October 3   2015, Saturday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal Child Sexual Abuse: An Epidemic

Quotes from a Delhi High Court case

The court termed child sexual abuse as an "epidemic".

Court: “ not only parents, but even trial courts dealing with such cases, should create an atmosphere where the victims can depose truthfully against "sexual perpetrators"

Justice P S Teji: "Children who have suffered sexual abuse at the hands of the sexual perpetrators do not only suffer from physical pain but are also subjected to mental and emotional trauma. The results of child sex abuse are severe and far reaching,"

"Child sexual abuse is one of the most pervasive social problems faced by our society. Its impact is profound because of the sheer frequency with which it occurs and because of the trauma brought to the lives of the children who have experienced this crime. Child sexual abuse is an epidemic."

The trial court should "ensure the examination of the child witness by giving due protection to him and bringing the child out of the pressure".

"The parents of such victims have even a greater role to play in helping and aiding the child in overcoming the trauma."

Some facts

· A study conducted by Aram Foundation, an NGO working for child rights, has found that about 29% of students studying in 71 schools and 56 colleges in Coimbatore, Erode, Salem, Tirupur and Dharmapuri have suffered sexual abuse.

· As per a study conducted by Tulir CPHCSA in 2006, in which more than 2,211 school-going children in Chennai were interviewed, child sexual abuse prevalence rate was 42%.

· Another study conducted in 2007 backed by the government of India, in which 1,25,000 children were interviewed in 13 states, more than half (53%) said that they had been subjected to one or more forms of sexual abuse

· Eight cases of sex crimes against children have been registered every day in the last two years. About 6,816 police cases were registered from November, 2012— when the Protection of Children against Sexual Offences Act (POCSO)—came into force up to March, 2015. The highest number of FIRs has been registered in Rajasthan followed by Maharashtra, Uttar Pradesh, Madhya Pradesh and Kerala according to data available with the National Commission for Protection of Child Rights (NCPCR). The number of convictions is only 166 that is, 2.4% of the total cases registered while in 389 cases accused were acquitted. (TOI)
Breaking news
Dormant viral genes may awaken to cause ALS

Scientists at the National Institutes of Health discovered that reactivation of ancient viral genes embedded in the human genome may cause the destruction of neurons in some forms of amyotrophic lateral sclerosis (ALS). The results, published in Science Translational Medicine, suggest a link between human endogenous retroviral genes (HERVs) and ALS. The findings also raise the question of whether antiretroviral drugs, similar to those used for suppressing HIV, may help some ALS patients.
Dr Good Dr Bad
Situation: A patient with stable angina was on beta-blockers
Dr Bad: It will also increase survival
Dr Good: It will relieve angina but not survival
Lesson: In patients with stable coronary heart disease who have not had a recent acute MI, beta-blockers are indicated to treat angina but not to improve survival (J Am Coll Cardiol 2014;64(3):247-52).
Specialty Updates
