No Ifs About The Butts, No Matter How Much You Puff

One of the most powerful and cost-effective mediums to educate consumers about the hazards of smoking is the pictorial health warning on the package of tobacco products itself. It has universal reach, and the cost of package warnings is paid for by the tobacco companies, not the government. It is empirically established from the experiences of other countries that strong pictorial health warnings on tobacco products are powerful communication tools that can take the message of the health hazards of tobacco to the masses, including the illiterate. Health warnings on tobacco product packages are critical to any effective tobacco control strategy, as they deter non starters and motivate consumers to quit. Read more

Article 11 of the WHO Framework Convention on Tobacco Control (WHO FCTC – the global tobacco treaty to which India is a signatory) obligates its parties to ensure that tobacco products packages carry appropriate health warnings describing their harmful effects. According to Dr Samlee Plianbangchang, WHO Regional Director for Southeast Asia, "Tobacco is the only legally available product that kills people, and 1.2 million people die from tobacco use in our region annually. An effective tobacco control strategy is, therefore, not just a programmatic necessity but also a moral imperative."

The Cigarette and Other Tobacco Products Act, 2003, also mandates pictorial warnings on all tobacco products in India, with annual rotation of pictures/ photographs used in these graphic warnings.

Alas! The death peddling lobby of tobacco/ cigarette manufacturers seems to have a stronger hold on the Indian government, than the right to health of its millions. After many initial delays, India finally put out pictorial warnings on tobacco products from May 31, 2009. These proved to be very mild and hence ineffective. The hazy images of lungs and a scorpion's picture on gutkha and cigarette packets were ludicrously funny, and not scary, to say the least. As per its commitment to the FCTC, and its own obligations to implement domestic laws, the government agreed to replace them, with scarier pictures of cancer stricken mouths, by 1st June 2010. To the dismay of the anti-tobacco activists and all health conscious people, this date was then shifted to 1st December 2010, and now to December 2011.

Once again our democratic government has buckled under the pressure tactics of the tobacco industry. According to a news published recently (click on the link to read the news), a RTI query, filed by Voluntary Health Association of India (VHAI), has revealed that the new pictorial warnings on tobacco products were deferred due to pressure from the tobacco industry, including ITC and the Pan Shop Owners Association, which comprises retailers of cigarettes, bidis, chewing tobacco and betel leaf. The government has unashamedly 'admitted' that the new pictorial warnings on tobacco packs have been deferred because of the 'pressure' exerted by the industry and other interested parties. The RTI revealed that the tobacco lobby had also approached the Union Health and Family Welfare Minister of Government of India, Shri Ghulam Nabi Azad to delay the implementation. Union Law Minister Shri Veerappa Moily, received a letter from Paan Shops Owners Association of India dated, March 25, 2010, which said, "Due to graphic tobacco warnings, our retailers have seen a decline in the business of our members. About 60 to 70 per cent of the business of these shopkeepers comes from tobacco products, but the impact has been felt beyond just these products as customers are not visiting these outlets. We sincerely hope you will give due consideration to the voice of aam aadmi, that is to defer the introduction of the new health warnings."

The Health Ministry also admits to have received anti-pictorial warning representations from tobacco giants like the ITC and Tobacco Institute of India. One of them, from ITC and dated March 5, 2010 said: 'Rotation of designs every year is not worthwhile as any changes in the graphic elements of the tobacco packs will require substantial redesign of the packs which in turn would necessitate procuring of new printing cylinders and ancillary equipments for a large number of packs.'

Tobacco majors argued that they have large unsold stocks and must be allowed to expend these before the warnings are changed. They threatened to maintain the current halt on fresh production - a move that can impact the labour intensive industry including cultivators.

So the Cabinet not only took a decision on Dec 7 to further defer the pictorial warnings by a year, but the Ministry of Health and Family Welfare, through a Gazette notification dated 20.12.2020, amended the Cigarettes and Other Tobacco Products (Packaging and Labelling ) Rules 2008. For Rule 5 the following has been substituted --“Rotation of Specified Health Warnings—The Specified Heath Warning on tobacco packs shall be rotated every two years from the date of notification of the rules or earlier, as the case may be, as specified by the Central Government.”

It would be worth mentioning here that while Indian tobacco products warn consumers with hazy images of lungs and scorpion, other nations clearly depict the devastating impact of tobacco on a smoker’s health through graphic pictorial warnings. A picture from Uruguay shows a baby surrounded by cigarette-smoke rings, warnings from Thailand (it has implemented 9 different pictorial warnings on 50% surface area of cigarette packs) show pictures of a mutilated and cancer-affected mouth.
While Bangladesh has six different types of text warnings covering 30 percent surface area of all smoking tobacco products, Maldives has mandated five different types of textual warnings covering 30 percent surface of the cigarette package.

Even our next door neighbour Pakistan has introduced gory pictorial warnings on all tobacco packs from August 30 in a bid to deter consumers from smoking or chewing tobacco. It has made it mandatory for 40% of all tobacco packs — on both sides — to carry the image of a rotting mouth suffering from cancer along with a health warning.

On the contrary, India, where 2,500 people die daily due to use of tobacco, has put off the introduction of strong and gory pictorial warnings till December 2011. But there is a ray of hope from the judiciary, if not from the executive. Even as the government backed down under pressure, the Supreme Court recently banned plastic packaging for tobacco products. In a reference to the fight against cancer, the Apex Court said that unlike the government, it could not remain a mute spectator to the public health menace and asked the government to implement the order by March 2011, even if it "brings the entire tobacco industry to a standstill."

We can only hope (and fight) for better sense to prevail upon the rulers of our country, so that they do not barter the lives of millions for financial gains of a miniscule, yet powerful segment of society.


Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Diabetes Media Initiative (CNS-DMI).She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP.  Email: shobha@citizen-news.org, website: www.citizen-news.org)  




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Support the doctor of the adivasis

Christmas wasn't merry...
2011 will be unhappy
until Dr. Binayak Sen is free!
Some of us were fortunate to spend a few hours with this soft spoken civil liberties activist sometime back. His humility was touching and inspiring. It is extremely painful that an insecure state has imprisoned him again on irrational grounds. We hope that this humane spirit will return to remote parts of rural Chattisgarh to continue working for the benefit of some of the most excluded Indians through his organization, Rupantar, soon. Read more




Please express your solidarity with the campaign to release him in one or more of the ways below:

a. Signing the petition to the President of India: "Indian Justice Has Failed Dr Binayak Sen"

b. Following the posts on:

Free Binayak Sen Campaign
Facebook - FREE DR BINAYAK SEN CAMPAIGN
Twitter - @binayaksen

c. Joining or organizing protests (online and/or offline) against the ludicrous judgement and unnecessary life sentence

d. Blogging (text or audio/visual), talking, texting, tweeting, writing (poems, opinions, comments), spreading awareness in support of the critical action to secure Dr. Sen's freedom

e. Any other manner - please share your relevant word(s) and deed(s) via Facebook and Twitter

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Palestinian leaders receive the Caravan in Damascus

Before leaving Diyarbakir on 19th December, 2010, for the last stop-over in Turkey, Gaziantep, the Asia to Gaza Solidarity Caravan visited the grave of Ali Haydar Bengi, the local man who got killed in the Israeli attack on flotilla from Turkey on 31 May, 2010, in international waters of Mediterrean Sea. His is one among the many graves with flowers planted on top in the graveyard but Bengi is now considered a proud martyr in Turkey as well as among Kurds. The members of caravan stood in silence for some moments at his grave. Read more


Like all meetings in Turkey the one in Gaziantep was also organized in a sports complex. A student of Jamia Millia Islamia of New Delhi, Aslam Khan, said in his speech that supporting the cause of Palestine is important because success here will mean a setback to the march of imperialism globally.

The members of caravan were promised that they would be given Syrian visa on arrival. The process was smooth. The visa fees for 81 members from 9 countries was waived. The members waited in their buses as exit stamp was placed on their passports on Turkey side and visa was issued on the Syrian side at Eajaz. They changed into waiting buses from hosts in Syria. The Governor of Alappo province, Ali Ahmed Mansoora, was there to receive the caravan at the border. Five roadside receptions, including at Edlip and Homs, were given on the way to Damascus by people who came out with Syrian and Palestinian flags and hand written placards. Some of there were spontaneous.

The Red Crescent of Iran has decided to donate USD 7,00,000 worth of medicines to be sent with this caravan. With the money donated for ambulances and medical-surgical equipments by the Iranian parliament the total contribution from Iran alone as aid to Gaza has reached USD 1 million now.
Charitable Association for Palestinian Relief hosted a meeting for the caravan on 21st December in Damascus. Ahmad Abdul Karim, on behalf of this organization as well as a member of Baath Party in Syria, assured his full support to the Asian caravan. Palestinian leaders Ramzam Abdullah of Islamic Jihad Movement in Palestine and Ahmad Jibril Abu Jehad, of leftist orientation, also spoke on the occasion.

Another high point of the caravan was meeting on 22nd December in Damascus which was addressed by Khalid Meshal, Head of the Political Affairs of Hamas, the group in power in Gaza. Khalid Meshal paid his tributes to Mahatma Gandhi for his inspiring struggle against the colonialism. He thanked the caravan, especially the two families - an Indian and a Pakistani - who were accompanying it as well as the families of caravan members who couldn't come for their support. He said he was happy to receive the caravan in Damascus and hoped that one day he will receive them in liberated Gaza and finally in liberated Palestine at Jerusalem.

Khalid Meshal made is clear that Palestinians are fighting for a real state without any occupation and with Jerusalem as its capital. All mosques and churches, including the Al Aqsa mosque, will be free in this Palestine and Jews, Muslims and Christians will live together as equal citizens. At the end of the meeting the Indian organizer Feroze Mithiborwala presented him a copy of Mahatma Gandhi's autobiography.

In an interview later in response to a question on Indian government's changing stand vis-a-vis Israel he said India, as an ancient civilisation, has had a traditional relationship with Arab world and it too had to fight against the imperialist power, hence it would do well to reflect on its position. In reponse to another question as to why, unlike Yasser Arafat, he was not reaching out to the world and especially to India, Khalid Meshal said he would be happy to come to India if invited. It is noteworhty that Brazil had recognized Palestine as a state just the previous day.

In the evening the caravan members were invited by Khaled Abed Al-Majeed, General Secretary of the Palestinian Popular Struggle Front, to visit the refugees in Yarmouk camp where close to one lakh people live. Damascus is home to about 5 to 6 lakhs Palestinian refugees.

On 23rd December, some members of the caravan were invited to Beirut where they met the former Prime Minister of Lebanon and now the President of International Committee to Break the Siege of Gaza, Dr. Salim Hoss. In an informal chat, at his apartment on the 6th floor of a building in the heart of city, he said one should be prepared for the worst from Israel which commits barbaric acts in the name of self defence whereas it is actually the Arab nations which have to worry about their self defence against Israel. He admitted that Lebanon has been the victim of Israeli aggression often but lately because of facing stiff resistance Israel has become careful. He said that Palestinian refugees in Lebanon, numbering about 50,000 were quite well behaved even though the Lebanese government was not able to take complete care of them.

Former member of parliament, Osman Saad, welcomed the caravan in Saida, capital of South Lebanon, the next day after which it was taken to the hilltop war museum at Mleeta, centre of valliant resistance against the Israeli occupation of Lebanon. Beginning with the first attack on Lebanon in 1975, Beirut was invaded in 1982, the second Arab capital to fall to Israel after Jerusalem in 1948. It tool 15 years of struggle before Israel partially withdrew from Saida and villages surrounding Mleeta in 2000 before its conclusive defeat in 2006. While the South Lebanon Army was fighting along with the Israeli forces it was Hizbullah which emerged as the saviour of Lebanese society.

