Editorial 1 : A playbook to handle gestational diabetes better
Context
A new series published in The Lancet on gestational diabetes takes a deep dive into the subject to come up with suggestions for greater focus on the pregnancy-related cnondition, and a shift to a holistic life-course approach in its management.
Gestational diabetes
- The Lancet this time deals with gestational diabetes, which refers to hyperglycaemia or high blood sugar levels first diagnosed during pregnancy
- A common medical disorder in pregnancy, it reportedly has a global prevalence of 14%.
- Age, family history of diabetes, and high BMI are major risk factors, so it comes as no surprise that rates are rising alongside a broader crisis of non-communicable diseases, such as obesity and cardiometabolic disorders, among women of childbearing age.
- There is increased complications associated with gestational diabetes its long term impact on the mother and infant, its rising incidence, the need to detect it earlier than is being done currently, modern treatment methodologies, and the need for a lifestyle approach to prevent onset of GDM and complications.
Complications
- Gestational diabetes is associated with an increased risk of pregnancy complications,but it also threatens serious long-term complications for both mother and baby.
- Up to 31% of type 2 diabetes cases in parous women are attributable to gestational diabetes.
- Babies born to women with gestational diabetes are at increased risk not only of short-term perinatal morbidity and mortality but also of long-term complications, such as type 2 diabetes, obesity, cardiovascular diseases, and neurodevelopmental disorders.
- There are two major barriers to providing appropriate care for these women: first, resources, and second, the isolation of secondary maternal care from primary care, meaning crucial information about a woman’s pregnancy and how it might affect their long-term health is lost.
- But many other factors probably play into this failure, including a misconceived paternalistic wish to avoid further worrying women, childbearing mostly happening to young and physically well women for whom the long-term risks of non-communicable diseases might seem too distant, and a health-care ecosystem that prioritises the baby’s health after birth over that of the mother.
Glycaemic exposure
- The pathophysiology of glycaemic dysregulation in gestational diabetes pregnancies, and the many maternal, placental, and fetal factors from early to late pregnancy that underlie pregnancy outcomes and programming for the future health of mothers, and offspring exposed to gestational diabetes.
- It is important to focus on the intergenerational impact of gestational diabetes. The Lancet series is helpful in the sense that it is where a call for action emerges.
Conclusion
Researchers have recommended early testing of all pregnant women. They recommended universal screening of all pregnant women during the early weeks of the first trimester. Further, they have proposed a testing strategy that has worked well in India: a two hour postprandial blood sugar level of over 110 mg/dl during the eighth to 10th week of pregnancy can predict the risk of GDM.
Editorial 2 : Reasi and the ‘years-old’ issue of cross-border terror
Context
In India’s responses to Pakistan-backed terror, New Delhi needs to sharpen its definition of what is an ‘unacceptable’ terror attack.
Continuing challenge
- The possibility of the Reasi attack’s links with terrorist groups in Pakistan remains high.
- The Jammu division has witnessed many terrorist incidents over the past few months, including after the Reasi attack.
- They profile the persistence of the terrorist challenge India has faced for almost 35 years especially in J&K.
- Pakistan and separatists in J&K were encouraged by the success of the Afghan Jihad. Pakistan thought that if a superpower could be defeated by Afghan Islamist groups, other such groups could be used to pressure India in Kashmir through mass uprisings, violence against minorities, and terrorist actions against prominent personalities and the security forces, leading this country to abandon Kashmir.
- The Indian state and its security forces took time to craft defensive counter-insurgency and counter-terrorism approaches in the first half of the 1990s.
- The Pakistan Army and its political class are committed to the “Kashmir cause”. In the late 1980s and early 1990s, both Nawaz Sharif and Benazir Bhutto who became Pakistan’s Prime Ministers in turn were supportive of the promotion of separatism in J&K by the army and intelligence agencies, through the use of terror.
- Ms. Bhutto decided not to hold talks with India in 1994 unless India was willing to purposefully engage Pakistan on J&K in a manner Pakistan prescribed.
- Pakistan desired a structured dialogue with India which would focus on all issues — humanitarian, conflict resolution and the development of cooperative mechanisms.
- However, India wished to discuss Pakistani terrorism as a separate issue in the dialogue process.
India’s choosing diplomacy, dialogue
- Thus, a combination of force and the restoration of political activity was used to address the problem in Kashmir: a problem within India’s internal jurisdiction.
- Under the Simla Agreement of 1972, India was committed to resolving this issue peacefully, through negotiations. However, in 1972, the idea that Pakistan would promote terrorism through Islamist non-state actors under its control had not been contemplated.
- Hence, the constraints imposed by the Simla Agreement became void once Pakistan resorted to terrorism and India could legitimately treat Pakistani terrorism as a ‘strategic’ issue, i.e., one which required the application of force in the external sphere. However, India chose the path of diplomacy and dialogue.
- India and Pakistan agreed on the mechanics of a bilateral composite dialogue in September 1998.
- The composite dialogue listed ‘terrorism and counter-narcotics’ as one of the eight issues of engagement.
- It became clear to India from the very first bilateral exchange on this issue in October 1998, that Pakistan was unwilling to address India’s concerns.
- This has continued to remain Pakistan’s attitude because the calibrated use of terrorist groups against India became a part of its security doctrine from the 1990s.
- The problem with the diplomatic approach was that public opinion in India was for military action after an ‘unacceptable’ terrorist attack or provocative and ‘unacceptable’ Pakistani action.
- Earlier, India had seriously considered using its military forces against Pakistan in December 2001, as a reaction to the terror attack on Parliament.
- The A.B. Vajpayee government mobilised the Indian armed forces but eventually decided not to go to war because President Pervez Musharraf gave an assurance that Pakistan would not use territory under its control to promote terrorism against India. It did not keep its word.
The use of pre-emption
- Where India actually departed from the use of diplomacy and used military force against Pakistani terrorism was after the Pulwama attack of 2019.
- It undertook the Balakot aerial strike (2019) and also announced a doctrine of pre-emption.
- Earlier too it had used force in a limited way by way of undertaking surgical strikes in the wake of the Uri terrorist attack of September 2016.
- Despite these undertakings, the ambiguity on the use of force remains.
- Besides, the doctrine of pre-emption is based on the right to take out terrorist targets if preparations are being made in Pakistan to launch an ‘unacceptable’ terrorist attack. The question is what is ‘unacceptable.
- It may be also pointed out that India used the full strength of its defence forces to defeat Pakistan’s regular military intrusion in Kargil in 1999, but that situation obviously did not come within the rubric of terrorism. Hence, sustained kinetic action did not pose a dilemma.
Conclusion
After the Reasi attack, External Affairs Minister S. Jaishankar expressed the ambitious intention of finding a solution to years-old cross-border terrorism. He could begin the process of putting a curb on Pakistani terror by pointing out to the international community that the first step on an escalatory ladder between nuclear countries is the use of terror.
