Search This Blog

Monday, October 25, 2021

Cloaca Maxima - a sewer system that has functioned for 2500 years....

Here is a picture of the Senate in Rome. This building was built in 44 BC, under Julius Caesar, and itself replaced earlier Senates.

After a Roman magistrate served his term in office, it usually was followed with automatic appointment to the Senate.

The Senate controlled money, administration, and the details of foreign policy.

The power and authority of the Senate derived from precedent, the high caliber and prestige of the senators, and the Senate's unbroken lineage, which dated back to the founding of the Republic in 509 BC.

The Cloaca Maxima was a sewer system built in Rome in 600 BC. I photographed its outfall at the Forum in Rome. 

The eleven aqueducts which supplied water to Rome by the 1st century AD were finally channeled into the sewers after having supplied the many public baths, public fountains, imperial palaces and private houses. The continuous supply of running water helped to remove wastes and keep the sewers clear of obstructions.

The Cloaca Maxima was well maintained throughout the life of the Roman Empire and even today drains rainwater and debris from the center of town, below the ancient Forum. In 33 BC it is known to have received an inspection and overhaul from Agrippa who was a colleague of Julius Ceaser.

The outfall of the Cloaca Maxima into the River Tiber is still visible today.

The Forum of Ancient Rome

As legend has it, Rome was founded in 753 B.C. by Romulus and Remus. A line of seven kings followed in non-hereditary succession. All the kings after Romulus were elected by the senate.

Rome’s era as a monarchy ended in 509 B.C. with the overthrow of its seventh king, Lucius Tarquinius Superbus, whom ancient historians portrayed as cruel and tyrannical. Rome turned from a monarchy into a republic, a world derived from res publica, or “property of the people.” 

The power of the monarch passed to two annually elected magistrates called consuls. They also served as commanders in chief of the army. The magistrates, though elected by the people, were drawn largely from the Senate, which was dominated by the patricians, or the descendants of the original senators from the time of Romulus.

Politics in the early republic was marked by the long struggle between patricians and plebeians (the common people), who eventually attained some political power through years of concessions from patricians.

Shown here are public spaces of Ancient Rome, called the Forum. 

Sunday, October 17, 2021

The Umbrella Pines of Rome

 The Triumphal way, at the end of which stands the Arch of Constantine. 

These iconic Umbrella Pine trees are everywhere in Rome. 

Apparently Mussolini planted many. 

But now these trees are mortally threatened by a pest that got into Italy from the USA. 

Neighbourhood Associations are releasing large numbers of ladybirds in an effort to combat that pest.
Most monuments in Rome are framed by these trees, as this image from Wikimedia shows. 

Saturday, October 16, 2021

The Arch of Constantine

I read documents / articles, and watch documentaries on history quite a bit. So was thrilled to find this channel where history professors show / describe answers to questions I always had... 

For example, my husband and I spent quite a long time trying to figure out the arch of Constantine, a prominent beautiful building in the centre of Rome. It had roughly done figures in the centre, and beautifully sculpted figures on top. Why was there so much difference in style ? 

It must have been important for the time, as it was built on the procession way, where emperor's walked in triumph. It was evidently a lot about war, but what was it saying ?

But the professors explain it beautifully here... 

Ancient Rome is worth understanding a bit, as along with Ancient Greece, whose successor it was, it laid the foundation of modern Europe - and the English speaking world, along with it. Its laws, infrastructure concepts, public institutions like the judiciary and parliament, even architecture styles are the bedrock of these societies to this day. 

Every successful nation in the West to this day, aims to be the Roman empire all over again. It is then worth it to understand Ancient Rome's achievements, but also its vanities and corruptions.

Sunday, October 10, 2021

The inability of India's discoms to pay for more expensive power

I read more widely around the ‘inability of discoms to pay for more expensive power’ as in the current scenario.

June 2019 article – Before the recent high prices of coal and gas arrived : The article asked : Why is India unable to provide 24x7 electricity despite building morepower stations?

Unless distribution companies pay their record debt, which would reach Rs 2.6 lakh crore by 2020, it won’t be possible to increase power generation.

At the root of the contradictions between almost-universal electrification, surplus electricity and the inability to supply it around-the-clock to Indian homes, is a debt that burdens state-owned electricity distribution companies nationwide, impairing their ability to build and maintain power grids and equipment.

The inability or refusal of state governments to increase power bills, has led to more borrowing and power shortages and made distribution companies reluctant to buy available electricity, which means continuing blackouts and erratic power supply.

India currently has around 356 gigawatts of installed generation capacity against a peak demand of about 177 gigawatts.

The nub of the issue: power generation cannot be increased unless distribution companies pay their dues.

The distribution company debt of Rs 2.6 lakh crore (dated to 2020) would be more than the Centre’s combined 2017-’18 spending on: highways, national railways, metro-rail systems, national food subsidies, cash transfers for national social-security schemes or direct benefit transfers, cooking-gas subsidies and capital expenditure for the defence services, space technology applications and satellites.

The accumulated losses of dicoms, and efforts to do something about it, have a long history.

In 2015, India’s distribution companies collectively recovered less than 80% of their operational costs. On March 2015, they had accumulated losses of about Rs 4.3 lakh crore.

