• CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause.
• An estimated 17.1 million people died from CVDs in 2004, representing 29%of all global deaths. Of these deaths, an estimated 7.2 million were due to coronary heart disease and 5.7 million were due to stroke.
• Low- and middle-income countries are disproportionally affected: 82% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women.
• By 2030, almost 23.6 million people will die from CVDs, mainly from heart disease and stroke. These are projected to remain the single leading causes of death. The largest percentage increase will occur in the Eastern Mediterranean Region. The largest increase in number of deaths will occur in the South-East Asia Region.

(Source: http://www.who.int/mediacentre/factsheets/fs317/en/index.html)

According to the World Health Organization (WHO), the most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity and tobacco use. Behavioural risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease. The effects of unhealthy diet and physical inactivity may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity.

CVDs poses imminent threat to India as India is already the country with the dubious distinction of the larges numbers of CVD cases. It is perhaps one of those typical paradoxes that signify India- the double burden of under-nutrition and obesity. WHO states that at least 60% of the world’s population leads a sedentary life failing to complete the recommended amount of physical activity required to induce health benefits. Physical inactivity is ranked as the fourth leading risk factor for all deaths globally, contributing to 1.9 million deaths each year (Source: http://www.who.int/en/).

This is partly due to insufficient participation in physical activity and an increase in sedentary behaviour during occupational and domestic activities. Effective public health measures are urgently needed to improve physical activity behaviours in all populations. At present, it might appear to be a luxury to think about CVD in the context of apparently more immediate health problems, it is important to note threat CVD is the biggest killer in India and perhaps also one of the most silent. Given that, public health measure cannot afford to ignore CVD. It is also a challenge because in many cases, the link between CVD and healthy lifestyle including a regular health check-up is missed resulting in CVD catching people unawares. Also, given that people are unable to access basic health even during illness, spending for health check ups without any apparent discomfort is not something that most of India can afford. That makes it all the more for communication on health to include messages on diet, physical activity, reduced smoking etc making clear the link with CVD.

How can the awareness about CVDs be inculcated?

• Concept of Karma features prominently in literature / discussions about disability, with disability perceived either as punishment for misdeeds in the past lives of the PWD, or the wrongdoings of their parents
• Presence of the PWD is considered inauspicious during such occasions as wedding
• There is low acceptance of children with disabilities attending regular schools
• Persons with disability face significant challenges in getting married and having families. In PWD/non-PWD marriage, it is expected dowry would always need to be adjusted.
• Mythologies and Bollywood films often show PWDs in various forms of negative roles – either wicked and cruel or dependent and pitiable.
• There is low acceptance of children with disabilities attending regular schools.

(Source: World Bank Report: People with Disabilities in India: From Commitments to Outcome, 2007)

People with disabilities experience found substantial social marginalization in the Indian society. Indeed, attitudes of society, families, caregivers and PWD themselves often contribute to converting impairments into disabilities. The different sets of attitudes interact and the negative views about PWD in the broader community are likely to be internalized in many cases by PWDs themselves and their household members. In this regard, community action has actually failed the PWDs.

The social status of the PWD’s family often has an impact on their potential acceptance in society. Changing societal attitudes to people with disabilities, even among PWD themselves, presents many challenges. However, a basic starting point is facts. A good example in case is the leprosy campaign. Despite availability of multi drug therapy that made leprosy curable, the biggest barrier to eliminating the disease is ignorance and stigma. To address this, the BBC World Service Trust developed a campaign in India, in partnership with Doordarshan TV and All-India Radio emphasizing on curability, availability of free medicines and messages supporting inclusion. Independent impact assessment of the program demonstrated positive impact of the program.

It therefore makes sense to undertake, among other things, awareness campaigns emphasizing that stigma attached to disability is driven by ignorance and that disability is not a pre-ordained event. Similarly, putting the experience and success stories of persons with disabilities into the public arena needs to be done with the idea to stress of possibilities rather than disabilities. .

Building on this, steps need to be taken to address the medical and social causes and consequences of impairment and disabilities. Finally, unless attitudes change, little change is possible in improving the quality of life of the PWDs.

In terms of livelihood and development- public works programs are both good development and good politics.

