Partial lifting of COVID 19 Lockdown in Rajasthan - Economy, Productivity, Science and People

In Rajasthan except for eight districts - Jalor, Sirohi, Rajsamand, Ganganagar, Hanumangarh, Bundi, Baran, and Chittorgarh, every district has reported a corona virus infection case. Jaipur leads the tally with 170 cases, Jodhpur and Jhunjhunu, having 34 and 32 cases, Bhilwara and Tonk 28 and 27 cases, Kota and Banswara 17 and 12 cases, Jaisalmer 19 cases, and there are 42 Iran evacuees who are being treated. The other districts have single digit reported cases. As on 13th April the total number of cases in Rajasthan is 700. The numbers are increasing everyday, with Jaipur becoming a hotspot of the cases. Rajasthan has also successfully dealt with epidemic spread in Bhilwara district, which is now famously touted as Bhilwara model. Goldman Sachs estimated the growth rate of GDP at 1.6% declining by 400 basis points because of lockdown of 21 days. In case of a quick retraction of COVID-19 pandemic across the globe by Mid May, KPMG India estimated India's GDP growth in the range of 5.3 per cent to 5.7 per cent. In a second scenario where India controls the virus spread but there's significant global recession, the growth may be in between 4 per cent to 4.5 per cent. KPMG India in its report estimated India's GDP growth rate falling below 3% if the virus spreads further in India and lockdown sees an extension. Motilal Oswal Research suggests that a single day of complete lockdown could shave off 14-19 basis points from annual growth. Barclays said the cumulative shutdown cost will be around $120 billion, or 4 per cent of GDP. Mr. Yashwant Sinha, for Finance Minister of India, estimated the cost of 21-day countrywide lockdown at 1 percentage point of GDP. The global recession and uncertainties of future would make a 2 percentage points decline in growth rate(for 2020-21) possible. If we look at the district's tally we find that most of the districts left out are smaller districts and they share their boundaries with affected districts and other states. Jalor and Sirohi share their border with Gujarat, and Ganganagar and Hanumangarh share their border with Punjab and Haryana. The probability of finding more cases in these districts is also very high, if intensive testing is done. The state government has ordered a state level survey to do wide testing in the state. The big question of whether to lift the lockdown or not is closely related to the economic activity, because the argument given by those who favour lifting of the lockdown, argue that the productivity loss will bring bigger problems for the poor and the vulnerable. Advance estimate of state gross domestic product (SGDP) is Rs, 711627 crores at constant prices. If we look at the breakdown of Gross State Value Added across various sectors - it is 25.19% agriculture, 30.67% Industries, and 44.14% services, as per the advance estimate figures of 2019-20. Agriculture Doing an analysis sector by sector, in Agriculture, as per Economic Review the advance estimates of Rabi crop are as follows - Production in lakh tonnes Cereals Pulses Oilseeds Sugarcane Cotton 133.19 27.44 65.79 2.5 26.63 lakh bales If we see the district wise concentration of these crops, it is as follows - Wheat Ganganagar, Hanumangarh, Jhunjhunu Barley Ganganagar, Jaipur, Hanumangarh Millets Jalore Sirohi, Kota, Dungarpur Gram Bikaner, Churu, Kota, Dungarour Masoor Bundi, Pratapgarh Matar Jaipur, Sikar Cotton  Ganganagar Sunflower Sugarcane  Ganganagar Tarameera Nagaur, Jaipur, Dausa Rape and Muster Tonk, Alwar, Baran Linseed Nagaur, Pratapgarh, Kota Ganganagar, Hanumangarh, Jalore and Sirohi have not reported any cases. The probability of having cases in the rural areas is lower, thus the lockdown should be lifted in these areas to ease out the harvesting of the crops. Jaipur is the hotspot of corona virus spread, but most of the cases have been found in the city, in a particular area, Ramganj. While Ramganj should be completely locked, government can think of having partial lockdown in the rural areas of Jaipur, with a strict ban on moving outside the district, and entering inside the city. Jaipur City should be sealed.             