The liver is one of the hardest working organs in the human body. It detoxifies harmful substances, helps with digestion, stores nutrients, and regulates metabolism.

Despite its remarkable resilience – and even its ability to regenerate – the liver is not indestructible. In fact, many everyday habits, often overlooked, can slowly cause damage that may eventually lead to serious conditions such as cirrhosis (permanent scarring of the liver) or liver failure.

One of the challenges with liver disease is that it can be a silent threat. In its early stages, it may cause only vague symptoms like constant fatigue or nausea.

As damage progresses, more obvious signs may emerge. One of the most recognisable is jaundice, where the skin and the whites of the eyes turn yellow. While most people associate liver disease with heavy drinking, alcohol isn’t the only culprit. Here are five common habits that could be quietly harming your liver.

1. Drinking too much alcohol

Alcohol is perhaps the most well-known cause of liver damage. When you drink, your liver works to break down the alcohol and clear it from your system. But too much alcohol overwhelms this process, causing toxic by products to build up and damage liver cells.

Alcohol-related liver disease progresses in stages. At first, fat begins to accumulate in the liver (fatty liver), often without any noticeable symptoms and reversible if drinking stops. Continued drinking can lead to alcoholic hepatitis, where inflammation and scar tissue begin to form as the liver attempts to heal itself.

Over time, this scarring can develop into cirrhosis, where extensive hardening of the liver seriously affects its ability to function. While cirrhosis is difficult to reverse, stopping drinking can help prevent further damage.

Even moderate drinking, if sustained over many years, can take its toll, particularly when combined with other risk factors like obesity or medication use. Experts recommend sticking to no more than 14 units of alcohol per week, and including alcohol-free days to give your liver time to recover.

2. Poor diet and unhealthy eating habits

You don’t need to drink alcohol to develop liver problems. Fat can build up in the liver due to an unhealthy diet, leading to a condition now called metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD).

Excess fat in the liver can impair its function and, over time, cause inflammation, scarring, and eventually cirrhosis. People who are overweight – particularly those who carry excess weight around their abdomen – are more likely to develop MASLD. Other risk factors include high blood pressure, diabetes and high cholesterol.

Diet plays a huge role. Foods high in saturated fat, such as red meat, fried foods and processed snacks, can raise cholesterol levels and contribute to liver fat accumulation. Sugary foods and drinks are also a major risk factor. In 2018, a review found that people who consumed more sugar sweetened drinks had a 40% higher risk of developing fatty liver disease.

Ultra-processed foods such as fast food, ready meals and snacks packed with added sugar and unhealthy fats also contribute to liver strain. A large study found that people who ate more processed foods were significantly more likely to develop liver problems.

On the flip side, eating a balanced, wholefood diet can help prevent – and even reverse – fatty liver disease. Research suggests that diets rich in vegetables, fruit, whole grains, legumes, and fish may reduce liver fat and improve related risk factors such as high blood sugar and cholesterol.

Staying hydrated is also important. Aim for around eight glasses of water a day to support your liver’s natural detoxification processes.

3. Overusing painkillers

Many people turn to over-the-counter painkillers such as paracetamol for headaches, muscle pain, or fever. While generally safe when used as directed, taking too much – even slightly exceeding the recommended dose – can be extremely dangerous for your liver.

The liver breaks down paracetamol, but in the process, produces a toxic by-product called NAPQI. Normally, the body neutralises NAPQI using a protective substance called glutathione. However, in an overdose, glutathione stores become depleted, allowing NAPQI to accumulate and attack liver cells. This can result in acute liver failure, which can be fatal.

Even small overdoses, or combining paracetamol with alcohol, can increase the risk of serious harm. Always stick to the recommended dose and speak to a doctor if you find yourself needing pain relief regularly.

4. Lack of exercise

A sedentary lifestyle is another major risk factor for liver disease. Physical inactivity contributes to weight gain, insulin resistance, and metabolic dysfunction – all of which can promote fat accumulation in the liver.

The good news is that exercise can benefit your liver even if you don’t lose much weight. One study found that just eight weeks of resistance training reduced liver fat by 13% and improved blood sugar control. Aerobic exercise is also highly effective: regular brisk walking for 30 minutes, five times a week, has been shown to reduce liver fat and improve insulin sensitivity.

5. Smoking

Most people associate smoking with lung cancer or heart disease, but many don’t realise the serious damage it can do to the liver.

Cigarette smoke contains thousands of toxic chemicals that increase the liver’s workload as it tries to filter and break them down. Over time, this can lead to oxidative stress, where unstable molecules (free radicals) damage liver cells, restrict blood flow, and contribute to scarring (cirrhosis).

Smoking also significantly raises the risk of liver cancer. Harmful chemicals in tobacco smoke, including nitrosamines, vinyl chloride, tar, and 4-aminobiphenyl, are all known carcinogens. According to Cancer Research UK, smoking accounts for around 20% of liver cancer cases in the UK.

Love your liver

The liver is a remarkably robust organ – but it isn’t invincible. You can protect it by drinking alcohol in moderation, quitting smoking, taking medications responsibly, eating a balanced diet, staying active and keeping hydrated.

If you notice any symptoms that may suggest liver trouble, such as ongoing fatigue, nausea, or jaundice, don’t delay speaking to your doctor. The earlier liver problems are detected, the better the chance of successful treatment.

Dipa Kamdar is Senior Lecturer in Pharmacy Practice, Kingston University.

This article was first published on The Conversation.

Paul Farmer in Pathologies of Power speaks evocatively of the crossroads at which humankind today finds itself. Healthcare, he observes, can be considered either a “commodity to be sold” or “a basic social right”. It cannot be both at the same time. Which of these pathways we will choose, he declares, is the highly consequential choice that people of goodwill must make “in these dangerous times”. He terms this as “the great drama” of our times.

As this “great drama” plays out in the world today, what choice are policymakers making?

The majority are opting for a significant, even paramount, role for for-profit private health providers in universal healthcare and the statutory right to health care. Their assumption is that the private sector will bring in efficiency, choice, high-quality healthcare and by bridging the resource gaps in public health systems, it will enhance the access of excluded groups. The result of these policy choices is a retreat of the state from direct healthcare provisioning, the crumbling of even the aspiration of a welfare state and the largescale transfer of scarce public funds to the private medical sector.

In this essay, I interrogate the legitimacy of these assumptions. The question I ask is whether there is not inherent in this choice of largescale public health provisioning by large corporate hospitals the potential for grave conflicts of interest? Is there not an intrinsic clash between, on one side, profit-seeking and, on the other, equitable quality healthcare that is based on need and not the capacity to pay?

A challenge literally of life and death for policymakers is to find ways to best bridge the massive chasms between health needs and health access, especially of the poor.

Thinktank Oxfam, in its briefing paper Sick Development, explains that a “poorly evidenced, but largely unchallenged, narrative has emerged that says extending healthcare to those most denied it can be done by funding for-profit, fee-charging healthcare providers and encouraging more private finance, including private equity firms, to do the same”.

The stark and unconscionable reality of our world remains one in which half the world’s population are still excluded from access to even the most essential healthcare. Sixty people every second suffer catastrophic and impoverishing costs paying for healthcare out-of-pocket.

These approaches of placing the life and health of impoverished people in the hands of profit-driven large corporations would be “deeply unpopular in European nations but are being exported to the Global South, with little democratic oversight and with significant taxpayer-backed budgets”, says the briefing paper.

What advocates of private health provisioning wilfully ignore is extensive evidence that for-profit private hospitals frequently block, bankrupt or even detain patients who cannot pay. Commercial and market-based approaches in healthcare can entrench and exacerbate the gap between rich and poor, and between women and men.

They also skew resources away from already under-funded government services while further excluding those who are excluded because they cannot pay or are socially oppressed. For-profit health providers lack incentives to prevent ill-health. Instead, the system hatches perverse incentives to misdiagnose or over-treat.

Policymakers and scholars do admit to the potential for conflicts of interests between profit and care. But the solution that we repeatedly encounter – as we did in our last chapter – is for robust and reliable regulatory systems for holding private health care providers accountable to high professional, ethical and equity standards. The argument is that if a coherent and legally enforceable robust ecosystem of state regulation, legal mandates, legal accountability, transparency and accountability is in place, these – with the active participation of patients and communities – can ensure that private health care providers are kept aligned with right to health goals.

This may sound convincing on paper. However, the reality is that accountability mechanisms on the ground are frequently found to be ineffective due to many reasons, such as weak implementation, fragmentation, and power asymmetries.

Even where formal mechanisms for transparency and accountability are in place, they often fail in practice due to institutional weakness, regulatory capture, legal ambiguity, and the concentration of power among private healthcare actors. State regulators may be underfunded or politically constrained. Courts may defer to legislative silence or interpret contracts narrowly. Local governments often lack autonomy and resources. Patients and families face barriers such as legal illiteracy, fear of reprisal, and inaccessible complaint systems. This is even more the case in low- and middle- income countries where the juggernaut of private corporate healthcare provisioning is most triumphal.

In a salutary way, Oxfam draws attention to the impacts of enormous inequality in power, status and information between provider and patient inherent in healthcare provision. What makes for-profit healthcare different from public healthcare is the perverse incentive for profit-seekers to exploit this inequality for commercial gain. “All of Oxfam’s interviews with patients and their relatives for this research laid bare the brutal reality that exploitation and extortion of patients and carers by for- profit healthcare providers are frighteningly easy, due to the universal willingness of human beings to make infinite sacrifices to save the life of a loved one”.

Besides this rare sense of empowerment of impoverished patients to hold doctors to account, effective regulation of the private health sector requires both resources and robust state capacity. Studies establish that these are scant in low- and even middle-income countries, therefore it is unsurprising that regulation in these countries is often found to be wanting. But the only reasons for weak regulation of the private health sector may not just be that they lack in budgets and capacity.

The even more fundamental constraints may be that there is little political will to hold powerful big business in check. And this may apply not just to low- and middle-income countries, but equally to rich countries. The reality of governments worldwide is of the formidable and ever-growing power of big business in policy making – of what Oxfam describes aptly as “elite capture” of the contemporary neo-liberal state; and, indeed, growing cronyism.

Such elite capture of policy making is pervasive and increasingly normalised. When Donald Trump was sworn in as President of the United States in January 2025, prominent among those in attendance were the world’s three wealthiest people – Tesla CEO and the world’s richest person Elon Musk (worth $433.9 billion), Amazon founder Jeff Bezos (worth $239.4 billion) and Meta’s Mark Zuckerberg ($211.8 billion). Their combined wealth was greater than the entire wealth of half the American population. The early months of Trump’s presidency – at the time I write this – is tarnished by the massive influence that Musk is visibly exercising on public decision-making in the world’s most powerful executive office.

The estimated value of the healthcare industry, including pharmaceutical and medical equipment companies, insurance and corporate hospital chains is a staggering $7 trillion. Health entrepreneurs are entering in growing numbers and power in billionaire lists of the richest people in many countries.

The president of leading health corporations in Brazil – Proparco and Rede D’or – is Brazil’s 10th richest billionaire. Ranjan Pai, controller of British International Investment-backed Manipal Group, saw his real-terms wealth grow by US$1.48bn in just one year alone. The cumulative impact of decades of neo-liberal policies is the effective transfer of power from public institutions to private enterprises.

Public health analyst Amit Sengupta regards that the state’s active role in facilitating the dominance of the private sector in healthcare not just a techno-managerial choice, but the wilful and wanton abdication by the state of its primary duties, by transferring responsibility for universal health care to the for-profit private health sector. Sengupta identifies what he calls “regulatory capture”, in which designated “experts” are drawn in by the state to assist and advise the state on the regulation of the very industries from which the “experts” are drawn.

Against the sobering reality of this landscape of the political economy of much of our world, I am troubled by the assumption that is still widely purveyed by policymakers globally, that states have the power, the capacity and the will to regulate the private health sector, to ensure that they promote the public good rather than private profits. I wonder how effective can we expect regulations and remedies in law to be to actually prevent the conflict between the duty of equitable health provisioning and the corporate pursuit of profit?

Oxfam, in its briefing paper, documents how in Kenya and India patients are imprisoned by private hospitals for not paying their bills. The statutorily mandated right to emergency care is denied. Treatment is impossibly expensive. Patients entitled to free care are instead pushed deep into poverty, being forced to pay high fees to access health services.

During the Covid-19 pandemic, some hospitals acted appallingly, profiteering even more than in normal times from people’s suffering and their fear of this new disease. Oxfam concludes that global and domestic taxpayers’ money is being ploughed into back expensive, for-profit private hospitals that block, bankrupt or even detain patients who cannot pay.

The report tells macabre stories of how a leading private hospital chain in Nairobi, Kenya, did not even release the corpses of patients who died for up to two years if the families could not pay the bills.

A newborn baby was held for three months for the same reason, and her mother would come each day to the hospital to breast-feed her. A schoolboy was held hostage for 11 months until his parents paid the bills.

In Nigeria, a normal child delivery costs as much as nine months’ income for the poorest 50% of Nigerians. A caesarean birth was even more expensive, costing as much as 24 years’ income for the poorest 10%. The bill for one patient who died from the Covid-19 virus in a private hospital in Nigeria cost an incredible US$116,000.

The bottom line is this: Consider a most powerless, excluded woman or girl child – suffering savage discrimination because of her race, caste, religion, sexuality or her undocumented status – who seeks life-saving healthcare from a highly privatised healthcare system dominated by giant and politically powerful corporate hospitals. Can she realistically rely on state regulation of giant private health providers to ensure stoutly her right to high quality health care so her life is saved?

For clues to this question, I will in this essay focus my microscope on the experience of one of the most privatised health care systems in the world, India. Some observers rate this to be the most privatised healthcare systems in the world, surpassing even the United States.

Why is it instructive to look closely at the functioning of India’s private and corporatised health system? The hospital industry accounts for 80% of India’s total healthcare market. India has one of the highest out-of-pocket spending levels on health in the world. Out-of-pocket spending as a proportion of total health spending is a leading cause of impoverishment in India. Thirty-seven per cent of Indians experience catastrophic health expenditures in private hospitals.

The abdication of the state in provisioning healthcare is spectacular. The Economist in 2017 observed that India’s extreme reliance on private healthcare is not ideological as much as the outcome of the reality that “government has done such a lousy job” of providing healthcare.

Over many years, India’s budgetary investment in public health has hovered from 0.8% to 1.1% of the country’s gross domestic product, among the lowest in the world. India stands fifth from the bottom in its public spending on health globally. And too little of even this paltry resource has gone into strengthening public health delivery and particularly into building primary healthcare. China invests three times this abysmal level.

In India’s mixed healthcare system, out-of-pocket spending and the market provision of services predominate. Only a little over a quarter of total health expenditure in India is borne by the state; the rest is out-of-pocket private spending and capital investments by the private sector. As much as 87% of private health spending is by individuals who lack insurance cover. Official data reveals that anything between 55 to 68 million people are pushed into poverty because of private health spending.

Private health care accounts for 80% of all health transactions in India. Eighty out of 100 trained doctors in India work in the private health sector (and this is after a significant number have migrated to countries of the Global North, earning high salaries that spiral further up the benchmark of aspirations of doctors who continue to live and work in India). India ranks 155th out of 167 countries on hospital bed availability. Seventy-two per cent of hospitals and 60% of hospital beds are in the private sector. Eighty per cent of all out-patient health services and 60% of in-patient health services are supplied by the private sector.

A quarter of a total of one million private health enterprises in India are middle to large medical establishments. In 2016, investments in private hospitals and diagnostic centres crossed 4000 million US dollars, including significant foreign capital transfers. Of 425 medical colleges in India, more than half are private medical colleges, accounting for 48% of all MBBS seats, with dizzyingly steep fees. They make large investments in land, buildings and equipment which they recover through sky-high fees. Naturally, the education they offer does little to prepare students for public service.

A common defence of private sector investments in health, often with international aid and financial institutions significantly contributing the capital for these, is that these fill gaps in public health systems resulting from low available public funds.

The Oxfam briefing paper First, Do No Harm, nails the disingenuity, indeed the complete falsehood of these claims. It looks at where large corporate hospitals funded by World Bank’s private sector arm, the International Finance Corporation are located. It finds that these private corporate hospitals have done nothing to bridge the access gaps suffered by impoverished rural populations.

For most private hospitals are concentrated in highly populated urban areas, and that too in the more economically developed states, because this is where more income and therefore profit can be generated. Seventy-eight per cent of the International Finance Corporation direct investee chain hospitals are in Million Plus population cities. Sixty per cent of hospitals are in Tier 1 cities, 35% are in Tier 2 cities and only 4% are in smaller habitations.

Of the 144 hospitals listed on the corporate websites of these chains, only one is in a rural area. Only 14% of the hospitals are in the 10 states ranked lowest in terms of the overall performance of the health system based on the Annual Health Index 2021; and not a single hospital operates in four of these 10 states.

Insurance helps create the mirage that unaffordable healthcare is actually affordable, although studies reveal that not more than 25% Indians can actually afford private insurance. And the net outcome of the state bearing the costs of private insurance of impoverished households is the transfer of scarce public resources to the private sector which arguably could have been better spent on strengthening primary healthcare in the public sector.

The near-complete absence of mechanisms to prevent the conflict of interest in public health policy decision-making (including privatisation and purchase of medical equipment) creates fertile ground for kickbacks and profiteering by health administrators and government doctors. This conflict of interest often veers decision-makers away from choosing optimal, rational and low-cost options.

To map, in some granular detail, how the private health sector actually operates in an environment of low regulation like in India, I will draw partly on inside accounts by seasoned health practitioners, teachers and scholars.

Seventy-eight such ethical doctors came together – many of them working in corporate hospitals choosing to be whistle-blowers – to reflect on the rot that has set into the vocation of health care. Their voices come together in a book titled Dissenting Diagnoses: Voices of Conscience from the Medical Profession, that should be compulsory reading for everyone seeking policy pathways to equitable and ethical healthcare.

A similar sombre account emerges from Healers or Predators? Healthcare Corruption in India. In this book, policy makers, practitioners and public health scholars examine the deep-rooted crisis of the consistent denial of basic healthcare to the overwhelming majority of Indian citizens.

I also draw from reports by Oxfam, a leading global voice for equity in health provisioning, particularly two that closely examine the functioning of private corporate hospitals established by global development aid and international funding institutions, in its briefing papers Sick Development and First, Do No Harm.

The picture that emerges from these searching and brave accounts by health insiders is sordid, terrifying and utterly unconscionable. We see how since the 1990s, in the “whirlwind” of privatisation, public health is consistently starved of funds and investments, and a relatively well-intentioned service-oriented vocation with the public health sector in the commanding heights is transformed first into a market-led commodity, and then into a corporate-led profiteering industry.

Pharmaceutical companies, medical equipment manufacturers, insurance companies, private medical colleges, international vaccine manufacturers, corporate hospitals and diagnostic centres, all join hands to convert health care into a high-premium commodity that becomes intractably inaccessible to the working and destitute poor.

It is not as though corruption was not rampant within public systems and does not continue to be so. But, as Kaveri Gill argues, in the public health sector, redress and reform are conceivably feasible if there is political will. Private sector corruption, on the other hand, appears beyond redress and redemption because corporate power is formidable, the spoils tremendous, corrupt practices pervasive and regulatory mechanisms feeble.

Senior health practitioner Mani also affirms that corruption also characterised public healthcare when it dominated the Indian health scene in the first decades after freedom. There were surgeons who would not operate on patients unless they first met then in their private chambers and paid them a hefty fee. Doctors employed touts in bus stands and railway stations to waylay patients and lure them to their door, for a commission. But he said these were in the past exceptions, condemned by the majority of the medical community.

However today such practices have become the norm. “We advertise ourselves”, he laments. “We employ touts to bring patients to us, we pay commissions to the doctors who send patients to us, we perform unnecessary and expensive tests and accept and even demand cutbacks from the diagnostic laboratories, we prescribe the most expensive of drugs and are rewarded for this by the pharmaceutical industry, and we even abet our patients’ efforts to defraud insurance companies. What will we not stoop to?”

Dr George Mathai, a physician from Alibag similarly grieves that “the very objectives and motivations for joining the medical profession have changed. Nowadays the only reason for joining the medical profession is to make as much money as one can, with as little work as one can get away with”. The personal conduct and ethical practice of doctors have hit new lows, as they prioritise profits over the welfare of patients. The social logic of “patients first” has given way almost fully to “profits first”.

Spurred and bribed by the pharmaceutical industry and owners of corporate hospitals, doctors prescribe unnecessary tests, expensive medicines and redundant, even harmful procedures, all at soaring costs with inflated bills. The result is that patients have to bear unnecessary, sometimes catastrophic expenditures because private hospitals have invidious links with drug manufacturers, pharmacies and middlemen of many kinds, including even autorickshaw drivers.

A senior and highly respected physician Dr Vijay Ajgaonkar bewails the many ethical distortions of the private health sector. Terminally ill 70- and 80-year-olds are kept in ICU and put on ventilators, even when there is no chance of their recovery, only to inflate hospital bills. In the process, they ruin the family and stretch the suffering of the patient. They don’t let him die in peace surrounded by his family members. In the ICU, there are tubes in his nose and mouth: he cannot speak even if he wants to. Even dead patients are sometimes retained on ventilators to further inflate hospital bills. Hospital agents converge like hawks at road accident sites to grab as many patients as they can. Doctors boast later about the numbers of “lambs” they have caught.

Ajgaonkar speaks bitterly of the bribes distributed by pharmaceutical companies, that include holidays abroad, expensive liquor, clothes, even expensive jewellery. The result, for instance, is that insulin that sold for Rs 30 rupees is now priced at Rs 150. Ethically the cost of research had long been recovered so the costs should instead have been reduced. Instead, the price is raised five times!

Many other doctors also report that medicines with no greater benefits than cheaper versions are widely prescribed to benefit the pharmaceutical companies. The companies make small changes in the formula of medicines that carry no additional benefit, then raise the price greatly while withdrawing the cheaper medicine from the market and encouraging doctors to prescribe the expensive version. There is no reason for ethical doctors to not prescribe only generic medicines which would cost them much less. Instead, doctors prescribe expensive antibiotics when cheaper ones would be no less effective.

The plunder of patients does not end here. Hospitals further mark up the costs of medicines in their bills to sometimes five or 10 times the maximum retail price. Even more egregiously, sometimes patients are administered much higher doses of medicines than are required, even risking the health of the patient. Likewise, patients are charged two to five times the price of coronary stents, and experts estimate that nearly a third of all stenting procedures in India are inappropriate.

“Doctors have now become servants of the pharmaceutical companies”, a physician observes dryly. Medical representatives take young doctors under their wings, benefit them materially and “retrain” them to adapt their practices in ways that maximise the company’s profits. They also draw doctors into bogus medical trials.

“One of the tricks played by the corporate hospitals is that they rarely give you a full prescription listing all the medicines”, a patient reported to Oxfam. “The nurse just gives you a slip. That way it is difficult to know the prices they are charging.” Oxfam finds that this problem is widespread in India. Its report refers to recent studies that found that profit margins for medicines, consumables and diagnostics ranged from 100%-1,737% in four of the largest private hospitals in Delhi, and that these items made up almost half the cost of patient bills.

It is noteworthy that the scandalously inflated costs of the doctor-pharmaceutical company nexus are borne entirely by the patient. The patient pays for the medicine, but has no control over the choice of the medicine. It is this monopoly over decision-making that a doctor possesses that is exploited by pharmaceutical companies to maximise their profits at the expense of the powerless patient.

The massive growth of multi-speciality corporate hospitals has metamorphosised health care into a highly lucrative industry. Hospitals have been reinvented from havens of healing and care to oases of luxury and privilege.

Gadre and Shukla observe that with its massive growth with liberalisation and expansion of the IT industry, an Indian city like Pune should have at least 50 public hospitals. It has only one. On the other hand, new, shining, multi-speciality private corporate hospitals are rising everywhere. They compare these aptly with shopping malls, which they resemble not just architecturally but in their business model. Just as malls have edged out small retailers that sold groceries and consumables, corporate hospitals have edged out the single-doctor practices and small nursing homes of the past.

“Hospital malls” have aggressively shifted the medical sector to the exclusive mercy of markets. Many of these private corporate hospitals claim to be charitable hospitals, which entitles them to concessional or free land and significant tax breaks. But in practice they rarely admit free patients, or if they are admitted, they are not respectfully treated.

Oxfam, too, records instances of refusal by private hospitals to extend free healthcare to patients living in poverty – although this was the conditions under which free or subsidised land was allotted to these hospitals. Poor patients also report to Oxfam instances of disrespectful behaviour by the staff of private corporate hospitals. “They don’t behave well to us when they know we are from the slum. When they learn that we are from the slum the hospital staff make us leave… We don’t take people there now… It is not for us. It is not for the poor families. It is for the rich people.”

Oxfam’s research also shows many cases of private hospitals unlawfully denying people emergency care, even though in India patients have a right to emergency care from all hospitals. For instance, a child was badly wounded and left unconscious by a traffic accident, but the private hospital denied treatment unless the family paid $1,200.

Unethical practices begin right from the stage of writing the prescriptions. The initial diagnosis that the doctor makes is wantonly graver than warranted by the patient’s condition, only to justify unnecessary diagnostics, drugs and procedures. Often there are no findings listed in the prescription, only the tests and medicines.

In corporate hospitals, patients are typically seen by multiple doctors and each bill the patient separately. There are no regulations or oversight about qualifications, or standard treatment protocols. Patients are also admitted to hospitals when all they need is OPD care. All a child with diarrhoea may need is the administration of ORH in their homes. Instead, they are admitted to hospital and given saline drips and a hefty bill at the end of this.

Oxfam also encountered shocking instances of medical malpractice and exploitation. For instance, a patient testified that the hospital staff said he had an 80% blockage to his heart and needed emergency surgery if his life was to be saved. He was sceptical, took a discharge, and consulted with a government doctor who repeated the tests and showed the diagnosis to be entirely false.

In another such instance, a man got admitted into a private hospital to have a problematic gallstone removed. The hospital ran several tests on him, including an ECG and echocardiogram to check the health of his heart. After the surgery the same tests were done, and doctors said he had an 80% blockage in his heart and that they would need to operate to save him. They even began treatment for this without his consent. It took the intervention of an influential local figure to secure his release. He then consulted a government doctor, who repeated the tests and then said to him: “Whoever is telling you that your heart is blocked is not telling you the truth.”

Oxfam also found grave cases of medical negligence confirmed by regulators even in the high-end World Bank financed corporate hospitals.

In one a patient is dropped on the floor leading to multiple fractures and death. Another dies because the patient is left unattended in an ambulance. In yet another death results because cotton wool is left in a patient’s brain after brain surgery. For one patient, the wrong leg is operated on, and for another a child is left permanently disabled. One baby is declared dead by doctors only to be discovered to be breathing as the last rites are performed. This on top of the widespread problems of overcharging, price rigging, and financial conflict of interest.

In corporate hospitals, investigations are not based on what the patient’s illness is, or whether the patient actually needs particular investigations. Doctors employed in large corporate hospitals are given targets of prescribing diagnostic tests even when these are not necessary.

Healthy pregnant women – to cite just one example – are pointlessly prescribed repeated hemograms, liver function tests and kidney function tests. Patients with confirmed diagnoses of depression are pointlessly prescribed expensive MRI and CT Scan tests. A gastroenterologist performs a series of endoscopies when only one is sufficient. Patients, influenced by marketing of corporate hospitals and diagnostic centres, themselves opt for “master check-ups”, most of which are unnecessary.

Ajgaonkar speaks of large public hospitals in Mumbai that have outsourced their radiology and lab departments to the private sector, only to benefit the private corporations. Pathologists also share that many pathological labs resort to what are informally called “sink tests”, in which the samples are just poured into the sink and a normal report sent. This can be dangerous for patients whose real maladies are missed.

Even more shocking than a superfluous test is when procedures and surgeries are prescribed that are not needed. A doctor confided that he was contemplating giving up his lucrative position in a corporate hospital. This was because of the pressure from the hospital management to deliver a target of 40% “conversions” of OPD visits to hospital surgery. His ratio was 15%. But he was caught in a dilemma. After studying so hard, he needed a job. And the only jobs he could find were in corporate hospitals. How long would he heed the voice of his conscience?

Another senior cardiologist also spoke of the pulls of his conscience that led him to leave his well-paid position in a corporate hospital where he was pressured by the management to recommend and perform unnecessary procedures like angioplasties. Another surgeon testified that often “totally unnecessary surgeries are done in corporate hospitals. For instance, a small gall bladder stone is causing no discomfort to the patient. But the patient is scared into surgery.

There are even shocking “pretend surgeries” in which small cuts and sutures are made with no actual surgery, but hefty bills presented. Gynaecologists report peers who are impatient with monitoring 14 to sixteen hours of labour and instead opt for a caesarean operation with a high bill.

A doctor explains it pithily, that first the hospital pays you a handsome salary, but then expects you to earn back that salary, even with – for instance – unnecessary kidney biopsies. Appendicitis and cataract operations and hysterectomies are performed when there is no need for these.

A surgeon speaks of his helpless regret when he sees how the bills for surgeries were inflated. The costs of surgery are routinely fixed in corporate hospitals at rates far higher than justified, but the patient has little choice, especially if beds and this surgery are unavailable in public hospitals. There is no regulation of what a doctor or hospital can charge.

For small procedures and surgeries, it is not uncommon to raise bills many times higher than what is warranted. The doctor cites the case of a very minor inguinal hernia procedure for which the patient was charged Rs 1.5 lakh.

Oxfam finds in low- and middle-income countries that the average starting cost of an uncomplicated vaginal birth delivery at a large private hospital amounts to over one year’s total income for an average earner in the bottom 40%. The cost of a caesarean birth amounts to over two years’ total income for the same person.

For an average earner in the bottom 10%, the starting cost for an uncomplicated vaginal birth at the private hospital rises to over nine years’ total income, and over 16 years for a caesarean birth. In First, Do No Harm Oxfam estimates that the cost of a two-day stay in a hospital in Delhi for a C-section is the equivalent of three to four months of Delhi’s average wage in Delhi-based IFC-funded Apollo, Max, and Fortis hospitals.

A doctor recounts the case of a man who died of a heart attack in a corporate hospital. They drew up an extortionate bill of Rs 16 lakh. His relatives could not afford it, so the hospital management resorted to the same strategy as the Nairobi hospital that I spoke of earlier. They hid the corpse. The police finally were called in to claim the body for the family. In another case, for a terminal and incurable case of cancer, the hospital prescribed an expensive and worthless regime that would impoverish the family long after the death of the patient.

Predatory over-charging reached even higher peaks during the pandemic. A large survey of over 2,500 Covid-19 patients in the state of Maharashtra found that private hospitals ignored government price cap with impunity. Seventy-five per cent of patients treated at private hospitals were overcharged by an average of Rs 1,56,000 (US$1,890). The research also revealed that average amounts of overcharging were far greater in larger corporate hospitals.

Public relations officers of corporate hospitals swarm doctors, offering them bulky “cuts” or commissions to refer patients to their hospitals. The practice of giving or receiving “cuts” or commissions for referrals to other specialists or diagnostic centres has also become routine.

Corporate hospitals institutionalise this by paying a portion of the money spent by a patient to the doctor who referred her to the hospital. Many hospitals pay 10%-15% of the total bill paid by the patient to the referring doctor. Diagnostic centres pay from 20%-50% to the referring doctor. Doctors frequently do not even record a patient’s history in any details. Instead, they just prescribe a set of investigations, for which they receive a cut or kickback. This is sometimes even more problematic in small nursing homes. Large corporate hospitals at least have rate-charts. In small hospitals, charges are often discretionary and therefore even more predatory.

Doctors and pathologists who refuse to participate in this morally grey zone of medical practice often find themselves with no work. Those who work in corporate hospitals report that their frustration that if they are scrupulous, their integrity does not benefit the patient who is still billed at levels that include the commissions.

Even other personnel connected in some way with corporate hospitals and nursing homes are also drawn into the embrace of “cuts”, even ambulance drivers and auto-rickshaw drivers. Late at night when relatives of a patient hail an autorickshaw to transport their patient to a particular hospital of choice, the driver refuses, insisting he would take them only to another hospital, one that has promised him a commission.

Doctors in smaller hospitals sometimes admit patients who they know they don’t have the competence to treat. They run up a high bill with the patient as her condition declines, then they refer them to corporate hospitals and harvest another “cut” from them.

Mani also describes many ways that doctors abet patients in unlawful ways. They certify fake illnesses to enable them to get leave or avoid a court appearance. Influential people soon after their arrest find doctors who certify that they suffer from grave ailments so they should be shifted from their prison ward to a much more salubrious hospital room.

Some unscrupulous doctors are also happy to abet for a high fee insurance fraud. The doctor records for the patient a diagnosis for a grave ailment from which the patient does not suffer, and bills expenses for expensive treatment that she or he did not receive. The reimbursement by the insurance company is shared between the patient and the doctor.

Independent research and testimonies of ethical insiders of the Indian health system strongly indicate that the mammoth expansion and domination of expensive private hospitals with feeble, even broken regulatory oversight or safeguards is, as summarised by Oxfam, “driving up healthcare inequality, diverting public funding and locking out opportunities for building truly universal and equitable health systems”.

This is because profit maximisation objectives in healthcare bring inherent risks to public health and patient rights. These have produced worse health outcomes and given less financial protection than similar investments in government-funded healthcare would have yielded. Worse still, evidence from countries like India shows that “by encouraging large-scale inclusion of for-profit hospitals, poor and marginalised people, particularly women, are being exposed to even greater risk of catastrophic and impoverishing healthcare bills”.

The wide claim of higher efficiency of private health provisioning is busted entirely by this disgraceful record of over-pricing, predatory marketing, and inappropriate medication, procedures and surgeries.

When maximising profits overtakes the healing and well-being of the patient, in the many ways we saw in this chapter, the private health sector no longer is the site of ethical treatment and care of patients. Instead, it mutates into a business for wealth accumulation by any means, many of these unethical and even unlawful.

One doctor observed wryly that corporate hospitals “maintain everything five-star style, but forget about the patient”. Another said that corporate hospitals want the doctor they employ only to earn them money. If the doctor wants to practice ethically, they have no place for him or her. And yet another – “there is no humanism to be found in corporate hospitals”.

I would evaluate the true worth of a health system by the respectful care it ensures to that most dispossessed and excluded woman or girl child who I started this essay with. There can be little doubt about one thing. And this is that the large shiny corporate “hospital malls” of our time have completely failed her.

