Topic 1: The rising incidence of paediatric inflammatory bowel disease in India
Context
Patients and doctors often struggle to diagnose IBD and it is often mistaken for tuberculosis.
Inflammatory bowel disease (IBD)
- IBD is a chronic autoimmune condition where the white blood cells or the body’s soldiers mistakenly identify cells in the human gut as their enemy and decide to attack it, causing ulcers in the mucosa.
- As a result children may develop fever, abdominal pain, loose stools and at times bloody diarrhoea.
- These children may not absorb macro and micronutrients and hence lose weight, muscle mass, become anaemic and may have vitamin deficiencies.
- There are two types of IBD — Ulcerative colitis which affects only the large bowel and Crohn’s disease which can affect any part of the gut from mouth to anus.
- Sometimes when we find it difficult to distinguish between these two conditions, we label it Indeterminate Colitis for a while until it evolves into one of the above conditions.
The possible reasons for IBD
- IBD can affect children of all ethnicities and socioeconomic status. Medical research is still ongoing to pinpoint the exact cause.
- What is known is that children who are susceptible to IBD often have a weak or dysregulated immune system which responds inappropriately to environmental triggers such as a virus or bacteria.
- There may also be genetic factors which predispose these children to IBD as sometimes it seems to affect members of the same family.
- The human gastrointestinal tract harbours millions of microorganisms; often referred to as gut microbiota and this plays an important role in IBD.
- The gut microbiota of each individual is unique and influences health and disease.
- The nature and composition of gut microbiota can be altered by frequent antibiotics.
- Similarly, westernisation of food habits and lifestyle is also strongly linked to changes in the gut microbiota and a predisposition to develop IBD.
The treatment and cure
- IBD - Crohn’s disease can be treated with very effective medications that control the inflammation and suppress the dysregulated and overactive immune system.
- These medications include steroids and a new class of drugs called biologics.
- But it is also possible to control the inflammation in the gut and heal ulcers in some children with the milder variety of Crohn’ disease; without drugs using ‘exclusive enteral nutrition’.
- Once the inflammation or acute flare up of the disease is under control, doctors aim to keep the disease under control (remission) for several years using milder immunosuppressant drugs and a special Crohn’s disease exclusion diet (CDED).
- IBD – Ulcerative colitis is also treated similarly, though another group of drugs called ‘aminosalicylates’ are used to treat milder forms of Ulcerative colitis.
- Exclusive Enteral Nutrition has not been found to be useful in treating Ulcerative Colitis.
- Both forms of IBD are often chronic and need several years of medical therapy.
- A small minority of children who have remained in very good control (remission) for several years continue to do well even after stopping medications.
- The larger majority of children seem to need medications to keep the disease in remission.
- Further a small proportion of children who have uncontrolled inflammation develop complications needing surgery.
Conclusion
- IBD has protean clinical manifestations ranging from a simple anaemia and failure to gain weight to fever, abdominal pain and loose stools that is why it is often mistaken with tuberculosis. .
- There is hence a need for increased awareness of this condition, both among the general public and medical community.
Topic 2: The tobacco epidemic in India
Context
Tobacco causes a wide range of diseases and affects those consuming it as well as those cultivating it. There is a need for up-to-date data to understand trends in tobacco use to tackle the tobacco industry.
Tobacco
- Tobacco is the most widely recognised preventable cause of disease and death in the world.
- After China, India has the world’s highest number of tobacco consumers — nearly 26 crore, according to an estimate in 2016-2017.
- Additionally, the health of more than 60 lakh people employed in the tobacco industry is also placed at risk because of the absorption of tobacco through the skin, which can cause various diseases.
- Tobacco’s deleterious influence extends beyond human health. It is a highly erosive crop that rapidly depletes soil nutrients.
- This requires more fertilizers to be used which further worsens soil quality.
- The plant is also a major contributor to deforestation. Up to 5.4 kg of wood is required to process 1 kg of tobacco.
- The production and consumption of tobacco generates nearly 1.7 lakh tonnes of waste every year in India. Therefore, tobacco production and use impose a heavy economic burden on India.
