Editorial 1: An ageing India needs age-responsive TB care
Introduction:
- India is moving towards a future where the elderly will make up a significant proportion of society, primarily due to advances in health care and increased life expectancy. In 2011, about 9% of India’s population were over the age of 60. This is expected to increase to 12.5% by 2030.
- The elderly represent a storehouse of wisdom, and respect for their rights and freedoms benefits society. On International Day of Older Persons (October 1), we must resolve to invest in the health of our elderly population, and pay attention to their unique needs. This is especially true in the case of tuberculosis (TB), which affects over 25 lakh Indians every year, and kills at least 1,000 every day.
Tuberculosis (TB)
| It is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs (pulmonary TB), but it can also affect other parts of the body (extra-pulmonary TB).Most infections show no symptoms, in which case it is known as latent tuberculosis. Around 10% of latent infections progress to active disease which, if left untreated, kill about half of those affected.Typical symptoms of active TB are chronic cough with blood-containing mucus, fever, night sweats, and weight loss. |
- India’s National TB Prevalence Survey, 2021, revealed that the prevalence of TB in people over the age of 55 was 588 (per one lakh population), much higher than the overall national prevalence of 316. These findings were the starting point for a first of its kind rapid assessment report on TB among the elderly, which we published earlier this year in collaboration with the National TB Elimination Programme (NTBEP) and the U.S. Agency for International Development (USAID), highlighting TB’s impact on the elderly and the need for age specific TB guidelines.
How TB impacts the elderly
- Symptoms of TB including cough, fatigue and weight loss are mistaken as signs of other diseases or dismissed as signs of old age. The risk of having a TB diagnosis delayed or missed altogether is higher for the elderly compared to other adults.
- Once diagnosed, management of TB among the elderly is often complicated by multiple comorbidities, particularly diabetes.
- Challenges in accessing health services: in rural and hilly areas, they struggle to travel to health facilities by themselves.
- Their access to reliable information on health is also limited — social networks inevitably shrink for the elderly.
- Older persons also experience infrastructure related challenges such as lack of adequate seating and lack of disable-friendly public infrastructure.
- Crucially, they may not have access to high quality nutritious food, which is critical for recovery.
- Most people over the age of 60 are no longer working; they are living off savings or they are completely dependent on families. There are some social welfare schemes for the elderly but these are limited in scope and difficult to access.
- Absence of social and emotional support systems: Many older people refer to their fragile mental health, accentuated by the loss of purpose and connection, loneliness from losing spouses or family, and the anxiety of not being ‘useful’.
- Ageism has been recognised by the World Health Organization (WHO) as a cause of poor health and social isolation.
Way forward: Building age responsive care
- We design and deliver TB care that is elder-friendly in following ways:
- We must move away from disease specific, vertical care programmes to holistic care models that reduce the need for the elderly to interact with multiple providers and facilities.
- Build capacity among health professionals at all levels for an improved clinical understanding of TB in the elderly and better management of multiple morbidities.
- Case finding among the elderly can be improved through (a) effective sputum collection, (b) transportation systems (c ) access to mobile diagnostic vans (d) active case finding at geriatric OPDs, residential homes for the elderly and other institutional settings.
- Technical and operational protocols that provide clear guidance on diagnosing and treating TB in the elderly —sample extraction protocols, comprehensive assessment of comorbidities and drug dosage adjustments etc.
- To address socioeconomic needs, we must have support protocols, with inputs from elderly people with TB. Examples include (a) an elder focused community care model with linkages to local caregivers; (b) doorstep delivery of medicines; (c ) age responsive peer support and counseling for older people and their families; (d) special help desks for the elderly at facilities; (e) support with documentation to access social support schemes.
- At a macro level, we must ensure rigorous gender and age disaggregated collection and analysis of data, to identify TB trends across age groups, and to make sure that the elderly are included as a separate age category in all TB reports.
- An important step towards building elderly friendly systems is strengthening collaboration within the health system.
- Finally, we need a stronger research agenda focused on TB in the elderly, (a) to better understand State Specific trends in case finding and outcomes among elderly people with TB; (b) substance use; (c ) drug resistance and comorbidity patterns across geographies; (d) uptake of TB preventive therapy in the elderly; (e) and intersectionality with other aspects of equity such as gender, disability, class, and caste.