I am grateful for research support from Rishiraj Bhagawati.

Harsh Mander is a peace and justice worker, writer, teacher who leads the Karwan e Mohabbat, a people’s campaign to fight hate with radical love and solidarity. He teaches part-time at the South Asia Institute, Heidelberg University, and has authored many books, including Partitions of the Heart, Fatal Accidents of Birth and Looking Away.

You stayed up too late scrolling through your phone, answering emails or watching just one more episode. The next morning, you feel groggy and irritable. That sugary pastry or greasy breakfast sandwich suddenly looks more appealing than your usual yogurt and berries. By the afternoon, chips or candy from the break room call your name. This isn’t just about willpower. Your brain, short on rest, is nudging you toward quick, high-calorie fixes.

There is a reason why this cycle repeats itself so predictably. Research shows that insufficient sleep disrupts hunger signals, weakens self-control, impairs glucose metabolism and increases your risk of weight gain. These changes can occur rapidly, even after a single night of poor sleep, and can become more harmful over time if left unaddressed.

I am a neurologist specialising in sleep science and its impact on health.

Sleep deprivation affects millions. According to the Centers for Disease Control and Prevention, more than one-third of US adults regularly get less than seven hours of sleep per night. Nearly three-quarters of adolescents fall short of the recommended eight-10 hours sleep during the school week.

While anyone can suffer from sleep loss, essential workers and first responders, including nurses, firefighters and emergency personnel, are especially vulnerable due to night shifts and rotating schedules.

These patterns disrupt the body’s internal clock and are linked to increased cravings, poor eating habits and elevated risks for obesity and metabolic disease. Fortunately, even a few nights of consistent, high-quality sleep can help rebalance key systems and start to reverse some of these effects.

Hunger hormones

Your body regulates hunger through a hormonal feedback loop involving two key hormones.

Ghrelin, produced primarily in the stomach, signals that you are hungry, while leptin, which is produced in the fat cells, tells your brain that you are full. Even one night of restricted sleep increases the release of ghrelin and decreases leptin, which leads to greater hunger and reduced satisfaction after eating. This shift is driven by changes in how the body regulates hunger and stress. Your brain becomes less responsive to fullness signals, while at the same time ramping up stress hormones that can increase cravings and appetite.

These changes are not subtle. In controlled lab studies, healthy adults reported increased hunger and stronger cravings for calorie-dense foods after sleeping only four to five hours. The effect worsens with ongoing sleep deficits, which can lead to a chronically elevated appetite.

Brain’s reward mode

Sleep loss changes how your brain evaluates food.

Imaging studies show that after just one night of sleep deprivation, the prefrontal cortex, which is responsible for decision-making and impulse control, has reduced activity. At the same time, reward-related areas such as the amygdala and the nucleus accumbens, a part of the brain that drives motivation and reward-seeking, become more reactive to tempting food cues.

In simple terms, your brain becomes more tempted by junk food and less capable of resisting it. Participants in sleep deprivation studies not only rated high-calorie foods as more desirable but were also more likely to choose them, regardless of how hungry they actually felt.

Slow metabolism

Sleep is also critical for blood sugar control.

When you’re well rested, your body efficiently uses insulin to move sugar out of your bloodstream and into your cells for energy. But even one night of partial sleep can reduce insulin sensitivity by up to 25%, leaving more sugar circulating in your blood.

If your body can’t process sugar effectively, it’s more likely to convert it into fat. This contributes to weight gain, especially around the abdomen. Over time, poor sleep is associated with higher risk for Type 2 diabetes and metabolic syndrome, a group of health issues such as high blood pressure, belly fat and high blood sugar that raise the risk for heart disease and diabetes.

On top of this, sleep loss raises cortisol, your body’s main stress hormone. Elevated cortisol encourages fat storage, especially in the abdominal region, and can further disrupt appetite regulation.

Metabolic reset

In a culture that glorifies hustle and late nights, sleep is often treated as optional. But your body doesn’t see it that way. Sleep is not downtime. It is active, essential repair. It is when your brain recalibrates hunger and reward signals, your hormones reset and your metabolism stabilises.

Just one or two nights of quality sleep can begin to undo the damage from prior sleep loss and restore your body’s natural balance.

So the next time you find yourself reaching for junk food after a short night, recognise that your biology is not failing you. It is reacting to stress and fatigue. The most effective way to restore balance isn’t a crash diet or caffeine. It’s sleep.

Sleep is not a luxury. It is your most powerful tool for appetite control, energy regulation and long-term health.

Joanna Fong-Isariyawongse is Associate Professor of Neurology, University of Pittsburgh.

This article was first published on The Conversation.

The Maharashtra government has ambitious plans for Palghar district. Seven large projects such as a bullet train that will pass through to Gujarat and the Vadhavan Port are aimed at transforming Palghar into another Mumbai to decongest the crowded metropolis to the south.

But the reality of this Adivasi-dominated district is starkly different from India’s commercial capital. Palghar, like other Adivasi-dominated districts in the wealthy state of Maharashtra, suffers from malnutrition, a dearth of livelihoods, depletion of forests and, crucially, maternal and infant deaths.

In April, Chief Minister Devendra Fadnavis announced an upgrade in health services in Maharashtra that would ensure healthcare access for communities within 5 km of where they live.

But the same month, health activists presented ground-level research on public healthcare and access in the district at the ninth Maharashtra Mahika Arogya Hakk Parishad in Palgarh’s Chahade village.

They highlighted major gaps in Palghar’s medical infrastructure to reiterate that extending equal healthcare access, especially for poor and marginalised residents, will be a formidable challenge for the state government.

Participants at the meeting highlighted the challenges of inadequate basic facilities and insufficient technicians and doctors in rural areas. They also emphasised the toll this takes on the lives of women and workers in the informal sector.

So underdeveloped is the health infrastructure in Palgarh that residents are compelled to visit private hospitals or travel north to Gujarat, with which it shares a boundary. For many, the nearest public hospital is in Silvassa, in the Union Territory of Dadra and Nagar Haveli. But this facility is often hard-pressed to accept patients from Maharashtra.

Fadnavis’s health plan comes at a time when the use of public health facilities in Maharashtra is lower than the national average.

Women pay the price

According to the 2011 census, Palghar district had a population of nearly 30 lakh, of which 37.39% is Adivasi. In 2014, Palghar – which sprawls out over 5,344 square km – was carved out from Thane district to improve its administration.

Despite this, the district’s health services are still underdeveloped. This is especially evident from the toll on pregnant women. In 2024, there were 14 maternal deaths in the district, a health official said. They were investigated by the statutory Maternal Deaths Review Committee to identify shortcomings in the medical system.

The health official said that Palghar has nine rural hospitals and three subdistrict hospitals but no tertiary hospital – which is equipped for specialist medical treatment and care. The district lacks an obstetrics ICU, which is crucial for emergencies.

The system is understaffed. There are no technicians or specialist doctors, said the official. There is also no government radiologist in the district. It has only two permanent gynaecologists and seven on call on a need basis. This absence of staff is especially acute in the four remote talukas of Mokhada, Wada, Jawhar, Vikramgad, said the health official.

Only in November, a pregnant woman from Sarni village died in an ambulance without oxygen. She had come to the rural hospital in Kasa but was sent on to Silvassa.

Women at the Maharashtra Mahika Arogya Hakk Parishad said the government promotes hospital deliveries but healthcare staff are indifferent and lacking in empathy.

Women experiencing distressful pregnancies were shunted from one healthcare facility to another while some died since they were not attended to on time, said advocate Meena Dhodade from the Bhoomi Sena.

Dhodade and her team investigated 12 of the 14 maternal deaths in Palghar taluka – an administrative unit of the district – between April 2023 to December 2024. They found that a young woman in her ninth month was turned away from the Manor government hospital since there were no proper facilities there. She was redirected to Silvassa but she died there after she was not attended to on time.

Another woman who could not access medical treatment at Safale died en route to the Palghar rural hospital. A private hospital, too, recorded the death of a pregnant woman.

In another instance, a woman who travelled to Valsad in neighbouring Gujarat for her delivery did not make it on time. Some women died after giving birth and in another case, a woman died of excessive bleeding after her delivery.

Dhodade said official records underestimated maternal deaths in Palghar taluka during the same period.She and her team investigated 12 incidents and found that two deaths were not registered. The women were between 20 to 24 years. Some suffered from anaemia.

According to the fifth round of the National Family Health Survey, 2019-’21, 54% of women in Maharashtra are anaemic. Anaemia is particularly high among rural women, young women between the ages of 15-19 and women from the Scheduled Tribes.

Madhu Dhodi, an activist of an organisation called the Kashtakari Sanghatna, said that of 28 women interviewed for her study in three villages, 22 who went to government hospitals were sent to other health facilities without any explanation. Women also said that there were often no doctors and that their babies had been delivered by nurses.

There have been other healthcare violations as well.

A young participant at the parishad said that two years after she underwent a caesarean procedure, she found a wire dangling from her body. She pulled it out, thinking it was a leftover thread from her surgery. She told a health worker, who took her to a nearby doctor. It turned out to be the remnants of copper T, a contraceptive, which had been inserted inside her without her knowledge.

Reliance on midwives

Some women said that after the delivery, they could not contact their families and felt isolated. Dhodi said the hospitals and primary health centres were also filthy, with no clean linen or even warm water. She pointed out that at times, there was no surgical thread available for post-surgery stitching.

Women at the parishad also said they preferred midwives as they felt safer with them. The Warli Adivasi community has relied on “soyeen”, or midwives, for generations.

Adivasi Ekta Parishad activist Kirti Vartha profiled 10 “soyeen” and found that some of them had delivered three generations of children. With the customary midwife practices vanishing, she said the government must provide training and support to health workers, especially in the absence of qualified doctors in the area.

She also said midwives should accompany pregnant women to hospitals or health centres. At times even the medical staff has relied on the knowledge and experience of the soyeens, she said.

Dr Nilangi Sardeshpande, project coordinator for Society for Health Alternatives or SAHAJ said the Centre had issued guidelines for midwife services in India and that one of the training centres is in Telangana.

Maharashtra’s maternal mortality rate is 33, far below the national average of 97. But in places like in Palghar, there are likely to be huge variations in ground-level data. The state has achieved the UN Sustainable Development Goal of bringing down maternal mortality rates but to reduce it further, the focus must be on marginalised communities.

On June 6, the Palghar district administration announced its healthcare preparations for the monsoon, focusing on maternal and child health. The plans include establishing contact with expecting or breastfeeding mothers in 82 villages and 137 hamlets with no road connectivity.

Exposed to the weather

Another challenge faced by women in Palgarh is the extreme weather, Since many women have jobs in the informal or unorganised sector, they often work outdoors, bearing the brunt of extreme weather – like heatwaves in summer.

Pradnya Gawad of the Rashtra Seva Dal studied women who sold vegetables on the street and fisherwomen. Many of them walked to the market, often carrying 15 kg of produce. There were no facilities for shade, water and toilets in the vicinity.

The women said they suffered from body aches, high blood pressure and that they couldn’t seek medical advice due to their work timings. It was worse during menstruation with no clean toilets or shady spots to rest.

The lives of brick kiln workers who migrate annually within the district were equally dire, illustrating the challenge of extending health services to marginalised residents.

Snehalata Gamre of the nonprofit Aarohan said that according to the study she carried out, the workers live in makeshift shanties with no water or power, and no access to food rations. They are paid a pittance of Rs 800 to Rs 1,000 per week per family, despite working for nearly 15 hours a day. Many complained of body ache, burning eyes and urinary tract infections. Gamre suggested establishing mobile dispensaries and providing food rations.

Meena Menon is a freelance journalist and a postdoctoral visiting fellow at the Leeds Arts and Humanities Research Institute, University of Leeds, UK.

In September 2024, a 38-year-old woman consulted Narendra Kotwal, director of endocrinology at Paras Health, Panchkula. She reported persistent fatigue, difficulty falling asleep, irregular menstrual cycles, mood disturbances such as irritability and low mood and had gained 5 kg over six months. The woman works nights at a call centre and lives close to a brightly lit digital billboard.

Kotwal, a retired lieutenant general in the Indian Army and president of the Endocrine Society of India, noted that the patient was overweight and exhibited features suggestive of insulin resistance – skin tags, a high waist-to-hip ratio and a large neck circumference – indicating a pre-diabetic state. That is not odd: A 2023 study showed that 136 million Indians are pre-diabetic, as we reported in August that year.

The patient also had pronounced dark circles under her eyes. Laboratory investigations revealed subclinical hypothyroidism and elevated evening cortisol levels, which disrupt the body's natural stress response and sleep cycle.

Kotwal attributed her condition primarily to light pollution or photo pollution – chronic exposure to artificial light at night during biologically-intended sleep hours.

Streetlights, illuminated billboards, neon signage, industrial and office lighting during night shifts, household lighting, and external security lights are the common sources of light pollution.

Kotwal’s prescription started with a series of light hygiene measures: installing blackout curtains, wearing an eye mask during sleep and using blue-light blocking glasses after sunset. Blue light is emitted by electronic gadgets such as smartphones and tablets. She was also advised to avoid screens for at least two hours before sleeping.

To restore the patient’s circadian (24-hourly) rhythm through chronotherapy, Kotwal recommended scheduled bright light exposure in the early evening to increase alertness during her desired wake phase, followed by a gradual dimming of ambient light to cue sleep readiness.

Stress management, including mindfulness and deep-breathing exercises, were also advised. Regular monitoring and control of the thyroid-stimulating hormone and of blood glucose levels formed an essential component of her long-term care.

Diligent adherence to this integrative regimen helped the patient experience significant recovery. However, Kotwal noted that in certain individuals, especially those with persistent sleep disruption and heightened stress, melatonin supplementation or sleeping pills may be required. Left unaddressed, such circadian misalignment may put individuals at the risk of – or exacerbate – metabolic disorders like type-2 diabetes.

Anoop Misra, chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, says clinical practice is increasingly showing up patients of hormonal imbalances and metabolic dysfunction such as diabetes, where light pollution and the ensuing stress and sleep disturbances are suspected contributors.

This is, perhaps, an outcome of 80% of the world living under light-polluted skies, according to a world atlas of artificial sky luminance generated in 2016.

Misra stressed the need to establish a direct cause-and-effect relationship between light pollution and metabolic disorders through controlled studies, which India has few of. However, a review of health studies conducted overseas shows that light pollution has a severe detrimental impact on human health, causing mental health issues, cancer and Alzheimer’s.

Effects of artificial light

Being exposed to artificial light at night reduces the production of melatonin, popularly called “the hormone of darkness” since it is produced at night. Insufficient melatonin, in turn, disrupts the body’s circadian rhythm, the biological clock regulating the sleep-wake cycle. The fallout of this isn’t just the obvious sleep disturbances – exacerbated metabolic, hormonal and immunological imbalances are some of the other outcomes.

A study published in Sleep and Vigilance in January 2021 described the role of melatonin in the development and growth of cancer, immune activity, anti-oxidation and free radical scavenging (neutralising free radicals that can potentially harm healthy cells and tissues).

Co-author Manisha Naithani, professor of biochemistry at the All India Institute of Medical Sciences, Rishikesh, explained that the damage starts in the part of the brain called the suprachiasmatic nucleus, when it receives light signals from photosensitive cells in the retina. The suprachiasmatic nucleus is a part of the brain, located in the front part of the hypothalamus, the central control of the endocrinological system. It works as the brain’s central clock, regulating the daily rhythm of the body.

Naithani’s study cites epidemiological evidence supporting the cancer link. “A Spanish study showed greater breast cancer risk and prostate cancer risk in people exposed to higher artificial light levels at night,” she said. “An Israeli study found a 73% increase in breast cancer incidence in areas with high night-time light.”

“Female shift workers such as nurses and police personnel have a higher breast cancer risk (see here and here),” she said.

Naithani pointed out that insufficient sleep is associated with hormone-sensitive cancers, meaning cancers that develop as an outcome of hormonal disturbances, such as breast, colorectal and endometrial cancers.

Some other side effects of exposure to artificial light at night are weight gain, gut inflammation, mood disorders and low resistance to environmental and emotional stressors.

A review study published in August 2024 established a clear link between light pollution and sleep disturbances leading to mood alterations, a finding in line with psychiatrists’ clinical experience.

“Poor sleep or insomnia is closely tied to depression and anxiety,” said Kersi Chavda, consultant psychiatrist, PD Hinduja Hospital & Medical Research Centre, Mumbai. “People living in brightly lit urban areas often report feeling more stressed, anxious, or down. Night-time light exposure also makes seasonal depression worse for some, since the natural contrast between night and day gets blurred. Some victims find it harder to concentrate and think clearly during the day.”

Both Naithani and Chavda cited the blue light from a cell phone, and LEDs, as a key contributor to light pollution. “Blue-enriched light affects the suprachiasmatic nucleus the most, causing chronic stress and potentially triggering inflammation and lowering immunity,” said Naithani.

“Children, shift workers and those already dealing with mental health challenges are most vulnerable,” added Chavda.

Higher outdoor night-time light has also been linked with a higher prevalence of Alzheimer’s disease. In fact, it was found to be a bigger risk factor for Alzheimer’s than factors such as alcohol abuse, chronic kidney disease, depression, heart failure and obesity, according to a study published in Frontiers of Neuroscience last year.

The challenge, Naithani said, is that the “potential detrimental effects of artificial light are not known to all, the hidden perils of light are yet to be brought in full public knowledge so that night-time light can be dealt with effectively.”

Low awareness

An online survey published in the Journal of Urban Management in September 2022 found very low awareness of light pollution among Indians aged 16 to 65 years – the age group that is most likely to have a nightlife and be exposed to various kinds of light pollution that the study described, such as light trespass, skyglow, over-illumination, light clutter and glare.

Recognise the many kinds of light pollution

Light trespass: refers to light spilling over the area it is meant to illuminate. For instance, when undesired street light enters someone’s window.

Skyglow: is the orange-pink glow that envelopes the night skies of many cities. Natural factors as well as artificial lighting emit skyglow and are further scattered through dust particles, gas and suspended water droplets.

Over-illumination: is the practice of using more light than what is needed for a specific activity or place. For instance, keeping lights on when no one is present.

Light clutter: is caused by excessively bright lights that can cause confusion. For instance, some streets have too much lighting and overly bright advertisement screens.

Glare: is the effect of bright light on eyes, such as when car headlights flash in the face of a pedestrian. Glare can impact eyes and vision in varying degrees, from being merely distracting to discomforting to disabling and in the worst possible case, blinding.

When respondents were asked how often they had heard of light pollution, 57% replied they hadn’t heard of it at all. When they were asked to explain light pollution, some of them said it referred to “violation of UV and other harmful rays in the sunlight”, “pollution which is not very harmful” and “maybe something related to the environment”.

The authors concluded that the lack of awareness extended the threat associated with light pollution.

Public lighting is widely perceived to contribute to safety but research does not prove this link. A study conducted in the UK showed that darkness does not increase the risk of certain types of crime. “Outdoor lighting may lower safety by making victims and potential theft articles more easily visible,” said Tanya Bedi, assistant professor, Department of Architecture, School of Planning and Architecture, Bhopal.

Poor enforcement

Artificial light at night has been shown to increase with the growth of a country’s gross domestic product. But this association is deeper. It’s not the GDP volume as such that increases night-time brightness but the physical expansion of cities through real estate, highways, and urban sprawl, explained Bedi.

Essentially, “as a nation develops, infrastructure indicators such as road and streetlight density contribute to brightness levels”, she said.

Studies in India comparing light pollution over time show how much more bright the night sky has become.

A study by Bedi and others at the School of Planning and Architecture, Bhopal, identified Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai as India’s most polluted cities from the perspective of light. Their research also found streets with illumination four times the Indian Standards recommendation.

A key reason for the excessive increase in night-time luminosity is the outburst of development with no strict regulations.

“Urban local bodies like municipal corporations, development authorities, and gram panchayats are responsible for public lighting,” said Bedi. “But compliance with the Indian Standards and the focus on curbing light pollution is usually hindered by a lack of awareness and specific regulations.”

Bedi’s study found the rampant use of low-mounted and densely packed luminaires, non-cut-off fixtures (fixtures that cannot direct the light downwards rather than upwards), and lamps of more wattage than required. Both administrative and local level measures are needed to reduce light pollution, she says.

Mumbai resident Nilesh Desai complained to the collector of Mumbai City about flood lights installed in the Wilson Gymkhana and the Police Gymkhana in Mumbai in 2017. Desai, who lives in the area, was disturbed by the excess lighting at night.

The collector took prompt action, ordering the lights to be switched off at 10 pm, and set up in a way that no resident is disturbed. He also instructed all gymkhanas to get prior permission to install lights.

Since then, Desai has also complained to the Brihanmumbai Municipal Corporation about lighting on construction sites that work round the clock, and digital hoardings, both of which are meant to be switched off at 11 pm.

The challenge is: “after the pandemic no enforcement is happening,” said Desai. “Night matches in the Police Gymkhana start at 11 pm, it is a pity that awareness about light pollution is very low. I have written to the police commissioner to switch off the Police Gymkhana lights after 10 pm but no action has been taken so far.”

Around the time Desai complained about light pollution from the gymkhanas near Marine Lines, Sumaira Abdulali, founder of Awaaz Foundation, a not-for-profit working on environmental issues, also studied light pollution in Mumbai.

“We found that coloured LED lights put up at Juhu beach for a ‘beautification’ project was contributing to light pollution,” Abdulali told IndiaSpend. “When we inquired, we were told that they were for safety but the light was focused and coloured so it could never serve to increase safety.”

“A review of street lighting on Mumbai’s main roads showed that it is quite effective in lighting up roads and isn’t intrusive,” added Abdulali. “However, what is intrusive and is getting worse over the years is lighting during festivals, and in recent years, digital hoardings, some building façades and construction sites, and advertisements of new properties. All these lights are intrusive, especially for drivers, in areas of natural beauty such as sea-fronts, and in residential areas, unless you use black-out curtains. Most people don’t use these, and why should they?”

Abdulali wrote to the civic body and objected to the civic body’s proposed hoarding policy, opposing brightly lit and moving digital hoardings as a safety hazard for drivers and a health hazard in residential areas. She was even called for a hearing in late 2024, but nothing has come of it as yet, she said.

IndiaSpend has reached out to the offices of the commissioners of the Brihanmumbai Municipal Corporation, the Municipal Corporation of Delhi and the Municipal Corporation of Greater Bengaluru. We will update this story when we receive a response.

Better lighting decisions

A salient characteristic of light pollution is that it is localised and hence controllable. Unlike air pollution, it doesn’t spread on a windy day.

“Government authorities should promote better lighting design,” said Bedi. “State governments should adopt reference standards to control existing and proposed external lighting usage so that the concerned authority – municipal corporations in urban areas and gram panchayats in rural areas – can take necessary action towards responsible parties to resolve light nuisances and enforce dimming schedules for non-essential lighting during off-peak hours. Also practical issues like how tender specifications are framed, and limited technical capacity for monitoring lighting design must be addressed.”

Practical strategies to mitigate light pollution include mandating the use of full cut-off luminaires and environment-friendly backlight-uplight-glare rated lighting fixtures to minimise glare and skyglow, said Bedi. “Further, energy efficiency concerns have pushed the widespread adoption of LEDs, but warm-toned LEDs can help reduce circadian rhythm disruptions in both humans and wildlife.”

Zoning can also play a key role in reducing light pollution. Creating lighting environmental zones, particularly in ecologically sensitive or biodiversity-rich areas, would allow for more adaptive and localised control, said Bedi. “Ward-level prioritisation maps would support a phased implementation approach, targeting the most ecologically vulnerable or light-polluted areas first.”

A lot can be done. But the experience of those who have complained shows that so far, light pollution isn’t being taken seriously enough.

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

Fitness enthusiasts have debated the question for decades: is it better to do cardio before or after lifting weights? Until recently, the answer has largely been down to preference – with some enjoying a jog to warm up before hitting the weights, while others believe lifting first is better for burning fat.

But a new study may have finally answered this long disputed question.

According to the study, the order of your workout does significantly affect how much fat you lose. Participants who performed weight training before cardio lost significantly more fat and became more physically active throughout the day compared to those who did cardio first.

The researchers recruited 45 young men aged 18-30 years who were classified as obese. The researchers split participants into three groups for 12 weeks. One group was a control group. This meant they stuck to their usual lifestyle habits and didn’t make any changes to their exercise regime.

The other two groups exercised for 60 minutes three times weekly. Participants were also given sports watches to objectively track daily movement. This helped the researchers avoid reliance on self-reporting, which can often be inaccurate.

Both exercise groups followed identical training programmes, differing only in exercise sequence. Strength training involved actual weights, with participants performing exercises such as the bench press, deadlift, bicep curl and squat. The cardio sessions involved 30 minutes of stationary cycling.

Participants in both groups experienced improvements in their cardiovascular fitness, muscle strength and body composition – specifically, they lost fat mass while gaining lean muscle mass. Interestingly, cardiovascular fitness improvements were similar regardless of sequence – echoing recent findings that exercise order has limited impact on cardiovascular adaptations.

But the real differences emerged when it came to fat loss and muscle performance. Participants who lifted weights first experienced significantly greater reductions in overall body fat and visceral fat – the type of fat most strongly linked to cardiovascular disease risk.

They also increased their daily step count by approximately 3,500 steps compared to just 1,600 steps for the cardio-first group. Additionally, the weights-first approach enhanced muscular endurance and explosive strength.

Why exercise sequence matters

The reason behind these findings is tied to how your body uses energy.

Resistance training depletes muscle glycogen stores – the sugar that’s stored in the muscles which acts as your body’s quick-access fuel. Imagine glycogen as petrol in your car’s fuel tank. When you lift weights first, you effectively drain this fuel tank, forcing your body to switch energy sources.

With glycogen stores already low, when you transition to cardio, your body must rely more heavily on fat reserves for energy. It’s akin to a hybrid car switching to battery power once the petrol runs low. This metabolic shift helps explain the greater fat loss seen in the weights-first group.

This recent study’s findings align with broader research. A comprehensive systematic review published in 2022 found resistance training alone can significantly reduce body fat and visceral fat, the type linked to chronic diseases. Muscles are metabolically active tissues, continuously burning calories even at rest, which amplifies these effects.

Conversely, performing cardio first might compromise your strength training effectiveness. Cardio uses up glycogen stores, leaving muscles partially depleted before you even lift a weight. It also induces fatigue and may reduce your muscles’ ability to produce explosive power and strength.

A recent systematic review on concurrent training (the practice of combining both resistance and aerobic exercise within the same program) supports this – highlighting that explosive strength gains might diminish if aerobic and strength training occur in the same session, especially if cardio is performed first.

These findings align with other research on concurrent training. A systematic review and meta-analysis examining exercise sequence effects found that resistance-first protocols produced significantly superior strength improvements compared to endurance-first training.

The American Heart Association’s 2023 statement on resistance training confirmed resistance exercise significantly improves lean body mass and reduces fat, especially when combined with other exercise types. However, resistance training alone was found less effective in improving cardiovascular health. This underscores the importance of including cardio in your exercise routine.

However, it is worth noting the study’s limitations. As it only involved obese young men, this means we don’t know how the results will apply to women, older adults or those with different body compositions. A 2024 review suggests adaptations may differ by sex, indicating the need for further research involving diverse populations.

The 12-week duration also may not capture long-term changes. Results also specifically only apply to concurrent training – performing both exercises in the same session.

Moreover, the study did not account for nutritional intake, sleep patterns or stress levels, all of which can significantly influence body composition outcomes. Future research should incorporate these factors to offer even more comprehensive guidance.

Workout sequence

Whether you prefer to do cardio before or after lifting weights, the message is clear: both will improve overall health. The only difference is that weight training before cardio provides advantages for fat loss, abdominal fat reduction and increased daily physical activity.

Interestingly, resistance training boosts confidence and energy levels, naturally encouraging more movement throughout the day, further aiding fat loss.

If cardiovascular fitness is your primary goal, the sequence matters less, as both ways equally boost aerobic fitness. However, if fat loss and optimising daily activity are your main objectives, evidence strongly supports placing resistance training first.

Jack McNamara is Senior Lecturer in Clinical Exercise Physiology, University of East London.

This article was first published on The Conversation.

At a tense meeting in Nigeria’s capital Abuja, health workers poured over drug registers and testing records to gauge whether US aid cuts would unravel years of painstaking work against tuberculosis in one of Africa’s hardest hit countries.

For several days in May, they brainstormed ways to limit the fallout from a halt to US funding for the TB Local Network (TB LON), which delivers screening, diagnosis and treatment.

“To tackle the spread of TB, you must identify cases and that is in a coma because of the aid cuts,” said Ibrahim Umoru, coordinator of the African TB Coalition civil society network, who was at the Abuja meeting.

“This means more cases will be missed and disaster is looming.”

This desperate struggle to save endangered programmes is being replicated from the Philippines to South Africa as experts warn that US aid cuts risk reviving a deadly infectious disease that kills around one million people every year.

President Donald Trump’s gutting of the US Agency for International Development has put TB testing and tracing on hold in Pakistan and Nigeria, stalled vital research in South Africa and left TB survivors lacking support in India.

The World Health Organization says “the drastic and abrupt cuts in global health funding” threaten to reverse the gains made by global efforts to fight the disease – namely 79 million lives saved since 2000 – with rising drug resistance and conflicts exacerbating the risks.

In Nigeria, TB Local Network is in the firing line.

The project was set up in 2020, during Trump’s first term, and received $45 million worth of funding from USAID. The US development agency said at the time it was committed to a “TB free Nigeria”.

Five years later and with the same president back in charge but now with a more radical “America first” agenda, USAID support for TB LON's community testing work was terminated in February, according to a TB LON official. The official did not want to be named because he was not authorised to speak on behalf of the project.

‘Hard work in jeopardy’

TB kills 268 Nigerians every day and cases have historically been under-reported increasing the risk of transmission. If one case is missed, that person can transmit TB to 15 people over a year, according to the World Health Organization.

Context spoke to half a dozen health workers who collect TB test samples for TB LON but had stopped doing so in January due to the US aid freeze.

Between 2020-2024, TB LON screened around 20 million people in southwestern states in Nigeria, and more than 100,000 patients were treated as a result.

“All that hard work is in jeopardy if we don’t act quickly,” Umoru said, adding that non-profits working with TB LON had laid off more than 1,000 contract workers who used to do TB screening.

Nigeria’s health ministry did not respond to request for comment on the effect of the USAID cuts on TB programmes.

In March, First Lady Oluremi Tinubu declared TB a national emergency and donated 1 billion naira ($630,680) to efforts to eradicate the disease by 2030.

In South Africa, medical charity Médecins Sans Frontières said TB and HIV programmes had been disrupted across the country, making patient tracking and testing more difficult, according to a statement sent to Context/the Thomson Reuters Foundation.

South Africa had an TB incidence rate of 427 per 100,000 people in 2023, government data showed, down 57% from 2015. TB-related deaths in South Africa dropped 16% over that period, the data showed.

Minister of Health Aaron Motsoaledi said in May that the government would launch an End TB campaign to screen and test five million people, and was also seeking new donor funding.

“Under no circumstances will we allow this massive work performed over a period of more than a decade and half to collapse and go up in smoke,” he said at the time, referring to efforts to tackle TB and HIV.

Blow to critical research

South Africa is also a hub for research into both TB and HIV and the health experts say funding cuts risk derailing this vital work.

The Treatment Action Group, a community-based research and policy think tank, says around 39 clinical research sites and at least 20 TB trials and 24 HIV trials are at risk.

“Every major TB treatment and vaccine advance in the past two decades has relied on research carried out in South Africa,” said Treatment Action Group TB project co-director Lindsay McKenna in a March statement.

People struggling with poor nutrition and those living with HIV – the latter affects eight million people in South Africa – were also more at risk of contracting TB as aid cuts made them more vulnerable by derailing nutrition programmes, community outreach and testing, said Cathy Hewison, head of MSF’s TB working group.

“It’s the number one killer of people with HIV,” she said.

In the Philippines, US cuts have disrupted TB testing in four USAID-funded projects, and affected the supply of drugs, Stop TB Partnership, a UN-funded agency said.

“The country has a nationwide problem with recurrent drug shortages, which is leading to a direct impact on efforts to eliminate TB,” said Ghazali Babiker, head of mission for MSF Philippines.

In Pakistan, which sees 510,000 TB infections each year, MSF said US cuts had disrupted TB screening in communities and other services in the hard-hit southeastern province of Sindh.

“We are worried that the US funding cuts that have impacted the community-based services will have a disproportionate effect on children, leading to more children with TB and more avoidable deaths,” said Ei Hnin Hnin Phyu, medical coordinator with MSF in Pakistan.

“We cannot afford to let funding decisions cost children’s lives.”

This article first appeared on Context, powered by the Thomson Reuters Foundation.

In January 2020, an official at a primary health centre in Jharkhand told Khageshwar Kumar about a drug-resistant tuberculosis patient who had stopped taking medicines for the last two months.

Kumar stepped in.

For 18 months, he visited the patient in Parasnath block in Giridih district three times a week, counselling him in sessions that lasted three hours or more.

“He had become suicidal. Even his family had given up on his treatment,” Kumar said. “For hours I would talk to him. I was able to help him because I was a TB patient myself. I can relate to how patients feel.”

Kumar is a TB Champion or TB Vijeta, a term coined for patients cured of the bacterial infection, who are then drafted to the National Tuberculosis Elimination Programme. Their role – to counsel other patients and raise community awareness.

In this case, Kumar’s efforts paid off. He convinced the patient to resume his medicines and helped him through their painful side-effects. The patient went on to finish his treatment in 2022 and is now employed with a private firm.

Khageshwar Kumar was diagnosed with tuberculosis in 2007 and cured the same year.

The 29-year-old began working as a TB Champion in Giridih in 2019 for an honorarium of Rs 6,000 per month. “The amount was small, but I had no other job and I was passionate about TB,” he said.

Since 2023, however, that money has stopped. Several TB Champions have dropped out of the programme in Jharkhand, though some like Kumar do limited volunteer service in spare time.

“For how long can we work for free?” Kumar asked.

A support group

The TB Champion programme was initiated in India in 2016 as a major component under the National Tuberculosis Elimination Programme, which aimed to eradicate tuberculosis by 2025.

The deadline, missed by India, has now been pushed to 2030.

