Millions of people use a wearable health and fitness tracker. These devices can be useful for monitoring activity levels, sleep quality and heart rate. But for some, wearables can have unintended consequences on wellbeing.

This is something I encountered recently. At a public talk, I got to chatting with a man who told me a story that stayed with me.

He’d just finished a long hike and felt great. Then he glanced at his smartwatch. Heart rate: 130 bpm. Instant panic.

About 30 minutes later he realised the cause: the altitude. Yet in that moment, he’d gone from feeling perfectly fine to feeling awful – all because of the smartwatch’s reading.

This man isn’t alone. Some users have found their wearable increased anxiety so much they needed to stop wearing it.

A key reason wearable health devices may increase anxiety for some people comes down to a mismatch in expectation and what the device says.

Our brain is a prediction machine. It continuously, automatically generates and updates a mental model of our environment by comparing its predictions to the sensory information it receives.

Processing every sensory input from scratch would be slow and inefficient. By predicting what it expects to encounter, the brain can interpret noisy sensory information quickly and usually accurately.

Some examples of this happening include feeling your phone vibrate when you’re expecting an important message – only to discover it never rang at all. Or being abel ot raed tihs snetnece despite the typos, because your brain predicts what should be there.

The same principle applies to our bodily states. Our brains don’t simply read bodily states, they predict them.

We move through the day with an internal model of what our body “should” be doing: roughly what our pulse, temperature and breathing typically feels like when we’re calm, active or nervous.

When sensory information arrives that doesn’t match those expectations – such as having a higher heart rate – the brain generates a “prediction error”. This alerts us that the sensory information does not meet our expectations.

Most prediction errors are trivial and simply a mismatch between expectation and incoming information. The brain often resolves these errors automatically by updating its model and adjusting its predictions.

Since this process usually happens automatically, we typically don’t notice it. But if it does reach the level of our conscious awareness, we may search for an explanation for why our expectations and experience differ.

So if your heart rate feels faster than expected, you may link this to the fact that you drank too much coffee. Because we expect our bodily sensations to vary throughout the day, such explanations may be enough to prevent us becoming concerned by the prediction error.

The same thing can happen when we get a wearable reading that goes against expectation. However, because smartwatch readings appear clear and objective, we may place greater weight on them and may not dismiss an unexpected reading as readily. Even if you feel perfectly fine, seeing an elevated heart rate on your smartwatch may make you think something is wrong and kick off a cycle of worry.

My research suggests this may particularly be a concern in people prone to anxiety, who already tend to pay close attention to their internal bodily signals.

Research my colleagues and I conducted during Covid also found the more anxious a person was generally, the more likely they were to monitor their bodily states through objective measures (such as taking their temperature).

This behaviour in people with anxiety is unsurprising. Hypervigilance towards the body can feel protective, a way to spot problems early and reduce uncertainty. But it can quickly lead to a cycle of worry and seeking reassurance.

When such safety-seeking behaviour is reduced through therapy, anxiety symptoms tend to ease – at least partly because people are less hyper-focused on their bodies.

Yet the relationship can go both ways. In that same Covid study, we found a bi-directional link between anxiety and attention to bodily signals. Paying more attention to bodily states increased anxiety, and anxiety increased attention to bodily states – a negative loop.

Emerging research hints that wearable devices might amplify that loop. In a study on people with atrial fibrillation, heart rate trackers were linked to more frequent symptom-checking and higher anxiety.

A larger study, involving a random sample of around 500 smartwatch users, found a similar pattern. People reported feeling anxious when their physiological data looked abnormal. Some participants even reported feeling dependent on their health tracker, and become frustrated when they couldn’t wear their device or forgot to. Some recognised the effect and considered giving the device up altogether.

However, wearables don’t appear to have the same effect on everyone. For some, this information can be reassuring and may even reduce anxiety.

Critically, we don’t know why for some wearables provide reassurance, and for others they increase anxiety.

Avoiding health anxiety

There are many reasons people may wish to use wearables. Often, it’s because this health information can be useful – such as alerting us to issues we may otherwise miss. But monitoring the body in this way can also sometimes make us feel worse.

Taken together, the current evidence suggests this effect may be especially pronounced in people prone to anxiety, as well as in conditions where hyper-monitoring the body or behaviour can be maladaptive – such as eating disorders.

As with many things in life, it’s all about moderation. If you find yourself worrying about your data more than your wellbeing, try an experiment: leave the watch off for a day or hide the data so you’re not receiving constant feedback about your body.

Notice how your body feels without the tracking. You might discover what that hiker did: that sometimes trusting what you feel is better.

Jennifer Murphy is Associate Professor in Psychology, University of Surrey.

This article was first published on The Conversation.

The Union government on Tuesday notified an amendment to the 1945 Drugs Rules to ban the over-the-counter sale of all syrups, including those consumed to treat cough. The purchase of syrups will require a doctor’s prescription.

The Ministry of Health and Family Welfare notified an amendment that removed the word “syrup” from the list of items exempted under 1940 Drugs and Cosmetics Act. The rules had earlier exempted syrups, lozenges, pills and tablets for cough.

With the amendment, the sale of cough syrups in villages with a population of less than 1,000 will be required to take place only through licensed pharmacies. The rules had earlier permitted the sale of cough syrups in smaller villages without requiring compliance with some retail sale licensing provisions.

Pills, tablets and lozenges for cough would continue to be available without a prescription.

The change had been made to “strengthen regulatory oversight of syrup formulations” and to align the exemptions with public health and safety requirements, the ministry said.

“The measure is expected to promote responsible distribution and sale of cough syrups while ensuring greater compliance with regulatory standards across the country,” it added.

The rules have been amended following a series of cases of contaminated cough syrups leading to deaths of children.

Starting September, deaths had been reported in Madhya Pradesh and Rajasthan. Several children, who had been suffering from fever and cold, consumed the Coldrif syrup, resulting in vomiting and difficulty urinating.

In February, Reuters quoted Drugs Controller General of India Rajeev Raghuvanshi as having said that the Central Drugs Standard Control Organisation had inspected about 90% of the manufacturers of cough syrup in the country and found compliance lapses.

Written by Nachiket Deuskar. Edited by Tanya Shrivastava.

When work gets stressful, the standard advice is familiar: exercise more, eat better, sleep more and cut back on unhealthy habits. But our new research study suggests not all healthy habits offer the same protection from chronic work stress.

Using data over 10 years from a long-running national survey of 2,871 Canadian workers, we examined whether five health-related behaviours outside work helped weaken the relationship between work stress and general health over time: nutrition, exercise, sleep quality, alcohol use and smoking frequency.

What we found was more uneven – and more interesting – than the usual wellness advice suggests. Some behaviours appeared to offer real stress-specific protection. Others were linked to health overall, but did not seem to buffer the effects of work stress specifically.

Some habits protect; others don’t

Sleep quality stood out most clearly. Nutrition also mattered. Exercise remained good for health overall, but did not buffer the health effects of work stress in the same way once the other behaviours were considered together.

For many workers, work stress is chronic. It builds through heavy workloads, difficult or unpredictable schedules, after-hours emails and text messages, and the feeling that work keeps spilling into evenings, weekends and family time.

Over time, that kind of stress can wear people down physically and psychologically. Research has linked work stress to burnout, depression, anxiety, fatigue, cardiovascular disease, Type 2 diabetes and mortality.

Our study asked: when stressful work conditions persist, are there things people do outside work that actually help protect their health? Our findings suggest the answer is yes, but selectively.

Sleep may matter more than people think

Sleep quality stood out as the strongest buffer against the health costs of work stress. Good sleep supports attention, emotional regulation, recovery and the self-control needed to maintain other healthy behaviours in the first place. In that sense, it functions less like one good choice among many and more like a foundational resource.

Nutrition also showed a meaningful buffering effect, suggesting that diet may help sustain the physical and psychological reserves needed to cope with sustained strain.

The exercise finding pushed against popular assumptions. While more frequent exercise was associated with better general health overall, it did not significantly weaken the relationship between work stress and health. This could reflect the way exercise was measured in the survey, or it could mean exercise helps health in ways that are real but not specifically stress-buffering.

Being healthy and being protected from stress are not always the same thing.

The alcohol finding was the most unexpected and warrants particular caution. Lower alcohol use was associated with better overall health, as expected. But the data showed that higher work stress was more strongly associated with poorer general health among people who reported lower alcohol use than among those who reported drinking more frequently.

This should not be read as evidence that drinking protects people from the health effects of work stress, however. People who drank more frequently still reported worse overall health. More likely, this pattern reflects something our data could not fully unpack, such as prior health conditions, different coping profiles or non-linear patterns in alcohol use and health.

Healthy habits don’t excuse unhealthy work design

When work is chronically stressful, some forms of self-care may protect health more than others. Most importantly, wellness interventions cannot compensate for a job that is structured to exhaust people.

Organisations are still responsible for designing healthy workplaces. Employees should not be expected to sleep or meal-prep their way out of excessive workload, unreasonable expectations or poor work design.

What our findings suggest is not that individual behaviour replaces organisational responsibility. Rather, certain behaviours may help protect people when work remains stressful and structural change is absent, incomplete or slow to arrive.

Our study is explicit that these behaviours should be understood as complementary to, but not substitutes for, broader organisational change.

That has practical implications for both workers and employers. For workers, the message is not to do everything perfectly. It’s that some behaviours may offer more protection than others when work stress is high, and sleep deserves to be taken especially seriously.

For employers, the lesson is not to moralise wellness or shift responsibility onto individuals. It’s to make protective behaviours easier to sustain by reducing after-hours communication, allowing real on-the-job breaks, improving scheduling and designing work in ways that do not erode recovery.

Nick Turner is Professor and Future Fund Chair in Leadership, Haskayne School of Business, University of Calgary.

A Wren Montgomery is Assistant Professor of Sustainability & General Management, Western University.

Erica Carleton is Associate Professor of Leadership, Hill and Levene Schools of Business, University of Regina.

Serra Al-Katib is MSc Student in Organization Studies, Levene School of Business, University of Regina, University of Regina.

This article was first published on The Conversation.

The latest Ebola outbreak is showing no signs of slowing.

On April 24, the first suspected case of the rare Bundibugyo strain of Ebola was detected in the Democratic Republic of the Congo. On May 17, the World Health Organisation declared the outbreak a “Public Health Emergency of International Concern”.

The current Ebola outbreak is the third-largest in world history, with 906 suspected cases and 223 deaths in the DRC alone as of May 27.

And it may have spread to other continents. Health authorities are now investigating a suspected case in Italy, and two possible cases in Brazil. All three are believed to be travellers returning from either the DRC or Uganda. One American man who tested positive for Ebola is currently being treated in Germany.

As concerns grow, the Coalition for Epidemic Preparedness Innovations has committed more than A$86 million in funding to fast-track the development of three potential vaccines, targeting the Bundibugyo strain.

But in the meantime, could this outbreak spread further? And how concerned should we be?

A deadly virus

Ebola is a rare but potentially fatal virus that mainly spreads through direct contact with the bodily fluids – such as blood, faeces and vomit – of an infected person.

Early symptoms of Ebola include sore throat, headaches, fever, fatigue and body pain. Severe Ebola cases can cause skin rashes, shortness of breath, vomiting, diarrhoea, abdominal pain and seizures.

Ebola was first identified in humans in 1976. Since then, there have been more than 40 outbreaks around the world, with the majority occurring in African countries.

The current outbreak is the third ever to be caused by the rare Bundibugyo strain. The majority of past outbreaks were driven by the more deadly Zaire strain, which kills up to 90% of people compared to up to 34% for Bundibugyo.

What is driving this latest outbreak?

The factors driving this latest outbreak also contributed to the devastating West African outbreak of 2014-’16, where more than 11,000 people died.

In both outbreaks, the virus had been circulating for months before an outbreak was declared, and initial cases had non-specific symptoms.

Both outbreaks also rapidly spread in urban areas. Transmission in health-care settings is another common factor.

Political instability and social unrest also contributed to both outbreaks. Most recently in the DRC, crowds have set fire to hospital tents, prompting some patients to flee isolation wards.

And certain cultural practices – including traditional burial rituals that often involve handling dead bodies – may have accelerated the spread of both outbreaks.

How it crossed continents

Similar to the West African outbreak, this latest Ebola outbreak has spread to other continents through travel.

Nine cases and one death have already been reported in Uganda, which shares a border with the DRC.

An American man who tested positive for Ebola while working in the DRC, is in a stable condition after being treated in Germany.

In Italy, authorities are monitoring a traveller who recently returned from the DRC to the city of Cagliari.

According to some reports, Brazilian authorities are investigating two suspected Ebola cases. They are believed to be two travellers, one who returned from the DRC to São Paulo and the other from Uganda to Rio de Janeiro.

Importantly, both suspected cases have been diagnosed with other illnesses. The São Paulo patient presented with fever and was later diagnosed with severe meningitis. The Rio de Janeiro patient tested positive for malaria after developing a cough, chills and diarrhoea, but has since tested negative for Ebola.

So for now, no Ebola cases have been confirmed in Brazil. But these suspected cases have prompted the country to activate its Ebola safety protocols, including patient isolation, laboratory testing, and epidemiological investigations.

Meanwhile, several countries have imposed travel restrictions to prevent Ebola from reaching their shores.

Both the United States and Canada are temporarily restricting entry for travellers from the DRC, Uganda and South Sudan. The US and other countries such as India and Mexico are also strengthening public health screening and disease monitoring measures, particularly at airports. Some countries have mandated a 21-day quarantine period for their citizens returning from the DRC.

Could it spread further, including to Australia?

At this stage, the risk of Ebola reaching Australia is very low.

Australia has not put in place any travel or quarantine requirements for affected countries, but federal health minister Mark Butler says authorities are still monitoring the outbreak “very closely”.

Based on lessons from past outbreaks, there are three main ways the current Central African outbreak could play out.

Without effective control measures, cases may surge in the coming months. Some models suggest that by mid-May, up to 1,000 cases had already occurred in the DRC, compared to official figures of about 900 cases. So the actual number of Ebola cases may be much higher than authorities realise.

In a more favorable scenario, a strengthened public health response could bring this latest outbreak under control. This would be possible with continued support from the international community, the rapid development of vaccines and community engagement.

However, the most realistic outcome is cases will continue to rise before authorities successfully contain the current outbreak.

Nevertheless, the international community responded much more swiftly to this outbreak, particularly compared to the devastating 2014-’16 West African outbreak. That alone may protect us from an outbreak of the same catastrophic scale and cost.

Abrar Ahmad Chughtai is Senior Lecturer, Infectious Diseases Epidemiology and Control, UNSW Sydney.

Holly Seale is Professor, School of Population Health, UNSW Sydney.

Md Saiful Islam is Lecturer, UNSW Sydney.

This article was first published on The Conversation.

For decades, people have been told that their weight problems can be solved by math: Calories in, calories out. If weight were a simple math equation, more people would likely be the weight they desire. But it is much more complicated.

There are several theories as to why it is difficult to lose weight. Some focus on genetics and metabolism while others claim environmental and social factors are more important. But which of these theories is correct, if any? Are people destined to be the weight their genetics, metabolism or environment dictate?

I am a diabetologist and physician specialiding in obesity medicine. Understanding what’s known and uncertain about these theories can help you potentially overcome your own biology to change your weight.

Set point weight

The concept of set point weight has been around since the 1950s. It suggests that the body has a regulatory system that defends a predetermined level of adipose tissue – commonly called fat – it maintains by changing hunger cues and energy expenditure. That predetermined fat level is governed by genetics, physiology and environmental factors.

This idea is supported by observations that after weight loss, appetite is increased and energy expenditure decreased until weight is restored. In theory, this process prevents the body from starving, even with significant weight loss. One study found that hormones that cause hunger remain elevated and hormones that promote fullness are suppressed for at least 62 weeks after weight loss, and even after regaining weight.

A related concept called metabolic adaptation seems to influence energy balance, although the evidence for this effect in people is less clear. This process refers to a reduction in energy expenditure beyond what is predicted by changes in body composition. In other words, as you lose weight, you burn fewer calories than expected for someone at that same weight who has not undergone recent weight loss.

Metabolic adaptation manifests as an increase in appetite and a decrease in resting metabolic rate, which is the energy you burn to sustain background processes such as heartbeat, temperature regulation, respiration and digestion, even if you lie in bed all day. In metabolic adaptation, resting metabolic rate decreases after approximately 5% weight loss. The energy burned from exercise decreases after around 10% weight loss.

This means that as a person loses weight, the amount of energy used for the background processes to stay alive decreases. Furthermore, a person must increase exercise as they lose weight to see continued weight loss. So the more weight a person loses, the harder it is to lose more.

This decrease in energy expenditure may persist for years after weight loss, as was seen in a study of participants in the TV show “The Biggest Loser”. However, some studies have found metabolic adaptation to not be as significant as once thought.

There are several strategies to overcome set point weight and the metabolic adaptation expected with weight loss. Bariatric surgery – a procedure for weight loss – appears to alter set point weight, reducing hunger without decreasing energy expenditure and patients rarely become underweight. GLP-1 and similar medications may not affect metabolic adaptation while reducing weight. Nutritional strategies include increased protein intake, decreasing glycemic load and increasing high-fiber foods, although evidence for the effectiveness of these tactics varies.

Set point suggests your body has one set weight it likes to stick at and will adjust your metabolism and appetite in order to move you toward and keep you at it.

Settling point model

An alternative theory to set point weight is called settling point. This model proposes that weight regulation occurs through passive feedback without biological control. Rather than the body actively controlling weight through changes in hormones, this theory suggests that body weight is a result of your habits and surroundings.

The settling point is defined as where body weight stabilises because energy intake equals energy expenditure. This is determined by the physical and metabolic costs of maintaining body mass. People with more body mass expend more energy due to the increased energy needed to move and maintain a larger body. Therefore, people living in a larger body would have larger food intake needs.

Settling point may sound like the old “calories in, calories out” model, but it also considers environmental and societal influences. Think of it as an open window. The room may warm from the sunlight during the day, then cool down overnight. Over time, the room will tend to hover around the same temperature. The temperature isn’t fixed but will naturally settle based on the weather, insulation and airflow. It may be colder in the winter and warmer in the summer.

Now let’s apply this concept to a person. If you have a job where you are on your feet all day and eat home-cooked foods most of the time, your weight might be stable. If you switch to a desk job and start eating more calorie-dense foods and larger portions, your weight may increase until it becomes stable again. In both scenarios, your weight eventually stabilises at different settling points based on your current set of circumstances.

However, the settling points theory fails to explain biological and genetic aspects of weight.

Dual intervention point model

The dual intervention point model integrates both set point weight and settling point. This theory proposes an upper and lower threshold that define the boundaries of each person’s “acceptable” body weight, called the zone of indifference. The lower threshold is the point where starvation is prevented while maintaining all biological and metabolic needs.

Within the zone of indifference, settling point concepts prevail: The body will adapt to energy and environment. But when body weight falls below the lower threshold, it triggers physiological mechanisms to defend against further weight loss and prevent starvation. The body’s hormonal systems increase appetite and reduce energy expenditure.

When body weight rises above the upper threshold, biological mechanisms should theoretically engage to prevent further weight gain. Researchers have documented this process in numerous studies in animals, hypothesising that this is most likely due to the increased risk of predation from weight gain. Animals with more fat are targeted or can’t get away from predators. However, this process isn’t always seen in people and there is weaker evidence supporting it.

The dual intervention point model also suggests that the zone of indifference varies widely between individuals. This would account for why some people maintain a relatively stable weight and others have greater variation over time. Some may recognise this as the old struggle of “losing the same 10 pounds over and over again”.

Additionally, the drifty gene hypothesis proposes that the upper threshold for the body to intervene has gradually drifted upward as people moved into safer, more stable environments. The evolutionary pressure to maintain a lean physique for survival, such as avoiding predators like a hungry lion, has largely disappeared.

Which theory holds the most weight?

So which theory of body weight regulation is correct? The answer is none of them fits real world experiences exactly. But there seems be to a difference between how your metabolism responds to active weight loss compared to weight maintenance, so how to approach each goal may be different.

Decreasing food intake seems to be the most beneficial for attaining weight loss. Conversely, exercise seems to be key for weight maintenance.

Overall, the big takeaway is that weight balance is complex. It isn’t a simple math problem to solve. Adequate medical care for overweight and obesity encompasses nutrition, exercise, sleep, stress and other factors that influence weight. Changes in these factors can be combined with medication or surgery to achieve a sustained reduction in weight.

Weight loss is often not linear, and plateaus are expected. Each case is individual, and one size – or theory – does not fit all.

Kim Pfotenhauer is Assistant Dean for Clerkship Education and Assistant Professor of Osteopathic Medicine, Michigan State University.

This article was first published on The Conversation.

For the last two weeks, Jaskirat Singh, a government school teacher in Punjab, has been going to a nearby village every afternoon after work.

The teacher from Amritsar knocks on doors, asking people hundreds of questions. “On average, I tick off eight households from my list every day,” Singh, who is in his 50s, told Scroll. “Then I return home exhausted around sunset,”

Singh is one of 28,000 government employees deputed by the Punjab government to conduct the state’s first ever Drug and Socio-Economic Survey – an exercise meant to quantify drug addiction in the border state and assess the socio-economic and educational background of those dependent on drugs.

Chief Minister Bhagwant Mann, while announcing the survey in April, had said that the aim was to “understand the drug problem and then make targeted policies which will have better outcomes”.

But, on the ground, enumerators like Singh are running into hurdles.

In the last 15 days, the government school teacher in Amritsar has surveyed 120 households. “Only two or three families conceded that some of their family members were into drugs,” he said.

The survey’s format makes the majority of respondents evade questions related to drugs, Singh said. “Which mother will reveal to a stranger that her son or daughter is into drugs?” he asked. The teacher requested that his real name not be disclosed, because he feared government action for speaking to the media.

Difficult to admit

Weeks after it began, the “drug census” of 65 lakh households has spawned more questions than answers. Opposition parties have called it a “pre-poll exercise” by the ruling Aam Aadmi Party to gauge voter sentiment in the final year of its term.

Most strikingly, experts have warned that the survey, carried out through a mobile app, might throw up a distorted picture.

“It’s likely that the survey will come up with a positive figure like 80% of Punjab is free from drugs,” said Mohan Sharma, an anti-drug activist and former project director of the Red Cross drug de-addiction centre in Sangrur district. “[In that case], the results will go in favour of the government.”

Before the state-wide census, the Punjab government had carried out a pilot study across 11 villages of the state, according to a report in The Tribune. That study, the government said, had established that local residents were forthcoming on information about drug addiction.

Enumerators say they have not encountered such frankness.

In contrast, most people not only dodge questions about family members using drugs, but even those related to availability of drugs in the neighbourhood.

Singh explained: “The survey asks if drugs are available in the neighbourhood. If a respondent says yes, then the app throws up a new bunch of questions like: Where are the drugs available? Who is selling those drugs?”

He said that residents “tend to avoid answering these questions in the affirmative because it leads to many other questions that they are not comfortable answering”.

Mohan Sharma, the veteran anti-drug campaigner who has been creating awareness about drug abuse for over two decades, said he was not surprised.

Over the years, Sharma and his team members have held hundreds of awareness programmes in villages. But to gain the residents’ confidence remains difficult.

“Every time, I ask those who have become addicted to come forward,” he said. “Despite promising them free treatment and counselling, hardly anyone does.”

Many families have pragmatic reasons to deny that their family members are addicted to drugs – or even that they died of an overdose, Sharma said.

“They would rather pass it off as a cardiac arrest because they have an unmarried girl at home,” he said. “If they say that their family member died of a drug overdose, nobody will want to marry her.”

Ritu Bala, assistant professor and head of Punjabi University’s department of social work, said the survey’s methodology does not align with the principles of social science research.

“You cannot ask sensitive questions straight away and then expect people to answer them easily. Nobody will give an honest answer,” Bala said. “In social sciences, this type of research is always done after framing a proper research methodology. One of the key elements of this type of research entails having a strong rapport between the enumerator and the respondent.”

Fails to address gaps

Several studies have been carried out in the past to assess the extent of drug abuse in Punjab.

A 2015 study by All India Institute of Medical Sciences and the Ministry of Social Justice and Empowerment had estimated that over 2.3 lakh individuals in Punjab were opioid-dependent, with heroin as the most common opioid used.

In 2017, a study by Chandigarh’s premier Postgraduate Institute of Medical Education and Research had estimated that 14.7 % (29.7 lakh) of Punjab’s population was addicted to substances like alcohol, tobacco, opium, charas and heroin.

Alcohol topped the list of substances abused, with 22 lakh people being dependent on it, the survey said. Between 1.7 lakh and 2.7 lakh people were addicted to opioids.

The latest estimate is included in a 2023 report tabled by the Parliamentary Standing Committee on Social Justice and Empowerment before Lok Sabha. It put the number of opioid-dependent population in Punjab at 21.36 lakh. Of these, 3.43 lakh users were children in the age group of 10-17.

Mohan Sharma, the former director of Sangrur’s de-addiction centre, says the ongoing survey makes a mistake by not categorising alcoholism as drug abuse.

“They have left out the main substance to which people are hooked,” he said. Sharma, who has authored five books on drug abuse, said alcoholism in Punjab has wreaked havoc in the society. “My research shows that there are at least 16 widows in every Punjab village who have lost their husbands to alcohol consumption. How can they leave out alcoholism from the survey?”

Moreover, experts warned that the survey is unlikely to plug existing gaps in the data – for example, on the number of women addicts.

In 2015, a survey by Punjab’s ministry of social justice and department of health had estimated that 1% of the state’s 2.32 lakh opioid users were women. Many argue that the numbers may be much higher.

Dr Ritu Bala, the assistant professor from Punjabi University, Patiala, had little hope that the Punjab government’s survey would help reach a credible number. “Do you think a woman is in a position to come forward and confess about her addiction in a survey?” she said. “Even men shy from accepting their dependence on substances. One can just imagine how difficult it’s for a woman.”

Drug survey or political feedback?

The Punjab government has also drawn criticism for the nature of questions included in a survey ostensibly about drug abuse.

The survey includes approximately 160 questions, which take around 30-35 minutes to complete. “Many of these questions are related to the government’s schemes for the public,” said another government school teacher in Ludhiana, who asked not to be identified. “Rather than a drug survey, it looks like a political feedback survey.”

The Ludhiana teacher said the survey includes questions about every government scheme launched by the Bhagwant Mann government. “We have to ask respondents if they have benefitted from a scheme. For example, we have to record how much a household saves monthly on account of free electricity provided by the government,” he said.

In many cases, he added, the respondents are unaware of many government schemes. “In that case, we have to explain that scheme to them and inform them how they can benefit from it,” he added.

Some questions suggest that the survey’s findings may be used to devise the ruling party’s strategy ahead of the Assembly elections scheduled early next year. For example, the survey asks respondents to identify three issues which should be addressed by the government on priority.

Opposition parties in Punjab have questioned the ruling Aam Aadmi Party government’s intent in carrying out the survey.

Early in May, Congress Punjab state president Amrinder Singh Raja Warring alleged that the census was a “pre-poll” move to gather voter data at the cost of public funds.

Ravneet Singh Bittu, Bharatiya Janata Party leader from Punjab, accused AAP national convener Arvind Kejriwal of trying to damage the image of the state through the survey. “Data has become a powerful tool in today’s world,” Bittu said. “There appears to be a conspiracy to defame Punjab’s youth through these figures.”

In the 25 years I have spent watching how new health technologies travel through the global system, they have followed a predictable route. There is one tier for wealthy populations whose chronic diseases are treated with the best available medicine. The other is for everyone else: they are told to manage with whatever their underfunded health system can afford.

The latest example is a new class of injectable drugs that are better known by their brand names – Ozempic, Wegovy, and Mounjaro, or by the shorthand GLP-1, which refers to the hormone they mimic.

These drugs mimic the hormone the body produces to regulate appetite and blood sugar, resulting in significant weight loss and improved metabolic health.

They have transformed how wealthy countries treat obesity and are moving through the global system faster than most new health technologies. But the two-tier pattern is following close behind.

The intellectual property situation is changing rapidly.

The patent on semaglutide – the active molecule in Ozempic and Wegovy – has already expired in India, Brazil, China, Canada, and Turkey, covering roughly 40% of the world’s population. This means manufacturers in those countries can now produce their own versions without paying licensing fees to the original developer.

One analysis estimates the cost of producing a generic injectable version could be as little as $28 (approximately Rs 2,700) per person per year, a fraction of the $936 (approximately Rs 90,000) a month that Ozempic costs in the United States.

On paper, access for patients in low- and middle-income countries looks unusually promising. In December, the World Health Organization added GLP-1 drugs to the Essential Medicines List and published a global guideline encouraging countries to manufacture generic versions, buy collectively to reduce costs and price them on a sliding scale based on a country’s ability to pay.

Under the surface, however, there’s a different story.

Data on availability and use in low-income and middle-income countries is scarce. Only a few high-income countries are likely to afford coverage for GLP-1 receptor agonists for obesity management.

The commercial machinery for selling these drugs to wealthy markets is scaling up at a speed the public health architecture cannot match.

Eli Lilly’s Mounjaro and Zepbound generated $39.5 billion in revenue in the first nine months of 2025 alone, surpassing Merck’s cancer drug Keytruda as the world's best-selling medicine.

This illustrates how global health markets work.

One tier of the global metabolism is for populations in high-income countries whose obesity is treated as a chronic disease requiring long-term pharmacological management, reimbursed by insurance systems and employer health plans.

Another tier for the populations in low- and middle-income countries who carry the heaviest burden of obesity and metabolic disease. They are told to manage with lifestyle counselling in health systems that cannot consistently provide insulin at affordable prices.

In 2022, one in eight people globally was living with obesity, double the figure from 1990. The prevalence of the condition is associated with a low socioeconomic position globally. The people who need these drugs most are, by definition, the people least likely to receive them under current market conditions.

Access to effective treatment is inversely correlated with need.

The patent expiry changes the price equation but not the governance question. The arrival of affordable injectable semaglutide generics in 160 countries by the end of 2026 will be a genuine breakthrough – but only if the health systems receiving them have the clinical guidance infrastructure, prescribing capacity, monitoring protocols, and regulatory frameworks to deploy them safely.

A drug entering the market before supporting health infrastructure exists creates a new set of problems, as recent pharmaceutical history shows.

In rural India, for instance, a randomised controlled trial between 2002 and 2005 showed that oral misoprostol, an inexpensive drug for preventing postpartum haemorrhage, significantly reduced maternal bleeding when administered by trained auxiliary nurse-midwives.

Yet global reviews showed correct use depended critically on health workers’ training and supporting guidance. Programmes distributing the drug without sufficient training led to misuse and worsened outcomes.

A drug alone is not enough. Without proper systems in place, its benefits cannot be realised.

GLP-1 therapies require regular injections, clinical monitoring for side effects, and careful dose adjustment. In health systems unable to reliably stock insulin, such infrastructure is unlikely to be in place.

There is also the manufacturer’s response to consider.

Brand-name manufacturers could seek to extend market exclusivity by creating patent thickets – filing multiple additional patents on delivery devices such as the injection pen for rather than the obesity drug itself. This creates a web of legal protection that prevents generic manufacturers from producing the complete product.