The caravan which has now grown to 164 members - 60 from India, 32 from Jordan, 20 from Iran, 13 from Indonesia, 10 from Lebanon, 9 from Pakistan, 6 from Turkey, 4 from Bahrain, 3 from Malaysia, 2 each from Japan and Bangladesh and 1 each from Syria, Azerbaijan and Tajikistan - is now awaiting the clearance from Egyptian authorities to leave the shores of Syria to sail to Egypt before its final entry into Gaza.

(Dr Sandeep Pandey is a Ramon Magsaysay Awardee (2002) for emergent leadership, who is a part of the Asia to Gaza peace delegation. He is a member of National Presidium, People's Politics Front (PPF), heads the National Alliance of People's Movements (NAPM) and did his PhD from University of California, Berkeley, USA. He taught at Indian Institute of Technology (IIT) Kanpur before devoting his life to strengthening people's movements in early 1990s. He can be contacted at: ashaashram@yahoo.com. Website: www.citizen-news.org ) 

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The Nicholas Factor

It is Christmas time once again. It is the season of rejoicing; of giving and receiving; of raising our hands in Thanksgiving. My earliest recollections of Christmas festivities are associated with the socks which, we as children (even in Hindu homes), would hang up somewhere (not by the fireside, as there would be none) on Christmas Eve for Father Christmas to fill up. We were always rewarded with sweets or a story book, or something similar, which was sometimes found tucked under our pillows next morning, if it did not fit inside our small socks. But then, we had small desires and these simple gifts made us immensely happy. Read more


It was only much later that I learnt that this custom of hanging up a Christmas stocking originated from the story of Bishop Nicholas on whom the Father Christmas legend is based. The story tells how a local nobleman had lost his fortune and was sadly unable to provide dowries for his three unmarried daughters. St. Nicholas decided to help in secret. He waited until it was night and crept through the chimney. He had three purses of gold coins with him. As he was looking for a place to keep this gift, he noticed the stockings of the three girls that were hung over the mantelpiece for drying, and so put one purse in each stocking. This led to the custom of children hanging stockings or putting out shoes, eagerly awaiting gifts from Santa Claus or Father Christmas.

Another remembrance is of the scene of Nativity, which is still enacted in many missionary schools/churches. That also had a gift component of the three wise men bringing presents of myrrh and incense for the infant Jesus. But it seems that now the humble manger, with the infant Jesus swathed in rags, is almost forgotten. And so are the humble stockings.

We, the modern day parents, sow the seeds of ambition in our children right from infancy. We teach them to think big and act smart in order to become rich and powerful. So their wish list does not fit in a stocking, and really stretches the purse strings of Santa. The more expensive and exclusive the gift, the higher is their happiness quotient. Need has now been overshadowed with greed.  It is not only the children, but even we adults have such skewed up notions about giving and receiving. The other day I was invited to the 1st birthday party of an acquaintance’s grandchild. All of us invitees were trying to outdo the other, carrying loads of gifts for a kid who was literally born with a silver (nay gold) spoon. To my surprise I found that most of the guests, at this supposedly kids’ party, were either business friends or high government officials. Even in such a high profile setting, differential treatment to the guests (depending upon their profit value) was more than obvious. One trio of father, mother and daughter was being particularly pampered by the host. The catering waiters were instructed to take special care of this special guest, who turned out to be some bigwig from the income tax department. Liquor was flowing openly for the men folk (and rather discreetly for the women). The soulful renditions of the hired ghazal singer were drowned in the din of noises. This did not look to me like a children’s party from any angle. It was pathetically amusing that neither the ambience, nor the few kids present there, gave it the feel of someone’s 1st birthday party. But then, perhaps I was being just too stupid and naive. Someone wisely whispered in my ears that such parties are held to enhance the business prospects of the host family—birthdays are just an acceptable excuse. The giving of gifts and partaking of the hosts’ generosity are actually part of the profit generating business strategies, and also an opportunity to show off one’s opulence and social status.

It is a sad commentary on our morality that the noble gesture of giving and receiving is now dictated by social and financial obligations to further our monetary interests. The size and cost of our gift is not dependent upon the needs of the receiver. It depends upon what we hope to gain (other than gratitude) from giving it. The worth of our presents is almost invariably inversely proportional to the economic status of the recipient. Why else do we give cheaper gifts to those who are below our own social/economic status?

If only, our giving could be gentle as silence (as goes one of the hymns I learnt in childhood), and if it keeps in mind the needs of the receiver (and not the greed of the giver), then we will be really blessed. Only if we could inculcate the magnanimous modesty of Saint Nicholas while filling up empty stockings!

The birth of Christ is an event which teaches humanity the lessons of austerity and humility. It teaches us to respect the poorest of the poor and to accept the graces, as well as tribulations of life with equanimity. Let us not forget the real meaning of Christmas, which is of forgiveness and humility. Let us give with humility and receive with grace whatever is offered to us—not only by way of Christmas gifts, but in every sphere of our lives. Let us also not shower money on our children, but teach them to be humble and respectful, and imbibe in them a love for humanity. If we share our bounties with the indigent, our wealth is bound to multiply.

At this time of the Yuletide season let our faith be reaffirmed in the goodness of humankind, so that God is in Her place in heaven and all is right with the world.

May peace and goodwill always prevail on the earth.


Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Diabetes Media Initiative (CNS-DMI).She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP.  Email: shobha@citizen-news.org, website: www.citizen-news.org) 

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SAARC Countries To Collaborate In The Field Of Health Care

The 70th Annual conference of the Association of Surgeons of India ASICON 2010, held recently in New Delhi was one of the largest medical conferences of surgeons in the world. Over 7000 national and international delegates from India, England, Scotland, USA, Egypt and SAARC nations attended the conference. Read more

Panel discussions on surgical education, live telecasts of basic and advanced surgical procedures, and sessions on innovations in surgery were some interesting highlights of ASICON 2010. Critical evaluations, discussions and debates on surgery and surgical practices took place in a very vibrant atmosphere, leading to constructive and positive outcomes from this interactive and informative meet.