Same strategy can be followed in the other districts. Surveilance for the rural spread of the cases can be done and in 4-5 days time, partial lockdown can be lifted in Kota Bikaner and Dungarpur districts. Inter-district movement will have to be restricted. Tonk is close to Jaipur, and is a small district. Tonk has also become a hotspot. Tonk should be kept under lockdown, for the next two weeks, as probability of virus spreading in rural areas is higher in Tonk. For the other districts, where the number of cases is less, the areas where the cases have been reported are to kept under complete lockdown, for two more weeks and partial lockdown can be lifted in the other areas. Government will have to assist in the marketing of agricultural commodities after two weeks, and preparations should be made for the same. Industry Industrial Production in Rajasthan is concentrated to a few districts. Industrial production in Rajasthan is largely divided into three parts, Manufacturing, Mining and Energy. The Gross Value Add of manufacturing sector in Rajasthan is about Rs. 94,419 crore in 2019-20 at current prices accounting for 9.82% of contribution to the total GSVA of the state. Mining contributes 6.62%. There are Industrial hubs in Rajasthan where the large scale industry is located. Textile industry in Bhilwara, Energy in Barmer, Automobile and Auto Components in Bhiwadi and Neemrana, Mining in Udaipur and Khetari, and Cement industry in some parts of Rajasthan. Large scale industrial houses should come forward to collaborate with the state government to do a surveillance of labour and other workers in the plant. The industrial houses should bear the cost of tests, and the lockdown should be lifted from plant to plant. In the Veneto region of Italy, as per Newyork Times, ‘Having the right antibodies to the virus in one’s blood — a potential marker of immunity — may soon determine who gets to work and who does not, who is locked down and who is free.’ The conservative president of the northeastern Veneto region has proposed a special “license” for Italians who possess antibodies that show they have had, and beaten, the virus. The former Prime Minister, Matteo Renzi, a liberal, has spoken about a “Covid Pass” for the uninfected. Rajeev Gandhi Center for Bio-Technology, has also developed prototypes of low-cost rapid test kits that are ready for industrial production. There are two kinds of kits. The first type is to identify the possibilities of infection in a patient. The second type will detect the antigens produced by human body on intrusion of this virus. Prof. Radhakrishna Pillai of RGCB said, ‘We have a dedicated R&D team that has developed this kit. This is hardly the size of a pregnancy testing kit. This is also very cost-efficient. Once we begin the mass production, we can get one kit at approximately Rs 350 to Rs 500. This will also enable us to increase the rate of testing and further streamline the list of suspected patients.’ ICMR has approved the use of rapid testing kits although WHO had issued a guidance that the kits should be used only for research purposes. Along with testing further preventive measures can be taken by the production houses. The labour and other workers should not be allowed to move out of the factory premises. Counselling and awareness campaigns should be organised for the workers sensitizing them on personal hygiene. Social distancing measures should also be taken with-in the factory premises. The dairy industry in the state has been functioning likewise. If this proposition works, we can find a way to send the industrial workers back to work. Production house owners will not be hesitant to get these tests carried out because the cost of testing would be less than the cost of loss of productivity. Starting with large scale industries, gradually MSMEs can also adopt this method. Services The contribution of services is maximum in the state. The service sector comprising of trade, hotels and restaurants, transport, storage and communication, Financial services, real estate, ownership of dwellings, professional services, public administration, and other services. Some of these like banking, telecoms, storage and electricity fall under the essential services and they are functioning during the lockdown also. Hotels and restaurants should not be opened. Schools and colleges should also remain closed. Malls are air-conditioned spaces and they should also remain closed. Public transport should not be re-started for two more weeks at least. Service sector has been functional in some areas because it is possible for the service sector to effectively use work from home facility. Limited transport of essential items within the districts could be allowed. Highways and roads need special attention. Clean toilets and cleanliness of food joints on roads is to be ensured. Some selected food joints on roads could be opened under the police surveillance. Safe water should also be made available at these joints. Public Administration  should function through work from home. Overall, partial lifting of lockdown from the rural areas, opening of production houses under surveillance and preventive measures and limited opening up of services sector could be an effective partial lockdown strategy for the state. Finally it will be the intelligence of people which will make the partial lockdown startegy successful.

