Sunday, 23 November 2014

The World Economic Recession

For quite some time there has been an economic recession all over the world. From time to time we hear of a recovery, but in fact there has not been, and there is unlikely to be, a genuine recovery of the world economy for a long time. I will try to explain.
An economic recession is a feature of an industrial, not agrarian economy. In agrarian economies, too, there were catastrophies, but these were due to natural calamities like drought, epidemics, etc. An economic recession is a feature peculiar to industrial economies.

There have been recessions every eight or ten years ever since the Industrial Revolution of the 18th Century in Western Europe. These, however, were followed shortly thereafter by recoveries. But there has been one Great Depression which lasted from 1929 to 1939, and was ended only by the Second World War (in which 50 million lives were lost) which generated the massive demand for armaments, supplies to armies and war affected civilian populations, and capital for reconstruction, etc. This Great Depression caused havoc in large parts of the globe, particularly in the developed countries.

We are now witnessing a persistent, and apparently unending, world economic recession, and its sweep is wider than that of the Depression of 1929, because while the latter affected mainly North America and Europe, the former is affecting the whole world, because while before the Second World War ( 1939-1945 ) many countries ( including India ) were largely unindustrialized, there has been a certain level of industrialization in most countries since then.

WHAT IS THE CAUSE OF SUCH ECONOMIC RECESSION OR DEPRESSION?

The principal cause of an economic recession (or depression) is lack of sales, which in turn is due to lack of purchasing power in the masses. There are other causes also, but these are only incidental, and not the main cause.

A large part of the world’s population is so poor that it hardly has sufficient purchasing power. Even in the developed countries there are many poor people.

Apart from the above, as the industrial economy develops, in the process industries tend to become larger and larger, to effect economy of scale, and more and more capital intensive ( that is, labour being replaced by machinery ). This is necessary for industries to face the competition in the market, otherwise their rivals will become larger and more capital intensive and drive them out of the market, by underselling them. This process is inevitable in most industries, but it leads to large scale unemployment, since many workers in a labor intensive industry are laid off when it becomes capital intensive. This generates unemployment.


Let me explain. There is competition between businessmen in the market. Let us take a simple illustration. Suppose A has a shop selling a loaf of bread for Rs.20. Next to his shop is the shop of B selling the same size and quality loaf for Rs. 18. What will happen ? The customers of A will gradually leave him and become the customers of B, and B will eliminate A by underselling him. Thus one businessman eliminates another not by tanks, guns or bombs but by underselling him.
Now the same thing happens on the national and even international level.


To reduce his sale price a businessman has to grow larger ( to effect economy of scale ) and to introduce new technology. This is because cost of labour is a big chunk of the total cost of production. So if the cost of labour is less, the cost of production is less, and if the cost of production is less, the businessman can sell at a cheaper price, and thus eliminate his business rival.. By introducing new and labour saving technology in his plant, the businessman can cut down his labour costs, and thereby his cost of production.


Suppose a manufacturer had 500 workers working in his plant. With the advance of technology he may get a new machinery which requires only 100 workers to produce the same amount of goods which he was producing earlier. This means 400 workers will become unemployed. Even if 100 of these 400 workers can get jobs elsewhere this still leaves 300 workers unemployed. When we enlarge our scene (because the same process is inevitable in most industries) we find large scale unemployment is being generated everywhere.

Now the worker, apart from being a producer, is also a consumer. Of course a worker in a steel factory does not consume steel. But he and his family consume food, clothes, shoes and various other articles. When he becomes unemployed his purchasing power becomes drastically reduced. And when unemployment is generated on a large scale, the market correspondingly contracts on a large scale, and this leads to a recession.

Thus we see that the very dynamics of an unregulated industrial economy is that by the very inevitable process of its growth it keeps destroying its market.

The goods produced have to be sold. But how can they be sold when people have lost their purchasing power (due to widespread unemployment)?

Mass production has to be accompanied by mass consumption. By taking purchasing power out of the hands of mass consumers the industrialists deny to themselves the effective demand for their products that would justify reinvestment of their capital accumulation in new plants (which would also provide employment ).

Before the Great Depression of 1929 high level of employment was generated by high level of debt in the form of mortgage debts (for housing etc.), loans to buy cars and other consumer goods, brokers loans (for buying shares, etc.). The same thing happened in recent times. But this cannot continue endlessly. A time comes when people cannot repay their debts (due to unemployment or cut in real wages). Then debtors curtail their consumption, which reduces demand, and the producing units have to close down or drastically cut production.

In modern economies, most businesses require loans for their normal operations. Banks normally retain a small fraction of their deposits (5% or less) and give the rest as loans to borrowers. When the banking sector does not work properly (because of defaults by loanees) businesses do not easily get loans, and consequently they have to curtail their production and lay off workers. As they curtail production they require less raw materials and other supplies. Hence their suppliers have to reduce their output and lay off their workers. The suppliers to these suppliers have to do the same.Thus, this can set off a chain reaction.

If manufacturers cannot sell they cannot generate enough revenue to repay their loans. The business goes bankrupt and the bank finds in its hand non performing assets. Hence banks want to lend less. This becomes a vicious cycle.

Depositors get scared because some banks have collapsed due to the non performing assets. Hence they start withdrawing their money, and more banks collapse.