The status of tobacco use in India
- The Global Adult Tobacco Survey (GATS), the Global Youth Tobacco Survey (GYTS), and India’s National Family Health Survey (NFHS) capture the status of tobacco use in India.
- GYTS assesses tobacco use in students between the ages of 13 and 15 years and GATS and NFHS in people above 15 years of age.
- Overall, the results of these surveys have been promising: tobacco use has gone down in the population groups studied by these surveys.
- An exception to this is tobacco use in women, which went up by 2.1% between 2015-2016 and NFHS 2019-2021. This said, a major caveat is that no survey has been conducted since the COVID-19 pandemic.
Awareness and control programmes
- India is one of the 168 signatories of the WHO’s Framework Convention on Tobacco Control (FCTC), launched in 2005.
- It aims to reduce tobacco usage worldwide by helping countries develop demand and supply reduction strategies.
- A law to govern tobacco sales in India has existed since 1975 and was amended in 2003.
- The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA) 2003 has 33 sections governing the production, advertisement, distribution, and consumption of tobacco.
- India also launched the National Tobacco Control Program (NTCP) in 2007. NTCP is designed to improve the implementation of COTPA and FCTC, improve awareness about the harms of tobacco use, and help people quit it.
- Apart from these interventions, tobacco taxation — a globally accepted method to effectively control tobacco use — is also applied in India.
- However, existing measures are poorly implemented. Smokeless tobacco products (SLTs) have predominantly been non-compliant with COTPA packaging guidelines.
- Smuggled tobacco products — both smoked and smokeless forms — have also been badly regulated.
- Further, while the COTPA bans direct advertisements, the position on indirect advertisements is unclear, which has allowed surrogate advertisements: they popularise the brand using a proxy product like elaichi, to promote tobacco manufactured by the same brand.
- The ICC Men’s Cricket World Cup 2023 displayed surrogate advertisements for at least two tobacco brands, which were endorsed by famous cricketers. These advertisements are problematic as they indirectly promote tobacco use.
Becoming more affordable
- The Indian government’s efforts to levy excise duty on tobacco have also been marred by tax evasion, such as by purchasing tobacco products in lower tax jurisdictions, and illegal methods such as smuggling, illicit manufacturing, and counterfeiting.
- Low tobacco taxes in India, which have not matched the rise in people’s income, have kept tobacco affordable over the years.
- A 2021 study in BMJ Tobacco Control reported that cigarettes, bidis, and SLTs had become more affordable in the preceding 10 years, and that transitioning to the Goods and Services Tax regime had rendered cigarettes and SLTs more affordable.
Tax measures and lobbying
- The tobacco lobby often argues that high taxes on tobacco lead to tax evasion. However, non-tax factors are equally, if not more, important.
- These factors include weak governance, high levels of corruption, poor government commitment to tackling illicit tobacco, ineffective customs and tax administration, and informal distribution channels for tobacco products.
- Effective lobbying has led to the exemption of cess on bidis and smaller tobacco manufacturers to be continuously extended.
- It is public knowledge that government officials, both in-service and retired, engage with the tobacco industry.
- Moreover, the Central government holds a 7.8% stake in ITC Ltd., India’s largest tobacco company. India’s score on the tobacco interference index — which calculates the degree of interference by the tobacco industry in governance — has also worsened since 2021.
Way forward
- COTPA, PECA, and NTCP provide a strong framework to successfully control tobacco production and use in India. But they need to be implemented more stringently.
- In addition, the tax on tobacco products also needs to be increased in line with the recommendations of the FCTC, inflation, and GDP growth.
- With government support, it is also possible to help tobacco farmers switch to farming alternate crops, avoiding loss of livelihood.
- In fact, for large-scale tobacco farmers, the net return per rupee of investment in jowar cultivation (1.84) is higher than tobacco (1.48).
- There is also a need for up-to-date data to understand trends in tobacco use to tackle the tobacco industry, which modifies its sales strategies based on readily available sales trends.