Editorial 2: A time to articulate new constitutional ideas for India
Context
- The Government of India is on a mission to decolonise the country. Edwin Lutyens and Herbert Baker’s grand Parliament building has just given way to Bimal Patel’s modern reinterpretation and the name “Bharat” is being used more frequently to describe the country, challenging the monopoly of “India”. So far, names and buildings are on the chopping block. But what about the Constitution? Should it change? If so, in what way? And following whose ideas?
Hind Swaraj
- When we think of the Constitution of India, our mind may naturally go back to 1950 when it came into force. But constitutional ideas in India predated it. An original and indigenous account of what the Constitution would look like was presented by Mahatma Gandhi in 1908.
| In Hind Swaraj or Indian Home Rule, Gandhi expresses his views on subjects like Swaraj and independence, modern civilization, mechanisation, economy etc. In the book, Gandhi repudiates European civilization while expressing loyalty to higher ideals of empire (“moral empire”). The book was banned in 1910 by the British government in India as a seditious text. |
- Gandhi was steadfast in his view that without decolonising the Constitution, we may become independent but would not have swaraj (self rule). The English would be driven away and India would get itself a new democratic government, but the nature of government itself would not change. It would be “English rule without the Englishman” which would “not be Hindustan but Englistan”.
- But what kind of constitution would India have? For him, a swaraj constitution ought to ideally be based on ancient village republics and not a large government in Delhi. The economy would be founded on ordinary Indians producing enough to be self sufficient and trading the rest at local markets. India would be united not because a constitution promised rights, but because Indians themselves considered it their duty to forge a nation out of a people.
- Gandhi’s follower, Shri Narayan Agarwal was given the task of drafting such a constitution to put Hind Swaraj into action. But Agarwal’s draft of the “Gandhian Constitution for Free India”, (1946) was less of a legal text and more a moral code. In it, the rights to personhood, liberty and equality would be contingent on a duty to be faithful to the state.
Handing it over to Ambedkar
- Gandhi pragmatically distanced himself from a constitution that bore his name. At that time, there was considerable momentum towards a progressive post-world war 2 constitution based on following provisions:
- a big state with the authority to ensure law and order
- separation of powers to prevent overreach
- a range of fundamental rights to capture the global move towards universal human rights for all.
- Gandhi found such a constitution “entirely Western” but grasped its prospect of consensus instinctively. He himself rang the death knell of the Gandhian Constitution by persuading Rajendra Prasad to appoint B.R. Ambedkar as the Chairperson of the Drafting Committee of the Constitution in August 1947. Ambedkar had a clear and well articulated vision of what India’s Constitution should look like, which was nothing like Gandhi’s.
Gandhi vs Ambedkar: Constitutional ideas:
- Ambedkar believed that India needed a powerful state machinery that could ensure law and order at the margins of the country. Gandhi on the other hand believed that a large state would be too distant from the people.
- For Ambedkar, the state would be duty bound to manage the economy and control industries for the common good. But for Gandhi, self sustaining villages based on agriculture and cottage industry were the way forward.
- Centuries of feudalism, sectarianism and casteism would be uprooted, in Ambedkar’s vision, through fundamental rights to life, liberty and equality for every individual. Gandhi thought that history could not be undone by a policy document such as a constitution — it needed individuals to change themselves.
- Gandhi had grave disagreement with each of Ambedkar’s visions but realised that they enjoyed a wide consensus across party lines. As a result, he was content in letting his ideal constitution wait its turn.
A constitutional moment?
- Today, we are much like India was in 1908 when Gandhi wrote Hind Swaraj — a nation in flux — than in 1950, when India was a nation imbued with newfound freedom. This is why it is a good time not to draft a new constitution, but to articulate a vision of what new constitutional ideas India needs. These ideas have to be built not just on the existing Constitution worked on by B.R. Ambedkar and other members in the Constituent Assembly but also with the Gandhian ideas they ignored as too radical.
- This is not a suggestion to be premodern as many Gandhian thoughts were. Rather, it is an invitation to ask the fundamental question that Gandhi did — what kind of constitution can bring good governance to India? Unlike names and buildings, constitutions do not, and should not change overnight. But that does not mean that they should not change at all.
