FEATURE

What is normal blood pressure?

Prof. B. M. Hegde,

hegdebm@gmail.com

“When people cheat in any arena, they diminish themselves-they threaten their own self-esteem and their relationships with others by undermining the trust they have in their ability to succeed and in their ability to be true.”

Cheryl Hughes

I have been wondering about this normal blood pressure for the last sixty years ever since I joined the I MBBS class in 1956. In the physiology class I was wondering what this normal blood pressure was and how did they find out the normal level in the first place? My teacher was not able to answer that to my satisfaction although she did not like my interference. Luckily those days the normal levels were much higher than now. I grew up in medicine and at some stage became a member of the International Society of Hypertension and met some of the “top” hypertensionologists to rub shoulders with them on an equal footing. None of them could quench my thirst. In the meantime I was doing my own research (no money or grant involved) and have published some of them since. I have also written a book on hypertension in 1996 published by the Bhavan in Mumbai with a foreword by one of the leading lights in the field, Barry Hoffbrand, the then editor of the British Postgraduate Medical Journal.

Here I stand O fool! With all my lore, no wiser than before about this enigma called normal blood pressure. Last month came another thunderbolt of a study (so called) proclaiming to the wide world that even “Normal” blood pressure needs to be treated with antihypertensive drugs to lower CVS and CNS mortalities and morbidities! On this side of the Atlantic an ethnic Indian researcher was presenting a paper in the European Hypertension Society meeting, another study which shouts at the top voice that a deadly combination of hypertension and depression kills millions in this world due to heart and brain attacks. He stressed that both must be vigorously hounded out of the human system to reduce heart and brain attacks! With this new study from Oxford of the need to treat even normal blood pressure I realise that I have been searching for a non-existent normal blood pressurewhich does not matter after all!

This brings back to mind that famous saying of a great teacher of hypertension, Professor Sir George Pickering’s tongue in cheek averment “More people in this world make a living “off” hypertension than dying “of” it. How very true? More curious am I about this drug treatment of depression along with hypertension to lower mortality. The human mind which gets depressed is not inside the human brain. Our reductionist chemical drugs that claim to treat depression ONLY act on the brain, provoking suicidal tendencies and cannot obviously do anything for the unhappy mind. None of the anti-depressants have been shown to be better than a placebo!I was reading some of the original comments on the (in) famous Oxford study of the need to treat even normal BP. Some of them are here for the reader’s benefit.

“Could our relentless pursuit of good health be making us sick? Advances in medicine have propelled health care to new heights and a vast array of diagnostic tests and drug therapies is now available. But are we getting too much of a good thing?” Australian TV comment.

“When I was a medical student, we used to define a normal blood pressure as being under 100 plus the person's age for the top number and 100 for the bottom number. Nowadays, it's 150/90, or if you're diabetic or you're worried about prehypertension, it's even as low as 140/80. By changing that threshold, you include millions more people in the range of abnormality and in the market for antihypertensive medication.This has raised questions about whether people with mild hypertension would benefit from blood-pressure medication. A Cochrane Review showed that most people with mild hypertension don't.The treatment of mild hypertension has had no benefit on either morbidity or mortality. That makes up the vast majority of people worldwide on treatment for hypertension.”Ion Heath.

“I feel it’s pretty arrogant to be so sure of the results of a partially completed study that it can be cut short!!!?? Finish the damn study!! This why studies are NOT reliable, they are not finished, or info was manipulated or lost or some self-appointed untrained or money oriented person starts making treatments up. Usually there’s some pharmaceutical company behind the studies….unless someone is saying to eat vegetables….and you can’t patent that!”

“I smell a rat with this.The renormalisation of medical metrics has been going on since drug companies began trying to increase sales of medications.It’s happened for cholesterol drugs, antidepressants and now blood pressure.What is normal,anyway?It seems we are less normal than we used to be - including the medical profession.”

Coming back to our original study from Oxford which proclaimed that treating normal blood pressure with antihypertensive drugs is good to save millions of lives I have several nagging questions. Incidentally, the study is published in the Lancet. It is retrospective meta-analysis of all studies done from 1953 till 2014. Obviously this is what statisticians call the Mix Master technique. It is like putting all kinds of fruits in a basket and blindly putting your hand in to pick one fruit to be shown as the representative of all the fruits in the basket. This is otherwise called “doctoring or sexing up” studies to suit your conclusions to benefit your master, who has funded you. If the conclusions of this study are acted upon drug companies will be richer by a thousand times.

Each one of the studies included in this meta-analysis has its own NNT (number needed to treat) and its own side effect profile. To give one example, the famous MRC study of mild to moderate hypertension published in the BMJ in 1985 has NNT of 850. That is to benefit one individual from stroke in the next five years one has to unnecessarily treat 850 healthy individuals with drugs which might have significant side effect in 75 individuals! Many such studies are included in this “great “study to make it in essence a company paid effort to get millions more to qualify to take antihypertensive drugs. What a way to “scientifically” increase your profits? While the company executives might laugh all the way to their banks, many orphans and widows might be grieving in the cemetery! I smell a rat here.

