Taking on TB
Keeping the prices of the new drug low is essential for increased treatment uptake
- The anti-tuberculosis drug pretomanid recently approved by the U.S. Food and Drug Administration will be a game changer for treating people with extensively drug-resistant TB (XDR-TB) and those who do not tolerate or respond to now available multidrug-resistant TB (MDR-TB) drugs. That pretomanid is only the third drug in the last 40 years to get FDA approval highlights the scarcity of new drugs to treat TB bacteria that are rapidly developing resistance against most available drugs. The all-oral, three-drug regimen of bedaquiline, pretomanid, and linezolid (BPaL) had a 90% cure rate in a phase III trial in South Africa involving 109 participants. In contrast, the current treatment success rate for XDR-TB and MDR-TB is about 34% and 55%, respectively. Importantly, the regimen was found to be safe and effective in curing TB in people living with HIV. The safety and efficacy were tested in 1,168 patients in 19 clinical trials in 14 countries. Unlike 18-24 months needed to treat highly-resistant TB using nearly 20 drugs, the BPaL regimen took just six months, was better tolerated and more potent in clearing the bacteria. The shorter duration is more likely to increase adherence to therapy and improve treatment outcomes. According to the World Health Organisation, in 2017, there were an estimated 4.5 lakh people across the world with MDR-TB, of which India accounted for 24%, and about 37,500 with XDRTB. With only a low percentage of MDR-TB cases being treated, the actual number of people who do not tolerate or respond to available MDRTB drugs and so will be eligible to receive the BPaL regimen is unknown. Though the total number of people who will require the new drug may not be high, these are people who have very little alternative treatment options that are safe and efficacious. Also, the number of those who would need a pretomanid-based regimen is increasing due to rising drug resistance.
- While the availability of a potent drug is welcome news, it remains to be seen if it would be made affordable, particularly in the developing countries where the burden of XDR-TB and MDR-TB is the highest. TB Alliance, a New York-based international NGO, which developed and tested the drug, has already signed an exclusive licensing agreement with a generic-drug manufacturer for high-income markets. Unlike in the case of bedaquiline, where its prohibitive cost has severely restricted access especially in the developing countries, pretomanid might become affordable. In line with the TB Alliance’s commitment to affordability and sustainable access, the drug will be licensed to multiple manufacturers in about 140 low- and middle-income countries, including India. Making the drug affordable to those with extreme form of drug resistance will be highly commendable and a desperately needed model to be followed. After all, there is a compulsion to keep the prices low and increase treatment uptake to stop the spread of highly drug-resistant TB bacteria. Studies have shown an increase in the number of new patients who are directly infected with drug-resistant bacteria.
- The “Idea of India” has always been grander in promise than in fulfilment. At Independence, the dream was that the people of a country of so much diversity — in language, religion, and tradition — would enjoy constitutionally guaranteed rights and through democratic means, build a just society. A cornerstone of this dream was respect for diversity that was written into the Constitution. It has been a mixed record, with as many failures as achievements. The events of the past two weeks, however, signal to us that the “Idea of India” is in danger of collapsing. We may soon have to accept the “New India” which places no value on pluralism, fraternity and autonomy.
- Everything about why and how the constitutional arrangements of Jammu and Kashmir (J&K) have been so radically changed violates the “Idea of India”.
A worrisome move
- The processes used to modify the “Holy Book” that is the Constitution are as important as the content of the amendments. Yet, as many lawyers and constitutional experts have already pointed out, the manner in which the Narendra Modi government has withdrawn the rights J&K enjoyed under Article 370 can only be described as abusing the spirit of the Constitution. Now that the Government has tasted success, it should be confident about using the same kind of skullduggery to aggressively alter the Constitution to further its agenda. Only the courts stand in the way and there the Government of India must be feeling that its own actions will pass muster.
- We also have the disappearance of J&K as a State. It is hard to think of anything more insulting to a people than to inform them one morning that their State has been turned into two Union Territories, effectively ruled from New Delhi. This is real “tukde tukde” work.
