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Deccan Herald, Page number 11 under Panorama, 7th March 2008

Behind bars: Supporting tribal rights is his crime

By Gopal Dabade
Nine months after the arrest of Binayak Sen, growing public voice against the
illegal detention is the only way to save him.

Most of us do not realise that the causes of ill-health lie outside the four walls of hospitals
and are often beyond the reach of most doctors. Things like lack of food, safe drinking
water and unclean living conditions cause ill-health. As do social inequalities and an unjust
society without human rights. Nowhere is this ill-health more obvious than in the case of
tribals, women and children among the marginalised. While most doctors prefer treating
patients within four walls, paying no attention to the ill-health prevailing outside, here is a
unique doctor — who paid closer attention to the problems outside the hospital. He even
ventured to find solutions by joining hands with the marginalised people in remote and
forsaken areas of Chhattisgarh.

To the tribals in the state, Dr Binayak Sen — winner of the Paul Harrison award —needs
no introduction but to the world outside, he is MD in pediatrics from the Christian Medical
College (CMC), Vellore. On one hand, our Union health minister is crying hoarse about the
refusal of doctors to work in rural areas. Dr Sen's venture into rural areas, however, has
landed him in jail. For the past nine months, the doctor has been languishing in
Chhattisgarh jail, despite national and international condemnation by human rights
organisations. During this period, Dr Sen has lost 20 kgs of body weight and continues to
ail from heart problems. The only crime he committed was to work for the rights of tribal
people, who fell victims to the state sponsored programme called Salwa Judum.

Dr Sen was arrested by the Chhattisgarh police on May 14, 2007. He was then sent to
Raipur Central Jail under state and national laws — the Chattisgarh Special Public Security
Act (CSPSA), 2005 and the Unlawful Activities Act (UAPA), 2004. Amidst painful delays
in legal proceedings, Dr Sen's bail petition was rejected by the high court on July 23, 2007
and by the Supreme Court on December 12, 2007. His application for parole to receive the
Keithan gold medal awarded to him in December 2007 by the Indian Academy of Social
Sciences was also rejected on technical grounds.

Dr Sen's association with Chhattisgarh dates back to 1981, when he started to work with a
trade union leader, Shankar Guha Niyogi, at Dalli-Rajhara. Along with trade union work,
he helped establish the Shaheed Hospital at Dalli-Rajhara in 1982. Thus was born a
hospital, where the very people who built it where able to use its facilities.

This pioneering effort by workers to build and run their own hospital and healthcare for
trade union workers and tribals has become a model for effective and low-cost healthcare
(general and special) for the marginalised. Later in 1994, he and his wife set up an NGO
Rupantar in order to provide medical and healthcare facilities for the poor. He got active
with the PUCL — People's Union for Civil Liberties, an organisation initiated by
Jaiprakash Narayan. According to PUCL, since 2005 the Chhattisgarh government has a
growing record of “crimes against humanity”, using excessive and unwarranted police
power in the name of resolving the Naxalite problem. The organisation has been
campaigning against Salwa Judum. In particular, they want the state to account for the 155
fake encounters that took place during 2005-2006.

They have been demanding investigation into killings and other illegal acts by the so-
called Salwa Judum movement in connivance with the state police. The state realised that
the only way to stop PUCL from exposing its illegal activities is to put Dr Sen behind bars.
When some of us met Dr Sen recently in jail, he remarked, “Let us not personalise my
arrest, but focus on the wider issues”. Lack of development, erosion of nutritional security
and the impact on public health of corporate-led industrialisation, are the issues he wanted
to be highlighted.

The state has failed to get any hard evidence to incriminate Dr Sen, but that hasn't stopped
Dr Sen from decaying in jail. The only way to save him is more voice of people against his
arrest. Those interested to join the cry can click on http://www.freebinayaksen.org
DECCAN HERALD, Monday, March 13, 2006

http://www.deccanherald.com/deccanherald/Mar132006/panorama1843482006312.asp

WHEN TOO MUCH IS A BAD THING

by
Dr Gopal Dabade

Are doctors influenced by the gimmicks on drug promotion of profit-making drug

companies? A study done by WHO unequivocally declares that drug promotion strongly
influences “prescribing behaviour” but doctors underestimate it. Company funding of
doctors, educational events and research are important elements in this influence. The
mighty question is whether drug promotion can be regulated?

