For decades, tackling tuberculosis has been more about protocols and less about the people it affects. The goals in the global TB strategy were simple: detect 70% of estimated cases, ensure at least 85% of them are on treatment and “compliant” through directly observed treatment or DOTS .

Decades later, it is clear that this approach has delivered limited results. TB, in its many shifting forms, has outsmarted us.

There is a growing realisation that protocols and compliance, while important, do not help understand the mindset or behaviour of those affected and their expectations from the health system.

Diagnosis and treatment are key but their success is dependent on how, and in what condition, they are delivered and whether they meet the expectations of those affected.

As a TB-endemic country, India needs to work harder on understanding why people get the disease, why detection is so challenging, and how their treatment journey and consequently adherence can be improved.

What also needs understanding is how stigma, mental health and poverty plague those affected by TB and how to address them. Perhaps most important is recognising that TB is both a social and an economic disease.

Few know that TB mortality declined in the West long before any medications were available. The peak of the TB epidemic in the 19th century was attributed to conditions that are still prevalent in India today: overcrowding, poor nutrition, now compounded by immunocompromising diseases such as diabetes that are rising in incidence.

The RATIONS study, or Reducing Activation of Tuberculosis by Improvement of Nutritional Status, published last year, enrolled 2,800 contacts of patients with active TB in Jharkhand and randomly allotted half of them to receive monthly food rations.

The risk of developing active pulmonary TB was reduced by 48% in this cohort of individuals with a high prevalence of malnutrition. Here is the simplest change that can be made – food security. The alleviation of hunger with nutritious food not only prevents active TB, it also arrests the chain of transmission.

On diagnosis, the presence of a cough that lasts for at least two weeks has always been thought to be necessary for testing for TB. However, a meta-analysis of 12 surveys from eight countries in Africa and four in Asia found that a majority of individuals with pulmonary TB did not report cough and this was more common among women.

This clearly shows that improving diagnosis requires better tools, possibly using artificial intelligence-based methods, integrating symptomatology and screening strategies to actively find those who are affected from subclinical disease, in their geographies.

Subclinical disease refers to there no outward symptoms of a disease, which can be detected through medical and laboratory tests. This is imperative if the aim is for early diagnosis and preventing transmission to close contacts.

Adherence to TB treatment has always been challenging, and patients have often been shamed and termed “defaulters” .

Is it that simple? Survivor testimonials and focus groups have highlighted the need for shortening the length of treatment (currently six months for drug-sensitive TB), improving access to free treatment, ongoing patient support, having a safety net while recovering from the disease.

Universally, those affected point to the need of making interactions with healthcare providers and caregivers devoid of stigma, and empowering, with joint decision-making.

Changing our status quo will require changing our standards of good care. Quality standards for TB care often focus on statistics but ignore the human aspects of the patient experience. This lacuna can lead to treatment strategies being disempowering and not person-centered. We need patients to be at the centre of policy-making and also listen to them for better programme design.

There is a two-month treatment strategy that has demonstrated success in drug-sensitive TB, and six-month strategy for drug-resistant TB, respectively, but neither is accessible in India presently.

Growing interest in TB research has led to a promising diagnostics and drug pipeline over the past two decades, but access remains the biggest challenge. The last year showed remarkable progress in access to drugs and diagnostics due to advocacy and activism. Access, however, has to be the responsibility of programmes – to ensure people get free, reliable, accurate and sensitive care that they need.

While the focus of progress in eradicating TB continues to revolve around protocolised diagnostic and treatment-based strategies, the last year has indicated that we need to focus equally on delivering high quality, people-centered care in a humane manner.

Treating those affected as without choices and agency is not just inhuman, it is counterproductive. Focusing on food, financial security, humane interactions and access to deliver high-quality care is as important as scientific developments. Investing in these are likely to yield better health-based outcomes that can help us mitigate this ancient scourge.

Dr Lancelot Pinto is at consultant pulmonologist and epidemiologist at Hinduja Hospital, Mumbai.

The Supreme Court on Tuesday gave one week’s time to Patanjali Ayurved’s Managing Director Balkrishna and co-founder, yoga guru Ramdev, to issue a public apology in the contempt proceedings initiated against the company for its misleading advertisements, reported Live Law.

Ramdev and Balkrishna also apologised to the division bench of Justices Hima Kohli and Ahsanuddin Amanullah. The court was hearing a petition filed by the Indian Medical Association against Patanjali Ayurved Limited accusing the company of carrying out a “smear campaign” against modern medicine and the Covid-19 vaccination drive.

“What we did at that point of time, it should not have been done,” Ramdev said, addressing the company’s decision to continue publishing misleading advertisements. “We will remember this in future. We released the advertisements on an impulse.”

In its previous hearings, the court reprimanded Balkrishna and Ramdev for an advertisement issued by their company on December 4 after it had said in an undertaking on November 21 that it would not make any “casual statements claiming medicinal efficacy or against any system of medicine”.

“You are doing good work but you can’t degrade allopathy,” the court said on Monday, reported The Indian Express. “Why are you asking for other methods to be stopped in favour of your methods?”

To this, Ramdev said that Patanjali wanted to bring out Ayurvedic products that are backed by research-based evidence.

The court posted the matter for April 23 and asked both Ramdev and Balkrishna to be present for the hearing.

Previous hearings

On April 12, the Supreme Court said that it was concerned about companies deceiving customers and creating risks to their health. The bench said that public health suffers because of such products despite the large sums of money they cost. “This is absolutely unacceptable,” the court said.

On April 10, the Supreme Court rejected Patanjali’s second apology and said that Balkrishna and Ramdev only expressed remorse when they were “caught on the wrong foot”.

The court remarked that Ramdev and Balkrishna tried to evade appearing before it personally by making false claims about foreign travel. It noted that though an application seeking exemption from personal appearance was filed on March 30, their flight tickets were dated March 31.

The bench also castigated the Uttarakhand State Licencing Authority for failing to act against Patanjali and its subsidiary Divya Pharmacy.

The court ordered the current and previous officers of the Uttarakhand Licensing Authority to file detailed affidavits explaining why they did not take any action against Patanjali under the Drugs and Magic Remedies (Objectionable Advertisements) Act, reported The Hindu.

During a hearing on April 2, the bench also questioned why the Ministry of Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) had chosen “to keep its eyes shut when Patanjali was going to town saying there [was] no remedy for Covid in allopathy”.

Also read: A brief history of Patanjali’s dangerous claims

As temperatures rise in Karnataka’s Malenadu region, located along the Western Ghats, the residents remain on high alert due to the resurgence of a tick-borne illness endemic to India – Kyasanur Forest Disease (KFD). Locally known as monkey fever or mangana kayile in Kannada, this viral haemorrhagic disease, caused by a Flavivirus in the family of Flaviviridae, carries an estimated fatality rate of 3% to 15%. Dengue, in comparison, kills around 2.6% of the infected, according to an estimate.

The zoonotic disease follows a predictable annual cyclic pattern, emerging during the peak winter months of November and December, reaching its zenith in the summer, and then disappearing completely with the onset of monsoon, only to resurface with varying intensity the following year.

Since January this year, the region has already recorded 12 deaths, and more than 250 positive cases of KFD. The recent demise of a seven-year-old child in Uttara Kannada district due to KFD has heightened concerns.

Highlighting the gravity of the situation, KP Sripal, a Shivamogga-based advocate and a member of the KFD Janajagruthi Okkoota, a civil society group advocating for better accountability and government protection against the disease, notes that this tragic incident marks the first child fatality from the disease in over 30 years.

While we couldn’t verify the claim due to a lack of data, Dr KJ Harshavardhan, deputy director of the government-run Virus Diagnostic Laboratory in Shivamogga, says that a child’s death is a rare occurrence in KFD cases. “Young children do not go into the forest often and they also have better immunity against the virus. This death is a rare one,” he tells Mongabay-India.

Health officials also observe a broader trend wherein KFD cases peak approximately every four or five years, although no official study has been conducted to substantiate this claim.

This trend could potentially be due to the four to five-year immunity the body builds against the virus after an attack, points out Shivamogga resident Darshan Narayan, a scientist with ATREE who has previously worked with the Indian Council of Medical Research and the state health department on the disease. Thus, 2024 holds particular significance, as the local residents and officials report that the last major outbreak in this region occurred in 2019.

A looming threat of deficient rainfall and intense heat, conditions conducive to the proliferation of ticks, provides additional risks this year. “The absence of customary December showers, which typically flush away ticks in their nymph stage – when they are most virulent – has been particularly concerning,” explains Harshavardhan. “While case numbers surged in January and February, there appears to be a promising downward trajectory in March,” he adds.

This Mongabay-India correspondent travelled to Kyasanur and Aralagodu villages, Shivamogga town, and surrounding areas to interview residents and officials at KFD’s hotspots.

Deaths of monkeys

Kyasanur Forest Disease was first identified in 1957 within the Kyasanur forest range, adjacent to a village of the same name in Soraba taluk of Shivamogga. The sudden death of numerous monkeys, followed by fevers in individuals with a history of forest exposure, prompted the then government (the Government of Mysore) to initiate emergency measures such as free distribution of antibiotics for typhoid.

Initially suspected to be typhoid and then yellow fever, subsequent investigations revealed ticks as carriers of an “unknown” virus. Interestingly, despite its name being associated interchangeably with the deadly disease, the village of Kyasanur never reported a death from the disease or has not had any positive KFD cases in the last 25 years, according to the records with Virus Diagnostic Laboratory, as noted by Darshan.

Reflecting on the pivotal days when the disease first emerged, Huchappa, a nonagenarian from Kyasanur village, recounts guiding four forest officers in masks and gloves to the site of the deceased monkeys in the forest. “We spent a fortnight in the forest, returning with the dead monkeys in gunny bags and two live monkeys, caught using sugarcane as bait, in a cage.”

He had a ringside view of the historical event unfolding as no other resident was willing to go into the forest with the officers. Huchappa hazily remembers those monkeys as bili manga or white monkeys, likely referring to Hanuman langurs.

Further laboratory analyses conducted on various tick specimens collected from monkeys, bovines, rodents, and humans, by the former Virus Research Centre in Pune, in collaboration with The Rockefeller Foundation, alongside state public health experts, led to the isolation and coding of the virus as P9605.

Land use change to blame?

During the early stages of detection and research, it was speculated that the virus might have been transmitted via ticks carried by migratory birds. However, the prevailing theory now suggests that the virus is endemic, and likely circulating within the Malenadu forests from an earlier period.

Due to the dense forest cover and minimal human activity within these regions, the virus remained relatively undisturbed. However, with deforestation and significant alterations in land use and ecological dynamics, the virus and its carriers were brought into closer proximity to human populations.

Sixteen tick species – most of them belonging to the genus Haemophysalis – out of 40 species of ticks recorded from KFD affected areas, have been found to be carrying the virus. The virus finds its maintenance and amplification within various host animals, each responding differently to infection.

Humans, acting as dead-end hosts, typically encounter the virus accidentally and do not contribute to its natural cycle. Small mammals such as porcupines, squirrels, and rodents serve as reservoir hosts, crucial for sustaining the virus’s circulation between ticks and reservoir hosts. Although these animals become infected by the virus, they typically do not display symptoms of illness.

In contrast, primates such as Hanuman langurs (Semnopithecus entellus) and bonnet macaques (Macaca radiata), serve as amplifying hosts. The virus undergoes amplification within their bodies, leading to symptomatic infection similar to that seen in humans. The occurrence of monkey deaths serves as a significant indicator, acting as a “sentinel event,” signalling a potential epidemic in the area.

From 1957-1971, the disease was confined to Shivamogga district. It started spreading to the neighbouring district of Uttara Kannada in 1972 and eight years later, in 1980, cases were reported from Chikkamagaluru and from Dakshina Kannada in 1982.

In 2012, the disease was reported from Chamarajanagara district and the Nilgiri district of Tamil Nadu. The following years saw it spread to neighbouring states of Kerala, Goa, and Maharashtra, as well as other districts of Karnataka like Belagavi, Gadag, Mysuru and Hassan.

Fear, stigma

“Lockdown struck our village a year prior to Covid-19,” recalls Chandrakala Ganapathi, a senior citizen of Aralagodu, a village in Sagara taluk, reflecting on the chaos that followed an outbreak of monkey fever in her tight-knit village of just 86 families (as per the 2011 Census). Monkey fever ravaged Aralagodu during the winter months of November and December in 2018, marking one of the most severe outbreaks of KFD in recent memory.

Caught amidst fear and misinformation, the neighbouring villages shunned Aralagodu residents, even prohibiting them from accessing public transportation, as recounted by the villagers.

Chandrakala, who, along with her husband Ganapathi, operates a homestay, shares the stark isolation they endured – neither relatives nor neighbours dared to visit during this period. Farm labourers from neighbouring areas refused to work in Aralagodu, and some of their own workers fell gravely ill with KFD.

Desperate, some residents shuttered their homes and sought refuge in nearby villages. Another resident Shivaraj, who spearheaded relief efforts within the village, says that there was an overwhelming influx of patients at the local public health centre, where four ambulances stood on standby.

Despite its annual cyclic nature, the monkey fever continues to instill fear and perpetuate social stigma, reminiscent of the initial stages of Covid-19 pandemic. Journalists, researchers, or anyone seeking information in the recent outbreak regions of Uttara Kannada and Chikkamagaluru districts are met with hostility and rejection.

During the 2019 outbreak, people believed that the disease was transmitted from human to human. In a 2020 paper addressing social stigma during infectious disease outbreaks, the authors say that stigmatisation and discrimination of individuals can also become barriers to accessing health care and adopting healthy behaviours.

Vaccine withdrawal

Residents of KFD hotspots have other concerns, too. This year, Chandrakala didn’t receive the usual WhatsApp message from the PHC nurse, Pushpa S, reminding her about the preventive vaccination shots.

Additionally, the distribution of Dimethyl phthalate (DMP) oil, which was previously freely provided by the public health centre to prevent tick bites, has also ceased. Some individuals, like plantation worker and KFD survivor Somavathi Mahaveera, received the oil in a brand new bottle without any accompanying explanation.

“The vaccine abruptly stopped early last year. We were anticipating booster doses, but there has been no supply so far,” remarks a perplexed Pushpa. In fact, the department of health and family affairs stopped the manufacturing and distribution of the KFD vaccine, arguably the only defence against the virus, in October 2022, citing potency issues.

A study conducted between 2005 and 2010 by the National Institute of Epidemiology, a sister agency of the National Institute of Virology under the Indian Council for Medical Research, discusses the effectiveness of the vaccine and confirms the loss of potency. The study attributes this decrease in efficacy to potential genetic drifts and variations in newer strains of the virus, as opposed to the strain used for vaccine development in the 1950s.

While Harshavardhan assures that a new vaccine is currently in development at the National Institute of Immunology in Hyderabad and is expected to be available next year, there is unofficial consensus in scientific circles that its completion may require additional time.

At least three other vaccines made abroad have shown effectiveness against the virus. One is commercially available and the other two are awaiting clinical trials.

Impractical preventive measures

In the absence of a vaccine, authorities are urging communities to adhere to preventive measures, which villagers find impractical. “We cannot stop going to plantations or forests because it is our livelihood,” explains Somavathi. She informs us that the tick-repellent DMP oil, though effective, poses challenges due to excessive sweating during outdoor labour activities.

The first one to be infected in Aralagodu in late 2018, Padmavathi, spent over Rs 1 lakh in treatment. She couldn’t access the government’s free medical care for the KFD-infected as she got infected before the outbreak became apparent.

Padmavathi mentions that fatigue has overwhelmed both her and her husband post-infection, making farming difficult. Extreme fatigue is a post-infection condition observed. Additionally, patients experience hair loss, and for women, an infection during menstruation can be fatal.

A 2023 paper that maps the sociodemographic features of the vulnerable population, identifies the poor, landless or smallholders, and households headed by the elderly as particularly susceptible to the disease.

Bheerappa tragically lost both his son and wife, who were labourers at arecanut plantations, to the infection within two days of each other. He recounts that his son and wife were reluctant to get the vaccination.

Apart from vaccine hesitancy, most village residents also shy away from reporting the case in the early stages for fear of having to visit large private hospitals that provide free medical assistance to the KFD infected at the government’s behest.

Changing symptoms and cure

The incubation period of KFD in humans typically spans two to four days. This illness is marked by a sudden onset of high fever and headache, accompanied by a range of symptoms such as body aches, diarrhoea, muscle pain etc., and haemorrhagic manifestations like gum, nose, or gastrointestinal bleeding.

In approximately 10-20% of cases, fever may recur with neurological symptoms such as mental confusion, drowsiness and other related manifestations. Doctors also caution that the viral load plays a critical role in determining the severity of the infection.

Treatment for KFD is currently limited to addressing symptoms. The symptoms, however, are evolving over time. Pushpa says, “Sometimes patients come without the typical headache accompanying fever, which was once considered a hallmark symptom. In some instances, only blood tests confirm KFD.” Unfortunately, by this point, treatment may be initiated too late to effectively combat the infection.

Despite the disease being around for over six decades, KFD’s changing epidemiological profile suggests it to be considered an emerging tropical disease, according to a 2018 study. There is an overwhelming consensus among the general public and experts that the virus strain may be drifting or mutating. “These opinions remain largely hypothetical in the absence of evidence,” says Dr Prashanth N. Srinivas at the Institute of Public Health in Bengaluru who has been studying the disease for a long time.

Darshan highlights the lack of human postmortems since 1992, which could provide valuable insights into histopathological variations resulting from the infection. However, Harshavardhan dismisses the importance of postmortem studies in medical treatment, arguing that since the disease is managed symptomatically, such studies wouldn’t significantly impact medical interventions.

Inaccurate, inadequate data

Missing or faulty data is another serious concern. KFD Janajagruthi Okkoota members accuse the authorities of consistently undercounting cases and conducting inaccurate death audits. The death of 18-year-old Ananya from Hosanagara taluk due to KFD early this year allegedly occurred because the authorities withheld her blood test results. This incident prompted them to send a letter to the prime minister alleging foul play.

Despite 22 reported KFD deaths from Aralagodu alone in 2018-’19, official records indicate zero deaths in 2018 and only 15 deaths in 2019 in Karnataka. Shivaraj highlights that many genuine cases of KFD are rejected based on the victim’s history of alcohol or tobacco use. “The reality is, almost everyone in our village consumes alcohol and smokes tobacco, but not all of them die from KFD,” he points out.

He adds that the monetary compensation ranging from Rs 2 to 2.5 lakh provides significant relief for the victims’ families. The government also offers free medical aid to confirmed KFD cases and inaccurate testing may result in denial of assistance.

Even monkey deaths are often misreported which Darshan says can be detrimental since infected ticks leave a monkey’s dead body when body temperature drops and spread in the nearest forest floor, creating a “hotspot”. “It’s crucial to steer clear of such areas to avoid an infection,” he says.

As KFD-affected regions anxiously await the development of an effective vaccine to alleviate the annual threat and anxiety of potential infections, experts stress the importance of additional measures to curb the spread of the virus. Srinivas emphasises the urgent need to halt rapid land use changes in forested areas, alongside the implementation of enhanced surveillance mechanisms and primary prevention strategies.

Darshan points out that while Kyasanur has not reported any positive cases in decades, the absence of sero-surveillance kits hinders his understanding of why. Srinivas advocates for medico-social audits, akin to death audits, to meticulously analyse cases and identify systemic failures. Experts suggest taking a One Health approach, concentrating on multisectoral collaboration between regional institutions involved in public, animal and environmental health domains.

“It is time for a permanent solution to this,” demands Sripal. KFD Janajagruthi Okkoota has put forward a series of demands to the government. “We are advocating for enhanced health surveillance in KFD-affected regions within the Western Ghats.” Their demands encompass the establishment of another diagnostic laboratory and research centre in Shivamogga, as well as improved reporting of cases and death audits.

This article was first published on Mongabay.

From the crispy crunch of fresh veggies to the creamy indulgence of decadent desserts, we all have different food preferences. Our palates develop uniquely, shaped by genetics, culture and personal experiences.

Food preferences play a significant role in shaping our dietary habits. Highly palatable foods rich in sugars, fats and salts often appeal to people’s tastebuds and provide immediate satisfaction. However, these foods are typically high in calories and low in essential nutrients, leading to weight gain, and a higher risk of physical and mental health conditions.

Now we have discovered that the food you choose to eat isn’t just linked to your physical and mental health, but also to your cognitive function, brain structure and genetics.

A widespread preference for fast food is likely contributing to an increase in obesity worldwide. According to the World Health Organization, in 2022 one in eight people worldwide were obese. This rate has doubled since 1990.

Obesity isn’t just linked with an increased risk of diseases including type 2 diabetes and cardiovascular disease, but also with a 30-70% higher risk of mental health disorders.

Benefits of a healthy, balanced diet

Our new collaborative study from Fudan University in China and the University of Cambridge in the UK, published in Nature Mental Health, used a large sample of 181,990 participants from the UK Biobank to examine how food choices are associated with cognitive function, mental health, metabolism, brain imaging and genetics.

We examined the consumption of vegetables, fruit, fish, meat, cheese, cereal, red wine, spirits and bread. We found that 57% of participants had food preferences for a healthy balanced diet. This included a balanced mix of all the foods we examined, with no excessive amounts in any category.

We further showed that those with a healthy balanced diet had better brain health, cognitive function and mental health than others. We compared the balanced diet to three other diet groups – low-carb (18%), vegetarian (6%) and high protein/low fibre (19%).

We found that people who ate a more balanced diet had better fluid intelligence (the ability to solve new problems), processing speed, memory and executive functions (a set of mental skills that include flexible thinking and self-control) than the other diets. This also corresponded to better brain health – with higher grey matter volumes (the outermost layer of the brain) and better structured neurons (brain cells), which are key markers of brain health.

Perhaps surprisingly, the vegetarian diet did not fare as well as a balanced diet. One reason for this may be that many vegetarians don’t get enough protein. Two healthy, balanced diets for the brain are the Mediterranean and Mind (Mediterranean intervention for neurodegenerative delay) diets.

These promote fish (especially those oily fish), dark leafy vegetables and fresh fruits, grains, nuts, seeds, as well as some meat, such as chicken. But these diets also limit red meat, fats and sugars.

In fact, research has shown that the Mediterranean diet can alter our brains and cognition. One study showed that people showed improved cognition after only 10 weeks on this diet.

Another study showed that following the Mediterranean diet was associated with lower levels of a harmful peptide known as beta-amyloid in the brain. Beta-amyloid, together with tau protein, are measures of the brain damage that occurs in Alzheimer’s disease.

Previous studies have also shown that Japanese diets, including rice, fish and shellfish, miso, pickles and fruits, protect against brain shrinkage.

We also discovered that there were some genes that may be contributing to the association between dietary patterns and brain health, cognitive function and mental health. This may mean that our genes partly determine what we like to eat, which in turn determines our brain function.

However, our food choice priorities are also affected by a number of factors, including price, allergies, convenience and what our friends and family eat.

Some people opt for going on diets, which may lead to weight loss, but involve cutting out entire food groups that are important for the brain. While there’s some evidence that ketogenic diets (low carb), for example, have beneficial affects on the immune system and mental health, it does seem that balanced diets, such as the Mediterranean diet, is best for overall brain health and cognition.

Ways forward

It is clear that adopting a healthy balanced diet and doing exercise can be good for our brains. But for many people, this is easier said than done, especially if their current food preferences are for very sweet or high fat foods.

However, food preferences aren’t destiny. For example, if you reduce your sugar and fat intake slowly and maintain it at a very low level over a number of months, you will actually begin to prefer that type of food.

Establishing healthy food preferences and an active lifestyle early in childhood is vital. Other important techniques are to eat slowly, pay attention to what you eat and enjoy it, rather than finishing a sandwich on the go or while looking at your mobile screen.

It takes time for your brain to register that you are full. For example, it has been shown that consumers generally eat more when watching television, listening to music, or in the presence of others, because the distraction decreases our reliance on internal satiety signals.

Social support from friends has also been shown to encourage adherence to healthy eating habits, as has cognitive behavioural therapy. Distraction is another excellent technique – literally anything you like to do (that isn’t eating) could help.

One interesting survey study found that how you set your priorities affects your food choices. If you are keen to remain healthy and to have a physically fit appearance, you will choose healthy foods.

We live in tough economic times. Socioeconomic status shouldn’t limit dietary choices, though this seems to currently be the case. Clearly, governments have an important duty to prioritise affordable healthy eating options. This will help many of us choose a healthy diet for either health reasons, reduced food prices, or both.

Now that we know that the food we eat can actually affect our brains and how well we perform cognitively, having a healthy balanced diet is more important than ever.

Barbara Jacquelyn Sahakian is Professor of Clinical Neuropsychology, University of Cambridge.

Christelle Langley is Postdoctoral Research Associate, Cognitive Neuroscience, University of Cambridge.

Jianfeng Feng is Professor of Science and Technology for Brain-Inspired Intelligence/ Computer Science, Fudan University.

Wei Cheng is Young Principal Investigator of Neuroscience, Fudan University.

This article was first published on The Conversation.

Americans seem to have quite a positive view of dietary supplements. According to a 2023 survey, 74% of US adults take vitamins, prebiotics and the like.

The business of supplements is booming, and with all the hype around them, it’s easy to forget what they actually are: substances that can powerfully affect the body and your health, yet aren’t regulated like drugs are. They’re regulated more like food.

Thanks in large part to a 1994 law, the Food and Drug Administration is essentially toothless when it comes to supplements. As the agency acknowledges: “FDA does not have the authority to approve dietary supplements before they are marketed. Companies can sell supplements without going through any sort of approval process, or even having to share safety evidence.”

As a research faculty member in graduate medical education, I’m responsible for teaching resident physicians how to understand and critically engage with health research. I also write about health, wellness and supplements for a broader audience. As a result, I spend a lot of time thinking about supplements.

It’s important to consider why so many people believe supplements can help them lead a healthier life. While there are many reasons, how supplements are marketed is undeniably an important one. In my years following the industry, I’ve found that three mistaken assumptions appear over and over in supplement marketing.

1. The appeal to nature fallacy

The appeal to nature fallacy occurs when you assume that because something is “natural” it must be good. The word natural is used a lot in the marketing of supplements. In the context of health, it often feels right to want natural medicine, remedies, prevention techniques and so forth.

For example, if I say “vitamin C,” what do you immediately think of? Probably oranges or citrus in general and flu prevention. But if I say “the flu shot,” what immediately comes to mind? Probably doctor’s offices, a little bit of pain and pharmaceutical companies.

One of these is clinically proven to prevent flu infections and lessen the severity of illness. The other has been marketed as though it does those same things, but there’s no clinical evidence to support this.

The supplement industry is awash with brand names that incorporate the word “nature,” invoking the appeal to nature fallacy. Also, look at websites and advertisements that urge customers to forgo “artificial” products in favor of “pure” and “natural nutrition”.

Using the word artificial to describe other products and natural to describe a specific supplement is intended to make you feel like that product will be superior to the competition and that you need it to be healthy.

To be clear, “natural” does not equate to “better,” but that’s what the marketing wants you to think.

2. Belief that more of a good thing is better

There’s another assumption that piggybacks on the appeal to nature fallacy: If something is natural, it must be good, and more of it must also always be better. If a little vitamin C is good for us, then a lot of it must be great!

The truth is that our bodies tightly regulate levels of the vitamins and minerals we consume. If you don’t have a deficiency, consuming more of a particular vitamin or mineral through a supplement won’t necessarily lead to health benefits. That’s why supplement skeptics sometimes say, “You’re just paying for expensive pee” – since your body will excrete the excess.

For an example of the more-is-better myth, look at basically any vitamin C supplement. The packaging often prominently displays dosages that can reach 750 or 1,000 milligrams. But adults need only about 75 to 120 milligrams of vitamin C per day. Similarly, look at vitamin D supplements that can come in dosages of 5,000 IU, or international units – a fact also often prominently displayed on packaging. But adults should have no more than 4,000 IU daily. Again, it’s easy to exceed what we need.

3. The action bias

Finally, the supplement industry likes to capitalise on the idea that doing something is better than doing nothing. This is the action bias. Taking action makes people feel like they have more control of a situation, which is especially powerful when it comes to health. “Even if I don’t need the extra vitamin C,” they might think, “I’ll take it just to be sure. What’s the harm?”

The examples in the last section show that supplements often contain many times the recommended daily intake of a particular vitamin or mineral. This assumes that taking that much of any of those particular substances is safe.

It is possible to have too much of a good thing. Too much vitamin C can lead to diarrhea, nausea, stomach cramps and more. Too much vitamin D can lead to conditions including nausea, vomiting and kidney stones. Supplements can also interact with prescribed medications.

For example, St. John’s wort is famous for interacting with contraceptives, immunosuppressive drugs, statins and chemotherapy by exacerbating or dulling their effects. When it comes to supplements, taking them isn’t necessarily better than not.

Be on the lookout for these marketing messages – they aren’t necessarily correct or good for your health. And talk with your doctor before taking any supplements.

Katie Suleta is a doctorate in Health Sciences candidate, George Washington University.

This article was first published on The Conversation.

The Supreme Court on Wednesday refused to accept a second apology from Patanjali Ayurved’s Managing Director Balkrishna and co-founder, yoga guru Ramdev, in the contempt proceedings initiated against the company for its misleading advertisements, reported Live Law.

The court said that they only apologised when they were “caught on the wrong foot”.

The Supreme Court also castigated the Uttarakhand State Licencing Authority for failing to act against Patanjali and its subsidiary Divya Pharmacy. “We will rip you apart,” a division bench of Justices Hima Kohli and Ahsanuddin Amanullah said, according to PTI.

The court was hearing a petition filed by the Indian Medical Association against Patanjali Ayurved Limited accusing the company of carrying out a “smear campaign” against modern medicine and the Covid-19 vaccination drive.

The court reprimanded Balkrishna and Ramdev for an advertisement issued by their company on December 4 after it had said in an undertaking on November 21 that it would not make any “casual statements claiming medicinal efficacy or against any system of medicine”.

On Wednesday, Senior Advocate Mukul Rohatgi, appearing for Balkrishna and Ramdev, told the court that the apology was “unconditional and unqualified”. The bench, however, did not accept the apology. “We consider it a wilful, deliberate disobedience of the undertaking,” Justice Kohli said.

The court also ordered the current and previous officers of the Uttarakhand Licensing Authority to file detailed affidavits explaining why they did not take any action against Patanjali under the Drugs and Magic Remedies (Objectionable Advertisements) Act, reported The Hindu.

“Why should we not come down like a ton of bricks on your officers,” Kohli asked. “They have been filibustering.”

The Supreme Court remarked that Ramdev and Balkrishna tried to evade appearing personally before the court by making false claims about foreign travel. It noted that though an application seeking exemption from personal appearance was filed on March 30, the flight tickets were dated March 31.

Previous hearing

In its previous hearing on April 2, the Supreme Court had reprimanded Balkrishna and Ramdev and granted them a last opportunity to file affidavits of compliance in the contempt of court proceedings.

On March 20, Balkrishna had tendered an “unqualified apology” and said that he had the highest regard for the rule of law, adding that Patanjali Ayurved would ensure it did not issue any such advertisements in the future.

He also said that the company’s media wing was not aware of the Supreme Court’s order halting the broadcast of such advertisements.

The apology came a day after the top court ordered Balkrishna and Ramdev, to appear before it in person. The court passed the order after the yoga guru failed to respond to a show cause notice in contempt proceedings initiated against his company.

The bench also questioned why the ministry of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) had chosen “to keep its eyes shut when Patanjali was going to town saying there [was] no remedy for Covid in allopathy”.

The case

On February 27, Patanjali Ayurved and Balkrishna were issued notices for contempt of court for continuing to publish “misleading advertisements” regarding Patanjali’s purported medicinal cures, despite the company making assurances to the Supreme Court in November that it would stop advertising such products.

The court has temporarily restrained Patanjali Ayurved from advertising any of its products meant to treat specific diseases and disorders listed in the Drugs and Magic Remedies Objectionable Advertisements Act.

The court had also cautioned the company in February against making statements critical of any system of medicine.

Several state units of the Indian Medical Association complained against Ramdev and Patanjali after a half-page Patanjali advertisement appeared in several newspapers on July 10, 2022, saying: “Misconceptions spread by allopathy. Save yourself and the country from the misconceptions spread by the pharma and medical industry.”

Also read: A brief history of Patanjali’s dangerous claims

This article was originally published in our weekly newsletter Slow Lane, which goes out exclusively to Scroll Members. If you would like to get perceptive pieces of reporting, opinion and analysis like this directly in your inbox every Saturday, become a Scroll Member or upgrade your membership today.

In early 2020, when India was fighting the first wave of the Covid-19 pandemic and the medical establishment was at sea about how to treat the viral disease, Patanjali Ayurved stepped in with a big claim.

Three months after the first case of Sars-CoV-2 infection was recorded in India, the ayurvedic company launched Coronil tablet. Its founder and yoga guru Ramdev claimed it was the “first evidence-based researched cure” to Covid-19.

In Mumbai, physician Jayesh Lele was aghast. Not only did the claim threaten to push already panicked citizens towards unscientific measures, it had apparent state endorsement. Two ministers of the Modi government – health minister Harsh Vardhan and transport and highways minister Nitin Gadkari – attended the launch of Coronil, at which Ramdev did not wear a protective mask.