The economic recession is thus caused by the reduction of purchasing power in the masses which is due to the very dynamics of unregulated growth. The productive capacity has been enhanced enormously, but the vast majority of people are too poor to buy.

The problem, therefore, is not how to increase production, but how to increase the purchasing power of the masses. Production can be increased easily several times because there are tens of thousands of engineers, technicians, etc., and there are immense reserves of raw materials in India. But the goods produced have to be sold, and how can they be sold when the people are poor or unemployed, and thus have very little purchasing power?

The problem is also not how to increase demand. The demand is there, but people do not have the money for purchasing goods. In India, for instance, 75% people live on bare subsistence incomes. This may not even be sufficient for buying necessities, like food or medicines, what to say of durable consumer goods like motor cars, refrigerators, computers, air conditioners and other goods.

The solution to the economic crisis can only be by raising the purchasing power of the masses. How this is to be done requires a great deal of discussion and creative thinking , and all serious thinkers must now address this main problem facing our country, and indeed the whole world.

The situation in India today is that while we have recently increased the number of billionaires in our country, the poor have become poorer and even the middle class is finding it difficult to make two ends meet because of rising prices. This is a dangerous trend and if continued is going to lead to widespread social turmoil and social unrest. It is totally unfair to the vast masses of our people and it will not be tolerated very long.

Society owes subsistence to all its citizens either in procuring work for them on a reasonable wage, or in ensuring a livelihood to those who are unable to work.

As stated by the great French thinker Rousseau in his book 'Discourse on Inequality' : “Nothing can be farther from the law of nature,however we define it, than that a handful of people be gorged with luxuries, while the starving multitude lacks the necessities of life.”

Unfortunately, most people are silent about this terrible plight of our people because those who should be speaking out are mostly beneficiaries of the present system, and hence do not want to disturb it.
It is time now that the patriotic intellectuals speak out on these issues.

Saturday, 22 November 2014

Jinhe naaz hai Hind par woh kahaan hain ?


A leading English weekly has on the front page of its 30th November issue the words ' India's Best Hospitals '.

Among these best hospitals is one where I took my wife when she was very ill with septicemia. I must say that the hospital saved her life. 

I was a sitting Supreme Court Judge then. My wife was sinking when I made an urgent call to the hospital. They sent an ambulance with a doctor, and her treatment started immediately on arrival of the ambulance. At the hospital, which is a state of art hospital, she was rushed into the I.C.U. where a team of 12 doctors, headed by one of the most renowned doctors in Delhi, immediately started treatment. After about 3 days in the I.C.U. she improved, though she had to stay in a private ward for another week or so.

I am relating this story to say that had I been an ordinary person in India this treatment would not have been possible. The treatment was extremely expensive, and cost several lac rupees, which could hardly have been afforded by an average Indian. Being a Supreme Court Judge all expenses for the treatment, including medicines and room rent in the private ward, were paid by the government. But could an ordinary Indian have afforded it ?

The top hospitals in India are no doubt very good,but how much percent of the Indian people can afford to go there ? My guess is less than 5%.

In many cities, and particularly in rural areas, people with ailments often go to quacks ( unqualified doctors ), because they cannot afford to go to qualified doctors. The number of quacks may possibly be 5 to 10 times the number of qualified doctors. The government hospitals are mostly no good, while the private clinics are exorbitantly expensive. So many people simply die because they cannot afford proper medical care.

On page 78 of the same issue it is mentioned that India has one of the highest mortality rates in the world. Many of them die from preventable causes like low birth weight, birth trauma, preterm births, pregnancy complications, tuberculosis and congenital cardiac disease. Infants die because of poor sanitation, dehydration, diarrhoea, etc Malnutrition is a major cause of infant mortality. Half the women in India are anaemic.

Page 100 of the issue mentions the tragic case of a vegetable vendor, Rambhor, who was hit by a speeding vehicle in Azadpur Mandi in Delhi. If he had been in any developed country, paramedics would have started life-saving procedures in the ambulance itself ( as was done for my wife ), and he would have reached a well equipped hospital in no time. In Delhi, however, he was transferred from one hospital to another for five hours.

The first hospital claimed that it did not have an I.C.U. bed. The second said its ultra sound facility did not work. The third said that the medico-legal documents were not in place.

Rambhor died in the premises of the last hospital without receiving any medical help.

Dr. Rajesh Garg, of the VCSG Government Medical Sciences and Research Institute, Uttarakhand, mentions this case in a report on the state of emergency medical services. He writes : " The death of Rambhor was not a routine death; it symbolizes the breakdown of emergency medical services in India ".
Jinhe naaz hai Hind par woh kahaan hain ?