The panel discussion on “Reforms in Surgical Education, Training and Practice for 21st Century India” was indeed an intense affair, with valuable inputs and suggestions from stalwarts in the medical fraternity. According to Dr.NK Pandey, President, Association of Surgeons of India, “ Some very interesting topics in medicine and surgery such as robotic cancer surgery, reconstructive surgery, management of brain tumours, laparoscopic procedures, pancreas transplantation, SILS (Single Incision laparoscopic surgery), NOTES (Natural Orifice Transluminal  Endoscopic Surgery),and many more such innovations in surgery were discussed through lectures, orations, and presentation of case studies, by various stalwarts in the world of medicine from India and across the globe.”

 Another very interesting session was” Innovations in Surgery” (or practice of what is colloquially called Jugaad in Hindi), where different innovations for modifying surgical instruments were discussed. Surgeons have modified surgical instruments to lower the cost of surgeries. Dr.R.K Karwasra, Head of Surgery & Surgical Oncology, PGIMS, Rohtak, explained close suction technique for NGA (Naso Gastric Aspiration). In this technique the harmful secretions from the stomach are removed by aspirating it through the nasal orifice, with the help of a nasogastric tube. This method does not require precious nursing time, and is more hassle –free and convenient to use.

The SAARC symposium, aptly titled Back to Basics, saw an active participation of the medical fraternity from Sri Lanka, Bangladesh, Nepal & Bhutan. It helped in ushering a deeper understanding of basic issues in surgical education, surgical training and surgical services daunting SAARC countries. It also opened the doors for more collaborative opportunities in healthcare between India and other SAARC nations. Dr.Narender Pinto of Sri Lanka hoped that such exchanges between India and other SAARC countries in the field of medical education and sharing of expertise in surgical practices among the surgeon fraternity would continue in the years to come.

 The climate of debate/discussion highlighting emerging trends in surgery, and live telecasts of basic/ advanced surgical techniques at the conference proved to be a tremendous experience even for seasoned surgeons.  The exchange of ideas at the conference is bound to enhance surgical acumen among doctors, and will go a long way in advancing the cause of surgery.

Shobha Shukla - CNS 


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Kurdish Turkey gives warm welcome to Gaza Caravan

The first Asia to Gaza solidarity caravan reached Tibriz from Tehran (Iran) on 13th December, 2010. On the way the people of Zanjan welcomed the caravan and offered lunch. The mayor of Tibriz, Alireza Novin, hosted the caravan. The member of the caravan from Republic of Azerbaijan, Hakim Alijade, was the most popular with the crowd as he spoke in Turkish which is a popular language in this region of Iran. Infact, Tibriz falls in the East Azerbaijan province of Iran. Upon reaching Tibriz and two days before crossing over into Turkey the caravan was greeted by the morale boosting news that seven members of parliament of Iran have decided to join the caravan to Gaza. Read more


The second largest contingent, after India, of 13 members in this caravan is from Indonesia. Irman Abdurehman from this group informed the audience at the meeting in Tibriz that a voluntary organization Mer-C is planning to build a 100 bed trauma centre and rehabilitation hospital in Gaza. Immediately after the 22 days brutal attack started on Gaza two years ago, in which 1366 people, half of whom were women, children and elderly, died, a team from Indonesia set off for Gaza on 1st January, 2009, and signed a MoU with the Palestinian health minister to set up this hospital here. The Palestinian government provided a 1.5 hectares waqf land for this purpose and the Indonesian government backed this effort by readily agreeing to contribute Rupiahs 10 billion, approximately equivalent to US $ 1 million, towards construction of this hospital. Mer-C has raised another Rp 13 billion. The Indonesians have decided to have a long term association with the people of Gaza and share their suffering by continuing to serve them.

Bazargaan was the last stop-over inside Iran before the caravan moved into Turkey. Insani Yardim Vakfi or IHH was the host organization here which is a big Islamic charity operating in 125 countries. More importantly, it was IHH which had organized the aid flotilla to Gaza which was attacked by Israel on 31 May, 2010, in which 9 people, Ibrahim Bilgen, Ali Haydar Bengi, Cengiz Songur, Cengiz Akyuz, Cevdet Kiliclar - a journalist shot from close range into forehead, Getin Topcuoglu - who beathed his last in his wife's arms on the ship, Fahri Yildiz, Furkan Dogan - 19 years old, and Necdet Yildirim died and one, Ugur Suleyman Sonmez, is still in coma. This single incident has changed the equation between Israel and Turkey. There is attempt by Israel and US to label IHH as a terrorist organization and IHH is taking legal action against Israel in order to identify the war criminals and prosecute them.

The caravan was taken to its first stop Van in the form of a convey of vehicles. Several roadside receptions were organized on the way. In the public meeting held in a sports complex a speaker from the each of the countries represented in caravan Bahrain, Indonesia, Malaysia, Azerbaijan, Iran, Pakistan, Japan and India spoke. Advocate Gulden Sonmez and her colleague Nalan Dal who coordinated the meeting on behalf of IHH were both present on the ship Mavi Marmara, among the approximately 560 passengers, which bore the brunt of the Israeli attack on flotilla. Among other members present on the ship and who attended the meeting on 17th December, 2010, at Van were Abdulhalim Almali, Mehmet Gaken, Selahattin Ozer, Muhlis, Abdullah Camioglu, all from Turkey, and journalist Quassima Ibn Salah, of Moroccon origin. Among these Abdulhalim Almali was also wounded and is still recovering.

Later Gulden Sonmez shared with the caravan the preparations for the forthcoming event on 26th December, 2010, when the ship Mavi Marmara, having been released by Israel and repaired, except for the marks of attack, will return to Istanbul. Fifty thousand people from all over the world are likely to assemble to receive it. On 31 May, 2011, IHH is planning to organize a flotilla of fifty ships to the spot where the attack took place.