Lele filed a right to information application with the Ayush ministry that regulates traditional systems of healthcare. “I asked if the ministry had collaborated with Patanjali on Coronil or if, as Patanjali had claimed, the certification was on the lines of requirements laid out by the World Health Organization,” Lele said. The ministry said no such approvals had been provided.

Coronil, at that point, had been only approved as an “immunity booster” by the Ayush ministry.

Before Lele could counter Patanjali’s frivolous claims, the damage was done. He said the presence of the senior Bharatiya Janata Party ministers was like a seal of approval for the product. In just four months of its launch, Patanjali sold Rs 250 crore worth of Coronil kits.

From then on, Lele – who is also the general secretary of Indian Medical Association, the largest body of allopathic doctors in India – began to closely follow and record Patanjali’s misleading claims.

The list was long. “They would advertise in national dailies and claim their medicines could cure diabetes, thyroid and fatty liver disease,,” he said. “We began to collect evidence.”

In June 2021, he filed a writ petition in the Supreme Court on behalf of Indian Medical Association against Patanjali’s deceptive advertisements and against the Union health ministry for supporting their claims.

On April 1, the Kerala drugs control department filed a complaint in Kozhikode court against misleading advertisements by Patanjali’s Divya Pharmacy.

A day later, while hearing the Indian Medical Association petition, the Supreme Court pulled up the company for continuing to defy its orders by publishing misleading advertisements about its products.

It refused to accept an apology from Ramdev and Patanjali’s managing director Balkrishna and asked why contempt proceedings must not be initiated against them. The next hearing is on April 10.

The court’s strictures, although important, is just one of the many warnings the company has received and chosen to ignore.

Past notices, warnings

In November, Patanjali gave an undertaking to the Supreme Court that it will not violate the law “relating to advertising or branding products manufactured and marketed by it and, further, that no casual statements claiming medicinal efficacy or against any system of medicine will be released to the media in any form”.

Patanjali was quick to forget the undertaking. A month later, it published a front-page newspaper ad in Chennai claiming to cure blood pressure, arthritis, diabetes, asthma, liver failure, kidney failure and cancer and heart problems.

The ad promoted a range of products by Patanjali’s manufacturing unit Divya Pharmacy for such ailments.

Why are such ads a problem? Not every advertisement making medical claims violates the law. But the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954, prohibits advertisements for 54 diseases.

This includes diseases with no cure such as cancer, diabetes, blood pressure and heart diseases – ailments that Patanjali claims its medicines can cure. Such ads can draw punishment up to six months with a fine.

No such action has been taken against Patanjali yet.

Meanwhile, the company’s business is flourishing. According to Patanjali’s website, since its inception in 2006, it has established markets in the United States, Canada, the United Kingdom, Russia, the United Arab Emirates and some European countries. Within India, it has over 47,000 retail counters, and warehouses in 18 states. It plans to start factories in six more states.

A powerful alliance

The presence of two ministers at Coronil’s launch was hardly unusual. By all accounts, Ramdev has powerful political allies in the Bharatiya Janata Party government at the Centre.

Prime Minister Narendra Modi inaugurated the Patanjali Research Institute in Haridwar in 2017 and has lent support to yoga and ayurveda.

In 2015, after the BJP came to power, the government gave Ramdev Z-category security – the third-highest level of security in the country. It is unclear what threat the yoga guru faced.

Perhaps that has offered immunity to Patanjali from any punitive action.

Between 2021 and now, Kerala-based ophthalmologist Dr KV Babu, filed multiple Right to Information queries with the government to understand whether action has been taken against Patanjali for misleading ads.

Two of Babu’s patients, who had glaucoma, had dropped out of treatment in 2019 to try Ayurvedic products, and returned in a worse state. It made him look closer at the claims Patanjali was making about Ayurveda.

“Till date the company has not been prosecuted by the Uttarakhand government,” Babu told Scroll.

Under India’s drug laws, Uttarakhand has the authority to take punitive action against Patanjali since the company’s manufacturing units are located there.

In 2022, Patanjali began to advertise that children with Type I diabetes can switch from insulin to their medicines and be cured. “This was a major public health disaster,” he said.

Babu wrote to the Uttarakhand government and the Union government to draw their attention to these claims. “I must have complained about various Patanjali ads about 10 times,” he said.

In April 2022, based on his complaint, a notice was served by the Uttarakhand government to Patanjali over its ads to cure arthritis, blood pressure, heart problems and diabetes. In May 2022, Patanjali stopped these ads, only to resume them in July 2022. The ads continued till January 2023.

In March 2023, the government informed the Rajya Sabha that there were complaints of 53 misleading ads of various drugs reported to the state licensing authority between August 2022 and March 2023 – all related to Patanjali products. The majority of the complaints were against BP Grit, which promises to control blood pressure, and Madhugrit, meant for heart conditions.

“The only action taken seems to be a notice to Patanjali,” Babu said. “No fine, no imprisonment.”

Babu is hopeful the Supreme Court will finally do what the government has failed to – stop Patanjali from misleading the public.

“Coaxing people to stop treatment and try their medicines without scientific evidence is equivalent to playing with their lives,” Babu said. “It has to be stopped.”

Scroll sent queries to Patanjali on the charges against them. The piece will be updated if they respond.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

Aerobic exercise like jogging, biking, swimming or hiking is a fundamental way to maintain cardiovascular and overall health. The intensity of aerobic exercise is important to determine how much time you should spend training in order to reap its benefits.

As an exercise science researcher, I support the American College of Sports Medicine’s recommendation of a minimum of 150 minutes per week of moderate aerobic exercise, or 75 minutes per week of high-intensity exercise. But what does exercise intensity mean?

There is a linear relationship between heart rate and exercise intensity, meaning as the exercise intensity increases, so does heart rate. Heart rate zone training, which uses heart rate as a measure of exercise intensity, has increased in popularity in recent years, partially due to the ubiquity of wearable heart rate technology.

The way exercise intensity is usually described is problematic because one person’s “vigorous” may be another’s “moderate.” Heart rate zone training tries to provide an objective measure of intensity by breaking it down into various zones. But heart rate can also be influenced by temperature, medications and stress levels, which may affect readings during exercise.

Heart rate, exercise intensity

The gold standard for determining aerobic exercise intensity is to measure the amount of oxygen consumed and carbon dioxide exhaled. However, this method is cumbersome because it requires people to wear a breathing mask to capture respiratory gases.

An easier way is to predict the person’s maximum heart rate. This can be done with an equation that subtracts the person’s age from 220. Although there is controversy surrounding the best way to calculate maximum heart rate, researchers suggest this method is still valid.

The American College of Sports Medicine outlines five heart rate zones based on a person’s predicted heart rate maximum. Zone 1, or very light intensity, equals less than 57% of maximum heart rate; zone 2, or light intensity, is 57% to 63%; zone 3, or moderate intensity, is 64% to 76%; zone 4, or vigorous intensity, is 77% to 95%; and zone 5, or near-maximal intensity, is 96% to 100%.

However, other organisations have their own measures of exercise intensity, with varying ranges and descriptions. For example, Orange Theory describes their zone 2 training as 61% to 70% of maximum heart rate. Complicating matters even further, companies that produce heart rate monitors also have higher thresholds for each zone.

For example, Polar’s zone 2 is up to 70% of maximum heart rate, while the American College of Sports Medicine recommends a zone 2 of up to 63%.

Adapting heart rate zones

Zone training is based on the idea that how the body responds to exercise is at least in part determined by exercise intensity. These adaptations include increased oxygen consumption, important cellular adaptations and improved exercise performance.

Zone 2 has received a lot of attention from the fitness community because of its possible benefits. Performance coaches describe zone 2 as “light cardio,” where the intensity is low and the body relies mainly on fat to meet energy demands. Fats provide more energy compared to carbohydrates, but deliver it to cells more slowly.

Because fat is more abundant than carbohydrates in the body, the body responds to the cellular stress that exercise causes in muscle cells by increasing the number of mitochondria, or the energy-producing component of cells. By increasing the number of mitochondria, the body may become better at burning fat.

On the other end of the spectrum of exercise intensity is high-intensity interval training, or HIIT. These workouts involve exercising at a high intensity for short durations, like an all-out sprint or cycle for 30 seconds to a minute, followed by a period of low intensity activity. This is repeated six to 10 times.

During this sort of high-intensity activity, the body primarily uses carbohydrates as a fuel source. During high-intensity exercise, the body preferentially uses carbohydrates because the energy demand is high and carbohydrates provide energy twice as fast as fats.

Some people who turn to exercise to lose fat may eschew high-intensity training for zone 2, as it’s considered the “the fat burning zone.” This may be a misnomer.

Researchers have found that high-intensity interval training produces a similar increase in markers for mitochondria production when compared to longer, moderate aerobic training. Studies have also shown that high-intensity exercisers build muscle and improve insulin resistance and cardiovascular health similar to moderate-intensity exercisers, and they made these gains faster. The main trade-off was discomfort during bouts of high-intensity exercise.

Moderate or high-intensity exercise

With varying guidelines around heart rate zones and conflicting evidence on the potential benefits of training in each zone, exercisers may be left wondering what to do.

In order to yield the health benefits of exercise, the most important variable to consider is adhering to an exercise routine, regardless of intensity. Because the body adapts in similar ways to moderate- and high-intensity exercise, people can choose which intensity they like best or dislike the least.

Notice that the American College of Sports Medicine’s recommendation for exercise falls under moderate intensity. This is equivalent to zone 3, or 64% to 76% of maximum heart rate, a range you can only meet in the upper levels of most zone 2 workouts. If you’re not seeing desired results with your zone 2 workouts, try increasing your intensity to reach the moderate level.

A commonly reported reason for not exercising is a lack of time. For people short on time, high-intensity training is a good alternative to steady-state cardiovascular exercise. For people who find exercising at such a high intensity uncomfortable, they can get the same benefit by doing moderate-intensity exercise for a longer period.

Jason Sawyer is Associate Professor of Exercise and Movement Science, Bryant University.

This article was first published on The Conversation.

In less than two weeks, Indians will vote in a sprawling seven-phase Lok Sabha election that starts on April 19 and ends on June 1.

While general elections have always been held in summer, this year the Indian Meteorological Department has forecast higher than average temperatures and almost double the number of heatwave days in this period – 10-20 days, as against four-eight days seen every summer.

Political workers campaigning in this heat, voters who attend large political rallies to hear leaders speak, and those who will queue up at polling booths – all risk exposure as they take part in one of the world’s biggest democratic exercises.

Is India prepared for an election in extreme heat conditions?

Scroll analysed IMD data to indicate how states voting in the first and second phases of election will be affected by the heat. On both days of voting – April 19 and April 26 – constituencies spread across north, western and central India may see temperatures close to 40 degrees Celsius.

We spoke to experts who underlined the health risks involved for party workers and voters, and argued for clear, detailed directions from the Election Commission and health authorities.

So far, the Union health ministry has issued an advisory regarding mass gatherings. The Election Commission has issued an advisory for political parties, though several party workers Scroll spoke to said they are yet to draw up campaigning schedules to avoid high temperatures.

The heat map

April 19 will mark the first phase of election with 21 states and Union territories going to the polls.

Scroll’s analysis of IMD data for 19 of these regions shows that in four states and Union territories, temperatures are likely to touch 38 to 40 degrees Celsius on that day – these include parts of Madhya Pradesh, Maharashtra, Puducherry and Rajasthan.

The analysis is based on IMD’s data of a two-week heatwave forecast, and a long-range forecast of maximum temperatures for about a month, from April 5 to May 2 – based on data available as on April 4.

In the week leading up to the first phase, temperatures are likely to surpass 40 degrees Celsius in parts of Uttar Pradesh, Madhya Pradesh, Jharkhand and Chhattisgarh.

On voting day, April 19, Lok Sabha constituencies like Sidhi, Chhindwara, Jabalpur, Bikaner, Churu, Sikar, Jaipur, Dausa, and Nagaur are likely to hover around the 38-40 degrees Celsius mark.

Temperatures will likely hover between 34 and 38 degrees Celsius in parts of Rajasthan (Alwar, Bharatpur, Karauli, Dholpur and Jhunjhunu), Maharashtra (Ramtek, Nagpur, Bhandara, Gadchiroli and Chandrapur), Uttar Pradesh (Nagina, Moradabad, Pilibhit and Rampur) and Bihar’s Aurangabad, Gaya, Jamui, and Navada. All these seats are scheduled to vote on April 19.

Similarly, Bastar in Chhattisgarh’s Bastar is likely to see temperatures between 34 and 36 degrees Celsius. The eastern parts of Tamil Nadu are expected to be hotter with temperature around 36 degrees Celsius, compared to western parts where temperature could hover below 34 degrees Celsius, data from IMD suggests.

April 26, the second phase of polling, will likely record temperatures up to 40 degrees in larger parts of the country, including most of central, eastern and northern India.

The northeastern states are expected to get a reprieve, with temperatures likely under 32 degrees Celsius.

Similarly, while Uttarakhand’s maximum temperatures are likely to range between 20-25 degrees on April 19, northern parts of the state could expect to be a degree hotter.

The risk

Experts say direct and indirect exposure to this kind of heat can have grave health impacts.

High temperatures can pose a risk, especially when political rallies are expected to amass huge crowds, who typically wait hours to hear star campaigners from various political parties.

Last year, a large gathering in Kharghar, Maharashtra, had proved how dangerous a scenario that can be. Thousands had sat under a harsh morning sun for six-seven hours at a state-sponsored ceremony to honour a social reformer. At least 14 people died of heatstroke following the event.

That was an example of direct exposure to heat, said Dileep Mavalankar, the former director of Gandhinagar-based Indian Institute of Public Health. “More common and much more prevalent is indirect heat stroke,” he said.

Those with comorbidities or the elderly are susceptible to falling sick even without direct exposure to heat. “In response to the heat, your heart pumps more and more to keep your body cool, you sweat, and your body becomes dehydrated quickly,” Mavalankar said, adding that in such situations, the heart, lungs, and kidneys could start failing.

Even if a region sees temperatures lower than 40 degrees Celsius, the risk to health will depend on humidity.

High humidity does not allow sweat to release, preventing the body from cooling. This could pose a greater risk of heatstroke compared to places with low humidity.

In such conditions of humid heat, Anjal Prakash, research director at Bharti Institute of Public Policy Indian School of Business, noted that public health and safety is vital. “The Election Commission could mandate cooler polling hours, provide hydration stations at polling booths, and disseminate heat safety guidelines widely to ensure the health of party workers and voters,” he added. Prakash is also an author of the biannual report prepared by the Inter Governmental Panel on Climate Change.

KS Hosalikar, head of climate research and services at the IMD, added that the present forecast indicates that both day and night-time temperatures are expected to remain above normal this summer. “This will have implications. If night temperature is high, warmer nights will not allow the body to cool down and relax. There will be some stress in the body the next morning,” Hosalikar said.
“We need to be more careful, especially for events during the afternoon,” he added.

How prepared are we?

The Indian Meteorological Department has written to the Election Commission, informing it of the forecasts. The National Disaster Management Authority has put out an advisory to the Election Commission, to be shared with all states and Union Territories.

The advisory issued by the NDMA is a general list of do’s and dont’s. It suggests that people avoid going out in the sun between 12 noon and 3 pm, wear light-weight cotton clothes, and drink ORS or oral rehydration solutions.

Earlier this week, the Union health ministry held a meeting to assess the preparedness to tackle heatwaves and issued an advisory similar to the National Disaster Management Authority. The health minister directed states to generate awareness, and create a central database to share field-level data on heat waves, including deaths and cases. No specific directions were publicly issued on election preparations.

“In terms of preparedness, we are ensuring we have beds allocated to treat cases of heatstroke in government hospitals and primary health centres are stocked with ORS,” said Dr Radhakishan Pawar, additional director of health in Maharashtra.

Pawar added that while the health ministry has issued a generic guideline for social gatherings. It does not explicitly refer to political parties. “By gathering, we mean all kinds of gatherings,” he said.

The campaign must go on

Party workers told Scroll that they have not discussed any measures to protect party workers and those attending their rallies from heatwave -like conditions. Nor have they got instructions from their leaders.

But workers said the public appears reluctant to attend outdoor events. In Andhra Pradesh, following heatwave warnings this week, political parties have begun to schedule their events in the mornings and evenings, skipping six hours of outdoor activities during the afternoon.

In Gwalior, Anirudh Tomar, who is a Congress worker, said he leaves home to do door-to-door campaigning at 6 am and continues till 10 am. “After that it becomes difficult to roam in the sun,” he said. He is forced to call for indoor meetings with local residents. “But in this heat, not many people want to step out,” he said. In the evening, he begins the door-to-door visits and continues till night.

The Congress has so far not discussed any measures to avoid heat in their latest campaign planning meeting, since the heatwave advisory by IMD was “very recent” and “unexpected”, said Kunwar Shehzad, spokesperson, Delhi Pradesh Congress Committee.

In Madhya Pradesh, Bharatiya Janata Party media coordinator Ashish Agrawal said BJP leaders will continue to campaign on ground, irrespective of heat or cold. “We have planned full-day schedules. BJP workers and leaders do not shy away from campaigning in heat,” Agrawal said.

What experts suggest

Several experts recommend that each state must have a tailor-made heat action plan to cater to local temperature deviations. But currently only 23 states have heat action plans in place.

There appears to be a lack of understanding about the severity of heatwaves among political party workers, said Prakash, from the Indian School of Business.

“Authorities need to carry out targeted campaigns highlighting the dangers of heatstroke and the importance of preventive measures through multiple channels like social media, educational workshops, and local outreach programmes,” Prakash said, adding that testimonials from heatwave survivors and experts could help encourage proactive action.

Mavalankar said it is important for the state disaster management authorities to get involved to “issue guidelines and instructions to the political parties” on avoiding and limiting impacts of heat waves while campaigning and holding public meetings.

“More localised heat-wave predictions are also needed,” he said, adding that such predictions by IMD need to go beyond the district level and up to city and village level for people to take preventive action more seriously.

Aditya Valiathan Pillai, a fellow at Sustainable Futures Collaborative who has worked on heat action plans, said it is also important for political parties and district administration to know the localised temperature within a maidan or a polling centre and communicate that to local residents instead of relying on the nearest weather station which could be several kilometres away. “It is an important way of signalling the risk people are exposed to if they sit for more than three or four hours under the sun,” he said. Awareness, he said, can help voters make decisions.

Pillai said since campaigning and rallies are core to Lok Sabha elections and the democracy, it is not possible to expect political parties to completely ban outdoor rallies.

Outdoor gatherings should be held under a shade, and be equipped with a cooling station, an ambulance, he said. District authorities should be on alert if anyone shows symptoms of heat stress, especially the elderly, pregnant women and those with comorbidities.

“What we are seeing now, in terms of heat, will get worse in the coming years,” he said. “We need to find ways to ensure public health is safeguarded instead of stopping rallies altogether since they are central to the exercise of democratic rights,” he said.

Jos Buttler struck a solid century as Rajasthan Royals sealed a six-wicket win against Royal Challengers Bengaluru in the 2024 Indian Premier League on Saturday in Jaipur.

The win in their first home match of the season means that the Royals have won each of their four opening matches of the season while Bengaluru have won only one of their five games.

It was a battle of the batters with Rajasthan captain Sanju Samson deciding to bowl first after winning the toss. The visitors finished their innings with a score of 183/3, and the Royals chased it down to score 189/4 with five balls to spare.

In the first innings, Virat Kohli and Faf du Plessis took advantage of the relatively placid pitch in Jaipur and put on an opening partnership of 125.

Kohli reached his half-century in 39 balls with Bengaluru at 53/0 after the first six overs. However, as the pitch started to get stuck in a little bit for the slower balls, the scoring rate of the visitors also started to drop. Rajasthan would get their first breakthrough with du Plessis being caught by Buttler in the deep off Yuzvendra Chahal at the end of the 14th over.

Nandre Burger also helped matters with the wicket of Glenn Maxwell for one as Kohli continued his charge. The Indian batter would finish with an unbeaten 113 off 72 balls, his eighth century in the tournament.

The chase began in a horrid fashion for Rajasthan who lost struggling Yashavi Jaiswal in the second ball of the innings. But then Samson and Buttler came together, much like Kohli and du Plessis, only in a more fluent fashion.

Samson reached his half-century in 30 balls while Buttler reached the 50-run landmark in 33 balls. While the partnership of 148 runs was broken courtesy a Mohammed Siraj delivery, Buttler was on hand to steady the ship with 36 needed off 32 balls. Riyan Parag and Dhruv Jurel were also dismissed cheaply, but the English batter finished things off with a six to seal the deal and reach his century.

Turning point of the match

The first sign of spin being the answer in curtailing the scoring was when Samson brought on Ravichandran Ashwin in the fifth over. The veteran spinner conceded only three runs compared to when Kohli and du Plessis had earlier hit Burger and Trent Boult for 42 runs.

After two overs of Ashwin where he conceded 10 runs, Chahal was brought on. This only slowed things down further for the Bengaluru batters who were unable to truly negotiate the Rajasthan spin twins, also hindered by the pitch slowing down oddly in patches.

Chahal and Ashwin conceded one boundary, two sixes and two wides in the eight overs between them. The fast bowlers in Boult, Burger and Avesh Khan were hit for 13 boundaries, three sixes and three wides between their 11 overs. Boult, the star of the win against Mumbai Indians didn’t get to complete his quota of four overs.

The difference that Chahal and Ashwin made was seen with how impact substitute Himanshu Sharma and Mayank Dagar, Bengaluru’s spinners, were hit all over the ground by Samson and Buttler during their innings.

The Field’s Player of the match

Buttler has been splendid for Rajasthan since they bought him back in 2018. He’s been a reliable opening batter for the side, helping to set the foundation for a strong line-up that follows him.

However, the 2022 Orange Cap (leading run scorer) winner hasn’t been able to fire in the previous three games in the 2024 season so far.

But against a weaker bowling attack in Bengaluru and assisted by a pitch that helped batters to time the ball well, Buttler was in fine form. His unbeaten 100 off 58 balls makes him The Field’s Player of the match.

Kumar Sangakkara, a fine batter in his day and now the coach of the Rajasthan side, described the Buttler-Samson partnership as ‘clinical’. But he also reiterated that while a conversation is certainly required when it comes to helping a player get back into form, what Buttler needed to do was “sit back and ignore the noise” – the noise here referring to his critics.

On Saturday night, with one run needed for the win and with Buttler on 94, as he struck that six that just managed to cross the boundary, Buttler leapt into the air and celebrated with a definite sigh of relief – the magic was back.

‘Just a matter of time with Jos’

Along with his coach, Buttler’s captain Samson was equally complimentary of the English batter’s efforts, saying that all Buttler needed to do was stick it out through the powerplay and then time the ball well enough.

In the post-match presentation ceremony, Buttler himself mentioned that the “anxieties and stresses” don’t go away despite having played the sport for a long time.

“It was a bit of luck to get it [the six] over the rope in the end, but I’m delighted to get the win. No matter how long you’ve played the game, you still have those anxieties and stresses. I had a really good tournament in South Africa [at the SA20 with Paarl Royals] so I felt like I needed one good innings to get going. I did feel very good in the last game [against Mumbai Indians] although I got out for 13. Sometimes you just have to tell yourself that it will be okay and it will end up being okay. Just gotta keep digging in and working hard. We just need to keep this momentum going.”

In the last 15 days, Anisha Pando has not taken her tuberculosis medicines.

The 12-year-old from Mudgaon village in Sarguja, a remote district in Chhattisgarh, was diagnosed with tuberculosis in August last year.

Her village is 30 km from the nearest health centre run by the non-governmental organisation Sangwari, which has tied up with the government to provide free tuberculosis medicines.

But like several health centres across the country, it is running out of medicines. “Since the stock is limited, her father has to travel frequently to collect the medicines,” the centre’s nurse Dhanvantiri Porte said. “He is a farmer. He cannot make so many trips. So she stopped her medication,” Porte said.
For the second time in seven months, a drug stockout is hampering tuberculosis treatment across India with medication in short supply in several states. In August last year, too, a shortage of drugs used to treat patients infected by resistant strains of bacteria had left patients and doctors anxious.

This time, those affected are drug-sensitive patients like Pando, who respond well to the first line of tuberculosis drugs.

‘Supplies delayed’

On March 18, the Central TB division wrote to all states, asking them to locally procure drug-sensitive medicines for the next three months.

Usually, the Central Medical Services Society, the agency responsible for procuring drugs for the health ministry, floats a tender and finalises a supplier for all tuberculosis drugs and related diagnostics material. This supply is then distributed to each state. Such bulk procurements also allow the government to buy drugs at a cheaper rate.

“Central procurement of ... [the drugs] is at an advanced stage. However, the supplies may get delayed due to unforeseen and extraneous circumstances,” the letter by the director- general of TB division, Dr Rajendra Joshi, stated.

Though states usually maintain a buffer stock of six months, most currently have medicines that will last less than a month.

Several state nodal officers are struggling to make arrangements to buy drugs on their own, especially with the model code of conduct in place for the Lok Sabha elections.

Earlier this week, Karnataka health minister Dinesh Gundu Rao wrote a letter to health minister Mansukh Mandaviya, flagging the shortfall in medicines. “Neither these medications are available in the quantities required by the state nor the procurement process can be hastened in view of both its manufacturing process as well as the prevailing model code of conduct,” Rao wrote. “While I do not wish to accuse the Union government of callousness, I have to point out that state support for TB patients has been jeopardised by this action of the Centre”.

With the supply from the government almost drying out, doctors are worried that patients may begin to drop out of treatment, said Dr Chetanya Malik, a physician who works with NGO Sangwari.

“Usually patients get medicines to last a month. Now they are expected to return every week or every few days,” said Malik. “Daily wagers cannot be expected to make so many rounds of health centres for medicines.”

In 2023, India notified 25.55 lakh new tuberculosis cases, including 1.43 lakh paediatric cases, data from the latest India TB report 2024 shows.

Mumbai-based health activist Ganesh Acharya said the absence of medicines risks turning more drug-sensitive patients into drug-resistant patients, who stop responding to the first line of drugs and require more potent drugs to kill the bacteria.

In 2023, 63,939 drug resistant patients were diagnosed in India. “This figure can increase if medicine supply is hampered so frequently,” Acharya said.

Dr Joshi, director general of Central TB Division, did not respond to calls and messages from Scroll over the drug shortage.

The January shortfall

In several states, as early as January, the supply of two drugs, both fixed dose combinations, began to dry out.

A fixed dose combination has two or more drugs combined in one tablet to reduce the number of medicines a patient has to take.

With tuberculosis requiring multiple medicines, a fixed dose combination makes it easier for patients to adhere to treatment and prevent them from dropping out.

Most Indian states currently have low stocks of 4-FDC, a fixed dose combination of isoniazid, rifampicin, pyrazinamide and ethambutol, which is given in the first two months of treatment to patients.

The second drug whose supply is a problem is 3-FDC, a fixed dose combination of three drugs – isoniazid, rifampicin, pyrazinamide.

Both these medicines are given to newly diagnosed TB patients.

In Chhattisgarh, there are 15,000 strips of 3-FDC, that will last a month. In some districts such as Sarguja, there is stock for only 13 more days, state officials said. “We are moving medicines to centres that do not have any stock,” a Chhattisgarh health officer, who requested not to be identified, told Scroll. “If we don’t get fresh stock in 15 days, there will be a total stockout in many centres,” the officer added.

Chhattisgarh had sent the Centre its requirements for TB medicines in mid-2023. “We did not initiate any procurement because the Centre does it. Now we have asked districts to procure at their level,” the officer said.

Maharashtra has 79,000 strips of 3-FDC, which will last another 13.5 days, an officer told Scroll on March 29. “We began the procurement process before the code of conduct set in. But that will take time,” the officer said. “Meanwhile, we have asked districts to buy medicines on their own from local suppliers.”

“Floating a tender may be difficult now since TB medicines are usually not procured at the state level,” a state officer from Chhattisgarh told Scroll.

The officer said all TB medicines are procured by the central government based on demands sent in advance by each state. The state is only tasked with distributing medicines to each government-run centre. Since the state does not usually procure, neither are “funds available to buy TB medicines at the state level” nor the tendering process is in place, the officer explained.

In Madhya Pradesh, state tuberculosis officer Dr Varsha Rai said there is a shortage of TB drugs but refused to elaborate on how long the stock will last. “We are in the process of procuring medicines through rate contracts,” she said.

Under a rate contract, no bids are called – a supplier is chosen and asked to provide the medicines.

In Punjab, state tuberculosis officer Dr Rajesh Bhaskar said they had anticipated a shortage several months ago and began to finalise suppliers. “There was a shortage of drug-resistant TB medicines last year from the Centre. To avoid that, we took out a rate contract several months ago so that we could place orders in case of an emergency,” he said.

According to data from the Central Medical Services Society, the central government called for a tender in September 2023 for 4-FDC and 3-FDC drugs.

The supply for the September tender is yet to begin. This year, the government called for an emergency tender for the drugs on March 8 and again on March 22.

The letter by the Central TB Division added that if districts or states are unable to procure and provide free drugs, patients can be reimbursed for the cost of drugs on a case-by-case basis.

Patients dropping out

In the absence of fixed dose combinations, several doctors are asking patients to take individual drugs for rifampicin, isoniazid, pyrazinamide and ethambutol. “We have switched some patients to individual drugs. But that means, they now have to take 8-9 tablets a day. Some may not prefer taking so many medicines,” said Malik.

This is just what happened in Sarguja.

Bijan Prasad Patra, 62, was put on the fixed dose combination, 3-FDC. From February, the medicines became scarce.

While individual tablets are available, he refuses to take them. “He is unable to take eight to nine tablets. He says it is difficult to eat food then. So he has stopped medication completely,” said nurse Dhanvantri Porte.

In Odisha’s Khordha district, NGO Sahyog has written to the district administration to procure medicines. “There is absolutely no stock of adult drugs and some paediatric combinations,” said Vijaylaxmi Rautaraoi, who works with Sahyog.

Rautaraoi said patients have begun to default on their regimen since not everyone can afford to buy from chemists. “Last week was World TB Day. And the government is not able to even provide medicines. How will India eliminate TB by 2025 if this is the condition?”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

The world has declared a time-out on sugar consumption. The harmful link between disease and dietary sugar was recently outlined in a comprehensive assessment of published studies.

Recognising this link between widely consumed food and disease is essential in marshalling forces to change harmful outcomes. These include coronary heart disease, obesity, type 2 diabetes, tooth decay and some cancers. For over a decade, my research has focused on the mechanisms by which fructose intake plays into disease.

A growing number of African countries have joined the worldwide efforts to reduce sugar intake. For instance, in an attempt to address obesity, diabetes and other non-communicable diseases, South Africa introduced a tax on sugar-sweetened drinks in 2018.

It’s hard to avoid sugar when it’s become a normal part of diets and when we celebrate special times with sweet treats. But being more aware of what sugar is and how it can affect our health is the first step.

What is sugar

Sugar is a class of naturally occurring sweet-tasting molecules found in fruits, vegetables, plants and the milk of mammals. It can be extracted from these natural sources and concentrated in processed foods.

The sweet-tasting molecules in sucrose (table sugar) are glucose and fructose.

Sucrose is a disaccharide. This is a molecule made of two simple sugars – glucose and fructose – in a 1:1 ratio and chemically bound. Sucrose is used in many processed foods.

High fructose corn syrup, also used in processed foods, is a mixture of the monosaccharides glucose and fructose. Usually the combination is 45% glucose and 55% fructose.

Sucrose and high fructose corn syrup are more concentrated in processed foods than in fruits and vegetables.

Both are considered added sugars when they are added to foods and drinks. Besides the sweet taste, they may be added for colour and texture, as a preservative or to aid fermentation.

There are other natural sugars found in the foods we eat. Lactose, or milk sugar, is a disaccharide made of two simple sugars – glucose and galactose – in a 1:1 ratio. It’s found in mammals’ milk and produced naturally to provide nutrition to offspring, and in other dairy products, such as cheese and ice cream.

Honey, made from nectar by honeybees, is primarily a mixture of glucose and fructose monosaccharides with some maltose, sucrose and other carbohydrates. Maltose, which is found in breakfast cereals and breads, is a disaccharide of two glucose molecules.

Naturally occurring sugars are made by plants, bees or mammals based on their needs.

The human body needs glucose as a fuel for every cell, especially brain cells. That’s one of the reasons why we need a stable blood glucose level throughout the day and night.

The way our bodies use fructose is different. It can be turned into glucose, used as fuel, or processed into fats, called triglycerides. Excessive fructose in our diets can lead to increases in blood triglycerides, liver fat, blood glucose, body mass index and insulin resistance (where the body cannot easily remove glucose from the bloodstream).

Increases in these markers can lead to an increased risk for metabolic dysfunction, type 2 diabetes and non-alcoholic fatty liver disease (or metabolic dysfunction-associated steatotic liver disease).

Because of the difference in how the body uses glucose and fructose, and evidence that a higher consumption of sugar leads to worse health outcomes, we must be mindful of the added sugar we eat.

What would happen

A group of scientists performed a study and published a set of research papers that detailed exactly what happened when over 40 children (aged eight to 18) stopped eating sugar and fructose for 10 days. The participants didn’t stop eating bread, hotdogs or snacks. They stopped eating fructose. These studies found significant reductions in:

• newly made triglycerides (or fats)

• fasting blood glucose

• blood pressure

• fat stored on organs, including the liver

• AST, which is a marker of liver function

• insulin resistance, as their cells were better able to remove glucose from the bloodstream

• body mass index.