Thursday, 20 November 2014

Jammu & Kashmir Floods: Dr. Peter Patel's draft report

Jammu & Kashmir Floods – September 2014
Assessment visit 1st November – 10th November to
 New Delhi and Srinagar by
Dr Peter Patel – International Project Director


Summary and Key Recommendations
1.0   People of Jammu and Kashmir this September witnessed one of the most disastrous flood in their region.   Figures for people and villages affected vary according to various reports.  However, there is no doubt that around 2 million people have been affected by this disaster, 2600 villages are affected in Jammu (1000 villages) and Kashmir and 390 villages were completely submerged.  A great part of Srinagar was transformed into a huge lake.  Many parts of Srinagar had over 20 feet of water with between 1 to 2 floors of buildings under water for several days.  Like any other natural calamity, majority of vital roads were submerged, communication, transport and health services were paralysed
1.1   In this visit a limited assessment could be made from visit to Srinagar from 4th to 7th November.   This is not meant to be a comprehensive report.  Most of the evidence has been gathered by visual review of Srinagar,  listening to local residents, media reports  and information provided by Department of Health.  A review of the City confirmed that most of the city areas were submerged under water.   The river Jhelum spilled over submerging Sonwar, Rajbagh, Jawahar Nagar, Gogji Bagh and Wazir Bagh neighbourhoods of city. The first and the second storey of the houses and hotels in Rajbagh that were packed with tourists were submerged.   Not surprisingly, all 4 major hospitals in Srinagar were badly affected by the floods and Kashmir Mirror reported that all these hospitals were mostly paralysed with large parts of their ground floors under water.  There was  huge loss and damage to expensive equipment and complete loss of functionality for weeks.
Recommendation 1: 
Undertake a full independent review of Business Continuity Plans of the 4 Srinagar hospitals.  Independent review panel should particularly consider whether there was a Business Continuity or Crisis Management plan.  If there was such a plan in place then consideration should be given to:
     1.  Who was responsible for implementing this plan?
     2.  Was the plan deliverable and effective?  What functions were affected by the
          September 2014 floods and what was contingency plan to ensure quick
          restoration of these functions?
     3.  What went right and what went wrong.
     4.  How many staff were trained and what resources were in place to implement the
          plan?
     5.  What lessons can be learnt from this disaster and what steps will be taken to
          mitigate damage in future from similar disasters.
2.0   Srinagar has a flood spill channel which was constructed in 1904 to relieve the strain on the Jhelum in the City of Srinagar.  It is supposed to take 2/3rd of the total flow in the river and was designed to help  river Jhelum to regulate its water levels while passing through the City of Srinagar.  There is clear evidence that this flood channel is no longer fit for purpose, badly maintained and poorly dredged.
Recommendation 2: 
Serious review should be taken on restoring functionality of the flood spill channel.  Visual evidence suggests that this channel and parts of Jhelum river has become dumping ground for building material, and commercial and domestic waste.  Significant part of the waste is non-biological and non-degradable enabling solidification at the bottom of the river and the channel.  Along with this there are building/construction encroachments along the shores.   Major efforts should be made to manage these effectively to ensure future risk mitigation from floods.
There is a lot of learning for Disaster Management Leads from this flood.  We are not sure if the following areas (see below) were taken into consideration and if yes, why were they not effective. 

Mitigation or Risk Mitigation - steps taken to control, reduce adverse effects or prevent a hazard from causing harm and to reduce risk to a tolerable or acceptable.  

There are four types of risk mitigation strategies that hold unique to Business Continuity and Disaster Recovery. It’s important to develop a strategy that closely relates to and matches your regional administration and economic profile.

Risk Acceptance: Risk acceptance may not reduce any effects in many cases but in all cases will allow an assessment of the risks, potential harm and damage and enable planning to reduce level of harm, morbidity or mortality.  Natural disasters are those where we have to accept unpredictable risks, however there should still be a strategy to mitigate from such disasters.  Total risk acceptance as it is done in commercial world is not an option for any government or organisation dealing with disaster management.  
Risk Avoidance: Opposite of risk acceptance. Actions that avoids any exposure to the risk whatsoever.
Risk Limitation:  Usually should be used along with risk avoidance and in many cases it is impossible to have 100% risk avoidance. 
Risk Transference: Risk transference is the involvement of handing risk off to a third party. Usually, a local or state government will use this strategy by passing transferring the handling of risks to Central government or a special central unit such as National Disaster Management Centre.

Did the State or Disaster management leads consider lowering of risks by considering and learning from past disasters?:   
  • Reducing the severity of potential consequences;
  • Reducing the probability of occurrence harmful effects;
§  Reducing the exposure to that risk.
3.0  Several thousands of families have lost their homes, crops and livestock.  Significant infrastructure was either disabled or destroyed. Hospitals, schools, shops and local administrative units have also been badly affected by significant damage, and thousands of businesses have lost everything they owned.    Poverty and unemployment has returned.  There is clearly an economic crisis in the region.  People of Kashmir are not aware of any support they will get immediately or over period of next 12 months for economic recovery which will enable them to restore their businesses.  Those who have become unemployed suddenly are not sure when they will be gainfully employed to support their families.  Poverty is setting and there is a big challenge to support these communities through these difficult periods.
Like with any major disaster, water and sewerage systems have been badly damaged.  To repair and restore these systems will take several months.  The first key challenge for survivors is access to clean water, safe food and sanitation.  The second key challenge for the survivors is to survive the harsh winter which has started and will last till end of March 2015.   We did not find any evidence for a ‘Winter mitigation and crisis management plan.’
While large part of the country recognised and appreciated the role of Army during these floods, many local communities and commentators were critical of the media’s uneven focus,  heavy coverage of Army support and not recognising a great job done by the local people.   Overall review based on local people’s comments and media reports indicate possibility of deficiency in rescuing many stranded communities, very poor support and absence of effective manpower and appropriate resources for distribution of aid.  This does not in anyway reflect truth and reality of the situation.  Those who would be affected by such calamities will always find few hours let alone few days wait  too long and inadequate.  It should be recognised that during such mega disasters, it is difficult to map extent of disaster and support needs of the communities over several thousands of square miles of land in absence of communication networks and immobilised infrastructure.  


