UHC India

Community Action for Health: Evidence from India

Social Participation in Health, known also as Community Action for Health or Community Participation in Health has a long and storied history. As global consensus grows on the centrality of this driver of health reform, we undertook to document lessons, with a focus on India’s national process as well as the experiences of the southern Indian state of Kerala. This is just a snapshot of the many experiences in the subcontinent with social participation and community action and we have aimed to use the novel method of Witness Seminars to carefully archive these histories from the perspective of its shapers – it’s witnesses. This resource is a intended for use by citizens, advocates, researchers and implementers to learn and act in to bring about societal change in the service of health.

Learn more about the method adopted to carry out this work at the national level here, and in Kerala, here.

Policy

Health policy and practice

The George Institute for Global Health draws on our latest evidence to produce statements, recommendations, and reports to inform policy, guidelines, and practices across the world. We engage with key decision makers to enact real change in health policy and practice where it is needed most.

Front-of-Pack Labelling in India - Empowering Indian Consumers to Make Healthier Food Choices

Front-of-pack labels (FoPLs) are an important tool to support consumers in making healthier food choices. A FoPL’s purpose is to inform consumers about the relative healthiness of products and indicate excessive energy, added sugars, saturated fats, and/or salt, which are associated with risk for non-communicable diseases (NCDs) including heart diseases, high blood pressure, diabetes mellitus, and obesity.

Many pre-packaged foods available in the market are processed with elevated levels of added sugars, salt, and/ or saturated fats, which are associated with increased risk of many diseases. We urgently need to adopt a front-of-pack labelling policy to help consumers make healthier food choices and reduce the country’s overall NCD burden. In this context, WHO India in partnership with The George Institute for Global Health undertook a study to assess the effectiveness of front of pack labels for processed food products.

Based on the findings of the study, a policy brief was developed to provide recommendations for the implementation of an effective FoPL as part of a comprehensive strategy to promote healthier diets. The implementation of front-of-pack labelling, supported by a robust campaign to enhance nutrition literacy in the population, can contribute significantly to the prevention and management of NCDs through positively influencing the dietary habits of consumers and assisting them in making healthier food choices.

Child Drowning

Childhood drowning - Stopping a silent epidemic

Drowning, particularly among children, is a largely invisible health crisis in low- and middle-income countries that has only recently begun to receive the attention it demands. Between 2016-20, researchers from The George Institute for Global Health examined the health burden stemming from drownings in parts of Bangladesh, India and Vietnam. The Institute’s ground-breaking research across the three countries revealed critical insights, raised awareness and offered policy makers and local communities evidence-based tools to help stop the silent epidemic.

Meta-research and Evidence Synthesis Unit

The defining feature of modern medicine and global health is its practice being informed by evidence gathered from exhaustive and systematic assessment of research evidence, critically appraised & contextualised to improve health of people worldwide.

The Meta-research & Evidence Synthesis Unit is focussed on conducting 'fit for purpose' evidence synthesis and meta-research to promote the use of evidence in healthcare decision making and improve the quality and conduct of primary research and evidence synthesis

The Unit works on the following domains: 

Non-communicable-disease-screening

Improving uptake for non-communicable disease screening: policy brief

The Ministry of Health and Family Welfare (MoHFW) - under the Ayushman Bharat Comprehensive Primary Healthcare (CPHC) program - launched a population-based screening program for all men and women of age group thirty years and above, with a specific focus on hypertension, diabetes, oral, breast and cervical cancers. The National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) operational guideline states that appropriate strategies that combine effective outreach and facility based UPHC services should be developed for NCD screening in urban areas in PHCs and the community health centres (CHCs).

With the above context, this request was received from the National Health Systems Resource Centre (NHSRC). The requester communicated that the Union Ministry of Health was in the process of streamlining the National Health Mission (NHM) and this rapid review was requested to offer evidence on interventions to improve NCD screening uptake in urban areas under the National Programme on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.