So, the companies borrowed money from banks, with interest rates as high as 14%-15%, to cover their costs, their cycle of losses cancelling out India’s other gains: more coal, more power plants, and more transmission lines

Under the UDAY scheme, the power ministry, state governments and distribution companies signed a memoranda of understanding that said state governments would take over 75% of the companies’ debts – outstanding as on September 2015 – through bonds with a maturity period of 10 years to 15 years.

The companies were given goals: reduce power and interest costs, monitor and reduce transmission losses and power theft and fix faulty meters. By charging more, distribution companies were to wipe out the difference between the cost of supply and average revenue by 2018-’19.

In 15 states that account for 85% of national aggregate technical and commercial losses, despite the debt takeover, the UDAY failed.

Distribution companies in three BJP-ruled states – Uttar Pradesh, Jharkhand and Maharashtra – were responsible for 87% of the outstanding amount not paid by consumers, said a May 20 study.

The Government’s electrification drive, begun in 2016, had some goals contradictory to the UDAY scheme. The electrification drive was meant to connect all the villages and households to the grid and to provide them with round-the-clock power.

The time-bound objectives [of electrification drives] and UDAY were converging and diverging on certain aspects, which resulted in a haywire situation for the implementation agencies, such as the distribution agencies.

The government electrified 26.30 million rural households to achieve 99.93% electrification over 16 months leading up to January 2019, a mammoth exercise whose implementation created problems for distribution companies: higher costs and reduced revenues from the newly connected households, mostly rural, paying low or no bills.

The blackouts continued primarily because the companies were reluctant to buy more power, either because they do not have the money or were afraid consumers will not pay.

Friday, October 08, 2021

Whats Next on the Ujjwala Scheme ?

The scheme had been virtually withdrawn in September 2019, although no formal declaration was made. Only three States — Haryana, Punjab and Andhra Pradesh — and five Union Territories, were declared kerosene-free at that time.

A 2021 report says that District Nodal Officers have highlighted the issue of PMUY beneficiaries finding it difficult to shell out around Rs 800 per cylinder in one go. This is even though the cylinder lasts them around three months, effectively costing around Rs 250 a month of LPG usage. The 5 kg LPG cylinder option may be more viable.

This was pointed out to the government by many agencies but it paid no heed during the initial years of the scheme. 

Currently on a per kg basis, the LPG in a 14.2 kg domestic cylinder costs around Rs 58 a kg. But it costs roughly Rs 94 a kg in a 5 kg cylinder. According to LPG dealers, the 5 kg cylinders were supposed to be for a migratory population like students, IT professionals , among others who can afford more expensive But it finds hardly any buyers nowadays. The higher cost per kg dissuades consumers that are anyway price sensitive. These issues are soon expected to be addressed by increasing availability of LPG in a 5 kg domestic cylinders that costs around Rs 60 per kg.

The three public sector oil marketing companies are waiting to recover around Rs 4,500 crore from existing PMUY beneficiaries.

PMUY beneficiaries buy LPG cylinders at full cost and recover the loaned amount from the subsidy that is accrued on domestic (14.2 kg) LPG cylinders.

This makes the cylinder unaffordable for a large chunk of beneficiaries who tend to use them sparingly. They often revert to biomass (firewood or cow dung which they get for no additional financial cost) for their primary cooking needs when LPG prices shoot up.

Audit Report of the Ujjwala scheme

My reading on fuels brought me to LPG, and to the present Government’s Ujjwala scheme which distributed crores of free LPG connections to the poor, starting from 2016. 

The end 2019 Government audit report of the scheme says that the targets of distribution were achieved. It reviews in detail the 5 crore target of the original Ujjwala scheme (called PMUY).

In order to rule out existing LPG connection in beneficiaries’ household, de-duplication was to be carried out on Aadhaar of all family members. Audit noticed that out of 3.78 crore LPG connections given under PMUY, 42 % were issued only on the basis of beneficiary Aadhaar which remained a deterrent in de-duplication.

PMUY envisaged release of LPG connection in the name of woman. However, 50% of the connections were released in the names of males. 

Test check in field audit revealed that 18 per cent of beneficiaries were those given benefits by LPG distributors to un-intended persons.

Encouraging the sustained usage of LPG remained a big challenge as only 3-4 refills each were availed of by beneficiary families per year. 

Many organizations had highlighted the importance of small 5 Kg cylinders to make PMUY successful considering high refill cost as a barrier to LPG usage. However, inadequacy of efforts was noticed in this direction as only 0.24 per cent of 3.78 crore beneficiary connections were provided 5 Kg cylinder connections.

24% of the beneficiaries had not even taken 3 refills over a year. This had hindered recovery of outstanding loan of ₹1235 crores.

The government audit report concluded that considering the audit findings on the basis of limited test check of sample cases, the entire LPG databases as well as physical records need to be scrutinized to identify and restrict release of connections to ineligible/male/minor beneficiaries/multiple connections.

The scheme had been virtually withdrawn in September 2019, although no formal declaration was made. Only three States — Haryana, Punjab and Andhra Pradesh — and five Union Territories, were declared kerosene-free at that time.

The founding of the fossil fuel infrastructure in India

 The longest fuel pipeline is being built from Kandla to Gorakhpur across 2805 kms, that saves transportation costs. That is great. 

The commentary in the video is bombastic, implying ‘this is being done for the first time’. Obviously, this is not the first time. 

