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Daily Current Affairs 06.09.2022 (Seat belts, head restraints and safety regulations, The ban on conversion therapy for the LGBTQIA+ community, Preventive detentions rose in 2021, Gorbachev, macro-economics, and Gandhi, The difficult path to India-Pakistan peace, Public health need not be led by doctors alone)

Daily Current Affairs 06.09.2022 (Seat belts, head restraints and safety regulations, The ban on conversion therapy for the LGBTQIA+ community, Preventive detentions rose in 2021, Gorbachev, macro-economics, and Gandhi, The difficult path to India-Pakistan peace, Public health need not be led by doctors alone)

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1. Seat belts, head restraints and safety regulations

What are the functions of seat belts and head restraints? Is India implementing its mandatory seat belt policy?

The death of Cyrus P. Mistry, former Chairman of Tata Sons, in a car crash in Maharashtra’s Palghar district has turned the focus on whether compulsory use of seat belts in cars — including by passengers in the rear seat — can save lives during such accidents.

The seat belt performs many functions, notably slowing the occupant at the same rate as the vehicle, distributing the physical force in a crash across the stronger parts of the body such as the pelvis and chest, preventing collisions with objects within the vehicle and sudden ejection.

The Road Transport Ministry said that during 2017, a shocking 26,896 people lost their lives due to non-use of seat belts with 16,876 of them being passengers.

G. Ananthakrishnan

The story so far: The death of Cyrus P. Mistry, former Chairman of Tata Sons, in a car crash in Maharashtra’s Palghar district on September 4 has turned the focus on whether compulsory use of seat belts in cars — including by passengers in the rear seat — can save lives during such accidents. Media reports cited police sources to say that Mistry and a co-passenger, Jahangir Pandole, who was also killed in the mishap, were not wearing seat belts. Although a full investigation has to follow, authorities said preliminary findings showed the car was moving at high speed, covering about 20 km in nine minutes from the last check post where it was recorded by CCTV.

How is a seat belt a life saver?

The focus in the aftermath is on the seat belt. The three-point seat belt engineered by Nils Evar Bohlin, a passive safety device first incorporated into a car by Volvo in 1959, and now standard in cars sold in India, is a low cost restraint system that prevents occupants of a vehicle from being thrown forward in a crash. In the U.S, unrestrained drivers and passengers represented 48% of all deaths in vehicle crashes during 2016, according to the National Highway Traffic Safety Administration.

In a car crash, particularly at moderate to high speeds, the driver or passenger who has no seat belt continues to move forward at the speed of the vehicle, until some object stops the occupant. This could be the steering wheel, dashboard or windscreen for those in front, and the front seat, dashboard or windscreen for those in the rear. The Centre for Road Safety at the Transport Department of New South Wales, Australia (NSW Centre), which has had a compulsory seat belt rule since 1971 explains that “even if the vehicle is fitted with an airbag, the force at which an unrestrained occupant strikes the airbag can cause serious injuries.”

Without an airbag, and no seat belt restraint, a severe crash leads to the occupant of the rear seat striking the seat in front with such force that “it is sufficient for the seat mountings and seat structures to fail,” says the NSW Centre. The seat belt performs many functions, notably slowing the occupant at the same rate as the vehicle, distributing the physical force in a crash across the stronger parts of the body such as the pelvis and chest, preventing collisions with objects within the vehicle and sudden ejection. Newer technologies to “pretension” the belt, sense sudden pull forces and apply only as much force as is necessary to safely hit the airbags. Absence of seat belts could lead to rear seat occupants colliding with internal objects in the car, or even being ejected through the front windscreen during the collision.

What role do head restraints play?

Head restraints, which are found either as adjustable models or moulded into the seats, prevent a whiplash injury. This type of injury occurs mostly when the vehicle is struck from behind, leading to sudden extreme movement of the neck backwards and then forwards. It could also happen vice versa in other circumstances. The injury involves the muscles, vertebral discs, nerves and tendons of the neck, says Johns Hopkins Medicine, and is manifested as neck stiffness, pain, numbness, ringing in the ears, blurred vision and sleeplessness among others.

