Smoking is bad for health. Period. I think that debate has been over for a long time. The idea of having a smoke once in a while is not so bad as the addictive nature of cigarettes. The same I can say for all forms of Tobacco consumed in India.
Smoking is not a few phenomena in the country. There is evidence of Bhang and Cannabis consumption for almost 2000 years. It is even prescribed in ancient texts as a medicinal practice to manage pain and neurological disorders. Most recently Hookah has been used by both the royalty as well as the common people.
Now tobacco accounts for almost 10 million deaths in the country. Add to it the impact it has on the cardiovascular system and respiratory system would make it a very lethal habit to cultivate. Cigarettes for example contain more than 7000 chemicals out of which more than 250 are harmful and more than 60 are carcinogenic. This brings me to Cancer which continues unabated in the country. Non Communicable diseases also continue to be boosted by the habit of chewing and smoking tobacco.
While India has implemented many laws including Cigarettes and Other Tobacco Products Act (COTPA) with the creation of a National Tobacco Control Programme (NTCP) in 2007. But the real reason why Indian government can never control or remove tobacco is the economics of it.
Today the tobacco industry caters to almost 120 million customers in India. The vast majority of tobacco is grown in Karnataka, Andhra, and Gujrat. Almost 50% of the tobacco consumed in India is the chewable type used in Gutka, Khaini and Zarda. Almost 30 % as bidis and only about 20% as cigarettes.
The below graphs give us a sense of the revenues from tobacco. This graph is particular to the cigarettes and the tax collection from smokers in the last decade.
There are many measures for controlling the consumption of cigarettes, there are Laws like COPTA, the ban on advertising, and the increasing control of public smoking in the country. But then who would kill the golden goose that gives almost 30,000 crores of revenue to the government from sale of tobacco products.
So on this World No Tobacco Day, I started thinking about what can be done to control the habit and reduce the disease burden of cigarettes while balancing the loss of revenue to the government?
Here is what I think can be done
Treat smoking or chewing of tobacco as addiction. These individuals should enter therapy just like how we would expect people with drug addiction to undergo therapy.
Focus on nutrition and health for the rural areas. One of the reasons why tobacco consumption is very popular, is because many people do not receive adequate nutrition. Tobacco consumption quells hunger and thats the sole reason why it should be tackled.
Create smoking zones and tobacco consumption zones all over cities to ensure that the concentration of efforts to manage the communication and addiction can be well coordinated. Ban all consumption outside of these zone.
But the biggest challenge is how can the government substitute the 43,000 crores that it receives from tobacco sales. Now that is a question I leave open for economists. Do let me know how and I would be happy to make that discussion to the right authorities.
We have been hearing this advice from many sources for the management of Covid19 effectively. For understanding more about Covid19, I went on to check for a simple metric i.e. percentage of confirmed Covid19 cases vis-a-vis a total number of tests conducted by various countries affected with Covid19. My data sources are shared at the end of the article. I have used a different data source for the month of May; the reason being comparable dataset was not available with the earlier source.
March Numbers
Country
Date
Total Tests
Total Confirmed Cases
%Confirmed
Spain
Mar 18, 2020
30000
11178
37.26
Italy
Mar 20, 2020
206886
41035
19.83
Iran
Mar 14, 2020
80000
11364
14.21
United States
Mar 19, 2020
103945
9415
9.06
India
Mar 20, 2020
14541
191
1.32
May Numbers
Country
Date
Total Tests
Total Confirmed Cases
%Confirmed
Spain
May 24, 2020
3556567
282370
7.93
Italy
May 24, 2020
3391188
229327
6.76
Iran
May 24, 2020
781286
133521
17.08
United States
May 24, 2020
14357969
1666829
11.60
India
May 24, 2020
2943421
132674
4.50
Just to mention, the source which I used earlier did not have the data for China so I could not include the same. Apart from China, I have shown the data for the countries which have got the maximum number of confirmed cases to date (in March) for illustration purpose and I also included our own country to put this in perspective. Now, if we compare the data for two instances; it shows different positivity rate (i.e. percentage of total confirmed cases / total test)
As we all know that lockdown was imposed in our country for preparing ourselves for fighting this long battle against Covid19 and a very important aspect in this battle is to increase our daily testing capacity as it’s the only way available to us to understand the spread of the virus in any particular community.
