The Tribune, Chandigarh, India

ARTICLE

Time to focus on job creation
Centre can act as a facilitator
by Jayshree Sengupta

Considering that there is a strong possibility of recession striking the US and the European Union, India’s economic problems may pale in importance. According to the latest data, India’s industrial growth rose to 8.8 per cent and manufacturing to 10 per cent in June 2011. Foreign direct investment inflows have also picked up. Though there is high food and general inflation, it is not yet in double digits. India’s public debt has also not reached the danger level.

The US, on the other hand, is combating its monumental debt problem with fiscal tightening measures so that the government does not go bankrupt. The problem of unemployment, though closely monitored, has been kept in the background. Many Americans are of the opinion that unemployment is the most serious problem facing the US, and not the budgetary cuts and the downsising of government spending. Unless there are more jobs, the consumer demand and revenue collection will deteriorate further.

According to the New York Times, the US has 9.1 per cent unemployment but it would be 16.1 per cent with 25.1 million people considered jobless if those who have only part-time jobs and those who have given up looking for work are also included.

Similarly, in India, slow employment growth is a serious problem facing the government. That jobs have been growing very slowly has come out clearly in the latest ( 66th round) National Sample Survey based on the data collected during 2009-2010 in its eighth quinquinnial round covering the five-year period between 2004-05 and 2009-10.

From the survey it is clear that 8 per cent GDP growth of the last five years has not translated into a higher level of job creation. There was a dramatic deceleration in total employment growth from an annual rate of 2.7 per cent during the previous five years period (1999-2000 to 2004-05) to only 0.8 per cent in the latest round. This means that India has been experiencing jobless growth during the last five years.

The latest NSS data also reveal that there has been an increase in employment of less than a million people in the country between 2004-05 and 2009-2010 despite the high level of economic growth. Another shocking revelation is that fewer women are taking up paid jobs in both rural and urban areas. Their participation in the labour force has been the lowest since 1993-94 in all age groups and not only in those age groups (15 to 24 years) undergoing education. There has been a 20 per cent decline in employment for self-employed women in the last five years. Why have so many women withdrawn from economic activities? Maybe, the number of women engaged in home-based crafts and handlooms have declined because of lack of capital or lucrative marketing outlets or due to competition from cheap Chinese imports. Maybe, women were working for exporters who faced losses (like in garments) during the last five years when the financial crisis hit Indian exports and they lost their jobs.

While it is true that a substantial number of young boys and girls (around 20 million) are engaged in studies and there has been around 50 per cent rise over the five-year period for both males and females going through education, it does not fully explain why employment growth has been so slow. More people have entered the job market in the last five years than in the previous five years, and clearly the supply of labour has not shrunk due to young people studying.

Also, it is hard to explain the fall in unemployment for both males and females because only “casual” jobs have increased and that too mostly in urban areas. In rural areas the increase in casual work and construction reflects that jobs have been created under MGNREGA. There is also some increase in employment in financial services and the real estate sector.

An increase in casual work indicates that rural migrants are joining the informal sector in the cities. The increase is marginal for rural women. For the rural migrants, only the lowest menial jobs like those of domestic help, maids, drivers, cooks and chowkidars are available. Most migrants arriving in cities from villages take up these types of jobs and live in awful conditions. Though these “casual” jobs have been increasing, they are without any safety net or benefits.

The data also point out that Indian agriculture is not growing fast enough to provide jobs to the 67 per cent of the rural population still dependent on it. Employment fell sharply for agricultural and non-agricultural workers taken together and there has been a slowdown in non-agricultural job creation. Agriculture is contributing only 14 per cent to the GDP and this means low productivity and surplus labour continue to plague the farm sector.

There has also been a decline in employment in manufacturing both in rural and urban areas which means that food processing and other allied activities which could have employed more people have not grown fast enough. If more jobs were available in villages, then there would not be so much pressure to migrate.

The problem today is that even if there are jobs, most young people are not “employable” as they lack proper education and have few marketable skills. The large numbers of school dropouts are barely literate and it is difficult for them to find jobs in cities except the lowest paying ones. Also, what will happen to 8 million children who are not attending school?

There has to be a plan to provide jobs for all in the future, keeping in mind that those who are currently studying are going to be in the employment market in the next five years. Even the US is contemplating a plan for providing jobs to the jobless by reconstructing old schools across the country, but it is not going to be easy. In India, more labour-intensive infrastructure projects could be encouraged but most highway and expressway projects are using prefab, machine-made units that require big machinery to assemble them. Most of the metro-projects are being built using capital-intensive techniques. Rural road building projects undertaken by state governments, on the other hand, can employ more people.

The Central Government can play the role of a facilitator in creating jobs in rural areas by setting up institutes for vocational training. It is more important to give them a purpose in life rather than let them idle away their time after they finish school. While inflation fighting has to continue till it comes down owing to falling international oil and commodity prices and a possible decline in the demand, creating jobs is most important for the health of the economy and the wellbeing of the people.

MIDDLE

Reformers and the revolted
by Uttam Sengupta

Aar na” in Bengali stands for ‘Aur Nahin’. Enough, no more. And every time I switched on the TV these last few days, an involuntary gasp, ‘oh, no’ would escape my lips.