The story of Covid-19 – Human Intelligence or the lack of it

An alien phrase, ‘ Zoonotic Spillover’, as it is called by wildlife epidemiologists or  transmission of a pathogen from a vertebrate animal to a human, will become very popular in the days to come, as it presents a global public health burden. Zoologists and disease experts have claimed that the destruction of natural habitats have enabled diseases that were once locked away in nature to cross into fast moving human beings across the globe. Scientists are unsure where the corona virus generated. It’s difficult to find that as well, as it would mean a live virus is to be isolated in a few suspected species to say with surety from where it generated. But the viruses very similar to the one that causes Covid 19 have been found in Chinese Horseshoe bats.

Zoonotic spillovers, happen because of human activity. We are increasingly transporting animals, for food, medicines or other purposes. When they are shipped or held in markets, there is a possibility that some viruses which are in animal body, get released to other animals or humans. Swineflu, Birdflu, ebola , and Nipah in the past have come because of this phenomenon. We are destroying the natural habitats of the animals, and they are mixing with humans in a weird way. Cutting down a forest for agriculture or habitation, can have far reaching effects on climate, disease emergence, carbon footprint, and floods. Corona gives a very important lesson, that a damage to the planet can also damage humanity more quickly than we think.

Corona Virus has burst out of quarantine in China and has engulfed the world posing a threat of the biggest economic downturn after the Great Depression of 1930. As the number of people infected worldwide, increase on the meter, the stock markets around the world are collapsing. The industries that are worst hit are the ones who are dependent on global supply chains. Apple warned on February 17^th that it would not be able to meet its revenue projections for the first quarter of the year. Carmakers, aviation, transport, energy and hospitality industries across the world are facing a shutdown situation, and the workers working for these industries will be unemployed. The merits of capitalism in the world which is considered flat will be under scrutiny.

In India, the first case of Corona Virus was found on January 30^th 2020. We could contain it till March 5^th when the count rose to 31. We crossed the mark of 150 on March 18^th and it was clear that the inevitable community transmission of Corona will happen in India, the same day the stock market closed 5% lower, Sensex at 28,896 and Nifty at 8,468. The RBI hinted at repo rate cut, as other central banks around the world were cutting interest rates. Governments around the world would be forced to inject huge amount of money in the economy through loose monetary policy.  Economists are predicting that Indian economic rate of growth which stands at 5% today may dip down by 1.5% for the coming financial year. Goldman Sachs warned on 20^th March that US GDP could plummet at the annual rate of 24%, during the second quarter, with unemployment peaking around 9% later this year. The collapse would be worse than the sharpest contraction during the Great Recession, when GDP dropped by a rate of 8.4% in the fourth quarter of 2008. It would also surpass the previous post-World-War-II record of 10% set in early 1958.

Janta curfew has been imposed in India on Sunday. A large part of success of India’s effort to contain Corona, will depend on public awareness. Whether we are able to reduce the rate of community transmission of virus will depend on two factors, self imposed restriction on physical contact with others as much as possible, and the ability of the health system to test and cure those who are infected and sick. Russia developed a better strategy to contain Corona, than the other Europeon countries. Vladimir Putin, the President of Russia said that the country has been able to stop the mass spread of Corona Virus. The number of confirmed Russian Corona Virus cases (253) is relatively low, although Russia shares a lengthy border with China and recorded its first case in January. Russia had shut down its borders with China, in January, and had set up quarantine zones. The Russians conducted large amount of testing of suspected Corona Virus cases standing at 156000, starting from early February, focusing on travellers from Iran, China and South Korea. But they did that for those coming from Italy much later.

India had put travel restrictions and had set up quarantine zones in the beginning of March. The surveillance at the airports began at the same time. The borders were sealed and the visas were cancelled. But, by then the imported virus had already been spilled in the local population. The first evidence of locally transmitted cases came by 18^th of March, and small towns like Bhilwara were locked down. The key strategies for India in the coming days would be to exercise self-isolation and to expedite health system response to the epidemic, by providing testing facilities and cure.

As of March 20, around 14,500 individuals had been tested in India, according to the ICMR data. We have fallen short of many countries in testing, and that will increase the local transmission of disease. India has .9 beds per 1000 population as compared to WHO standard of 5. There is a huge burden of NCDs in India, and a dearth of doctors, nurses and medical practitioners. There is a huge resource constraint. One in every eight Indians aged 50 and above is diabetic, and there is a very high burden of cardio-vascular diseases. Co-morbidities are likely to exist and the death toll is likely to be high.

Scientists at the National Institute of Virology isolated a strain of the novel corona virus. By doing so, India became the fifth country to successfully obtain a pure sample of the virus after China, Japan, Thailand and the US. ICMR said that isolation of the virus will help towards expediting the development of drugs, vaccines and rapid diagnostic kits in the country. The government has banned export of all ventilators, surgical/disposable masks and textile raw material used for making masks in the wake of the corona virus outbreak.

India is a very densely populated country, much more than China or Italy. There are 455 people per sq km, compared with 148 in China, 205 in Italy and 50 in Iran, according to the World Bank. The most powerful strategy of fighting against the virus at an individual level would be to protect oneself from someone who might be infected. A complete isolation done by families in the next 10-15 days will help in containing in virus. If the entire country is isolated in the family space, confined inside a household, it will drastically bring down the reproductive rate of the virus.  That is the reason, why success of Janta Curfew was critical. If the people of the country decide not to come out of the houses, in the next 10-15 days, during lockdown, only then the chances of an epidemic turning into a pandemic will be reduced in India.

