📰 Zika: doctors advise caution this festive season
•Days after the Indian Council of Medical Research’s surveillance system picked up over 30 positive cases of Zika virus – currently being reported by 86 countries worldwide – doctors in Delhi have advised extreme caution stating that the virus could travel with infected people during the festive season, which sees a lot of inter-State movement.
Similar symptoms
•Symptoms of Zika virus disease are similar to other viral infections such as dengue, and include fever, skin rashes, conjunctivitis, muscle and joint pain, malaise, and headache.
•R.K. Singal, principal consultant, director and co-ordinator of Medical and Allied Services, Internal Medicine, BLK Super Speciality Hospital, said: “Zika virus reaches people mainly through the bite of an infected Aedes mosquito. It can also spread during sexual intercourse with an infected person, from a pregnant woman to her foetus during pregnancy or around the time of birth, and through blood transfusion.”
•Dr. Singal added that most patients have only mild symptoms that include fever, rash, headache, joint pain, red eyes, and muscle pain.
•Rarely, serious complications include Guillain-Barré syndrome and acute respiratory distress syndrome. Symptoms can last for several days to a week.
•“There is no vaccine to prevent Zika,” he said.
•Dr. Singal added that the confirmation about the virus in Jaipur can be alarming for Delhi too, as this came in the middle of the festival season where many Indians travel, increasing the risk of spreading the virus.
Not common
•Treatment is mainly symptomatic, that includes bed rest, drinking fluids to prevent dehydration and paracetamol to reduce fever and pain.
•Zika virus is not common in India as of now. In 2017, only three laboratory-confirmed cases of Zika virus were reported in Gujarat.
•A total of 32 positive laboratory-confirmed cases of Zika virus infection has been detected so far in Jaipur, Rajasthan. And, this number will only rise, said a senior health official.
Gaining foothold
•In a release issued by him he added that Zika virus is gaining foothold in India and is now here to stay. Public awareness about Zika is low and diagnostic facilities are not available everywhere.
•He added that while enhanced surveillance, community-based including at international airports and ports, to track cases of acute febrile illness is the need of the hour, creating public awareness about the disease including preventive measures should be the focus. At the same time, the public should be assured that there is no need to panic.
📰 Empathising with victims of sexual assault
Proper public remembrance alone restores dignity and self-respect to the victim
•Last week saw several women come out publicly to speak about their suffering at the hands of sexual predators in our society. But do we, those of us who saw or heard them, really understand what they experienced, the full psychological impact of sexual assault? Do we grasp the therapeutic value and empowering nature of this very public act of remembrance of past injustice?
Always reliving the trauma
•For a start, these victims must have long endured unbearable stress and anxiety common among all victims of force and violence. They must have found it hard to focus on anything, suffered panic attacks, dreaded being alone, perhaps even consumed by thoughts of death or suicide. They must have relived that horrific moment several times, been startled when touched unexpectedly, jumped at unfamiliar sounds, felt the obsessive need to make themselves secure in their own home. In short, their bodies had been traumatised.
•As they tried to make sense of their suffering, they probably ended up blaming themselves for what had happened. To overcome guilt, they may have plunged into denial. And the longer the period of denial and repression, the deeper and more severe the trauma. Suppression of painful memory results in benumbing and disconnection from the world, a withdrawal from real human contact. Thus, they must have had feelings of profound social estrangement. Compounding all of this is a sense of complete helplessness generated by the failure to do anything to avenge the wrongdoing. This must induce a strong sense of shame. So, the victims that we recently saw, heard or read must have endured deep insecurity, estrangement, shame, guilt and virtually a complete loss of agency.
•But suffering does not stop at this. When persons are wronged, they not only suffer physically or psychologically but are morally scarred, the most injurious of which is the damage to their sense of self-respect. No one likes to be told that they are inferior creatures or count for nothing. But this precisely is what the wrongdoer conveys. When persons are abused, they receive a message of their irrelevance. Intentional wrongdoing attempts to degrade us. Since self-esteem hinges upon critical opinion of the other, the message sent by the wrongdoer significantly lowers the self-esteem of the wronged. In such circumstances, the insult and degradation inflicted on assaulted women must surely have caused deeper moral injury.
