Wednesday, February 29, 2012

Honor Killing and Killing of the Honor in Kerala

Dear Forum,

In Kodiyathur near Mukkom in Calicut district in Kerala 27 year old man was tied to a post and beaten to death by a moral brigade of 15 men. It seems, the victim, despite warning from the culprits, was accused of continuing an affair with a married woman.

The issue to be noted here is not the magnitude or the extra judicial nature of the punishment or that the victim did not break the law of the land since the woman's husband did not complain (IPC 497-adultery) etc.

This incident is only a tip of the iceberg of the ongoing sexuality related Human Rights violations regularly occurring in Kerala with institutionalized impunity since the victims are most often Sex Workers or MSMs.

In the late eighties a street sex worker was murdered in the police lock up in Calicut but the perpetrators escaped punishment and recently a boy in Calicut killed himself due to severe police harassment for supporting his brother to elope and marry his girlfriend despite severe obstructions from the police department.

Young people sitting on the beach get arrested regularly here.

Recently a prominent politician was man handled by the public in the full glare of the media, got arrested and charged for having caught travelling in a car with a lady who is not his wife.

The MP's car was stopped by a large group of moral public for been seen with a strange lady.

One of the earliest splits in Congress party in India took place - as the culmination of events triggered from an incident of a prominent congress politician caught with a strange lady in his car when it met with a minor accident-the product the Kerala Congress party which is a decisive ally in the UDF Govt.

These are only the signs of the continuations of ever prevailing intolerance towards sex in Kerala society and the major brunt of all this is taken by the Sex Workers and MSMs.

Cultural leaders, politicians, leftist groups and feminists are all guilty of silence on this matter.

Demanding sexual freedom and sexual excesses are not same.

Revolution in the attitude to sexuality should be inseparable from the agenda of social revolution itself and the social reform movements which caused marked improvements in Kerala society have completely failed to address the politics of sexuality.

The extremely conservative leftist groups have added to this failure by holding the ridiculous view that sexuality itself is an import of imperialism!

Tragically most of the feminists in Kerala belong to leftist groups and fails to discern that feminism should be more oriented to Human Rights than culture.

Patriarchal normativity in sex is one of the root causes of sexual violence and despite elaborate discourse on patriarchy many feminists fails to take note of the reality that sexuality itself is a social construct that rest on the structures built around a gendered society.

In the current Kerala society sexuality is an important arena of struggle more than any other where all need to fight for their rights but the tragedy is that the feminists are on the other side of the table since they cannot think of rights like sexual freedoms beyond cultural and matrimonial confines.

This attitude to sexuality is the greatest tragedy as well as the challenges of feminism in Kerala and unless and until the feminists in Kerala start accepting sexual freedom including sex work as work all these sex related atrocities here will continue unabated.

Tito Thomas (Advocate),
Director,
CSRD,Calicut

[Source: AIDS-INDIA eFORUM]

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Epi Updates (Times of India and Deccan Chronicle)

‘AIDS under control in Kerala’

TNN | Feb 12, 2012
http://timesofindia.indiatimes.com/city/kochi/AIDS-under-control-in-Kerala/articleshow/11854899.cms?prtpage=1

KOCHI: Kerala had managed to control HIV/AIDS and the number of affected persons was less compared to other states, said Dr M Prasannakumar of the Kerala State AIDS Control Society at the public health conference at IMA House on Saturday. He said that 2,200 new cases were being reported every year in the state but the number was minimal. He said that nearly 60% of HIV positive persons in Kerala were employed outside the state. Of the 10,000 pregnant women in the state, seven were tested positive. "We could trace 86 HIV positive pregnant women last year," Dr Prasannakumar said.