The longest cross-country pipeline in India before this one was the Mundra-Delhi pipeline running 1055 kms, commissioned in 2009. 

Oil production started in India in 1889 in Assam. Oil in colonial India was mostly exploited by a number of British companies to support British troops and industries in the United Kingdom.

After independence, the foreign companies continued to play a key role in the oil industry. This changed in 1956 when the government adopted an industrial policy that placed oil as a “schedule A industry” and put its future development in the hands of the state. The Oil and Natural Gas Commission was established for this purpose

In order to find the expertise necessary to reach these goals, foreign experts from West Germany, Romania, the US, and the Soviet Union were brought in. The increased focus on exploration resulted in the discovery of several new oil fields most notably the off-shore Bombay High field, which remains by a long margin, India's most productive well.

The Indian Oil Corporation which owns most of the refineries putting it within the top 20 oil companies in the world, was also established in the 1950s

Thursday, October 07, 2021

The Why and Impacts of the Energy Crisis

Why is there an Energy Crisis ? 

Renewables do not supply enough energy to replace coal and natural gas. 

Ageing, less efficient coal plants had been shut down in parts of the world and that has also led to power shortages. 

Price of coal and natural gas (the latter used to produce power and also heat homes in the developed world) has risen 250-300 % over one year. There are shortages of both in Europe, China and India. 

Australia, Indonesia, South Africa etc. are big exporters of coal, and countries are vying to get shipments from them. 

Energy prices to customers are controlled in many regions of the world and energy producers are suffering catastrophic losses as a result of the price rise. They have stopped / reduced importing coal / natural gas. Many countries are contemplating supporting such energy companies tide over some of their losses. 

Shipping vessels which bring the coal have also been in short supply all over the world for many reasons.

The emerging impacts of the energy crisis

India meets around three-quarters of its demand locally, but heavy rains have flooded mines and key transport routesCoal inventories at Indian power plants fell to around 8 million tons at the end of September, about 76% less than a year earlier.

A lack of coal means factories could shut in India. Supplies to power plants are currently short by between 60,000 and 80,000 tons a day on the impact of the prolonged rains that have drenched coal pits. More than half the power plants are on alert for outages.

Supplies of coal are being diverted away from key customers including aluminum smelters and steel mills.

“Until supplies stabilize completely, we are likely to see power outages in some pockets, while customers elsewhere may be asked to pay more for power,” said a Director at ratings firm Crisil.

 In China, industrial users of natural gas including makers of ceramics, glass, and cement may respond by raising prices. If Chinese factories have to contend with widespread power shortages, global prices for steel and aluminum will jump. 

Economies that can’t afford the fuel—such as Pakistan or Bangla­desh—could simply grind to a halt.

“If the winter is actually cold, my concern is we will not have enough gas for use for heating in parts of Europe,” the US State Department’s adviser for energy security said.

The stage is set for an all-out scramble among Asia, Europe, the Middle East, and South America for shipments of LNG from exporters such as the Qatar, Trinidad and Tobago.

Cutting back on energy will help the lights stay on longer

 From recent reading it became clear that there is an energy crisis not only in Europe, but also in China – and in India !

Here is Shekhar Gupta explaining why we may suffer blackouts / power cuts over the coming months in parts of India – hopefully planned and announced ones, rather than sudden. 

There are many reasons for what is happening and I will share them as I read – but cutting back on our energy consumption will help the lights stay on a bit longer for everyone. 


Home Lighting

1. In the early 90s, we moved to using 60 W filament bulbs instead of 100 W. In mid-90s, we replaced nearly all our filament bulbs with CFLs, thus reducing per light load to 18 and 36 W from 60 W. 

2. For the last few years, we buy only LEDs and are gradually replacing all bulbs as the past ones die out. All heavy use lights already have LEDs – 3 / 6 / 9 watts each usually. 

3. We find our selves becoming more economical in the use of lighting. One light suffices where two were put on habitually earlier. 

4. Natural light is utilized to the maximum by hanging transparent plastic curtain on the doors which get a lot of light. This plastic curtain keeps out the cold air in winter and hot air in summer, while letting in light. 

5. Window glasses are curtained off for the night only at sleep time as until then they continue letting in outside light. 

6. In consultation with our neighbours, we keep less of the lights of our common corridor on. 

7. Our torches are solar.

Cooling home in summers

8. Our mini honeycomb pad cooler uses just 90 W instead of the 350 W and above, for mid-sized woodwool coolers. 

9. We have just learnt that slower speeds in fans use much less electricity than full speed, so we will now use them at more optimum levels. 

10. We have started replacing old induction motor 90 W fans with new electronic motor 28 W fans – whenever old fans go out of order and cannot be repaired.

11. Our AC use is 10 % compared to our neighbours and only on the hottest days for short durations. The coolers carry on cooling after the AC is shut off. Coolers even circulate the cool air to a second room if both are occupied. 

12. All sun receiving areas of the house are shaded during summer with green nursery cloth. Tirpals / roller blinds / plastic curtains are used, preferably outside the sun receiving windows, so the glass does not heat up. 

Heating Home in Winters

13. We have maximized sun use when it is comfortable to be outside. Our balcony / garden are equipped with electric point for laptop, table and chair, so one can spend long hours outside. 

14. All sun receiving areas of the flat have conveniently placed furniture so one can spend the maximum time in direct heat from the sun. 