We have come close to daily testing capacity of 1 lakh+ tests a day which is almost 100 times increase from the initial days but still we are way behind when we see tests per million vis-à-vis other developed countries. Just to put this in perspective; India is doing 2135 tests / million population whereas Iran which has almost similar number of confirmed cases has been doing 9544 tests/ million population. And if we compare this with developed countries this number is in the range of 20000 – 75000 tests/ million population.
At the same time; we should not forget that various studies world over suggest that actual number of infected individuals are always higher than number of confirmed cases the reason being each country depending upon their testing strategies are able to identify the confirmed cases. Also, we should not forget that number of confirmed cases is a lagging indicator to understand the spread as the symptoms start to emerge only after 2 to 14 days from the day an individual got infected with the virus.
I am writing this article at a time when we are in lockdown 4.0 and have got relaxation in many parts of the country. This would be the real test of our healthcare infrastructure which we have managed to build during the national lockdown.
Key Points:
Positivity rate for India is less vis-à-vis other nations which also got impacted with Covid19 (which is a good sign)
We need to improve our testing capabilities to understand the level of community spread (as it is done in other countries); the reason being based on the historical evidence and current developments globally pandemic strikes in waves so we should not discard the possibility in our case as well.
We should also increase the use of rapid antibody test to ascertain the level of community spread.
We should be more concerned about deaths happening due to Covid19 as it is believed that 80% of the cases would be mild in nature; 15% would need hospital support and 5% would need ventilator support.
In our country, one can also debate the number of deaths happening because many of deaths happening in our country are not certified medically. But that is something we should discuss separately.
Again as always, questions and clarifications are welcome.
About the author
Yatindra Jha is a healthcare consultant with a focus on public health policy.
Just this week, we recorded the second episode for the India Health Talk, with Dr Sumeet Kad. During the recording we ended up discussing the privacy concerns around Aarogya Setu, the contact tracing application launched by the Government of India to track Covid19 cases in the country. Aarognya Setu today has more than 10 Crore downloads and is the largest contact tracing application in the world. How do we balance the privacy concerns with managing a pandemic like Covid19? Alo what can we learn about other applications across the world in this space?
While I understand the concerns, in my opinion, during a pandemic we may need to give up some control over our data and privacy for the greater good of society. Pandemic is a national emergency and Covid19 is probably the worst example of it. But using privacy to derail the efforts to combat Covid19 is not a good idea. In the long run this may be our downfall.
Below is the full recording of the episode. Do let me know your thoughts as well.
Charles Darwin in 19th century, proposed an interesting theory of evolution, and three of his theories have been validated time and again and become the law of natural selection.
The three laws of Darwin are
Prodigality of Production
Struggle for Existence
Survival of the fittest.
When we see the evolutionary aspect specific to human beings, man seems to be nurtured nature to a great extent through social and technological innovations that he brought to live a domesticated or tamed life far from wildness of nature.
Man seems to have tamed first law- prodigality of production by balancing with economic viability of nurturing child, that lead to the direction of minimizing birth rates , innovations in medicine aided this to minimize urge for having more children over centuries, defeating first law.
Man seems to have taken upper hand with his innovations and technological discoveries and minimizing the struggle for existence, in fact comforting himself to great extent to protect from vagaries of nature.
Survival of the fittest: This is the natural law, where how so ever the innovations at onestage or the other Man has to yield to the power of nature, still man is not able to win over to help the weakest of human being to survive over nature’s power.
Nature vs Nurture dialogue
Natural course:
In the course of human history, infectious diseases have been among the most important causes of mortality and morbidity for humans, including plague, smallpox, and tuberculosis (TB), measles, and diarrheal infections. Studies of the origins and distribution of infectious diseases examine the geographic distribution, life stage, and evolution of the infectious agent [malaria parasites, TB mycobacteria, cholera bacteria, influenza, severe acute respiratory syndrome (SARS and HIV); the geographic distribution and life cycle of intermediate hosts (arthropod vectors for many diseases, birds for avian flu, bats for SARS, and deer and ticks for Lyme disease spirochetes); the geographic distribution of diseases they cause in humans and other species; and the key clues that some population subgroups are strikingly more or less susceptible than others. Infectious agents are also important factors in major “noninfectious” inflammatory diseases, like certain cancers, atherosclerosis, and arthritis
Inter species race to super power: Evolution in Action
Within the microbial world, there is remarkable interspecies competition and cooperation. Microbes exchange genetic material, even with different genera. They compete for space and food sources, adapting to selective pressures. Fungi have been particularly adept at producing antimicrobial chemicals that protect them against bacteria. Starting with Fleming’s use of the extract of Penicillium to kill Gram-positive bacteria, patients have benefited from these antibiotics from nature. These chemicals may be isolated and used directly, or they may serve as lead compounds for drug development. However, microbes are not passive agents. They respond promptly to negative natural selection in the form of antibiotics by developing genetically transmitted resistance to the action of individual antibiotics or sets of antibiotics. If these microbes are pathogenic to humans, our response is to create generations of antibiotics; hence, the “race to superpower.”