•Imagine, in this midst of this experience, being confronted with colleagues, friends, even family, privately sympathetic to the trauma, but who advise you to remain silent in public, to keep the story to yourself, to move on. Imagine being told that public expression of your ordeal will only bring reprisals, harassment, more shame and dishonour. Asking victims to forget their tormented past is to treat them as if no great harm has been done, as if they have nothing to feel resentful about. Calls to let bygones be bygones, to wipe the slate clean or start afresh, only reinforces loss of self-esteem in the victim. Besides, this works unabashedly in favour of perpetrators, who believe that they have gotten away with their crime and grow in confidence that such injuries can be inflicted without resistance even in future. Therefore, rather than prevent, calls to forget end up facilitating wrong acts. If so, is it difficult to conclude that proper public remembrance alone restores dignity and self-respect to the victim?
•Victims need to tell stories of their victimisation, relate their version of events, express retributive emotions of resentment or moral hatred, point to the aggressor, and amplify his aggression. It is crucial that grave injustice done to them is publicly acknowledged by everyone as grave injustice, that perpetrators own up full responsibility for their reprehensible acts. Only then can victims move properly from a passive state of disengagement to active engagement with the world, learn to live their life again and rebuild relations with friends, family and members of the wider community. Because physical injury also leaves them mentally scarred and without any self-respect, this is the only route to reclaiming self-esteem.
Shattering the silence
•Breaking the dreadful miasma of silence that implicates everyone — victim, perpetrator and witness — is not easy. Perpetrators want silence because they want to shroud their guilt over their act or, even worse, extract an even greater sense of their own power and self-esteem by keeping the mouths of their victims shut. Victims are silent out of shame and fear; without conditions that bolster confidence and reduce apprehension and, in extreme cases, treat traumatic emotional disorders, they are usually reticent about entering the public domain. It is well known that only a minuscule proportion of rape victims acknowledge it, leave alone file cases. Finally, witnesses don’t speak out because of indifference, callousness, selfishness or a misjudgement of what social norms require.
•But there is no good alternative to public recall of such crimes. It brings them out into the open, challenges their denial or concealment by perpetrators, and contests versions that, by sanitising events, distort their true character. The purpose behind it is to get perpetrators or complicitous beneficiaries to admit to the knowledge of the crime and to own up responsibility for it. This is important because behind the mediatised drama of public acknowledgment lie painful stories of mutilated lives, broken families and personal betrayals. Public acknowledgement is the crucial first step towards proper healing and repairing impaired moral agency. It is also crucial for restoring social trust. Erasing injustice without collective recall, acknowledgment and eventual reparation can hardly serve as a sound foundation for a sane society.
📰 ‘Unethical to withhold bedaquiline while waiting for Phase III results’
Drug safety results of over 5,000 patients showed significant reductions in patient mortality while no new safety signals have emerged
•In a recent Rapid Communication, the World Health Organisation (WHO) made important changes in the regimens to treat patients with multidrug-resistant TB (resistant to isoniazid and rifampicin). Two of the injectables (kanamycin and capreomycin) previously used for treating MDR-TB patients are to be replaced with a fully oral drug regimen. And bedaquiline drug, specifically developed for treating MDR-TB patients, has been included in the fully oral regimen. The injectables have been removed as they cause hearing loss (ototoxicity) and have increased risk of treatment failure and relapse. The changes in the MDR-TB regimen apply to both adults and children, though limited data are available for children. The new WHO guidelines for MDR-TB treatment will be released later this year.
Phase III trials
•The new guidelines are not based on data from any Phase III trial of bedaquiline. In fact, no Phase III trial has been completed yet. WHO, therefore, relied on data of 50 studies and trials involving over 12,000 patients from 26 countries, including several countries where bedaquiline was used, to explore the safety and efficacy of the drug.
•But in the absence of Phase III trial results, how was WHO convinced about the safety and efficacy of the drug? “WHO has recommended that all patients receiving newer drugs such as bedaquiline be closely monitored using dedicated and standardised active pharmcovigilance [monitoring the effects of drugs] measures. WHO has also established a global Active TB Drug Safety Monitoring and Management (aDSM) database to generate evidence on safety of MDR-TB regimens utilising the newer TB drugs,” Karin Weyer, Coordinator, Diagnostics, Laboratories & Drug Resistance, Global TB Programme at WHO, Geneva said in an email to The Hindu. The data from this programme as well as safety data from observational studies and programmatic use of the drug in over 5,000 patients were analysed. “Results showed significant reductions in patient mortality while no new safety signals have emerged for both adults and children,” she said.