Anti-corruption movements raise my hackles. Having once refused to pay a bribe and paying the price by going to the court for 14 years, I know what Anna and his team are talking about. But the agitation is too pat, too ‘filmy’, too ‘TV-genic’.

Patriotism and politics both are in some ways the last refuge of the scoundrel and watching the sea of humanity waving the tricolour, beating breasts and chanting ‘Vande Mataram’, some of them gaping at TV cameras and mouthing ‘Mata Ram’ makes me wonder. The sight of Sri Sri Ravishankar, the godman of the rich and the trendy who claims to have restored peace everywhere from Kashmir to the North-East, makes me even more uncomfortable.

French students, who took over the Sorbonne for several days in the sixties, had explained that they were neither rebels nor revolutionaries. They were just the revolted. But Team Anna is behaving more and more like the principal opposition party, Parliament, the bureaucracy and the Supreme Court rolled into one. Reminds me of a reporter who would unfailingly remind public sector executives that they were ‘servants’ and he a member of the ‘public’.

An enlightening newspaper report informed that teenaged college students had discovered Ramlila Ground to be the perfect place for dating. Their parents, one of them explained, were actually proud of them when they returned late now and relayed back to them the sights and sounds of the ‘second freedom struggle’. One of the boys confided that he had made more girlfriends at the Ramlila Ground in two days than he could in college in the past two years.

Others would be flocking to the ground to partake of the free lunch. Apparently, it is not just daal-chawal but includes kachoris, samosas and poori-bhajis.

The ‘free lunch’ counters are a great idea and should perhaps continue even after we attain freedom for the second time. With the national capital attracting the unemployed from several states, the counters would work overtime. And the government could be asked to finance it at a later date. If it dared to refuse, we could have a third freedom struggle. Why, Ramlila Ground could be turned into a Hyde Park of sorts, where anyone with an agenda can expect to find a crowd willing to listen.

Pandit Nehru had threatened to hang ‘blackmarketeers and hoarders’ from the lamp posts. But they flourished like never before. Later, students hit the streets of Bihar shouting “Gali, gali mein shor hai/ K.B. Sahay ( the then CM) chor hai”. But chief ministers who followed became even more brazen. Jayaprakash Narayan called for a ‘Total Revolution’ and a war on corruption and price rise. The movement managed to topple a government but made no dent on either corruption or price rise. And now Anna…aar na.

Light a candle, wave a flag, wear a cap, walk in a crowd, chant a slogan, hold a placard, go on a fast …but for how long?

OPED-HEALTH

Patient safety
Whose responsibility is it?
According to the latest figures given by WHO, in developed nations, one out of 10 patients admitted in hospitals are at the risk of suffering from an adverse event. This figure is much higher in developing countries – may be even 10 times higher
Dr Jagjit Singh

Patient safety can be defined as the measures taken by individuals and organisations to protect healthcare recipients from being harmed by the effects of health care services. This may seem a bit intriguing at first — how can the patient be harmed by healthcare provider/hospital? But the fact is — it is true. Many of us may have experienced it ourselves or have a near or dear one affected by it. Patient safety is a serious global public health issue.

In recent years, countries have increasingly recognised the importance of improving patient safety. In 2002, World Health Assembly passed a resolution on patient safety. In 2004, an organisation, World Alliance on Patient Safety, was established by the World Health Organisation (WHO).

India has awakened to the issue of ensuring patient safety by starting a National Initiative for Patient Safety in 2008 at AIIMS. According to the latest figures given by WHO, in developed nations, one out of 10 patients admitted in hospitals are at the risk of suffering from an adverse event. This figure is much higher in developing countries – may be even 10 times.

What is an Adverse Event (AE)?

An event that results in unintended harm to the patient by an act of commission or omission (administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.) rather than by the underlying disease or condition of the patient. It may or may not be preventable e.g. patient falls, medication errors. For example, a patient who is prescribed some sedatives (sleep- inducing) medicine has a fall due to which he develops a fracture. In this case it was the patient’s sleepiness that may have caused him to trip and fall resulting in a fracture. Thus, though fracture is not a side-effect of sedatives, this unfortunate patient has experienced what can be labeled as an adverse event attributable to his undergoing treatment.

Adverse events may or may not be preventable

While some adverse events like adverse drug reactions – hypersensitivity/allergy to medications may not be preventable in the first instance many adverse events are preventable. These include errors during surgery e.g. operating on the wrong side of the body/limb, leaving behind an instrument/ gauze piece after surgery, medication errors, diagnostic errors etc. As far as unpreventable adverse events are concerned, little may be left in our hands to get control on these. However, the preventable errors should be tackled head-on to ensure patient safety.

Medication error is one of the commonest and easily preventable adverse events. Medication error has been defined by WHO as an error in the process of ordering, transcribing, dispensing, administering, or monitoring medications, irrespective of the outcome (i.e., injury to the patient). Thus an error occurring at any step of medication use –right from being prescribed (ordering) by the doctor to its administration and monitoring — is included in this term. As far as errors in prescribing are concerned it depends on the prescriber’s competence and experience.

