🛑The alarming rise in India recently in the incidence of mucormycosis — a rare fungal infection — in patients who have been diagnosed and treated for COVID-19 has come as no surprise to those of us in the medical oncology community. This outcome was our greatest fear as the administration of dexamethasone and other steroids began to become common. As oncologists who rely on steroids in many of our protocols, and having managed several cases of mucormycosis, we are acutely aware that treatment protocols need to differ from patient to patient due to the complexities in clinical presentation and an individual’s tolerance to treatment.
However, we find ourselves in a different position today because of the magnitude of cases being reported, and the inability of treating physicians to create individualised treatment protocols under this burden. Some States, including Tamil Nadu, have declared mucormycosis as a notifiable disease under the Epidemic Diseases Act. Guidelines and protocols need to be adapted and modified rapidly to arrest this growing epidemic. Why did the risk of mucormycosis overwhelming us come as no surprise? The estimated burden of mucormycosis in India is 14 per 100,000 in a study published in Current Fungal Infection Reports. This is almost 70 times higher than what is reported in other countries. In a multi-centre study across several tertiary-care hospitals in India, published in Clinical Microbiology and Infection, the rough estimate of proven mucormycosis was around 40 cases on an average over a 21-month period observed at each centre.
Focus on diabetes
It must be made absolutely clear that mucormycosis is not transmitted from one individual to the other, the way COVID-19 is. The most common cause is uncontrolled diabetes mellitus (raised blood sugars). Other causes include the treatment of some cancers; steroids, chemotherapy or immunotherapy, and solid organ or stem-cell transplantations. The common sites of presentation include rhino-cerebral involvement (i. e. , the fungus can damage the nose, paranasal sinuses, the eyes and the brain), and pulmonary involvement (i. e. , the fungus can cause pneumonia).
Raised blood sugars being a cause is of particular concern for multiple reasons. According to a study in The Lancet , the number of people with diabetes increased to 65 million in 2016 in India. The highest prevalence of diabetes was observed in Tamil Nadu, Kerala and Delhi. The crude prevalence of diabetes above 20 years of age has increased to 7. 7% in 2016, from 5. 5% in 1990. Further, there is an underlying higher genetic susceptibility to diabetes in Indians; some of these cases could get unearthed only after exposure to steroids.
The treatment of COVID-19 is, unfortunately, only worsening this situation. In a lab study published in Nature Metabolism, SARS-CoV-2 can potentially multiply in pancreatic cells and contribute to increased blood sugar levels in COVID-19 patients. Steroids form a very important aspect of treatment for COVID-19 because they lower death rates by reducing the cytokine storm phase which can develop in some patients. However, steroids when used excessively or prematurely, and without medical supervision can be harmful. Besides causing reduced immunity levels, steroids can also increase blood sugar levels which can cause additional harm if left unchecked. Dexamethasone, methylprednisolone or prednisone are among the steroids used in the treatment of COVID-19.
Mucormycosis is associated with very high morbidity and mortality. Its treatment requires a multi-disciplinary team approach that includes microbiology, pathology, radiology, infectious diseases, surgery, pediatrics, hematology, intensive care, dermatology, and pharmacology. A multi-disciplinary approach is simply not feasible on a large scale, especially in areas with limited medical access.
Surgery for mucormycosis can be debilitating requiring major resections. Additionally, there are limited antifungal drugs available for mucormycosis. The gold standard drug is liposomal amphotericin B, which is priced out of reach for many. Amphotericin B deoxycholate (conventional) is cheaper, but is associated with an unfavourable toxicity profile including kidney problems, abnormalities in electrolyte levels; reduced sodium, potassium, calcium and magnesium levels can lead to other toxicities. Some other expensive treatment options include posaconazole and isavuconazole. All these medicines often have to be administered for prolonged durations, making treatment protocols difficult to sustain on a large scale, given the cost implications and difficulty in drug administration due to its side-effects.