But across India, the programme is under stress, with multiple states complaining of delay in financial reimbursement or a complete freeze in funds.

Each state allocates a different amount as fee for the former tuberculosis patients. In some states, NGOs partner with the government and pay the amount.

In May, Nishant Kumar, joint director of the central tuberculosis division was asked why the programme was struggling at a conference. “TB Champions (programme) has not stopped,” Kumar said. “It is transitioning.”

But several counsellors Scroll spoke to said irregular payments are a problem.

In Haryana, Sagar Verma, who is the TB Champions Network President, said he received Rs 8,000 per month until 2024 through an NGO called World Vision that had partnered with the government. “It stopped due to funds shortage,” he said.

Verma now works at a district hospital in Haryana. “There are over 100 counsellors like me who are jobless in the state. We have approached state authorities multiple times to release funds for this programme,” Verma said. The last time, the counsellors engaged with tuberculosis patients in Haryana was March 2024.

In Odisha, counsellor Kailash Mishra has not received April’s honorarium till date. “The state government said that March funds have not reached them from the Centre.”

Mishra visits four patients every day and does regular district level reporting of cases apart from conducting community meetings to raise awareness. For this, he receives Rs 3,500 a month from the Odisha government. “The payment is frequently delayed,” he said.

“Many of us travel 200 km to district headquarters for meetings. Sometimes we also collect sputum to test for TB bacteria,” Mishra said. Although the National Tuberculosis Elimination Programme permits states to reimburse counsellors for such services, Mishra said no reimbursement is given to them.

Eldred Tellis, founder of Sankalp Rehabilitation Trust, said the issue has become acute in the last few months. “Whenever we approach state officials, they cite fund shortage,” he said. “The central ministry refuses to acknowledge this problem. This has not only cut the source of livelihood for TB Champions, it has also affected patient care.”

Other health activists agreed that the absence of the counsellors would hurt patients. “TB Champions fill a crucial gap in the programme by providing mental health support to patients,” said health activist Ganesh Acharya. “In their absence a major component will be lost.”

‘A vital part’

In 2016, Reach, a non-profit that partnered with the government on tuberculosis control, trained its first cohort of 25 TB Champions and went on to train 3,000 such counsellors.

Ramya Ananthkrishnan, director at Reach, said the aim was to provide a support group for TB patients. “They play a vital part. Some look at advocacy, some get deeply involved in the programme to handle treatment and diagnosis,” she said.

Across India, the National Tuberculosis Elimination Programme has trained over 30,000 champions till 2023.

In Mumbai, a hotbed of drug-resistant tuberculosis, the Brihanmumbai Municipal Corporation relied heavily on the TB Champions to carry out door-to-door visits and engage with the community.

Till last year, Maharashtra paid the highest compensation to the counsellors, at Rs 10,000 a month. Moreover, the counsellors were employed by the civic body on a contractual basis.

But in June 2024, the civic body discontinued the programme. About 25 people employed to counsel patients were rendered jobless.

“Few were retained and assured of payment. But since the last eight months, they have not been paid,” said activist Meera Yadav.

Yadav said that the funds meant for the programme were discontinued by the state’s TB division due to overall budget cuts.

A state government official requesting anonymity said funds under the National Health Mission have been "delayed consistently”.

“We use NHM funds for various diseases, including tuberculosis,” the official said. “This year, the funds were supposed to be disbursed by March. We have not received them till now.”

The delay and underutilisation of funds is apparent in the 2023-24 budget and expenditures made by the National Tuberculosis Elimination Programme.

Out of a budget of Rs 1,888 crore, the programme had spent only Rs 840 crore till March 15, 2024. For 2022-23, the programme spent Rs 910 crore out of the approved budget of Rs 1,666 crore.

Some officials employed with NGOs, who work with the government on tuberculosis, told Scroll that the abrupt end of funds from the United States Agency for International Development this January has also forced them to curtail spending on TB Champions.

Shazad Ahmed, who is a TB Champion in Balrampur, Uttar Pradesh, stopped receiving a monthly honorarium of Rs 8,000 from 2024. He was being paid by Reach.

He still continues to work though in the hope the government will resume payments. “I am working to help other patients. I will continue to work for free as long as possible.”

More and more people over the age of 50 are taking up physical exercise. Medical associations resoundingly agree that this is a good thing. Physical exercise is not only key to disease prevention, it is also a recommended part of treatment for many illnesses.

However, starting to move at this stage of life requires some care. This is especially true for those who have not previously been physically active, or for people who are overweight or obese.

It has been proven that starting to exercise with routines that are too demanding can lead to significant muscular and skeletal injuries, especially if combined with an inadequate diet. This risk is even greater after the age of 50, as the loss of muscle and bone mass is more pronounced due to natural ageing processes.

Before starting any new exercise programme, it is a good idea to carry out a complete analysis, especially to assess the need for micronutrient supplements.

Protein is key

In addition to micronutrients, the body also needs carbohydrates, fats and proteins – known collectivey as macronutrients. Proteins provide the body with the essential amino acids needed to maintain and develop muscle mass, and to prevent sarcopenia: age-related muscle injury, osteoporosis, and loss of muscle mass and strength (formerly referred to as frailty).

Protein requirements vary according to an individual’s clinical situation. In people over 50 years of age who are moderately physically active, protein requirements range from 1 to 1.5 grams per kilogram of body weight per day.

However, it is not advisable to increase protein intake without a corresponding increase in physical exercise. Too much protein can actually have harmful effects, especially on bone health, as it has been observed to increase calcium excretion in the urine (calciuria) due to decreased tubular calcium reabsorption.

Animal and vegetable protein

Protein sources should combine those of vegetable origin – soy, beans, seeds, peanuts, lentils, and so on – with those of animal origin, such as eggs, dairy products, chicken and fish.

While the ideal is to have balance of both, it has been shown that following a vegetarian diet is compatible with high-performance sports, so long as there is suitable medical and nutritional monitoring.

In addition to what you eat, it also matters when you do it. Spreading protein intake throughout the day is more beneficial than concentrating it in a single meal. You should also eat protein 30 minutes before or after exercise, as its absorption and availability in the body will be better.

Essential micronutrients

Some micronutrients – by which we mean vitamins and minerals – play a key role in physical exercise at this age. These include magnesium, calcium and vitamin D.

Magnesium aids muscle recovery and bone formation, and can be found in foods such as wheat bran, cheese, pumpkin seeds and flax seeds.

Calcium is essential for maintaining adequate bone mineralisation and preventing loss of bone mineral density (osteopenia) associated with calcium deficiencies in the blood.

Dairy products are known to be beneficial for bone health, both for their bioavailable calcium, and the vitamin D content in their whole milk. Certain plant-based foods, such as tahini (sesame paste), almonds, flaxseed, soya and hazelnuts, are also decent sources of calcium, but their phytate and oxalate content can hinder its absorption.

Lastly, oily fish (tuna, sardines, salmon, and so on) and egg yolks are considered complementary sources of vitamin D in dietary plans focused on people over 50 years of age who do physical exercise.

It is also vitally important to maintain proper hydration before, during and after exercise. Both dehydration and overhydration can affect performance, and increase the risk of muscle injury.

Exercise

So far we have seen how nutrition influences athletic performance and ultimately the risk of injury. But there is another part of the puzzle: the exercise you do.

There is actually no clear consensus on this, and there is ongoing debate about which type of exercise is the most appropriate according to age, gender or body composition. The question is whether it is better to prioritise strength exercises, alternate with cardio sessions, or do both on different days.

Despite the different theories on the subject, one thing is clear: regular exercise, adapted to the abilities of each individual and with good medical and nutritional monitoring, reduces the risk of multiple diseases and improves quality of life.

Patricia Yárnoz Esquíroz is Profesor Clínico Asociado, Universidad de Navarra.

This article was first published on The Conversation.

Predicting your risk of a range of health outcomes – from type 2 diabetes to depression and even your longevity – is as simple as testing how tight your grip is.

Grip strength refers to the power generated by the muscles of the hand and forearm to perform actions such as grabbing, squeezing an object or even shaking hands. This action involves a complex interplay between the various muscle groups located in the forearm, as well as the muscles within the hand itself.

Grip strength is a very cheap, easy and non-invasive measure of muscle strength. This test has been used since the mid-1950s as a measure of overall health. Since then, the simple test has been firmly established as a reliable marker of various aspects of health – with some researchers even suggesting grip strength can be used to determine a person’s risk of everything from type 2 diabetes to depression.

The standard method for measuring grip strength involves using a handheld dynanometer – an instrument which can measure a person’s power. This test is usually done while a person is sitting down. With their forearm bent at a 90-degree angle and wrist held in a neutral position, the person then squeezes the dynamometer as hard as they can – usually three separate times for one minute each.

The average of the highest readings from each hand, or sometimes just the dominant hand, is then recorded as the person’s grip strength. This can be measured in both kilograms or pounds. A grip strength value of under 29kg for men and 18kg for women is typically considered low. You can pick up a handgrip dynamometer for under £5 should you wish to test at home.

Not only is grip strength a trusted indicator of overall health, it’s also strongly correlated with overall muscle strength and lean body mass across a person’s lifespan.

Moreover, the stronger a person’s grip is, the more independent they will be in their daily life as they get older. This means they’ll be able to perform normal daily activities without assistance, such as rising from a chair and moving around the house.

A substantial body of evidence also shows low grip strength is not only linked with greater susceptibility of a wide range of chronic diseases – including cancer and cardiovascular disease – but greater risk of early death due to these chronic disease, as well.

Researchers have also observed links between low grip strength and greater risk of depression, anxiety and diabetes, to name a few.

There’s also a significant association between grip strength and a person’s lifespan. In this study, people who died before the age of 79 were 2.5 times less likely than those who lived to be 100 to be in the top 33% for grip strength when they were middle aged.

However, in a 12-year prospective study published in 2022, the authors reported that baseline hand grip strength was the same in participants that died between the beginning and end of the study as in those who survived. But walking speed, speed of standing up from a chair and leg press strength were all worse in the people that died than in t that survived. This tells us is that there are better predictors of longevity than grip strength – such as total body muscle mass and leg strength.

So why is it that such a simple measure can tell us about the risk of so many diseases, and ultimately death? The answer is that grip strength is a proxy measure of total muscle strength and size. This means that grip strength alone is not a cause of early mortality or disease, but is correlated with a cause of early mortality or disease (such as low muscle mass or muscle strength of the legs).

Muscle mass is crucial for overall health. It plays an integral role in our metabolism. For example, muscle helps regulate blood sugar by removing glucose from circulation. This may explain why muscle mass protects against developing diabetes.

Muscle also releases chemicals called myokines, which act upon other tissues and organs in the body – such as fat, our bones, the gut, liver and even our skin and brain. These myokines generally appear to have a protective effect on all of these tissues. This suggests muscle provides more than just the power we need to move our bodies.

Improving grip strength

Unless you’re a rock climber or otherwise need a strong grip, there’s not much point working specifically on improving your grip strength. Although grip strength is linked with longevity and disease, this is because grip strength is an estimate of total body strength.

As such, if you want to improve your health and strength, you should focus on training your leg strength. Leg strength is particularly important for health and fitness as it permits movement and helps you continue doing tasks independently in your daily life. Research also shows a correlation between leg strength and a person’s risk of chronic disease and their longevity.

You can also add in other movements such as deadlifts, press-ups and pull-ups to build strength in your core, back and arms.

Grip strength values serve as a very cheap and easy measure of a person’s overall health. It’s a cost-effective tool for measuring health but there are better ways to improve health with exercise.

Lawrence Hayes is Lecturer in Physiology, Lancaster University.

This article was first published on The Conversation.

The probability of any American having dementia in their lifetime may be far greater than previously thought.

For instance, a 2025 study that tracked a large sample of American adults across more than three decades found that their average likelihood of developing dementia between ages 55 to 95 was 42%, and that figure was even higher among women, Black adults and those with genetic risk.

Now, a great deal of attention is being paid to how to stave off cognitive decline in the aging American population. But what is often missing from this conversation is the role that chronic stress can play in how well people age from a cognitive standpoint, as well as everybody’s risk for dementia.

We are professors at Penn State in the Center for Healthy Aging, with expertise in health psychology and neuropsychology. We study the pathways by which chronic psychological stress influences the risk of dementia and how it influences the ability to stay healthy as people age.

Recent research shows that Americans who are currently middle-aged or older report experiencing more frequent stressful events than previous generations. A key driver behind this increase appears to be rising economic and job insecurity, especially in the wake of the 2007-2009 Great Recession and ongoing shifts in the labor market.

Many people stay in the workforce longer due to financial necessity, as Americans are living longer and face greater challenges covering basic expenses in later life.

Therefore, it may be more important than ever to understand the pathways by which stress influences cognitive aging.

Social isolation and stress

Although everyone experiences some stress in daily life, some people experience stress that is more intense, persistent or prolonged. It is this relatively chronic stress that is most consistently linked with poorer health.

In a recent review paper, our team summarised how chronic stress is a hidden but powerful factor underlying cognitive aging, or the speed at which your cognitive performance slows down with age.

It is hard to overstate the impact of stress on your cognitive health as you age. This is in part because your psychological, behavioral and biological responses to everyday stressful events are closely intertwined, and each can amplify and interact with the other.

For instance, living alone can be stressful – particularly for older adults – and being isolated makes it more difficult to live a healthy lifestyle, as well as to detect and get help for signs of cognitive decline.

Moreover, stressful experiences – and your reactions to them – can make it harder to sleep well and to engage in other healthy behaviors, like getting enough exercise and maintaining a healthy diet. In turn, insufficient sleep and a lack of physical activity can make it harder to cope with stressful experiences.

Prevention efforts

A robust body of research highlights the importance of at least 14 different factors that relate to your risk of Alzheimer’s disease, a common and devastating form of dementia and other forms of dementia. Although some of these factors may be outside of your control, such as diabetes or depression, many of these factors involve things that people do, such as physical activity, healthy eating and social engagement.

What is less well-recognised is that chronic stress is intimately interwoven with all of these factors that relate to dementia risk. Our work and research by others that we reviewed in our recent paper demonstrate that chronic stress can affect brain function and physiology, influence mood and make it harder to maintain healthy habits. Yet, dementia prevention efforts rarely address stress.

Avoiding stressful events and difficult life circumstances is typically not an option.

Where and how you live and work plays a major role in how much stress you experience. For example, people with lower incomes, less education or those living in disadvantaged neighborhoods often face more frequent stress and have fewer forms of support – such as nearby clinics, access to healthy food, reliable transportation or safe places to exercise or socialise – to help them manage the challenges of aging. As shown in recent work on brain health in rural and underserved communities, these conditions can shape whether people have the chance to stay healthy as they age.

Over time, the effects of stress tend to build up, wearing down the body’s systems and shaping long-term emotional and social habits.

Lifestyle changes

The good news is that there are multiple things that can be done to slow or prevent dementia, and our review suggests that these can be enhanced if the role of stress is better understood.

Whether you are a young, midlife or an older adult, it is not too early or too late to address the implications of stress on brain health and aging. Here are a few ways you can take direct actions to help manage your level of stress:

• Follow lifestyle behaviors that can improve healthy aging. These include: following a healthy diet, engaging in physical activity and getting enough sleep. Even small changes in these domains can make a big difference.

• Prioritise your mental health and well-being to the extent you can. Things as simple as talking about your worries, asking for support from friends and family and going outside regularly can be immensely valuable.

• If your doctor says that you or someone you care about should follow a new health care regimen, or suggests there are signs of cognitive impairment, ask them what support or advice they have for managing related stress.

• If you or a loved one feel socially isolated, consider how small shifts could make a difference. For instance, research suggests that adding just one extra interaction a day – even if it’s a text message or a brief phone call – can be helpful, and that even interactions with people you don’t know well, such as at a coffee shop or doctor’s office, can have meaningful benefits.

Lifelong learning

A 2025 study identified stress as one of 17 overlapping factors that affect the odds of developing any brain disease, including stroke, late-life depression and dementia. This work suggests that addressing stress and overlapping issues such as loneliness may have additional health benefits as well.

However, not all individuals or families are able to make big changes on their own. Research suggests that community-level and workplace interventions can reduce the risk of dementia. For example, safe and walkable neighborhoods and opportunities for social connection and lifelong learning – such as through community classes and events – have the potential to reduce stress and promote brain health.

Importantly, researchers have estimated that even a modest delay in disease onset of Alzheimer’s would save hundreds of thousands of dollars for every American affected. Thus, providing incentives to companies who offer stress management resources could ultimately save money as well as help people age more healthfully.

In addition, stress related to the stigma around mental health and aging can discourage people from seeking support that would benefit them. Even just thinking about your risk of dementia can be stressful in itself. Things can be done about this, too. For instance, normalising the use of hearing aids and integrating reports of perceived memory and mental health issues into routine primary care and workplace wellness programs could encourage people to engage with preventive services earlier.

Although research on potential biomedical treatments is ongoing and important, there is currently no cure for Alzheimer’s disease. However, if interventions aimed at reducing stress were prioritised in guidelines for dementia prevention, the benefits could be far-reaching, resulting in both delayed disease onset and improved quality of life for millions of people.

Jennifer E Graham-Engeland is Professor of Biobehavioral Health, Penn State.

Martin J Sliwinski is Professor of Human Development and Family Studies, Penn State.

This article was first published on The Conversation.

Humans and our ancestors have been running for millions of years. Back then, it helped us capture – or avoid becoming – prey. Now, we do it to keep fit, boost mental health, unwind in nature, or play our favourite sport.

But while many of us were taught how to ride a bike, throw and catch a ball, or kick a footy, it seems very few people are ever taught how to run. You might’ve wondered: am I running wrong?

Well, the truth is there’s no one right way to run. Your ideal technique depends on factors such as leg and foot length, muscle mass, and even how springy your tendons are.

It also depends on whether you’re out for your Sunday run or running full pelt in a sprint.

That said, thinking a little more about how to run can make it feel easier and faster, and reduce injury risk.

Here are five basics to keep in mind.

1. Feet: how you land matters

Some of us land on our heels, others on the balls of our feet. If you grew up running barefoot, you’ll more often land towards the forefoot.

Debate rages on which is best. The truth is heel-first striking stresses the knees a bit more while forefoot landing places more impact on the calves and Achilles tendon.

So, if you’re injury prone in one of those areas, it might be worth adjusting your style.

But for healthy runners, there’s no strong evidence one technique is better for injury.

If you’re considering a change, do it slowly over several months, ideally with expert help.

As you run faster, you’ll bounce more in each step. You’ll naturally land more on your forefoot, especially when sprinting.

2. Legs: softer landings and smoother strides

Three things are worth focusing on:

• minimise the twisting of the legs under your body as you land, to reduce strain on knees and ankles

• keep your pelvis level during landings (dropping or rotating it increases injury risk)

• don’t bounce too high; a smooth, low trajectory uses less energy and keeps impacts manageable.

These principles are perfectly demonstrated by Ethiopian former long-distance runner Haile Gebrselassie:

Just keep relaxed, and allow the knees and ankles to flex normally.

If you find your landing style causes stress or pain, consider running with slightly shorter strides.

Then there’s the “leg recovery phase” – when your leg swings forward after push-off. During jogging, we pull the leg forward briefly with our hip muscles, but otherwise it’s a pretty passive task.

In sprinting, however, the faster leg recovery powered by your hip can contribute about 25% of your forward propulsion in each step. So make sure you flex at the hip while you push back into the ground, so your legs act like scissors as they swing.

Also, the faster you run, the more your knee should flex, and the more the foot should rise under you. This helps the leg swing forwards faster.

In other words: pick your feet up more as you pick up the pace.

3. Arms: built-in shock absorbers

During jogging, your arms help with balance, absorbing bumps or stumbles, especially on uneven ground, as seen here:

They swing mostly passively and act as shock absorbers during jogging; they can’t do their job when they’re stiff. Relaxation is key.

To keep energy cost low, try bending your elbows to keep their mass closer to your shoulder and keep your shoulders relaxed.

When sprinting, your arms become more active. They help stabilise your whole body in the short time your feet are on the ground.

Top sprint coaches often insist the “drive arm” (the arm swinging backwards) contributes to forward propulsion, thanks to physics.

But the limited studies to date suggest the effect on propulsion is moderate; future studies might shed more light.

That said, the fastest sprinters, like Usain Bolt, are renowned for their aggressive backwards arm drive:

See how his drive arm whips backwards with rapid extension of the shoulder and elbow? Meanwhile, the recovery arm – swinging forwards – is more flexed and moves much slower.

4. Torso: lean just a little

When we run, the torso naturally rotates left and right. That’s fine, although when we run faster there should be less rotation. A more aggressive arm swing helps balance out these rotations.

Our pelvis then rotates in the opposite direction to the torso. The twisting helps us balance, but also contributes a little to forward force.

But as we run faster, these rotations should become smaller as we use our arms to balance better. As your speed increases, swing your arms a bit harder and your body, legs and other arm will follow.

Finally, it’s generally accepted that we keep our torso upright when we run relaxed, with only a very slight forward lean.

But if we want to speed up, leaning forward is a great way to accelerate quickly without doing too much tiring muscle work.

And for those with knee troubles, leaning forward a bit might help reduce impact on the knees.

5. Head: a balancing act

You might be tempted to tilt your head down when you run, to watch your feet or in an effort to accelerate forwards.

But during upright (non-sprinting) running, try to keep it in normal position. Rest your head quietly on the top of your shoulders, just as as evolution intended.

During sprinting, try looking about 20 metres in front of you (a slight chin tuck is fine). When jogging, try looking ahead toward the horizon.

Not sure what your own technique looks like? Try asking a friend to take a quick video of you running. Compare it to an experienced runner running at the same speed.

You might be surprised what you notice.

Anthony Blazevich is Professor of Biomechanics, Edith Cowan University.

This article was first published on The Conversation.

It’s a question that’s long been the cause of debate: is it better to shower in the morning or at night?

Morning shower enthusiasts will say this is the obvious winner, as it helps you wake up and start the day fresh. Night shower loyalists, on the other hand, will argue it’s better to “wash the day away” and relax before bed.

But what does the research actually say? As a microbiologist, I can tell you there actually is a clear answer to this question.

First off, it’s important to stress that showering is an integral part of any good hygiene routine – regardless of when you prefer to have one.

Showering helps us remove dirt and oil from our skin, which can help prevent skin rashes and infections.

Showering also removes sweat, which can quell body odour.

Although many of us think that body odour is caused by sweat, it’s actually produced by bacteria that live on the surface of our skin. Fresh sweat is, in fact, odourless. But skin-dwelling bacteria – specifically staphylococci – use sweat as a direct nutrient source. When they break down the sweat, it releases a sulphur-containing compound called thioalcohols which is behind that pungent BO stench many of us are familiar with.

Day or night

During the day, your body and hair inevitably collect pollutants and allergens (such as dust and pollen) alongside their usual accumulation of sweat and sebaceous oil. While some of these particles will be retained by your clothes, others will inevitably be transferred to your sheets and pillow cases.

The sweat and oil from you skin will also support the growth of the bacteria that comprise your skin microbiome. These bacteria may then also be transferred from your body onto your sheets.

Showering at night may remove some of the allergens, sweat and oil picked up during the day so less ends up on your bedsheets.

However, even if you’ve freshly showered before bed, you will still sweat during the night – whatever the temperature is. Your skin microbes will then eat the nutrients in that sweat. This means that by the morning, you’ll have both deposited microbes onto your bed sheets and you’ll probably also wake up with some BO.

What particularly negates the cleaning benefits of a night shower is if your bedding is not regularly laundered. The odour causing microbes present in your bed sheets may be transferred while you sleep onto your clean body.

Showering at night also does not stop your skin cells being shed. This means they can potentially become the food source of house dust mites, whose waste can be allergenic. If you don’t regularly wash your sheets, this could lead to a build-up of dead skin cell deposits which will feed more dust mites. The droppings from these dust mites can trigger allergies and exacerbate asthma.

Morning showers, on the other hand, can help remove dead skin cells as well as any sweat or bacteria you’ve picked up from your bed sheets during the night. This is especially important to do if your sheets weren’t freshly washed when you went to bed.

A morning shower suggests your body will be cleaner of night-acquired skin microbes when putting on fresh clothes. You’ll also start the day with less sweat for odour-producing bacteria to feed on – which will probably help you smell fresher for longer during the day compared to someone who showered at night. As a microbiologist, I am a day shower advocate.

Of course, everyone has their own shower preference. Whatever time you choose, remember that the effectiveness of your shower is influenced by many aspects of your personal hygiene regime – such as how frequently you wash your bed sheets.

So regardless of whether your prefer a morning or evening shower, it’s important to clean your bed linen regularly. You should launder your sheets and pillow cases at least weekly to remove all the sweat, bacteria, dead skin cells and sebaceous oils that have built up on your sheets.

Washing will also remove any fungal spores that might be growing on the bed linen – alongside the nutrient sources these odour producing microbes use to grow.

Primrose Freestone is Senior Lecturer in Clinical Microbiology, University of Leicester.

This article was first published on The Conversation.

As we enter the colder months in Australia, Covid-19 is making headlines again, this time due to the emergence of a new variant: NB.1.8.1.

Last week, the World Health Organization designated NB.1.8.1 as a “variant under monitoring”, owing to its growing global spread and some notable characteristics which could set it apart from earlier variants.

So what do you need to know about this new variant?

The current Covid situation

More than five years since Covid was initially declared a pandemic, we’re still experiencing regular waves of infections.

It’s more difficult to track the occurrence of the virus nowadays, as fewer people are testing and reporting infections. But available data suggests in late May 2025, case numbers in Australia were ticking upwards.

Genomic sequencing has confirmed NB.1.8.1 is among the circulating strains in Australia, and generally increasing. Of cases sequenced up to May 6 across Australia, NB.1.8.1 ranged from less than 10% in South Australia to more than 40% in Victoria.

Wastewater surveillance in Western Australia has determined NB.1.8.1 is now the dominant variant in wastewater samples collected in Perth.

Internationally NB.1.8.1 is also growing. By late April 2025, it comprised roughly 10.7% of all submitted sequences – up from just 2.5% four weeks prior. While the absolute number of cases sequenced was still modest, this consistent upward trend has prompted closer monitoring by international public health agencies.

NB.1.8.1 has been spreading particularly in Asia – it was the dominant variant in Hong Kong and China at the end of April.

Where does this variant come from

According to the WHO, NB.1.8.1 was first detected from samples collected in January 2025.

It’s a sublineage of the Omicron variant, descending from the recombinant XDV lineage. “Recombinant” is where a new variant arises from the genetic mixing of two or more existing variants.

The image shows more specifically how NB.1.8.1 came about.

What does research say

Like its predecessors, NB.1.8.1 carries a suite of mutations in the spike protein. This is the protein on the surface of the virus that allows it to infect us – specifically via the ACE2 receptors, a “doorway” to our cells.

The mutations include T22N, F59S, G184S, A435S, V445H, and T478I. It’s early days for this variant, so we don’t have much data on what these changes mean yet. But a recent preprint (a study that has not yet been peer reviewed) offers some clues about why NB.1.8.1 may be gathering traction.

Using lab-based models, researchers found NB.1.8.1 had the strongest binding affinity to the human ACE2 receptor of several variants tested – suggesting it may infect cells more efficiently than earlier strains.

The study also looked at how well antibodies from vaccinated or previously infected people could neutralise or “block” the variant. Results showed the neutralising response of antibodies was around 1.5 times lower to NB.1.8.1 compared to another recent variant, LP.8.1.1.

This means it’s possible a person infected with NB.1.8.1 may be more likely to pass the virus on to someone else, compared to earlier variants.

What are the symptoms

The evidence so far suggests NB.1.8.1 may spread more easily and may partially sidestep immunity from prior infections or vaccination. These factors could explain its rise in sequencing data.

But importantly, the WHO has not yet observed any evidence it causes more severe disease compared to other variants.

Reports suggest symptoms of NB.1.8.1 should align closely with other Omicron subvariants.

Common symptoms include sore throat, fatigue, fever, mild cough, muscle aches and nasal congestion. Gastrointestinal symptoms may also occur in some cases.

What about the vaccine?

There’s potential for this variant to play a significant role in Australia’s winter respiratory season. Public health responses remain focused on close monitoring, continued genomic sequencing, and promoting the uptake of updated Covid boosters.

Even if neutralising antibody levels are modestly reduced against NB.1.8.1, the WHO has noted current Covid vaccines should still protect against severe disease with this variant.

The most recent booster available in Australia and many other countries targets JN.1, from which NB.1.8.1 is descended. So it makes sense it should still offer good protection.

Ahead of winter and with a new variant on the scene, now may be a good time to consider another Covid booster if you’re eligible. For some people, particularly those who are medically vulnerable, Covid can still be a serious disease.

Lara Herrero is Associate Professor and Research Leader in Virology and Infectious Disease, Griffith University.

This article was first published on The Conversation.

In today’s digital world, people routinely turn to the internet for health or medical information. In addition to actively searching online, they often come across health-related information on social media or receive it through emails or messages from family or friends.

It can be tempting to share such messages with loved ones – often with the best of intentions.

As a global health communication scholar studying the effects of media on health and development, I explore artistic and creative ways to make health information more engaging and accessible, empowering people to make informed decisions.

Although there is a fire hose of health-related content online, not all of it is factual. In fact, much of it is inaccurate or misleading, raising a serious health communication problem: Fake health information – whether shared unknowingly and innocently, or deliberately to mislead or cause harm – can be far more captivating than accurate information.

This makes it difficult for people to know which sources to trust and which content is worthy of sharing.

Allure of fake health information

Fake health information can take many forms. For example, it may be misleading content that distorts facts to frame an issue or individual in a certain context. Or it may be based on false connections, where headlines, visuals or captions don’t align with the content. Despite this variation, such content often shares a few common characteristics that make it seem believable and more shareable than facts.

For one thing, fake health information often appears to be true because it mixes a grain of truth with misleading claims.

For example, early in the Covid-19 pandemic, false rumors suggested that drinking ethanol or bleach could protect people from the virus. While ethanol or bleach can indeed kill viruses on surfaces such as countertops, it is extremely dangerous when it comes into contact with skin or gets inside the body.

Another marker of fake health information is that it presents ideas that are simply too good to be true. There is something appealingly counterintuitive in certain types of fake health information that can make people feel they have access to valuable or exclusive knowledge that others may not know. For example, a claim such as “chocolate helps you lose weight” can be especially appealing because it offers a sense of permission to indulge and taps into a simple, feel-good solution to a complex problem. Such information often spreads faster because it sounds both surprising and hopeful, validating what some people want to believe.

Sensationalism also drives the spread of fake health information. For instance, when critics falsely claimed that Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases and the chief medical adviser to the president at the time, was responsible for the Covid-19 pandemic, it generated a lot of public attention.

In a study on vaccine hesitancy published in 2020, my colleagues and I found that controversial headlines in news reports that go viral before national vaccination campaigns can discourage parents from getting their children vaccinated. These headlines seem to reveal sensational and secret information that can falsely boost the message’s credibility.

The pull to share

The internet has created fertile ground for spreading fake health information. Professional-looking websites and social media posts with misleading headlines can lure people into clicking or quickly sharing, which drives more and more readers to the falsehood. People tend to share information they believe is relevant to them or their social circles.

In 2019, an article with the false headline “Ginger is 10,000x more effective at killing cancer than chemo” was shared more than 800,000 times on Facebook. The article contained several factors that make people feel an urgency to react and share without checking the facts: compelling visuals, emotional stories, misleading graphs, quotes from experts with omitted context and outdated content that is recirculated.

Visual cues like the logos of reputable organisations or photos of people wearing white medical coats add credibility to these posts. This kind of content is highly shareable, often reaching far more people than scientifically accurate studies that may lack eye-catching headlines or visuals, easy-to-understand words or dramatic storylines.

But sharing content without verifying it first has real-world consequences. For example, studies have found that Covid-19-related fake information reduces people’s trust in the government and in health care systems, making people less likely to use or seek out health services.

Unfounded claims about vaccine side effects have led to reduced vaccination rates globally, fueling the return of dangerous diseases, including measles.

Social media misinformation, such as false claims about cinnamon being a treatment for cancer, has caused hospitalisations and even deaths. The spread of health misinformation has reduced cooperation with important prevention and treatment recommendations, prompting a growing need for medical professionals to receive proper training and develop skills to effectively debunk fake health information.

How to combat it

In today’s era of information overload in which anyone can create and share content, being able to distinguish between credible and misleading health information before sharing is more important than ever. Researchers and public health organisations have outlined several strategies to help people make better-informed decisions.

Whether health care consumers come across health information on social media, in an email or through a messaging app, here are three reliable ways to verify its accuracy and credibility before sharing:

• Use a search engine to cross-check health claims. Never rely on a single source. Instead, enter the health claim into a reputable search engine like Google and see what trusted sources have to say. Prioritise information from established organisations like the World Health Organization, Centers for Disease Control and Prevention, United Nations Children’s Fund or peer-reviewed journals like The Lancet or Journal of the American Medical Association. If multiple reputable sources agree, the information is more likely to be reliable. Reliable fact-checking websites such as FactCheck.org and Snopes can also help root out fake information.

• Evaluate the source’s credibility. A quick way to assess a website’s trustworthiness is to check its “About Us” page. This section usually explains who is behind the content, their mission and their credentials. Also, search the name of the author. Do they have recognised expertise or affiliations with credible institutions? Reliable websites often have domains ending in .gov or .edu, indicating government or educational institutions. Finally, check the publication date. Information on the internet keeps circulating for years and may not be the most accurate or relevant in the present context.

• If you’re still unsure, don’t share. If you’re still uncertain about the accuracy of a claim, it’s better to keep it to yourself. Forwarding unverified information can unintentionally contribute to the spread of misinformation and potentially cause harm, especially when it comes to health.

Questioning dubious claims and sharing only verified information not only protects against unsafe behaviors and panic, but it also helps curb the spread of fake health information. At a time when misinformation can spread faster than a virus, taking a moment to pause and fact-check can make a big difference.

Angshuman K Kashyap is PhD candidate in Health Communication, University of Maryland.

This article was first published on The Conversation.

This year marks the 25th year of the ban on smoking in public places, a landmark judgement of the Kerala High Court. Subsequently, the Cigarettes and Other Tobacco Products Act, 2003, was passed, which prohibited smoking in public places and introduced penalties for violations.

Despite decades of policy action, however, India is the world’s second-largest consumer and producer of tobacco, and consequently faces a formidable public health and economic challenge.