The head restraint built into the seat must be properly placed and aligned with the neck, to prevent the injury in a vehicle accident. A study done by the Insurance Institute for Highway Safety (IIHS) in the U.S. estimated that claims for neck injuries were lower by 11% when the seats and restraints were rated good by it, compared to those rated poor. The ratings system has resulted in newer models, since 2015, almost fully getting a good rating.

How does India regulate and enforce safety?

On February 11, 2022, the Ministry of Road Transport and Highways issued a draft notification providing for three-point seat belts to be provided in all vehicles coming under the M1 category, that is, for carriage of passengers comprising not more than eight seats in addition to the driver’s seat, for vehicles manufactured from October 1. Also, it stipulated relevant Indian Standards to be followed by the manufacturers for both seat belts and reminder systems alerting occupants to wear them.

What stands out is that the amended Motor Vehicles Act of 2019 already requires the occupants of a passenger vehicle to wear a seat belt. As per Section 194(B) of the Act, whoever drives a motor vehicle without wearing a safety belt or carries passengers not wearing seat belts shall be punishable with a fine of one thousand rupees.

Evidently, although cars are equipped with seat belts, the enforcement for rear seat occupants is virtually absent in India. U.S. research findings published in the Journal of Safety Research by Laurie F. Beck and colleagues show that seat belt use was low in states with weak laws or no laws at all, and riders of taxi services are high risk groups. The IIHS study found that rear seat passengers who did not buckle up were eight times more likely to suffer serious injuries than those who did.

The toll from non-compliance in India is high, as taxicabs often have missing seat belts. In one of the few questions on the subject asked in Parliament, the Road Transport Ministry said, during 2017, a shocking “26,896 people lost their lives due to non-use of seat belts and 16,876 of them were passengers. No specific data with regard to loss of lives due to non-usage of seat belts by rear seat passengers is available with the Ministry,” it added.

In the aftermath of the accident in which Cyrus Mistry died, there have been suggestions that automotive technology should bring about compliance by making it impossible to operate the vehicle if seat belts are not fastened. As of July, the European Union’s General Safety Regulation requires new vehicles to incorporate advanced emergency braking technology that launches automatically when a collision is imminent, and intelligent speed assistance to reduce speed suitably besides accident event recorders, all of which are relevant to the Palghar crash. Making high quality dash cameras standard in cars could be a start to help record accidents and establish the cause.

2. The ban on conversion therapy for the LGBTQIA+ community

What is the National Medical Commission directive to State Medical Councils? Why is the therapy considered to be dangerous?

The National Medical Commission (NMC) has written to all State Medical Councils, banning conversion therapy and calling it a “professional misconduct”.

In 2021, Justice N. Anand Venkatesh of the Madras High Court issued a slew of interim guidelines for the police, activists, Union and State Social Welfare Ministries, and the National Medical Commission, regarding the LGBTQIA+ community, to “ensure their safety and security to lead a life chosen by them.”

Parents too need to be sensitised, because the first point of abuse often begins at home, with teenagers being forced to opt for “conversion” therapies.

Sudipta Datta

The story so far: The National Medical Commission (NMC), the apex regulatory body of medical professionals in India, has written to all State Medical Councils, banning conversion therapy and calling it a “professional misconduct”. In a letter dated August 25, it also empowered the State bodies to take disciplinary action against medical professionals who breach the guideline. The letter said the NMC was following a Madras High Court directive to issue an official notification listing conversion therapy as a wrong, under the Indian Medical Council (Professional Conduct, Etiquettes and Ethics) Regulations, 2002.

What is conversion therapy? What are the risks?