15. Blowers and Oil Radiators use 1000 or 2000 W at a time. In contrast halogen rod heaters use 125-400 W rods for heating and one can use multiple rods for faster heating. 

16. But as we have become more conscious of what global warming implies, we find ourselves dressing up even more warmly at home – as a result, in recent winters we have not needed to use heaters at all. 

17. Hot water is used only for bathing, not for washing of hands or washing utensils. Ofcourse, someone unwell would use the hot water stored in the geyser for washing hands, or an especially dirty utensil would be washed in hot water. 

18. Small carpets on the floor at crucial places (like by your bed) keep you warmer and make you step back from using heaters a bit. Ditto by using blankets as ground covers on ALL SLEEPING AND SEATING SURFACES – beds and sofas. 


19. All computers are now switched off for the night as are spike busters connecting them to power sources. 

20. When we are getting up from our computers, we are more conscious to immediately put them to sleep while we are away. 

Use of Appliances

21. Having become more economical in our use of electricity, we now use the full capacity of an oven while baking rather than partially. For example, all shakarkandi (sweet potato) is baked together in larger quantitiy at a go. 

22. Washing Machines are ofcourse used only at full load. 

23. Hot things are not put inside the Fridge but allowed to come to room temperature before putting them in the fridge.

24. In summer, water from the fridge is mixed with normal temperature water in thermoses to get the right temperature for drinking water. The fridge does not have to be opened day long for drinking water then, thus conserving on electricity use.  

25. We are away from our home now and then, like most people. In the past, the fridge was left on when we were away. Now we plan in such a way that we try to consume the perishables, or take them with us to our home in another city. Milk packets are packed with ice in an ice box for travel to another city, and so on. However this cant be done for every trip.

Wednesday, June 23, 2021

Marriage in Harappan Times

At Harappa, there is evidence for matrilocality - where husbands go to live with their wives' community. 

Nearly all cemetery inhumations conform to a similar layout that is not readily differentiated into distinct social classes.

Joe Ravi, CC-BY-SA 3.0, Wikimedia
The skeletons found are generally healthy people which indicates an improved access to resources. A study found that the few burials that have been found (only 600 so far across hundreds of years of urbanized living across hundreds of settlements) may have related to first generation immigrants. These burials show they were respected and that mobility between villages and cities existed as also trade. 

A study from Farmana, in present day Haryana, showed trade links with present day Punjab in Pakistan, and Gujarat as well. There were signs of matrimonial linkages as well. 

More burials found at Rakhigarhi at Haryana have unearthed a man and a woman together, possibly in a matrimonial relationship. This may point to the earliest marriage (4700 years ago) for which evidence has been found. 

Uptill now historians believed the earliest marriage had taken place about 4400 years ago, in Mesopotamia. 

Historians believe that some of the beautiful painted jars found at various sites may have been used as marriage gifts. 

A bangle found at Susa in ancient Mesopotamia was made from materials found only along the Indus coast. Historians have speculated that 'it is possible that the woman wearing this bangle was part of a marriage alliance with a distant trading family in Susa. Such long distance marriage contracts can be documented historically and ethnographically. In the absence of strong state control, long distance kin relationships would have been a form of insurance in trade relations.'

Tuesday, June 22, 2021

A high degree of planning is evident in Indus Valley Cities' Infrastructure

Please note : the text following is from a variety of internet sources that i did not at the time bookmark. Nothing original below - just mix and match from various creditable historians. 

Terracotta pipes used for washing basins and manholes constructed by the Indus Valley people are still in good condition after nearly five thousand years.

Almost all houses in Mohen Jodaro had a bathroom, always constructed at the side of the building adjacent to the street for the convenient disposal of wastewater into the street drains. Latrines found in the houses were placed close to the street wall for the same reason. 

Ablution places were placed adjacent to the latrines, thus conforming to one of the most modern of sanitary maxims. Bathrooms and latrines situated on the second floor were drained using terracotta pipes with a fitting valve placed in the boundary wall of the building.

The street lights system, watch and ward arrangement at night to outwit the law breakers, specific places to throw rubbish and waste materials, public wells in every street, well in every house etc. revealed the high sense of engineering and town planning of the people.

The corners of the street rounded off perhaps to enable the heavy carts to take turn easily. The streets intersected in right angles and so arranged that the prevailing winds could work as a sort of suction pump and thereby clean the atmosphere automatically. 

No building was allowed to be constructed arbitrarily and encroaching upon a public highway. The owners of the pottery kilns were not allowed to build the furnaces within the town obviously to save the town from air pollution.

Devices known from Persia as “wind catchers” were attached to the roofs of some buildings which provided air conditioning for the home or administrative office.

All of thes Indus civilization cities had been pre-planned. Unlike those of other cultures which usually developed from smaller, rural communities, the cities of the Indus Valley Civilization had been thought out, a site chosen, and purposefully constructed prior to full habitation.  

Scholar John Keay comments: “Our overwhelming impression is of cultural uniformity, both throughout the several centuries during which the Harappan civilization flourished, and over the vast area it occupied.” 

The ubiquitous bricks, for instance, are all of standardized dimensions, just as the stone cubes used by the Harappans to measure weights are also standard and based on the modular system. Road widths conform to a similar module; thus, streets are typically twice the width of side lanes, while the main arteries are twice or one and a half times the width of streets. Most of the streets so far excavated are straight and run either north-south or east-west.