In consultation with the requester, the remit of this review was defined for two components:

  • Component I : Different strategies used to increase the uptake of screening for hypertension, diabetes, oral, breast and cervical cancers in adult patients over 30 years in urban areas
  • Component II : Enablers and barriers of screening for hypertension, diabetes, oral, breast and cervical cancers in adult cancers in adult patients over 30 years in urban areas.

This review was completed in a span of one month and a few key policy considerations are:

  1. Community-based outreach facilities, capacity-building, and integration of screening services within existing health services should be considered to improve screening uptake. 
  2. Health education (contextually tailored, in local languages), along with integration of screening into existing health system, demand-side.
  3. Improving access to screening services through various initiatives such as financial incentives (e.g. transport costs) or providing transportation could help create awareness and uptake. 
  4. Ensuring privacy and having female health care workers or providers available at health facilities can address embarrassment related to the screening procedures. In addition, standard protocols to be followed. 
  5. Encouragement to attend screening by other women in the community (particularly for cancers) or health care workers has been identified as an important facilitator for accessing and availing screening services 
     
Health and Well-being of Waste Workers in India

Health and Well-being of Waste Workers in India

Waste workers include government-employed sanitation workers; privately contracted door-to-door garbage collectors; and waste pickers who work in the informal sector. India has over 5 million sanitation workers. While there are no official data on the number of persons engaged in waste picking in India, it is estimated at up to 1.5 million persons, which is approximately 10 percent of the global waste picker community. A waste picker is “a person or groups of persons informally engaged in collection and recovery of reusable and recyclable solid waste from the source of waste generation - the streets, bins, material recovery facilities, processing and waste disposal facilities for sale to recyclers directly or through intermediaries to earn their livelihood.” Waste pickers in informal employment collect over 80 percent of the total recyclable waste, contributing significantly to savings for the government, and to environmental health. 

Access to health care and good quality health services is severely iniquitous, with marginalised and historically oppressed communities, such as waste pickers, facing numerous impediments to the attainment of health and well-being. Their experiences of health inequity and precarity are shaped by intersectional vulnerabilities, stemming from caste, class, gender, region of origin, mother- tongue, religion, religion, degree of formality of employment, nature of occupational (e.g., picking, sorting, or selling waste) and place and conditions of residence.

Waste pickers are exposed to various occupational hazards, physical, chemical, and biological, and encounter numerous impediments to the attainment of optimal health and well-being, in access to information; strategies for disease prevention, management, and rehabilitation; economic and social security; and opportunities for health promotion and recreation.

The Accountability for Informal Urban Equity Hub (ARISE) at The George Institute for Global Health, India (TGI) engaged in a policy content review, participant-observation, in-depth interviews, focus group discussions, and community meetings with waste workers at the ARISE project sites, and present the following recommendations for policy and research.  

Recommendations for policy

  1. Health and well-being interventions need to be tailored to the specific needs of waste pickers, particularly informal workers. 
  2. Waste workers need to be recognised as an occupational community engaged in diverse activities related to cleaning, collection, sorting, processing, and sale of discarded materials. 
  3. The ability to access services needs to be delinked from specific documentation, and assistance with obtaining documentation needs to be provided to waste workers. 

Recommendations for research

  1. The lives, livelihoods, occupational and social security of waste picker communities need to be explored, ideally through participatory research. 
  2. The health conditions, occupational hazards, practices for health promotion, disease prevention and management, recreation, and recourse to health care among waste picker communities need to be understood and documented, and effective interventions designed for improvements in their health and well-being.

Contact Josyula K Lakshmi (jlakshmi@georgeinstitute.org.in) or Shrutika Murthy (smurthy@georgeinstitute.org.in) for more details or clarification.