•“In contrast to the Phase IIb data, we have data of much larger number of patients and mortality is significantly lower in the bedaquiline group. This should reassure the sceptics,” Soumya Swaminathan, Deputy Director-General (Programmes), WHO, Geneva said in an email.
•The Phase IIb trial involving smaller number of MDR-TB patients showed that the drug was cardiotoxic and hepatotoxic (toxic to the liver) and seemed to cause more deaths. In June 2013, WHO published interim guidance for bedaquiline use, recommending its use in MDR-TB patients only when other treatment options were not possible. And in December 2012, the U.S. Food and Drug Administration granted accelerated approval to the drug for use in “serious or life-threatening conditions”. WHO again reviewed available evidence based on five studies at the end of 2015 and released a report in June 2016. The review showed a reduction in mortality in patients receiving bedaquiline, but there were unexplained serious adverse events of respiratory origin. Hence, the original WHO interim guidance was retained.
•Against this background, why did WHO not wait for the Phase III trial results before revising its guidelines? “Part of the WHO core mandate is to ensure that MDR-TB patients have access to life-saving treatment. For bedaquiline, there is much more data available already (than for delamanid drug, for example) that it drastically cuts down on patients dying from disease and improves the chance for cure while not creating any new safety concerns. Given the complexity of MDR-TB treatment, the low cure rate currently reported globally for treatment success and the evidence from postmarketing surveillance, the use of bedaquiline (and other second-line medicines) is warranted in order to provide life-saving treatment to patients. Treatment can, therefore, not ethically be withheld while waiting for the phase III trial to be completed,” said Dr. Weyer.
No significant difference
•According to her, the data for delamanid is much less definitive, despite the fact that a phase III clinical trial has been completed; Phase III trial using delamanid did not show any significant difference in curing the disease or reducing deaths thus belying the initial promise.
•“Phase III trials are important because they strengthen the certainty in the evidence when reviewed by international practices such as GRADE [Grading of Recommendations Assessment, Development and Evaluation], which is also used by WHO for public health policy development,” Dr. Weyer said. “[But] trials are often mounted around specific research objectives and do not usually address all possible concerns that decision-makers may have. The WHO, therefore, uses the international GRADE method to formulate evidence-based policy recommendations.”
•The GRADE approach allows the findings from studies of different types to be summarised with a comprehensive assessment of certainty of their results based on standardised parameters. These findings are then collated into a formal recommendation, which often contains clearly specified conditions for implementation.
•None of the second-line medicines for MDR-TB treatment are without adverse effects. But most of the adverse effects can be managed if detected rapidly, with the exception of ototoxicity (hearing loss), which is irreversible and associated with the injectable drugs. “This is why WHO is stressing the need for active drug safety monitoring and management as a core principle of clinical care in MDR-TB,” Dr. Weyer stressed.
•To make detailed information on clinical management of MDR-TB patients, including monitoring and managing drug adverse effects, WHO is currently updating the Companion Handbook. It will be released together with the upcoming new WHO guidelines.
📰 Human–leopard conflict in the Himalaya
‘High-risk’ zones need special conservation attention
•Human–animal conflict is common in the Himalaya like any other region where wildlife and people live together. A study of patterns of leopard attacks here reveal that some areas are high-risk zones requiring urgent conservation measures for the safety of both man and beast.
•The foothills of the eastern Himalaya in northern West Bengal — called the dooars, a landscape comprising tea plantations and forests — alone have witnessed more than 700 leopard attacks on people between 1990 and 2016. In the western Himalaya (Pauri Garhwal in Uttarakhand), numerous leopards have been killed in retaliation to the human deaths and injuries they have caused.
Attack patterns
•Scientists at the Wildlife Institute of India studied patterns of leopard attacks in both these regions. To list leopard attacks from 2000 to 2016, they accessed published literature, newspaper reports and data on monetary compensation awarded by forest departments. They visited 101 sites of attacks to confirm the details of incidents. On an average, leopards killed more than three and injured 11 people in Pauri each year between 2006 and 2016; in turn, 121 leopards met their ends at the hands of people. In the dooars, while 420 people were injured between 2011 and 2016 alone, there were barely any retaliatory killings.