Monday, June 21, 2021

Villages in the Indus Valley

I have been reading on the Indus Valley Civilization for the last few years. I share highlights with friends and relatives on whatsapp. 

But perhaps they are not all interested in so much detail. So I decided to record some of my readings here. 

Read a study of four village sites of the Indus Valley (there are nearly 1100 of them spread over 1.5 million sq kms !). These village sites are in Haryana and Rajasthan. 

The study concluded that the villagers had access to high quality luxury goods in small nos. - articles made from gold, lapus lazuli, etc. Such items have been found at other village sites too. So these articles were not limited to the cities. 

Agate, lapis lazuli, gold and carnelian beads
 from two of the villages.
The study goes into details of the pottery that must have been produced in these villages. It found designs, materials and process different from that found in large cities, though related. This has been observed at other sites as well. So there was a trend for regional aesthetics and preferences. 

The study concluded that the villages were production centres for goods other than agriculture as well. They were not isolated from the cities but not totally dependent on them as well. 

Many such villages are also laid our in grid pattern with wide streets, public buildings and fortified walls. So size of the settlement did not limit the essential features of the indus valley civilization. 

Saturday, May 01, 2021

The Only Disease Eradicated in the History of Mankind has been a Virus !

Only one disease has been completely eradicated so far - small pox - caused by a virus !

What follows is the story of how humanity did it...

A Virus Humanity Won Over

In 10,000 BCE, a deadly new virus emerged in Northeast Africa, killing indiscriminately and causing a disease we now know as smallpox. 

Around 180 AD, Small pox killed an estimated 5.5 million people in the Roman Empire, including the Emperor, and hastened its decline.

Smallpox kept revisiting countries and continents periodically with global migration patterns : China in the 4th century, Europe in the 7th century - and continued to kill millions of people. Generations watched helplessly as their children succumbed to the disease or were disfigured or blinded by it. 

The Japanese smallpox epidemic of 735–737 is believed to have killed as much as one-third of Japan's population.

Between 1868 and 1907, there were approximately 4.7 million deaths from smallpox in India.

During the 20th century, it is estimated that smallpox was responsible for 300 million deaths worldwide.  For perspective, the flu is supposed to have killed a 100 million people in 2018-2020. 

In the early 1950s an estimated 50 million cases of smallpox occurred in the world each year. As recently as 1967, 15 million people contracted small pox and two million died from it that year.

For Centuries, Inoculation was the only cure for Small Pox

Inoculation was likely practiced in Africa, India, China and Turkey long before the 18th century, when it was introduced to Europe. In China, powdered smallpox scabs were blown up the noses of the healthy. People would then develop a mild case of the disease and from then on were immune to it. There are hints of the practice in China from the 10th century.

Inoculation referred to the subcutaneous instillation of smallpox virus into non-immune individuals. The inoculator usually used a lancet wet with fresh matter taken from a ripe pustule of some person who suffered from smallpox. The material was then subcutaneously introduced on the arms or legs of the non-immune person. 

There were problems with inoculation though – some percent of the people still died, and some developed syphilis or other disorders due to the contamination that occurred in the procedure. 

A self-taught inoculator from Scotland, Notions found success in treating people from at least the late 1780s through a method devised by himself, despite having no formal medical background. His method involved exposing smallpox pus to peat smoke, burying it in the ground with camphor for up to 8 years, and then inserting the matter into a person's skin using a knife, and covering the incision with a cabbage leaf. He was reputed not to have lost a single patient despite inoculating thousands.

Establishing the idea of Vaccination

Edward Jenner, an Englishman, was the first to demonstrate that vaccination offered a reliable defense against smallpox. It was also a reliable defense against other illnesses, such as poliomyelitis, measles, and tetanus, although this was not known in Jenner's lifetime. 

It was 1796 before Jenner made the first step in the long process whereby smallpox, the scourge of mankind, would be totally eradicated - he vaccinated a small boy against small pox. 

In those years and throughout history, small pox killed 30% of those it infected and left nearly all the rest of its victims disfigured, or blind, or both. Some of its variants killed 100% of those they infected. 

Although he received worldwide recognition and many honors, Jenner made no attempt to enrich himself through his discovery. He actually devoted so much time to the cause of vaccination that his private practice and his personal affairs suffered severely. 

But his efforts bore fruit and soon most countries in Europe and in Americas had taken up national vaccination programmes around the beginning of the 19th century.

Many scientific discoveries were needed  to make large scale vaccinations possible

Until the end of the 19th century, vaccination was performed either directly with vaccine produced on the skin of calves or, particularly in England, with vaccine obtained from the calf but then maintained by arm-to-arm transfer. 

At that time, an Englishman, Sydney Copeman, found that vaccine suspended in 50% chemically-pure glycerine and stored under controlled conditions contained very few "extraneous" bacteria and produced satisfactory vaccinations. All vaccinations supplied by the Government were subsequently from Copeman. 

In early 1950s, Leslie Collier, an English microbiologist developed a method for producing a heat-stable freeze-dried vaccine in powdered form. The dried vaccine was 100% effective when reconstituted after 6 months storage at 37 °C, allowing it to be transported to, and stored in, remote tropical areas.

