India.

Generic drugs: Review and experiences from South India

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Abstract

The cost of pharmaceuticals, as a percentage of total healthcare spending, has been rising worldwide. This has resulted in strained national budgets and a high proportion of people without access to essential medications. Though India has become a global hub of generic drug manufacturing, the expected benefits of cheaper drugs are not translating into savings for ordinary people. This is in part due to the rise of branded generics, which are marketed at a price point close to the innovator brands. Unbranded generic medicines are not finding their way into prescriptions due to issues of confidence and perception, though they are proven to be much cheaper and comparable in efficacy to branded medicines. The drug inventory of unbranded generic manufacturers fares reasonably when reviewed using the World Health Organization-Health Action International (WHO-HAI) tool for analysing drug availability. Also, unbranded generic medicines are much cheaper when compared to the most selling brands and they can bring down the treatment costs in primary care and family practice. We share our experience in running a community pharmacy for an urban health center in the Pathanamthitta district of Kerala State, which is run solely on generic medicines. The drug availability at the community pharmacy was 73.3% when analyzed using WHO-HAI tool and the savings for the final consumers were up to 93.1%, when compared with most-selling brand of the same formulation.

Keywords: Drug availability, drug industry/legislation and jurisprudence, drugs, economic competition, essential medicines, generic*, generic medicines, global health, India, patents as topic/legislation and jurisprudence*, poverty, unbranded generics

Introduction

The World Health Organization (WHO) estimates that almost 30% of the world population lacks access to essential medicines and that the figure will rise to more than 50% in some countries of Africa and Asia.[1] The cost of the pharmaceuticals is the main factor that hampers access to medicines and the governments in poor countries seem to be doing very little to counter this problem. The public sector availability of essential medicines was less than 50% in most of the countries of Africa and Asia.[2] This is appalling in the face of increases in healthcare expenditure in most of the developing nations, mostly financed through secured loans by international development banks and consortia.

The situation in India is not very different than that of other developing nations. Healthcare expenditures have been growing in India, both in real terms and also when considered as a proportion of the Gross Domestic Product (GDP).[3] However, even with this recent increase in healthcare spending, India’s expenditure on health is nowhere near that of OECD (Organisation for Economic Cooperation and Development) nations.[4] The total public spending on healthcare in India accounted for only around 1.2% of GDP in 2012, with the per-capita spending on health around USD 160. This is a miniscule amount when compared against the OECD per-capita healthcare spending of USD 3,484 in 2012.[3,4] This shows that the healthcare spending in the country is set to rise further in the coming years and the healthcare industry is all set for a boom time.

The cost of medicines and pharmaceuticals as a percentage of total healthcare spending has also been rising worldwide.[5] It is the fastest-growing item in the healthcare budgets worldwide and it varies between 20-60% in various healthcare budgets of countries.[6] By 2020, the prescription drug market in United States of America is set to grow to USD 700 billion (B) and China will be USD 260 B.[5] Though no credible predictions about the Indian pharmaceutical industry are available, it is quite safe to assume that Indian pharmaceutical industry will also grow manifold. The growth of the pharmaceutical market worldwide and its increased share in total healthcare spending will reignite the age-old debate on how to balance the cost of innovation in drug research and universal access to the fruits of that research.[7]

Rise of Generics

The role of generic medicines in reducing the healthcare expenditure has been recognised for a long time. Multiple studies have proven that saving through substitution of originator brands by cheaper generic medicines, savings in the range of 10-90% can be achieved.[8] Most national governments have been encouraging the use of generic medicines worldwide and many healthcare systems have policies of substituting expensive branded original medications with generic medicines.[9] In the United States, generic substitution (GS) is an accepted practice and at the end of 2012, almost 80% of all the prescriptions were of generic medications. This has resulted in a substantial moderation of expenditure growth in widely used drugs and significant savings to the economy.[6] In the United Kingdom, GS is now a standard practice in hospitals operated by the National Health Service (NHS) and medical schools have included generic prescribing as a part of their medical training.[10]

In India, the procurement price of essential medicines is generally lower than the mean International Reference Pricing (IRP) but availability of these drugs in the public sector has always been a problem. The exorbitant cost of some of the commonly used medications in private pharmacies makes it inaccessible to majority of the poor.[11] Also, the difference between procurement prices and retail prices in case of some of the generic medicines, were as high as 28 times, which shows a very high margin of profit-taking in view of limited price control mechanisms.[11] It is in this light, that the government revised the National Pharmaceutical Pricing Policy in 2012. It gave methods to calculate ceiling prices for drugs which are under the National List of Essential Medicines (NLEM) which was modified in 2011. It gave a formula for deciding the ceiling prices for drugs under NLEM, using a market-based pricing (MBP) method, taking into account the prices of all manufacturers having a market share of more than 1% nationally.[12] The Drug Price Control Order of 2013 was a follow-up to the National Pharmaceutical Pricing Policy and gave the price ceiling for 348 drugs and over 600 formulations. However, the action was considered inadequate by many activists lobbying for cheaper drugs and they termed it as a sell-out to international pharmaceutical companies.[13]

Indian Pharmaceutical Industry

The multiplicity of brands and manufacturers makes it difficult to decipher the actual market dynamics and the structural issues in the Indian pharmaceutical industry. The complexity of the market and the intensity of the competition between companies in India have made the country a hub for manufacture of generic medicines, earning a sobriquet “pharmacy of the developing world.”[14] This, along with a favorable governmental stance has made India a powerhouse in this field, bringing it into direct confrontation with certain developed nations where most of the big multinational pharmaceutical companies are located[14] There have been many instances when the Indian Patents Office and the Supreme Court of India effectively used certain flexibilities of the Trade Related Aspects of Intellectual Property Rights (TRIPS) agreement of the World Trade Organization and also the safeguards embedded in the Indian Patents Act. The compulsory licensing of Sorafenib, a drug used in treatment of advanced liver and renal cancer and the rejection of patent application for Imatinib, a drug used in the treatment of leukaemia, were considered as landmark decisions by many state and non-state organizations involved in pharmaceutical sector.[15,16]

