health care services or not, it is reasonably clear that in order to ensure that any health-financing and health-systems design is responsive to the above three characteristics, the government will need to play a very active role. In the Indian context, the High Level Expert Group on Universal Health Coverage, appointed by the government of India in 2012, determined that in order to offer universal health care in India, against actual national expenditures of close to Rs. 2,500 (PPP $150) per capita (public plus private), the total amount needed was between Rs. 1,500 (PPP $100) and Rs. 2,000 (PPP $125) per capitaâ€”well within the reach of India as a nation. At a consolidated level the government (state plus center) currently spends close to Rs. 600 (PPP $40) per capita on health care, which is only about a third of the total amount that is needed. At close to 1% of GDP this makes India among the bottom ten countries in the world in terms of share of public expenditure on health care. With this limited amount of money the government attempts to run a bare-bones primary health care system which is focused almost solely on the delivery of babies. And, through its network of secondary and tertiary hospitals, as well as a national health insurance scheme focused on the very poor, the government seeks to provide very limited access to other forms of health care to a small fraction of the population. Other than this the government has taken little or no interest in any other aspect of health care financing or provision, with the result that over 70% of health care at all levels is provided by a highly fragmented and essentially unregulated private sector with payments being made by households on an out-of-pocket basis. As a direct consequence, the overall health status of the population continues to remain poor and health care expenditures have been shown to be one of the most important reasons for impoverishment and indebtedness of households. Clearly this governmental approach would need to change quite dramatically, and it would need to shift from seeing itself as a provider of maternity services to becoming the enabler of health-system solutions for the country 36 Health and South Asia as a whole. If the government were to be able to come up with the required amount of money through its existing tax resources, then it could use that money to facilitate the creation of health systems which would ensure that all the three characteristics of health care are addressed. Countries such as the United Kingdom, Thailand, and Spain have taken this route. For India too this is an entirely feasible path but, despite strong activism in this direction, there is no real indication that the government is willing to allocate the full extent of the financial resources required from its existing tax revenues. Some countries, such as the United States, are trying to design national-level health solutions by mandating that individuals buy one form or another of private health insurance without getting too closely involved, except in the case of the elderly and the very poor. It remains to be seen whether such approaches are likely to produce the desired impact. Even if they eventually work out in the United States, in India, given a very poorly developed health infrastructure, high levels of poverty and income inequality, and very poor enforcement capacity, such approaches are highly unlikely to succeed. An intermediate approach has been to pool the limited tax resources that are available with mandated contributions from formal-sector employees into the form of social health insurance. Austria, Belgium, Germany, Israel, Japan, and South Korea are some of the countries that have successfully taken this route. Even in India such an approach is already being employed for low-income formal-sector employees (wages below Rs. 180,000 / PPP $12,000 per annum) where, between them and the employer, 6.5% of the wage is required to be paid to a government-run health insurance scheme. There is no reason why such an approach cannot be extended to the rest of the formal sector within India. The appeal of this approach for India is that since it explicitly offers health care in return for this contribution, it can be viewed as a more efficient form of consumption spending on health care and not as an additional form of taxation. The pooled tax and social health insurance contributions would then be adequate and could be set aside exclusively for the provision of free, universal health care to all the citizens of the country, both rich and poor. Once these resources are pooled and made available at the national level, the key question becomes one of how health care should actually be paid for by the government. Other than in the United States, where the debate still rages, it is already very clear that the only way to go is to build health systems which integrate primary, secondary, and tertiary care provision and to have individuals become members of one such system and not be permitted to choose each component separately. The payment to the health system would broadly need to be made on a per-enrolled-person basis (capitation) with some flexibility at the edges to provide additional incentives to influence health-seeking behavior and to take care of very expensive and rare diseases whose incidence may not be evenly distributed throughout the population. While there are many countries in which such health systems are government-owned, there are also Harvard South Asia Institute 37 several instances in which privately owned health systems have done an equally good job of providing cost-effective, high-quality health care. Given the limited capacity that the Indian government has to deliver health care, out of necessity each Indian state would need to find its own answer to the question of ownership and management of health systems. However, it is also generally accepted1 that health systems, whether government-run or privately owned, would need to be tightly regulated and paid not on a budgetary basis but on a capitation basis with the money pool held outside the control of the health ministry, particularly if the ministry also controls the government-owned health care delivery system. Once the two central health-financing questions are answered, some of the other constraints, such as supply of human resources and availability of medicines, would fortunately not be binding ones for India. India already meets more than 22% of the global demand for generic medicines and has the local capacity to manufacture all of the essential drugs that are needed at a very low cost. In terms of manpower while there is a shortage of allopathic practitioners (400,000 physicians against a demand of 1.2 million with only 30,000 being added every year), there is a very large availability (over 700,000) of formally trained practitioners in Indian systems of medicine whose five and half years of training, for the most part, mirrors that of allopathic practitioners. They can easily be trained through a short, six-month to a year-long, bridge training program to become very effective allopathic primary-care providers in a manner similar to family nurse practitioners in the United Statesâ€”particularly if such an effort is combined with universal deployment of best-practice primary care protocols which are strongly enforced through the use of good health management information systems and clinical decision support systems. India has strong internal information-technology capability and expects to have fiber-optic-enabled broadband in every village by December 2014. Establishing high-quality health systems, while challenging, should therefore not pose a fundamental problem once the resources have been found and the necessary regulatory architecture put in place. 38 Health and South Asia 1. This was a point of major departure for the High Level Expert Group on Universal Health Coverage, which believed that with strong management reform such a separation would not be necessary and that the government needed to remain the principal if not the sole provider of all health care services. Harvard South Asia Institute 39 40 Health and South Asia Courtesy of Marcelle Goggins. Heath and Inequality in South Asia S. (Subu) V. Subramanian and Malavika Subramanyam Despite frequent calls to make economic growth socially inclusive, data from India suggest that income inequality exists and continues to widen. A 2012 national-level survey of expenditure patterns found that in urban India the wealthiest 5% of families spent about fifteen times more than the poorest 5%, while in the villages they spent nine times more. As former president Pratibha Patil noted on January 25, 2008, the underprivileged and disadvantaged sections of Indian society have yet to find a place to enjoy “the sunshine of the country’s growth and development.” Some of this disquiet is reflected in health achievements in India. How health is distributed across different social groups provides an insight into understanding the extent of social justice in a given society. India’s performance in enhancing the health and well-being of its people underscores this social disparity. Indian society is stratified by wealth, education, gender, and urban versus rural residence, as well as by religion and caste. Studies have shown substantial social inequalities in mortality, morbidity, and health behaviors in India. The dimensions along which health inequalities are patterned are mainly wealth and education. Caste, a unique feature of Indian society, is also associated with a few health outcomes. Our study of socioeconomic patterning in mortality found that there was a strong graded relationship between household wealth and mortality. Persons from the poorest families were 86% more likely to die than the wealthiest group, even after accounting for age, gender, and other factors likely to influence mortality. Crucially, as standard of living goes down, mortality goes up in a systematic manner, suggesting the presence of a mortality gradient. We also Harvard South Asia Institute 41 found that mortality is patterned along caste groupings. Caste is acquired by birth and most people self-identify as belonging to “scheduled caste,” “scheduled tribe,” “other backward class,” and “other” caste (terminology used by the Indian government). Scheduled caste includes “untouchables,” or dalits; scheduled tribes consist of over 400 different tribes that tend to be geographically isolated (often in the hills, forest areas, or islands); and other backward class is a diverse collection of intermediate castes that were considered low in the traditional caste hierarchy but above the scheduled castes. “Other” caste, its name notwithstanding, is the category of upper-caste Hindus. Despite substantial heterogeneity within each of these categories, they are routinely used for population-based health monitoring. We have found that members of scheduled tribes have considerably higher odds of mortality when compared with the privileged caste group. In Hindu-majority India, health disparities by religion do exist, with Hindus and Christians experiencing lower mortality than Muslims. However, these differences, as well as mortality differences between urban and rural areas, could be explained by the fact that a majority of Muslims and rural dwellers tend to be poor. When we accounted for the difference in wealth between these groups, religious grouping and urban-rural residence were no longer related to mortality. In addition to mortality, our studies have investigated socioeconomic disparities in nutritional deficiencies such as anemia (abnormally low hemoglobin level in the blood) and underweight (abnormally low weight for a given age). The strongest predictors of anemia and underweight among women were household wealth and education. Women in the lowest fifth of wealth or with no formal education had substantially higher odds of having anemia or being underweight than women higher on the socioeconomic ladder. And similar to mortality, the odds of having anemia or being underweight increased in graded manner as levels of educational attainment or standard of living came down. Women in rural areas were considerably more likely to be underweight than those in urban areas. However, prevalence of anemia did not vary between urban and rural areas. While lower castes were more likely to have low height for their age and low weight for their height, no such pattern was observed for underweight or anemia. Contrary to popular belief, boys were more likely to be anemic, as well as undernourished. Health behaviors such as smoking and chewing tobacco or drinking alcohol are an important outcome examined