Recommendation 3: 
It is important to make clear that this recommendation does not indicate that these steps are not being taken by the State Government.  Much of the assessment was limited because of two days of curfew in the region, there by restricting amount of reliable information gathering and evaluation.  
a)  It is recommended that government officials undertake a rapid review of supply of clean water, safe sewerage and removal of garbage, assessment of contamination of water supply from chemicals and hazardous waste.  We did not have any access to reports on assessment of chemical contamination.  Regular monitoring of water supplies should continue even when earlier testing indicates safe water.  It is important to understand that when such disaster occur, water supplies can be contaminated even at later date because of damaged sewerage and subsequent contamination of water because of poor sanitation facilities.  Ensure quick repair and restoration of water and sewerage systems and upgrading of the system instead of use of short term ‘bandaid/sticky plaster’ method.
b)  Much work needs to be done to mitigate increase in morbidity and mortality from cold and freezing temperatures of severe Kashmir winter.  Most affected people who have lost their homes will be living either in over-crowded shared homes or equally overcrowded poor temporary shelters.   It is predicted that the winter pressures will increase mortality within the babies, infants the elderly.   Winter usually sees an increase of upto 30% in illnesses and many deaths occur as result of respiratory illnesses or heart attacks.  Most homes and offices will not have dried completely, and the resulting damp will continue to increase winter related illnesses. 
There should be continued needs assessment which could  be carried out jointly with NGOs and provision should be made to keep people warm and well with clothing, blankets and nutritious food.  The regional commissioner has assured us that large quantities of blankets have been distributed and all the affected communities have adequate supplies.  However, anecdotal briefings have suggested that many families who did not stay in camps but went to stay with relatives have not received any aid.
4.0  Jammu & Kashmir State Disaster Management policy makes a good reading along with Jammu and Kashmir NIDM publication.  These documents while well written raises many questions within the residents of Jammu and Kashmir, many Indians and independent NGOs.
The Jammu and Kashmir Disaster Management policies states:
a)  Area flood mapping using GIS and Remote Sensing will be prepared to make future preparedness plans.
b)   Forecast and warning system using modern scientific know-how will be improved.
c)   Proper river bank protection by constructing embankments and using anti-erosion measures will be taken up on a large scale. Involvement of PRIs by taking benefit of schemes like MNREGA will be given priority.
d)   In flood prone areas, evacuation capabilities should be enhanced.
e)   Construction of residential colonies on river banks and flood plains will not be allowed. Offenders will be dealt under law.

A number of people is Srinagar and New Delhi I talked to were clearly not convinced that these policies have either been implemented or if implemented were effective during the floods of September 2014.   Most people in Srinagar confirmed that there had been adequate warnings about impending floods.  However, most residents chose to ignore these warnings.  We could not establish whether the whole of region was adequately informed.  There was some confusion between the people providing the warnings and those receiving the warnings.  Most people I talked to stated that there was absence of clarity regarding which areas were safe areas, inadequate information on how long and how bad the floods were going to be and poor support for people to move from their homes to a safer areas. 

Most importantly, we have identified absence Community Disaster Preparedness Strategy and Management plan.  Every person we talked to in Srinagar or in New Delhi had never heard of Community Disaster Preparedness and had little understanding of their (communities) responsibility for disaster preparedness and limiting harm or damage from such crisis.

The NIDM Jammu and Kashmir plan published in 2012 is a good starting document along with the J & K Disaster Management Policy  2011 document.  Both documents show that the officers of the State have an excellent understanding of Disaster Management.  However, there are indications that the operating structures are ‘silo’ and ‘role’ culture based systems and likely to fail because of bureaucratic nature of command control, responsibilities of the nodal officers and compartmentalised  structures.  It is possible that the challenges faced during the September floods were as a result of these plans and consideration should be given to finding an integrated approach (both vertical and horizontal integration) in future. 

There is evidence that areas listed in c), d) and e) need strengthening and implementing.  Visible evidence around Srinagar also indicated that a large proportion of housing built in the region which was badly damage was of very poor standard. Many new or recently build properties also appeared to be of similar lower quality.  It is no surprise that these buildings could not withstand the September 2014 floods.  Considering the impact of the floods, the key concern for Disaster Management Authority should be whether these buildings will be able to survive a moderate earthquake.

This should not be taken a blame apportioning but lessons to be learnt. 

Recommendation 4: 

1.   Review information gathering as stated in a) and b)  above and improve planning for mitigation, improve community communications and effectiveness for community preparedness.
2.  Reconsider logistics and implementation of purpose stated in d) above.
3.  Ensure early implementation of purpose state in c) and e) above.
4.  Strengthen building regulations to ensure that all new buildings and reconstructions are built to appropriate specifications to reduce serious damage from floods and earthquakes.