When a patient is recovering from COVID-19 infection, it is certainly going to be a challenge to perform debilitating surgeries and administer these antifungal drugs for a prolonged duration. In the case of rhino-cerebral mucormycosis especially, surgery is usually required in addition to antifungal drugs. If these surgeries cannot be performed, the outcome is dismal . It is also important to keep in mind that treatment for mucormycosis will require prolonged hospital admissions. Given the health-care constraints we are faced with, this infection should be avoided at all costs.
Monitoring is essential
What can be done to reduce the number of cases and the intensity of mucormycosis? Steroid use at home for COVID-19 should be only under the supervision of a health-care worker. The control of blood sugars during steroid intake is crucial to avoiding mucormycosis. When patients are medicating themselves at home, monitoring of capillary blood glucose is essential. If high blood sugars are encountered, a tele-consult with a doctor is advisable. Going a step further, health authorities may consider arranging for blood glucose monitoring for patients at home on steroids, and also promoting awareness campaigns on the importance of controlled blood sugar levels.
Patients on steroids for COVID-19 should report symptoms of mucormycosis at the earliest. Among other symptoms, they should look out for facial swelling on one side, protrusion of the eyeball, new-onset visual disturbances, headache and vomiting, new onset swelling or ulcers with blackish discolouration, and prolonged fever. COVID-19 treatment experts and policy-makers may consider widespread training of health-care personnel including Accredited Social Health Activists (ASHAs) and nursing professionals to raise awareness on mucormycosis while educating people locally.
The prolonged requirement for hospital admission linked to COVID-19 will also lead to a rise in other hospital-acquired infections necessitating the use of multiple antibiotics. We are staring at the grim reality of managing large numbers of patients with other long-standing side-effects of steroids. Additionally, the concern is the alarming increase in multi-drug resistant bacterial infections for which we are grossly unprepared.
1.Rely On-(Phrasal Verb)-to depend on (someone or something). पर निर्भर होना
2.Pulmonary (Adj)-relating to the lungs. फेफड़ा-संबंधी
3.Prevalence (N)-the fact that something is very common or happens often. व्यापकता
4.Susceptibility (N)-the tendency to be easily affected or influenced by something.
5.Morbidity (N)-the condition of suffering from a disease or medical condition.
6.Multi-Disciplinary (Adj)-involving different subjects of study in one activity.
7.Debilitating (Adj)-(of a disease or condition) making someone very weak and infirm.
8.Resections (N)-the process of cutting out tissue or part of an organ.
🛑For more than 50 years, well-intentioned and more cynical , local and external actors involved in the attempts to bring peace and reconciliation to historical Palestine have religiously adhered to the two-state solution as the only way forward.
The idea of partitioning Palestine between the settler movement of Zionism, and later the state of Israel and the indigenous population of Palestine is not new. It was first offered by the British in 1937 and rejected by the Palestinians already then. The Zionist movement was hardly 50 years old and was already offered by the new British occupiers of Palestine, a chunk of the Palestinian homeland as a future state. This in the 1930s and 1940s would have been an offer to decolonise India by partitioning it between a British India and local India or to propose the decolonisation of Algeria by dividing it between a French Algeria and a local Algeria. Neither the Indian anti-colonial movement nor the Algerian one would have ever consented to such a post-colonial arrangement; nor did the British and French dare to offer it when they reconciled with the fact that they will have to leave their colonial empires and go back to Europe.
But even when decolonisation was achieved in India in 1947, not only the British but also the so-called civilised world through the United Nations insisted that the Palestinians should give half of their homeland to the settler movement of Zionism. The Palestinians attempted to convince the international community that the prakin to oblem was not only about dispensing with half of their homeland but that the settler movement of Zionism would not be content with just half of the country and intended to take as much of it as possible and leave in it as few Palestinians as possible. This ominous prediction turned out to be chillingly accurate and true in less than a year after the UN insisted that partition was the only solution for Palestine. Under the guise of UN support, the new Jewish state took over nearly 80% of historical Palestine and ethnically cleansed almost a million Palestinians (more than half of Palestine’s population), and in the way demolished half of Palestine’s villages and most of its towns in nine months in 1948; an event known by the Palestinians as the Nakba, the catastrophe .