A total of 6,000 persons are undergoing treatment for HIV/AIDS in the state. The number of HIV-affected persons is high in districts that are closer to the Tamil Nadu border. Dr K Suresh, epidemiologist and public health consultant of the World Bank in India, said that the standard of public health education in the country was declining. "Even universities are not following a uniform syllabus on public health," he said. Health experts discussed a variety of topics including vector management, community-based palliative care and maternal health interventions. The conference will conclude on Sunday with a session on developing standardized competency framework for public health professionals in India. The valedictory function will have B Ekbal, former vice-chancellor of Kerala University, as the chief guest.

http://timesofindia.indiatimes.com/city/kochi/AIDS-under-control-in-Kerala/articleshow/11854899.cms?prtpage=1

Palakkad tops in HIV/AIDS cases

February 12, 2012 By Vinod Nedumudy DC Kochi

http://www.deccanchronicle.com/print/94301

Don’t be surprised to know that the district that cares the most for the bed-ridden is also the district having the most number of HIV/AIDS patients in the state. Palakkad has reported the highest number of HIV/AIDS patients in the state, 2,825 persons, according to the latest statistics released by the Kerala AIDS Control Society. In another key finding, the society has detected that 2,200 persons are detected with HIV every year in the state. Of 10,000 pregnant women, seven are being detected with HIV/AIDS, while in 2011 alone 86 pregnant women were detected with the deadly disease. The total number of people identified with the infection across the state is 15,000 While four in every 1,000 sex workers in other districts are found infected with HIV, 36 sex workers in Palakkad contracted the disease. “The sex workers in other districts are better paid than those in Palakkad and hence the number of clients per each sex worker a day in other districts is 1 to 2 while in Palakkad it is 5 to 6 per day. Hence the chances of contracting the disease are on the upper side in Palakkad,” according to Dr M. Prasanna Kumar, team leader and head of technical support unit for Kerala State AIDS Control Society.

The maximum cases are reported from Chittur, Alathur and Palakkad taluks. Another interesting fact is that even agriculture labourers are found infected with the disease in Palakkad while it is nil in other districts. The proximity of Palakkad to Coimbatore in Tamil Nadu where the prevalence rate of AIDS is over one percent, is cited as the main reason for the high incidence. The illicit liquor trade flourishing in the district is another reason. Close on the heels is Thrissur, with 2,012 registered cases and Thiruvanathapuram follows suit with 1,700 HIV cases. The least affected is Wayanad with 200 cases, while in Ernakulam the numbers rests at 1,000. Low prevalence is also reported from Alappuzha, Idukki and Kottayam. The society is yet to study the reasons for the high prevalence in Thrissur.

http://www.deccanchronicle.com/print/94301

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Monday, February 27, 2012

Palliative Care: NEJM Article mentions how Kerala's prohibitive rules have changed

Painful Inequities — Palliative Care in Developing Countries

Daniela Lamas, M.D., and Lisa Rosenbaum, M.D.

N Engl J Med 2012; 366:199-201 January 19, 2012

http://www.nejm.org/doi/full/10.1056/NEJMp1113622

Excerpts:

In many countries, physicians learn only about opiates' side effects, not their potential benefits, said Dr. M.R. Rajagopal, a palliative care physician in India. “Modern principles of pain relief and palliative care still aren't taught to medical students in 80% of the world,” he said, noting that many physicians in India finish training without ever seeing a morphine tablet.

Rajagopal recalled treating a patient with nasopharyngeal cancer whose pain was eventually controlled with morphine. The patient was also undergoing radiation therapy, and when his primary care doctor saw his morphine prescription, he tore it up, saying, “Never let me catch you with that again. That will destroy you.” Like many physicians, he feared opioid addiction and refused to believe that radiation alone was inadequate to treat the pain.

In Kerala, India, the opportunities for treating pain were similarly restricted until a few years ago. Physicians had to secure five licenses from different government bodies before they could prescribe a milligram of morphine. Often, one license expired before another was obtained, and the physician would have to start the process again without having administered a dose. In response to the efforts of Rajagopal, the palliative care physician, Kerala's rules have changed, but in most Indian states prohibitive hurdles remain (see Table).