The participants also reported feeling better and were better behaved.

The World Health Organization has made recommendations for adults and children to reduce their sugar intake to about 58 grams, or 14 teaspoons, per day or between 5% and 10% of total caloric intake.

This is not a lot of sugar.

Consider that a 300ml bottle of Coca-Cola or 240ml cup of sugarcane juice contain about 30 grams of sugar. One piece of mandazi, a popular deep-fried Kenyan wheat snack, has about 4 grams of sugar, or about 6% of the WHO’s recommended intake contained in each small piece.

Lowering intake

First, keep track of everything you eat during a typical day, what you eat, when you eat and how much you eat. Secondly, give yourself a star for the fresh vegetables and whole fruits you eat, and identify the foods that have added sugars.

Now, set an attainable goal that details one thing you can change to either:

1) increase the whole fruits or vegetables you eat or

2) decrease the amount of added sugar that you eat each day.

This way, you can be mindful of the added sugar you consume and adjust what you eat accordingly.

Grace Marie Jones is Associate Professor, College of Osteopathic Medicine, Touro University.

This article was first published on The Conversation.

Home advantage at the Indian Premier League reigned supreme once again as the Gujarat Titans romped home to a seven-wicket win against Sunrisers Hyderabad on Sunday.

Having won the toss and deciding to bat first, the Hyderabad side posted 163/8 on a sweltering hot Ahmedabad afternoon. Travis Head and Mayank Agarwal got things off to a flyer until the Afghan spin duo of Noor Ahmed and Rashid Khan along with Azmatullah Omarzai pulled things back in the middle.

Abhishek Sharma and Heinrich Klaasen, the heroes of the record-breaking innings against Mumbai Indians, made decent contributions, but the pitch that had helped the openers during the Powerplay starting slowing down. In the end, the sixth-wicket partnership between Abdul Samad and Shahbaz Ahmed helped Hyderabad post a competitive total.

The home side began the chase well with captain Shubman Gill striking 36 off 28 balls before departing in an unlikely fashion, mistiming a slice and Samad holding on to the catch. However, impact player Sai Sudarshan along with David Miller put on a brilliant 64-run partnership for the third wicket and ensured that Gujarat pocketed the two points with ease.

Turning point of the match

Until the 15th over, Hyderabad were on course for a win. Pat Cummins had marshalled his troops well enough and the asking rate for Gujarat was climbing to nine runs per over. Despite Miller and Sudarshan looking settled enough, the target looked difficult to achieve.

Then came Mayank Markande for his third over. Prior to bowling the 16th over, he had conceded only nine runs in two overs and taken the wicket of Gill.

But unfortunately for the spinner, Miller and Sudarshan had decided that he was going to be their guinea pig and chose his over to accelerate in the chase.

The over began with a wide, which was a sign of things to come.

Then Miller turned on beast mode and smashed two back-to-back boundaries – finding the gap between long-on and deep midwicket, and then hitting one over extra cover.

Another wide, a single and then Sudarshan had the strike. A few steps down the pitch and the impact player came true to his role, hitting a six over long-on.

Markande’s misery wasn’t done yet as Miller rounded off the over with a six as well, taking 24 runs off one over and completely changing the odds in the favour of the home side.

The Field’s Player of the match

Whenever Gill has needed something to happen, he turned to his strike bowler in Mohit Sharma. The 35-year-old medium pacer usually comes towards the latter half of the innings and delivers a mix of point-blank range yorkers and slower balls with impeccable consistency. His efforts of 3/25 in four overs is what makes Sharma The Field’s Player of the match.

Helped by the likes of Noor Ahmed and Rashid, Sharma himself needed to stick to things and that is what he did. In the final over of the match, he broke the Samad-Shahbaz partnership and stifled Washington Sundar, Hyderabad’s impact substitute, ultimately conceding only three runs.

As Cummins said to the host broadcasters, the score posted by Hyderabad was slightly below-par and for a team that just posted the highest-ever total in an IPL a few days ago, Sharma was solid in his entire spell.

‘I practice what I do generally’

In his comments during the post-match presentation ceremony, Gill was full of praise for Sharma.

“It’s not easy to bowl three to four overs back-to-back in this heat,” said the Gujarat Titans captain.

It was Sharma’s spell that earned him the official Player of the Match award and it was also him that allowed for Gujarat Titans to peg back the much vaulted Hyderabad batting line-up.

Not only was Sharma able to take advantage of the pitch that continue to slow down as the innings wore on, his consistency was such that he only conceded one boundary – a six in his third over that Samad struck over the long-on boundary.

The important thing is knowing when to use the variation and being ahead of the batter. Because when you’re ready with two balls, the batter is also ready. So you need to play with one fielder’s position to deceive the batter. They may be ready for the slower bouncer, but they’re not ready for the slower ball slightly wide. For night games, we practice with a wet ball to deal with dew. But in these situations, these things are uncontrollable, so the bowler’s mindset matters more.

Last December, Khalid Shaikh missed 20 days of school and had to be hospitalised for nearly two weeks, as he battled a serious bout of typhoid that gave him fever, splitting headaches, stomach and body pain.

His family spent Rs 1 lakh on his treatment.

The 15-year-old and his friend had eaten food from a street vendor. Both ended up with typhoid, a water-borne disease caused by the bacteria Salmonella Typhi that attacks multiple organs, causes vomiting and, in rare cases, leads to death. The bacteria spreads through contaminated food and water, often in unsanitary environments.

India accounts for more than half of the global typhoid burden.

When Shaikh first developed a headache and stomach ache, a local doctor prescribed antibiotics. Then followed high fever that recurred every four hours. He was admitted to a hospital in Jogeshwari, a western suburb of Mumbai. When his fever did not subside, his parents shifted him to the Kokilaben Dhirubhai Ambani hospital.

“The doctors there suspected typhoid,” his mother Shabina Shaikh said. The teenager was given a strong dose of antibiotics because milder ones did not work on him. Twenty days after discharge, the typhoid relapsed. This time, he was in hospital for three more days.

Shaikh is a classic example of antimicrobial resistance, a condition in which the drug is not able to kill or control the bacteria because the bug grows resistant to it.

Antibiotic therapy is the only treatment option for typhoid. “Increasing hospitalisation and treatment is leading to antimicrobial resistance,” said Shaikh’s treating doctor Tanu Singhal, an infectious disease specialist.

As a result, doctors often have to resort to increasing the dosage of drugs.

In south Mumbai’s Bombay hospital, physician Dr Gautam Bhansali said until a few years ago, typhoid patients responded well to a daily dose of 1 gram ceftriaxone, an antibiotic that prevents bacteria from growing. “Now I have to use 2 grams twice a day,” he said. “This means additional cost of treatment but also increases resistance risk in the bacteria,” he said.

All these factors – antimicrobial resistance, the high burden of the disease and its treatment cost – led the National Technical Advisory Group on Immunisation, or NTAGI, a body that advises the government on vaccinations, to strongly recommend introducing the typhoid vaccination in 2022, a year before Shaikh contracted typhoid.

In its recommendation, a technical committee of NTAGI warned that India could record 4.6 crore typhoid cases and 89,300 deaths in a 10-year period “if nothing was done”.

It advised the government to provide free typhoid vaccines for children aged between nine months and 12 months and conduct a one-time campaign in schools under the universal immunisation programme to vaccinate older children.

In the same meeting, the group had also recommended introducing the human papillomavirus, or HPV, vaccine against cervical cancer, the second-most common cancer amongst women, in India’s immunisation programme.

While the health ministry has agreed in principle to introduce the HPV vaccine, on typhoid it remains undecided even after two years.

The case for a typhoid vaccine

The World Health Organization first recommended typhoid vaccination for countries where typhoid was endemic in 2008. But discussions in India began much later.

The health ministry decided to conduct typhoid surveillance to assess the disease burden only in 2016. Until then, there was no data on its incidence.

A Surveillance for Enteric Fever in India, or SEFI, consortium began to collect data from 18 sites, including urban and rural regions.

Between 2017 and 2020, the consortium generated enough data to suggest that typhoid incidence varies, from low in rural areas – 12 cases per one lakh children admitted in hospitals for fever – to very high in some urban populations – 1,622 cases per one lakh children.

In Vellore, Delhi and Kolkata, typhoid incidence was higher than 500 cases per lakh children. In sites where only hospital data was surveyed, Chandigarh and Anantpur had a high incidence of the disease. The study also looked at the use of antibiotic drugs for typhoid and found it 2.5 times higher in Pune than in other sites.

Overall typhoid incidence was found to be higher than measles or rubella, vaccines for which are a part of the universal immunisation programme in India.

“There was enough data to suggest that typhoid burden is high. In a lot of cases, it is not even diagnosed,” said Dr Gagandeep Kang, a former member of NTAGI and chairperson of the typhoid working group that recommended the vaccine.

In 2018, the ministry began a pilot study to assess the impact of vaccination. For this, health workers immunised 3.2 lakh children aged between nine months and 14 years with a conjugate vaccine in Navi Mumbai.

The study, carried out between 2018 and 2021, found that vaccination reduced the risk of infection by 56%. Dr Shanta Datta, the study's co-author from National Institute of Cholera and Enteric Diseases, said this was “enough evidence for a vaccine to be used” in the national programme.

“Typhoid is a serious disease. If not treated, people could die. Considering the risk it presents, a vaccine is the safest option to prevent the infection,” Datta told Scroll.

Another study published this year analysed the cost of the Navi Mumbai vaccination drive. For the government, the cost of the vaccine and related supplies was Rs 127.70 per person, while the cost of delivering it ranged from Rs 30 to Rs 44.

In the private sector, the cost of typhoid conjugate vaccine, currently manufactured by Bharat Biotech, Biological E and Zydus Cadila, is much higher, ranging between Rs 1,500 and Rs 2,000. But there is no data on how many people have taken this shot. “Awareness about it is quite low,” Dr Singhal, from Kokilaben Dhirubhai hospital, said.

Till March 2023, the World Health Organization has prequalified two conjugate vaccines against typhoid, both have long-lasting immunity – Bharat Biotech’s Typbar TCV and Biological E’s Typhibev.

An urban problem

But several experts argue that a vaccine might not be the answer to India’s typhoid burden.

Epidemiologist and virologist Dr Jacob T John argued that typhoid does not uniformly infect the entire population. “It is an urban phenomenon.” Which is why, he added, immunising the entire population indiscriminately is not the best solution.

He gave the example of Japanese Encephalitis, which affects a select population, and said interventions on typhoid should only be made in limited geographic regions.

“The presence of typhoid indicates something is wrong with the water supply,” John said. “If we chlorinate and filter water, typhoid will not occur. This will also eliminate other water-related infections like cholera and dysentery. That is a cheaper solution”.

Kang, the former NTAGI member, however, said there is enough evidence to suggest typhoid poses a threat to public health. “Our priorities are people who are the poorest and most vulnerable, and they are also the ones most at risk of typhoid – for example, urban slum areas,” she said.

This pool cannot buy vaccines on their own. Kang said the technical group recommended that the government try out different mechanisms to immunise them – either through a phased introduction in which children of various age groups are immuned in phases, or targeted introduction of vaccines, in which immunisation is carried in pockets with high typhoid incidence.

Another expert on typhoid, Dr Jacob John, who is a community health professor in Christian Medical College, Vellore, said if the government is able to conduct targeted immunisation in the urban population, then the typhoid burden can be controlled. “But we must remember that urban and rural areas are not water-tight compartments. There is migration between the two,” he said.

Jacob John also headed the Surveillance for Enteric Fever in India study and said that typhoid incidence has not reduced over the years despite best efforts to improve sanitation. “When we get to good sanitation, like the West, we will not need a vaccine,” he said. “But that will not happen in the immediate future. We still need a huge quantum of investment to improve our water supply and sanitation. And because it will take a long time, we need other solutions.”

The answer, he said, could lie in introducing vaccines in the universal immunisation programme. “We are seeing cases of drug resistant bacteria in Pakistan. Gujarat is noting cases of resistance too. There are reports of ceftriaxone and azithromycin resistance. Which means we are left with fewer antibiotics to work,” he said.

Other constraints

A member of the NTAGI, who did not want to be identified, said that the delay in introduction of the typhoid vaccine was due to “other priorities” and “constraints” of the health ministry.

The vaccine is recommended for children aged between nine and 12 months. In this window, the measles, mumps and rubella vaccines also have to be administered. Health officials say that two or more shots in such a short span may not be welcomed by parents.

The current focus is on measles coverage, where India is lagging at present, the official added.

For many families dealing with the fallout of typhoid, these arguments ring hollow.

It has been a month since Neeshka Kothare, aged 20, first developed a sore throat and then recurring fever, followed by bouts of vomiting. She continues to have a high-grade fever for a few hours every day. She was diagnosed with typhoid earlier this month.

Kothare was recently part of an education tour to Bhopal. She suspects unclean drinking water served to them spread infection amongst all students. Students and teachers complained of sore throat, and some like Kothare, worsened, developing typhoid and a persistent fever of over 99 degrees.

Earlier this month, Kothare required intravenous injection of antibiotics for three days. She still has fever and continues to take cefuroxime antibiotics. Before this, she was put on azithromycin, another antibiotic to treat infections.

“If I knew about a vaccine, we would have given it to her. It is not-an-easy-to-tackle infection,” her mother Sanjana Kothare, a lawyer, told Scroll.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

The notion that enjoying a casual beer or sipping on your favourite wine could not only be harmless but actually beneficial to one’s health is a tantalising proposition for many. This belief, often backed by claims of research findings, has seeped into social conversations and media headlines, painting moderate alcohol consumption in a positive light.

As researchers at the Canadian Institute for Substance Use Research, we find ourselves frequently revisiting this topic, delving deep into the evidence to separate fact from wishful thinking. Can we confidently say, “Cheers to health?”

Beliefs about moderate drinking

The commonplace belief that moderate drinking can be beneficial to health can be traced back to the 1980s when researchers found an association suggesting that French people were less likely to suffer from heart disease, despite eating a diet high in saturated fat.

This contradiction was thought to be explained by the assumption that the antioxidants and alcohol found in wine might offer health benefits, leading to the term “French paradox.”

This concept reached a broader audience in the 1990s, following a segment on the American news show 60 Minutes which had a profound impact on wine sales. Later research expanded on this idea, suggesting that frequently drinking small amounts of any type of alcoholic beverage might be good for health.

This idea was formalised into what is now known as the J-shaped curve hypothesis. Put simply, the J-shaped curve is a graphical representation of the apparent relationship between alcohol consumption and death or disease. According to this model, abstainers and heavy drinkers are at higher risk of certain conditions, such as heart disease, compared to moderate drinkers, whose risk is lower.

Current perspectives

People used to think that tobacco use was good for health, historically describing it as a remedy for all disease. As scientific understanding has advanced, however, tobacco use has been increasingly recognised as a leading cause of preventable disease and death.

Like tobacco, alcohol was once used in medicine and has since become recognised as a major cause of preventable mortality and illness. For instance, recent global estimates suggest alcohol is responsible for 5.3% of all deaths.

Furthermore, in Canada, the revenue generated from selling alcohol does not come close to covering the damage it causes, leaving the government $6.20 billion short every year. However, much of these costs can be attributed to heavy drinking.

So where does this leave moderate drinkers? We recently set out to answer this question by analysing data from over 4.8 million people from more than 100 studies, covering more than 40 years.

We found that many studies exaggerate the benefits of moderate drinking due to methodological flaws known as selection biases. No matter if we analysed the studies as one big group, using statistical methods to try and lessen these mistakes, or if we separated the good studies from the not-so-good ones, one thing was clear: moderate alcohol consumption does not appear to offer the health benefits once believed.

Explaining the contradiction

Selection biases represent data distortions caused by how research participants are selected. Such biases lead to unfair comparisons between groups, which skews analyses towards finding a J-shape curve. Essentially, it is like comparing two runners in a race, where one wears heavy boots and the other wears lightweight running shoes. Concluding that the second runner is more talented misses the point; it is not a fair comparison.

Here are five examples of selection bias in the context of the alcohol J-shaped curve which can accumulate as people age:

1. Poor health, less alcohol. As health declines, especially in older age, people often reduce their alcohol consumption. Not distinguishing between those who cut back or quit for health reasons can falsely indicate that moderate drinking is healthier.

2. Unhealthy lifetime abstainers. Comparing moderate drinkers with individuals who have never consumed alcohol due to chronic health issues may falsely attribute health advantages to alcohol consumption.

3. Moderate in other ways. Moderate drinkers often lead balanced lifestyles in other areas, too, which may contribute to their perceived better health. It is not just moderate drinking, but also their healthier overall opportunities and choices, such as better health-care access and self-care, that make them seem healthier.

4. Measurement error. Assessing alcohol consumption over a short period of time, like a week or less, can lead to a misclassification of drinkers. Heavy drinkers who happened to not consume alcohol during the week of assessment would be incorrectly classified as abstainers, for example.

5. Early alcohol-attributable deaths. The inevitable exclusion of individuals who may have died from alcohol-related causes before a study of older people starts can result in a “healthy survivor” bias, overlooking the earlier detrimental effects of alcohol.

Continuing the conversation

We should be skeptical of results suggesting that moderate drinking is healthy because selection biases can muddy the waters. For instance, multiple implausible J-shape curve relationships have been published, including between moderate drinking and liver disease.

We are well aware that this news might not be what you were hoping to hear. It might even stir up feelings of unease or skepticism. For many people, limited alcohol consumption is enjoyable. However, it is not without risk and it is important for people to understand these risks to make informed decisions about their health.

The risks are reflected in the 2023 Canadian Drinking Guidance. The guidance attempts to “meet people where they are at”, suggesting that one to two drinks per week represent a low risk of harm, three to six drinks a week represent a moderate risk, and seven or more drinks a week represent an increasingly high risk. Ultimately, they enable people to make informed decisions that best suit their health and well-being.

James M Clay is Postdoctoral Research Fellow, Canadian Institute for Substance Use Research, University of Victoria.

Tim Stockwell Scientist, Canadian Institute for Substance Use Research and Professor of Psychology, University of Victoria.

This article was first published on The Conversation.

Our brains change more rapidly at various times of our lives, as though life’s clock was ticking faster than usual. Childhood, adolescence and very old age are good examples of this. Yet for much of adulthood, the same clock seems to tick fairly regularly. One lap around the Sun; one year older.

However, there may be a stage of life when the brain’s clock starts speeding up. The brain starts changing without you necessarily noticing it. It may even be caused (partly) by what’s in your blood. This stage of brain ageing during your 40s to 50s, or “middle-ageing”, may predict your future health.

Psychologists studying how our mental faculties change with age find that they decline gradually, starting in our 20s and 30s. However, when assessing people’s memory of everyday events, the change over time appears to be especially rapid and unstable during middle age. That is, even among healthy people, some experience rapidly deteriorating memory, while for others, it may even improve.

This suggests that the brain may be going through accelerating, as opposed to gradual, change during this period. Several structures of the brain have been found to change in midlife. The hippocampus, an area critical for forming new memories, is one of them.

It shrinks throughout much of adulthood, and this shrinkage seems to accelerate around the time of middle age. Abrupt shifts in the size and function of the hippocampus during middle age could underlie memory changes like the ones mentioned above.

Ultimately, what allows the brain to carry out its functions are the connections between brain cells – the white matter. These connections mature slowly throughout adulthood, especially the ones connecting areas of the brain that deal with cognitive functions such as memory, reasoning and language.

Interestingly, during middle age, many of them go through a turning point, from gaining volume to losing volume. This means that signals and information cannot be transmitted as fast. Reaction time starts deteriorating around the same time.

Through the white matter connections, brain areas talk to each other and form interconnected networks that can perform cognitive and sensory functions, including memory or vision. While the sensory networks deteriorate gradually throughout adulthood, the cognitive networks start deteriorating faster during middle age, especially those involved in memory.

Much like how highly connected people in society tend to form cliques with each other, brain regions do the same through their connections. This organisation of the brain’s communication allows us to perform some of the complex tasks we might take for granted, such as planning our days and making decisions.

The brain seems to peak in this regard by the time we hit middle age. Some have even referred to middle age as a “sweet spot” for some types of decision-making, but then the network “cliques” start to break up.

It’s worth stating at this point why these subtle changes matter. The global population aged 60 and over is set to roughly double by 2050, and with this, unfortunately, will come a considerable increase in dementia case numbers.

Focus on old age

Science has long focused on very old age, when the detrimental effects of time are most obvious, but, by then, it can often be too late to intervene. Middle age could be a period when we can detect early risk factors of future cognitive decline, such as in dementia. Critically, the window of opportunity to intervene may also still be open.

So, how do we detect changes without having to give everyone an expensive brain scan? As it turns out, the contents of blood may cause the brain to age. With time, our cells and organs slowly deteriorate, and the immune system can react to this by starting the process of inflammation. Inflammatory molecules can then end up in the bloodstream, make their way to the brain, interfere with its normal functioning and possibly impair cognition.

In a fascinating study, scientists from Johns Hopkins and the University of Mississippi analysed the presence of inflammatory molecules in the blood of middle-aged adults and were able to predict future cognitive change 20 years down the line. This highlights an important emerging idea: age in terms of biological measures is more informative about your future health than age in terms of years lived.

Importantly, biological age can often be estimated with readily available and cost-effective tests used in the clinic.

“Middle ageing” may be more consequential for our future brain health than we think. The hurried ticking of the clock could be slowed from outside the brain. For example, physical exercise confers some of its beneficial effects on the brain through blood-borne messengers. These can work to oppose the effects of time. If they could be harnessed, they might steady the pendulum.

Sebastian Dohm-Hansen Allard is PhD Candidate, Anatomy and Neuroscience, University College Cork.

Yvonne Nolan is Professor in Neuroscience, University College Cork.

This article was first published on The Conversation.

We’re living longer than in previous generations, with one in eight elderly Australians now aged over 85. But the current gap between life expectancy (“lifespan”) and health-adjusted life expectancy (“healthspan”) is about ten years. This means many of us live with significant health problems in our later years.

To increase our healthspan, we need planned, structured and regular physical activity (or exercise). The World Health Organization recommends 150-300 minutes of moderate-intensity exercise – such as brisk walking, cycling and swimming – per week and muscle strengthening twice a week.

Yet few of us meet these recommendations. Only 10% meet the strength-training recommendations. Lack of time is one of the most common reasons.

Walking is cost-effective, doesn’t require any special equipment or training, and can be done with small pockets of time. Our preliminary research, published this week, shows there are ways to incorporate strength-training components into walking to improve your muscle strength and balance.

Why walking is not enough

Regular walking does not appear to work as muscle-strengthening exercise.

In contrast, exercises consisting of “eccentric” or muscle-lengthening contractions improve muscle strength, prevent muscle wasting and improve other functions such as balance and flexibility.

Typical eccentric contractions are seen, for example, when we sit on a chair slowly. The front thigh muscles lengthen with force generation.

The research

Our previous research found body-weight-based eccentric exercise training, such as sitting down on a chair slowly, improved lower limb muscle strength and balance in healthy older adults.

We also showed walking down stairs, with the front thigh muscles undergoing eccentric contractions, increased leg muscle strength and balance in older women more than walking up stairs. When climbing stairs, the front thigh muscles undergo “concentric” contractions, with the muscles shortening.

It can be difficult to find stairs or slopes suitable for eccentric exercises. But if they could be incorporated into daily walking, lower limb muscle strength and balance function could be improved.

This is where the idea of “eccentric walking” comes into play. This means inserting lunges in conventional walking, in addition to downstairs and downhill walking.

In our new research, published in the European Journal of Applied Physiology, we investigated the effects of eccentric walking on lower limb muscle strength and balance in 11 regular walkers aged 54 to 88 years.

The intervention period was 12 weeks. It consisted of four weeks of normal walking followed by eight weeks of eccentric walking.

The number of eccentric steps in the eccentric walking period gradually increased over eight weeks from 100 to 1,000 steps (including lunges, downhill and downstairs steps). Participants took a total of 3,900 eccentric steps over the eight-week eccentric walking period while the total number of steps was the same as the previous four weeks.

We measured the thickness of the participants’ front thigh muscles, muscle strength in their knee, their balance and endurance, including how many times they could go from a sitting position to standing in 30 seconds without using their arms. We took these measurements before the study started, at four weeks, after the conventional walking period, and at four and eight weeks into the eccentric walking period.

We also tested their cognitive function using a digit symbol-substitution test at the same time points of other tests. And we asked participants to complete a questionnaire relating to their activities of daily living, such as dressing and moving around at home.

Finally, we tested participants’ blood sugar, cholesterol levels and complement component 1q (C1q) concentrations, a potential marker of sarcopenia (muscle wasting with ageing).

What did we find

We found no significant changes in any of the outcomes in the first four weeks when participants walked conventionally.

From week four to 12, we found significant improvements in muscle strength (19%), chair-stand ability (24%), balance (45%) and a cognitive function test (21%).

Serum C1q concentration decreased by 10% after the eccentric walking intervention, indicating participants’ muscles were effectively stimulated.

The sample size of the study was small, so we need larger and more comprehensive studies to verify our findings and investigate whether eccentric walking is effective for sedentary people, older people, how the different types of eccentric exercise compare and the potential cognitive and mental health benefits.

But, in the meantime, “eccentric walking” appears to be a beneficial exercise that will extend your healthspan. It may look a bit eccentric if we insert lunges while walking on the street, but the more people do it and benefit from it, the less eccentric it will become.

Ken Nosaka is Professor of Exercise and Sports Science, Edith Cowan University.

This article was first published on The Conversation.

Tuberculosis remains India’s most pressing health concern with the infectious disease killing an estimated 1,400 Indians per day, according to the Centre’s 2017 TB elimination plan.

But what is often overlooked is how TB affects the health of women and children.

TB kills more women globally than all other causes of maternal mortality combined, according to the WHO Global TB Report, 2015.

According to the central government, India reports the maximum TB cases every year, globally, as well as the highest TB mortality. India’s gender-responsive framework for TB states that more than a million women and girls are diagnosed with TB in India every year. There are no figures and neither are any collected on how TB affects gender minorities, like queer individuals.

The crisis of TB is rarely recognised as a gendered one.

In addition to clinical manifestations, TB also affects the social fabric and economic stability of families. An estimated one lakh women lose their roles as mothers and wives due to the stigma of TB, according to the India TB Report 2001 & 2020.

A study by the National Institute of Research in Tuberculosis, Chennai, found that parental TB led to 11% children dropping out of school and 20% children having to take up jobs to support their families. An estimated three lakh students may have permanently left school due to a parent suffering from TB.

Narratives from trans individuals and gender minorities indicate that there are challenges in accessing even a diagnosis and it is harder still to receive and continue treatment.

Between the numbers is a woman from Dharavi, whose journey through TB epitomises the silent struggles faced by many. Then, there is the trans woman who eventually gave up in her struggle against TB, unable to access care in the public sector and or the unaffordable private sector.

Stories like these of spending months in search of diagnosis, battling stigma and enduring the abandonment by families sheds light on the harsh reality of women and gender minorities in struggling with TB in India.

Despite their hardships, these survivors embody resilience.

Women and other gender minorities living in violently patriarchal societies face unique challenges in accessing timely diagnosis and treatment for TB. It is particularly difficult for gender minorities to seek care due to structural and social barriers, stigma in the health system and widespread poverty.

Societal stigma associated with the disease, coupled with limited agency and socioeconomic status of these groups, contributes to significant delays in getting healthcare.

Research shows that married women, fearing desertion or blame, hide their TB diagnosis, leading to an interruption in their treatment, which can have adverse outcomes. The burden of household responsibilities exacerbates the challenges faced by women, making it difficult for them to prioritise their health needs.

Additionally, the prevalence of indoor air pollution in rural areas, where it is mostly women who cook in poorly ventilated spaces, increases the risk of TB transmission and chronic lung diseases among them.

India’s response to TB must be gender-responsive and inclusive of all gender and sexual minorities and groups.

The government’s gender-responsive framework, introduced in 2019, is a welcome step in this direction. Mobilising political commitment and resources to ensure gender-equitable access to TB services, which is women and queer-friendly, is paramount. Healthcare programmes must be sensitised to the unique constraints faced by women and gender minorities in accessing care and completing treatment.

A good starting point is the widespread dissemination and training of the gender responsive framework. India needs an attitudinal change, strict guidelines on gender-responsive care and training. This should extend to the private sector as well.

There is a need for specific campaigns aimed at women and queer groups to help raise awareness about TB and reduce stigma within communities. Gender-responsive clinics that cater especially to gender minorities and their needs and provide nutritional supplementation can improve treatment outcomes.

Moreover, investing in the development of new tools, such as shorter treatment regimens and affordable diagnostics, is essential to tackling TB effectively.

Addressing the gender dimensions of TB in India is not only a matter of public health but also a human rights imperative.

Empowering women and queer individuals to access TB services and supporting them through their treatment journey is crucial for eliminating the disease as a public health threat in India.

By prioritising gender-responsive approaches, India can move closer to achieving its goal of ending TB and ensuring the health and well-being of all its citizens – leaving no one behind.

Akshata Acharya, a survivor of multi-drug resistant TB, is an author, theatre enthusiast. Manasi Khade, a survivor of extremely-drug-resistant TB, is a creative professional. They are both Fellows associated with Survivors Against TB, collective of survivors, advocates and experts working on TB and related comorbidities.

Dengue, caused by the virus transmitted by the bite of the female Aedes aegypti mosquito and, to a lesser extent, the Aedes albopictus mosquito, is an acute illness characterised mainly by high fever, body aches and redness of the skin.

A small fraction of those displaying symptoms can experience a worsening disease at the end of the first week. These cases, classified as dengue with warning signs and severe dengue by the World Health Organisation, are the most worrying, leading to significant morbidity and mortality in tropical and subtropical regions worldwide.

In dengue with warning signs, in addition to the classic symptoms, there may be small amounts of blood on the mucous membranes, haematomas, abdominal pain, vomiting, dehydration, restlessness, dizziness, excessive tiredness and drowsiness.

Severe dengue is a result of a greater systemic inflammatory reaction, which alters blood clotting and leads to fluid loss. The consequences can include intense bleeding and a sudden drop in blood pressure, which are responsible for the shock associated with dengue fever, the main cause of death.

The number of people with severe disease is small compared to the total incidence of the disease. Of the three million confirmed cases of dengue in Brazil in 2023, only 0.1% had the worst symptoms of the disease, according to the World Health Organization.

However, as the number of cases continues to rise in 2024, this small percentage exerts a big impact, with even more pressure on health services. Brazil recorded more than a million suspected cases and dozens of deaths from dengue fever in 2024 up to the beginning of March 2024, according to the Ministry of Health, a quite significant increase compared to the same period in 2023.

This situation is part of a major global increase in the disease, which has already registered five million cases in 129 countries.

The main victims

Young children and older people can find it more difficult to cope with severe infections due to immunity issues. Another important factor related to severe dengue is that it is more frequent in the second and third infections. As there are four viruses causing dengue worldwide, DENV-1, DENV-2, DENV-3 and DENV-4, a given person can be infected four times.

The chance of developing the most serious symptoms in the first infection is low but increases in the second and third, especially among those in people with other illnesses. This appears to be because antibodies produced by the body against one dengue virus type facilitate the entry of a second dengue virus, which is not completely neutralised.

It would seem these enter the cells more easily and multiply more quickly. This mechanism is known as “antibody-dependent enhancement”. With the number of cases rising, the phenomenon needs special attention.

To avoid this situation, it is preferable to have protection against all four types of dengue viruses. In times of cyclical outbreaks, we can no longer remain uncovered. It will then be up to vaccination to help us achieve this goal.

Single-dose vaccine

A dengue vaccine must be able to elicit high efficacy against the four viruses, be safe and be able to, ultimately, help contain the virus spread. In other words, it must induce protection against at least three and preferably to all four dengue viruses at the same time, as if it were four vaccines in one.

Offering this possibility in less time, that is, in a single dose, could be the game changer for guaranteeing complete protection more quickly, potentially putting a stop onto outbreaks, and protecting those who need it most.

The Butantan Institute has been working on the development of a dengue vaccine since the late 1990s. We recently published the primary phase 3 results of the vaccine candidate in The New England Journal of Medicine.

With just one injection, it provides good protection in a very elastic age range, from two to 60 incomplete years, according to the published results. It also has the differential of being able to be applied to those who have or have not already been infected by the dengue virus.

Protection was observed in all age groups, with 90% in adults aged 18 to 59, 77.8% in those aged seven to 17 and 80.1% in children aged two to six. The analysis of the effectiveness of the immunogen was carried out over two years with just under 17,000 volunteers in 16 research centres. The study is in its final phase and will complete in June 2024.

The next step will be to finalise the dossier with all the study information to apply for registration at Brazil’s National Health Surveillance Agency, Anvisa, by the second half of 2024.

At a time when dengue is advancing worldwide due to climate change, the arrival of a new single-dose vaccine to prevent epidemics and deaths could be a key weapon in the fight against dengue.

Esper Georges Kallás is Diretor do Instituto Butantan e Professor Titular do Departamento de Moléstias Infecciosas e Parasitárias, Faculdade de Medicina da USP.

This article was first published on The Conversation.

During the monsoon months, when vector and water-borne diseases sweep through Barwani, the 400-bed district hospital overflows with patients, with many huddling on the floor.

Throughout the year, beds are scarce in the government-run hospital – the only major health facility that most people in this Adivasi belt in south-west Madhya Pradesh can afford to access.

The scarcity could soon grow worse.