by public health professionals, because of their impact on the risk of developing several diseases. We have observed social disparities in these behaviors across household wealth, education, and caste. Individuals with the lowest household wealth or having no formal education were three times more likely to consume tobacco or alcohol than those at the top of the wealth and education spectrum. Our study also found that members of scheduled tribes and scheduled castes were more likely to 42 Health and South Asia consume tobacco or alcohol than â€œotherâ€? castes. Marked gender differences were observed, with men substantially more likely than women to consume tobacco or alcohol. However, religious affiliation and urban-rural differences were not related to the probability of tobacco or alcohol consumption. Two observations are pertinent regarding the robust associations of health with wealth and education. First, both wealth and education are independent predictors of health outcomes in India. Second, there is a social gradient in health observed in India: people comprising the second from the bottom socioeconomic level have worse health than those above them but better health than those below. The gradient is observed regardless of whether we consider wealth or education. This social gradient in health has been consistently observed in developed countries and is increasingly being noticed in other low-income and middle-income countries as well. The implication is that the entire spectrum of the socioeconomic distribution needs to be considered when addressing public health issues. Caste-based segregation no doubt persists in practice and affects access, but most significantly, the distance between castes is decreasing and boundaries are more fluid. Caste, therefore, tells us less and less about income, occupation, and education, since its distinctiveness both in ritual status and occupational identity has now lost its earlier unity and coherence. Many of the health inequalities in India are not inevitable or immutable and can be amenable to public policy via improving living standards and educational opportunities in a fair and equitable manner. Yet the pathways to redress these challenges require serious consideration. There is a need to target programs and interventions that are simultaneously oriented both toward the poorest and most marginalized and also across populations, in order to address a range of socioeconomic measures across society. The full implications of the social gradient and its role in mediating relationships between economic development and health in India therefore still need to be fully reflected in the changes and choices made in health policies. The steps India takes to improve the health of its population in a fair and equitable manner will be critical, from the perspective of enhancing human development and sustaining its progress in economic growth. Harvard South Asia Institute 43 44 Health and South Asia Courtesy of Lisa Kristine. Leapfrog Technology and Epidemiology at the World’s Largest Human Gathering Satchit Balsari In January 2013, a public health team led by the FXB Center for Health and Human Rights at Harvard, with support from the South Asia Institute and the Harvard Global Health Institute, conducted research at the Kumbh Mela in Allahabad, India. Satchit Balsari, a physician and a researcher, was part of the team. At dusk, a group of medical students in Allahabad trudged up a little hill overlooking the Kumbh Nagri, a temporary city on the banks of the Ganga and Yamuna that, in its short lifetime, hosted the world’s largest human gathering. Unwinding after a long day’s work, the students sipped chai and congregated around a large table in the “dining tent” to sync their iPads to the Internet. Within minutes they had uploaded thousands of data points to a remote server several continents away—data that would help them look for impending epidemics in the densest congregation of humans known to man. They gazed intently at the analytical graphs being generated by their data. Reassured that all was well, they began their journey out of the fairgrounds. It had been another ordinary day at the Kumbh Mela. Millions had come to wash away their sins and had gone home elated. A million others would arrive the next morning. As the students looked down at the sea of electric lights that now illuminated this most magnificent yet ephemeral city, they could hardly believe that the bustling township did not exist until a few months ago and that it would soon be gone, enduring only in the memories of those who had witnessed it. From January to March 2013, over a 55-day period, over 80 million pilgrims attended the Kumbh Mela to bathe at the Sangam, or confluence, of the Ganga, Yamuna, and erstwhile Saraswati rivers. On February 10th, on the Harvard South Asia Institute 45 most auspicious bathing day, Mauni amavasya, officials reported 20 million visits at the Mela. The faithful arrived from all corners of India, some traveling hundreds of miles to partake in this religious extravaganza. The festival, held once every twelve years, attracted seers from Hinduism’s many sects and denominations, and their thousands of followers who sought darshan. Festivities revolved around religious discourses, plays, demonstrations, and communal feasts. But most importantly, all who visited the Mela desired a holy dip at the Sangam, in the hope of attaining moksha—freedom from the perpetual cycle of rebirth. Serving the millions who visit this fleeting city is a colossal enterprise whose unwritten mission is to ensure that “the pilgrims are safe, and that they have a good time.” Pilgrim safety is the impetus behind the massive mobilization of infrastructure and human resources that characterizes planning and execution at the Mela. Over the last century, devastating stampedes and large epidemics have marred the Kumbh Mela. In fact, the origins of the nineteenth-century worldwide cholera epidemic have been traced to the Mela (from where cholera spread via Indian hajjis to the Middle East and subsequently to Europe and America). Consequently, Mela authorities have always paid close attention to crowd control, stampede mitigation, provision of safe water, adequate sanitation, and the promotion of food hygiene. Thirty-five thousand toilets, 7,000 sanitation workers, and 46 tube wells meet the water and sanitation needs of the 2013 Mela. In addition to the meticulous preventive measures undertaken, the Mela authorities provided ten clinics and one 200-bed “central hospital” staffed around the clock. The clinics were distributed across the various administrative sectors of the Kumbh Nagri (township). Each clinic was staffed by a physician, a nurse, and a pharmacist, and included a 20-bed inpatient unit and a semi-open outpatient area. When the Mela population rose significantly around the main bathing events, the clinics were at their busiest, sometimes attending to several hundred patients a day. At each clinic, the patients huddled around the doctor’s table, awaiting their turn and listening in to their companions’ woes. Turn by turn, they sat down and informed the doctor of their ailments. The physicians recorded these symptoms or “chief complaints” in a notebook, and promptly prescribed a medication—often without as much as even a glance at the patients. Satisfied that they had been given allopathic medications for their diseases, the patients retreated to the pharmacy to pick up a free, three-day supply of pills. This fleeting patient encounter was no different from similar events occurring daily in thousands of clinics across India, where overworked clinicians juggled patient expectations, meager resources, and efficient medical practice. Yet the seemingly rudimentary records captured in the doctors’ notebooks at the 11 Mela clinics did contain enough information to implement a disease-surveillance system looking for potential epidemics at the Kumbh Mela. The challenge, however, was to access all the data in real time. 46 Health and South Asia An “epidemic” is defined as the occurrence of disease at a rate higher than what is normally expected in a population. For example, in the case of cholera, a single case could herald an epidemic, but in the case of influenza (flu), the incidence of new cases would have to be higher than the expected seasonal numbers within a population to trigger worries about an epidemic. Herein lay the problem. To look for epidemics at the Mela, one needed to know how many new cases of a particular disease were showing up at the clinics every day, and whether these numbers were above the expected norm. New cases were recorded in the paper notebooks, but the notebooks across the 11 clinics were themselves separated by several kilometers and a dense sea of humanity, making access to them difficult and time-sensitive data collation impossible. Epidemic surveillance necessitated frequent and simultaneous access to information stored in the notebooks across all the clinics. The public health contingent of Harvard’s Kumbh Mela team sought to provide a solution to this challenge of real-time data gathering. Collaborating with India’s apex disaster-response agency, we recruited an enthusiastic team of medical and public health students from Mumbai and Allahabad to implement an innovative disease-surveillance tool. The students were divided into groups of four or five, given rented iPads, and assigned to one of the five clinics that the surveillance project was piloted in. Using a commercially available data-collection “app” and a homegrown analysis program, EMcounter, the students were instructed to transcribe data from the paper notebooks to their iPads. The EMcounter program allowed the students to record epidemiologically relevant data: age, gender, chief complaint, and prescribed medications— just enough information to power a robust disease-surveillance system. The logistics around this data-collection endeavor represented a microcosm of the many challenges the Mela posed. Navigating the Kumbh Nagri required good topographical knowledge and crowd-dodging dexterity. Several students had rented motorcycles to travel through the crowded Mela streets. Aaron Heerboth, our student team leader, an intrepid graduating medical student from New York, chose to run between the sector hospitals to meet his daily quota of cardio. He devised staggered start times across the five sites, leaving him ample time to be present at the start of data collection at every clinic to give the teams a pep talk before they dived into hours of laborious data transcription. It took him over four hours to cover all the sites, and frequent and repeated negotiations with local physicians, to record the necessary data in their notebooks. At the end of each day, the teams met at Lakshmi Kutir—a tent hotel erected on a hill in sector 14. Within minutes, data from the ten iPads were uploaded to a remote server using mobile hotspots. Once data upload was completed, the EMcounter tool instantaneously generated graphs showing the number of patients presenting to the clinics, the frequency and proportions of various diseases, the types of medicines prescribed, and the age and gender distribution of the patients. The team plotted these Harvard South Asia Institute 47 data every day, allowing Mela administrators to study the daily rise and fall of disease presentations as the population numbers ebbed and flowed. Any deviation from expected projections would signal an impending epidemic. Our team tracked over 50,000 patients for a period of three weeks, including the busiest bathing day. In addition to implementing a surveillance tool, the project provided administrators critical information on resource allocation, service utilization, clinical-practice patterns, and inventory. Subsequent analysis and deliberations with local stakeholders have allowed us to make recommendations for better matching supply and demand in future Melas. The mobile, tablet-based surveillance system has the potential to significantly enhance disease surveillance in large gatherings. A handful of medical students equipped with a few portable computers successfully demonstrated the ability of smart technology to solve “big data” challenges in transient and resource-poor settings. The technology employed was ubiquitous, independent of heavy infrastructure, and required little training. The EMcounter team is now working on providing similar solutions that can be quickly deployed via smartphones and tablet computers in other transient settings like refugee camps, disaster shelters, and remote health care facilities in low-income settings. Though health care systems in India have been slow to