The Global Adult Tobacco Survey 2016-’17 says that nearly 267 million Indian adults – about 29% of the adult population – use tobacco in some form. More recent estimates suggest there are around 253 million tobacco users in India as of 2022. The lack of updated national surveys since 2022 limits precise tracking of current trends, highlighting the need for frequent surveys to inform evidence-based policymaking.

While the ban under act has led to reduced passive smoking, enforcement remains inconsistent across states, according to the Report on Tobacco Control in India 2022, by the Ministry of Health and Family Welfare.

Nicotine is among the most addictive substances in the world, with some researchers deeming it to be more addictive than cocaine and heroin. “The tobacco industry takes advantage of this by targeting young people through advertisements and behavioural strategies, aiming to create lifelong customers,” says Ravi Mehrotra, Program Lead at the India Cancer Research Consortium, affiliated with the Indian Council of Medical Research. “A significant portion of tobacco users, including smokers, begin using tobacco products before age 18.”

One-third of all daily smokers aged 20-34 had started smoking tobacco on a daily basis before attaining the age of 18, the Global Adult Tobacco Survey found.

Every state has different enforcement policies, as a result of which India has no uniform evaluation metrics for the outcomes. In states with weaker enforcement, limited funding and inadequate training for enforcement officers hinder compliance with the act.

“Today, the cessation facilities available in India are very few, and there has been little to no scientific study or random clinical trials to see how many people have benefited and what the actual quit rate is due to these facilities,” says Mehrotra, who serves on the board of directors of the India Cancer Genome Atlas and is the founder of the Centre of Health Innovation & Policy foundation.

In India, smoking causes 930,000 deaths each year while smokeless tobacco leads to 350,000 deaths – together adding up to about 3,500 deaths every day, estimates suggest. In addition, over 200,000 people die from causes attributable to second-hand smoke exposure. The economic cost is staggering: tobacco use cost India nearly Rs 1.7 trillion in 2017-’18, taking into account the healthcare expenses and lost productivity.

Geographical variations

The National Family Health Surveys suggest a decline in tobacco consumption. In 2019-’21, 38% men aged 15 to 49 years reported using some form of tobacco, down from 57% in 2005-’06. Among women, this number fell from 11% to 9%. North East Indian states report the highest prevalence of tobacco use.

Driving factors

Several factors contribute to the widespread use of smoking tobacco in India. From a behavioural science perspective, a 2023 paper groups the reasons for tobacco use initiation into six categories based on the Capability, Opportunity, Motivation-Behaviour (COM-B) model.

Psychological capabilities play a role, as many individuals lack knowledge about the harmful health effects of tobacco, struggle with self-control, or face mental challenges. Many people start using tobacco believing it will relieve stress, anxiety, or improve mood. Individuals with mental health disorders are particularly vulnerable.

Pratima Murthy, director, National Institute of Mental Health and Neurosciences, Bengaluru, and an expert in addiction psychiatry and tobacco cessation, points out the mental health links to smoking.

“Research shows that the risk of smoking is doubled among people with depression, and those with depression are more likely to develop dependent patterns of tobacco use and experience more severe withdrawal symptoms.”

Integrating tobacco cessation into mental health services at primary health centres could address higher relapse rates among individuals with depression or anxiety.

Physical opportunities, including the widespread presence of tobacco advertising, easy access to tobacco products, and seeing celebrities smoke on screen, create an environment that encourages smoking initiation. Social opportunities, like peer pressure, parental tobacco use, cultural traditions that normalise tobacco, and notions of masculinity, further reinforce the habit.

For example, in Uttar Pradesh and elsewhere, the cultural practice of chewing paan with tobacco, often offered at social gatherings, normalises smokeless tobacco use, particularly among women.

One notable driver of physical opportunities is the widespread sale of single cigarettes. Nearly 75% of all cigarettes are sold as single sticks, estimates show, making them more affordable and accessible, especially to minors and low-income users. “This practice undermines the impact of health warnings and taxation, as single sticks do not display the mandated graphic warnings and evade higher taxes applied to full packs,” explains Mehrotra.

Automatic motivation, such as using tobacco to manage emotions, seeking temporary pleasure, or engaging in risk-taking, and reflective motivation, which includes beliefs about perceived benefits, underestimating risks, and coping with stress – also drive people to start smoking or to persist with the habit.

India has implemented strict tobacco control measures, including large pictorial health warnings covering 85% of tobacco packaging.

However, as Mehrotra points out, “They have been shown to have some effectiveness, but the impact can diminish over time. Many young people become desensitised to the current warning labels.”

Regularly updating and strengthening warning labels and combining them with other anti-tobacco campaigns is therefore essential. The Ministry of Health and Family Welfare announced new packaging and labelling rules in December 2024, introducing stronger warnings and a national quitline number, effective from June 2025.

According to the World Health Organization, the most effective way to discourage tobacco smoking has been to increase the taxes on it and other smoking products. “The single best way of increasing the effectiveness of tobacco control is increasing the taxes.

In countries like Australia, where the cigarette tax is as high as 69%, there has been a significant decline in smoking in the past decade,” said Mehrotra. While India’s cigarette taxes, reaching 53% of retail price, are high, they fall short of WHO’s 75% benchmark, limiting their impact on reducing affordability.

Quit smoking efforts

The government has made several efforts for individuals seeking to quit smoking. The National Tobacco Control Programme focuses on establishing Tobacco Cessation Centres in district hospitals, offering free behavioural counselling, medication, and nicotine replacement therapy. This also reflects in the data: About 32% of people who use tobacco reported trying to quit in the 12 months prior to the 2019-’21 health survey.

With only 600 centres nationwide, however, India has roughly one cessation centre per two million people, with rural areas particularly underserved.

The National Tobacco Quit Line provides community-based counselling through a toll-free number, and the m-cessation initiative uses text messaging to support quitting. Specialised institutes like NIMHANS in Bengaluru and Tata Memorial Centre in Mumbai offer tobacco cessation services. AI-powered apps like QuitNow, tailored for Indian users, could complement m-cessation by offering personalised quitting plans.

Community-based programmes

There is an urgent need to strengthen community-based programmes and implement effective screening initiatives, especially in rural and underserved areas. Mehrotra urges the community leaders and social workers to focus on their level with the help of technology.

“Leveraging the widespread availability and affordability of mobile devices and internet connectivity, community health workers can use smartphones and tablets to conduct screenings, maintain records, and ensure that no one is left out of follow-up care.”

Mehrotra stresses the need for early screening and cancer detection to minimise the burden on healthcare and personal expenses. “Early screening is essential because many individuals, especially women from lower-income groups who are busy with daily work, may not recognise the importance of getting checked for early signs of disease. By making screening accessible, affordable, and trusted, health systems can detect health issues in asymptomatic individuals and improve outcomes across communities.”

Rakesh Gupta, president, Strategic Institute for Public Health Education and Research, and a tobacco control advocate, tells IndiaSpend how the model was established by the National Tobacco Control Program in Punjab, a state that has seen a significant decline in tobacco consumption.

“We had a state-level coordination committee, which included most of the stakeholder ministries, like the health department, the education department, and the home department under which they have the police. All the stakeholders are part of the state-level coordination committee, and meetings were held every three months.” There are enforcement squads at the state level, district level and block level with similar bodies to ensure cooperation on the ground.

These enforcement squads are responsible for raiding premises which violate the tobacco laws frequently. “The NTCP [National Tobacco Control Programme] in the state earned enough through challans (fines) in these squares to regulate its tobacco enforcement. This framework is being replicated in states like Rajasthan, Bihar, Uttar Pradesh and Karnataka, though ensuring these are enforced properly is a challenge. It depends on the state programme officer, state nodal officer, and the political will in the state.”

India needs to find a collective will to eradicate smoking from its public places, through community-led interventions that prevent the initiation altogether, and take inspiration from model states to establish policies tailored to their regions.

IndiaSpend reached out to the health ministry for comments. We will update this story when we receive a response.

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

You might’ve noticed some physiotherapists advertise they offer treatments for headaches and wondered: would that work?

In fact, there’s a solid body of research showing that physiotherapy treatments can be really helpful for certain types of headache.

Sometimes, however, medical management is also necessary and it’s worth seeing a doctor. Here’s what you need to know.

Cervicogenic headache

Cervicogenic headache is where pain is referred from the top of the neck (an area known as the upper cervical spine).

Pain is usually one-sided. It generally starts just beneath the skull at the top of the neck, spreading into the back of the head and sometimes into the back of the eye.

Neck pain and headache are often triggered by activities that put strain on the neck, such as holding one posture or position for a long time, or doing repetitive neck movements (such as looking up and down repeatedly).

Unlike in migraine, people experiencing cervicogenic headache don’t usually get nausea or sensitivity to light and sound.

Because this is a musculoskeletal condition of the upper neck, physiotherapy treatments that improve neck function – such as manual therapy, exercise and education – can provide short- and long-term benefits.

Can physio help

Migraine is a neurological disorder whereby the brain has difficulty processing sensory input.

This can cause episodic attacks of moderate to severe headache, as well as:

• sensitivity to light and noise

• nausea and

• intolerance to physical exertion.

There are many triggers. Everyone’s are different and identifying yours is crucial to self-management of migraine. Medication can also help, so seeing a GP is the first step if you suspect you have migraine.

About 70%-80% of people with migraine also have neck pain, commonly just before or at the onset of a migraine attack. This can make people think their neck pain is triggering the migraine.

While this may be true in some people, our research has shown many people with migraine have nothing wrong with their neck despite having neck pain.

In those cases, neck pain is part of migraine and can be a warning (but not a cause or trigger) of an imminent migraine attack. It can signal patients need to take steps to prevent the attack.

On the other hand, if the person has musculoskeletal neck disorder, physiotherapy neck treatments may help improve their migraine. Musculoskeletal neck disorder is what physiotherapists call typical neck pain caused by, for instance, a sports injury or sleeping in a weird way.

You may have heard of the Watson manual therapy technique being used to treat migraine. It involves applying manual pressure to the upper cervical spine and neck area.

There are currently no peer-reviewed studies looking at how effective this technique is for migraine.

However, recent studies investigating a combination of manual therapy, neck exercises and education tailored to the individual’s circumstances show some small effects in improving the number of migraine attacks and the disabling effects of headache.

Manual therapy and neck exercises can also give short-term pain relief.

However, in some cases the neck can become very sensitive and easily aggravated in migraine. That means inappropriate assessment or treatment could end up triggering a migraine.

Physiotherapy can help with migraine but you first need a comprehensive and skilled physical assessment of the neck by an experienced physiotherapist. It’s crucial to identify if a musculoskeletal neck disorder is present and, if so, which type of neck treatment is needed.

It is also important people with migraine understand how their migraine is triggered, what lifestyle factors contribute to it and when to take the appropriate medications to help manage their migraines.

A trained physiotherapist can provide some of this information and help patients make sense of their condition and recommend the patient see their GP for medication, when appropriate.

Tension headaches

Tension type headache is the most common type of headache, characterised by a feeling of “tightness” or “band-like” pain around the head.

Nausea and sensitivity to light and noise are not usually present with this type of headache.

Like migraine, tension type headache is often associated with neck pain and also has different aggravating factors, not all of which are due to the neck.

Again, a detailed assessment by a trained physiotherapist is needed to identify if the neck is involved and what type of neck treatment is best.

There is some evidence a combination of manual therapy and exercise can reduce tension type headache.

Physiotherapists can also provide education and advice on aggravating factors and self management.

Seeking help

There are many types and causes of headache. If you suffer frequent headaches or have a new or unusual headache, ask a doctor to investigate.

There is good evidence physiotherapy treatment will improve cervicogenic headache and emerging evidence it might help migraine and tension type headache (alongside usual medical care).

If you are wondering if you have cervicogenic headache or if you have bothersome neck pain associated with headache, ask your doctor to refer you to a skilled physiotherapist trained in headache treatment. A careful assessment can determine if physiotherapy treatment will help.

Zhiqi Liang is Lecturer in Physiotherapy, The University of Queensland.

Julia Treleaven is Associate Professor in Physiotherapy, The University of Queensland.

Lucy Thomas is Teaching and research academic in Physiotherapy, The University of Queensland

This article was first published on The Conversation.

Knowing the calorie content of foods does not help people understand which foods are healthier, according to a study I recently co-authored in the Journal of Retailing. When study participants considered calorie information, they rated unhealthy food as less unhealthy and healthy food as less healthy. They were also less sure in their judgments.

In other words, calorie labeling didn’t help participants judge foods more accurately. It made them second-guess themselves.

Across nine experiments with over 2,000 participants, my colleague and I tested how people use calorie information to evaluate food. For example, participants viewed food items that are generally deemed healthier, such as a salad, or ones that tend to be less healthy, such as a cheeseburger, and were asked to rate how healthy each item was. When people did not consider calorie information, participants correctly saw a big gap between the healthy and unhealthy foods. But when they considered calorie information, those judgments became more moderate.

In another experiment in the study, we found that asking people to estimate the calorie content of food items reduced self-reported confidence in their ability to judge how healthy those foods were − and that drop in confidence is what led them to rate these food items more moderately. We observed this effect for calories but not for other nutrition metrics such as fat or carbohydrates, which consumers tend to view as less familiar.

This pattern repeated across our experiments. Instead of helping people sharpen their evaluations, calorie information seemed to create what researchers call metacognitive uncertainty, or a feeling of “I thought I understood this, but now I’m not so sure”. When people aren’t confident in their understanding, they tend to avoid extreme judgments.

Because people see calorie information so often, they believe they know how to use it effectively. But these findings suggest that the very familiarity of calorie counts can backfire, creating a false sense of understanding that leads to more confusion, not less. My co-author and I call this the illusion of calorie fluency. When people are asked to judge how healthy a food item is based on calorie data, that confidence quickly unravels and their healthiness judgments become less accurate.

Why it matters

These findings have important implications for public health and for the businesses that are investing in calorie transparency. Public health policies assume that providing calorie information will drive more informed choices. But our research suggests that visibility isn’t enough – and that calorie information alone may not help. In some cases, it might even lead people to make less healthy choices.

This does not mean that calorie information should be removed. Rather, it needs to be supported with more context and clarity. One possible approach is pairing calorie numbers with decision aids such as a traffic light indicator or an overall nutrition score, which both exist in some European countries. Alternatively, calorie information about an item could be accompanied by clear reference points explaining how much of a person’s recommended daily calories it contains – though this may be challenging because of how widely daily calorie needs vary.

Our study highlights a broader issue in health communication: Just because information is available doesn’t mean it’s useful. Realising that calorie information can seem easier to understand than it actually is can help consumers make more informed, confident decisions about what they eat.

What still isn’t known

In our studies, we found that calorie information is especially prone to creating an illusion of understanding. But key questions remain.

For example, researchers don’t yet know how this illusion interacts with the growing use of health and wellness apps, personalised nutrition tools or AI-based food recommendations. Future research could look at whether these tools actually help people feel more sure of their choices – or just make them feel confident without truly understanding the information.

Deidre Popovich is Associate Professor of Marketing, Texas Tech University.

This article was first published on The Conversation.

Despite the popularity of semaglutide drugs like Ozempic and Wegovy for weight loss, surveys suggest that most people still prefer to lose weight without using medications. For those preferring a drug-free approach to weight loss, research shows that certain nutrients and dietary strategies can naturally mimic the effects of semaglutides.

Increased intakes of fibre and monounsaturated fats (found in olive oil and avocadoes) — as well as the time of day when foods are eaten, the order that foods are eaten in, the speed of eating and even chewing – can naturally stimulate increased production of the same hormone responsible for the effects of semaglutide drugs.

As a family physician with a PhD in nutrition, I translate the latest nutrition science into dietary recommendations for my patients. A strategic approach to weight loss rooted in the latest science is not only superior to antiquated calorie counting, but also capitalises on the same biological mechanisms responsible for the success of popular weight-loss drugs.

Semaglutide medications work by increasing the levels of a hormone called GLP-1 (glucagon-like peptide 1), a satiety signal that slows digestion and makes us feel full. These drugs also simultaneously decrease levels of an enzyme called DPP-4, which inactivates GLP-1.

As a result, this “stop eating” hormone that naturally survives for only a few minutes can survive for an entire week. This enables a semi-permanent, just-eaten sensation of fullness that consequently leads to decreased food intake and, ultimately, weight loss.

Nevertheless, medications aren’t the only way to raise GLP-1 levels.

What you eat

Fibre – predominantly found in beans, vegetables, whole grains, nuts and seeds – is the most notable nutrient that can significantly increase GLP-1. When fibre is fermented by the trillions of bacteria that live in our intestines, the resultant byproduct, called short chain fatty acids, stimulates the production of GLP-1.

This may explain why fibre consumption is one of the strongest predictors of weight loss and has been shown to enable weight loss even in the absence of calorie restriction.

Monounsaturated fats – found in olive oil and avocado oil – are another nutrient that raises GLP-1. One study showed that GLP-1 levels were higher following the consumption of bread and olive oil compared to bread and butter. Though notably, bread consumed with any kind of fat (be it from butter or even cheese) raises GLP-1 more than bread alone.

Another study showed that having an avocado alongside your breakfast bagel also increases GLP-1 more so than eating the bagel on its own. Nuts that are high in both fibre and monounsaturated fats, like pistachios, have also been shown to raise GLP-1 levels.

How you eat

However, the specific foods and nutrients that influence GLP-1 levels are only half the story. GLP-1 is a good example of how it’s not just what you eat that matters, it’s also how you eat it.

Studies show that meal sequence – the order foods are eaten in – can impact GLP-1. Eating protein, like fish or meat, before carbohydrates, like rice, results in a higher GLP-1 level compared to eating carbohydrates before protein. Eating vegetables before carbohydrates has a similar effect.

Time of day also matters, because like all hormones, GLP-1 follows a circadian rhythm. A meal eaten at 8 am stimulates a more pronounced release of GLP-1 compared to the same meal at 5 p.m. This may partly explain why the old saying “eat breakfast like a king, lunch like a prince and dinner like a pauper” is backed by evidence that demonstrates greater weight loss when breakfast is the largest meal of the day and dinner is the smallest.

The speed of eating can matter, too. Eating ice cream over 30 minutes has been shown to produce a significantly higher GLP-1 level compared to eating ice cream over five minutes. However, studies looking at blood sugar responses have suggested that if vegetables are eaten first, the speed of eating becomes less important.

Even chewing matters. One study showed that eating shredded cabbage raised GLP-1 more than drinking pureed cabbage.

Not as potent as medication

While certain foods and dietary strategies can increase GLP-1 naturally, the magnitude is far less than what is achievable with medications. One study of the GLP-1 raising effects of the Mediterranean diet demonstrated a peak GLP-1 level of approximately 59 picograms per millilitre of blood serum. The product monograph for Ozempic reports that the lowest dose produces a GLP-1 level of 65 nanograms per millilitre (one nanogram = 1,000 picograms). So medications raise GLP-1 more than one thousand times higher than diet.

Nevertheless, when you compare long-term risk for diseases like heart attacks, the Mediterranean diet lowers risk of cardiac events by 30 per cent, outperforming GLP-1 medications that lower risk by 20 per cent. While weight loss will always be faster with medications, for overall health, dietary approaches are superior to medications.

The following strategies are important for those trying to lose weight without a prescription:

• Eat breakfast

• Strive to make breakfast the largest meal of the day (or at least frontload your day as much as possible)

• Aim to eat at least one fibre-rich food at every meal

• Make olive oil a dietary staple

• Be mindful of the order that you eat foods in, consume protein and vegetables before carbohydrates

• Snack on nuts

• Chew your food

• Eat slowly

While natural approaches to raising GLP-1 may not be as potent as medications, they provide a drug-free approach to weight loss and healthy eating.

Mary J Scourboutakos is Adjunct Lecturer in Family and Community Medicine, University of Toronto.

This article was first published on The Conversation.

For over two years, Rajeshwar Madankar has struggled with constant body pain and headaches.

It began when the 27-year-old farmer from Maharashtra’s Yavatmal district sprayed the insecticide, chlorpyrifos, on his cotton farm one morning.

He made the mistake of not covering his face. “That day it was windy, and I accidentally inhaled some of the insecticide,” he said.

By the evening, he had a headache. In a few days, he was vomiting almost every evening.

Chlorpyrifos is used on a variety of food crops to control soil-borne insects, mosquitoes and roundworms. Eating, inhaling or touching the insecticide can lead to nerve and muscle damage. The World Health Organisation lists it as “moderately hazardous”. Studies link it to possible a cancer risk and growth concerns in newborns, apart from neurotoxicity.

“We usually mix 20 ml to 30 ml of the insecticide in a bucket, he may have used more,” said Aakash Suresh Masram, another farmer in Yerad village.

At the Yavatmal district hospital, the staff ran blood tests. “The doctor told me that the insecticide led to poisoning,” Madankar told Scroll.

Other farmers suspect that the insecticide has been damaging their health too, Masram said. “Several farmers in our village have stopped using chlorpyrifos insecticide after Madankar’s illness,” he said.

The farmers’ fears have been vindicated at a global meet of the Stockholm Convention on Persistent Organic Pollutants in Geneva that ended on May 9. The convention is an international environmental treaty that aims to reduce the impact of pollutants on human health by encouraging countries to limit or stop their use.

The organisation has decided to eliminate the use of chlorpyrifos in a phased manner.

But Indian farmers may not benefit from the decision.

India, along with seven other countries, has sought an exemption from the decision, raising concerns among experts of continued health risk to farmers from the insecticide.

Several countries including the United Kingdom, Switzerland, Norway, Uruguay and Iraq, along with the European Union, last fortnight supported the inclusion of the insecticide in Annex A of Stockholm Convention. This document mandates the gradual elimination of the insecticide.

India opposed its complete elimination because it says that there is a lack of alternatives to chlorpyrifos, which, it says, is need to ensure the country’s food security. It said it will continue to use chlorpyrifos for the next five years for at least 12 crops – wheat, rice, gram, beans, sugarcane, barley, apple, groundnut, onion, cotton, mustard and brinjal.

However, AD Dileep, chief executive officer of Pesticide Action Network in India, argued that there are easily available chemical and non-chemical alternatives to chlorpyrifos.

“No consultation was held by the government with experts before it sought an exemption,” Narasimha Reddy Donthi, an international campaigner on climate change, told Scroll. “The decision seems to be industry driven. We fail to see any apparent reason for the continued use of such a harmful chemical,” he added.

Having reviewed proposals to list three pesticides under the #RotterdamConvention, delegates at #BRSCOPs could not agree to list any

That includes chlorpyrifos—a pesticide just listed last week by Stockholm Convention as a persistent organic pollutant

➡️ https://t.co/UvuXgRfUOq pic.twitter.com/ahz7g6GoDv

— Earth Negotiations Bulletin (@IISD_ENB) May 5, 2025

In 2023-24, 1416.22 metric tonnes of chlorpyrifos were consumed in the country. Currently, India and China are the largest producers of this insecticide.

The Indian government’s stand is surprising given that its own panel had recommended a ban on the insecticide.

In 2018, a sub-committee formed by the Union agriculture department reviewed the use of 27 pesticides and insecticides, including chlorpyrifos, and concluded that all 27 may be banned in India. In 2023, however, the central government banned only four out of the 27 pesticides.

Health concerns

It is difficult to establish a direct link between the insecticide and its health impact due to the paucity of adequate scientific studies to prove the adverse effects.

“But it is well established that chlorpyrifos is highly toxic, especially for farmers, children and workers in the field,” said Kumar, from the Pesticide Action Network. “There is no safe level of exposure to it.”

In 2024, Punjab banned 10 pesticides used for paddy cultivation due to high residues in the harvested crop. One of the insecticides was chlorpyrifos, which was found beyond permissible limits in basmati rice, leading to export rejections.

Another 2013 study in ScienceDirect found chlorpyrifos residues in breast milk in Punjab, raising concerns over pesticide exposure in breastfed infants.

Lack of government monitoring

Donthi, the campaigner who works with Pesticide Action Network, said in a field survey report in 2022, they found rampant use of chlorpyrifos by farmers on various crops.

The Food Safety and Standards Authority of India also raised an alert on chlorpyrifos’ use in an advisory to all states in 2019. The letter stated that tests carried out on multiple vegetables found that “residues of chlorpyrifos were exceeding the maximum residual limit” set by the authority.

Another study in 2024 found chlorpyrifos residues in 33% of food samples tested.

Pranav Rawat, an apple grower from Shimla in Himachal Pradesh said he is aware of the long-term impacts of spraying the insecticide. Despite that, he said that apple farmers continue to heavily rely on chlorpyrifos in the state.

“It’s easily available in the market and the government gives it on subsidy,” he claimed. “It’s also very effective in killing the insects. But that itself should be an indicator about why it is very harmful to human health as well.”

He added that usually farmers are more interested in its immediate ability to kill insects, rather than thinking about the long-term health impacts.

Rawat stopped the use of chlorpyrifos in 2023. He now uses neem oil which he has found to be less harmful on pollinators like bees.

He also explained that farmers tend to exceed the maximum permissible quantity of the insecticide. “If for example the recommended level is to mix 200 ml of chlorpyrifos per 200 liters of water, farmers use 400 ml or even 600 ml. No one is there to check and regulate farmers on the ground.”

Aashesh Mehta, an apple cultivator in Himachal Pradesh, however said that awareness amongst farmers is rising. "Not everyone uses this insecticide," he said. "I have never used it."

With inputs from Vaishnavi Rathore

Dr Gnaneshwar no longer thinks twice about flipping on light switches, using the computer or getting print outs at the Yelheri primary health centre in Karnataka’s Yadgir district.

Up until 2022, the primary health centre at which Gnaneshwar is the medical officer had only erratic electricity supply. It had to rely on a power back-up system that would run out in hours. Power cuts meant performing operations by torch or candlelight, baby warmers not working smoothly and no proper cooling for medicines or vaccines.

That changed three-and-a-half years ago. The installation of a solar energy system brought continuous power supply to the health centre – and immense relief. In addition, the staff living nearby do not have to sweat it out, particularly at night.

“Now the laboratory and the storage facilities run seamlessly and even patients are happier,” said Gnaneshwar. “There is no darkness now.”

The problems that the Yelheri centre dealt with before solar power are still faced by most primary health centres across India. Some of them are even in need of basics such as water supply.

Yelheri is one of the 2,500 Karnataka government health facilities to be powered by solar energy, said Huda Jaffer, director of the SELCO Foundation, a social enterprise based in Bengaluru.

Karnataka’s Saurya Swasthya or“solar for health” initiative was launched with the SELCO Foundation in November 2024 with the aim of powering 5,000 health centres. The state has 12,000 health centres, including primary health centres and sub-health centres.

As of 2024, SELCO had helped set up power systems in 8,000 health centres across India. The target for 2025 is to increase this to 10,000 centres and over 25,000 by 2027, Jaffer said.

Across India, solar power is helping rural health care centres overcome a huge infrastructure gap. As a factsheet by the Power For All initiative explains, rural health centres provide crucial “last-mile medical services such as immunisation, child deliveries and neonatal care, all of which cannot be delivered without regular electricity supply”.

In remote regions, solar power is a gamechanger.

Lalengliani Khawlhring, a pharmacist at Hlimen Urban Primary Health Centre in Mizoram’s Aizawl Municipal Council, had joined the centre in 2015 when it did not have constant power supply. Since 2024, when a solar power system was installed, the freezers in the medicine store room have operated smoothly.

Vaccines must be stored at a specific temperature or else they spoil.

“I am no longer tense now about medicines and vaccines,” Khawlhring said in a conversation in April.

Solar not only provides power but also climate resilience to vulnerable communities, especially in states like Odisha, that are prone to extreme events and disasters, said Jaffer. In Odisha, frequent cyclones risk destroying power lines, which leaves solar as a decentralised and reliable source of power during such instances. In remote, rural areas, solar often becomes the only energy source.

Solar-powered healthcare, however, remains a philanthropic initiative, with the support of corporate social responsibility funds. In Karnataka, for instance, the state government and SELCO Foundation have been prime movers with substantial grants from the IKEA Foundation and the Waverly Street Foundation.

Powering healthcare

Nearly 97% of Indian households are electrified, according to a 2020 study by the thinktank Council on Energy, Environment and Water. However, access to power for primary health centres is lower: a 2019 study by the thinktank showed that though 91% of primary health centres had electricity connections in 2012-’13, power supply was irregular for nearly half.

The health ministry’s Rural Health Statistics 2021-’22 said that 3.7% of 24,935 rural primary health centres and 11.4% of 1,57,935 rural sub health centres did not have power supply.

Years before Karnataka’s solar push, Chhattisgarh had begun tapping solar energy for health infrastructure. Up until 2006, one in every three primary health centres in Chhattisgarh did not have power or suffered due to erratic supply.

As of 2023 however, nearly all of the state’s 800 primary health centres and most district hospitals and community health centres are powered by solar energy, according to Jain.

In a conversation in April, Sanjeev Jain, sustainable energy consultant and former chief engineer with the Chhattisgarh State Renewable Energy Development Agency, said, “We were energy security experts and not medical experts but we found that there was increased footfall of patients and staff was retained due to better facilities.”

A typical primary health centre has a mean daily electricity requirement of around 45.8 kWh or kilowatt hours. A solar system of 5 kWp capacity – kilowatt peak measures solar photo voltaic output – can meet 70% of its peak demand. The Chhattisgarh State Renewable Energy Development Agency deployed 2 kWp solar systems to augment electricity supply at the primary health centres.

According to Power For All, Chhattisgarh’s solar energy initiative helped improve healthcare services for 80,000 patients per day and saved up to 80% energy costs for the health centres. Jain said the next target is to install solar power in about 5,000 sub-health centres in Chhattisgarh, with support from the health ministry.

Smaller states in the North East, like Mizoram, Meghalaya, Sikkim, and Karnataka in south India have been trendsetters in powering health centres with solar electricity. In Meghalaya, all health centres use solar power while in Mizoram, 60% of health centres run on solar electricity.

Ninety per cent of Tripura’s primary health centres run on solar power. States such as West Bengal, Kerala, Odisha, Gujarat, Andhra Pradesh, Kerala, Tamil Nadu and Maharashtra are working on similar programmes. Even so, the share of solar power production in India is 5.20% while coal remains a major source of power at 74%.

Solar troubleshooting

Apart from installing solar systems, independent research organisations such as the World Resources Institute India help nonprofits conduct energy audits and integrate energy efficiency and clean energy measures in their health centres.

Audits are crucial to assess the energy needs of the centres, say Lanvin Concessao and Rishikesh Mishra of World Resources Institute, India, which has helped set up solar power connections for 35 charity-run hospitals in rural India.

“The audits also tell us about the energy efficiency of their present medical and non-medical appliances used in the hospitals or centres and on how the solar system should be designed,” said Mishra.

Setting up solar and battery storage involved a lot of ground work in the form of designing energy systems and capacity building, and training staff on the specifics of energy installation. Often, the remote monitoring systems do not work due to bad internet connectivity or software problems, said Concessao.

Concessao said there is a strong push for solar in the Indian Public Health Standards, 2022, and the National Programme on Climate Change and Human Health. This has made budgetary allocations possible for solar systems to be built and maintained, backing research and development practitioners and building awareness.

SELCO’s Jaffer said the aim is not only solar power systems but more efficient medical technology and better health facilities that factor in heat stress and use power efficiently. The Centre’s Surya Mitra programme includes training for Arogya Raksha Samitis or health committees at the village level to understand solar systems and skill training for the youth in solar systems.

Other than installation costs and maintenance, as always with solar energy, there are challenges of using batteries and disposing of them. Most solar systems rely on lead acid batteries but lithium ion is slowly gaining popularity. In Chhattisgarh, Jain said all new systems are using lithium ion which can last for 10 years.

Meena Menon is a freelance journalist and a visiting postdoctoral fellow at the Leeds Arts and Humanities Research Institute, University of Leeds.

This story is part of The 89 Percent Project, an initiative of the global journalism collaboration Covering Climate Now.

Intermittent fasting is not only a useful tool for weight loss, it’s also shown to have many benefits for metabolic health – independent of weight loss. Yet many people may find intermittent fasting to be a challenge, especially if following the 5:2 version of the diet where calories are severely restricted two days a week.

But my latest study shows that you don’t need to severely restrict your calories to get the metabolic benefits of intermittent fasting. Even just restricting the number of carbs you eat twice a week may be enough to improve your metabolic health.

Intermittent fasting appears to be so beneficial for health because of the way it alters our metabolism.

After a meal, our body enters the postprandial state. While in this state, our metabolism pushes our cells to use carbohydrates for immediate energy, while storing some of these carbs as well as fat for later use. But after several hours without food, in the postabsorptive “fasted” state, our metabolism switches to using some of our fat stores for energy.

In this regard, intermittent fasting ensures a better balance between the sources it uses for energy. This leads to improved metabolic flexibility, which is linked with better cardiometabolic health. In other words, this means lower risk of cardiovascular disease, insulin resistance and type 2 diabetes.

My colleagues and I previously ran a study to demonstrate the effects of a fast on the body. We observed that following a day of both total fasting or severe calorie restriction (eating around only 25% of each person’s daily calorie requirements), the body was better at clearing and burning the fat of a full English breakfast the next day. Fasting shifted the body from using carbs to using fat. This effect carried on both during the fast and the next day.

Our research has also compared the effects of intermittent fasting to a calorie-matched or calorie-restricted diet. Both groups followed the diet until they lost 5% of their body weight.

Despite both groups losing the same 5% of body weight, and at the same rate, the intermittent fasting group had greater improvements in their metabolic handling, similar to what we saw in the previous trial.

Other researchers who have compared the effects of the 5:2 variant of the intermittent fasting diet to a calorie-matched, calorie-restricted diet have also found fasting is beneficial for metabolic health.

Metabolic effects

But why exactly is intermittent fasting so beneficial for metabolic health? This is a question I sought to answer in my latest study.

For people who follow the 5:2 intermittent fasting diet, typical fasting days are, by their nature, very low in calories – equating to only a few hundred calories per day. Because people are consuming so few calories on fasting days, it also means they’re consuming very few carbohydrates. Given the postprandial state is governed by carbohydrate availability, this begged the question as to whether it’s the calorie restriction or the carbohydrate restriction that’s creating the metabolic effect when intermittent fasting.

We recruited 12 overweight and obese participants. Participants were first given a very low-carb diet one day. Another day, they were given a severely calorie-restricted diet (around 75% fewer calories than they’d normally eat). After each fasting day, we gave them a high-fat, high-sugar meal (similar to an English breakfast) to see how easily their bodies burned fat.