  • In obese patients with type 2 diabetes undergoing bariatric surgery, gastric bypass induces more beneficial changes in composition of the gut microbiota than sleeve gastrectomy, suggests new research presented at the European Association for the Study of Diabetes (EASD) 2015 Meeting.
  • Marie-Claire Arrieta, PhD, from the University of British Columbia in Vancouver, Canada, and colleagues report in Science Translational Medicine that children with lower levels of Lachnospira, Veillonella, Faecalibacterium, and Rothia bacteria in their gut in their first 3 months were at higher risk for to develop allergic asthma and tended to receive more antibiotics than healthier children before they turned 1 year old.
  • A cross-sectional survey of close to 9,000 middle- and high-school students (mean age 15.2) found increased social networking time to have a dose-dependent relationship with poor nutritional choices, like skipping breakfast and consuming sugar-sweetened beverages and energy drinks, reported Hugues Sampasa-Kanyinga, MD, of Ottawa Public Health in Ontario, and colleagues.
  • The American Association of Clinical Endocrinologists (AACE) has issued a position statement on the use of testosterone-replacement therapy in response to the US FDA's announcement regarding cardiovascular effects of testosterone, placing more emphasis on potential benefits and emphasizing the uncertainty about the FDA's advice. The statement is published in Endocrine Practice.
  • Many patients with heart failure and preserved ejection fraction (HFpEF) have unrecognized atrial fibrillation (AF) that is associated with small, subclinical cerebral infarcts leading to cognitive dysfunction, propose researchers based on their analysis of participants in the long-running Atherosclerosis Risk in the Community (ARIC) cohort study. It may therefore be wise to screen patients with HFpEF for paroxysmal AF that would be missed by standard ECG at periodic clinic visits.
  • A post hoc analysis of two pivotal Phase III clinical trials has shown that treatment with reslizumab reduced clinical asthma exacerbations (CAEs) by 75% versus placebo in a subgroup of patients with late onset asthma (diagnosed at 40 years of age and older) with elevated blood eosinophils, who were inadequately controlled on inhaled corticosteroids (ICS).
  • Reports of subarachnoid hemorrhage (SAH) in young adults who used synthetic marijuana, published in the September 29 issue of Neurology, suggest a possible new adverse effect of chemical-rich synthetic cannabis products. Two such cases, reported in the September 29 issue of Neurology, were not due to an aneurysm or to vascular malformation in the brain, and both involved severe vasospasm.
  • For infants with acute bronchiolitis, nebulized hypertonic saline (HS) can reduce the risk for hospitalization in outpatients and reduce the length of hospital stay among inpatients, suggests a new study published in the October issue of Pediatrics.
  • Current cervical cancer screening practices remain less cost-effective and are linked to less health benefit then they would be if current guideline recommendations were followed, according to a model-based cost-effectiveness study published online September 29 in the Annals of Internal Medicine.
  • A study from Kenya published in JAMA Ophthalmol shows that clinical features do not reliably distinguish ocular surface squamous neoplasia from benign conjunctival lesions when histology cannot be evaluated, and toluidine blue vital staining is good for screening but not for diagnosis.
Number of people over 60 years set to double by 2050