Considering the Indian scenario, we can divide the brands into innovator brands (IB), most-selling generics (MSG), and least-priced generics (LPG).[17] The IBs will be at the highest price point, followed by MSGs and LPGs. A new category of generic drugs known as unbranded generics (UB) are also coming into the market now. These drugs are usually manufactured by not-for-profit organizations or are subsidised by certain non-governmental organizations (NGO).[18] Though the price points of these different categories of drugs are different, their efficacies are comparable. This fact has been proved by multiple studies all over the world and it belittles the reasoning which goes behind differential pricing of the same drug.[19,20] Even though it has been proved that there is not much difference in efficacy between the above categories of drugs, physicians tend to prescribe drugs manufactured by highly-reputed companies. Their trust is often misplaced as most of these leading companies market drugs manufactured by less-known manufacturers.[18]

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A Model Community Pharmacy: Experiences from South India

Pushpagiri Medical College, which is a teaching hospital in Kerala state of India partnered with a social organization, Bodhana Social Service Society, involved in poverty alleviation and income generation programmes, to start an urban health center with an objective to improve patient accessibility to cost-effective medical care. The urban health center serves a population of 10,000, spread over 5 municipal wards of Tiruvalla municipality and was intended as a model for cost-effective primary care. A comprehensive population survey was carried out before the start of the project and the health center started functioning in September 2014. As a part of the initiative, a community pharmacy was opened to stock unbranded generic drugs manufactured by two non-governmental organizations. Low-Cost Standard Therapeutics (LOCOST), Baroda and Comprehensive Medical Supplies India (CMSI), Chennai were the two NGOs providing us with the drugs which were needed at the community pharmacy.[21,22] The drugs were provided to us at a nominal cost, after we provided an undertaking that the Pushpagiri Medical College is a charitable institution with no intention of making profits. Also, the physicians working at the health center made a collective decision to prescribe all the drugs generically and the pharmacist was advised to dispense the cheapest generic brand.

The drug inventory available with these not-for-profit manufacturers were fairly comprehensive when reviewed using the World Health Organization-Health Action International (WHO-HAI) tool for quantifying availability of essential medicines.[23] The WHO-HAI tool is a validated method for measuring availability of drugs in a health system and includes 30 core medicines: 14 essential medicines for global burden of disease and 16 medicines specific to the WHO region [Table 1].[24]

Table 1

Drug inventory of LOCOST, Baroda and CMSI, Chennai: Review using WHO-HAI tool for WHO South East Asian Region

The WHO-HAI tool showed a drug availability of 73.3% for LOCOST, Baroda and 43.3% for CMSI, Chennai. This is much better when compared to drug inventory in public hospitals in other parts of India, assessed using the same methodology.[11] There are a multitude of companies and NGOs manufacturing UB medicines and the drug inventory of a health system can be made comprehensive through a mixed purchase model where procurement is done from multiple vendors.[23]

Similarly, unbranded generic drugs offered significant savings to the health system in terms of costs involved for procurement. When reviewed against the MSBs, UB medicines were costing only a fraction of the maximum retail price (MRP) of MSPs [Table 2].

Table 2

Comparison of drug prices of most-selling brands and their generic counterparts: drugs identified by WHO-HAI tool for WHO South East Asian Region[17,25]

The community pharmacy has been in operation since September 2014, and stocks over 120 formulations manufactured by unbranded generic manufacturers. In addition, it also supplies LSG to augment the drug inventory of the pharmacy. There is a family physician and a general practitioner who run the center, apart from regular specialist visits from Pushpagiri Medical College Hospital. The urban health center has an outpatient load of 20-25 patients a day within 6 months of starting operations. The staff from the center is providing services to 3 old-age homes and a few surrounding schools and the drugs from the community pharmacy is being used for free supply during the medical camps conducted by the department of community medicine.

The patients and the physicians have responded positively to this novel initiative and the general acceptability has been found to be high, though objective studies to assess the same are yet to be done. Some physicians have suggested replicating this model in other similar health initiatives also. The financial sustainability of the model is still unproven, and the urban health center along with the community pharmacy is being sustained with large subsidies provided by Pushpagiri Medical College and Bodhana Social Service Society. The cost of setting-up such a facility was around INR 500,000, which includes the furniture, basic medical equipment, basic lab accessories, and first round of procurement for the community pharmacy and is exclusive of the capital expenditure on the building. The average monthly expenditure in running the health center, has been around INR 150,000 a month, including salaries, cost of consumables and medicines and exclusive of building rent and depreciation. The income earned by the center is around INR 40,000, and there is an excess of expenditure over income to the range of more than INR 100,000 a month, which is subsidised by Pushpagiri Medical College and Bodhana Social Service Society. Both the organizations are charitable societies run by a prominent religious group and the subsidies are meant to further their commitment to social causes.

The community pharmacy concept faced the following key challenges:

  • Absence of intermediaries for drug procurement results in inordinate delays in transit, mainly on account of the tardy services rendered by private logistics companies
  • Advance payment in full has to be remitted to the bank accounts of these NGOs for supply of drugs, which goes against the standard practice of procurement followed in hospitals. This has been an issue with the internal audit department
  • The difference between procurement price and the MRP is minimal and this is causing worries of long-term financial sustainability of the community pharmacy model
  • Packaging of the drugs is unattractive in some cases, resulting in difficulty to convince patients about the efficacy of the drug
  • We have faced difficulty in convincing some of the specialist doctors on the quality of the drug, despite providing ample literature proving the efficacy of unbranded generic drugs.

The Way Forward

Many studies have revealed apprehensions among physicians in prescribing UB medicines to their patients. Most of these apprehensions are related to quality of the product and the fear of losing patients.[26] Along with these unfounded concerns, poor patient acceptability due to various issues like poor packaging, lack of brand promotion initiatives, etc., are affecting the extend of penetration of UB drugs in the country, even though India is becoming a lifeline for all developing countries in the supply of generic medicines.[27] The government and the policy makers in India and other similar developing countries should focus on building the confidence of physicians and the patients regarding unbranded generic medications. The demand side management should include a multifaceted approach in which issues of different stakeholders are addressed and affirmative actions taken in favour of unbranded generic medicine manufacturers.[27] Another important issue is concerning the inherent deficiencies and implementation status of the Drug Price Control Order of 2013. The said order has been criticised extensively for being myopic in its approach, as the number of formulations included is less than 20% of the whole pharmaceutical market. Also, it gave ample space for pharmaceutical companies to tweak their marketing strategies by focussing on formulations and dosages not covered by the Drug Price Control Order. It also leaves out the important area of fixed-dose combinations (FDCs), a potential loop-hole for the pharmaceutical companies to exploit fully. It is indeed distressing to note that more than 90% of the diabetic drug market is out of the purview of this order.[13] The policy makers in the country needs to get a realisation that the share of drugs in out-of-pocket expenditure (OPP) is around 80% in India and a tighter regulatory framework is needed to protect the consumers against exploitation.[28]

In the future, we intend to do a study on the perception about generic drugs, among the treating physicians and the patients who form the clientele of the community pharmacy. This can help us to understand the issues which affect the actual stakeholders and find means to improve the acceptability and penetration of generic medicines. Also, after the yearly financial audit, we plan to do a cost-benefit analysis to objectively analyse the efficacy of the model in monetary terms.

