The Tribune, Chandigarh, India

ARTICLE

UP IAS officer’s suspension
Politicians abhor an independent civil service
by R.K. Raghavan

1. “We must ensure that the officer is not unfairly treated".
—Sonia Gandhi to Prime Minister Manmohan Singh on suspended IAS officer Durga Shakti Nagpal

2. "If officers make mistakes, they are punished, like children in school. This is how a government runs". — UP Chief Minister Akhilesh Yadav

3. "There are rules, and rules will be followed". — Prime Minister Manmohan Singh

Three unexceptionable statements from three personalities who enjoy enormous clout in the nation's life! While the UPA chairperson's stand may be slightly laced with politics, I would like to give her the benefit of the doubt and look upon it as a genuine attempt to save a hapless woman civil servant from the cold-blooded attempt of a predatory politician for whom the average IAS officer is a plaything. (Read in conjunction with his latest challenge to the Centre asking the latter to take back all IAS officers.) Yadav's statement is too simplistic to be taken on face value. It does not conceal a certain arrogance that goes with electoral success. It conveys a warning that no IAS or IPS officer in Uttar Pradesh could afford to ignore. The Prime Minister is being just correct and bland, as is his wont. I am afraid the UP government will respond to him politely saying that they had not breached any rule in acting against Nagpal. This is one instance where a government could seem both law abiding and vindictive.

The Nagpal episode confirms — if one were needed -- that the average politician abhors an independent and conscientious civil service. What he desires is an unquestioningly obsequious bureaucrat (of both the IAS and IPS variety) who will act as a paid servant on daily wages. It is an entirely different matter that a large chunk of the All India Services have themselves brought about this unfortunate situation by being both servile and dishonest, sometimes acting as a conduit for money to be passed on to their political bosses.

By all accounts, Nagpal, a recent entrant to the IAS, has been victimised because she had the guts to take on the 'sand mafia'. This is difficult to prove, a situation exploited by those who are in power and who are not immediately accountable. What has been reported from Uttar Pradesh, however, happens every other day in many States. A few instances come to public knowledge, and many do not.

Sardar Patel, the Iron Man, who singlehanded ensured the continuance of the Steel Frame (as the ICS was referred to under the British) in post-Independence India, should be turning in his grave. Pandit Nehru, the first Prime Minister, left it to his deputy to handle this sensitive matter, and the nation greatly benefited from the free hand given to a remarkable statesman, who had only national interest at heart.

The concept of All India Services, a band of gifted young men and women, recruited by the Federal government and assigned to the States to spend most of their career in States to which they are assigned, has become fuzzy and nearly unworkable over the years. It is too delicate an arrangement — which no foreigner can comprehend — that survived in earlier years solely on the goodwill and decency in polity. Neither quality marks the scene now.

The UP happening revives the debate whether the All India Services deserve to exist in their present form. The joint disciplinary control it imposes is beginning to be increasingly untenable. The country had undoubtedly been a beneficiary from the wisdom and practical ability that the Services brought to the district administration. This was until about 1975, when the Emergency ushered in a whole new concept of a 'committed civil service' and a 'committed judiciary'. While the latter could recover from the unconscionable assault on its structure and values, unfortunately the IAS and the IPS could not.

There is a clear chasm between the demands of the political class on the one hand, and the law of the land and the rules that govern the IAS and the IPS on the other. Very few observers address this blatant contradiction. The civil service is governed by conduct rules which dictate probity, allegiance to the Constitution of India, and adherence to laws such as the Prevention of Corruption Act 1988. This was what possibly actuated Nagpal's unbending stand. But she has had to pay a huge price. All charges of insensitivity to communal harmony slapped on her are said to be fragile. They may not stand judicial scrutiny. The lightning speed with which a charge-sheet has been served on Nagpal should itself invite the ire of courts when the matter goes before them. It is obvious the State wanted to preempt any action by the Centre. I would in particular like to see what the head of the administration, viz., the Chief Secretary, has recorded in the relevant file. If he could not stand up to pressure, who else in the civil service could?

As long as there is a blatant conflict between what a Chief Minister wants and what is permitted under the settled law, minister-civil servant relationship will remain contentious. This is an unequal contest where the politician can fix a civil servant with absolute ease. A suspension from service is traumatic and brings ignominy and a loss of reputation to the officer that is irreparable. Also, gone are the days of a mere punitive transfer. These are times of sheer intimidation, framing of specious charges and a threat of physical attacks on a courageous officer and his or her family. When this is the case, it is preposterous to expect even a modicum of independence on the part of IAS and IPS officers?