Conversion or reparative therapy is an intervention aimed at changing the sexual orientation or gender identity of an individual with the use of either psychiatric treatment, drugs, exorcism and even violence, with the aim being to make the individual a heterosexual. The conversion therapy umbrella also includes efforts to change the core identity of youth whose gender identity is incongruent with their sex anatomy. Often, the therapy is offered by quacks with little expertise in dealing with the issue. According to the American Academy of Child and Adolescent Psychiatry (AACAP), the interventions under conversion therapy are provided under the false premise that homosexuality and diverse gender identities are pathological. “They are not; the absence of pathology means there is no need for conversion or any other like intervention.” Further, according to AACAP and other health experts, conversion therapy poses the risk of causing or exacerbating mental health conditions, like anxiety, stress and drug use which sometimes even lead to suicide.

What is the role of the Madras High Court in the ban?

On June 7, 2021, Justice N. Anand Venkatesh of the Madras High Court gave a landmark ruling on a case he was hearing about the ordeal of a same-sex couple who sought police protection from their parents. Pending adequate legislation more protective of the community, Justice Venkatesh issued a slew of interim guidelines for the police, activists, Union and State Social Welfare Ministries, and the National Medical Commission to “ensure their safety and security to lead a life chosen by them.” The ruling prohibited any attempt to medically “cure” or change the sexual orientation of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual or of any other orientation) people. It urged the authorities to take action against “professional[s] involving themselves in any form or method of conversion therapy,” which could include the withdrawal of licence to practice medicine. On July 8, 2022, the court gave an order to the National Medical Commission directing it to “issue necessary official notification by enlisting ‘Conversion Therapy’ as a professional misconduct.” The NMC issued the directive to State Medical Councils on August 25.

What were some of the other guidelines issued by the court?

In its 2021 verdict, the Madras High Court directed the police, for example, to close complaints of missing persons’ cases, “without subjecting them to harassment”, if it found on investigation that the parties were consenting adults belonging to the LGBTQIA+ community. The court asked the Ministry of Social Justice & Empowerment to draw up a list of NGOs and other groups which could handle the issues faced by the community, and gave it a time of eight weeks from the date of the order. This March, the court pulled up the Ministry for failing to compile a comprehensive list. The court said the community should be provided with legal assistance by the District Legal Services Authority in coordination with law enforcement agencies. Asking agencies to follow the Transgender Persons (Protection of Rights) Rules, 2020, and the Transgender Persons (Protection of Rights) Act, 2019, in letter and spirit, the court said it was imperative to hold sensitisation programmes for an all-out effort to understand the community and its needs.

How can schools, colleges and medical professionals help?

Experts say schools and colleges must effect changes in curricula for a better understanding of the community. As late as 2018, medical books listed homosexuality and lesbianism as a “perversion”. People of a different sexual orientation or gender identity often narrate harrowing tales of bullying, discrimination, stigma and ostracisation. Gender-neutral restrooms should be compulsory in educational institutes and other places. Parents too need to be sensitised, because the first point of misunderstanding and abuse often begins at home, with teenagers being forced to opt for “conversion” therapies. Health professionals point out that even adults opting for sex reassignment surgeries need to get proper guidance like therapy pre and post operation; for an ordinary citizen, the cost too can be prohibitive.

3. Preventive detentions rose in 2021

Number of people in custody or detained at the end of year highest since 2017

Preventive detentions in 2021 saw a rise by over 23.7% compared with the year before, with over 1.1 lakh people being placed under preventive detention, according to statistics released by the National Crime Records Bureau (NCRB) last month.

Of these, 483 were detentions under the National Security Act, of which almost half (241) were either in custody or still detained as of 2021-end. Over 24,500 people placed under preventive detention were either in custody or still detained as of 2021-end — the highest since 2017 when the NCRB started recording this data.

In 2017, the NCRB’s Crime in India report found that 67,084 persons had been detained as a preventive measure that year. Of these, 48,815 were released between one and six months of their detention and 18,269 were either in custody or still in preventive detention as of the end of the year.

The number of persons placed under detention has been increasing since 2017 — to over 98,700 in 2018 and over 1.06 lakh in 2019 — before dipping to 89,405 in 2020. Data pertaining to 2021 showed that 1,10,683 persons were placed under preventive detention last year, of which 24,525 were either in custody or still detained as of the end of the year and the rest were let go within one to six months.