The Madhya Pradesh government has decided to allocate a quarter of the beds in all district hospitals that it runs to private organisations, who will then set up medical colleges. Urban development minister Kailash Vijaywargiya said this has been done to incentivise the private sector to invest in healthcare and improve hospital infrastructure – a recommendation first made by the central government think tank Niti Aayog.

But health activists fear that this would adversely impact healthcare access for the poor. While public hospitals are bound to provide free treatment, the private organisations have been allowed to charge fees on 25% of hospital beds.

At the Barwani district hospital, the new rule means that 100 of the total 400 beds will no longer be available for free treatment. “If the available [free] beds are reduced, where will poor patients go?” asked Amulya Nidhi, health activist with Jan Swasthya Abhiyan. “Already, government hospital beds are falling short.”

Madhya Pradesh has 55 district hospitals and 12 government medical colleges. State government data shows there are 16,850 beds in 52 of the 55 district hospitals. A 25% reservation will lead to the allocation of more than 4,200 beds for paying patients.

On March 5, the Jan Swasthya Abhiyan, a collective of health activists, wrote to the state government pointing out that the plan will deprive the poor of affordable treatment.

The Niti Aayog model

In 2017, government think tank Niti Aayog had recommended that district hospitals be operated through public-private partnerships to improve health infrastructure across the country.

The think tank updated the guidelines in 2021 to link district hospitals with private medical colleges. The guidelines state that the government will provide land and basic infrastructure in the form of a district hospital to a private partner, which has to invest in developing a medical college.

The Niti Aayog’s justification is that government hospitals suffer from a dearth of qualified doctors and that the government alone cannot bridge the gap in medical education.

The National Medical Commission requires a minimum number of hospital beds to start a medical college, based on the number of MBBS seats proposed. The provision of government hospital beds will make it easier for a private player to get permission to start a college.

In 2023, the Uttar Pradesh government approved the handover of six new medical colleges under the public-private partnership mode. The same year in Maharashtra, the state government announced it will hand over the Aundh district hospital to private companies to increase its facilities and bed strength. Health activist Abhijeet More said this led to multiple protests. The project is on hold for now.

If Madhya Pradesh implements its new proposal, it might become the first state to hand over beds in all its district hospitals to private organisations and convert them to medical colleges.

Past attempts

Madhya Pradesh’s experiments with a similar model in the past have been unsuccessful. In 2015, the state government handed over the Alirajpur district hospital and a primary health centre in Jobat, both Adivasi-populated areas, to a Gujarat-based non-profit.

According to the agreement, the state government would pay the salaries of some doctors while the non-profit would pay for the rest of the staff. SR Azad, a health activist, told Scroll that the government did not issue a tender and directly appointed the non-profit to take over the hospital.

“The government told us that the decision was taken to improve the maternal mortality rate, neonatal mortality and rate of anaemia in the region,” Azad said. But the non-profit had no prior experience of working in Madhya Pradesh.

Azad said that in the one year that the non-profit managed the hospital and healthcare centre, there was no significant improvement in the local region’s mortality rate or anaemia. The National Family Health Survey, 2019-’21 showed that anaemia among children under the age of five increased from 74.5% in 2015-’16 to 76.4% in Alirajpur.

In 2016, the Jan Swasthya Abhiyan filed a public interest litigation in Jabalpur High Court against the public-private partnership model. “It is the government’s responsibility to improve the health indicators in a district,” said Azad, explaining the petition’s rationale. “They cannot put the responsibility on private players.”

The court ordered a stay on the public private partnership in Alirajpur in 2016, Azad said.

In 2021, the state government handed over a community health centre in Sanwer in Indore district to the Aurobindo Institute of Medical Sciences. The community health centre covered more than 150 villages.

The government was forced to stop the pilot project the same year following local concerns that it would increase the referral to Aurobindo hospital where patients will be forced to pay for treatment.

Despite these failed attempts, on March 4, the state cabinet approved a proposal to involve private organisations in creating new medical colleges by handing over government district hospitals to them.

Nidhi, from Jan Swasthya Abhiyan, said the consistent attempts of the government shows “they are either not willing to take responsibility of public hospitals or are creating favourable policies to benefit privatisation”.

Madhya Pradesh additional chief secretary for health Mohammad Suleman and medical education commissioner Tarun Pithode did not respond to calls and messages from Scroll. Principal secretary for health, Vivek Porwal, told Scroll that he has recently joined his post and cannot comment on the cabinet meeting’s decision to hand over district hospitals.

Karnataka’s failed model

Two decades ago, the Karnataka government tried to implement a similar model. In 2002, the state government set up the Rajiv Gandhi Super Specialty hospital in Raichur and handed over the 73-acre campus with hostel, staff quarters and hospital building to Apollo Hospitals Enterprise Limited to provide specialised treatment for various diseases.

The state government drew up an agreement to pay Rs 1 crore per month for revenue expenditure to Apollo. Under the terms of the agreement, the private hospital would have to provide free treatment to below-poverty-line patients in Raichur.

A decade later, a state government inspection of the hospital found that it lacked several services that were part of the agreement. Out of 340 beds, only 154 were functional, of which only 58% were occupied by patients in 2010-’11. The below-poverty-line patients admitted covered only 11% of total beds in hospital.

In May 2012, the Karnataka government terminated the agreement with Apollo.

In 2022, the Karnataka government again decided to hand over nine district hospitals to private organisations to run them as medical colleges. Gopal Dabade, president of Drug Action Forum, Karnataka, said there were massive protests in Chigateri in Davangere district where the local district hospital was part of the handover.

The decision was rolled back when Congress came to power in 2023 in Karnataka. Local activists, however, say that the government is still considering a partnership with private agencies for healthcare.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

The last two terms of the Narendra Modi government have seen a massive push towards building sanitation and drinking water facilities.

In 2014, when it came to power, the Bharatiya Janata Party announced the launch of the Swachh Bharat Mission to construct toilets in each household. The party promised to increase the number of households with toilets from 39% in 2014 to 100% by 2019.

In October 2019, India declared itself open-defecation free, which meant people were no longer relieving themselves in the open and had access to a household toilet. But numerous reports (read here and here) have pointed out that open defecation continues in India.

The reasons are many: toilets constructed have poor drainage, or are poorly built in the first place. Many Indians continue to defecate in the open despite having a toilet.

In 2019, a second phase of Swachh Bharat Mission (rural) was launched for a period of five years to make arrangements for solid and liquid waste management in all the villages in the country by 2024.

Government data shows 398 out of 746 districts in India have achieved that status. About 4.37 lakh villages have liquid waste management and 2.69 lakh have solid waste management.

Drinking water

Ahead of the 2019 Lok Sabha elections, the BJP promised in its manifesto to provide piped water connection and safe drinking water to every household in rural India by 2024. This became the Jal Jeevan Mission.

In the first term of the Narendra Modi government, too, the number of water connections in rural India went up – from 13% in 2014 to 16.8% by 2017-2018.

In 2019, at the time of the launch of the Jal Jeevan Mission, there were 3.23 crore rural tap water connections.

In the last five years, the number of connections have risen to 14.07 crore, or 73% of the total 19.2 crore rural households in India.

That figure, however, may be misleading because not every house with a tap water connection is supplied with safe drinking water. Experts have pointed out that the scheme relies on groundwater reserves to supply water to households, and does not rely on rainwater harvesting. In many places, groundwater depletion and depletion in levels of natural reservoirs is affecting water supply under this scheme.

The lack of pipeline maintenance and high water charges in rural regions have also come in the way of the mission. In a report, Scroll found that villages listed as beneficiaries of Jal Jeevan Mission continue to rely on local wells to draw water while their household taps run dry.

Change in budget allocation

The BJP-led government focussed on sanitation in its first term, and shifted its focus to drinking water in the second. The change is marked by a noticeable shift in budget.

Between 2014 and 2018, the budget for the Swachh Bharat Mission (rural) saw a rise, from Rs 2,908 crore in 2014-’15 to Rs 16,948 crore in 2017-’18. It began to decline the year after, coming to as low as Rs 5,000 crore in the revised budget of 2022-’23.

As the funds for sanitation shrunk, the budget for drinking water almost doubled – from Rs 5,500 crore in 2018-’19 (revised budget estimates) to Rs 10,001 crore in 2019-’20.

For 2023-’24, the Department of Drinking Water and Sanitation has allocated 91% of the budget to Jal Jeevan Mission and 9% to Swachh Bharat Mission (rural).

The estimated budget for drinking water supply for 2023-’24 is Rs 70,000 crore; Rs 7,192 crore has been provisioned for the Swachh Bharat mission. The decline in funds is likely to worsen what critics have called a “build-neglect-rebuild” feature of the mission – an excess focus on building infrastructure to the detriment of operations and maintenance.

Can you pass me the whatchamacallit? It’s right over there next to the thingamajig.

Many of us will experience “lethologica”, or difficulty finding words, in everyday life. And it usually becomes more prominent with age.

Frequent difficulty finding the right word can signal changes in the brain consistent with the early (“preclinical”) stages of Alzheimer’s disease – before more obvious symptoms emerge. However, a recent study from the University of Toronto suggests that it’s the speed of speech, rather than the difficulty in finding words that is a more accurate indicator of brain health in older adults.

The researchers asked 125 healthy adults, aged 18 to 90, to describe a scene in detail. Recordings of these descriptions were subsequently analysed by artificial intelligence (AI) software to extract features such as speed of talking, duration of pauses between words, and the variety of words used.

Participants also completed a standard set of tests that measure concentration, thinking speed, and the ability to plan and carry out tasks. Age-related decline in these “executive” abilities was closely linked to the pace of a person’s everyday speech, suggesting a broader decline than just difficulty in finding the right word.

A novel aspect of this study was the use of a “picture-word interference task”, a clever task designed to separate the two steps of naming an object: finding the right word and instructing the mouth on how to say it out loud.

During this task, participants were shown pictures of everyday objects (such as a broom) while being played an audio clip of a word that is either related in meaning (such as “mop” – which makes it harder to think of the picture’s name) or which sounds similar (such as “groom” – which can make it easier).

Interestingly, the study found that the natural speech speed of older adults was related to their quickness in naming pictures. This highlights that a general slowdown in processing might underlie broader cognitive and linguistic changes with age, rather than a specific challenge in memory retrieval for words.

Findings

While the findings from this study are interesting, finding words in response to picture-based cues may not reflect the complexity of vocabulary in unconstrained everyday conversation.

Verbal fluency tasks, which require participants to generate as many words as possible from a given category (for example, animals or fruits) or starting with a specific letter within a time limit, may be used with picture-naming to better capture the “tip-of-the-tongue” phenomenon.

The tip-of-the-tongue phenomenon refers to the temporary inability to retrieve a word from memory, despite partial recall and the feeling that the word is known. These tasks are considered a better test of everyday conversations than the picture-word interference task because they involve the active retrieval and production of words from one’s vocabulary, similar to the processes involved in natural speech.

While verbal fluency performance does not significantly decline with normal ageing (as shown in a 2022 study), poor performance on these tasks can indicate neurodegenerative diseases such as Alzheimer’s.

The tests are useful because they account for the typical changes in word retrieval ability as people get older, allowing doctors to identify impairments beyond what is expected from normal ageing and potentially detect neurodegenerative conditions.

The verbal fluency test engages various brain regions involved in language, memory, and executive functioning, and hence can offer insights into which regions of the brain are affected by cognitive decline.

The authors of the University of Toronto study could have investigated participants’ subjective experiences of word-finding difficulties alongside objective measures like speech pauses. This would provide a more comprehensive understanding of the cognitive processes involved.

Personal reports of the “feeling” of struggling to retrieve words could offer valuable insights complementing the behavioural data, potentially leading to more powerful tools for quantifying and detecting early cognitive decline.

Opening doors

Nevertheless, this study has opened exciting doors for future research, showing that it’s not just what we say but how fast we say it that can reveal cognitive changes.

By harnessing natural language processing technologies (a type of AI), which use computational techniques to analyse and understand human language data, this work advances previous studies that noticed subtle changes in the spoken and written language of public figures like Ronald Reagan and Iris Murdoch in the years before their dementia diagnoses.

While those opportunistic reports were based on looking back after a dementia diagnosis, this study provides a more systematic, data-driven and forward-looking approach.

Using rapid advancements in natural language processing will allow for automatic, detection of language changes, such as slowed speech rate.

This study underscores the potential of speech rate changes as a significant yet subtle marker of cognitive health that could aid in identifying people at risk before more severe symptoms become apparent.

Claire Lancaster is Lecturer, Dementia, University of Sussex.

Alice Stanton is PhD Candidate, Dementia, University of Sussex.

This article was first published on The Conversation.

India was the third most polluted country globally in 2023 with regard to air pollution, according to the sixth Annual World Air Quality Report released on Tuesday by the Swiss technology company IQAir.

Bangladesh was the top ranking country followed by Pakistan.

The report said that Delhi was the most polluted national capital, while Bihar’s Begusarai was the most polluted metropolitan area of 2023 globally.

India is home to 12 out of the world’s top 15 ranked cities with regard to air pollution. These are: Guwahati, Greater Noida, Siwan, Saharsha, Goshaingaon, Katihar, Bettiah, Samastipur, Muzaffarnagar, Gurugram, Arrah and Dadri.

The report analysed PM2.5 data from 7,812 cities across 134 countries, regions and territories. PM2.5 refers to tiny airborne particles that are about 30 times smaller than the width of a human hair and can easily be breathed into the lungs and the bloodstream.

The volume of such particles is measured in micrograms per cubic metre of air (μg/m³). One µg/m3 means that one cubic metre of air contains one microgram of suspended particulate matter.

PM2.5 is one of six common airborne pollutants that are monitored and regulated by environmental agencies worldwide, including by India’s Central Pollution Control Board, due to its significant impacts on human health and the environment.

Common components of PM2.5 include sulfates, black carbon, nitrates and ammonium. Human-made sources of PM2.5 include combustion engines, industrial processes, power generation, burning of coal and wood, agricultural activities and construction.

IQAir’s report found that the average annual concentration of PM2.5 in India exceeded the World Health Organization’s prescribed annual threshold by more than 10 times. The World Health Organization’s Global Air Quality Guidelines prescribed a “safe” annual average PM2.5 concentration of 5μg/m³.

The annual average concentration of PM2.5 in India stood at 54.4μg/m³ in 2023, a marginal increase from 53.3μg/m³ in 2022, according to IQAir’s analysis.

In 2023, the annual average concentration of PM2.5 in Bangladesh was 79.9μg/m³. In Pakistan, this figure stood at 73.7μg/m³.

In India, the spike in pollution levels in 2023 posed significant health risks to an estimated 1.36 billion people living in the country.

In the National Capital Region, the report flagged an alarming surge in PM2.5 levels that rose by 10% compared to the previous year and peaked at a monthly average concentration of 255 μg/m3 in November.

“The data indicates pressing environmental challenges that India faces, posing significant health risks to its vast population,” Avinash Chanchal, the campaign manager at Greenpeace India, said. “Vehicle emissions continue to play a significant role in exacerbating air pollution, accounting for 40% of PM2.5 emissions in the nation’s capital.”

In contrast, the countries that met the World Health Organization’s annual PM2.5 guideline, of an average concentration of 5μg/m³ or less, were: Australia, Estonia, Finland, Grenada, Iceland, Mauritius and New Zealand.

Advances in technology in recent decades have obviated the need and desire for humans to move. Many of the world’s population sit for long periods throughout the day, whether in front of a computer at work or in front of a TV at home. Given that the human body is made to move, all this sitting is clearly bad for our health. A new study from the University of California, San Diego, confirmed this – and then some.

A total of 5,856 female participants aged 63 to 99 years were asked to wear an activity monitor on their hip for seven days at the start of the study. The researchers then followed them for a decade, during which 1,733 participants died.

The researchers used artificial intelligence to work out from the activity monitor how much time the participants were sitting and then linked this to their risk of death. The data showed that participants who sat more than 11 hours a day had a 57% higher risk of dying during the study period than those who sat less than nine and a half hours a day.

But regular exercise will undo the health risks of sitting too much, right? Not according to the study by the University of California, San Diego. The risk of an early death was still there even with higher amounts of moderate-to-vigorous exercise. A 2019 study also found that higher amounts of exercise didn’t undo the risk of diseases such as type 2 diabetes, heart disease and stroke that come with sitting too much.

However, a study from Australia found that doing between 9,000 and 10,500 steps each day lowered the risk of premature death, even in people who sat a lot.

The contradictory findings could be explained by the activity monitors being worn on the hip in the UCSD study and on the wrist in the Australian study, which might lead to different estimates of sitting time.

The Australian study also didn’t use any special software in the activity monitor data to work out when participants were sitting or standing, meaning that standing would have been incorrectly picked up as sitting.

For example, if a participant stood still for half an hour, this would be picked up as half an hour of sitting. This could mean that the Australian study overestimated the time its participants spent sitting.

The evidence from the UCSD study looks to be better, highlighting the need to sit less. Current guidelines from the World Health Organization support this, recommending that adults should limit the amount of time sitting and break up long periods of sitting.

How much is too much

So how much sitting is too much? The UCSD study says 11 hours per day. Other research says just seven hours each day could be too much. There is lots of research too, that shows you shouldn’t sit for longer than 30 minutes in one go as this can increase your blood sugar levels and blood pressure.

So what can you do to avoid sitting for long periods?

A sit-stand desk could help if you’re an office worker. Or you could get up and move around between job tasks or while on a call. At home, you could stand up during TV ad breaks or while the kettle is boiling. Some smart devices and wearables buzz if you have been sitting for too long as well.

But what if you can’t stand or walk? A 2020 study found that small bursts of arm exercise (for example, two minutes every 20 minutes) lowered blood sugar levels in wheelchair users. As long as you are doing something that means you aren’t sitting still, there are health benefits to be had.

Daniel Bailey is Senior Lecturer in Sport, Health and Exercise Sciences, Brunel University London.

This article was first published on The Conversation.

India’s workforce will be middle-aged: The median age will increase to 38 in 2050 from 30 in 2025, according to projections made by the longitudinal ageing study in India – LASI.

This is part of the demographic transition process, in which the number of births and deaths fall. When the birth rate remains constant as death rates of both children and the elderly decline, the population experiences a bulge (and an economic boom). However, if the birth rate falls, the number of working age people reduces and the proportion of the elderly increases.

The proportion of elderly is increasing in the less developed nations, with about eight in 10 of the world’s elderly people expected to be living in developing nations in 2050. This causes a change in the age-dependency ratio, which has consequences for the allocation of resources towards education, healthcare and social security for the population.

“As we live longer, it is important to ensure that the elderly are able to lead a healthy, fulfilling life,” says this United Nations Population Fund paper. Health and well-being are determined not only by our genes and personal characteristics but also by the physical and social environments in which we live our lives, said AB Dey, a geriatrics specialist and head of the geriatrics department at the All India Institute of Medical Sciences, who was also one of the principal investigators on the LASI team.

“Environments play an important role in determining the physical and mental capacity across a person’s life course and into older age, and also how well we adjust to loss of function and other forms of adversity that we may experience at different stages of life, and in particular in later years,” he explained.

With both older people and the environments in which they live poised to change, it is imperative that the government act now to allow healthy ageing, according to experts.

The first part of our series on ageing India analyses the problems before the country as it advances in age without necessarily advancing economically.

Demographic transition

In 2050, the proportion of children in the Indian population under the age of 14 will be less than that of the elderly (over 60 years) for the first time in India. While those over the age of 60 will be 19.5% of the population (nearly one in five), those under the age of 14 will be 18.5% of the population.

At present, Kerala has the highest proportion of elderly population at 19.6% (which is almost equal to the projected proportion of elderly for India in 2050). Himachal Pradesh, Tamil Nadu and Maharashtra also have a high number of people aged 60 and above, as per LASI.

More women are present in that age group than men: the sex ratio for 60 years and above is 1,065 females per 1,000 males. It is more skewed in urban areas (1,084 women per 1,000 men) than in rural areas (1,055 women per 1,000 men). In contrast, the sex ratio in the age group of children is higher in rural (941) than in urban areas (912).

That is because women live longer than men, as per economist Arun Kumar, a retired professor of economics from Jawaharlal Nehru University in New Delhi.

“Women bear children, so they have a stronger immune system. Secondly, women have largely been at home, which is a less stressful thing than going out to work or in earlier times, hunting. High stress levels lead to earlier deaths,” he explained.

Urban women have access to better healthcare, more nutrition and are less likely to be poor than rural women, which explains why the sex ratio is higher for urban women in that age group, he added.

Income loss

India is one of the countries where the population is “growing old before growing rich”, meaning the growth in incomes for a large section of the population has not increased.

There are at present 62 dependents (children under the age of 14 and old people above the age of 65) for every 100 working people in India, as per the LASI report. While the population of the youth will continue to increase for the next 15-20 years, unless they have jobs, the dependency ratio will remain high and the demographic dividend will become a demographic disaster, said Kumar.

Automation also threatens to replace workers in call centres, back process jobs and the like, which will hurt employment prospects further, he added. “We need to address the problems of health, education and employment immediately,” said Kumar.

About 36% of the elderly (aged 60 years and older) are currently working. Of these, about a fifth (21%) are agricultural labourers, meaning they have no employer-provided social security or pensions.

Pensions and family support pay for the needs of the elderly, chief among which is healthcare. Only 5.7% of the country’s elderly get pensions, as per the LASI study. In addition, around 59% of older women do not receive any income.

Health, safety, dignity

In addition to shortage in the labour force and reduced savings, population ageing presents a new set of challenges for the healthcare system. This may require realigning primary healthcare services to better care for the new diseases among the target population.

The leading cause of death in India are non-communicable diseases – heart disease, cancer, chronic respiratory diseases, diabetes – for both men and women. Developed states such as Kerala and Tamil Nadu have a higher burden of non-communicable diseases than states such as Uttar Pradesh and Bihar, according to national health data analysed by the Indian Council of Medical Research, Public Health Foundation of India and the Institute for Health Metrics and Evaluation.

Attention is required for age-related diseases such as those caused by an inevitable biological decline (cataract and macular degeneration that affect eyesight, sensorineural deafness, osteoporosis and osteoarthritis which weaken the bones, cognitive impairments like Alzheimer's disease and dementia, heart failure, etc.), metabolic diseases (hypertension, coronary artery disease, stroke, diabetes), or environmental exposure (such as cancer and COPD), according to Dey.

“Older people commonly present to the health system with cognitive decline, frail health, increased risk of infection, heart attack, stroke, cancer, visual impairment, deafness, depression etc., in multiple numbers and combinations,” he said.

Government-funded health insurance is available under Pradhan Mantri Jan Arogya Yojana to the bottom 40% of the population. The Union government provides assistive devices to the elderly from the below-poverty-line category under the Rashtriya Vayoshri Yojana.

“Since 1999, after the adoption of the National Policy on Older Persons and the launch of the National Programme for Health Care of Elderly in 2010, initiation of the Integrated Programme for Older Persons in 2018, Ayushman Bharat and Health and Wellness Centers etc. were steps in the right direction in securing the welfare of older people,” said Dey.

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

A recent study of US veterans found that 10% of those diagnosed with dementia actually had a liver condition called hepatic encephalopathy, or HE – a treatable condition.

The liver can be damaged by several things, including alcohol, fatty deposits and hepatitis viruses. When the damage continues over several years, the liver becomes scarred (known as cirrhosis) and, at a certain point, can no longer perform one of its critical tasks: detoxifying the blood. Toxins (mainly ammonia) can build up and get into the brain, interfering with brain function. This is HE.

HE can be very mild and difficult to diagnose. Symptoms can be as subtle as changes in sleep pattern or irritability. As the condition worsens, symptoms such as forgetfulness, disorientation or confusion emerge. In its most severe form, it can cause coma and death.

Once diagnosed, it can be treated, initially with laxatives that help to remove ammonia and other toxins that accumulate in the gut. This is followed by treatment with an antibiotic (rifaximin) that kills some of the harmful ammonia-producing bacteria in the gut. If it is very severe, HE can even be a reason to have a liver transplant.

Silent condition

HE is easier to spot and treat if we know the person has cirrhosis. The trouble is that cirrhosis is a silent condition until it reaches very late stages when the liver starts to fail. HE is much harder to diagnose in the general population. The symptoms of change of mood, behaviour, confusion and forgetfulness are also all seen in people with dementia.

Dementia is a condition caused by long-term damage to brain function. This is most commonly caused by reduced blood supply to the brain because of damage to small blood vessels through diabetes or high blood pressure (vascular dementia). Other forms of dementia include Alzheimer’s disease, where deposits damage the brain causing typical symptoms of forgetfulness and confusion.

The new US study examined medical records of former soldiers treated by the Veterans Health Administration over 10 years with a diagnosis of dementia made on at least two separate occasions.

The team looked at clinical data including blood results from this group and used them to calculate an FIB-4 score (a score based on liver blood results and age), which can be used to predict liver damage. Over 175,000 people were included in the analysis. Of these, 10% (18,390 people) had a FIB-4 score of more than 3.25 (an accepted cut-off for the diagnosis of liver scarring).

The researchers found that a high FIB-4 score was more common in those with viral hepatitis and heavy alcohol users – risk factors for liver disease.

A high score was less likely in people who had diabetes, high blood pressure or kidney disease – all risk factors for dementia. This suggests that people with a high FIB-4 score may actually have liver disease with HE causing their symptoms rather than dementia.

The researchers went on to confirm these findings by looking at a separate group of people that were assessed for dementia at their hospital and found similar results, with 9% having a high FIB-4 score and potential cirrhosis.

This study suggests that around 10% of people diagnosed with dementia may instead have underlying silent liver disease with HE causing or contributing to the symptoms – an important diagnosis to make as HE is treatable.

New avenue

It is the first study of its kind to analyse routinely collected health data in this way. However, we should treat these results with some caution.

First, the data is from military veterans – 97% male and 80% white ethnicity – and hence not representative of the wider population. Second, FIB-4 was used as a marker of cirrhosis. It is a useful score that is easily calculated, but accuracy depends on the cause of liver disease and is lower in older people. Finally, having a high FIB-4 score does not necessarily mean that the person has HE.

This study opens an important new avenue of research. It raises the awareness of checking for liver disease in people with general symptoms of dementia. This is likely to be a growing problem as the rates of both dementia and cirrhosis are increasing. But we still need better data to fully understand the number of people with HE incorrectly given a diagnosis of dementia and how best to identify and treat them.

Ashwin Dhanda is Associate Professor of Hepatology, University of Plymouth.

This article was first published on The Conversation.

For six years, the Bodyline Multispecialty Hospital in Ahmedabad has been providing free dialysis sessions every month to over 600 patients. The hospital also pays Rs 300 per session for transport to these patients.

In return, the government pays the hospital Rs 2,200 per dialysis session under the Centre’s Pradhan Mantri Jan Arogya Yojana, a cashless insurance scheme for the poor that offers a cover of up to Rs 5 lakh for medical treatments. Bodyline Hospital empanelled itself under the scheme in 2018.

But, over the last two years, government reimbursements have been declining, said Dr Chintan Dwivedi, the hospital’s chief executive officer.

“Most of the patients in our hospital are beneficiaries of PMJAY,” said Dwivedi. “Only a small percentage are private patients who pay.”

With expenditures on dialysis machines, consumables and salaries remaining steady, Bodyline Hospital’s finances are under stress.

As of February 26, it is awaiting Rs 3.4 crore for procedures it conducted over the last three to four months under the Pradhan Mantri Jan Arogya Yojana.

“If we spend on 100 patients, we only earn back from, say, 30 patients,” said Dwivedi. “Financially, we can’t survive for long.”

Dwivedi’s challenge is not unique. In Gujarat alone, as of February 26, hospitals empaneled under the Centre’s insurance scheme are awaiting payments to the tune of Rs 300 crore from 2021 till July 2023. Some of the funds were cleared in the last one week.

Gujarat state officials, who did not wish to be identified, claim that the dues amount to Rs 120 crore since in some cases the treatment was never provided to beneficiaries.

Even so, the massive amount has forced at least 300 empanelled hospitals in Gujarat to form an association late last year and collectively push for recovery of the pending amount.

“Several hospitals are looking at shutting down services under the scheme,” said Dr Ramesh Chaudhary, spokesperson for the PMJAY Empanelled Private Hospital Association in Gujarat.

Chaudhary, who owns Mahadev Orthopedic and Cancer Care Hospital in Palanpur, said the delay in payments and rejection of claims had pushed him to the verge of bankruptcy and he was forced to shut down his intensive care unit.

The problem extends far beyond Gujarat.

On February 29, private hospitals in Haryana threatened to stop patient admissions under PMJAY if their dues are not paid by March 15. The state has 983 empanelled private hospitals.

The hospitals were owed Rs 200 crore, said Dr Dhirendar Soni, secretary of Indian Medical Association in Haryana.

Hospitals in Kerala, where doctors have approached the Kerala High Court, and Tamil Nadu have also flagged mounting unpaid dues under the scheme.

“Private hospitals under PMJAY are bleeding,” said Dr Jayesh Lele, secretary general of the Indian Medical Association, an umbrella body of doctors.

The delay in payments, hospital authorities told Scroll, is pushing them to reconsider admitting patients under the flagship insurance scheme.

PMJAY and funding

The Centre and state together fund PMJAY with the Centre taking responsibility for a greater share.

The state can implement the scheme through a trust, or through insurance companies, or using a mixed approach.

Most states appoint an insurance company as a third-party authority to settle claims for hospitals. For each beneficiary, the state pays the premium amount to the insurance company.

In return, the insurance provider has to pay the hospital where the beneficiary seeks treatment. In some states, like Kerala, the third party authority only scrutinises and approves the claims and the government makes direct payment to hospitals.

Of 31.5 crore Ayushman Bharat beneficiaries, 6.3 crore have received treatment across India as of March 1. The insurance scheme covers 1,400 medical procedures. Of the 29,811 empanelled hospitals across India, 12,631 are private hospitals.

When PMJAY was launched in 2018, small and medium-scale hospitals, which usually have a 10- to 25-bed capacity, hoped that there would be a large volume of patients under the scheme that would help them make some profit as well as treat the poor and needy.

But empanelment has pushed many hospitals into losses. “We spend most of our time chasing the government for payment,” said Chaudhary of the association of empanelled hospitals in Gujarat. “Most hospitals regret getting empanelled.”

At least 3,543 hospitals across India have not admitted any patient under the scheme since the last six months and another 6,551 hospitals have been inactive since their empanelment.

Gujarat hospitals

On February 13, the PMJAY Empanelled Private Hospital Association, Gujarat, warned of a symbolic protest from February 26-29.

The protest was called off after Union Health Minister Mansukh Mandaviya met Gujarat doctors and assured them that the dues will be paid. Only Though some of the dues have been cleared, and hospitals are now considering discontinuing their empanelment.

According to the association, hospitals had been following up on unpaid dues with the state government for more than a year.

The owners of multiple hospitals told Scroll that there have been two problems since 2021: delay in processing of claims and multiple rejections or deductions in payments.

Chaudhary, the association’s spokesperson, said that before a patient undergoes a surgery, they submit documents for approval from the state and the third-party authority, which is usually the insurance company. This process is online.

Once the approval comes through, the surgery has to be conducted within 30 days by private hospitals and 60 days by public hospitals. According to the scheme, the hospital has to be paid within 15 days of the surgery. But data from Gujarat shows only 5% of payments are made within that timeframe.

“The patients are treated for free under the cashless service,” Chaudhary said. “But if, after their discharge, the TPA [third-party authority] rejects our claim or deducts amount, there is nothing we can do.”

Chaudhary was referring to instances where the third-party authority makes deductions before releasing the final payment on account of minor discrepancies in paperwork.

The payment process is offline, said Chaudhary, which means that it cannot be tracked on any portal. In 2021, Gujarat had appointed Oriental Insurance Company as the third party authority. In 2023, the state government appointed Bajaj Allianz. The insurance company did not respond to an email and a query about the high rate of rejections.

Arbitrary rejections

Hospitals have highlighted that insurance companies frequently reject claims due to minor reasons.

“They say the admission and discharge date don’t match on documents, or some document is missing, or there is some clerical error,” said Mulesh Bhati, owner of Manavta Hospital in Faridabad. Bhati said the hospital appeals against the decision with district authorities, “but they don’t do anything”.

Manavta Hospital’s claims worth Rs 60 lakh have been rejected since 2018, said Bhati. The hospital admits 70 to 80 patients under the scheme per month. “Slowly, we have been forced to reduce the number of patients we admit under PMJAY,” he said. “I got my hospital empaneled to serve the poor, but it is difficult to sustain.”

In multiple cases, insurance companies provide approval to conduct a patient’s surgery but deduct payments later, citing errors in documentation or lack of certain documents.

There is a grievance redressal mechanism under which hospitals can approach a nodal officer in the health department. But district or state officials have not been proactive in dealing with these complaints.

Comprehensive and saturation coverage of #PMJAY in every village & town under Ayushman Bhav Campaign!

Launched on 17 Sept, the campaign has reported-

➡️ Ayushman Card - 7 Crore+
➡️ Total Footfall - 17 Crore+
➡️ Ayushman Sabhas - 1.19 Lakh+
➡️ ABHA Card - 11 Crore+#AyushmanBhav pic.twitter.com/Ee8QAXu7V4

— National Health Authority (NHA) (@AyushmanNHA) February 26, 2024

Hospitals put brakes on PMJAY

Hospital admissions under PMJAY had increased sharply across India since mid-2021, but have declined since. Data from the portal shows that hospital admissions decreased from 13.16 lakh in October 2023 to 6.4 lakh in November 2023.