 

 

Snakes, the ecosystem, and us: it’s time we change

Snakes, the ecosystem, and us: it’s time we change

Executive Summary: Snakes are often killed at sight, even if not venomous. Social and cultural connotations, some more negative than others, and fear of snakebite shape our attitudes towards snakes and lead to human snake conflict. But snakes play an important role in our ecosystem and provides us economic and therapeutic benefits. It is high time we now start valuing the importance of snakes in biodiversity to make our societies healthier.

Snakes, as serpent deities are revered in various cultures - as a symbol of fertility, rebirth, afterlife, medicine, healing and prosperity.[1-4] Paradoxically, in communities, they are also considered as a threat to life and livelihood. Ophidiophobia, the fear of the snakes, is one of the most common phobias of animals (affecting 2-3% human population).[5, 6] Snakes are often killed on sight, for fear of snakebite.

Globally, up to 138,000 people die due to snakebite every year with nearly 2.7 million people suffering serious injuries and permanent disabilities.[7] However, about 85-90% of snakes species worldwide are non-venomous.[8] Most snakes are not aggressive in nature, and often bite in defence, or when threatened or provoked.[9] Killing snakes for fear of snakebites is problematic – as decreased snake population is detrimental not only for the environment but also for humans. Snakes serve critical role as predators, as preys, as ecosystem engineers, and provide economic and therapeutic benefits to humans (Figure 1).

Snakes, the ecosystem

Snakes as predators, feed on frogs, insects, rats, mice, and other rodents, helping to keep prey population under control. Snakes are also eaten by other species - thus playing a key role in the food-chain as prey. Skunks, mongooses, wild boars, hawks, snake eagles, falcons, and even some snake-species are Ophiophagus, i.e. species who feed on snakes as their primary diet.[10-12] The king cobra (Ophiophagus hannah), eastern king snake (Lampropeltis getula), black-headed python (Aspidites  melanocephalus), eastern indigo snake (Drymarchon couperi) are some ophiophagus snakes.[13-15] Declining snake population not only effects ophiophagus species, but has effects across many trophic levels. A disrupted ecosystem in the context of climate change, an increased probability of natural disasters has the potential to cause massive loss of life and livelihood.[16-18] The declining population of snakes has been documented globally.[19] 

Snakes as ‘ecosystem-engineers’ facilitate ‘secondary seed dispersal’, thus contributing to reproduction of plants.[20-22] When snakes swallow rodents (who consume seeds), the seeds are expelled through excretion into the environment in an intact manner. As snakes have larger home ranges than rodents, seeds tend to disperse at greater distances from the parent plant.[23] This mechanism supports growth and survival of plant species without struggling for common resources of light, water, and soil nutrients and hence essential for biodiversity and ecological restoration.[24]  

Snakes also play a role in disease prevention and provide benefits to agricultural communities. Rodents are carriers of many zoonotic diseases (like Lyme disease, leptospirosis, leishmaniasis, hantavirus) which affects humans, dogs, cattle, sheep, and other domestic animals.[25-28]. A sudden increase in rodent population might lead to zoonotic diseases outbreaks.[29]. Increase in population of rodents leads to loss of crops.[30] By eating rodents, snakes keep the population of rodents under control, thus preventing zoonotic disease transmission, and contributing to food security.[31] Estimates suggest that nearly 200 million people can be fed by food grains that are destroyed by rodents every year.[30] Offering natural, environmental-friendly, and free service to mitigate against rodents, snakes are truly “farmer’s friends”.[32] 

Snakes are also a source of many medicines. The only proven and effective therapy for snakebite - the snake-anti venom, is also derived from snake venoms.[33] Snake venom is injected into horses and sheep. The animals’ plasma with antibodies against the venom is collected and purified to produce the life-saving, snake anti-venom. [34] Snake venom has therapeutic value beyond anti-venom production. Many drugs derived from snake venoms are used in clinical practice (Table 1). [35-38] However, the therapeutic potential of snake venoms remains unexplored. Venom researchers continue to discover and investigate many more compounds. 

With the effects of climate change now evident, it is time now to start valuing the importance of biodiversity in making our societies healthier. Let’s save the snakes! 