While the number of persons placed under preventive detention has seen an increase in 2021, the NCRB data showed that the number of people arrested in such a manner under the National Security Act had dipped significantly compared with the year before.

Preventive detentions under the NSA increased to 741 in 2020. This number dropped to 483 in 2021.

Use of provision

Among other laws under which the NCRB has recorded data on preventive detentions are the Goonda Act (State and Central) (29,306), Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act, 1988 (1,331), and a category classified as “Other Detention Acts”, under which most of the detentions were registered (79,514). Since 2017, the highest number of persons to be placed under preventive detention has consistently been under the “Other Detention Acts” category.

Shwetank Sailakwal, advocate-on-record, who has researched preventive detention laws and procedures in India, pointed out that several laws such as the Unlawful Activities (Prevention) Act and Maharashtra Control of Organised Crime Act also provide for making preventive detentions.

According to Section 151 of the Code of Criminal Procedure, the police are empowered to make preventive arrests if they believe they must do so to prevent the commission of “any cognisable offence”. This detention can be extended beyond 24 hours if required “under any other provisions of this Code or of any other law”.

Preventive Detention

  • Constitutional Provisions:
    • Article 22 grants protection to persons who are arrested or detained. Detention is of two types, namely, punitive and preventive.
      • Punitive detention is to punish a person for an offence committed by him after trial and conviction in a court.
      • Preventive detention, on the other hand, means detention of a person without trial and conviction by a court.
    • Article 22 has two parts—the first part deals with the cases of ordinary law and the second part deals with the cases of preventive detention law.

Note: The 44th Amendment Act of 1978 has reduced the period of detention without obtaining the opinion of an advisory board from three to two months. However, this provision has not yet been brought into force, hence, the original period of three months still continues.

  • The preventive detention laws made by the Parliament are:
    • Preventive Detention Act, 1950. Expired in 1969.
    • Maintenance of Internal Security Act (MISA), 1971. Repealed in 1978.
    • Conservation of Foreign Exchange and Prevention of Smuggling Activities Act (COFEPOSA), 1974.
    • National Security Act (NSA), 1980.
    • Prevention of Blackmarketing and Maintenance of Supplies of Essential Commodities Act (PBMSECA), 1980.
    • Terrorist and Disruptive Activities (Prevention) Act (TADA), 1985. Repealed in 1995.
    • Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act (PITNDPSA), 1988.
    • Prevention of Terrorism Act (POTA), 2002. Repealed in 2004.
  • Issues related to Preventive Detention Laws in India:
    • No democratic country in the world has made preventive detention as an integral part of the Constitution as has been done in India.
    • The governments sometimes use such laws in an extra-judicial power. Also, there remains a fear of arbitrary detentions.

4. Editorial-1: Gorbachev, macro-economics, and Gandhi

Concepts of free trade, financial freedom, and privatisation are not the right solutions for India’s citizens

“You see, Sasha, this is how it goes,” a tired Mikhail Gorbachev said to his closest aide when he lay down to rest after transferring power to his successor, Boris Yeltsin, in 1991. Gorbachev, who passed away last week, has been hailed for his role in ending the ideological conflict between communism and capitalism, and also bringing down the Iron Curtain and ending the Cold War between the North Atlantic Treaty Organization (NATO) and the Soviet Union.

Russia today

Sadly, Gorbachev lived to see history return with a vengeance. NATO is expanding eastwards; Russia is threatened: Ukraine is its battleground. On the economic front, Russia has not recovered from the shock it got from Boris Yeltsin’s “big bang” capitalisation imposed by U.S. economists. Perversely, an unintended effect of the big bang is the return of authoritarianism under Vladimir Putin. Gorbachev had favoured a slow transition to a “mixed economy” like the Indian model and had approached Rajiv Gandhi for advice. I was a member of a small team of Indian business leaders which had travelled to Moscow and Riga in 1989 to explain the “Indian model” to economists at the Academy of Sciences of the Soviet Union. However, the “Washington economics” model prevailed. Led by a triumphant United States, and economists in U.S. think tanks, the World Bank and the International Monetary Fund, the wave of opening domestic economies to international flows of trade and finance swamped Russia; it also reached India’s shores in 1991.