What we found was that the shift to fat burning and improved fat handling of the high-calorie meal were near identical following both the traditional calorie-restricted “fast” day and the low-carb day. In other words, restricting carbs can elicit the same favourable metabolic effects as fasting.

It will be important now for more studies to be conducted using a larger cohort of participants to confirm these findings.

Such findings may help us address some of the practical problems we face with intermittent fasting and traditional low-carb diets.

For intermittent fasting diets, severe calorie restriction on fasting days can increase the risk of nutritional deficiencies if not careful. It can similarly be a trigger for disordered eating.

Strict carb restriction can also be challenging to adhere to long-term, and may lead to an unhealthy fear of carbs.

The other limitation of both intermittent fasting and continuous carb restriction is that weight loss is a likely outcome. Hence these approaches are not universally beneficial for those who need to improve their health without losing weight or those looking to maintain their weight.

We are now testing the feasibility of an intermittent carb restriction diet, or a low-carb 5:2. So instead of restricting calories two days a week, you would restrict the number of carbs you consume twice a week. If this is proven to be beneficial, it would offer the benefits of fasting without restricting calories on “fast” days.

Adam Collins is Associate Professor of Nutrition, University of Surrey.

This article was first published on The Conversation.

On May 7, as India launched military strikes in Pakistan, the government quietly released a tranche of data that to a great extent reveals the true cost of the Covid-19 pandemic.

India recorded at least 37.4 lakhs excess deaths in 2020 and 2021 compared to two pre-Covid years, 2018 and 2019, according to the data on registered births and deaths released last week.

Excess deaths or mortality refers to the difference between the total number of deaths during a pandemic or any other natural disaster compared to the number of deaths that would have been expected under normal conditions. The difference is an indicator of the likely death toll, as it captures deaths that went unreported.

The total deaths in 2018 and 2019 was 145 lakh. But the number of deaths in the two pandemic years – 2020 and 2021 – was 183 lakh, shows data from the civil registration system, which is the official record of births and deaths registered with the local government bodies.

This indicates 37.4 lakh excess deaths. In contrast, India’s official Covid-19 toll till date is 5.33 lakh. The first death due to the virus was reported in March 2020.

That is to say, India possibly undercounted Covid-19 deaths by seven times. If the government releases civil registration data for 2022, the gap could be higher. The civil registration system records events such as births, deaths and still births.

“The latest report confirms what we already know. India had undercounted its deaths caused by Covid-19,” said public health expert Chandrakant Lahariya.

The excess mortality figures in India is closer to the World Health Organisation’s estimates of excess deaths during the Covid-19 pandemic in the country.

The mathematical model by the WHO had estimated 47.4 lakh excess deaths for India in the period between January 2020 to December 2021.

When the WHO had released its report on excess mortality in 2022, the Indian government had objected and questioned the “validity and robustness of the models” used by the international organisation.

Since many births and deaths go unregistered, especially in rural regions, the government also conducts a sample registration system survey to estimate deaths.

The civil registration system counted 37 lakh excess deaths in 2020 and 2021, compared to 2018 and 2019. However, according to the sample registration system, there are 19 lakh excess deaths in the same period – which is four times the official Covid-19 toll.

Scroll looked deeper into the state-wise CRS and SRS data to understand how Covid-19 mortality varied by state. Our analysis of the state-wise CRS and SRS data shows that Gujarat, Bihar, and Chhattisgarh were worst hit by the pandemic, even though their official tolls remained low.

What the latest government data shows

Across India, the total number of deaths recorded in 2021 was 102 lakh and the corresponding figure for 2020 was 81 lakh, CRS data shows.

The figure is a big jump from pre-Covid years.

In 2018, India registered deaths of 69 lakh people and in 2019, 76 lakh.

While the overall registered births between 2020 and 2021 decreased slightly by 0.1 %, deaths rose by a significant 25.9%.

Moreover, data from the SRS indicates that the Covid-19 pandemic affected rural areas more than urban centres. The death rate in rural areas stood at 7.9, while it was 6.6 in urban areas – a reflection of the difference in healthcare facilities in these regions.

States guilty of massive undercount

In some states, the estimate of excess deaths was higher than others.

In Bihar, there was a 65.9% jump in the total registered deaths in the first two years of Covid-19 pandemic compared to the two pre-Covid years of 2018 and 2019.

The state recorded 3.78 lakh excess deaths in the state in this period. Its official Covid-19 toll till date is 12,315 deaths – which means the state’s likely toll is 30 times the official figure.

The death rate – the number of deaths per 1,000 people – in the state also rose from 5.5 in 2019 to 6.6 in 2021, data from the SRS report shows.

Dr Shakeel from Jan Swasthya Abhiyaan in Bihar blamed the state’s poor health infrastructure for the devastating impact of the pandemic. “People had nowhere to go for treatment,” he told Scroll.

Another state which massively underreported its death toll was Gujarat.

The state has reported only 11,101 deaths due to Covid-19 from 2020 till 2025.

But if excess mortality of just 2020 and 2021 is considered, the Covid-19 toll stands at 3.53 lakh – that is to say, the state undercounted deaths by at least 31 times.

Moreover, compared to 2018 and 2019, Gujarat saw a 39.5% jump in registered deaths in the pandemic years.

The rise in Gujarat’s death rate has also been the sharpest compared to other states, from 5.6 in 2019 to 8.5 in 2021.

Similarly, Chhattisgarh’s death rate rose from 7.3 to 10.1, SRS data shows.

Uttar Pradesh, the most populous state, recorded 3.74 lakh excess deaths in 2020 and 2021 compared to 2018 and 2019. This is 15 times more than its official total Covid-19 toll of 23,743.

Madhya Pradesh’s Covid-19 toll, too, could be 28 times higher than it reported. The state recorded 3 lakh excess deaths, but has only 10,788 Covid-19 deaths in official records.

In the south, Telangana and Andhra Pradesh also underreported their Covid-19 deaths.

Andhra Pradesh recorded 2.33 lakh excess deaths, 15 times more than its official toll so far of 14,733. Telangana’s official Covid-19 toll is 4,111, about 17 times less than the excess deaths found in 2020 and 2021 – 72,730 more people died compared to 2018 and 2019.

Better performers

The gap between excess deaths and the Covid-19 toll is narrow in only a few states like Kerala, Delhi, Rajasthan, Maharashtra, and Karnataka. This means that these states made an effort to count and report Covid-19 deaths truthfully.

Shakeel blamed the lax Covid-19 fatality reporting on a poor system of classifying medical deaths in many states. “The cause of death certification is still not undertaken in many hospitals in Bihar,” Shakeel pointed. “If that was done, our official Covid toll would be much higher.”

Across India, only 23.4% of registered deaths are medically certified to list the cause of death.

Seventeen people in Kachchh, who developed fever and respiratory distress towards the end of August 2024, died in quick succession between September 3 and 9, prompting authorities to rush teams to the affected area – villages Bekhada, Sanhrovand, Medhivandh and Morgar in Lakhpat taluka, and Bharavandh and Valavari in Abdasa taluka.

“Door-to-door visits to every household helped to identify others who were sick, and they were all started on symptomatic treatment,” Jayesh Katira, deputy director, epidemic in Gujarat’s health department, told IndiaSpend.

But the authorities struggled to name the disease, prompting the media to report the outbreak as a “mystery” disease (see here and here).

“When the causative organism or agent of a disease, and its mode of transmission from one person to another hasn’t been identified, lay people and the media tend to label it ‘mysterious’,” said Anil Kumar, principal advisor, National Centre for Disease Control, and president, Indian Association of Epidemiologists.

Back in Kachchh, samples drawn from the patients were sent for testing to the National Institute of Virology in Pune.

“When we face an unknown disease, we test for diseases that have recently been seen in different parts of the country as well as for seasonal diseases that may have just emerged,” Katira explained.

Tests for the Nipah virus, the Hantavirus, Crimean Congo haemorrhagic fever and other viral infections occurring in humans all came negative, and so did the zoonotic link. Essentially, the samples were also tested for diseases originating in cattle.

However, “microbiology tests showed that a single patient was infected by various types of bacteria, which we believe worsened a simple viral infection,” added Katira. So, “we attributed the deaths to an airborne respiratory infection.”

Daily surveillance and treatment helped contain the outbreak, with two more people succumbing in the ensuing week. The Kachchh experience suggests that an outbreak of disease, no matter how virulent, can be brought under control with the right intervention.

“Epidemiologists don’t call diseases ‘mysterious’, because the cause of occurrence and channel of transmission can always be identified with careful investigation,” said Kumar.

Sometimes, he agreed, “the environment can cause the causative agent to undergo some change, in which case the investigation can take time”. The term ‘mysterious’ suggests that the disease cannot be figured out or controlled, which is not the case. Kumar recommends the scientific terminology: “an illness of unknown aetiology”.

Pathogen combinations

The combination of a virus and bacteria made it more challenging to identify the cause of disease in Kachchh. A mix of pathogens was also confirmed to be behind the outbreak of disease in the Democratic Republic of Congo in 2024.

In early December, the World Health Organization had reported the outbreak of disease in Panzi, a remote region in the country’s Kwango province. More than 400 people had taken ill, with fever, headache, cough, weakness and a runny nose. Thirty-one patients had succumbed to the disease, which at the time, was considered “undiagnosed”.

A WHO update on December 27 said that laboratory tests suggested “a combination of common and seasonal viral respiratory infections and falciparum malaria, compounded by acute malnutrition” had caused the severe infections and deaths, “disproportionally affecting children under five years of age”.

Kumar explained that “it is possible that combinations of various bacteria/viruses and agent hosts and environmental factors lead to atypical presentation cases and outbreaks”.

However, he emphasised that “a careful high quality epidemiological investigation using advanced tools and technology can determine the channel of transmission and precipitating factors leading to the outbreak.”

Comorbidities increase vulnerability

According to the WHO, underlying malnutrition is believed to have compounded the severity of illness in Panzi, the Democratic Republic of Congo. In Kachchh, Katira pointed out that the affected area is mostly inhabited by a cattle-rearing community. “Due to the inclement weather, they would have faced some hardship, and may also have skipped meals, due to which their immunity may have been compromised.”

Of the 17 deaths in Kachchh, at least two occurred due to myocardial infarction (or heart attack) and one person also had cancer, Katira said. Essentially, “the presence of non-communicable diseases also lowers immunity.”

In Chhattisgarh’s Sukma district, where seven deaths were reported to have occurred due to an ‘unknown’ disease in October 2024, the chief medical & health officer Kapil Dev Kashyap clarified that the deceased had suffered from severe diarrhoea. There too, a couple of the fatalities were elderly and had comorbidities (diabetes and hypertension).

Rainfall effect

Rainfall prior to the outbreak of disease was a common factor in Kachchh, Sukma and in the Congo.

In the early days of September 2024, Kachchh saw heavy rainfall events, a factor that Katira associates with the easier transmission of viruses. While viruses are always present in the environment, Katira explained, high humidity and rain are ripe conditions for their spread.

In fact, in Panzi, the high number of cases of fever and other symptoms was not considered an aberration in view of the onset of the rainy season. What stood out was the high number of fatalities.

The residents of Chitalnar village in Sukma had developed severe diarrhoea after inclement weather.

“The people drink raw river water, and the area had seen heavy rainfall prior to the loss of life,” Kashyap told IndiaSpend. “They had contracted a water-borne infection.”

Poor infrastructure in rural India

Kachchh and other parts of west Gujarat saw 75% more than normal rainfall during the 2024 monsoon season, a factor that could predispose the area to disease outbreaks.

Heavy rain creates particularly challenging conditions for those living in kuccha homes. Heavy rain also cuts off access to health services for many people.

“People were cut off, making early diagnosis and treatment difficult,” Katira told IndiaSpend, of residents of the affected villages.

Liaqat Ali, a member of the panchayat of Lakhpat, a village located about 45 km away from the affected area, told IndiaSpend that their approach roads to the nearest community health centre in Dayapar, which services the area, would have been inundated.

“Roads in this area are very bad at the best of times; during heavy rainfall the situation deteriorates,” said Ali.

Ali also pointed out that the community health centre was understaffed, with just three of seven posts filled, and that conditions that should have been manageable in it – such as a pregnancy with some complications – were referred out.

“Provisioning health services in rural India is a challenge,” said Kashyap, speaking in the context of Sukma district, where he is posted. “We have 20-30 villages where we have no health workers, we have been unable to identify the right people to employ and train.”

Health workers are the most basic rung in the public health infrastructure, followed by sub-centres, primary health centres and community health centres. India had 167,275 sub-centres, 26,636 primary health centres and 6,155 community health centres, as of June 2024. In recognition of the “time to care”, or the time taken to reach a care centre, the government has mandated that every habitation in a challenging terrain should have a sub-centre within a 30-minute walk. However, the skills of the staff also need to be addressed.

When 38 people from related families fell sick in village Badhal, in Rajouri district, Jammu & Kashmir, in early December 2024, they sought health services but still, 17 succumbed over the next six weeks – once again, supposedly of a “mystery” disease.

While the sickness started after a marriage in the family, the sarpanch of Badhal Mohammed Farooq told IndiaSpend that he didn’t attribute the sickness nor the deaths to anything consumed at the event because “neighbours and others who attended the marriage should have fallen sick too”.

News reports cited cadmium toxicity as the reason for the sickness and deaths.

IndiaSpend reached out to the chief medical & health officer of Rajouri, Manohar Lal Rana, the state surveillance officer for Jammu Division Harjeet Rai, and the senior superintendent of police, Rajouri, Gaurav Sikarwar, to understand how such toxicity might have developed, what sort of exposure might the community have had, and over how much time would the disease have developed. They declined to comment, saying the matter was still under investigation.

Teams from many reputed hospitals across the country have visited the area to investigate the cause of disease. A source in the know, who did not want to be named as he was not authorised to speak to the media, made this interesting statement: “Now if people in the affected area develop the same symptoms, no one will die.”

The source indicated that “when the first few people fell sick, the caregivers were clueless. They had never seen anything like it so they had no precedent to follow.”

“It is only after losing so many victims and having so many expert medical teams visit the area and share their opinion, that the local health staff would be able to treat a patient with similar symptoms,” said the source.

Essentially, health professionals in basic health centres lack the experience to treat many diseases.

Low acceptance of modern medicine

Sometimes, patients’ socio-cultural beliefs and lack of awareness pose obstacles to their timely treatment.

Chitalnar, in Sukma, lies about 4 km away from a sub-centre, and about 10 km away from the nearest doctor stationed in the primary health centre in Pushpal. But when its residents fell sick, they first visited faith healers, according to Kashyap. “During that time, their condition worsened, they developed dehydration.”

After word got out, the authorities quickly created a mini hospital in a room in the village, where many of the sick were treated, and they also distributed oral rehydration solutions. However, the delay in accessing health services proved fatal for a few of those who had first fallen sick. Kashyap said a couple of the deaths had occurred in the district hospital, two had occurred in transit when the patients were being taken to the hospital, and a couple of patients had died at home.

A similar situation arose in Udaipur district’s Kotra block, where 17 children were reported to have died of a mystery disease over 30 days in October 2024. Kotra is predominantly populated by tribal people, who live in far-flung scattered villages. Ghata, one of the affected villages, has a doctor but people delayed seeking medical assistance for their children, panchayat member Lasma Ram told IndiaSpend.

Lasma Ram attributed the deaths to “seasonal diseases” and “mosquito bites”.

After word got out about the deaths, the investigating team constituted by the district health authority conducted door-to-door health screening and found several confirmed cases of malaria. Possibly, the children who died may also have succumbed to malaria.

“The health department had no medical reports or other documents to rely on, and so could not confirm the cause of mortality,” Udaipur district’s chief medical and health officer Ashok Aditya told IndiaSpend.

No disease is too complicated

Confirming the cause of mortality is tricky sometimes. Still, experts caution against mislabelling outbreaks.

“We must steer clear of labelling any diseases as ‘mysterious’ or too complicated to explain to the public,” Jayaprakash Muliyil, epidemiologist and consultant, Department of GI Sciences, Christian Medical College, Vellore, told IndiaSpend. “There is always a cause of disease, and India has sufficient trained epidemiologists to identify diseases.”

Muliyil stressed the need to share scientific information with people “in the interests of public health, even if it means informing people that the diagnosis of a disease is still a work in progress”.

He also noted that “there is a tendency to mask diseases to suppress information, or under-report deaths, sometimes for political reasons, which is counter-productive to public health”. Suppressing information only enhances rumours and gives rise to anxiety.

Lapses in public health communication stood out quite starkly during the Covid-19 pandemic, the lessons behind those lapses have yet to be fully assimilated in the public health response to disease outbreaks, said Abhay Shukla, national co-convenor, People’s Health Movement.

Citing the 5 Ts of public health communication – Transparency, Trust, Timeliness, Truthfulness and Two-way exchange – Shukla explained that in about 10% of outbreaks, the cause may initially not be clear at local level and remains so for some time. But even then, “whatever is known should be conveyed to the people”.

“Even letting people know the status of the investigation is helpful, the communication lines must be kept open,” said Shukla.

Trust is trickier because it isn’t built in a day. Trust in health systems is an outcome of successive good experiences with a health service point. However, it is a reflection of the gaps in health services – especially in remote regions – that people sometimes don’t sufficiently trust the health system to accept special measures during emergencies, said Shukla. “People aren’t passive objects, they must be made partners in the control of outbreaks. But this requires building trust in the system and responding actively to people’s queries.”

“Messaging must be timely and regular,” added Shukla. “Silences generate rumours and negative emotions. The messaging must also be realistic, and based on the actual ground situation, and create channels for people to clarify their doubts.”

Back in Badhal, everyone knows that high-level teams from various big institutions have investigated the deaths. But the sarpanch Farooq lamented, “we still don’t know the cause, and so, we remain fearful.”

“People no longer celebrate events together,” said Farooq. “Nor do they want to eat or drink anything in each other’s homes. Everyone thinks their family could suffer the same fate. If you get to know [the cause of the disease], please let us know too.”

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

Have you had a blood test to check your cholesterol level? These check the different blood fat components:

• total cholesterol

• LDL (low-density lipoprotein), which is sometimes called “bad cholesterol”

• HDL (high-density lipoprotein), which is sometimes called “good cholesterol”

• triglycerides.

Your clinician then compares your test results to normal ranges – and may use ratios to compare different types of cholesterol.

High blood cholesterol is a major risk factor for cardiovascular disease. This is a broad term that includes disease of blood vessels throughout the body, arteries in the heart (known as coronary heart disease), heart failure, heart valve conditions, arrhythmia and stroke.

So what does cholesterol do? And what does it mean to have a healthy cholesterol ratio?

Blood fats

Cholesterol is a waxy type of fat made in the liver and gut, with a small amount of pre-formed cholesterol coming from food.

Cholesterol is found in all cell membranes, contributing to their structure and function. Your body uses cholesterol to make vitamin D, bile acid, and hormones, including oestrogen, testosterone, cortisol and aldosterone.

When there is too much cholesterol in your blood, it gets deposited into artery walls, making them hard and narrow. This process is called atherosclerosis.

Cholesterol is packaged with triglycerides (the most common type of fat in the body) and specific “apo” proteins into “lipo-proteins” as a package called “very-low-density” lipoproteins (VLDLs).

These are transported via the blood to body tissue in a form called low-density lipoprotein (LDL) cholesterol.

Excess cholesterol can be transported back to the liver by high-density lipoprotein, the HDL, for removal from circulation.

Another less talked about blood fat is Lipoprotein-a, or Lp(a). This is determined by your genetics and not influenced by lifestyle factors. About one in five (20%) of Australians are carriers.

Having a high Lp(a) level is an independent cardiovascular disease risk factor.

Knowing your numbers

Your blood fat levels are affected by both modifiable factors:

• dietary intake

• physical activity

• alcohol

• smoking

• weight status.

And non-modifiable factors:

• age

• sex

• family history.

What are cholesterol ratios

Cholesterol ratios are sometimes used to provide more detail on the balance between different types of blood fats and to evaluate risk of developing heart disease.

Commonly used ratios include:

1. Total cholesterol to HDL ratio

This ratio is used in Australia to assess risk of heart disease. It’s calculated by dividing your total cholesterol number by your HDL (good) cholesterol number.

A higher ratio (greater than 5) is associated with a higher risk of heart disease, whereas a lower ratio is associated with a lower risk of heart disease.

A study of 32,000 Americans over eight years found adults who had either very high, or very low, total cholesterol/HDL ratios were at 26% and 18% greater risk of death from any cause during the study period.

Those with a ratio of greater than 4.2 had a 13% higher risk of death from heart disease than those with a ratio lower than 4.2.

2. Non-HDL cholesterol to HDL cholesterol ratio (NHHR)

Non-HDL cholesterol is the total cholesterol minus HDL. Non-HDL cholesterol includes all blood fats such as LDL, triglycerides, Lp(a) and others. This ratio is abbreviated as NHHR.

This ratio has been used more recently because it compares the ratio of “bad” blood fats that can contribute to atherosclerosis (hardening and narrowing of the arteries) to “good” or anti-atherogenic blood fats (HDL).

Non-HDL cholesterol is a stronger predictor of cardiovascular disease risk than LDL alone, while HDL is associated with lower cardiovascular disease risk.

Because this ratio removes the “good” cholesterol from the non-HDL part of the ratio, it is not penalising those people who have really high amounts of “good” HDL that make up their total cholesterol, which the first ratio does.

Research has suggested this ratio may be a stronger predictor of atherosclerosis in women than men, however more research is needed.

Another study followed more than 10,000 adults with type 2 diabetes from the United States and Canada for about five years. The researchers found that for each unit increase in the ratio, there was around a 12% increased risk of having a heart attack, stroke or death.

They identified a risk threshold of 6.28 or above, after adjusting for other risk factors. Anyone with a ratio greater than this is at very high risk and would require management to lower their risk of heart disease.

3. LDL-to-HDL cholesterol ratio

LDL/HDL is calculated by dividing your LDL cholesterol number by the HDL number. This gives a ratio of “bad” to “good” cholesterol.

A lower ratio (ideal is less than 2.0) is associated with a lower risk of heart disease.

While there is lesser focus on LDL/HDL, these ratios have been shown to be predictors of occurrence and severity of heart attacks in patients presenting with chest pain.

If you’re worried about your cholesterol levels or cardiovascular disease risk factors and are aged 45 and over (or over 30 for First Nations people), consider seeing your GP for a Medicare-rebated Heart Health Check.

Clare Collins is Laureate Professor in Nutrition and Dietetics, University of Newcastle.

Erin Clarke is Postdoctoral Researcher, Nutrition and Dietetics, University of Newcastle.

This article was first published on The Conversation.

Antibiotics are widely considered one of the most important advances in the history of medicine. Their introduction into clinical practice during the 1940s marked a major milestone in the control of infectious diseases, and these medicines have since improved human health and prolonged life expectancy.

Today, bacterial resistance to antibiotics has become a global threat, and presents a major challenge to medicine. Antibiotics’ extensive and often indiscriminate use in medicine, veterinary clinics and agriculture has created the ideal conditions for antibiotic-resistant bacteria to emerge.

However, this phenomenon is older than previously thought. Bacteria already had resistance mechanisms long before the discovery and introduction of antibiotics into clinical practice. This indicates that antibiotic resistance is a much more complex, widespread and deep-rooted ancestral evolutionary phenomenon than initially assumed.

Studies have documented antibiotic resistance mechanisms in micro-organisms isolated from natural habitats, where human influence is minimal or non-existent. These environments include deep underground layers and the ocean floor, as well as ancient environments such as isolated caves and permafrost.

Interestingly, many of the resistance mechanisms described in these untouched environments – whose origins date back thousands or even millions of years – are similar or even identical to those observed in present-day pathogenic bacteria. This suggests that the conservation and transmission of resistance mechanisms throughout evolution provides a selective advantage.

Surviving in the ice

The resistance genes found in permafrost samples from 30,000 years ago bear a striking resemblance to those found today. These strains were as resistant as more modern ones that have been observed to resist β-lactam antibiotics, tetracyclines and vancomycin.

Staphylococcus strains resistant to aminoglycosides and β-lactams have also been isolated from 3.5 million year old permafrost samples.

There are even older examples, such as Lechuguilla Cave in New Mexico, USA, an environment considered isolated for 4 million years. Nevertheless, a 2016 study found Streptomyces and Paenibacillus bacteria in Lecheguilla that were resistant to most of the antibiotics used in clinical practice today.

“Methicillin-resistant Staphylococcus aureus” is the full name for a multidrug-resistant bacterium that causes serious infections. A 2022 study concluded that certain strains were resistant long before the use of this group of antibiotics – it was their adaptation to hedgehogs infected by similar antibiotic-producing fungi that gave them a survival advantage.

An arms race to survive

Research has revealed that competition for resources and adaptation to different habitats were key factors in the evolution of antibiotic resistance.

In pre-drug environments, natural antibiotics not only played an ecological role in inhibiting the growth of competitors, but also supported the survival of producer species. In addition, very small amounts of antibiotics acted as communication molecules, influencing the interactions and balance of microbial communities.

This dynamic environment favoured the evolution of defensive strategies in antibiotic-exposed micro-organisms, whether antibiotic-producing or co-existing. This, in turn, drove the diversification and spread of resistance mechanisms over time.

However, the presence of these mechanisms in isolated, pre-antibiotic-era environments raises questions about how resistance has originated and spread throughout microbial evolution. The study of these processes is key to understanding their impact on the current antibiotic resistance crisis.

Looking forward by looking backward

It is now suggested that antibiotic resistance genes may have been transmitted first from environmental micro-organisms to human commensal organisms, and then to pathogens. This process of transfer from the environment to the human environment is random: the more prevalent a resistance mechanism is in the environment, the more likely it is to be transferred.

Reservoirs of resistance in the environment can accelerate bacterial evolution towards multiple drug resistance under antibiotic pressure. It is therefore crucial to consider the vast diversity of these resistance genes within microbial populations when developing or implementing new strategies to combat antibiotic resistance.

As Winston Churchill said, “the longer you can look back, the further you can look forward”. This reflection underlines the importance of studying the past in order to understand and anticipate future risks. Researching ancestral resistance not only provides information on the evolutionary history of resistance genes, it can also help us predict how they will evolve in the future.

This knowledge allows us to anticipate potential resistance mechanisms, which improves our ability to meet future challenges in the fight against antibiotic resistance.

M Paloma Reche Sainz is Profesora de Microbiología de la Facultad de Farmacia, Universidad CEU San Pablo, Universidad CEU San Pablo.

Rubén Agudo Torres is Profesor Colaborador Doctor. Departamento de Química y Bioquímica, área de Bioquímica y Biología Molecular, Universidad CEU San Pablo.

Sergio Rius Rocabert is Profesor colaborador doctor en microbiología. Virólogo e inmunólogo., Universidad CEU San Pablo.

This article was first published on The Conversation.

Over the last two decades more than a million Indians reported that they had been bitten by snakes on average every year. Nearly 60,000 of them died annually.

The numbers seem enormous. But the toll could be significantly reduced with appropriate grassroots interventions and policy reforms.

The key for framing effective policy, it is clear, is robust data and proper analysis. This helps determine what interventions are needed, where they must be made and with whom.

Karnataka is well-poised to serve as a model for India’s snakebite prevention and management initiatives. In February 2024, Karnataka’s Department of Health and Family Welfare declared snakebite a notifiable disease – a first in the country.

Notifying it under the Epidemic Diseases Act, 2020, means that any healthcare facility, government or private, must mandatorily report a snakebite incident on the Integrated Health Information Platform. This ensures that information is pooled in one central location.

Anecdotal references, opinions and personal experiences tend to drive decisions in the absence of data. In the case of snakebite, that can be the difference between complete recovery or a lifetime of struggle or loss of life.

The Karnataka government’s action is part of a coordinated effort that includes initiatives to identify and notify snakebite treatment facilities statewide, ensure doctor training at the grassroots, reinforce the National Health Mission’s snakebite treatment protocols and launch information, education and communication material on prevention and management for communities that are at risk.

The impact of this policy decision is clear in the numbers alone. In 2023, just over 6,000 cases were reported across the state. In 2024, this figure rose to over 14,000. This does not mean that incidents of snakebite have increased – just that more cases are now being reported.

These figures will help understand which regions bear the highest burden and how different groups are affected. They also give policy makers critical data about what time of the day bites occur the most, which parts of the body are vulnerable, whether there is a lag between the bite occurring and hospital admission, and more.

This could hold the key to developing strategies for prevention and better bite management practices.

Unfortunately, some media reports have portrayed the rise in reported figures as an increase in snakebite. Not only is this inaccurate, it fosters fear in communities that are already vulnerable to snakebites.

As a consequence, snakes are killed indiscriminately out of fear or are relocated to alien habitats where they suffer the same fate.

Karnataka offers a model for national action not just because of the initiatives undertaken by its department of health and family welfare, but also the state forest department.

The forest department has enabled research that has shaped the scientific understanding of studies on geographical venom variation (the venom of snakes, even within the same species, across regions) that have led to an evolved understanding of the ecology of venomous snakes and helped establish a venom production unit. It has also trained officers about human-snake interaction.

At the heart of snakebite mitigation lies the need to preserve community tolerance for snakes. When snakebite deaths and disabilities are reduced, so is the fear-driven retaliation against snakes. Governments, the media and researchers must work together to advance and sustain this balance.

Sumanth Bindumadhav is the director of wildlife department at Humane World for Animals India (formerly Humane Society International India).

Gerry Martin is a renowned herpetologist and founder trustee of The Liana Trust.

The common cold sore virus, which is often caught in childhood, usually stays in the body for life – quietly dormant in the nerves. Now and then, things like stress, illness or injury can trigger it, bringing on a cold sore in some people. But this same virus – called herpes simplex virus type 1 – may also play an important role in something far more serious: Alzheimer’s disease.

Over 30 years ago, my colleagues and I made a surprising discovery. We found that this cold sore virus can be present in the brains of older people. It was the first clear sign that a virus could be quietly living in the brain, which was long thought to be completely germ-free – protected by the so-called “blood-brain barrier”.

Then we discovered something even more striking. People who have a certain version of a gene (called APOE-e4) that increases their risk of Alzheimer’s, and who have been infected with this virus, have a risk that is many times greater.

To investigate further, we studied brain cells that we infected with the virus. They produced the same abnormal proteins (amyloid and tau) found in the brains of people with Alzheimer’s.

We believe that the virus stays mainly dormant in the body for years – possibly decades. But later in life, as the immune system gets weaker, it can enter the brain and reactivate there. When it does, it will damage brain cells and trigger inflammation. Over time, repeated flare-ups could gradually cause the kind of damage that leads to Alzheimer’s in some people.

We later found the virus’s DNA inside the sticky clumps of these proteins, which are found in the brains of Alzheimer’s patients. Even more encouragingly, antiviral treatments reduced this damage in the lab, suggesting that drugs might one day help to slow or even prevent the disease.

Large population studies by others found that severe infections, specifically with the cold sore virus, was a strong predictor of Alzheimer’s, and that specific antiviral treatment reduced the risk.

Our research didn’t stop there. We wondered if other viruses that lie dormant in the body might have similar effects – such as the one responsible for chickenpox and shingles.

Shingles vaccine

When we studied health records from hundreds of thousands of people in the UK, we saw something interesting. People who had shingles had only a slightly higher risk of developing dementia. Yet those who had the shingles vaccine were less likely to develop dementia at all.

A new Stanford University-led study gave similar results.

This supported our long-held proposal that preventing common infections could lower the risk of Alzheimer’s. Consistently, studies by others showed that infections were indeed a risk and that some other vaccines were protective against Alzheimer’s.

We then explored how risk factors for Alzheimer’s such as infections and head injuries could trigger the hidden virus in the brain.

Using an advanced 3D model of the brain with a dormant herpes infection, we found that when we introduced other infections or simulated a brain injury, the cold sore virus reactivated and caused damage similar to that seen in Alzheimer’s. But when we used a treatment to reduce inflammation, the virus stayed inactive, and the damage didn’t happen.

All of this suggests that the virus that causes cold sores could be an important contributor to Alzheimer’s, especially in people with certain genetic risk factors. It also opens the door to possible new ways of preventing the disease, such as vaccines or antiviral treatments that stop the virus from waking up and harming the brain.

What began as a link between cold sores and memory loss has grown into a much bigger story – one that may help us understand, and eventually reduce, the risk of one of the most feared diseases of our time.

Ruth Itzhaki is Professor Emeritus of Molecular Neurobiology at the University of Manchester and a Visiting Professorial Fellow, University of Oxford.

This article was first published on The Conversation.

Endometriosis affects nearly 200 million people worldwide. This chronic condition is characterised by tissue resembling the lining of the womb growing outside of the uterus.

This common condition has devastating effects on patients’ wellbeing. It causes chronic pain (particularly during their periods), infertility and symptoms similar to irritable bowel syndrome, including bloating, constipation, diarrhoea and pain during bowel movements.

While there are ways of managing endometriosis, these treatments can be invasive and often don’t work for everyone. This is why many patients seek out their own ways of managing their symptoms.

A frequent question we get from patients is: “Can you recommend a diet that will help me manage my pain and gut symptoms?” While ample advice exists online, there’s little information from clinical studies to adequately answer whether or not diet can have an effect on endometriosis symptoms.

So we conducted an international online survey, inviting people with endometriosis to share their experiences of how diet has affected their endometriosis pain symptoms.

Diet and pain

Before publishing the survey online, we collaborated with a local Scottish endometriosis patient support group to come up with appropriate questions.

The final survey included multiple-choice and free-text questions about the participant’s demographics, their pain, their use of diet in managing symptoms and their sources of dietary advice. It was promoted online through social media and patient support groups. The survey received 2,599 responses from 51 countries. The age of participants ranged from 16-71.

Most respondents reported experiencing pelvic pain (97%) and frequent abdominal bloating (91%). This highlighted how common these symptoms are in people with endometriosis.

Participants were also asked to rate the average level of their abdominal and pelvic pain over the past month, on a scale from zero to ten. The responses highlighted a wide range of pain experiences, though most respondents either rated their average pain a four (can mostly be ignored but with difficulty) or a seven (makes it difficult to concentrate, interferes with sleep and takes effort to function as normal).

The majority (83%) of respondents also reported making dietary changes to control symptoms. Around 67% noted this had a positive effect on pain.

