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OJAANK IAS ACADEMY

Down To Earth (May 2022)

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1. PUBLIC HEALTH

CONTEXT

• At The maternal care ward in Madhya Pradesh’s Tikamgarh District Hospital, 19-year-old Sarita (name changed) is in distress. “I have no idea how my one-week-old son is doing,” she says. Her baby was born severely underweight and puking, and was admitted to the Sick Newborn Care Unit (SNCU).
• The young mother admits she did not come in for any antenatal care (ANC) checkups prior to delivery. The World Health Organization (WHO) mandates at least four Anc check ups during pregnancy to monitor the mother and child’s health.
• Sarita is one of 28 new mothers in the maternal care ward, which is most of the time filled to capacity. About half of the 200 beds at the Tikamgarh District Hospital are allocated for expectant and new mothers.
• As per the “Indian Public Health Standards”, a set of guide lines under the National Rural Health Mission, district hospitals seeing more than 75 childbirths a month need one senior doctor and one staff nurse for the postnatal care unit, while those with over 100 childbirths a month need nine nurses for ante- and postnatal care.
• The Tikamgarh District Hospital meets these standards, with four senior doctors, nine medical students and around 20 nurses in the maternal and child care units.
• However, with the staff working in eight hour shifts and the hospital conducting 30-40 deliveries on average daily, resources are stretched. “Ideally, a mother should stay in the facility for 48-72 hours after a normal delivery. But we are not always able to accommodate them.
• So in case of a normal delivery, we discharge her within a day,” says a nurse on condition of anonymity.
• The reason for poor maternal and child healthcare at Tikamgarh is the increase in pregnant women choosing institutional childbirth. Some 89 per cent of all deliveries in the district take place in hospitals and health centres, says the National Family Health Survey (NFHS)-5 for 2019-21, up from the 28 per cent recorded by district officials in 2005.
• This trend is mirrored across the country. The overall rate of in. situational deliveries is at a historic 88.6 per cent, as per NFHS-5 (see Massive surge’, p16), more than double the 40.8 per cent in NFHS-3 in 2005-06.

GOVERNMENT PUSH

• The surge in hospital births across the country is largely attributed to incentivised institutional delivery schemes launched by the Central government over the past 15 years.
• Broadly, three major schemes incentivise institutional delivery. The first is the Janani Suraksha Yojana (JSY) launched in 2005, under which women opting for childbirth in hospital or health care centres-sub-centres, public health centres, community health centres, district hospitals, medical colleges and private hospitals are promised a direct cash transfer of रु 1,300-2,000 in rural areas and रु1,000-1,400 for urban areas.
• The scheme targeted nine states lagging in socio-economic indicators-Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Rajasthan, Jharkhand, Odisha, Chhattisgarh and Assam.
• These account for nearly half of India’s population, over 60 per cent of its maternal deaths and 70 per cent of its infant deaths, says a 2013 PLOS One study by researchers from Umea University and Karolinska Institutet in Sweden.
• “In the early 2000s, institution al deliveries were low mainly because access to the services were limited. With the National Health Mission and schemes like jsy, the indicator has improved considerably,” says Usha Ram, professor, International Institute of Population Science (see ‘Key initiatives’, p18).
• Nine states saw a rise of 50-64 percentage points in institutional deliveries since 2005-06; Madhya Pradesh leads with a 64.5 percentage point rise, says NFHS-5 data
• As per the Union Ministry of Health and Family Welfare (MOHFW)’s annual report for 2020-21, Jsy beneficiaries rose from 0.73 million in financial year (FY) 2005-06 to over 10 million in 2019-20. Expenditure was up from रु38 crore in 2005-06 to रु1,773.88 crore in 2019-20. “In FY 2020-21 (up to September, 2020) the expenditure reported is रु703.64 crore (provisional),” it says.
• In June 2011, MOHFW launched the Janani Shishu Suraksha Karyakram (JSSK). It entitles pregnant women to several benefits for free, including the transport between home and institution, delivery procedures, drugs, diet, diagnostics and blood transfusion services.
• In 2013, the cost of treating “complications during ante-natal and postnatal period and sick infants up to 1 year of age” was included. As per MOHFW’s Health Management Information System, in 2020 21, nearly 17 percent of the country’s pregnant women got free drugs; 19 percent availed free di agnostics; 19 percent got free diet services; and 7 per cent got free transport under JSSK.
• The Pradhan Mantri Surakshit Matritva Abhiyan was launched in 2016 to provide free, assured and quality ANC. As of January 5, 2021, more than 26.3 million ANC checkups have been conducted in over 17,000 government facilities, says the MOHFW 2020-21 annual report.
• Other schemes, like the 2017 LaQshya Programme (Labour Room Quality Improvement Initiative), do not directly incentivise institutional delivery but include provisions that make it an attractive option. LaQshya focuses on bettering quality of care in labour rooms and maternity operation theatres in public facilities.
• As of October 14, 2020, some 2,805 public health facilities have been identified. Of these, 262 labour rooms and 229 operation theatres have gotten national certification for meeting the initiative’s quality standards, while 614 labour rooms and 538 theatres have got state certification for the same, says data with MOHFW.
• Apart from the national scheme, at least seven states have launched their own programmes to incentiv ise institutional deliveries.
• These include Shramik Seva Prasuti Sahayata Yojana in Madhya Pradesh, Janani Suvidha Yojana in Haryana), Ayushmati Scheme in West Bengal, Chiranjeevi Yojana in Assam and Gujarat, and Mamta Friendly Hospital Scheme in Delhi