This is a well-documented strategy in the pharmaceutical market. There is no reason to believe GLP-1 manufacturers will behave any differently from their predecessors.

The governance architecture required to prevent this does not currently exist at the global level. The inclusion of GLP-1medicines on the WHO Essential Medicines List means the world’s leading health authority considers a drug a basic necessity – but it does not mean any government is required to fund it, any insurer is required to cover it or any manufacturer is required to supply it at an affordable price.

Developing transparent, evidence-based strategies for allocating access to GLP-1 drugs, deciding which patients qualify, under what clinical conditions, and who bears the cost, is especially critical in low- and middle-income countries, where affordability and equity challenges are most acute.

However, overcoming these hurdles will require political will that multilateral health diplomacy has consistently struggled to generate for interventions that threaten pharmaceutical revenue.

What is missing from most discussions of GLP-1 equity is an honest account of who makes the decisions that determine access to these medicines. It is not the World Health Organization, nor the health ministries in most countries.

The decisions are made by pharmaceutical companies setting tiered prices, by insurance systems determining coverage criteria, by multilateral lenders deciding whether obesity treatment counts as productive health investment, and by donor governments deciding whether to include metabolic disease in their bilateral health agreements.

For instance, the bilateral health agreements the United States is currently negotiating with 31 countries – described by the US State Department as a shift from aid to trade – say almost nothing about obesity or metabolic disease. They are focused on HIV, malaria, and maternal health: the conditions that generate the most optics and the most straightforward programme metrics.

The chronic disease burden of obesity or metabolism that will define the health economics of the developing world for the next 50 years is not part of that conversation.

That absence is a diplomatic choice.

The question global health diplomacy needs to confront is not whether GLP-1 drugs should be available everywhere. They should. The question is who bears the cost of building the system that makes availability meaningful, and who bears the cost when that system does not exist and the drugs arrive anyway.

In global health, the answer to both questions has historically been the same population: the one that was already carrying the heaviest burden before the new technology arrived.

That is what a two-tier global metabolism means in practice.

Sunoor Verma is a former cardiothoracic surgeon and director of partnerships and advocacy at the World Innovation Summit for Health, Qatar Foundation. He writes in a personal capacity and his views are independent of his institutional affiliations.

Some of the most powerful interventions to slow or improve frailty are also the most ordinary: regular movement, adequate nutrition and meaningful social connection.

It almost sounds too simple for a condition now recognised as one of the strongest predictors of hospitalisation, disability, poor recovery from illness or surgery, nursing home admission and death in later life.

Older adults living with frailty have less physiological reserve: the body’s spare capacity to cope with illness, injury or stress. A relatively small event, such as a chest infection, a medication change or even a few days in bed, can trigger a sudden loss of independence. Meanwhile, a more robust older adult may recover quickly from a more serious illness.

How we age can vary greatly, even between people of the same age. One 82-year-old may stay active and independent, while another struggles to rise from a chair and becomes increasingly dependent after a short hospital stay.

The growing recognition that frailty, rather than age alone, shapes how people age is changing the way clinicians and researchers think about later life. While living longer is one of society’s greatest achievements, frailty and its evidence-based management have become increasingly important public health and clinical concerns.

Checking for frailty is now routine in many healthcare settings for adults aged over 65. Assessment increasingly focuses on how robust or frail a person is physically, cognitively and socially

Frailty assessment

There are two main ways frailty is assessed. The first sees frailty as a physical syndrome marked by weakness, exhaustion, slow walking speed, unintentional weight loss and low physical activity. People with one or two of these features may be considered “pre-frail”, while those with several are considered frail.

The second approach views frailty as the accumulation of health problems over time. In this model, chronic illnesses, mobility problems, memory difficulties, hearing or vision loss, poor nutrition and social isolation all contribute to a reduced ability to cope with a stressful event for the body, such as a fall, infection or hospital stay.

Frailty is often spoken about as though it is permanent, something a person simply becomes. You are either robust or frail, independent or dependent, strong or declining. But research suggests the reality is far more fluid.

Frailty exists on a spectrum from robustness to pre-frailty, mild frailty, moderate frailty and severe frailty, and people may move in either direction over time. Although frailty often progresses, it can sometimes be delayed or improved, depending on the underlying cause and the support available.

Frailty isn’t always permanent

A large review involving more than 42,000 older adults found that, over an average follow-up period of almost four years, around 14% of people improved their frailty status, nearly 30% became more frail, and just over half remained stable. The findings suggest frailty is dynamic and, for some people, potentially reversible.

Rather than simply asking whether someone is frail or not, clinicians are increasingly looking at where a person sits on the frailty spectrum and what supports might help build resilience. Early signs such as slowing down, fatigue or unintentional weight loss are now recognised as an important opportunity for intervention through relatively simple lifestyle changes.

Regular physical activity that includes resistance-based exercise, such as using weights, elastic bands or body weight to build strength at least twice per week, can help improve frailty or slow its progression. The benefits can be even greater when exercise is combined with nutrition or cognitive interventions, such as memory, attention and problem-solving activities.

An Irish trial of a home-based frailty programme delivered through primary care targeted older adults living with mild frailty or less. The programme combined strengthening exercises, regular walking and dietary protein guidance. Frailty rates in the intervention group fell from 17.7% to 6.3% after three months, while they slightly increased in those receiving usual care.

Recovery also appears to depend on more than physical health alone. In a study of more than 5,000 adults aged 75 and older, nearly one-third of those who were frail at the start of the study recovered to a less frail state within two years. Recovery was more likely among those who took part in exercise-based social activities, rated their own health more positively, trusted their community and regularly interacted with neighbours.

Activities that challenge memory, attention and problem-solving can support cognitive health and may help reverse frailty. Psychological resilience, the ability to adapt to stress or difficult life events and recover from them over time, has also been linked to better frailty outcomes.

Frailty is now recognised as more than an inevitable part of ageing. While it remains a powerful predictor of hospitalisation, disability and death in later life, growing evidence shows it can often be prevented, slowed or improved. Everyday choices, including how much we move, who we spend time with and the activities that give us purpose and connection, can help support healthier ageing.

Ide O'Shaughnessy is Associate Professor, School of Allied Health, University of Limerick.

Christina Hayes is Assistant Professor, Ageing Research Centre, University of Limerick.

Katie Robinson is Professor of Occupational Therapy, University of Limerick.

This article was first published on The Conversation.

Consumption of ultra-processed foods – including soft drinks, snacks and ready meals – is growing worldwide, despite evidence they are unhealthy.

Ultra-processed foods make up about 70% of packaged food products on supermarket shelves, and even more in convenience stores.

In our new research, we explore how companies that produce these foods play on human nature to make such products seem the easiest, most rewarding and compelling option.

We show that ultra-processed foods are designed to make us crave them and eat more. They are marketed to all groups, particularly children, in a way that makes them seem the most delicious and convenient option, giving the best value-for-money, despite many health harms.

Our attraction to ultra-processed foods is no coincidence. Ultra-processed foods companies combine a range of tactics to drive up consumption. Many of these tactics exploit the ways we think, feel and behave.

Why we keep eating UPFs

Ultra-processed foods are the most processed foods on the market. According to medical journal The Lancet, they are commercial formulations made from cheap ingredients extracted or derived from whole foods, combined with additives, but mostly containing little to no whole food in the end product.

Ultra-processed foods are heavily branded and marketed, and most are produced by large international corporations.

But diets high in UPFs carry a risk of developing a wide range of serious health conditions, including excess weight or obesity, type 2 diabetes, hypertension, heart disease, cancer, chronic kidney disease and depression, as well as premature death.

Our research asked why we keep eating diets high in ultra-processed foods when we know how unhealthy they are. To answer this, we decided to zoom out and explore the system that develops, produces and markets ultra-processed foods, and investigate how human nature is caught up in it.

We reviewed a decade of published research on the food science and marketing of ultra-processed foods, and then worked with experts in these fields to create and refine system diagrams to visualise how it works.

These maps are called “causal loop diagrams”, and their power is in showing reinforcing (positive) feedback loops that drive the system towards its ultimate purpose: selling more ultra-processed foods.

We found the system is made up of many interconnected loops that capture parts of human behaviour and biology as key elements.

Designed for maximum consumption

One feedback loop includes the use of addictive combinations of ingredients, particularly refined carbohydrates and fats. Biologically, carbohydrates (including but not limited to sugars) and fats activate different reward pathways between the gut and brain. When they are consumed together, their effects become addictive.

These ingredients can be combined in many different concentrations to hit sensory “sweet spots”. In other words, they maximise pleasure and craving responses while minimising negative responses.

Further strategies include processing methods that suppress peoples’ natural sense of being full or speed up digestion in order to give an immediate but quickly fading sense of “reward”, making us want more, sooner.

UPF marketing strategies

In terms of marketing, products are formulated to be easy and convenient to store and eat, and to appeal to our sense of getting good value.

Various promotional techniques aim to capture consumers’ attention and desire, as well as giving the illusion of healthiness. Strategies targeting children in particular employ popular culture associations with coolness or fun.

Another example of a feedback loop is how corporations collect large and complex data on our purchasing habits and our online lives, informing targeted digital marketing on social media platforms. This tends to be effective at driving purchases, providing more data to further refine these promotion strategies.

Overall we identified 11 different reinforcing feedback loops. Our research is the first study to show this web as part of the ultra-processed foods system, designed to essentially trap people into buying and eating more and displacing healthier options in diets.

This product-level system also connects with feedback loops further up the supply chain in economic and financial spheres of the global UPF production.

This matters because unhealthy diets and excess body weight cause 18% of preventable premature death and disability in New Zealand. Both risk factors are linked to eating too much ultra-processed foods.

Unfortunately, New Zealand hasn’t undertaken national nutrition surveys since the 2000s and we have to rely on data from similar countries such as Australia to estimate that ultra-processed foods make up about half of our energy intake.

What to do about it

Diets high in ultra-processed foods are not the result of people’s free personal choice or weak willpower, but of an intentionally designed system.

Our research shines light on how the ultra-processed foods system is taking advantage, particularly of children. International experts have framed ultra-processed foods as a major global health issue, and advise strong government policy to regulate these products to counter some of these mechanisms.

Policy leadership already exists in other parts of the world, particularly in Latin America. New Zealand could follow other countries that have implemented taxes on ultra-processed foods and sugary drinks, regulations restricting advertising to children, strong front-of-pack labelling and transparency policies such as public disclosure of lobbying in government.

Complacency is not an option. The food system needs rebalancing so that it serves and nourishes people now and in the future.

Kelly Garton is Senior Research Fellow in Population Health, University of Auckland, Waipapa Taumata Rau.

Boyd Swinburn is Professor of Population Nutrition and Global Health, University of Auckland, Waipapa Taumata Rau.

This article was first published on The Conversation.

We’ve all heard the advice: eat your fruit and vegetables, get your vitamins, and stay healthy. For the most part, that guidance holds up. But some nutrients have a more complicated story, and vitamin B12 is a fascinating example.

Also known as cobalamin, B12 is essential for life. It helps the body produce red blood cells, keeps the nervous system functioning, and plays a central role in how cells copy and repair DNA.

B12 is found naturally in animal products such as meat, fish, eggs, milk and cheese. Some cereals and breads are also fortified with it, helping people who do not eat meat get enough. Most people following a varied diet get the recommended amount, but vegans, people with certain gut conditions and older adults who absorb nutrients less efficiently may need supplements.

Without enough B12, things can go wrong, sometimes seriously, especially if deficiency is not recognised and treated. Yet in recent years, researchers have been asking whether high levels of B12 intake or high levels of B12 in the blood could be linked to cancer.

Staying balanced

The body is constantly making new cells. Every time a cell divides, it needs to copy its DNA accurately. Vitamin B12 is critical to that process. When levels are too low, DNA can be copied incorrectly, leading to mutations that, over many years, may increase the risk of certain cancers, particularly colon cancer. This is why B12 deficiency is taken seriously.

A 2025 case-control study from Vietnam found what researchers described as a U-shaped relationship between B12 intake and cancer risk, with both lower and higher intakes associated with increased risk. Because this kind of study can show an association but cannot prove cause and effect, the takeaway is not that B12 is dangerous. It is that balance matters.

It might seem logical that if B12 helps healthy cells thrive, taking extra doses should offer extra protection against cancer. But research does not fully support this. Vitamin B12 supports cell growth generally, not only the growth of healthy cells. One concern is that, if pre-cancerous cells are already present, very high availability of growth-supporting nutrients such as B12 could, in theory, support their growth too. But this remains difficult to prove in humans.

Overall, studies of high-dose B vitamin supplements taken over long periods have not shown clear protective effects against cancer incidence or cancer deaths. One analysis did report a reduced risk of melanoma, but this was a cancer-specific finding rather than evidence that high-dose B vitamins prevent cancer generally. Some observational research has also suggested a slight increase in lung cancer risk linked to long-term, high-dose B6 and B12 supplementation, particularly among men and smokers, although this kind of study cannot prove that the supplements caused the cancers.

Doctors have noticed that many cancer patients show unusually high levels of B12 in their blood. This raises an important question: does elevated B12 contribute to cancer, or can cancer itself cause B12 levels to rise?

Research in 2022 concluded that high B12 in cancer patients is often an “epiphenomenon”. In other words, the vitamin appears alongside the disease but does not necessarily trigger it. Further research from 2024 reached a similar conclusion.

This effect is thought to involve two main mechanisms. First, tumours can affect the liver, which stores large amounts of B12. When the liver is damaged or under strain, it may release more B12 into the bloodstream. Second, some tumours may increase proteins that bind to B12 in the blood. This can push blood test readings higher without necessarily meaning the body’s cells are receiving or using more B12.

Useful indication

Researchers are also recognising that elevated B12 may not be a cause of cancer, but it could be a useful marker of whether cancer is present or progressing. A large 2026 study found that colon cancer patients with very high B12 levels survived a median of around five years, compared with nearly eleven years for those with normal levels.

Similar patterns have been found in oral cancer and in patients receiving immunotherapy, where elevated B12 has been associated with poorer outcomes. This means that unexplained, persistent high B12, especially when it is not caused by supplements, should not be ignored. It may point to liver disease, blood disorders or an underlying cancer that has not yet been detected.

For most people, this is not something to worry about. B12 from a normal diet containing meat, fish, eggs, dairy or fortified foods is not usually the issue: it is very difficult to consume too much B12 from food alone. Deficiency remains a more common and better-established problem than excess.

The concern is prolonged high-dose supplementation without medical advice, or a blood test showing persistently high B12 when someone is not taking supplements.

The broader message is simple: more is not always better. Cancer cannot be prevented by loading up on any single vitamin. Long-term habits matter more: eating a balanced diet, exercising regularly, avoiding smoking, protecting your skin and attending routine health screenings.

So what about vitamin B12? Get enough through food or supplementation if you need it, especially if you are vegan, older or have a condition that affects absorption. But leave the megadoses on the shelf unless a doctor advises them. With B12, as with many nutrients, the goal is not as much as possible. It is the right amount.

Ahmed Elbediwy is Senior Lecturer in Cancer Biology & Clinical Biochemistry, Kingston University.

Nadine Wehida is Senior Lecturer in Genetics and Molecular Biology, Kingston University.

This article was first published on The Conversation.

Parveena Khatun, 45, runs a tea stall on Baba Gangnath Marg in Delhi’s Munirka. The shortage of cooking gas cylinders has affected Parveena’s income.

When supplies fell in March, she kept her stall closed for a week but without the income, survival became difficult. Then, she built a brick stove (chulha), bought coal and gathered firewood. In Delhi’s intense summer, working throughout the day on a chulha is dangerous.

Temperatures around the chulha remain high, leading to thermal discomfort and heat stress, and the set-up leaves Parveena gasping for breath at the end of the day. Her hands have burn marks – she’s never worked on a chulha before.

“Yesterday afternoon,” said Parveena, who moved to Delhi from Bihar’s Siwan in 2002, “the heat was so intense that between the smoke and the heat, I started feeling dizzy. I sat under a tree for a while and washed myself with cold water; my whole body was restless.” She was speaking of April 23, when Delhi saw a maximum temperature of 43 degrees celsius.

The Commission for Air Quality Management issued an order on March 13, 2026, giving temporary permission to burn diesel and biomass (wood, dung cakes, and coal) and waste-derived fuel in Delhi-NCR, which has been extended until May 13, 2026.

Solid fuel like firewood, cow dung and dry grass are highly damaging to health, as IndiaSpend reported in April 2019. Cooking on traditional chulhas leads to incomplete combustion, and emission of particles such as suspended particulate matter, carbon monoxide, polyaromatic hydrocarbons, polyorganic matter and formaldehyde. All these are harmful for respiratory health.

Women and younger children who spend the most time at home are the most vulnerable, we had reported. Exposure to air pollution during pregnancy leads to outcomes such as low birth weight and stillbirth.

In 2022, India saw 113 deaths per 100,000 people due to household air pollution, according to the Lancet Countdown on Health and Climate Change report 2025. For the estimated population of 1.46 billion that year, this works out to 1.65 million deaths from indoor pollution. Household air pollution also contributes to 22%-52% of ambient air quality, studies suggest.

And this is before the effects of heat are considered.

Each time a woman cooks over a chulha in this heat, her body is fighting two battles at once – trying to cool down while also breathing in harmful smoke, explains Vidhya Venugopal, professor of occupational and environmental health at the Sri Ramachandra Institute of Higher Education and Research, Chennai. “It is a killer combination. This is far more dangerous than either problem alone and can quickly lead to exhaustion, dizziness, and breathing difficulties. For women working long hours outdoors, this combination can become a serious health emergency.”

A May 2025 study in Geo Health shows that risk of premature mortality during hot and polluted days was higher than normal days. “The compound increase in PM2.5 and temperature intensity could elevate the risk of fatality,” the study said.

Another study published the same month in Environment International, which analysed 3.6 million deaths across 10 Indian cities between 2008 and 2019, found that air pollution becomes much more dangerous as temperatures rise.

Shortage, black market

The war in West Asia has led to stalled shipments, and India depends on imports for 60% of its liquefied petroleum gas consumption. Domestic production rose 25%, and is being directed to household consumers, after which hospitals and educational institutions are being prioritised.

Since the first week of April, reports of migrant workers returning home from Delhi-National Capital Region began surfacing, with a large number of labourers seen heading back from Delhi’s railway stations.

By May 8, the government said, commercial LPG availability stood at 70% of pre-crisis levels. But many roadside eateries depend on the black market for their cooking gas needs.

India’s LPG consumption fell 16% this April, compared to April 2025, government data released by the Petroleum Planning and Analysis Cell show.

“At retail shops, gas is being sold for Rs 350-400 per kg,” Parveena said. “If I buy Rs 100 worth of gas for Rs 400, I would have to raise the price of a cup of tea from Rs 10 to Rs 40. Who would buy it?"

Prices for commercial cylinders, which stood at Rs 1,768.5 for 19 kg on March 1, rose to Rs 3,071 earlier this month.

“I have a domestic connection, but the cylinder ran out 15 days ago. I am using the chulha at both my stall and home,” said Parveena, whose elder daughter is studying for a bachelor’s degree and the younger just finished school. “I have booked a refill, but it hasn’t arrived yet.”

Reena Kumari, 30, living in the Coolie Camp of Vasant Vihar, was cooking on a chulha in the bright afternoon sun. The family does not have a gas connection, and earlier got the 5-kg cylinder refilled, but now shops have stopped refilling them. “Even where gas is available, it’s costing Rs 400 for one kg. I cannot afford it.

“I have two small children who get very distressed by the smoke and start crying. But I have to cook; I won’t let the children starve.” Kumari’s husband is 34, and works as a cook in a hotel.

"Every time someone cooks over wood or coal in a closed kitchen, they breathe in smoke that is far more toxic than outdoor city pollution,” said Venugopal. “In the short term, this causes burning eyes, coughing, and headaches – but over the years, it quietly damages the lungs and heart, sometimes leading to serious diseases like COPD [chronic obstructive pulmonary disease] or even lung cancer. The tragedy is that for many families, there is simply no other option.”

The government has asked states to improve access to free-trade LPG cylinders, which hold 5 kg gas and have lower documentation needs. These are typically meant for consumers such as migrant workers and students. The government has doubled allocations to states and oil companies are organising awareness campaigns. Retail prices of refills have also increased.

The shift back to polluting cookstoves

Sanghamitra Patra, 28, who came to Delhi from Odisha in search of employment in 2022, runs Chandini dhaba in Munirka. Since the crisis began, she has been running it using two wood stoves. “While cooking on the chulha, the flames spread far. It feels like being thrown into a furnace,” she says.

Her family does not have an LPG connection. Earlier, she used to buy refills by paying delivery persons a little extra but now, a refill costs up to Rs 4,000 on the black market. “My two children go to school; I can’t even make lunch for them. After school, they come here to the dhaba to eat."

“I had never cooked on a chulha before. Now I only make dal, roti, and rice because it takes much longer to cook on the chulha,” she said. “The dhaba gets filled with smoke, so many customers turn back. My income has decreased by half. It has become difficult to pay the rent for the shop and the house.”

“Women, especially those in low socio-economic status, are the ones standing over the fire for hours every day, so they breathe in the most smoke and feel the most heat,” Venugopal said. “When you add poverty, poor nutrition, limited healthcare, and no real choice of fuel, the body simply has fewer resources to cope and recover. These women are not weak, but they are being exposed to hazards – an impossible situation with no support."

On April 24, the Union Ministry of Petroleum and Natural Gas stated in a press conference that the supply of domestic LPG remains smooth. Meanwhile, at an Indane gas agency in Masoodpur, near the Jai Hind Camp slum, long queues were seen on April 23 at 4 p.m. Ramveer, a gas mechanic at the agency, explained that the crowds were there to resolve persistent technical issues with their bookings. When asked about the 5 kg cylinders, he said they are not seeing many new applications.

We reached out to the ministry for comment on the challenges faced by migrant workers and concerns over the affordability of the 5 kg cylinders. We will update this story when we receive a response.

Double burden of pollution

Urban slums suffer from a double burden of pollution. They are exposed to the high ambient particulate matter of cities and the household air pollution from unclean cooking fuels. According to a survey report by CEEW, 45% of urban slum households in India use traditional fuel like dung cakes and firewood for cooking.

"Migrant workers were never adequately covered by clean fuel access even under conditions of good LPG supply,” said Kalpana Balakrishnan, professor and dean (research) at SRIHER. “The crisis has heightened the need for expanding clean energy access to all vulnerable populations, including the urban poor, who often face risks greater than the rural poor.

“In lower socio-economic status households, cooking expenses account for more than 30% of their limited income. Any financial shock forces them to look for alternatives,” Balakrishnan added. “However, India has made significant progress in clean cooking, especially through the Pradhan Mantri Ujjwala Yojana. Despite this, it has been challenging to bear the costs of increasing usage and to reach the bottom 10% of the poorest population. Now, the rising number of people reverting to solid fuels has made the situation even more serious."

"Those who can afford to switch to solar should be encouraged, freeing up LPG for the most vulnerable,” she added. “Cities like Delhi can rebalance energy use through redesigned, smarter subsidy structures and lead the transition to renewable cooking nationwide."

Shivam Bhardwaj is an independent journalist based in Bareilly.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

Iodine deficiency is often seen as a problem of the past, but this isn’t entirely true. During the 20th century, the iodisation of salt became one of the most effective public health interventions for preventing conditions caused by a lack of this mineral, including goiter (enlargement of the thyroid gland) and preventable damage to neurological development.

The World Health Organization (WHO) still views iodised salt as a safe and effective strategy, while UNICEF notes that it is the most widely used way of improving iodine intake worldwide.

However, the success of this simple measure means iodine has all but disappeared from public debate. And today, in several countries, signs of insufficient intake are once again being detected in certain groups, particularly in pregnant or breastfeeding women and people on restrictive or poorly planned diets.

What we are witnessing is not a dramatic resurgence of the most severe symptoms everywhere, but rather a silent risk of deficiency in contexts where vigilance has waned.

Iodine’s role in the body

Iodine is an essential micronutrient for the synthesis of thyroxine (T4) and triiodothyronine (T3), hormones that regulate metabolism, growth, and many physiological processes. Adequate intake during pregnancy and early childhood is particularly important for the normal development of the central nervous system and for the early stages of brain maturation.

In addition, the body’s needs increase during pregnancy and breastfeeding due to increased maternal production of thyroid hormones, greater renal excretion of iodine, and the transfer of this mineral to the fetus and the infant.

Why deficiency is on the rise again

The issue is not that people have stopped consuming salt, but rather that the type of salt they consume has changed, as have the sources of sodium in their diet. In recent years, iodised salt has been replaced in many households by “gourmet” or “natural” salts. These include sea salt, pink Himalayan salt, flaked salt and kosher salt, which are often perceived as more sophisticated or healthier, even though they are not always iodised.

In a way, iodised salt has an image problem. Compared to the culinary prestige of its trendy rivals, it has come to be viewed as something ordinary, outdated even.

Today, lot of our salt intake also comes from processed and ultraprocessed foods, meaning the use of iodised salt cannot be guaranteed. For this reason, the World Health Organization has called for coordination between policies that aim to reduce sodium intake and those that promote iodised salt.

The makeup of our diets has also changed a lot. Iodine is naturally present in all seafood, some dairy products and in eggs, though the quantity may vary from one region or food system to another. When a person reduces or cuts out several of these sources at once while not also consuming iodised salt or fortified foods, the risk of deficiency increases.

The result is that a basic, inexpensive, and effective micronutrient has fallen out of the spotlight just as certain groups are once again at risk of not getting enough iodine.

Plant-based diets

Vegetarian and vegan diets can be healthy, but they must take iodine into consideration. A 2023 review in the British Journal of Nutrition concluded that people following a plant-based diet, especially vegans, may find it hard to get the recommended amount of iodine from these foods alone.

This does not mean a plant-based diet is inherently lacking – and the solution is straightforward. Just as vitamin B12 is is commonly recommended for those who reduce their consumption of fish or dairy – or when people replace animal products with unfortified plant-based alternatives – so too should iodine.

Pregnancy and breastfeeding

Iodine deserves special attention during pregnancy. There is strong evidence that a severe deficiency of this micronutrient can affect fetal development and thyroid function, which is why many organisations use specific thresholds to assess iodine status in pregnant women. The US National Institutes of Health states that a urinary concentration of 150–249 micrograms per liter (μg/L) in pregnant women is considered adequate for the general population.

But there is a caveat to this. Concerns about mild or moderate deficiency are legitimate, but there is no conclusive evidence as to the cognitive benefits of supplementing all pregnant women who show a mild deficiency. Reviews and trials have indicated that there is plausible biological concern, and some studies suggest an association with poorer outcomes, but controlled experiments have not unanimously shown clear improvements in infant neurodevelopment.

Nevertheless, several scientific societies have adopted a cautious stance. The American Thyroid Association, for instance, states that women who are planning to conceive, pregnant or breastfeeding should receive 150 μg of iodine daily in prenatal or multivitamin supplements, usually in the form of potassium iodide, to help meet increased requirements.

Why ‘more salt’ is not the answer

Another important clarification is needed here. Advocating for iodised salt does not mean recommending a higher salt intake. The WHO maintains its recommendation to reduce sodium intake due to its link with high blood pressure and cardiovascular disease. In terms of public health, the solution is not “more salt”, but less – though the salt we do eat should be iodised.

In fact, the WHO itself has emphasised that reducing salt intake and fortifying salt with iodine are compatible, provided the concentration of the mineral is properly adjusted and salt used by the food industry is also fortified.

This point is key because it avoids two common pitfalls: turning the issue into a nostalgic defence of table salt, or the other extreme of assuming that any reduction in sodium intake will automatically solve all health problems without any nutritional consequences. But it is possible to strike a balance between preventing cardiovascular disease and iodine deficiency.

José Miguel Soriano del Castillo is Catedrático de Nutrición y Bromatología del Departamento de Medicina Preventiva y Salud Pública, Universitat de València.

This article was first published on The Conversation.

Chronic obstructive pulmonary disease, or COPD, is one of the world’s leading causes of death, responsible for 3.5 million deaths in 2021 alone. It is often thought of as a disease of older smokers. But that picture is too simple. COPD usually develops slowly over many years, often long before symptoms become obvious.

COPD is a long-term lung condition that makes it harder to move air in and out of the lungs. It includes damage to the airways, often described as chronic bronchitis, and destruction of the tiny air sacs in the lungs, known as emphysema. Because this damage builds up gradually, many people do not realise anything is wrong until symptoms become difficult to ignore. There are treatments that can help, but there is no cure, and by the time COPD is diagnosed the damage is often permanent.

Common symptoms include a long-term cough, bringing up mucus and shortness of breath. These symptoms often appear later in life, which helps explain why COPD is so often seen as an older person’s disease. But in many cases, the damage started decades earlier.

Many environmental irritants can harm the lungs, but cigarette smoke remains the main cause of COPD. Cigarette smoke contains thousands of chemicals, including toxic gases and cancer-causing substances, that injure lung tissue and trigger oxidative stress, a form of cellular damage that drives inflammation.

Inflammation is part of the body’s normal defence and repair system. Usually, it settles once the source of harm has gone. But in COPD, the lungs may be exposed to cigarette smoke day after day, so the inflammatory response never properly switches off.

Over time, immune cells sent to repair the damage can end up injuring the lungs further. The airways become narrower, the lungs produce more mucus, and the tiny air sacs known as alveoli can break down. Together, these changes make breathing increasingly difficult.

As the disease progresses, the lungs are physically altered in ways that cannot be fully reversed, even if someone stops smoking. COPD inflammation also does not always respond well to standard anti-inflammatory medicines such as steroids, which is one reason prevention matters so much.

Although cigarette smoking remains the main driver of COPD, e-cigarettes are also raising concerns. Vaping aerosols can contain nicotine, ultrafine particles and flavouring chemicals that may irritate the lungs and contribute to inflammation. The long-term effects are still unclear because these products are relatively new.

That matters particularly for younger people. In Great Britain, recent survey data suggest that 7% of 11- to 17-year-olds currently vape. While that does not mean they will go on to develop COPD, it does mean more young lungs are being exposed to substances whose long-term effects are not yet fully understood.

COPD is often diagnosed only after major lung damage has already occurred. Because it develops so gradually, people may dismiss early breathlessness, coughing or mucus production as a consequence of getting older, being unfit or smoking. Respiratory organisations warn that symptoms such as cough, phlegm and shortness of breath should not be treated as a normal part of ageing, while studies show that COPD remains widely underdiagnosed, including among people with respiratory symptoms.

The burden on health systems is huge. A 2023 study estimated that COPD could cost the global economy around INT$4.3 trillion between 2020 and 2050. International dollars adjust for differences in prices between countries; in broad terms, this is roughly equivalent to US$4.3 trillion in US purchasing power, or about £3.2 trillion if treated as US dollars at current exchange rates. Hospital admissions often rise in winter, when people with COPD are more vulnerable to bacterial and viral infections that can worsen symptoms and speed up decline.

That is why the most important window for action may come much earlier in life. By the time many people are diagnosed, the disease has been developing for years. Better education about lung health at school age could help people understand that choices made in their teens and twenties may shape their breathing decades later.