With advances in medicine helping more people to live longer lives, the number of people over the age of 60 is expected to double by 2050 and will require radical societal change, according to a new report "World report on ageing and health 2015" released by the WHO for the International Day of Older Persons (1 October). Dr Margaret Chan, Director-General of WHO said, “Today, most people, even in the poorest countries, are living longer lives. But this is not enough. We need to ensure these extra years are healthy, meaningful and dignified. Achieving this will not just be good for older people, it will be good for society as a whole.” The report finds that there is very little evidence that the added years of life are being experienced in better health than was the case for previous generations at the same age. (Source: WHO)
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Media
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eSPIRITUAL
Why is the Garun Puran not read in routine life?
As per Hindu mythology, Garun Puran should not be read unless there is a death in the family. What can the rationale behind this?

One of the philosophies of Vedanta is that one should always talk and think positive and face adversity like a cricketer right from the first ball he faces. He always thinks he is going to score a 100 till he gets out. Similarly, every person should think that he will live up to 100 years until the last moment of death. Once he dies, he is not there to know how many years he lived. It is only the family who would know this. As far as he is concerned, till the last moment, he had been thinking that he would live for 100 years.

It is true that one should plan his old age and write a will in time but that is for the safety of the family and has nothing to do with your life.

Because Garun Puran talks about death, therefore, it is normally recommended that we do not talk about it in routine life.
Medicofinance
Components of financial planning process
  • Investment review: Analysis and recommendations.
  • Insurance review: Analysis and recommendations.
  • Employee benefits: Review and recommendations; coordinate with personal assets and spousal plans.
  • Disability income: Analysis and recommendations; 10-year projections of taxes, cash flow and net worth.
  • Estate distribution: Costs and taxation analysis methods of reducing probate costs and estate duties.
(Source: IJCP)
Industry News
  • IAMAI launches Mobile10X: The Internet and Mobile Association of India (IAMAI) has teamed up with Google India and Paytm to launch an industry forum with the aim of facilitating a 10-fold increase in mobile app revenue over the next five years. Under this, five mobile startup hubs will be set up across the country in the next five years. As per the IAMAI, the Mobile10X programme will seek to increase the number of quality developers to 5 lakh from 50,000 and mobile app revenue to Rs 10,000 crore from Rs 1,000 crore. (Source: Techcircle.in - Varun Arora)
  • India a bright spot in a slowing world economy: Washington: IMF chief Christine Lagarde has said that global growth will likely be weaker this year with only a modest acceleration expected in 2016 but India remains a bright spot. "India remains a bright spot. China is slowing down as it rebalances away from export-led growth. Countries such as Russia and Brazil are facing serious economic difficulties. Growth in Latin American countries, in general, continues to slow sharply," Lagarde said. (Source: Economic Times – PTI)
  • India's manufacturing output declines in September: India's manufacturing sector output slipped to a seven-month low of 51.2 in September, as order flow turned sluggish amid "difficult economic climate", a Nikkei survey said on Thursday. The Nikkei India Manufacturing PMI--a composite monthly indicator of manufacturing performance -- stood at 51.2 in September, down from 52.3 in August. (Source: Times of India – PTI)
  • Next big start up cities: Looking at data, it may not appear that there is a wide entrepreneurial gap between Bengaluru and the National Capital Region (NCR) belt. Startups in the NCR region have together raised $436.31 million (Rs 2,880 crore) from venture capitalist (VC) firms compared with the $456.63 million (Rs 3,014 crore) entrepreneurs in Bengaluru. But the actual fact is that the gap between the two is much larger. NCR, Mumbai and Pune have been suggested to come the closest to replicating Bengaluru's startup success. (Source: The Economic Times - Shailesh Menon)
eMEDIPICS
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A CME was organized by IMA HQs on World Heart Day 'Cardiology - Yesterday, Today & Tomorrow' at IMA House, New Delhi
Inspirational Story
Never Give Up

Life is how you want it to be, open your eyes, and you will see… No matter what, you can have fun, and always remember, when it’s done … The memories of what has been, the mistakes, so you won’t make them again… The good times, but the not–so-good times too, because these memories will see you through.

Never forget friends who've come and gone, Sing life’s praises as a beautiful song Loving and being loved are the greatest gifts, Close your heart, and these you’ll miss Life is how you want it to be, Open your eyes, and this you’ll see…

Just one note: Never Give Up!
Humor
Funny definitions

Dictionary: A place where success comes before work…
Medicolegal
Achieving Privacy and confidentiality in day to day practice- an ethical dilemma

Pragya Sharma
Lecturer, Dept. of Clinical Psychology

Smita N Deshpande
Head, Dept. of Psychiatry,
De-addiction Services
PGIMER- Dr. Ram Manohar Lohia
Hospital, New Delhi

Doctors in busy settings face an ethical dilemma. Maintenance of confidentiality and privacy becomes problematic due to the use of shared rooms. At times, the patient hesitates to share medical information due to this fact. More funds and better infrastructure may not always be possible. What is your preferred solution in such circumstances?

a) Ignore the issue as sharing information is culturally acceptable in India

b) Acknowledge overcrowding, try to make the patient comfortable within the shared setting

c) Extend work hours, push back appointments to ensure one patient per room at a time

d) Whisper/ talk in low voices

Do write in with your views and solutions.