Nurture Course:
Man continues to evolve not only biologically but also through anthropological social means and tactics to make his life better. In the process nurtured a parallel evolution in his sphere called “Culture” leading to dynamic changes in food habits, living, and protection from nature. Organizing politically to streamline set of cultural patterns across the globe for the benefit and wellbeing of the species Homo sapiens.
Current Pandemic COVID19 and course of nurturing: Nature continued to keep checks and balances to the course of nurture by man. Famines, floods, cyclones etc. of geographical nature have changed the course of the human nurturing process. Human association with wild animal food habits has been tapered for a quite long time as man continued to be civilized, however, the famines lead man to go back to wild and survive the nature’s fury.
Living on animal meat wild is not new to humans, since hunter- gathers time, man is accustomed to live on animals wild or domesticated. In the course of human evolution as he evolves as social being, his biological capacities of disease resistance has taken back seat, thus man lost capacity to gel with powerful biome of the nature. Between 1958- 1961 China faced severe famine, and survival has become a challenge, then Man took the recourse and restarted sourcing food from wild, in large scale supported by policies and politics, wild animal meat has become source of food, that lead to 360 degree turnaround from domestication to wild way of feeding, living on wild meat.
This has taken economic scale and China is spread with Vet markets all around, where anything moving is commercialized and dined. The human incapacity to fight resistant biome (Microbes) in the wild off late lead to many epidemics in a course of 5 decades, we have Ebola, Zeta virus Sars, H1NI, and now Covid19, the origin may be China or Africa or any other place, the change in food habits nurtured by culture and rapid decrease in immunity of human beings due to nurturing, lead to the scale of pandemics we have been witnessing now. The frequency of epidemics increasing, as man power to wild is plummeting due to excessive nurturing and cultural domestication.
If we see Nature vs Nurture scenario in comparison of two contrary theories one Biological theory of Darwin on Natural selection vas Malthus sociological & statistical theory of Demographic transition, the direction of trajectory is evident
Darwin vs Malthus: Darwin’s law- 1. Prodigality of Production 2. Struggle for existence 3. Survival of the fittest. Malthusian demographic theory states stage1- High birth rates – High death rates stage 2- High birth rates – Low death rates 3. Low birth rates- Low death rates. With evolution of medicine and technology. Darwin’s 1st law becomes redundant, so Population is controlled. Human innovations minimized Man’s struggle for existence. Man’s penchant to reverse natural process of survival of the fittest is challenged by innovations and man said its “survival of the weakest”. This principle of evolved man is challenged again by COVID 19 and pandemics in the past. Man Vs Nature– struggle continues.
Inference: The struggle of man to tame the nature continues, man continues to takerecourse to duck nature fury through pandemics, resistant biomes and changing natural process which are unknown and stronger. The only ammunition is to build, develop robust public health structures, functions and processes along with rapid innovation in medicine to tame unknown natural enemies like resistant biomes, whether its viral, bacterial, protozoans, helminths etc. and remain vigilant to natural transitions and transformations. Human might of nurturing through technology, medicine, culture appears to be miniscule in the larger scheme of nature’s innovations.
About the author
Bhaskara Venkatesh is a master’s in Anthropology and works as a senior manager with the technology industry.
On 15th March 2020, India had just crossed 100 cases. Italy was at 24.7k cases, US at 3.6k cases, Brazil had just gone past 200 cases, Germany had crossed 5.8k cases and Russia at just 63 cases. In the last two months even with varying amount of restrictions, COVID19 has still wrecked havoc in these countries and the world.