The decrease, several hospitals told Scroll, is due to a frustrating wait for the recovery of claims. In at least 10 states, for more than 50% of the cases, it takes longer than 45 days to settle claims.

In Haryana, several hospitals said they have limited or stopped patient admission under the scheme because of the delay in the disbursement of funds.

Pawan Hospital, a 55-bed facility in Faridabad, empanelled itself under PMJAY in 2018. The hospital’s chief executive officer, Madhav Gadasiya, said around Rs 5 lakh is pending for surgeries done in the last three months. “We have reduced (PMJAY procedures) to 10 in a month,” said Gadasiya.

“For every surgery, we pay the doctor immediately,” he said. But it takes months for us to recover that cost from the government.”

In addition to the delayed payments and rejected claims, the low cost of treatment packages under the scheme, set by the government, is adding to the financial problems of hospitals.

“The scheme is mostly supported by small and medium-scale hospitals,” said Dr AK Ravikumar, chairman of IMA Hospitals Board of India. “If the government does not increase the rates or make timely payments, these hospitals will find it hard to survive.”

Gadasiya of Faridabad’s Pawan Hospital said the fixed rates are already low and further deductions from the final claim makes it impossible to earn any profit.

Fund allocation

Doctors and hospital owners said the poor financial management of PMJAY has resulted in these problems.

Ravikumar said a major reason why PMJAY is failing in multiple states is “a mismatch in demand and outflow”. “The budgeted allocation is less than the required demand and even that allocation is not fully utilised,” he told Scroll.

The government’s yearly records reflect what Ravikumar says. Last February, the government allocated Rs 7,200 crore for 2023-’24 for PMJAY, but revised it to Rs 6,800 crore by this year.

In 2022-’23, the budget for the scheme was Rs 6,412 crore. But for nine months of 2022, the government had released only 18% of the funds. Though allocation is high, spending remains low. “This is a good scheme on paper,” said Ravikumar. “But financial management is poor.”

Chaudhary, of the association of Gujarat hospitals, said it appears that the government “does not really intend to spend on the scheme”.

Data from the Kerala Private Hospital Association shows that private hospitals in the state are owed over Rs 400 crore under PMJAY. Last month, the association filed a writ petition in Kerala High court demanding payment of the dues. “We have been made to understand that the government has absolutely no funds for PMJAY,” advocate Hussain Thangal, who is representing the association, told Scroll. “For public hospitals, the pending dues could be over Rs 1,000 crore,” he said.

Forty-two private hospitals have removed their names from the scheme in the last six months in Kerala, Thangal said.

In Thiruvananthapuram, Sree Gokulam Medical College and Research Foundation is waiting for a payment of Rs 5 crore. “The amount is pending for the last six months,” said Anant Kumar, the hospital’s public relations officer.

“When we signed the MoU with the government, it stated payments will be made within 15 days of surgery,” he said.

Kumar said the hospital empaneled itself under PMJAY to serve the poor. “We don’t expect huge profits,” said Kumar. “But at least don’t reject our claims and pay us on time.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

In 2009, an article in Monthly Index of Medical Specialities drew attention to a psychiatric drug from Denmark being sold in the Indian market.

In the article, the editor of the journal, Dr Chandra Gulhati, pointed out that India’s drug regulatory authorities should never have approved the sale of the drug, Deanxit, for a simple reason – the medicine was prohibited for sale in Denmark itself.

This was a violation of India’s Drugs and Cosmetics Act, 1940, which says that a drug can only be imported in India if it has been approved for sale in the home country.

In 2013, the Union health ministry banned the sale of Deanxit, which was a fixed dose combination of flupenthixol and melitracen.

Though the Danish manufacturer, Lundbeck, moved court against the order, it eventually wound up its operations and left India in 2021.

But 10 years after the ban, the combination of flupenthixol and melitracen continues to be sold by at least 10 other companies in India under various brand names. This is the story of how gaps in India’s drug regulatory system and legal hurdles made it difficult for drug regulators to remove a contested drug from the Indian market.

No clinical trials done

A fixed dose combination, or FDC, combines two or more drugs to treat a particular ailment. Each of the drugs in a fixed dose combination have a certain role to play in treatment. In the case of Deanxit, flupenthixol acts as an anti-psychotic drug and is used to reduce anxiety while melitracen is used to regulate the mood and reduce depression.

Psychiatrist Dr Soumitra Pathare says he is not convinced of melitracen’s ability to work as an anti-depressant. While flupenthixol has been approved for use in India, melitracen has not. “If out of the two, melitracen is not really effective, why will I prescribe it to my patients?” he asked.

Under the Drugs and Cosmetics Act, 1940, a new drug can be approved in India only after it has undergone stages of clinical trials to check its efficacy on the Indian population.

As a report of a parliamentary standing committee noted in 2012, since melitracen had not been individually approved earlier, any fixed drug combination in which it is used would be considered a new drug and needed to be tested in clinical trials.

Did that happen in the case of Deanxit?

When the parliamentary committee asked the health ministry about this, it drew a blank. In its report, the 59th parliamentary committee noted, “Except for giving file number (12-62.95- DC) and the date of approval (28-10-1998), the Ministry failed to provide any documents and information on the regulatory process that led to its [Deanxit’s] approval.”

Lawyer Prashant Reddy said the process by which Deanxit was approved for sale on the Indian market was itself suspect and based on incomplete information. “Clinical trial studies give credibility to a drug. But a high quality study remains missing for this fixed dose combination,” Reddy said.

More importantly, clinical trials needed to be conducted to find out if the fixed drug combination was effective for each indication it would be prescribed for.

Deanxit was marketed for psychogenic depression, depressive neuroses, masked depression and psychosomatic affections, but neither did the drugs controller general of India, who heads the Central Drugs Standard Control Organisation, look into such trial data nor did the company submit it, as two parliamentary committee reports pointed out.

Denied approval in most countries

In May 2012, the 59th parliamentary standing committee submitted a scathing report on the function of the Central Drugs Standard Control Organisation.

The approval for Deanxit figured high on the list of the irregularities.

The committee strongly criticised the drug authority for allowing Deanxit to be sold in India. The lack of clinical trial data was just one of the many reasons it cited.

Under rule 30B of the Drugs and Cosmetics Act, 1940, the import and marketing of any drug that is prohibited in its country of origin is banned in India. The report found that Deanxit was being imported and marketed despite this provision.

The committee also flagged what Gulati had pointed out – that Deanxit was approved only in 23 countries, all with poor drug regulatory systems. “Countries like the USA, Canada, those in the European Union had not approved it,” Gulati told Scroll.

The committee also said that it was “strange that the manufacturer is concentrating on tiny markets in unregulated or poorly regulated developing countries like Aruba, Bangladesh, Cyprus, Jordan, Kenya, Myanmar, Pakistan, and Trinidad instead of countries with far more patients and profits”.

In Lebanon, a study of 125 patients using Deanxit found that 36% suffered from Deanxit-use disorder, that is, they became addicted to the drug. The study observed that most patients in Lebanon “were prescribed Deanxit by their physicians but reported inadequate knowledge of its side-effects and risk of abuse”.

In India, no such studies have been undertaken, though doctors who prescribe it say their patients have not reported any adverse events.

An investigation, and a statement

In March 2013, following the parliamentary committee’s recommendation, the Drug Controller General of India formed an expert committee to investigate the approval process of the drug.

But a month later, the inquiry appeared to hit unexpected roadblocks.

The health ministry issued a statement stating that there were no violations in its approval. It quoted data submitted by a psychiatrist named Dr Udayan Kasthigar from Lady Hardinge Medical College in Delhi from a study that found flupenthixol and melitracen effective on depressive disorders. No data on the patient sample size or control group was provided. This was not even a clinical trial.

The government said it had based its approval on the findings of this study. The study data was submitted in August of 1998, and the Drug Controller General of India approved Deanxit quickly two months later.

Surprisingly, the expert committee appointed by drug controller to investigate the approval advised Lundbeck, the Danish manufacturer of Deanxit, to submit a proposal to conduct Phase IV clinical trials to establish the safety and efficacy of the drug. It did not recommend any action at that point and also ignored the omission of Phase I, II and III trials within India.

‘A strong whiff of collusion’

But while the health ministry officially defended its stand of approving the fixed dose combination internally it was reviewing the process of its approval.

The New Drug Advisory Committee, an arm under the CDSCO that advises the body on new drugs and clinical trials, held a meeting in March 2013 to discuss flupenthixol and melitracen. It pointed out that melitracen was “not efficacious as a single agent in depression” and flupenthixol had “potentially serious neurologic side-effects”.

The committee questioned the need to continue its marketing in India.

In April 2013, a second report by a parliamentary committee (called the 66th report on Health and Family Welfare) observed that the “case of Deanxit conveys a strong whiff of collusion and cover up”. This report came a year after the 59th parliamentary report and found that despite “an open and shut case that needs immediate action”, the government failed to take any action.

The parliamentary committee said that while the DCGI set up an expert committee to recommend action in case of Deanxit, no action was ever recommended and the ministry never followed up.

Like the previous report, this too raised red flags over the lack of clinical trials. It said that melitracen should have undergone phase-wise clinical trials in at least three to four sites and covered 100 patients. “Such trials were not conducted,” the report said.

The report said it was “strange” that drug controller approved the drug based on a vague study by a psychiatrist of Lady Hardinge.

The parliamentary committee recommended action against CDSCO officials who approved the drug and to reverse the approval given to Lundbeck to market and sell the drug in India.

Bans and stay orders

Finally, a month later, the Drugs Technical Advisory Board of CDSCO recommended a ban on the drug. The move led to a long-drawn legal battle.

The Danish manufacturer, Lundbeck, approached Karnataka High Court and argued that the government had not given it a chance to present Phase IV trial data. Phase IV trials are carried out only after a drug has been marketed and sold in the country. The court observed that annually 63 lakh prescriptions had been made for flupenthixol and melitracen and called the ban a “knee jerk reaction”. Three months after the first ban, the court struck it down.

The court also asked the government to allow Phase IV trials. Over the next one year, the DCGI found multiple gaps in the Phase IV trial proposal submitted by Lundbeck and asked for changes.

In 2014, the government again announced a ban on flupenthixol and melitracen. This time it took three years to get the ban revoked. In December 2017, based on a joint petition by Mankind, a pharmaceutical company that had also begun to manufacture the fixed dose combination, and Lundbeck, the Karnataka High Court set aside the drug controller’s order and allowed the companies to restart manufacturing.

In 2018, activist Dinesh Thakur filed a petition in the Delhi High Court seeking a ban on this drug and two other drugs over safety concerns.

In 2019, the drugs technical advisory board, an arm of CDSCO that gave technical advice to the government on Drugs and Cosmetics Act, formed a sub-committee to examine flupenthixol and melitracen. A member of this committee, requesting anonymity, told Scroll that the fixed dose combination’s approval did not follow the necessary protocol and “ideally it should not be marketed until all clinical trials had been done”.

“Even our hands are tied because of the court order,” the member said.

Finally, after delaying the approval for a trial for eight years, in June 2021, the DCGI granted Mankind the permission to conduct Phase IV clinical trials on the FDC. This happened despite several committees constituted by the government recommending a ban on the drug.

The Fixed Dose Combination problem

The case of the flupenthixol and melitracen combination is emblematic of India’s larger failure to regulate fixed dose combinations.

In an article, health activist Dinesh Thakur and lawyer Prashant Reddy state that since 1983, India has issued 444 orders under Section 26A of Drugs and Cosmetics Act to ban drugs, most of them fixed dose combinations like Deanxit. This section allows the government to ban a drug in public interest.

But many of these orders, like in the case of flupenthixol and melitracen, remain entangled in litigation. Meanwhile, their sale continues.

Experts point out that several pharmaceutical companies introduce fixed dose combinations to price their product higher than available individual drugs, but the combination may not necessarily have better efficacy in certain cases.

To counter this practice, in 1982 the Indian government introduced a provision to prohibit such fixed dose combinations if they lack therapeutic value or efficacy in treatment.

“The problem is that the government strategy is completely wrong when it comes to fixed dose combinations,” said Reddy. He said that the government hardly went into an appeal if a local court or high court set aside their order to ban a particular fixed dose combination.

KL Sharma, former joint secretary in the Union health ministry between 2014 and 2017, said in his tenure fixed dose combinations were reviewed by a specially formed committee that recommended a ban on 349 of them. “In most cases, we found that no proper clinical trials were conducted and they were being marketed illegally,” Sharma said.

The government banned all 349 fixed dose combinations in March 2016, which led to over hundreds of court cases across India during his tenure. “All these cases were transferred to the Supreme Court which asked the government to reexamine the ban,” Sharma said. “After three years, the government again banned the FDCs. The companies again went to court.”

Sharma claimed that the courts lack the “competency to look into the technical and scientific nature of such cases”. “And the government should have gone into an appeal [in these cases] which it did not,” he added. In case of Deanxit, too, the government made no appeal against Karnataka High Court’s order.

Scroll sent questions on the approval process of Deanxit and the continued sale of the flupenthixol and melitracen combination in India to the Union ministry of health and the Central Drugs Standard Control Organisation. The story will be updated if they respond.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.

“I don’t want to imagine a world without him,” a mutual friend said to me when she learned of Arif’s stage-four cancer. I knew exactly what she meant. It wasn’t the prospect of losing someone close to us that startled her but the idea that someone with his way of being, the empathetic sharpness that defines how he relates to the world, would soon be gone. Arif is like a velvet mirror, reflecting the world in its full complexity, yet rounding off its sharp edges. What happens when we are only left with mirrors made of glass, with their coolly accurate representations that make it harder for us to see the unity behind the seemingly disconnected pieces of our torn social fabric?

Many people feel their friends are extraordinary. Perhaps it’s a way of making ourselves feel special. Perhaps it’s a natural response to learning of a friend’s terminal illness, a way to find meaning in the face of the absurdity of an untimely death. Perhaps this essay too is just an attempt to process grief. Still, I’ve never met anyone quite like Arif and I doubt I ever will.

My first memory of him is at a bar in Lake District, leaning casually against the counter, holding a glass of water. It was late autumn, the intense yellow of the afternoon sun penetrating the room and throwing a shadow on Arif’s face. We were at a retreat for Gates Cambridge scholars – a scheme much like its older cousin, the Rhodes scholarship at Oxford – and the room was buzzing with highly accomplished people looking busy and sounding distinguished. Arif was different. His slightly crouched shoulders and gentle smile indicated he was more approachable than the rest of the crowd. When he listened, he didn’t interrupt, and when he looked, he looked straight in the eye. He was present.

Living in the moment is what we talked about years later, as we sat inside Arif’s Georgian apartment in Bath, overlooking the Somerset hills. By then, we had both finished our doctorates and started in our university posts. Arif was 41 and had been fighting cancer for three years. Even though he had only just launched his academic career as a social scientist studying inequality and poverty after two decades of studies and hard work, he only had one or two years to live according to his doctors. Crippled by chemotherapy, he was increasingly unable to teach or do research. His academic career was brought to a standstill and his attention was firmly fixed on every passing moment.

He was first diagnosed in April 2020: ampullary cancer, affecting the spot where the pancreatic duct and bile duct join and empty into the intestine. It is a rare condition, afflicting about one in 2.5 million people, because of which research is limited, treatment options scarce and survival rates low. Arif was diagnosed early enough for his doctors to try to remove the tumour, and in May, he underwent the Whipple procedure, a seven-hour highly invasive and dangerous operation that involved removing part of the pancreas, bile duct, gallbladder and duodenum. It was successful. Six months of chemotherapy followed to make sure the cancer was gone. At the end of it, he was barely recognisable – his skin was clinging to his bones and the sparks from his eyes were gone. But at least he survived and the cancer was in remission. A year and a half later, in September 2022, it came back with a vengeance and spread to his lungs. This time, there was little the doctors could do. Arif enrolled in a clinical trial at Oxford for an experimental treatment that may or may not help. It was a Hail Mary.

What does it mean to be a good friend to someone facing untimely death, someone at the precipice simultaneously of a promising academic career and of a personal tragedy? The best answer I could come up with was to try to help Arif tell his story, to try and put words to the wisdom I saw in him. And so as we sat in his living room every other Sunday afternoon – the mid-point between his chemotherapy cycles when he had the most energy – I tried to trace his story full of improbable events and unexpected turns.

Narrating time

Becoming a senior lecturer in an elite British university was an incredibly unlikely feat. Arif was born in Nooran Abreind in the Muzaffargarh district of Pakistan’s Punjab province to a village schoolteacher of little means and even fewer connections. His father was the first person in the family to receive any education, and he worked hard to create more opportunities for Arif and his seven siblings. This was no easy task in an area with no electricity and the nearest road a two-hour walk away. Arif’s parents wanted him to become a doctor, but he had other ideas. “By that time, I had been reading enough literature, especially lots of Urdu classics that I would somehow get access to in that village, and also cheap fiction, so I got way more interested in human experiences,” he told me. “Human conditions were much more fascinating to me than their anatomy or pathology.”

We certainly had that in common. I found myself immersed in a kind of sad fascination with Arif’s predicament, looking for answers to increasingly dark questions. Why is this story so absurd? Is his tragedy a metaphor for the futility of the world’s quest for equality, the universe’s way of showing a middle finger to those who try to beat the odds stacked against them? And what of the decades of research Arif was hoping to do? Will his unfinished agenda be a hole in the world’s knowledge of itself, or will someone else step in and fill it? But then again, isn’t the whole point of Arif’s work that the lived experience it is grounded in has been experienced by very few academics?

“You’re a lecturer who has carved out a career by walking on thin ice as you sought to bring insights from your past experiences into academia,” Arif said to me when I asked him that last question. “And then you suddenly don’t have time to bring it all together, to pursue any of the tasks that you set for yourself. Then who are you? You struggle to recognise yourself.” For a moment, Arif’s soft-spokenness was gone, and I thought I detected a tinge of anger in his voice. “And, when everything that you built was really around that now abruptly fading idea of the self that you pursued for so long, how would you relate to everyone else around you?”

In our conversations, Arif referred to Muzaffargarh, his birthplace, as a “middle of nowhere”. As a member of the British intellectual elite, he was now in the middle of it all (Britain, after all, likes to think it’s still the centre of the world). But I wondered if he found himself in “the middle of nowhere” not in space but in time. With his future taken away from him, the past, which was all about reaching a goal that now seemed out of reach, no longer made sense.

It is an academic’s job to make sense of the seemingly nonsensical, and so Arif did: “Our identities are heavily shaped by our understanding of time. Our sense of the present is deeply rooted in our recollection of our past.” And as he pointed out to me, speaking as much from the experience of proximity to death as he did with his academic hat on, we are guided by our ambitions for the future when we pick the memories we hold on to and the ones we consign to our personal ash heaps of history. Letting the “mundane” fade while focusing our attention on our preferred stories, we build a bridge between our past, present and future. But what happens to all those memories if one day we realise we simply have no future?

Sometimes we don’t have a choice but to cast them aside, as Arif found out in his hospital ward: “As life got reduced to the task of living one day at a time, or even one second at a time, my eyes and thoughts were fixated on the drops coming from the drip into my veins, because everything else was not any more bearable than the chemo… When the scale of time is reduced to that, then of course you cannot carry the burden of those grand narratives that you once constructed. You just go calm. That’s what your body is doing, anyway.”

Honourable place

It was strange to hear Arif speak of shouldering grand narratives – if anything, he had spent much of his life shattering them, I thought. As a young man, having performed off the charts in school and resisted the pressure to become a doctor, he found himself studying economics at Quaid-i-Azam University in Islamabad, and went on to work on rural development projects across Pakistan. He then pursued an influential career as a policy analyst, contributing to various national reforms. Although the work was initially fulfilling, it soon started to feel off. When I asked Arif to explain what seemed wrong, he told me about research studies that he worked on with a number of colleagues, including mentor Geoff Wood, a professor of international development in the UK, which raised the “architects and contractors” dilemma. One of the studies looked at research into the role of Pakistani think-tanks in shaping debates about international development. Unsurprisingly, it concluded that it was the West and its powerful institutions – the World Bank, the International Monetary Fund, the United Nations and bilateral aid agencies – that called the shots. The Pakistani think-tanks didn’t get paid to think but to advocate policy designs made thousands of miles away. “And suddenly I realised that I was not really the architect of the change I thought I was inducing,” he said. “I felt like I was merely a contractor. And it was not the honourable place to be in.” So Arif left the world of development and became an academic.

Arif’s honourable place is not a place of relentless critique, virtue signalling or showing off his command of fancy academic words. It is a place of seeking the truth, and the truth begins with the poor themselves. “When it comes to the poor, their lives are often reduced to statistics, and their narratives to factual accounts,” Arif believes. When I first heard him make similar comments, I found it refreshing: here is an economist who understands that people are not numbers. Over the years I have known Arif, I have seen him lean into this position with ever more vigour. During our years at Cambridge, I saw him pour through seven decades of longitudinal data from Pakistan to understand whether the mass expansion of schooling since World War II helped to stop poverty passing from one generation to the next. He would then travel to far-flung regions of the country to listen first-hand to the stories behind the numbers. Baffled with the complexity of these stories, he went on to develop a nuanced approach to listening to the voices of the poor. The goal was to neither romanticise nor pathologise poor lives in revealing their power in everyday struggles against oppressive structures. With the help of his doctoral supervisors – Professor Madeleine Arnot and Professor Anna Vignoles – he was trying to combine breadth with depth in a way I had never seen anyone else try with quite so much verve.

There are generally two kinds of scholars who study poverty: those who work with charts, tables and formulas, and those who think about stories. The numerati claim to have the full picture and so they tend to have the ear of the politicians and the media, while the narrative-wallahs are often consigned to the margins (unless they are good wordsmiths and manage to turn stories into bestsellers). Arif’s search for the honourable place led him to transcend this divide, to put the aim before the method, and integrity before going with the flow. Arif no longer refers to himself as an economist. He is simply a scholar of poverty and inequality, a maverick social scientist who does not adhere to norms and expectations of “the field”, whatever that means.

When I learned of Arif’s diagnosis, I felt pangs of my own quest for the honourable place, for trying to do the right thing. I knew our time was limited and I felt the pressure of wanting to get to the heart of this story before it was too late. So I pushed harder: “Tell me one thing. There are loads of people working on poverty out there. Many of them grew up in poverty. Many of them talk to poor people. What’s different about your approach?” I was bracing myself for a very technical answer but Arif responded as a human being. “We cannot fully empathise with people we don’t know – and know not just as academic constructs, but at a deeper personal, emotional, relational level,” he said. “We can’t wish away our positionality as researchers.” He sees the poor – that huge, faceless, voiceless category of people to be ‘reformed’ and ‘saved’ – as individuals with a face, with a voice, with agency, with wisdom. “I mean, without empathy, which is inherently tied to our own experiences and journeys, how could we even ask the right kinds of questions?” Arif said to me, before closing his eyes and taking a long pause, after which we called it a day, for he had no more energy to talk.

Wellsprings of empathy

As our conversations progressed, Arif lost much weight. He also lost his hair, his appetite and the ability to button a shirt due to nerve damage in his fingers caused by chemotherapy. But he never lost his sense of humour and optimism. It wasn’t a pose, an attempt to hold it together for the sake of family and friends. The nonchalance with which he spoke about dying betrayed a reservoir of experience. He was no stranger to death and he didn’t take it for granted that he managed to stick around into his forties. This, undoubtedly, had something to do with empathy being so central to his way of being.

Arif grew up in the 1980s, the decade of Zia-ul-Haq’s military dictatorship in Pakistan and a bloody war. “The Cold War project was what valorised Islamic Jihad against the Soviets in Afghanistan and it deeply penetrated Pakistani society, given the military dictatorship’s need to legitimise its own power,” Arif told me. This played out in everyday life through sectarian violence and extremism. “Unfair death was all around me, and I felt that most of the time I had narrow escapes.”

One such narrow escape is forever etched in Arif’s memory. As a 17-year-old college student, he woke up one day to the sound of gunfire coming from a nearby Shia mosque. Twenty-two worshippers who were inside at the time of the attack were slaughtered. Arif knew all of them (in a small town, everyone is more than a neighbour, as he put it). Two of the victims were brothers who were in Arif’s circle of friends – they studied in the same college, took the same bus and played cricket together. No group ever took responsibility for the attack, and though arrests were made, the suspects were soon released and the seeds of distrust were forever sown in the community. “While of course it was a tragedy, there was also this sense of gratitude of just being alive, of just surviving another event,” he said. In a way, the cancer too was simply just another event.

Perhaps it was the relentless violence in the age of terrorism and the subsequent Global War On Terror, perhaps it was curiosity or maybe it was the beginning of a quest for higher meaning that led Arif to Sufism. As a teenager, he was invited to join a spiritual gathering in a neighbouring town. The procession was led by a man in his 80s, who had renounced worldly pursuits, dedicated his life to prayer and service, and represented a very different model of Islam from the radicalism of the era. “Khidmat mein Khuda milta hai”, you find God in serving his creation, he would tell Arif while introducing him to basic tenets of Sufism. Fascinated, Arif spent much time with him over the following year, learning about his spiritual beliefs and joining him in acts of service. Arif would serve food and clean after the poorest in the community, and be served by people far more privileged than him. “The more privileged you were, the more service was expected of you,” he recalled. These experiences taught Arif that there was nothing natural about the deeply unequal social order around him. He grasped the arbitrariness of privilege and came to see service as a path to social harmony, an antidote to violence and poverty both. Years later, Arif would hear echoes of these messages in lectures by his economics teacher and mentor Professor Asad Zaman who tore apart neoclassical economic theory, helping Arif see that God’s creation could be served through a different kind of economics.

Listening to these stories helped me understand some of Arif’s unlikely choices. In the final year of his PhD, he joined Britain’s first intergenerational housing scheme, where he socialised with people in their 70s and 80s. He would spend up to 20 hours a week organising potlucks, birthday celebrations and excursions to Cambridge’s mediaeval colleges. Most doctoral students in their final year would never dream of making such a commitment. In the cut-throat world of elite academia, any time spent volunteering is time not spent writing an article for a prestigious journal or chasing that dream tenure-track job. But Arif’s instinct was to get involved and it paid off. Halfway through the scheme, the team learned that hospital visits by people living in the intergenerational house fell dramatically, an irony not lost on Arif, who would find himself practically living in the hospital only two years later. “In retrospect, living in the old home also taught me to come to terms with fragility, vulnerability and dependency that I had to confront far sooner than I thought,” he told me.

The unfinished agenda

The more Arif and I talked about his life, the more I realised that becoming an academic was not a matter of personal ambition to him but a vocation, a culmination of a lifetime of gentle learning in a harsh world. This only magnified the sense of impending loss. Like the rest of the world, academia is getting more polarised by the day: liberal activist scholars who are often better at shouting than listening are pitted against conservative thinkers relying on colonial, elitist methods, as a silent majority looks on, burying their heads in the sand. The neoliberal university adds up to a kind of Hieronymus Bosch painting, a hellscape of disconnected elements, where someone like Arif is exceedingly rare, not just for his ability to tackle messy, polarising subjects with nuance and grace but also for the originality of his thought. It turns out that when you seek the truth, rather than the approval of whichever camp you supposedly belong to, you actually come up with new ideas.

But what good is all that when you cannot do research, write or teach? For academics, productivity is everything. “There is no comparison of what I felt I was up to doing three years ago and now,” Arif said to me with a heavy sadness. “I sit down and write just one paragraph or compose one email or attend just one meeting, and then I am done for the day.” I really felt for him. For an original thinker, the only thing worse than being stuck on the publish-or-perish hamster wheel is being left out of the world of ideas entirely. And so, as our conversations progressed, I started gently steering us towards the most painful subject of all: what was Arif planning to do with the three-odd decades of the academic career he once thought he had in front of him?

He had no prescriptions, no silver bullets for ending poverty. What he did have was a method and a deep understanding of the development machine. In our conversations, we spoke of intergenerational poverty, longitudinal studies, ways of capturing and amplifying the voices of the poor. But I came away thinking that his most significant unfinished agenda was something bigger: to make slow research more central to the study of poverty.

Slow research is what it says on the label – slowing down, taking our time. Some academic disciplines have a long tradition of slow research. Anthropologists, for example, can spend years immersed in a community of people to try to understand the culture shared among its members. But poverty researchers, many of whom are economists, tend to work much faster. On the face of it, this is justified by the urgency of the issue, the need to act quickly where human lives are at stake. But lurking beneath the surface is a set of assumptions – about who the poor are, what they need, what kind of a future awaits them – that many researchers take as a given. As Arif put it, “Most of the time, the people driving action on the ground are trying to construct a world rather than understand a world.” His idea is that if we slow down, we might have a shot at grasping what we are dealing with before we intervene.

The true academic’s foremost role, Arif believes, is to actually understand what a social reality is. Having lived experience of that reality helps. This doesn’t mean that every poverty researcher needs to have lived in poverty to comprehend it. Still, the lived experience does make a difference. When I pressed Arif on what the difference is, he went quiet for a moment, then said: “I do not have a preconceived answer – I think there was an answer to come later through the work I planned to do. So maybe that’s part of the unfinished agenda.”

The sadness in his voice betrayed a deep disappointment at being unable to do more, almost as if the cancer was his fault. Our culture feeds us the idea that when we lie on our deathbed, we ought to be able to look back at a lifetime of individual achievement. But meaningful change takes countless people, nameless individuals who together shift the needle. When I listened to Arif speak about his unfinished agenda, I could not help but think that he was not just a victim of cancer. He was also a victim of a toxic performance culture that cared more about what he hadn’t done than what he did do, a culture that denies a good death to those who have lived a good life.

The peace within

But cosmic scales don’t operate according to human culture. During our student years at Cambridge, Arif and I would often talk about our romantic pursuits. We both thrived in the world of ideas but we also hoped to find love. And in between the surgeries, the endless chemotherapy sessions, the trips to the emergency room and the sleepless nights, Arif did.

If Arif is an unlikely academic, Sana is an unlikely wife. She had come to London to study education and peacebuilding after years teaching at a girls’ college in Waziristan, a region at the Afghan-Pakistan border torn apart by the War on Terror. The two met through a mutual friend just before Arif first got diagnosed with cancer. Months later, I sensed the internal conflict within him: as much as he yearned for love, he thought it unfair to share the burden of his illness with a potential partner he had just met. While he could not move on from his cancer, she could, and he wanted her to. But Sana had other ideas.

Arif was visiting his family in Pakistan in September 2022 when he received the fateful call from his doctor telling him the cancer came back. In those very moments, he got a call from Sana, who was in the UK, and told her the news. I never thought to ask him what exactly happened during that phone call. It felt too personal a question. All I know is they soon decided to get married with the blessings of their families. Arif got on a plane to Mecca where he did his Umrah – the non-compulsory pilgrimage that, unlike the Hajj, can be done any time of the year – and Sana boarded a plane in London with the same destination. Their families found them an imam who performed their nikah and returned to England together. Next time I saw Arif, he was a married man.

His attention shifted from grieving what wasn’t to celebrating what was. He spoke to me of the joy of walks without a destination through the serene Mendip Hills in his backyard, the delight at catching up with old friends, the fun of experimenting with new recipes in the kitchen. Ever the scholar, he tried to wrap his head around this transformation, and told me that perhaps his old life was “full of this whole bullshit”. When I asked him what he meant, he answered that “the actual everyday experience, the mundane interactions with the people I was working with, maybe that was the actual real life and everything else was an illusion”.

It seemed that Arif found a new way of narrating time. In one of our conversations, he told me about just how destabilising it can be to have one’s image of the future shattered the way his was. The loss of the future makes survival in the present so very hard. “Coping with that struggle in the present pushes you back into the past,” Arif asserted. “You re-think certain moments, certain stories of the past to recalibrate them with the present. That’s an incredible human kind of possibility, of creativity that gives us resilience. This struggle between the present, the past, the future, has helped us survive for millions of years.” Had he said that in our first conversation, I would have thought of it as some academic hypothesis, the stuff of psychology research. But seeing the transformation in him over the months as his cancer progressed and his conception of the past and the future changed, I understood exactly what he meant – the paradox of inner peace being possible through inner struggle.

In our last interview, the possibility of Sana and Arif having children came up. I asked Arif what he would have wished to pass onto his child if they decided to start a family. He took a deep breath, looked into the distance, thought for a few moments, then spoke with unexpected confidence: “I would tell them that as human beings, as individuals, we are capable of a lot. A lot. But that requires a lot of hard work. You should dream high, but you need to be willing to pay the price.” The price Arif paid was a heavy one, but seeing him there in his living room, the rolling hills outside the window, Sana next to him, I thought he had fulfilled dreams he didn’t even know he had.

Dementia is a progressive loss of cognitive abilities, such as memory, that is significant enough to have an impact on a person’s daily activities.

It can be caused by a number of different diseases, including Alzheimer’s, which is the most common form. Dementia is caused by a loss of neurons over a long period of time. Since, by the time symptoms appear, many changes in the brain have already occurred, many scientists are focusing on studying the risk and protective factors for dementia.

A risk factor, or conversely, a protective factor, is a condition or behaviour that increases or reduces the risk of developing a disease, but does not guarantee either outcome. Some risk factors for Alzheimer’s disease and dementia, such as age or genetics, are not modifiable, but there are several other factors we can influence, specifically lifestyle habits and their impact on our overall health.