South Asia has a history of public works- many structures were developed as public work prior to the British rule. At present, Nepal has several public works programs based on both cash and food. In the remote and intractable hill districts (known by the omnibus category of the “Karnali Zone”) the government implements a food for work program, for which the World Food Program delivers food. There are similar programs in southern Nepal.

Bangladesh similarly has a long history of both food and cash based public works programs. Its success in dealing with the chronic floods and cyclones is well known, but lesser known is the fact that public works programs have come to the rescue of households who have been hit by these disasters. Sri Lanka is considering similar interventions for its internally displaced persons. Bangladesh’s 100 Day Employment Program was evaluated independently by BRAC and the World Bank. The results have been very encouraging, showing reasonably good targeting of the poorest and efficient delivery of the program. Building on the experience of the 100 Day Employment Generation Program the Government of Bangladesh is now implementing the Employment Generation Program for the Poorest (EGPP), a cash-based workfare program. (http://blogs.worldbank.org/endpovertyinsouthasia/employment-programs-any-other-name).

Development around public works can be an important way to develop rural infrastructure. Paved roads, clean ponds, watersheds, canals, developed fisheries, grain banks, seed banks, storage facilities, the possibilities of the things that can be undertaken through public works are wide. These can be livelihood generation programs, anti-poverty program, safety net initiatives; land improvement programs, disaster management programs and so on. However, the business at usual approach persists. In the absence of strong rural civil society, there is just not enough pressure to perform. While initiatives like the Mahatma Gandhi National Rural Employment Generation Scheme provide the platform to undertake a wide variety of programs, the opportunities have not been optimized in many parts of the countries.

While the program might appear as civil society driven and entitlement approach based, the role of the wider civil society is rather limited. The program is yet to be ‘owned’ by the groups working across the rural belts- that has unfortunately not happened. Performance of the widely acclaimed measures like citizen monitoring and social audits mandated twice a year have been uneven across states- while some have done remarkably good work backed up with insightful reflection (for example Rajasthan  -http://rdprd.gov.in/PDF/Implementation%20of%20NREGA-8.10.08.ppt )  others are still struggling with finding work against job cards issued (for example, West Bengal-www.ansiss.org/doc/seminar2007July20-22/jean_dreze.doc). In general, the demand of public works programs far outweighs the supply. Unless these issues are addressed, the opportunities offered by the program would remain grossly underutilized- and the marriage of politics and development would not happen.

Do you think that Public Work can work as a development strategy?

By 2020, depression is predicted to become the leading disease burden in developing countries. Community-based studies of mental health in urban areas of developing countries have documented prevalence rates of between 12 and 51 per cent (Source: Cited in UN Habitat Report Cities in a Globalized World, Global Report on Human Settlement, 2001).

According to this report, prevalence of anxiety and depression is typically higher among women than men, and among lower-income communities, with variations reflecting differential exposure and vulnerability to diverse risk factors, including control over resources, marriage patterns, cultural ideology, long-term chronic stress, exposure to stressful life events, coping strategies and social support.

Urban environments, and low-income urban environments in particular, are characterized by harsh physical and social environments, poor quality of life characterized by poor-quality housing, lack of access to basic services like water and sanitation and low paying employment and income generation opportunities. Day-to-day life in these contexts can amount to chronic stress.

The strategies that low-income households employ to cope with such stresses are numerous, including working longer hours, engaging in informal work, taking up more than one job at a time, deploying children into income-generating activities, exploring new niches in the informal sector and maximizing the use of the meager resources available. While these strategies build some degree of resilience, the chronic stress of poverty and stressful life-events can have very negative direct and indirect effects on physical and mental health.

Urbanization has also been associated with a breakdown of extended families and increase in single parent households that has implications for the coping strategies themselves, and for physical and psychological well-being.

Under these circumstances the need for support- social, emotional and practical/ logistical- cannot be overstated. Social support refers to the degree to which a person’s basic social needs are fulfilled through interaction with others. Emotional support is the building block of relationship and comprise such feelings as love, empathy, companionship. In addition to these, there is a need for and practical support expressed as goods, services, information that people need in order to lead a meaningful life. These support systems act as key resources drawn upon to cope with or to ‘buffer’ the potential mental health effects of chronic or short-term stress.