5.00  Review of Health Needs – A significant part of our assessment and review was facilitated by Mr G H Kaloo, President of J & K Press Association.  I would like to acknowledge full open and transparent process of providing information by the Directorate of Health - Kashmir, extensive discussions with doctors of the Directorate of Health Services, Kashmir,  Mr Rohit Kansal, Div Commissioner and Dr Saleem-ur-Rehman, Director Health Service Kashmir.   

We would like to commend the Directorate of Health – Kashmir for their robust understanding of health needs and public health risks following major floods.  A Crisis Management Centre was set up at Division of Epidemiology and Public Health.  Evidence was presented through discussions, documentation and visit to Crisis Management Centre.  The Centre was well prepared to gather and analyse information they were receiving from the region.  Team led by  Dr Rehana Kousar along with Dr S M Kadri, Dr Ijtaba Shafi and Dr Rashid Para shared all requested information on disease monitoring and management of post-floods immunisation programme.   

Displacement related Health Problems:

After any disaster there is significant risk of communicable disease transmission to the displaced population.    The risk is higher when large population is affected such as in Kashmir floods and non-availability of safe water, food or sanitation over several days. 
Additional risks are associated with nutrition status, age of the population and level of
the level of immunity to vaccine-preventable diseases such as measles and access to healthcare services. 

Risk Factors for Communicable Disease Transmission.

Effective response to health needs of any disaster affected population requires a robust communicable disease risk assessment.   We believe that the Directorate of Health – Kashmir had this in place.  There was evidence that the key staff in the Directorate had taken into consideration to identify endemic and epidemic diseases that are common in the affected area.  In its post flood support delivery they had taken into consideration living conditions of the affected population, including number, size, location, and density of settlements and availability of safe water and adequate sanitation facilities.   Reports presented by the Directorate also show that they had taken into consideration degree of access to healthcare and functionality of healthcare infrastructure under their control.

The Department was more than adequately prepared for monitoring water-borne diseases, such as typhoid fever, shigellosis, cholera, leptospirosis and hepatitis A & E (through jaundice monitoring) and vector-borne diseases, such as malaria, dengue and dengue haemorrhagic fever.   

It is commendable that the Directorate had also taken into consideration spread of most flood borne diseases and there was good evidence of mass immunisation programmes for measles.   More than 9.37 lacs of measles vaccinations have been administered in Kashmir valley.

Floods have certainly resulted in power cuts and this would have resulted in affecting functioning of health facilities.  Consideration should be given to damage to vaccine/drugs cold chain and any vaccines or drugs affected by this should be destroyed.  We understand that the Directorate of Health has already taken appropriate steps in this area.  Furthermore they have also advised people not to purchase or use medicines affected by floods.  Retail pharmacies in the region have been instructed to destroy all medicines affected by floods.

Most of the data gathered was raw figures of recorded infections or symptoms from different districts.  The information was well mapped.  Despite of huge risk factor posed by this major flood, raw data available on reported and diagnosed infection indicated no significant increase in enteric/diarrheal diseases or jaundice symptoms as compared to previous year’s figures.   The medical team attributed this low rate to rapid distribution of over 11 lacs of chlorine tablets,  provision of health education on water and food safety in camps and most affected regions.  The change in weather to lower temperatures also contributed to reduction and limiting of many traditional enteric infections.   It was recommended that in future the team should analyse the data on the basis of per 1000 population and also record age of the patients.  This would enable identification of  clusters/pockets of infection(s) at either camp sites or overcrowded localities where there may have been breach of sanitation and water or food pollution or rise in acute respiratory infections.  Recording of age would also enable whether babies/children or old people were mainly affected as compared to young healthy adults.

Non-epidemic diseases:  We did not discuss or review other areas of increased risk of infection of water-borne diseases contracted through direct contact with polluted waters, such as wound infections, dermatitis, conjunctivitis and ear, nose and throat infections.  Limitations of resources, diverse provision of health care through private and public sector, limited access to health care and challenges of recording and gathering data for all health care needs from a population dispersed over a large geography is a very complex and difficult task for any developing country.

Infectious disease risks from dead bodies:

There is always a potential for spread of infection from dead bodies post disaster.  An increase in large number of dead bodies post any disaster may increase concerns of disease outbreaks.  It is important to understand risks of epidemics as result of dead bodies post disaster.  In majority of the cases the deaths post natural disasters are as a result of trauma or drowning.  In such instances, the human remains do not pose a risk of epidemics.   Dead bodies do pose a risk when the death(s) are as a result of infections such as cholera, typhoid or haemorrhagic fevers.    We do not have accurate figures for number of deaths in Jammu and Kashmir floods.  Media reports indicate over 300 people were dead by mid-September

Dead bodies do pose significant risk to persons who are involved in close contact with the dead.  Such personnel in Kashmir floods could be military personnel, rescue workers, volunteers, health care workers and others involved in recovery of the bodies and post death funeral management.  These personnel are at risk of being exposed to chronic infectious agents (Table 1).