embrace digitalization, we hope that the Nasik Kumbh Mela in 2015 employs digital medical record keeping, obviating the need for manual data transcription. As demonstrated, temporary health centers can easily use the Internet and mobile computers to create effective surveillance and monitoring systems for their patients and providers, even where no such systems have existed to date. Lowand middle-income countries have been known for adopting precisely these kinds of leapfrog technologies, whether they be the ubiquitous use of mobile phones before consumers had landlines, or the use of “micropower” energy sources before villages had access to centralized electricity grids, or the distribution of light-emitting diode (LED) lights where there were no incandescent lightbulbs. It is our hope that the surveillance system at the 2013 Kumbh was another successful illustration of the power of leapfrog technology that has come to define our age. 48 Health and South Asia Harvard South Asia Institute 49 50 Health and South Asia Courtesy of PostiveNegatives. Graphic Violence and Trauma in Sri Lanka Benjamin Dix I arrived in Sri Lanka in December 2004, two days after the tsunami, and worked for Norwegian People’s Aid and then the UN for nearly four years in the Liberation Tigers of Tamil Eelam (LTTE) stronghold known as “Vanni” in north Sri Lanka. Throughout those years, I made many close friends within the community across Vanni and always considered it a privilege to be working in such an environmentally stunning, culturally rich, and politically fascinating area. I have worked in a number of countries but the hospitality and genuine friendships that were formed in Vanni were incredibly strong. Throughout 2007 the security situation in Vanni began to spiral as the government of Sri Lanka (GOSL) and the LTTE began what was to be their “final battle.” It was tragic to witness the destruction of Vanni and the death of so many civilians as the two sides battled. What struck me was the impact and increased vulnerability that multiple displacements had on communities. Families fled their native homes and took many of their belongings with them; however, after a number of displacements, people shed most items and ran from the relentless shelling with whatever they could carry. On September 16, 2008, at 11:05 a.m. the UN evacuated Vanni because the GOSL stated that it was no longer able to guarantee our safety. The abandonment of civilians and many national staff members caught between the warring parties left a profound sadness inside me that has never really lifted. Being part of a humanitarian evacuation is a complete sense of failure where the ramifications are beyond comprehension. The media coverage of the Sri Lankan conflict was purposely limited; this was a new style of counterinsurgency led by the GOSL. By removing Harvard South Asia Institute 51 humanitarian space, only allowing government media to the battle theater and rejecting all pleas for help from civilians trapped as terrorist propaganda, the GOSL managed to crush the LTTE and tens of thousands of civilians in a few gruesome months of warfare. Two years after the climax of the conflict I decided that I wanted to tell about this episode in history. I wanted to find a way to inform an audience unfamiliar with Sri Lanka about the situation and tell the story of people that were forced to live through the war and the aftermath. Visiting a Sri Lankan friend who had become a refugee in Chennai, India, in 2011, we celebrated, with a modest lunch, the successful arrival of her husband in Zurich. He had spent US$20,000 and four months with agents traveling from Chennai to Nairobi, Istanbul, Kiev, and finally to Zurich. The story was incredible and I realized how people were affected by conflict long after the bombs stopped falling. So I began to look at telling the story from this perspectiveâ€”from the asylum seeker, reflecting back on his life. I struggled with the medium of telling this complex story, but I wanted it to resonate with non-academics and engage a general readership. I had been a fan of graphic novels on conflict, such as Palestine by Joe Sacco, Persepolis by Marjane Satrapi, and of course, Maus by Art Spiegelman, and found them to be a compelling way to engage with these complex topics. I enjoy the medium of the comic book, and seeing the faces, expressions, and the geography of where a story is set. Presenting the story as sequential art takes the reader into a different space with the narrative, where we have to both read and see the page. The exceptional artist Lindsay Pollock, with whom Iâ€™m fortunate to be collaborating, and I began to interview Tamil asylum seekers across London and record their testimonies of surviving the conflict, their journeys to the UK, and their lives as asylum seekers. The methodology of creating the narrative has proven to be an emotional but fascinating experience. We interview a number of people for each chapter and build the fictionalized and anonymous composite narrative from all those interviews. We then storyboard the chapter and pencil the rough draft of the chapter. The fascinating process is taking that penciled chapter back to the respondents and encouraging them to edit the chapter to represent the most factual account. We then ink the pages for the finished comic strip. The final stage is to source (from my own database and the Internet) reference material of images, film clips, reports, and web links and embed them behind appropriate panels of the illustrations on the The Vanni website (www.thevanni.co.uk). The online reference material is central to the project as it tackles global issues of conflict, migration, and asylum, and features Sri Lanka as its case study to build the narrative; but the themes are global and not unique to Sri Lanka. Therefore, by embedding websites, academic journals, and multimedia behind the illustrations we create an innovative space where students and general readers can learn about these topics through the interactive medium. 52 Health and South Asia Surprisingly, the most difficult interviews we conducted were not the stories of torture at the end of the conflict at the hands of the government soldiers. Although it was difficult to listen to detailed accounts of being hanged upside down, burned with cigarettes and electric wire, many reports of sexual violence, and weeks of solitary confinement in dark cells, the harder stories focused on seeking asylum in the UK. The process of seeking asylum for an individual whose life is in serious jeopardy if he or she fails the process and is returned to his or her country is deeply problematic. One testimony of a young man we recorded, who had failed the asylum process and was being returned to Sri Lanka, made a deep impression on me. The individual jumped off a balcony with a sheet around his neck but failed to kill himself, ending up in the hospital with a twisted spine. The sheer desperation of returning to further torture and potential problems for family members led this educated, fit, and healthy twenty-seven-year-old to try and take his own life. The long and inhumane process of seeking asylum, of not being able to progress with life, forever waiting with a question mark of being sent back, is a mental torture that many individuals find too much to bear. The story I wanted to tell is not so much about conflict but more about the rippling effects that conflict has on families that can last for years, even generations. Respondents whom we have worked with have found the process of developing The Vanni therapeutic, and everyone involved has been supportive. Firstly, they are happy that someone actually cares about their underreported stories; and secondly, because of the medium of sequential art, the stories are completely anonymous. By positioning the protagonist, Antoni, as an asylum seeker in London, I hoped that a Western audience would identify more with his character as someone they sit next to on the bus, rather than a refugee in a jungle on the other side of the world. Presenting The Vanni as a graphic novel has attracted the attention from various organizations, so we developed a company called PositiveNegatives Ltd that develops affective communications through sequential art and multimedia. We are now producing a project on Somali migrant communities in Europe for the Open Society Foundation, and Iâ€™m currently collecting stories in the Syrian refugee camps in Jordan for an illustrated project for the BBC. Harvard South Asia Institute 53 54 Health and South Asia Harvard South Asia Institute 55 56 Health and South Asia Harvard South Asia Institute 57 58 Health and South Asia Harvard South Asia Institute 59 60 Health and South Asia Courtesy of Elizabeth Lopez. Water Pollution and Public Health in India: The Potential for a Market-Friendly Approach Michael Greenstone, Raahil Madhok, Rohini Pande, and Hardik Shah Ensuring the availability and quality of freshwater resources ranks among the worldâ€™s most pressing environmental and health challenges. And India is no exception. More than a decade of rapid economic growth, marked by increased industrialization, urbanization, and population growth, has produced a gloomy scenario for water security and public health.1 The World Health Organization (WHO) conservatively estimates that water insecurity in India results in 400,000 deaths per year, and the total annual economic loss from water pollution alone is INR 366 billion (USD 6.1 billion).2 A new era of environmental policy in India is needed to balance economic growth and environmental health. The past four decades saw the emergence of strong pollution regulations, rooted in the water and air acts of the 1970s and 1980s, but their impact remains muted.3 There have been significant advances by regulators and courts in monitoring and enforcing standards, but these have been countered by the growing burden of pollution accompanying rapid economic development.4 Regulating water quality remains particularly difficult since many pollution sources, such as agriculture and industry, are themselves important drivers for Indiaâ€™s growth. By harnessing economic incentives, market-based environmental policy offers a transparent, predictable, and potentially low-cost approach for ambitious pollution reductions. However, relatively little remains known about the functioning and impact of such programs in emerging economies. A research-policy collaboration including Harvard and MIT researchers and Indian regulators will evaluate a pilot market-based water quality trading (WQT) initiative in Indiaâ€™s Gujarat state. Spanning more than 350 polluting plants and covering organic pollutants, as measured by chemical oxygen demand (COD), Harvard South Asia Institute 61 the WQT pilot will quantify whether and how market-based environmental regulation provides the industry with more flexible means to meet regulatory standards as well as reduce water pollution concentrations. Below, we first describe the exisiting environmental landscape in India and then the potential benefits from a water trading scheme. An extensive scientific literature illustrates water pollution’s toll on human health. In developing countries especially, widespread exposure to polluted drinking water has contributed to the prevalence of cholera and other diarrheal diseases, intestinal worms, trachoma, and schistosomiasis.5 Globally, diarrheal diseases commonly spread through contaminated water are the second leading cause of death. In India it is estimated that they claim the lives of 300,000 children under five each year—the most of any country in the world.6 A recent report estimates that in India the number of total years lost due to ill health, disability, or death from inadequate water quality is 30.5 million annually.7 Another study of Indian household water quality argues that waterborne diseases result in the loss of 200 million workdays each year. Resulting production losses are almost 4% of India’s GDP.8 A significant fraction of water pollution reflects inadequate sewage disposal facilities. However, there is also growing concern over the role played by industrial effluent disposal. While small-scale industries (SSIs) have been a critical engine of India’s recent growth, currently accounting for 8% of GDP, they are also responsible for over two-thirds of the country’s industrial water pollution.9 Between 2001 and 2011 the number of SSIs grew by 30 million, a fourfold increase.10 This incredible expansion has contributed to the growing load of concentrated industrial wastewater discharged into rivers and streams, which the Central Pollution Control Board (CPCB) identifies as the most important cause of deteriorating water quality in urban areas.11 Among samples taken by CPCB from 1995 to 2010, an average of 57%–69% had concentrations of organic contaminants, measured by biological oxygen demand (BOD), which classified the corresponding rivers as unfit even for bathing.12 In the 1980s the CPCB began a high-profile effort to clean up India’s iconic Ganges River. This subsequently evolved into the National River Action Plan (NRAP), an ongoing effort to build dozens of sewage treatment plants along India’s rivers.13 A recent evaluation of NRAP, however, fails to find any effect of the program on water quality. 