This is one of the few occasions when the IAS Association has reacted with commendable speed. But there is little that will come out of it in favour of Nagpal, as in the case of Ashok Khemka of Haryana. The Department of Personnel at the Centre (that works under the Prime Minister) is the cadre authority for the IAS, and is looked upon as the guardian for the Service. Its record, however, is mixed, one that does not inspire much confidence that it would be able to undo the alleged injustice to Nagpal.

The writer is a former Director of the CBI

MIDDLE

The eagle with stretched wings
by Sanjeev Trikha

Some moments, some individuals, some talk sometimes lend a distinct meaning and direction to one's life. Only last year I was privileged to meet a person who left an indelible impact on my thinking and way to look at life.

The gap between the morning and evening shifts of examinations where I was put on a flying squad duty compelled me to pass time at the staff room of Govt. College, Sirsa. Sitting alone and surfing through the thought process on such occasions is my favourite pastime. At times such analysis guides you to some untouched emotions and sentiments never experienced before.

On one such afternoon I was busy jostling with the thought process concerning work culture in government institutions. Suddenly, I was dragged out of my thoughts by a 6 ft tall, stoically built, handsome young man, stretching his handless half arm towards me for a hand shake.

After a momentary initial hesitation, I greeted him with a soft touch and hold of his handless arm ending just below the elbow. The gentleman had lost both his hands and part of his arms in some accident. He introduced himself as an Associate Professor of English literature. The oozing confidence in his talk spoke volumes of his personality and bent of mind.

I tried my best to avoid glancing at his amputated arms, which were peeping from the half-sleeve shirt he wore but my eyes repeatedly stopped there. With the apprehension that the gentleman might feel bad of it, I tried every bit to look straight in his eyes only. But I knew that the suspense of those handless arms would not allow me to be my natural self in the conversation ahead.

I finally mustered courage to ask him about the accident. To my amazement, he told me that the accident occurred when he was a class 5 student. How did he complete his studies after such a major accident?

He said: "In fact I started taking studies seriously only after this accident". He continued, "In the initial stage I used to write with my foot but later on when the wounds of arms got settled I practised writing with the pen struck in the grooves left in the arm".

He did not appear to curse destiny at all. He appeared extremely happy and contended with the feeling that he has valiantly fought all the odds and has emerged victorious. 'Even the darkest hour has only sixty minutes' was his way to look at life.

"Nothing is impossible in this world. Only a sincere, dedicated and passionate effort with belief in one's self is needed," he said.

We discussed the system, its shortcomings and ways to overcome the obstacles. The optimism in his words and conviction in his thoughts was like a whiff of fresh morning breeze. When he stood up to depart, he said, "This system is not handicapped the way I was at one time. If Harjinder can surpass the obstacles posed by nature, why can't this system overcome the man-made hindrances?"

As we finally bade goodbye to each other, this time I took the initiative of extending my arm for a hand shake which was very warmly reciprocated with the confident offering of the denuded handless arm. The touch this time was deliberately extended by me as I felt extreme vibrations of positivity in that hold. As he moved away, the loose sleeves of his half-sleeve shirt swayed with every step forward. The sleeves on the armless shoulders looked like the wings of an eagle getting stretched for new flights and renewed heights.

OPED — Health

In India, TB kills 750 people every day. With drug-resistant TB on the rise, everything from diagnostic tests to the use of new TB drugs needs strict monitoring to control this killer bacterium
Formidable killer: drug-resistant tuberculosis
Madhukar Pai

With over 2 million TB cases reported per year, the disease continues to be one of the leading cause of death in India. Tribune photo: Manoj Mahajan

From the Wall Street Journal to the TIME magazine, India has been in the international news. The spotlight is on drug resistant tuberculosis (TB), a form of TB that is very difficult to diagnose and treat. Not only is India battling severe forms of TB, the country is also struggling to procure sufficient quantities of basic anti-tuberculosis drugs, despite being the world's largest manufacturer of generic drugs. Insufficient budgets and poor commitment from politicians and bureaucracy is threatening to undo all the gains made over the past decade.