References

1. The World Medicines Situation 2011. The World Health Organisation. [Last accessed on 2015 Mar 2]. Available from: http://apps.who.int/medicinedocs/documents/s18772en/s18772en.pdf .
2. Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: A secondary analysis. Lancet. 2009;373:240–9. [PubMed]
3. Health Expenditure, Total (% of GDP) | Data | Table. [Last accessed on 2015 Mar 2]. Available from: http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS .
4. Microsoft Word-Briefing-Note-INDIA-2014-doc-Briefing-Note-INDIA-2014.pdf. [Last accessed on 2015 Mar 2]. Available from: http://www.oecd.org/els/health-systems/Briefing-Note-INDIA-2014.pdf .
5. Daemmrich A, Mohanty A. Healthcare reform in the United States and China: Pharmaceutical market implications. J Pharm Policy Pract. 2014;7:9. [PMC free article] [PubMed]
6. Hoffman JM, Li E, Doloresco F, Matusiak L, Hunkler RJ, Shah ND, et al. Projecting future drug expenditures–2012. Am J Health Syst Pharm. 2012;69:405–21. [PubMed]
7. Sax P. Spending on medicines in Israel in an international context. Isr Med Assoc J. 2005;7:286–91.[PubMed]
8. Cameron A, Mantel-Teeuwisse AK, Leufkens HG, Laing RO. Switching from originator brand medicines to generic equivalents in selected developing countries: How much could be saved? Value Health. 2012;15:664–73. [PubMed]
9. Hassali MA, Alrasheedy AA, McLachlan A, Nguyen TA, Al-Tamimi SK, Ibrahim MI, et al. The experiences of implementing generic medicine policy in eight countries: A review and recommendations for a successful promotion of generic medicine use. Saudi Pharm. 2014;22:491–503. [PMC free article][PubMed]
10. Duerden MG, Hughes DA. Generic and therapeutic substitutions in the UK: Are they a good thing? Br J Clin Pharmacol. 2010;70:335–41. [PMC free article] [PubMed]
11. Kotwani A, Ewen M, Dey D, Iyer S, Lakshmi PK, Patel A, et al. Prices and availability of common medicines at six sites in India using a standard methodology. Indian J Med Res. 2007;125:645–54.[PubMed]
12. Copy of f1.pdf – NPPPNotification.pdf [Internet] [Cited 2015 Mar 2, Last accessed on 2015 Mar 2]. Available from: http://www.nppaindia.nic.in/NPPPNotification.pdf .
13. Paying the Price – The Hindu. [Last accessed on 2015 Mar 2]. Available from: http://www.thehindu.com/opinion/op-ed/paying-the-price/article4912732.ece .
14. Kapczynski A. Engineered in India–patent law 2.0. N Engl J Med. 2013;369:497–9. [PubMed]
15. Bhaumik S. India’s rejection of Novartis’s patent is but a small step in the right direction. BMJ. 2013;346:f2412. [PubMed]
16. Lancet Oncology. Is India ready to lead the battle for fair access to medicines? Lancet Oncol. 2013;14:437. [PubMed]
17. Bhargava A, Kalantri SP. The crisis in access to essential medicines in India: Key issues which call for action. Indian J Med Ethics. 2013;10:86–95. [PubMed]
18. Amit G, Rosen A, Wagshal AB, Bonneh DY, Liss T, Grosbard A, et al. Efficacy of substituting innovator propafenone for its generic formulation in patients with atrial fibrillation. Am J Cardiol. 2004;93:1558–60. [PubMed]
19. Kesselheim AS, Stedman MR, Bubrick EJ, Gagne JJ, Misono AS, Lee JL, et al. Seizure outcomes following the use of generic versus brand-name antiepileptic drugs: A systematic review and meta-analysis. Drugs. 2010;70:605–21. [PMC free article] [PubMed]
20. Asia Pacific Ecumenical News-News. [Last accessed on 2015 Mar 2]. Available from: http://apenews.org/newsread.asp?nid=163 .
21. LOCOST: Medicines within the Common Man’s Reach | The Alternative. [Last accessed on 2015 Mar 2]. Available from: http://www.thealternative.in/business/locost- affordable-medicine-drugscommon-man-reach .
22. Where Are We Now: Assessing the Price, Availability and Affordability of Essential Medicines in Delhi as India Plans Free Medicine for All. [Last accessed on 2015 Mar 2]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733775 . [PMC free article] [PubMed]
23. Madden JM, Meza E, Ewen M, Laing RO, Stephens P, Ross-Degnan D. Measuring medicine prices in Peru: Validation of key aspects of WHO/HAI survey methodology. Rev Panam Salud Publica. 2010;27:291–9. [PubMed]
24. Drug Price List. List of Generic Names in Alphabetical Order. [Last accessed on 2015 Mar 2]. Available from: http://www.medindia.net/drug-price .
25. Generic Index | DrugsUpdate India. [Last accessed on 2015 Mar 2]. Available from: http://www.drugsupdate.com/generic/listing .
26. Waning B, Diedrichsen E, Moon S. A lifeline to treatment: The role of Indian generic manufacturers in supplying antiretroviral medicines to developing countries. J Int AIDS Soc. 2010;13:35. [PMC free article][PubMed]
27. Shrank WH, Choudhry NK, Liberman JN, Brennan TA. The use of generic drugs in prevention of chronic disease is far more cost-effective than thought, and may save money. Health Aff (Millwood) 2011;30:1351–7. [PubMed]
28. Thakkar KB, Billa G. Light at the end of the tunnel: The Great Indian Pharmacoeconomics story. Front Pharmacol. 2013;4:153. [PMC free article] [PubMed]
Source:www.ncbi.nlm.nih.gov

Why infertility is on a rise in India

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Determining the root cause of infertility is a complex process and it involves a lot of research and investigations. Ranging from the simple and visible problem of cyst, fibroid or hormonal imbalance to a very complex genetic disorder or even due to some occupational hazards like exposure to chemical substances or radioactive elements; it can be anything.