Medication error can occur during prescribing

There are a number of incidents where a wrong medication has been prescribed owing to a misdiagnosis or inadequate knowledge about the disease or medication in question. Prescribers (mostly doctors in our setup) should ensure they know everything about some drugs, which they use routinely; rather than trying to know something about every drug available in the market. Knowing exactly the medication’s effects, mechanism of action, pharmacokinetics and side-effect profile along with recommended dose can enhance proper use and minimise errors in the prescribing process.

Since every prescription is a medico-legal document it must be written legibly in ink or online on computer. Nobody can deny the terribly illegible prescription which may not be deciphered even by experienced pharmacists, at times, leading to potentially serious medical mishaps. The problem is compounded when two drug names sound alike but have totally different medications. For example, Zyntec is the trade name of Ranitidine, a drug for peptic ulcer while Zyrtec is a name for Cetirizine, an antihistaminic agent. Inderal is a Beta blocker while Inferal is used in asthmatics. Giving the former in place of the latter can induce an attack of acute asthma in the patient which can be life threatening.

Medication error can occur during drug administration

Administration involves obtaining the medication in a ready-to-use form. It is usually done by staff nurses in hospitals. It may involve counting, calculating, mixing, labeling or preparing medication in some way. It also involves checking for allergies in the patient and observing the 5 Rs rule — right drug, right patient, right dose, right route, and right time. Drug administration can go wrong if a wrong drug is given to a patient, if the right (intended) drug is given to the wrong patient or in the wrong dose or through wrong route or at a wrong time. It may be also be due to omission, failure to administer the drug and due to inadequate documentation.

Patients who are most at risk of medication error include those on multiple medications, patients with co-morbid conditions e.g. renal impairment, pregnancy, patients who cannot communicate well, patients who have more than one doctor, patients who do not take an active role in their own medication use, children and babies (dose calculations required).

Inexperience, rushing through the job, trying to do two things at once, interruptions, fatigue, overwork, failure to check and double-check, poor teamwork and communication gap between colleagues are some of the situations when the staff is most likely to contribute to a medication error.

Absence of a safety culture in the workplace e.g. poor reporting systems and failure to learn from past near misses and adverse events, absence of memory aids for staff, inadequate staff numbers etc all can contribute to endangering patient safety.

What actions can be taken to enhance patient safety?

To reduce medication errors it is important that they are reported, that data is collected and analysed on a large scale and that results are shared amongst the relevant institutions. This requires a change in the culture in the healthcare system to one where safety is paramount and reporting is encouraged and maximised.

There is also a need to set up national reporting systems and databases to store information and a cohesive strategy for communicating findings effectively across the countries. To encourage reporting of adverse events, even seemingly trivial, it is important to eliminate fear culture among healthcare staff. The strategy recommended nowadays is not to blame an individual for an error but to look into the whole event as a systems failure. This means moving from ‘who did it’ to ‘why and how did it happen’. In this way the point of care where the event occurred can be analysed to ascertain the cause and prevent any error at that point of care in the future.

This is called root cause analysis and can enhance patient safety if done properly. Just as the aviation industry utilises the black box recording to get to the cause of every air accident, the healthcare industry must analyse each error to enhance patient safety.

How can patients contribute to their own safety?

It is indeed true that patient safety lies in the hands of the healthcare providers. Nonetheless, the patient’s role in his/her own safety can’t be underestimated. An alert and well-informed patient can at times prevent errors from occurring. Indeed, all patients should be encouraged to be actively involved in their own treatment process.

When prescribing a new medication doctors must provide patients with the following information: name, purpose and action of the medication; dose, route and administration schedule; special instructions, directions and precautions; common side-effects and interactions; how the medication will be monitored.

They should also encourage the patients to keep a written record of their medications and allergies and encourage them to present this information whenever they consult a doctor. This type of patient education is unfortunately not much practised in our setups for the reason that it is time consuming and that most patients are not literate enough to grasp it. However, the changing socioeconomic scenerio and rising literacy levels will create more and more patient awareness and relevance of such education. No doubt, imparting knowledge to patients, their relatives and even the medical staff is a duty of the doctor, which literally means to teach (from ‘Docere’ in Latin).

When a visit to the doctor goes horribly wrong

An adverse event is a happening that results in unintended harm to the patient by an act of commission or omission (e.g., administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.) rather than by the underlying disease or condition of the patient. It may or may not be preventable e.g. patient falls, medication errors.

Medication error has been defined by WHO as an error in the process of ordering, transcribing, dispensing, administering, or monitoring medications, irrespective of the outcome (i.e., injury to the patient). Thus an error occurring at any step of medication use –right from being prescribed (ordering) by the doctor to its administration and monitoring — is included in this term.

Drug administration can go wrong if a wrong drug is given to a patient, if the right (intended) drug is given to the wrong patient or in the wrong dose or through wrong route or at a wrong time. It may be also be due to omission, failure to administer the drug and due to inadequate documentation.

The writer is Assistant Professor, Department of Pharmacology, Govt Medical College and Hospital, Chandigarh