Of procuring drugs, and gendering health care

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This week in health: drones that deliver medicines, India’s draft Menstrual Health Bill and why bats are shielded from deadly viruses.

After the excitement from the courts last week, and the Nobel announcements earlier, this week was rather quiet on the health front. But we took the downtime provided by the lull to engage in a rather important debate, particularly on the heels of the recent scarcity of anti-tuberculosis drugs, about procurement of drugs in the country. While different models exist in the country, variegated by the States’ existing plans to procure drugs in their respective territories, of late the question has been doing the rounds — of centralised procurement in health care. Murali Neelakantan and Ashish Kulkarni argued this week that this was a powerful health idea. They looked at the McDonalds’ model of using a ‘pooled buyer structure’ in procurements. “Many countries and international organisations have shown that a pooled buyer model for drug procurement addresses many issues that are related to price efficiency, stockouts and quality concerns. But for reasons that have remained mysterious for decades, the Central Government chooses to ignore the merits of pooled procurement when it comes to schemes such as the Central Government Health Scheme (CGHS), the Pradhan Mantri Jan Arogya Yojna (PMJAY) and the Employees’ State Insurance Scheme (ESI),” the authors write. However, private hospitals have realised the benefits of such a pooling arrangement and employed it effectively to cut costs and efforts.

Quoting from a recent paper, “A National Cancer Grid pooled procurement initiative, India”, the authors endorse the viability of this idea. C.S. Pramesh et. al. demonstrated that group negotiation, uniform contracts, and, finally, purchases by hospitals associated with the National Cancer Grid for 40 drugs resulted in savings of ₹13.2 billion. Without pooled procurement, the cost would have been ₹15.6 billion, with savings ranging from between 23% to 99%. The Centre is aware of the benefits though, as visible in the way the National AIDS Control Organisation procures male contraceptives from the market with HLL Lifecare sets the benchmark price and others in the market see the wisdom in offering competitive/reasonable pricing.

The authors also say centralised procurement would also ensure better quality by having the supplies tested independently, rather than having to rely on the drug regulator to do so. This is in addition to the cost savings, and the model has reportedly been employed by buyers in many developed countries.

There’s clearly to be more caution in terms of emerging infections and a One Health approach must guide health administrators in future. The Union Health Secretary Sudhansh Pant recently informed attendees at the national conclave on “Augmented Zoonotic Diseases Surveillance at Human-Wildlife Interface” that 75% of emerging infectious diseases are zoonotic. “Limited knowledge and skill to identify zoonotic diseases, coupled with limited diagnostic facilities at all levels has resulted in neglect of the infectious diseases due to zoonotic pathogens,” he cautioned. The event doubled up as a national conclave for Endorsement of the “National Action Plan for Prevention and Control of Snakebite Envenoming”, organised by the Centre for One Health, National Centre for Disease Control (NCDC). “The Central Government is taking several measures to promote One-Health and NCDC through its various technical divisions is undertaking activities pertaining to pandemic preparedness likely to emerge from zoonotic threats at human, animal and environment interface,” he said.

On to further information on zoonotic diseases, can we overlook the role of bats? Sridhar Sivasubbu and Vinod Scaria say bats have grabbed the headlines of late for the wrong reasons. Their notoriety stems from the fact that many deadly viruses use bats as a reservoir host, including coronaviruses, Nipah, Ebola, Marburg virus, and Hendra virus, among others. The COVID-19 pandemic also cast a bright spotlight on the habits of bats. Bats, they argue, do host a wide variety of pathogens, including ones deadly to other mammals, but they themselves don’t get infected. But why? Emerging evidence suggests that a set of immune-related genes have been undergoing positive selection in bats, adapting them to control the spread of viruses while mitigating the antiviral inflammatory response. As a result, the bats are shielded from the effects of the clinical response of their bodies to these viruses. The heightened pro-inflammatory activity is what makes these viruses deadly in humans.

On the subject of zoonotic infectious diseases, here’s more on COVID-19, and this time, more light has been shed on the manifest effects of long COVID. R. Prasad writes on a possible pathway for Long COVID pathogenesis being uncovered. Researchers assessed the metabolite profile of individuals with Long COVID and found serotonin abundance is reduced both during acute COVID-19 and in individuals with multiple long-term symptoms. Perhaps this is the first step towards ameliorating the situation for a number of people across the world suffering mild, moderate, and deadly effects after COVID-19.

Staying on COVID-19, here is another piece on mRNA vaccines, that will provide better clarity on the revolutionary technology developed into a fine art in record time, during the COVID-19 pandemic. But could there be more, asks John Fraser: Beyond COVID-19 vaccines: what else could mRNA technology do for our health?

Bringing in the gender lens to shine a light on health care, this week, some good news, though belated came in the name of the draft Menstrual Health Bill. There’s a rather rudimentary and belated acknowledgement of the inevitable nature of menstruation and the myriad problems it can cause among women. The draft that is up for comments and suggestions on the website, claims officially aims to address the long-standing challenges associated with menstruation in India. The document records: “Historically, this biological phenomenon has been overlooked, resulting in negative impact on girls, women, families and the environment. With time, awareness has increased, but we need more investment to comprehensively address the diverse requirements of all individuals who menstruate. India, with its vast and diverse population, acknowledges the critical importance of this issue and places great emphasis on framing a comprehensive menstrual hygiene policy. This policy is essential for effectively addressing the needs of all who menstruate and promote a positive transformation within our society.