Israeli Prime Minister Banjamin Netanyahu has refused to apologize for the attack or pay compensation to the families of the deceased and injured. After UNHRC came up with an indicting report on the attack, another four member committee has been set up by the UN Secretary General with the objective of mediating between Israel and Turkey.

The next stop-over for the caravan was Diyarbakir, home of one of the martyrs of Mavi Marmara, Ali Haydar Bengi, after again being given several roadside receptions in cities falling on the way. The convoy had grown to about hundred vehicles on its second day in Turkey. In Diyarbakir police refused permission to hold an indoor meeting. People carrying placards with slogans in support of Gaza and Palestine and against Israel as well as photo of Ali Haydar Bengi, had lined the street. As a result a stree crossing meeting on an open truck was organized which was addressed among others by Fehmi Bulent Yildirim, the President of IHH, and the Indian organizer Feroze Mithiborwala. Mehmet Ali Zebec, from whoes body 9 bullets were taken out after the attack on Mavi Marmara, was present in the meeting in Diyarbakir. Hundreds of pigeons, symbols of peace, were released as a mark of commitment of the movement to liberate Gaza and Palestine.The route of the caravan passed through the Kurdish areas of Turkey, where there is a simmering movement for autonomy. IHH wanted to convey to the people that as the caravan composed of people of different religious and ethnic backgrounds, Turks and Kurds needed to live together in harmony. In fact, after the attack on Mavi Marmara people with different shades of opinions in Turkey have come together on the question of ending the siege of Gaza. As Yildirim mentioned in a press conference later, anybobdy who had a soft corner for Israel was disillusioned now.

Common people who came to public events of the caravan in Turkey wanted their pictures to be taken with the caravan members to express their emotions of solidarity. They warmly shook hands and hugged the visitors. The caravan has been able to provide a channel to the people's sentiments. Like in Iran, men, women and children came out on streets to support the caravan and send their greetings to Gaza.

 (Dr Sandeep Pandey is a Ramon Magsaysay Awardee (2002) for emergent leadership, who is a part of the Asia to Gaza peace delegation. He is a member of National Presidium, People's Politics Front (PPF), heads the National Alliance of People's Movements (NAPM) and did his PhD from University of California, Berkeley, USA. He taught at Indian Institute of Technology (IIT) Kanpur before devoting his life to strengthening people's movements in early 1990s. He can be contacted at: ashaashram@yahoo.com. Website: www.citizen-news.org ) 


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Hopes rest on a new rapid diagnostic test for tuberculosis (TB)

One of the best chances of stemming the tide of tuberculosis (TB) epidemic in low- and middle- income countries is to thwart the transmission cycle – by diagnosing TB early, and treating it successfully without delay. The microscope has been around since 1882 as the key standard TB diagnostic tool, and with low sensitivity (50-60%) and other challenges in detecting TB in varying conditions and co-morbidities, it is clear that it is high time we use better, more effective and efficient tools to accurately detect TB, and neither mis-diagnose nor miss TB diagnosis in myriad settings. Read more

This was a clear thought emerging out of the 'International Symposium on Tuberculosis Diagnostics: Innovating to make an impact' (ITBS 2010), organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi, India (16-17 December 2010) with support from the Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND).

Although high-income countries have moved on to using better and modern diagnostic tools, many low- and middle- income countries still rely principally on sputum smear microscopy.

One of the diagnostic tools that the World Health Organization (WHO) recently endorsed is a fully automated Nucleic Acid Amplification Test (NAAT) - Xpert ® MTB/RIF - a new and novel rapid test for TB, especially relevant in high TB burden countries. According to the WHO, the test could revolutionize TB care and control by providing an accurate diagnosis for many patients in about 100 minutes, compared to current tests that can take up to three months to have results. This WHO endorsement of the NAAT has come after 18 months of rigorous assessment of its field effectiveness in the early diagnosis of TB, as well as multidrug-resistant TB (MDR-TB) and TB complicated by HIV infection, which are more difficult to diagnose.

THREE-FOLD INCREASE IN DIAGNOSING DRUG-RESISTANT TB POSSIBLE
According to the WHO, evidence to date indicates that implementation of this test could result in a three-fold increase in the diagnosis of patients with drug-resistant TB and a doubling in the number of HIV-associated TB cases diagnosed in areas with high rates of TB and HIV.

But this new 'while you wait' test incorporates modern DNA technology that can be used outside of conventional laboratories. It also benefits from being fully automated and therefore easy and safe to use.

WHO is now calling for the fully automated NAAT to be rolled out under clearly defined conditions and as part of national plans for TB and MDR-TB care and control. Policy and operational guidance are also being issued based on findings from a series of expert reviews and a global consultation held last week in Geneva. The consultation was attended by more than a hundred representatives from national programmes, development aid agencies and international partners.  

75% REDUCTION IN PRICE FOR COUNTRIES MOST AFFECTED BY TB
Affordability has been a key concern in the assessment process. Co-developer FIND (the Foundation for Innovative and New Diagnostics) announced recently it has negotiated with the manufacturer, Cepheid, a 75% reduction in the price for countries most affected by TB, compared to the current market price. Preferential pricing will be granted to 116 low- and middle- income countries where TB is endemic, with additional reduction in price once there is significant volume of demand.

"There has been a strong commitment to remove any obstacles, including financial barriers, that could prevent the successful roll-out of this new technology," said Dr Giorgio Roscigno, FIND's Chief Executive Officer in a WHO communique. "For the first time in TB control, we are enabling access to state-of-the-art technology simultaneously in low, middle and high income countries. The technology also allows testing of other diseases, which should further increase efficiency."

WHO is also releasing recommendations and guidance for countries to incorporate this test in their programmes. This includes testing protocols (or algorithms) to optimize the use and benefits of the new technology in those persons where it is needed most.

Though there have been major improvements in TB care and control, tuberculosis killed an estimated 1.7 million people in 2009 and 9.4 million people developed active TB last year.