14 Meanwhile, the uniform pollutant concentration standards set by the water act are ill suited to stem the tide of pollution from the proliferation of SSIs. Even if plants meet these discharge concentration standards at any single point in time, the sheer quantity of effluent from additional annual plant openings will likely overwhelm the dilution capacity of many rivers. Furthermore, high fixed costs associated with many pollution abatement techniques can make it very costly for SSIs to meet some of the concentration standards. In effect, SSIs are roughly required to spend as much on abatement as larger plants, even 62 Health and South Asia though the former face higher marginal costs of abatement than the latter. More broadly, the current form of regulation does not allow for the flexibilities that minimize compliance costs for the desired level of environmental quality, and this creates incentives to seek out ways to evade the regulations. To reduce the burden on small industries and improve compliance, CPCB began a Common Effluent Treatment Plant (CETP) scheme in the 1990s to collectively treat industriesâ€™ wastewater.15 While this achieves economies of scale in pollution abatement, it does so at a high cost since industries must still meet a uniform concentration standard before pumping their wastewater into the CETP. The potential for a new approach lies here. By stating that regulation should account for the net adverse impact from an industry or operation, Indiaâ€™s 1986 Environmental (Protection) Act opens the door to a load-based approach to regulation. In the Indian context an attractive application of a load-based regulatory approach is a cap-and-trade or water quality trading (WQT) market. A WQT market targets total pollution load, rather than concentrations from individual sources. Arguably, this is the relevant margin for action since pollution concentration in a river depends on the total amount of pollution emitted, not the concentration of pollution in the effluent of individual sources without any restriction on the number of sources. By setting an aggregate cap for a group of sources and allowing them to trade pollution permits under this cap, market incentives promote lowest-cost pollution control while stoking innovation in cleaner production processes. Industrial plants, rather than meeting a fixed concentration standard, face a price for their pollution and choose how much to emit, within reasonable limits, taking this price into account. The price makes pollution costly and encourages industries to cut back.16 The proposed pilot project in Gujarat will set up an emissions trading market for improving the effectiveness of a CETP near Ahmedabad, Gujaratâ€™s largest city. The CETP under study can handle a collective incoming effluent volume of 16 million L/day with a COD concentration of 3,000 mg/L. At present, more than 350 dye, chemical, and textile plants are covered by the CETP. To enable a rigorous experimental evaluation we will phase plant enrollment into the WQT market. In the first phase, roughly half the plants will trade, while the other half will continue to have to meet regulatory standards at the individual plant level. In the second phase, all plants will enter the market. At the end of phase one, we will compare outcomes across plants that did and did not enter the WQT market to obtain rigorous estimates of regulatory compliance (via frequent estimates of COD) and cost savings generated by a WQT market. Although industrial wastewater discharge is one of many sources of water pollution, a single CETP industrial cluster is a practical setting to pilot market-based regulation since the small scale would allow for careful implementation and development of market rules and monitoring infrastructure. Harvard South Asia Institute 63 Apart from being one of the first rigorous evaluations of a WQT scheme in a developing country, this pilot is unique in at least one more way. The close research-policy collaboration involving MIT and Harvard researchers and the Gujarat Pollution Control Board (GPCB) provides a space for the information and data collected to not only be used for research outputs, but also to reinforce the regulatory capacity of the GPCB. The symbiotic relationship allows both actors to meet their goals; researchers will gather high-quality evidence on the impact of a water quality market, and the GPCB will use the collected data to ensure compliance with water quality norms and, more broadly, strengthen its water-policy agenda. 64 Health and South Asia 1. 2. Central Pollution Control Board (CPCB), Status of Water Quality in India, 2009 (New Delhi, 2009), http://cpcb.nic.in/WQSTATUS_REPORT2010.pdf. 2009. World Health Organization, Guidelines for Drinking-Water Quality: Third Edition; Incorporating the First and Second Addenda, vol. 1., Recommendations, 2007 (Geneva, 2007), http://www.who.int/ water_sanitation_health/dwq/gdwq3rev/en/; Jyoti Parikh, “Environmentally Sustainable Development in India” (2004), cited in M. N. Murty and Surender Kumar, “Water Pollution in India: An Economic Appraisal,” an IDFC report (New Delhi, 2011), http://www.idfc. com/pdf/report/2011/Chp-19-Water-Pollution-in-India-An-Economic-Appraisal.pdf. Michael Greenstone and Rema Hanna, “Environmental Regulations, Air and Water Pollution, and Infant Mortality in India,” NBER Working Paper No. 17210 (Cambridge, MA, 2011), http://www.nber.org/papers/w17210.pdf ?new_window=1. Central Pollution Control Board, Status of Water Quality in India, 2010 (New Delhi, 2010), http://cpcb.nic.in/WQSTATUS_REPORT2010.pdf. World Health Organization, “Facts and Figures on Water Quality and Health,” http:// www.who.int/water_sanitation_health/facts_figures/en/. World Health Organization, “Diarrhoeal Disease Fact Sheet,” http://www.who.int/ mediacentre/factsheets/fs330/en/; The Million Death Study Collaborators, “Causes of Neonatal and Child Mortality in India: A Nationally Representative Mortality Survey,” Lancet 376, no. 9755 (2010): 1853–60. Murty and Kumar, “Water Pollution in India.” David Mckenzie and Isha Ray, “Urban Water Supply in India: Status, Reform Options and Possible Lessons” (working paper no. 224, 2005; final version forthcoming in Water Policy), http://erg.berkeley.edu/publications/Isha%20Ray/McKenzieRay-India-urbanwaterforWP.pdf. Planning Commission, Government of India, Report of the Working Group on “Effectively Integrating Industrial Growth and Environment Sustainability” (New Delhi, 2012), http:// planningcommission.nic.in/aboutus/committee/wrkgrp12/wg_es0203.pdf. 3. 4. 5. 6. 7. 8. 9. 10. Ministry of Micro, Small and Medium Enterprises, Government of India, Annual Report 2011–2012 (New Delhi, 2012), http://msme.gov.in/MSME-Annual-Report-2011-12-English.pdf. 11. Central Pollution Control Board, Evaluation of Operation and Maintenance of Sewage Treatment Plants in India, 2007 (New Delhi, 2007), http://www.cpcb.nic.in/upload/NewItems/ NewItem_99_NewItem_99_5.pdf. 12. Central Pollution Control Board, Status of Water Quality in India, 2010. 13. Planning Commission, Government of India, Report of the Working Group on Rivers, Lakes, and Aquifiers in Environment and Forests for the Eleventh Five Year Plan (2007–2012) (New Delhi, 2007), http://planningcommission.nic.in/aboutus/committee/wrkgrp11/wg11_rivers.pdf. 14. Greenstone and Hanna, “Environmental Regulations, Air and Water Pollution.” 15. Central Pollution Control Board, Performance Status of Common Effluent Treatment Plants in India (New Delhi, 2005), http://cpcb.nic.in/upload/Publications/Publication_24_ PerformanceStatusOfCETPsIinIndia.pdf. 16. Esther Duflo et al., “Towards an Emissions Trading Scheme for Air Pollutants in India,” Ministry of Environment and Forests discussion paper (New Delhi: 2010), http://moef. nic.in/downloads/public-information/towards-an-emissions-trading-scheme-for-airpollutants.pdf (last accessed January 23, 2011). Harvard South Asia Institute 65 66 Health and South Asia Courtesy of Parul Agarwal. TraumaLink: Helping People Survive Traffic Accidents in Bangladesh Jon Moussally, Eric Dunipace, and Ryan Fu Something has been keeping us up at night. We’re worried—not about jobs or school, but about something far worse. We’re worried about traffic accidents. In the US, most people have only a peripheral experience with traffic accidents. Sure, we see them on the highway—usually they’re not too bad, and sometimes we’re guilty of looking at them when they are—but for the most part, traffic accidents will not be a problem that touches people’s lives. We can hop in our cars or cross the street without ever thinking that this might be our last trip. However, in many countries across the world, this fear is justified. Globally, there are about 2 million traffic fatalities and another 20–50 million injuries every year. Unfortunately, most of the social and economic burden of traffic accidents falls on developing countries, and there is no end in sight. If current trends continue, road-traffic injuries will be the third leading cause of global death and disability by 2020. Bangladesh is no exception. In 2009, there were about 20,000 traffic-related fatalities and 400,000 injuries nationwide, according to the World Health Organization. Admittedly, this is fewer than the number of traffic deaths recorded in the US in the same year—40% fewer, in fact. Even after accounting for the differences in population size, the total number of accidents is only 20% greater than that in the US. So, why do we care about Bangladesh? The answer is twofold. First, the scale of the problem in Bangladesh is actually much greater than it initially appears to be. Consider the number of vehicles on the road in each country. In the US, there were 250 million registered vehicles in 2009, while in Bangladesh there were only a million. That means that there was about 1 death for every 10,000 vehicles in the US, while in Bangladesh there were over 150. Harvard South Asia Institute 67 If vehicles in the United States were as deadly as they are in Bangladesh, there would be approximately 4 million deaths due to traffic accidents each year. Second, there is no system to help those injured by traffic accidents in Bangladesh. Worse yet, most traffic-accident victims are young and otherwise healthy, making these preventable deaths all the more tragic. In a culture that relies so heavily on family and community ties, the loss of a child or breadwinner has profound and multigenerational consequences. It is therefore not surprising that road-traffic injuries are a leading cause of severe poverty in Bangladesh. We came to appreciate the gravity of this problem when we visited Bangladesh on a trip organized by the Harvard School of Public Health in early 2013. Learning about the scale of the problem shocked us; learning about how little had been done to solve it left us outraged. Every day traffic accidents needlessly kill people, even though simple, easily taught maneuvers could save their lives. Something had to be done, so we created TraumaLink. TraumaLink will offer basic prehospital trauma services to victims of traffic injuries by combining widespread community-based trauma training with an emergency hotline. Through the power of these local communities, we will change the current paradigm in Bangladesh. Currently, there is no prehospital system. There is no hotline number available to summon trained first-aid responders and no publicly run ambulance service. Moreover, even if a private vehicle is available, transport times can still be excessive due to severe traffic congestion. People still donâ€™t know where to take patients to receive appropriate care even when traffic isnâ€™t an issue. These obstacles are particularly concerning for road-traffic accidents, because traumatic injuries are exquisitely time-sensitive. Many patients die at the scene of a crash because of a blocked airway or uncontrolled bleeding, both of which can often be easily addressed. Among those who do not immediately succumb to their injuries, more will die within the first few hours if they do not receive appropriate