The survey listed 20 different diets (plus “other”), allowing participants to select all the diets they’d tried and explain which had affected their pain symptoms. Some of the most popular diets patients had tried included: reducing alcohol intake, going gluten-free, going dairy-free, drinking less caffeine and reducing intake of processed foods and sugar.

Around half of participants reported improvements in their pain after adopting at least one of these diets. For the most popular diets, a reduction in pain was reported by 53% who reduced alcohol consumption, 45% who went gluten-free and dairy-free and 43% who reduced caffeine intake.

Reducing inflammation

This survey, which was the largest of its kind to date, was only conducted in English. This might have limited participation. Additionally, the changes were self-reported, meaning we cannot confirm that the dietary modifications directly caused the changes in pain.

Still, our findings show diet may be an important tool in managing the pain caused by endometriosis. Importantly, no specific diet benefits everyone, so it may take some trial and error to figure out what works best. It’s also worth noting that diet changes appeared to be less beneficial for those with the most severe symptoms.

Research into why people with endometriosis experience pain has identified excess inflammation as a key factor. Inflammation is the body’s mechanism for fighting off an infection or recovering from an injury. In people with endometriosis, it’s thought that the inflammatory response is overstimulated – triggering sensitisation of nerves and amplifying the perception of pain.

Certain foods may also promote inflammation in the body. For instance, it’s thought that gluten and dairy could promote inflammation due to the way they interact with the cells lining the gut and the byproducts they produce when broken down by the gut microbes. These byproducts have the potential to move around the body and cause more widespread inflammation. Alcohol is also known to be pro-inflammatory.

Reducing intake of certain foods may therefore help reduce overall inflammation levels in people with endometriosis. This may explain why the participants in our study, and others, reported seeing improvements in their symptoms as a result of cutting out inflammatory foods.

Now we need properly controlled clinical studies that monitor food intake, real-time recording of pain and IBS-like symptoms, and precise measurement of inflammation in the body, in order to understand the reasons why diet may help people with endometriosis.

This is something our research team is already working on. We’re launching a large study with over 1,000 people who have endometriosis. Each participant will donate stool and blood samples, record food intake details and report on the use of pain medications, supplements, prebiotics, probiotics and dietary modifications. The long-term goal with this project is to support a more holistic and personalised approach to caring for people with endometriosis.

Philippa Saunders is Professor of Reproductive Health, University of Edinburgh.

Andrew Horne is Director of the Centre for Reproductive Health, University of Edinburgh.

Francesca Hearn-Yeates is PhD Candidate, Centre for Reproductive Health, University of Edinburgh.

This article was first published on The Conversation.

Why do large private hospitals in India track global oil prices and regime changes around the world? As the preferred tertiary healthcare provider to many unwell people in oil-rich countries, it determines how many patients they treat, according to Max Hospitals’ Medical Value Tourism team.

India issued 463,725 visas for medical travel in 2024, a number that depends on its relations with other countries, the economic conditions in those countries and the global economy, among other things.

“We haven’t issued many visas to Afghan patients since 2021, because India does not officially recognise the current Afghan regime,” said Anas Abdul Wajid, chief sales and marketing officer at Max Healthcare, New Delhi. The political upheaval in Bangladesh and the souring of ties between India and its neighbour means that fewer Bangladeshi patients will visit India, he explained.

Medical tourism is of value not just to hospitals but also to other businesses that benefit from the inflow of patients and their families from abroad.

“Khamsa ashra [15 in Arabic],” said a baker in response to an inquiry about the price of his flatbread from a Sudanese man. The baker can count up to 20 in Arabic, Pashto and Russian, he claimed. Behind his stall in Sector 50 in Gurugram is a restaurant that sells Arabic-style roasted meats, and on either side are hotels and accommodations for patients.

Unable to speak the language and unaccustomed to the climate and crowded public spaces, patients said they are driven to India because it is the most affordable option and meets the standards of quality that they are not assured of in their home countries.

Affordable care, better quality

When one-year-old Zulqarnain Ali was diagnosed with biliary atresia, a condition that would require a liver transplant, his parents had two options: get the surgery done in their home country of the Philippines or to travel to Japan, the United States or India.

The Philippines is also an emerging medical tourism destination, ranking 24th of 46 countries on the 2020 Medical Tourism Index. India ranks 10th on the index. “We ruled out the Philippines because his chances of survival would be lower there,” Ali’s mother, Cassandra, said. “Japan and the USA would be expensive, which left us with India.”

Fluent in English, they travel to their hotel from Max Super Specialty hospital in Saket (and at times around the city) using Uber. Other than having to cook food in a kitchenette in a hotel room, their stay has been comfortable, the couple told IndiaSpend.

Cassandra donated part of her liver to her son for the surgery in the first week of March, and the surgery was a success. They will stay in India for another month, when the doctors will clear their son to travel back home.

In 2023 alone, there were 18,378 organ transplant surgeries performed in India, close to a tenth of which (1,851) were performed on foreigners, according to a report from National Organ and Tissue Transplant Organisation. The National Capital Region accounted for a bulk of these: 1,445 transplants among foreigners were performed in Delhi NCR.

Of the total transplants performed on foreigners, only nine involved a deceased donor. The rest were from live donors who donated their bone marrow, a kidney or a part of their liver. Organ donations in India are governed by the Transplantation of Human Organs and Tissues Act 1994. Foreign nationals can get on the registry of patients in need of organs, but they will be considered for allocation only if there is no Indian available to take the organ anywhere in India.

“The patient brings a donor with them, and usually it is a blood relative. We do DNA tests to ensure that there are no commercial interests involved. This is at the hospital level,” explained Abdul Wajid. The National Organ and Tissue Transplant Organisation requires the donor and recipient to provide proof of relationship.

Safety concerns, food options

Spicy food and crowded public places are what struck Serdar Niyazov as the most different from his home country Turkmenistan. With a population of 7 million, the Central Asian country has fewer people than Delhi (16.8 million) or Mumbai (12.8 million).

“My wife and I don’t mind the spicy food as much as my daughter. Every restaurant I go to, I ask them not to add any spice to my food but they don’t listen. My daughter tastes the food, and after one bite, puts it down saying that it’s too spicy for her,” said the former engineer from Turkmenistan, whose name has been changed here to protect his privacy. Niyazov added that his daughter is slowly getting used to the food.

This is his family’s second trip to India. His seven-year-old daughter, who was operated on for epilepsy last month, first came here when she was one. “The doctor says that she has made considerable recovery and they can take her off her medication gradually and stop it eventually.”

While there are several small hotels and restaurants that cater to international patients in and around Max Super Specialty Hospital in New Delhi, where the Alis and the Niyazovs are staying, Gurugram has transformed to meet the needs of foreign patients, and has more facilities for them, we found.

Abu Ismail (name changed) sat in his hotel lobby, his back turned to the dust and heat outside as he recited verses from the Quran. A resident of Iraq, the 55-year-old spoke no English.

“My brother is being treated for cancer at Fortis Hospital,” he explained with the help of a translation app on his phone. The phone and a visiting card from the hotel’s manager, which has the address and phone number of the hotel, are crucial for his stay in Gurugram.

The hotel where he will live for the remainder of his six-month stay is a four-storeyed building with four flats on each floor. None of the staff speak Arabic or English but inquire about their guests’ special needs through their phones or at times, a translator, according to manager Teg Bahadur.

Bahadur and his colleagues provide laundry and housekeeping services to their guests with special regard for hygiene (since many of them are immunocompromised). At times, they have to intervene in arguments with autorickshaw and cab drivers on behalf of their guests. “Some of them stay for months in a country that is foreign to them. We have to make sure that they are comfortable.”

Bahadur’s establishment is one of several that cater to overseas patients undergoing treatment in Gurugram’s Medanta and Fortis Hospitals. Pharmacies and dentists’ clinics in the lanes nearby have signboards that advertise their services in Arabic and Russian. Auto rickshaw drivers read their destinations off hotel visiting cards, such as the one Abu Ismail has in his front pocket, to ferry the families back.

Bangladesh, Arabic-speaking countries

India was the 10th most attractive destination for medical tourism, as per the Medical Tourism Index 2020-’21.

Bangladeshi patients were given 323,498 visas in 2024, the highest number of visas for treatment in India (around 70% of all visas). This number will likely fall since the strain in the relations between India and Bangladesh, according to Abdul Wajid.

This is what happened with Afghanistan in 2021. The number of Afghan nationals who visit India for treatment has fallen to one person in 2024 from 22,463 in 2021 – the year in which the Taliban overthrew the US-backed regime in the landlocked South Asian country. India responded by moving its embassy from Kabul to New Delhi in August 2021.

Nepal nationals who may have availed of treatment in India are not listed here, because Nepali nationals can enter India without a visa.

India is one of the most affordable destinations for medical value travel, and is preferred by the uninsured even in developed countries like the United Kingdom and United States. In 2024, 1,911 people travelled to India from the US on medical visas, as did 785 people from the UK, data from the external affairs ministry show.

Visa process, sector regulation

Treatment at a private hospital for breast cancer, the most frequently occurring cancer among women in India, starts at $3,800 (Rs 3.25 lakh). That is ten times the median expenditure by an Indian household on inpatient activities in a year (Rs 35,000). But this is often a cheap option, especially for patients who do not have the same facilities in their own countries.

“Most West Asian governments, [such as Oman and the United Arab Emirates], bear the cost of treatment of their sick, and India is one of the most popular destinations for them because of the low cost of treatment compared to western countries,” explained Abdul Wajid.

Other ways in which the overseas patients pay is through insurance or through nonprofits in their home country or in India. Sometimes, they pay out of pocket.

In the mid-2020s, India’s medical tourism sector was estimated to be worth $5-$6 billion, with the segment expected to grow to $13 billion by 2022, according to a NITI Aayog report.

Niyazov, who paid out of pocket for his daughter, was all praise for the e-visa process. “That is because India reciprocates the ease with which its citizens are given visas to the foreign country,” explained Abdul Wajid. Indians can enter Turkmenistan, Niyazov’s home country, by paying a fee ranging between $35-$1015 (Rs 2,983- Rs 86,525).

While this works for countries that are popular tourist destinations, it has a discouraging effect on citizens of poorer countries with whom India has no incentive to negotiate better terms, explained Abdul Wajid. “Nobody wants to go to Nigeria or Ethiopia from India for medical reasons, so even if they do charge us a high medical visa fee, we are not missing out on much.

“However, the Indian government also charges high fees from medical tourists from those countries, which discourages patients at times.”

To make it easier for foreigners to visit India for treatment, the Indian government allows e-visas for patients and attendants. It included Medical Value Travel as one of the “Champion Service Sectors”, sectors for which the government had set up a Rs 5,000 crore dedicated fund in 2018.

At the same time, the government should bring in more regulations for the sector, according to Abdul Wajid.

“A person sitting in another part of the world has no way of knowing if the healthcare facilitator they have contacted in their home country will take them to a world-class hospital or a nursing home with questionable credentials,” explained Abdul Wajid. He has come across patients who were left stranded in India without getting the required treatment and had to be transferred to a better facility, he recounted. “They have no means of getting a redressal.”

IndiaSpend has reached out to the Ministry of External Affairs, Ministry of Health and Family Welfare and the Delhi government to ask about the means of redressal available to a foreigner treated in India, the number of people who were duped into coming to India in an inadequate medical establishment, the effect of regime change in Bangladesh and Afghanistan on the number of visas given to people from these countries and the government’s plan for promoting India as an Medical Value Tourism destination abroad. This story will be updated when they respond.

For those who get connected to the right doctors and facilities, medical treatment in India is a boon. “Both doctors who treated my daughter were very helpful, and we are optimistic that our daughter will lead a healthy life,” said Niyazov.

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

Artificial sweeteners are being added to a growing number of foods to reduce their sugar content while maintaining their appealing taste. But a growing body of research suggests these non-nutritive sweeteners may not always be a healthier and safer option. So what is our best option if we want to enjoy sweet-tasting foods without the harms of eating sugar?

Artificial sweeteners were originally developed as chemicals to stimulate our sweet-taste sensing pathway. Like sugar molecules, these sweeteners act directly on our taste sensors in the mouth. They do this by sending a nerve signal to the body that a high-carbohydrate food source has been consumed – telling the body to break it down to use for energy.

In the case of sugar consumption, this also stimulates our dopaminergic system. This is the part of the brain responsible for motivation and reward, linked to sugar cravings. From an evolutionary perspective, this means we’re hardwired to seek out high-sugar food for a source of energy and to ensure our survival. However, excessive consumption of sugar is well known to lead to health problems, such as metabolic disruption which can cause obesity and diabetes.

Similarly, when artificial sweeteners, rather than sugar, cause this stimulation, there’s increasing evidence of similar metabolic imbalances. This happens despite the fact that artificial sweeteners do not seem to stimulate the dopamine system.

Indeed, a study published earlier this year showed that within two hours of consuming sucralose (an amount equivalent to the sugar in two cans of soft drink), participants exhibited increased physiological hunger responses. The research measured blood flow to the hypothalamus, the region of our brain responsible for appetite control. They found that sucralose increased blood flow to this area of the brain.

Studies have also shown that sweeteners can stimulate the same neurons as the appetite hormone, leptin. Over time, this could cause our hunger threshold to increase – meaning we need to eat more food to feel full. This suggests that consuming artificial sweeteners makes us more hungry, which could ultimately make us consume more calories.

And it doesn’t stop with feeling hungrier. A large study, which was conducted over 20 years, found a link between sweetener consumption and greater accumulation of body fat. Interestingly, the study found that people who regularly consumed large amounts of sweeteners (equivalent to three or four cans of diet soda per day) had a nearly 70% greater incidence of obesity compared to those who consumed minimal amounts of artificial sweeteners (equivalent to half a can of diet soda per day).

The study also considered this response to be independent of the amount of calories the participants consumed each day. To verify this, they reviewed food questionnaires to assess self-reported dietary intake. While self-reported consumption can have discrepancies, the study also used a coding nutrition data system to verify dietary intake. The results indicate that artificial sweeteners may be making us more likely to form fat in our body – regardless of what we’re consuming alongside the artificial sweeteners.

A study published earlier this month also found that daily consumption of artificially sweetened drinks positively correlated with the incidence of type 2 diabetes. But given these drinks contain a range of additives – including acidifiers, dyes, emulsifiers and sweeteners – it’s uncertain if this link can be entirely attributed to artificial sweeteners.

What you need to know

So is it time to give up sweeteners completely? Maybe not. There are many studies which add to the controversy by showing that short-term substitution of sugar with artificial sweeteners reduces body weight and body fat.

Numerous studies have also shown that artificial sweetener consumption has no association with the development of diabetes or even with indicators of diabetes, such as fasting glucose or insulin levels. However, many of these studies were performed over relatively short time periods (up to 12 months) and only compared people consuming artificial sweeteners versus sugar. This makes it hugely confusing for all of us to know what we should do.

To address this, earlier this month, the Scientific Advisory Committee on Nutrition (SACN), which advises the UK government on nutrition, released a position statement on the use of non-sugar sweeteners. This was in response to the World Health Organization, which suggested that sweeteners shouldn’t be used as a means of weight control due to their low-level association with risk of developing obesity and type 2 diabetes.

The SACN similarly concluded that non-sugar sweetener intake be minimised, especially for children. But they also stated that intake of sugars in general needs to be reduced. This is really at the heart of the issue. Artificial sweeteners may have significant negative health impacts, but are they as bad for us as sugar? The overwhelming literature on the negatives of excess sugar consumption currently suggests no – but our understanding of artificial sweeteners is still not as extensive as that for sugar.

We need more research on artificial sweeteners to better understand their effects. Work is currently ongoing to collate a database of all clinical trials investigating sweetener use. This will allow us to better understand the sweetener research landscape and highlight areas where more work is needed.

Until then, what should we do if we have a sweet-tooth? Unfortunately, like everything with nutrition, it’s best to only consume artificial sweeteners in moderation.

There are no clear guidelines on the amounts of sweeteners we should or shouldn’t be consuming yet. But one of the guidelines from the recent SACN review is that the industry clearly label the amount of artificial sweeteners in food and drink. So hopefully it will be easier for us to make these choices in the future.

Havovi Chichger is Professor, Biomedical Science, Anglia Ruskin University.

Caray A Walker is Senior Lecturer in Microbiology, Anglia Ruskin University.

This article was first published on The Conversation.

CT scans are a vital part of modern medicine. Found in every hospital and many clinics, they give doctors a fast and detailed look inside the body – helping to diagnose everything from cancer and strokes to internal injuries. But a new study suggests there may be a hidden cost to our growing reliance on this technology.

The study, published in Jama Internal Medicine, warns that CT scans performed in the US in 2023 alone could eventually lead to over 100,000 extra cancer cases. If the current rate of scanning continues, the researchers say CT scans could be responsible for around 5% of all new cancers diagnosed each year.

That figure has raised concerns. Especially when you consider that the number of CT scans done in the US has jumped by 30% in just over a decade. In 2023, there were an estimated 93 million CT exams carried out on 62 million people.

The risk from a single scan is low – but not zero. And the younger the patient, the greater the risk. Children and teenagers are especially vulnerable because their bodies are still developing, and any damage caused by ionising radiation may not show up until many years later.

That said, over 90% of CT scans are performed on adults, so it’s this group that faces the largest overall impact. The most common cancers linked to CT exposure are lung, colon, bladder and leukaemia. For women, breast cancer is also a significant concern.

What makes this latest estimate so striking is how much it has grown. In 2009, a similar analysis projected around 29,000 future cancers linked to CT scans. The new number is over three times higher – not just because of more scans, but because newer research allows for a more detailed analysis of radiation exposure to specific organs.

The study also makes an eye-catching comparison: if things stay as they are, CT-related cancers could match the number of cancers caused by alcohol or excess weight – two well-known risk factors.

Not all scans carry the same level of risk. In adults, scans of the abdomen and pelvis are thought to contribute the most to future cancer cases. In children, it’s head CTs that pose the biggest concern – especially for babies under the age of one.

Often life-saving

Despite all this, doctors stress that CT scans are often life-saving and remain essential in many cases. They help catch conditions early, guide treatment and are crucial in emergencies. The challenge is making sure they’re only used when really needed.

Newer technologies could help reduce the risk. Photon-counting CT scanners, for example, deliver lower doses of radiation, and MRI scans don’t use radiation at all. The researchers suggest that better use of diagnostic checklists could also help doctors decide when a scan is necessary, and when a safer alternative like MRI or ultrasound might do the job.

It’s worth noting that this study doesn’t prove CT scans cause cancer in individual people. The estimates are based on “risk models” – not direct evidence. In fact, the American College of Radiology points out that no study has yet linked CT scans directly to cancer in humans, even after multiple scans.

Still, the idea that radiation can cause cancer isn’t new. It’s scientifically sound. And with the huge number of scans being done, even small risks can add up.

CT scans save lives, but they’re not risk-free. As medical technology evolves, so too should the way we use it. By cutting down on unnecessary scans, using safer alternatives where possible, and keeping radiation doses as low as practical, we can ensure CT scans continue to help more than they harm.

Justin Stebbing is Professor of Biomedical Sciences, Anglia Ruskin University.

This article was first published on The Conversation.

The burning pyres that line city streets, the mass anonymous graves, the bodies floating in the Ganga, loved ones choking to death outside hospitals: it is incredible how these memories of nightmares in a loop from the pandemic have so quickly faded from public memory.

In the national elections that followed in 2024, pledges that states would do enough to protect and promote the health of every person in this vast teeming land were hardly heard. India has one of the most privatised health care systems in the world, and one of the lowest levels of public spending on health as a percentage of the total gross domestic product. The tragedy of mass deaths – according to some estimates as high as five million – has not changed this.

India lags way behind most countries in the world also in promising the right to health as a constitutionally guaranteed right. Today the constitutions of more than half the countries in the world have references to the right to health. India is not one of these. What the right to health mandates is that the state acts (and also does not act) in ways that enable each individual to attain the highest possible levels of health which includes both physical and mental well-being.

This requires of course the state to establish health centres, clinics, diagnostic centres and hospitals in sufficient numbers. These should be geographically close to every individual; should have sufficient numbers of well-trained health personnel, medical equipment and drugs; should not impose cost burdens on the patient that she cannot bear; should be culturally sensitive; and should not discriminate against any vulnerable and socially stigmatised minority.

But while all of this is necessary for every individual to achieve their highest level of attainable health, it is by no means sufficient. If, for instance, one is starving, malnourished, homeless, living in unsanitary habitations with no provisions for safe drinking water and waste disposal, subjected to domestic violence, lives in conflict zones, works in unsafe, unhealthy conditions, simply the availability of high-quality affordable and culturally appropriate curative health services in the vicinity of where one lives would not be sufficient to ensure that they accomplish the highest attainable health standards their body is capable of.

This is something that the finest socially embedded health practitioners and policy makers have long understood intuitively and empirically. Let me give just two redolent examples from the last two centuries.

My first story dates back to the late 19th century when the deadly bubonic plague ravaged the industrial port city of Bombay in India. It began in Yunnan province of China in 1855, spread to Hongkong in 1894 and reached Bombay in the summer of 1896. The British colonial government deployed highly repressive strategies to control the spread of the epidemic, for the first time bringing in soldiers. It authorised armed soldiers to raid homes with infected persons, to burn their belongings and clothes on street corners, to forcefully hose down homes with disinfectants and sometimes pull down their homes, shifting patients to plague camps where they died shortly after.

A British health officer recalls that they “treated houses as though they were on fire discharging into them from steam engines and flushing pumps” huge quantities of water full of disinfectants. But none of this succeeded in halting the ferocious spread of the infection. In months more than 10,000 people had died. Riots and strikes broke out in 1898 against the repressive state measures. To escape, a mass exodus of the residents of Bombay began as they returned to their villages, carrying the infection to far corners of the country. Ultimately the plague took 12 million lives in India.

A section of the colonial administrators located the cause of the epidemic beyond bacilli and rodents. Hundreds and thousands of workers with their families had migrated to the rapidly growing port city to work as cotton mill and dock workers. Mill workers were accommodated in tenements called chawls near the mills. There were no building regulations and the tenements were built without light or ventilation. Informal workers lived under tents or on pavements. There was little drainage and sewerage. Cesspools of stagnant water full of waste and excreta became ideal breeding grounds for rodents. This section of colonial administrators observed that to prevent the recurrence of another epidemic, every resident of the city had to be assured homes with three things that come completely free – air, sunlight and clean water.

This understanding led to the establishment in 1898 of the Bombay City Improvement Trust, which began the laying of roads, drainage and sewage lines. Middle class settlements came up that were airy, well-lit and well-ventilated. But the lesson was mostly forgotten for the working classes. In the Bombay – now Mumbai – of today, more than half the population lives in slums and pavement homes that continue to be unfit for healthy and dignified human habitation.

My second story is from the other side of the globe, only decades later. The extraordinary, even singular life of the Canadian doctor Henry Norman Bethune – captured in his biography The Scalpel, the Sword by Ted Allan and Sydney Gordon – has fascinated and inspired me since I was a young man.

Bethune, born in Ontario, interrupted his medical studies twice, first in 1911 to volunteer for a year as a labourer-teacher in remote lumber and mining camps in northern Ontario to teach immigrant mine workers reading and writing English. And second, in 1914 during World War I he served as a stretcher-bearer in France.

He commenced a very lucrative private practice in Detroit as a successful surgeon, and led a hedonistic private life, interspersed with bouts of heavy drinking. Making more and more money became the driving force of his life.

But then he was diagnosed with tuberculosis. In the 1920s, this medical verdict was like signing a death warrant. He was sent to a sanitorium to await almost certain demise. Before he went to the sanitorium he divorced his wife to spare her suffering. He wrote to her later from the sanitorium of how he awaited “the angel of death”.

In the sanitorium one day, bored of reading a novel, he turned to a medical book and read in it of a radical new treatment for tuberculosis of artificially collapsing the tubercular lung, allowing it to rest and heal itself. Called pneumothorax, physicians believed this procedure was too new and risky. But since only one of his lungs was infected, Bethune insisted they experimented with him. The procedure was successful, and he fully recovered.

He remarried his divorced wife, but returned to what he regarded as his rebirth to a new life. He was 37, and he looked at the ruin and waste of the years he left behind him. “Never again would any living being lie under his scalpel as a remote and separate organism posing a mere problem in mechanics,” he resolved. “A man was flesh and dreams; his knife would save the dreams as well as the flesh.”

In this, Bethune devoted himself obsessively to the treatment of TB. He was no longer interested in his regular practice, in the making of money. He developed new and innovative techniques of surgery in the treatment of TB. His compulsive single-minded dedication led his wife to divorce his wife a second time, and many clashes with his peers. But his reputation grew, but he encountered a paradox. “The more advanced our curative surgery, the more cases of TB we would get”, he would say. Scientific knowledge about the disease had peaked, but the hospitals and sanitoriums were overflowing with more patients than they could accommodate. For every case he and his colleagues cured, 10 more would appear.

Why, he asked. His answer was that there was a disease engulfing the world which was far more lethal than medieval cholera or the tubercular bacilli. This was poverty. It was 1929. Banks, factories and mines were plunging into bankruptcy. The newspapers were full of reports of the depression and unemployment, in city slums and starving farmlands. Bethune found that all his successes over five years inside the operation theatre were being undone by the mounting impoverishment outside. “The poor man dies” he lamented “because he cannot afford to live”. Hunger was rampant, yet Canada burned its wheat. Millions were without clothes, yet the United States ploughed down its cotton fields.

He joined public demonstrations for food and milk. He declared he would provide treatment free of charge to any patient who could not afford to pay. He found himself drawn more and more to communism, especially when he found that Russia’s socialist policies had brought TB down to half. Workers had priority in treatment, exactly the reverse of what prevailed in his own homeland, and hospitals and sanitoriums were far more lavish than anything in his country.

He developed a charter of what he called “socialised medicine”, that called for the abolition of private practice, “taking private profit out of medicine”. Medical reforms like limited health insurance, he said, were just bastard forms of socialism born out of belated humanitarianism out of necessity. Health services should become a public good, supported by public goods, available to all based not on income but on need. All health workers should be paid out of public funds.

Medical ethics, he was convinced, should be reformed from being a professional etiquette between doctors to “a code of fundamental morality and justice between medicine and the people”. Doctors should not ask “how much do you have?”. Instead they should ask – how best can I serve you?

Bethune’s socialist beliefs took him next to Spain to join the fight against fascism in 1936. There he pioneered blood transfusion in the frontlines of war, taking blood donated by civilians in bottles for wounded soldiers in battle zones. In 1938 he went to China, where he is still honoured for pioneering forms of guerrilla medical service and the idea and practice of the barefoot doctors.

It is extraordinary how Bethune’s charter of what he called “socialised medicine” anticipated in many ways the frontiers of our most radical thinking today on the right to health. On the high table of policy making in new India, these conversations have barely begun.

I am grateful for research support from Rishiraj Bhagawati.

Harsh Mander, justice and peace worker and writer, leads Karwan e Mohabbat, a people’s campaign to counter hate violence with love and solidarity. He teaches at FAU University of Erlangen-Nuremberg, and Heidelberg University, Germany; Vrije University, Amsterdam; and IIM, Ahmedabad.

Winter weather makes it hard for everyone to get around. But for many, especially older people, the whole world can feel like an icy sidewalk every day of the year, particularly if they already have problems with their mobility that puts them at higher risk of falling.

For people who have trouble getting around, stairs, bathrooms and kitchens are among the most treacherous features of typical homes, loaded with potential hazards, such as hard surfaces, slippery floors, accessing high and low cupboards, elevation changes and more.

The danger is worse at night, especially for older people due in part to changes in vision and certain medications.

Vehicles are another major challenge for people with mobility issues, especially getting into and out of them, let alone driving them.

Pope Francis showed his own vulnerability in early February when he stumbled after his walking stick broke. He managed to stay upright but had fallen twice in the preceding weeks. When we don’t move around as much, other health issues can arise, requiring hospitalization.

The Pope’s public stumble and slow recovery triggered concerns over the 88-year-old’s health and gave the rest of us good reason to consider our own vulnerability.

Recognising risks

As a professor of rehabilitation science who researchers and teaches occupational therapy with a focus on optimising mobility in later life, I spend my working days thinking about how to make life better by keeping seniors living well and reducing the risks they face.

In my personal life, I do my best to help my mother stay healthy. I recognise that some of the adapted features we made to her daily activities and living space are helpful to me knowing, as her primary caregiver, that her environment is set up to support her independence.

Older people often miss or ignore signs that their own mobility is waning, because it typically happens gradually. We may not be conscious of how much we’re using our arms to get out of a chair, that we’re leaning against the wall of the shower while washing, hesitating to pick up a dropped item, or less comfortable driving at night or at higher speeds.

These are some of the early signs we may need help. Since it’s easy to miss them, it’s important to think consciously and deliberately to avoid a fall or a collision that results in major injury like a broken hip, wrist or worse.

No one takes pleasure in admitting it might be time for a grab bar or a cane, but assistive devices can prevent injury. Even those who already use such devices may not recognise that their needs change over time, or that their equipment – even a cane – may need maintenance or replacement.

Failing to take precautions, though, can have severe and lasting repercussions, so it’s vital to be honest with ourselves.

Prevention and risk reduction

The upside of taking stock of our situation is that by preventing falls and driving safely, we can continue to participate fully for much longer than was possible even a generation ago.

There is plenty of research to show, of course, that diet and exercise can make a significant difference in preserving and even improving mobility while reducing vulnerability, but people don’t always pause to consider their physical environment and other strategies until after an injury.

Here are some ways you can help yourself or someone in your life whose mobility may be waning:

• Install low lighting – even a plug-in night light or two can help – that illuminates the path from bedroom to bathroom.

• Add a second handrail to cover both sides of staircases inside and outside of the home, especially steep stairs that lead to the basement or attic.

• Stay up-to-date with vision and hearing tests. Always use the eyeglasses and hearing aids, as prescribed.

• Install “tall” toilets that make sitting and standing up easier.

• Scan the house for tripping hazards, such as throw rugs, and remove them.

• Re-organize cupboards to put the most frequently used items in easy reach.

• Use non-slip footwear made with safety in mind. The Toronto Rehabilitation Institute has done some helpful studies on footwear and safety, including in ice and snow.

• Schedule a home visit from a licensed occupational therapist who can make recommendations suited to your mobility needs, including taking a look at your mobility devices to be sure they are still suitable and are in good working order. An occupational therapist together with a qualified contractor can ensure grab bars, ramps and other features are installed appropriately.

• Plan ahead for the time when you can no longer drive by considering alternative transit options and lifestyle changes that might be necessary.

Mobility matters because it allows us to live independently and participate fully in our everyday activities. By proactively addressing potential hazards, we can enhance our quality of life and continue to enjoy the freedom that mobility provides.

Brenda Vrkljan is Professor of Occupational Therapy, School of Rehabilitation Science, McMaster University.

This article was first published on The Conversation.

Aside from recent outbreaks of polio in war-torn regions of the world, the deadly virus is close to being eradicated, thanks to vaccines.

All vaccines work by training our immune systems to recognise a harmless piece of a virus or bacteria so that when the real thing is encountered later, the immune system is prepared to defeat it.

There are two types of polio vaccine in use. One is the inactivated poliovirus vaccine (IPV), and the other the live-attenuated oral poliovirus vaccine (OPV).

The IPV is made by “killing” large quantities of poliovirus with a chemical called formalin, making it unable to replicate. The immune system is then “trained” to recognise the poliovirus – which is thankfully rendered safe by formalin.

The OPV vaccine contains a weakened (or “attenuated”) version of the virus. These changes in the virus’s genetic code stop it from causing disease. However, as the OPV vaccine is still capable of replicating, it can revert to a form that can cause disease, with the potential to cause paralysis in unvaccinated people.

Because of these risks, scientists are now looking for safer ways to create vaccines – methods that don’t require growing large amounts of the live virus in high-security labs, as is done for IPV.

Our research team has taken an important step towards producing a safer and more affordable polio vaccine. This new vaccine candidate uses virus-like particles (VLPs). These particles mimic the outer protein shell of poliovirus, but are empty inside. This means there is no risk of infection, but the VLP is still recognised by the immune system, which then protects against the disease.

This vaccine candidate uses technology that’s already being used in hepatitis B and human papillomavirus (HPV) vaccines. Thanks to VLPs, since 2008, there have been no cervical cancer cases in women in Scotland who were fully vaccinated against HPV. Over the past 10 years, our research group has worked to apply this successful technology in the fight to eradicate polio.

Vaccine success

Throughout the 19th and 20th centuries, polio was a major global childhood health concern. However, the development of IPV (licensed in 1955) and of OPV (licensed in 1963), almost eliminated polio-derived paralysis. Due to the success of the Global Polio Eradication Initiative, introduced in 1988, most cases of paralytic polio are now caused by the vaccine.

Despite the success of these vaccines, they both have safety concerns that could threaten to compromise eradication of the disease.

IPV, for instance, is expensive to make because it needs stringent safety measures to prevent the accidental release of live poliovirus and so is mostly used in wealthy countries. OPV is five times cheaper than IPV, and due to its lower cost and ease of use, it is used almost exclusively in developing countries.

OPV has been instrumental in the near eradication of “wild polioviruses” (the naturally occurring form) around the world. But in areas where vaccination rates are low and enough people are susceptible to infection, the weakened virus (OPV) can replicate.

Unfortunately, each round of replication increases the potential for the virus to revert to a form of polio that causes illness and paralysis. This is already evident in new vaccine-derived outbreaks across several countries in Africa, Asia and the Middle East, which now accounts for most paralytic polio cases worldwide. So, once all remaining strains of wild poliovirus have been successfully eradicated, OPV use will have to stop.

Safer vaccine

The next generation of polio vaccinations is likely to be produced in yeast or insect cells. Our research shows that VLPs produced in both yeast and insect cells can perform equally or better than the current IPV.

These non-infectious VLPs are also easier to produce than IPVs. They would not need to be handled under such stringent laboratory conditions as IPVs, and they are more temperature stable, thanks to genetic alteration of the outer shell. The new vaccines, then, will be less expensive to produce than IPVs, helping to improve fair and equal access to vaccination – ensuring that once polio is eradicated, it will stay eradicated.

As we move closer to wiping out polio worldwide, these next-generation vaccines could be the final tool we need – safe, affordable and accessible to all.

Lee Sherry is Postdoctoral Research Associate, School of Infection and Immunity, University of Glasgow.