Table 1: Snake venom derived drugs which are approved for clinical use [35-39]
 

Snake speciesName of DrugDisease / Condition
Jararaca pit viper snake(Bothrops jararaca)Captopril EnalaprilHypertension; Cardiac failure
Saw-scaled viper(Echis carinatus)TirofibanAcute coronary syndrome; Unstable angina
Brazilian lancehead snake(Bothrops moojeni)BatroxobinAutologous fibrin sealant in surgery
Chinese cobra (Naja naja atra)CobratideChronic arthralgia; sciatica; neuropathic headache
South-eastern Pygmy Rattlesnake(Sistrurus miliarius barbourin)EptifibatideAcute coronary syndrome, percutaneous coronary intervention

Author contributions

Conceptualisation - SB and DB; Writing original draft – DB; Writing- review and editing – SB, DB; Guarantor – SB and DB

Acknowledgement 

The authors acknowledge feedback received from Maarinke van der Meulen and Jagnoor Jagnoor from The George Institute for Global Health.

Publication Note 

The working paper is a part of a deep-thinking report on snakebite. 

Suggested Citation 

Beri D, Bhaumik S. - Snakes, the ecosystem, and us: it’s time we change. The George Institute of Global Health. July 2021. Available online at www.georgeinstitute.org. The article is licensed under CC BY-NC 2.0