treatment; this highlights the need for rapid access to medical care. We will solve these gaps in several ways. To facilitate the disposition of our resources, we will create a twenty-four-hour hotline to offer rapid crash-scene response by trained first-aid volunteers. Our operators will streamline the transfer of patients to an appropriate medical center based on our regularly updated registry of clinical facilities and their capacities to treat injured patients. When a traffic accident occurs, a victim or bystander can call our widely publicized hotline number any time of day and reach a call-center operator trained in crisis management and guided by predefined protocols. The operator will determine where the accident occurred and dispatch local volunteer first responders to the scene using our automated system and an established database of volunteers. These first responders will provide basic first aid for the victims, update the operators about any further resource needs, and stay on 68 Health and South Asia the scene until transportation arrives. Additionally, operators will help guide those providing transportation by directing them to the nearest appropriate health care facility based on the severity of the patient’s injuries. Until the injured patients arrive safely at the hospital, the case will remain open and our operators will follow the patients’ progress closely. While trauma care is critically important, so is having the money to operate our service. However, funding in the nonprofit world is cyclical and sometimes inconsistent. To free TraumaLink from having to constantly chase donor money, we will instead fund our efforts through corporate sponsorships from leading Bangladeshi companies. With increasing competition and media scrutiny of businesses in Bangladesh, leading companies are aggressively advertising to develop strong, socially conscious brands that appeal to a fragmented customer base. TraumaLink will give these corporations the opportunity to do so. Moreover, TraumaLink is extremely affordable. For instance, one telecom operator spends over US$10 million annually on advertising alone, while the cost of national coverage for TraumaLink is only US$500,000. A small portion of one company’s advertising budget would fully fund our efforts. With our lifesaving service and low cost, TraumaLink offers a unique opportunity for local businesses. We hope that TraumaLink will serve as a model throughout the developing world because of our low-cost, scalable, and self-sustaining model. There have been other successful programs in Bangladesh that use community-based trauma first aid training, but they have been constricted by inconsistent donor funding. In contrast, our service model is unique because we are organized as a social business—a business entity formed and run as a private company but built to solve a societal problem rather than generate profits for shareholders. In that vein, TraumaLink’s goal is to be a leader in both emergency trauma care and advertising services in Bangladesh, and we are proud of the progress we have made thus far. Our idea was selected as a finalist in the 2013 Deans’ Health and Life Sciences Challenge at Harvard, and we have also established a number of partnerships with respected academic and nongovernmental organizations in Bangladesh. This widespread and diverse network will allow us to “train the trainers” and allow us to quickly reach a critical mass of first responders. Our partnerships will also help us strengthen our community-engagement efforts and encourage faster adoption of our services. In January we will begin our pilot along a stretch of the Dhaka–Chittagong Highway, the busiest and most dangerous road in Bangladesh. Despite the enormous task of organizing this effort, we are encouraged, as over 250 citizens in our pilot area have said they would use our service. The Bangladeshi people have an amazing history of using grassroots, community-centered initiatives, and we know that TraumaLink will offer them another valuable opportunity to do so. Harvard South Asia Institute 69 70 Health and South Asia Courtesy of Keren Rohe. The Pharmacy of the Developing World Achal Prabhala When the Indian Supreme Court ruled on Novartis AG v. Union of India in April 2013, the decision made headlines the world over, and for good reason: it was a nail-biting finish to eight years of suspense over Indian patent law. That law—the Patents Act, 1970—had been amended decisively in 2005 to comply with the country’s obligations to the World Trade Organization (WTO). As its effects became apparent at home and abroad, however, it generated a strange combination of jubilation, hostility, and misunderstanding. These conflicting emotions finally culminated in what has come to be known as the Novartis case. The Nobel Prize–winning relief organization Médecins Sans Frontières (MSF) calls India the “pharmacy of the developing world.” The Indian generic medicine industry is now crucial to the global public health system: its resounding effect, especially within the developing world, as highlighted in the HIV/ AIDS crisis that gripped parts of Africa, Asia, and Latin America from the cusp of the twentieth century onward, is well known. Less well known, perhaps, is that the wheels of this pharmaceutical revolution were set in motion as far back as the 1950s. The story of India’s role in the global access to medicines movement, while yet unfolding, might be broken up into three chapters. The first chapter is set in socialist India, when Justice Rajagopala Ayyangar, building on the work of a similarly minded reformer, Justice Bakshi Tek Chand, rewrote Indian patent law to ensure that essential commodities like medicines could be produced competitively, and therefore, affordably. One device to achieve this goal was to disallow product patents, a policy in line with the sovereign legislation of several European countries at the time. The Indian Patents Act of 1970 came into force in 1972. By then, the indigenous pharmaceutical industry had gained traction—one Harvard South Asia Institute 71 early pioneer, Cipla, had been operating for close to four decades—and was thus ideally poised to take advantage of the commercial opportunities presented by the rewritten law. By the 1990s, a nascent domestic industry had come into its own. The world had changed, and the doors to the Indian economy had been thrown open. Generic medicines had firmly established themselves as a phenomenon, strong at home and growing in strength globally. But a second, unanticipated chapter in this story was about to begin, in a period characterized by shadow games which the Indian government could barely understand, let alone play. In 1994, India signed on to the WTO, which replaced the General Agreement on Tariffs and Trade (GATT) as the organization that would regulate— and facilitate—world trade. In doing so, it signed the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), a trade rule that was one of many it was bound to. At the time, Indian trade negotiators had little or no capacity to negotiate, and small Indian firms were no match for the juggernaut that installed TRIPS at the WTO in the first place—the combined lobbies of the pharmaceutical and technology industries, led by Pfizer and IBM. (Jagdish Bhagwati, the noted protrade economist, and a fierce critic of the inclusion of TRIPS at the WTO, jokingly suggests that if you have to specify that a trade rule is “trade-related,” it is probably not.) Faced with the reality of the WTO and TRIPS, at first, the Indian government faltered. In this period of indecision, which lasted through the better part of the 1990s, both the EU and the US took India to the WTO Dispute Settlement Mechanism (a forum to adjudicate sovereign disputes) and won. India was forced to make amends for its inaction on protecting product patents registered after 1995, and set up a “mailbox” system whereby applications could be filed, pending amendments to the patent law that only had to take effect by 2005, as per the allowances provided by the WTO to a developing country. (Least developed countries, LDCs, had even longer to comply.) In the period between 1994 and 2005, faced with an uncertain future, the Indian generic industry splintered. Some firms stayed on course and continued to serve domestic and developing country markets, while others realigned into outsourced manufacturing and research hubs for pharmaceutical giants in the US, Europe, and Japan. Crucially, the period between 1994 and 2005 was also the time when HIV/AIDS moved from being a crisis of rich countries to a vast tragedy in the developing world. The activism of brilliant and dedicated people from South Africa and Brazil to Thailand and India, and to the US and Europe (where, having won the battle to develop medicines for HIV/AIDS, activists then struggled to make them affordable to the world), made the modern-day access to medicines movement. Their cause? A rational and reactive patent system that respected people’s right to life. Their goal? To enable the cheapest possible treatment that only generic medicines—invariably from India—could provide. Cipla made headlines in 2001 when it offered MSF the cocktail of antiretroviral 72 Health and South Asia medicines required to treat HIV/AIDS for $350 per patient per year, given that the prevailing price in the US for exactly the same medication exceeded $10,000. By the year 2005, Indian generic medicines were the vital lifeline for hundreds of millions of people around the world. To consumers, they presented a chance to live at the cheapest possible price (if not always an affordable price); to humanitarian organizations, they were a means by which more could be done with public funds; to several developing country governments, they were what made public health budgets feasible. Nevertheless, India was obligated to update its patent law, and the world watched with apprehension. Fortuitously, the ruling coalition in India at the time, the United Progressive Alliance, depended heavily on the Left parties for support, and a dramatically original patent law was ushered in—a law that struck an original and inspired balance between the needs to foster innovation and make medicines affordable. Thus began the third chapter in this story. Indian patent law, as amended in 2005, was unprecedented. The bar had been raised; the law now required patent applications to show true worth in a variety of fields. One of the many particularities in the new law was that while it recognized incremental innovation, it asked for evidence of the worth of the increment in return for a temporary monopoly. This was to stem a long-standing practice wherein pharmaceutical firms routinely tweaked existing inventions—often to little or no effect—in order to extend the valuable monopolies they had been granted and thereby keep prices up. Practically speaking, this meant that a high percentage of patent applications routinely approved in the US, Europe, and Japan—where weak standards are the norm, their patent systems having been gamed beyond recognition by deeply entrenched lobbies—would be rejected in India for being unworthy of patent protection. And this is exactly what happened in one notable case: a brand of imatinib mesylate marketed by Novartis as Glivec, which happened to be a miraculous treatment for chronic myeloid leukemia. In 2006, Novartis’s application for patent protection of the beta-crystalline form of Glivec was rejected by the Indian patent controller on the basis that it could not show incremental efficacy. (The original compound, imatinib mesylate, having been patented before 1995, was ineligible for patent protection under Indian law.) Novartis appealed, and meanwhile also challenged the Indian government in the Madras High Court in 2007 for instituting an allegedly unconstitutional patent law. (Since Switzerland, Novartis’s home base, would not issue a complaint against India at the WTO about the provision under which the application for Glivec was struck down, Novartis did the next best thing and sued the government of India, in India.) Novartis lost the case. In 2009, Novartis’s appeal against the patent controller’s decision was rejected, and the firm’s final challenge to this rejection was the case heard in the Supreme Court in 2013. When upholding the rejection of Novartis’s patent application on Glivec, the Supreme Court did not consider human rights or treatment access or even constitutional justice; the court relied instead on a thorough and detailed analysis Harvard South Asia Institute 73 of the claims in the application as they held up against relevant sections of Indian patent law. Effectively, the