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12 Jan 2023 : The Hindu Editorial Analysis

Editorial 1 : Reducing preterm births and stillbirths

Nelson Mandela had said, “There can be no keener revelation of a society’s soul than the way in which it treats its children”.
 

Context:

Two global reports released on January 10, 2023 — on child mortality and on stillbirths — prod us to reflect on whether India is doing enough for ensuring the health and survival of every child.
 

Findings of the reports:

  • The report on child mortality — Levels and Trends in Child Mortality, by the United Nations Inter-agency Group for Child Mortality Estimation (UNIGME) — estimates that globally, five million children died before their fifth birthday (under-five mortality) in 2021.
  • Over half of these (2.7 million) occurred among children aged 1-59 months, while the remainder (2.3 million) occurred in just the first month of life (neonatal deaths).
  • India’s share in these child mortalities was estimated at 7,09,366 under-five deaths; 5,86,787 infant deaths (death before first birthday); and 4,41,801 neonatal deaths. Many of these are preventable.
  • In addition, the Sample Registration System (SRS), released in September 2022, showed wide inter-State variations in child mortality in India. For every 1,000 live births, the infant mortality rate in Madhya Pradesh was six-fold of the rate in Kerala. The children in rural parts in any age subgroup have much higher mortality rates than their urban counterparts.

 

Two neglected challenges

  • At the root of many child deaths are two neglected challenges.
  • The first challenge is of children being ‘born too early’ (preterm births), which means they are born alive before 37 weeks of pregnancy are completed. Preterm babies are two to four times at higher risk of death after birth in comparison to those born after 37 weeks of gestation.
  • Globally, one in every 10 births is preterm; in India, one in every six to seven births is preterm. India has a high burden of preterm births, which means newborns in the country are at greater risk of complications and mortality.
  • Studies have shown that preterm births contribute to one in every six under-five child deaths. However, three out of every four deaths due to preterm birth-related complications are preventable.
  • The second challenge is of stillbirths, the subject of the second report titled ‘Never Forgotten’, also by the UNIGME. A baby who dies any time after 22 weeks of pregnancy, but before or during the birth, is classified as a stillborn. Globally, an estimated 1.9 million stillbirths happened in 2021.
  • In 2021, the absolute estimated number of stillbirths in India (2,86,482) was greater than the death amongst children in 1-59 months of age (2,67,565). The rates and number of both preterm births and stillbirths are unacceptably high and drive the neonatal, infant and child mortalities upwards in India. Thus, they demand urgent interventions.
  • One of the reasons preterm births and stillbirths do not get due attention is lack of granular and reliable data. Over decades, while countries have strengthened the mechanisms for tracking child mortality, the data on stillbirths and preterm births are scarce.

 

Funding India’s healthcare system:

There are multiple reasons why India’s health system needs more government funding:

  1. children continue to die from preventable causes
  2. pregnant women do not receive good quality care
  3. aggregate mortality hides the inequities in health outcomes
  4. the brunt of those inequities is borne by the poorest and marginalised families
  5. primary healthcare system is underfunded

Some cosmetic changes are not be enough to improve health outcomes. We need dedicated funding frameworks.

 

Way forward:

The known and proven solutions

  • The majority of stillbirths and preterm births can be prevented by scaling up known and proven interventions and improving the quality of health services. For reducing both stillbirths and preterm births, the focus must be on:
  1. increasing access to family planning services
  2. improving antepartum services such as health and nutrition, including the intake of iron folic acid by pregnant mothers
  3. providing counselling on the importance of a healthy diet
  4. optimal nutrition
  5. identification and management of risk factors.
  • The measures to prevent, detect early and manage diseases which put mothers at high risk, such as diabetes, hypertension, obesity and infections, will also help in reducing preterm births and stillbirths. And it is possible to reduce future neurological complications for preterm babies by ensuring the Kangaroo mother care and early initiation of exclusive breastfeeding, among others.
  • Half the stillbirths happen before delivery due to antepartum causes and the remaining during delivery (intrapartum). Monitoring labour and functional referral linkages and improving the quality of health care services will prevent stillbirths.
  • However, the interventions can be best delivered if data on preterm births and stillbirths are better recorded and reported. The maternal and perinatal deaths surveillance guidelines need to be effectively implemented and the International Classification of Diseases’ definition for perinatal mortality must be adopted. The use of this classification will help standardise the causes of stillbirth reporting. Alongside, India needs to identify the hot spot clusters of stillbirths and preterm births for local and targeted interventions.
  • In mid-2022, a Delhi-based not-for-profit, the Foundation for People-Centric Health Systems, drafted a report, which was endorsed by seven other organisations and professional associations including the Federation of Obstetric and Gynecological Societies of India and the Indian Association of Preventive and Social Medicine. It underscored the need for multi-stakeholder collaboration and flagged the need for better data. It is time for all stakeholders to work together and for health policymakers to take note of these challenges and start interventions.