However, this area is often neglected and there are considerable knowledge gaps concerning the interrelationships of mental illness with social support and cohesion. In this context, the understanding of social capital defined as the density and nature of the network of contacts or connections amongst individuals in a given community that can act as support, needs to be better understood and strengthen. Social capital is being increasingly recognized as an important ‘fall back mechanism’. Given this, it is important to emphasize its significance in policies to mainstream initiatives that can strengthen social capital. Can we do it?

What can be done to address the issues of mental health in urban scenarios?

• Every minute, one child dies of pneumonia in India according to the latest.

• Annually across the world, two million children under five years of age die of pneumonia. The disease contributes of 20% of childhood mortality cases.

• Pneumonia kills more children than AIDS, measles, and malaria combined, and yet many children do not receive affordable solutions proven to prevent and control pneumonia.

• Globally, 15 countries contribute to three quarter of childhood pneumonia cases.

Source: World Health Organization, 2009

In order to enhance awareness about Pneumonia, on the 2^nd of November, the world observe the first World Pneumonia day. It is a good step at it will help to draw the attention required to prompt governments and international health agencies to develop, implement, and monitor comprehensive programs that arrest pneumonia. Given that global health funding are allocated and interventions planned allocated and implemented based on the perceptions of problems, it is important to educate international developmental organizations and policy makers about such silent killers as Pneumonia.

India alone accounts for 44 million cases on pneumonia, the highest in the world. The incidences are high because of low immune system consequent on widespread malnourishment. The disease gets exacerbated by high density of population and poverty. Indoor air pollution due cooking with biomass fuel and parental smoking aggravates the situation, especially in case of children living in crowded homes.

While vaccination for pneumonia is available, it is not listed as mandatory, is expensive and therefore out of the reach of the poor. There is an urgent need to save children from pneumonia if neonatal, infant and child mortality rates in the state have to be brought down. This will need a well concerted action comprising a focus to create access to both preventive and curative services- a combination of vaccination, education / awareness and treatment at affordable costs for the poor. India cannot achieve the Millennium Development Goal 4 of reducing child mortality by two-thirds unless it tackles the pneumonia burden. Are we serious enough?

Does Pneumonia get the attention it deserves in National health policies?

Despite the increasing participation of women in the migration process, migration research remains gender blind. According to the census of India, 2001, about 42.4 million migrants out of total 65.4 million female migrants cited marriage as the reason for migration. Thus while marriage remains an important factor, it is important to consider the cases of 23 million women who migrated. However, migration policies and program in India where they exist are rarely gender sensitive.

To begin with, It is also important to acknowledge the diverse patterns of women’s migration going beyond the Indian stereotypes of the male member going off to the cities to work while women and children staying back. While there are numerous studies on the condition of men who migrate, corresponding knowledge about women who stay back is limited to occasional documentation of exclusion from property rights. What is often missed out is that as men circulated between town and country, wives and children undertook the labor of cultivation. Despite their long absence men retained their proprietary interests in the village and their status as heads of the family.

The recently released report of the World Survey on the Role of Women in Development 2009 states that while migration and the ability to remit can be empowering for women, many women migrants face long working hours and increased financial obligations. The increase in professional smuggling means that some women who believe that they are migrating to legitimate occupations find themselves trapped into forced prostitution, domestic service under conditions that resemble bonded labour.

In this context, the importance of investment in education assumes importance in order to address the human capital and capability deficits of the current generation of working women. Poor women who missed out on the expansion of educational opportunities may find themselves trapped in jobs with few promotion opportunities because of their lack of education and skills. Increased education and training for women can also increase their opportunities for migration under skilled-migration schemes. A variety of approaches, including non-formal education, technical and vocational training, agricultural extension services, workplace training, lifelong learning and training in new technologies, are needed to assist such women in searching for better jobs.

In some countries, including India, efforts have been made to limit female migration in an attempt to protect women from the abuse they may encounter in the labour market, particularly. The laws are intended to protect the workers, but also risk limiting women’s mobility and access to employment.

The process of globalization of the Indian economy has a strong implication on mobility patterns, including those of women. It is important therefore to rethink and re-conceptualize the migration process of women as their roles in the decision-making processes; building and maintaining of migration networks redefine their familial roles and social and economic status.

What are the possible implications of rising numbers of women migrating for reasons other than marriage?

As is common in the summer months, rural water-supply has again emerged as a problem. According to a newspaper report, in some tribal belts of Andhra Pradesh, women have to forgo their daily wages as they spend around three hours a day fetching water from another tandha (small tribal village) as all water sources in their thanda has dried up. Groundwater levels are so down that digging bore-wells have also not yielded any results .