Supreme Court’s decision confirmed the 2005 amendments to the Patents Act as valid, reasonable, and here to stay, and understandably, this did not sit well with the global pharmaceutical industry whose business model the judgment threatened to upturn. Detractors of the judgment shouted themselves hoarse: this was the end of investment for research in India; this was the end of innovation in the pharmaceutical industry. Oddly enough, the effect of the 2005 changes to Indian patent law might have been to ensure access to medicines, but the point of the changes foretells only better prospects for innovation in medicine. It’s a simple point, and worth noting: a high bar forces participants to jump high; a low bar invites them to jump low. As the British Medical Journal notes, “Pharmaceutical research and development turn out mostly minor variations on existing drugs, and most new drugs are not superior on clinical measures.”1 The situation, in fact, is so dire that the global innovation landscape—as evidenced in a country like the US—is filled, in the majority, by secondary patents. A landmark study from researchers Kapczynski, Park, and Sampat2 suggests that secondary patents in the US, on average, add between six and seven years of patent life on to the original compound, which would explain the push toward relatively inexpensive tweaking, and the subsequent abandonment of slow, painstaking, and expensive breakthrough innovation. Indian patent law, however, for all its salubrious effects on access, still offers only a potentially positive effect on innovation. This is because India is a tiny market by value—housing an estimated 1.3% of the world’s pharmaceutical economy. The US, Europe, and Japan, all combined, still account for some 75% of this economy—which would imply that the outcry against Indian patent law (an outcry that has lately been ratcheted up, as the US pharmaceutical industry lobbies calls for the US to launch a complaint against India at the WTO) is not against the potential commercial harm represented by the law per se, but what it symbolizes to the rest of the world. In April 2013, when the Supreme Court announced its decision in the Novartis case, India had won a lone battle. The bullying and the belittling had been withstood; government representatives who met media after the decision appeared relaxed and confident. But for Indian patent law to truly affect the global access and innovation landscapes, it was clear that it would have to be exported. Here was a success in search of company. Six months down the line, in October 2013, the ripples have multiplied and we have our first wave. The government of South Africa announced a Draft National Policy on Intellectual Property in September 2013,3 signaling its intention to refine patent laws in much the same direction as India. The announcement was met with wide support, especially from a coalition of interested civil society parties4 including MSF, the Treatment Action Campaign (TAC), and Section27, among the country’s foremost organizations fighting for access to treatment. 74 Health and South Asia Shortly thereafter, in October 2013, Brazil launched its own patent reform process, shepherded by Brazilian parliamentarian Newton Lima from the ruling Workers’ Party and launched in the Brazilian Chamber of Deputies. The report, Brazil’s Patent Reform: Innovation towards National Competitiveness,5 coordinated by Pedro Paranaguá and published by the Center for Strategic Studies and Debates, closely mirrors South Africa’s—and by extension, India’s—and attempts at rationalizing the patent system. Both the South African and Brazilian processes will take months, if not years, to come to fruition. Yet the widespread support each initiative has received—not only from civil society the world over, but also from within the highest levels of government in each country—is a sign that the access and innovation benefits of the Indian model are apparent and achievable. This, then, is the enduring victory of a pharmaceutical model that works equally for producers and users—a third chapter in the story of access to medicines that unfolds more easily and travels much further than anyone could have expected at the outset of this journey. Harvard South Asia Institute 75 1. Donald W. Light and Joel R. Lexchin, “Pharmaceutical Research and Development: What Do We Get for All That Money?,” British Medical Journal 345 (August 2012), http://www. bmj.com/content/345/bmj.e4348. Amy Kapczynski, Chan Park, and Bhaven Sampat, “Polymorphs and Prodrugs and Salts (Oh My!): An Empirical Analysis of ‘Secondary’ Pharmaceutical Patents,” PLOS ONE 7, no. 12 (December 2012), http://www.plosone.org/article/info:doi/10.1371/journal. pone.0049470. Republic of South Africa, Draft National Policy on Intellectual Property, 2013 (Pretoria, 2013), http://www.thedti.gov.za/invitations/36816_4-9_TradeIndustry.pdf. Fix the Patent Laws (website), http://www.fixthepatentlaws.org/. Chamber of Deputies, Government of Brazil, Brazil’s Patent Reform: Innovation towards National Competitiveness (Brasília: Center for Strategic Studies and Debates, 2013), http:// infojustice.org/wp-content/uploads/2013/09/Brazilian_Patent_Reform.pdf. 2. 3. 4. 5. 76 Health and South Asia Harvard South Asia Institute 77 78 Health and South Asia Courtesy of Elizabeth Lopez. Emergency Care in Karachi Erum Sattar Karachi, Pakistan’s bustling commercial hub and the capital of Sindh Province with an estimated population between 18 and 20 million people, has no ambulance service in the public sector. For emergency medical transportation citizens have to rely on a mix of NGOs and philanthropic organizations running their own ambulance services and ambulances attached to particular hospitals— or they have to arrange transportation privately by hiring taxis, pickups, and rickshaws. Road-traffic accidents and other acts of violence on city streets add an additional layer of complexity to the city’s emergency-response landscape. Compounded by the problem of families and bystanders having to make difficult decisions in times of medical emergencies is the fact that before the arrival of Aman Ambulance on the city’s landscape in 2009, ambulance services operating in the city were transport services only. These services usually involved smaller vehicles that are not properly equipped with larger lifesaving devices. Aman Ambulance, by contrast, uses modified Toyota HiAce vans that have equipment onboard necessary for staff to perform medical interventions en route to hospitals (though drivers of other services are, however, given some basic training enabling them to transport patients with back injuries). With its heavily promoted “Call 1021” emblazoned on its bright yellow ambulances, Aman Ambulance is the result of the vision of Aman Foundation’s founder and trustee, Arif Naqvi. To date, Aman Ambulance has performed over 365,000 patient interventions and provided assistance in over 100,000 cases of disasters and calamities. As the only ambulance service in Karachi with an intervention capability, Aman Ambulances are staffed with trained medical personnel. The Basic Life Support Ambulance is staffed with an emergency medical nurse or a paramedic, and the Advanced Life Support Ambulance has a doctor onboard, in addition Harvard South Asia Institute 79 to a paramedic. There are over 4,000 primary hospital transfers in Karachi per day. Of these, over 2,600 transfers are by private means, which could indicate nonlethal cases in which ambulance services are not used. A range of private, public, and philanthropic service providers operate a total of 400 ambulances, with Aman operating 100 of them that cater to the remaining 1,400 daily hospital transfers across the city. Compared to a range of charges by other providers, Aman charges a nominal rate of 200 rupees, about 2 dollars per hospital transfer. Emergency medical dispatchers receive 1,200 calls around the clock from across the city at Aman’s Command and Control Center. Aman Ambulance uses ProQA, the emergency medical dispatcher (EMD) software that offers the automated tools needed to provide the best prehospital patient care. During the course of an emergency medical call, ProQA guides the process of collecting vital information from the caller, obtaining the patient’s status, choosing an appropriate dispatch level, and instructing the caller with medically approved protocols until the dispatched units arrive at the scene. Aman’s dispatchers monitor ambulances across 9 stations covering 80 forward bases or key points across the city. Aman soon found that of its planned ambulances of 100, it could only keep 80 ambulances on the road, as 20 would require maintenance at any given time. To keep its ambulances and their onboard lifesaving equipment fully functional, it additionally had to establish an in-house ambulance maintenance unit, as Karachi lacked a system for such emergency-vehicle maintenance. While an in-house ambulance workshop raises overall costs, given the city’s weak response capacity it is an essential component of the overall ambulance service. Another weak link in the city’s emergency-response systems is the lack of any training facility for emergency-response personnel. Aman has had to fill this gap by also starting an in-house emergency medical paramedic training facility as it found that there was no facility from which it could readily recruit personnel. As part of its commitment to evaluate impact and to enhance operational capacity, Aman’s Measurement Learning and Evaluation Department (MLE) is working to digitize ambulance data under a research grant from the Hamburg Center for Health Economics. Paper-based ambulance reports contain valuable data on patient history, diagnosis, and care during transport, and this information can be used to evaluate clinical quality and final outcomes. MLE has created a cloud-based, real-time data entry system, optimized for use of ambulance staff, to digitize ambulance reports and make the information available to the emergency medical service (EMS) managers. This exercise will serve as a basis for the long-term digital integration between ambulance records and Command and Control records. In addition, the MLE team has also developed an Android app for real-time data tracking. The app will move ambulances to a paperless system, while allowing real-time tracking of operational and quality indicators. In addition, MLE, along with the Operations and Command and Control teams, uses real-time data entry to measure and analyze the quality of EMS care and outcomes of EMS interventions. The project is expected to yield useful information 80 Health and South Asia about the impact of Aman EMS, while increasing the quality of emergency care delivered in ambulances. Monitoring such real-time impact will enable Aman to share its learning and systems with the broader public health system and other emergency-care providers—thus strengthening the city’s overall emergency-response capacity. Despite Aman’s achievements to date, operating in a tough urban environment poses major challenges to its model. No one player is large enough to fix the city’s emergency-response systems. Coordinated action by all actors will be needed to evolve a joint strategy to improve Karachi’s disaster preparedness. The problem is systemic as Karachi’s hospitals, whether public or private, are not equipped to receive patients from ambulances on which any intervention has been performed—once a patient arrives at an emergency ward in any large hospital, emergency-room doctors have an attitude of “this is now our patient and our case to deal with,” and don’t yet have the mindset or operative readiness to work in tandem with an ambulance service that can provide onboard emergency medical care, including stabilizing functions on patients en route to a health facility. Further, there is neither an organized center directing cases to other facilities when the demand for services falls disproportionately on any particular facility, nor is there a coordinating body that has a list of such facilities, including the available treatments they are able to provide. Patients, families, and indeed ambulance drivers are faced with being turned away from particular facilities and are asked to take a patient to another facility because the hospital does not have the capacity to treat certain emergency conditions; transfers to multiple facilities risk patient survival rates and increase costs for families. Aman Ambulance has stepped into this overall dysfunctional emergency public health infrastructure. Aman’s basic aim is to demonstrate excellence, at first on its own. The goal of successfully demonstrating a model is to encourage