It’s like searching for a needle in a haystack. Infertility, in both men and women, has become quite common these days. Research suggests there has been a 20-30 per cent rise in the last five years in India. It is no longer an urban phenomenon, nor is it confined to women.

In a modernised society, the problem of infertility has widened its reach that has impacted men, due to urban settings and surfacing in Tier 2 and Tier 3 cities too. Increasing infertility rates are based on the lifestyle changes resulting in stress and obesity caused by lack of physical exercise, changes in eating habits and pollution accompanied by medical disorders like diabetes.

About 45 per cent of couples face infertility problems as it not only limited to women, the most common problems men face are low sperm count, morphology abnormalities and low motility of sperm.

Things you should know

1. Female infertility is easier to understand as in majority of cases, the problem is known. But, on the other hand infertility in men is tough to recognise at the early stage.

2. Stress is another factor of rising infertility in urban India. Stress of the profession, long working hours with erratic timings are key factors. Stress management is important increase the chances of conceiving.

3. One should keep a check on the nutritional deficiencies and maintain a healthy routine with balanced diet. Know the best fertility diets and best food. Take all nutrients in moderation to boost your fertility after consulting your doctor.

4. Most of the infertility cases are due to tubal issues which mean the fallopian tubes are blocked and you have to undergo some tests.

5. Healthy lifestyle is necessary for fertility. There have been studies that a majority of the infertility cases are occurring due to lifestyle diseases like endometriosis, rising obesity, irregular menstrual cycles and any more.

6. Age has direct and distinct correlation with infertility. Body strength, resistance, immunity and hormonal levels are at their peak during age and hence it is important to keep these factors under consideration. The vitality and sustainability of our body gets declined as we grow old. Therefore, it is always better to start infertility treatment at the early age.

7. Diagnosing the root cause and deciding the treatment is the turning point in the whole process and experience of handling a wide variety of cases by the experts plays a major role in it.

8. Male infertility is extremely complex to diagnose and cure. Often, we try to find out the fundamental reason by various tests and research. Semen samples are tested in the laboratory to know the sperm count, sperm strength and other factors. Hormonal levels are checked to determine the testosterone levels. Physiological problems like defects in genital organs, STD or VD, retrograde ejaculation are also checked.

9. Dealing with infertility becomes further complicated with the strain in relationship between the couple. Both partners must keep the relations absolutely tuned and no internal conflicts or friction should arise. This is the time of providing complete physical, mental and emotional support to each other.

10. Known as unexplained infertility such a situation can often be quite frustrating for everyone involved. Unfortunately, it is quite common and can sometimes hinder the fertility treatment process. Up to 15 per cent of couples who visit a fertility clinic for treatment receive a diagnosis of unexplained fertility.

Myths

1. A woman’s menstrual cycle is 28 days.

Fact: Normal cycle lasts anywhere from 21 to 36 days.

2. A sperm lives for several hours.

Fact: In fertile cervical liquid, a sperm can live up to five days.

3. A man with a high sex drive will have normal sperm count.

Fact: There is no correction between virility and fertility for men and some men with a normal sex drive may have no sperm at all.

4. Infertility is primarily caused by females.

Fact: Studies have shown that infertility problems are caused by men and women equally, with 20 per cent of infertility problems being a combination of both.

5. Having sex daily increases the chances of conceiving.

Fact: Having sex every other day at the time of ovulation, most often between days 12-16 of a woman’s cycle, is sufficient since sperm live an average of two days.

6. Fertility problems begin at 35.

Fact: While women fertility peaks in their 20’s, it changes throughout a one’s life. While some women remain fertile even into their late 30’s, others experience fertility problems at a younger age. Experts say that chances of conceiving decline with age, particularly after the age of 35.

7. Single embryo transfer lowers the success rate of pregnancy.

Fact: Women have a limited number of eggs. When they run out, the menopause occurs.

Prevention

1. Minimise your exposure to toxic chemicals.

2. Aim to eat an optimal fertility diet.

3. Have an STD check.

4. Avoid coffee, smoking and alcohol.

5. Maintain a healthy lifestyle.

6. Do not ignore it.

India Virtually Eliminates Tetanus as a Killer

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A year after eliminating polio, India has scored another public health victory. Following a 15-year campaign, the country has virtually eliminatedtetanus as a killer of newborns and mothers.

Tetanus, caused by a bacterium common in soil and animal dung, usually infects newborns when the umbilical cord is cut with a dirty blade. Mothers often receive the infection by giving birth on dirty surfaces or being aided by midwives with unwashed hands.

The disease — also known as lockjaw, after its muscle spasms — usually sets in about a week after a birth and is invariably fatal if not promptly treated. Fifteen years ago, the World Health Organization estimated that almost 800,000 newborns died of tetanus each year; now fewer than 50,000 do.

But the effort to reduce tetanus has gone slowly. The World Health Assembly — the annual gathering of the world’s health ministers in Geneva — originally set 1995 as the target date for its global elimination as a health threat.

Unlike polio or smallpox, tetanus can never be eradicated because bacterial spores exist in soil everywhere, said Dr. Poonam Khetrapal Singh, the director of the W.H.O.’s Southeast Asia region.

India has reduced cases to less than one per 1,000 live births, which the W.H.O. considers “elimination as a public health problem.” The country succeeded through a combination of efforts.

In immunization drives, millions of mothers received tetanus shots, which also protect babies for weeks.

Mothers who insisted on giving birth at home, per local tradition, were given kits containing antibacterial soap, a clean plastic sheet, and a sterile scalpel and plastic clamp for cutting and clamping the cord.

The country also created a program under which mothers were paid up to $21 to give birth in a clinic or hospital. “Lady health workers” from their neighborhoods were paid up to $9 per mother and up to $4 for bus or taxi fare to make sure women in labor went to clinics. The workers earned the full amount only after visiting each baby at home and giving tuberculosis shots.

The program succeeded despite corruption. The Times of India recently reported that an audit had found clearly fraudulent payments — including some to a 60-year-old woman registered as having been pregnant five times in 10 months.

Did You Know Running Was Injurious To Health? You Will After Reading This.

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“What do I talk about when I talk about running?” If you’re bestselling Japanese novelist and ultramarathoner Haruki Murakami, you raise questions existential in nature. But Indian sprinting enthusiasts keep their thoughts grounded, musing on the best ways to beat traffic, pollution and stray animals. If you’re a female runner, the last category includes those out to cop a feel.