COPD care has traditionally focused on treating symptoms once they appear. But by then the lungs may already be permanently damaged. Seeing COPD as a disease that develops slowly over decades could shift attention towards earlier prevention and, ultimately, reduce its human and economic cost.

This article was first published on The Conversation.

While some people can spring out of bed at six in the morning and go straight into their day, others prefer to wake up later as they’re most productive in the afternoon or evening. This difference is due to your chronotype – the biological tendency to prefer certain times of day for sleep, waking and activity.

But these aren’t the only factors affected by your chronotype. A growing body of research also suggests that your chronotype can affect the benefits you see from exercise.

People who naturally rise early and feel sharpest in the morning are “early chronotypes”, whereas those who prefer to wake later and function better in the afternoon or evening are “late chronotypes”. People who fall in between are “intermediate chronotypes”.

Your chronotype is determined by your circadian rhythms – the body’s natural daily cycles that repeat around every 24 hours. Although these are strongly influenced by our environment, they function even without external cues such as daylight and food. These rhythms affect our physiology, behaviour and health.

Our circadian rhythms are controlled by the body’s circadian system, which is made up of tiny biological clocks composed of proteins, which are found in organs and tissues. These clocks rely on genes that help coordinate when different processes happen, such as when we feel alert or sleepy.

The circadian system also influences many other bodily functions, including blood pressure, heart rate, blood sugar regulation and blood vessel function. As these factors are also affected by physical activity, this may explain why aligning your workouts to your natural chronotype can be beneficial.

Some studies support this, suggesting that the time of day people exercise can influence health outcomes – including cardiovascular fitness and reducing the risk of cardiovascular disease, obesity and some cancers.

However, as these were observational studies (which only show associations rather than cause and effect), they can’t definitively prove that the findings were solely caused by the timing of the exercise.

But a recent randomised controlled trial has investigated whether aligning workouts with chronotype could enhance the benefits of exercise. The researchers specifically looked at people who were at risk of cardiovascular disease.

Participants were grouped according to their chronotype, which was measured using a specialist questionnaire. Morning types exercised between 8–11am and evening types exercised between 6-9pm. A third group exercised at the opposite time to their chronotype (morning types in the evening and evening types in the morning).

Participants whose exercise was aligned with their chronotype experienced greater improvements in blood pressure, aerobic fitness, blood glucose, cholesterol and sleep than participants whose training times were misaligned with their chronotype.

But though these improvements show that timing exercise to your chronotype can enhance its health benefits, there are a couple of important nuances.

Even the group that exercised at the supposedly wrong time still experienced health benefits, showing that exercise is beneficial even when it doesn’t align with your chronotype. The study also did not include intermediate chronotypes, who make up around 60% of the adult population. For these people, the timing of exercise may be less important.

Based on the available evidence, exercise timing appears to be a meaningful consideration, particularly for people who are strong morning or evening chronotypes.

Beyond your chronotype

So how do you know your chronotype?

Most people have an intuitive sense of this based on when they naturally prefer to sleep and wake. However, work schedules and care-giving responsibilities often force us into routines that conflict with our chronotype. Over time, this makes it harder to be sure of your chronotype.

For this reason, researchers developed a questionnaire to help you determine your chronotype. The 19 questions include what time you feel you’re at your peak and how easy you find it to wake up in the morning.

Once you have a clearer sense of your chronotype, you can start thinking about when to schedule your training.

However, chronotype isn’t the only factor that can affect training and how you respond to exercise. This is good news for those who may not be able to align workouts with their chronotype.

For instance, body temperature usually peaks in the afternoon regardless of chronotype, which enhances muscle function. This is why strength, speed and coordination tends to be best in the afternoon, making it a prime window for resistance training and technical practice for most people.

Habitual training time can also shift performance over time as the body adapts to the time you regularly train. So even if you’re naturally a night owl, consistent morning training may eventually make you perform better at that time.

Another critical factor to consider when deciding when to workout is sleep.

If you haven’t slept well the night before, research suggests it’s better to exercise earlier in the day, regardless of your chronotype. This is because the drive to sleep, known as “sleep pressure”, builds steadily from the moment you wake up and peaks just before you fall asleep. By evening, growing sleep pressure makes exercise feel harder and can impair your performance.

Exercising late in the evening can also reduce sleep quality, particularly when the session is intense. As a general rule, leave at least a two-hour gap between exercise and bedtime.

There’s no single best time to exercise that works for everyone. While the evidence on the long-term health benefits of matching exercise time to chronotype is growing, some principles apply broadly.

Peak performance varies by chronotype, and matching your workout time to yours may help you train harder and achieve better health benefits. However, any exercise is better than none – regardless of timing.

If you’re a night owl but can only train in the morning, a warm-up is essential. Wear extra clothing and start with 10-15 minutes of light aerobic activity to gradually increase body temperature and increase alertness.

If evenings are your only option, opt for moderate or low-intensity activities (such as yoga or a jog) to avoid disrupting sleep.

Paul Hough is Lecturer Sport and Exercise Physiology, University of Westminster.

This article was first published on The Conversation.

You’re standing in a supermarket aisle, weighing up whether to buy a microwave meal or a bunch of fresh carrots.

We all know making healthy eating choices can be tough. That’s especially true if you are hungry, or have a hungry household to feed.

There are so many reasons for this, and many are outside our control. But one you might not be aware of is a psychological concept known as “decision fatigue”.

So what exactly is decision fatigue? And could it help or hinder your healthy eating goals?

What is decision fatigue?

Decision fatigue, also known as choice overload, describes what happens when we make many effortful decisions over time.

Whenever you make a decision, you use a small amount of mental energy. As that energy runs low, you tend to make worse decisions.

This means you’re more likely to act without thinking, or simply choose what is easy or familiar. You might also find it harder to plan ahead and resist certain impulses.

This means you might be more likely to grab a takeaway instead of the ingredients to make a meal, or default to familiar comfort foods instead of making intentional, healthy choices.

How might it affect my eating habits?

The average person makes hundreds of food decisions each day.

You may think you’re just choosing a meal. But that one decision involves making many layered choices about what and how much you eat, as well as where, when and how you eat it.

You may make these choices subconsciously or automatically. But they each require to you weigh up various factors, such as taste, costs, time, expectations and more.

When decision fatigue sets in, you’re less likely to make thoughtful, health-focused choices. Instead, you may gravitate towards options that require less effort and offer quick rewards. You may also become more influenced by outside cues. An example of this is advertising that promotes convenient but high-calorie options such as fast food, snacks or indulgent treats.

Having too much information can make these decisions even harder. Nutrition advice often assesses the value of foods by how much protein, fat, fibre or vitamins they contain. This way of thinking, sometimes called nutritionism, can make food choices more complex. Instead of choosing food as food, we try to calculate and juggle many numbers at once.

Not the only factor

Several other factors may affect your food choices.

One is stress. One study from 2022 showed parents who experience high levels of both stress and decision fatigue found it more difficult to stick to positive food-related behaviours, such as making meals from scratch or eating together as a family.

Another is tiredness. One 2017 study showed time of day affected meal choices. It found between mealtimes, and especially in the afternoon, people were more likely to choose the simpler default food choice than one that required more consideration. This suggests having lower blood sugar and less mental energy meant people made less considered decisions.

How can I reduce my decision fatigue?

Here are four tips.

Have healthy foods on hand

When we’re low on mental or physical energy, we usually turn to what’s easy or familiar. That’s why it’s important to have healthy food options within reach. Thankfully, this doesn’t need to be complicated. It could look like pre-cutting fruit or having some healthy frozen meals in the freezer. And research suggests removing unhealthy foods – for example from the pantry or fridge – can be just as helpful when you’re trying to make healthier food choices.

Plan your meals

Planning meals could help too. This may involve setting some weekend time aside to decide what meals you’ll cook and eat. That’s instead of making last-minute decisions at the supermarket or on the drive home. Meal kits and batch cooking, which both reduce the number of food-related decisions you have to make, may also reduce decision fatigue.

Reframe your eating choices

How you frame choices may also improve your eating habits. For example, you may be more likely to “eat a colourful meal” rather than simply telling yourself to “eat more vegetables”.

Outsource some of the decision-making

If you’re looking for healthy, tasty recipes, you don’t need to re-invent the wheel. You can find a wealth of free ideas on the Eat for Health, Heart Foundation and National Nutrition Foundation websites. And if making food decisions feels overwhelming, Accredited Practicing Dietitians and Registered Nutritionists can help you turn complex nutrition advice into manageable steps.

The bottom line

We often think eating should be simple and intuitive, but blame ourselves when it doesn’t feel that way. However, the concept of decision fatigue shows healthy eating is not just about willpower. It’s also about noticing when you’re tired, stressed or time-poor, and taking practical steps to make healthy foods the easiest option.

Emma Beckett is Senior Lecturer, Nutrition and Food Science, Australian Catholic University.

This article was first published on The Conversation.

Most people know about “good” and “bad” cholesterol. But few realise there is another type called lipoprotein(a). It can raise the risk of heart attacks and strokes, even in people who do everything right.

This lesser-known cholesterol particle, often written as Lp(a), is gaining increasing attention from researchers and drug companies.

Lp(a) isn’t included in routine cholesterol tests and there’s currently little we can do about it. That may now be changing.

What is lipoprotein(a)?

Lipoprotein(a) is a cholesterol that carries lipoprotein – particles made of fats and proteins – in your blood. It’s structurally similar to LDL (low-density lipoprotein, or “bad” cholesterol), but with an additional protein attached called apolipoprotein(a).

This extra protein component seems to make Lp(a) more likely to contribute to the build-up of fatty deposits in arteries. It may also promote blood clotting. Together, these processes increase the likelihood of cardiovascular disease (heart disease and stroke).

Large-scale studies and international guidelines now recognise Lp(a) as a risk factor for heart disease and stroke.

What determines your Lp(a) levels?

Unlike most other cholesterol measures, Lp(a) is largely determined by genetics.

Around 70%-90% of variation in Lp(a) levels is inherited. This is driven mainly by differences in the LPA gene, which controls the structure of apolipoprotein(a).

Because of this strong genetic control, Lp(a) levels are usually set early in life and remain relatively stable over time, with little influence from diet, exercise or body weight.

There are some smaller influences. Levels can vary by sex, ethnicity and hormonal changes, and may be slightly affected by factors such as menopause or kidney disease.

How does it affect your risk?

A growing body of research shows higher Lp(a) levels are associated with an increased risk of heart attacks, strokes and aortic valve disease.

Importantly, the relationship appears continuous. In long-term studies, cardiovascular risk rises step by step as Lp(a) levels increase.

Lp(a) also adds to overall risk. For example, someone with high LDL cholesterol and high Lp(a) is likely to be at higher risk than someone with elevated LDL cholesterol alone.

For people with higher Lp(a) levels, cardiovascular risk rises mainly when inflammation is elevated.

This helps explain why some people develop cardiovascular disease despite otherwise favourable risk profiles.

Can you lower lipoprotein(a)?

There are currently few options to lower Lp(a).

Lifestyle changes that improve heart health, such as eating well, being physically active and not smoking, remain essential. But they have minimal effect on Lp(a) itself.

Most commonly used cholesterol-lowering medications, including statins, do not reduce Lp(a). In some cases, statins may even increase Lp(a) slightly. Despite this, statins still reduce overall cardiovascular risk and remain a cornerstone of treatment.

Some newer drugs, such as PCSK9 inhibitors, can lower Lp(a), but typically only by a modest amount of around 15%-30%.

Several drug companies, including Novartis, Amgen and Eli Lilly, are racing to develop treatments that specifically lower Lp(a). These new medicines work very differently from statins. Instead of helping the body clear cholesterol from the blood, they use a “gene silencing” approach that reduces how much Lp(a) the liver makes in the first place.

This means it switches off production of cholesterol rather than trying to remove what is already there.

In early clinical trials, these drugs have lowered Lp(a) levels by 80–90%, far more than existing treatments. This is why Lp(a) is suddenly getting attention.

If upcoming trials show these large reductions also lead to fewer heart attacks and strokes, it could change how cardiovascular risk is assessed and treated, especially for people whose risk is driven largely by genetics rather than lifestyle.

Should you get tested?

Lp(a) is not included in standard cholesterol tests. A specific blood test is required.

Medicare doesn’t cover these blood tests, so if your doctor orders one you’ll have to pay out of pocket – around A$25 to $80 – plus any costs associated with the consultation.

International guidelines now recommend measuring Lp(a) at least once in adulthood, particularly for people with a family history of early heart disease or unexplained cardiovascular risk.

Because levels are largely genetically determined and stable, a single measurement is often considered sufficient for most people.

What should you focus on?

Learning you have high Lp(a) can feel frustrating, especially given the limited options to lower it directly.

But it’s important to see Lp(a) as one part of your overall cardiovascular risk.

There are still many factors you can influence to lower your overall risk, and particularly your LDL cholesterol. These include:

• LDL (bad) cholesterol

• blood pressure

• smoking

• physical activity

• diet quality

• managing conditions such as diabetes

For people with elevated Lp(a), managing these factors may be even more important.

What happens next?

Research into Lp(a) is moving quickly. If current clinical trials show targeted therapies reduce cardiovascular events, testing and treatment may become more common.

For now, awareness is an important first step.

If you are concerned about your cardiovascular risk, it may be worth discussing Lp(a) testing with your doctor, especially if you have a strong family history of heart disease.

At the same time, the broader message to maximise heart health through healthy behaviours remains unchanged. Even as new risk factors emerge, the foundations of good heart health are still the things we can control.

Lauren Ball is Professor of Community Health and Wellbeing, The University of Queensland.

Kirsten Adlard is Honorary Research Fellow, The University of Queensland.

This article was first published on The Conversation.

For many people, news of a virus outbreak on a cruise ship immediately brings back memories of Covid-19 spreading when the Ruby Princess docked in Sydney in March 2020. Of the passengers and crew who disembarked, 575 had Covid. The virus then spread to the community.

So it’s understandable people are concerned that passengers from the MV Hondius need to be quarantined after potential exposure to Andes virus, a rodent-borne hantavirus.

However, the comparison with Covid only goes so far. Andes virus is serious and authorities are right to respond cautiously. But experts, including from the World Health Organization, note it doesn’t have the characteristics needed to become “the next Covid”.

As of May 11, European health authorities have reported nine cases linked to the cruise ship, including seven confirmed and two probable cases. Three deaths have been reported.

Five Australians and one New Zealander are being repatriated to Australia for quarantine and monitoring. The passengers will initially quarantine at the Centre for National Resilience near RAAF Base Pearce in Western Australia.

Here’s what you need to know about Andes virus, the risk of transmission, and how it’s different to the virus that caused Covid.

How do hantaviruses spread?

Hantaviruses are a group of viruses usually carried by mice, rats and other rodents. People are most commonly infected after inhaling tiny particles of contaminated rodent urine, droppings or saliva.

Most hantaviruses are not known to spread between people. Andes virus is the exception. After the initial spillover from infected rodents, it is the only hantavirus with well-documented person-to-person transmission.

But that doesn’t mean it spreads easily between people. Further human-to-human spread is uncommon, but it can occur in close-contact settings such as households, among caregivers, during intimate contact, or after prolonged exposure in crowded or poorly ventilated indoor areas.

That is very different from SARS-CoV-2, the virus that causes Covid. SARS-CoV-2 spreads very efficiently through the air. People could infect others before they even realised they were sick.

Early estimates suggested each person infected with SARS-CoV-2 passed the virus to roughly two or more others, on average, in populations who had never encountered it before.

Andes virus can cause onward human-to-human transmission, but requires a perfect storm of conditions: symptomatic people in crowded, poorly ventilated spaces with close contact over time. This was the case on the MV Hondius.

This difference in transmission potential is why SARS-CoV-2 caused a pandemic and Andes virus has only produced contained outbreaks.

What are the symptoms of Andes virus?

Early symptoms of Andes virus infection can look like many other illnesses, including fever, headache, muscle aches, nausea and fatigue.

In some people, infection can progress to hantavirus pulmonary syndrome, a life-threatening condition in which breathing becomes difficult.

How long after contact can you get symptoms?

The WHO recommends people exposed to Andes virus monitor for symptoms for 42 days after their last potential exposure.

This reflects the outer limit of the time between infection and symptom onset. It doesn’t mean people are infectious for 42 days.

Australian authorities have announced the returning passengers will initially spend three weeks in quarantine, with further monitoring arrangements to follow.

Melbourne’s Doherty Institute will undertake the testing using polymerase chain reaction (PCR), which detects the virus’s genetic material and blood-based antibody testing, known as serology.

A negative test early after exposure is useful, but not always definitive. If the virus is still incubating, there may not yet be enough viral genetic material or antibody response to detect.

How does the virus progress?

The long incubation period reflects how Andes virus progresses, compared to SARS-CoV-2.

COVID symptoms typically appear within days because the virus replicates rapidly in the respiratory system.

Andes virus progresses differently. Severe disease is linked to blood-vessel dysfunction and inflammatory responses. The breathing problems associated with the complication hantavirus pulmonary syndrome aren’t caused by the virus directly destroying lung tissue, but by the immune system’s delayed response. This causes fluid to leak into the lungs and makes breathing difficult.

How deadly is it?

Fatality rates vary significantly between hantavirus species.

European and Asian hantaviruses typically cause death in less than 1%-15% of cases, while hantavirus pulmonary syndrome from American strains, including Andes virus, can reach up to 50%.

For context, in 2025, eight countries across the Americas reported 229 hantavirus cases and 59 deaths. These are severe infections, but they remain rare events.

A virus doesn’t become a pandemic simply because it’s deadly.

Can Andes virus be treated?

There is no specific antiviral drug for Andes virus. Health care for infected people focuses on close monitoring, supporting their breathing and managing complications to the heart and kidneys.

There is no licensed vaccine to prevent Andes virus.

However, there is also good news in how quickly the scientific response has come together after this outbreak started. Swiss laboratories collaborated quickly to sequence the complete genetic code of the virus from one patient and made it publicly available within days.

This gave researchers around the world a reference to compare other cases against. This can support faster confirmation of suspected cases, while helping public health teams identify which cases are linked to the outbreak and who needs monitoring or isolation.

Bottom line

The instinct to see another Covid in every viral outbreak is understandable but, in this case, misleading.

The Andes virus is dangerous to those infected, but it isn’t a good candidate for pandemic spread. It incubates slowly, typically spreads through close contact, and transmission appears most efficient when people are symptomatic.

It’s important to get the Andes virus under control but it’s not a pandemic threat like COVID.

Rhys Parry is Research Fellow, Virology, The University of Queensland.

This article was first published on The Conversation.

On the morning of March 27, a group of eager onlookers gathered around a robot and a computer screen at a convention centre in Mumbai. Among them was Maharashtra Chief Minister Devendra Fadnavis.

They watched as a doctor, wearing polarised 3D glasses, manoeuvred two arms of the robot.

The patient, though, was 800 km away.

Suryabhan Sambharkar lay in Nagpur’s Government Medical College, with a second robot and its multiple arms docked on his lower body.

It began to operate on Sambharkar’s hernia, getting its directions via the internet from the robot in Mumbai.

The robotic arms operated for about 40 minutes. Then, the doctor stopped and rose. He had made a point – that robots could be used for telesurgery.

A team of doctors in Nagpur took over and finished the surgery, without the help of the robot.

“The robot was specially arranged to showcase the telesurgery,” said Dr Raj Gajbhiye, dean at the Government Medical College.

The robot in Mumbai had been supplied for the medical conference by Medbot, a Chinese multinational company that develops surgical robotic systems, and was an associate partner for the event.

“I had not heard of robotic surgery before this,” 52-year-old Sambharkar, who works at a cloth store and earns Rs 10,000 per month, told Scroll later as he recovered at his home.

He said his family agreed to the surgery only because the government paid for it.

But did Sambharkar need robotic surgery?

Several experts Scroll spoke to said a robot would have offered no additional benefit to the patient.

“For a simple non-complicated hernia procedure, a laparoscopic surgery is preferable to robotic,” a surgeon based in South Mumbai told Scroll.

Laparoscopy too is a minimally invasive procedure, where instruments and a camera are inserted in the body through small incisions to operate inside the stomach or pelvic region.

A robot-assisted surgery takes longer and costs more. A hernia surgery using a robot costs between Rs 1.5 lakh and Rs 4 lakh, about a lakh more than a common procedure using a laparoscope. It also takes an hour extra to dock and undock the robot’s arms on the patient.

But as more private hospitals install and advertise robotic systems, patients are being pushed to undergo robotic procedures even for small operations, patients and doctors told Scroll.

What is robotic surgery?

A robotic surgery is not carried out by the robot on its own, without human guidance.

The procedure is conducted by a surgeon, who controls the multiple mechanical arms of the robot through an electronic console. The robotic arms cut, operate and stitch according to the surgeon’s commands.

“It is just a tool. A surgeon still has to be skilled in doing an operation,” robotic surgeon Dr Imran Hamzawala said.

When Hamzawala moved to India from the United Kingdom over a decade ago, trained in both robotics and laparoscopy, he found that hardly any hospitals here had robots.

The first surgery using a robot was done in AIIMS, Delhi, in 2006. By 2020, there were fewer than 100 robotic machines installed in India. In 2025, the figure rose to over 500, data from the Clinical Robotic Surgery Association shows.

Nearly 50,000 robotic procedures were conducted in India in 2025, as opposed to 12,800 surgeries conducted between 2010 and 2020.

Hamzawala, who is a gynaecologist and a cancer surgeon, said he found a robot extremely useful. “It magnifies the body part being operated on 10 times and gives a 3D high definition visualisation,” he said.

Tiny blood vessels appear enlarged on the console screen, drastically reducing the risk of accidentally snipping them. Hamzawala found it useful in removing the delicate tissue lining outside a uterus in patients with endometriosis.

“It also gives the surgeon more comfort during a long surgery,” Hamzawala, who is associated with a company that makes such robots, said. “The surgeon can sit at the console and direct the robotic arms. The risk of injury reduces, the incision is smaller than an open surgery and the recovery is quicker,” he said.

Dr Avinash Supe, director at Hinduja hospital, also agreed that robotic surgeries benefit where precision is required in complex procedures involving “oncology, [or the] pelvic and anorectal [regions]”.

Surgeons, however, cautioned against its indiscriminate use.

Dr Rahul Mahadar, a Dombivali-based surgeon, said that “for many procedures that are minimally invasive, laparoscopy is better than robotic surgery” because the incisions made are smaller.

“The incision required to insert a robot’s arm is 8 mm, compared to a laparoscope’s incision of 5 mm. Mini laparoscopy makes a 3 mm incision,” he said.

Despite that, certain hospitals push for robotics even if it is not required, Mahadar said.

‘Costs to recover’

Over 20 international and Indian companies manufacture robots. The largest share in the market is held by Intuitive Surgical, which makes the Da Vinci robotic systems.

Of the 50,000 surgeries carried out in 2025 in India, 45,000 were conducted using Da Vinci robots.

Nearly 250 Intuitive robots are used in India. It is followed by Indian manufacturer SS Innovations that has sold 160 robots across Indian hospitals, data from Clinical Robotic Surgery Association shows. Other manufacturers include Medbot Surgical, Meril, and Stryker, which have a smaller footprint.

A robotic system, including the console and the arms, can cost Rs 20 crore and upwards. Indian models are cheaper. Annual maintenance on these systems is another 5%, roughly Rs 1 crore, per year. “These are costs that the hospital has to recover. They push doctors to encourage robotics to patients,” a surgeon said, requesting anonymity.

Doctors, too, need to perform simple procedures using robots to gain experience. As a result, patients are being nudged to opt for robotic surgeries, even if they are more expensive.

For a patient, this can mean an additional cost of Rs 1.25 lakh to Rs 10 lakh depending on the procedure. “This is the giant elephant in the room,” the surgeon said.

A Mumbai-based joint and spine surgeon, who has recently learnt robotics, said such surgeries drive up costs in other ways.

In the case of orthopaedic robotics machines, doctors are forced to use implants from the same manufacturer. “We use cheaper Indian-made implants for hip or knee which are of good quality,” they said. “But if I am using a robotic system from Medtronic, it will be compatible only with its own implants. That further escalates the surgery cost.”

Training surgeons

Another area of concern is the absence of uniform guidelines in training doctors in robotic surgery.

When a hospital buys a robot, they send a few surgeons to be trained by the manufacturer in sessions that last from a day to five days. Intuitive System, which has been in the market since the past two decades, has a streamlined training process at their centre in Bengaluru. Surgeons said newer companies are still struggling to form a training module.

Once trained, the doctors then conduct a set number of surgeries under a mentor to get certification before they operate independently. Hamzawala is one such mentor.

But doctors Scroll spoke to said nobody checks whether a surgeon has gained adequate knowledge before operating independently.

Some doctors said they found the training inadequate.

Robotic training is yet not part of MBBS or post graduation curriculum. Moreover, a patient has no means to verify how qualified a doctor is in robotic surgery.

A South Mumbai-based gastrointestinal surgeon said he underwent online training and two sessions on a simulator. “I am still not confident of doing a robotic procedure,” the surgeon said. “But my hospital will still allow me to do it. There is no safeguard.”

Delhi-based Dr Vivek Bindal, chairman of Clinical Robotic Surgery Association, admitted that “a uniform module for training under robotics is a must.” “We have begun courses for doctors to learn robotic surgery. They have to give an exit exam,” Bindal said.

These courses, even when they exist, are not affiliated with the National Medical Commission.

The gastrointestinal surgeon Mahadar said if a proper training module is not formed, a surgeon may commit an error. “Rarely do robotic arms malfunction. If there is a failure, it is because of a surgeon’s mistake,” Mahadar said.

‘A long battle’

Last year, surgeons at Yashoda Superspecialty hospital in Kaushambi advised 35-year-old Ujjwal Chaudhary to undergo a robotic surgery for large umbilical hernia.

“The surgeon had pointed out to him that he is slightly obese and a robotic procedure would be better for him,” said his brother Arpit Rathi.

The family was told that robotic surgery would be painless and the recovery faster. The family found that a routine laparoscopic surgery would cost Rs 1.5 lakh, while the robotic surgery billed up to Rs 2.5 lakh.

“Initially we faced some problems with insurance clearance because they had approved a normal laparoscopic procedure but it eventually got approved under the corporate policy,” Rathi said.

On May 26, 2025, Chaudhary was wheeled into the operation theatre. “The surgery was exceptionally long, it went on till the evening. The surgeon told us that his intestine was cut accidentally and they had to stitch it,” Rathi said. Chaudhary’s wife was asked by the surgeon to “pray”.

The next day, Chaudhary’s blood pressure fell and he complained of abdominal pain. An ultrasound and CT scan were conducted. It showed that he required an exploratory laparotomy, a life-saving procedure when the bowel is ruptured.

Chaudhary underwent a second surgery on May 29, this time a laparoscopic procedure. By May 30, he required ventilator support.

In the wee hours of June 2, he passed away, leaving two children behind.

“We tried to find out what went wrong during the robotic surgery. We tried to find how trained the doctor was in robotics. But the hospital gave no further information on the number of procedures done,” Rathi claimed.

According to the hospital’s website, the surgeon who operated on Chaudhary received certification for console training in 2023 and later underwent advanced training the same year. The hospital did not respond to Scroll’s email inquiring about the robotic surgery, the training doctors are mandated to undergo and the monitoring.

Rathi has approached the National Consumer Disputes Redressal Commission, the district court in Ghaziabad and the Uttar Pradesh Medical Council.

“Our case raises questions on the quality of training doctors receive for these new technologies,” Rathi said.

The state medical council is yet to begin hearing in their case. “It will be a long battle,” he says.

The insurance check

As private hospitals push robotic surgeries, insurance companies have put in place a few checks – and have even rejected full reimbursement for the procedure if a laparoscopic intervention was rejected without valid reasons.

Most insurance companies have complied with directives from the Insurance Regulatory and Development Authority of India, making it compulsory for insurers to cover robotic surgeries.

But they added clauses to robotic procedures that lead to only partial coverage for individual insurances.

Mumbai-based Suman Sharma underwent a robotic surgery for bladder cancer in HN Reliance hospital in Mumbai on March 9. Her insurance coverage was Rs 10 lakh. The surgery cost Rs 13.17 lakh. “But the insurance company reimbursed only Rs 3.5 lakh,” her relative said.

Her insurer, Star Health, stated that the total billed amount was in excess of what the policy allowed, documents seen by Scroll show. It also deducted an amount, citing the high cost of the hospital room. The relative, requesting anonymity, said they plan to appeal with the insurance ombudsman.

Milind Gurav, an insurance broker, said it is common for insurance companies to refuse full coverage for robotic procedures. “Most insurance companies, both public and private, in order to comply with IRDAI’s mandate, provide insurance but cap robotic procedures at 50% of sum insured,” he said. “For full coverage of robotic surgeries, some insurance companies charge a premium ranging between 5% to 10%,” he added.

That means that patients have to pay more to get insured under robotic procedures.

Gurav pointed out: “We have noted that certain private hospitals and senior doctors push for robotic surgery unnecessarily. If normal treatment works, why will an insurer pay more for using robotics?”

Child malnutrition remains one of the most pressing challenges in India. Nearly one-third of children under the age of five are stunted: a condition reflecting chronic undernutrition that has lasting consequences for physical growth, cognitive development, and later-life outcomes.

But these outcomes are not evenly distributed. A closer look reveals stark inequalities across social groups. In earlier work , we show that children from historically marginalised caste groups are significantly more likely to be stunted than their more advantaged counterparts. These gaps are large, persistent, and visible across the country.

What explains these gaps? A substantial body of research has pointed to factors such as poverty, sanitation, birth order, and gender bias. These are undoubtedly important. Yet, taken together, they do not fully account for the scale of the disparities we observe across caste groups.

In recent work published in the Journal of Economic Behavior & Organization, we take a step further and ask whether caste-based discrimination may be an important part of the story.

A simple comparison across a historical boundary

To examine this, we make use of a historical and social divide within India: the Vindhyas mountain range. The Vindhyas have long marked a boundary between the regions where the areas to the North of the Vindhyas range comprise the North Central and Central plains, also known as the Indo-Gangetic plain, once home to the Indus Valley Civilisation around 3000 BCE, and later known as “Aryavarta” during the Vedic period (c 1500-600 BCE).

This is what was historically the historical geographical span of Hinduism, bounded to the south by the Vindhyas mountain range.

Drawing on this history, we suggest that the caste system and practices such as untouchability more strongly define the social code of the caste system to the North of the Vindhyas range compared to the South of the Vindhyas range.

This variation provides a useful lens. If discrimination plays a role in shaping child health, we might expect outcomes for marginalised groups to differ across this boundary in ways that are not observed for more advantaged groups.

What we see in the data

We begin with a simple comparison. Figure 2 below plots stunting rates and height-for-age scores for children living within 100km to the north and south of the Vindhyas. The contrast is revealing.

For children from Hindu upper-caste groups, there is little to no difference in stunting rates or height outcomes across the boundary. In other words, living north or south of the Vindhyas does not appear to matter for this group.

For children from the Scheduled Castes, however, the picture is very different. Those living to the south of the Vindhyas have substantially better outcomes – lower stunting rates and higher height-for-age scores – than those living to the north.