Nicola Stonehouse is Professor in Molecular Virology, School of Molecular and Cellular Biology, University of Leeds.

This article was first published on The Conversation.

“Avoid screens before bed” is one of the most common pieces of sleep advice. But what if the real problem isn’t screen time − it’s the way we use social media at night?

Sleep deprivation is one of the most widespread yet overlooked public health issues, especially among young adults and adolescents.

Despite needing eight to 10 hours of sleep, most adolescents fall short, while nearly two-thirds of young adults regularly get less than the recommended seven to nine hours.

Poor sleep isn’t just about feeling tired − it’s linked to worsened mental health, emotion regulation, memory, academic performance and even increased risk for chronic illness and early mortality.

At the same time, social media is nearly universal among young adults, with 84% using at least one platform daily. While research has long focused on screen time as the culprit for poor sleep, growing evidence suggests that how often people check social media − and how emotionally engaged they are − matters even more than how long they spend online.

As a social psychologist and sleep researcher, I study how social behaviours, including social media habits, affect sleep and well-being. Sleep isn’t just an individual behaviour; it’s shaped by our social environments and relationships.

And one of the most common yet underestimated factors shaping modern sleep? How we engage with social media before bed.

Emotional investment

Beyond simply measuring time spent on social media, researchers have started looking at how emotionally connected people feel to their social media use.

Some studies suggest that the way people emotionally engage with social media may have a greater impact on sleep quality than the total time they spend online.

In a 2024 study of 830 young adults, my colleagues and I examined how different types of social media engagement predicted sleep problems. We found that frequent social media visits and emotional investment were stronger predictors of poor sleep than total screen time. Additionally, presleep cognitive arousal and social comparison played a key role in linking social media engagement to sleep disruption, suggesting that social media’s effects on sleep extend beyond simple screen exposure.

I believe these findings suggest that cutting screen time alone may not be enough − reducing how often people check social media and how emotionally connected they feel to it may be more effective in promoting healthier sleep habits.

Sleep disruption

If you’ve ever struggled to fall asleep after scrolling through social media, it’s not just the screen keeping you awake. While blue light can delay melatonin production, my team’s research and that of others suggests that the way people interact with social media may play an even bigger role in sleep disruption.

Here are some of the biggest ways social media interferes with your sleep:

• Presleep arousal: Doomscrolling and emotionally charged content on social media keeps your brain in a state of heightened alertness, making it harder to relax and fall asleep. Whether it’s political debates, distressing news or even exciting personal updates, emotionally stimulating content can trigger increased cognitive and physiological arousal that delays sleep onset.

• Social comparison: Viewing idealised social media posts before bed can lead to upward social comparison, increasing stress and making it harder to sleep. People tend to compare themselves to highly curated versions of others’ lives − vacations, fitness progress, career milestones − which can lead to feelings of inadequacy and anxiety that disrupt sleep.

• Habitual checking: Social media use after lights out is a strong predictor of poor sleep, as checking notifications and scrolling before bed can quickly become an automatic habit. Studies have shown that nighttime-specific social media use, especially after lights are out, is linked to shorter sleep duration, later bedtimes and lower sleep quality. This pattern reflects bedtime procrastination, where people delay sleep despite knowing it would be better for their health and well-being.

• Fear of missing out, or FOMO: The urge to stay connected also keeps many people scrolling long past their intended bedtime, making sleep feel secondary to staying updated. Research shows that higher FOMO levels are linked to more frequent nighttime social media use and poorer sleep quality. The anticipation of new messages, posts or updates can create a sense of social pressure to stay online and reinforce the habit of delaying sleep.

Taken together, these factors make social media more than just a passive distraction − it becomes an active barrier to restful sleep. In other words, that late-night scroll isn’t harmless − it’s quietly rewiring your sleep and well-being.

Break the habit

You don’t need to quit social media, but restructuring how you engage with it at night could help. Research suggests that small behavioral changes to your bedtime routine can make a significant difference in sleep quality. I suggest trying these practical, evidence-backed strategies for improving your sleep:

• Give your brain time to wind down: Avoid emotionally charged content 30 to 60 minutes before bed to help your mind relax and prepare for sleep.

• Create separation between social media and sleep: Set your phone to “Do Not Disturb” or leave it outside the bedroom to avoid the temptation of late-night checking.

• Reduce mindless scrolling: If you catch yourself endlessly refreshing, take a small, mindful pause and ask yourself: “Do I actually want to be on this app right now?”

A brief moment of awareness can help break the habit loop.

Brian N Chin is Assistant Professor of Psychology, Trinity College.

This article was first published on The Conversation.

The Maharashtra government on Wednesday announced a plan to implement the National Education Policy 2020 from the academic year 2025-’26, reported The Indian Express.

The plan makes it compulsory for students in Classes 1 to 5 in Marathi and English medium schools to learn Hindi as a third language. The policy’s three-language formula will replace the prevailing two-language structure in these schools.

Schools that teach in languages other than English and Marathi already follow the three-language formula, as they are required to offer English, Marathi and their medium of instruction.

A resolution issued by the school education department outlines the rollout of the “5+3+3+4” structure recommended under the National Education Policy.

This structure divides school education into four stages:

• Stage 1 (Foundation): Three years of pre-primary education, followed by Classes 1 and 2.
• Stage 2 (Preparatory): Classes 3 to 5.
• Stage 3 (Middle): Classes 6 to 8.
• Stage 4 (Secondary): Classes 9 to 12.

The education department’s Deputy Secretary Tushar Mahajan said in a notice: “This new policy restructures the previous 10+2+3 system into a 5+3+3+4 format, covering education from foundational to higher levels. The policy is being gradually implemented in the state. It is built on five pillars: Access, Equity, Quality, Affordability, and Accountability, and aligns with the [United Nations’] Sustainable Development Goals to be achieved by 2030.”

The phased implementation will begin with Class 1 in 2025-’26 and will cover all grades by 2028-’29. The state has said it plans to train 80% of teachers in new pedagogical methods by 2025 to support the policy transition, reported India Today.

As part of proposed changes in school curricula, textbooks of the Maharashtra State Education Board will now be based on content developed by the National Council of Educational Research and Training with adaptations that reflect Maharashtra’s local context, especially in social sciences and languages. Class 1 textbooks are presently published by Balbharati, the state textbook bureau.

Director of the State Council for Educational Research and Training Rahul Rekhawar said: “The curriculum content for the first three years of pre-primary section is already prepared. It has to be implemented in association with the Women and Child Welfare department which regulates anganwadis. SCERT is going to hold teacher training workshops for anganwadis to effectively implement the new curriculum for pre-primary.”

While the curriculum will be introduced in stages, the SCERT has also prepared bridge courses for classes where students will transition directly from the old to the new curriculum.

Many of us turn to Sudoku, Wordle or brain-training apps to sharpen our minds. But research is increasingly showing one of the best ways to boost memory, focus and brain health is exercise.

Our new research reviewed data from more than 250,000 participants across 2,700 studies. We found exercise helps boost brain function – whether it’s walking, cycling, yoga, dancing, or even playing active video games such as Pokémon GO.

Moving your body improves how we think, make decisions, remember things and stay focused – no matter your age.

What the science says

Our review adds to a growing body of research that shows regular physical activity improves three key areas of brain function:

• cognition, which is your overall ability to think clearly, learn and make decisions

• memory, especially short-term memory and the ability to remember personal experiences

• executive function, which includes focus, planning, problem-solving and managing emotions.

We conducted an umbrella review, which means we looked at the results of more than 130 high-quality research reviews that had already combined findings from many exercise studies. These studies usually involved people starting a new, structured exercise program, not just tracking the exercise they were already doing.

To assess the effects on cognition, memory and executive function, the original studies used a range of brain function tests. These included things like remembering word lists, solving puzzles, or quickly switching between tasks – simple activities designed to reliably measure how well the brain is working.

The improvements were small to moderate. On average, exercise led to a noticeable boost in cognition, with slightly smaller but still meaningful gains in memory and executive function.

The benefits showed up across all age groups, though children and teens saw major gains in memory.

People with attention-deficit hyperactivity disorder (ADHD) showed greater improvements in executive function after physical activity than other population groups.

The brain started responding fairly quickly – many people experienced improvements after just 12 weeks of starting regular exercise.

Generally, the greatest benefits were seen in those doing at least 30 minutes of exercise on most days of the week, aiming for a total of about 150 minutes per week.

What’s happening in the brain

Activities such as walking or cycling can increase the size of the hippocampus, the part of the brain responsible for memory and learning.

In one study, older adults who did aerobic exercise for a year grew their hippocampus by 2%, effectively reversing one to two years of age-related brain shrinkage.

More intense workouts, such as running or high-intensity interval training, can further boost neuroplasticity – the brain’s ability to adapt and rewire itself. This helps you learn more quickly, think more clearly and stay mentally sharp with age.

Another reason to get moving

The world’s population is ageing. By 2030, one in six of people will be aged over 60. With that comes a rising risk of dementia, Alzheimer’s disease and cognitive decline.

At the same time, many adults aren’t moving enough. One in three adults aren’t meeting the recommended levels of physical activity.

Adults should aim for at least 150 of moderate exercise – such as brisk walking – each week, or at least 75 minutes of more vigorous activity, like running.

It’s also important to incorporate muscle-strengthening exercises, such as lifting weights, into workouts at least twice a week.

Everyday movement counts

You don’t need to run marathons or lift heavy weights to benefit. Our study showed lower-intensity activities such as yoga, tai chi and “exergames” (active video games) can be just as effective – sometimes even more so.

These activities engage both the brain and body. Tai chi, for instance, requires focus, coordination and memorising sequences.

Exergames often include real-time decision-making and rapid response to cues. This trains attention and memory.

Importantly, these forms of movement are inclusive. They can be done at home, outdoors, or with friends, making them a great option for people of all fitness levels or those with limited mobility.

Although you may already be doing a lot through daily life – like walking instead of driving or carrying shopping bags home – it’s still important to find time for structured exercise, such as lifting weights at the gym or doing a regular yoga class, to get the full benefits for your brain and body.

Real-life applications

If you’re a grandparent, consider playing Wii Sports virtual tennis or bowling with your grandchild. If you’re a teenager with signs of ADHD, try a dance class, and see if it impacts your concentration in class. If you’re a busy parent, you might be more clear-headed if you can squeeze a 20-minute yoga video session between meetings.

In each of these cases, you’re not just being active, you’re giving your brain a valuable tune-up. And unlike most brain-training apps or supplements, exercise delivers far reaching benefits, including improved sleep and mental health.

Workplaces and schools are starting to take note. Short movement breaks are being introduced during the workday to improve employee focus.

Schools that incorporate physical activity into the classroom are seeing improvements in students’ attention and academic performance.

Exercise is one of the most powerful and accessible tools we have for supporting brain health. Best of all, it’s free, widely available and it’s never too late to start.

Ben Singh is Research Fellow, Allied Health & Human Performance, University of South Australia.

Ashleigh E Smith is Associate Professor, Healthy Ageing, University of South Australia.

This article was first published on The Conversation.

One of the lasting memories from my teenage years is what I now recognise as an obsession with weight control. Thin was in, and magazines promoted a variety of diets, each claiming effectiveness, often accompanied by images of beautiful, slim models. Not much has changed.

Diets, intermittent fasting, weight-loss surgery, and more recently, weight-loss injections continue to be marketed as solutions for shedding pounds. Achieving a healthy weight is widely regarded as essential for overall wellbeing.

Many studies have explored the relationship between weight changes and mortality, as well as mortality in obese people with heart disease. These studies often suggest that excessive weight is unhealthy and that people with obesity and heart disease should lose weight.

However, findings from a recent study, of which I was a co-author, challenge this assumption. Our research indicates that significant weight loss – greater than 10kg – can actually increase the risk of early death in obese people with cardiovascular disease.

This study was based on data from over 8,000 participants in the UK Biobank, a comprehensive resource for medical research that includes genetic data.

While it’s known that rapid weight loss can signal underlying health issues and lead to serious complications, the weight changes in our study were observed over an average of nine years, meaning for some participants, these changes were relatively quick.

This creates a paradox. While both obesity and cardiovascular disease are known to increase the risk of early death, in obese people with cardiovascular disease, weight loss – intended to improve health – can have the opposite effect.

The relationship between body weight and illness is complex. Though obesity contributes to cardiovascular problems, studies have also shown an increased risk of early death in those with chronic heart failure who are lean, and in people with coronary artery disease whose weight fluctuates.

Obesity rates are rising, but simply focusing on weight loss may not be the answer.

Weight loss variability

For weight loss to be effective, we must consider the diverse factors contributing to weight gain, which vary from person to person. Genetics play a significant role in appetite and metabolism, and they can also influence lifestyle factors like overeating, inadequate exercise and poor dietary choices that lead to obesity.

In our study, my colleagues and I couldn’t account for all the factors behind the participants’ obesity or the methods they used to lose weight. This means we can’t definitively determine which weight-loss strategies – whether in terms of duration, diet or physical activity – pose the greatest risks.

The conventional approach to healthy weight – using body mass index (BMI) – may not apply to everyone. BMI is increasingly recognised as having limitations. Some people may tolerate higher weights without adverse health effects. The real question isn’t how quickly weight should be lost, but how quickly it should be lost for each person.

Given the current evidence, we cannot accurately determine an ideal weight range that’s universally beneficial for health. However, intriguing patterns are emerging from various countries.

For instance, Tonga has a high rate of obesity, yet it experiences significantly lower rates of heart-disease-related deaths than many European countries where obesity is less prevalent. Tonga also reports lower levels of alcohol consumption and suicide than most European nations.

Health encompasses both physical and mental wellbeing. Shifting the focus to holistic wellbeing and happiness may offer more lasting health benefits. Treating obesity requires a comprehensive approach, addressing all underlying factors contributing to the condition.

Barbara Pierscionek is Professor and Deputy Dean, Research and Innovation, Anglia Ruskin University.

This article was first published on The Conversation.

For seven months last year, Aktari Mohammed Khan had to make frequent visits to Lokmanya Tilak Municipal hospital, 10 km from her home in Mumbai.

Khan had splitting headaches due to a neurological condition called occipital neuralgia. With no money to afford private treatment, she had to travel in crowded buses till the hospital in Sion, where a government neurologist treated her for free.

The 38-year-old lives in a tiny hutment in a slum in Mankhurd, where a large number of people displaced by various development projects in Mumbai have been settled over the years. Most of the slum’s residents live in cramped, poorly ventilated spaces and have little access to healthcare.

For years, they have demanded a government hospital for their needs.

In 2013, the Mumbai Metropolitan Region Development Authority decided to construct a hospital for the rehabilitated people of Mankhurd. The hospital was supposed to have a high-tech operation theatre, a maternity wing and was to have been finished by 2015.

After a delay of 10 years, the hospital is nearly ready and has been handed over to the municipal corporation.

Domestic worker Sunita Gazdhane said they have waited for the hospital to open up for years. The 50-year-old lives in a hutment across the new hospital building. “It will be a huge relief for slum dwellers,” said Gazdhane, who visits a private clinic whenever she is ill. “I spend between Rs 100 and Rs 200 there.”

But there is a catch.

The Brihanmumbai Municipal Corporation, short on staff and funds, is in process of handing the hospital over to a private organisation to run.

Khan, whose four sons work in a landfill not far from their home, said she was disappointed with the news. “How will we ever pay for private treatment?” she asked.

Ateeque Ahmed Khan, a leader of the All India Majlis-e-Ittehadul Muslimeen, who contested for the Mankhurd Shivaji Nagar Assembly seat in 2024, asked what “purpose a government hospital will serve in a poor locality if it is privatised”.

For Mankhurd’s residents, it is vital for the entire hospital to be run at government rates, he said.

Besides the Mankhurd hospital, the municipal corporation has announced plans to give away five major hospitals in Borivali, Bandra, Vikhroli, Govandi and Mulund to private players under the public-private partnership model, said Ashok Jadhav, chairman of the Municipal Mazdoor Union.

Each of these hospitals currently serves a significant slum population, who stand to lose out because of the decision.

Municipal workers protest

The municipal corporation has so far floated tenders for two hospitals to be handed over to private players – one in Borivali and the second in Mankhurd.

In Borivali, a newly redeveloped Shri Harilal Bhagwati hospital with 490 beds will be given out to a private player for 30 years.

According to the tender, accessed by Scroll, the private organisation will have to reserve 147 beds for poor patients, according to rates fixed by the civic body, and can charge private rates on the remaining 343 beds.

In the Mankhurd hospital, which has 410 beds, only 150 beds will be reserved for free for patients like Khan. The private partner can profit from the remaining 260 beds.

Four other hospitals that the corporation plans to give away are the KB Bhabha hospital in Bandra, the MT Agrawal hospital in Mulund, the Madan Mohan Malviya Shatabdi hospital in Govandi and Krantiveer Mahatma Jyotiba Phule Hospital in Vikhroli.

All the hospitals have either undergone a recent expansion funded by the municipal corporation or were in the process of completing it. In its 2020-’21 budget, the civic body had estimated the revamp of Bhagwati hospital in Borivali to cost Rs 592 crore, that of MT Agrawal hospital to cost
Rs 457 crore, the Shatabdi hospital in Govandi to cost Rs 500 crore and the redevelopment of the Bandra Bhabha to cost Rs 287 crore. It has allocated Rs 1,849 crore for the hospitals in the last four years.

A former additional municipal commissioner at the Brihanmumbai Municipal Corporation said the hospitals’ capacity was expanded to meet the growing patient load.

Bhabha hospital’s bed strength grew to 497 beds, MT Agrawal hospital now can accommodate 470 beds, and the Shatabdi hospital’s bed strength was increased to 580. The Mahatma Jyotiba Phule is still undergoing an expansion.

The redeveloped hospitals have departments like cardiology, plastic surgery, urology, and gastroenterology, making it easier for people to access free treatment closer to their homes.

But a health department official said the civic body is fund-strapped as well as short on staff, making it difficult to handle the 17 hospitals under it. This finally led to the decision to hand over the five hospitals, with nearly 2,500 beds, to private partners.

The move has run into opposition from municipal employees, who will be removed from the hospitals.

Pradeep Narkar, from the Municipal Mazdoor Union, said their union has begun to approach MLAs and MPs to gather support against the decision. “At least 2,000 nurses, staffers and doctors will be relieved from these hospitals once they get handed over,” Narkar said. Their union has already held a protest outside Bhagwati hospital.

The Brihanmumbai Municipal Corporation has promised that the staff will be absorbed in other hospitals with vacancies. For example, there are about 2,230 vacant posts in the KEM, Sion and Nair hospitals.

“But our opposition is also to the idea of PPP,” Narkar said. “These hospitals are meant for the public who depend on the government to provide affordable treatment.”

Past experience

The municipal corporation’s former executive health officer Dr Mangala Gomare said the public-private partnership model is a good option if the civic body has no manpower to manage hospitals or maternity homes.

“But the challenge is monitoring the private partner and whether they are following all the terms of the contract,” Gomare said, adding that they need a separate cell to monitor such projects.

For instance, the corporation handed over three maternity hospitals in Goregaon, Mulund and Deonar to private players in 2019. Gomare said monitoring had posed a problem when she was in charge.

Dr Abhijeet More, from Jan Swasthya Abhiyaan, an organisation that works on public health, said the lack of supervision allows the private partner to profit disproportionately. “This finally affects the health services a poor person receives,” he said. “We have seen in the past that this model has failed in the BMC hospitals.”

In 2018, the Brihanmumbai Municipal Corporation handed over the administration of intensive care units of six hospitals to Jeevan Jyot Charitable Trusts.

Five years later, a first information report was filed against the trust for recruiting doctors with Bachelor of Ayurvedic Medicine and Surgery and Bachelor of Homeopathic Medicine and Surgery degrees, instead of trained intensivists, to treat patients in intensive care units. The municipal corporation had to terminate the contract.

After the Jeevan Jyot incident, similar contract with Criticare and Associates to run intensive care units of two hospitals was terminated.

The civic body had also handed over the Seven Hills hospital in Marol to a private player in 2005. The contract had to be terminated in 2018 after numerous lapses were found in the implementation of the contract.

In Govandi, activist Jameela Shaikh helps local residents avail Ayushman Bharat cards to get free treatment under the Pradhan Mantri Jan Arogya Yojana. “People in this area are very poor,” she said. “They earn Rs 20,000 per month. With that earning they buy rations, pay children’s school fees and rent. There is hardly any money left for healthcare.”

She added: “If the Shatabdi hospital is privatised, many poor people will have nowhere to go. Instead of expanding services, the BMC is stripping them of their health rights.”

More than five years since Covid-19 was declared a pandemic, we’re still facing the regular emergence of new variants of the virus, SARS-CoV-2.

The latest variant on the rise is LP.8.1. It’s increasing in Australia, making up close to one in five Covid cases in New South Wales.

Elsewhere it’s become even more dominant, comprising at least three in five cases in the United Kingdom, for example.

So what is LP.8.1? And is it cause for concern? Let’s look at what we know so far.

Offshoot of Omicron

LP.8.1 was first detected in July 2024. It’s a descendant of Omicron, specifically of KP.1.1.3, which is descended from JN.1, a subvariant that caused large waves of COVID infections around the world in late 2023 and early 2024.

The World Health Organization designated LP.8.1 as a variant under monitoring in January. This was in response to its significant growth globally, and reflects that it has genetic changes which may allow the virus to spread more easily and pose a greater risk to human health.

Specifically, LP.8.1 has mutations at six locations in its spike protein, the protein which allows SARS-CoV-2 to attach to our cells. One of these mutations, V445R, is thought to allow this variant to spread more easily relative to other circulating variants. V445R has been shown to increase binding to human lung cells in laboratory studies.

Notably, the symptoms of LP.8.1 don’t appear to be any more severe than other circulating strains. And the WHO has evaluated the additional public health risk LP.8.1 poses at a global level to be low. What’s more, LP.8.1 remains a variant under monitoring, rather than a variant of interest or a variant of concern.

In other words, these changes to the virus with LP.8.1 are small, and not likely to make a big difference to the trajectory of the pandemic.

Will cases rise?

COVID as a whole is still a major national and international health concern. So far this year there have been close to 45,000 new cases recorded in Australia, while around 260 people are currently in hospital with the virus.

Because many people are no longer testing or reporting their infections, the real number of cases is probably far higher.

In Australia, LP.8.1 has become the third most dominant strain in NSW (behind XEC and KP.3).

It has been growing over the past couple of months and this trend looks set to continue.

This is not to say it’s not growing similarly in other states and territories, however NSW Health publishes weekly respiratory surveillance with a breakdown of different COVID variants in the state.

Sequences of LP.8.1 in the GISAID database, used to track the prevalence of variants around the world, increased from around 3% at the end of 2024 to 38% of global sequences as of mid March.

In some countries it’s climbed particularly high. In the United States LP.8.1 is responsible for 55% of cases. In the UK, where LP.8.1 is making up at least 60% of cases, scientists fear it may be driving a new wave.

Will vaccines work?

Current Covid vaccines, including the most recently available JN.1 shots, are still expected to offer good protection against symptomatic and severe disease with LP.8.1.

Nonetheless, due to its designation as a variant under monitoring, WHO member countries will continue to study the behaviour of the LP.8.1 variant, including any potential capacity to evade our immunity.

While there’s no cause for panic due to LP.8.1 variant at this stage, Covid can still be a severe disease for some. Continued vigilance and vaccination, particularly for medically vulnerable groups, is essential in minimising the impact of the disease.

Thomas Jeffries is Senior Lecturer in Microbiology, Western Sydney University.

This article was first published on The Conversation.

The Madhya Pradesh Police on Monday arrested a man accused of impersonating a British doctor and performing surgeries at a hospital in Damoh district, allegedly resulting in at least seven deaths, Hindustan Times reported.

The man, identified as Narendra Yadav, was arrested from Uttar Pradesh’s Prayagraj and will be brought to Madhya Pradesh, Damoh Superintendent of Police Shrutkirti Somvanshi said.

“Communications are being made with hospitals across India where he has worked previously,” the superintendent of police added, according to The Times of India.

Yadav was said to have been posing as Dr N John Camm at Mission Hospital in Damoh. During his two-month tenure at the hospital, Yadav allegedly treated nearly 70 patients and performed surgeries on 13 of them, seven of whom died, according to The Times of India.

He was said to have been hired through a Bhopal-based agency with a monthly salary of Rs 8 lakh.

Ahead of his arrest on Monday, the police filed a case against Yadav under several sections of the Bharatiya Nyaya Sanhita pertaining to cheating and forgery. Relevant sections of the Madhya Pradesh Ayurvedic Council Act were also invoked, Hindustan Times reported.

A team from the National Human Rights Commission also arrived in Damoh on Monday to investigate the matter. The team recorded statements from the family members of the deceased.

The matter came to light in February after a patient filed a complaint raising doubts about Yadav.

Earlier, Deepak Tiwari, the chief of the Damoh Child Welfare Committee, had said that the matter came to light in February after a patient filed a complaint raising doubts about Yadav.

Damoh Child Welfare Committee chief Deepak Tiwari said that according to the patient, the doctor was not able to conduct a diagnosis. “When we got behind the matter, he [Yadav] fled the area,” Tiwari said.

A committee was formed to investigate the matter after complaints were sent to the district collector and the chief medical and health officer, he added.

“After he ran away, we also gave a complaint to the police about his suspicious behaviour,” an unidentified official at the hospital said. “We also submitted all the documents related to him to the administration and probe committee.”

The police had found that Yadav’s medical documents were forged.

We are riddled with microplastics. It is in our bloodstream, in our lungs, in our liver – pretty much anywhere you look in the human body, you will find minuscule bits of plastic.

And there are many ways for us to ingest, inhale or otherwise absorb these tiny fragments. For example, a single plastic teabag sheds over 10 billion microplastic particles into a cup of tea.

And if you redecorate your home and sand down the old paintwork, the plastic binders in the paint can release microplastics into the air, which you might then inhale. You could swallow them when you drink from single-use plastic water bottles. Now another source of microplastics in the body has been discovered: chewing gum.

Chewing gum contains long molecules called polymers. Some brands of gum contain natural polymers from tree sap. Others contain synthetic polymers derived from the petroleum industry. These various polymers are similar to plastics – and some actually are plastics. Chewing gum polymers, both natural and synthetic, can release microparticles when they are worn down by chewing.

In the chewing gum study – which was presented at the American Chemical Society meeting 25 March – a single volunteer chewed ten brands of chewing gum – five natural and five synthetic. Saliva samples were taken from the volunteer’s mouth and put under the microscope. Surprisingly, microplastics were found in both the natural and synthetic chewing gums.

The researchers, from the University of California, Los Angeles, calculated that one piece of gum could shed hundreds or a few thousand microplastic particles into the mouth, where they probably ended up being swallowed.

The types of plastics found in the gums were polystyrenes (used for things like takeaway food containers), polyethylenes (such as those used to make plastic grocery bags) and polypropylenes (which are used to make, among other things, car bumpers and medicine bottles).

But, before we start worrying about the microplastics liberated by chewing gum, we need to know how large they were.

Size matters

The microplastics found in the saliva of the gum-chewing volunteer were 20 micrometres or more in size. That is about the diameter of the thinnest human hair. But from the perspective of a cell in the human body, 20 microns is huge (a red blood cell, for instance, is about seven microns in diameter).

This is important because the microplastics that are known to be capable of harming cells and embryos are 500 to 1,000 times smaller than that (20 to 500 nanometers). These super-small microplastics are called nanoplastics.

Nanoplastics are bad news because they are small enough to be engulfed by living cells via a process called endocytosis. When nanoplastics are absorbed into cells, they can cause all sorts of trouble, such as triggering the cell to produce toxic molecules called reactive oxygen species. These toxins may not kill the cell outright, but they can weaken it.

Likewise, the plastic particles that have been shown to cause birth defects in animal embryos are also the very small ones (the nanoplastics), not the much larger microplastics that were found in the saliva of the gum chewer.

The chewing gum study is fascinating. It shows how easily we can unwittingly expose ourselves to hundreds of microplastics. However, we cannot confidently assign any kind of health risk to chewing gum.

The microplastics that are liberated by the chewing of gum are relatively huge, and we know nothing about the effects – if any – of such large particles in the human body. And we don’t know if chewing gum releases nanoplastics at all. The trouble is that nanoplastics are so tiny that they require specialised apparatus to detect them. For that reason, the researchers in the US who studied chewing gum decided not to look for them.

Some commentators think that the potential health risks of microplastics have been exaggerated, while others criticise the quality of some of the scientific studies on microplastics. We are inclined to agree with these criticisms. Hopefully, it will not be too long before we truly understand whether the microplastic scare will turn out to be justified – or just hype.

Michael Richardson is Professor of Animal Development, Leiden University.

Meiru Wang is Postdoctoral Researcher at Leiden University, Associate Scientist II at Stowers Institute, Developmental Biology, Molecular Biology and Nanotoxicology, Leiden University.

This article was first published on The Conversation.

About 10% of Americans say they have chronic insomnia, and millions of others report poor sleep quality. Ongoing research has found that bad sleep could lead to numerous health problems, including heart disease.

Dr Julio Fernandez-Mendoza is a professor of psychiatry and behavioral health, neuroscience and public health sciences at Penn State College of Medicine. He discusses the need for sleep, why teenagers require more sleep than adults, and how you can get a good night’s sleep without medications.

The Conversation has collaborated with SciLine to bring you highlights from the discussion that have been edited for brevity and clarity.

How much sleep is enough for adults and for adolescents?

Julio Fernandez-Mendoza: Adults who report getting about seven to eight hours of sleep per night generally have the best health, in terms of both physical and mental health, and longevity.

But that recommendation changes with age. Adults over age 65 may need just six to seven hours of sleep per night. So older people, if otherwise healthy, should not feel anxious if they’re getting just six hours. Young people need the most – at least nine hours – and some younger children may need more.

How can insufficient sleep harm our health?

Fernandez-Mendoza: Our team was the first to show that those complaining about insomnia – difficulty falling or staying asleep – were more likely to have high blood pressure and be at risk for heart disease.

In both teens and adults, we found that insomnia and shortened sleep may lead to elevated stress, hormone levels and inflammation. These problems tend to show up before you develop heart disease.

What about people who have more serious sleep problems?

Fernandez-Mendoza: Good sleep hygiene habits include cutting down on caffeine and alcohol, quitting smoking and exercising regularly. I also recommend not skipping meals, not eating too late at night and not eating too much.

But people with a persistent sleep problem may need to make more behavioral changes. Research studies point to a set of six rules that can improve your sleep. You can follow these changes consistently in the short term, and then choose how to adapt them into your lifestyle down the road.

First, get up at the same time no matter what. No matter how much sleep you get. This will anchor your sleep/wake cycle, called your circadian rhythm.

Second, do not use your bed for anything except sleep and sexual activity.

Third, when you can’t sleep, don’t lie in bed awake. Instead, get out of bed, go into another room if you can, and do an activity that’s enjoyable or relaxing. Go back to bed only when you’re ready to sleep.

Fourth, get going with daily activities even after a poor night’s sleep. Don’t try to compensate for sleep loss. If you have chronic insomnia, don’t nap, sleep in, or doze during the day or evening even after poor sleep the previous night.

Fifth, go to bed only when you’re actually sleepy enough to fall asleep.

And sixth, start with the amount of sleep you’re now getting – with the lowest limit at five hours – and then increase it weekly by 15 minutes.

These six rules are evidence-based and go above and beyond simple sleep hygiene habits. If they don’t work, see a provider who can help you.

Do you have advice specifically for adolescents?

Fernandez-Mendoza: Adolescence is a unique developmental period. It’s not just the obvious physical, emotional and behavioral changes that occur during adolescence and puberty – there are changes in a teenager’s brain that can alter their sleep patterns.

When an adolescent goes through puberty, their internal clock changes so that their sleep schedule shifts to later hours. While it’s true that adolescents are more engaged at night because of their social relationships, there’s also biology behind why they want to stay up late – their internal clocks have shifted. It’s not just choice.

School start times for most adolescents are at odds with that biological shift. So they don’t get enough sleep, which affects their performance in school. Research suggests that schools with later start times are more closely aligned with the science on child development and don’t put adolescents at risk by making them wake up earlier than their bodies are biologically inclined to.

Parents can help their teens get better sleep. Set a time for kids to stop doing homework and put away electronics. Instead, they can watch TV with the family or read – something relaxing and enjoyable that will help them wind down before bed.

You can also gradually move back their wake-up time. Start on weekends, waking them up 30 minutes earlier every day, including school days, until the child reaches the desired wake-up time. Don’t try to reshift them suddenly – for example, waking up a teenager at 5 a.m. like it’s the military – because that doesn’t work. They won’t get used to it, since it’s at odds with their internal clock. So, do it little by little. If that doesn’t work, see a clinical provider.

What kind of treatments can a sleep clinician provide?

Fernandez-Mendoza: People should get help if they feel they sleep poorly, if they’re fatigued during the day, or if they snore or grind their teeth. All these issues deserve attention.

Some people may think a sleep provider just prescribes expensive medication, but that’s not true. There are behavioral, non-drug-based treatments that work. Cognitive behavioral therapy is the first-line treatment recommended for insomnia. Light therapy may also help, which is the use of a bright light therapy lamp at a given time during the day or evening, depending on the person’s sleep problem.

Watch the full interview to hear more.

SciLine is a free service based at the American Association for the Advancement of Science, a nonprofit that helps journalists include scientific evidence and experts in their news stories.

Julio Fernandez-Mendoza is Professor of Psychiatry and Behavioral Health, Neuroscience, and Public Health Sciences, Penn State.

This article was first published on The Conversation.

A 54-year-old woman in Mumbai had suffered fatigue, weakness and shortness of breath for several months. She appeared pale and her skin had a slight yellowish discolouration.

“Laboratory tests showed she was anaemic, her haemoglobin was 8.3 g/dL, which is below 12.0 gm/dL, the lower limit of the normal range for women, but her serum iron level was normal as were her vitals, so we had to consider other causes of anaemia,” the treating doctor Bharesh Dedhia, head of Intensive Care at PD Hinduja Hospital & Medical Research Centre, Khar, Mumbai, told IndiaSpend.

For a long time, iron and folate deficiencies were thought to be the main causes of anaemia. However, recent studies show that vitamin B12 deficiency is also quite common, said Pankaj Malhotra, professor and head of Clinical Haematology & Medical Oncology at the Post Graduate Institute of Medical Education & Research, Chandigarh.