Here are the responses received
  • I will go for a) Ignore the issue, as sharing information is culturally acceptable in India unless someone specifically asks for not sharing a small part of information. Saranya Devanathan, Psychiatrist
  • I think we cannot see 2 or 3 patients in one room. The patient’s right of privacy cannot be compromised for any reason. Each patient should be interviewed in a single room, and the patient and the family members should also be seen separately at least once and as and when needed. Infrastructural issues cannot be the excuse for inefficient treatment. Prof. Anil Agarwal, Psychiatrist
  • Lack of infrastructure is not an excuse for not observing privacy and confidentiality Patients should be seen alone as well as with family members. Prof. Satish Malik
  • Explain that the other person too is a doctor like me and assure that she would maintain confidentiality. Sudhakar Bhat, Psychiatrist
  • It is very difficult to provide a separate place and extending work hours may not be possible for doctors. They can talk in low voices and make the patient as comfortable as possible. If the issue really demands confidentiality like HIV or any other which patient is not at all confident to discuss in overcrowded situations, then extra time can be given after the crowding hours. Respecting the privacy of the patient is very important. Triptish Bhatia, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • Firstly, we can have cabins or space with glass partitions, which prevent the sound from reaching other places. Secondly, if we are to be economical then probably the patients, of course depending upon their problem and certainly alongside giving him assurance and confidence about confidentiality, can be asked to record their voices in their phones and then ear phones can be used as a medium to listen to the voice recorded by the patient. These ear phones shall be inserted/worn by both - the patient as well as the client so that they are on the same track of conversation. But, this can be done only at the time of case history taking. If the client is educated, he can write and the doctor can ask and clarify. Enquiry questionnaires could be used. Structuring the room accordingly can help. I don't know how much do we support online counselling and case history taking. However, people (doctors and patients) who are ready for the online case history-taking, shall be taken separately by doctors at say a particular day and they must be given facility and services of the same with helpers available around in a particular room Or can be done in a booth placed to be able to communicate with the doctors in any given area within the compound. Parul
  • Lack of rooms is a fact in mental health care. But mental health service cannot and should not be stopped due to this fact only. Privacy is definitely an important issue but when infrastructure is not adequate then also treatment means a lot. When any country does not have adequate infrastructure then decision should be taken according to what is available in nearby surrounding. So treatment comes first as per hierarchy of decision criteria. So the clinician should explore the possibility of privacy if possible. S/he may evaluate himself/herself, the nature of information forthcoming during the interview and take decision accordingly whether to ensure privacy or not. However privacy of any nature should be given due respect. But this suggestion is for setting where rooms are not available in adequate number. So the clinician may also ask the patient and family about their comfort level. However it has been observed that people do not care that much in a hospital outpatient department as they have their mind made up for such crowded places. And again people feel a kind of security being stranger in the crowd. If there are not too many patients then privacy must be secured for the patient. But during a rush this issue should be dealt by considering the nature of the problem and the sensitivity of the patient and the family.
    Ranjita Thakur
Breaking news
Drug regulator seeks to amend pharma manufacturing laws

New Delhi: After facing heat from the American and European counterparts over quality issues, the Indian drug regulator is set to draft an amendment to existing pharmaceutical manufacturing laws to bring them on par with international standards. The Drug Controller General of India (DCGI) will move a proposal before the government within the next six months to amend the Drugs and Cosmetics Act, 1940, and the Drugs and Cosmetics Rules, 1945, in an attempt to raise drug manufacturing standards in line with those recommended by the World Health Organization (WHO). “We have decided to revisit the present laws and bridge the gap between Indian manufacturing practices and the WHO good manufacturing practices (GMPs),” said G.N. Singh, the drug controller general of India. “The new standards in India will be up to the global marks.” DCGI will be evaluating the regulations and GMPs in the US, Europe, Canada, Japan and Australia as part of this process… (Source: Live Mint - Shine Jacob)
MAKE SURE
Situation: A patient on penicillin antibiotic developed a relapse of fever while still on antibiotic.
Reaction: Oh my God! Why was the antibiotic continued for so long?
Lesson: Make sure that drug fever is always excluded in such situations. Antibiotics are the most common cause of drug fever, accounting for approximately one–third of episodes. This especially applies to beta–lactams, sulfonamides and nitrofurantoin (Am J Med Sci 1987;294:275).
Updates
Union Health Ministry approves new MD courses at AHRCC in Odisha
The Union Health Ministry has approved two new MD courses in Acharya Harihar Regional Cancer Centre (AHRCC) at Cuttack in Odisha. The two new MD courses approved by the Ministry are in pathology and anaesthesiology. “The central government has decided to grant exemption under section (IA) of the Post-Graduate Medical Education Regulation, 2000 for starting MD course in the specialities of Pathology and Anaesthesiology in Acharya Harihar Regional Cancer Centre, Cuttack, Odisha,” Nadda wrote to Pradhan. Pradhan said the gesture of the Centre is unique as this facility was earlier provided to select health institutions like Dr Ram Mohan Lohia Hospital. AHRCC, however, does not have the MBBS course facility. (Source: EH News Bureau)
MRCGP (INT) South Asia AKT 2015 Exam on 18th November 2015

Last date for Submission of application is 9th October 2015. Interested candidates kindly contact Hony Secretary Dr. A. Raja Rajeshwar. Crash course for preparation of AKT 2015 starts from 1st week of October 2015. If interested contact IMA CGP HQ or Hony Secretary Dr A Raja Rajeshwar, Phone. No 98414 28855 & 72996 28855 and also visit our website ww.imacgpindia.com. We request you to kindly pass on the message to your friends & Colleagues to join the course.