When we formalise this comparison using a statistical (difference-in-differences) framework, the differences remain large. SC children living south of the Vindhyas are, on average, about 0.24 standard deviations taller and roughly 7 to 8 percentage points less likely to be stunted than their counterparts to the north. Given a baseline stunting rate of around 29%, this represents a sizable improvement.

Could it be something else?

Of course, differences across regions could reflect many factors. We therefore conduct a series of checks to rule out alternative explanations. First, we show that the results are robust to different ways of defining the comparison area – expanding the geographic window or excluding areas very close to the boundary. The patterns remain stable.

Next, we examine whether the results could be driven by economic or socioeconomic differences. Household wealth, as expected, is strongly associated with child health outcomes overall – children from wealthier households are less likely to be stunted. However, what matters for our analysis is not the level of outcomes, but how they differ across the north and south of the Vindhyas.

Here, we find no evidence that wealth explains the pattern we observe. In particular, poorer households do not experience any additional improvement from living south of the Vindhyas. In other words, while wealth matters in general, it does not account for the north-south differences in outcomes.

We then turn to other disadvantaged groups. If the observed pattern simply reflected broader socioeconomic disadvantage, we should expect to see similar improvements for all such groups.

However, this is not what we find. For groups that are economically disadvantaged but not historically subject to caste-based discrimination – such as Scheduled Tribes or higher ranked Muslims – we do not observe comparable differences across the boundary.

By contrast, the pattern is present for groups with a history of caste-based exclusion, such as the lowest rung of Muslims, who are described as Dalit Muslims. This suggests that the observed differences are not driven by disadvantage alone, but are more closely linked to the legacy of caste-based discrimination.

We also conduct placebo exercises, shifting the boundary arbitrarily northward or southward. These comparisons yield no meaningful differences, suggesting that the patterns we observe are specific to the historical divide marked by the Vindhyas.

Taken together, these results make it less likely that the observed differences are driven by general regional or economic factors.

What about underlying mechanisms?

We also explore a wide range of factors that are known to influence child health – maternal education and health, household conditions, sanitation, access to water, and broader community characteristics.

These variables matter. Accounting for them reduces the overall gap in outcomes between caste groups, highlighting the importance of material conditions and public health infrastructure.

However, a key finding remains: these factors do little to explain the difference we observe across the Vindhyas for SC children. The improvement in outcomes for those living to the south persists even after accounting for these variables.

A suggestive conclusion

Taken together, the evidence points to a consistent pattern: differences in child health outcomes across this historical boundary are concentrated among groups historically exposed to caste-based discrimination and are not easily explained by observable economic or environmental factors.

This does not allow us to make a definitive causal claim. But it is consistent with the idea that caste-based discrimination may play an important role in shaping early childhood outcomes.

If so, this has important implications. Efforts to reduce child malnutrition often focus – rightly – on improving income, nutrition, and public health infrastructure. But our findings suggest that addressing deeply embedded social norms and exclusionary practices may also be critical.

Understanding and tackling these underlying social barriers could be an important step toward reducing persistent inequalities in child health in India.

Ashwini Deshpande is Professor and Head, Department of Economics and Academic Director, CEDA, Ashoka University. Her email ID is: ashwini.deshpande@ashoka.edu.in.

Rajesh Ramachandran is Monash University, Malaysia. His email ID is rajesh.ramachandran@monash.edu.

This article was first published by the Centre for Economic and Data Analysis, Ashoka University.

The outbreak of hantavirus poses no immediate public health threat to India, chief of the National Institute of Virology told PTI on Friday.

The comments came amid concerns about two Indians reportedly having been infected by the hantavirus on board a cruise ship in the Atlantic Ocean. Both were asymptomatic and are under observation, The Indian Express quoted unidentified Union health ministry officials as saying.

The cases appear to be isolated ones and there was no evidence of community spread of the infections so far, PTI quoted Dr Naveen Kumar, the director of Indian Council of Medical Research's virology research institute, as saying.

Unlike the SARS-CoV-2 virus that causes Covid-19, hantavirus does not spread easily among humans, Kumar told the news agency.

“Human-to-human transmission is extremely uncommon,” he told PTI. “...Limited person-to-person transmission has only been documented with some South American strains such as Andes virus.”

Kumar was quoted as saying that India has the laboratory surveillance capacity to identify suspected cases of hantavirus. He urged people working in rodent-prone environments such as ships, warehouses, storage facilities and poorly ventilated spaces to maintain hygiene.

On Thursday, the World Health Organization said that more cases of hantavirus infections could emerge after the disease killed three passengers of the cruise ship MV Hondius. However, the global health authority said that it would be “a limited outbreak” if public health measures are implemented by countries.

The deaths on board the cruise ship in the Atlantic Ocean have sparked global health concerns.

Abdirahman Sheikh Mahamud, who heads the World Health Organization’s emergency alert and response operations, said on Thursday that the organisation was focussing on “a cluster in a confined space with close contact”.

“We don’t anticipate a large epidemic with the experience our member states have and the actions they have taken,” The Guardian quoted him as saying. “We believe that this will not lead to a subsequent chain of transmission.”

What is hantavirus?

Hantavirus is a zoonotic disease, meaning it is communicable from animals to humans. It is carried by rodents that can cause a range of severe illnesses among humans, and possibly death. People usually get infected by Hantavirus through contact with infected rodents or their droppings or saliva.

There are no vaccines and no specific treatment that cures hantavirus diseases, according to the World Health Organization. But early supportive medical care, such as close clinical monitoring and management of respiratory, cardiac and kidney complications, can help improve the chances of survival, according to the global health body.

Prevention depends largely on reducing contact with infected persons and rodents. Andes hantavirus found in South America is a known virus for which limited human‑to‑human transmission among close contacts has been documented, according to the World Health Organization.

In humans, the symptoms usually begin between one week to eight weeks of exposure to the virus. The symptoms typically include fever, headache, muscle aches and gastrointestinal problems such as abdominal pain, nausea or vomiting.

Edited by Nachiket Deuskar

The World Health Organization on Thursday said that more cases of hantavirus infections could emerge after the disease killed three passengers of a cruise ship.

However, the global health authority said that it would be “a limited outbreak” if public health measures are implemented by countries.

The deaths on board the cruise ship MV Hondius in the Atlantic Ocean have sparked global health concerns.

What is hantavirus?

Hantavirus is a zoonotic disease, meaning it is communicable from animals to humans. It is carried by rodents that can cause a range of severe illnesses among humans, and possibly death. People usually get infected by Hantavirus through contact with infected rodents or their droppings or saliva.

There are no vaccines and no specific treatment that cures hantavirus diseases, according to the World Health Organization. But early supportive medical care, such as close clinical monitoring and management of respiratory, cardiac and kidney complications, can help improve the chances of survival, according to the global health body.

Prevention depends largely on reducing contact with infected persons and rodents. Andes hantavirus found in South America is a known virus for which limited human‑to‑human transmission among close contacts has been documented, according to the World Health Organization.

In humans, the symptoms usually begin between one week to eight weeks of exposure to the virus. The symptoms typically include fever, headache, muscle aches and gastrointestinal problems such as abdominal pain, nausea or vomiting.

No large epidemic anticipated, says WHO

Abdirahman Sheikh Mahamud, who heads the World Health Organization’s emergency alert and response operations, said that the organisation was focussing on “a cluster in a confined space with close contact”.

“We don’t anticipate a large epidemic with the experience our member states have and the actions they have taken,” The Guardian quoted him as saying. “We believe that this will not lead to a subsequent chain of transmission.”

Infections on board the cruise ship

A passenger is believed to have contracted the hantavirus before boarding the ship and infected others as it sailed across the Atlantic Ocean, AFP reported. A Dutch couple who had travelled around South America before boarding the ship in Argentina’s Ushuaia on April 1 were the first fatalities.

A German passenger died on May 2. Her body remains on the ship, AFP reported.

On Wednesday, three persons were evacuated from the ship when it anchored off Cape Verde. A fourth landed in Amsterdam on Thursday, AFP quoted the ship’s operator as saying.

The company said that no persons were showing symptoms of the infection on board. The ship is sailing towards Spain’s Canary Islands, where it is expected to reach on Sunday.

On April 24, the body of the Dutch citizen was taken off the cruise in Saint Helena, an island in the southern Atlantic Ocean. Twenty-nine passengers had disembarked there, AFP quoted the ship's operator as saying.

The operator said it was working to trace all passengers and crew who got on or off the ship since March 20.

The World Health Organization informed 12 countries that their citizens had disembarked from the ship at Saint Helena.

Five confirmed cases, more suspected

World Health Organization chief Tedros Adhanom Ghebreyesus told reporters on Thursday that five confirmed and three suspected cases had been reported so far. This includes the three deaths.

“Given the incubation period of the Andes virus, which can be up to six weeks, it is possible that more cases may be reported,” he said.

Ghebreyesus was referring to the rare strain detected aboard the Hondius, which can be transmitted between humans.

Persons suspected to be or known to have contracted the hantavirus are being treated or isolated in the United Kingdom, Germany, the Netherlands, Switzerland and South Africa.

Source unknown

On Thursday, the health authorities in Argentina said that they had not yet been able to determine where the outbreak began, AFP reported.

“With the information provided so far by the countries involved and participating national agencies, it is not possible to confirm the origin of the infection,” the country’s health ministry said. The statement followed a meeting with the authorities from all Argentine provinces.

Argentine officials have been quoted as saying that they plan to test rodents in the coastal city of Ushuaia, from where the cruise ship had set sail on April 1.

Spreads differently to coronavirus, influenza

World Health Organization expert Maria Van Kerkhove said that there were no further symptomatic cases on board of the cruise, “which is a good sign, but of course, there is a long incubation period of the Andes virus”.

The hantavirus spreads “very, very differently” to the novel SARS-CoV-2, which causes Covid-19, and influenza and requires a more prolonged contact, she added.

Written by: Nachiket Deuskar. Edited by: Tanya Shrivastava

Antibiotics are one of the greatest breakthroughs in medical history. They turned once-deadly infections into treatable illnesses and made modern healthcare possible. But bacteria are changing, and some of the drugs we have depended on for decades are becoming less effective.

Around the world, infections are becoming harder to treat. This problem is known as antimicrobial resistance. It happens when bacteria evolve ways to survive medicines designed to kill them. It is estimated that drug-resistant infections already cause about 1.27 million deaths every year worldwide.

The World Health Organization has warned that we may be moving towards a “post-antibiotic era” in which common infections once again become dangerous, and even routine injuries or procedures carry serious risk.

A century ago, that was normal. A cut from gardening, a sore throat or childbirth could turn into a life-threatening infection. Doctors had few effective treatments, and infectious diseases such as pneumonia, tuberculosis and diarrhoea disease were among the leading causes of death. The arrival of antibiotics changed that dramatically.

Penicillin, discovered by Alexander Fleming in 1928, marked the beginning of one of the most important revolutions in medicine. Before antibiotics, tuberculosis was one of the world’s deadliest infectious diseases. In 1882, it killed one in seven people living in the US and Europe. Once antibiotics became available, many bacterial infections that had once been deadly could be treated effectively.

Antibiotics not only cured infections, but also made modern medicine far safer. Many procedures rely on them to prevent or treat infection, including caesarean sections, organ transplants, joint replacements and cancer chemotherapy.

Without effective antibiotics, these treatments would become much more dangerous. Fleming himself recognised that risk. When he accepted the Nobel Prize in 1945, he warned that misuse of penicillin could lead to resistance.

Living in a microbial world

The human body contains about 30 trillion human cells, but it also carries tens of trillions of bacteria on the skin and inside the body. Together, these communities form the microbiome, the vast collection of microbes that live in and on us. Many of them are not harmful. In fact, they help digest food, produce vitamins and support the immune system, the body’s defence system against disease.

So life is a finely balanced relationship between humans and the microbial world. But bacteria are ancient and extraordinarily adaptable. They have existed on earth for more than 3.5 billion years and survive in some of the harshest places imaginable, from deep-sea vents to polar ice.

Bacteria multiply very quickly and can also swap genetic material, meaning they can share useful survival traits with one another. Some produce substances that break down antibiotics before the drugs can do any damage. Others alter the parts of their cells that antibiotics are designed to attack.

Some develop tiny molecular pumps that push antibiotics back out of the bacterial cell. Others find alternative ways to carry out the jobs that the drug was meant to block.

These changes happen through random genetic variation, which means natural differences arise as bacteria reproduce. But heavy antibiotic use creates strong evolutionary pressure. When antibiotics kill bacteria that are vulnerable to them, the resistant bacteria are left behind to survive and multiply.

Conditions for resistance

Antibiotics are among the most commonly prescribed medicines in the world, and they are often used when they are not needed. In some countries, they are still prescribed for illnesses such as colds and flu, even though antibiotics do not work against viruses. In the UK, prescribing is more tightly controlled, but inappropriate use and public misunderstanding remain a concern.

Large amounts are also used in agriculture and livestock production. This can further encourage resistant bacteria to emerge and spread.

Across Europe, antimicrobial resistance is now recognised as a major public health threat. The European Centre for Disease Prevention and Control estimates that antibiotic-resistant infections cause more than 35,000 deaths each year across the EU and European Economic Area.

Doctors are now seeing infections that are difficult, and sometimes impossible, to treat. Some of the most worrying include methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and carbapenem-resistant enterobacterales (CRE). MRSA can resist several commonly used antibiotics. VRE no longer responds to vancomycin, while CRE can withstand carbapenems, some of the most powerful antibiotics available.

What a post-antibiotic world could look like

If antibiotic resistance continues to rise, the consequences for healthcare could be severe. Many routine medical procedures depend on antibiotics to prevent infection. Without them, surgeries such as hip replacements, organ transplants and some cancer treatments may become too risky to perform.

Even common infections could once again become life-threatening. A simple urinary tract infection could spread into the bloodstream. A skin wound could develop into a severe invasive infection, meaning an infection that spreads deep into the body.

One of the greatest concerns is sepsis, a life-threatening condition in which the body overreacts to an infection and begins damaging its own tissues and organs. Early treatment with antibiotics saves many lives. But when bacteria are resistant, those treatments may fail. That makes sepsis much harder to treat, and in severe cases doctors may have very few options left.

Healthcare could begin to resemble the pre-antibiotic era, when infection was one of the biggest dangers of everyday life.

Reasons for hope

The situation is serious, but it is not hopeless. Scientists are developing new ways to fight infection. Some researchers are exploring bacteriophages, often shortened to phages, which are viruses that infect and kill bacteria.

Others are working on anti-virulence drugs. Rather than killing bacteria outright, these drugs aim to disarm them by blocking the tools they use to cause disease. The hope is that this may place less evolutionary pressure on bacteria to develop resistance.

Another promising approach is host-targeted therapy. This means boosting the body’s own ability to fight infection, rather than attacking the bacteria directly.

Better diagnostic tests, stronger infection prevention and more careful use of antibiotics could also help preserve the drugs we still have. Antibiotics transformed medicine in the 20th century and saved countless lives. But they were never a permanent victory over microbes.

The challenge now is not just to develop new treatments, but to protect the antibiotics that still work. If we can do that, the post-antibiotic future many scientists warn about may never arrive.

Steven W Kerrigan is Professor of Precision Therapeutics, School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences.

This article was first published on The Conversation.

Insomnia may have been torturing humanity since ancient times, but over the last 20 years scientists have made progress in their understanding of chronic sleep deprivation.

Today, sleep deprivation is one of the most widespread reported psychological problems in Britain, with about a third of the adult population in England reporting frequent insomnia symptoms.

Insomnia rarely occurs on its own, which brings us to one of the biggest changes scientists have made in our understanding of chronic sleep deprivation. The vast majority of people with insomnia often have other mental and physical health conditions, like diabetes, hypertension, chronic pain, thyroid disease, gastrointestinal problems, anxiety or depression.

In its diagnostic history, insomnia coupled with another illness or disorder was called secondary insomnia. That meant that insomnia was considered a consequence of those other underlying conditions. As such, until fairly recently doctors did not generally attempt to treat secondary insomnia.

But in the early 2000s, both research and clinical practice evidence started to indicate that this approach was wrong. Scientists argued that insomnia could precede or long survive a primary condition. Abandoning this distinction between primary and secondary insomnia was a major advance in acknowledging that insomnia frequently was an independent disorder, requiring its own treatment.

What’s more, researchers have been accumulating strong evidence that helping people with their sleeping problems could actually lead to improvements in their other health conditions. Chronic pain, chronic heart failure, depression, psychosis, alcohol dependency, bipolar disorder, PTSD, can all improve for patients if they address their sleeping problems.

Who gets insomnia?

Over the past two decades, we have acquired more rigorous and international data illustrating how ubiquitous insomnia is. Insomnia affects almost everyone, though women, older people and people of lower socio-economic status are more vulnerable to it.

These groups experience a combination of biological, psychological and social risk factors that expose them to long-term sleep-disruption. For example, women often experience acute hormone fluctuations, pregnancy and birth, breastfeeding, menopause, domestic violence, caregiving roles, higher prevalence of depression and anxiety – all of which can lead to more opportunities for prolonged sleep disruption.

Some current issues in insomnia research include the need to understand different types of insomnia symptoms, and their relationship to health and performance risks. For example, there is evidence that difficulty initiating sleep (as opposed to difficulty staying asleep, or waking up too early in the morning) is associated with an increased risk of depression.

Similarly, scientists still have questions on changes in things like brain activity, heart rate, or stress hormones that accompany insomnia. In common with all other mental health disorders, we are still yet to find biomarkers of insomnia.

However, research has helped us understand some things people can do to prevent insonmia episodes progressing to chronic insomnia, which is harder to treat. When insomnia symptoms happen more nights than not, and last for more than three months, then a diagnosis of insomnia disorder, or chronic insomnia, can be made.

One of the most common and harmful habits that develop during periods of insomnia is lying in bed, trying to sleep. Scientists have learned that lying in bed awake leads to perpetual cognitive arousal and, in time, it teaches your brain to stop connecting bed and being asleep.

Thus, if you cannot sleep at night, get up and do something else absorbing, but calming – read, write a list for the following day, listen to calming music or do some breathing exercises. When you feel sleepy again, get back to bed. If you are tired the following day, a well-placed short nap is fine, in the afternoon, for a maximum of 20 minutes. However, one must be careful with daytime sleeping, as it may reduce sleepiness at nighttime, and going to sleep may become even more difficult.

For those who do struggle with insomnia, there are effective treatments recommended. The story of the profound changes from secondary insomnia to insomnia disorder speaks of the power of clinical diagnosis in providing a pathway to treatment.

Cognitive behavioural treatment for insomnia is a package of techniques designed to maximise sleepiness at bedtime. It involves structured steps which aim to modify behaviour and mental activity. There are some predictors of treatment success: shorter duration of insomnia symptoms (years, rather than decades), less depression or pain and more positive expectations towards CBTI. But CBTI is broadly effective across all groups of people with insomnia.

Even so, only a tiny proportion of people reporting insomnia symptoms seek medical help. People may consider insomnia symptoms trivial or manageable, or they may be unaware of the options. It may also be due to the unavailability of treatment options. CBTI remains largely unavailable in clinical practice, mainly due to doctors’ unfamiliarity with the treatment programme, and limited funding.

This pushes patients towards sleeping tablets, which are not an acceptable long-term solution. Sleeping tablets are associated with significant cognitive and motor impairment, increased risk of falls, dependence, tolerance and withdrawal symptoms, daytime lethargy, dizziness and headaches.

The main truly “new” class of sleeping pills are the dual orexin receptor antagonists (DORAs), which have shown a safety profile in many ways better than the traditional sedatives, especially around dependence concerns. But DORAs are not risk free or “mild” pills. They are relatively new to the market, first approved in the UK in 2022. So we lack long-term data to assess their safety for long-term use in people with insomnia.

A decent alternative is online self-delivered CBTI, on platforms such as Sleepful, which are free to access.

We have made great strides in sleep medicine over the past 20 years for people with insomnia, we just need to realise the potential of such profound changes by providing the right help for those suffering with it.

Iuliana Hartescu is Senior Lecturer in Psychology, Loughborough University.

This article was first published on The Conversation.

Being regularly active can improve your mental well-being, reduce your chances of disease and increase your lifespan.

The World Health Organization recommends that adults get at least 150 minutes of moderate activity (brisk walking, easy cycling) or at least 75 minutes of vigorous activity (running, tennis), along with at least two strengthening sessions, per week. But only 73% of adults meet these guidelines worldwide, and 51% of Canadian adults are considered physically inactive.

I’m a professor in Health Sciences at Simon Fraser University and I study how behaviours relate to health and disease. I also write a blog on the role health behaviours play in your health.

What is physical inactivity?

Physical inactivity is defined as not meeting the minimum guidelines for being active. Being physically inactive, however, doesn’t mean you’re not active at all. You could still be doing light activity, like general walking or household chores – just not moderate or vigorous activity. And in general, people who are inactive spend more of their time being sedentary.

Sedentary activities are those of very little or no movement and include sitting, lying down and standing. For most people, the majority of sedentary time is spent sitting.

Various studies report adults spend on average six hours per day sitting. But these studies are based on self-report. The few studies that have used direct measures of activity (such as accelerometers) indicate it may be closer to 10 hours of sitting per day.

This is a concern as the WHO labels physical inactivity as the fourth leading modifiable risk factor for death. It’s estimated that with a 10% increase in activity, 500 million early deaths could be prevented.

Biological changes and health concerns

From a biological perspective, being inactive is more than the opposite of being active. This is because sedentary activities result in unique physiological changes. When you sit, your metabolism slows down. This makes sense, as your energy needs are much lower. It’s not much different from a car engine shutting down at a stoplight.

Prolonged sitting can lead to an accumulation of fats (triglycerides) in your blood. As your body needs less energy when sitting (or lying) down, production of certain enzymes goes down. One of those is lipoprotein lipase, which breaks down fats in the blood so muscles and organs can use fat for energy.

In rodent studies, LPL decreased when the rodents were inactive. With continuous sitting over months and years, the excess fats can impair insulin and glucose metabolism, and increase your risk for Type 2 diabetes.

Other health risks include weakened muscles. Muscles need movement to keep strong. If they’re not being used, they shrink and get weaker. Varicose veins and deep vein thrombosis can also result from the continually pooling of blood in the lower legs that comes with sitting. And over years, your risk for dementia, cancer, heart disease and early death rise.

It’s quite common to wonder if being active can compensate for sitting. The short answer is yes – being active, even in the presence of long periods of sitting, is better for you than not being active. But it depends on how active you are, and how much you sit.

In a study I co-authored, we found increased sitting was associated with early death regardless of how active you are. But the risk was worse for those who were less active. For those who met the WHO’s physical activity guidelines, sitting for more than six hours per day had the same risk as those who sat less than six hours per day but did not meet the guidelines.

Managing sitting and sedentary behaviour

We’re not going to do away with sitting, nor should we. Sitting is needed to provide time for rest and recovery. Also, many tasks are more comfortably performed while sitting. At present, there isn’t a specific target for sitting time, other than to reduce how much siting you do.

Standing is often mentioned as a solution. And the standing desk industry has exploded in recent years. While standing will result in less sitting, standing for long periods has a similar effect on metabolism as sitting. Other health concerns of prolonged standing include muscle fatigue, varicose veins and potential for greater risk for heart disease.

Replacing sitting (or standing) with movement is the best solution. Our study found replacing 30 minutes of sitting with movement reduced risk for early death by two per cent in people who sat more than four hours per day. But getting up and moving for 30 minutes may not be possible in all situation, so it’s important to reduce continuous, uninterrupted sitting time.

Breaking up sitting every 20-30 minutes with two minutes of activity (light walking, jumping jacks, squats or anything else) is enough to keep your metabolism running and manage insulin and glucose levels. To remind yourself, set your phone alarm every 20-30 minutes and get up and move.

Other ways to decrease sitting time include taking phone calls while pacing in the office and holding walking meetings.

While most people are aware that being active has health benefits, it’s also important to know that being sedentary has health risks. Physical inactivity can adversely affect your health.

Scott Lear is Professor of Health Sciences, Simon Fraser University.

This article was first published on The Conversation.

How is it possible to spend tens of billions of dollars developing drugs to treat a serious disease that affects millions of people, and yet end up with something that does not work? This is a mystery that has bedevilled Alzheimer’s research for years.

A new review of the evidence has concluded that the leading class of Alzheimer’s drugs “ probably result in little to no difference” in a range of measures, including reducing dementia severity. This finding was quickly used to further justify the NHS’s decision two years ago not to fund these drugs.

These findings are disappointing, not just for researchers and drug companies, but also for the tens of millions of people and their families suffering from the effects of a devastating disease.

Medical research is often reported through success stories, but Alzheimer’s disease has remained stubbornly resistant to the development of life-changing breakthroughs. This has not gone unnoticed. A couple of years ago, investigative journalists uncovered significant fraud in important studies underpinning some of the science behind the leading Alzheimer’s drugs.

While this fraud is not solely responsible for the lack of progress in Alzheimer’s research, it does reveal how vested interests can distort science and how commercial interests can sometimes override indications that a specific approach may not actually be working. It also reveals how social, political and economic factors can distort and hold back entire fields of research.

A century of science, still no answers

The German psychiatrist Alois Alzheimer first identified the disease that bears his name in 1906. Over the subsequent years, it was found to be characterised by abnormal protein deposits in the brain called amyloid “plaques” and similarly misfolded protein tau tangles.

As these misfolded proteins are not found in healthy brains, it was assumed that they were the cause of the disease. But subsequent studies showed that the amounts of these protein deposits did not correlate well with disease severity, unlike similar diseases, where misfolded protein deposits occurring in other parts of the body led directly to organ failure.

This complex relationship between the pathological changes in the brains of people with Alzheimer’s and the psychological progression of the disease has split the research field for many years.

At one point, those proposing that amyloid deposits (or at least the molecular processes leading to them) were the main cause of the disease were even referred to as “Baptists”, while those holding tau as responsible were called the “Tauists”. Although these have been the main two theories as to the cause of the disease, there have been numerous others, such as linking the disease to the abnormal behaviour of neurotransmitters, inflammation, presence of pollutants, age-related changes, DNA damage, viruses and even sleep disturbance.

In situations like this, when there are many competing theories, researchers who start working on one theory can start to become entrenched. This is an unfortunate byproduct of competitive funding models, where research money tends to flow to the researchers who are most successful at arguing that their approach is the most promising and therefore worthy of receiving more research money. This is an interesting example of how science is not always an entirely objective endeavour.

This pressure on researchers to publish papers and attract funding is probably a contributing factor to the significant fraud linked specifically to some working on the amyloid hypothesis for Alzheimer’s. In one case, a researcher in the US was forced to resign from his university following the retraction of a much-cited paper, and the discovery that over 20 other papers may have similarly questionable data.

In a separate case, an academic faced fraud charges, while a pharmaceutical company they worked with came under investigation for allegedly misleading investors. Both of these cases were in connection with a different approach to treating Alzheimer’s, namely, targeting a protein called filamin A.

Indeed, controversies within Alzheimer’s research have become so frequent that they have inspired an entire book dedicated to examining the issue.

Matthew Schrag, a neuroscientist who played a key role in exposing elements of fraud in Alzheimer’s research, said: “You can cheat to get a paper. You can cheat to get a degree. You can cheat to get a grant. You can’t cheat to cure a disease. Biology doesn’t care.”

While scientific breakthroughs undoubtedly underpin much of modern life, the example of Alzheimer’s research serves as a reminder that the path from defining a problem to discovering a solution is rarely straightforward.

It would be nice to think that the main incentive for most researchers might be solving a problem or curing a disease, but the actual situation is far more complex. Research relies on funding, and researchers get jobs based on reputation, often in the form of publications. Because of this, the wrong behaviour can become incentivised.

The complexity of Alzheimer’s disease and the lack of obvious answers or cures make this field particularly susceptible to distortion by the social factors that can influence science.

As researchers and pharmaceutical companies compete for funding and investment, the science starts to get lost behind the games that are played. The end result is not only financial loss and lack of progress, but in the case of this devastating disease, millions of people also end up suffering through a lack of effective treatments.

Simon Kolstoe is Associate Professor of Bioethics, University of Portsmouth.

This article was first published on The Conversation.

Social media videos are claiming that mouthwash can raise risk of blood pressure – and potentially damage heart health.

According to some of these videos, this is caused by mouthwash wiping out “good” oral bacteria that are important for the cardiovascular system. While it’s a striking message, don’t throw your mouthwash away just yet. The reality is far more complex.

Our mouths contain a wide variety of bacteria. Together, these bacteria form a balanced and diverse microbiome which helps prevent the overgrowth of other bacteria linked to disease, supports normal metabolic functions and contributes to both good oral and overall health.

One of the important roles these oral bacteria have is converting the nitrate in our food (typically from sources such as leafy greens) into nitrite. When we swallow nitrite, the body turns it into nitric oxide. This happens via the nitrate-nitrite-nitric oxide pathway, also called the enterosalivary pathway. It’s one example of how bacteria contribute to keeping the body healthy.

Nitric oxide plays an essential part in regulating blood pressure and supporting brain function and muscle function.

But according to some online influencers, the reason mouthwash harms heart health is because it affects the “healthy” bacteria – the ones that produce nitric oxide.

Mouthwash and heart health link

Several small studies have actually found that giving people mouthwash can change the balance of bacteria in the mouth. This may reduce the bacteria’s ability to turn nitrate from vegetables into nitrite, which the body needs to make nitric oxide.

One study of 19 healthy volunteers found that the adults who used chlorhexidine mouthwash for seven days saw a small increase in blood pressure and reduced levels of nitrite.

An intervention study also reported that rinsing with 0.12% chlorhexidine gluconate mouthwash twice daily for one week significantly increased blood pressure in 27 healthy adults.

In another trial of 15 adults who already had high blood pressure, three days of chlorhexidine use further increased blood pressure.

The key detail that may be missed out of some of these online social media videos is the type of mouthwash used in these studies.

Many of the studies which have found a link between mouthwash use and blood pressure gave participants chlorhexidine. This is a strong, over-the-counter antiseptic mouthwash only recommended for short-term use in people with gum disease or after dental procedures where its antimicrobial effects are beneficial.

Chlorhexidine disrupts oral bacteria to help with infection control – including the bacteria that convert nitrate into nitrite. This makes it an ideal mouthwash to use for researchers wanting to study the nitrate-nitrite-nitric oxide pathway. However, it also means the findings may not reflect what happens with milder, everyday mouthwashes.

A trial with 12 healthy adults investigated the effect of three different mouthwashes (and gargling water, which acted as a control) on oral bacteria.

After drinking a nitrate-rich juice, researchers measured how much nitrate was converted to nitrite by oral bacteria. Water and the mild mouthwash (which didn’t contain harsh ingredients such as chlorhexidine) caused a typical response, where nitrate was converted into nitrite.

But the cetylpyridinium chloride mouthwash (which also has strong, anti-bacterial effects) partially blocked the conversion of nitrate to nitrite. The strongest chlorhexidine mouthwash almost completely stopped this process. This is consistent with their stronger antibacterial effects. The stronger types of mouthwash were also linked to higher systolic blood pressure.

Alcohol (ethanol) is another common ingredient in many mouthwashes, although formulations usually also include other active ingredients – such as essential oils. This makes it difficult to isolate the specific effects of alcohol.