Benjamin Rubin, an American microbiologist developed the bifurcated needle. Easy to use with minimum training, cheap to produce, using four times less vaccine than other methods, and repeatedly re-usable after flame sterilization, it was used globally.

The Final Push for Eradicating Small Pox

In Northern Europe a number of countries had eliminated smallpox by 1900, and by 1914, the incidence in most industrialized countries had decreased to comparatively low levels. In the 1950s, a number of control measures were implemented, and smallpox was completely eradicated in Europe and North America.  

The first hemisphere-wide effort to eradicate smallpox was made in 1950 by the Pan American Health Organization. The campaign was successful in eliminating smallpox from all countries of the Americas except four. 

In 1958 Professor Viktor Zhdanov, Deputy Minister of Health for the USSR, called on the World Health Assembly to undertake a global initiative to eradicate smallpox. At this point, 2 million people were dying from smallpox every year. Overall, the progress towards eradication was disappointing, especially in Africa and in the Indian subcontinent. 

In 1966 an international team, the Smallpox Eradication Unit, was formed under the leadership of an American, Donald Henderson, who was trained at the CDC. In 1967, the World Health Organization intensified the global smallpox eradication effort. Under Henderson’s leadership, the WHO established a network of consultants who assisted countries in setting up surveillance and containment activities, which were as crucial as vaccination in containing small pox. 

Early on, donations of vaccine were provided primarily by the Soviet Union and the United States, but by 1973, more than 80 percent of all vaccine was produced in developing countries.

Victory – after 3500 years of the first proven disease case !

After two years of intensive searches, what proved to be the last endemic case anywhere in the world occurred in Somalia, in October 1977. A Global Commission for the Certification of Smallpox Eradication chaired by Frank Fenner examined the evidence from, and visited where necessary, all countries where smallpox had been endemic. In December 1979 they concluded that smallpox had been eradicated.

On May 8, 1980, the World Health Assembly announced that the world was free of smallpox and recommended that all countries cease vaccination: 

“The world and all its people have won freedom from smallpox, which was the most devastating disease sweeping in epidemic form through many countries since earliest times, leaving death, blindness and disfigurement in its wake”.

The cost of the eradication effort, from 1967 to 1979, was roughly $300 million US dollars. Roughly a third came from the developed world, which had largely eradicated smallpox decades earlier. The United States, the largest contributor to the program, has reportedly recouped that investment every 26 days since in money not spent on (a) vaccinations and (b) the costs of incidence. 

Thursday, April 29, 2021

Awake Proning to help with Oxygen Saturation

Patients on mechanical ventilation are known to halve their mortality by being administered proning positions (lying on your stomach, on your side, sitting up or walking about - but not lying on your back {supine position} or very little). 

But not many studies had been done for awake non-intubated patients in regard to proning, whether done by self or in hospital settings. 

However such studies have gathered pace during the Covid-19 pandemic. 18 such studies are summarized below. 

In one study in Nebraska, USA, after patients were educated on the benefits of awake self-proning, compliance was voluntary. The risk of intubation was lower in proned patients after adjusting for disease severity. No prone patient died compared with 24.6% of patients who were not prone.

Conclusions: Awake self-proning was associated with lower mortality and intubation rates in coronavirus disease 2019-infected patients. Prone positioning appears to be a safe and inexpensive strategy to improve outcomes and spare limited resources.

As the pandemic progresses, scarce resources (e.g., ICU beds and mechanical ventilators) may become a rate-limiting factor in the care for these patients. Therefore, therapies to prevent the need for intubation and mechanical ventilation are desperately needed.

We hypothesized that patients with COVID-19 and respiratory distress, not yet intubated but at high risk for intubation, might benefit from prone positioning. 

Ten adult patients at an academic medical center with confirmed positive PCR testing results, with rapidly increasing oxygen requirements necessitating ICU admission but not yet requiring intubation, were determined to be appropriate clinical candidates for proning.

Patients were asked to alternate every 2 hours between a prone and supine (lying on your back) position during the day and sleep in a prone position at night, as tolerated.

Oxygenation rapidly improved after prone positioning, and at 1 hour after assuming a prone position, median oxygen saturations had increased from 94% to 98%.

After prone positioning, work of breathing had improved, as evidenced by a reduced median respiratory rate from 31 to 22 breaths/min.

Eight of the 10 patients did not require intubation (being put on mechanical ventilator).

At 28 days of follow-up, all patients had been discharged from the hospital to their homes.

We enrolled 56 patients for a study in Italy. Prone positioning was feasible (i.e., maintained for at least 3 h) in 47 patients. It was effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients.

Among 29 eligible patients in New York, 25 had at least 1 awake session of the prone position lasting longer than 1 hour; 4 refused the prone position and were intubated immediately. 

We found that the use of the prone position for awake, spontaneously breathing patients with COVID-19 severe hypoxemic respiratory failure was associated with improved oxygenation. In addition, patients with an Spo2 of 95% or greater after 1 hour of the prone position was associated with a lower rate of intubation.

Many critical hypoxemic patients were treated in wards in a Paris hospital due to lack of intensive care units bed availability. 

Twenty-seven patients were included in a study - confirmed Covid-19 hypoxemic patients who benefited from at least one prone position were included. Eighteen patients were responders (defined as an improvement of SpO2/FiO2 of more than 50) during the first posture and have a shorter length of hospital stay than non-responder patients. 