•The researchers find that around 97% of animal attacks in the dooars and 60% in Pauri resulted in human injuries. While a majority of the victims in Pauri were children and youth, middle-aged tea estate workers were most at risk in the dooars.
•Despite this, 368 interviews with locals in both areas revealed that 41% of respondents in Pauri and 75 % in the dooars were positive towards the presence and conservation of leopards.
•“The high percentage of positivism in the dooars is largely due to the strong foundation of Joint Forest Management activities that have long been practised here, leading to better awareness and participation of local communities in conservation,” said S. Sathyakumar from Wildlife Institute of India, and coauthor of a study published in the journal PLOS ONE.
Predictive map
•As part of the study, the team also used these data to develop a predictive risk map. This reveals that central and northern Pauri, as well as the protected and peripheral areas of central and south-western dooars are ‘high risk zones’.
•They suggest that immediate measures — including regular monitoring by wildlife managers and local response teams, providing proper lighting in villages and clearing bushes around houses — would be crucial to mitigate conflict.
📰 IL&FS saga: What is the lowdown on bailout after default?
What is it?
•It all started with a default in August on a ₹1,000 crore short-term loan extended by the Small Industries Development Bank of India (SIDBI) that led to a trail of several defaults in following weeks. To its many bond investors and business partners, it became increasingly clear that the complex financial conglomerate, Infrastructure Leasing and Financial Services (IL&FS), was facing a severe cash crunch.
How did it come about?
•The crisis at the company may have become pronounced in the current financial year, but trouble had been brewing since 2016 when banks went slow on lending and IL&FS had to rely on short-term loans to service its debt even as it built long-term assets. This gave rise to a huge asset-liability mismatch. The IL&FS group has a total debt of ₹91,000 crore.
Why does it matter?
•Since a significant amount of its debt was in the form of short-term loans from banks, mutual funds and non-banking finance companies, the immediate impact of its cash crunch was felt on mutual funds and NBFCs. On September 21, panic gripped the stock market after DSP Mutual Fund sold ₹200 crore-₹300 crore worth of commercial papers of Dewan Housing Finance (DHFL) at a discount. The DHFL stock tanked 42% on that day. Some other NBFCs also felt the heat as panic set in. The debt market was also not immune to the goings-on at IL&FS. Liquidity was already tightening in September owing to factors like corporate advance tax outflows and increase in festive season loan demand. The crisis at IL&FS further impacted liquidity and pushed short-term rates up by 50-100 bps within a week. To address the liquidity crisis in the debt market, the Reserve Bank of India freed up more funds for banks to lend and decided to infuse ₹36,000 crore of liquidity through open market operations in October.
•The State Bank of India, the country’s largest lender, also stepped in to support with liquidity as it decided to triple its target for loan purchase from NBFCs to ₹45,000 crore for the current financial year. The government also stepped in to address the governance issues at IL&FS. Based on a report of the Ministry of Corporate Affairs, which indicated serious deficiencies in IL&FS, the holding company, and its subsidiaries, the government moved the National Company Law Tribunal to dismantle the board and bring in new members to avoid a collapse. The board is expected to submit a resolution plan by October 31.
What lies ahead
•The biggest challenge for the IL&FS board is to raise funds in quick time so that fresh defaults can be avoided. One way to get money is to sell assets. A more permanent way of getting funds is to raise equity capital. Capital can be raised through a rights issue. The proposal for a rights issue was mooted by the previous board too, but they were unable to convince the large shareholders. The Life Insurance Corporation of India is the largest shareholder in IL&FS with a 25.34% stake, followed by Orix Corporation of Japan with 23.54%. Another option is to sell stakes to a new promoter. Again, that was also mooted by the previous board, but some existing shareholders could not agree on valuations. So the new board has its task cut out. As Uday Kotak, the newly appointed chairman of IL&FS, indicated, the crisis is much bigger and more complex than it was initially thought. For example, the new board found that there are 348 entities in the group, significantly larger than the 169 entities it was aware of. “And this underscores the task at hand,” Mr. Kotak said.
•It is also to be seen if the new board, which the government has thrown its weight behind, could convince the shareholders for more fund infusion. Economic Affairs Secretary Subhash Garg has said the challenges facing the firm will be “substantially resolved” in six to nine months. That suggests a long haul ahead.