In 1967, Israel occupied the rest of historical Palestine, and in the process expelled another 300,000 Palestinians. Like all settler colonial projects, it had to navigate between a wish to take over indigenous territory while downsizing the number of native people living on it. It was impossible after 1948 to repeat a massive ethnic cleansing, so it was substituted by incremental ethnic cleansing (the last stage in this process was one of the root causes that ignited the cycle of violence last week — the proposed eviction of Palestinians from Shaykh [Sheikh] Jarrah, an East Jerusalem neighbourhood, as part of an overall attempt to Judaise East Jerusalem). Incremental ethnic cleansing is not the only way of achieving the old Zionist goal to turning historical Palestine into a Jewish state. Imposing military rule in the West Bank and the Gaza Strip after they were occupied was another means which enclaved the people there without basic human and civil rights. Imposing a version of an Apartheid regime on the Palestinian minority in Israel is another method and the constant refusal to allow the 1948 refugees to return completes the matrix of power that allows Israel to retain the land and disregard a demographic reality by which the Jews are not the majority in historical Palestine.
It is Israel that decides
The two-state solution, offered for the first time by liberal Zionists and the United States in the 1980s, is seen by some Palestinians as the best way of ending of the occupation of the West Bank and at least the partial fulfilment of the Palestinian right for self-determination and independence. This is why the Palestine Liberation Organization was willing to give it a go in 1993, by signing the Oslo Accords. But the Palestinian position has no impact in the current balance of power. What mattered is how Israel interprets the idea and the fact that there is no one in the world that could challenge its interpretation.
The Israeli interpretation, until the rise of Benjamin Netanyahu to power in 2009, was that the two-state solution is another means of having the territories, the West Bank and the Gaza Strip, without incorporating most of the people living there. In order to ensure it, Israel partitioned the West Bank (which is 20% of historical Palestine) into a Jewish and an Arab part. This was in the second phase of the Oslo Accords, known as the Oslo II agreement of 1995. The Palestinians were forced to accept it under American and Egyptian pressure. One area, called area C, which consists of 60% of the West Bank) was directly ruled from 1995 until today by Israel. Under Mr. Netanyahu, Israel is in the process of officially annexing this area while at the same time ethnically cleansing the Palestinians living in it. The remaining 40% of the West Bank, areas A and B under Oslo II, were put under the Palestinian Authority, which optimistically calls itself the state of Palestine, but in essence has no power whatsoever, unless the one given to it, and withdrawn from it, by Israel.
The Gaza Strip was divided too. But the Jewish part was small and could not be defended from the local national movement’s wrath . So, the settlers were taken out in 2005 and Israel hoped that another Bantustan, like the one in areas A and B, would be established there under the Palestinian Authority’s rule and under the same conditions. But the people of Gaza opted to support a new player, Hamas, and its ally, the Islamic Jihad, which resisted this offer. They supported them not only because there was a return to religion in the face of the ongoing predicaments but also because there was big disappointment from the compliance of the PLO with the Oslo arrangements. Israel responded by imposing a callous siege and blockade on the Gaza Strip that, according to the UN, made it unliveable.
To complete its strategy that included the partition of the West Bank, its Bantustanisation, and the siege of Gaza, Israel passed in 2018 a citizenship law, known as the nationality law, which made sure that the Palestinian citizens who live in Israel proper (which is Israel prior to the 1967 occupation of the West Bank and the Gaza Strip) and who are supposedly equal citizens of the Jewish state, will in essence become the “Africans” of a new Israeli Jewish apartheid state: living in a permanent regime that discriminates against them in all aspects of life on the basis of their nationality.
The endless negotiation on the two-state solution was based on the formula that once the two states become a reality, Israel will stop these severe violations of the Palestinian civil and human rights, wherever they are. But while the wait continued, more Palestinians were expelled and the Jewish settler community in the West Bank doubled and tripled and took over the fertile land, leaving no space for Palestinian expansion. The presence of more than 600,000 Jewish settlers, with a very high rate of natural growth, means that Israel will never consider moving them out; and without that, even a soft version of a two-state solution is impossible.