Finally, it will be a natural human intelligence which will be able to contain the virus, by doing self isolation and observing restraint, as it was the lack of it that caused the spread of disease in the first place.

Can we prevent corona virus spread in India?

Florida has declared a public health emergency, and Berlin has reported a first case. It is now clear that the corona virus outbreak that happened in China, has now spread to second, third and fourth countries. In India, Kerala has reported three cases, Delhi, Hyderabad and Jaipur, one each.The Corona Virus has spread to 34 more countries in a month. At Mumbai International Airport, passengers arriving from China, Hong Kong, Thailand, Singapore, South Korea, Japan, Nepal, Indonesia, Vietnam, Italy, Iran and Malaysia are being screened. WHO has not yet declared it a pandemic, but that is what it looks like it is. 

The virus gets spread by droplets that are infused into the air, during coughing and sneezing. one way to prevent this virus from spreading is to do 'social distancing', that is shutting any kind of social mingling activities. India is a very densely populated country. If infected cases are found, localities and cities will have to be shut down, to prevent its spread. Schools, colleges, religious places, public transport, metro railway, malls and public parks come under this category. Evidence has shown that crowded emergency rooms of the hospitals are the entry points for the virus too. Front line health workers at a risk. 

Preventing the virus to enter the Indian territory is the best public health response that the country should provide to its citizens. This would mean stopping Visas for the affected nations, and conducting screening at all the international airports, seaports and borders in the country. The virus entering into the country through neighboring countries is also a threat as cases have been found in Nepal and Pakistan. Often the results of the screen tests do not come immediately, and the person could be spreading the virus before his test results arrive. 

Health authorities in many countries are frantically trying to prepare for a possible spread of the virus epidemic. Hospitals run out of testing kits, respirators, oxygen, masks, gown, gloves and drugs when the epidemic spreads and stockpiling by hospitals needs to be done. Doctors will have to be educated to reuse equipment carefully. Isolation wards and units have to be prepared in order to keep patients quarantine. The mortality of the disease is 2%, old and those with weak immunity are at risk. 

The way an epidemic hitchhikes depends upon a variable, the reproductive rate R - the rate at which a new case will give rise to further cases. R is going to be high in countries where public health interventions are less. Physical barriers, good hygiene and reducing various forms of mingle can help in bringing the R down. Well-equipped healthcare facilities, enough supplies and public awareness can provide a better response to the epidemic.

The good thing about Corona is that the fatality of the virus is low. The fatality rate in Hubei, the province of China, where Wuhan is located, is 2.9%. All those who test positive with mild symptoms, are health wise not facing much discomfort, little cough and fever, at the initial stages. If they self-isolate themselves at home, for 14 days and take regular medicines, they will be fine, but they will have to wait for another 14 days before they get back to normal life, so that they do not infect others. An awareness among the people to self-report and self-isolate will definitely help in containing the disease from spreading. A strong messaging system within the country would also be effective

A situation of panic in the case of any epidemic makes things worse. This disease is indeed like any other flu, and can eventually be handled by medicine and care. Just a little bit of extra care taken by an infected person, about not spreading the infection can help in controlling things. A sudden influx of patients in Chinese hospitals, made them overwhelmed. India will not be able to impose as strict restrictions as China, but an aware population, that neither dismisses the risk not panic, and handles the times of crisis with compassion and courage, will put India in good stead. Government will have to take steps to restrict public gatherings, and compensating a loss of job, or wages, to the poor and the vulnerable. A digitized service industry, as is available in parts in the country will help too in containing the spread. Finally, those who panic for losing wealth because of the loss of health, will also have to exercise patience to keep the nation fit, economically and physically. 

Can Machine Learning outdo teaching?

Four years ago, when I was heading the MOOCs division of my University, we had a bunch of young people, running a start-up on graphics and animation based educational courses, give us a presentation. They explained human embryonic development, through graphics in a short film of fifteen minutes. I was amazed by the effectiveness of dissemination of knowledge through graphics. But a disturbing thought was also lingering in my mind, what I had seen was much exciting than the boring biology lessons, I had received in school, and was delivered in a much lesser time too. Would e-content take over class room teaching? The question lingered in my mind and I asked it to our senior Professor. He shrugged, feigning indifference and said, 'For how many years have you had a Guru Shishya parampara?' He meant that nothing could take over the human element in the learning process, and no technology can replace a 'Guru'. Nothing else could be more reassuring to me. I believed him.