Bobby Ramakant - CNS 


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Flashback: CNS Stop-TB Initiative in 2010

As we move towards the end of 2010, we would like to take this opportunity to wish you all Seasons Greetings and a happy, healthy and peaceful new year in 2011. We at CNS Stop-TB Initiative will like to thank our thousands of visitors for their support and participation on a range of issues around tuberculosis (TB) control and TB-HIV co-infection. Read more

The Stop-TB eForum in 2010

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The Stop-TB eForum was established by the Health and Development Networks (HDN) in early 2001 in lead up to the first Stop TB Partners' Forum to facilitate online information exchange and dialogue on a range of TB-related issues on a daily basis.

MoU

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In 2010, a memorandum of understanding between the Stop TB Partnership, the International Union Against Tuberculosis and Lung Disease (The Union) and the International HIV/AIDS Alliance was signed to continue supporting the Stop-TB eForum over coming years. We thank the Stop-TB members for speaking their world through the platform.

ISSUES in 2010 on Stop-TB eForum

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Reflecting back on the year, we are pleased to remind you of a few issues and topics that struck a particular cord with members, generating lively dialogue. Some of these issues include:

- TB in mobile populations

- Jailing ('confining') of TB patients

- The Global Plan to Stop TB 2011-2015

- TB care and control in civil/ political unrest

- TB care and control in natural calamities

- Infection control in healthcare settings

- TB in children

- TB in people using injecting drugs

- TB/HIV collaborative activities in different countries

- Drug-resistant TB - both multi-drug resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB)

- Role of affected communities in driving the responses to TB/HIV

- TB and poverty

- Issues around research for new and better TB diagnostics, drugs and vaccines

- TB related stigma

- Tuberculosis and tobacco use

- Tuberculosis and diabetes co-morbidity

- Hepatitis C, TB, HIV and injecting drug-use in prisons

- TB-HIV co-infection

- Adherence to anti-TB treatment

- Isoniazid preventive therapy (IPT)
- Lung health
- Year of the lungs (2010)

ON-SITE ISSUE-BASED COVERAGE of TB conferences in 2010:

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With support from the community writers of Citizen News Service (CNS) CNS provided on-site coverage from a range of events related to TB in 2010.

1. 41st Union World Conference on Lung Health, Berlin, Germany

FIFTY FIVE (55) CNS articles are online at: http://www.citizen-news.org/search/label/Berlin%202010  

2. Consultative workshop of TB and poverty sub-working group of Stop TB Partnership  (29-30 October 2010)

CNS coverage is online at: http://www.citizen-news.org/2010/12/cns-coverage-from-tb-and-poverty-sub.html

3. Open Forum 4: on key issues in TB drug development, Addis Ababa, Ethiopia (18-19 August 2010)

CNS coverage online at: http://www.citizen-news.org/2010/09/cns-coverage-in-lead-up-to-and-on-site.html  

4. XVIII International AIDS Conference, Austria (July 2010)

CNS Coverage online at: http://www.citizen-news.org/2010/08/cns-coverage-in-lead-up-to-and-on-site.html  

5. "Research and development of new TB vaccines" Symposium, Zaragoza, Spain (3-4 June 2010)

CNS coverage online at: http://www.citizen-news.org/2010/06/cns-coverage-from-research-and.html

6. 2nd Global Forum on TB Vaccines, Tallinn, Estonia (21-24 September 2010)

CNS coverage online at: http://www.citizen-news.org/2010/10/cns-coverage-from-2nd-global-forum-on.html

7. International Symposium on Tuberculosis Diagnostics (ITBS 2010) - 16-17 December 2010

CNS coverage online at: http://www.citizen-news.org/search/label/ITBS%202010

ARCHIVES

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The Stop-TB eForum archives are available online at: www.HealthDev.org/stop-tb

HealthDev.net

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HealthDev.net continues to host online consultation 24 hours/ 365 days a year and be welcome to speak-your-world on www.HealthDev.net  

Winter break

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The Stop-TB eForum will be closing today for the winter-break and resume postings on Monday, 3rd January 2011.

A joy-filled Christmas and happy New Year!

CNS Stop-TB Initiative

Email: stoptb@citizen-news.org 

ASICON 2010 showcases modern advancements in surgery

The 70th annual conference of Association of Surgeons of India (ASICON) being held in All India Institute of Medical Sciences (AIIMS) campus, New Delhi, India, is showcasing recent and most modern advancements in surgery. More than 7000 surgeons from India and other countries are participating in ASICON 2010 (15-20 December ,2010), said Dr NK Pandey, national President of Association of Surgeons of India (ASI) and Managing Director of Asian Institute of Medical Sciences (AIMS). Dr Pandey is a recepient of the most coveted award in medicine in India - Dr BC Roy Award. Read more

Many illustrious surgeons from India are present in ASICON 2010 including BC Roy Awardee and President ASI Dr NK Pandey, honorary secretary of ASI Dr RK Karwasra, President-elect of ASI Dr BK Sinha, Treasurer of ASI Dr PS Bakshi and WHO Director-General's Awardee (2005) and former Head of Surgery Dept CSMMU Professor (Dr) Rama Kant.

"The 70th  annual conference of the Association of Surgeons of India (ASICON) showcases advancements in surgeries in the recent decade. Surgery, which is both art and science, is the most vital and critical part of medical science. Numerous types of surgeries and procedures were telecasted live from hospitals in India and abroad to the venue in ASICON city ,which is set up in the All India Institute of Medical Sciences (AIIMS) Delhi campus. Basic and advanced procedures were shown live to the audience. Around 1300 research papers were presented too" said eminent Surgeon Dr NK Pandey.