Table 1 – Infectious Agents linked to dead bodies post natural disasters

Bloodborne

Hepatitis B
Hepatitis C
HIV

Gastrointestinal

Rotavirus diarrhoea
Campylobacter enteritis
Salmonellosis
Enteric fevers (typhoid and paratyphoid)
Escherichia coli
Hepatitis A & E
Shigellosis
Cholera

Respiratory

Tuberculosis


·         Tuberculosis can be acquired if the bacillus is aerosolized (residual air in lungs exhaled, fluid from lungs spurted up through nose/ mouth during handling of the corpse).
·         Exposure to bloodborne viruses occurs due to direct contact with non-intact skin of blood or body fluid, injury from bone fragments and needles, or exposure to the mucous membranes from splashing of blood or body fluid.
·         Gastrointestinal infections are more common as dead bodies commonly leak faeces. Transmission occurs via the faeco-oral route through direct contact with the body and soiled clothes or contaminated vehicles or equipment. Dead bodies contaminating the water supply may also cause gastrointestinal infections
Source:  WHO Flooding and communicable diseases fact sheet

We were unable to establish whether suitable precautions for these persons were in place from our discussions or from copies of reports we received.  We recommend that Disaster Management Plans and Directorate of Health should include mandatory training in appropriate use of body bags or recovery and storage materials, use of  disposable gloves, good hygiene practice and vaccination for hepatitis B and tuberculosis.   Disposal of bodies should respect local custom and practice where possible.   However, it would be very difficult to monitor the whole region effectively, as many dead bodies would be handled by relatives without adequate protection or knowledge and the need for immediate or early burial because of religious and cultural considerations.    Consideration should be given to protecting individuals and volunteers from mohollas and educating mohalla committees of potential risks posed by dead bodies.  This could form part of Community Disaster Preparedness education.

Tetanus booster should be considered for all personnel involved in rescue and those injured people with open wounds or serious cuts.  Director of Health should also consider use of passive tetanus vaccination for appropriate personnel and wounded people.   The above recommendation does not in any way imply that this has not been considered or is not in the disaster management plan.

Vaccination against Hepatitis A:

Generally mass immunisation for prevention of Hepatitis A is not recommended.  However, this is a recommendation only and should be reviewed on the basis of local situation.   All personnel involved in management of drinking water, food chain, waste management, contaminated water or sewerage management, sewerage  should be considered at high-risk and should be offered hepatitis A vaccination.  Where an outbreak of hepatitis A is confirmed, than hep A immunisation of all contact is strongly recommended. 

Other considerations - Moulds and mildews

We did not discuss longer term implications to health resulting from damp accomodation and its impact.  As a result of rapid change in regional weather there has been very little time for most buildings to dry.  Therefore we anticipate health problems arising from dampness where there could be heavy exposure to moulds and mildews.  The key health consideration should be given to those suffering from allergies and asthma.  There is significant risk of contracting upper respiratory diseases with cold-like symptoms.  People affected would present with wheezing and difficulty in breathing, dizziness, soar throats etc.    Babies/infants, children, elderly people,  pregnant women and immunocompromised are some of the groups who are at risk from damp and mould related triggering of health problems.   

Other Diseases Associated with Crowding:

In most natural disasters crowding is a key factor for the displaced population.   It is not usually the disaster itself but the collateral impact from crowded living created as a result of the disaster which responsible for spread of many communicable diseases.    Kashmir floods are no exception to this.  Crowding in most conditions is responsible for the transmission of several communicable diseases.  Directorate of Health – Kashmir has already dealt with managing risks of measles outbreak through mass immunisation programme and other water borne transmission of infections. 

This part of the report will deal with potential of other communicable diseases which are not considered as immediate risk and should be considered as part of on going disease control programmes.

A large number of homes were destroyed during the floods.  As a result of change in the weather conditions majority of the displaced and affected population will not be able to rebuild their homes this winter.  This has resulted in continued crowded living conditions in temporary shelters and shared homes with relatives and now provides major challenges for Kashmir healthcare providers.

It is recommended that the Health Directorate also focuses on spread of respiratory pathogens in post-disaster settings including those referred to as Acute Respiratory Infections (ARI) in many reports.  These would include viral (influenza, RSV, adenoviruses), bacterial (Strep pneumoniae, pertussis, tuberculosis, Legio­nella, Mycoplasma pneumoniae), and diseases transmitted via the respiratory route (measles, varicella, Neisseria meningitides).    C. Sandrock  (Infectious Diseases After Natural Disasters. California Preparedness Education Network. A program of the California Area Health Education Centers. March 7, 2006.)  has reported an increase in illnesses after Hurricane Katrina.  The propor­tion of ARI was 12% four days after the levee overflowed and 20% during the next four weeks.

Tuberculosis:  Most people do not associate Tuberculosis (TB) with natural disasters.  However, this is a misplaced thinking and there is good evidence that TB does spread among displaced populations.   Most infectious disease experts recognize that because of Inadequate access to healthcare, nutrition deficiency and overcrowding among refugees has led to in an increased spread of TB within this group ( Surmieda MR, et al. Surveillance in evacuation camps after the eruption of Mt. Pinatubo, Philippines. MMWR. CDC Surveill Summ. 1992;41:963.).   Literature has recorded a four fold increase in TB dur­ing the war in Bosnia and Herzegovina in 1991 and during the civil war and famine in Somalia in 1991-92, the incidence of TB increased four-fold.   In Somali refugees of 1985, 26% of deaths were attributable to TB.  