HIGH MATERNAL DEATHS

• The schemes for promotion of institutional deliveries aim to reduce childbirth-related health complications. This would lead to lower infant and maternal mortalities. But this has not happened.
• A closer look at the nine states targeted for the schemes shows that they continue to have the highest maternal mortality ratio (MMR), a majority of which are well beyond the national average of 103, as per the Sample Registration System report for 2017-19 by Registrar General of India.
• “While the country as a whole may be able to meet the target of limiting MMR to 70, as per the UN’s Sustainable Development Goals for 2030, unless the lagging states are given an impetus, they will continue to perform poorly,” says Ram.
• Several studies also conclude that an increase in institutional de livery does not guarantee a reduced MMR. The 2013 PLOS One study that assessed the relation between institutional birth proportion and maternal mortality, notes: “Women in rural areas reach lower level facilities which are ill-equipped to handle complications. These inadequacies present a challenge to a mother having a safe delivery…”.
• As early as 2011, MOHFW noted in an internal evaluation of JSY, available online, that an increase in institutional deliveries has “not necessarily meant increased access to skilled birth assistance because most nurses and ANMS [Auxiliary nurse midwives] who are actually providing services were not trained.”
• While MMR continues to warrant concern, other indicators such as neonatal mortality rate (NMR) and infant mortality rates (IMR) show better results (see “Notable drop’ and ‘Lower figures’).
• An April 2021 study published in the journal Geographies calculates NFHS-4 data for 2015-16 and breaks down NMR and IMR (see ‘Impact of incentivisation, p18).
• In Assam, Rajasthan, Uttar Pradesh and Bihar, where a majority of deliveries took place in public institutions, difference between NMR for public and home births is equal to or less than 10 deaths per 1,000 births. Barring Assam, other states saw higher NMR in private institutions than home.
• The other five states saw a difference of under 17 deaths per 1,000 births. “Safe delivery is associated with lower risks of neonatal deaths, but increases in institution-based deliveries were not consistently associated with de creased neonatal mortality rates,” the study notes.

RESOURCE WOES 

• The experience of Tikamgarh district provides some insight into the reasons behind the poor maternal and child health indicators.
• Despite the high rate of institutional deliveries, the district’s NMR is 30 per 1,00 births as per NFHS-5, says Aditya Tiwari, district programme manager, National Health Mission. MMR of the Sagar division—which includes Panna, Tikamgarh, Damoh, Sagar, Chhatarpur and Niwari districts—is 189.
• Even with 22 public health centres, seven community health centres and one hospital, Tikam garh’s health infrastructure has several gaps.
• In 2010, the district hospital did not have the capacity to perform a caesarean section; patients were referred to Jhansi Medical College, a two-and-a-half hours’ drive away. Today, the four senior doctors perform the procedure.
• The lack of awareness amongst expectant mothers is also a problem. Of the 28 women in the hospital’s maternal care ward, only one had gotten three ANC checkups, while others had gotten either two or none.
• Most of the 110,000 people in the district reside in rural areas. «Since women in rural areas have more children, they are more likely to be anaemic. Poor nutrition is a key concern,” says Priyanka Sharma, a gynaecologist at the hospital.