References  

  1. Antoniou, S.A., et al., The rod and the serpent: history's ultimate healing symbol. World J Surg, 2011. 35(1): p. 217-21.
  2. Behjati-Ardakani, Z., et al., An Evaluation of the Historical Importance of Fertility and Its Reflection in Ancient Mythology. Journal of reproduction & infertility, 2016. 17(1): p. 2-9.
  3. Bird, S.R., "Australian Aborigines". In William M. Clements (ed.), in The Greenwood Encyclopedia of World Folklore and Folklife. 2006 Greenwood Press: Westport, CT. p. 292–299.
  4. Mundkur, B., The Roots of Ophidian Symbolism. Journal of the society for Psychological Anthropology, 1978. 6(3): p. 125-158.
  5. Ceríaco, L.M., Human attitudes towards herpetofauna: the influence of folklore and negative values on the conservation of amphibians and reptiles in Portugal. J Ethnobiol Ethnomed, 2012. 8(8).
  6. Polák J, et al., Faster detection of snake and spider phobia: revisited. Heliyon, 2020. 6(5): p. e03968.
  7. World Health Organization, Factsheet: Snakebite envenoming. 2021: p. Cited 15 June 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/snakebite-envenoming.
  8. Meyers, S.E. and P. Tadi, Snake Toxicity. [Updated 2021 Jan 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2021: p. Cited May 27, 2021. Available from: Available from: https://www.ncbi.nlm.nih.gov/books/NBK557565/.
  9. Coelho, C.M., et al., Are Humans Prepared to Detect, Fear, and Avoid Snakes? The Mismatch Between Laboratory and Ecological Evidence. Frontiers in psychology, 2019. 10: p. 2094-2094.
  10. Animal Hype, What Animals Eat Snakes? (A List Of Snake Predators). 2021(Cited May 31, 2021. Available from: https://animalhype.com/facts/what-animals-eat-snakes/).
  11. Dykstra, J., What animals eat snakes? Grunge 2019. Cited May 31, 2021. Available from: https://www.grunge.com/161123/what-animals-eat-snakes/.
  12. Zainal Abidin, S.A., et al., Malaysian Cobra Venom: A Potential Source of Anti-Cancer Therapeutic Agents. Toxins, 2019. 11(2): p. 75.
  13. Jackson, K., N.J. Kley, and E.L. Brainerd, How snakes eat snakes: the biomechanical challenges of ophiophagy for the California kingsnake, Lampropeltis getula californiae (Serpentes: Colubridae). Zoology (Jena), 2004. 107(3): p. 191-200.
  14. McCracken, J., Aspidites melanocephalus - Black-headed Python. Animal Diversity Web, 2020 (Cited May 31, 2021. Available from: https://animaldiversity.org/accounts/Aspidites_melanocephalus/).
  15. Oddly cute pets, What Snake Eats Other Snakes? 2019 (Cited May 31, 2021. Available from: https://oddlycutepets.com/what-snake-eats-other-snakes/).
  16. World Health Organization, Factsheet: Biodiversity and Health. 2015(Available from: https://www.who.int/news-room/fact-sheets/detail/biodiversity-and-health).
  17. Pyšek, P., et al., Scientists' warning on invasive alien species. Biol Rev Camb Philos Soc, 2020. 95(6): p. 1511-1534.
  18. Adebayo, O., Loss of Biodiversity: The Burgeoning Threat to Human Health. Annals of Ibadan postgraduate medicine, 2019. 17(1): p. 1-3.
  19. Reading, C.J., et al., Are snake populations in widespread decline? Biology letters, 2010. 6(6): p. 777-780.
  20. Hämäläinen, A., et al., The ecological significance of secondary seed dispersal by carnivores. 2017. 8(2): p. e01685.
  21. Glaser, L.B., Snakes act as 'ecosystem engineers' in seed dispersal. Cornell Chronicle, 2018 (Cited May 21, 2021. Available from: https://news.cornell.edu/stories/2018/02/snakes-act-ecosystem-engineers-seed-dispersal ).
  22. Sunyer, P., et al., The ecology of seed dispersal by small rodents: a role for predator and conspecific scents. 2013. 27(6): p. 1313-1321.
  23. Hasik, A., Snakes spreading seeds. Ecology for the masses, 2018(Cited May 31, 2021. Available from: https://ecologyforthemasses.com/2018/08/16/snakes-spreading-seeds/).
  24. Ruxton, G.D. and H.M. Schaefer, The conservation physiology of seed dispersal. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 2012. 367(1596): p. 1708-1718.
  25. Moola, S., et al., Leptospirosis prevalence and risk factors in India: Evidence gap maps. 0(0): p. 00494755211005203.
  26. Centers for Disease Control and Prevention, Rodents. 2010: p. Accessed 03 April 2021. Available from: https://www.cdc.gov/rodents/index.html.
  27. Himsworth, C.G., et al., Rats, cities, people, and pathogens: a systematic review and narrative synthesis of literature regarding the ecology of rat-associated zoonoses in urban centers. Vector Borne Zoonotic Dis, 2013. 13(6): p. 349-59.
  28. Rabiee, M.H., et al., Rodent-borne diseases and their public health importance in Iran. PLoS neglected tropical diseases, 2018. 12(4): p. e0006256-e0006256.
  29. Miller, J., A World Without Snakes. In Forestry and Wildlife. 2020 (Cited June 02, 2021. Available from: https://www.aces.edu/blog/topics/forestry-wildlife/a-world-without-snakes/).
  30. Singleton, G.R., et al., Impacts of rodent outbreaks on food security in Asia. Wildlife Research, 2010. 37(5): p. 355-359.
  31. Jowit, J. and A. Searle, Snake numbers ‘in decline'. The Hindu, 2010 (Cited June 02, 2021. Available from: https://www.thehindu.com/opinion/op-ed/Snake-numbers-lsquoin-decline/article16242431.ece).
  32. Save The Snakes, Why Snakes? 2021(Cited May 31, 2021. Available from: https://savethesnakes.org/s/why-snakes/).
  33. Ferraz, C.R., et al., Multifunctional Toxins in Snake Venoms and Therapeutic Implications: From Pain to Hemorrhage and Necrosis. 2019. 7(218).
  34. World Health Organization, Snakebite envenoming. 2021 (Cited May 31, 2021. Available from: https://www.who.int/snakebites/antivenoms/en/).
  35. Bansal AB, Sattar Y, and Jamil RT, Eptifibatide. [Updated 2020 Nov 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2021: p. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541066/.
  36. Bordon, K.d.C.F., et al., From Animal Poisons and Venoms to Medicines: Achievements, Challenges and Perspectives in Drug Discovery. 2020. 11(1132).
  37. Mohamed Abd El-Aziz, T., A. Garcia Soares, and J.D. Stockand, Snake Venoms in Drug Discovery: Valuable Therapeutic Tools for Life Saving. Toxins, 2019. 11(10): p. 564.
  38. Péterfi, O., et al., Hypotensive Snake Venom Components-A Mini-Review. Molecules (Basel, Switzerland), 2019. 24(15): p. 2778.
  39. Takacs, Z. and S. Nathan, Animal Venoms in Medicine, in Encyclopedia of Toxicology (Third Edition), P. Wexler, Editor. 2014, Academic Press: Oxford. p. 252-259.