Overall life expectancy is a good measure of the well-being of a nation’s citizens. When all citizens are well-nourished, when public health systems function well, and when violence in society is low, an average person lives longer. International comparisons reveal that GDP per capita is an insufficient contributor to longevity. Many countries with substantially lower incomes outperform the U.S. in life expectancy. Cuba is one place above the U.S. in longevity tables even though its income per capita is just 14% of U.S. incomes.

Between the big bang capitalist reforms of the Russian economy in 1991 and 1994, life expectancy fell from 64 to 57 years. Ten million Russian men (6.7% of the Russian population) ‘disappeared’. Their deaths were caused by suicides, alcohol poisoning, homicides, and heart attacks brought upon by despair with joblessness and hopelessness, created by wholesale privatisation of the economy and disruption of social safety nets. “Catastrophes of this magnitude typically occur only during pandemics and wars,” says George DeMartino, author of The Tragic Science: How Economists Cause Harm (Even As They Aspire To Do Good). Yet, losses of this magnitude had not occurred even in the U.S. Civil War (2.1% of the U.S.’s population), or the flu pandemic of 1918-1920 (2.8% of world population). The Russian deaths were caused by the imposition of an economic ideology that claimed that everyone will be better off with the aid of some mysterious hand when the state is pushed back, the economy is deregulated, and capitalist spirits are let loose.

Ideological wars

The 20th century was a violent period in human history: with two gory world wars, many wars for independence from colonialism, and a long Cold War which brought the world to the edge of a nuclear holocaust. Gorbachev helped to bring the world back from the nuclear precipice. The 20th century also witnessed ideological battles among economists: communism, socialism, and capitalism; the role of the state vis-à-vis private enterprise; the rights of nations to resist the “Washington model” and shape their own economic models to fit their needs. While Russia was tragically overrun by global capitalism, China took its own course with remarkable results.

The capitalist model that spread around the world after the fall of the Berlin Wall is founded on two fundamental ideas. One is the ideology of “property rights” trumping human rights. In capitalism, whoever owns something has the right to determine how it will be used; and whosoever owns more shares in a property must have a greater say. Thus, one dollar owned gives one vote in governance, and a million dollars, one million votes. Whereas the democratic principle of “human rights” requires that every human being, black or white, or whether billionaire or pauper, has an equal vote in governance.

The shift in balance from democracy to capitalism in the last 30 years is made vivid by the creation of international tribunals who adjudicate disputes between foreign investors in countries and the governments of those countries. Governments of countries represent the interests of millions, even billions, of people in their countries. On the other side in the dispute are a few investors of capital. Global trade rules, and national financial and trade regulations too, have veered too much towards the needs of financial investors, making it easier for them to enter and exit countries whenever they will, while stopping human migrants from searching for better opportunities across national borders.

Ideologies of elected governments and free markets were the joint victors of the ideological war between the West and the Soviet Union. The two victors are now clashing with each other even in the West. When appliances designed to run on AC power are plugged into sockets providing DC power, there will be blow-outs. Similarly, when institutions of governance designed to run on fundamentally different principles are plugged into each other, something will blow up.

Another core idea of capitalism is Hardin’s “Tragedy of the Commons”. It says that communities cannot manage shared resources; therefore, common property must be privatised for its protection. With the operation of the mechanism of ‘cumulative causation’, wealthy people become more wealthy. When a public resource is privatised, those who already have wealth can buy it; and in bidding wars, those with more wealth will win and become even wealthier. Thus, when capitalism is unleashed, inequalities will increase, as they have in Russia and around the world since the 1990s.