INFRASTRUCTURE IS KE

• While Tikamgarh district suffers from inadequate resources, Nuh district in Haryana highlights the need for good infrastructure. The disrtict records the poorest performance in health indicators in the state, even with an institutional delivery rate of 91 percent.
• MMR and IMR for the district are high at 95 and 32, respectively. However, they have declined since 2018, when Nuh was declared an “Aspirational District” by government think tankniti Aayog. An Aspirational District is one of the Centre’s chosen districts for prioritised funding and development.
• However, smaller healthcare centres continue to face problems. At the public health centre in Ghasera village, the delivery hut only has four beds. Over the past year, the centre has seen some 2,700 deliveries-more than the district hospital.
• Another problem is that Nuh has a high fertility rate of 4.9, more than double state’s 2.1, as per the Census 2011. At the community health centre in Punhana village 38 km from Nuh, which Down To earth.

INSTITUTIONAL DELIVERY HAS SAVED MANY LIVES, BUT THERE ARE CONCERNS ON THE QUALITY OF CARE

• Earth visited on March 14, there were four women, all in the 25-35 age group, who had given birth in the last 24 hours. One of them already had three children while others had eight each. All four were highly anaemic, but only one came in for the ANC checkups.
• Unlike Tikamgarh, JSSK has seen greater success than jsy in Nuh district. “Most women do not have bank accounts, so where will the money go? Under JSSK, they get direct benefits when they come to a healthcare centre for a delivery,” says Kapil Dev, Senior Medical Officer at the Punhana centre.
• As per MOHFW, some 37,134 women in Haryana availed JSY services in 2019-20 and over 200,000 women availed JSSK services during the period.

EXPAND SCOPE

• Experiences of Tikamgarh and Nuh districts show that schemes incentivising institutional deliveries need to widen their scope. The 2011 evaluation of JSY notes, “An infrastructure development plan focused on the actual patterns of use could close the remaining gaps in a very short time.”
• Sanghita Bhattacharyya, senior public health specialist at the Public Health Foundation of India, a public-private initiative, argues that eligibility criteria for such schemes should be expanded.
• Some are applicable only if the mother is at least 19 years of age, some only for the first child while others require proof of poverty, she says. “An 18-year-old pregnant woman living below the poverty line is most vulnerable but would not make the cut for several schemes,” she adds.

2. CLEAN FOSSILE

CONTEXT

• NATURAL GAS, a fossil fuel, has been seen as a “transition” or “bridge” fuel that will facilitate a move away from polluting coal, and fill interim energy needs before zero-carbon renewable energy can be fully scaled up.
• Natural gas emits roughly half the carbon dioxide (CO2) as compared to coal. But leakages of methane—an extremely potent greenhouse gas—during its production, supply and usage almost wipe out its emissions benefit. Methane has a higher global warming potential than CO2

Therefore, the first question is if natural gas-LNG or piped—can be seen as the transition fuel in a world that now has an extremely shrunk carbon budget?