As an antimicrobial, alcohol may influence the oral microbiome. Some studies have even suggested a possible association between mouthwashes containing alcohol and increased oral cancer risk. However, there are currently no studies that have specifically examined the effects of ethanol-only mouth rinses on the oral microbiome or cardiovascular health.

Overall, the body of evidence suggests that a mild, over-the-counter mouthwash, like the kind most people buy at stores, may be less likely to significantly interfere with nitrate-to-nitrite conversion or affect blood pressure.

In a long-term study of 354 adults, better routine oral hygiene, such as brushing and flossing, was linked to a lower risk of cardiovascular death over nearly 19 years. Regular mouthwash use did not appear to have any influence on heart health outcomes. This was true for milder mouthwashes containing flouride and alcohol, as well as stronger, anti-bacterial mouthwashes such as chlorhexidine and cetylpyridinium chloride.

The type of mouthwash matters

Together, these studies suggest that some types of mouthwash (such as chlorhexidine) disrupt beneficial oral bacteria and the nitrate-nitrite-nitric oxide pathway when used long term. But more research needs to be done to truly understand the long-term effects of other types of mouthwash on cardiovascular health – including mild everyday mouthwash brands and those containing alcohol.

Mouthwash comes in different types for different purposes, so it’s important to check the active ingredient on the back of the packaging. Alcohol-free and milder mouthwashes appear to have less effect on the heart-healthy bacteria than stronger types.

However, be aware to check the ingredients as even alcohol-free options can contain antibacterial agents such as cetylpyridinium chloride. As such, it’s best to choose one that fits your needs and use it in moderation. Strong mouthwashes containing chlorhexidine are best reserved for helping gum disease or oral infections.

It’s also worth noting that oral health and untreated infections can also contribute to heart disease more broadly. For example, a systematic review of 82 studies concluded that chronic oral disease and tooth loss was associated with risk of heart problems. This is why maintaining a healthy balance of mouth bacteria matters beyond your teeth.

Take care of your oral and overall health by keeping up with brushing, flossing, visiting your dentist and choosing a mouthwash that works for you.

Joanna L’Heureux is Postdoctoral Researcher, Public Health and Sport Sciences, University of Exeter.

This article was first published on The Conversation.

In 2025, while researching the recent rapid increase in the number of medical colleges in India, I discovered that this aspect of the country’s medical education policy was based, shockingly, on a non-existent World Health Organization recommendation: the “ideal” 1:1,000 doctor-to-population ratio.

Despite there being no such “WHO norm,” Indian policymakers have been employing it in decision-making for more than a decade. Even after substantially raising the numbers of medical colleges and doctors on the basis of that imaginary norm, many policymakers and experts continue to assert that India suffers from a shortage of biomedical or “allopathic” doctors. This “permanent shortage” stance seems like a manifestation of policy amnesia; not too long ago, there was a general consensus in the country’s public health discourse that India had an adequate number of doctors.

Indeed the arc stretching from the claim by AIIMS experts in 2000 that the doctor-population ratio had “already exceeded that required by the country,” to the comment in a 2005 government report that the aggregate of doctors in India was “not very low,” to confident assertions by 2012 that India had an “abysmally low” doctor-population ratio, constitutes an extraordinary U-turn in policy discourse.

With health indicators in India still worse than global averages, and health inequalities among the worst in the world, any assertion that the country has “too many doctors” risks being dismissed as unserious and insensitive. However, such a cursory dismissal is the product of a ubiquitous blind spot in health policymaking worldwide: the unquestioned assumption of a constant and ever-positive relationship between the number of doctors and health outcomes.

This assumption neglects the equally significant impact of other healthcare practitioners (midwives and nurses, community health workers, informal practitioners, AYUSH doctors and the like) of the geographic distribution – and not just absolute numbers – of practitioners, of the organisation and infrastructure of health services, and of broader social, economic, and political factors.

Hence, “too many doctors” could mean that a region has more doctors relative to other healthcare practitioners, or that disproportionately more resources are being channeled toward training doctors relative to investments in other domains, which also lead to better health outcomes, such as nutrition, clean water, and sanitation infrastructure.

Still, considering that a well-qualified and skilled doctor is a significantly positive contributor to the community, can a country ever actually have “too many” doctors? The deep permeation of the doctor shortage narrative has meant there is little academic appetite today to consider the possibility of a region possessing an adequate number of doctors, however defined, let alone an excess. Still, there are important instances of researchers and experts taking such a scenario seriously in the past.

Measures taken to Increase Availability of Doctors

🔹 There are 13,88,185 registered allopathic doctors and 7,51,768 registered AYUSH practitioners in the country, with a doctor-population ratio estimated at 1:811 at 80% availability

🔹 Hard area allowance provided to… pic.twitter.com/ZJ6haWI6SD

— PIB India (@PIB_India) March 27, 2026

‘Doctor anomaly’

In the latter half of the 20th century, many scholars looked broadly at the relationship between the number of doctors per capita (doctor “supply”) and health outcomes. Some found what they called the “doctor anomaly”: an unexpected positive correlation found in high-income countries between the number of doctors and mortality rates in younger populations. The authors – including the renowned Archie Cochrane – did not consider this correlation as causal, but indicated that it warranted further research.

A later article with a more global scope claimed to reject this finding. Another study argued that “on the margin,” doctors most likely have “no effect upon health outcome”, ie, beyond a certain density of doctors, having more doctors does not lead to any additional public health benefits.

A scholar specifically looking at the United States argued that, with respect to health level differences among population groups, “other socioeconomic and cultural variables are now much more important than differences in the quantity or quality of medical care,” and that “there is no reason to believe that the major health problems of the average American would be significantly alleviated by increases in the number of hospitals or physicians”.

Arguments urging policymakers to re-orient the country’s “doctor-centric” and “hospital-centric” healthcare system and stressing the importance of what are called the social, political, and economic determinants of health, were also common in the health policy discourse in India during this time.

In the late 1960s, policymakers were beginning to reconsider their primary reliance on doctors to achieve the state’s public health objectives, particularly because most doctors were choosing to practice in urban India or abroad, and not in rural areas where healthcare was most urgently needed. The long-in-the-making implementation of a national community health workers scheme in 1977 – vehemently opposed by doctors’ associations – was a major manifestation of this reduced importance of doctors in the health policy discourse.

A few years later an expert committee opined that India was slated to graduate more doctors than needed by its healthcare services. There were 220,000 biomedical doctors and the committee estimated that India “will not need more than 250,000 doctors” during that decade, which gave a doctor-population ratio of about 1:2,700. By the early 1990s, India had attained a doctor-population ratio of 4.4:10,000 (ie, 1:2,300), a ratio which then-policy experts deemed to be an excess of supply. Indeed, several other countries around this time were also acknowledging an “overproduction” of doctors.

‘Optimal Quantity’

There is no universally-accepted method or statistical measure to determine how many doctors makes for an optimal quantity. The closest is the WHO calculation of the global median density of “doctors, nurses, and midwives” being 49 per 10,000 population. The most commonly used indicator, the doctor-population ratio, is difficult to accurately measure due to, among other things, significant uncertainties in determining the number of practicing doctors and the relative proportions of primary care physicians and specialists. Besides, the definitions of an optimal ratio differ in different countries and time periods.

In the context of the current discourse on the shortage of physicians, we must also remember thatthere is “little rigorous research measuring the extent to which increasing the supply of physicians promotes greater utilization and even less evidence on whether it ultimately translates into improved public health”.

The research that does exist, like studies from Brazil and Bangladesh, has shown that physician supply has little effect on crucial health indicators like the infant mortality rate, with “other healthcare professionals, such as trained health workers, midwives, and qualified birth attendants” capable of providing “basic neonatal health services” potentially as well as doctors.

In the Indian context, the exercise of determining optimal doctor numbers is further complicated by the presence of several hundred thousand doctors of indigenous systems of medicine known as AYUSH doctors, as well as the widespread prevalence and public patronage of primary care practitioners with no formal medical qualifications, often called rural medical practitioners or RMPs.

For example, when we add the number of AYUSH doctors (who usually practice as primary care providers across India) to calculate the country’s overall doctor-population ratio, India can be said to have achieved the hallowed 1:1,000 target in 2007, when the government estimated the ratio to be 1:870.

However, subsequent ratio calculations excluded AYUSH doctors. In an ironic about-face, the government, after dedicating enormous resources to achieve the non-existent “WHO norm” of 1 biomedical doctor per 1,000 people, formally declared the achievement of that target in 2022 – but only through calculations that once again incorporated AYUSH doctors.

Shortage rhetoric

As of 2026, the official estimate of the combined doctor-population ratio is 1:811, not very different from what it was in 2007 (and probably even before). Nevertheless, the rhetoric on shortage continues, despite it being almost four years since the Union government announced the achievement of its own target.

Apart from the possible needlessness (in terms of public health) of this narrative, the consequent massive growth of medical colleges in India over a short time-span has been mind-boggling and raises many concerns about the quality of training that India’s future doctors are now receiving.

The government claims the increase to be from 387 to 780 colleges between 2013-’14 and 2024-’25 (an average of 2.9 medical colleges each month over the past decade). While India has thus added, on average, one medical college per 10 days for 11 years straight, it has, unsurprisingly, not been able to keep up the same pace in raising the input of the essential resources for medical training like teachers, cadavers, physical infrastructure, etc.

AIIMS -- top medical colleges in India -- have 37.4% vacant faculty positions out of 6,297 sanctioned posts, shows the government data.

Maximum 57.4% vacant posts at AIIMS Rajkot and minimum 22.8% in AIIMS Bhopal. #MedicalEducation https://t.co/vSo6BaY3O1 pic.twitter.com/jU5dBb2kN5

— Sanjay Maurya (@MeSanjayy) February 11, 2026

A section of public health experts in India has been urging policymakers to focus not on aggregate numbers and ratios of doctors, but on issues like geographic maldistribution and rural access. They have pointed out that many of the problems that we think will be improved by adding more doctors – eg, access to biomedical services and shorter waiting times – can be better resolved by addressing physician maldistribution and governmental neglect of public health services and infrastructure.

Indeed, the ignorance about the existing literature, which offers different ideas than the mainstream policy discourse, and the amnesia about the history of the discourse – at times claiming shortages, at other times asserting excesses – constitute major challenges in how policymakers and experts have approached the topic of optimal doctor numbers. The almost obsessive concern in recent times with raising the quantity of doctors has already led to anxieties about unemployment, even though one of the rationales behind building more colleges was to help young people find employment in the future.

All of these are worrying developments, and it is high time policymakers and experts took seriously the possibility that India presently has, and will have in the near future, an excess of biomedical doctors – or at least an absence of shortages. Every policy decision hereafter on healthcare and education in India needs to take into account these new potential realities.

Kiran Kumbhar is a CASI Postdoctoral Research Fellow.

This article was first published on India in Transition, a publication of the Center for the Advanced Study of India, University of Pennsylvania.

Iran said on Saturday that it was reimposing strict military controls on the strategic Strait of Hormuz, alleging “repeated breaches of trust” by the United States, CNN reported.

A day earlier, Tehran had fully reopened the Strait of Hormuz to commercial vessels after a 10-day ceasefire between Israel and Iran-backed militant group Hezbollah in Lebanon.

However, on Saturday, Iran said it had been forced to restore tighter controls on shipping due to what is described as repeated violations by the US and acts ​of “piracy” under ⁠the guise of a blockade of Iranian ports, Reuters reported.

There was no immediate response from the United States.

Here are more top updates from the conflict in West Asia:

• On Saturday, Iranian Parliamentary Speaker Mohammad Bagher Ghalibaf on social media said: “With the continuation of the blockade, the Strait of Hormuz will not remain open.” He added that passage through the waterway would require authorisation from Iran.
• United States President Donald Trump said that he may not extend the tentative ceasefire with Iran if negotiations fail to produce an agreement by Wednesday, CNN reported. Trump also said that Washington would obtain Tehran’s stockpile of highly enriched uranium one way or another, cautioning that the transfer could come “in a much more unfriendly form” if negotiations fail.
• Earlier, the president said that Tehran has “agreed to everything” in talks with Washington, including working together to remove enriched uranium from Iran and take it to the US, according to CNN.
• Trump’s administration on Friday issued a waiver allowing countries, including India, to purchase sanctioned Russian oil and petroleum products, that were loaded onto ships as of Friday. The US Treasury Department said that the waiver allows these purchases till May 16. An earlier 30-day waiver had expired on April 11. The move is aimed at easing global energy prices, which have increased amid the conflict in West Asia.

The war

The US and Israel launched an attack on Iran on February 28, claiming that Tehran’s action posed an existential threat to Israel. Washington acts as a guarantor of Israel’s security. Iran retaliated by striking Israel and US military bases in the region and targeting major cities in Gulf countries.

Tehran also effectively blocked the Strait of Hormuz, the narrow waterbody connecting the Gulf to the Arabian Sea, for most international commercial vessels, triggering a global energy crisis. About 20% of global petroleum supply passes through the maritime chokepoint.

Washington and Tehran had on April 8 agreed to a two-week ceasefire to allow further negotiations to end the conflict. While Israel, which was not involved in the talks, has not struck Iran since the ceasefire took effect, it had continued to attack Lebanon until Friday’s deal. However, peace talks that were held in Islamabad collapsed on Sunday.

Israel has been claiming that Iran is close to obtaining a nuclear weapon, which could alter the regional security balance. Tehran has long maintained that its nuclear programme is for civilian purposes.

South Africa is facing an alarming increase in non-communicable diseases and related mortality. According to Statistics South Africa, deaths due to non-communicable diseases such as type 2 diabetes and hypertension increased by over 58% between 1997 and 2018.

The crisis of overweight and obesity in the country adds to the risk of these diseases. Nearly 40% of the adult population is overweight. Although physical activity can help prevent and manage many non-communicable diseases, 47% of adults do not engage in any physical activity. Most people struggle to meet the World Health Organization’s recommended 150-300 minutes of moderate-intensity aerobic physical activity per week.

A significant part of the challenge is that people have adopted an “all or nothing” approach to physical activity. The perception is that one has to participate in structured workouts, such as gym sessions, running, or cycling.

Instead, research has shown that even brief, low-intensity movements can yield measurable physical and mental health benefits. Even everyday tasks count. New evidence shows that short movement bouts of less than five minutes can have positive health implications.

As researchers in exercise science and sports medicine we have observed that physical activity is particularly low in South Africa. Only 19.8% of adults meet the WHO’s guideline, against the global average of 73%.

Our study of 62 office-based workers at the University of the Witwatersrand also showed the short-term health impact of height-adjustable, sit-to-stand desks. Our intervention reduced prolonged sitting and slightly improved indicators such as body mass index and blood pressure. Given South Africa’s high burden of obesity and sedentary lifestyles among office workers, these improvements are encouraging and support global health messaging that even modest increases in daily movement can positively influence health.

These findings were the springboard for the “Mzansi, what’s your move?” campaign at the university. We want to encourage staff and students to move more by showing how simple actions add up to physical activity. The campaign is supported by a series of comics and murals on campuses.

Here, we highlight some of the actions that we used in our campaign to encourage everyone to get moving. These are daily tasks that may seem mundane but count as physical activity, while reflecting people’s realities.

Housework

Many people do not consider housework a form of physical activity. But tasks like sweeping, mopping or vacuuming require sustained movement and engage multiple muscle groups.

Scrubbing floors, washing windows and cleaning bathrooms involve movements such as squatting and stretching. Working in the garden can strengthen muscles too.

As part of our campaign, we’ve developed comic strips that highlight movements that can be done at home and in the community. We emphasise how all family members can move in ways that fit their lifestyles and physical abilities.

Active commuting

Walking or cycling to work or school contribute significantly to daily physical activity. Studies have shown that active commuting is associated with lower body fat, reduced blood pressure, and improved mental well-being.

Including movement into daily travel routines is a practical way to accumulate physical activity without setting time aside. Walking briskly to a train station, cycling a few kilometres to work, or taking a longer walking route to drop off children at school accumulates over time. Even seemingly small changes, such as getting off the bus one stop early or taking the stairs instead of the elevator, produce measurable health benefits over weeks and months.

However, achieving the full benefits of active commuting is complex and it relies on cities building and maintaining road infrastructure. In South Africa, safety is a legitimate concern for all road users. A 2024 Statistics South Africa report shows that more pedestrians than car occupants died in road crashes in 2007, 2013, and 2019. Another safety concern relates to the country’s high crime rates. People may be reluctant to walk, even in their own neighbourhoods.

These challenges are not insurmountable. For starters, people should consider people moving in groups, joining walking and running clubs.

Beyond what individuals can do, municipalities can do something about green spaces. This includes ensuring that parks are safe to walk in and are clean. Broken pavements and bicycle lanes need to be maintained in all neighbourhoods.

Incidental movements

Incidental movements refer to small bouts of activity that occur throughout the day. Integrating these movements into everyday life can yield significant health benefits, especially in office contexts, where many people sit for extended periods. Employers can try nudging staff, for example to use the stairs instead of elevators, with simple posters or painted footprints. Another way to encourage physical activity is to centralise shared equipment (printers, bins, water stations) so that staff walk short distances.

Micro-breaks also provide opportunities for informal movements. Stretching during meetings or after long sitting periods, standing discussions instead of seated ones, and walking meetings for small groups all contribute to the physical activity of employees.

In 2024, we investigated the short-term impact of physical activity interventions such as high-intensity interval training and moderate-intensity continuous training on 43 labourers at the University of the Witwatersrand. The number of participants in this study was small, but the findings show that our intervention reduced indicators such as waist circumference, body mass index, blood glucose and blood pressure, and improved physical fitness.

Way forward

People don’t need a gym membership or a strict workout schedule to get moving. Simple, everyday activities all add up to meaningful physical activity. Small movements help to reduce the risks of chronic diseases, strengthen muscles, boost mental wellbeing, and counteract the harmful effects of prolonged sitting.

These “movement snacks” make exercise accessible, manageable and sustainable, particularly for people who find structured workouts intimidating or time-consuming.

Merling Phaswana is Senior Lecturer, University of the Witwatersrand.

Philippe Gradidge is Professor, University of the Witwatersrand.

This article was first published on The Conversation.

Thirty-five-year-old Ritu Bhalla was twice diagnosed with blood cancer, at the ages of four and 11. She developed chronic hepatitis B as a long-term side-effect after cancer treatment.

Three years ago, while waiting for a follow up consultation in a hospital in Delhi, a woman who was not part of the hospital staff approached Bhalla – she asked her to provide a blood sample and sign a consent sheet to take part in a gastrointestinal clinical trial. But she did not explain why.

Bhalla asked for the information sheet or details of the study, but that only annoyed the woman, who she assumed was a trial coordinator, she said. Since no one came forward to explain the study, she refused to participate.

Experts say Bhalla’s experience isn’t a one-off occurrence. This is even as India’s regulatory framework covering clinical trials was significantly strengthened after the Supreme Court’s intervention in 2013, and subsequent amendments were made to the Drugs & Cosmetics Rules.

New rules include provisions for compensation to trial participants, and recording consent on video, especially among vulnerable populations. These, and mandatory registration of ethics committees with the central licensing authority, CDSCO, have improved safeguards for participants, said Poonam Bagai, founder and chairman, CanKids…KidsCan, which also hosts the Pediatric Cancer Research Institute (pCRI), an initiative focused on patient-centred paediatric oncology research.

However, “the video recording of the consent process of vulnerable trial participants isn’t happening,” said Amulya Nidhi of the Swasthya Adhikar Manch, a not-for-profit working in the clinical trials space.

Bagai said the consent process still often lacks true comprehensibility, limiting informed decision-making. “Consent forms may exist, but the key question is whether patients and families genuinely understand what participation means,” she said, noting that low health literacy remains a significant barrier in India. “Consent or assent for paediatric populations is another important area to address.”

Studies conducted among rural adolescents and hypertensive adults show that anywhere between 60% and 75% of the population is insufficiently informed.

“Many patients who participate in clinical trials in India aren’t aware that they could suffer an adverse drug reaction, contrary to getting better, nor are they aware of their rights in such an eventuality,” said Nidhi.

Further, “the Supreme Court has recommended the establishment of an apex committee to approve new clinical trials, and for those approvals to be based on a risk-benefit-analysis, on the innovation quotient of the new therapy and its usefulness versus existing therapies, and on the unmet medical needs of the country. Still, no such apex committee meeting has happened; and trials are being independently approved,” said Nidhi.

As India moves to expand clinical trials, with the 2026-’27 budget allocating Rs 10,000 crore over five years to strengthen biopharma and establish 1,000 accredited new clinical trial sites, there is a pressing need to improve patient awareness and ensure their rights are upheld.

To successfully scale clinical trials, a mindset shift from “guinea pig” to “aware patient” and the promotion of active patient participation is key, said Pooja Sharma, CEO, APAR Health, an organisation working to promote patient-centric research.

Awareness must to eliminate vulnerability

Low health literacy can make families more vulnerable, especially at emotionally difficult moments such as a serious diagnosis like cancer, Bagai said.

“At the same time, limited understanding may also prevent families from considering participation in legitimate research that could offer meaningful treatment opportunities,” she added.

National level policies and programmes are seen as the best way to promote health literacy but so far these have failed in delivering health information to underserved populations, according to an analysis of health inclusivity by the Economist.

“The need of the hour is widespread public awareness initiatives in urban as well as rural India, something like the Reserve Bank of India does to create awareness in the financial sector,” said Alishan Naqvee, one of India’s leading healthcare lawyers.

“Such campaigns need to be carefully crafted, as we are a large population with a huge disease burden,” said Naqvee. “A campaign shall not discourage participation in clinical trials, just as the RBI’s campaigns do not discourage people from opening bank accounts.”

In particular, awareness campaigns must target the most vulnerable people. For instance, “many trials are conducted in tribal areas, where there is a lack of health facilities and services, among less educated people,” said Vinod Shende, a health rights activist from Pune, Maharashtra. “Investigators organise free treatment camps, and illiterate, poor people get taken in.”

Alongside potential participant awareness, Sharma said there is a need for more aware researchers, who must understand “patient centricity”, and more aware clinicians who must be “aware of research as a care option”.

Subject recruitment grey area

India’s regulatory framework still doesn’t lay down clear guidelines for the recruitment process. “In India,” Nidhi said, “patients are usually enrolled from hospital out-patient clinics, unlike in the West where the trial is advertised and details such as the ethics committee members and other bits of information are clearly stated.”

Greater transparency in recruitment extends to informed consent. “Patients must be informed of the possibility of an adverse drug reaction, and that they have the right to pull out of the trial and be compensated for a loss,” said Nidhi, stressing that “this still doesn’t happen as it should.”

In the case of early phase clinical trials, unexpected adverse effects or even benefits are unknown at the time of designing the trial, and hence not mentioned in the consent documents. But patients must be made to understand this.

In August 2025, a participant of a trial for cardiac failure drugs who was promised Rs 20,000 for partaking was allegedly threatened by the company conducting the trial in Hyderabad, when he complained of severe chest pain and enormous worry because a fellow participant had succumbed to similar complaints a few days previously. Contrary to being treated, the participant was given Rs 500 and referred to a government hospital.

“It’s important to observe how consent functions on the ground,” said Preetisha Choudhury, a scholar researching the regulation of informed consent in clinical trials at the Department of Law, North-Eastern Hill University in Meghalaya’s Shillong. “In many instances, patients may have signed a consent form but not truly understood the purpose of the trial, the risks involved, and their right to withdraw.”

“Socio-economic vulnerability and therapeutic misconceptions can affect [a] patient’s understanding of a trial,” she added.

Therapeutic misconceptions refer to patients anticipating better care through the trial than existing treatment, and being attracted to participate in trials because of the promise of free treatment. Intense patient counselling is crucial to minimise “therapeutic misconceptions”, concluded this Tata Memorial Centre study of cancer trials.

Finance administration

An additional affidavit to a public interest litigation first filed in the Supreme Court in February 2012, by the Swasthya Adhikar Manch in April 2025, alleging investigator impropriety at the Sheth VS General Hospital, Ahmedabad, a municipal-run hospital, prompted a probe by the Drugs Controller General of India.

A preliminary report by a five-member team of the Ahmedabad Municipal Corporation confirmed financial irregularities in 58 clinical trials being conducted in the hospital, involving more than 500 patients.

About 15 doctors including the hospital’s medical superintendent were found to have diverted Rs 1.87 crore to their personal accounts over the previous four years.

Eight contractual doctors were dismissed and one faculty member was suspended.

A member of the Ahmedabad Municipal Corporation’s investigating team, on the condition of anonymity, told IndiaSpend that he blamed gaps in the regulatory framework for this scandal.

“Our existing regulatory framework adequately addresses the clinical aspects but it omits the financial and administrative aspects of a trial,” he said. “We need a policy covering the disbursements of funds, essentially, which stipulates how the trial budget should be disbursed – how much the principal investigator will get, how much the co-investigator will get, how much the hospital will get, and so on.”

“We studied the agreements of 62 clinical trials being conducted at the Sheth VS General Hospital, and insofar as the patients-related part was concerned, everything was in order,” he continued. “But the disbursements under different expenditure heads varied for each, which isn’t appropriate. We need a standard, fair policy for clinical trial budget disbursements across India.”

“Disbursements to the hospital supporting the trial, to cover the overheads, must also be clearly mentioned in the policy; it shouldn’t be left to the discretion of the institution,” said the investigating team member, adding that “Sheth VS General Hospital’s share hadn’t been disbursed.”

A senior officer of the Ahmedabad Municipal Corporation reportedly told the Times of India in 2025 that the investigating Drugs Controller General of India team didn’t recall “conducting routine inspections at the VS Hospital clinical trial site over the past four years”.

“It appears that the DCGI is short of regulators to monitor trials across the country,” said Nidhi.

As 1,000 new accredited trial sites come online, Bagai pointed out that the government will need to strengthen monitoring. “Oversight should be risk-based and enabling, ensuring ethical standards without discouraging responsible research.”

“Expansion is not inherently problematic,” said Choudhury. “But without careful monitoring, public trust may suffer.”

IndiaSpend has reached out to the health ministry and the Ahmedabad Municipal Corporation for comment on financial irregularities and trial monitoring lapses. The Ahmedabad Municipal Corporation directed us to individual officers but has not provided a response on record. The health ministry did not respond to queries at the time of publishing. We will update this story when we receive responses.

Ethics committee

Every institution conducting trials must have an ethics committee in place to review consent documents, monitor the conduct of clinical trials and even halt their progress if irregularities are identified in their conduct, and safeguard participant’s rights.

Ideally, the institution should appoint a third-party autonomous ethics committee composed of institutional representatives, community representatives, local health not-for-profits and public health experts.

Bagai added that patient and caregiver representation within ethics review and oversight processes is important, though structured participation remains limited in practice.

It’s also important that the ethics committee doesn’t report to the institution, said Nidhi. “Only then can it provide the right checks and balances.”

In the Sheth VS General Hospital, the trials were being overseen by an external private ethics committee.

Now that the budget has tabulated plans to increase infrastructure and accredited sites to strengthen research capacity, the focus must also be on growing ethical safeguards at the same pace, said Choudhury.

Accreditation for ethics committees on the lines of accreditation for hospitals (National Accreditation Board for Hospitals domestically and the Joint Commission International globally), may be an appropriate safeguard.

“Our ethics committee is registered with the DCGI [Drugs Controller General of India] as well as the Department of Health Research and is one of the very few ethics committees in India to be accredited by international agencies such as Strategic Initiative for Developing Capacity for Ethical Review,” said Sachin Punatar, member secretary, IEC-3 (ethics committee), ACTREC, Tata Memorial Centre, Navi Mumbai.

With the planned expansion of clinical trial sites, Nidhi proposed that the government appoint a representative for each, possibly as a member of the ethics committee.

Punatar said that in order to maintain the highest standards, new trial sites and newly registered ethics committees should be closely monitored until they acquire adequate experience.

Healthier clinical trial scenario

Clinical trials are considered as one of the best ways to advance science and improve patient outcomes. “India needs more clinical trials, particularly in oncology where survival outcomes remain uneven across geographies and innovation is critical,” Bagai said. Incidentally, of thousands of registered clinical trials running in India, oncology is among the fastest growing segments.

In oncology, there has been a tremendous improvement in patient outcomes through decades of research, said Punatar. “Trials to test new medicinal products in patients who have exhausted all standard therapies may offer a ray of hope for patients who may not have any further treatment options.”

However, nothing has been said so far about the kind of trials to be run at the 1,000 new trial sites, nor the kinds of sites to be promoted, said Nidhi.

“Clarity would help patients’ rights groups mobilise adequate support,” he said. “Trials should take place in public institutions.”

To strengthen accountability, Shende underscored the need for a speedy, easily accessible grievance redressal mechanism, helpline and online portal for patients participating in the trial, and for action to be taken on these complaints within a specific timeframe.

“Faster and more accessible grievance mechanisms would strengthen accountability,” agreed Choudhury, while also underscoring the need for “a more contextual consent model that adapts communication to participants’ realities”.

Additionally, “if India is investing Rs 10,000 crore in research infrastructure, some of that investment should also support patient education and patient-advocacy capacity building,” said Bagai.

Global frameworks such as the US FDA’s Patient-Focused Drug Development initiative and the European Medicines Agency’s patient engagement framework show that patient involvement improves trial design, retention and ethical robustness. So, “government engagement with initiatives such as PACER, which build the capacity of patient advocates to participate in research design, patient-led research, and public education, will be vital to creating a more ethical and patient-centred clinical research ecosystem,” Bagai said.

“For India to become a global clinical research hub, the focus must extend beyond laboratories and trial sites to building informed patients and informed communities.”

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

For many older adults, life is full of routines. Making breakfast, paying bills, shopping, driving, managing appointments and keeping track of medications are tasks done almost automatically. For most, these routines run smoothly, but for some, small disruptions begin to creep in.

These small struggles matter. Perhaps it starts with uncharacteristically forgetting to add an item to the grocery list or misplacing a pair of glasses. Maybe a chequebook gets mismanaged, or a favourite recipe becomes harder to follow.

These moments can be brushed off as part of aging or blamed on a busy mind. Yet, when these new difficulties persist over time, they may be more than just minor frustrations; they might be early signs of something far deeper.

Understanding functional changes

Daily functioning is a key measure of independence, reflecting not only memory, but the co-ordination, planning and attention required to navigate everyday life. Changes here are often subtle, and they can go unnoticed by family members or health-care providers.

Clinicians have long recognised that loss of functional independence, like difficulty performing everyday activities, is a hallmark of dementia. It is, in fact, part of the formal diagnostic criteria for dementia.

What is less widely appreciated is that these functional changes can emerge years before dementia is diagnosed, providing an early signal that the brain may be at risk. Even when memory seems intact, persistent new struggles in daily tasks may indicate that cognitive decline is starting quietly.

Persistent versus temporary struggles

Recent studies tracking older adults without dementia have found that those who experience persistent difficulties in activities of daily living (like preparing meals, shopping or driving) face a higher risk of developing Alzheimer’s disease in the years ahead.

In addition, these persistent impairments are linked to biological markers of the disease, detectable in spinal fluid long before memory loss becomes obvious. By contrast, temporary or occasional difficulties do not carry the same risk.