Most of us who visit our doctor are familiar with medical representatives – those neatly
dressed, well-groomed, young men in neckties with a bagful of gifts and drug literature.
These medical representatives are at the doctor’s clinic to promote their companies’
products. This is only one way that drug companies try to influence the doctor's
prescription. There are other ways too such as giving away gifts, drug samples,
sponsorship of conferences etc. Drug companies spend huge amounts of money on drug
promotion to doctors. The result is that the consumer is burdened when he buys the drug.
In the year 2002, almost $21 bn was spent by drug companies on drug promotion in the
US. In developing countries like India medical representatives are frequently the only
source of information on medicines.

If drug promotion leads to better prescribing, more scientific use of medicines or improved
cost-effectiveness then there would be no concern. But on the contrary heavy promotion of
new drugs leads to widespread prescribing and use before the safety profile of these
products is fully understood.

Newer and more expensive medicines displace older, less costly ones without evidence of
an improvement in outcome.

Both WHO and NGO have been expressing concern about inappropriate drug promotion.
At the 1977 Roundtable on WHO's Ethical Criteria for Medicinal Drug Promotion there
was agreement that inappropriate promotion of medicinal drugs remains a major public
health problem both in developing and developed countries. The only difference is that in a
developing country like India the consumer has to pay through his nose and end up in debt
just to pay drug bills.

Attempts to control drug promotion have largely been unsuccessful because of the reliance
on a combination of voluntary codes adopted by industry associations and medical
organisations.
On the surface, voluntary self-regulatory codes from the pharmaceutical industry may look
like a sensible approach to controlling promotional activities of companies; and lacking
government-industry adversaries.

In a highly competitive industry, the desire of individual companies to prevent competitors

from getting an edge could be harnessed to serve the public interest through a regime of
voluntary self-regulation run by a trade association.

In order to control promotion, government regulation, training of students, media exposure

of abusive promotion, provision of reliable exposure to non-commercial medical
information to medical doctors and the public are useful. Unfortunately none of these
exists in India.

http://deccanherald.com/deccanherald/jan42007/editpage22538200713.asp
DECCAN HERALD, 4th January 2007

Medication: Out of reach of people

Despite earning huge profits, pharmaceutical companies do not care for public health.
Nutritional anaemia is rampant and a major public health problem, mostly affecting
women and children and is a sensitive indicator of poverty. The treatment for this problem
is also simple. A preparation containing iron in the form of ferrous sulphate with folic acid
for a duration of two to three months is the most effective treatment, which is well
established in the medical field. But the issue is not that simple. In fact, as per a study,
there are hardly any proper drugs to treat this problem. In other words there is a poverty of
drugs to treat the condition that affects the poor and the marginalised.

A study by Drug Action Forum-Karnataka has revealed that drugs available in the market
to treat anaemia are unscientific, i.e. they do not match any standard textbook medicine or
the World Health Organisation's (WHO) recommendations. While textbooks and the WHO
advise that the scientific way of treating anaemia needs only ferrous sulphate with folic
acid, drug companies add up a whole lot of things to this.

Profit motive:-
For example, Vitamin C is added; drug manufacturing companies argue that it enhances
absorption of ferrous sulphate, i.e. iron. Textbooks explain that such a combination is not
only useless but may even prove counter productive as this may unnecessarily increase
chances of side effects of iron and give no added advantage. Apart from this, some
companies add Vitamin B-12 to iron. A popular misconception among people is that it
gives strength! The list of items that the drug companies add goes on. Even zinc, copper,
Vitamin B-6, alcohol and haemoglobin are added.