Running as a sport has taken off in India. According to Vivek Singh, joint MD of Procam International which kicked off the Standard Chartered Mumbai Marathon run in 2004, today there are over 100 recognized distance races in India. However, urban infrastructure hasn’t kept pace with its popularity. Those training for marathons face several hazards daily. Last month, The New York Times reported that international athletes competing in the Delhi Half Marathon had difficulty breathing because of smog; earlier, in October, Bangalore marathoners took a train to the finish line after their pace car got them stuck in traffic.

“Where are the spaces to run?” asks Preeti Aghalayam, a professor at IIT Madras who has been running for the last 12 years. Parks across most cities aren’t much use to those whose average weekday run is 10 km. Sandeep Srivastava, a Delhi-based runner, calls it “mind-numbing” to train for a 20+ km marathon in a park. “Four rounds of the park next to my house is 1.2 km.I’d have to do almost 80 rounds,” says Srivastava, a management consultant who participated in his first marathon in 2007.

marathon

AP (File Photo)

Residents of coastal cities like Chennai and Mumbai have the option of running on the beach or beach front, but the humidity can be sapping. Plus, they have to dodge morning walkers.

Which is why most Indian marathoners are, by default, road runners.”We’re okay with asphalt, tar, concrete, even cobblestones,” says Aghalayam. What they run into is a different story . “Bus and truck drivers are the worst; they see us but they won’t stop,” says Suresh Pathi of Jayanagar Jaguars (JJ), one of Bangalore’s oldest running groups. Pathi’s group, which has mapped routes across Jayanagar, starts at 5am and winds up by 7 am to beat traffic and pollution. Unless you have access to a school, college facility or stadium, it’s tough to do interval, strength training and track workouts, all important for long-distance runners, so JJ members carry their own equipment — ladders, hurdles, steppers, etc — in their cars.

Having a facility in the vicinity doesn’t necessarily mean you’re a step up — Srivastava, a Mayur Vihar resident, says the infrastructure that came with the Commonwealth Games is being abused. The CWG village track, which surrounds a football field, is blocked by players relaxing at off-time. “How would they feel if I sat in the middle of the field during their game?” he asks. The cycling track from Akshardham to Noida is overrun by bikers and even cars driving at breakneck speed, making listening to music while running a dangerous distraction. “Why ask for infrastructure when the attitude of people using it has gone from bad to worse,” says the 50-year-old who is often greeted with jeers like ‘Hey tau, how to lose weight?’ and ‘Ghutney aapke theek hain?’ Aghalayam says that women on early morning runs are most vulnerable. “Men come on two wheelers and squeeze your butt as you run. Recently, a friend was teased by a bunch of young guys on a bullock cart,” she says, recommending running in groups, sticking to familiar, well-lit roads, going against the traffic and being clearly visible in bright clothes as safeguards.

Stray dogs, cats and even monkeys, if you’re running in shaded areas with a water bottle in hand, are a menace. On the flip side, encountering a swift deer is inspiring, says Aghalayam who often runs on the IIT campus. Pollution literally has Srivastava in tears. “Crops are burnt on the Yamuna belt where I run. For the last year-and-a half, the sweat from my forehead running into my eyes burns like someone has put acid on them. I have to keep stopping and washing my eyes with water,” he says.

Despite the hurdles, no one’s hanging up their running shoes. Enthusiasts have found solutions and silver linings -Aghalayam says training in humid conditions helps ace races in drier towns while Srivastava has a way to maximize results from park running. “One round clockwise, the other anti-clockwise to use all your muscles,” he says. And while runners who’ve participated in international marathons come away impressed by daily running conditions abroad, Aghalayam, for one, wouldn’t trade tracks. “There is still an innocence to the Indian running fraternity that you won’t find in the US, where people are more focused on meeting personal goals. Here, we don’t mind if you finish five minutes ahead. We’ll still take a selfie together at the end.”

Polio Vaccines Now The #1 Cause of Polio Paralysis

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The Polio Global Eradication Initiative (PGEI), founded in 1988 by the World Health Organization, Rotary International, UNICEF, and the U.S. Centers for Disease Control and Prevention, holds up India as a prime example of its success at eradicating polio, stating on its website (Jan. 11 2012) that “India has made unprecedented progress against polio in the last two years and on 13 January, 2012, India will reach a major milestone – a 12-month period without any case of polio being recorded.”

Polio Vaccines Now The #1 Cause of Polio Paralysis

This report, however, is highly misleading, as an estimated 100-180 Indian children are diagnosed with vaccine-associated polio paralysis (VAPP) each year. In fact, the clinical presentation of the disease, including paralysis, caused by VAPP is indistinguishable from that caused by wild polioviruses, making the PGEI’s pronouncements all the more suspect.1

According to the Polio Global Eradication Initiative’s own statistics2 there were 42 cases of wild-type polio (WPV) reported in India in 2010, indicating that vaccine-induced cases of polio paralysis (100-180 annually) outnumber wild-type cases by a factor of 3-4. Even if we put aside the important question of whether or not the PGEI is accurately differentiating between wild and vaccine-associated polio cases in their statistics, we still must ask ourselves: should not the real-world effects of immunization, both good and bad, be included in PGEI’s measurement of success?

For the dozens of Indian children who develop vaccine-induced paralysis every year, the PGEI’s recent declaration of India as nearing “polio free” status, is not only disingenuous, but could be considered an attempt to minimize their obvious liability in having transformed polio from a natural disease vector into a manmade (iatrogenic) one.

VAPP is, in fact, the predominant form of the disease in developed countries like the US since 1973.3  The problem of vaccine-induced polio paralysis was so severe that the The United States moved to the inactivated poliovirus vaccine (IPV) in 2000, after the Advisory Committee on Immunization Practices (ACIP) recommended altogether eliminating the live-virus oral polio vaccine (OPV), which is still used throughout the third world, despite the known risks.

Polio underscores the need for a change in the way we look at so-called “vaccine preventable” diseases as a whole. In most people with a healthy immune system, a poliovirus infection does not even generate symptoms. Only rarely does the infection produce minor symptoms, e.g. sore throat, fever, gastrointestinal disturbances, and influenza-like illness. In only 3% of infections does virus gain entry to the central nervous system, and then, in only 1-5 in 1000 cases does the infection progress to paralytic disease.