Just a few days ago, this thing called 'Machine Learning', managed to occupy my thoughts once again. Machine Learning is a branch of AI, which empowers computers to pick up patterns, that they were not explicitly programmed to perceive, or simply speaking, computers can pick up patterns that human mind will take long to perceive, just by doing some data analytics. Education Initiatives, an Indian company has developed a code called Mindspark,  that is run on 2.5 million answers to a set of 45000 questions, to diagnose common errors that the students tend to commit. Mindspark will infer a thinking pattern that is responsible for a certain error and will suggest remedial exercises. It is basically, getting into the mind of a student, studying his thinking pattern and structure, identifying the possible reasons for it, and suggest a solution.

The students can receive customized solution through this technology. Mathematics and Language can be easily taught to a student in his early years of learning, through this software. Customized exercises can be generated to handle individual problems. Many American companies like Aleks, Knewton and Dreambox Learning, Geekie a South American company, Byju's from India, and 17zuoye from China are providing such solutions. Voice Recognition systems will make the technology much more user friendly. What this technology right now cannot do is that friendly pat on the back that the teacher gives when a student becomes successful with something that he is struggling with, or a 'raise your hands' punishment that one received for uttering something really stupid in the class. From an older generation's point of view, some of the best memories of school life will be eliminated by the technology, but that is an older generation's viewpoint.

Studies have shown that software assisted teaching pedagogues are more successful. Philip Oreopoulos, and Andre Nickow for J-Pal conducted 41 randomised control trials comparing students taught by software assisted methods, to students taught by conventional methods, and found that the software assisted students got better scores. In one such study done by J-Pal in Indian settings by Karthik Mularidharan, Alizendro Ganimian, and Abhijeet singh, it was found that at an Indian after-school, course, students assisted by Mindspark, brought better results in Math and Language, than those who didn't, for a fraction of the cost. Studies have also shown that in softer subjects, Humanities and Liberal Arts, mimicking a teacher is a little difficult.

A teacher cannot provide an individual feedback to a class of students more than 30. That is the reason 30 is an ideal class. The software replaces a teacher in providing individual feedback. But the critical success of software lies in the fact that a student is assisted further in learning at his own pace, without getting bogged down by the performance of others. But sometimes digital displays can create a lot of confusion in the mind of a student. Max Ventilla, a former Googler has done just that, he has created a school called the Altschool in California, where the student is assisted in personalized learning. Teachers save time by not marking or planning lessons and the students learn from each other. However, giving children such attention is not cheap, the cost per student is $27000 per year.

We live in a Googleable world. A child growing up in this world might be tempted not to fill up his mind by information. Would that mean he would be spending more time on thinking? Cognitive scientists argue that human minds are not built to think and thinking hard about things does not come naturally. There is a famous quote by George Barnard Shaw,' I Have Made an International Reputation for Myself by Thinking Once or Twice a Week, because others attempted to think only two or three times a year.' 

Rand report, a report on a study done on school children using high tech personalized learning at 62 schools said that those who used the tech fared better than the children from ordinary schools, particularly those who were at the bottom of the class. Personal Help, argues Mr. Mark Zukerberg in the form of tech solutions is way better. The early adopters prove it. Whether Rand Teachers were highly motivated teachers or not is not proven by the study though.

We live far away from silicon valley, so we are curious about it. Will children of my family be able to perform well in the clog wire of machines, AI and codes in future, I am forced to think. I am uncertain about the answer. But, I was a few days ago telling my brother to get my niece trained in music and art. Information, she will gather with not much difficulty in future. Her academic abilities are explained in far greater detail in her report card these days, anyway.

Will tech make the craft of teaching better? We all remember our favorite teachers by not 'what' they taught in class, but 'how' they taught it in class. Unanimously, we would agree that they were favorites because they gave us personal attention.

Do we produce enough Food to feed people in India?

As per the CNNS survey, only 6.4% of kids in India, under two get a 'minimum acceptable diet', the rest 93.6% do not get an adequate diet. This would mean that children less than two years around all of us are not getting adequate diet. This could be my helper's child, driver's child, some child in the neighborhood or worse, some child in my family. Is it because of non-availability of adequate food? Government claims to be net-exporter of food, which means that we export more than we import. India is home to 270 million hungry people, as per Oxfam's report, our position is 103rd in 2018 Global Hunger Index.