• The second question is if gas should be the transition fuel in economies like India or the continent of Africa that requires energy security or should it be used in the countries of the already developed world, which have overused their share of the carbon budget?
• Third, if natural gas must be produced and used, should it be done without abatement of methane? Currently methane’s abatement process is talked about but hardly implemented across the world (see ‘Methane abatement’, p39).
• Then there is the issue of CO, emissions from LNG, and the technologies and cost involved in reducing the emission through carbon capture utilisation and storage (CCUS) method in which the CO, emissions are captured and stored.
• The oil and gas industry is also gung-ho about the manufacture of blue hydrogen from natural gas. This, then, is seen as the future of to fuel, where the old industry becomes the energy transition-literally.
• But this seemingly clean gas is not so clean, point out environmental groups. The Natural Resources Defense Council (NRD). a US-based environmental advocacy grow highlights that the “extraction, transport, liquefaction and re-gasification of LNG can be almost equal to the emissions produced from the actual burning of the gas, effectively doubling the climate impact of each unit of energy created from gas transported overseas”.
• According to NRDC estimates, the life cycle GHG emissions for solar power are less than 7 percent of LNG emissions; GHG emissions for wind power are even lower less than 2 per cent of LNG emissions.
• In May 2021, the International Energy Agency (IEA) said that there must be no new oil and gas investment beyond those committed in 2021, if the world is to achieve a net zero emissions energy sector by 2050.
• In its Net Zero by 2050 report, it stated that in 2050, natural gas demand must fall by 55 per cent compared to 2020.
• “The focus of energy security will evolve as reliance on renewable electricity grows and the role of oil and gas diminishes,” said the report. IEA has also said that as far as LNG is concerned, no new projects should be planned for construction, if the world is to achieve its global net zero emission goal by 2050.
• Most important a this coming period, natural gas traded as LNG must fall by 60 percent over 2020 levels, not to be increased as the world would now like to see.
• It was because of this carbon intensity of natural gas that US LNG investment and exports has slowed down. On March 8, 2022, a coalition of 120 advocacy groups urged the six largest US banks to stop financing LNG exports.
• “More than 20 new and expanded export facilities are currently proposed to liquefy and ship methane gas from the Gulf Coast of Texas and Louisiana to foreign markets.
• If built, these projects would lock in fossil fuel production for decades to come and exacerbate harm to Gulf Coast communities already facing disproportionate rates of industrial pollution from the fossil fuel industry and the impacts of extreme weather driven by climate change,” said a statement by California-based environmental group Sierra Club.
• But the industry remains undeterred. It is seeing the Russia-Ukraine war as a rallying point for cleaner natural gas as compared to coal.
• It also remains buoyant that it can abate the emissions from gas-regardless of the fact that it continues to struggle to control the same emissions from burning of coal. Natural gas is clean, says industry and we can make it part of the energy transition.

METHANE ABATEMENT

• METHANE LEAKS from the extraction and transport of LNG can constitute up to 14 per cent of its life-cycle emissions, according to The US-based think tank Natural Resources Defense Council (NRDC). Methane is also purposefully flared or vented during natural gas development.
• Flaring refers to the controlled combustion of methane. while venting involves its direct release into the atmosphere.
• Thus, despite having a lower carbon content than coal, LNG’s climate benefits are almost wiped out due to its methane emissions, and this must be tackled urgently. In 2020, natural gas produced about 38.5 million tonnes of methane, according to the IEA. This needs to reduce to 13.3 million tonnes in 2030 for a net-zero emissions energy sector by 2050
• The IEA suggests that it is technically and theoretically possible to avoid around three-quarters of today’s methane emissions from global oil and gas operations.
• Methane can be captured and monetised commercially, thus making methane emissions reductions a low-cost effort. But all this will cost— big time. And as yet, it is clear that it is not happening.
• The US produced around 13.82 million tonnes of methane from its oil and gas operations in 2021. In 2016, the Barack Obama administration sought to control methane emissions from this sector, by announcing new emissions standards and leak detection and repair requirements.
• These were rolled back in 2019, under the presidency of Donald Trump, who proposed eliminating requirements from oil and gas companies to control leaks of methane from new wells, storage facilities and pipelines. It also proposed reducing the regulation of air pollution from the oil and gas industry.
• This course has been reversed, at least in intention, by his successor and Obama’s former associate Joe Biden, who announced a target to slash methane emissions by more than 50 per cent by 2030 during COP 26 in Glasgow.
• It would require companies to monitor 300,000 of their biggest well sites every three months, ban the venting of methane produced as a by-product of crude oil into the atmosphere, and require upgrades to equipment such as storage tanks, compressors, and pneumatic pumps”.
• The US also announced the Global Methane Pledge along with the EU. Joining countries committed to “a collective goal of reducing global methane emissions by at least 30 percent from 2020 levels by 2030 and moving towards using best available inventory methodologies to quantify methane emissions, with a particular focus on high emission sources.”
• In a world with a short fuse, the question is if this methane abatement will happen as fast as needed.