The situation continues to worsen despite initiatives like the National Rural Drinking Water Program (NRDWP). In many thandas, providing water through tankers does not work because of their location in remote and at times inaccessible locations.

The drinking water problem is also rife in the sub urban areas and small towns. There is almost a cyclic relationship between the summers and the monsoons- while some measures are taken during the summer, the water supply points are damaged in the floods during the monsoons. There are reports of families now depending on the percolation pits dug in the river beds. A recent report states that in village Laxmipuram, 10 kms from Kurnool town, the entire population is dependent on percolation pits in the Hundri river bed. Villagers spend an hour every day to fetch water from the pit. While many have piped water supply at home, the quality of water is so poor that it cannot be consumed.

As India lauds itself for its economic achievements, access to drinking water continues to be a major problem for a huge part of the population. According to the Human Development Report, 2009, around 89 percent of the Indians are using improved water sources (2006 data). However, given that according to the same report, 75.6 percent of the population lives on less than two dollars a day. (http://hdrstats.undp.org/en/countries/data_sheets/cty_ds_IND.html). These two figures really do not go very well together as the access of the poor to safe drinking water is likely to be impaired.

There is also the issue of contamination with most water sources reportedly contaminated by sewage and agricultural runoff. India has made progress in the supply of safe water to its people, but gross disparity in coverage exists across the country. Also, although access to drinking water has improved, the World Bank estimates that 21% of communicable diseases in India are related to unsafe water. In India, diarrhea alone causes more than 1,600 deaths daily (http://water.org/projects/india/)

Given the situation, it is important to take urgent measures to improve access to safe drinking water. Given that it is intrinsically linked with overall health and nutrition of the people, it is an issue that needs immediate interventions if we are serious about human development.

What can be done to improve access to safe drinking water?

More than 900 participants from 87 countries are currently participating in the 62nd World Newspaper Congress of the World Association of Newspapers and News Publishers (WAN-IFRA) in Hyderabad. However, the breaking news, brought to light by noted journalist P Sainath in The Hindu is of a few dailies in Maharashtra eulogizing the achievements of the Chief Minster of the state during the election time. In all three rival dailies the same report appears, with different bylines. Moreover, none of the newspapers mention of the word advertisement or sponsored feature next to the item, just goes to show how low journalistic ethics have stooped in India.

While the coverage of the ‘achievements’ were not ‘advertisements’ as it was not mentioned and the accounts of election expenditures do not reflect any spending on ads, it might be worth mentioning that had these been ads, the bill for the same would have run into few crores, given the profile of the newspapers in which these appeared, drastically exceeding the election expenditure limit. The issue is that of illegal cash transactions and tax evasion worth crores of rupees- and both media outlets and politicians are guilty of not just of financial wrongdoing but connivance to subvert professional ethics and undermine democratic processes and principles.

Unfortunately, the trend is not limited to Maharasthra, it is a national phenomenon. Governments patronize newspapers by giving Government advertisements in the newspapers have become so common and a regular source of revenue for the local forth estate that often feels obliged to give maximum (and usually favourable) coverage to the party during the elections. Also, with many television channels and newspapers being owned by members of the political parties, it is difficult to differentiate between ‘news’ and ‘views’, between real ‘achievements’ and ‘advertisements’ and between ‘criticism’ and ‘propaganda’.
Is the forth estate, often hailed as the watchdog for the society is blatantly conniving with those in power to influence public opinion? Is this a new revenue model? Or as Sainath asks- Is ‘paid news’ getting institutionalized?

It is important that the Election Commission of India (ECI) takes note of the practice and takes immediate action to counter it. Similarly, the Press Council of India should also take some bold decisions to discourage the misuse of media and setting self-regulatory mechanisms to curb the menace.

The print-media has been the torch-bearer and custodian of public opinion and this responsibility. India has always taken pride in the freedom that media exercises. However, with such alliances, the integrity of the press is under scrutiny? Will the media please take it as a wake up call?

What kind of regulatory mechanisms should be put in place to reduce political influences on press?

Corporal punishment is a violation of a right of the Child to protection from all forms of violence, abuse and maltreatment in any setting. The Convention on Child Rights (CRC) to which the Government of India is a signatory, states that learning environments should respects children’s dignity and discipline in school should be administered in a manner consistent with children’s dignity.