- Since the early 1950s, States have been periodically divided and new ones created. Consultation of some form or the other has always been an integral part of the process. Nothing like the sudden disappearance of the State of J&K has happened before. In a supposedly federal system, the Centre has been able to ram through the necessary legislative changes while keeping 8 million people cut off from the rest of the world and without allowing them to express their views. In the past five years, we have undoubtedly had the most centralised government since the time of Mrs. Indira Gandhi. Should we or shouldn’t we be worried about what more is in store for us? Was it short-sightedness or fear that made all the regional parties — the Dravida Munnetra Kazhagam being the only major exception — endorse the break up of J&K into two Union Territories?
- Spirit behind special rights
- There are legitimate reasons why in our diverse society, the Constitution has ordained special rights, for instance, for Dalits and Adivasis; for Manipur, Mizoram, Nagaland and Sikkim (under Article 371); and so too for J&K until now under Article 370. A uniformity of rights across the nation and all classes does not necessarily make for a cohesive society. In fact, the opposite is the case in a country of vast diversity. Special rights for specific communities and regions enable them to feel a “oneness” in a large country that has so many kinds of differences. Here, the guarantees promised to J&K were especially important because of the circumstances surrounding the State’s accession to India.
- The autonomy offered by Article 370 has been contentious for two reasons. One, it was enjoyed by a State that remained divided between India and Pakistan. Two, the constitutional provision applied to India’s only Muslim majority State. These two features should have made it all the more important to preserve the guarantees contained in Article 370. However, for the Rashtriya Swayamsevak Sangh and the Jan Sangh/Bharatiya Janata Party, for whom uniformity has always come first, abolition of Article 370 has been a core demand.
- Contentious Article 370 always was, but it was never adhered to in any measure. In this, there have been no saints in either New Delhi or Srinagar. If one systematically emptied the promise of autonomy right from the 1950s onwards with a series of presidential notifications, the other used it as a bargaining chip to feather its nest. Though emptied of content, Article 370 has retained an important symbolic value for the people of J&K as recognition of its unique character.
- It has been argued that whatever the merits of the Modi government’s actions, the “Kashmir situation” of the old was no longer sustainable. But we must remember that the iron glove of this government has only made matters worse since 2014: every year since then has seen an increase in violence — of incidents of terrorism, security personnel killed and innocents murdered. When the lockdown in J&K is finally lifted, New Delhi will find that it will be dealing with a sullen population that feels its land has been occupied. We must fear a surge in violence for months and perhaps years, with or without a spurt in terrorism from across the border.
- The middle and upper classes in the rest of India have welcomed the decisions of early August. This is not surprising. The long-running violence in J&K first made them weary, and then indifferent. So they now endorse “firm” actions that will put Kashmiris in their place. We talk about Kashmir not being integrated with the rest of India, when, truth be told, the rest of India has never integrated itself with Kashmir. Before the violence, Kashmir was only a place of natural beauty that was worth a brief holiday or one where film stars pranced on hillsides. We never saw Kashmiris as fellow citizens with the same dreams as all of us. We only saw them as residents of a State that Pakistan coveted, a people whose allegiance to the nation we thought was suspect and a State that was the cause of so much armed conflict and terrorism.
- The same middle class that seeded the freedom movement, which gave the ideas for a modern Constitution and then led the nation-building project around “The Idea of India”, has now embraced an aggressive nationalism that dismisses the pluralism of India. We now do not seem to care one bit about what the people of Kashmir feel. We have been the least concerned the past fortnight about the lockdown they have been placed under. We openly talk about the possibility of buying up land in Kashmir. Lawmakers speak without being reprimanded about men from the rest of the country marrying “fair” Kashmiri women. And we look forward to effecting a demographic transformation in the Valley. How far we have travelled from when India drew up its Constitution.
- There have been three days in the Republic’s history on which “The Idea of India” has been shaken to its roots.
- The first was June 25, 1975 when an Emergency was declared and many of our Fundamental Rights were suspended. The people’s vote rescued India at the time. The next was December 6, 1992 when the Babri Masjid was destroyed. We managed to limp away, though with neither atonement nor punishment. Now we have August 5, 2019, when the Constitution was subverted in spirit if not in letter, when federalism was shoved aside and the rights of the people of a member of the Union were stamped on.
- It is difficult to see “The Idea of India” recovering from this latest body blow.