Due to the fact that polio spreads through the fecal-oral route (i.e. the virus is transmitted from the stool of an infected person to the mouth of another person through a contaminated object, e.g. utensil) focusing on hygiene, sanitation and proper nutrition (to support innate immunity) is a logical way to prevent transmission in the first place, as well as reducing morbidity associated with an infection when it does occur.

Instead, a large portion of the world’s vaccines are given to the third world as “charity,” when the underlying conditions of economic impoverishment, poor nutrition, chemical exposures, and socio-political unrest are never addressed. You simply can’t vaccinate people out of these conditions, and as India’s new epidemic of vaccine-induced polio cases clearly demonstrates, the “cure” may be far worse than the disease itself.

1 Cono J, Alexander LN (2002). “Chapter 10: Poliomyelitis” (PDF). Vaccine-Preventable Disease Surveillance Manual.

2 http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

3Strebel PM, Sutter RW, Cochi SL, et al. Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect Dis 1992;14:568-79.

 

It’s 11/12/13 – the last consecutive date for another 90 years.

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Briefly this afternoon it’ll be 11/12/13 14:15 and 16 seconds

Today is the 11th day of the 12th month of the 13th year in the millennium and at 14:15 and 16 seconds this afternoon the date and time will briefly read: 11/12/13 14:15.16.

11/12/13 is the last date this century with three consecutive numbers – the next for the UK will be February 1, 2103.

Dubbed ‘noughts and crosses day’ by Ron Gordon, a retired teacher from California who has launched a competition to devise an interesting way to celebrate the day, 11/12/13 is one of a number (no pun intended) of numerical anomalies known as ‘sequential days’.

Sequential days are extremely rare and there are usually a mere handful of them a century – in the UK we won’t see one for another ninety years, though in the US (where they write dates the wrong way around) the last one for nearly a century will occur on the 13th of December next year: i.e. 12/13/14.

Another numerical anomaly are the so-called ‘Odd Days’. There are only six of these days a century and they occur when every number in the date is an odd number. The last such date occurred last month on the 9th of November – or 09/11/13.

Mr Gordon also coined the term ‘Trumpet Day’ to describe the date on the second day of the second month in the twenty-second year i.e: 02/02/22.

We’ll next celebrate trumpet day in 2022 (if people still care about these things). Another trumpet day could occur in the US (where as previously discussed they write the date wrongly) on the 22nd of February 2022 i.e. 2/22/22 – which in the UK will correctly read 22/02/22.

There’s also Square Root Day – 4/4/16 (the last one was on March 3, 2009) and the ‘Ones Upon A Day’ 01/11/11.

All given their names and celebrated by – you guessed it – Ron Gordon. So, are people excited about the unusual date? Not according to the Times of India.

In a report published today they mournfully noted that couples weren’t excited about tying the knot on 11/12/13 noting that bookings ‘especially for weddings’ were ‘abysmal’ in the Nagpur district. Spoilsports.

TB resistance is a ‘ticking time bomb’

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Increasing resistance to tuberculosis drugs around the world is a “ticking time bomb”, says the World Health Organization (WHO).

It estimates almost 500,000 people around the world have a type of TB which is resistant to at least two of the main types of drugs used to treat the disease.

Ranjhu Zha with her 65 year old mother Parvati, who has extensively drug-resistant TB

But most are not diagnosed and are walking around spreading these more deadly strains.

More than half the cases are in China, Russia and India.

The WHO says the overall number of people developing the disease is falling, but 8.6 million people were diagnosed with TB last year, and more than a million people died from the disease.

Through the hot, winding, cramped streets of Mumbai’s sprawling Dharavi slum, we have come to meet Ranjhu Zha and her family.

The family of five is crammed into a space no more than about 2 sq m.

Ranjhu sits with her son and mother on the floor.

Her mother Parvati is wearing a surgical mask.

She has what is known as an extensively drug-resistant form of TB (XDR-TB).

It is not responding to most of the main drugs used to treat the disease.

“Start Quote

We’re just silently watching this epidemic unfold and spread before our eyes”

Dr Ruth Mcnerny TB Alert

She caught the disease from her 23-year-old grand-daughter Bharati, who died of TB in June.

She was resistant to two of the main drugs used to treat the condition.

“My daughter was as beautiful as a flower,” says Ranjhu.

“But slowly, slowly she wasted away. I remember her always.

“But what is the point in thinking about someone who is no more? She is never coming back.”

Tuberculosis is an airborne disease. It’s very contagious and can spread from person to person by breathing in an infected person’s germs.

The cramped conditions in places like the Dharavi slum create the perfect environment for the fast spread of TB and other diseases.

People are living cheek by jowl and there’s not much ventilation.

Ranjhu says her daughter wasn’t given the full course of treatment when she first developed TB, and that made her resistant to the two main types of TB drugs.

Ranjhu’s mother is now getting treatment from the medical charity Medecins Sans Frontieres.

She says she has not been able to get the right drugs from government schemes.

Rampant misuse of antibiotics

Her treatment includes painful injections every day and will last around two years.

MSF says her treatment costs somewhere in the region of $10,000 (£6,000). Standard TB treatment costs around $50.

Drug-resistant TB

  • Multidrug-resistant TB (MDR TB) is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent TB drugs.
  • Extensively drug resistant TB (XDR TB) is a rare type of MDR TB that is resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs, such as amikacin, kanamycin, or capreomycin).

“There are several drugs used to treat TB,” says Lorraine Rebello, medical services manager at the MSF TB and HIV clinic in Mumbai.

“But when two of the primary drugs that are essential to treating TB – rifampicin and isoniazid – are no longer killing the TB bacteria, then the patient has drug-resistant TB.”

The Indian government’s Revised National TB Control Program aims to provide free TB treatment to every tuberculosis patient in the country.

But the WHO says out of the estimated 64,000 drug-resistant cases in India in 2012, only 16,588 were diagnosed.

Lorraine Rebello puts the rise in cases she has seen down to a number of factors.

“Start Quote

What could happen is progressively multi-drug resistant TB takes over from normal tuberculosis”

Dr Mario Raviglione Director, Global TB programme at the World Health Organization

“We have a huge unregulated private sector,” she says.

“We have doctors who are not properly medically qualified, like Ayurvedic doctors who are treating drug-resistant TB.

“They probably don’t have the knowledge to treat the condition, but they prescribe a cocktail of drugs.

“Some patients are even going to pharmacies without prescription and buying drugs over the counter. So we are seeing a rampant misuse of antibiotics.”

Dr Mario Raviglione, director of the WHO’s Global TB programme, describes the situation as a public health crisis.