For the full text, please visit http://www.nejm.org/doi/full/10.1056/NEJMp1113622

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Saturday, February 25, 2012

Kerala's Social Determinants and Tamil Nadu's Health System

Affordable Southern remedies for better health

K Srinath Reddy

http://ibnlive.in.com/news/affordable-southern-remedies-for-better-health/224911-55.html

Forbes India | Jan 28, 2012

When can a baby girl born in Madhya Pradesh expect to live as long and healthy as a baby girl born in Kerala, overcoming the six-fold higher risk of dying before her first birthday? When will a rural Indian have the same level of satisfaction about the healthcare he or she receives, as a foreign medical tourist featured in the brochures of corporate hospitals? Will the 40 million Indians, who are annually pushed into poverty because of unaffordable healthcare costs, be relieved of the crushing burden of catastrophic health expenditures in a country where private, out-of-pocket spending accounts for 71 per cent of all health financing?

While the Indian media is currently concerned over the fluctuating growth rates of the economy, it is the health indicators which should cause considerable concern.

Our infant and maternal mortality rates (presently 47 and 210 respectively) do not compare with those of Sri Lanka (11 and 47, respectively, a few years ago). While 42 per cent of our children below three years are undernourished, 15 per cent of urban adolescents are overweight, calling for nutrition policies that provide adequate and appropriate nutrition at each stage of life. India is home to a third of the world's measles cases as well as 61 million persons with diabetes. Smoking claims a million lives each year, with chewing tobacco adding to the world's highest load of oral cancer. In 2000, India lost 9.2 million potentially productive years of life due to early cardiovascular deaths occurring in the 35-64 years age range. This loss is projected to rise to 17.9 million years in 2030. We need a health system that can deal with the unfinished agenda of underdevelopment as well as the maladies of maladapted modernity.

With the emergence of new infectious diseases and a rapid rise in heart diseases, stroke, diabetes, cancers, mental illness and injuries, the health system has to respond to new challenges through creation of capability for prevention, early detection and cost-effective treatment. All this while continuing to emphasise maternal and child health, and traditional infections like tuberculosis, malaria and AIDS as the prime public health priorities. India's poor health indicators reflect the cumulative consequences of neglecting primary healthcare in all its dimensions.

Good health is inconceivable without an assurance of safe water, domestic and public sanitation, adequate nutrition and clean environment to all segments of the population. Easy access to dependable health services which can avert or ameliorate common ailments, an expected feature of good primary healthcare, is mostly unavailable in both rural and urban areas.

The National Rural Health Mission (NRHM) has attempted to strengthen primary healthcare, with focus on maternal and child health. While some success has been recorded in recent years, evidenced by a steady, but not speedy decline in infant and maternal mortality rates, much greater investment is needed in infrastructure, health workforce, management systems, community empowerment and governance. Urban primary healthcare too needs attention, with well dispersed community health centres forming the base of a three-tier network of healthcare facilities.For this challenging agenda to be successfully addressed over the next decade, we need to increase the level of public financing in health from around 1.2 per cent of the GDP at present to at least 3 per cent, to make it comparable to China (2.3 per cent) and Thailand (3.3 per cent). India spends $132 per capita on health, compared to $193 in Sri Lanka, $309 in China and $345 in Thailand. More public funding helps to reduce out-of-pocket spending.

The increased funding should be spent on strengthening primary healthcare infrastructure and district hospitals; scaling up the size and quality of the health workforce (ranging from community health workers to nurses and doctors); free supply of essential drugs and vaccines; and creation of a tax-funded system of universal health coverage wherein an essential health package of primary, secondary and tertiary services will be available, free of charge, to every Indian citizen. Such a system would be based on a single payer system rather than a fragmented system of multiple insurance providers. The government will be the guarantor of universal health coverage, even if it is not the sole provider. Health services will be provided by a network of public facilities and contracted in private providers.