Uncontrollable climate change is an existential “tragedy of the commons” for all life on Earth. Twentieth century capitalism does not have solutions: in fact, it is the problem. The time has come to reform economics. Principles of equity and ethics, and fair sharing of power and resources, must constrain unbridled drives for efficiency and productivity to increase the size of the economy that have become the thrusts of economic policies globally.

Gandhi’s ethical economics

New models of cooperative governance are required to realise the promise of humanity’s shared commons. With his concepts of perestroika and glasnost, Gorbachev wanted to save common citizens from being oppressed by powerful people. His successors, ill-advised by economists, handed over the Russian economy to unbridled capitalism. Oppression by the state was replaced by exploitation by capitalists. Ten million Russian men died prematurely. And Russians lost pride in their identity and history. More men are now losing their lives on the battlefront in Ukraine in Putin’s bid to protect Russia and recover Russian pride.

“This is how it goes,” Gorbachev observed when he resigned. India’s policymakers should heed history’s lessons. Concepts of free trade, financial freedom, and privatisation, promoted by macroeconomists, are not good solutions for India’s billion citizens struggling for resilience in their lives. India’s policymakers seem obsessed with increasing the size of the economy. The shape of an economy matters more than its size for human well-being. India’s economic governance must be guided by Mahatma Gandhi’s calculus, with principles of human rights and community management, to realise the promise of our commons, and provide “poorna swaraj” to all citizens.

5. Editorial-2: The difficult path to India-Pakistan peace

The failure to manage the domestic audience in Pakistan is a recurrent trope that has overwhelmed peace attempts

After the unceremonious ouster of Imran Khan from the seat of government in Pakistan and the promulgation of Shehbaz Sharif as Prime Minister, there have been signs of a thaw in India-Pakistan relations. It was reported that the Pakistan Army chief, General Qamar Bajwa, had countenanced backchannel talks and a “limited trade resumption package” with India. This was to help alleviate some of the stresses on Pakistan’s flailing and cash-strapped domestic economy that was veering on the edge of a default in the face of a widening current account deficit and high inflation brought on by the after-effects of a global novel coronavirus pandemic, unprecedented floods, and decades of poor planning.

As a respite, the International Monetary Fund (IMF) recently agreed to a one-year extension for Pakistan’s 39-month, $6 billion Extended Fund Facility programme begun in 2019, and further added an additional $1.17 billion to its coffers. To ease its situation further, especially considering the devastating impact of the floods on food supply in Pakistan, Pakistan’s Finance Minister Miftah Ismail had indicated his openness to import “vegetables and edible items from India”. However, Mr. Sharif had to quickly retract Mr. Ismail’s suggestion and restate his government’s commitment to prioritising a resolution of the Kashmir dispute before normalisation of bilateral relations could take place. There has been no official confirmation of India’s proposal to provide food aid to Pakistan, nor of any Pakistani request for the same.

Domestic pressures

It is abundantly clear that Mr. Sharif, despite the obvious economic benefit of seeking trade in essential commodities with India, is unable to overcome the pressures of domestic public opinion in Pakistan. His predecessor’s controversial and unpopular departure via a vote of no-confidence and upcoming general elections in Pakistan has swayed Mr. Sharif’s decision-making. Mr. Khan’s party, the Pakistan Tehreek-e-Insaaf, won a convincing victory in the hugely important Punjab by-polls earlier this year. Meanwhile, the stock of the Sharif-led coalition is sinking as he has been forced to introduce austerity measures and rollback public subsidies to meet the IMF’s demands.

A simple application of rational choice theory would suggest that Mr. Sharif’s choice is fairly straightforward. Pakistan should ask India, a large agricultural producer in the neighbourhood, to provide it essential aid in its moment of crisis. India’s Prime Minister Narendra Modi had even tweeted that he was “saddened to see the devastation caused by the floods in Pakistan”. This suggests an implicit willingness to provide food aid if required. It is worth noting that India provided essential vaccine supplies to Pakistan during the COVID-19 pandemic and there is precedence for cooperation between the two nations when faced with such emergencies. But still, Mr. Sharif could not muster the political will to serve Pakistan’s short-term interests, despite the fact that such trade would not create long-term dependencies on India, or require extreme concessions, or entail a compromise of principles.