With India now sitting at the threshold of 100K cases, we look at the effect various lockdowns has had on the Covid19 situation in India. We also take a look at how the countries continue to recover from COVID19.
We dig further in to our classification of Indian States with a new methodology that scores the states basis various parameters.
Note: We have removed Korea and Sweden from the study to Include Brazil and Russia. This gives us a better representation of the top countries with respect to no of cases reported
India and The world
On the 62nd day after crossing 100 cases India has the second highest daily growth rate (7 Day Rolling Average). If we look at the table only Brazil is ahead of India
India has had 3 Lockdowns and we will start Lockdown 4.0 from tomorrow. These lockdowns have ensured that we have done much better in the number of reported cases than other countries in the study. But has the curve really flattened out? When we look at the other countries, we see that most of the countries have nearly managed to flatten the curve albeit at a very high number of reported cases. Currently on a logarithmic scale India, Russia and Brazil are showing strong signs of growing while other countries have a flat curve.USA, Italy and Iran have all flattened their curve. (Spain and France also show a flat curve though not included in the below graph)
For India, the lockdown has ensured that we miss the steep growth path of other countries but we are still poised to hit a huge number, albeit at a slower rate. This means we have just prolonged our battle with the disease.
Although, India may seem to be trending towards a higher number of cases all may not be lost. India is doing well in terms of its recovery rate and outcome percentage.
Recovery Rate
Recovery Rate, i.e. no of people recovered by total outcomes continues to improve for the world and for India. India’s recovery rate has now crossed 90%. For the world it stands at 85%. The other countries in the study have also improved their recovery rate
Outcome Percentage
Recovery rate should be studied along with the outcome curve, i.e. how many cases have had an outcome with respect to active cases. For e.g Russia has a 96% recovery rate but 76% of the cases still await an outcome. Similarly Iran has a 93% recovery rate at a 85% outcome rate which more or less signifies the actual recovery rate for the country.
India has a good recovery rate with a decent outcome%.
Net Active Cases
Definitions
Net Active Cases = Total Cases – (Cases Recovered+Total Deaths)
India’s Net Active cases are at just a little above 53K. Except for Iran and Germany, all the other countries are much ahead of India. With India’s high recovery rate, it clearly shows that India is also recovering at a much higher pace than the other countries.
India has also seen a declining trend in the net active case added each day. In the past seven days we have added around 1700 net active cases per day compared to higher than 1900 net active cases in the week before.
This is a positive sign for the Indian Medical Fraternity as the reducing number of new active cases added does prevent the medical system from getting overwhelmed.
Lockdown Effect on India
When we take a look at the effect lockdown had on our growth rates, it can be observed that lockdown 1 certainly slowed us down, but lockdown 2 and lockdown 3 failed to have the desired effect of flattening the curve.
If we look at the Indian States, Maharashtra has had no effect in the lockdown. Its contribution to the cases in fact has grown during the three lockdowns.
Similarly Delhi is another state that has been contributing heavily during the lockdowns showing minimal effect of the lockdown.
States Classification
We have changed the methodology of classification of states (Good, States to be Watched and Worry States) from May onwards. We were classifying the states on the basis of their 7DAGR only. Now we have also included the following to arrive at a weighted score
Total Cases Reported
Cases/Mil
Test/Mil
Growth Rate
Positive%
Outcome%
Recovery Rate
Basis these parameters we have arrived at a group of
Good States
States to be Watched
Worry States
The Good States
As on 16th May 2020, the following states qualify as the Good States. These states are characterized by low growth rates, low cases/million, higher Outcome% and high recovery rates.
Haryana – Haryana has seen a recent spike in cases most of which are related to Delhi. Haryana, despite being surrounded by Delhi, UP, Punjab and Rajasthan (All these states have high number of cases) has done very well in terms of new cases. The Growth rate is below 4% and with aggressive testing it has maintained a low positive percentage also.
Jammu And Kashmir – This state saw a huge spurt in cases during the first lockdown. Most of the cases here were either linked to the religious event in Delhi or pilgrims returning from Iran. The state was once a worry state and now has come in the good states
Karnataka – There has been spurts seen in state but overall the state has maintained its low positive percentage and cases/million. The recovery rate is a bit lower compared to its peers but with outcome% also below 50%, the recovery rate may go up.