- Policymaking by tweet may have arrived in India, for the Defence Minister, Rajnath Singh, appears to have altered a key pillar of India’s nuclear doctrine when he tweeted that India’s ‘future’ commitment to a posture of No First Use of nuclear weapons ‘depends on the circumstances’. Using the commemoration of the first death anniversary of Prime Minister Atal Behari Vajpayee as the setting for this declaration, Mr. Singh’s announcement marks a significant revision of India’s nuclear stance, seemingly without any prior structured deliberation or consultation. Of course nuclear doctrine, like any directive guiding national security, needs to be a dynamic concept that responds to changing circumstances. However, this raises the question of what has changed in India’s strategic outlook that requires a revision of one of the two foundational pillars of its nuclear doctrine.
- India is one of two countries — China being the other — that adheres to a doctrine of No First Use (NFU). Our knowledge of India’s nuclear doctrine is based largely on a statement circulated on January 4, 2003 by the Cabinet Committee on Security (CCS), which said that it had ‘reviewed progress in operationalizing India’s nuclear doctrine’, and was making public the relevant details as appropriate (summarised in seven points). The first said that India would maintain ‘a credible minimum deterrent’ and the second point avowed ‘[a] posture of “No First Use”: nuclear weapons will only be used in retaliation….’ The remaining five points flow mainly from these two points mentioned. India has maintained that it will not strike first with nuclear weapons but reserves the right to retaliate to any nuclear first strike against it (or any ‘major’ use of weapons of mass destruction against Indian forces anywhere) with a nuclear strike ‘that will be massive and designed to inflict unacceptable damage’. This is not a statement by the faint-hearted — with two nuclear neighbours, the NFU simply raises the nuclear threshold in order to bring stability into a volatile environment.
- It is almost exactly 20 years to the day since since any of this was first mentioned officially. On August 17, 1999, the then caretaker Bharatiya Janata Party government released a draft Nuclear Doctrine in order to generate discussion and debate on India’s nuclear posture. There was much discussion and criticism of the doctrine, as indeed of the timing of the release of the draft, coming as it did just weeks before a national election. It was known that the first National Security Advisory Board, a group of 27 individuals convened by K. Subrahmanyam, and comprising strategic analysts, academics, and retired military and civil servants, had completed their draft some months earlier; however, their report was only released a couple of weeks before polling began on September 5, 1999.
- It has ever been thus. Following criticism of the draft doctrine, the government appeared to move away from it. It was never discussed in Parliament and its status remained unclear for three and a half years until it was abruptly adopted by the CCS with minor modifications in 2003. The draft’s emphasis on NFU, however, remained unchanged. The adoption of the nuclear doctrine came soon after Operation Parakram (2001-02), when the threat of a nuclear exchange on the subcontinent had figured prominently in international capitals, if not in New Delhi and Islamabad. The public adoption of the doctrine was in part an attempt by New Delhi to restate its commitment to restraint and to being a responsible nuclear power.
Restraint as a pivotal point
- Restraint has served India well. India used the strategic space offered by its repeated proclamations of restraint to repulse the intruders in Kargil 20 years ago and regain occupied land despite the nuclear shadow created by India and Pakistan’s nuclear tests of 1998. Raising the nuclear threshold gave India the space for conventional operations and gained it sympathy in foreign capitals despite the fears of nuclear miscalculation that were widespread from Washington DC to London to Tokyo. India’s self-proclaimed restraint has formed the basis for its claims to belong to the nuclear mainstream — from the initial application for the waiver in 2008 from the Nuclear Suppliers Group in order to carry out nuclear commerce with the grouping, to its membership of the Missile Technology Control Regime, the Wassenaar Arrangement and the Australia Group and its ongoing attempts to join the Nuclear Suppliers Group.
- While revoking the commitment to NFU does not necessarily equate with abandoning restraint, it does leave India’s doctrine more ambiguous. Ambiguity, in turn, can lead to miscalculations, as India found out with Kargil (1999), where it would appear that Rawalpindi misread India’s resolve to carve out space for conventional military operations despite the new nuclear overhang. Neither does adhering to the NFU symbolise weakness, for India is committed to a devastating response to nuclear first use — a stance which underscores India’s understanding of nuclear weapons as meant primarily to deter.
- Of course, NFU has had its critics among those who advocate a more muscular nuclear policy for India. Indeed, Bharat Karnad, a member of the first National Security Advisory Board that drafted the basis of this current nuclear doctrine, made it known at the time that he considered NFU ‘a fraud’ which would be ‘the first casualty’ if war were to break out.