Ramesh Chand a member of NITI Aayog predicted a demand of 257.70 million tonnes of food grain in 2015, the country produced 275.11 million tonnes that year, it was an year of average monsoon. During the drought year, the supply could barely match the demand. Per capita food grain availability per annum was 186.2 kg in 1991, it was 177.3 kg between 1903-1908, while in 2017 it was 189.1 kg. In 2015 China's per capita per annum food grain availability was 450 kg, Bangladesh 200 kg and US 1100 kg. In 2012 there was 30% gap in actual and recommended dietary intake in rural India, and 20% in urban India. The per capita income has risen 1400 times between 1991 to 2016, from Rs. 6270 to Rs. 93293, the income distribution, however has been skewed. An average Indian does not have enough purchasing power.

Some experts claim that hunger and malnutrition exist due to distribution problems. Some states have surplus production but poor management, lack of cold storage, and transportation facilities leaves many hungry. In the budget speech FM declared that we have achieved self-sufficiency in pulses production this year. We produce more of food grain, that we require except for drought years, and more fruits and vegetables too.

In India, a large number of farmers have committed suicide, particularly in states like Andhra Pradesh, Maharashtra, Karnataka, Kerala and Madhya Pradesh. When I look at the farmer suicide data and randomly try to co-relate it to under 2 children malnourishment data, I find that the two states where there are maximum farmer suicides, Andhra Pradesh and Maharashtra are having 1.2% and 2.2% children with adequate diet. Close to them are Gujarat Telangana and Karnataka at 3.6%. All these states are developed states, then why do children not have enough food to eat?

Malnutrition exists in India, at the same time, when we have reached the Moon and the Mars. It is a battle that needs to be won, but looking at the basic data, we get an idea that it is a winnable battle. How? We have to figure out. CNNS report is an eye opener. 

A case for Community Health Officer and Nation's Health !

Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Doctors treat individual patients. Public Health takes into account the health concerns of the entire community. Health cannot be ensured without addressing the environmental factors - socio-political-economic-physical-psychological. Thus, community health interacts with many variables in the periphery, and a public health specialist needs to be far more equipped than a doctor is.

The Great Plague of London, from 1665-66, and the Cholera outbreak in 1832, forced officials to realize, that London had to create a new sewer system. The 1848 Public Health Act was passed to help individual cities improve the sanitary conditions of their towns. Vaccination became a requirement for all by the mid-1850s. In the early 1900s  many acts were passed and the England's public health, was being structured.

In India, under the British rule, Bhore committee was formed in 1943, known as the Health Survey and Development Committee, and it submitted its report in 1946. Some of its major recommendations were -

1.Integration of preventive and curative services of all administrative levels.

2. Development of Primary Health Centres in 2 stages :

Short-term measure – One primary health centre as suggested for a population of 40,000. Each PHC was to have 2 doctors, 1 nurse, 4 public health nurses, 4 midwives, 4 trained dais, 2 sanitary inspectors, 2 health assistants, 1 pharmacist and 15 other class IV employees. Secondary health centre was also envisaged to provide support to PHC, and to coordinate and supervise their functioning.

Long-term program (also called the 3 million plan) of setting up primary health units with 75 – bedded hospitals for each 10,000 to 20,000 population and secondary units with 650 – bedded hospital, again regionalised around district hospitals with 2500 beds.

3. Major changes in medical education which includes 3 - month training in preventive and social medicine to prepare “social physicians”.

While Britain made efforts to develop public health in its own country, as early as early 1800s, it was not done in the colonies. The Indian Medical System was developed for the sole purpose of keeping the army healthy. In 1952, the proposal of the Bhore Committee was accepted by the newly elected government of independent India, but it was only partially implemented. Preventive and Promotive care primarily took a back seat, the 'social physicians' were never recruited. No concious efforts were made to develop a public health cadre in India, until 2017, when for the first time the health policy talked about -

'The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria. The policy also advocates an appropriate career structure and recruitment policy to attract young and talented multidisciplinary professionals. Medical and health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training would also be considered. States could decide to locate these public health managers, with medical and non-medical qualifications, into same or different cadre streams belonging to Directorates of Health. Further, the policy recognizes the need to continuously nurture certain specialized skills like entomology, housekeeping, bio-medical waste management, bio medical engineering, communication skills, management of call centers and even ambulance services' (Health Policy 2017)

The Mukherjee Committee in 1966 prescribed a system of targets and incentives and identified ANMs( Auxiliary Nursing Midwifery) and other village-level workers as agents for the populizing  health programs in the community. In the 1950s and 1960s, training of ANMs mainly focused on midwifery and mother and child health.

In 1973, the Kartar Singh Committee of the Government of India combined the functions of the health services and changed the role of ANMs. The committee recommended that there should be 1 ANM available per 10,000-12,000 people.