The aam aadmi in India probably thinks that TB is an old disease with little or no relevance to them in 2013. The reality, actually, is scary. India has the world's highest burden of TB. TB kills one person every two minutes in India and 750 people every day. Even today, India reports over 2 million TB cases per year. TB continues to be one of the leading causes of death in India. The disease severely affects economically productive young adults, and thus has a big impact on the country's economy.

Who is at risk

TB is curable, yet…

India has the world's highest burden of TB.
TB kills one person every two minutes in India - we report 2 million cases of TB per year.
While TB can affect many organs, lungs are often the most important site of this disease.
Drug resistant tuberculosis is a form of TB that is very difficult to diagnose and treat.
The most common form of drug-resistant TB in India is multi-drug resistant TB (MDR-TB), which is resistant to Isoniazid and Rifampicin, two most important first-line antibiotics.
Hospitals in Mumbai have reported even worse forms of drug-resistance — 'totally drug-resistant tuberculosis' (TDR-TB).
About 50% of patients with drug-resistant TB die because it needs prolonged and expensive treatment, the second-line TB drugs are costly.
Another reason behind high casualty is, use of spurious drugs. About 10% of Isoniazid and Rifampicin drug samples failed basic quality testing this year.

The worrisome truth is that everyone is at risk of — all ages and people from all walks of life. Poor people are disproportionately affected and are especially vulnerable because of poor nutrition, overcrowding, and poor living conditions. Smoking, HIV infection, indoor air pollution, and diabetes are other major risk factors that increase the risk of developing TB.

Tuberculosis is caused by a bacterium called Mycobacterium tuberculosis. While TB can affect many organs, lungs are often the most important site of this disease. TB is spread when infected people cough and spit out sputum, releasing millions of TB bacteria in the air. In a crowded country, this means everyone can be exposed to TB. And because there is no good vaccine against TB, nobody is protected. TB anywhere is TB everywhere!

The good news is that TB is curable, if diagnosed early and treated completely. Ensuring early diagnosis and complete adherence to treatment is therefore a critical goal for all TB control programmes.

Why does drug-resistance emerge

Since no national surveys have been conducted, nobody knows the actual number of drug-resistant TB cases in India. But there are clear signs that severe forms of drug-resistance have emerged. The most common form of drug-resistant TB in India is multi-drug resistant TB (MDR-TB), which refers to TB that is resistant to Isoniazid and Rifampicin, two of the most important first-line antibiotics.

While MDR-TB is severe enough, hospitals in Mumbai have reported even worse forms of drug-resistance — what they called 'totally drug-resistant tuberculosis' (TDR-TB) — suggesting that this form of TB was incurable because of resistance to all the TB drugs tested.

Why should we care about emergence of drug-resistance? The answer is straightforward. Drug-resistant TB requires extensive treatment (for 2 years or longer) with multiple, unpleasant drugs and outcomes are poor. About 50% of patients with drug-resistant TB die because of it. Treatment of drug-resistant TB is also very expensive because of the high cost of second-line TB drugs.

Thankfully, most cases of TB are not drug-resistant. The bacteria do respond to antibiotics, but will still require at least 6 months of treatment. Persons with TB must take medications without stopping. Otherwise, TB bacteria can become resistant to the common, first-line drugs that are used. This usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs.

Studies in India, especially in the private sector, show that doctors often create their own TB drug combinations and rarely adhere to Indian or International Standards for TB Care. Irrational prescriptions play a major role in making the TB bacteria resistant to standard drugs.

Drug-resistance can also emerge when the supply of drugs is not continuous; or when poor quality drugs are used. This is one reason why the current drug shortage in India is a big concern. Research studies have shown that India is a big market for fake (counterfeit) drugs. A study published this year showed that 10% of Isoniazid and Rifampicin drug samples failed basic quality testing.

What can patients do

For a start, all individuals with cough for more than 2 weeks must get their sputum tested for TB. Sputum testing is available free via thousands of designated microscopy centers run by the government. If patients seek care in the private sector, they must demand sputum testing over blood tests for TB. If TB is diagnosed, the most important thing a person can do to prevent the emergence of drug-resistance is to take medications exactly as prescribed. Treatment should not be stopped early, even if symptoms improve.

Patients who cannot afford to buy drugs must seek treatment in the public sector where TB drugs are given free. Currently, the Indian government is planning to make free TB drugs available to the private sector as well. For patients with MDR-TB, free treatment is available via public hospitals, especially those with wards designed for MDR-TB patients.