These risk factors include depression, lack of physical activity, social isolation, high blood pressure, obesity, diabetes, excessive alcohol consumption and smoking, as well as poor sleep.

We have been focusing our research on the question of sleep for over 10 years, particularly in the context of the Framingham Heart Study.

In this large community-based cohort study, ongoing since the 1940s, the health of surviving participants has been monitored to the present day. As researchers in sleep medicine and epidemiology, we have expertise in researching the role of sleep and sleep disorders in cognitive and psychiatric brain aging.

As part of our research, we monitored and analysed the sleep of people aged 60 and over to see who did – or did not – develop dementia.

Sleep as a risk or protective factor

Sleep appears to play an essential role in a number of brain functions, such as memory. Good quality sleep could therefore play a vital role in preventing dementia.

Sleep is important for maintaining good connections in the brain.

Recently, research has revealed that sleep seems to have a function similar to that of a garbage truck for the brain: deep sleep could be crucial for eliminating metabolic waste from the brain, including clearing certain proteins, such as those known to accumulate in the brains of people with Alzheimer’s disease.

However, the links between deep sleep and dementia still have to be clarified.

What is deep sleep

During a night’s sleep, we go through several sleep stages that succeed one another and are repeated.

NREM sleep (non-rapid eye movement sleep) is divided into light NREM sleep (NREM1 stage), NREM sleep (NREM2 stage) and deep NREM sleep, also called slow-wave sleep (NREM3 stage). The latter is associated with several restorative functions.

Next, REM sleep (rapid eye movement sleep) is the stage generally associated with the most vivid dreams. An adult generally spends around 15% to 20% of each night in deep sleep, if we add up all the periods of NREM3 sleep.

Several sleep changes are common in adults, such as going to bed and waking up earlier, sleeping for shorter periods of time and less deeply, and waking up more frequently during the night.

Loss of deep sleep

Participants in the Framingham Heart Study were assessed using a sleep recording – known as polysomnography – on two occasions, approximately five years apart, in 1995-1998 and again in 2001-2003.

Many people showed a reduction in their deep slow-wave sleep over the years, as is to be expected with aging. Conversely, the amount of deep sleep in some people remained stable or even increased.

Our team of researchers from the Framingham Heart Study followed 346 participants aged 60 and over for a further 17 years to observe who developed dementia and who did not.

Progressive loss of deep sleep over time was associated with an increased risk of dementia, whatever the cause, and particularly Alzheimer’s type dementia. These results were independent of many other risk factors for dementia.

Although our results do not prove that loss of deep sleep causes dementia, they do suggest that it could be a risk factor in the elderly. Other aspects of sleep may also be important, such as its duration and quality.

Strategies to improve deep sleep

Knowing the impact of a lack of deep sleep on cognitive health, what strategies can be used to improve it?

First and foremost, if you’re experiencing sleep problems, it’s worth talking to your doctor. Many sleep disorders are underdiagnosed and treatable, particularly through behavioural (ie, non-medicinal) approaches.

Adopting good sleep habits can help, such as going to bed and getting up at consistent times or avoiding bright or blue light in bed, like that of screens.

You can also avoid caffeine, limit your alcohol intake, maintain a healthy weight, be physically active during the day, and sleep in a comfortable, dark and quiet environment.

The role of deep sleep in preventing dementia remains to be explored and studied. Encouraging sleep with good lifestyle habits could have the potential to help us age in a healthier way.

Andrée-Ann Baril is Professeure-chercheure adjointe au Département de médecine, Université de Montréal.

Matthew Pase is Associate Professor of Neurology and Epidemiology, Monash University.

This article was first published on The Conversation.

As a clinical psychologist, I often have clients say they are having trouble with thoughts “on a loop” in their head, which they find difficult to manage.

While rumination and overthinking are often considered the same thing, they are slightly different (though linked). Rumination is having thoughts on repeat in our minds. This can lead to overthinking – analysing those thoughts without finding solutions or solving the problem.

It’s like a vinyl record playing the same part of the song over and over. With a record, this is usually because of a scratch. Why we overthink is a little more complicated.

On the lookout for threats

Our brains are hardwired to look for threats, to make a plan to address those threats and keep us safe. Those perceived threats may be based on past experiences, or may be the “what ifs” we imagine could happen in the future.

Our “what ifs” are usually negative outcomes. These are what we call “hot thoughts” – they bring up a lot of emotion (particularly sadness, worry or anger), which means we can easily get stuck on those thoughts and keep going over them.

However, because they are about things that have either already happened or might happen in the future (but are not happening now), we cannot fix the problem, so we keep going over the same thoughts.

Who overthinks

Most people find themselves in situations at one time or another when they overthink.

Some people are more likely to ruminate. People who have had prior challenges or experienced trauma may have come to expect threats and look for them more than people who have not had adversities.

Deep thinkers, people who are prone to anxiety or low mood, and those who are sensitive or feel emotions deeply are also more likely to ruminate and overthink.

Also, when we are stressed, our emotions tend to be stronger and last longer, and our thoughts can be less accurate, which means we can get stuck on thoughts more than we would usually.

Being run down or physically unwell can also mean our thoughts are harder to tackle and manage.

Acknowledge your feelings

When thoughts go on repeat, it is helpful to use both emotion-focused and problem-focused strategies.

Being emotion-focused means figuring out how we feel about something and addressing those feelings. For example, we might feel regret, anger or sadness about something that has happened, or worry about something that might happen.

Acknowledging those emotions, using self-care techniques and accessing social support to talk about and manage your feelings will be helpful.

The second part is being problem-focused. Looking at what you would do differently (if the thoughts are about something from your past) and making a plan for dealing with future possibilities your thoughts are raising.

But it is difficult to plan for all eventualities, so this strategy has limited usefulness.

What is more helpful is to make a plan for one or two of the more likely possibilities and accept there may be things that happen you haven’t thought of.

Why these thoughts are showing up

Our feelings and experiences are information; it is important to ask what this information is telling you and why these thoughts are showing up now.

For example, university has just started again. Parents of high school leavers might be lying awake at night (which is when rumination and overthinking is common) worrying about their young person.

Knowing how you would respond to some more likely possibilities (such as they will need money, they might be lonely or homesick) might be helpful.

But overthinking is also a sign of a new stage in both your lives, and needing to accept less control over your child’s choices and lives, while wanting the best for them. Recognising this means you can also talk about those feelings with others.

Let the thoughts go

A useful way to manage rumination or overthinking is “change, accept, and let go”.

Challenge and change aspects of your thoughts where you can. For example, the chance that your young person will run out of money and have no food and starve (overthinking tends to lead to your brain coming up with catastrophic outcomes!) is not likely.

You could plan to check in with your child regularly about how they are coping financially and encourage them to access budgeting support from university services.

Your thoughts are just ideas. They are not necessarily true or accurate, but when we overthink and have them on repeat, they can start to feel true because they become familiar. Coming up with a more realistic thought can help stop the loop of the unhelpful thought.

Accepting your emotions and finding ways to manage those (good self-care, social support, communication with those close to you) will also be helpful. As will accepting that life inevitably involves a lack of complete control over outcomes and possibilities life may throw at us. What we do have control over is our reactions and behaviours.

Remember, you have a 100% success rate of getting through challenges up until this point. You might have wanted to do things differently (and can plan to do that) but nevertheless, you coped and got through.

So, the last part is letting go of the need to know exactly how things will turn out, and believing in your ability (and sometimes others’) to cope.

What else can you do

A stressed out and tired brain will be more likely to overthink, leading to more stress and creating a cycle that can affect your wellbeing.

So it’s important to manage your stress levels by eating and sleeping well, moving your body, doing things you enjoy, seeing people you care about, and doing things that fuel your soul and spirit.

Distraction – with pleasurable activities and people who bring you joy – can also get your thoughts off repeat.

If you do find overthinking is affecting your life, and your levels of anxiety are rising or your mood is dropping (your sleep, appetite and enjoyment of life and people is being negatively affected), it might be time to talk to someone and get some strategies to manage.

When things become too difficult to manage yourself (or with the help of those close to you), a therapist can provide tools that have been proven to be helpful. Some helpful tools to manage worry and your thoughts can also be found here.

When you find yourself overthinking, think about why you are having “hot thoughts”, acknowledge your feelings and do some future-focused problem solving. But also accept life can be unpredictable and focus on having faith in your ability to cope.

Kirsty Ross is Associate Professor and Senior Clinical Psychologist, Massey University.

This article was first published on The Conversation.

Yet another controversy is brewing in the biosimilar space with Swiss company Roche falling back on a time-tested strategy to leverage India’s inadequate regulatory laws to question the safety and efficacy of biosimilars manufactured by Indian competitors. This is the third time that Roche and its affiliates have deployed this strategy over the last two decades. A bit of context is necessary to understand this strategy and Roche’s success in deploying it in India.

First, it is important to understand the drugs in question. Biosimilars are copies of a class of drugs called biologicals. These are large molecule drugs which are generally manufactured with processes involving living organisms. These drugs include not just the century old anti-diphtheria serum which is produced by innoculating horses with diptheria toxin, but also the more recent biologics like trastuzumab, one of the first blockbuster biologicals manufactured with the aid of biotechnology.

Biologicals, unlike small molecule drugs, are not easy to reverse-engineer. Even when competitors succeed, these biosimilars that they manufacture are likely to vary from the original product, unless they get access to the exact cell lines used by the innovator.

This raises the question of whether it is possible for competitors to manufacture biosimilars that are therapeutically interchangeable with the original product; ie, can a doctor prescribe the (usually more affordable) biosimilar in place of the original biological?

This is a policy question that must be answered by a law that lays down clear scientific standards which provide a legal guarantee that biosimilars are as safe and efficacious as the original biological.

Countries like the United States responded to these challenges by enacting laws such as the Biologics Price Competition and Innovation Act of 2009 as part of the “Obamacare” reforms to create legal pathways for the launch of biosimilars which were aimed to reduce the astronomical prices at which biologics were being sold in the United States.

In India on the other hand, this critical regulatory issue has always been handled through ambiguous guidelines. For example, in 2012, the government announced the “Guidelines on Similar Biologics” and again in 2016, a new iteration of these rules was announced by the government.

There are two major problems with this legal approach adopted by India. First, the guidelines lack the force of law and by that we mean, the fact that neither government nor industry can be held liable for violating these guidelines. Only Parliament can enact law or specifically delegate the power to the government to create rules. The present guidelines on similar biologics are unable to trace their lineage to Parliament and hence lack the force of law.

Second, the existing biosimilar guidelines are poorly drafted, leaving the door open for innovators like Roche to raise a cloud of doubt over the launch of new biosimilars.

Returning to the most recent controversy, this pertains to clinical trials being conducted by an Indian company to test a biosimilar of Pertuzumab that was invented by Roche. Since comparator clinical trials have to be conducted in comparison to a “reference product”, which in this case is Roche’s product, the Indian company had to procure Roche’s products for their clincal studies.

Roche, which presumably keeps close track of the sales of its drugs (which are expensive and subject to stringent storage protocols) has now raised questions on how and where the Indian company accessed the “reference products” for the purpose of its clinical trials. Reporting on the issue states that Roche has complained to the regulator, the Central Drugs Standard Control Organisation, that the samples procured by the Indian company may be of “questionable quality”, “compromised” or “spurious”.

Given the drug regulator’s “see no evil, speak no evil and hear no evil” approach to its job, we are unlikely to receive a clear-cut answer to Roche’s complaint. This silence will ultimately affect the credibility of the biosimilar to be launched by the Indian company on conclusion of its clinical trials.

Oncologists treating cancer patients are unlikely to risk prescribing the new biosimilar to their patients meaning that patients (or their insurers) will have to cough up more for Roche’s drug. We have seen this happen in the past.

The same tactic has been employed on two previous occasions for two other biosimilars. The first instance was in 2001, when Dr Reddy’s Laboratories launched a biosimilar for Neupogen (India did not recognise pharmaceutical patents at the time allowing Dr Reddy’s Laboratories to launch biosimilars). At that time, Piramal, which held the exclusive rights for Roche’s drug in India, complained that Dr Reddy’s Laboratories was not just misrepresenting certain aspects of its biosimilar but also that there were serious issues of safety and efficacy with DRL’s product.

Anji Reddy recounted the episode in his autobiography, Unfinished Agenda, quoting a top executive of Piramal as saying, “it's a battle for safe and effective drugs for the patients – to ensure that doctors are not misled and get correct information from pharma companies”. While defending the biosimilar by Dr Reddy’s Laboratories, Anji Reddy also remarked that the controversy led to reduced sales of their product and that leading oncologists expressed their unwillingness to take the risk of prescribing DRL’s biosimilar in light of the allegations.

Roche used a similar playbook on multiple other occasions in the last decade to block the launch of biosimilars of its blockbuster breast cancer drug – trastuzumab, sold under the brand name of Herceptin. This time around, Roche sued multiple Indian companies launching biosimilars on the grounds that they were trying to misrepresent their products as being similar to Herceptin.

Roche’s case was weak but convincing enough to confuse the courts into action. A cycle of injunctions and appeals followed against the launch of biosimilars. But the real damage to these biosimilar manufacturers was occurring outside the courtroom and in hospitals. By framing the issue in terms of regulatory law, instead of patent law, Roche in all likelihood managed to cloud the credibility of these biosimilars in the minds of oncologists.

The company was betting on the fact that Indian doctors already have little faith in the quality of medicine in the Indian market. This lack of faith was evidenced most recently when the medical community rose in revolt to a mandate issued by the National Medical Commission to prescribe only generic drugs. The ultimate loser in this regulatory dysfunction are poor and hapless patients who need to pay more for medicine.

The only way to fix this recurring problem with the launch of new biosimilars and encourage greater competition in the market for very expensive biologics is for the Ministry of Health to introduce a comprehensive legislation that builds confidence, especially among the medical community, that all biosimilars launched in the Indian market have established their safety and efficacy.

In particular, the law should mandate the supply of reference products for clinical trials and categorically allow biosimilars to be marketed as being therapeutically interchangeable with the biological of which it is a copy as long as their safety and efficacy is clinically demonstrated. To be meaningful, these reforms will have to be accompanied by a comprehensive, bottom-up reform of India’s rickety drug regulator.

The writers co-authors of The Truth Pill: The Myth of Drug Regulation in India

I’ll often lie awake until three or four in the morning, before drifting off for just a few hours. Then comes the dreaded alarm clock. My mind and body are exhausted all the time – there’s always this knot of anxiety in my chest, doing away with any hope of a good night’s sleep.

Simon* is a National Health Service mental health nurse with the who, like millions of people in the UK, suffers from insomnia: a sustained difficulty in initiating and maintaining sleep. His job is to support the recovery of people with severe mental illness, but his own sleep problems have had a profoundly negative impact on his mental health.

Most of us experience a bad night’s sleep from time to time, but can usually get back on track within a night or two. People suffering from insomnia, by contrast, have sleep problems that last for months or years at a time, taking a major toll on their health and wellbeing.

Around a third of people will experience insomnia at some point in their life, with women and older people more often affected. Nearly 40% of sufferers fail to recover within five years. People with insomnia have an increased risk of diabetes, high blood pressure and cardiovascular disease. Insomnia is also a major risk factor for mental illness, and often co-occurs with mood disorders such as depression and anxiety.

Many different life events can increase your chances of sustained sleep deprivation. Both the financial burden and confinement arising from the Covid-19 pandemic were associated with greater risk of insomnia, which is in turn likely to have led to a rise in mental health problems.

Yet, very little is known about why and how a prolonged absence of sleep gives rise to mental illness. Our team at the University of York has pioneered research into whether sleep deprivation disrupts the brain’s ability to suppress intrusive memories and distressing thoughts – classic symptoms of psychiatric disturbance.

It has also led us to ask whether it might one day be possible to treat mental illness while patients are sleeping – for example, by using sounds to normalise irregular patterns of brain activity during rapid eye movement, or REM, sleep.

Why are some badly affected

They put their hand over my face so I couldn’t breathe. Now I can’t wear anything that covers my mouth or nose for fear of reliving [that experience]. Mask wearing was a big problem for me during the pandemic – and it was always worse when I slept badly. Just the sight of other people wearing masks could bring it all back.

Helen* is a domestic abuse survivor who suffers from post-traumatic stress disorder, or PTSD, a debilitating condition characterised by flashbacks, nightmares and severe anxiety. She told us her symptoms would always get worse after a bad night’s sleep – a pattern reported by other PTSD sufferers we spoke to.

We can all sometimes encounter intrusive and unwanted thoughts, usually in response to reminders – for example, seeing a former partner and being reminded of an unpleasant breakup. While unsettling, these thoughts are infrequent, short-lived and, usually, quickly forgotten.

This is in stark contrast to the highly lucid, distressing thoughts experienced by people with PTSD. Sufferers often engage in avoidant behaviour, such as not leaving home to reduce the likelihood of having to confront reminders of their trauma.

However, the symptoms of PTSD can also partly be explained by a breakdown of the brain mechanisms we rely on to push such intrusive thoughts out of conscious awareness. Because intrusive thoughts arise from unpleasant memories, another way people ward them off is by suppressing the offending content from their memory. But PTSD sufferers often exhibit a deficit in their ability to engage in this process of memory suppression, resulting in persistent unwanted patterns of thinking.

And what if lack of sleep reduces our ability to suppress unwanted thoughts and memories? This could lead to a downward spiral of more persistent and frightening intrusive thoughts, severe anxiety, and chronic sleeplessness – culminating in psychiatric disturbance.

Although a wealth of research has shown that sleep deprivation leads to psychological instability, our study was the first study to examine how an inability to control intrusive thoughts might underpin this relationship. For this reason, we worked with young adults without a diagnosed mental health disorder, allowing us to determine how even healthy brain processes go awry when people do not get enough sleep.

Effects of sleep deprivation

Our group of young adults (aged 18-25) were asked to memorise face-image pairs, comprising a male or female face with a neutral expression next to a unique scene. They would memorise each pair over and over again, so that any face presented in isolation would serve as a powerful reminder of the scene it was paired with – in the same way a reminder of an unpleasant event in the real world can trigger a distressing thought.

The face-scene learning took place late in the evening – after which half the participants went to sleep in our laboratory, and the other half stayed awake for the entire night – watching movies, playing games and going for short walks outside. They could eat and drink, but psychological stimulants such as caffeine were strictly prohibited. We would wake anyone in this group who nodded off.

Next morning, all participants were shown the faces only, in random order, with the following instructions. If the face was inside a green frame, the participant should allow the associated scene to come into their mind. A red frame meant they should engage in memory suppression to block out the scene – in the same way we sometimes purge unwanted thoughts from our conscious experience.

Our sleep-deprived participants reported having more “intrusions” (failed memory suppression attempts) than those who had slept normally. And only well-rested participants got better at suppressing the unwanted memories over time. This suggests that sleeplessness does long-term harm to our ability to suppress intrusive memories and, hence, unwanted thoughts.

What’s going wrong inside a sleep-deprived person’s brain? To address this question, we repeated our study, but this time with participants undergoing functional magnetic resonance imaging (fMRI) – a powerful neuroimaging technique that allows us to determine which brain regions are engaged during particular cognitive operations (in this case, keeping intrusive memories at bay).

Memory suppression relies on a brain region known as the right dorsolateral prefrontal cortex (rDLPFC). When a reminder triggers retrieval of an unwanted memory, the rDLPFC inhibits activity in the brain’s memory processing centre, the hippocampus, to push that memory out of the person’s mind.

Our fMRI study showed that, when participants were attempting to suppress unwanted memories, activity in rDLPFC was reduced after a night of sleep deprivation relative to a night of restful sleep. Moreover, activity in the hippocampus was stronger after sleep deprivation than restful sleep, suggesting that a breakdown of control by rDLPFC had allowed unsolicited memory operations to emerge with impunity, opening the door to intrusive patterns of thinking.

Better sleep, mental health

REM sleep, discovered by Eugene Aserinsky and Nathaniel Kleitman in 1953, is a unique stage of sleep characterised by rapid movement of the eyes and a high propensity for vivid dreaming.

As the brain enters REM sleep, it undergoes dramatic changes that are thought to play an important role in regulating our mental health. For example, levels of the neurotransmitter acetylcholine, which modulates the processing of disturbing memories, are markedly increased in REM sleep relative to other sleep stages, mirroring levels seen in wakefulness. Abnormalities of REM sleep are linked to various psychiatric mood disorders including PTSD, and associated with the intense nightmares experienced following trauma.

So, could the brain mechanisms that allow us to control intrusive memories be especially influenced by the amount of REM sleep we obtain over the course of a night? To investigate this, our fMRI study included polysomnography – a sleep monitoring technique that enabled us to identify when participants were in REM sleep, based on both their eye movement and discrete brainwave patterns.

Among our participants who slept, those who had more REM sleep showed stronger engagement of their rDLPFC when suppressing unwanted memories the next morning. This suggests REM sleep may indeed support mental health by restoring the brain systems that help to shield us from unwelcome thoughts.

Emotional intensity of memories

When we think back to a traumatic or painful life event, we get a sense of the unpleasant feelings, such as sadness or anger, that accompanied the original experience. However, the intensity of these feelings is usually much reduced, allowing us to draw on past events without being consumed by negative emotions.

Suppressing unwanted thoughts has been shown to weaken the memories that lead to them, meaning they are less likely to intrude into our consciousness in the future. This relates not only to the content of the memories (the “what, when and who”) but also their emotional charge – the intensity of the emotions we felt at the time. In other words, memory suppression helps us move on from prior adversity by gradually cleansing our memories of unpleasant experiences, and the negative emotions associated with them.

Conversely, failing to suppress an unwanted memory is likely to cause its emotional charge to linger, meaning that emotional responses to future reminders will remain more intense.

We tested this by showing our participants scenes that were either emotionally negative (such as a car crash) or neutral (such as a forest). In the morning, after completing the memory retrieval and suppression task (with green and red-framed faces), participants were then asked to give intensity ratings for the negative and neutral scenes again.

Our findings were clear – and corroborated by further tests using an objective index of emotional arousal, skin conductance responses. Among participants who had slept, emotional responses to the suppressed negative scenes became less intense over time.

But among the sleep-deprived, emotional ratings for negative scenes remained elevated, regardless of whether the scenes were suppressed or not. This suggests that a breakdown of memory suppression mechanisms after sleep loss prevented participants from being able to “deal with” these negative emotions.

In the context of psychiatric mood disorders that co-occur with chronic sleep disturbance, failure to suppress memories of emotionally disturbing events, together with an inability to reduce the unpleasant feelings embedded within those memories, could contribute to a strong tendency of mood-disordered individuals to focus on negative interpretations of the past.

Furthermore, anxiety arising from intrusive memories may also obstruct the sleep that is needed for recovery, leading to a vicious cycle of emotional dysregulation and sleeplessness.

The importance of forgetting

In the film Eternal Sunshine of the Spotless Mind (2004), the main characters have their memories of their turbulent relationship erased. Far from improving their quality of life, this leads to further complications, serving as a cautionary tale.

However, there are situations where aiding the forgetting process may help. For example, people who have experienced traumatic experiences can struggle to cope with unwanted memory intrusions. In these extreme cases, where the usual brain processes that allow for forgetting aren’t functioning properly, it could be beneficial to induce forgetting.

Generally, forgetting is thought of as “bad”, with people worrying about forgetting where they put the car keys, or when their wedding anniversary is. But far from being a problem, this is how memory is supposed to work. Sometimes, we want to just forget information that isn’t relevant to our daily lives, to prevent it from interfering with our goals. And sometimes, we want to forget embarrassing or emotionally scarring events.

Ultimately, the purpose of a functioning memory system is to make sensible and accurate decisions in the present, based on our past experience. The “adaptive” nature of forgetting allows us to get rid of irrelevant memories, making sure the memories that remain are as relevant to future decisions as possible. From this perspective, forgetting is as important as remembering. Simply put, forgetting is a feature of memory, not a bug.

While forgetting is a catch-all term we use for the loss of a memory, it isn’t a single process in the brain. Memories can be forgotten via active processes, such as memory suppression. But this can also happen via passive processes including “decay”, where the physical trace of a memory in the brain breaks down over time, or “interference”, where new memories that are similar to previous ones lead to confusion-impaired retrieval.

For example, if you park your car in a new location in the supermarket you often visit, you might forget this new location because the usual place you park comes more readily to mind.

Forgetting is a complex phenomenon that unfolds over different timescales and via different processes, both while awake and asleep. While some memories can fragment, others are forgotten as a whole, so that all aspects of the memory are no longer accessible.

That forgetting is likely to occur during sleep has been underappreciated by psychologists, because research on sleep has largely focused on the role it plays in strengthening memories. But we and other researchers have recently reasoned that if forgetting is a fundamental part of a functioning memory system, then sleep should play as much of a role in forgetting as it does in retention.

Previous research, including our own, has shown that the presentation of specific sounds during sleep can boost memory. If you were to learn the location of a cat on a computer screen, and during learning we played a “meow” sound, the presentation of the same sound during sleep would lead to better location memory following sleep. This selective boosting of a specific memory during sleep is called “targeted memory reactivation”.

We have recently shown that this technique can also be used to induce “selective forgetting”. We asked our participants to learn pairs of words or names before going to sleep. We used famous names, location and object words to allow participants to create vivid images in their minds for each pair, so they would be more likely to remember them after a night’s sleep.

But we also made sure the pairs overlapped by sharing one common word. When people learn these overlapping pairs, they compete against each other, and this competition can lead to forgetting some of the words. We thought a similar forgetting effect might be seen by using targeted memory reactivation when participants were sleeping.

We found the presentation of the word during sleep caused reactivation and strengthening for one pair, but this had a disruptive effect for the other pair. This suggests we could use targeted memory reactivation to selectively strengthen and weaken memories during sleep, presuming we can create interference between two memories. This could be beneficial in the case of people whose brain processes aren’t functioning properly, not allowing them to “healthily forget” disturbing and intrusive memories.

Although such a treatment is still a long way off, our work raises the possibility of using sound cues during sleep – in combination with psychological techniques such as cognitive behavioural therapy – to decrease the crippling emotional grip a particular memory has on a patient.

Modifying REM sleep

Given the strong link between REM sleep and mental health disorders, REM sleep may represent a powerful therapeutic target for treating and preventing various psychiatric conditions. By delivering sounds in synchrony with naturally occurring brain rhythms, it is possible to modify patterns of brain activity that are associated with memory processing in REM sleep.

In one study, we used a computerised algorithm to track rapidly emerging patterns of brain activity in real time while people were asleep (based on polysomnography data). When the algorithm detects the emergence of a particular brain rhythm, it delivers short bursts of sound to increase the intensity of that brain rhythm (akin to pushing a swing as it reaches the highest point of its cycle).

We have showed this technique can be used to modify distinct brain rhythms in REM sleep. In future, such auditory stimulation could potentially provide a means of renormalising aberrant patterns of brain activity in REM sleep to treat psychiatric disturbance.

For example, by integrating this technology with devices that are already available for people to monitor their sleep at home, the playing of particular sounds while someone is sleeping could provide a simple and cost-effective therapy for reducing mood disturbance.

However, this is a long way from being a reality, and many studies would be required to evaluate the feasibility of such an approach before it could be used as a therapeutic tool.

Targeting sleep

High-risk patients undergo routine observations, sometimes as regularly as every ten minutes, all night and every night. Torches are shone into their rooms – to check they’re breathing – and there’s a lot of noise as doors are open and closed. It has a terrible impact on their sleep.

Heather* is a consultant forensic psychiatrist who works on a secure mental health ward in the North of England. She describes how the ward regime (in this case, routine welfare checks on high-risk individuals performed throughout the night) impact on patients’ sleep.

A number of people with severe mental illness receive treatment in secure inpatient units. Although the goal of these psychiatric hospitals is to provide a therapeutic setting to support the improvement of mental health, many features of the inpatient environment, such as noise at night or the ward regime, can worsen patients’ sleep disturbances – intensifying the symptoms of their illness, including low mood, impulsivity and aggression.

At the same time, chronic sleeplessness often reduces patients’ engagement with psychological therapies (due to them sleeping in the day or lacking motivation), lengthening their admission and recovery time.

In a recent international scoping review, we found that only a small number of non-pharmacological sleep interventions had been tested in psychiatric inpatient settings, despite clear evidence that these improve both sleep and mental health outcomes.

New digital technologies can give a clear indication of patient welfare without the need for the noise and disruption Heather describes, providing an environment that is more conducive to healthy sleep. Future studies could test the potential for integrating these digital technologies with sleep-based therapies to speed up recovery times.

Achieving this goal is not only contingent on more research, but also on the capacity for carrying out scientific studies at scale. For example, all of the studies we have described were performed in tightly controlled laboratory environments, usually involving large and expensive pieces of equipment (for example, polysomnography systems).

Though recent efforts have shown promise in the feasibility of moving these techniques into people’s homes, much more work needs to be done outside of the lab before digitised, sleep-focused interventions for mental illness become a reality.

We envisage a future in which sleep is a routine target for reducing or preventing symptoms of mental illness, both in psychiatric inpatient settings and in people’s homes. Although there is much work still to do, sleep research is at an exciting juncture between bench and bedside, and offers a viable solution to the growing global burden of mental illness.

*Some names in this article have been changed to protect the anonymity of the interviewees.

Scott Cairney is Associate Professor of Psychology, University of York.

Aidan Horner Associate Professor in Psychology and Neuroscience, University of York.

This article was first published on The Conversation.

Back pain is common. One in thirteen people have it right now and worldwide a staggering 619 million people will have it this year.

Chronic pain, of which back pain is the most common, is the world’s most disabling health problem. Its economic impact dwarfs other health conditions.

If you get back pain, how long will it take to go away? We scoured the scientific literature to find out. We found data on almost 20,000 people, from 95 different studies and split them into three groups:

• acute – those with back pain that started less than six weeks ago

• subacute – where it started between six and 12 weeks ago

• chronic – where it started between three months and one year ago.

We found 70%-95% of people with acute back pain were likely to recover within six months. This dropped to 40%-70% for subacute back pain and to 12%-16% for chronic back pain.

Clinical guidelines point to graded return to activity and pain education under the guidance of a health professional as the best ways to promote recovery. Yet these effective interventions are underfunded and hard to access.

Injury, pain

Most acute back pain episodes are not caused by serious injury or disease.

There are rare exceptions, which is why it’s wise to see your doctor or physio, who can check for signs and symptoms that warrant further investigation. But unless you have been in a significant accident or sustained a large blow, you are unlikely to have caused much damage to your spine.

Even very minor back injuries can be brutally painful. This is, in part, because of how we are made.

If you think of your spinal cord as a very precious asset (which it is), worthy of great protection (which it is), a bit like the crown jewels, then what would be the best way to keep it safe? Lots of protection and a highly sensitive alarm system.

The spinal cord is protected by strong bones, thick ligaments, powerful muscles and a highly effective alarm system (your nervous system). This alarm system can trigger pain that is so unpleasant that you cannot possibly think of, let alone do, anything other than seek care or avoid movement.

The messy truth is that when pain persists, the pain system becomes more sensitive, so a widening array of things contribute to pain. This pain system hypersensitivity is a result of neuroplasticity – your nervous system is becoming better at making pain.

Reduce chance of lasting pain

Whether or not your pain resolves is not determined by the extent of injury to your back. We don’t know all the factors involved, but we do know there are things that you can do to reduce chronic back pain:

• understand how pain really works. This will involve intentionally learning about modern pain science and care. It will be difficult but rewarding. It will help you work out what you can do to change your pain

• reduce your pain system sensitivity. With guidance, patience and persistence, you can learn how to gradually retrain your pain system back towards normal.

Pain sensitivity

Learning about “how pain works” provides the most sustainable improvements in chronic back pain. Programmes that combine pain education with graded brain and body exercises (gradual increases in movement) can reduce pain system sensitivity and help you return to the life you want.

These programmes have been in development for years, but high-quality clinical trials are now emerging and it’s good news: they show most people with chronic back pain improve and many completely recover.

But most clinicians aren’t equipped to deliver these effective programmes – good pain education is not taught in most medical and health training degrees. Many patients still receive ineffective and often risky and expensive treatments, or keep seeking temporary pain relief, hoping for a cure.

When health professionals don’t have adequate pain education training, they can deliver bad pain education, which leaves patients feeling like they’ve just been told it’s all in their head.

Community-driven not-for-profit organisations such as Pain Revolution are training health professionals to be good pain educators and raising awareness among the general public about the modern science of pain and the best treatments.

Pain Revolution has partnered with dozens of health services and community agencies to train more than 80 local pain educators and supported them to bring greater understanding and improved care to their colleagues and community.

But a broader system-wide approach, with government, industry and philanthropic support, is needed to expand these programmes and fund good pain education. To solve the massive problem of chronic back pain, effective interventions need to be part of standard care, not as a last resort after years of increasing pain, suffering and disability.

Sarah Wallwork is Post-doctoral Researcher, University of South Australia.

Lorimer Moseley Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy, University of South Australia.

This article was first published on The Conversation.

At least one in ten people have depression at some point in their lives, with some estimates closer to one in four. It’s one of the worst things for someone’s wellbeing – worse than debt, divorce or diabetes.

One in seven Australians take antidepressants. Psychologists are in high demand. Still, only half of people with depression in high-income countries get treatment.

Our new research shows that exercise should be considered alongside therapy and antidepressants. It can be just as impactful in treating depression as therapy, but it matters what type of exercise you do and how you do it.