Leader equations

This episode sheds light on the enduring nature of India-Pakistan relations. Due to the deep securitisation of the Kashmir dispute in Pakistan’s social imaginary, it is quite challenging for Pakistan’s leadership to sustain any sort of peacemaking with India, even if strong material incentives are present. It is known that the electoral costs of such an undertaking would be suicidal, making Pakistani peacemakers susceptible to popular backlash.

In my research on conflict termination, I have found that the personal reputations of leaders as well as moments of weakness can be useful to trust-building processes between rivals. Mr. Sharif and Mr. Modi have reputations that are conducive. Mr. Modi, as former Prime Minister A.B. Vajpayee’s successor, was seen by Nawaz Sharif, Shehbaz Sharif’s brother and former Pakistani Prime Minister, as a populist leader capable of countenancing an Indian compromise on the Kashmir dispute. It is likely that this view still holds sway.

Similarly, the Modi government in India has long seen the Sharif regime in Pakistan as supportive of stability in bilateral ties. Mr. Modi had even made a surprise visit to Lahore in 2015 to meet Nawaz Sharif and demonstrate his sincerity in resolving pending disputes. Pakistan’s weakness and need for food aid is also apparent in the given circumstances. India too would like to refocus its overstretched defence capacities on handling China. Still, a breakthrough remains elusive.

In the 1950s

This was also the case in 1953 when Mohammed Ali Bogra and Jawaharlal Nehru negotiated the Kashmir dispute. Bogra was a Bengali and desirably seen in New Delhi as lacking Punjabi sentimentality on Kashmir. Nehru on the other hand was considered a strong, popular, and secular leader who was able to withstand the crosscurrents of public opinion in India. Then too, Pakistan faced economic distress. Bogra and Nehru made reciprocal visits to New Delhi and Karachi. They got close to an agreed solution on Kashmir, but each time, Bogra’s inability to foster domestic coalitions to support the peacemaking process with India overrode the negotiations. The ire of domestic publics against Bogra as well as the disapproval of his cabinet colleagues were insurmountable. Such failure to manage domestic audience costs in Pakistan and insulate the peace process from spoilers has been a recurrent trope and has derailed several India-Pakistan peace dialogues.

In the circumstances, much will depend on the outcome of the next general elections in Pakistan and the choice of Gen. Bajwa’s successor. If the Sharif-led coalition government returns to power and a similar-minded army chief is appointed, there may indeed be renewed opening for a sustained backchannel dialogue and trade. However, these talks too are likely to remain unfruitful until there is bipartisan support in Pakistan on the need to normalise ties with India and the two states enter a long period of de-securitisation. This may be too much to ask for. But, without it, the price of peace with India will be too high for Pakistan’s leaders. As long as the option of peace (or in this case, trade) forces Pakistan’s leaders to choose between their survival as political agents and the larger interests of the state, the answer is likely to disappoint.

6. Editorial-3: Public health need not be led by doctors alone

It is a separate profession requiring a specific set of competencies

It is common for heads of health services at national, state or district levels in India to be orthopaedic or cardiac surgeons or ophthalmologists who have no training in public health. There is also suboptimal representation of public health professionals in State and Central advisory bodies of health. During the pandemic, many doctors with no training in public health provided expert advice on public health issues. This is because it is felt that public health does not require specific competencies, and anyone can do this work.

A poor understanding

Public health is essentially multi-disciplinary and means different things to different people. Many, even within public health, have a poor understanding of it. For example, recent Central government guidelines specify an MBBS degree to be a prerequisite for becoming a public health specialist. Some people have commented on the exclusion of grassroots public health workers — ASHA workers, auxiliary nurse midwives and multipurpose workers — from the cadre.