 

Policy solutions

  • Three weeks from now, the Union Budget will be presented in Parliament. It is likely that the government will list its achievements in the health sector. While achievements should be celebrated, it is equally important that policymakers pause to reflect on the neglected challenges. Stillbirths and preterm births are highly sensitive ‘tracer indicators’ of the quality of maternal and child health services in particular, and overall health services in general.
  • In the National Health Policy of 2017, the government had committed to investing 2.5% of the GDP on health by 2025. Six years since then, the government’s allocation for health has increased only marginally. Even by the best estimate, it is around 1.5% of the GDP. The Indian government’s investment on health is among the lowest in the world. Yet, there does not seem any urgency on its part to increase funding for health.

 

Conclusion:

The two recent reports are reminders that it is time for the government to allocate more funds for health, starting with the upcoming Budget.

Editorial 2 : Lessons from Russia’s Ukraine war

Introduction:

Russia is “a riddle, wrapped in a mystery, inside an enigma”, said Winston Churchill in 1939, referring to the West’s muddled understanding of Joseph Stalin’s Soviet Union. These words still ring true as the world, 10 months into Russia’s invasion of Ukraine, tries to understand President Vladimir Putin’s real intentions for going to war.

 

Putin’s dilemma:

  • Before the war, Mr. Putin had created an aura of power around himself and Russia. He disrupted Georgia’s ambition to join the North Atlantic Treaty Organization (NATO); made forays into West Asia neutralising Israel and Turkey, both American allies; took Crimea without a fight; and turned Russia again into an energy superpower. But that aura has slipped as Russia’s superior troops have been struggling to cope with battlefield setbacks in Ukraine.
  • There is still a lack of clarity and uncertainty on Russia’s objectives in Ukraine and what it will do next to meet them. Despite tactical setbacks, Russia continues to fight with one hand tied behind its back. When Russian troops were retreating, Mr. Putin went ahead with the annexation of four Ukrainian regions, which practically closed off the path towards talks. He then offered talks even as his missiles kept pounding Ukrainian infrastructure.
  • While it would take time to comprehend the different layers of the conflict which is still unfolding before us, the war itself offers some key lessons to understand contemporary geopolitics. It marks, to use Churchill’s phrase, “the end of the beginning” of unilateralism, while also reminding great powers of the pitfalls of long wars.

 

A new world

  • After the disintegration of the Soviet Union in 1991, the U.S. had established a de facto unilateral hierarchy, which is rare in international relations; global politics has historically been dominated by multiple pillars. But the U.S. was at the pinnacle of its power in the 1990s. In recent years, however, there have been signs of the passing of American unilateralism. America’s wars in the Muslim world did not proceed as Washington had expected.
  • As the U.S. got stuck in Afghanistan and Iraq, Russia became more aggressive, Iran more defiant, and China more powerful. If Russia’s intervention in Georgia and its annexation of Crimea; Iran’s growing militancy in West Asia; and America’s defeat in Afghanistan were some signs of a shift in the global order, the Ukraine war, the largest land war in Europe since the end of World War II, was its sharpest manifestation.
  • Irrespective of Russia’s performance in the war, Mr. Putin’s decision to send troops to a NATO ally challenging the post-Soviet security architecture of Europe would go down in history as one of the pivotal moments of 21st century geopolitics. After a brief period of unilateral hierarchy, the world is returning to, what Realists call, its essential anarchy in which great powers compete for maximising their powers. But it is not clear what kind of an order, if an order emerges at all, will replace American unilateralism.
  • The U.S. seems to have realised that the world has changed. Its response to Russia’s aggression in Ukraine is a leaf from its Cold War play book. It has taken pains to keep the Western alliance together. It wants a coalition of democracies against dictatorships. It admits that the ‘rules-based order’ (translation: American-centric world) faces systemic challenges from Russia and China. But at the same time, it doesn’t want a direct conflict with Russia. It seeks to bleed Russia out in Ukraine, an approach that U.S. President Ronald Reagan had towards the Soviet Union in Afghanistan.