"Newer and more advanced specialities are being added to surgery. The technique of natural orifice technological endoscopic surgery (NOTES) is a an extremely critical development in the field of surgery. It will introduce a dynamic shift in the field of surgery by taking surgical precision to a new level and cutting down on recovery time. The evaluation process for this has already started. In this surgery, not even a stitch is required. Also the simulator based surgical training, which is the latest and very important development, will bring down the rate of mistakes in surgery by almost five hundred percent. The safety aspect for the patient is doubled. Minimally invasive techniques introduced in the recent past have resulted in a drastic reduction of morbidity and mortality occurring due to surgical procedures. Patients benefit by reduced pain and a faster recovery because of the procedure" further added Dr NK Pandey, who is the surgeon heading the premier healthcare centre - Asian Institute of Medical Sciences.

"The need of the hour is to develop a comprehensive health plan, so that benefits of modern medicine and good health reach to the remotest of areas, and rural population benefits from these advancements. Unfortunately, health infrastructure needs to develop at a much faster pace in order to meet demands of growing healthcare needs of the population, be it hospital beds, medical education college or universities" rightly said Dr NK Pandey.

The ASI through it's network of chapters all over the country is working to benefit the poor who need basic healthcare amenities and most importantly need to learn the importance of preventive healthcare practices.Also the association through it's chapters also has a valuable data bank to suggest the pattern and type of diseases on the rise in different geographical locations in the country.

The ASI also plans to collaborate with various nodal government health agencies to further it's agenda of making India a surgical hub, furthering medical tourism and making latest surgical techniques accessible to the backward and rural areas through it's network. (CNS)

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Early diagnosis and treatment for tuberculosis can turn the tide

Although significant advances in tuberculosis (TB) control have taken place over the past years, the TB levels are not going down as fast as expected earlier (10% decline every year was projected). Not to say that commendable work hasn’t happened in TB control – rather TB control has received major thrust over the past decade certainly in terms of programming, strategy (new Global Plan to Stop TB 2011-2015 was just released in October 2010), funding and research initiatives as well. However despite of all the good, the new TB cases continue to emerge and TB levels haven't reduced as earlier estimated (TB rates are coming down, but coming down too slowly). Read more

If we diagnose TB early, we also prevent TB from spreading to others. Cutting TB transmission cycle can potentially turn the tide, said experts.

WE ARE NOT DETECTING TB EARLY ENOUGH Where are we missing the defining pulse? Most likely we are not detecting TB early enough and mis-diagnosis and missed-diagnosis of TB are other challenges among many others that continue to puzzle us, said Dr Pawan Sharma, convener of the 'International Symposium on Tuberculosis Diagnostics: Innovating to make an impact' (ITBS 2010).

The ITBS 2010 is being organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi, India (16-17 December 2010) with support from the Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND).

"In roughly 55 years we have squandered our precious legacy of chemotherapy for TB…" said Dr William E Bishai from John Hopkins University. According to the World Health Organization, anti-TB drug resistance is a result of poor programme performance of DOTS – the WHO recommended strategy for treating TB. Patients with drug-resistant forms of TB – like multi-drug resistant TB (MDR-TB) or extensively drug-resistant TB (XDR-TB) have severely limited treatment options, or at times with XDR-TB, there is virtually no option left for treatment. For patients with XDR-TB that have no treatment option left it is like going back to the pre-antibiotic era before 1940s where TB was not treatable.

"How did we get into this mess?" asked Dr William Bishai. Lack of prevention (vaccines), lack of treatment, lack of diagnostics and biomarkers and lack of appreciation of complexity were key reasons listed by Dr Bishai for the difficult challenge TB poses today.

"Microscope remains the fundamental diagnostic tool since 1882 when Dr Robert Koch invented it" said a representative of Foundation for Innovative New Diagnostics (FIND).

In a study done in India, it was found that the direct costs incurred on TB diagnosis and treatment were just 1/5 of the total costs a patient incurs during TB therapy (direct cost: 0.5 billion, indirect costs: 2.5 billion). A lot of these costs a patient incurs happen before he or she gets to the proper TB clinic – and a significant amount of time is also lost as well, at times spanning months and years till proper therapy begins. Also in terms of spreading TB infection, it is very important to diagnose TB as early as possible to cut transmission cycle.

The DOTS expansion has not resulted in better case detection rates (case detection has more or less remained steady) – despite of rapid expansion of DOTS - so we need to do more than implementing DOTS, said the FIND representative.

In a study done by Dr Girzybowski, it was found that if any of the parents have smear-negative TB, children were found to have the same chance to get infected with TB as someone in the community (which is much lower), however if the parent had smear positive TB, then at least 35% chance exist of the children to get infected with TB.

No doubt, there is a strategic need for early diagnosis of TB, and sensitivity and speed of the diagnostic tools are keys to cut the transmission cycle, said FIND representative.

Another good example comes from Peru where Peruvian TB control programme is doing all what is possible to do in that scenario. TB rates in Peru dropped phenomenally in early years but since past 5 years, the rates have more or less remained same. Probably the need to diagnose TB early in those who are currently either being missed or those who get diagnosed very late is crucial and compelling.

Just last week, the WHO endorsed a new and novel rapid test for TB, especially relevant in countries most affected by the disease. The test could revolutionize TB care and control by providing an accurate diagnosis for many patients in about 100 minutes, compared to current tests that can take up to three months to have results.

"This new test represents a major milestone for global TB diagnosis and care. It also represents new hope for the millions of people who are at the highest risk of TB and drug-resistant disease." said Dr Mario Raviglione, Director of WHO's Stop TB Department. "We have the scientific evidence, we have defined the policy, and now we aim to support implementation for impact in countries."

WHO's endorsement of the rapid test, which is a fully automated NAAT (nucleic acid amplification test) follows 18 months of rigorous assessment of its field effectiveness in the early diagnosis of TB, as well as multidrug-resistant TB (MDR-TB) and TB complicated by HIV infection, which are more difficult to diagnose.

Evidence to date indicates that implementation of this test could result in a three-fold increase in the diagnosis of patients with drug-resistant TB and a doubling in the number of HIV-associated TB cases diagnosed in areas with high rates of TB and HIV.