One of the key insights in this new research is the difference between temporary lapses and persistent functional changes. While almost everyone misplaces keys or forgets a name from time to time, chronic struggles that linger or worsen over months and years may reveal early disruptions in the brain’s ability to co-ordinate complex tasks.

These disruptions can be one of the earliest indicators that cognitive decline is on the horizon, even before conventional cognitive tests can detect it.

Families, especially those who live with or spend time daily with an older adult, are often the first to notice subtle but steady changes in function, like moments when their loved one struggles to follow a familiar schedule, double-checks every step in a process that used to be second nature or avoids tasks that were once routine. Recognising these patterns early can help families seek timely evaluation, support and planning.

Looking beyond cognitive screening tests

These findings also underscore the value of integrating functional assessments into routine health care. Traditionally, cognitive screening has focused on memory, attention or language tests. More recently, including assessments of changes in behaviour or neuropsychiatric symptoms have been included in dementia guidelines, even at screening of cognitively unimpaired older persons.

Measuring the ability to manage daily life may provide a window into brain health that is both a practical and potentially more culturally adaptable approach to early detection than cognitive screening. Standard cognitive screening tests can be affected by language, education or cultural background. For example, someone may score lower simply because the test uses unfamiliar words, assumes certain schooling or reflects cultural norms that differ from their own.

In contrast, observing changes in everyday function over time focuses on real-life abilities and can reveal early signs of brain changes, offering a practical and widely applicable way to detect risk.

Shifting the focus in aging and brain health

The story of everyday struggles as early warning signs challenges common perceptions of aging. What looks like normal forgetfulness may, in some cases, be a signal to pay closer attention. These subtle changes are not personal failures — they are clues, pointing to the need for care, support and awareness.

It’s also important to keep this in balance: not every struggle points to dementia, and many older adults maintain their independence without experiencing any decline in daily functioning. But for those whose difficulties persist and accumulate, the pattern is meaningful.

Based on the latest research, it is this persistence, rather than occasional slips, that is most strongly linked to future cognitive decline and brain changes associated with Alzheimer’s disease.

By shifting the focus from episodic forgetfulness to ongoing functional changes, families and health-care providers can act sooner. Support strategies, such as simplifying routines, using reminders or providing assistance with complex tasks, can help maintain independence while also serving as a form of early intervention. Early recognition also allows for better planning, access to resources and timely medical evaluation.

A window into brain health

Ultimately, the story of functional change in aging is one of vigilance and insight. Paying attention to what may seem like small, everyday difficulties can offer a glimpse into the brain’s health years before memory loss becomes obvious.

It’s a reminder that the subtle ways life becomes harder can carry vital information, and that early attention to persistent changes may make a meaningful difference in the course of aging and cognitive health.

If you’re interested in contributing to research on everyday function and brain health, Canadian studies like CAN-PROTECT and BAMBI are exploring how subtle changes in daily life may signal early risk for Alzheimer’s.

Both studies are led by Dr Zahinoor Ismail, a clinician scientist at the University of Calgary and one of the authors of this story. BAMBI is based in Calgary, while CAN-PROTECT is an online study open to participants across Canada. By joining such studies, you can help advance research that could make a real difference.

Maryam Ghahremani is Research Data Scientist at Hotchkiss Brain Institute, University of Calgary.

Zahinoor Ismail is Professor, Cumming School of Medicine, University of Calgary.

This article was first published on The Conversation.

Midlife can bring an unsettling realisation for many women: the years spent caring for others, raising children, managing work, running households and maintaining family life have taken a toll on their bodies.

Women in midlife may face a greater risk of chronic health issues due to decades of what psychologists call “self-silencing” – putting others’ needs first and holding back your own feelings. This pattern prioritises caregiving and maintaining harmony in relationships, often leading women to suppress their own needs, avoid conflict and hold back their true feelings.

Common forms of self-silencing include pleasing people, suppressing emotions, inhibiting self-expression and carefully monitoring what they say in order to avoid upsetting others.

Midlife itself is a period of significant transition, involving physical, hormonal, social and psychological changes. For women who tend to self-silence, this stage of life can bring additional strain. Studies show they may report greater mental and physical health symptoms, such as low mood, fatigue, poor sleep and increased aches and pains.

A growing number of studies suggest that long-term patterns of emotional suppression and stress in relationships are associated with a range of health problems, including depression, heart disease and stroke. Some research has also associated these patterns with metabolic conditions such as diabetes and chronic inflammatory illnesses, including autoimmune disorders and cancer.

Although these studies cannot show that self-silencing directly causes these conditions – only that the patterns tend to occur together – the findings have been consistent. A study from the University of Plymouth, for example, found that women with fibromyalgia were more likely to report a history of childhood trauma alongside lifelong patterns of self-silencing.

For many people, these coping styles begin early in life. Children growing up in threatening or unstable environments may learn to minimise their own needs, hide distress or avoid conflict as a way of protecting themselves. Over time, this way of keeping safe becomes an ingrained way of relating to others.

Midlife is often when women reach a crisis point and seek support – though accepting help can be difficult for those who are used to neglecting their own needs. They often become highly skilled at coping alone and may play down their struggles because they don’t want to burden others.

Learning to put yourself first

Research consistently shows that social support can have a positive effect on wellbeing. Sharing emotions with a supportive person can buffer against the physiological effects of stress, and practical support with everyday responsibilities can reduce feelings of being overwhelmed and the isolation that often comes with self-silencing.

Health professionals and therapists can also play an important role. Trauma-focused therapies such as EMDR and IFS can help women process childhood trauma, ease depression, improve health and reduce chronic pain.

Research in women’s health also recognises that when women do not assert their needs, it can generate anger and resentment. Left unexpressed, these feelings can lead to chronic depression.

Assertiveness training – delivered by psychotherapists and coaches – supports women to express their needs, opinions and boundaries in a clear and respectful manner, developing strategies to communicate preferences, say no and protect their time and space. Building these skills can reduce psychological distress and improve confidence and self-esteem.

Alongside assertiveness, psychologists recognise the importance of self-compassion – offering ourselves the same care, understanding and kindness we would extend to a loved one.

Kristen Neff, a professor and pioneer in the field, recommends three key practices: recognising and validating feelings of pain and suffering; acknowledging that suffering is a shared human experience; and maintaining mindful awareness of emotions, rather than being overwhelmed by them. In practice, this means reminding yourself that things are hard right now, that you are not alone and that you will get through it.

Further research has found real health and wellbeing benefits for women in midlife who practise self-compassion. Those who do tend to feel less stressed, and are more likely to maintain healthy habits that improve their health.

Neither self-compassion nor assertiveness are quick fixes, but both can play an important role in protecting emotional and physical health. When women learn to recognise their own needs, assert their boundaries and offer themselves kindness rather than criticism, they reduce feelings of stress – and the negative effects this has on the body.

For generations, women have been encouraged to care for others and maintain harmony in relationships – valuable and much-needed qualities. But they can come at a personal cost when women feel unable to express their own needs alongside them.

Understanding the links between social expectations, emotional expression and health may open up important conversations about how we can best support women to care for others without abandoning themselves.

Lowri Dowthwaite-Walsh is Lecturer, Psychology, University of Lancashire.

This article was first published on The Conversation.

Dengue, a mosquito-borne disease, affects millions of people every year across Asia, Africa and Latin America. And it’s expanding geographically as warmer temperatures and urban growth allow mosquito populations to thrive in new regions.

At first glance, dengue seems like an obvious candidate for vaccination. It is caused by a virus. Infection triggers an immune response. Vaccines against similar viruses already exist.

But dengue is complicated. It is not caused by just one virus, but by four closely related ones known as serotypes. When someone is infected with one, the immune system usually protects them against that specific type – but not against the other three. In some cases, a previous infection can actually make a new infection happen more easily.

Little wonder that dengue is one of the most common mosquito-borne viral diseases in the world. Scientists estimate that around 390 million infections occur every year, and it’s an important public health concern in Africa.

Currently, one dengue vaccine is established in global clinical use. Dengvaxia is only for use if a person has been infected before. A newer vaccine – TAK-003 – has been recommended by the World Health Organization for use in children aged 6–16 years in settings with high dengue transmission, regardless of prior infection status. It is administered in two doses. Additionally, next-generation vaccines are being developed, including one in Brazil.

Our work as researchers studying viral immunology and mosquito-borne diseases focuses on understanding how immune responses shape protection against viruses such as dengue.

Our recent research reviewed decades of dengue vaccine studies, including clinical trials and immunological analyses. The evidence shows that dengue vaccines must generate a carefully balanced immune response against all four viral serotypes. If protection is incomplete or uneven, it may increase the risk of severe disease in some individuals.

Understanding these immune mechanisms is essential for designing safer and more effective vaccines.

Overall, vaccine performance still varies depending on factors such as prior infection, age and transmission intensity, meaning that vaccination strategies must be carefully tailored to each population.

Dengue in Africa

Dengue outbreaks and evidence of transmission have been documented in Kenya, Tanzania, Sudan, Senegal and Côte d’Ivoire. It may be even more widespread on the continent than previously recognised, partly because testing and surveillance systems are still developing in many regions.

The disease spreads through the bite of infected Aedes mosquitoes, particularly Aedes aegypti. These mosquitoes breed in standing water, which is often near where people live. Dengue symptoms include high fever, headache, pain behind the eyes, muscle and joint pain, nausea and rash.

Most people recover within about a week, but in some cases the infection can become severe and lead to bleeding, organ damage or shock. Transmission tends to increase during rainy seasons, when mosquito populations expand.

In recent decades, cases have risen sharply as urbanisation, travel and climate change have expanded mosquito habitats.

The search for a vaccine

Infection with one dengue serotype usually provides long-term protection against that specific version. The problem arises when a person later becomes infected with a different serotype.

Instead of offering protection, antibodies from the first infection can sometimes help the second virus enter cells more easily.

This process, known as antibody-dependent enhancement, has been linked to more severe disease, including dengue hemorrhagic fever and shock. In simple terms: the immune system’s memory can sometimes backfire. That biological feature has made vaccine development uniquely difficult.

Our research revealed several important patterns.

First, vaccine performance depends heavily on whether someone has previously had dengue. In some large trials, vaccines provided good protection for people who had been infected before. But for individuals who had never encountered the virus, protection was weaker and in some cases, the risk of hospitalisation increased after later infection.

Second, the quality of antibodies matters as much as the quantity. It is not enough to produce high levels of antibodies. Those antibodies must be strongly neutralising, meaning they can fully block the virus. Weakly neutralising antibodies may fail to stop infection and could contribute to enhanced disease.

Third, age and transmission intensity influence outcomes. In areas where dengue circulates widely and many people are exposed early in life, vaccine performance patterns differ from regions where first exposure occurs later.

Why this matters now

Countries that previously had limited dengue activity are now facing outbreaks. Vaccines remain one of the most powerful public health tools.

But incomplete understanding can erode public trust. Confusion around dengue vaccination in the past contributed to fear and misinformation in some communities.

For example, the introduction of the Dengvaxia vaccine generated controversy in the Philippines after follow-up studies showed that vaccine outcomes differed depending on whether people had previously been infected with dengue. Clear explanation of what happened and why is essential.

Evidence from multiple clinical trials, epidemiological studies and immunological research groups worldwide shows that dengue vaccines must be evaluated not only for overall effectiveness but also for how they perform in different populations. These include people with and without prior infection, different age groups, and regions with varying levels of transmission.

Our research also demonstrates that immune responses must be carefully measured. Protection is not simply about generating antibodies. It is about generating the right kind.

These insights are already shaping newer vaccine strategies. Some candidates focus on improving balanced immunity across all four serotypes. Others aim to refine how immune responses are stimulated to reduce the possibility of enhancement.

Preparing for disease outbreaks

Several lessons emerge for countries preparing for dengue outbreaks.

First, vaccination strategies must be tailored to epidemiological context. In regions where most adolescents or adults have already been infected, certain vaccines may offer substantial benefit. In lower-transmission settings, pre-vaccination screening to determine prior exposure may be necessary.

Second, long-term safety monitoring is critical. Dengue vaccine effects may only become fully visible years after rollout, once vaccinated individuals experience natural infection. Surveillance systems must be strong enough to detect patterns early.

Third, communication must be transparent. Public confidence depends on clear explanations of both benefits and risks. Complex science does not need to be simplified into misleading certainty. It can be explained honestly and clearly.

Finally, research investment must continue. Dengue illustrates that not all viruses follow simple rules.

The broader lesson extends beyond dengue. As mosquito-borne diseases spread due to environmental change, other complex viruses may pose similar challenges. Learning how to design vaccines for biologically intricate pathogens is increasingly important.

Marielena Vogel Saivish is Research Fellow in Virology (Post-Doc position), The University of Texas Medical Branch.

This article was first published on The Conversation.

India is sleepwalking toward a diabetes disaster. An estimated 101 million Indians are living with diabetes and an additional 136 million are pre-diabetic, said an Indian Council of Medical Research-India Diabetes study published in The Lancet Diabetes & Endocrinology in July 2023.

The International Diabetes Federation’s Diabetes Atlas, puts the figure even higher, at 89.8 million diagnosed adults, with projections suggesting that number will grow to a massive 156.7 million in 2050.

India is referred to as the diabetes capital of the world. But what makes the country’s crisis so uniquely devastating is how this is the product of a form of structural violence perpetuated by economic policy failures, the collapse of the food system and the chronic neglect of the well-being of working-class Indians.

The cruelty of this situation is compounded when accounting for the low wage rates in India. There has been a virtual stagnation of real wages since 2014, according to data from the Labour Bureau related to rural India, analysed by economists Jean Dreze and Arindam Das.

In the decade leading to that period, the increase in real wages was strong at 5% to 6% a year. But in the succeeding decade, the rate of increase has been close to zero.

Meanwhile, the India Employment Report 2024 of the International Labour Organisation noted that the average real monthly wages of regular workers fell from Rs 12,100 in 2012 to Rs 10,925 in 2022. An economy growing at 6% to 7% a year that fails to provide meaningful wage growth to its workers is unequal but also is structurally violent.

For those at the bottom of the income pyramid – and to some extent for the diminishing middle-class – putting nutritious food on the table is walking a financial tightrope. Vegetables, pulses, eggs, fruit and dairy products, which nutritionists say help prevent diabetes, are now luxuries.

What is affordable are refined carbohydrates: polished rice, white flour and sugar – the exact ingredients of a diabetogenic diet.

On top of that, there have been disturbing findings about the quality of food itself. A study published in November 2023 in Scientific Reports by researchers from the Indian Council of Agricultural Research, found that five decades of breeding programmes of the Green Revolution have systematically reduced the nutritional content of the staple grains of India.

Zinc concentration in rice has dropped by approximately 33% since the 1960s and iron by 27%. In wheat, zinc declined by 30% and iron by 19%. The study warns that if current trends continue, rice and wheat stand to lose up to 45% of their food value by 2040.

In other words, India’s population is eating less and also eating food that delivers less nourishment per mouthful.

The repercussions can be seen in hospital wards and clinics. The International Diabetes Federation estimates that Indians suffering from diabetes spent $109.5 (approximately Rs 10,000) on treatment in 2024, even as diabetes-caused deaths crossed 334,000 that year alone.

Over 50% of all the burden of disease today in India is attributed by experts to unhealthy diets. An estimated 56.4% of India’s total burden of disease is diet-related, as has been observed in the Indian Council of Medical Research-National Institute of Nutrition Dietary Guidelines for Indians, 2024.

These are the hallmarks of a health catastrophe.

Workers, whose real wages have been stagnant for a decade, cannot afford healthy diets, as prescribed by medical science. The only food they can afford is nutritionally impoverished, a legacy of agricultural policies that have favoured quantity over quality. Workplace stress, fuelled by long hours and job insecurity, and also the erosion of labour protections, increases the risk of metabolic stress.

The policy response to this crisis has been inadequate. India’s National Programme for Prevention and Control of Non-Communicable Diseases can only do so much given the under-resourced, fragmented public health infrastructure. There is no universal screening for diabetes, and nearly 57% of diabetics in India are undiagnosed, said the Indian Council of Medical Research-India Diabetes study.

The rise in type 2 diabetes among Indians is a clear indictment of policy failures, and hardly an urban lifestyle disease.

It is the result of an economic model that has failed to share prosperity, an agricultural system that has exchanged nutrition for tonnage and a food economy where inflation has exceeded wages year after year.

Anand Prakash is an assistant professor at SVKM Narsee Monjee Institute of Management Studies’ School of Economics in Bengaluru.

As early as the 1880s, there was evidence that smoking tobacco damaged your lungs. But it took almost 100 years to definitively show that smoking causes lung cancer.

So, what about vapes?

Until now, most research that has looked at the cancer risk for people using vapes, also known as electronic or e-cigarettes, has mainly focused on their role as a gateway to smoking tobacco. This is because we know people who vape are more likely than non-smokers to take up smoking.

But whether they cause cancer by themselves has been unclear. There are still no long-term studies. But now a comprehensive review of the evidence I conducted with colleagues, published today, has found vaping likely causes oral and lung cancers.

What we looked at and what we found

Given there is no long-term research on whether vaping directly causes cancer, we had to look for effects on the body that we know are linked to cancer.

We identified all peer-reviewed research published between 2017 and mid-2025 that looked at health impacts of vapes considered indicative of potential cancer causation.

The aerosol that vapers inhale contains a complex range of chemicals, including nicotine and its byproducts, and vapourised metals. This aerosol demonstrates almost all of the ten “key characteristics of carcinogens” identified by the World Health Organization.

Blood and urine analyses from vapers confirmed they had absorbed chemicals from e-cigarette chemicals that we know are linked to cancer. These studies revealed nicotine and its breakdown products present in their bodies, including carcinogenic (cancer-causing) metals from the heating element and organic compounds from vapourising e-liquids.

There is no doubt vaping alters tissues in the mouth and lungs. We found evidence of mutations in DNA from the mouth and lungs in those who vaped, which is further evidence of carcinogen exposure.

There was also evidence of changes to cancer biomarkers in the lung and mouth tissue of vapers. Cancer biomarkers are changes in cell or molecular structure that precede a tumour developing. Some of these can be observed under a microscope, such as inflammation, while others such as oxidative stress are detected by molecular analysis.

We also examined experiments on mice which found the aerosols in vapes caused lung cancer, as well as cases reported by dentists who thought that oral cancers in certain individual patients (who didn’t smoke) were caused by them vaping.

Our review did also examine studies that had addressed the possibility vaping may cause cancer. However none of these covered the wide range of evidence we had assessed.

What this means

The evidence shows nicotine-based vapes are likely to cause oral and lung cancer. We just don’t yet know how many cases it will cause.

But in the evidence we looked at, there was rising concern, and a significant shift in the conclusions that had been drawn.

Between 2017 and 2019, researchers tended to say there wasn’t enough evidence to conclude that vapes cause cancer. This included papers that typically looked at cancer biomarkers and carcinogenic mechanisms.

By 2024 and 2025, almost without exception, authors were expressing concern. They noted that the idea vaping has a lower cancer risk than smoking could no longer be supported, given the evidence we now have.

Our study, which looks at cancer caused by vapes in their own right, marks a new approach to what we know about the link between cancer and vaping.

What we still don’t know

We still don’t have direct evidence that there are more cancer cases than expected among people who vape.

The fact it took 100 years to demonstrate that smoking causes cancer indicates it will take decades to make a similar case for vaping. And it will be challenging, because definitive proof will depend on a population of people who only vape, not people who smoke and vape.

So we need large and carefully planned studies, which will then allow us to monitor and detect cancer early, and precisely determine if it is caused by – or worsened by – vaping. Lives can be saved by these means, but only if this research is funded and started now.

Bernard Stewart is Professor, Paediatrics and Child Health, UNSW Sydney.

This article was first published on The Conversation.

Easter chocolate is all over supermarket shelves. Some people reach straight for milk chocolate eggs while others pause at the darker varieties, assuming they’re healthier.

Dark chocolate has gained a reputation as the “better” choice because it usually contains more cocoa and less sugar than milk chocolate.

But is dark chocolate actually healthier?

Let’s see how the evidence stacks up.

How do they compare?

All chocolate begins with the cocoa (or cacao) bean. Cocoa beans are the seeds of the Theobroma cacao tree, a tropical plant native to Central and South America.

Processing the bean gives you cocoa solids (the bitter part) and cocoa butter (the fat part that gives chocolate its smooth texture).

Chocolate is made from cocoa solids, cocoa butter and sugar. Milk chocolate also contains milk powder or condensed milk.

Dark chocolate typically contains a much higher proportion of cocoa solids, usually 50%-90%.

Milk chocolate generally contains 20–30% cocoa solids, with the remaining bulk made up of milk ingredients and sugar.

How about nutritional benefits?

Because dark chocolate contains more cocoa solids than milk chocolate, it naturally provides slightly higher amounts of certain minerals.

This table shows the differences between milk chocolate (30% cocoa) and dark chocolate (more than 60% cocoa) per 20-gram serve. That’s about one row of a Lindt chocolate block.

As you can see, dark chocolate provides more minerals such as magnesium, iron and zinc. It also contains noticeably more caffeine (but far less than in a typical cup of coffee, which would contain about 100mg).

Milk chocolate offers significantly more calcium due to its milk solids, but it generally contains more added sugar.

Cocoa is naturally rich in plant compounds called polyphenols. These act as antioxidants in the body, helping to protect the body’s cells from damage.

Because dark chocolate contains more cocoa, it naturally contains higher levels of these compounds. In fact, dark chocolate contains roughly five times more flavanols (a type of polyphenol) than milk chocolate.

Compared to other foods often praised for their antioxidant content, cocoa contains around 17 times more catechins (another type of polyphenol) per serving than black tea. It also contains around three times more than red wine.

Does dark chocolate improve your health?

Research into cocoa and dark chocolate has produced some interesting findings, particularly about heart health.

Cocoa flavanols appear to help blood vessels relax and support better blood flow. Some clinical trials have reported small reductions in blood pressure and improvements in measures of blood vessel function after consuming cocoa products.

There is also broader evidence suggesting diets rich in flavanols may be linked with a lower risk of cardiovascular disease overall.

However, these findings come with important caveats.

Many of these trials use cocoa extracts containing high levels of flavanols. Others contain specially formulated chocolate rather than the typical chocolate bars or Easter eggs you’d find in supermarkets. The doses tested are also often far larger and far more concentrated than what people normally consume.

A large umbrella review (a review of reviews) involving more than one million participants did find links between eating chocolate and lower risks of cardiovascular disease, stroke and diabetes.

But the overall quality of evidence was rated as weak or very low, largely because many of the studies were observational. Observational studies can identify patterns, but they cannot prove chocolate itself caused those benefits.

The bottom line is that cocoa does contain beneficial plant compounds but the chocolate most of us enjoy is not a health supplement.

But I thought dark chocolate has less sugar?

Choosing dark chocolate doesn’t automatically make it the healthier option, especially where sugar is concerned. Some dark chocolate contains surprisingly high amounts.

Depending on the cocoa percentage and recipe, some dark chocolate products contain 40%-50% sugar.

So a 150g dark chocolate Easter bunny containing 50% sugar, for example, can contain about 19 teaspoons of added sugar.

This applies to Easter eggs too. Some dark chocolate Easter eggs sold in supermarkets still list sugar as one of their first and main ingredients, ahead of cocoa butter. This means sugar makes up a significant chunk of what you’re eating.

So it’s always worth flipping the packet over and checking the ingredients list and nutritional panel to be sure.

What to choose this Easter?

Dark chocolate has a nutritional advantage over milk chocolate. But how much depends on the cocoa percentage and how it’s been made.

As a general rule, aim for 70% cocoa or more, and flip the packet over before you buy. In a higher-quality dark chocolate, cocoa should appear first in the ingredients list – not sugar.

A higher-quality dark chocolate might have its ingredients listed in this order: cocoa mass, cocoa powder, cocoa butter, sugar, vanilla.

A lower-quality dark chocolate might look like this: sugar, cocoa mass, cocoa butter, emulsifiers, flavour, milk solids.

If sugar is listed first, it’s the largest ingredient by weight.

Beyond that, choose chocolate you actually enjoy and watch your portion size. Remember that your overall diet matters far more than a few Easter eggs.

The real health benefit of Easter chocolate? The enjoyment of sharing it.

Lauren Ball is Professor of Community Health and Wellbeing, The University of Queensland.

Emily Burch is Accredited Practising Dietitian and Lecturer, Southern Cross University.

This article was first published on The Conversation.

Harish Rana, the first person in India to be granted permission for passive euthanasia by the Supreme Court, died at the All India Institute of Medical Sciences in Delhi on Tuesday, The Indian Express reported.

Rana died at 4.10 pm on Tuesday, the hospital stated. He had been in a permanent vegetative state since 2013.

The court had, on March 11, allowed life support to be withdrawn for the 31-year-old. The order had been passed on a plea filed by the family of Rana, who suffered a severe traumatic brain injury in August 2013 after falling from the fourth floor of a building in Chandigarh.

This was the first instance in which the court’s directions on passive euthanasia, laid down in a 2018 judgement, had been applied.

Three days after the court’s ruling, Rana had been moved from his home in Ghaziabad to the All India Institute of Medical Sciences.

Also read: From Aruna Shanbaug to Harish Rana, India’s long reckoning with the right to die with dignity

In 2018, a five-judge Constitution bench of the Supreme Court had recognised and given sanction for passive euthanasia, and allowed living wills or advance directives.

In that judgement, the court had ruled that the right to life under Article 21 of the Constitution includes the right to live with dignity. The court had held that the constitutional right includes the smoothening of the process of dying in case of a terminally ill patient or a person in a persistent vegetative state with no hope of recovery.

Rana’s family had approached the court seeking permission to withdraw life-sustaining treatment in the form of clinically assisted nutrition and hydration administered through a PEG tube.

A Percutaneous Endoscopic Gastronomy tube is a device inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids and medication.

On March 11, the court had noted that continuing the treatment was only prolonging Rana’s biological existence without any therapeutic improvement. It also observed that the primary and secondary medical boards, along with Rana’s parents, had reached the opinion that the clinically assisted nutrition and hydration should be discontinued as it was not in the best interest of the patient.

The court stated that when the medical boards have certified withdrawal of life support, there was no need for the court to intervene.

However, it added that since this was the first case to reach the court, it was appropriate to examine the matter.

It also recommended that the Union government bring in a comprehensive legislation on passive euthanasia.

The bombs, the stranded ships and LPG shortages have made it to the headlines. The acid rain, the oil spills and the carbon cost of rerouting ships remain hidden in plain sight.

Four weeks ago, the US and Israel launched airstrikes on Iran. Since then, much of the world’s attention has been consumed by oil prices, geopolitics and the terrifying question of how far this conflict might escalate.

But there is another story unfolding whose echoes will probably reverberate for longer.

Oil prices may correct once the Strait of Hormuz opens up, but the contaminated water and soil will take decades to recover, if at all they do. The environmental consequences of this war are already crossing borders, contaminating oceans, disrupting long term energy transition strategies and pumping enormous quantities of greenhouse gases into the atmosphere.

This piece is an attempt to map out the short-term environmental damage that is already visible and why we should all care about it.

Black skies over Tehran

Let’s start with the obvious. The most visceral images from the war so far have been of the sky over Tehran turning black. And then literally pouring toxic liquid over the city.

On March 7-8, Israeli strikes hit four major oil storage facilities and a distribution centre in and around Tehran. Unrefined oil leaked into the streets, fires raged for days and then it rained. The rain was black. Tehran residents reported an oily, dark residue coating their cars, windows and skin. Iran’s Red Crescent warned that the rain was “highly dangerous and acidic” and could cause chemical burns and serious lung damage.

Here’s the science behind it. When crude oil burns, especially “sour” crude that is rich in sulphur, it releases sulphur dioxide and nitrogen dioxide into the atmosphere. These gases react with moisture in the air to form sulphuric acid and nitric acid. When it rains, that acid comes down with the water. Add in the soot and the particulate matter, you have a toxic cocktail falling from the sky onto a city of 10 million people.

Even when it does not rain, the pollutants remain suspended in the air for days. Tehran’s geography makes things worse. The city sits in a basin surrounded by the Alborz mountains, which frequently results in a phenomenon called temperature inversion – a layer of warm air sitting above cool air near the surface. The pollutants released near the surface get trapped in the cool layer and are unable to disperse. It is the same phenomenon that makes Delhi smoggy, except in Tehran, the pollutants aren’t from just traffic.

The water, soil and food

The air pollution is visible – you can see the black skies in photographs. What is harder to see, but potentially more enduring, is the contamination seeping into soil and water.

Michael Oppenheimer, a Princeton climate scientist, points out that oil can seep into the ground and contaminate streams, rivers and reservoirs. In a region as arid as Iran, where water is already scarce, polluting what little surface water exists is a death sentence. The contamination is also reaching agricultural areas. Particles from the fires can produce toxins that end up in the soil and get taken up by crops.

Perhaps the cruellest dimension is that Iran was already dealing with severe environmental stress – drought, rising temperatures, desertification, and dying wetlands. The war has layered new damage on top of existing vulnerabilities.

Oil spills in the ocean

While the world watches oil prices, oil is actually spilling into the ocean.

The Conflict and Environment Observatory has documented at least 12 merchant ships struck in ports or in the Persian Gulf since the conflict began. The most striking case though was far from there – IRIS Dena, the Iranian vessel torpedoed by a US submarine off the coast of Sri Lanka on March 4. Oil patches appeared along the Hikkaduwa coast, a popular tourist area and ecologically sensitive zone, three days after the sinking.

In the Persian Gulf itself, the risks are compounding. Electromagnetic jamming has disrupted vessel navigation and communication systems, increasing the risk of accidental collisions and spills in already congested waters.

The Persian Gulf hosts the world’s second-largest dugong population, heat-adapted coral communities and over 700 fish species. If oil spills, it doesn’t disperse easily in the enclosed, shallow Gulf. It coats mangrove forests that serve as fish nurseries, smothers coral reefs and poisons the food chain.

Oil spilled in the Gulf during the Iran-Iraq war of the 1980s was linked to the near-total annihilation of the region’s hawksbill sea turtle population and the destruction of a major portion of its green turtles.

Carbon cost of rerouting

So what happens when the Strait of Hormuz remains shut? Well, the cargo has to find an alternate route. And it is not just the Strait of Hormuz route that is impacted.

Europe-Asia shipping normally uses the Suez Canal route through the Red Sea. These ships don’t pass through Hormuz at all. But the broader West Asia instability, particularly the threat of renewed Houthi attacks in the Red Sea, which Iranian-linked forces have carried out before, is pushing those ships to reroute around Africa via the Cape of Good Hope too.

UNCTAD estimates that a round trip from Singapore to northern Europe via the Cape of Good Hope produces 70% higher emissions than the Suez canal route. A 2024 modelling study found that Suez Canal disruption increases shipping carbon footprints by nearly 50%.

The same applies to aviation. The Iranian airspace is completely closed and the Gulf airspace has been closed, on and off, to civilian aircraft. Flights are being rerouted, which means longer routes, more flying time and eventually more fuel burnt and more emissions.

Dirty choices

The energy shock from this war is pushing many countries backwards on the journey towards cleaner fuels.