 

 

 

CEDAW

Submission to Australian Parliament's Human Rights Sub-Committee on women and girls in the Pacific

The George Institute for Global Health and The Australian Human Rights Institute have jointly prepared a submission to assist the Australian Parliament's Human Rights Sub-Committee prior to its upcoming public hearing for the inquiry into women and girls in the Pacific.

This submission relates to our recent work on the implementation of women’s health rights in the Pacific. This work seeks to improve the health of women and girls worldwide, including in the Pacific, through the development of the United Nations Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) Implementation Map on Women’s Health. The Map is a unique tool that measures government responses to CEDAW recommendations on women’s health across 30 countries in the Asia-Pacific region.

It is a collaboration between the George Institute for Global Health and the Australian Human Rights Institute and is led by Dr Janani Shanthosh.

 

Triangular road sign with damage. Depicting child with ball and car

Six reasons why: Compelling co-benefits of lowering speed on our streets

With a growing global population and increasing urbanisation, cities are facing huge pressures in terms of population density, transport, air quality, access to opportunities for physical activity, and climate change. We urgently need to adopt policies that address these issues and the threats to safety and health the present. 

The Stockholm Declaration signed at the 2020 Global Ministerial Conference on Road Safety states that global leaders have a shared responsibility to protect road users from crash forces beyond the limits of human injury tolerance. This requires a focus on safe speeds, including: 

  • ZERO SPEEDING: use of effective speed management approaches, and
  • 30 KM/H: mandating a 30 km/h speed limit in urban areas to prevent serious injuries and deaths to vulnerable road users when human errors occur.

The benefits of lower urban speed limits go well beyond saving lives and reducing injuries from road traffic collisions. This policy brief outlines six compelling co-benefits which support progress towards the Sustainable Development Goals (SDGs). There is growing evidence of the link between lowered urban speed limits and:

  • The prevention of road traffic injuries, notably to pedestrians and cyclists (SDG targets 3.6, 11.2)
  • The promotion of physical activity through more active transport (walking or cycling) and the prevention of non-communicable diseases (NCDs) as a result (SDG target 3.4)
  • The improvement of air quality and a reduction in related short- and long-term health issues as a result, while also addressing a major contributor to climate change (SDG targets 3.9, 11.6, 13.2) 
  • Increased social connectivity and access to goods and services (SDG target 10.2)
  • Enhanced equity, as a result of focusing on the safety and health concerns of the most vulnerable in our communities, and 
  • Economic gains for businesses and governments. 

 

POLICY RECOMMENDATIONS

In addition to setting and enforcing urban speed limits of 30 km/h or less, policymakers should consider implementing: 

  • National policies that prioritise walking and cycling;
  • National policies that invest in and promote public transport as an alternative to private vehicles; 
  • National and sub-national policies that encourage planning of liveable urban spaces;
  • Education programmes and social marketing to increase public demand for safer speeds;
  • Monitoring and evaluation of the impact of walking and cycling policies.

Read the full policy paper here (PDF 949 KB)