This wish list cannot even be partially fulfilled, without system reform, innovation and political will. To ensure reforms in pooled drug procurement, supply chain management, healthcare facility accreditation, programme evaluation, human resource development and portability of health financing, new regulatory and facilitatory structures and systems are needed.

Competency-linked cadres for public health and health management should be created, to improve the design and delivery of health programmes. Information technology-enabled service delivery models, e-health, m-health and telemedicine can enhance outreach and effectiveness of healthcare. The complementary roles of Central and state governments need to be clarified and collective commitment to the creation of a robust and corruption-free health system must be generated across the political spectrum.

Even as the health system is progressively strengthened, policies and programmes in other sectors, which impact health, need to become sensitive and responsive to public health concerns. From agriculture and food processing to urban design and transport, there are many actors who can contribute to better health of our people. While convergence of services is needed at the frontlines, co-ordination of policies is required at the central level. Social determinants like education, employment, income and gender equality are also important enablers of good health.

I do not have a simple prescription for transforming health in India. In a complex system like health, a package of interventions is needed for successful, speedy and sustainable change. If I were permitted only one wish, I would like to see the whole of India having a health system like that of Tamil Nadu and social determinants like Kerala. Both states are now being cited internationally as examples of good health at low cost. The compass clearly points to southern models, if we wish to travel towards good health.

http://ibnlive.in.com/news/affordable-southern-remedies-for-better-health/224911-55.html

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ToI Report on Swanthanatheeram

Sex workers chart out a new career path

TNN | Jan 31, 2012

http://timesofindia.indiatimes.com/city/kochi/Sex-workers-chart-out-a-new-career-path/articleshow/11693624.cms

ALAPPUZHA: Swanthanatheeram, the self-help groups (SHGs) of women sex workers in the district, instituted by the Kerala State Aids Control Society (KSACS), is proving to be a big success with around 40 erstwhile sex workers taking up alternative jobs to make a living.

No one exemplifies Swanthanatheeram's success than 50-year-old Santha (name changed) a former sex worker who now plays the chenda (a percussion instrument) to make a living.

"I became a sex worker after my husband deserted me and my three daughters 14 years ago as I had to educate my children and also marry them off. But after I joined Swanthanatheeram in 2007 after much persuasion, I learned to play sinkari melam (chenda ensemble) along with 12 members of my SHG. Now we perform in temples, churches and houses during all kinds of festivities," she told TOI.

"Now we are busy and have a lot of programmes as it is the festival season. I earn Rs 800 for a performance and we have at least three programmes a week," she says.

SHGs also have other success stories to tell. Five sex workers learnt to drive the auto rickshaw and bought auto rickshaws with SHGs help and are now leading a decent life; 10 sex workers, trained as hospital helpers, have found jobs in various hospitals; and another group of 12 women are all set to learn sinkari melam.

It was in September 2007 that KSACS constituted SHGs of sex workers in the district as part of its Suraksha project, which aimed to reduce the rate of HIV transmission among sex workers, and drug users.

Paulose Kuriakose, district manager, Suraksha, told TOI that initially the SHGs had only 11 members. Now there are 35 SHGs, and of the 1,821 commercial sex workers identified by the KSACS in the district, 1,002 have joined the SHGs. And as many as 40 have completely abandoned sex work and are making a living through the activities of their SHGs.

Dr Nisha R S, a councillor with KSACS in Alappuzha, said many of the sex workers had left the field after they realized they could earn a decent income through their SHGs.

Five sex workers learnt to drive autorickshaw, 10 trained as hospital helpers and another group of 12 women are all set to learn sinkari melam.

-- Sajimon P S

http://timesofindia.indiatimes.com/city/kochi/Sex-workers-chart-out-a-new-career-path/articleshow/11693624.cms

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South Indian Harm Reduction Network (SIHRN)

Network to Reduce Drugs Dependency in South India

Saturday January 28, 2012 10:30:38 PM, Syed Ali Mujtaba, ummid.com

http://www.ummid.com/news/2012/January/28.01.2012/network_on_hiv.htm

Chennai: The launch of the South Indian Harm Reduction Network (SIHRN) in Chennai heralds a welcome initiative for people dependent on drugs, especially those living with HIV and AIDS in the Southern States.