3. ENERGY SECURITY

Context

• IN THE energy chessboard, there are now new buzzwords—affordable, reliable, sustainable and secure sources.
• The war with Russia has brought the memories of the 1970s energy crisis back to Western economies—this is when because of the Yom Kippur war of 1973 and the Iranian Revolution of 1979, the supply of oil from the West Asia was disrupted.
• An oil embargo was imposed by members of the Organization of Arab Petroleum Exporting Countries (OAPEC), leading to spikes in fuel prices and economic losses across the world.
• This energy crisis led the world to discuss the need for domestic energy security; it also temporarily energised the alternative energy business as solar was seen as the way out.
• But this crisis, as many others in the world, became a faint memory as things went back to business as usual and global trade in oil and gas exploded.
• Now, once again, energy security is back on the table. Europe’s dependence on Russian oil and gas has thrown up similar spectre of shortage and high energy prices, though this time it is because of the embar go being imposed by the importing countries in retaliation. .
• This also feeds into the narrative of wonks who would believe that it is time countries discussed energy security even as they talked about clean energy.
• This issue then spills out of the discussion on oil and gas—which is produced by some countries in the world and some of whom are the favoured few. It is then about chains of all new sources of energy minerals and components that are to make the renewable energy work.
• This then brings in China into equation as it controls the world’s rare erals that are crucial for the new economy; including the batteries that drive the vehicles of the future. Even Ruse and Ukraine are crucial parts of the sun chain needed for the low-carbon transition.
• Both Russia and Ukraine are major producers of several metals and minerals that are crucial for clean energy transition.
• As per an article by the World Economic The rum. Russia accounts for 7 per cent of the world’s mined nickel (a scarce metal needed to make electric vehicle batteries); one-third of the world’s palladium (used in the car industry to control vehicle emissions); one tenth of the world’s aluminium and copper and a fifth of battery-grade nickel.
• Ukraine is the world’s largest supplier of a group of chemical elements known as “noble gases” (include neon and krypton) that are used to make semiconductor chips, a critical component of all electronic systems including those found in automobiles, renewables machinery and other technology. Ukraine supplies almost 90 per cent of its semi-conductor grade neon to the US. Now that Ukraine is under attack, the US has reportedly asked its semiconductor industry to “diversify its supply chain”.
• Just a few months before being attacked by Russia, Ukraine was to auction off exploration permits to develop its reserves of lithium, copper, cobalt and nickel-metals crucial for the clean energy transition.
• Ukrainian researchers speculate that the country’s eastern region holds one of the world’s largest reserves of lithium oxide—close to 500,000 tonnes—which is processed to ex tract lithium, critical to rechargeable batteries used in everything from mobile to electric vehicles.
• In November, there was cut-throat competition between European Lithium, an Australian-listed firm, and Chinese company Chengxin Lithium for securing rights to two promising lithium de posits in the country.
• Even though mining work has not begun in the region, the move was crucial for Ukraine to establish itself as a major player in the clean energy future, while supplying the world with the critical metal whose demand is going to double by 2025 due to increase in battery demand for electric vehicles.
• So far, the war has not interfered with the flow of energy metals. But analysts worry that the conflict and future sanctions on commodities may disrupt supply, which can snowball in a world still struggling to recover from the pandemic and trying to transition away from fossil-fuels.
• Though price swings of these materials have been as violent as in oil and natural gas since the war-on March 8, the London Metal Exchange suspended nickel trading for only the second time in its 145-year history after its prices increased by 250 per cent in 48 hours-prices have continued a northward march since last year.
• Its impact will be particularly worse for Europe that now banks on clean energy to hedge against inflation and to achieve energy security.
• Estimates show that EU’s demand for rare earths could increase 10-fold by 2050; demand for lithium will grow 60 times and cobalt by 15 times. But just like its energy supplies, Europe heavily depends on other countries for these critical raw materials.

The European Raw Materials Alliance

• In September 2021, the European Raw Materials Alliance (ERMA), established by the European Commission for securing raw materials for European market, released an action plan which says, Europe has significant rare earth reserves but no primary production takes place within the EU, which recycles just less than 1 per cent of rare earth elements.
• While the EU is a world leader in the manufacturing of electric motors, it is almost fully import dependent for rare earth permanent magnets, critical for applications like wind power, electric mobility and communications technology.
• Russia, for instance, supplies the majority of the feedstock for Europe’s only commercial rare earth separation plant in Estonia.
• As per the ERMA action plan, China sends 16,000 tonnes of rare earth permanent magnet to Europe each year, which represents 98 per cent of the EU market.
• All, this then adds to the energy vulnerability of Europe, even as it moves away from Russia oil and gas. In March, ERMA has said it will support development of a rare earth separation plant in Poland, which will source its raw material from Malawi.
• Overall, the issue of supply chains is now an important issue with the proponents of globalisation. Energy has been weaponised and now when climate change is banging on our doors and windows, can the world stay on course in spite of this war? Or, will the war accelerate climate change? Clearly, there is much at stake.