others to adopt a similar approach and thereby to expand delivery of high-quality care to the underserved. However, in working toward its broader vision of helping build a working emergency medical response ecosystem in a large metropolis, Aman has recently partnered with the Edhi Foundation, as the name is synonymous with trust and service delivery in Pakistan. The Edhi Foundation operates the largest private philanthropic fleet of ambulances in the world. The two organizations have agreed that Edhi will divert cases requiring en route medical intervention to Aman, and Aman will likewise divert less acute calls, assessed as such after triage evaluation by its Command and Control personnel, to Edhi. While this is a great first step at collaboration and moves Aman out of the phase of solely operating on its own, much remains to be done, particularly as Aman’s longer-term aspirations include demonstrating the success of its approach to the government, as well as working with the public sector and other providers to enhance the city’s overall response capacity. While this will require a different and enhanced skill set than what Aman has been able to build on its own, the future of public health demands nothing less from all actors in an Harvard South Asia Institute 81 ecosystem—with Aman leading the way toward a collaborative future in which actors pool resources to build sector excellence. Aman urgently needs to commit resources and personnel toward evolving and helping build a sustainability strategy to consolidate its considerable achievements to date and work with others in the ecosystem to strengthen the city’s overall disaster preparedness. Given Karachi’s public health system, which is unable or unwilling to take the lead in helping build such a system, Aman’s considerable accomplishments and services risk being one functional piece of an overall dysfunctional ecosystem. To make a lasting impact, Aman’s philanthropic effort must respond to the challenge of sustainability. 82 Health and South Asia Harvard South Asia Institute 83 84 Health and South Asia Courtesy of RMA Architects. Health by Design: A Conversation with Rahul Mehrotra Sharmila Sen How is public health in South Asia affected by design—architectural, industrial, and urban? The following is an excerpt from a conversation between Sharmila Sen and Rahul Mehrotra. Rahul Mehrotra is an architect and planner, as well as professor at Harvard’s Graduate School of Design. Give us the bad news first, Rahul. Let us begin with an example of how design has failed to improve public health in India. What are some examples of bad design that negatively impacts public health? Bad design in South Asia is everywhere! This is most severely felt in the public domain. Look at our streets and sidewalks. Simple parameters like slopes and the way the edge of a sidewalk is made are examples of bad design. Badly made aspects of the public realm lead not only to physical accidents but also result in stagnant water that propagates diseases such as typhoid and malaria. In short, bad design in the public realm is totally hazardous to your health! So, what can be done to improve bad design in the public realm and elsewhere in South Asia? What can and should the next generation of designers focus on? If you can make suggestions to a bright, young designer who hopes to make a difference in this realm, where would you point him or her? The next generation of designers in South Asia should focus on solving problems of sanitation—this is critical for public health. One of the biggest problems in South Asia in the coming decades is going to be public health on account of the lack of toilet facilities. We need simple public amenities in our teeming metropolises. Mumbai, for example, has barely one WC for 1,200–1,300 people. Sadly enough, professionals in the design field are not even marginally involved in this problem. This stems from the lack of motivation in this globalizing economy to Harvard South Asia Institute 85 engage with these kinds of risky problems that don’t fetishize architecture and design indulgences per se. Of course, the lack of patronage for such projects makes the problem even worse. However, if young designers hope to make an impact on the built landscape they must engage with issues such as improving public health, sanitation, and general community well-being—especially the health and well-being of the poor. Rahul, tell us a bit about your current design projects. Where do you turn to for inspiration when it comes to designing environmentally sustainable and “healthy” buildings? I find indigenous materials and techniques for enhancing passive ventilation and cooling very inspiring. We often look at certain indigenous techniques and materials when we design our new buildings. Consider, for instance, the famous wind scoops from Sindh in Pakistan—the air is sucked in through the tunnels and humidified and cooled for dry climates. Recently, we have been studying the thatched huts the government sets up during the summer in Rajasthan, India. These huts are used to distribute water to the public during the hot, dry months. The entire hut and the water stored in it are kept cool without electricity. Just passive evaporative cooling does the job—such a simple but elegant solution! This is the ultimate water cooler that uses no energy, but harnesses simple passive techniques founded completely on indigenous ideas. “Green design” seems to be a rather fashionable term being bandied about globally. Tell us what is the most misunderstood aspect of green design. The biggest problem with the discussions about green design is that the discourse has been co-opted by the high technologies, architects, and engineers. Resultantly, there has developed an entire green industry that perpetuates the narrative of chemical and mechanical fixes to any problem. Sadly enough, we now call these “intelligent buildings”! Unfortunately, what gets overlooked in the process is the low technology that sometimes produces the most intelligent responses to climate, lack of resources, and local cultures. So, low-tech solutions might yield the most intelligent of designs. That is indeed a fascinating thing to keep in mind as we look for “smart” everything! Before we wrap up today, can you share some insights you have gleaned from your recent work on public toilets in Mumbai? I got involved in the project for the public toilets with an NGO called SPAARC. I was motivated to do this because of the critical problem with sanitation in Mumbai. As importantly, I found out that NGOs and the government were about to embark on building 300 public toilets without an architect involved! For me this is not only completely crazy but also a sad reflection of the detachment of the profession from issues where design could matter and actually contribute to society. Once we started, we began to see many possibilities in terms of spatial arrangements for the design of these buildings. We stacked the 86 Health and South Asia toilets with the facilities for women and children on the upper floors to ensure their safety. We introduced the idea of a caretakerâ€™s house on the upper floorâ€” the penthouse in the slum for the person from the lowest caste. We attached a community center to this space. We raised money from the private sector to provide solar panels so that toilets could be off the grid, not dependent on the city for power, and be illuminated throughout the night. Again, these decisions to ensure illumination throughout the night were based on the need to make the facilities truly accessible to women and children, the most vulnerable segments of the urban poor population. Unfortunately, despite these innovations, the project failed. Upon retrospection, I think we had not really managed to successfully engage the community and foster a sense of ownership of these spaces within the community. We had failed to make the local residents actual participants of the planning process. So, even though our designs were spot on, people did not feel that crucial sense of ownership, and the space was misused by vested interests. The most important lesson I learned from this design process is that the public toilets need to be more fully embedded in the community they serve. We will try againâ€”this is not an issue with which I have disengaged. Thank you very much, Rahul, for these observations about design and for sharing your stories with us. Harvard South Asia Institute 87 88 Health and South Asia Courtesy of Project Prakash. Project Prakash: Merging Science and Service Pawan Sinha For most scientific enterprises, the societal benefits are realized long after the research effort. However, in rare instances, even the process of conducting research directly benefits peopleâ€™s lives. Project Prakash is one such instance. Its genesis lies in the confluence of a crucial humanitarian mission and a fundamental scientific quest. The overarching mission of Project Prakash is to bring light into the lives of curably blind children and, in so doing, illuminate some of the most fundamental scientific questions about how the brain develops and learns to see. India shoulders the worldâ€™s largest burden of childhood blindness. It is estimated that nearly half a million children in the country are either blind or severely visually impaired. The visual handicap, coupled with extreme poverty, greatly compromises the childrenâ€™s quality of life; fewer than 50% of these children survive to adulthood. These numbers take on added poignancy when one notes that in 40% of the cases, the blindness is treatable or preventable. Most children, however, never receive medical care because the treatment facilities are concentrated in major cities, while 70% of the population lives in villages. These circumstances effectively ensure that a blind child in a financially strapped rural family will live a dark and tragically short life. For blind girls, the outlook is even direr. Many are confined at home and denied contact with the outside world. There is, clearly, a humanitarian crisis that needs to be urgently addressed. To this end, Project Prakash seeks to identify and treat blind children, and simultaneously, build awareness amid the rural populace about treatable and preventable blindness. Embedded in the humanitarian aspect of Project Prakash is an unprecedented opportunity to study one of the deepest scientific questions: How does the brain learn to extract meaning from sensory information? Harvard South Asia Institute 89 The humanitarian initiatives of Project Prakash are creating a remarkable population of children across a wide age range who are just setting out on the enterprise of learning how to see. We have begun following the development of visual skills in these unique children to gain insights into fundamental questions regarding object learning and brain plasticity. This is a rare window into some of the most fundamental mysteries of how the brain learns to acquire meaning from the world. On an applied note, as new eye treatments become available and existing treatments reach children who are currently blind, the basic question we have to confront is how to proceed with their integration into the sighted world. In this context, Project Prakash holds the potential to make a significant impact by directly assessing how extended visual deprivation influences childrenâ€™s subsequent development of visual skills. This undertaking is a prerequisite to developing strategies to compensate for particular deficits. Supported by the National Institutes of Health in Washington, DC, as well as private, science-oriented US foundations, the Prakash initiative has so far screened over 40,000 children; over 400 of them have been treated surgically and 1,400 nonsurgically. It has been tremendously gratifying to see the dramatic changes that treatment has brought about in the lives of these children. Simultaneously, the scientific data gathered have begun challenging some long-held dogmas in neuroscience about learning and brain plasticity. The findings reveal that the brain maintains significant ability to change even after many years of profound visual deprivation. In a matter of a few months after their sight surgeries, the Prakash children begin to be able to use vision for complex tasks like recognizing objects and moving independently. Recently, Project Prakash provided the answer to a famous question in philosophy. In An Essay Concerning Human Understanding, John Locke quotes William Molyneux as stating the problem in this way: If a blind adult is taught by his touch to distinguish between a cube and a sphere, can the same man distinguish between these shapes solely using his visual