In 1975, the Srivastava Committee recommended expansion in the role of ANM. Recommended expansion included the role of an ANM as a multipurpose health worker. Along with maternity care, the committee recommended that ANM's work should include child health (immunization) and primary curative care of villagers. The Indian Nursing Council (INC) accepted the recommendations of the committee and included them in the syllabus in 1977. This decision also reduced the training period of the ANM from 24 months to 18 months.

In 1986, the National Education Policy gave the ANM program a status of Vocational Education. However, only a few states of India have made the ANM course a vocational course at the higher secondary level of schooling. According to the latest guidelines by INC, the minimum age for admission to ANM course should be 17 years while the maximum age limit is 35 years.

In 2005, the National Rural Health Mission (NRHM) was launched, which focused on improvising primary health care in villages and further increased the importance of the ANM as a link between health services and the community.

 Before the launch of NRHM in 2005, there was provision of one ANM per sub-centre. Later it was found that one ANM was not adequate to fulfill the health care requirements of a village. In 2005 NRHM made provision of two ANMs (one permanent and one contractual) for each sub-centre. The ANM is usually selected from the local village to increase accountability

The Accredited Social Health Activist (ASHA) is a community health worker. Depending on the area covered by the sub-centre, each ANM is supported by four or five ASHAs. ASHA brings pregnant women to the ANM for check-ups. She also brings married couples to the ANM for counseling on the family planning. ASHA brings children to immunization sessions held by the ANM. ASHA acts as bridge between the ANM and the village.

Ayushman Bharat operational guidelines gave a  key addition to the primary health team at the SHC-HWC, the Mid-level Health Provider (MLHP) who would be a Community Health Officer (CHO). The qualification of CHO, much in line with ANMs, is B.Sc Nursing or GNM. The rationale for introducing this new cadre of health provider is to:

1)Augment the capacity of the Health and Wellness Center to offer expanded range of services closer

to community, thus improving access and coverage with a commensurate reduction in OOPE.

2)Improve clinical management, care coordination and ensure continuity of care through regular

follow up, dispensing of medicines, early identification of complications, and undertaking basic

diagnostic tests.

3) Improve public health activities related to preventive and promotive health and the measurement

of health outcomes for the population served by the HWC (Health and Wellness Center).

In principle, the community health officer would be the nodal workforce to prepare a report on health status of the population served by HWC. This would be made possible by creating a digital health eco -system 'National Health Stack', where digital personal health records captured at the PHC level, will be stored in a national database, under a unique identity number (UIN). National Digital Health Blueprint (NDHB), 'which is more than an architectural document', as it provides an implementation plan of 'National Digital Health Eco-system' has been released on 15th of July, by Ministry of Health and Family Welfare, Government of India.

In future, there would be a wealth of local data, easily retrievable from a national database, to measure and monitor health outcomes. In principle, this looks like a perfect plan, but there is a missing link here, a very important one.

The missing link is the availability of qualified and skilled public health workforce at all levels of care, primary, secondary and tertiary, to work for preventing disease, prolonging life and promoting health through the organized efforts of society. As of now, ANM, ASHA and proposed CHOs, are the only public health cadres we have in India. They are not qualified or trained, they will join the work force, learn on job, and make a delivery. Their role will be further extended as and when required, and accordingly, they will be provided training for the job. The way we developed ANMs, we will develop CHOs. There is just one difference, the CHOs will be computer literate and will be trained to capture personal health data, digitally.

There is a long list of capabilities that a public health workforce should have in order to function effectively, but I will address that in a separate post.

Public health has had several success stories in India, smallpox, polio, TB, and HIV being some of them. Yet, season after season, we have instances of dengue and swine flu outbreaks, physical inactivity is increasing, stress levels are getting higher, pollution is becoming dangerous, malnutrition is rampant and tobacco abuse is increasing. Can a public health workforce possibly help that ? The answer is YES, for the simple reason that when a patient comes to a hospital with a problem, a doctor can diagnose a disease, but cannot scan his socio-economic-political-psychological environment, where usually the cause is.

Community Health Officer at HWC, should be made responsible to study such causes for a population of about 3000-5000, covered by one HWC, contribute in planning public health interventions and execute them. Community Health Officer will be the pivotal unit, in primary care, tilting the axis towards preventive and promoting care. Its historic. Many state governments have announced several positions for community health officers, which is a welcome move, but getting in a workforce whose roles and responsibilities are not very well defined, for such an important function is inapt and uneconomical.

Investing in public health brings better economic value, its just about time to do intense brainstorming about, what value should public health officials at various levels, can add to nation's healthcare.

The citizens deserve it. 

The idea of health !