Bobby Ramakant - CNS

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Winning project pictures life with Tuberculosis

The TB Photovoice Project, the winner of the 2010 TB Survival Prize, started as a one man's way to deal with the loss of his beloved ones to tuberculosis (TB). By now, it is touching the lives of many people around the world, helping – through pictures and narratives – to empower and raise the voices of persons and communities affected by the disease. Read more

The Tuberculosis Survival Prize is given each year by the Tuberculosis Survival Project, with support from the Lilly MDR-TB Partnership. The prize, an annual award of USD 2000, is awarded in recognition of innovation in TB/MDR-TB advocacy and social mobilization by individuals, groups or NGOs working in the field of HIV/TB or TB/MDR-TB. During a ceremony at the 41st Union World Conference on Lung Health in Berlin, Germany (November 11-15) the prize this year went to TB Photovoice.

The TB Photovoice Project provides cameras to community members (survivors, caregivers, friends, family) affected by TB, who take photographs that help them identify and improve their communities. The photographs and their stories represent what is happening in the participants' lives and serve as a point for discussion about what can be done to change the present situation in regards to TB, adherence, support, stigma, education and related issues. These photographs and their accompanying narratives give a face and voice to TB. There are initiatives in among others Brazil, Mexico, Thailand and the United States. The Stop TB Survivor award enables the project to start up a TB Photovoice in Kenya too.

Romel Lacson, founder of the Amaya-Lacson TB Photovoice Project, was personally affected by the disease, losing both his wife Claudia Amaya and their newborn daughter Emma to tuberculosis meningitis in 2004. "The project was sort of my reaction to that," he said at the sidelines of the conference. "I did not have TB myself but my family and my wife's family were providing care of her throughout the time she was in hospital. We felt very isolated, very disconnected from the world. When Claudia passed away it turned my life upside down. I had to try to make sense."

Over the years, the various initiatives - in partnership with local organizations - gave different meanings to TB Photovoice. "They have a basic foundation for it but depending on the mission of the particular organization and on the coordinator who is implementing and facilitating it, it really takes a character of its own," Lacson says. Yet there are core aspects that remain, such as photography, using images, narrative storytelling, dialogue, group discussions and ethical use of the camera. "Part of the training is to instill a sense of responsibility of the photographer that they take pictures that don't invade people's privacy or are not going to hinder any kind of confidentiality of what happened."

Eva M. Moya is involved with setting up TB Photovoice projects throughout the U.S.-Mexico border and in Mexico. With resources of the Amaya-Lacson Foundation a pilot TB Photovoice (Voices and Images of Tuberculosis) Project in the United States-Mexican border region was started in 2006. "We immediately realized we had to do it in a bi-national fashion,” Moya recalls. “It is a border community where tuberculosis knows no boundaries, where it doesn't need a visa to travel north or south."

Two groups of persons affected by TB were formed and received training, setting up photo galleries within four months. Policy and decision makers were invited and witnessed the work of the participants, and were asked to make commitments. "One of the beauties of this methodology is that you can actually see commitments," Moya says. "Which you can follow through time with decision, policy makers and health authorities so that there could be improvement. Whether it is in the area of access of services, in the leveraging of resources, or in making services much more focused on the person and services that are free of stigma and discrimination."

Through a partnership with Project Concern International SOLUCION TB the TB Photovoice (Voices and Images of Tuberculosis) initiative now includes nine projects in Mexico. Galleries that continue to move between communities. It was followed by Nuestra Casa, a three-dimensional house that reflects the life and stories of people affected by TB.

TB Photovoice asks its participants to be critical of their own community and their reality. "We ask them to tell us what it is that they see, to explain what is happening in their lives, to indicate where the problems, issues and challenges are. And then to be able to work with solutions," Moya says. Eventually many participants become activists. "There is a lot of overcoming of fears, sometimes of embarrassment, of distress, of sadness, of actually even rage, because several of our participants were unfortunately misdiagnosed. And they sort of transform that into a very powerful experience and they say well, we need to let the larger community know. It is very powerful when the story comes from the person affected and is presented to decision and policymakers, because it comes actually from the perspective of having lived the experience."

Rachel C. Orduño, one of the first participants in the U.S.-Mexico border project, lived the experience. She was diagnosed with TB in 2006 after three years of many misdiagnoses. Her treatment lasted 9 months. Her (at that time) 3 year old niece also had active TB and six other family members were treated for latent TB. Orduño remembers feeling helpless, frustrated and angry because of the misdiagnosis. Participating in the TB Photovoice Project altered these emotions.

"For people who are going through treatment, TB survivors, it is really important to share with other people," Orduño stresses. "For me TB Photovoice was first and foremost a support group. We gave each other advice and support and direction. The activist and advocacy aspect of it came later, once we felt like we can do something about it: we can't just ask the medical establishment to take care of us, we can't expect the government to look after us, we need to do something."

For Orduño that motivation came from being a group, having people to share ideas and the feeling of having something to contribute. "Now I don't see the power differential of the medical expert and the patient," she says. "Now it is the medical professional who got a lot of training plus the persons affected by the TB experience, the experience that makes us the experts. And seeing how we can be partners in developing a lot more effective treatments, how to reach the public at large and the public services."

The project even helped diminish her feelings of guilt. "That is something else that people don't tell you, that sometimes you feel very guilty for transmitting the disease to your most loved ones," she says. "I learned that for every year that I was untreated and had active TB, I could have infected 15 other people. So I may have possibly caused 45 infections. However by speaking up now, by spreading the word that we can do something about it, every one of us, all of us who have been directly been affected by TB and every medical professional and everyone who knows their story, we can all contribute. We can all try and do our best to recognize the symptoms and just be aware that TB is out there everywhere in the world. Anyone that breathes is at risk so everyone has a moral obligation and it would be a public service to do your part to contain it."

Babs Verblackt - CNS 
(The author is a freelance journalist and a Fellow of CNS Writers' Bureau)

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