There is a serious concern in the southern states of India over under reporting numbers of people injecting drugs and infected with HIV/AIDS.

Tamil Nadu and Kerala have been delivering services for drug injectors for many years now, and injecting epidemics have been reported more recently in Andhra Pradesh and Karnataka.

Civil Society and Community Organizations stated their concern over the numbers of deaths being reported and the lack of facilities for care and support currently available through national and state administered services.

The current services for HIV management through needle syringe exchange programs and medication for replacing illicit or grey market opiates have been largely successful but they are simply not enough.

The challenge of co-morbidities including the presence of TB and Hepatitis C along with HIV require wider access to health systems including hospitals.

There is also a huge demand for medically assisted detoxification and rehabilitation services and a scale up of the fledging Opioid Substitution Treatment Programs in the region.

It is in this context that the South Indian Harm Reduction Network that has been launched has a huge role to play.

In a freewheeling interview with A. Sankar, Convener, SIHRN and L. Samson, President, SIHRN, the goals and objectives of the new organization was spelled out.

SIHRN aspires to bring ownership of treatment to affected communities. It wants to mainstream services that include wider health care, psycho-social support, reintegration related to employment, family support and legal aid, Sankar said.

SIHRN wants to register state level networks that will work closely with state governments and the affected communities. It also wants to strengthen services for people injecting drugs under States AIDS Control Societies. SIHRN likes to advocate for an improved quality of life for drug dependent people, Sankar added.

L. Samson, President, SIHRN said the challenge is to keep people secure in access to various types of treatment. SIHRN resolve to widen the scope of services to draw together agendas such as homelessness and drug treatment with the key stakeholders managing HIV and AIDS services for people injecting drugs.

Counseling is the glue that will hold the populations adherent to services, as optimism is required to counter the despair felt by the severe stigma and discrimination experienced at mainstream health services, and the abuse on the streets by ill informed law enforcers, Mr. Samson concluded.

The meeting of South Indian Harm Reduction Network SIHRN was held under the auspices of the Indian Harm Reduction on January 28, 2012 in Chennai. It was supported by Sharan, a NGO working on HIV/AIDS in India.

The meet was coordinated by Indian Community Welfare Organization-I.C.W.O, a NGO based in Chennai. More details on this can be obtained from A.J. Hariharan of ICWO, who can be contacted at fieldmaster2000@gmail.com.

Syed Ali Mujtaba is a journalist based in Chennai. He can be contacted at syedalimujtaba@yahoo.com
http://www.ummid.com/news/2012/January/28.01.2012/network_on_hiv.htm

Tuesday, February 7, 2012

Critiquing the 'Kerala Model' of Health

Cracking the Kerala Myth: Image as a state-led success crumbles in the face of hard facts

2 January 2012

By: Arvind Panagariya
http://economictimes.indiatimes.com/articleshow/11335631.cms?prtpage=1

That Kerala has the best indicators of health and education outcomes among all Indian states and enjoys a low rate of poverty is beyond question. The state unequivocally enjoys the highest male and female literacy rates and life expectancy at birth, and the lowest rates of infant mortality, maternal mortality and malnutrition.

Because the communist and other left-of-centre governments have ruled Kerala for the better part of its post-Independence history, analysts routinely attribute its superior achievements in health and education to the high priority these governments have allegedly assigned to equity and related social goals over time. This view has gained so much currency that, while its advocates feel little obligation to offer supporting evidence, detractors remain ill at ease to insist upon it.