Decolonise, build a new state
The whole premise of the two-state solution is wrong and that is why it did not materialise. It is based on the assumption of parity and of framing the conflict as one fought between two national movements. But this is not a “conflict” as such. This is a settler colonial reality which began in the late 19th century and continues until today. The late scholar, Patrick Wolfe, described settler colonial movements as motivated by a logic he called “the elimination of the native”. Sometimes it led to genocide , as it happened in North America, sometimes it translated to an ongoing ethnic cleansing operation, which is what has unfolded in Palestine. The two-state solution is not going to stop the ethnic cleansing; instead, talking about it provides Israel international immunity to continue it.
The only alternative is to decolonise historical Palestine. Which means that we should aspire to a state for all its citizens all over the country, based on the dismantlement of colonialist institutions, fair redistribution of the country’s natural resources, compensation of the victims of the ethnic cleansing and allowing their repatriation . All this will be so that settlers and natives should together build a new state that is democratic, part of the Arab world and not against it, and an inspiration for the rest of the region which desperately needs such models to push it forward towards a better future.
1.Cynical (Adj)-contemptuously distrustful of human nature and motives. मानवद्वेषी
2.Chunk (N)-a part of something, especially a large part.
3.Ominous (N)-giving the worrying impression that something bad is going to happen.
4.Wrath (N)-extreme anger. रोष, क्रोध
5.Predicaments (N)-a difficult, unpleasant, or embarrassing situation. मुश्किलों
6.Compliance (N)-the act of obeying an order, rule, or request. अनुपालन
7.Callous (Adj)-feeling or showing no sympathy for others. निर्दयी, संवेदनाहीन
8.Siege (N)-Invading and taking control by force. घेराबंदी
9.Conflict (N)-a serious disagreement or argument, typically a protracted one. संघर्ष
10.Repatriation (N)-the return of someone to their own country. स्वदेश में आगमन
🛑Monsoon likely to be delayed by 2 days, may hit Kerala by June 3: IMD
Sanjeeb Mukherjee | 30/05/2021 | 12 hours ago
The much-awaited onset of the southwest monsoon is expected to be delayed by two days and the rains are now likely to hit the Kerala coast on June 3 instead of June 1, the India Meteorological Department (IMD) said.
"The delay is because of the weak westerly winds near Kerala coast which is why rainfall and cloudiness is not increasing," Director General of IMD, Mritunjay Mohapatra, told Business Standard.
He said further that the depth of westerly winds also should increase to sustain rainfall.
The met meanwhile, added that due to strengthening of lower level southwesterly winds, fairly widespread rainfall activity with isolated heavy falls are very likely over northeastern states during next five days.
The normal onset date for the monsoon over Kerala is June 1. This marks the start of the four-month rainfall season for the country.
Earlier this month, the IMD had predicted the arrival of monsoon over Kerala by May 31 with an error margin of plus or minus five days.
Monsoon is expected to be normal this year.
In complete divergence, private weather forecasting agency, Skymet today said that the southwest monsoon has in fact already arrived over Kerala today.
"A set of environmental conditions need to be fulfilled as a criterion for the arrival of monsoon. By and large, all parameters have satisfied the required threshold, essentially the rainfall and depth and speed of westerly winds over the Southeast Arabian Sea and adjoining Equatorial Indian Ocean. Rainfall amounts are verified from the available data on the official website," Skymet said in a statement.
It added that in the absence of any major monsoon trigger, the onset may be slightly mild.
🛑PSU banks to follow template with three loan buckets for recast 2.0
Subrata Panda | 30/05/2021 | 13 hours ago
Public sector banks, including the country’s largest lender State Bank of India (SBI), have come out with a templated approach for restructuring retail and small business loans of up to Rs 25 crore under the Reserve Bank of India’s (RBI) Covid restructuring package 2.0. They have also come out with standardised products to make funds available to business entities for improving healthcare infrastructure and to individuals for meeting Covid treatment expenses.