Walk, run, lift or dance away depression

We found 218 randomised trials on exercise for depression, with 14,170 participants. We analysed them using a method called a network meta-analysis. This allowed us to see how different types of exercise compared, instead of lumping all types together.

We found walking, running, strength training, yoga and mixed aerobic exercise were about as effective as cognitive behaviour therapy – one of the gold-standard treatments for depression. The effects of dancing were also powerful.

However, this came from analysing just five studies, mostly involving young women. Other exercise types had more evidence to back them.

Walking, running, strength training, yoga and mixed aerobic exercise seemed more effective than antidepressant medication alone, and were about as effective as exercise alongside antidepressants.

But of these exercises, people were most likely to stick with strength training and yoga.

Antidepressants certainly help some people. And of course, anyone getting treatment for depression should talk to their doctor before changing what they are doing.

Still, our evidence shows that if you have depression, you should get a psychologist and an exercise plan, whether or not you’re taking antidepressants.

Join a programme and go hard

Before we analysed the data, we thought people with depression might need to “ease into it” with generic advice, such as “some physical activity is better than doing none”.

But we found it was far better to have a clear programme that aimed to push you, at least a little. Programmes with clear structure worked better, compared with those that gave people lots of freedom. Exercising by yourself might also make it hard to set the bar at the right level, given low self-esteem is a symptom of depression.

We also found it didn’t matter how much people exercised, in terms of sessions or minutes a week. It also didn’t really matter how long the exercise programme lasted. What mattered was the intensity of the exercise: the higher the intensity, the better the results.

Hard to stay motivated

We should exercise caution in interpreting the findings. Unlike drug trials, participants in exercise trials know which “treatment” they’ve been randomised to receive, so this may skew the results.

Many people with depression have physical, psychological or social barriers to participating in formal exercise programmes. And getting support to exercise isn’t free.

We also still don’t know the best way to stay motivated to exercise, which can be even harder if you have depression.

Our study tried to find out whether things like setting exercise goals helped, but we couldn’t get a clear result.

Other reviews found it’s important to have a clear action plan (for example, putting exercise in your calendar) and to track your progress (for example, using an app or smartwatch). But predicting which of these interventions work is notoriously difficult.

A 2021 mega-study of more than 60,000 gym-goers found experts struggled to predict which strategies might get people into the gym more often. Even making workouts fun didn’t seem to motivate people. However, listening to audiobooks while exercising helped a lot, which no experts predicted.

Still, we can be confident that people benefit from personalised support and accountability. The support helps overcome the hurdles they’re sure to hit. The accountability keeps people going even when their brains are telling them to avoid it.

So, when starting out, it seems wise to avoid going it alone. Instead:

• join a fitness group or yoga studio

• get a trainer or an exercise physiologist

• ask a friend or family member to go for a walk with you.

Taking a few steps towards getting that support makes it more likely you’ll keep exercising.

Let’s make this official

Some countries see exercise as a backup plan for treating depression. For example, the American Psychological Association only conditionally recommends exercise as a “complementary and alternative treatment” when “psychotherapy or pharmacotherapy is either ineffective or unacceptable”.

Based on our research, this recommendation is withholding a potent treatment from many people who need it.

In contrast, The Royal Australian and New Zealand College of Psychiatrists recommends vigorous aerobic activity at least two to three times a week for all people with depression.

Given how common depression is, and the number failing to receive care, other countries should follow suit and recommend exercise alongside front-line treatments for depression.

I would like to acknowledge my colleagues Taren Sanders, Chris Lonsdale and the rest of the coauthors of the paper on which this article is based.

Michael Noetel is Senior Lecturer in Psychology, The University of Queensland.

This article was first published on The Conversation.

For Nepali nurse Anshu, being picked for a job programme in Britain was long overdue recognition of her years of study and work – and a chance to boost her earnings.

“I finally feel my work has been valued,” said the 28-year-old, who asked to be identified only by her first name. She hopes her current monthly salary of 26,000 rupees ($196) at a private hospital in Nepal will rise to more than 10-times that in Britain.

But as she and several dozen other nurses prepare to leave, the bilateral government pilot under which they were recruited has fuelled concerns about an acute shortage of nurses and other medical professionals in the South Asian country.

Though only 43 nurses were accepted for the pilot phase, an official at the country’s Department of Foreign Employment told Context a second phase was planned and that Britain eventually wanted to recruit 10,000 Nepali nurses.

While that would help Britain plug labour gaps in the National Health Service, it could exacerbate Nepal's shortages, nursing officials said.

“The situation is already worrying,” said Hira Kumari Niraula, director of Nepal’s Nursing and Social Security Division, a government body involved in the provision of public health services.

“Recently we started community health nursing and school nurse programmes to make nursing service available in needy communities. But the challenge is in many places we are not able to find nurses who are willing to work,” Niraula added.

Nepal currently has less than half of the 45,000 nurses that it needs working in the country’s hospital, rural clinics and other healthcare facilities, according to the Nepal’s Nursing and Social Security Division.

It is among 55 countries included in a World Health Organization red list of nations facing a severe shortage of healthcare workers.

“We are in a shortage situation but the government is encouraging nurses to migrate. Then who will stay in Nepal?” Niraula said.

The DoFE has defended the agreement signed with Britain, saying such accords ensure migrant nurses' rights and help deter illegal migration and labour exploitation.

“There is news that Nepali nurses are being cheated, abused, and exploited abroad as they take backdoor entries,” said DoFE information officer Kabiraj Upreti. “This agreement can be a milestone.”

No future

From Zimbabwe to the Philippines, concern is growing about the loss of qualified medical staff attracted by better salaries to take up health and care jobs in countries such as Britain, Australia, Canada and the United States.

In Nepal, more than one-third of the 115,900 nurses registered with the Nepal Nursing Council have sought documents to practice overseas.

About half of Nepal’s migrant nurses went to the United States, followed by Australia and Dubai. Just over 500 have already migrated to Britain.

But the causes of the country’s medical staffing shortfall go beyond migration, said Roshan Pokharel, secretary of the Ministry of Health and Population.

“We are very much aware that a large number of health workers are migrating. But that's not their problem. It’s our problem that we are not able to provide permanent, long-term, and stable jobs to our health workers,” Pokharel said.

“Government has allocated only around 4% of the total budget to the health sector which is just not enough,” he added.

Limited financial resources for healthcare in the country of 30 million mean the lure of better-paid jobs abroad is stronger than ever for many nurses.

Tired of demanding working conditions and low pay, Grishma Basnet, 25, who works in the intensive care unit at a private hospital in the capital, Kathmandu, has applied to work in the United States and is awaiting news on where she will go.

“I have to look after three patients in the ICU, whereas the global standard is one nurse should only look after one patient in the ICU. Isn’t this exploitation?” said Basnet, who said she earned 15,000 rupees per month at present.

“Why should I stay in this country? There is no future here,” she said.

This article first appeared on Context, powered by the Thomson Reuters Foundation.

Often a posture assigned to teenagers and disaffected youth, slouching is traditionally considered to be a “bad” posture – with some claiming it will damage your spine and cause pain.

The term itself hails from medieval Norse meaning “lazy fellow” – and later the middle English word meaning “walking, sitting or standing with a loose attitude”.

In the last 150 years or so, posture has come to be associated with aspects of a person’s value, dignity, respectability and morality. Erect posture has been deemed “healthy”, “the aesthetic utopia”, “dignified”, “a backbone against subjugation”, “attractive” and “good” by various cultures, political movements and even social media influencers.

So it’s not difficult to see then how slouching came to be considered “bad” for us since it’s long been considered to be a bodily representation of negativity.

But while posture is heavily overlaid with psychological meaning, is it really that bad for our spines if we slouch? Are certain postures really “good” and others “bad”?

The great news is that in the past two decades, there’s been a plethora of rigorous clinical studies conducted which have concluded that there’s no relationship between slouching and spinal pain. There’s also no evidence that people who slouch are more likely to suffer with back or neck pain compared to non-slouchers.

There’s also no clear evidence that slouching while sitting at your desk or while using your phone causes damage to the spine. Even the UK government’s latest guidance on working with screens puts less emphasis on an idealised posture at the workstation.

Instead, they emphasise the importance of adopting comfortable positions, varying your positions, avoiding awkward positions (such as flexing or arching your back or neck) and including regular breaks from your static posture throughout the day. All of these tips will help reduce the risk of developing pain and muscle fatigue.

So if you experience back or neck pain, you can rest assured that the posture you adopt when walking or sitting probably isn’t to blame as much as you might have been led to believe. Instead, it’s probably related more to other features of life – such as how stressed or physically active you are and if you have previously had back pain.

There’s a pretty good reason why slouching doesn’t damage our spines, and that is because our spines are designed to allow movements as diverse as Olympic weightlifting to limbo dancing.

Our spines aren’t going to be damaged by a bit of sitting down, even if we happen to be wiggling our fingers on a keyboard at the same time. And while standing desks are popular, prolonged standing is no more comfortable for the spine than prolonged sitting

The best thing to do throughout your day, to both make your body feel more comfortable and to increase your productivity and positive sense of wellbeing is to break up prolonged periods at your desk with breaks to walk, stretch, stand or sit down.

Positive posture

But there is one area where slouching may have a negative effect. Slouching has been linked to poorer information and memory recall, as well as worse mood when compared to sitting upright.

These memory and mood problems are shown to be rapidly improved when moving from a slouched to erect posture. So perhaps there is some truth to the notion that slouching may still be a bodily representation of negativity.

But aside from that, the evidence overwhelmingly suggests there’s no single, ideal or good posture. Differences in spinal posture are not related to pain. And, in fact, posture naturally varies from person to person – and can even vary depending on race, sex, and even mood.

So if you’re a sloucher, rest assured that it isn’t really bad for you and is as good as any other posture you adopt. Comfortable postures are safe and sitting is not dangerous.

Overall, the human spine is designed to be on the move rather than static in one posture for long periods, which is why movement and changing your posture throughout the day is important to reduce fatigue and subsequent discomfort.

If you can’t move around and spend all day slouched in front of the computer, this may cause you some discomfort – but it’s not actually damaging your spine.

Dr Chris McCarthy is Research Fellow, Rehabilitation, Manchester Metropolitan University.

This article was first published on The Conversation.

Remember the sadness that came with the last time you failed miserably at something? Or the last time you were so anxious about an upcoming event that you couldn’t concentrate for days?

These types of emotions are unpleasant to experience and can even feel overwhelming. People often try to avoid them, suppress them or ignore them. In fact, in psychology experiments, people will pay money to not feel many negative emotions. But recent research is revealing that emotions can be useful, and even negative emotions can bring benefits.

In my emotion science lab at Texas A&M University, we study how emotions like anger and boredom affect people, and we explore ways that these feelings can be beneficial. We share the results so people can learn how to use their emotions to build the lives they want.

Our studies and many others have shown that emotions aren’t uniformly good or bad for people. Instead, different emotions can result in better outcomes in particular types of situations. Emotions seem to function like a Swiss army knife – different emotional tools are helpful in specific situations.

The benefits of sadness

Sadness occurs when people perceive that they’ve lost a goal or a desired outcome, and there’s nothing they can do to improve the situation. It could be getting creamed in a game or failing a class or work project, or it can be losing a relationship with a family member. Once evoked, sadness is associated with what psychologists call a deactivation state of doing little, without much behavior or physical arousal. Sadness also brings thinking that is more detailed and analytical. It makes you stop and think.

The benefit of the stopping and thinking that comes with sadness is that it helps people recover from failure. When you fail, that typically means the situation you’re in is not conducive to success. Instead of just charging ahead in this type of scenario, sadness prompts people to step back and evaluate what is happening.

When people are sad, they process information in a deliberative, analytical way and want to avoid risk. This mode comes with more accurate memory, judgment that is less influenced by irrelevant assumptions or information, and better detection of other people lying. These cognitive changes can encourage people to understand past failures and possibly prevent future ones.

Sadness can function differently when there’s the possibility that the failure could be avoided if other people help. In these situations, people tend to cry and can experience increased physiological arousal, such as quicker heart and breathing rates. Expressing sadness, through tears or verbally, has the benefit of potentially recruiting other people to help you achieve your goals. This behavior appears to start in infants, with tears and cries signaling caregivers to help.

Overcoming obstacles

Anger occurs when people perceive they’re losing a goal or desired outcome, but that they could improve the situation by removing something that’s in their way. The obstacle could be an injustice committed by another person, or it could be a computer that repeatedly crashes while you’re trying to get work done. Once evoked, anger is associated with a “readiness for action”, and your thinking focuses on the obstacle.

The benefit of being prepared for action and focused on what’s in your way is that it motivates you to overcome what’s standing between you and your goal. When people are angry, they process information and make judgments rapidly, want to take action, and are physiologically aroused. In experiments, anger actually increases the force of people’s kicks, which can be helpful in physical encounters. Anger results in better outcomes in situations that involve challenges to goals, including confrontational games, tricky puzzles, video games with obstacles, and responding quickly on tasks.

Expressing anger, facially or verbally, has the benefit of prompting other people to clear the way. People are more likely to concede in negotiations and give in on issues when their adversary looks or says they are angry.

Preparing for danger

Anxiety occurs when people perceive a potential threat. This could be giving a speech to a large audience where failure would put your self-esteem on the line, or it could be a physical threat to yourself or loved ones. Once evoked, anxiety is associated with being prepared to respond to danger, including increased physical arousal and attention to threats and risk.

Being prepared for danger means that if trouble brews, you can respond quickly to prevent or avoid it. When anxious, people detect threats rapidly, have fast reaction times and are on heightened alert. The eye-widening that often comes with fear and anxiety even gives people a wider field of vision and improves threat detection.

Anxiety prepares the body for action, which improves performance on a number of tasks that involve motivation and attention. It motivates people to prepare for upcoming events, such as devoting time to study for an exam. Anxiety also prompts protective behavior, which can help prevent the potential threat from becoming a reality.

A jolt

There is less research on boredom than many other emotions, so it is not as well understood. Researchers debate what it is and what it does.

Boredom appears to occur when someone’s current situation is not causing any other emotional response. There are three situations where this lack can occur: when emotions fade, such as the happiness of a new car fading to neutral; when people don’t care about anything in their current situation, such as being at a large party where nothing interesting is happening; or when people have no goals. Boredom does not necessarily set in just because nothing is happening – someone with a goal of relaxation might feel quite content sitting quietly with no stimulation.

Psychology researchers think that the benefit of boredom in situations where people are not responding emotionally is that it prompts making a change. If nothing in your current situation is worth responding to, the aversive experience of boredom can motivate you to seek new situations or change the way you’re thinking. Boredom has been related to more risk seeking, a desire for novelty, and creative thinking. It seems to function like an emotional stick, nudging people out of their current situation to explore and create.

Using the toolkit

People want to be happy. But research is finding that a satisfying and productive life includes a mix of positive and negative emotions. Negative emotions, even though they feel bad to experience, can motivate and prepare people for failure, challenges, threats and exploration.

Pleasant or not, your emotions can help guide you toward better outcomes. Maybe understanding how they prepare you to handle various situations will help you feel better about feeling bad.

This article first appeared on The Conversation.

In the largest study of its kind, scientists have discovered that a blood test detecting specific proteins could predict dementia up to 15 years before a person receives an official diagnosis.

The researchers found 11 proteins that have a remarkable 90% accuracy in predicting future dementia.

Dementia is the UK’s biggest killer. Over 900,000 people in the UK are living with the memory-robbing condition, yet less than two-thirds of people receive a formal diagnosis. Diagnosing dementia is tricky and relies on various methods.

These include lumbar punctures (to look for certain telltale proteins in the cerebrospinal fluid), PET scans and memory tests. These methods are invasive, time-consuming and expensive, putting a heavy burden on the the National Health Service.

This means that many people are only diagnosed when they have memory and cognitive problems. By this point, the dementia may have been progressing for years and any support or health plan may be too late.

Those with undiagnosed dementia, and their families, cannot attend clinical trials, have an organised healthcare plan or access essential support. So improving dementia diagnosis would provide earlier support and give patients a longer, healthier and more prosperous life.

In this latest study, researchers at the University of Warwick in England and Fudan University in China examined blood samples from 52,645 healthy volunteers from the UK Biobank genetic database between 2006 and 2010. Over the ten- to 15-year follow-up period, around 1,400 developed dementia.

The researchers used artificial intelligence and machine learning to analyse 1,463 proteins in the blood. They identified 11 proteins associated with dementia, of which four could predict dementia up to 15 years before a clinical diagnosis.

When combining this data with more regular risk factors of age, sex, education and genetics, the dementia prediction rate was around 90%.

These proteins found in the plasma (the liquid component of blood) are biological markers for the changes that occur in dementia sufferers over a decade before clinical symptoms first appear. They act as warning signs of the disease.

Why these proteins

The four proteins most strongly associated with all-cause dementia, Alzheimer’s disease (accounting for 70% of all dementias) and vascular dementia (accounting for 20%) are GFAP, NEFL, GDF15 and LTBP2.

Scientists showed GFAP to be the best “biomarker” for predicting dementia. GFAP’s function is to support nerve cells called astrocytes.

A symptom of Alzheimer’s disease is inflammation, and this causes astrocytes to make a lot of GFAP. Consequently, people with dementia display increased inflammation, resulting in higher levels of GFAP, making it a prominent biomarker.

The study showed that people with higher GFAP were more than twice as likely to develop dementia as people with low levels. Smaller studies have also identified GFAP to be a potential marker for dementia.

NEFL is the second protein that is most strongly associated with dementia risk. This protein relates to nerve fibre damage. Combining NEFL or GFAP with demographic data and cognitive tests significantly improves the accuracy of dementia prediction.

Proteins GD15 and LTBP2, both involved in inflammation, cell growth and death, and cellular stress, are also strongly linked to increased dementia risk.

But despite the study’s discovery, other scientists warn that the new biomarkers require further validation before they can be used as a screening tool.

The bigger picture

Other initiatives are also promoting the adoption of blood tests as a widespread screening method in diagnosing dementia, including the Blood Biomarker Challenge, a five-year project aiming to use NHS blood tests to diagnose diseases that lead to dementia by looking at traces of brain proteins leaked into the bloodstream.

The exciting advent of new dementia drugs such as lecanemab and donanemab, not yet approved for use in the UK, has the potential to slow the progression of Alzheimer’s disease.

Patients seeking lecanemab or donanemab treatment would require an early-stage diagnosis of Alzheimer’s disease. Alzheimer’s Research UK estimates that only 2% of patients undergo such diagnostic testing.

The study shows that blood tests are an effective way to detect dementia early by identifying specific proteins, providing the patient with the best possible opportunity to receive life-changing treatment.

Early diagnosis of dementia would result in a more effective treatment. A simple blood test has the potential to replace the costly, time-consuming and invasive tests currently used for dementia patients, ultimately improving the quality of many lives.

Rahul Sidhu is PhD Candidate, Neuroscience, University of Sheffield.

This article was first published on The Conversation.

Dry scalp? Blocked ears? Crusted eyes? Our bodies produce many different unusual, sometimes repellent secretions, and their function doesn’t always seem entirely clear. But each has their own important role, which often goes unappreciated.

Flaky or dry scalp is an extremely common condition, but in severe cases it certainly doesn’t feel trivial. Put aside notions that it’s a factor of poor hygiene – the underlying cause is not completely clear, but it may be exacerbated by hair care regimes which dry or irritate the scalp. What is known is that flakes of dandruff are comprised of cell complexes, arising from sloughed off skin.

The outermost layer of the skin (the epidermis) is comprised in part of dead cells, that act as an essential protective barrier. Dead cells shed more easily, and will be replaced with new ones as skin constantly regenerates and grows. If this happens at too great a rate, the result is dandruff.

The first measure is to try an over the counter anti-dandruff shampoo. These contain antifungal and anti-inflammatory compounds both understood to have dandruff healing properties since fungi and inflammation are believed to be potential factors in the development of a crusty scalp. These compounds – selenium and coal tar for instance – can also help relieve the symptoms of itch which may often prove worse than the flaking.

It’s worthwhile trying a different formula if the first doesn’t work. Certain conditions like psoriasis and eczema can also be the underlying cause, and may require alternative treatment.

Scabs function beautifully

Scabs are the body’s natural response to being wounded. Cuts, punctures or breaks in the skin open up blood vessels to the atmosphere around us. In response, the bloodstream recruits its clotting agents – the platelets – to help plug the gap. Platelets bring blood cells together to form a clot, creating a bung to stop bleeding, and prevent bacteria shifting from the skin into the circulation, where they can do more damage. When the clot dries out, a scab is formed.

Scabs can look horrible, but don’t worry – they’re meant to. Sometimes pus forms which can give scabs a yellow rather than reddish-brown colour, and might suggest that an infection is brewing. Redness of the uninjured skin around and tracking away from the scab is another telltale sign of possible infection too.

Resist the temptation to pick off a scab from the skin, no matter how tempting it may seem. They may be unsightly, or itchy, but they’re performing the job they’re supposed to – keeping out bugs and allowing wounds to heal. Take good care of them instead, by keeping them untouched and clean, and wait for them to shed themselves.

The eyes have it

Sleep sand. Eye bogies. Doze dust. The debris we find in the corners of our eyes each morning goes by many different names. Few of us know exactly what it is, why it’s there, or its scientific name, rheum.

Tears lubricate the exposed surface of the eyes, stopping them from getting dry and sore. They also hose away grit and dust and have natural antibacterial properties to fight infections.

But our eyes make more than just tears. The lids have many little glands which discharge natural oily substances allowing tears to spread evenly across the eye and prevent them evaporating away. In addition, mucus-secreting glands, much like those in the nose that make snot, make a thin mucus which also helps to trap and eliminate rogue particles.

In large amounts, oil and mucus can irritate the eyes, but normally get swept away by tears and blinking during the day. By night, our eyes remain shut and rheum builds up. Whether they take on the appearance of sticky bogies or crusts depends on how dry they get overnight, and may be proportional to how long you sleep.

(Ear) waxing lyrical

Ear wax is a largely invisible entity – more often felt than seen. Notice a feeling of blocked or congested ears, or a smothered sense of hearing, and the wax in your ears might be becoming problematic.

It also has a clinical name – cerumen. In part, it’s made of oils and sweat from glands lining the ear canal. The majority of ear wax though is keratin, the natural protein that toughens skin, hair and nails. This is because the ear canal is lined with skin, all the way up to the ear drum. In mixing with the secretions, shed skin produces a waxy substance ranging in colours across the brown spectrum.

Fresh, healthy earwax tends to be yellow to honey-brown in colour, whereas older, thicker earwax becomes darker brown, sometimes even black. Notice red or green staining, then blood or bacteria may be mixing with the wax. Among other diagnoses, this raises the possibility of an ear infection, especially if there’s also a runny or foul-smelling discharge.

Like many of the other bodily secretions, cerumen also traps debris and other nasties (even insects) that could irritate or damage the delicate ear drum. But problems arise if the wax builds up or hardens too much, blocking conduction of sound to the drum, and dampening your hearing.

Nothing smaller than an index finger (with well-trimmed nails) should ever go in your ear canal. Stop cleaning with cotton buds too. All this does is compress cerumen into little impacted cakes. Instead, medicinal olive oil from the pharmacy can help soften it down, making it easier for the ear to clear it naturally.

Blood, sweat and tears – and wax, skin and mucus – can cause many commonplace issues. But look beyond these minor ailments and be grateful that they’re there. You’d be sorry if they weren’t.

This article first appeared on The Conversation.

A health manifesto released by the Indian Medical Association ahead of this year’s Lok Sabha election has raised concerns about the present state of the country’s drug regulatory system, inadequate government spending on health and high out-of-pocket expenditure that is pushing more people into poverty.

The manifesto, released on February 8, also flagged rising antimicrobial resistance and gaps in the functioning of the government-funded Pradhan Mantri Jan Arogya Yojana.

The Indian Medical Association, an umbrella body of 3.6 lakh allopathic doctors, has submitted the manifesto to all major political parties, including the Bharatiya Janata Party, Indian National Congress, Trinamool Congress, Aam Aadmi Party, Nationalist Congress Party, and Samajwadi Party with the aim to push healthcare concerns higher on political parties’ agendas.

IMA releases health manifesto for 2050

Indian medical association released health manifesto targeting better health parameters by 2050 in a meeting of members of the parliament which was held at New Delhi on 7 th Feb 2024 pic.twitter.com/Jqu6mIlaRa

— Indian Medical Association (@IMAIndiaOrg) February 8, 2024

The manifesto noted that India’s overall health spending (public and private) – estimated to be 3.8% of the country’s gross domestic product – is lower than most low and middle income countries, where the average share of health spending is around 5.2% of the gross domestic product.

“India’s health system is overwhelmingly financed by out-of-pocket [OOP] expenditures incurred by households,” the manifesto said. “…Government funding, provided by both the central and state governments, currently constitutes approximately one-third of all health spending, with states accounting for nearly two-thirds of total government health expenditure.”

Urging political parties to focus more on healthcare and increase spending on it, the Indian Medical Association also drew their attention towards the country’s weak drug control infrastructure.

In the last two years, India has come under the spotlight due to allegations of spurious or adulterated drugs causing deaths in other countries. In 2022, over 70 children died in The Gambia allegedly because of toxic cough syrup made in India. Later that year, 18 children died in Uzbekistan after consuming cough syrup made by an Indian firm, while in 2023, multiple people in Sri Lanka lost their vision allegedly due to Indian-made eye drops.

The Indian Medical Association said India currently faces a shortage of drug testing facilities and drug inspectors, lacks uniformity in drug enforcement, and lacks adequate monitoring of manufacturers and their compliance with good manufacturing practices.

Also read: India’s cough syrup testing regime has a deadly blind spot

Expand health insurance scheme in private sector, says IMA

The Pradhan Mantri Jan Arogya Yojana, a government-funded insurance scheme that was launched by Prime Minister Narendra Modi in 2018, provides a cover of Rs 5 lakh for treatment in empanelled hospitals. So far, 31 crore people have been issued cards under the scheme, and six crore out of them have benefited from it.

The scheme has 29,607 empanelled hospitals, of which 12,572 are private-run ones and 17,035 are government-run ones.

The Indian Medical Association said that the government is diverting more funds under the scheme to government hospitals, which already provide free treatment to patients. It suggested that the scheme should instead be expanded in private hospitals, which cater to a larger population and can provide more beds for treatment.

“PMJAY should be exclusively used for strategic purchase from private sector,” the medical association said. “Pricing of services should be based on independent scientific costing in district level basis.”

The organisation also said there was a need to revisit the prices paid to hospitals under the current insurance scheme.

Medical colleges

Data from the Indian Medical Association indicates that 1,08,915 students enrolled in 706 medical colleges get MBBS degrees each year in the country. “This is posing a huge challenge for quality maintenance in our medical colleges,” its manifesto said.

Scroll had previously reported on how the BJP-led government is on a spree to construct new medical colleges without ensuring adequate teaching staff. The Indian Medical Association has raised concerns on similar lines, and said that the National Medical Commission Act, 2019, needs “to be amended to incorporate a provision to support medical education through accruable developmental funds by the government”.

Also read: Maharashtra proves race to build new medical colleges is no fix for Indian healthcare

Needs of senior citizens

By 2050, the number of people aged 60 years or more is expected to rise to almost 20% of the total population, according to the Indian Medical Association. “This change is likely to result in a rise in the prevalence of conditions like dementia,” the organisation noted. “At present, approximately 8.8 million Indians aged 60 years or older are living with dementia, which is considered an emerging epidemic.”

The Indian Medical Association has urged political parties to create specialised units for geriatric care in tertiary hospitals and to integrate geriatric medicine into the medical curriculum. It has also called for a strong policy to treat non-communicable diseases among senior citizens.

The focus of the government’s non-communicable diseases programme – that deals with cancer, heart ailments and diabetes – is currently on young adults, not older citizens.

Once considered one of the best in the region, Sri Lanka's healthcare system is ailing, laid low by the exodus of hundreds of doctors and, with patients left languishing, experts are calling on the government to act to stop the loss of talent.

More than 1,700 medical officers – an umbrella term for doctors and other healthcare professionals –have left Sri Lanka over the past two years, according to the Government Medical Officers’ Association trade union, which shared data exclusively with Context.

This compares to the departure of around 200 doctors and other health workers in 2021. The latest exodus has dealt a heavy blow to the island nation's much-praised universal health system on which most of its 22 million people depend.

“It is very sad to see the lack of doctors. The little support we had is slipping away,” said Srimal Nalaka, 47, who had been waiting for six hours for his monthly diabetes checkup at a state-run hospital south of the commercial capital Colombo.

“The economic crisis has hit us all, but for those of us with health issues the impact is even more severe,” said Nalaka, who has a diabetic ulcer on his right leg.

The worst may be yet to come.

A health ministry report, also shared exclusively with Context, showed that 4,284 doctors obtained “Good Standing” certificates – considered mandatory to verify an individual's professional status to foreign regulators – from the Medical Council between June 2022 and July 2023, indicating that they too are thinking about leaving.

The same report also revealed that more than 5,000 doctors had acquired medical licences from Britain, Australia and countries in the Middle East, and a similar number have reserved slots for foreign licensing exams this year and in 2025.

More than two million Sri Lankans have left the country to work or study abroad since 2022, when the country defaulted on its debt and sank into its worst financial crisis in more than seven decades.

And while the economy is clawing its way back towards recovery, the healthcare system is still poorly, with ever-longer waiting lists and a lack of access to quality treatment and medicines in a country with 1.2 doctors per 1,000 people, according to World Bank data from 2021.

Chamil Wijesinghe, a Government Medical Officers’ Association spokesperson, said hospitals were already severely strained before the financial crisis.

“We are urging the president and the government to take greater responsibility for the lives of innocent citizens. Urgent measures and policies are needed to retain the existing doctors,” said Wijesinghe.

“But the government is comatose.”

The federal health ministry did not respond to requests for comment on the concerns raised by the Government Medical Officers’ Association.

No money, no treatment

President Ranil Wickremesinghe has already put forward the idea of seeking compensation from the countries that recruit Sri Lankan doctors. Last August, he asked the government to raise the issue with the World Health Organization.

When asked about progress on the president's request, Palitha Mahipala, the secretary to the ministry of health, said the issue had to be handled with careful consideration and diplomacy.

Last year, Wickremesinghe also reversed an earlier order that reduced the retirement age of public employees, including doctors, from 65 to 60 to ease staff shortages. And in January, the cabinet approved his proposal to double the Disturbance, Availability & Transport allowance for doctors.

This action, however, triggered a strike in February after trade unions unsuccessfully lobbied for the allowance to be extended to other healthcare workers as well.

The challenge of keeping talented, expensively trained medical professionals at home is not unique to Sri Lanka. In many African countries, notably Nigeria and Zimbabwe, poor pay and difficult working conditions have driven doctors and nurses to seek employment abroad.

Zimbabwe’s Vice President Constantino Chiwenga has even announced plans to criminalise the foreign recruitment of health staff, and says it is wrong that Zimbabwe spends vast sums training health workers only for them to be poached by richer countries.

In Sri Lanka, where medical studies are publicly funded, it takes seven years to become a medical officer and up to 15 years to train as a specialist doctor.

Wijesinghe of the Government Medical Officers’ Association said the authorities have to make it more attractive for doctors to stay. The Government Medical Officers’ Association presented an eight-point proposal to the president last October, with the key focus on improving salaries, benefits, incentives, and facilities for doctors.

In the meantime, low-income households are suffering most because they cannot afford private care or increasingly expensive medicines.

For RS Siva, a 72-year-old retired engineer, the lack of specialist doctors at a government hospital meant he had to dip into his savings to pay for private care to have an operation on a small bowel obstruction.

“If I had no savings for a medical emergency like this, I wouldn't be alive today,” he said.

“The daily rate for the private room was 100,000 rupees ($319), and the doctor charged 500,000 rupees ($1,596) for the surgery alone,” he said as he recovered at home.

Long-term effects

For many Sri Lankans, these costs are prohibitive, leaving them dependent on the public sector, which provides nearly 95% of in-patient care and about 50% of out-patient care.

Aside from the immediate effects on staffing at hospitals, the brain drain will also hit education.

Medical experts warn that with more skilled healthcare workers flying out, there will be significant gaps in mentoring and training medical students.

A health ministry panel, which compiled the report on those leaving, found that fewer doctors were taking part in selection examinations for postgraduate training, meaning there would be fewer consultants in the future.

It added that a “considerable number” of doctors, who had initially enrolled in post-graduate training programmes, had dropped out of their courses.

Sirimal Abeyratne, the head of the department of economics at the University of Colombo, said there was no quick fix to the brain drain and its disproportionate effects on the poorest.

“No overnight policy changes can solve this issue. In Sri Lanka, the exit door is open, but our entrance is closed. Our labour market is not open to foreign talent,” he said.

Nalaka, who runs a small grocery store, said doctors should give their country a second chance.

“I have to choose between putting food on the table and buying insulin,” he said. “We need solutions that keep our doctors here, caring for us at home.”

This article first appeared on Context, powered by the Thomson Reuters Foundation.

If you’re one of the one in three Australians whose New Year’s resolution involved losing weight, it’s likely you’re now contemplating what weight-loss goal you should actually be working towards.

But type “setting a weight loss goal” into any online search engine and you’ll likely be left with more questions than answers.

Sure, the many weight-loss apps and calculators available will make setting this goal seem easy. They’ll typically use a body mass index calculator to confirm a “healthy” weight and provide a goal weight based on this range.