Why do drug companies add up unnecessary ingredients? The only reason that comes to
our mind is that they want to make more profit. It only adds up to the cost of the drug.
Most of the preparations to treat anti anaemia sold in the capsule form, which again is not
advisable. Tablet form is most suited. The cost of the drugs is several times higher (even 45
times higher) than the scientific ones. Scientific and correct preparations are not available
with most local chemists. Local chemists argue that it is not profitable enough to keep such
drugs, as they do not have a good profit margin. This is a good example to show that
market forces cannot take care of people's health.
One wonders if the drug companies in India are not making enough profit to manufacture
such primary drugs. The Indian drug industry is the most profit making one today. It is one
of the leading global players in manufacturing drugs — 4th in terms of volume and 13th in
terms of production. Despite such huge profits, the industry has been reluctant to
manufacture drugs needed to treat anaemia and other common complaints.

Forced poverty:-
The National Sample Survey (NSS) shows that “one quarter of hospitalised Indians fall
below the poverty line due to hospitalisation and drug related costs”. A substantial amount
of money of the patient is spent to buy drugs. According to an estimate, it is 40 to 50 per
cent, which is almost double that in the US and other European countries.

It is to be noted that in spite of such a successful and highly profit making Indian drug
industry, 65 per cent of the Indian population does not have access to basic, simple and
essential medicines. This in reality means lack of medicines to treat even simple symptoms
like fever.
These life saving, essential drugs which could be manufactured at low cost are not
available at even government health centres. There is often a shortage, which is
outrageous, as the poor are compelled to go to government health centres.
These issues should attract urgent intervention of the government for a public health cause.
So, till the government wakes up people will continue to be anaemic.

http://www.deccanherald.com/Content/Apr182008/editpage2008041763232.asp
IN PERSPECTIVE, Health in the political agenda,
By Gopal Dabade
It remains to be seen whether political parties would include health on their agendas.

The heat is on in Karnataka with elections around the corner and political
parties searching for “the common man” or aam-aadmi – a person whom
nobody bothered about till recently. All political parties are interested in
giving away what ever seems to attract the voters. The common man also
wants to make most of the situation but in these dynamics the real issues
are buried. This article focuses on health in the context of elections in
Karnataka.

The health statistics of the state is quite alarming. The IMR (Infant
Mortality Rate) which describes the number of children who do not live
beyond their first birthday is a sensitive index of the general health of the
population is 55 per thousand in the state compared to 10 per thousand in
Kerala. Still more pathetic is the wide gap between the rural and urban in
Karnataka.

Rural scene

The IMR in rural areas is around and that of the urban 25. Which means it
is really three times more. The nutrition profile of children is not heart
warming. For instance, 70 per cent of children below 6 years and 50 per
cent of women suffer from anaemia. All these figures just mean that the
people, especially children and women just do not have enough to eat;
they sleep empty stomach, as anaemia is a sensitive indicator of the
poverty in the population. The condition of children is really deplorable as
37 per cent of children are malnourished and where as only 55 per cent of
the children are fully vaccinated.

The huge gap between the urban and rural is manifest clearly in state’s
health budget allocations. The state provides only 3 per cent of its budget
to health, where as the same is 17 per cent in neighbouring states. The
further break up of this 3 per cent is still distressing because 44 per cent of
this 3 per cent is earmarked for the big hospitals in the cities and a meagre
3 per cent only for the rural health care institutions – which include the
rural based primary and sub-centre health care facilities.

It is obvious that those people, who are in need of maximum health care –
the rural masses, are the ones who are often maximally deprived.
Undoubtedly this divide has to be addressed and repaired immediately. It
also needs to be clarified that their health profile will not show any
improvement unless proper changes in the health policy to focus on rural
health. Unfortunately this is not happening. Should such an important
issue not be introduced into the election agenda?

Scarcity of doctors

The scarcity of doctors and their unwillingness to work in rural areas has
been highlighted in the media. Recently the union health minister
threatened to increase the duration of the medical course and compel the
to-be doctors to work in rural areas. A total number of 1,679 posts of the
doctors continue to be vacant in the Karnataka government health service.

This in spite of the fact that Karnataka boasts of having the highest
number of medical colleges churning out 3,335 doctors annually! It is well
known fact that successive governments have permitted new medical
colleges to open but even government health centers themselves lack
doctors. Obviously no amount of new medical colleges or high tech
hospitals would help solve the problem.