 

Limits of power

  • The Ukraine war also tells us about the limitations of great powers in shaping the outcome of conflicts with smaller ones. The U.S. intervention in Vietnam, its invasion of Afghanistan, and the Soviet intervention in Afghanistan are some of the best examples of great powers getting stuck in smaller theatres. But historical examples do not deter offensive nations.
  • When Mr. Putin ordered his special military operation, it is possible that he expected quick results. But he miscalculated the power of Ukrainian nationalism and the resolve of the West, which he thought was weakened by internal divisions and external setbacks such as the humiliating retreat from Afghanistan, in resisting the Russians.
  • What Ukraine had to do was to survive the initial Russian thrust. When that was achieved, it opened avenues for Russia’s rivals in the West to start supplying Ukraine with money, weapons including advanced rocket systems and artillery, intelligence and mercenaries.
  • If the war was left to Russia and Ukraine, the former would have, in theory, secured a victory. Despite initial miscalculations, the Russians made incremental gains in the early months of the war. But what changed the ground reality was Western help to Ukraine.
  • Once Ukraine established a counteroffensive momentum, the West’s engagement further deepened. It is now ready to send Patriot missile defence systems and armoured vehicles, which will bolster Ukraine’s defences and better prepare it for land battles post-winter.
  • This puts Mr. Putin in a spot. What started off as a minor conflict in eastern Ukraine in 2014 has now snowballed into a de facto war between Russia and the collective West within the borders of Ukraine. His limited war machine is under enormous pressure, but he can’t retreat unless he is ready to accept political and geopolitical costs. This is a dangerous slope.

 

China’s takeaway

  • What does the war hold for China, the dragon in the room? There were enhanced tensions between China and the U.S. over Taiwan last year. U.S. President Joe Biden has repeatedly said that the U.S. would defend Taiwan in the event of an attack from China. This signalled a shift in Washington’s policy of ‘strategic ambiguity’.
  • When former U.S. House Speaker Nancy Pelosi visited Taiwan, China responded with live military drills around and across the self-ruled island. One argument in American strategic circles is that defeating Russia in Ukraine would discourage Chinese President Xi Jinping from making any adventurous move towards Taiwan. If Russia gets away with Ukraine, that would embolden Mr. Xi, they argue.
  • But on the other side, the Ukraine war and the West’s collective pursuit to punish Russia has driven the giant bear deeper into the embrace of the Chinese dragon. If, during the Cold War, the U.S. strove to exploit the divisions between the Soviet Union and China (to prevent the formation of a strong Eurasian alliance), China and Russia, under Mr. Xi and Mr. Putin, respectively, are boasting of their ‘no limits’ relationship today.
  • Also, one of the reasons for the U.S. pivot from West Asia and Afghanistan was to focus its resources on tackling the rise of China, the only revisionist power with the capabilities to challenge the ‘rules-based order’. But the U.S. last year got dragged more and more into Europe in a Cold War-type entanglement and spent enormous resources on Ukraine.
  • China would like to see the U.S. being distracted in Europe while it strengthens its ties with Russia and spreads its influence elsewhere. The question that could come back to bite the U.S. in the near term would be whether the time, resources and energy it is spending on Ukraine (to weaken Russia) is worth it in a changing world where China is its most powerful rival.

 

Conclusion:

India has to brace itself for a rapidly changing world order. Its newfound policies of multi-alignment and strategic autonomy may now be more relevant than the earlier stances of non-alignment.