Chronic diseases, genetic conditions, bone marrow problems, the excessive breakdown of red blood cells, long-term blood loss, thyroid disorders, and certain medications can also cause anaemia. Infections like malaria and tuberculosis are major contributors to anaemia, especially in poorer communities, explained Malhotra.

In addition, exposure to polluted air could also trigger changes in the body that reduce the absorption, storage and distribution of iron, studies show.

This has policy implications for the elimination of anaemia, especially in the light of its rising national prevalence across population segments – women of reproductive age, children and men.

India’s Anaemia Mukt Bharat programme launched in 2018 focuses on iron and folic acid supplementation and making available rice fortified with micronutrients. But “merely ingesting more iron isn’t enough to ensure the iron is actually absorbed and lowers anaemia,” said Anura Kurpad, professor of physiology, St John’s Medical College, Bengaluru. “Anaemia due to other causes isn’t addressed through these measures, and there is the issue of potential side effects of universal fortification.”

Experts say India needs to focus more on finding out the cause of anaemia before treating it, encouraging dietary diversification, limiting the use of iron-fortified cereal, and ensuring iron supplements are absorbed into the body. The government should also create more awareness about the importance of an optimal level of haemoglobin and on combating the side-effects of iron supplementation, our reporting shows.

Not just iron deficiency

India’s nationwide survey of over 100,000 teenagers (10-19 years old) conducted between 2016 and 2018 found that iron deficiency was the main reason for anaemia. Other causes included a lack of folate, vitamin A, vitamin B12, vitamin D and zinc.

A January 2025 study published in the European Journal of Clinical Nutrition, conducted in eight Indian states, throws up new insights on anaemia. It concluded that “iron deficiency accounts for less than a third of the overall prevalence of anaemia”. Further, the study found that “other” reasons were responsible for the major proportion of anaemia in all the age groups studied, albeit the prevalence of anaemia was lower than thought in adolescents, adults and the elderly, by testing venous blood instead of capillary blood.

Narrating these possible causes based on all the research available, co-author of the study, Kurpad, who is also professor of physiology, St John’s Medical College, Bengaluru, said besides iron deficiency, “a further third [of anaemia in India] is caused by a deficiency of vitamins B12 and folic acid, and the remainder of the prevalence may be caused by air pollution and other indeterminate reasons related to the environment”.

Other causes of anaemia include chronic diseases such as chronic kidney disease, rheumatoid arthritis and cancer. It develops when chronic disease and inflammation cause a fall in the production of erythropoietin, a hormone produced by the kidneys to stimulate the production of red blood cells.

Dedhia’s patient had two chronic diseases – chronic kidney disease, for which she had been on dialysis for five years, as well as rheumatoid arthritis, for which she was on medication. Medicines to stimulate the production of red blood cells, iron supplementation, and vitamin B12 and folate supplementation to support red blood cell production, helped increase her haemoglobin level to a near normal level in about three months.

Since anaemia can have many causes, Dedhia underlined the need for thorough diagnosis and a treatment plan.

To effectively tackle anaemia, we must look at all possible causes besides nutrition, said Malhotra. “This includes checking for infections, particularly in rural areas, and managing chronic diseases.”

Anaemia, air pollution

Experts compared satellite images of fine particulate matter (PM 2.5) pollution in districts across India on the day prior to the National Family Health Survey IV, with the district-wise anaemia rates for children and women of reproductive age. What emerged was a clear relationship between the level of pollution and anaemia rates, according to studies published in Nature.

Every 10 micrograms per cubic metre (µg m–3) increase in exposure to fine particulate matter (PM 2.5) increased the average anaemia prevalence by 10% among children, and by 7.23% among women of reproductive age.

Another study published last year in BMC Geriatrics showed an association between indoor air pollution, typically from the use of unclean fuel, with anaemia, which was more pronounced in elderly (above the age of 45 years) men than women.

Exposure to polluted air causes anaemia in two ways. First, “fine particulate matter triggers the production of cytokines, proteins that fight inflammation and signal the liver to secrete hepcidin, a hormone that reduces the absorption, storage and distribution of iron,” explained Kurpad, a co-author of the study on the relation between pollution and anaemia.

“Cytokines are also known to suppress the bone marrow, so fewer red blood cells are produced,” he added. All of India’s population is exposed to unhealthy levels of ambient PM 2.5, according to the World Bank. In the study on air pollution and anaemia, industrial activity was seen to be the biggest contributor of such pollutants, followed by the unorganised, domestic, power, road dust, agricultural waste burning and transport sectors.

For reference, burning an incense stick for 15 minutes has been shown to push up the indoor PM 2.5 concentration to 197 µg m–3, which is 13 times higher than the 15 µg m–3 maximum exposure advised by the World Health Organization in 24 hours.

Kurpad pointed out that meeting India’s clean-air targets could theoretically reduce the overall prevalence of anaemia among women of reproductive age to 39.5%, and take 186 districts below the national target of 35%.

In other words, transitioning to clean energy would accelerate India’s progress towards the “anaemia-free” mission target. The challenge is “state level initiatives to control pollution haven’t worked to any significant level as yet”, he said.

At the individual level, anaemia arising from air pollution can be mitigated by a diet rich in antioxidants but fruits containing these antioxidants, like vitamin C, are expensive.

“Guava is the best option as a seasonal fruit, papaya is useful but oranges are too expensive,” said Kurpad. “Banana is the most commonly eaten fruit by the poor; while it’s good to fill the stomach it has no antioxidants.”

Diet diversification

So far, India’s food policies have mainly focused on providing enough grain to prevent hunger.

To address anaemia, the government introduced fortified rice in 2021 as part of the subsidised food distribution programme, school meals and child nutrition programmes. By 2024, fortified rice was part of India’s Public Distribution System for foodgrains to the poor, in rice-eating states, and this will continue until 2028.

In Haryana, early research shows that fortified flour has shown positive results, but other states have yet to adopt it, Malhotra said.

In view of many people relying on cereals with a low-iron content and an increasing preference for fast food, anaemia is becoming more common. So, Malhotra suggested expanding the food fortification programme to include iron, folic acid and vitamin B12 in staples like rice, wheat, and salt.

However, “an excessive intake of iron has been associated with diabetes”, and universal iron fortification could have serious implications in view of India’s diabetes epidemic,” said Kurpad.

One in 15 or 101 million Indians are diabetic, and millions more are pre-diabetic, a situation that has been fuelled by cereal-based diets, sedentary lifestyles and rising obesity, said Kurpad, and underscored the need to reconsider grain-centric nutritional policies.

“Policy and nutrition in India has progressed linearly rather than parallelly, solving first one problem and then another,” said Kurpad. “Instead, we need to consider the bigger picture, and opt for holistic solutions that could help solve multiple problems.”

Kurpad recommends fortifying diets through diet diversity that brings fruits and vegetables to an accessible level through intensive horticulture rather than solely agriculture.

Public policies that feed the masses the right type of diversified foods could help ensure that the poor eat more vegetables and fruits than just potatoes, green chillies and bananas, the least expensive options, especially iron-rich foods as well as those that help absorb iron.

Fortification not enough

A food may be iron-rich, either naturally or through fortification, but the nutrient must be absorbed by the body to be of use.

“Pushing nutrition through fortification has not had the spectacular effect we had thought it would possibly because iron is not absorbed as well from fortified foods,” said Kurpad.

Instead, Kurpad said, “we need to add nutrients to pull fortified iron into the body”.

For instance, vitamin C helps improve the absorption of iron but it needs to be consumed in a greater quantity than iron. An intake of vitamin C in a meal, which is about five times more than iron (weight for weight), can increase iron absorption from less than 5% to anywhere up to 25%.

What’s important is that the “vitamin C-rich foods like citrus fruits should be eaten along with the iron-rich meals,” said Malhotra.

Simultaneously, the consumption of phytates (a form of phosphorus in plants such as tea leaves), tannins (tea and coffee), and calcium should be avoided during iron-rich meals because they block the absorption of iron.

In rural Haryana, adding guava, a vitamin C rich fruit, to a mung bean-based meal served to 6 to 10-year-olds reduced the prevalence of anaemia by half, over a period of seven months, according to a study published in the Journal of Nutrition in December 2024.

“Adding guava to students’ mung bean-based (green gram) mid-day meal, which contains a moderate amount of iron, helped improve the bioavailability of iron, and hence, the concentration of haemoglobin,” Varsha Rani, a study co-author and assistant professor, Foods & Nutrition, Chaudhary Charan Singh Haryana Agricultural University, told IndiaSpend.

“We chose guava because it is the richest source of vitamin C after Indian gooseberry (amla),” continued Rani. “Since amla can’t be eaten without processing, guava becomes a vitamin C hero. In our study, the combined nutrients reduced iron-deficiency anaemia but could not increase the iron stores in the body, possibly because the iron content in mung beans was not high enough.”

Mass awareness campaign

Anaemia isn’t just a nutritional problem, it’s also an awareness problem, according to Rahul Bhargava, principal director & chief of haematology at Fortis Hospital, Gurgaon, who also said that “door-to-door screening and delivering an iron (and any other) capsule will not solve anaemia”.

We’ll be fighting a losing battle until the community is part of the solution,” said Bhargava. “People must understand what a normal haemoglobin level can do for their health, and be motivated to achieve that.”

Without understanding, an anaemic person is likely to stop taking supplementation in the eventuality of experiencing constipation or any other side effect. Essentially, “people adjust to a suboptimal haemoglobin level, and then find it difficult to take supplementation,” said Bhargava. “But someone who has experienced the productivity that follows a normal haemoglobin level will make an effort to get back on track if it falls.”

Politicians must take the lead in publicising this message through mass media like Mann Ki Baat, the radio show, according to Bhargava. “It isn’t the government’s job to continuously screen for anaemia but it is the job of those in government to inspire people to ask why their haemoglobin level is less than normal,” he said.

“We need large-scale awareness campaigns to encourage healthy eating, promote iron supplements, and reduce the stigma around anaemia,” emphasised Malhotra.

High-risk groups like adolescent girls and women of reproductive age with menstruation-related problems are most in need of comprehensive nutrition and healthcare services, including information to manage anaemia.

We reached out to joint secretary in the Ministry of Health and Family Welfare, Meera Srivastava, Zoya Ali Rizvi, deputy commissioner (Nutrition); and Manisha Verma, additional director general (Media & Communications) for their comments on the varied causes of anaemia in India, and on the government’s plan to tackle these, on a holistic programme and community involvement to tackle anaemia but have not heard back. We will update the story when we receive a response.

Sufia Khatoon, age 38, a resident of Kolkata, has struggled with anaemia, experiencing menstruation-related issues, weakness, intense muscular pain around bones and weight loss, for which she has seen multiple doctors to try to understand how to manage her condition.

“I was told to take Hemfer XT for six months to get over the anaemia, but no one had any suggestions on overcoming the constipation that occurs nor on anaemia recurring, so what is an ideal maintenance dose to keep your body active and hormones in check,” said Khatoon. “The right information is hard to come by.”

Anaemia is as much a national health emergency as Covid was, said Bhargava. “We need to prioritise creating anaemia awareness just as we prioritised creating awareness of Covid, PCR testing and so on among the masses. Else, malnourished human resources will stall India’s progress towards becoming a developed nation by 2047. Let’s hear politicians say: ‘Ab ki baar, haemoglobin 12 ke paar’.”

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

The Union Ministry of Environment, Forests and Climate Change claimed in the Rajya Sabha on Thursday that there is no definitive data “to establish a direct correlation of deaths including lung cancer exclusively with air pollution”

“Air pollution is one of the many factors affecting respiratory ailments and associated diseases,” Minister of State for Environment Kirti Vardhan Singh told Parliament in response to a question by Bharatiya Janata Party leader Ashok Shankarrao Chavan.

Chavan’s question referred to two recent studies published in the journal The Lancet Respiratory Medicine, one of which suggests a rapid increase in the global incidence of lung cancer and the other estimating that air pollution caused 16 lakh deaths in India in 2021 – with emissions from fossil fuels like coal and liquid natural gas being responsible for 38% of them.

Chavan asked the government to respond to the claims made in the studies and detail the steps it had taken to alleviate air pollution.

“Health is impacted by a number of factors which include food habits, occupational habits, socio-economic status, medical history, immunity, heredity, etc. of the individuals apart from the environment,” Singh responded.

The minister said that the studies in Lancet Respiratory Medicine were “conducted using statistical models and have limitations” and said that, according to government data, only 25 of 291 cities experienced “severe” air quality in 2024.

Air pollution is measured by the air quality index, or AQI. An index value between 0 to 50 indicates “good” air quality, between 51 and 100 “satisfactory” air quality and between 101 to 200 “moderate” air quality.

As the index value increases, air quality deteriorates. A value of 201 and 300 means “poor” air quality while between 301 and 400 indicates “very poor” air. Between 401 and 450 indicates “severe” air quality while values of more than 450 are as “severe plus”.

At these levels, healthy people can experience respiratory illnesses from prolonged exposure to air pollution.

Also read: Fact check: Is there no link between air pollution and health, as a Union minister claims?

Ten million people are diagnosed with dementia worldwide each year – that’s more than ever. According to the Alzheimer’s Society approximately one million people in the UK are currently living with the disease. Studies predict this figure will rise to 1.6 million people by 2050.

Alzheimer’s disease is the most common cause of dementia and leads to a decline in memory and thinking skills. This is a physical illness that causes the brain to stop working properly and gets worse over time. Identifying the onset of Alzheimer’s early can help patients and caregivers find the right support and medical care.

One way to detect Alzheimer’s early is by spotting changes to people’s use of language. This is because new speech problems are one of the first signs of a mental decline that could indicate the onset of this disease.

Here are five early, speech-related signs of Alzheimer’s disease to look out for:

1. Pauses, hesitations and vagueness

One of the most recognisable symptoms of Alzheimer’s disease is trouble remembering specific words, which can often lead to frequent or long pauses and hesitations. When a person with Alzheimer’s is struggling to remember a word, they may talk vaguely such as saying “thing”, or describing and talking around a word. For example, if someone is having trouble remembering the word dog, they may say something like “people have them as pets … they bark … I used to have one when I was a child”.

2. Using words with the wrong meaning

Trouble remembering the right word can be an early feature of Alzheimer’s. People with Alzheimer’s might replace a word they are trying to say with something related to it. For example, instead of saying “dog”, they might use an animal from the same category, saying “cat” for instance. In the early stages of Alzheimer’s disease, however, these changes are more likely to be related to a broader or more general category such as saying “animal” instead of “cat”.

3. Talking about a task rather than doing it

Someone with Alzheimer’s may struggle with completing tasks. Instead of performing a task, they may talk about their feelings toward the task, express doubts, or mention past abilities. They might say, “I’m not sure I can do this” or “I used to be good at this”, rather than discussing the task directly.

4. Less word variety

A more subtle indicator of Alzheimer’s disease is the tendency to use simpler language, relying on common words. People with Alzheimer’s often repeat the same verbs, nouns and adjectives instead of using a broader vocabulary. They can also use “the”, “and” or “but” frequently to connect sentences.

5. Difficulty finding the right words

People with Alzheimer’s can have trouble thinking of words, objects or things that belong in a group. This is sometimes used as a cognitive test for the disease. For example, those with Alzheimer’s may struggle to name things in a specific category, such as different foods, different parts of the body or words that start with the same letter. This gets harder as the disease progresses, making these tasks increasingly challenging.

Age is the biggest risk factor for developing Alzheimer’s – the chance of developing the disease doubles every five years after the age of 65. However, one in 20 people diagnosed with Alzheimer’s disease are under the age of 65. This is referred to as younger – or early-onset Alzheimer’s disease.

While forgetting words now and then is normal, persistent and worsening problems in remembering words, speaking fluently, or using a variety of words could be an early sign of Alzheimer’s disease. Identifying these signs early can be particularly important for people at higher risk of developing Alzheimer’s disease as they age, such as people with Down Syndrome.

Sarah Curtis is Doctoral Candidate, Language use in Down Syndrome and Alzheimer's Disease, School of Arts and Humanities, Nottingham Trent University.

This article was first published on The Conversation.

Earlier this month, Kohinoor Khatik came down with loose motions and bouts of vomiting. The doctor who examined her said she had contracted a water-borne illness.

“People keep falling ill here,” said her husband Jalil Khatik, who spent Rs 800 on medicines for his wife.

Khatik blames the frequent illnesses to the “open drains” and dirt in his neighbourhood in Maharashtra’s Jalgaon district.

More specifically, he blames the contaminated water around the community toilet near his house in Amalner town. “Waste overflows every time someone uses the toilet. The septic tank has not even been cleaned once,” Khatik claimed.

As a result, residents in the neighbourhood often suffer from diarrhoea. The frequent health expenses take a toll on his limited income, said Khatik, who runs a small butcher shop.

While Maharashtra recorded a steady decline in diarrhoea cases between 2011 and 2021, there has been a striking reversal in the last three years.

Between 2022 and 2024, the state saw an 80% rise in water-borne illnesses such as cholera, typhoid and gastroenteritis, which are categorised as acute diarrhoeal diseases.

In 2024, 1.95 lakh cases of acute diarrhoeal disease were reported, up from 1.35 lakh cases in 2023 and 1.08 lakh cases in 2022, data from the Integrated Disease Surveillance Programme and the state epidemiology department shows.

Jalgaon district, where Khatik lives, recorded a 219% rise in acute diarrhoeal diseases over these three years.

What explains this surge? A new analytical study undertaken by UNICEF Mumbai throws up a possible answer.

It suggests that poorly constructed septic tanks for toilets built under the Swachh Bharat Mission might have contributed to the contamination of water sources and the unprecedented rise in diarrhoea cases in Maharashtra.

The study looked at state government data on toilets constructed, the number of districts with septic tanks, and compared it with the rise in cases of diarrhoea over the last few years.

“We are not saying that septic tanks are bad,” said Yusuf Kabir, in-charge of water supply, sanitation and climate in UNICEF Mumbai. “What is problematic is the way they are constructed and faeces is managed.”

The study found that besides faulty construction, the delay in emptying septic tanks in rural Maharashtra is leading to ground water and soil contamination.

The ground reality

In 2014, the Narendra Modi government launched the Swachh Bharat Mission to provide financial assistance to households to build toilets.

It led to a significant adoption of septic tanks in rural areas. Until then, rural households mostly had single or double-pit toilets.

In Amalner taluka, former corporator Amin Patel said most toilets built under the government scheme were constructed with an adjoining septic tank.

Across rural Maharashtra, over 4.3 million toilets have septic tanks. The majority, about 2.5 million, were constructed between 2015 and 2019 during the government push for Swachh Bharat Abhiyaan (rural).

In nine districts, including Jalgaon where Khatik lives, septic tanks account for more than 50% of all types of toilets in rural areas.

For the first few years, these newly built toilets worked well, said sanitation expert Shrikant Navrekar.

The World Health Organisation noted 3 lakh fewer diarrhoea deaths in India in 2019, compared to 2014, which it attributed to “improved sanitation” , a statement cited on the Swachh Bharat Mission dashboard.

So, what went wrong?

“Now the septic pits have filled up, and nobody is cleaning them,” said Navrekar, who works with the Nirmal Gram Nirman Kendra. “The effluents of septic tanks are flowing out in many places I visited,” he added. “It is being directed into open drains without treatment.”

Delay in cleaning

In a rural household, a septic tank usually requires emptying every three to five years. If it is not cleaned, faecal matter can overflow or leak from the septic tank’s walls.

Both situations contaminate soil, ground water, and can pollute the water supply system.

By now, the septic tanks of toilets constructed between 2015 and 2019 would ideally require at least one round of emptying.

But that has largely not happened, a survey by the All India Institute of Local Self Government, or AIILSG, found.

The survey was funded by the Maharashtra government and covered 6,448 septic tank toilets in four districts – Ahilyanagar, Chandrapur, Parbhani and Pune. It was carried out with technical support from UNICEF for the water supply and sanitation department.

The survey found that 78% septic tanks built between 2000 and 2020 have never undergone faecal sludge cleaning.

Sagar Patil, senior technical officer with AIILSG, told Scroll that of the 6,448 toilets, 68% were constructed under the Swachh Bharat Abhiyaan. “In the septic tanks that were never cleaned, we found that faecal sludge was percolating into the soil,” Patil said.

In Dhar village in Jalgaon, Kabir Mujawar built a toilet in his home in 2017. He also created a septic tank with it. Mujawar has not emptied it once in these seven years.

“We don’t know who to approach and how to empty it,” Mujawar said.

In Amalner town, Shaukat Fakir constructed a toilet with a septic tank in 2018. Five people in his house use the toilet daily. “Nobody explained the process of emptying the tank to me when the toilet was built,” he told Scroll.

The municipal body in Amalner is tasked with the cleaning of household septic tanks, but it has not once emptied Fakir’s tank. Fakir has not even contacted the civic body to clean the tank. His neighbour’s septic tank, he claims, has begun to overflow. His 16-year-old daughter has fallen ill multiple times.

In urban areas or towns, the municipal body or Nagar Parishad is entrusted to clean the septic tanks but in villages no such authority is assigned.

Even in cities, sanitation expert Anand Jagtap, formerly head of Mumbai’s slum sanitation department, said most municipal bodies are lax in undertaking the cleaning of tanks. “They authorise private contractors to do it but there is no mechanism to supervise,” he said.

A costlier alternative

It is not the lack of cleaning that has made septic tanks a source of pollution. Many tanks, especially in rural areas, have been built poorly.

Kabir, from UNICEF, said local masons in villages often do not have technical knowledge of constructing a septic tank. “Many still promote septic tanks because there are higher profit margins in its construction,” he said.

The government assistance of Rs 15,000 per household is not enough to construct a good quality toilet, said former corporator Amin Patel. “As a result construction is compromised and technical specifications are skipped,” he said.

Kabir argued that it is a myth that “septic tanks are better than single or twin pit toilets.”

A single pit toilet stores faecal sludge in an underground circular chamber attached to the toilet and has to be cleaned once it is filled to capacity. It requires little or no water. A twin pit allows the use of a second pit when the first pit or chamber is filled. The faecal matter in the first pit takes up to a year to convert into compost.

In contrast, a septic tank has two underground chambers attached to the toilet. One chamber stores the solid matter or faecal sludge while waste water flows into a smaller second chamber from where it is discharged into the soil after undergoing anaerobic decomposition.

Besides being more expensive, septic tanks are more difficult to clean.

The faecal sludge has to be removed once the tank is full by a hired contractor and further processed at a sewage treatment plant. In contrast, a single or twin pit can be cleaned by a resident and it yields manure that can be used in farming.

Moreover, the septic tank chamber requires a water-proof wall lining that stops the faecal sludge from leaking.

But the household survey by AIILSG, cited by the Unicef, found that most of the septic tanks had no waterproof lining at the base or at the sides. “Most tanks were made of bricks, with no waterproof plastering,” said Patil, the senior technical officer of AILLSG.

Villages residents were also not aware about the technical requirements for constructing a septic tank or that it is supposed to be emptied once every three to five years, he added.

Lack of sewage treatment plants

Even if the faecal sludge is emptied, villagers do not know where to dispose of it. The sludge must undergo treatment at a sewage treatment plant before it is discharged.

UNICEF’s Kabir said that out of 4.3 million toilets with septic tanks in rural Maharashtra, only over 55,000 are connected with fecal sludge and sewage treatment plants.

Of 40,300 villages, over 1,000 are connected with a treatment plant. “This means that the rest of the rural households have no option of emptying the septic tank and discharging the feces in a treatment plant. Instead, it ends up in surface water bodies, dumping ground or agricultural fields,” Kabir said.

Across Maharashtra, there are only 155 operational sewage treatment plants, state environment minister Pankaja Munde informed the state assembly on March 17.

In Jalgaon city, social activist Farukh Qadri has helped many slum dwellers build toilets. He said private contractors are hired to clean the tank. “They throw the sludge in open drains,” he said.

Minister Munde informed the assembly that 47% of the state’s total sewage, or 4,344 million liters, is discharged into rivers by villages, nagar palikas and municipal corporations without treatment.

In villages, unsafe disposal could have worrying implications.

In Maharashtra, 81.4% piped drinking water schemes draw their water from underground sources, the Unicef study pointed. Groundwater contamination due to septic tanks or unsafe disposal in water bodies could directly affect drinking water supply. In Jalgaon, which has a high number of septic tanks, at least 93.8% of piped water schemes rely on groundwater for supply.

Except Gadchiroli, Gondia, Hingoli and Nashik, diarrhoea cases have increased across all districts of Maharashtra.

Districts such as Jalgaon, Pune, Raigad, Satara, Sangli, Sindhudurg, Kolhapur and Ratnagiri, which have a large number of septic tanks, have seen a significant spike in diarrhoea cases.

Sanitation expert Navrekar said he often found the location of septic tanks too close to water bodies, leading to risk of contamination.

Dr Raju Sule, from the epidemiology cell of Maharashtra’s health department, said there has been a general rise in communicable diseases after Covid-19. He agreed that poor sanitation directly causes water-borne illnesses. “But we will have to specifically map whether water-borne diseases have any link with how septic tanks are built and maintained,” he said.

Data from state health department accessed by Scroll shows that cholera cases rose from five in 2023 to 1,028 in 2024, gastroenteritis cases rose from 0 to 669 in the same period and jaundice cases from 23 to 827 cases across Maharashtra.

Anand Jagtap, former Mumbai’s sanitation head, said water-borne illnesses could also happen from poor hand washing practices and unclean cooking. “But the threat of such infections increases significantly if faecal matter comes in easy contact,” he said.

“Swachh Bharat mission focussed on construction of toilets, but it neglects disposal of waste,” Jagtap added. “The programme needs to look at safe excreta management to make it a success.”

Getting a headache and feeling sick are common side-effects for many medicines. Indulging in risky sexual behaviour or pathological gambling – not so common.

But a BBC investigation has highlighted that some drug treatments for restless leg syndrome and Parkinson’s disease can lead to such risky behaviour.

Over 150,000 people in the UK live with Parkinson’s – a degenerative condition that affects the brain. The main part of their brain that is damaged is the area that produces dopamine, a chemical messenger that regulates movement. Less dopamine in the brain can lead to symptoms such as tremors, muscle stiffness, slow movements and problems with balance.

Another movement disorder is restless legs syndrome (RLS), which affects between 5% and 10% of people in the UK, US and Europe. Twice as many women as men have RLS among those aged over 35.

People with RLS feel they need to uncontrollably move their legs, and may experience a crawling, creeping or tingling sensation in them. Usually, the symptoms are worse at night when dopamine levels tend to be lower. Although the exact cause of RLS is unknown, it has been linked to genes, underlying health conditions, and an imbalance of dopamine.

One of the main treatments for movement disorders is a group of drugs called dopamine-receptor agonists, which include cabergoline, ropinirole, bromocriptine and pramipexole. Dopamine-receptor agonists increase the levels of dopamine in the brain and help regulate movement.

Dopamine is known as the “happy” hormone because it is part of the brain’s reward system. When people do something fun or pleasurable, dopamine is released in their brain. But using dopamine-receptor agonist drugs can elevate these feelings, leading to impulsive behaviour.

While common side-effects include headaches, feeling sick and sleepiness, these drugs are also linked with the more unusual side-effect of impulse-control disorders. These include risky sexual behaviour (hypersexuality), pathological gambling, compulsive shopping, and binge eating. Hypersexuality encompasses behaviour such as a stronger-than-usual urge to have sexual activity, or being unable to resist performing a sexual act that may be harmful.

Previous reported cases include a 53-year-old woman taking ropinirole and exhibiting impulsive behaviour such as accessing internet pornography, using sex chat rooms, meeting strangers for sexual intercourse, and compulsive shopping. Another case highlighted a 32-year-old man who, after taking ropinirole, started binge eating and gambling compulsively, such that he lost his life savings.

When the drug was first being prescribed in the early 2000s, it was thought that impulse-control disorders were a rare side-effect associated with these drugs. But in 2007, a UK Medicines and Healthcare Products Regulatory Agency public assessment report advised that “healthcare professionals should warn patients that compulsive behaviour with dopamine agonists may be dose-related”.

Between 6% and 17% of people with RLS who take dopamine agonists develop some form of impulse-control disorder, while up to 20% of people living with Parkinson’s may experience impulse control disorders.

But the true figures may be even higher, as many some patients may not associate changes in behaviour with their medication, or may be too embarrassed to report it. Case reports show that in most instances, impulsive behaviour stops when the drug is stopped.

Lawsuits

There have been several individual and class-action lawsuits against pharmaceutical companies including GlaxoSmithKline, which produces ReQuip® (ropinirole), and Pfizer, which makes Cabaser® (cabergoline). Patients taking action against these companies claimed they were unaware of these impulsive behaviour side-effects.

For example, in 2012, a French court ordered GlaxoSmithKline to pay £160,000 in damages to Didier Jambart, after he experienced “devastating-side effects” when taking the firm’s Parkinson’s drug Requip. And in 2014, an Australian federal court approved a settlement against Pfizer for a class-action lawsuit regarding its Parkinson’s drug, Cabaser. 150 patients claimed they did not have warning of potential side-effects – including increased gambling, sex addiction and other high-risk activities – of taking Cabaser.

It is now clearer in the patient information leaflets given with all prescribed medication for movement disorders that impulsive behaviour can occur in some patients.

In 2023, the Medicines and Healthcare Products Regulatory Agency advised there had been increased reports of pathological gambling with a drug called aripiprazole. This antipsychotic drug, used in the treatment of schizophrenia and mania, partly acts as a dopamine-receptor agonist.

Any drug that increases dopamine levels could theoretically be linked to impulse control disorders, and it is important to keep monitoring patients and their behaviour in such cases.

Not everyone will experience side-effects. Before you begin any course of treatment, your doctor or pharmacist should explain the potential side-effects – but it is also important to read the information leaflet with any medicine. And if you experience any impulsive behaviours with these medicines, speak to your doctor or pharmacist immediately.

Dipa Kamdar is Senior Lecturer in Pharmacy Practice, Kingston University.

This article was first published on The Conversation.

Tejal, a young and ambitious girl from a poor informal settlement in Vadodara, was hopeful about building a career – until TB entered her life. From one doctor to another and through innumerable tests, it took her over a year to be diagnosed with drug-resistant TB. By the time she held the final report in her hands, she had seen countless doctors and was close to Rs 50,000 in debt.

“Why was I not diagnosed in one go?” she asked. “Why is it so hard to diagnose TB?”

Diagnosis is the first and most critical step in addressing and treating TB. An accurate diagnosis is not only the basis for treating an individual – it is also essential for investigating others in their family and immediate environment. While science has made remarkable strides in TB diagnosis and treatment, for many, the journey from the first symptom to a confirmed diagnosis remains fraught with challenges.

Access to accurate diagnostic services continues to be a major hurdle in India. Many health centres still rely on outdated methods like sputum smear microscopy, which are less effective – especially for people with HIV or children. While modern molecular diagnostics exist, they are often too expensive or unavailable where they’re needed most.

Even in urban settings, where platforms like GeneXpert are available, long wait times, overcrowded facilities, shortages of cartridges, and administrative red tape often deter people from following through. Meanwhile, private-sector testing is unaffordable for most, rendering diagnosis virtually inaccessible.

Significant barriers

In India, access and affordability are deeply linked, and they remain significant barriers to timely TB diagnosis. While the government offers free TB testing, public healthcare facilities are often overcrowded, with long queues and frequent stockouts of diagnostic tools. This forces people to seek private testing, where costs are prohibitively high. Even when tests are technically free, hidden expenses such as travel, lost wages, or multiple visits make diagnosis inaccessible for many. This financial strain discourages early testing and contributes to delayed diagnoses – further fueling the spread of the disease.

Bridging this gap requires strengthening public diagnostic services and ensuring truly cost-free access for the most vulnerable, with support mechanisms in place to ease the hidden burdens.

Beyond access and affordability lies the challenge of awareness. Many people do not recognise TB symptoms until it’s too late. A persistent cough, weight loss, and night sweats are often mistaken for exhaustion or seasonal illness. Most doctors don’t even order a TB test until the disease has progressed. Stigma is another powerful force – it thrives in silence. TB remains stigmatised, seen as a disease of the poor and the weak. This perception prevents people from seeking the diagnosis they urgently need.

Trust in healthcare systems is crucial. Many communities have had experiences that make them wary of doctors and hospitals – long wait times, dismissive treatment, or impersonal interactions. Diagnosis, then, is not just about medical tests. It is about creating spaces where people feel safe enough to come forward. Community health workers, trained from within these communities, can bridge this gap. When someone sees a familiar face – someone who understands their fears – they are more willing to seek diagnosis.

Programme design

One of the biggest gaps in TB programmes has been treating communities as beneficiaries, not partners. The design and delivery of diagnostic services must start with the people. What do they need? What barriers do they face? What solutions do they see? These questions must guide policy and programme design. When communities are included from the beginning, the solutions that emerge are more sustainable and effective.

So, how do we close the TB diagnostic gap? We must invest in a variety of diagnostic tools that can be deployed at multiple levels of the health system. Multi-disease platforms are worth exploring, as molecular diagnostics can detect multiple infectious diseases simultaneously – saving both time and cost.

We also need intensified case finding alongside diagnostic expansion. Most people do not seek diagnosis or health services until much later – so early case detection within communities is essential. At the same time, we must build public awareness and trust in early diagnosis, while ensuring treatment is accessible and uninterrupted throughout the care cycle.

Education campaigns must be rooted in local realities tuberculosis in the languages people speak, through community leaders, TB survivor voices, and culturally relevant storytelling. This not only increases awareness but also reduces stigma, one of the key deterrents to diagnosis.

TB survivors and their stories hold immense power. A person who has navigated the labyrinth of delayed testing, misdiagnosis, or stigma can help reshape how the health system approaches diagnosis, making it more person-centred and compassionate. If we truly want to close the TB diagnostic gap, we need to invest heavily in new diagnostics, all the way to the last mile—so that anyone, anywhere, can get tested without facing the hurdles of access, cost, or unreliability.

Ending TB requires investment, community participation, intensified case finding, and a rethinking of how we approach TB diagnosis. The best solutions will come from community consultations and from the lived realities of those for whom early diagnosis could mean the difference between life and death.

March 24 is World TB Day.

Chapal Mehra is a public health specialist and the Convenor of Survivors Against TB (SATB), a collective of survivors, advocates and experts working on TB and related comorbidities. Vashita Madan is the communications lead with SATB.