Malnutrition, over crowding, poor monitoring and access to health care some of the factors for transmission, mor­bidity, and mortality of TB in displaced peoples.   Currently, TB and particularly MDR TB poses huge health threat in India.  The Directorate of Health should pro-actively consider diagnoses, management and control of TB among the flood affected community.   Ensuring continuity of care of previously known cases should be a top priority.  The second most important priority should be detection and management of new cases.   (Epidemics After Natural Disasters, David M. Lemonick, MD, FAAEP, FACEP
Based on a presentation at the 2011 AAPS Annual Scientific Meeting, Tysons Corner, VA, June 21-22)

Meningitis:  It is well recognised that meningococcal meningitides is transmitted from person to person, particularly in situations of crowding.   WHO (2005 & 2006) has reported cases and deaths from meningitis among those displaced in Aceh and Pakistan.  Large outbreaks have not been recently reported in disaster-affected populations but are well-documented in populations displaced by conflict. 

Prompt response with antimicrobial prophylaxis, as occurred in Aceh and Pakistan, can interrupt transmission. Large outbreaks have not been recently reported in disaster-affected populations but are well-documented in populations displaced by conflict.    Haj immunisation programme may provide protection to those already immunised but serious consideration should be given to non-immunised population at risk.

Acute respiratory infections (ARI) are a major cause of illness and death among
displaced populations.  Elderly population of the age of 65, people with certain long term conditions and children <5 years of age are the risk groups.   Some of the factors linked to increased risks of death have been lack of access to health services and availability or affordability of antimicrobial agents for treatment.   As already mentioned above that over crowding as result of displacement from floods and severe winter conditions will be a major factor for increase in ARI and deaths this winter.   In addition to this,
exposure to open-flame cooking and malnutrition, will also contribute to morbidity and mortality from ARI.    

Evidence of Disaster Related ARI deaths:  In 2004 tsunami, ARI was responsible for most of the deaths among survivors of Aceh.    A four fold increase in the incidence of ARI was recorded in Nicaragua in the month fol­lowing Hurricane Mitch in 1998.

It may be difficult for any health service to consider management and preparation for all documented ARI.  It is recommended that plans should be drawn up to reduce impact from seasonal influenza and Streptococcal  pneumoniae in high risk population.   Serious consideration should be given to rehabilitation programmes and community based initiatives for ‘keeping well-keeping warm.’  


Polio:  While India has been declared polio free, continued efforts should be made to provide polio immunisations.  Pakistan is one of the three countries where polio is still endemic.   Because of close proximity of Kashmir region with Pakistan and challenges from flood displacement, polio monitoring and immunisations should continued in robust manner.   

Mental Health:

All disasters will cause both emotional and physical trauma.  Most health systems of developing countries are poorly prepared for managing mental health problems of the displaced population as a direct result of stress, fatigue and poor living conditions.

Various reports attribute a major health hazard of floods to mental stress or psychological distress due to exposure to extreme disaster events.  People who have experienced devastating floods will have seen loss or injury to their families, destruction of their homes and business, loss of employment and economic stability, and exacerbation of personal health problems.  It is recognised the floods pose long-term psychological impact on the victims.   In developing countries most people do not have insurance or savings to repair their homes, restart their business resulting in mental trauma and psychological challenges.  Post-flood recovery in Kashmir is going to be prolonged.    Common mental disorders will be anger because of delayed or poor support from the system for rebuilding their lives, anxiety about managing and supporting family and finance, depression in many cases, hopelessness and lethargy, sleep deprivation and hyperactivity.  Little attention is paid to behaviour changes in children and female family members.

Post-disaster management plan should consider providing appropriate support to manage mental health of the affected population through the health system by provision of mental health counsellors, emotional support through community networks mohallas and trained volunteers from NGOs.  In severe cases, access to expert Psychological Services should be available.  Local authorities should consider community assurance programmes to the victims who would be worried about future floods.  Rapid rehabilitation and reconstruction programmes, support for clean-up and employment generation could be enabling factors for reduction in anxiety and depression.  Some experts also identify increase in exacerbations in people suffering from hypertension and cardiovascular diseases as a result of increased in stress post flooding.

Recommendation 5:

1.  Focus should be on managing the health needs of the surviving disaster-affected populations.
2.  Keep infectious disease control programme active and effective.
3.  Continue to provide public health education and support for the affected community and improve provision of water treatment and sanitation.
4.  Prepare and implement a robust winter pressure plan to manage many of the post disaster health problems with focus on reduction of morbidity and mortality.
5.  Assure access to primary healthcare services and continue surveillance of communicable diseases. 
6.  Provision of a robust and effective mental health support system.
Next Steps
Jammu and Kashmir
Proposed Action
Lead Person(s) Responsible
Pilot project for managing seasonal influenza and pneumococcal infections in affected communities.
It is proposed to pilot immunisation of upto 1000 at risk people for seasonal influenza and pneumococcal (Streptococcus pneumoniae) as soon as possible this winter.  The project should be undertaken in partnership with Directorate of Health – Kashmir and local NGOs.  Results and outcomes should be monitored with similar weighted unvaccinated population.
Funding will be raised by Justice Markandey Katju and Mr G H Kaloo.
Action:  Directorate of Health to provide information on current market cost of the above vaccines and review its capacity and ability to deliver the project in or around Kashmir Valley.