- However, consensus among the remaining members of the board clearly coalesced around an understanding of nuclear weapons not as war-fighting armaments but as weapons of last resort, meant to deter the threat and use of nuclear weapons. It was this understanding that was then used to bring India into the nuclear mainstream. It is also this understanding that has formed the basis of India’s nuclear posture, from force structure to numbers to its overall nuclear diplomacy.
- All of these points are up for revision with the announcement at Pokhran, which is where the BJP chose to remember Atal Behari Vajpayee on his first death anniversary. At a time when there are multiple queries regarding the state of India’s economy, the road map to normalcy in Jammu and Kashmir, the strength of India’s federalism, to name a few, we can now add questions about what has changed in India’s security environment to warrant a review of its nuclear doctrine. India’s neighbours will be as interested in the answers as this country’s citizens.
- The recent accident in Rae Bareli in which a rape survivor’s two aunts died, and which left her and her lawyer in a critical condition, has drawn much media attention. The rape accused, Bharatiya Janata Party (BJP) MLA Kuldeep Singh Sengar, was arrested in April last year after the survivor attempted to immolate herself in front of the Uttar Pradesh Chief Minister’s residence while demanding justice. Consequent to the death of the two individuals, one of whom was also a witness in the case, charges pertaining to attempt to murder were added to those already present against Sengar.
- On June 2 this year, Assistant Sub Inspector Suresh Pal, assigned to protect murder witness Rambir, was accidentally killed when the assailants missed their aim while attempting to kill the witness. In 2017, in the Asaram Bapu case concerning the rape of some women devotees, three witnesses were killed and as many as 10 attacked in an attempt to weaken the case. In fact, it was the killing of the three, followed by a Public Interest Litigation, which prompted the apex court to issue directions to the Centre and the States to frame laws for protection of witnesses.
- Maharashtra’s law
- Following this, Maharashtra came out with the Maharashtra Witness and Protection and Security Act 2017, which was notified in January 2018. However, the Centre, and most other States, are yet to act on the directive.
- Meanwhile, the apex court gave its assent last year to the Witness Protection Scheme, which was drafted by the Centre in consultation with the Bureau of Police Research and Development and the National Legal Services Authority. The Centre was to implement the scheme after circulating it among all States and Union Territories and obtaining their comments. However, the scheme was meant to be a measure in force only till the government brought out its own law on the issue. Though the Centre is scheduled to bring an Act on the subject by the end of this year, it has not made much progress.
- Lax implementation
- As regards the existing measure, though its objective is to ensure the safety of witnesses, so that they are able to give a true account of the crime without any fear of violence or criminal recrimination, its implementation on the ground leaves much to be desired. The Unnao matter would have been hushed up but for the fact that the survivor attempted to immolate herself in front of the Chief Minister’s residence.
- Further, though the scheme provides for police personnel to be deployed to protect the witness on the basis of threat perception, it is silent on the punishment to be given to those policemen who, while being charged with providing security, themselves threatened the witnesses. Why were the policemen tasked with protecting the Unnao survivor not with her when she travelled to Rae Bareli? Were they aware that a sinister plan had probably been hatched to eliminate her relatives?
- Above all, what emboldens the criminals the most is the support they get from the police. The shadowy politician-police nexus is so strong that no policeman, at the mercy of political leaders for his career progression, dares take any action against his ‘master’. As long as this nexus continues, the delivery of criminal justice in India will remain a casualty.
- The Witness Protection Scheme calls for more elaborate and stricter laws to be incorporated so that criminals find no loopholes that can be exploited to their advantage. The sooner the Centre comes up with a legislation codifying the protection to be given to witnesses, the better it is for India’s criminal justice system.
UAE to give Modi highest civilian award
- Prime Minister Narendra Modi will visit the UAE on August 23 and 24 where he will receive the Order of Zayed, the highest civilian award of the country. An External Affairs Ministry statement on Sunday said Mr. Modi would pay a state visit to Bahrain on August 24 and 25 where he would launch the renovation of a temple of Shreenathji.
- “The order in the name of Sheikh Zayed bin Sultan Al Nahyan, founding father of the UAE, acquires special significance as it is awarded to Prime Minister Modi in the year of the birth centenary of Sheikh Zayed,” the statement said.
- The visit acquires importance as it would be the first by Mr. Modi to a leading member of the Organisation of Islamic Countries after India had changed the status of Kashmir.