Part of this confusion comes from not being able to differentiate between public health as a discipline and the public health sector. All those who work for the State or Central government are public sector health workers, but they are not doing public health. Providing medical care at a primary health centre does not make the person a public health professional. Also, health workers have no training in public health; they are grassroots-level service providers. Asking them to be part of public health cadre trivialises the profession of public health. It is important to understand that public health is a separate profession with a specific set of competencies.

I use four ‘A’ s — academics, activism, administration and advocacy — to describe public health work. Academics refers to a good understanding of evidence generation and synthesis by having a good grounding in epidemiology and biostatistics. These competencies are also critical for monitoring and evaluating programmes, conducting surveillance, and interpreting data and routine reporting.

If academics is the brain behind the discipline, activism is at the heart of it. Public health is inherently linked to ‘social change’ and an element of activism is core to public health. Public health requires social mobilisation at the grassroots level by understanding community needs, community organisation, etc. This requires grounding in social and behavioural sciences. It also includes the study of how non-health determinants, including social and commercial factors, influence health and how these can be addressed.

Administration refers to administering health systems at different levels: from a primary health centre to the district, State, and national level. This includes implementing and managing health programmes, addressing human resource issues, supply and logistical issues, etc. It includes microplanning of programme delivery, team building, leadership as well as financial management to some extent. A good understanding of the principles of organisational management and health administration is key for acquiring this competency.

The final function is related to advocacy at different levels. In public health, there is little that one can do at an individual level; there must be communication with key stakeholders to change the status quo at different levels of government. This requires clear enunciation of the need, analysis of alternative set of actions and the cost of implementation or non-implementation. Good communication and negotiation skills are critical to perform this function. The related subjects are health policy, health economics, health advocacy and global health. These four functionalities can be applied to any specific or general problem such as environment or nutrition or infectious disease and can be considered to be similar to super-specialisation in other medical fields. Pandemic management required all the four competencies in equal measure.

Training

Training in these competencies in India is provided through a three-year MD in Community Medicine and a two-year Masters in Public Health. The first is exclusively reserved for doctors (the extra year is devoted to provision of medical care), while the second is open to non-medical persons as well. In addition to classroom teaching, public health trainees are posted in communities and at different levels of the health system. Such exposure helps them put all these competencies together to evolve into trained public health professionals. The trainees develop a systems approach and a long-term perspective, which are the crux of this discipline. This is different from a clinical approach, which is focused on individuals and where the time-frame is usually short, if not immediate.

None of the four core public health functions need a medical qualification. The training mentioned above has nothing to do with the human body. Unlike clinical disciplines, it does not divide humans into organs or systems. It is important to recognise that the organ-/system-based medical training inculcates a deeper but narrower thinking as appropriate to it, but this is inappropriate for a broader public health approach aimed at working with communities or health systems. While one could argue that medical knowledge helps understand health issues better, one could also contend that this is not the most effective use of the years spent learning medicine.

Historically in India, public health has been medicalised as it was largely a medical college-driven discipline. It is the resistance of this medicalised public health fraternity that explains the continuing need for a public health professional to have a medical degree. This has also resulted in denying nursing, dental, and other health professionals to contribute more to public health. This needs to go in national interest.

Many doctors and other health professionals work at the grassroots level and develop a good sense of public health due to their inclination. But they do not become public health professionals as they may not have the necessary skills. Nevertheless, they are valuable. Clinicians with training in epidemiology and biostatistics would not qualify to be public health professionals as they lack not only other essential and critical expertise but also an appropriate perspective. Short training or even a year-long distance learning course cannot create a public health professional in the same way that it cannot create a physician or a cardiologist.

It is critical that health professionals, the government, and the public recognise public health as a specific set of competencies and give it the importance that it deserves. The Health Ministry’s recent proposal for the creation of cadres for public health professionals and health management at the State, district and block levels is a welcome step. However, it is not sufficient. There is also a need to look at the quality of public health training being provided. Only this will attract the best and the brightest people into this discipline, which is very important for the nation’s health. This is one lesson that we should learn from the pandemic.

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