The National Policy on Education (1986, modified 1992) states that “corporal punishment will be firmly excluded from the educational systems”.

The Right of Children to Free and Compulsory Education Act, 2009 (No 35 of 2009) (26 August, 2009) prohibits physical punishment and mental harrasment to the to the child.

The Act states:
(1) No child shall be subjected to physical punishment or mental harassment.
(2) Whoever contravenes the provisions of sub-section (1) shall be liable to disciplinary action under the service rules applicable to such persons. The enactment of the new legislation is the first step towards the universal prohibition of corporal punishment in schools and other educational institutions.

However, as is always the case in India, implementation is a serious challenge. Only 17 states/union territories in India have prohibited corporal punishment in schools under the National Policy on Education and even in states that have prohibited, there is no way to know if the guidelines of corporal punishment are followed. However, from what appears from sporadic newspaper reports and experiences of interacting with students, teachers and parents, corporal punishment is often an accepted and sanctioned part of education.

The Right of Children to Free and Compulsory Education Act, 2009 that has seen civil society engagement in its formulation is considered to be more comprehensive. However, there are apprehensions that the provisions of the Right of Children to Free and Compulsory Education Act, 2009 may be inadequate in that disciplinary action will be determined by “service rules”. The threat of such disciplinary action, of possibly losing their job, however may not be enough to deter teachers. Equal protection demands that the criminal law should be available and enforced. The Juvenile Justice (Care and Protection of Children) Act (2000, amended 2006) provides punishment for cruelty to juveniles or children both in and beyond childcare institutions. The Act makes no exceptions and intends to punish cruelty by those in authority and applies equally to parents, guardians and teachers.

Physical and other forms of humiliating and abusive treatment are not only a violation of the child’s right to protection from violence, but also counter-productive to learning and indeed to child development. However, public action also need to change societal attitudes towards corporal punishment has to be understood by the society first, before policies have an impact.

What should be policy priorities in dealing with corporal punishment?

Shortage of nursing staff is a global problem existing both in the developed and developing parts of the world. While the developed nations get around the problem by recruiting nurses from other countries to fill its vacancies, the developing countries are struggle with acute shortage.

The global migration of nurses is particularly high. It is common for Indian nurses to migrate to other countries, especially the neighbouring gulf countries attracted by better pay and opportunities of international exposure and professional development. The situation is  severe in smaller island nations such as Jamaica where, according to World Health Organization (WHO) estimates,  eight percent  of its generalist nurses and 20 percent of its specialist nurses leave for more developed countries each year.  Between 2002 and 2006, more than 1800 nurses left the Caribbean to work abroad. English-speaking Caribbean nations currently have 1.25 nurses for every 1000 people; 10 times fewer than countries in the European Union and the United States of America Situation is almost similar in India. According to the Indian Nursing Council, 2.4 million nurses will be needed by 2012 to provide a nurse-patient ratio of one nurse per 500 patients. (Source: http://www.who.int/bulletin/volumes/88/5/10-020510/en/index.html).

Shortage of nurses is an important concern because it compromise health service delivery both in terms of quality and quantity. According to WHO, India, empirically, the states with the worst health-care human resource shortages are also the ones with the worst health indicators and highest infant and child mortality.
Paucity of training is cited as one of the main reasons for the global nurse shortage. In India, for example, the focus of nurse training is often an issue, with curricula more suited to teaching skills useful in developed countries rather than in resource-poor settings in nurses’ home countries. This is true for most of the developing countries. There is also an issue of trainers. The faculty-student ratio for nursing training in developing countries is reported to be as high as 1:45 compared with a 1:12 ratio in developed countries (Source: http://www.who.int/bulletin/volumes/88/5/10-020510/en/index.html).

Also, while nurse shortages occur at every level of the health-care system in India, recruitment and retention of nurses to rural areas is especially difficult and therefore needs special attention. Expereinces around the world have shown that in some cases different incentives (including rural allowance, better educational opportunities, and better insurance coverage) to remain in nursing posts in rural areas work well. In general, incentive packages tailored to local conditions are more likely to be effective.

Increasing nursing training opportunities, better pay, good working conditions- these are the three fundamental considerations to make nursing an attractive profession. Are we working on it?

What can be done to attract more students to nursing?