capabilities if his sight is restored? Called the â€œMolyneux Query,â€? this question had remained open for the past over three centuries until work with the newly sighted Prakash children finally resolved it. We believe that the findings thus far represent just the tip of the iceberg in terms of insights regarding brain function that working with the newly sighted can reveal. Coverage of the humanitarian and scientific outcomes of Project Prakash in the popular press has had collateral benefits; it has raised awareness about the problem of childhood blindness among the public at large and also governmental policy makers. True to its name, the project has illuminated lives and also illuminated science. The magnitude of the problem of childhood disabilities in India is daunting, and the challenge of unraveling brain mechanisms of learning is among the hardest in science. But we are encouraged that Project Prakash has begun to serve as a nucleus for bringing together the resources, expertise, and 90 Health and South Asia commitment needed to mount appropriate responses. With Project Prakash, we have a unique and unprecedented opportunity to address issues of great humanitarian, health, and scientific significance. The key challenge we need to confront now is scaling the project. We have to reach out to many more children and provide them the best possible medical care. Furthermore, we need to provide the treated children with the beginnings of an education to facilitate their entry into the social mainstream. Thus, there is a need to integrate medical care, scientific research, and education, while scaling up the project significantly. The most effective way of accomplishing this is to set up a new facility dedicated to childrenâ€™s care, which would physically integrate a hospital, a school, and a cutting-edge research center. This proposed Prakash Center for Children can transform the lives of countless children with disabilities both in India and abroad. It will also have a profound impact on fundamental science. Realizing this dream is an audacious goal, but one that can have a transformative impact on many lives and minds. Harvard South Asia Institute 91 92 Health and South Asia Courtesy of Jennifer Weaver. Medical Innovation for Low-Resource Global Markets Conor Walsh The Medical Innovation for Low-Resource Global Markets program is a project-oriented, multidisciplinary initiative we started in 2012 that provides Harvard students with the opportunity to spend a summer in India and collaborate with local students and health care workers to create novel medical technologies that address clinical needs. The core philosophy of the program is that in order for students to understand how to innovate in low-resource settings, they need to spend time on the ground in the region to interact directly with the stakeholders and understand the social, economic, and technological context in which this innovation takes place. This has strong crossover with the current health care climate in the US as cost constraints are becoming increasingly important. Currently, India is rapidly emerging as a hotbed for health care innovation and through the program, Harvard students and faculty can get exposure to this and play a role in creating and commercializing engineering solutions that are affordable and reflect the health priorities of an emerging economy. Apart from the benefit to Harvard and its students, the program has the potential to develop affordable health care solutions not only for patients in the region, but also in more developed economies. The program began in 2012 through an Omidyar Network grant from the South Asia Institute. That summer, four students from the Harvard Kennedy School, the Harvard School of Engineering and Applied Sciences (SEAS), and the Harvard Business School visited regional hospitals in India to identify unmet clinical needs in the region and explore the potential for innovative low-cost solutions. The multidisciplinary team was based at Narayana Hospital in Bangalore for ten weeks where Professor Tarun Khanna of Harvard Business School had ongoing research collaborations, and in addition visited hospitals in Tamil Harvard South Asia Institute 93 Nadu and Mumbai. Bangalore was chosen as the main site as it hosts some of Indiaâ€™s top hospitals and is considered the Silicon Valley of India, presenting numerous opportunities for collaboration. The students identified three strategic focus areas and spent three weeks working in each area, observing procedures, identifying problems, and analyzing them to assess the needs of clinicians. Once a shortlist of clinical problems and potential solutions had been identified, they returned to the hospitals and conducted interviews with the physicians to gain a deeper understanding of the problems and get feedback on potential solutions. One of the problems identified during the summer of 2012 related to cataract surgery. Cataracts are the leading cause of blindness and visual impairment in the developing world, responsible for 48% of world blindness and causing severe disability in 78 million people as of 2011. The majority of patients who suffer from cataract-related blindness could be given sight with proper surgery. However, the current instruments used during the most delicate step of cataract surgery are extremely rudimentary and pose major difficulties for surgeons, while more precise laser-assisted alternatives are prohibitively expensive. The Harvard team identified the need for a low-cost tool to cut the lens capsule during cataract surgery. Building on this work, a SEAS senior developed a solution in the form of a vibrating blade driven by piezoelectric actuators as part of his ES100 Engineering Design Project. The Capzzular project won a 2013 Thomas Temple Hoopes Prize. Building on the success of the first summer program, in early 2013 applications for the second summer program were solicited, with nearly twenty students across Harvard applying. Five Harvard students were selected and again based in Bangalore at the Indian Institute of Science (IISc) with Professor B. Gurumoorthy where they collaborated with other engineering students from the Centre for Product Design and Manufacturing. In addition, Donal Holland, a joint PhD student between Trinity College, Dublin, and SEAS provided on-site mentorship. The student team included members with backgrounds in engineering, medicine, architecture, computer science, and anthropology. The students spent four weeks visiting hospitals and health centers throughout the Karnataka region to observe procedures and interview clinicians, eventually focusing on problems faced by staff at rural clinics. Owing to shortages of staff and resources, these clinics are capable of treating only a small number of illnesses and must refer most patients to larger hospitals, which are often hours away. In emergency situations, the staff may need to assist a patientâ€™s breathing or clear their airways during transport, and the students found that many clinics did not have adequate ventilation and suction devices. They spent the next six weeks gaining a deeper understanding of the need and designing and prototyping two medical devices with weekly design-review meetings with the Harvard team calling in remotely via Skype. One of the solutions developed, a low-cost manual suction device, will be developed further by the IISc students as part of a masterâ€™s program in product design and manufacturing. 94 Health and South Asia The experience of the last two summer programs has begun the process of bringing together students, faculty, innovators, and clinicians in the US and India. Harvard provides the ideal environment for this type of activity with its global ties, diverse schools, and research disciplines, and its more recent focus on design, innovation, and entrepreneurship. My research group, the Harvard Biodesign Lab at SEAS and the Wyss Institute, has provided the necessary mentorship and training in medical-device innovation for students participating in the program to date, and the South Asia Institute has provided critical regional support and connections. The President’s Innovation Fund for International Experiences provided support for on-site mentorship and promotion. There is much work remaining in order to create a sustainable and productive program such as building collaborations between different Harvard schools as well as academia, industry, and hospitals in the US, India, and ultimately other global markets. It is a truly multidisciplinary initiative in which students combine social science and engineering methods to gain a global perspective and tackle some of the world’s most pressing health problems. For the Harvard students, the multidisciplinary collaboration has been one of the highlights of the program. According to William Lewis, a summer 2013 participant from Harvard Medical School, “everyone approaches the problem differently and brings a separate set of skills, and as a result, I feel that our creative process has generated lots of exciting, ‘outside-the-box’ solutions.” Harvard South Asia Institute 95 CODA As he thus saw rightly the evils of the world, the evils of disease, old age, and death, pride of self in an instant departed from him, pride resulting from his strength, youth, and life. He did not give in to dejection or delight; he did not give in to doubt, or to sloth or sleep; he felt no attachment to sensual delights; he did not hate others or treat them with contempt. Ashvaghosha, The Life of the Buddha (First or second century CE) Translated by Patrick Olivelle, Clay Sanskrit Library (New York: New York University Press, 2008) But among other things I was much surprised to see that almost everybody was spitting something red as blood. I imagined it must be due to some complaint of the country, or that their teeth had become broken. I asked an English lady what was the matter, and whether it was the practice in this country for the inhabitants to have their teeth extracted. When she understood my question, she answered that it was not any disease, but [due to] a certain aromatic leaf called in the language of the country pān, or in Portuguese betele. She ordered some leaves to be brought, ate some herself, and gave me some to eat. Having taken them, my head swam to such an extent that I feared I was dying. Niccolaò Manucci, Storia do Mogor: or, Mogul India, 1653–1708, Vol. 1 Translated by William Irvine (London: John Murray, 1907) 96 Health and South Asia CODA For here the cleavage was between Brahman and non-Brahman; Moslems and English were quite out of the running, and sometimes not mentioned for days. Since Godbole was a Brahman, Aziz was one also for purposes of intrigue: They would often joke about it together. The fissures in the Indian soil are infinite: Hinduism, so solid from a distance, is riven into sects and clans, which radiate and join, and change their names according to the aspect from which they are approached. Study it for years with the best teachers, and when you raise your head, nothing they have told you quite fits.… Nominally under a Hindu doctor, he was really chief medicine man to the court. He had to drop inoculation and such Western whims, but even at Chandrapore his profession had been a game, centering around the operating table, and here in the backwoods, he let his instruments rust, ran his little hospital at half steam, and caused no undue alarm. E. M. Forster, A Passage to India (New York: Harcourt Brace and Company, 1924) It is April 7th, 1919, and in Amritsar the Mahatma’s grand design is being distorted. The shops have shut; the railway station is closed; but now rioting mobs are breaking them up. Doctor Aziz, leather bag in hand, is out in the streets, giving help wherever possible. Trampled bodies have been left where they fell. He is bandaging wounds, daubing them liberally with Mercurochrome, which makes them look bloodier than ever, but at least disinfects them. Salman Rushdie, Midnight’s Children (New York: Knopf, 1981) Harvard South Asia Institute 97 NOTES 98 Health and South Asia NOTES Harvard South Asia Institute 99 NOTES 100 Health and South Asia NOTES Harvard South Asia Institute 101 NOTES 102 Health and South Asia NOTES Harvard South Asia Institute 103 Cover and interior design by Marissa Giambrone trauma emergency care philanthropy medicine computational neuroscience w-cost medical device urban planning ogy epidemiology vision public health ter pollution policy design engineering e ageing graphic novel gender violence health patent law intellectual property pharmaceuticals healthcare financing ality environment leapfrog technology ambulance innovation computational