4. Drug Debacle

Context

• Bombay Natural History Society, India’s oldest biodiversity conservation group, wrote a letter urging the Union Ministry of Environment, Forest and Climate Change (MOEFCC) to ban the use of three veterinary drugs known to kill vultures in the country.
• The letter warns that the ram pant use of the three non-steroidal anti-inflammatory drugs (NSAIDS) threatens to undo the Centre’s two decades of work to arrest the dwindling vulture population in the wild.
• Surprisingly, the three drugs—aeclofenac, ketoprofen and nimesulide—were introduced as alternatives to diclofenac, the NSAID that India banned in 2006 for animal use because it caused wide spread vulture deaths.
• Vultures were quite common till the 1980s. Currently, eight species in the country face extinction, says Rinkita Gurav, manager, raptor conservation, World Wide Fund for Nature, India.
• The country’s vulture population crashed from over 40,000 in 2003 to 18,645 in 2015, as per the last vulture census conduct d by intergovernmental body Bird Life International,
• Even diclofenac, which is only permitted for human use, is being misused for cattle treatments. Such treatments are usually prescribed by quacks,” says Vibhu Prakash, deputy director, Bombay Natural History Society (BNHS).

DEFAULT CHOICE

• In 2005-06, a little over 10 per cent of cattle carcasses had diclofenac residue. This came down to below 2 per cent by 2013, except for Rajasthan where it was still over 5 per cent, claims India’s second National Vulture Conservation Action Plan (2020-25), released by MOEFCC. Vulture populations are considered safe if the diclofenac prevalence in carcasses drops to below 1 percent.
• Bohra estimates Bikaner, home to the Jorbeer vulture conservation centre and animal carcass dumping site, has a vulture population of 1,795 (give or take 137). In the absence of a national death registry, Bohra has kept a log of vulture deaths in the district for research.
• He has counted 184 vulture deaths in the district in 2020, which is roughly 10 per cent of the total vulture population in the district.
• In some years, the number goes up to 300. “At least 20 vultures have died this year. Some of them have died due to electrocution, while some others have died due to the consumption of NSAIDS.
• When Down To Earth visited Rajasthan’s second largest cowshed in Bhadriya village, Jaisalmer, it found that diclofenac and other NSAIDs are part of its treatment pro cess for cattle.
• “They are effective against seasonal flu. We also use them as painkillers. There are 20 30 cows that undergo treatment at a point of time,” says a compounder at the cowshed, which has over 50,000 heads of rescued cattle. The cowshed dumps almost five carcasses a day.
• Pesticide poisoning also threatens vultures across the country. On March 17, 2022, Kamrup district in Assam reported 97 vulture deaths after they consumed two pesticides smeared carcasses that had been kept by farmers to kill stray dogs.

EMPTY PROMISES

• India’s vulture conservation action plan for 2020-25 recommends a ban on the veterinary use of the three drugs.
• It adds that the Drug Controller General of India (DCGI) must institute a system that removes a drug from veterinary use if it is found to be toxic to vultures.
• The country is also a signatory to the Convention on Migratory Species’ Multi-species Action Plan to Con serve African-Eurasian Vultures, which recognises NSAIDS as a major threat to vultures in India. Still, little seems to have moved on the ground.

SMALL VICTORIES

• Till recently, train collision was a major reason for vulture deaths in Jaisalmer and Bikaner. It was arrested in 2019 by the construction of walls along the railway tracks. “Stray cows would often forage near the railway tracks and get hit by trains.
• Then vultures would come to eat the carcasses and get run over by trains,” says Bishnoi. In January 2018, Jaisalmer saw 42 vulture deaths because of train collision.
• In 2015, Tamil Nadu became the first state to ban the veterinary use of ketoprofen in Nilgiri, Erode and Coimbatore districts. “The government wants us to produce more scientific evidence to put a state-wide ban,” says Subbaiah Bharathidasan, co-founder of non-profit Arulagam.


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