19th Aug 2019: The Hindu Editorial Analysis
1) Unclear doctrine: On ‘No First Use’ nuclear policy
- Defence Minister Rajnath Singh has been somewhat careful in speaking of envisioning (picturing) a change in India’s nuclear deterrence posture (preventive model). In place for 16 years, since January 4, 2003, when the doctrine was adopted formally, New Delhi has said consistently that India’s nuclear weapons were based on punitive (penal) retaliation, in case deterrence failed (means to serve as a preventive measure and with no first use policy). The retaliation to a nuclear strike, any nuclear strike, whether by tactical or theatre (in combat area) or something bigger, would be crushing (destructive) enough to deter (prevent) the possible use of nuclear weapons by an adversary (enemy).
- But on the first death anniversary of former Prime Minister A.B. Vajpayee, and in the nuclear proving ground in Pokhran, the Minister (Defence) said two things: that the no-first-use has served India well so far, and that what happens in future depends on circumstances.
- There ought to be no scope for confusion here. Security is, after all, a dynamic concept. It was the security environment in the neighborhood coupled with the pressure brought by the Comprehensive Nuclear Test Ban Treaty that forced India out of the nuclear closet and, at the same time, to adopt the no-first-use posture.
- The structures associated with the doctrine, the command, and control that can survive a nuclear strike, the redundancies (structure) that are in-built, the secure communications, have all been developed keeping in view the posture perspective. But there is a danger that the minister’s remark could spark off a nuclear arms race, given the strategic paranoias (state of mind) that have been at work in this part of the world for over half a century.
- In the elections of 2014, the BJP’s manifesto had references to an intention to update and revise the nuclear doctrine, but that went nowhere. It is conceivable that nuclear weapons could fall into the hands of non-state actors in Pakistan, but even in such scenarios that warrant pre-emptive (preventive) action, a nuclear strike cannot be a viable option.
- It would have been much better if Mr. Singh had elaborated on his thoughts so that a debate could have taken place, and not kept his remarks enigmatic (not clear inaction or understanding). In a nuclear circumstance, it is much better to convey the overwhelming (intense) nature of the deterrence than to keep the potential adversary (enemy) guessing.
- In this respect, it is a good idea for the government to make public any periodic review in its strategic posture. The no-first-use policy comes with being a confident nuclear power. For him to state the future is open is to say nothing and at once imply everything. In matters of nuclear doctrine, it is important to be clear above all else. Nothing should be left to interpretation.
2) Taking on TB: On new anti-tuberculosis drug
- The anti-tuberculosis drug pretomanid recently approved by the U.S. Food and Drug Administration (FDA) will be a game-changer for treating people with extensively drug-resistant TB (XDR-TB) and those who do not tolerate or respond to now available multidrug-resistant TB (MDR-TB) drugs.
- That pretomanid is only the third drug in the last 40 years to get FDA approval (why?) highlights the scarcity of new drugs to treat TB bacteria that are rapidly developing resistance against most available drugs. The all-oral, three-drug regimen of bedaquiline, pretomanid, and linezolid (BPaL) had a 90% cure rate in a phase III trial in South Africa involving 109 participants.
- In contrast, the current treatment success rate for XDR-TB and MDR-TB is about 34% and 55%, respectively. Importantly, the regimen was found to be safe and effective in curing TB in people living with HIV. The safety and efficacy were tested in 1,168 patients in 19 clinical trials in 14 countries. Unlike 18-24 months needed to treat highly-resistant TB using nearly 20 drugs, the BPaL regimen took just six months, was better tolerated and more potent in clearing the bacteria. The shorter duration is more likely to increase adherence to therapy and improve treatment outcomes.
- According to the World Health Organisation (WHO), in 2017, there were an estimated 4.5 lakh people across the world with MDR-TB, of which India accounted for 24%, and about 37,500 with XDR-TB. With only a low percentage of MDR-TB cases being treated, the actual number of people who do not tolerate or respond to available MDR-TB drugs and so will be eligible to receive the BPaL regimen is unknown.
- Though the total number of people who will require the new drug may not be high, these are people who have very little alternative treatment options that are safe and efficacious. Also, the number of those who would need a pretomanid-based regimen is increasing due to rising drug resistance. While the availability of a potent drug is welcome news, it remains to be seen if it would be made affordable, particularly in the developing countries where the burden of XDR-TB and MDR-TB is the highest.
- TB Alliance, a New York-based international NGO, which developed and tested the drug, has already signed an exclusive licensing agreement with a generic-drug manufacturer for high-income markets. Unlike in the case of bedaquiline, where its prohibitive cost has severely restricted access especially in the developing countries, pretomanid might become affordable. In line with the TB Alliance’s commitment to affordability and sustainable access, the drug will be licensed to multiple manufacturers in about 140 low- and middle-income countries, including India.
- Making the drug affordable to those with an extreme form of drug resistance will be highly commendable and a desperately needed model to be followed. After all, there is a compulsion to keep the prices low and increase treatment uptake to stop the spread of highly drug-resistant TB bacteria as studies have already shown an increase in the number of new patients who are directly infected with drug-resistant bacteria.
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