Dr Rehana Kousar and team members.
NGO lead:  Mr G H Kaloo.
Dr Peter Patel to advice on planning and KPI.
Community Support programme – ‘Keeping Warm – Keeping Well’  for winter ending March 2015.
Action:  Survey the needs for blankets, food and warm clothes for the affected community.  It is proposed that Mr G H Kaloo and local NGOs will carry out needs assessment for the above.  Based on the needs assessment and prioritisation, Justice Katju will appeal for funds for purchase of appropriate goods and support and Mr G H Kaloo with the support of local NGO volunteers distribute the aid to the displaced community.
NGO volunteers will measure impact of the support at the end of March 2015 by surveys and face to face interviews of the beneficiaries.




Mr G H Kaloo to work with NGOs and Directorate of Health and Mr Katju.
Community Disaster Preparedness Training Centre & Course
The key weakness identified from Kashnir 2014 floods disaster was absence of community preparedness for floods and understanding their responsibilities following disaster warnings.
It is proposed to start a ‘Community Disaster Preparedness Course’ for disaster mitigation.  The project will aim to establish a regional Training Centre with focus on training the trainers in the first instance.  The trainers then will systematically train the communities at risk. 
Action:  Outline plan for the course material to be provided by end of Feb. 2015 by P Patel.  Mr G H Kaloo to work with local NGOs and State Disaster Management Team to agree to joint working.  It is proposed to train  1. Around 50 trainers by end of September 2015  2.  Trainers to train 25 communities and carry out evaluation of training through agreed KPIs.







Dr Peter Patel Course lead
Mr G H Kaloo – Regional NGO lead.
J & K State lead to be identified.

Faculty of Disaster Medicine
1.  It has been agreed that Directorate of Health will establish a training Faculty for Disaster Medicine for Jammu and Kashmir in partnership with the New Delhi Faculty for Disaster Medicine.   An invitation to join as the founder members of Indian Faculty of Disaster Medicine has been accepted by Dr Saleem-ul-Rehman (Director) and a team of 4 doctors have from the Directorate of Health have been nominated to lead this project.  There are no dedicated Institutes or training courses available in Asia for Disaster Medicine.   Faculty of Disaster Medicine is a project of ‘Saving Lives’ programme of UK and is a long term project to build trained healthcare HR capacity and increase understanding of resource needs and management of all kinds of disasters.
Action:  Srinagar team to join development week-end 20- 22nd March in Pune for the Faculty.
2.  Disaster Management Training
Resulting from visit to RIHFW Dhobiwan, a request was made for Disaster Management Trainers.  Peter Patel agreed to provide a group of trainers in 2015 as part of development the Faculty for Disaster Management.   
Action:  P Patel to liaise with team from Dhobiwan Centre to develop the programme.
 Dr Peter Patel to provide pocket book for BLS ‘aid memoire’ prepared for Goa.

Dr Peter Patel
Justice M Katju
Dr Naresh Trehane – Medanta,  New Delhi
Dr Yatin Mehta – Medanta, New Delhi
Dr Rehana Kousar and team, Srinagar





Dr Peter Patel for ‘Saving Lives’
Lead from Dhobiwan to be agreed.

Provision of Community Mobile Clinic
A brief meeting was held with Dr Ludana, Clinical Lead of regional NGO.  The lead and the NGO were recommended by Mr G S Kaloo and Dr Rehana Kousar.  It was agreed that Dr Ludana will make a business case for need of a mobile Clinic for provision of urgent care, field screening service and health education of people living in remote communities.  It was agreed that the project will work in partnership with the local health services.
Action:  Dr  Peter Patel to evaluate the business case.  Subject to approval by  ‘Saving Lives’ advisors and establishing local needs, PP to raise funds for provision of a 4 x 4 off road vehicle for use as Community Mobile Clinic.



Dr Ludana
G H Kaloo
Justice M Katju
Dr Rehana Kausar for the Directorate.






Next Steps
New Delhi
Proposed Action
Lead Person(s) Responsible
Actions for Kashmir – See above
Asif Azmi
Justice M Katju
Mr G H Kaloo
Dr Peter Patel
Establish Faculty for Disaster Medicine – New Delhi.
New Delhi Faculty to be lead for all future faculties in the north of India.  Immediate partner – Jammu and Kashmir Faculty of Disaster Medicine.
Justice M Katju and Dr Naresh Trehan  from Medanta-Medicity have been invited to become trustees of ‘Saving Lives – India Foundation’ and have accepted.

Peter Patel and Ravi Varma to formalise the invitation by letter.
 Pune founder team have been informed and all founder team members have welcomed the proposal.  Dr Yateen Mehta has been appointed by Medanta-Medicity to lead on the project. 

Actions:  Dr Peter Patel to provide a briefing paper for Justice Katju and Asif Azmi.  Dr Peter Patel to provide details of the proposed launch of the Faculty in Pune on 20-22 March 2015.   Final plan to be agreed with Pune Management team by 15th December and circulated to all other partners.

Invitation to potential delegates for launch programme to go out by 10th January 2015. Invitation to go to Dr Pawar Vats – Public Health for Food Safety, New Delhi
Invitation to go to Mrs Vats – Public Health Lead, Edinburgh.  Prof Keith Porter, Royal College of Surgeons – Edinburgh for follow up for Pre-hospital Emergency Course.









Peter Patel