In India, the LPG crisis is perhaps the most striking. India imports roughly 67% of its liqueified petroleum gas, and about 90% of those imports transit the Strait of Hormuz. With the strait effectively closed, commercial LPG supply has reduced. Restaurants across the country are considering switching to coal and firewood.

India’s environment ministry has actually advised state pollution control boards to permit the use of these dirtier fuels in a direct reversal of the government’s decade-long push under the Ujjwala Yojana scheme to move 104 million of India’s poorest households from firewood and cow dung to LPG. As Dainik Jagran put it, “A foreign war they had no part in, conducted through a strait they have never seen, has reached directly into their kitchens and extinguished the flame that a government scheme lit for them.”

The pattern extends well beyond India. The Philippines is ramping up coal-fired power generation to counter soaring LNG costs. Australia said it would temporarily loosen fuel quality standards to boost available supply.

Carbon emissions from the war

War itself is a carbon emitter. The world’s militaries collectively have a bigger carbon footprint than all but three countries. Research on the Gaza conflict found that just the first 120 days produced more emissions than 26 individual countries do in an entire year.

The Iran war involves submarine operations, long-range bomber sorties and missile defence systems. The emissions bill will be staggering.

The post-dated bill

We have real-time dashboards tracking oil prices, casualty counts, and missile trajectories. We don’t have a single live tracker for the tonnes of toxins settling into Tehran’s groundwater, or the hectares of ocean landscape being destroyed in the Gulf. The things we measure are the things we act on.

The environmental cost of this war is not being measured, and so it will not be acted on, until the bill arrives, decades from now, in the form of cancers, dead fisheries and barren soil.

But by then, the war will be a Wikipedia article and we will all be dead.

Sailee Rane leads the strategy for Ecosystem messaging at Rainmatter foundation and run the Youtube channel The Climate Brief. This article first appeared on her Substack Sunny Climate, Stormy Climate.

A couple of years ago, in a meeting, a colleague asked me why we need to consider gender or sexuality in tuberculosis care. “TB can happen to anyone who breathes,” this person said. “Aren’t we all equally vulnerable?”

Yes, TB is an airborne illness and we are all vulnerable. But equally vulnerable? Four countries account for over half the global burden of drug-resistant TB – a form of TB that is resistant to first-line medication and requires stronger medicines. Among them, India leads the tally, accounting for 32% of global cases of drug resistant-TB.

While we are all vulnerable to TB and drug-resistant TB, the extent of vulnerability differs. Socioeconomic determinants such as the lack of access to well-ventilated houses, food insecurity and cultural barriers to healthcare access put some people at a higher risk for TB than their socioeconomically privileged counterparts.

Further, vulnerability to TB varies by gender, sexuality and related cultural barriers in accessing care.

Gender inequities

Women in rural areas hesitate to seek care where female health providers are unavailable. Women in traditional settings may not be allowed to travel without a male companion, and are dependent on others for healthcare access. Their default role as family caregiver often means that they tend to themselves last, in the best-case scenario, and in the worst-case, are unable to tend to their health needs.

Married women affected by drug resistant-TB report being abandoned by their husbands and in-laws after their diagnosis. Some are compelled to consume medication in hiding, given the stigma attached to TB. If you are an unmarried woman affected by drug-resistant TB, the burning question is not, “Will you survive this?” It is, “Who will marry you?”

Meanwhile, LGBTQIA++ persons, given the social stigma they face, may lack access to safe housing, stable income, and nutrition, thus increasing their vulnerability to TB. Further, LGBTQIA++ men, women and non-binary persons face discrimination within the health system on account of their gender and sexual identity.

This is a significant barrier to care-seeking and affects the quality of care LGBTQIA++ persons receive. They are also less likely to have family support during their treatment, given that families often ostracise them for not conforming to heteronormative roles.

For men, anointed as breadwinners by society, a drug-resistant TB diagnosis and its lengthy treatment could lead to both loss of work and wages, affecting their perceived social status. The fear of losing income and status, and TB-related stigma are barriers to seeking and continuing care. Further, substance use that is frowned upon in women, is often encouraged in men as a marker of perceived masculinity, increasing men’s vulnerability to TB.

Gender-responsive care

While the experience of inequities differs based on gender and sexual identity, all persons need care that addresses these inequities, care that is gender-responsive. So, what does gender-responsive drug-resistant TB care look like?

The 2024 version of India’s National Framework for a Gender-Responsive Approach to Tuberculosis is a good starting point. it is a great example of how national TB programmes and affected communities can work together as partners in care and policy design. It outlines what gender-responsive care looks like at different stages of the TB-care cascade.

However, the journey from ideas to implementation in drug-resistant TB care settings is one that national TB programmes must map out. While the path each programme takes will differ based on local context and needs, there are a few things all national TB programmes must ensure to make drug-resistant TB care gender-responsive.

LGBTQIA++ persons, cis women and cis men affected by TB must be engaged as equal stakeholders in defining the care they deserve. This means engaging them as members in government committees where policy decisions are made and involving them as co-architects of gender-responsive drug-resistant TB care interventions. It also means having them co-design gender-responsive care capacity building interventions.

Gender-responsive care capacity building needs to focus on skilling both existing health providers as well as medical students to ensure that gender-responsiveness is woven into the fabric of our health system. Capacity building curriculum should include simulated learning, allowing health personnel to effectively understand how best to provide care in real-world settings.

Finally, a key barrier to designing gender-responsive interventions in drug-resistant TB is the lack of social science and clinical research involving LGBTQIA++ persons. Evidence-based interventions need evidence. To that end, research priorities must reflect the needs and preferences of LGBTQIA++ persons and research must include LGBTQIA++ persons as participants keeping ethical considerations in mind.

If the end is gender-responsive drug-resistant TB care, then the means must be gender-responsive as well. Only then can we have equitable and accessible drug-resistant-TB care.

Ashna Ashesh is a lawyer, public health professional and multidrug-resistant-TB survivor associated with Survivors Against TB, a collective of survivors, advocates and experts working on TB and related comorbidities.

March 24 is World Tuberculosis Day.

India is ageing fast. The population aged 60 and above in the country is projected to more than double from 100 million in 2011 to 230 million in 2036. By last year, the elderly made up 11% of the country’s population; with improvements in life expectancy and falling fertility, there will be more elderly than children in India by 2050, as we reported in March 2024.

Is India prepared to cater to the needs of her growing elderly population? Not quite, experts say.

In this first of a two-part series, we examine how fast India is ageing and whether the country is prepared. We look at gaps in infrastructure – from old age homes to home-care services – and the lack of regulation and accountability in an unorganised but rapidly growing sector.

A 2024 NITI Aayog report said that the senior care system faces many challenges “due to the lack of a comprehensive, integrated policy for care and support”. There are infrastructure- and capacity-gaps “for supporting the health and welfare of the elderly, evidence-based knowledge repositories for geriatric illness management, enabling frameworks and monitoring mechanisms, and emergency response systems”, it said.

The Ministry of Social Justice and Empowerment, the nodal ministry that looks after the welfare of the elderly population in the country, spearheads several schemes and programmes aimed at addressing the different challenges faced by the elderly. Some key initiatives include the Atal Pension Yojana, Rashtriya Vayoshri Yojana (which provides assisted living devices), and schemes that address their livelihood needs.

And in her budget announcement this year, India’s finance minister Nirmala Sitharaman addressedgeriatric care whilst talking about reforms in the health sector, adding that in the coming year, 150,000 multi-skilled caregivers will be trained.

On ground, however, elderly care specialist Pankaj Mehrotra feels that the welfare needs of the elderly have hardly been met in the country, “apart from three-four states, like Kerala”. “Housing and welfare are state subjects, so the nodal ministry can recommend a lot of things but it is on the state to take it further,” Mehrotra said.

We have a long way to go, said Gitali Thakur, social entrepreneur and CEO of AgeWell Care, which provides home-based care for the elderly.

Gaps in infrastructure

There are 696 senior-citizen homes across the country supported by the government; an additional 84 have been selected to be supported for the financial year 2025-’26. The government does not keep information on private senior citizen facilities or old age homes. This, said Mehrotra, is a big gap.

A study by Tata Trusts, Samarth and United Nations Population Fund said that not only do senior living facilities run by private organisations “address the needs of a fraction”, “there is no way of evaluating the quality and appropriateness of the services”. It leaves the elderly residents of these homes vulnerable, and offers no incentives to the facility owners and managers to improve, it goes on to add.

“Many old age homes are unregistered and unregulated,” Mehrotra added, “The government has a framework for senior care homes but these are just guidelines and states have to develop their own Standard Operating Procedure, which not every state has done. The central framework itself is not at par with other developed countries.”

The Tata Trusts study also added that the number of old age homes in India is grossly inadequate. It looked at a sample set of more than 480 old age homes and more than 60 senior living facilities in 84 locations.

“[The study] projected the sample set to countrywide population data extracted from 2011 census of India, and arrived at an estimate of around 1,150 facilities and the capacity to house around 97,000 elderly residents,” it said. Forecasting likely demand driven by increasing elderly population, the study said that there is a “crying need to enhance the capacity almost eight to ten-fold over the next decade”.

Missing accountability

But it’s not just living facilities that there is a gap in. Home-care services – in which chronically ill patients or those recovering, are provided care at their home – is also much in demand, as we will see in the second part of this series.

Sixty-five-year-old Elina Ghosh, lives alone in Delhi. Her husband died three years ago and her daughter works and lives in a different country. “I have been recently diagnosed with Parkinson’s disease,” Ghosh, who retired as a school teacher, said. “Shraboni, my daughter, has therefore been very worried about me living alone. After a lot of deliberations, we decided to hire a home-based caregiver.”

While their journey has only begun, Ghosh worries about the quality of services once her disease progresses. Her aunt in Jabalpur, paralysed after a recent stroke, has struggled to find trained, reliable caregivers.

Kolkata-based geriatric specialist Antarikhya Bordoloi agreed with Ghosh’s observation. “There are now a number of private organisations offering home-based care services for the elderly, but most of them are either not well trained or well managed,” she said.

The biggest problem here, she pointed out, was accountability. “Southern India is a little ahead in geriatric healthcare as compared to other parts of India. Most of the time, the primary objective of these caregiver service providers is to earn money on a long term basis from families who are dependent on caretakers because they live in a different state or country,” she said.

Thakur, whose organisation trains caregivers and provides services, added that while there are now professional courses available, there is no standardisation. “This is an unregulated, unorganised sector,” she said. It is a sector that is, however, growing fast.

Growing silver economy

As India’s elderly population grows with increasing life expectancy – currently 72 – so are opportunities to invest in the sector. According to the government, India’s silver economy, driven by goods and services aimed at the elderly, is valued at approximately Rs 73,000 crore as of 2024, withprojections indicating manifold growth over the years.

“The elderly care sector is metro-centric and accessible to few,” Thakur said, “Seventy percent of the elderly population live in rural areas. To address this, I feel we need more community-level initiatives.”

An example is the community-based palliative care model in Kerala. In this, local volunteers – shopkeepers, teachers, students – are trained to provide not just basic medical support, but also companionship and emotional support to those with serious illnesses.

But scaling such models has proven difficult. Kerala’s network developed over decades, supported by high literacy rates, strong local governance, and civil society engagement – conditions not easily replicated in other states

“Ageing is not yet recognised as an issue that needs to be worked on – neither at the policy level, nor at the political level – which is why the healthcare system does not focus much on elderly care,” Thakur says. “Private sector initiatives are few and expensive and therefore not accessible to all.”

IndiaSpend reached out to the social justice and empowerment ministry for comment. We will update this story when we receive a response.

This is the first of a two-part series. In the second part, we will examine how limited home-based palliative care pushes families toward hospitals.

Azera Parveen Rahman is an independent writer currently based out of Bhuj in Gujarat. She writes mainly on development, environment, art and culture, and has been in this field for more than 15 years.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

Honey is often praised for a range of health benefits, from soothing a sore throat and helping you get to sleep to healing woulds and lowering risk factors for diabetes and heart disease.

Honey’s acidity has the potential to prevent bacterial growth, while its density and stickiness generates osmotic pressure (in the same way as quicksand) which restrain bacteria.

Other compounds in honey contribute anti-inflammatory and antioxidant effects.

But do the claims about honey for specific health problems and injuries stack up to science? Let’s check what the evidence says.

What’s in honey

Honey contains up to 20% water. The remaining 80% is made of simple sugars: monasaccharides that we rapidly digest. Fructose (32-28%) and glucose (26-31%) are the main ones, followed by small amounts of sucrose and others.

This can increase blood sugar levels to varying degrees. The glycemic index (GI) measures how fast blood sugars rise after eating or drinking. The GI of different Australian honeys ranges from 35 (low) to 72 (high), though most food labels don’t contain GI information.

Honey also has traces of vitamins (A, B1, B2, B6, C), minerals (potassium, magnesium, iron, zinc), amino acids (protein) and enzymes from plant, bee and insect secretions.

Nutrients vary depending on where the honeybees collected pollen, the time of honey harvest and how long it has been stored.

Can honey heal wounds?

A 2015 Cochrane review update assessed the effects of honey in treating acute burns, lacerations and chronic wounds, compared to topical treatments or other dressings.

It found high-quality evidence that honey dressings healed second-degree burns four-five days faster than conventional dressings. There was moderate-quality evidence that wounds infected after surgery healed faster with honey.

A 2020 review evaluated antimicrobial activity of Manuka and medical-grade honeys against a range of multi-drug resistant bacterial species. It found all honeys were effective against most species and could be considered for use in antibiotic-resistant infections.

Only sterilised medical-grade honey that has been processed to remove contaminants, and meets safety and antibacterial standards, should be used, with guidance from your doctor.

Does it help adults sleep?

Research on the effects of honey on sleep is limited.

One trial compared sleep quality of 68 adults admitted to hospital. Half were given a mixture of milk (150mL) and honey (30g) twice a day, and half were not.

Those in the honey-mixture group said they slept better after day three. But these results could be biased, because participants were aware they were getting honey-milk and drinking it can be associated with feeling of comfort.

Can it soothe sore throats or help kids sleep?

Five studies in children have compared honey mixtures to over-the-counter cough medicines or no medication. Each study linked honey to better sleep and less severe coughs in children.

But before you rush out to stock up on honey, there are major limitations related to the honey used. The quantity and type of honey given varies across the studies, with no certainty about which components are present. So the results need to be interpreted with caution.

Chemical analysis of some honey varieties found traces of the “feel-good” brain chemical serotonin and the hormone melatonin, which affects sleep and circadian rhythm. But the researchers concluded the small amounts detected were more likely to affect activity of the bees, rather than affecting human behaviour.

What about for diabetes, heart disease and cancer care?

For diabetes, a 2023 review of 48 clinical trials found honey had some positive effects on a range of risk factors, including glucose tolerance and wound healing. However, the honey dose and type weren’t standardised, so the researchers concluded that honey could be used in addition to, but not instead of, regular medications.

For heart disease, a 2022 analysis combining findings from trials evaluated the impact of honey on blood fats. It found no effect on several risk factors for heart disease: total cholesterol, triglycerides (another type of blood fat), low-density lipoprotein (LDL or bad) cholesterol or high-density lipoprotein (HDL or good) cholesterol.

However a 2025 meta-analysis of propolis (bee glue) did find significant reductions in triglycerides, LDL (bad) cholesterol, fasting blood sugars, insulin and systolic blood pressure (the top number on a reading). But given most propolis supplement trials have only lasted a few months and supplements are expensive, that money is likely better spent on healthy foods.

For cancer patients, a 2023 review found honey alleviated ulceration and inflammation in the mouth following chemotherapy or radiotherapy, and it reduced some of the toxic effects of chemotherapy.

Can it affect your mind?

Some honeys have psychotropic, or mind-altering effects. “Mad honey” comes from plant nectar of Rhododendron species and naturally contains grayanotoxins, which have pharmacological and toxic effects.

These include nausea, dizziness, low blood pressure, severe bradycardia (an abnormally slow heart rate), neurological complications and even life-threatening cardiac arrhythmia (irregular heart beat).

It’s illegal to import or sell “mad honey” in Australia but Nepal and Turkey have historically used it for medicinal and psychoactive properties.

Who shouldn’t have honey?

Although commercial honey is pasteurised, the process does not kill spores of the bacteria Clostridium botulinum. This is why babies under one year and immunocompromised people shouldn’t have honey.

Clare Collins is Laureate Professor in Nutrition and Dietetics, University of Newcastle.

This article was first published on The Conversation.

Half of people in the UK use a wearable device, such as a fitness tracker or smartwatch. These devices collect data relating to health and physical activity levels – including heart rate, step count and sleep quality. With the emergence of AI, such devices will probably become even more sophisticated – potentially able to diagnose our health problems before our GP.

But while wearables can be really useful when it comes to understanding many aspects of your heart health, they still have many shortcomings – so it’s important not to rely on them for everything.

A key strength of modern wearables is the fact that they record such a wide range of useful data, and track trends over time. This makes them perfect for measuring whether any lifestyle changes you’ve made are working for you, and what effects they might be having. For instance, your wearable can tell you if your health kick has had a measurable affect on your sleep quality or blood pressure.

In addition to measuring step count and physical activity, many of the most commonly worn wearables collect cardiovascular data via photoplethysmography (PPG). This is where a light located at the back of the wearable interacts with tiny blood vessels in the skin to give an estimate of changes in blood volume. These changes can be used to accurately measure heart rate, rhythm and blood oxygen levels.

Many currently available devices are also able to record electrocardiographic (ECG) data. This also records your heart’s electric activity, including heart rate and rhythm.

This is why some wearables, particularly those with ECG technology, could be useful in cardiology consultations.

There are currently limitations to the ECGs a cardiologist would normally use to diagnose heart rhythm issues. These ECG monitors only record heart rhythm data for a limited period, such as 24 or 72 hours. This could mean doctors don’t get a full picture of heart health.

But since many people who own a smartwatch or fitness tracker wear them for many hours of the day and over many weeks, this means their wearable may be recording at the time when cardiac symptoms – such as palpitations – occur. This means wearables may overcome the inherent limitations with clinical ECG recordings.

For instance, a recent study demonstrated that smartwatches can reliably detect atrial fibrillation (a heart rhythm disorder that increases risk of stroke) in patients at risk of the condition. And wearables can also be useful for regularly and accurately monitoring daytime blood pressure.

So, wearables have the ability to provide data that is highly useful to a cardiologist in helping determine a probable diagnosis. But just how much can we rely on this data?

Wearable limitations

Most wearables that detect blood pressure do so via PPG data, which measures blood pressure differently to an inflatable blood pressure cuff. Wearables may also only provide a blood pressure range rather than absolute results. This means a patient may not know whether their “true” blood pressure is normal or not.

The British and Irish Hypertension Society, which formally validates and endorses cuff-based blood pressure monitors, currently doesn’t have a framework to validate wearables. This means no wearables on the market which provide blood pressure monitoring have been officially validated.

There’s also a lack of standardisation across the market for how different wearables produce data for particular metrics. This means it’s possible different devices could give different readouts – even if they’re looking at the same person. If wearables are to be integrated into the healthcare system in future, then standardised, validated methods would be needed.

There are also potential issues in how wearables are positioned within the market with regard their medical capabilities.

Some are advertised as having medical-grade measuring capabilities. However, the majority of devices on the market have not been approved as medical devices by regulatory bodies. This distinction is important for the average consumer to understand, so they don’t trust the device’s data more than they should.

While wearables can be extremely useful for understanding many aspects of your day-to-day heart health, there’s still much about them that will need to be improved before they become a standard part of cardiac care.

Quality assurance and compatibility across different brands will be key, as will ensuring a patient’s data is both reliable and accessible to healthcare staff on their electronic health records.

These are important issues that must be addressed soon if wearable technology is to become a standard part of NHS treatment by 2035, as outlined in the NHS’s ten-year plan for England.

Kevin O’Gallagher is MRC Clinician Scientist and Consultant Cardiologist, King's College London.

This article was first published on The Conversation.

The Supreme Court on Tuesday ordered the Union government to frame a policy to ensure that those who suffered adverse side effects of the Covid-19 vaccine are fairly compensated, Bar and Bench reported.

The court said that the policy must be on a no-fault basis, which refers to a provision in law or insurance where the compensation for injuries, losses or damage is provided irrespective of who caused it.

A bench of Justices Vikram Nath and Sandeep Mehta passed the directive on a writ petition filed by a couple who have claimed that their daughters died to adverse effects of the vaccine, Live Law reported.

The plea sought an investigation by an independent committee into the deaths of their daughters, along with directions to release autopsy and probe reports expeditiously, Bar and Bench reported.

The petition also urged that the parents be monetarily compensated, and sought directions to the government to frame guidelines for early detection and treatment of persons suffering from adverse side effects of vaccines.

On Tuesday, the court also held that existing mechanisms for monitoring adverse events following immunisation be continued and directed data to be placed in the public domain periodically, Bar and Bench reported.

The court clarified that the introduction of a compensation scheme should not be viewed as an “admission of liability” on the Union government’s part.

Further, the bench held that there was no requirement of setting up a new expert panel to examine the side effects of Covid-19 vaccinations.

“It is clarified that the judgement shall not preclude any person from pursuing remedy available in law,” the court added.

In September 2022, the Kerala High Court directed the National Disaster Management Authority to prepare guidelines for identifying deaths triggered by Covid-19 vaccination after-effects and for compensating the dependents of such persons.

The union government had then approached the Supreme Court, challenging the High Court order, by arguing that only Covid-19 was declared a disaster and not deaths linked to the vaccines administered against the disease.

The government had contended that this would mean there is no policy under the Disaster Management Act that grants compensation for such deaths, Bar and Bench reported. .

This plea by the Union government was heard together with the plea filed by the parents of two girls who died to due to side effects of the vaccine.

Also read: How India failed those who were harmed by the Covid-19 vaccine

About half of the global population menstruates at some point in their lives. Disposable products, such as tampons and pads, are some of the most popular products used around the globe to manage menstrual flow.

Unfortunately, studies have shown that many personal care products, including shampoo, lotion, nail polish and menstrual products, contain hazardous chemicals. Items used in or near the vagina are of particular concern because they are in contact with vaginal mucous membranes – the moist tissue lining the inside of the vagina that secretes mucus. These tissues can absorb some chemicals very efficiently.

People use menstrual products 24 hours a day for multiple days monthly, over the course of many years. Tampons, which are used internally, are surrounded by the permeable vaginal mucous membrane for up to eight hours at a time.

I am an environmental epidemiologist, and I study chemical exposure, its sources and its health effects. As a person who menstruates, I also must make my own decisions around menstrual products and manage the challenge of finding accurate information about women’s health risks, which receive less research attention and funding than men’s health.

In 2024, I co-authored the first paper that detected metals in tampons, including toxic metals like lead and arsenic. My colleagues and I also wrote a review paper that surveyed the scientific literature and found about two dozen studies measuring chemicals in menstrual products.

The various chemicals that these studies detected were typically at concentrations low enough to make their health impact unclear. However, they included chemicals known to disrupt the endocrine system, which makes and controls hormones that are essential for bodies to function.

Contaminants in menstrual products

The first modern tampon in the US was patented in 1931. Nearly a century later, tampons still are made primarily from cotton, rayon or a blend of the two.

Chemicals may get into tampons and other menstrual products in a number of ways. Some chemicals, like heavy metals, are present in soil, either naturally or due to pollution, and may be absorbed by cotton plants.

Other chemicals, such as zinc, may be intentionally added to menstrual products to prevent the growth of harmful bacteria. Still others, such as phthalates – synthetic chemicals used to manufacture plastics – may leach into menstrual products from plastic packaging or be added as part of a fragrance.

Research suggests that these chemicals are present in a large proportion of menstrual products – we found lead present in all 30 tampons we tested. What we don’t yet know is if these chemicals can get into people’s bodies in a high enough concentration to cause health effects in either the reproductive system or elsewhere in the body.

Limited regulations

The US Food and Drug Administration regulates tampons, menstrual cups and scented menstrual pads as Class II medical devices, which carry moderate to medium risk. Unscented menstrual pads are Class I medical devices, which are considered low-risk. These categories are based on the risk the device may present to a consumer who uses it in the intended way.

FDA guidance for Class II devices offers only a few general guidelines with respect to chemicals. For menstrual tampons and pads, it recommends – but does not require – that products should not contain two specific dioxin products or “any pesticide and herbicide residues.” Dioxins are a chemical by-product of the bleaching process to whiten cotton, and they are associated with cancer and endocrine disruption. Using non-chlorine bleaching methods can reduce dioxin formation.

The most stringent regulation of tampons in the US occurred after an illness called toxic shock syndrome became a public concern in the 1970s and 1980s. Menstrual toxic shock syndrome occurs when the bacteria Staphlococcus aureus grows in the vagina on inserted menstrual products and releases a toxin called TSST-1. This substance can be absorbed through the vaginal mucosa and cause a variety of symptoms, including fever, high blood pressure, shock and even death.

During this epidemic, in which at least 52 cases were recorded and seven people died over a period of eight months, tampons were associated with the syndrome – especially a highly absorbent tampon called Rely, which was pulled from the market.

In response, the FDA created a task force that recommended standardizing the tampon absorbencies and advised consumers to use the lowest absorbency for their flow. This is why tampons in the US now come in a range of absorbencies, from light through regular to super and ultra, so that users can choose the level they need while minimising risk of toxic shock.

‘Soup of chemicals’

Just because a chemical is present in a menstrual product doesn’t mean it can get into the body. However, chemicals like lead and arsenic are known threats to human health. So it’s important to study whether harmful chemicals present in menstrual products could contribute to health problems.

Humans in the modern world live in what expert toxicologist Linda Birnbaum, former director of the National Institute of Environmental Health Sciences, calls a “soup of chemicals.” Simply being present on Earth means being exposed to many chemicals, at different concentrations, all at once. This makes it difficult to unravel the relationship between a single chemical exposure and health.

Nonetheless, science has shown that chemical exposure from at least one menstrual product – vaginal douches – does affect health. Vaginal douching is the process of washing or cleaning the inside of the vagina with water or other fluids.

The American College of Obstetricians and Gynecologists recommends avoiding this process, which can harm healthy bacteria in the vagina, increasing the risk of vaginal infections and other diseases.

In addition, a 2015 study found that women who use vaginal douches have higher concentrations of a chemical called monoethyl phthalate in their urine. Exposure to this substance is associated with reproductive health problems, such as reduced fertility and increased pregnancy risk.

Can chemicals be absorbed?

Scientists are working now to determine what concentrations of metals and other chemicals can leach out of tampons and other menstrual products. One 2025 study estimated that volatile organic compounds, a group of chemicals that vaporize quickly, can be absorbed through the vaginal mucosa. Volatile organic compounds may be added to menstrual products as part of fragrances, adhesives or other product components.

My team and I are now shifting our focus to the relationship between menstrual product use, various chemicals, and menstrual pain and bleeding severity. We want to see whether some chemicals will be elevated in menstrual blood, whether these chemical levels are higher in people who use tampons, and whether the chemicals are associated with greater menstrual pain and bleeding.

States are starting to act on this issue. For example, in 2024, Vermont became the first U.S. state to ban multiple chemicals from disposable menstrual products. California bans PFAS, a widely used group of highly persistent chemicals, from menstrual products. New York adopted a law in December 2025 barring multiple toxic chemicals from menstrual products.

California also enacted a law in October 2025 that requires manufacturers of disposable tampons and pads to measure concentrations of arsenic, cadmium, lead and zinc in their products, and to share those measurements with the state, which can publish them. More information like this will help support informed choices for millions of consumers who rely on menstrual products every month.

Jenni Shearston is Assistant Professor of Integrative Physiology, University of Colorado Boulder.

This article was first published on The Conversation.

Five years ago, Eldred Tellis heard about a “wonder drug” that could give a fighting chance to people at high risk of contracting AIDS.

Tellis’s work involves one such group – drug users in Mumbai, many of them unlettered. “They share needles often and do not understand the consequences,” said Tellis, who founded the Sankalp Rehabilitation Foundation to advocate for the healthcare of addicts. “Several end up contracting HIV.”

The human immunodeficiency virus, or HIV, spreads through unprotected sex and the sharing of needles. The virus attacks the immune system and, if not treated, develops into the deadly acquired immunodeficiency syndrome or AIDS.

But the new drug, Lenacapavir, holds out hope. If injected once every six months, it can prevent the onset of AIDS even in people at high risk. “When we heard about it, we realised we could save many with Lenacapavir,” he told Scroll. “Not just drug users. Even sex workers who have no choice when their customer refuses to use a condom” stand to benefit.

Lenacapavir has shown a 96% reduction in HIV incidence, and is 89% more effective than current oral medications. Last year, the World Health Organisation recommended Lenacapavir as a pre-exposure prophylaxis.

The drug is yet to get permission for use in India. But when it does, it may be unaffordable for most Indians.

In the last few years, Gilead Sciences, the American pharmaceutical giant that made the drug, put in several applications to patent the drug in India.

If granted, the patents would make the drug prohibitively expensive, Tellis said. In the United States, Gilead has priced the drug at $28,218 per patient per year – an unaffordable Rs 25.8 lakh per year for an Indian patient.

To make sure that HIV patients in India have a chance at affording the drug, Tellis registered four pre-grant oppositions with the Indian Patent Office in 2021. “This drug is the best possible tool to prevent HIV and it must be made accessible to those at risk,” Tellis said, explaining his reason for filing an opposition on behalf of Sankalp Rehabilitation.

UNAIDS agrees. “It is beyond comprehension how Gilead can justify a price of $28,218 [for a game-changing medicine],” said Winnie Byanyima, executive director of UNAIDS, in a statement issued last year. “I urge Gilead to do the right thing. Drop the price, expand production, and ensure the world has a shot at ending AIDS.”

Between 2021 and 2025, nine pre-grant oppositions were filed in India against Gilead’s patent applications on Lenacapavir, including the one by Sankalp Rehabilitation Foundation.

Last year, while adjudicating one of the applications, the patent office heard both sides, the manufacturer and Tellis. Its decision is pending.

What Gilead proposes: ‘Sustainable access’

A patent gives a pharmaceutical company a legal right to prevent others from producing, using or commercialising a drug formulation for a certain period. “Often to seek more profits, pharma companies attempt to increase their patent duration by making minor tweaks in their drug,” said Tellis.

This could include a minor change in dosage, or formulation, or the method of administering the drug, he said.

This is called patent evergreening.

Several attempts have been made to extend patents to crucial drugs in India. In some cases, the court has stepped in.

In 2013, Swiss pharma company Novartis’s plea to extend the patent of cancer drug Imatinib was rejected by the Supreme Court.

More recently, the Indian Patent office rejected Johnson and Johnson’s application for bedaquiline, a popular life-saving medication for drug-resistant tuberculosis patients.

So far, objections to Gilead’s pre-grant applications on Lenacapavir have been filed in India, Thailand, Vietnam and Argentina. In 2025, Argentina rejected one such application, which could allow generic drugs to enter the market. This may set a global precedent, activists hope.

In a pre-print paper in the medical journal Lancet, experts pointed out that the cost of manufacturing Lenacapavir could be as low as $25 to $40 if the global demand is between 5 and 10 million people. In India alone, the demand would be huge – there were 64,470 new HIV infections in 2024 and there are 25.61 lakh people with HIV in the country.