“What could happen is progressively multi-drug resistant TB takes over from normal tuberculosis.

“If this happens not only would millions of patients potentially die of this form of TB, but if I look at it from an economic perspective the cost of dealing with millions of potential cases is enormous.”

He describes the fact that 80% of multi-drug resistant TB cases around the world are not being treated as a “ticking time bomb”.

“Killing you slowly”

Dr Ruth Mcnerny, senior lecturer at the London School of Tropical Medicine, who works with TB charity TB Alert, says: “We’re just silently watching this epidemic unfold and spread before our eyes.

TB treatment in developing countries

  • Normal TB treatment takes at least six months to treat and costs around $50 (£30)
  • Multidrug-resistant TB treatment can take at least two years and costs around $2,500 (£1,500)
  • Extensively drug-resistant TB can cost many thousands of dollars to treat. Estimated 45,000 cases globally

“TB is very clever because it kills you very slowly. And while it’s killing you very slowly you’re walking around spreading it.

“The issue of TB is if you get someone on treatment, they’ll become non-infectious quite quickly.

“But if the treatment’s not working because it is a drug-resistant strain, then they stay infected and they stay spreading drug-resistant TB.

“The treatment for drug-resistant TB is very, very difficult and at some stage it becomes impossible.”

In India, the government says it is doing all it can to improve diagnoses and treatment.

Hanmant Chauhan heads the TB programme for the state of Maharashtra.

He says around 8,000 multi-drug resistant TB patients have been treated in the last three years.

“We are taking every step so that every TB affected person gets treatment as soon as possible,” he says.

Tuberculosis symptoms

  • A persistent cough, usually for more than three weeks
  • Night sweats for weeks or months
  • Weight loss
  • Fatigue
  • High temperature
  • Shortness of breath

“We are also trying to see that the disease doesn’t spread. We are trying to make people aware about the precautions and treatment, so that the patients get the treatment and TB gets eradicated soon.”

Back in Ranjhu’s slum her 16-year-old son Santosh is studying for exams.

He sleeps on the floor of his tiny home with his infected grandmother and three other relatives.

He knows he is at high risk of catching this particularly deadly form of TB.

“I do feel scared but what can we do, we only have this one place to stay all together,” he says.

“If she removes the mask which makes her so uncomfortable because it is so hot and stuffy here, there is always a danger we will also catch the disease.”

Microsoft designs stress-busting bra.

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Microsoft working on a smart bra to measure mood

A sketch from the research paper
Two sensors were embedded in the bra

Microsoft researchers have designed a smart bra that can detect stress.

The prototype contains removable sensors that monitor heart and skin activity to provide an indication of mood levels.

The aim was to find out if wearable technology could help prevent stress-related over-eating.

Mood data was provided to the wearer via a smartphone app in order to highlight when “emotional eating” was likely to occur.

A team from Microsoft’s visualisation and interaction research group embedded an electrocardiogram and electro-dermal activities sensors as well as a gyroscope and accelerometer in the bra.

In their paper, the researchers say using a bra “was ideal because it allowed us to collect EKG [electrocardiogram] near the heart”.

Efforts to create a similar piece of underwear for men worked less well, largely because the sensors were located too far away from the heart.

The women testing the technology reported their emotions for about six hours a day over a period of four days.

“It was very tedious for participants to wear our prototyped sensing system, as the boards had to be recharged every three to four hours,” Microsoft senior research designer Asta Roseway said.

Electric shock

Wearable technology is increasingly being used to monitor a range of health conditions.

Last month saw the release of a Twitter-connected bra, that tweeted every time it was unhooked to encourage women to self-examine their breasts.

And last year a patent was awarded to a US firm that was working on a wearable device that analysed breast heat in order to detect cancer.

Meanwhile in response to a series of rapes in India, three engineering students developed a bra loaded with sensors and an electronic circuit that is activated when someone attempts to grope a woman wearing it.

Coming soon to you: the information you need.

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The day when your hat can extrapolate your mood from your brain activity and make a spa appointment on your behalf may not be far away.

The next big thing in the digital world won’t be a better way for you to find something. If a confluence of capabilities now on the horizon bears fruit, the next big thing is that information will find you.

Devices from your phone to your appliances will join forces in the background to make your life easier automatically.

Welcome to contextual search, a world where devices from your phone to your appliances will join forces in the background to make your life easier automatically.

Contextual, or predictive search, started with the now-humble recommendations pioneered by companies such as Amazon – where metadata applied behind the scenes led you to products with similar attributes via pages that made helpful suggestions such as “customer who bought this also bought…”.

But when such technology grows and expands to everything around us, it could result in what Andrew Dent, a strategist with virtualisation company Citrix Systems, calls “cyber-sense”. This is information from a growing field of devices that know more about you than ever before.

Today your smartphone knows your location, so everything from the local weather to nearby Facebook friends is available. What about tomorrow when your jacket can measure your vital signs or a hat can extrapolate your mood from your brain activity?

Connect it with information on your schedule (from your calendar), spatial information such as whether you’re running or at rest, the time of day and a hundred other factors, and machines everywhere can decide on, find and present the information they think you need.

The field is opened even wider by search technology that finds abstract connections for you, rather than you starting a search at a given point. A system out of Bangalore, India called CollabLayer lets you watch for specific keywords you assign to almost any kind of data in a network.

But you can also submit a collection of documents to CollabLayer when you don’t really have a search term in mind. The system extracts links between what it thinks are key entities and graphs them in a “semantic map”. Such a method can give search a heuristic or “proactive” approach that doesn’t really need the input of a user.

It’s a similar proposition to the semantic web framework championed by the W3C, the consortium led by the father of the worldwide web, Sir Tim Berners-Lee. It aims to connect content across the web regardless of file formats, expanding the scope of what our data can do for us.

Put contextual search together with the “Internet of Things” concept and the real-world applications becomes obvious. When your smart car realises a brake pad is a bit worn, it asks your GPS where you are, checks your calendar to see when you have some free time, asks the manufacturer for a workshop near you that has the part, makes an appointment and sends you a text or email with everything set up before you had any idea.

With APIs (application programming interface – the “translation tool” between two applications) cheaper than ever for interconnecting search systems, software isn’t the issue.

One issue is sheer volume – there’s more contextual data than anyone can possibly process manually. Business Insider recently reported on a Moscow technology conference, where a professor added up the amount of data in the world that’s about you (not just what you generate yourself). The result was 44.5 gigabytes per person, compared with just 500 megabytes per person in 1986.

