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    • Foods in Indian homes are usually stored in covered containe

    2019-04-29

    Foods in Indian homes are usually stored in covered containers and consumed within a day of preparation. Many households (about 80%) cook food twice a day, and more than half serve food hot; many reheat leftover foods. Fewer than 10% of Indian homes have refrigerators, and hence campaigns about cross-contamination, reheating, or thawing might be of little relevance. Even without powered refrigeration, many Indians practise traditional ways of storing leftover foods, including storage in a cool place, in water, or in a porous dish with water on its lid. Food is often cooked in small quantities to avoid storage problems. The safety implications of common practices for food storage and consumption need to be better understood so that associated risks can be effectively communicated and feasible alternatives encouraged. Hand washing is relatively routine in India, and is often customarily done before handling or consuming of food. Normative hand washing does not, however, guarantee safety of the foods handled, because a great deal of hand washing is symbolic and done without soap. These customary practices can be strengthened by encouragement of universal access to and use of soap, which can reduce the risk of diarrhoeal diseases by 40–42%. In many Indian homes, the domestic hearth is an area of sanctity and tends to be located next to the area of worship. However, with an estimated 37% of Indians living in poverty, most homes do not have a separate designated kitchen, such that living, cooking, and eating happen in a common place within the house (31%) or veranda (courtyard; 28%). Many households (76%) cook with solid fuels such as firewood, coal, or cow-dung cakes, which release smoke that leads to lacrimation and nasal discharge, posing a food safety hazard. Migration towards cleaner fuels is hindered by factors of affordability, availability, and accessibility. Similarly, availability of safe drinking water is beyond the control of the common consumer.
    We read with great interest the Comment by Soumyadeep Bhaumik and colleagues (Sept, p e129) advocating universal access to health-care information. The communication is important and timely; however, we believe that Bhaumik and colleagues have extrapolated their arguments and made disproportionate and dubious claims to support their viewpoint. For instance, on the basis of the study by Jafar and colleagues, the authors say that a quarter of Pakistani physicians are unaware of the cediranib guidelines “because they do not have adequate information about medicines” and thereby prescribe sedatives. Bhaumik and colleagues then reiterate that governments are legally obliged to ensure adequate access to health-care information. However, the gaps in the practices of Pakistani physicians appear to be because of lack of continued medical education sessions and a subdued tutorial system in medical schools (as elaborated by Jafar and colleagues) rather than inadequate access to health-care information. The National Family Health Survey of India emphasises the need to hydrate children who have diarrhoea, but there is no evidence to show that such an intervention in the home setting improves mortality. The eight out of ten practitioners who are unaware of childhood pneumonia symptoms in the developing world represent a similar example, whereby medical education seminars and rigorous tutorials can improve the situation. Thus, the major dilemma seems to be in the implementation of rather than access to health-care information. Although we strongly believe that health information should be available to all, several fundamental questions need to be answered. To ensure such a provision, funding needs to be made available. Where would sternum funding come from? These funds would be redirected from the health budget and research allocations. For example, in 2012, the research council in the UK spent US$161 million to provide gold open access in the UK. Whether cutting down on medical research (with a proven potential to save human lives) to ensure health-care access to all is justified poses great ethical considerations.
    We thank Haris Riaz and colleagues for their interest in our Comment. The term access in the context of our Comment not only implies open access to newly generated research findings, but also incorporates making pre-existing knowledge available to health-care workers and caregivers. Making essential health-care information available at the end-user level through seminars and tutorials, among other modalities, is indeed an indispensible part of ensuring access in the truest sense of the term. As mentioned by Riaz and colleagues, continued medical education and recertification procedures are necessary, which are basically structured methods to assure information dissemination, reinforcement, and retention. We advocate the very same outcomes, not only for medical professionals, but also for health-care providers and caregivers at all levels.