D. A Raja Rajeshwar
National Secretary - IMA CGP Hqrs, Chennai
Faculty Secretary - IMA CGP, Tamilnadu
Tunnel to connect AIIMS main campus and Trauma Centre

An underground tunnel connecting the AIIMS main campus and its Trauma Centre is set to become operational by November beginning, thus drastically reducing the time for transfer of patients in critical condition between these two places to 3 to 4 minutes. (TOI)
Chemists’ strike on October 14 against online medicine sale

Expressing solidarity with the bandh called by the All India Organisation of Chemists and Druggists (AIOCD), the Utkal Chemists’ and Druggists’ Association (UCDA) has decided that 20,000 chemists across the State would go on strike on October 14. “The move directly violates the Drugs and Cosmetics Act, 1940. Section 65(10) (A) of the Act clearly mentions that one can purchase medicines after showing the doctor’s prescription from the medicine store while Section 65 (B) of the Act says that prescription should carry the patient’s name and address,” said association general secretary Chaudhury Prabir Das, adding that such rules cannot be followed in case of online trading of medicine. (The Pioneer)
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Safety Alerts List of Drugs, Medical Devices and Cosmetics declared as Not of Standard Quality/Spurious/Adulterated/Misbranded for the Month of August 2015
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Joint Commission issues alert on fall in hospitals

Falls are common and costly in healthcare settings, and not just among the elderly and frail. The Joint Commission wants more attention paid to fall prevention. Falls resulting in injury are a "prevalent patient safety problem," and not just among the elderly and frail, the JC notes in a Sentinel Event Alert issued September 28. (Medscape)
Binge drinking among adolescents

A clinical report released by the American Academy of Pediatrics (AAP) details alcohol abuse by children and adolescents in the US and offers guidance and recommendations to combat this high-risk behavior. The report states that among youth who drink, the proportion that drinks heavily is higher than among adult drinkers. Among those who drink, binge drinking increases from approximately 50% in those aged 12 to 14 years to 72% among those aged 18 to 20 years. Alcohol use is also associated with the leading causes of death and serious injury in this age group, including motor vehicle accidents, homicides, and suicides.
GP Tip: Abdominal wall tenderness test

While the patient is supine with abdominal muscles relaxed, the examiner palpates the tender spot. The patient is then asked to tense the abdominal muscles, and the tender spot is palpated once again. If the tenderness is worse, the abdominal wall muscles are most likely the source of the pain, rather than the underlying abdominal cavity. (Source: IJCP)
Injuries cost the United States $671 billion in 2013

Fatal and nonfatal injuries cost the United States $671 billion in 2013, according to two studies published in the October 2 issue of the Morbidity and Mortality Weekly Report. The reports describe lifetime medical and work loss costs for injury-related deaths and treatments in hospitals and emergency departments, analyzed by age, sex, and unintentional or violent injury. "Injuries cost Americans far too much money, suffering, and preventable death," Centers for Disease Control and Prevention (CDC) director Tom Frieden, MD, MPH, said in a CDC news release. "The doubling of deaths by drug poisoning, including prescription drug overdose and heroin, is particularly alarming." Of the costs related to injuries in 2013, $214 billion was related to fatal injuries and $457 billion to nonfatal injuries, according to the first article. This total economic burden includes in excess of 3 million hospitalizations, 27 million emergency department visits not leading to hospitalization, and 192,945 deaths. (Medscape)
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eWELLNESS
Adverse drug reactions are preventable

Over 50% of all adverse drug reactions treated in hospitals and emergency care are preventable. Many preventable drug reactions like drug overdoses and internal bleeding associated with the improper use of blood thinners and painkillers are life–threatening, especially in the elderly. There are many reasons for these reactions and may include poor coordination of care, lack of time and knowledge among health professionals, and lack of patient education, according to Swedish researchers, who conducted a meta–analysis of 22 studies. Human error is inevitable, and therefore systems must be made to reduce the error. The study concluded that:
  • In outpatient setting, the frequency of preventable adverse drug reactions resulting in hospitalization or emergency treatment is 2%; of these, 51% are preventable.
  • In the elderly, 71% of drug reactions are preventable.
  • In admitted patients the frequency of harmful drug reactions is 1.6% and 45% of them are preventable.
  • A third of preventable adverse drug reactions are life–threatening.
eMEDI QUIZ
The blood vessel related to the paraduodenal fossa is:

1. Gonadal vein.
2. Superior mesenteric artery.
3. Portal vein.
4. Inferior mesenteric vein.

Yesterday’s Mind Teaser: The commonest variation in the arteries arising from the arch of aorta is:

1. Absence of brachiocephalic trunk.
2. Left vertebral artery arising from the arch.
3. Left common carotid artery arising from brachiocephalic trunk.
4. Presence of retroesophageal subclavian artery.