Kerala – This state was on its way to 100% recovery but with the return of Migrant Populations and Expats, there has been a minor spurt of cases. It will be interesting to see whether Kerala is able to control its cases as it had done previously.
Punjab – Punjab had more or less weathered the COVID19 storm in the first two lockdowns, but a sudden upsurge of cases from the last week of April saw Punjab come in the “Emerging Bad” category in my last article. But it has been an aberration due to infected pilgrims returning from Nanded and Punjab has controlled the situation well, to move in to the good states.
Jharkand – Less number of tests, but lesser cases and growth rate puts this state among the good states.
States to be watched
These states are those states that have either started showing a positive trend i.e. moving from a Worry State to a Good State or a negative trend i.e. moving from a Good State to a Worry State.
Andhra Pradesh – This state is on the way down and will probably move towards the good states in a day or two if the trend continues.
Madhya Pradesh – Another state on the way down. This state was showing alarming trends during the month of April and was a worry state. It has still not completely slowed down but is definitely on its way down
Odisha – This was an encouraging state but recent trends show a very huge growth rate and will probably move to a Worry State soon.
Rajashtan – Another state that was showing huge growth numbers in April has slowed down very well. It had moved down to a good state but another spurt of cases moved it back to States to be watched
Telangana – We are not sure of the numbers for this state as they have stopped reporting number of tests done. Hence we are keeping this state as a state to watch
Uttar Pradesh – Like Rajashtan, UP was also supposed to burst with cases. But UP has maintained its trend, although a lot more testing needs to still happen in UP.
The Worry States
The States that add most to the growth of the Indian cases have been categorized as the worry states. These states have high number of cases, a higher penetration of cases in the population, a high positive% and low outcome%.
Bihar – We had categorized this as an “Emerging Bad” State in our last article. It has now turned as a worry state. It has poor testing, a high growth rate and a low outcome%. This state may become a major problem especially with the migrant population traveling back.
Delhi – Delhi has tested a lot but it still has a high positive% and a high penetration rate. Delhi had slowed very well but with opening up of the wholesale market, cases have started zooming up again.
Gujarat – Gujarat was showing signs of slow down but still has a long way to go before it comes into a good state. high number of cases, poor recovery rate along with a sub 5% growth rate is making this state a huge worry for India.
Maharashtra – The state that refuses to slow down. Even after 54 days of crossing 100 cases the states growth rate of cases is still above 6%. This state has not slowed down once and daily number of cases have just shown an increasing trend. This is the most worrisome state in India, more so because of poor recovery rate also.
Tamil Nadu – A Covid19 explosion in one of its market turned this good state in to a huge worry state for India. This state is seeing a resurgence in cases after it was able to contain very well the effect of the religious event in Delhi, surge. The good part is that recovery rate is very high but still outcome% is very low.
West Bengal – Poor testing, High Growth Rate, very bad recovery rate along with questionable data sharing makes this state a time bomb. This state may explode or already has but we do not have the data for it.
In all, these worry states have to slow down. If they slow down and go below 4% India will see a reduction in cases. Also we should hope that in the coming days the list of Good States increases and worry states keeps going down.
CPM19 – The Road Ahead
On 2nd May, we predicted 75K cases for India by 17th May. There was another projection that the model made which showed more than 100K cases which was rejected as we were quite hopeful that growth trend would stabilize and we will not cross 3000 cases added per day.
This has not really happened and India has infact overshot our number by at least 18k cases. Nevertheless we will still try to predict the number for 31st May using this model.
We have used the CPM model to predict the growth trend for the states basis their classification as The Good State, States to be Watched and The Worry States. The prediction shows that by end of May we may very well be close to 150K cases. That’s another 60K cases in the next 15 days. The good news is that we may start showing a slow down in new cases reported after reaching a peak of close to 4900 cases per day. This may mean that we might start flattening the curve by end of this month.
If our prediction holds true we may see a step towards the end of this pandemic in India although as we said before the road to recovery is a very long one. Also as India continues to ease the lockdown the road ahead may still be very bumpy.
About the Author
Sanjeev Prakash is an Analytics and Marketing professional with more than 12 years of experience in Analytics, Data Management, Sales, Brand Management, Corporate Communications, Market Research and Customer Relationship Management. Sanjeev has an MBA from IMT Ghaziabad and a degree in economics.