Our study found that prone position in wards improved alveolar exchange during posture and is well tolerated. However, oxygenation improvement did not seem to persist when the position was stopped.

Elharrar et al. have yet ascertained that only 25% were responders (had sustained improvements) to prone position.

On the other hand, Sartini et al. found that 12 of 15 patients had persistent oxygenation improvement after the posture’s end.

In a London hospital, forty eight of 138 patients managed outside of a critical care unit with facemask oxygen, high flow nasal oxygen or continuous positive airway pressure, underwent prone positions. 

Prone position was associated with significant improvement in oxygenation, lower ICU admission, tracheal intubation, and shorter ICU length of stay. Lack of response to PP may be an indicator of treatment failure, requiring early escalation.

The main outcome reported was that prone positioning improved P/F ratio from 17.9 to 28.2 kPa after 81 average min across 36 subjects, of which 26 had a response of ≥20%. Results from 32 subjects indicate that the response persisted on return to supine. 

In the current report, death or progression to extracorporeal membrane oxygenation was more frequent in those displaying a diminished response to further prone manoeuvres.

Six relevant studies, including an observational cohort study with 50 patients, and five case series with 53 patients were identified. All studies included, noted improved clinical symptoms after proning. In Elharrar et al., Caputo et al., and Paul et al., improved oxygen saturation of 20%, 10%, and 6% respectively from the baseline is observed. 

Additionally, in Paul et al. study, FiO2 requirements were titrated from 0.8 to 0.4 within one hour of proning. In the studies of Sartini et al. and Sztajnbok et al. PaO2: FiO2 was noticed to improve. 

In patients who underwent awake proning, it was noticed that only 13/50 (26%) in Caputo et al., 1/15 (6.7%) in Sartini et al., and 5/ 24 (20.8%) in Elharrar et al. studies needed mechanical ventilation. 

Similar results of reduced need for mechanical ventilation and improved oxygenation were found in Ng et al. study.

A total of 45 subjects were included (30 cases and 15 controls). The median duration of prone positions achieved was 7.5 h on the 1st day. 

The need for mechanical ventilation was higher in the control group (5/15; 33.3%) versus prone group (2/30; 6.7%). 

At 30 min, there was a statistically significant improvement in the mean ROX index of cases compared with that of the controls. 

No significant adverse effects related to intervention were noted.;year=2021;volume=38;issue=7;spage=6;epage=10;aulast=Sryma

An area of current study is the use of proning in awake, spontaneously breathing COVID-19 patients with respiratory failure outside of the ICU in an attempt to prevent escalation to intubation and mechanical ventilation. 

In one study, 50 patients with mild to moderate ARDS from COVID-19 requiring oxygen therapy outside of the ICU were treated with a protocol of prone positioning three times per day for 30-60 minutes alternating with supine positioning. 

Prone positioning was associated with significant increases in oxygenation during proning and after returning to the supine position as well. 

At 45-day follow-up, there were two deaths out of the 50 study subjects, seven patients required ICU admission, and 41 patients had been discharged from the hospital.

Awake proning is a practice that was adopted early in the pandemic as a means to avoid, or at least delay, endotracheal intubation to lessen the burden of ICU care.  

2994 patients were included in a systematic review and meta-analysis of observational trials comparing in-hospital intubation and mortality rates in patients treated with awake proning vs standard care.

27% of the Awake Prone needed intubation eventually, vs. 30% in Standard Care.

 11%  of the patients in the Awake Prone trials died eventually, vs. 22% in standard care.

Awake proning was associated with significant improvement of oxygenation parameters

Some studies showed this was sustained after patients returning to supine position. One study each showed that 50% of patients retained improved oxygenation after returning to supine position; and the other study said improvement was lost after returning to supine position.

A prospective study of 30 COVID patients admitted in our Hospital critical care isolation. Awake prone positioning and non-invasive ventilation showed marked improvement in SaO2 and PaO2 in COVID-19 patients with improvement in clinical symptoms with reduced rate of intubation with superiority of non invasive ventilation.

In the absence of effective targeted therapies for COVID-19, optimisation of supportive care is essential. Lung injury with features of acute respiratory distress syndrome (ARDS) appears to be the principal characteristic of severe acute respiratory syndrome coronavirus 2 infection. Recent guidance by the UK Intensive Care Society advocates awake prone positioning to become standard of care for suspected or confirmed COVID-19.

Valter et al applied prone positioning to four patients with indications for mechanical ventilation and found rapid improvements in PaO2—all patients avoided mechanical ventilation  and tolerated prone positioning well. 

In an observational study of 15 patients receiving non-invasive respiratory support for acute hypoxaemic respiratory failure, repeated prone positioning led to transient but substantial improvements in oxygenation. 

In a prospective observational study of 20 patients receiving non-invasive ventilation for moderate-to-severe ARDS, PaO2/FiO2 ratio increased by 25–35 mm Hg following awake prone positioning; but 78% of participants with severe ARDS eventually required mechanical ventilation (MV), and therefore awake prone positioning should not delay the use of MV when indicated.

In summary, awake prone positioning appears to be safe and may slow the respiratory deterioration in select patients with COVID-19, who require oxygen supplementation or NIV/CPAP. This in turn may reduce demand for MV, easing the strain placed on intensive care services around the world.