When Scroll asked Gilead why it was filing patents that could put the drug out of reach of Indian patients, Ryan Mckeel, the firm’s executive director for public affairs, said it is “pursuing a strategy to enable broad, sustainable access to Lenacapavir for HIV prevention globally".

Mckeel was referring to the royalty-free voluntary licence agreement Gilead signed with six generic manufacturers in October 2024 to make the drug for 120 low- and low-middle income countries, including India.

At least three manufacturers are from India, including Dr Reddy’s Laboratories Limited. “We believe this approach has the potential to be the most efficient strategy for enabling registration as quickly as possible in India so it can reach people who want and need it most,” Mckeel added.

When Scroll contacted Dr Reddy’s, it declined to comment on the price of the drug.

Leena Menghaney, an expert on medicine law and policy, said that simply signing a voluntary licence agreement will not bring down prices of medicines like Lenacapavir to $40. For that to happen, India will have to approve generics of the drug and must decisively roll out a pre-exposure prophylaxis programme at large scale, she said.

“Access to preventive regimens that can stop HIV infection among vulnerable populations is a core part of right to health,” Menghaney said.

A long struggle

Tellis, now 66, has spent a lifetime fighting to keep drugs affordable for Indian masses. Over the years, he has filed oppositions against patents for crucial Hepatitis C, tuberculosis, HIV, and more recently Covid-19 drugs.

His first success came in 2012, when the Indian authorities cancelled pharma firm Roche’s patent on a crucial drug to treat Hepatitis C. It was a landmark decision because the patent had been granted under the Trade-Related Aspects of Intellectual Property Rights or TRIPS, which advocated at least 20 years for a patent.

Later, Tellis also filed opposition to Gilead’s patent application on Sofosbuvir, another Hepatitis C drug. This drug cost 84,000 US dollars for a three-month course. “Our application pushed the government to bring the manufacturing cost to less than 100 dollars in India,” Tellis said. “It benefitted lakhs of patients.”

The process to win such patent oppositions is tedious and long. It needs a coalition of experts from the pharmaceutical sector, legal fraternity, public health activists, and NGOs.

Tellis often seeks the help of the Third World Network, a network of experts and groups that work to ensure equitable distribution of world resources.

To make a persuasive case against a patent application by a pharma giant, a person needs technical advice and understanding on how a drug is formulated and what loopholes pharma companies exploit in order to extend the patent.

Chetali Rao, senior scientific advisor at Third World Network, said a safeguard in the Indian Patent law under Section 3(d) prevents evergreening of a patent if the formulation of a medicine is changed without much change in its therapeutic value.

“In the case of Lenacapavir, too, Gilead has filed for patent extension for salts by minor tweaks in the drug. The therapeutic value does not change,” she told Scroll. “We are basing our opposition on that ground.”

Access for all

Patients at risk of contracting AIDS told Scroll that Lenacapavir might be a better alternative to existing preventive treatments.

Mannu BJ, a 46-year-old from Delhi, was put on prophylaxis treatment against HIV but dropped out of it. The treatment was expensive and involved taking a daily dose of medicine, a regimen he found hard to maintain.

Murugesh, a counselor at Humsafar Trust said that the people at the highest risk of HIV infection are also the ones who can least afford to prevent it. “Even if we convince someone to take it, they drop out in a few months.

But Mannu believes Lenacapavir might change things. “If it is introduced, many will start taking it. One injection in six months is easy to comply with. It can help bring down new infections,” he said.

Hari Shankar, an HIV positive resident of Delhi who actively campaigns for drug availability for patients, said “the production has to be opened up to generic manufacturers”.

Murugesh added: “India must approve Lenacapavir fast, and ensure that it remains accessible to all.”

Cancer treatment follows a familiar pattern: doctors spot symptoms, diagnose the disease and start treatment. But scientists are now exploring a radical shift in how we tackle cancer. Instead of waiting for tumours to appear, they want to catch the disease decades before it develops.

This approach is called “cancer interception”. The idea is simple: target the biological processes that cause cancer long before a tumour ever forms.

Researchers are hunting for subtle early warning signs. These include genetic mutations that quietly build up in our cells, giving them advantages against our immune defences.

They’re also looking at precancerous lesions like moles or polyps, and early visible changes in tissue. All of these appear long before cancer becomes obvious.

Large genetic studies reveal that as people age, their bodies accumulate small groups of mutated cells called clones that grow silently. Scientists have studied this particularly well in blood. These clones can help predict who might develop blood cancers like leukaemia, and the genetics, inflammation and environmental factors strongly influence them.

Crucially, doctors can measure and track these changes over time. This opens up possibilities for early intervention.

A 16-year study followed around 7,000 women and uncovered how these mutations work. Some mutations helped clones multiply faster, while others made them particularly sensitive to inflammation.

When there was inflammation, these sensitive clones expanded. Breaking down these patterns helps researchers identify people with a higher chance of developing cancer later.

Not a sudden event

The research reveals something fundamental about cancer. It’s not a sudden event that instantly produces a tumour.

Instead, cancer develops through a slow, multi-step process with detectable warning signs along the way. These early signs could become powerful targets for stopping cancer before it starts.

Scientists are developing blood tests to spot cancer long before symptoms appear. These tests, called multi-cancer early detection tests (MCEDs for short), search for tiny fragments of DNA in the blood.

MCEDs work by looking for circulating tumour DNA, or ctDNA – DNA fragments that cancerous or precancerous cells release into the bloodstream. Even very early cancers shed this DNA, so the tests might detect disease long before it shows up on a scan.

The results so far look promising. MCEDs can boost survival rates through early detection, especially for colorectal cancer. When doctors diagnose colorectal cancer at stage one, 92% of patients survive five years. But when they catch it at stage four, only 18% survive that long.

The tests aren’t perfect, though. They miss some cancers entirely, and positive results still need follow-up tests to confirm.

Even so, research suggests MCEDs could become crucial for catching cancers that usually go unnoticed until much later. The potential to save lives is significant.

Heart doctors already use a similar approach. They calculate a person’s risk using age, blood pressure, cholesterol and family history, then prescribe drugs like statins years before a heart attack happens.

Cancer researchers want to copy this model. They envision combining genetic mutations, environmental factors and MCED results to guide early cancer prevention.

But cancer differs from heart disease in important ways. Cancer doesn’t follow a predictable path, and some early lesions shrink or never progress.

There’s also the risk of over-diagnosis. Being told you’re at higher risk when you feel perfectly healthy creates anxiety.

Cancer prevention tools also vary widely in their effectiveness, unlike statins that work broadly across different cardiovascular risk groups. The risk-based model shows promise, but needs careful handling.

Treating cancer risk instead of cancer itself raises difficult ethical questions. When someone feels completely healthy, judging whether intervention will truly help them becomes harder.

There’s a danger of causing unnecessary worry or harm. Scientists warn that doctors sometimes overestimate benefits and underestimate risks, particularly for older adults.

MCED tests bring their own ethical concerns. Accuracy isn’t the only issue that matters.

The tests sometimes flag cancer when none exists, leading to follow-up scans and biopsies that patients don’t actually need. The anxiety from all of this carries a high cost, both for patients and the healthcare system.

If these tests are expensive or only available privately, they could make health inequalities worse. This concern hits hardest in low-income countries.

In the US, the medicines regulator is investigating how MCED blood tests should work. They’re examining how reliable the tests need to be and what follow-ups doctors should require to keep patients safe.

The UK is following suit. The National Cancer Plan for England, published on February 4, 2026, commits to providing 9.5 million extra diagnostic tests through the NHS each year by March 2029.

The plan also states that ctDNA biomarker testing will continue in lung and breast cancer. It will extend to other cancers if proven to be cost effective.

What all this shows is clear. Cancer doesn’t suddenly appear; it’s a steady process that begins decades earlier. Catching it before it grows could save countless lives. The question now is how to do that safely, fairly and effectively.

Ahmed Elbediwy is Senior Lecturer in Cancer Biology & Clinical Biochemistry, Kingston University.

Nadine Wehida is Senior Lecturer in Genetics and Molecular Biology, Kingston University.

This article was first published on The Conversation.

Depression is a complex and deeply personal experience. While almost everyone has periods of sadness, low mood or grief, depression is different. Major depressive disorder is persistent, interferes with day-to-day activities, and can affect work, life and relationships.

One in five people will experience depression in their lifetime. Women are nearly twice as likely as men to develop it – a disparity that emerges around puberty and persists into adulthood.

But what causes it? The short answer is: many different things.

While there are various theories, we know brain chemistry, genes, hormones, stress, lifestyle and personality can all play a role. How these interact can vary greatly from one person to another.

Imbalance of brain chemicals

The traditional “monoamine hypothesis” of depression was proposed more than half a century ago, in the 1950s. This theory suggests the root cause of depression is a deficiency in certain brain chemicals (or neurotransmitters) called monoamines – serotonin, dopamine and norepinephrine.

Several antidepressants have been developed based on this. They primarily work by increasing levels of monoamines such as serotonin.

However, it has become clear that the “chemical imbalance” explanation is an oversimplification.

Research over the past few decades has not found consistent evidence that individuals with depression always have lower levels of serotonin, or any single neurotransmitter.

And while antidepressants can increase serotonin levels within hours, improvements in mood typically take days or weeks to emerge. This delay suggests depression cannot be explained by neurotransmitter levels alone.

Current understanding recognises depression as a complex condition influenced by multiple interacting factors, including genetics, trauma, medications, diet, sleep patterns and social interactions.

Genetic factors

According to one 2021 review, around 30 to 50% of the risk someone will develop depression may be inherited.

No single “depression gene” has been found. But large studies have identified over 100 genetic risk markers on chromosomes.

The genetic risk of depression is also thought to be “polygenic”. This means multiple genetic variants (each carrying a small effect) interact and collectively contribute to someone’s genetic risk.

One important and longstanding research question has been whether there is a genetic reason women are more likely than men to develop depression.

In 2025, a large study revealed substantial overlap between men and women’s genetic risk. However, on average, women with depression tend to carry more of the genetic variants linked to depression.

This suggests that there may be a greater genetic risk for depression in women and perhaps a stronger environmental influence on depression risk in men.

Still, carrying a genetic risk does not mean someone will necessarily develop depression. The interplay between genetic and non-genetic factors is complex.

Hormones and biological sex

Hormones – the body’s chemical messengers – also play an important role in mood and wellbeing.

In women, estrogen and progesterone levels naturally fluctuate across different life stages, including the menstrual cycle, pregnancy, the period after childbirth and menopause.

Our 2025 review found some women are more sensitive to these normal hormonal shifts, and more vulnerable to mood disturbances.

For instance, in the premenstrual phase of their cycle, around 8% of women experience a severe depression, with intense mood swings and irritability, called premenstrual dysphoric disorder.

Similarly, the dramatic hormonal changes during pregnancy and after childbirth (combined with sleep loss and stress) can contribute to postnatal depression.

Later in life, fluctuating and falling estrogen levels during the menopause transition years may also increase the risk of developing depressive symptoms or intensify existing ones.

Hormonal contraceptives – which contain synthetic forms of estrogen and progesterone – have also been linked to mood changes and depression symptoms. In fact, these are some of the most common reasons women stop taking them.

These effects appear to depend on the specific type and amount of progesterone used in the formulation.

These findings show how hormones can act as biological triggers, and help explain why women are statistically more likely to experience depression at certain stages of life.

The effect of hormones on depression in men has predominantly focused on the protective role of testosterone, but findings remain inconclusive.

Stress factor

Chronic or repeated stress can have lasting effects on both the brain and body.

When we experience stress, our bodies activate the hypothalamic–pituitary–adrenal (HPA) axis, also known as the “stress-response system”. This helps us cope by maintaining balance in our body – what scientists call physiological homeostasis.

But when stress is constant or overwhelming, this system can become dysregulated. Stressful or traumatic experiences in childhood – such as neglect, abuse or severe adversity – can also disrupt the stress-response system.

As a result, we overproduce the stress hormone cortisol. High or persistent cortisol levels can alter the structure and functioning of key brain areas (the hippocampus and pre-frontal cortex) which are important for regulating mood and memory.

Cortisol can also trigger the release of inflammatory chemicals, which then cross into the brain or influence neural signals, leading to mood changes and depressive symptoms.

Importantly though, not everyone who experiences stressful life events becomes depressed.

Some people may be more vulnerable due to genetic factors, early life adversity or differences in brain chemistry. Others might cope with the same stress without developing depression or other conditions.

Does personality play a role?

Personality traits also influence how people respond to stress and may affect their risk of developing depression.

People who tend to experience anxiety, sadness and self-doubt are more likely to develop depressive symptoms, especially after stressful events. In contrast, traits such as resilience, optimism, and emotional stability seem to protect against depression.

This suggests that personality plays an important role in shaping both vulnerability and resilience to depression.

Lifestyle choices

These include not smoking, limiting alcohol use, eating a balanced diet, staying physically active, getting enough sleep, maintaining a healthy body weight and having social supports.

Research shows these healthy habits and lifestyle factors can have a protective effect on mental health. They may even reduce the impact of genetic risk factors for depression.

No single cause or treatment

Depression arises from a mix of factors – biological (genes and hormones), psychological (personality and thoughts) and social (stress and life events).

Treatment options are based on all of these factors, as well as considering how severe the depression is and whether a person has responded to previous treatments.

While science has made some progress in understanding depression, what underpins each person’s experience is unique.

Caroline Gurvich is Associate Professor and Clinical Neuropsychologist, Monash University.

Eveline Mu is Research Fellow in Women's Mental Health, Monash University.

Jayashri Kulkarni is Professor of Psychiatry, Monash University.

Sixty-two-year-old Kusum Devi* developed sudden and severe lower back pain on the night of her daughter’s wedding. She was rushed to a nearby hospital in Surat, Gujarat. Eventually, investigations revealed that she had chronic lymphocytic leukaemia, blood cancer that needs life-long medication.

Neither the state health insurance scheme nor the Union government’s flagship Pradhan Mantri Jan Arogya Yojana covers the medicine prescribed to treat her cancer. Acalabrutinib (100 mg) costs about Rs 8,500 for a month’s course, a sum she can ill afford.

The Indian Cancer Society stepped in to support Kusum with up to Rs 5 lakh, as a result of which she is physically stable.

Government health insurance excludes many drugs and outpatient treatments. Drug price controls should fill this gap – but do not adequately address rare and specialised diseases, according to a report commissioned by the National Pharmaceutical Pricing Authority, India’s drug price regulator.

Outlets under the Pradhan Mantri Bhartiya Janaushadhi Pariyojana – aimed at facilitating the sale of centrally procured reasonably-priced generic medicines – stock about 2,110 medicines and 315 surgical items, including 384 medicines covered in the National List of Essential Medicines (NLEM 2022).

Essential medicines are “those that satisfy the priority health care needs, based on efficacy, safety, quality and total cost of the treatment”, and which are subject to price control measures detailed in the Drug Price Control Order 2013.

Certain drugs used to treat rare and complex cancers have not been included. Some examples are Nivolumab and Pembrolizumab, which are checkpoint inhibitors for melanoma, lung and other cancers; and Bevacizumab, an anti-angiogenic therapy for colorectal and lung cancers. While Bevacizumab costs about Rs 8,000 for a vial of 100 mg, the other drugs cost Rs 1- Rs 2 lakh for a vial (see here and here).

Beyond pharmaceuticals, medical devices present similar price control gaps. Some such as cardiac stents and knee joint replacements have designated ceiling prices under the Drug Prices Control Order 2013. Others are treated as non-scheduled items where the National Pharmaceutical Pricing Authority monitors annual price increases but doesn’t set ceilings.

This is the second of a two-part investigation into India's medicine affordability crisis. Part 1 examined why generic medicines – despite 17,000 Jan Aushadhi stores – don’t reach the poorest citizens. This concluding part examines a different crisis: specialised medicines for cancer and rare diseases that fall outside generic frameworks entirely.

This affects millions of Indians. India has about 2.5 million people living with cancer. More than 700,000 people are diagnosed with cancer annually while about 550,000 lose their lives to the disease.

Cancer is one of the most expensive non-communicable diseases to treat, for which – various studies show – between 34% and 84% patients incur catastrophic expenditure rates, as IndiaSpend reported in August 2024.

The World Health Organization defines catastrophic health spending as out-of-pocket payments that exceed 40% of a household’s capacity to pay for healthcare. The WHO defines capacity to pay for health care as total household consumption minus a standard amount to cover basic needs (food, housing and utilities).

Another 100 million Indians struggle to live with rare diseases, according to the Indian Organization for Rare Diseases—because they are hard to diagnose and expensive to treat. It can take up to five years to correctly diagnose a person with a rare disease, while proven treatments exist for only about 5% of rare diseases. And at a high price at that.

While the government offers a one-time Rs 50 lakh payout to patients for treatment, this is insufficient. Treating a rare disease can cost up to Rs 1 crore and more annually, by the government’s own admission.

Drug pricing mechanism

In 2019, the National Pharmaceutical Pricing Authority invoked para 19 of the Drugs Prices Control Order 2013 to limit trade margins of select cancer medicines to 30%, a much needed move considering “margins on cancer medicine are sometimes as high as 90%”, said MR Rajagopal, chairman emeritus, Pallium India, and adjunct professor of global oncology, Queen's University, Canada.

This price capping was considered a pilot before extending it to other therapeutic segments but similar caps haven’t been applied.

India is majorly focusing on the National List of Essential Medicines for price control with the ceiling prices of scheduled drugs based on a simple average of market prices.

Non-scheduled drugs are subject to annual price increment limits, typically 10% of the maximum retail price, which must be reported in the prescribed forms. However, their base price isn’t fixed by the regulator; they are free to set the initial retail price when launching the product.

Overseas, many countries effectively regulate pharmacy margins and wholesale margins, according to the CCI report. This includes setting prices based on their price in a basket of other countries; on the price of generics or therapeutically similar drugs available domestically; on the value it delivers to patients, healthcare systems and society rather than just the production cost; or Health Technology Assessment (for new drugs and medical technologies) the way Australia, Brazil, Germany and others do. India does none of this.

“All these methods ensure that drug costs reflect both clinical benefit and public affordability,” said Kritika Krishnamurthy, director of the Bridge Policy Think Tank, the organisation behind the National Pharmaceutical Pricing Authority-commissioned review of drug pricing.

“Introducing such systematic approaches in India would create a more predictable and equitable framework for medicine prices, bridging the gap between patient access and industry sustainability,” she said.

IndiaSpend has approached Kumar Aman Bharti, director (Cost) in the National Pharmaceutical Pricing Authority, for reasons for the government approach to drug price setting. We will update this story when we receive a response.

Need for reimbursements

“Government initiatives so far have worked but patients need much more financial support for cancer treatment which is a huge challenge,” said Usha Thorat, managing trustee and honorary secretary, Indian Cancer Society. “Government hospitalisation schemes cover only 40% of the population. But even middle-class families not covered by such schemes are unable to afford cancer treatment.”

Reducing custom duties on cancer drugs in the budget 2026-’27 is a welcome step for affordability, said Krishnamurthy. For emerging therapies such as cell and gene therapies, she suggested, the government should provide incentives such as capital subsidies, tax holidays, and technology transfer provisions “while ensuring pricing transparency through Health Technology Assessment and value-based frameworks”.

For rare diseases, Krishnamurthy said India should prioritise government reimbursement schemes alongside a technical committee to attract foreign manufacturers for local production.

In Australia or China, a Pharmaceutical Benefits Scheme and National Reimbursement Drug List respectively help to financially protect people, according to the Bridge Policy Think Tank’s report on drug pricing in India as against other nations.

“If supply-side price controls are limited, then public reimbursement mechanisms must expand to protect patients,” said Krishnamurthy. “Without one or the other, affordability challenges inevitably shift the burden to individuals.”

Price controls, however sophisticated, cannot help with medicines that exist and are included in NLEM but still don’t reach patients.

Medicine accessibility

Narayani Soman*, 82, diabetic and hypertensive, survived a stroke. She could drag herself around and get some housework done with her one functional arm. However, her husband, 86 years old, diabetic and with chronic lung disease, was frail and almost completely bed-bound.

All the medicine they needed was available in their nearest primary health centre in rural Kerala. But it had to be picked up, which Narayani’s failing strength didn’t allow.

“Even in states where free medicines are available in the government system for the poor, the patient is often unable to access it,” said Rajagopal. “Availability in a hospital isn’t the same as accessibility to a patient, but health systems don’t recognise this difference.”

Morphine is a good example of a medicine that is included in the National List of Essential Medicines 2022, but which is often not accessible when needed.

In most of the Global North and in some low income countries like Uganda, morphine is considered the gold standard for pain relief in cancer patients; they use it legally, safely and effectively.

In India, Kerala has effectively used morphine for 27 years but in most of the country, “about a million people with advanced cancer need oral morphine to alleviate pain but despite sufficient morphine powder being made domestically, and morphine being categorised ‘essential’, it is inaccessible to more than 96% patients because of demand side and supply side issues,” said Rajagopal.

Between 1985 and 2014, the Narcotic Drugs and Psychotropic Substances Act made it challenging to prescribe morphine for pain relief and palliative care. An amendment to the Act in 2014 should have changed the situation but “the amended laws haven’t been widely implemented in a sustained way across states,” said Rajagopal. “USA’s very visible opioid epidemic is driving the implementation of the amendment; possibly because the condition of terminal cancer patients isn’t as visible.”

On the demand side, Rajagopal said, “generations of Indian doctors haven’t seen the use of morphine and tend to prescribe transdermal patches instead. But morphine is 100 times cheaper than a transdermal patch of fentanyl and most of the time equally effective and in some instances, more effective.”

Millions like Kusum – without NGO support, without reimbursement schemes, in the world's “Pharmacy” – face the same impossible math: treatment or financial ruin.

*Names changed on request.

Charu Bahri is a freelance writer and editor based in Mount Abu, Rajasthan.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

Depression and anxiety affect millions of people worldwide.

While treatments such as medication and psychotherapy (sometimes called talk therapy) can be very effective, they’re not always an option. Barriers include cost, stigma, long waiting lists for appointments, and potential drug side effects.

So what about exercise? Our new research, published today, confirms physical activity can be just as effective for some people as therapy or medication. This is especially true when it’s social and guided by a professional, such as a gym class or running club.

Let’s take a look at the evidence.

What we already knew

Physical activity has long been promoted as a treatment option for anxiety and depression, largely because it helps release “feel good” chemicals in the brain which help boost mood and reduce stress.

But the evidence can be confusing. Hundreds of studies with diverse results make it unclear how much exercise is beneficial, what type, and who it helps most.

Over the past two decades, researchers have conducted dozens of separate meta-analyses (studies that combine results from multiple trials) examining exercise for depression and anxiety. But these have still left gaps in understanding how effective exercise is for different age groups and whether the type of exercise matters.

Many studies have also included participants with confounding factors (influences that can distort research findings) such as other chronic diseases, for example, diabetes or arthritis. This means it can be hard to apply the findings more broadly.

What we did

Our research aimed to resolve this confusion by conducting a “meta-meta-analysis”. This means we systematically reviewed the results of all the existing meta-analyses – there were 81 – to determine what the evidence really shows.

Together, this meant data from nearly 80,000 participants across more than 1,000 original trials.

We examined multiple factors that might explain why their results varied. These included differences in:

• who they studied (for example, people with diagnosed depression or anxiety versus those just experiencing symptoms, different age groups, and women during pregnancy and after birth)

• what the exercise involved (for example, comparing aerobic fitness to resistance training and mind-body exercises, such as yoga; whether it was supervised by a professional; intensity and duration)

• whether the exercise was individual or in a group.

We also used advanced statistical techniques to accurately isolate and estimate the exact impact of exercise, separate from confounding factors (including other chronic diseases).

Our data looked at the impact of exercise alone on depression and anxiety. But sometimes people will also use antidepressants and/or therapy – so further research would be needed to explore the effect of these when combined.

What did the study find

Exercise is effective at reducing both depression and anxiety. But there is some nuance.

We found exercising had a high impact on depression symptoms, and a medium impact on anxiety, compared to staying inactive.

The benefits were comparable to, and in some cases better than, more widely prescribed mental health treatments, including therapy and antidepressants.

Importantly, we discovered who exercise helped most. Two groups showed the most improvement: adults aged 18 to 30 and women who had recently given birth.

Many women experience barriers to exercising after giving birth, including lack of time, confidence or access to appropriate and affordable activities.

Our findings suggest making it more accessible could be an important strategy to address new mothers’ mental health in this vulnerable time.

How you exercise matters

We also found aerobic activities – such as walking, running, cycling or swimming – were best at reducing both depression and anxiety symptoms.

However, all forms of exercise reduced symptoms, including resistance training (such as lifting weights) and mind-body practices (such as yoga).

For depression, there were greater improvements when people exercised with others and were guided by a professional, such as a group fitness class.

Unfortunately, there wasn’t available data on group or supervised exercise for anxiety, so we would need more research to find out if the impact is similar.

Exercising once or twice a week had a similar effect on depression as exercising more frequently. And there didn’t seem to be a significant difference between exercising vigorously or at a low intensity – all were beneficial.

But for anxiety, the best improvements in anxiety symptoms were when exercise was done:

• consistently, for up to eight weeks, and

• at a lower intensity, such as walking or swimming laps at a gentle pace.

What does it mean

Our research shows exercise is a legitimate and evidence-based treatment option for depression and anxiety, particularly for people with diagnosed conditions.

However, simply telling patients to “exercise more” is unlikely to be effective.

The evidence shows structured, supervised exercise with a social component is best for improving depression and anxiety. The social aspect and the accountability may help keep people motivated.

Clinicians should keep this in mind, offering referrals to specific programs – such as aerobic fitness classes or supervised walking and running programs – rather than general advice.

The findings also suggest this kind of exercise can be particularly effective when targeted to depression in younger adults and women who’ve recently given birth.

The takeaway

For people who are hesitant about medication, or facing long waits for therapy, supervised group exercise may be an effective alternative. It’s evidence-based, and you can start any time.

But it’s still best to get advice from a professional. If you have anxiety or depression symptoms, you should talk to your GP or psychologist. They can advise where exercise fits in your treatment plan, potentially alongside therapy and/or medication.

Neil Munro is PhD Candidate in Psychology, James Cook University.

James Dimmock is Professor in Psychology, James Cook University.

Klaire Somoray is Lecturer in Pyschology, James Cook University.

Samantha Teague is Senior Research Fellow in Psychology, James Cook University.

This article was first published on The Conversation.

Coffee first entered human lives and veins over 600 years ago.

Now we consume an average of almost two kilos per person each year – sometimes with very specific preferences about blends and preparation methods. How much you drink is influenced by genes acting on your brain’s reward system and caffeine metabolism.

Coffee can raise your blood pressure in the short term, especially if you don’t usually drink it or if you already have high blood pressure.

But this doesn’t mean you need to cut out coffee if you have high blood pressure or are concerned about your heart health. Moderation is key.

So how does coffee affect your blood pressure? And if yours is high, how much is OK to drink?

What is high blood pressure

Blood pressure is the force blood exerts on artery walls when your heart pumps. It’s measured by two numbers:

• the first and biggest number is systolic blood pressure, which is the force generated when your heart contracts and pushes blood out around your body

• the lower number, diastolic blood pressure, is the force when your heart relaxes and fills back up with blood.

Normal blood pressure is defined as systolic blood pressure of less than 120 millimeters of mercury (mm Hg) and diastolic blood pressure of less than 80 mm Hg.

Once your numbers consistently reach 140/90 or more, blood pressure is considered high. This is also called hypertension.

Knowing your blood pressure numbers is important because hypertension doesn’t have any symptoms. When it goes untreated, or isn’t well-controlled, your risk of heart attacks and strokes increases, and existing kidney and heart disease worsens.

About 31% of adults have hypertension with half unaware they have it. Of those taking medication for hypertension, about 47% don’t have it well-controlled.

Coffee and blood pressure

Caffeine in coffee is a muscle stimulant that increases the heart rate in some people. This can potentially contribute to an irregular heartbeat, known as arrhythmia.

Caffeine also stimulates adrenal glands to release adrenaline. This makes your heart beat faster and your blood vessels to constrict, which increases blood pressure.

Blood caffeine levels peak between 30 minutes and two hours after a cup of coffee. Caffeine’s half-life is 3-6 hours, meaning blood levels will reduce by about half during this time.

The range is due to age (kids have smaller, less mature livers so can’t metabolise it as fast), genetics (people can be fast or slow metabolisers) and whether you usually drink it (regular consumers clear it faster).

The impact of caffeine on blood pressure from coffee (and cola, energy drinks and chocolate) varies. Research reviews report increases in systolic blood pressure of 3–15 and a diastolic blood pressure increase of 4–13 after consumption.

The effect of caffeine also depends on a person’s usual blood pressure. An increase in blood pressure may be more risky if you have hypertension and existing heart or liver disease, so it’s best to discuss your coffee consumption with your doctor.

What else is in coffee

Coffee contains hundreds of phytochemicals: compounds that contribute flavour, aroma, or influence health and disease.

Phytochemicals that directly affect blood pressure include melanoidins, which regulate the body’s fluid volume and activity of enzymes that help control blood pressure.

Quinic acid is another phytochemical shown to lower systolic and diastolic blood pressure by improving the lining of blood vessels, allowing them to better accommodate blood pressure rises.

Can coffee cause hypertension?

In a review of 13 studies that included 315,000 people, researchers examined associations between coffee intake and the risk of hypertension.

During study follow-up periods, 64,650 people developed hypertension, with the researchers concluding coffee drinking was not associated with an increased risk of developing the condition.

Even when they examined data by gender, amount of coffee, decaffeinated versus caffeinated, smoking or years of follow-up, coffee was still not associated with an increased risk of developing hypertension.

The only exceptions suggesting lower risk were for five studies from the United States and seven low-quality studies, meaning those results should be interpreted with caution.

A separate Japanese study followed more than 18,000 adults aged 40–79 years for 18.9 years. This included about 1,800 people who had very high blood pressure (grade 2-3 hypertension), with systolic blood pressure of 160 or above or diastolic blood pressure of 100 or above.

Here, risk of dying from cardiovascular disease, including heart attack or stroke, was double among those drinking two or more cups of coffee a day compared to non-drinkers.

There were no associations with death from cardiovascular disease for those who had either normal blood pressure or mild (grade 1) hypertension (systolic blood pressure 140–159 or diastolic blood pressure 90–99).

The bottom line

There is no need to give up coffee. Here’s what to do instead:

1. know your blood pressure, health history and which food and drinks contain caffeine

2. consider all factors that influence your blood pressure and health – family history, diet, salt and physical activity – so you can make informed decisions about what you consume and how much you move

3. be aware of how caffeine affects you and avoid it before having your blood pressure measured

4. avoid caffeine in the afternoon so it doesn’t affect your sleep

5. aim to moderate your coffee intake by drinking four cups or less a day or switching to decaf

6. if you have systolic blood pressure of 160 or above or diastolic blood pressure of 100 or above, consider limiting to one cup a day, and talk to you doctor.

Clare Collins is Laureate Professor in Nutrition and Dietetics, University of Newcastle.

This article was first published on The Conversation.