Business loans have been divided into three categories. For loans under Rs 10 lakh, PSU banks will follow a standard restructuring plan while loans between Rs 10 lakh and Rs 10 crore will follow a graded approach. For loans above Rs 10 crore, the lenders will put in place a common outreach programme and follow a graded restructuring approach. There will be standard application and assessment formats and simplified documentation process.
As far as individuals are concerned, customers can access the banks’ portal or manually submit their application in the banks’ branches, post which the application will be processed and the resolution plan will be invoked within 30 days of the application. And, post invocation, the plan will be implemented within 90 days.
As far as small ticket business loans are concerned, data of eligible units have been extracted by banks and bulk SMSs have sent to these customers, including already restructured accounts. Offer cum acceptance letters along with applications have been generated centrally by banks.
SBI chairman Dinesh Kumar Khara, addressing a press conference along with Indian Banks Association (IBA) chairman Rajkiran Rai G, said, “ Various steps have been taken to ensure that the implementation of resolution framework 2.0 announced by the RBI should be in place by all the public sector banks. We have all come out with a templated approach for restructuring loans given to individual borrowers, small businesses, MSMEs”.
“The idea behind this is, those who are involved in the implementation process should not face any hardship”, he said. “We have tried to use as many channels as possible to reach out to the customers so that we are in a position to mitigate the hardships of the customers”, he added.
According to Rajkiran Rai G, customers of public sector banks do not differentiate between banks, especially small borrowers. Having different schemes for restructuring confuses people so we thought a templated approach for small borrowers will be easy.
“It is too early to say how many will take up the restructuring scheme”, Rai said. “Last time we saw that the number of customers who opted for restructuring was not that high”, he said.
Under the first restructuring announced by the RBI last year, around 8.5 lakh small and medium enterprises were eligible but only 60,000 of them availed of the facility.
With regards to the moratorium, Sunil Mehta, IBA CEO, said, “Right now restructuring will take care of the requirement of 80 per cent of the borrowers. And, depending on the severity of the second wave, RBI may come out with additional measures”.
The RBI on May 5 came out with the second restructuring package, wherein they said borrowers i.e. individuals and small businesses and MSMEs having aggregate exposure of upto Rs 25 crore and who have not availed restructuring under any of the earlier restructuring frameworks (including under the Resolution Framework 1.0 dated August 6, 2020), and who were classified as ‘Standard’ as on March 31, 2021 will be eligible to be considered under Resolution Framework 2.0.
Apart from streamlining the restructuring process, the public sector banks have come out with three products, under which fresh lending will be provided to vaccine manufacturers, hospitals, pathology labs, manufacturers and suppliers of oxygen, ventilators, and other stakeholders. Under the emergency credit line guarantee scheme (ECLGS 4.0), hospitals and health care facilities will get loans upto Rs 2 crore to set up oxygen plant along with power back up. The interest rate on such loans will be 7.5 per cent and the tenor of the loan will be for a maximum of 5 years.
Business loans for healthcare facilities to expand or set up health infrastructure is the second product, where the target group will get funding of Rs 10 - 100 crore, depending on the geography, with a tenor of 10 years. The interest rate charged by banks for such loans will vary based on the cost of funds of each bank.
Also, banks will provide unsecured covid loans to individuals for covid treatment. An individual can avail upto Rs 5 lakh for a maximum period of 5 years. SBI will charge an interest rate of 8.5 per cent for such loans.
Fresh lending under “Covid loans” will get priority sector tag hence banks are offering loans at concessional rates, public sector bankers said.
The RBI in its relief package has also provided a Rs 50,000 crore liquidity window, which will be available with tenors of up to three years at the repo rate to boost provision of immediate liquidity for ramping up Covid related healthcare infrastructure and services in the country.
Khara said the utilisation of the RBI’s liquidity window will depend on the banking sector’s liquidity. If there is ample liquidity in the banking system, then the utilisation of the RBI’s window will be less.