27 patients with confirmed COVID-19 pneumonia admitted to a Switzerland Hospital were included in the study. 10 patients were randomised to self-prone positioning and 17 to usual care.

 Self-prone positioning was easy to implement. Self-prone positioning in patients with COVID-19 pneumonia requiring low-flow oxygen therapy resulted in a clinically meaningful reduction of oxygen flow, but without reaching statistical significance.

In a study of 25 patients with COVID-19 and hypoxemic respiratory failure managed outside the ICU in France, 63% were able to tolerate prone position for more than 3 hours. However, oxygenation increased during prone position in only 25% and was not sustained in half of those after resupination.

27 spontaneously breathing adults with COVID‐19 admitted to Austin Hospital in Australia were selected for a study.

Twenty (74%) patients received proning at least once, six (22%) never received proning despite clinical indication (e.g. refused) and for one patient proning was documented but no data were available.

For the patients who received proning, the median number of treatments per patient was three, and their duration was 105 minutes.

In summary, in spontaneously breathing patients with COVID‐19, on an analysis of close to 100 treatments, we found no evidence of reproducible response to proning and no relationship between the effect of proning on first treatment with subsequent treatments.

Infection with SARS-CoV-2 can result in Coronavirus Disease–19 (COVID-19). While the majority of patients are asymptomatic or have mild disease, approximately 14% develop more severe disease including hypoxemic respiratory failure and/or Acute Respiratory Distress Syndrome (ARDS). A synthesis of 35 studies (414 patients) was carried out, that examined the use of awake prone positioning for non-intubated patients with hypoxemic respiratory failure.

The duration of prone positioning sessions varied from <1 h to >18 h and was not reported in three studies. All studies demonstrated improvements in oxygenation while patients were in the prone position except one. When reported, improvements in oxygenation were generally not sustained after returning to the supine position except in two studies in which patients were receiving NIV (Non-Invasive Ventilation assists breathing by supplying a mixture of air and oxygen using positive pressure to help the patient to take deeper breaths). One hundred twenty-one patients (29%) of the 414 patients required invasive mechanical ventilation. Adverse events were variably reported and included 42 deaths among the 414 patients (10.1% of all patients).

In summary, although awake prone positioning may be a promising therapy for patients with hypoxemic respiratory failure (including those with COVID-19), the supporting evidence is limited to case reports and cohort studies.

60 patients diagnosed with acute hypoxic respiratory failure secondary to COVID 19 pneumonia requiring 4 or more litres of oxygen to maintain a saturation of  92% were recruited in this study. 

Thirty patients each were randomised to either standard care or awake prone group. Patients randomised to the standard care were allowed to change their position as per comfort and patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day.

In the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. The median maximum prone duration per session was 2 hours. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the two groups and there were no adverse events.

Monday, March 08, 2021

Dunkirk !

 I am watching a week by week recreation of WW2

In week 44, June 1940, Nazi Germany had overrun most of Europe, and USSR had annexed Eastern European countries.

The Netherlands and Belgium had surrendered to the Nazis in May, and France in June.

Dunkirk: 9 Lesser-Known Facts - HistoryExtra
Allied forces were beaten back to Dunkirk in France, just across the English Channel from Britain. To prevent their capture by the Nazis, a desperate operation was launched to rescue them via sea to take them back to England.

2 lakh british and 1.4 lakh mainly french soliders were rescued, but 0.8 lakh were left behind in Dunkirk (half of them British and the other half French) to hold off the Nazis while their compatriots escaped.

But all the equipment had to be left behind, desperately needed by Britain which now faced the Nazi war machine alone. The US had refused to be drawn in the war, despite British requests. 

The operation commenced after large numbers of BelgianBritish, and French troops were cut off and surrounded by German troops during the six-week Battle of France.

Winston Churchill, Britain's Prime Minister during World War II, called Dunkirk a "miracle of deliverance".

Initially it was thought the Germans would reach the beach within two days, allowing time for only 45,000 troops to be brought to safety.

But thanks to a combination of German confusion and Allied bravery, enough British and French troops were saved to see out the rest of the war.

After Nazi Germany invaded Poland in 1939, the British sent in troops to defend France. However, as Nazi Germany moved forward into Belgium and the Netherlands in May 1940, the allies made a near-fatal error.

The French-German border was defended by a series of barriers and weapons called the Maginot Line, but the area to the north was only blocked by a forest.

The forest was thought to be too thick to require heavy defence, but the Germans found a way through.

They marched around the back of the Allies in France and forced them over into Belgium, where they were faced with more Germans to the north.

The only option left was to retreat to Dunkirk, where they could be taken back to England.

With the majority of Britain and France's entire armies in one area - surrounded by the Germans - this could have been the turning point of the war. But Hitler ordered his troops to halt for three days. Attacking the trapped BEF, French, and Belgian armies was left to the Luftwaffe - Germany's air force. 

Evacuations from Dunkirk commenced on 26th May 1940, while 40,000 men of the French First Army fought a delaying action against seven German divisions.

The Allies were gifted with time. Naval ships, vehicles, passenger ferries, fishing boats, yachts and boats owned simply for pleasure were assembled.

A handful of civilians even joined the mission, sailing out into the Channel voluntarily.

Over the course of nine days this fleet, supported by British planes overhead, was able to rescue most of the troops.