Answer for Yesterday’s Mind Teaser: 3.Left common carotid artery arising from brachiocephalic trunk.
Answers received from: Dr.Rajeshwar Singh, Dr Jainendra Upadhyay, Dr.K.Raju, Dr Avtar Krishan, Daivadheenam Jella, Dr.B.R.Bhatnagar,
Answer for 1st October Mind Teaser: 4. Pre-existing neurological deficits.
Correct Answers received from: Dr Bitaan Sen & Dr Jayashree Sen, Dr K V Sarma, Dr K Raju, Dr Avtar Krishan, Daivadheenam Jella.
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News published in the Hindi daily "Dainik Bhaskar", Jabalpur regarding "Central Govt. Permitted Pharmacists can open Clinic and Practice Medicine".

Dr RK Pathak
Hony State Secretary
IMA MP State Branch
Press Release
Swachh Bharat Abhiyaan – the year that was and the year to come

It wasn’t long ago when PM Narendra Modi unveiled the "Clean India Mission/ Swachh Bharat Abhiyaan" to highlight the crucial issues that had been hindering India’s growth from time immemorial. The motive behind this national level campaign was to clean up the country over the next five years. The initiative that was launched on 2nd October 2014 is the biggest ever cleanliness drive that had seen more than 3 million people participating in it including several government employees, officials, celebrities and students from India.

The PM’s message on 2nd October last year laid emphasis on Mahatma Gandhi's dream of a clean India, and subsequently he appointed 9 Navratnas to carry forward the message. They then went ahead and nominated nine more, and the chain carried forward. Appointed twice by Mr. Satish Upadhyaya and Dr. Sonal Mansingh, Padma Shri Awardee Dr K K Aggarwal has strived to work towards helping make India a clean and healthy Nation since.

He has been working towards this cause within his individual capacity as well as his professional capacity. As the President of Heart Care Foundation of India and Honorary Secretary General of the Indian Medical Association he has initiated several activities and supported causes including:
  • Creating a concept of Swachch Bharat, Swasth Bharat hour at the Indian Medical Association and urging all its 2.5 lakh members to observe 4-5 pm every Friday as cleanliness hour and spend that time cleaning medical establishments across the country
  • The Indian Medical Association became a supporter of the Mission Clean India Movement by Alkem Pharmaceuticals. The biggest ever cleanliness drive by doctors, the movement saw participation of doctors from 135 cities across the country
  • Heart Care Foundation of India during its annual event the Perfect Health Mela recognized and appointed 9 Navratnas from the medical profession
  • The Indian Medical Association released newspaper advertisements on safe water to prevent diarrhea, jaundice and typhoid deaths in the country
  • An ongoing campaign has been initiated to create public awareness about section 269 of the Indian Penal Code which states that whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.
Speaking on Section 269, Padma Shri Awardee, Dr KK Aggarwal – President HCFI said, "Most people remain unaware of the fact that public urination, spitting, garbage disposal are all crimes under Section 269 of the Indian Penal Code with an imprisonment for up to 6 months. We have been working towards spreading this awareness both amongst the medical fraternity and the general public. We plan to continue this campaign over the next one year."

Some of the issues barring Clean India dream include “open defecation”, “manual scavenging” and “lack of adequate waste disposal management” are restricting India’s growth. A joint report prepared by UNICEF and WHO says 597 million people practice open defecation in India. The reasons for this are that about 792 million people in India do not have access to the proper sanitation facilities. It is essential that basic health and sanitation awareness is raised in the country and necessary infrastructure provided.

By maintaining proper sanitation and hygiene, over 50% of the disease health burden and subsequent budget can be done away with. While there has been progress in the cleanliness of the country in the past one year, we must not lose focus and continue to work towards this cause.
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