On another track, a recent study by Apollo Hospitals shows 25% of breast cancer incidence in women under less than 40 years of age. Listing the key findings from screenings, the hospital said that 25% of breast cancer cases among Indian women occurred at the age of 39 years or less. The recorded minimum age at the time of breast cancer diagnosis is 23 years. The data also showed that the median age of breast cancer incidence among Indian women is almost 10 years earlier than in Western countries such as the U.S. and the U.K.: breast cancer diagnosis among Indian women is at an average of 53 years, lower than the median age of 62 years in these western countries. There is probably a felt need for reevaluating and advancing cancer screening for women even before the recommended 40 year milestone, experts have said.

Here is an equally serious charge, one that comes from Health Minister Mansukh Mandaviya himself, who flagged concerns over the misuse of technology exacerbating gender imbalances. Modern technologies including IVF procedures, the Non-Invasive Prenatal Test (NIPT), and compact diagnostic equipment, which facilitate sex selection under the pretext of family balancing, continue to pose challenges in ensuring a gender balance in the country said Health Minister Dr. Mansukh Mandaviya, during the 29th meeting of the Central Supervisory Board (CSB) held recently. The latest Sample Registration Survey report indicated that the gender gap has witnessed a two-point decrease in 2020 compared to a five-point gap in 2015, though ten states have effectively reversed the gender gap, positively impacting female survival rates.

Meanwhile, did you know that the families of India’s first cases of two rare disease patients struggle for inclusion under national policy? Families of patients with rare diseases have been waging long-drawn-out battles in the corridors of power and courts, and here, Afshan Yasmeen records the particular cases of two families, with one child each, diagnosed with the rarest of rare diseases — Infantile Hypophosphatasia and Niemann Pick — who are struggling to get these genetic disorders included under the Centre’s National Policy for Rare Diseases (NPRD).

Sleep is highly underrated for what it can do, or what denial of sleep can do to the human body. In modern times, with stress and anxiety, besides hectic schedules weighing heavily on people, sleep often becomes the casualty. But did you know, that fearing insomnia itself can be pretty harmful?Leon Lack and Nicole Lovato explain that when they looked at the impact of sleep problems on life expectancy, they found no evidence sleep symptoms alone shorten one’s life. Only when daytime symptoms such as fatigue, memory problems and distress are included is there a small increased risk of dying prematurely. However, it’s difficult to know if that excess mortality can be explained by undiagnosed heart, kidney, liver or brain disease causing those daytime symptoms. Although there is stronger evidence of increased mental health problems, especially depression, with insomnia. The typical daytime impairments of fatigue, distress, cognitive impairments and irritability certainly lower the quality of life. Life becomes more of a challenge and less enjoyable. Over time, this can trigger hopelessness and depression in some people. This is enough reason to seek help to improve sleep and quality of life. They have also recommended cognitive behavioural therapy as a drug free, long term effective treatment for people with sleep issues.

And if you must know, there’s a bit of a kerfuffle between nations as the race is on to pick the next regional head of the World Health Organisation. The contest between Bangladesh and Nepal for the regional head of the WHO has become increasingly heated, with allegations of “nepotism” and “sexism” being hurled at the candidates, and the election to be held in Delhi less than two weeks away, write Suhasini Haidar and Kallol Bhattacharjee.

Our tailpiece this time, is a bunch of stories on the intersection between tech and health care. There is much technology employed in the healthcare sector, the drone probably is coming late to the party. Here, Bindu Shajan Perappadan writes about how ICMR has now begun delivering medications via drones across rough Himachal terrains. Health providers say AI chatbots could improve care, but racism fears linger. Based on a new study led by Stanford School of Medicine researchers caution that popular chatbots are perpetuating racist, debunked medical ideas, prompting concerns that the tools could worsen health disparities for Black patients. And Dr. Mohan Rajan sees the magic of artificial intelligence applications in the field of ophthalmology.

From the Health page

If you have a few moments, do tarry here, and check out the following important health stories:

Tamil Nadu ropes in volunteers to provide food baskets for severely ill, undernourished TB patients, reports Serena Josephine M. What does the Supreme Court’s abortion verdict mean for reproductive justice in India? Saumya Kalia interviews a reproductive rights expert to break down the judgment. An NGO says a law to deal with trauma could help prevent lakhs of deaths in India, reports Soibam Rocky Singh. Gaza’s doctors struggle to save hospital attack survivors as West Asia rage grows. Pfizer to price COVID-19 tratment Paxlovid at $1,390 per course. AIIMS to have integrated health study centres, finds Bindu Shajan Perappadan. Explained: The story of Svetlana Mojsov, and the controversy around revolutionary diabetic drugs.Supreme Court intervention gives MBBS interns a fair deal in the stipend issue, by C. Maya.Health Ministry denies compromise on OTT smoking rules, reports Aroon Deep.

For a smattering of our regional content:

Andhra Pradesh

Conduct health camps for women at least once in a month, Chief Minister Jagan Mohan Reddy tells officials.

Karnataka

Health Department says around 1.73 lakh school children in Karnataka suffer from refractive errors, reports Jayanth R.

Bengaluru start-up has its eyes set on democratising cell therapy for incurable diseases, writes Shilpa Elizabeth.

COVID-19 fatality numbers swell by 25,000 after verification by the Revenue Dept. panel.

Kerala

Upper income limit pushes 1,200 kids with Type 1 diabetes out of ‘Mittayi’ scheme in Kerala.

Dengue, leptospirosis cases remain a concern in Ernakulam.

Medical claim cannot be denied even if patient discharged on same day, says grievance body.

Tamil Nadu

Minimally invasive procedure used to treat two patients with chest tumours in Chennai.

People battling mental illness run SIEMAT canteen in Chennai to break the stigma, documents Meghna M.

Directorate of Public Health and Preventive Medicine takes measures for monsoon preparedness.

Telangana

Telangana’s elderly population projected to reach 17.1% by 2036: UNFPA, reports Siddharth Kumar Singh.

As always, do put us on your radar, as we bring more health content your way. Get more of The Hindu’s health coverage here.

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