What can healthcare providers do

Doctors must ensure quick and accurate diagnosis, follow recommended treatment guidelines, monitor patients' response to treatment, and make sure their patients complete full therapy. In patients who show no signs of improvement with standard TB treatment, and in people who have previously been treated for TB, doctors should suspect MDR-TB and order tests that can detect drug-resistance.

There are now several WHO-approved TB tests in the Indian market that can rapidly detect drug-resistant TB. GeneXpert is one such test. This DNA-based test can accurately detect resistance to Rifampicin within 2 hours and allow the doctor to begin the correct MDR-TB therapy. It can also detect lung TB and extra-pulmonary TB with great accuracy.

This test is now widely available across a chain of Indian private laboratories for INR 1700, via a special Initiative for Promotion of Affordable and Quality TB tests (www.ipaqt.org). Laboratories in this IPAQT initiative are also offering other WHO-approved TB tests (e.g. line probe assay and liquid cultures) at affordable prices. Any private lab can join this initiative, so long as they meet the eligibility criteria, and agree to follow guiding principles.

Incorrect diagnosis of TB can lead to incorrect treatment. The Indian government recently banned the use of antibody blood tests for diagnosing TB and this was widely advertised. Other blood tests such as "TB-Gold" and "TB Platinum" are not meant to diagnose active TB. They are meant to detect latent TB infection and one in three Indians is latently infected. So, doctors should not use such blood tests to start treatment for active TB.

Better regulation of antibiotics

In India, antibiotic abuse is widespread and there are few regulations to prevent widespread, over-the-counter sale. To prevent drug-resistance, it is critical that pharmacies and chemists do not dispense TB drugs without a valid doctor's prescription. This is mandated by law, but rarely enforced. Doctors must be very cautious about prescribing anti-TB drugs without confirming the disease with quality-assured laboratory tests.

In December 2012, the U.S. Food and Drug Administration approved a drug called Bedaquiline, as part of combination therapy to treat adults with MDR-TB when other alternatives are not available. This is the first new TB drug approved in over 40 years. Other new TB drugs or combinations are expected within the next 2 - 3 years.

However, the excitement about the impending introduction of new TB drugs must be tempered with the reality of the Indian landscape. Before new TB drugs enter India, mechanisms must be put in place to ensure that they do not get abused for all sorts of ailments. New TB drugs must not be dispensed without prescriptions from qualified, specialist practitioners. Doctors must strictly follow guidelines on TB treatment, and avoid creating their own drug regimens. We have waited a long time for new TB drugs. We need to protect them and make sure they last.

What can the government do

TB control in India is at a decisive juncture. Unless we increase our capacity to manage and treat TB, we will see an increasing number of MDR-TB cases in the future. India's Revised National Tuberculosis Control Programme (RNTCP) has done well to expand basic diagnostic and treatment services to cover 100% of the Indian population. The diagnosis and treatment of patients with MDR-TB is one area that is currently deficient. The RNTCP needs to provide a large section of the patients with adequate drug-susceptibility testing and second-line drugs. This will require the Indian government's budget for RNTCP to greatly increase. New tests like GeneXpert need to be urgently scaled-up in public hospitals and clinics. Drug procurement systems need to be improved, and fake drugs must be ruthlessly stamped out via better regulation and enforcement.

What can the private sector do

Most TB patients seek care in the private sector, at least initially. The private sector, unfortunately, has been a source of mismanagement of TB and hence, drug resistance. This includes the use of incorrect diagnostics (e.g. blood tests), incorrect regimens and lack of supervision to ensure all TB patients complete treatment. Thus, every effort must be made to engage the Indian private sector and improve the quality of care provided by private practitioners.

The IPAQT initiative by private laboratories is a positive example of how the private sector can think beyond economic gains and play a critical role in TB control. This initiative is already having an impact by replacing suboptimal blood tests with WHO-approved tools. Similar efforts are needed to replace substandard TB drugs and irrational combinations with high quality, affordable drugs. The Indian pharma industry could play a huge role here, and give back to the society.

TB is one of India's greatest public health challenges but sadly it lacks support from the rich and the famous. What India desperately needs is one celebrity or high net-worth individual to take up the fight against TB. That might just help turn the tide.

Dr Madhukar Pai is Professor, McGill University, and Associate Director, McGill International TB Centre, Montreal, Canada