The availability of drugs in primary health centers and other government

health outlets needs immediate attention. Look at these terrible figures! A
mere Rs 75,000 is sanctioned for every primary health centre that needs to
address the health needs of a population of 30,000. This works out to be
just Rs 2.50 per person per year! This is provided the corrupt medical
bureaucracy do not gobble it up.

In view of these harsh realties whether political parties would include

health or not on their election agendas remains to be seen. If the health of
the vast majority of people could be addressed through these elections
then the coming elections would certainly be different from the earlier
ones.

http://www.deccanherald.com/Content/Apr32008/editpage2008040260701.asp

Deccan Herald, Thursday, 3rd April 2008,

IN PERSPECTIVE

The Menace of combo drugs,

Dr Gopal Dabade

India should enforce legislation against the Fixed Dose Combination (FDC) drugs.
The beans have been spilt. This is what happens when top bureaucrats have difference of
opinion and bring their differences to the streets. The Drug Controller of India, New Delhi
found out that the State Drug Controller of Tamil Nadu, had given licenses to manufacture
Fixed Dose Combinations (FDCs) of drugs that he himself would have objected to. What
was initially a war of words between the two bureaucrats soon ended with litigation in the
High Court of Tamil Nadu.

In a big blow to the Drug Controller of India's efforts to phase out FDCs of drugs from the
Indian market, the court has given a stay on a petition filed by Confederation of Indian
Pharmaceutical Industries (CIPI), in November 2007.

Combination of drugs

We need to get to some medical jargons before understanding this issue. What are FDCs?
FDCs are combination of two or more active drugs presented to the patient (or consumer)
in a single dosage form. An example: Paracetamol is a drug used to treat fever and
Ibuprofen is a drug used to treat inflammation. When these two drugs are combined and
given in a single dosage form it is known as FDC. Text books of medicine or of
pharmacology or the medical scientific community do not accept this combination and so
this is known as “irrational combination”.

And there are several such FDCs in the Indian market! The Drug Controller of India has
objected to around 300 FDCs (market worth around Rs 3,500 crore) that the State Drug
Controller of Chennai has cleared by giving manufacturing permission to various drug
companies.

A group of public health experts who have examined this issue in depth say that there are
several such unscientific drug combinations in the Indian market. For example, an analysis
of the top-selling 300 drugs showed that that 60 per cent of them are irrational. Further
FDCs which account for more than 90 per cent of the total retail sales in India do not find
any mention in standard textbooks of medicines.

The list includes several categories, apart from common pain-killers, of drugs like many
FDCs of antibiotics, antimicrobials and antidiarrhoeal. Even drugs needed to treat the
common conditions like anemia and cough do not confine to standard scientific guidelines
and thus are irrational FDCs. The World Health Organisation explicitly mentions that
"Indeed, it can be argued that the very existence of an FDC discourages adjustment of
doses to the patient's need".

FDCs are not new in the Indian market but what is worrying is that initially it started with
few dozen drugs and then they flooded the market in the next two decades.

Need for legislation

Responding to the pressure for newer products, drug companies used to invent
combinations of two or more drugs, often launched without an assessment of their
therapeutic benefits. In response the Health Ministry has amended the Drugs & Cosmetics
Act in 1988 to address this new development.

So the rule 122 (E) of the Drugs & Cosmetics Act requires submission of all relevant pre-
clinical and clinical trial data for FDC drugs. In addition, the amendment makes it
abundantly clear that the state Drug Controlling authorities have no power to issue licences
for FDCs. Most of the State Drug Controllers in any case do not have the expertise or
facilities to assess the merits and demerits of drug combinations.

Not all FDC's are bad. In fact FDCs have certain advantages in certain specific and
selected situations. Indeed out of the total number of 347 essential drugs mentioned in the
latest list of essential medicines by WHO (March 2007), only 26 (7.5 per cent) are
acceptable FDCs. Apart from these most of the FDCs are not only unnecessary but are big
public health problems.

India needs to take a lesson from its neighbouring Bangladesh. As a result of Bangladesh
Drug Ordinance 1982, several hundreds of FDCs were removed from the market. This
ordinance was based on the World Health Organisation’s essential drug list and
recommendations. There is an urgent need in India too to clear the mess. Will it happen?
Only time will tell.