Your screen will fill with trim-looking influencers touting diets that will help you drop ten kilos in a month, or ads for diets, pills and exercise regimens promising to help you effortlessly and rapidly lose weight.

Most sales pitches will suggest you need to lose substantial amounts of weight to be healthy – making weight loss seem an impossible task. But the research shows you don’t need to lose a lot of weight to achieve health benefits.

Using BMI

We’re a society fixated on numbers. So it’s no surprise we use measurements and equations to score our weight. The most popular is BMI, a measure of our body weight-to-height ratio.

BMI classifies bodies as underweight, normal (healthy) weight, overweight or obese and can be a useful tool for weight and health screening.

But it shouldn’t be used as the single measure of what it means to be a healthy weight when we set our weight-loss goals. This is because it:

• fails to consider two critical factors related to body weight and health – body fat percentage and distribution

• does not account for significant differences in body composition based on gender, ethnicity and age.

Health benefits

Losing just 5%-10% of our body weight – between 6 kg and 12kg for someone weighing 120kg – can significantly improve our health in four key ways.

1. Reducing cholesterol

Obesity increases the chances of having too much low-density lipoprotein (LDL) cholesterol – also known as bad cholesterol – because carrying excess weight changes how our bodies produce and manage lipoproteins and triglycerides, another fat molecule we use for energy.

Having too much bad cholesterol and high triglyceride levels is not good, narrowing our arteries and limiting blood flow, which increases the risk of heart disease, heart attack and stroke.

But research shows improvements in total cholesterol, LDL cholesterol and triglyceride levels are evident with just 5% weight loss.

2. Lowering blood pressure

Our blood pressure is considered high if it reads more than 140/90 on at least two occasions.

Excess weight is linked to high blood pressure in several ways, including changing how our sympathetic nervous system, blood vessels and hormones regulate our blood pressure.

Essentially, high blood pressure makes our heart and blood vessels work harder and less efficiently, damaging our arteries over time and increasing our risk of heart disease, heart attack and stroke.

Like the improvements in cholesterol, a 5% weight loss improves both systolic blood pressure (the first number in the reading) and diastolic blood pressure (the second number).

A meta-analysis of 25 trials on the influence of weight reduction on blood pressure also found every kilo of weight loss improved blood pressure by one point.

3. Reducing risk for type 2 diabetes

Excess body weight is the primary manageable risk factor for type 2 diabetes, particularly for people carrying a lot of visceral fat around the abdomen (belly fat).

Carrying this excess weight can cause fat cells to release pro-inflammatory chemicals that disrupt how our bodies regulate and use the insulin produced by our pancreas, leading to high blood sugar levels.

Type 2 diabetes can lead to serious medical conditions if it’s not carefully managed, including damaging our heart, blood vessels, major organs, eyes and nervous system.

Research shows just 7% weight loss reduces risk of developing type 2 diabetes by 58%.

4. Reducing joint pain and the risk of osteoarthritis

Carrying excess weight can cause our joints to become inflamed and damaged, making us more prone to osteoarthritis.

Observational studies show being overweight doubles a person’s risk of developing osteoarthritis, while obesity increases the risk fourfold.

Small amounts of weight loss alleviate this stress on our joints. In one study each kilogram of weight loss resulted in a fourfold decrease in the load exerted on the knee in each step taken during daily activities.

Focus on long-term habits

If you’ve ever tried to lose weight but found the kilos return almost as quickly as they left, you’re not alone.

An analysis of 29 long-term weight-loss studies found participants regained more than half of the weight lost within two years. Within five years, they regained more than 80%.

When we lose weight, we take our body out of its comfort zone and trigger its survival response. It then counteracts weight loss, triggering several physiological responses to defend our body weight and “survive” starvation.

Just as the problem is evolutionary, the solution is evolutionary too. Successfully losing weight long-term comes down to:

• losing weight in small manageable chunks you can sustain, specifically periods of weight loss, followed by periods of weight maintenance, and so on, until you achieve your goal weight

• making gradual changes to your lifestyle to ensure you form habits that last a lifetime.

Setting a goal to reach a healthy weight can feel daunting. But it doesn’t have to be a pre-defined weight according to a “healthy” BMI range. Losing 5%-10% of our body weight will result in immediate health benefits.

Nick Fuller is Charles Perkins Centre Research Program Leader, University of Sydney.

This article was first published on The Conversation.

Ayushman Bharat

In its 2014 election manifesto, the Bharatiya Janata Party promised to frame a new health policy for India and to initiate a national health assurance mission to ensure universal health coverage in the country.

In 2017, it drafted the National Health Policy which signalled a shift from a public healthcare model focused on government-run hospitals to an insurance-based model.

Since 2018, the government has been providing health insurance up to Rs 5 lakh per family per year under the Pradhan Mantri Jan Arogya Yojana. An analysis showed private hospitals empanelled under the scheme are admitting fewer patients than government hospitals.

The insurance scheme also failed to deliver during the Covid-19 pandemic: only 11.9 % of eligible patients received free treatment when hospitalised.

As part of the National Health Policy, the government also announced that it would set up health and wellness centres to provide an expanded range of services over and above primary health centres. So far 1.5 lakh such centres have been set up. But not every centre provides yoga, oral care, palliative care, screening for mental health, or basic management of non-communicable diseases as the guidelines for such centres promise.

Health spending

The National Health Policy of 2017 recommended that the overall government expenditure on public health should be at least 2.5% of GDP. From 1.13% of the GDP in 2014-’15, the government spending on health rose to 2.1% of the GDP in 2022-’23. However, the share allocated to the health ministry in the Union budget remained the same at 1.9% during this period.

Out-of-pocket expenditure – the health expenses borne by patients – is considered a major indicator of a country’s success at providing affordable healthcare to its people. India has a higher out-of-pocket expenditure as a percentage of current health expenditure than countries like Ghana, Bhutan, Indonesia, Maldives, Sri Lanka, according to the World Health Organization.

The average out-of-pocket expenditure in India declined from Rs 3,197 in 2015-’16 to Rs 2,916 in 2019-’21. Comparable data is not available for the previous decade.

All India Institutes for Medical Sciences

In 2014, the BJP promised to set up All India Institutes for Medical Sciences, or AIIMS, in every state. Delhi has the oldest such specialised medical college.

In the past decade, the Modi government has established 15 new AIIMS. Many, however, are functioning with limited services in the out-patient and inpatient departments.

Medical colleges

In 2014, India had 387 medical colleges for 806 districts. The BJP government has increased the number to 706 medical colleges. But many new colleges lack doctors and other staff, forcing patients to travel long distances to access older, overcrowded hospitals.

In 2022-’23, all 246 medical colleges surveyed by the National Medical Council failed to meet 50% teacher attendance.

Malnutrition

The past decade has seen Indian children fare worse on some malnutrition indicators as per the National Family Health Surveys.

In the 2015-’16 survey, among children below the age of five, 7.5%% were severely wasted or had less weight for their height. This increased to 7.7% % by 2019-’21.

In the same age group, the incidence of obesity has risen from 2.1% to 3.4% during the same period.

The percentage of stunted children or those with low height for their age has reduced marginally from 38.4% in 2015-’16 to 35.5% in 2019-’21.

The BJP had promised full vaccination coverage for children and pregnant women by 2022. The latest data shows 76.4% children aged below two are fully vaccinated.

Alternative medicine

The Modi government has invested heavily in ayurveda, unani, siddha, and homoeopathy as promised in the BJP manifesto. In 2014, a separate ministry was created for traditional medicine.

The budgetary allocation for the Ayush ministry has increased at a faster pace than the health ministry. In 2023-’24, it was allocated Rs 3,647 crore in 2023-’24, an increase of 20% from the previous year.

Telemedicine

In 2019, the Modi government launched a telemedicine service called e-Sanjeevani, which claims to have served 19.3 crore people so far.

Many government doctors, however, said the pressure to meet daily targets had forced them to falsify records to show patients they saw in person as telemedicine consultations.

Disease control

The BJP’s promise to end diarrhoea remains pending. Nearly 8% of children surveyed in 2019-’20 had suffered from the disease that year.

The national mosquito control mission that the BJP promised to set up in its 2014 manifesto, is yet to be launched.

In its 2019 manifesto, the BJP promised to eliminate tuberculosis. For this, India would have to reduce TB prevalence to one case per million population. India currently has 188 cases per lakh population. In 2020, TB is estimated to have killed 4.93 lakh Indians.

Read more: A decade under Modi

Forgetting in our day to day lives may feel annoying or, as we get older, a little frightening. But it is an entirely normal part of memory – enabling us to move on or make space for new information.

In fact, our memories aren’t as reliable as we may think. But what level of forgetting is actually normal? Is it OK to mix up the names of countries, as US president Joe Biden recently did? Let’s take a look at the evidence.

When we remember something, our brains need to learn it (encode), keep it safe (store) and recover it when needed (retrieve). Forgetting can occur at any point in this process.

When sensory information first comes in to the brain we can’t process it all. We instead use our attention to filter the information so that what’s important can be identified and processed. That process means that when we are encoding our experiences we are mostly encoding the things we are paying attention to.

If someone introduces themselves at a dinner party at the same time as we’re paying attention to something else, we never encode their name. It’s a failure of memory (forgetting), but it’s entirely normal and very common.

Habits and structure, such as always putting our keys in the same place so we don’t have to encode their location, can help us get around this problem.

Rehearsal is also important for memory. If we don’t use it, we lose it. Memories that last the longest are the ones we’ve rehearsed and retold many times (although we often adapt the memory with every retelling, and likely remember the last rehearsal rather than the actual event itself).

In the 1880s, German psychologist Hermann Ebbinghaus taught people nonsense syllables they had never heard before, and looked at how much they remembered over time. He showed that, without rehearsal, most of our memory fades within a day or two.

However, if people rehearsed the syllables by having them repeated at regular intervals, this drastically increased the number of syllables that could be remembered for more than just a day.

This need for rehearsal can be another cause of every day forgetting, however. When we go to the supermarket we might encode where we park the car, but when we enter the shop we are busy rehearsing other things we need to remember (our shopping list). As a result, we may forget the location of the car.

However, this shows us another feature of forgetting. We can forget specific information, but remember the gist.

When we walk out of the shop and realise that we don’t remember where we parked the car, we can probably remember whether it was to the left or right of the shop door, on the edge of the car park or towards the centre though. So rather than having to walk round the entire car park to find it, we can search a relatively defined area.

Impact of ageing

As people get older, they worry about their memory more. It’s true that our forgetting becomes more pronounced, but that doesn’t always mean there’s a problem.

The longer we live, the more experiences we have, and the more we have to remember. Not only that, but the experiences have much in common, meaning it can become tricky to separate these events in our memory.

If you’ve only ever experienced a holiday on a beach in Spain once you will remember it with great clarity. However, if you’ve been on many holidays to Spain, in different cities at different times, then remembering whether something happened in the first holiday you took to Barcelona or the second, or whether your brother came with you on the holiday to Majorca or Ibiza, becomes more challenging.

Overlap between memories, or interference, gets in the way of retrieving information. Imagine filing documents on your computer. As you start the process, you have a clear filing system where you can easily place each document so you know where to find it.

But as more and more documents come in, it gets hard to decide which of the folders it belongs to. You may also start putting lots of documents in one folder because they all relate to that item.

This means that, over time, it becomes hard to retrieve the right document when you need it either because you can’t work out where you put it, or because you know where it should be but there are lots of other things there to search through.

It can be disruptive to not forget. Post traumatic stress disorder is an example of a situation in which people can not forget. The memory is persistent, doesn’t fade and often interrupts daily life.

There can be similar experiences with persistent memories in grief or depression, conditions which can make it harder to forget negative information. Here, forgetting would be extremely useful.

Decision making

So forgetting things is common, and as we get older it becomes more common. But forgetting names or dates, as Biden has, doesn’t necessarily impair decision making. Older people can have deep knowledge and good intuition, which can help counteract such memory lapses.

Of course, at times forgetting can be a sign of a bigger problem and might suggest you need to speak to the doctor. Asking the same questions over and over again is a sign that forgetting is more than just a problem of being distracted when you tried to encode it.

Similarly, forgetting your way round very familiar areas is another sign that you are struggling to use cues in the environment to remind you of how to get around. And while forgetting the name of someone at dinner is normal, forgetting how to use your fork and knife isn’t.

Ultimately, forgetting isn’t something to fear – in ourselves or others. It is usually extreme when it’s a sign things are going wrong.

Alexander Easton is Professor of Psychology, Durham University.

This article was first published on The Conversation.

Dietary supplements are a big business. The industry made almost US$39 billion in revenue in 2022, and with very little regulation and oversight, it stands to keep growing.

The marketing of dietary supplements has been quite effective, with 77% of Americans reporting feeling that the supplement industry is trustworthy. The idea of taking your health into your own hands is appealing, and supplements are popular with athletes, parents and people trying to recover more quickly from a cold or flu, just to name a few.

A 2024 study found that approximately 1 in 10 adolescents have used nonprescribed weight loss and weight control products, including dietary supplements.

Notably, that systematic review found that nonprescribed diet pill use was significantly higher than the use of nonprescribed laxatives and diuretics for weight management. These types of unhealthy weight control behaviors are associated with both worsened mental health and physical health outcomes.

As a licensed clinical social worker specialising in treating anxiety disorders and eating disorders and a biomedical research director, we’ve seen firsthand the harm that these supplements can do based on unfounded beliefs. The underregulated market of dietary supplements is setting consumers up to be misled and potentially seriously harmed by these products.

The wild west

The Food and Drug Administration specifies that supplements must contain a “dietary ingredient” such as vitamins, minerals, herbs, amino acids, enzymes, live microbials, concentrates and extracts, among others.

Unfortunately, manufacturers can claim that a product is a supplement even when it doesn’t meet those criteria, such as products containing the drug tianeptine, a highly addictive drug that can mimic the biological action of opioids. Some of these products are labeled as dietary supplements but are anything but.

Products containing kratom, a substance with opioidlike effects, which are sold over the counter in many gas stations, claim to be herbal supplements but are mislabeled.

Under a 1994 law, dietary supplements are classified as food, not as drugs. This means dietary supplements are not required to prove efficacy, unlike drugs. Regulators also don’t take action on a product until it is shown to cause harm.

However, the FDA’s website states that “many dietary supplements contain ingredients that have strong biological effects which may conflict with a medicine you are taking or a medical condition you may have. Products containing hidden drugs are also sometimes falsely marketed as dietary supplements, putting consumers at even greater risk.”

In other words, supplements are regulated as food instead of drugs, even though they can interact with medications and may be laced with hidden drugs not included on the label.

Manufacturers of dietary supplements can make claims about their products that fall into three categories: health claims, nutrient content claims and claims about the product’s function, structure or both, all without needing to provide supporting evidence.

Misbranding and false advertising are rampant with dietary supplements, including false claims of curing cancer, improving immune health, improving cognitive functioning, improving fertility, improving cardiovascular health and, of course, promoting weight loss and weight control.

FDA crackdown

You can find supplements that claim to be good for just about every health condition, concern or goal, so it should be no surprise that there are supplements marketed for weight loss.

In August 2021, the FDA cracked down on some of these weight loss products because of the presence of undeclared drugs. For example, of the 72 products recalled, the drug sibutramine, sold as Meridia, was found in 68 of them.

While the FDA may take further action beyond the recalls, the agency acknowledged that it is not able to test every weight loss supplement for contamination with drugs.

These crackdowns demonstrate some progress, though several issues remain. Warning label placement, ingredients and beliefs based on misleading or false advertising are still highly problematic.

Some weight loss supplements may have FDA warnings on them. Of those that do, the disclaimers are rarely displayed on the front of the product label, so consumers are less likely to see them.

Ingredients in weight loss supplements can and do have adverse effects. They have caused people to be admitted to the emergency room for cardiovascular and swallowing problems, including in young, seemingly healthy people.

Eating disorders

Mental health concerns and eating disorders are on the rise. As a result, researchers are examining unhealthy weight control behaviors, including the use of dietary supplements and how accessible they are to adolescents and children.

People who have eating disorders often suffer related health issues such as bone loss, osteoporosis and vitamin deficiencies. In response, their doctors may prescribe dietary supplements like calcium, vitamin D and nutritional supplement shakes. But these are not the dietary supplements of concern.

The concern is with supplements that promote weight loss, muscle building or both.

People with eating disorders may be attracted to dietary supplements that claim quick and pain-free weight loss or muscle gain. Additionally, dietary supplement users may struggle with an increase in compulsive exercise or other unhealthy weight control behaviors.

Diet pill and supplement use has also been associated with increased risk for developing eating disorders and disordered eating, as well as low self-esteem, depression and substance use. While dietary supplements do not solely cause eating disorders or disordered eating, they are one contributing factor that may be addressed with preventive measures and regulations.

Allure of protein powders, supplements

Protein powders and other fitness supplements also have wide appeal. Research shows that girls are more at risk than boys for using weight loss supplements. But a growing problem in boys is the use of fitness supplements such as protein powder and creatine products, a compound that supplies energy to the muscles.

Use of fitness supplements sometimes signifies a preoccupation with body shape and size. For example, a 2022 study found that protein powder consumption in adolescence was associated with future use of steroids in emerging adulthood.

Protein powders make claims of building lean muscles, while creatine boasts providing energy for short-term, intense exercise.

Protein itself is not harmful at recommended doses. However, protein powders may contain unknown ingredients, such as certain toxins or extra and excessive sugar. They can also be dangerous when used in excess and to replace other foods that possess vital nutrients.

And while creatine can usually be safely used in adults, overuse can lead to health problems and is not recommended for minors. Ultimately, the impact of long-term use of these supplements, especially in adolescents, is unstudied.

Possible solutions

One proposed regulation by researchers at Harvard University includes taxing dietary supplements whose labels tout weight loss benefits.

Another policy recommendation involves banning the sale of dietary supplements and other weight loss products to protect minors from these underregulated and potentially dangerous products.

In 2023, New York successfully passed legislation that banned the sale of these products to minors, while states including Colorado, California and Massachusetts have considered or are considering similar action.

Ultimately, medical professionals recommend that parents and caregivers encourage their children to get protein and vitamins from whole foods instead of turning to supplements and powders. They also recommend encouraging teens to focus on balanced nutrition, sleep and recovery, and a variety of resistance, strength and conditioning training.

Emily Hemendinger is Assistant Professor of Psychiatry, University of Colorado Anschutz Medical Campus.

Katie Suleta is PhD Candidate in Medicine and Health, George Washington University.

This article was first published on The Conversation.

Everyone can agree that exercise is healthy. Among its many benefits, exercise improves heart and brain function, aids in controlling weight, slows the effects of aging and helps lower the risks of several chronic diseases.

For too long, though, one way of keeping fit, aerobic exercise, has been perceived as superior to the other, resistance training, for promoting health when, in fact, they are equally valuable, and both can get us to the same goal of overall physical fitness.

Aerobic exercise such as running, swimming and cycling is popular because it provides great benefits and with ample scientific evidence to back that up.

What has been far less influential to date is that resistance training — whether that’s with dumbbells, weightlifting machines or good old push-ups, lunges and dips — works about as well as aerobic exercise in all the critical areas, including cardiovascular health.

Resistance training provides another benefit: building strength and developing power, which become increasingly important as a person ages.

Building and maintaining muscle strength keeps us springing out of our chairs, maintaining our balance and posture and firing our metabolism, as my colleagues and I explain in a paper recently published by the American College of Sports Medicine.

So, if aerobic exercise and resistance training offer roughly equal benefits, how did we end up with so many runners and cyclists compared to weightlifters?

It was a combination of timing, marketing and stereotyping.

The rise of aerobics

The preference for aerobic exercise dates back to landmark research from the Cooper Centre Longitudinal Study, which played a pivotal role in establishing the effectiveness of aerobics — Dr Ken Cooper invented or at least popularized the word with his book Aerobics, spurring desk-bound Baby Boomers to take up exercise for its own sake.

Meanwhile, resistance training languished, especially among women, due to the misguided notion that weightlifting was only for men who aspired to be hyper-muscular. Charles Atlas, anyone?

Cultural influences solidified the dominance of aerobic exercise in the fitness landscape. In 1977, Jim Fixx made running and jogging popular with The Complete Book of Running. In the 1980s, Jane Fonda’s Complete Workout and exercise shows such as Aerobicize and the 20 Minute Workout helped solidify the idea that exercise was about raising one’s heart rate.

The very word “aerobic,” previously confined to the lexicon of science and medicine, entered popular culture about the same time as leg warmers, tracksuits and sweatbands. It made sense to many that breathing hard and sweating from prolonged, vigorous movement was the best way to benefit from exercising.

All the while, resistance training was waiting for its turn in the spotlight.

The value of resistance

If aerobics has been the hare, resistance training has been the tortoise. Weight training is now coming up alongside and preparing to overtake its speedy rival, as athletes and everyday people alike recognize the value that was always there.

Even in high-level sports training, weightlifting did not become common until the last 20 years. Today, it strengthens the bodies and lengthens the careers of soccer stars, tennis players, golfers and many more.

Rising popular interest in resistance training owes a debt to CrossFit, which, despite its controversies, has helped break down stereotypes and introduced more people, particularly women, to the practice of lifting weights.

It’s important to recognise that resistance training does not invariably lead to bulking up, nor does it demand lifting heavy weights. As our team’s research has shown, lifting lighter weights to the point of failure in multiple sets provides equal benefits.

Strength and ageing

The merits of resistance training extend beyond improving muscle strength. It addresses a critical aspect often overlooked in traditional aerobic training: the ability to exert force quickly, or what’s called power.

As people age, activities of daily living such as standing up, sitting down and climbing stairs demand strength and power more than cardiovascular endurance.

In this way, resistance training can be vital to maintaining overall functionality and independence.

Redefining fitness narrative

The main idea is not to pit resistance training against aerobic exercise but to recognise that they complement each other. Engaging in both forms of exercise is better than relying on one alone. The American Heart Association recently stated that “…resistance training is a safe and effective approach for improving cardiovascular health in adults with and without cardiovascular disease.”

Adopting a nuanced perspective is essential, especially when we guide older individuals who may associate exercise primarily with walking and not realize the limitations imposed by neglecting strength and power training.

Resistance training is not a one-size-fits-all endeavour. It encompasses a spectrum of activities tailored to individual capabilities.

It’s time to redefine the narrative around fitness to make more room for resistance training. It’s not necessary to treat it as a replacement for aerobic exercise but to see it as a vital component of a holistic approach to health and longevity.

By shedding stereotypes, demystifying the process and promoting inclusivity, resistance training can become more accessible and appealing to a broader audience, ultimately leading to a new way to perceive and prioritize the benefits of this form of training for health and fitness.

Stuart Phillips is Professor, Kinesiology, Tier 1 Canada Research Chair in Skeletal Muscle Health, McMaster University.

This article was first published on The Conversation.

Fermentation, one of the oldest food production and preservation techniques, has seen a huge revival in recent years. From craft beers and kombucha to yoghurt, sauerkraut and pickles, fermentation is central to producing these foods and drinks. There are different types of fermentation, one of which is lactic acid fermentation.

Lactic acid (also known as lactate) is best known for the burning sensation we feel in our muscles when exercising, which acts as a signal to the body to lower the intensity of the activity.

When it comes to fermentation and food storage, lactic acid is produced by lactic acid bacteria – necessary for creating a low pH environment that stops food spoiling. Some lactic acid bacteria produce lactic acid only. Others produce lactic acid as well as a wide range of other organic acids, which further acidify and create an environment that’s free of oxygen. Lactobacillus brevis is one such bacterium.

This microorganism, when viewed under the microscope, can be described as rod-shaped with rounded ends. It’s also Gram positive – meaning that it stains an indigo colour when tested using the Gram staining technique. It thrives at a temperature of 30-40 degrees Celsius and a slightly acidic pH (pH 4-6).

Most importantly, it’s a superstar when it comes to fermentation – producing lactic acid, acetic acid and carbon dioxide during the process.

Why might you want a microbe that makes organic acids and carbon dioxide?

One of the several food products where Lactobacillus brevis is naturally found is sauerkraut. Traditionally produced sauerkraut has long been known to be a good source of lactic acid bacteria. These bacteria are also found in pickles, in the tibicos grains used to make kefir and are a natural component of the gut microbiome.

During sauerkraut preparation, Lactobacillus brevis and other lactic acid bacteria, such as Lactococcus and Leuconostoc species, help to ferment cabbage. During this process, the bacteria break down sugars in the cabbage, producing carbon dioxide and lactic acid, giving rise to the unique attributes of this fermented product.

When I open a jar of sauerkraut, I am always pleasantly surprised by the fizzing sound and appearance of the jar contents. It’s the production of the carbon dioxide that results in the impressive effervescence. The lactic acid and acetic acid are responsible for the tangy, slightly sour or acidic taste.

Also, because these are organic acids, they naturally lower the pH of the fermented cabbage – meaning that most contaminating microorganisms that favour a neutral pH will no longer be a part of the environment. Lactic acid bacteria also produce antimicrobial compounds such as bacteriocins, which prevent the growth of other contaminating bacteria. These effects make fermentation an excellent preservation technique.

In terms of gut health, the microbiome is complex. It’s unique to each person and can be influenced by several factors, including diet. Some lactic acid bacteria have been reported as being probiotic – meaning they’re live microorganisms that improve gut health. Also, although sauerkraut is promoted as containing probiotic bacteria, questions remain regarding the viability of these bacteria at the time of consumption – and whether they’re present in sufficient numbers to be beneficial.

Just as the microbiome itself is an ever-changing landscape, so too is this field of research as investigations continue to be carried out. But if you do decide to join me in adding sauerkraut to your diet for its unique taste and texture – and possible health benefits – bon appétit.

Leanne Timpson is Lecturer in Microbiology, Nottingham Trent University.

This article was first published on The Conversation.

Your blood serves numerous roles to maintain your health. To carry out these functions, blood contains a multitude of components, including red blood cells that transport oxygen, nutrients and hormones; white blood cells that remove waste products and support the immune system; plasma that regulates temperature; and platelets that help with clotting.

Within the blood are also numerous molecules formed as byproducts of normal biochemical functions. When these molecules indicate how your cells are responding to disease, injury or stress, scientists often refer to them as biological markers, or biomarkers. Thus, biomarkers in a blood sample can represent a snapshot of the current biochemical state of your body, and analysing them can provide information about various aspects of your health.

As a toxicologist, I study the effects of drugs and environmental contaminants on human health. As part of my work, I rely on various health-related biomarkers, many of which are measured using conventional blood tests.

Understanding what common blood tests are intended to measure can help you better interpret the results. If you have results from a recent blood test handy, please follow along.

Normal blood test ranges

Depending on the lab that analysed your sample, the results from your blood test may be broken down into individual tests or collections of related tests called panels. Results from these panels can allow a health care professional to recommend preventive care, detect potential diseases and monitor ongoing health conditions.

For each of the tests listed in your report, there will typically be a number corresponding to your test result and a reference range or interval. This range is essentially the upper and lower limits within which most healthy people’s test results are expected to fall.

Sometimes called a normal range, a reference interval is based on statistical analyses of tests from a large number of patients in a reference population. Normal levels of some biomarkers are expected to vary across a group of people, depending on their age, sex, ethnicity and other attributes.

So, separate reference populations are often created from people with a particular attribute. For example, a reference population could comprise all women or all children. A patient’s test value can then be appropriately compared with results from the reference population that fits them best.

Reference intervals vary from lab to lab because each may use different testing methods or reference populations. This means you might not be able to compare your results with reference intervals from other labs. To determine how your test results compare with the normal range, you need to check the reference interval listed on your lab report.

If you have results for a given test from different labs, your clinician will likely focus on test trends relative to their reference intervals and not the numerical results themselves.

Interpreting your blood test results

There are numerous blood panels intended to test specific aspects of your health. These include panels that look at the cellular components of your blood, biomarkers of kidney and liver function, and many more.

Rather than describe each panel, let’s look at a hypothetical case study that requires using several panels to diagnose a disease.

In this situation, a patient visits their health care provider for fatigue that has lasted several months. Numerous factors and disorders can result in prolonged or chronic fatigue.

Based on a physical examination, other symptoms and medical history, the health practitioner suspects that the patient could be suffering from any of the following: anemia, an underactive thyroid or diabetes.

Blood tests would help further narrow down the cause of fatigue.

Anemia is a condition involving reduced blood capacity to transport oxygen. This results from either lower than normal levels of red blood cells or a decrease in the quantity or quality of hemoglobin, the protein that allows these cells to transport oxygen.

A complete blood count panel measures various components of the blood to provide a comprehensive overview of the cells that make it up. Low values of red blood cell count, or RBC, hemoglobin, or Hb, and hematocrit, or HCT, would indicate that the patient is suffering from anemia.

Hypothyroidism is a disorder in which the thyroid gland does not produce enough thyroid hormones. These include thyroid-stimulating hormone, or TSH, which stimulates the thyroid gland to release two other hormones: triiodothyronine, or T3, and thyroxine, or T4. The thyroid function panel measures the levels of these hormones to assess thyroid-related health.

Diabetes is a disease that occurs when blood sugar levels are too high. Excessive glucose molecules in the bloodstream can bind to hemoglobin and form what’s called glycated hemoglobin, or HbA1c. A hemoglobin A1c test measures the percentage of HbA1c present relative to the total amount of hemoglobin. This provides a history of glucose levels in the bloodstream over a period of about three months prior to the test.

Providing additional information is the basic metabolic panel, or BMP, which measures the amount various substances in your blood. These include:

• Glucose, a type of sugar that provides energy for your body and brain. Relevant to diabetes, the BMP measures the blood glucose levels at the time of the test.
• Calcium, a mineral essential for proper functioning of your nerves, muscles and heart.
• Creatinine, a byproduct of muscle activity.
• Blood urea nitrogen, or BUN, the amount of the waste product urea your kidneys help remove from your blood. These indicate the status of a person’s metabolism, kidney health and electrolyte balance.

With results from each of these panels, the health professional would assess the patient’s values relative to their reference intervals and determine which condition they most likely have.

Understanding the purpose of blood tests and how to interpret them can help patients partner with their health care providers and become more informed about their health.

This article first appeared on The Conversation.

India is often perceived as a country with a young population, while European and North American populations are regarded as ageing. Although this is true, the country’s demographics are rapidly shifting, according to a United Nations study. And people aged 60 and over are expected to constitute 20% of the population by 2050.

Given this trend, there have been numerous attempts – using different methods – to determine the prevalence of dementia on the subcontinent. A new study, published in PLOS One, suggests that the prevalence of dementia in India is higher than previously thought.

The researchers investigated the number of people with dementia in India by establishing how many people aged 60 and over in the country have a neurocognitive disorder.

Neurocognitive disorders – changes to cognition (thinking) because of a potential underlying brain disorder – are commonly divided into minor and major disorders. Dementia is considered a major neurocognitive disorder, while mild cognitive impairment, a common early stage of dementia, a minor neurocognitive disorder.

The study results showed that nearly one-sixth (17.6%) of people over 59 in India have a mild neurocognitive disorder, while 7.2% have a major neurocognitive disorder.

Extrapolating these estimates to the Indian population over 59 years of age (104 million) suggests that 24 million of those people have potentially mild cognitive impairment, while 9.9 million potentially have dementia.

There are 14.5 million people over 60 in the UK, meaning the dementia rate is about 6.5%, whereas, according to this latest study, the dementia rate in India is about 9.5%. However, the sheer size of the estimates in the study explains why the United Nations is paying closer attention to the ageing and dementia population in India. But how were mild cognitive impairment or dementia established in the study?

Mild cognitive impairment and dementia are commonly based on performance on cognitive tests and whether cognitive changes affect everyday activities.

For mild cognitive impairment, people will have mild cognitive changes, but they do not affect their everyday activities. Whereas for dementia, people will have cognitive changes that will affect their everyday activities.

Within the study, participants were asked to perform cognitive tests and their family members were asked to report changes in their everyday activities. For example, if they had slight memory changes but they did not affect their everyday activity would mean they would be considered to have mild cognitive impairment.

But if they had more significant memory problems and their family reported noticeable changes to their everyday activities, they then would be considered to have dementia.

Shortcomings

Despite cognition and everyday activity being key to dementia diagnostics worldwide, they have significant shortcomings, in particular for assessments in developing countries, such as India.

The main reason for this is that most cognitive tests were developed for literate populations with higher levels of formal education, whereas low formal education and illiteracy remain very prevalent in older and rural populations of developing countries.

For the current study, nearly half of their participants had either no formal education or were illiterate. This, therefore, creates uncertainty if the cognitive changes are because of the lower education or literacy levels of the person being tested or the first signs of dementia.

But what else can we do to determine if someone is either at risk or has dementia?

Blood might be the answer. A simple blood test to determine someone’s risk for dementia has been the holy grail in dementia research for decades. Now such blood tests have become a reality, at least in research studies.

Dementia blood tests are still so new that they have not made it into the clinics, but it seems only a matter of time until these tests will be widely available across memory clinics and doctor’s surgeries.

Having a blood test result might remove the ambiguity of whether changes to cognition are the first signs of dementia or relate to other factors, such as level of formal education.

People in developing countries, such as India, will particularly benefit from such blood tests as the relevance of cognitive changes is then not as important anymore but can be used to support a diagnosis.

It will be interesting to see whether the estimates for mild cognitive impairment and dementia in the populations will change because of the new blood tests, as they might be more specific in determining who really has the disease or is at risk of it. A few drops of blood might change our perceptions of dementia in the future.

This article first appeared on The Conversation.