I was attending a conference, a couple of years back. The speaker, who is a very well-known CEO of a state of the art hospital in India, and an eminent doctor, responded to a question asked by me, whether in India we could have cycling tracks; he snapped back at me with an imperious gesture, that you are asking for cycling tracks in the cities, where half the India doesn't have roads. I wondered, cycling tracks were for road safety in the cities and to prevent environmental hazard, how would that be a counter argument for constructing rural roads. But, I was too intimidated to speak, I had a very senior doctor admonishing me. 

A research study done by Dr. David Bishai, from JHU, reiterates that there is a zero sum game between preventive and curative care. It says,"too often, only a single, limited government health budget is available for investments in both non-personal preventive and curative personal health services. the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends." In India we have seen that primary health care always receives lesser funds than the secondary and tertiary health care. Under Ayushman Bharat, there was an announcement made to transform 150000 sub-centers into Health and Wellness centers in the country by 2022. The budgetary allocation for these centers has been Rs.249.96 crores in urban areas and Rs.1349.97 crores in rural areas, for the year. This means about Rs.107000 to each center. Even if you have the same allocation for the next three years, it will be just Rs. 3,00,000 per center. It will be very difficult to fulfill the infrastructural requirement alone, with this much of money. At each HWC, we need to have a community health officer, supply of drugs, diagnostic facilities, paramedics and yoga instructors, it is clear that this much is not enough. Should we generate CSR funding for HWCs? I will write more on that in a separate blog. 

Health is a human right. The earliest health system was created to respond to this basic right of a human being. For years, it continued to function like that and health care providers offered their services with an altruistic ardour. Modern healthcare system positioned health in a market system. The demand and the supply determined the price. Preventive care took a beating under the argument that the more the people fall sick, the more there would be a demand for healthcare. The lesser the supply the bigger price it could fetch. Market economy argument is based on allocational efficiency, but health and education are such sectors, where allocational efficiency is not determined by market forces as there are huge externalities generated by these services. 

I was talking to Dr. D.K.Mangal, my senior colleague and a veteran public health exponent, about Dr. Bishai's proposition. He said that with the advent of allopathy, health care providers turned into providers of curative care and the entire system is centred around that. Resultantly, primary health always takes a back seat. He said, one solution to the problem could be to change the construct of curative care and bring it totally under the public good/service domain by banning private practice entirely, and connect it to primary health. The other solution to the problem is to delink the healthcare from curative centred infrastructure and  create a parallel primary health infrastructure based on preventive and promotive health models to create a balance. 

A few months ago, I was having a discussion with Dr. David Bishai, and he said that a 'community health officer', preparing a quarterly report on the health data, collected by him for the people registered at his HWC, bringing to light, the 'winnable battles', for his area, would illicit very quick action from the providers. Public health interventions could be planned based on these reports provided by the CHO, so that the healthcare reaches 'the last mile'.

'If we don't take active steps to address the problem, perhaps the technology will force us to do it, science will', was how Dr. Mangal concluded his discussion with me. I too agree with him. Technology is a great leveller. Dr. Narayan Murthy, talking about technology said, "It has improved transparency, conquered distance and class barriers. It has the potential to create a fair society and enhance the accountability of the rich, the powerful and the elite to the poor and disenfranchised in every society."

The word 'Arogya' in sanskrit means 'overall well being'. Conventional Indian thinking around the idea of health was prevention of disease rather than treatment of disease. If we focus our entire attention towards developing a model of healthcare, which is clinic driven, the system will merely diagnose the disease and treat it. The system will never focus on the environment from where the patient is coming from, the possible psychological, environmental and physical causes of disease, and to address those causes. Allocation of human, physical and monetary resources, in that case will also be on 'cure', and it will result in a very inefficient allocation. Research in the right direction of 'arogya' will not happen. It will require a complete revamping of the health system. To achieve a preventive or 'arogya' focus, the redefining of the roles and responsibilities of all major stakeholders,  be it doctors, pharmacies, diagnostics, patients and policy makers. A more judicious and efficient allocation of resources will be possible only if pursue 'arogya'. 

Digital Health, Data Analytics, Tele-medicine, Internet of things, Artificial Intelligence, and Genetic Engineering will help in developing a fair health system. Would it create a balance between primary and tertiary, preventive and curative health care systems in future? Will science develop to an extent that the gene would be modified and be made into a 'designer gene', so that the disease and old age will be eliminated? But, for that too we will have to allocate the resources in the right direction. 

We all think alike, across geographies, nations, sectors and age-groups. We are a minority though, but waves of change could be felt.