Yet, like all conventional wisdom, this too must be subjected to careful empirical scrutiny and, if need be, challenged. Begin with equity. Going by the latest available calculations from the expenditure survey conducted by the National Sample Survey Organisation (NSSO), Kerala had the highest rural and urban inequality among the largest 15 (by population ) Indian states in 2004-05. The state has shown consistently high, if not the highest, levels of inequality since NSSO began conducting large-scale "thick" expenditure surveys in 1973-74.

High inequality means that, contrary to claims by many, Kerala could not have achieved the decline in poverty without significant increases in income. Indeed, data on incomes and expenditures support this inference. An ongoing joint study of the 15 largest states by Columbia University and the National Institute of Public Finance and Policy shows that since 1980-81, the earliest year from which systematic gross state domestic product (GSDP) data are available, Kerala consistently ranks among the top five states by per capita GSDP. Indeed, in the latest 2009-10 thick NSSO expenditure survey, Kerala tops the list of states ranked by per capita expenditures in both rural and urban areas.

Given Punjab and Haryana had enjoyed higher per capita expenditures than Kerala in 1983, this fact points to faster growth in per capita expenditures in the latter than the former. Poverty levels in urban and rural Kerala have, thus, fallen not because its left-of-centre governments promoted equity but because per capita expenditures rose rapidly, thanks in large part to inflows of remittances.

But what about education and health? In a nutshell, Kerala enjoys the highest indicators in these areas because it started at the highest level at Independence. In 1951, it had a literacy rate of 47% compared with 18% for India as a whole and 28% for Maharashtra, the closest rival among the large states. By 2011, these rates had risen to 94, 74 and 83%, respectively. The gains made, thus, equal 47, 56 and 55 percentage points for Kerala, India and Maharashtra, respectively. Even Bihar, the poorest state in India, made a gain of 50 percentage points over the six decades, beating Kerala!

The story is no different in health. Take just two indicators for which i am able to obtain data going back to the 1970s: life expectancy at birth and infant mortality per 1,000 live births. Life expectancy during 1970-75 was 62 in Kerala, 50 in India and 54 in Maharashtra. By 2002-06, the three entities had added 12, 14 and 13 years, respectively, to these life expectancies. Among the large states, Tamil Nadu and UP made the most impressive gains: 17 years each. In a similar vein, whereas Kerala lowered its infant mortality rate by 46 deaths per 1,000 live births between 1971 and 2009, Gujarat achieved a reduction of 96, Tamil Nadu of 85 and Maharashtra of 74.

Can we find compelling evidence of successful public sector interventions in education and health as the source of sustained high levels of education and health in Kerala? The answer to even this question is in the negative. Consider health first. True, setting aside the small state of Goa, whose public expenditures on health are consistently three to four times those of Kerala, the latter has ranked first or second in per capita public expenditures on health since 1991-92.

But this observation masks two facts. One, these expenditures have hovered around a bare 1% of GSDP. Two, and much more importantly, private expenditures on health dwarf public expenditures in Kerala: in 2004-05, the latest year for which we have data, whereas public expenditures amounted to just 0.9% of GSDP, private expenditures were a gigantic 8.2%. The corresponding India wide figures were 0.9 and 3.6% of GDP, respectively.

The proportion of the population accessing public health services reinforces this story. In 2004, only one-third of rural and one-fifth of urban population chose the public health system for non-hospitalised treatment. Likewise, only about one-third of the population in both rural and urban areas chose public facilities for hospitalised treatment.

This same pattern is observed in education. NGO Pratham carries out extensive surveys of children in school up to 16 years of age in rural India. According to its latest report ASER 2010, excluding two or three tiny northeastern states, at 53% Kerala has the highest proportion of students between ages 7 and 16 in private schools in rural India. The corresponding figure for the nearest rival, Haryana, is barely 40%. No matter how we look at it, the conventional and dominant story of Kerala as a state-led success crumbles in the face of hard facts.

(The writer is a professor at Columbia University.)

http://economictimes.indiatimes.com/articleshow/11335631.cms?prtpage=1

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