The other issue is commercialisation, and whether we have to be slaves to a single technology company for all this to work in the real world. With its vast desktop and mobile ecosystem, Google is the closest to a de-facto standard, and already a new Google service in the US lets you conduct contextual searches from what’s essentially your own information.

But for the brake pad example to work, a lot of proprietary systems need access to each other’s APIs, and history has shown large technology companies tend to protect their own patch. As Jared Carrizales, chief executive of Heroic Search says, “Sorry to disappoint, but I don’t think this capability will be available en masse on any other platform than Google.”

It might take an open source platform or a platform-agnostic public system to make contextual search truly seamless, but can the support base behind non-profit efforts sustain such a far-reaching infrastructure, and will governments want to compete directly with some of their biggest taxpayers?

Howard Turtle, director of the Centre for Natural Language Processing at Syracuse University, says it will take a few VHS versus Beta-style “standards wars”, but even then, individual preferences will generate whole new tiers of processing. “Of course, it also raises all sorts of privacy and security issues,” he adds.

So with the will and means that might already be in place, an ability to commercialise the services might be the only stumbling block to an internet that knows what you want.

Can technology help avoid stampedes?

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Crowds at the Hajj
The Hajj attracts millions of pilgrims each year, but they are very tightly packed together

It seems the cruellest and most unnecessary of deaths – to be crushed in the midst of a crowd.

But even in the 21st Century such deaths are still common, as a stampede at a recent Hindu festival in India, which killed about 115 people, proved all too sadly.

Horror quickly turned to anger as the Indian media reported that better crowd management could have prevented the tragedy.

But can technology also play a role in making sure that such disasters are not repeated?

At the Hajj pilgrimage, the world’s largest Islamic gathering, which takes place in October, the authorities now use live crowd analytics software, which can not only spot problems in the crowd but also claims to be able to predict where overcrowding is likely to happen.

Live data feeds come into a large operations room where they are analysed by military personnel, the police and other crowd managers.

The software provides accurate and real-time data on crowd numbers, densities, distributions and flows.

“Crowds can be dangerous places. Whether triggered by factions within the crowd, by natural disasters or misguided crowd managers, there is a long history of crushes, stampedes and failed evacuations,” said Fiona Strens who co-founded CrowdVision, the firm behind the software.

“It spots patterns of crowd behaviour that indicate potential danger such as high densities, pressure, turbulence, stop-and-go waves and other anomalies.”

As large-scale events go the Hajj is one of the biggest and it has a pretty bad track record; over the years thousands of lives have been lost.

One of the worst incidents occurred in 2006 when a stampede on the last day of the pilgrimage killed at least 346 pilgrims and injured another 200.

Crowd behaviour

As part of his PhD research, CrowdVision co-founder Dr Anders Johansson analysed the CCTV images of the pilgrims before and during the crush in 2006, and realised that there were patterns of behaviours that, spotted early enough, could have prevented it.

In 2007, his system was installed in Mecca and it has been monitoring the pilgrimage every year since.

Muslim pilgrims
The Saudi authorities believe such technology helps save lives

While the company doesn’t like to tempt fate, since its involvement, no fatalities have occurred.

That isn’t entirely down to the technology though, admits Ms Strens.

“In recent years the Mecca authorities have invested in better infrastructure, planning and technology to assure pilgrim safety but we play a very important role providing the real-time data and insights needed to inform operational decision-making,” she said.

For their part, the Saudi authorities are pleased to have such a technology partner.

“The live crowd analysis greatly improves safety of pilgrims,” said Dr Salim al Bosta, crowd management expert, at the ministry of municipal and rural affairs.

But crowd scientist Keith Still, who was special adviser on the Hajj from 2001 and 2005, is more sceptical about how much technology can help in such places.

“Any technology has to be coupled with a crowd management plan,” he told the BBC.

In fact he thinks that technology installed at the Hajj in 2006 – before CrowdVision’s involvement – actually contributed to the tragedy that unfolded.

“Tech firms offered the Saudis new systems and there was an over-reliance on technology. There was lots of digital signage put up to direct the crowds but it was just a mess,” he said.

He is also sceptical about whether the technology used by CrowdVision can work in a live situation.

“It spots shockwaves in the crowd but if these are happening then you are already at a point where people could be crushed or seriously injured. Whoever is in control has fundamentally lost control of the situation by then,” he said.

“It could become an exercise in futility.”

For him, the value of CrowdVision lies more in its ability to precisely count how many people are at an event.

“If you need to track capacity such tools are great but it is a long way away from being a risk management system,” he said.

Street protests

City crowd
People seem to be spending more time in crowds

Cities around the world are getting more and more overcrowded. By 2050 the UN expects the world’s population to top nine billion, with nearly 70% of them living in towns.

And people are spending more time in crowds. Large-scale music and sporting events are commonplace, as are big screens that beam events to public places to allow those outside of venues to watch the action.

Spontaneous street protests are also on the rise, thanks to the proliferation of social media and smartphones.

Technology that can monitor crowds is going to become increasingly important, thinks Ovum analyst Joe Dignan.

“Understanding how people move through a city will help develop smart transport systems and keep people safe in times of danger whether natural or manmade,” he said.

Whether crowds gather to protest, to party or just to be entertained, things can turn ugly in an instant.

Heat maps created by CrowdVision to show how people behaved during a practice evacuation of a city skyscraper illustrate how danger points can build up even when the crowd is flowing well and is relatively calm.

The maps showed that even when the crowd was re-entering the building after the evacuation, there were some dangerous queues building up.

CrowdVision’s heat map of a crowd at a music festival

Nowhere is crowd control more important than at a music festival and the software developed by CrowdVision suggests that organisers may be making fundamental errors by posting stewards at the front of crowds.

“The maps suggested the problems were actually in the middle of the crowd,” said Ms Strens.

“If the stewards had tablets with real-time information on them, they could see exactly where they needed to be,” she added.

Such a solution may not have been realistic for Madhya Pradesh, the Indian state where the recent stampede occurred.

It seems likely the stampede was sparked by panic, following rumours a bridge people were crossing was about to collapse.

The bridge had itself been built in response to a stampede at the same temple some seven years earlier, when attendees had been crushed crossing the river.

It illustrates that, however carefully planned an event is, there is often no accounting for human behaviour.

Technology may help but it is only ever going to be part of the solution, according to Prof Still.

“The best way to avoid this in the future is education on crowd safety,” he said.