Would anyone tell me what is normal BP anyway. I know the average human BP but not the NORMAL BP. If one converts averages into normals we are straight away adding between 5-25% false positives, another profitable business. RCTs, the multiple studies that form the basis of this conclusion, themselves, have been seriously questioned for their authenticity. What is this circus all about? If blood is flowing laminarly inside the blood vessels, naturally it cannot exert any lateral pressure as Co Sine 90 is zero. So, what is Blood pressure?

“Recognition should come to the reporter who uncovers public cheating or proves a convicted man innocent.”   Phil Donahue

EMPOWERING A MILLION LIVES

Kavitha Srinivasa

The Swades Foundation, founded by Ronnie and Zarina Screwvala , works with a single-minded focus to create a lasting change in rural India, adding to India’s growth story.

When UTV founders, Ronnie and Zarina Screwvala, divested their stake to the Walt Disney Company in January 2012, they found themselves at interesting crossroads. While Ronnie went on to lead the Disney- UTV combined entity in India as its Managing Director, Zarina sought new challenges.

Toying with different ideas she enrolled herself in a philosophy class. While entering class one day, she read a quote by Lao Tsu, “When you let go of who you are, you become what you might be.” She recalls this as one of the most defining moments of her life. Zarina had almost signed up permanently lifting a million people out of poverty, Zarina knew in her heart, that this seemingly impossible task was her calling. She quit UTV and joined their foundation, then known as SHARE and together they embarked on their mission of rural transformation, of creating an India where the urban and rural divide does not exist. 

“We are not naïve about the task we’ve set, but we are determined to create communities that will have the ability to contribute substantially to India’s growth story,” says Ronnie Screwvala, Founder Trustee, Swades Foundation.

As they embarked upon the Swades Journey, the couple travelled the length and breadth of the country and even abroad to learn first-hand from the phenomenal work that others were doing. Ronnie and Zarina then poured in all their learnings from nine months of extensive travels to create a model of development which is both scalable and easy to replicate. “We realized poverty is both mental and material and there is no silver bullet to ending poverty. We truly believe our 360 degree model with interventions  across the five  critical areas of Health & Nutrition, Water & Sanitation, Agriculture & Livelihood, Community Mobilization and education will enable us to achieve our dream”, says Zarina Screwvala, Founder and Managing Trustee, the Swades Foundation.

The Foundation operates with a unique strategy: Engage, Execute, Empower and Exit. It engages rural communities with corporate, young urban India, not-for-profit organizations and Governments, to execute programmes that empower communities to transform their own lives, enabling the Foundation to exit.

“We don’t want to be around for too long as we feel that the rural people should empower themselves through sustainable livelihood,” explains Zarina.

We take a large geographical area, study it thoroughly, and work out multiple solutions within that geography at the household level; our dream is to create a model of rural transformation for others to follow,” says Zarina. “In three years, we have grown from a staff of 25 people to 300 full time and 1,200 paid community volunteers and a reach of 39,000 people to 471,000 people! “She adds.

THE JOURNEY FROM SHARE TO SWADES

SHARE (Society to Heal Aid Restore Educate)- Ronnie and Zarina’s first steps into philanthropy- began by providing training and employment opportunities for young mentally challenged adults through sheltered workshops in the Dharavi and Chembur areas of Mumbai. Since the past two decades SHARE has been working in the Raigad region of Maharashtra. “Around ten years ago when we went into the village of Raigad we thought the education of the girl child was a crucial factor. While it is still true, we also found that water is the most crucial factor. Since then we have been working towards making drinking water available for all,” remembered Zarina.

Working closely in the area of water & Sanitation projects, SHARE has directly and positively impacted the lives of over 39,000 villagers, created 111 farmers groups, 276 Women’s Self Help Groups, 574 Water Harvesting Projects and 1,400 sanitation blocks.

“Our greatest victory in our years as SHARE is building trust with our community members in the villages of Raigad. They recognized us as a Foundation that truly worked for their benefit, towards their empowerment. When we decided to ramp up our operations, it made perfect sense to stay in this geography as we knew we’ll move ahead in our journey with the priceless asset of trust,’ says Praveen Aggarwal, Chief Operating Officer, Swades Foundation, explaining the choice of Raigad as the launch pad for the Foundation’s transformational activities.

The average annual household income in these six blocks of Raigad is Rs.25,000/-. The goal is to increase this to Rs. 2 lakh per household per year, through the Foundation’s unique strategy and holistic approach.

Zarina reminisces the Eureka moment which led to the rebranding of their Foundation. “We were having a casual conversation with a few Harvard students at our home one day when Ronnie shared our dream of empowering a million lives in rural India. One of the students matter-of-factly said that it sounded like the movie Swades, which we had produced in 2004. We instantly knew that no better name could embody our vision, our dream… The ‘Swa’ in our name reflects ‘empowered self’ forming the core of everything we do.”  

HEALTH SOLUTIONS

During a routine visit to the anganwadis, Zarina found that most children were anemic and stunted though the anganawadi workers were regularly providing nutritious food and heath supplements like tonics to them. Upon probing further, it was found that the tonic was bitter to taste and the children refused to drink it. A pediatrician was consulted and the bitter tonic was replaced by a sweet syrupy one. Naturally, it brought a smile to the children’s faces. Healthy children are happy children! “What’s key is to understand your consumer. We have brought this learning of ours from the media space into philanthropy and it works like magic. We don’t always need complicated solutions, sometimes simple solutions can last a lifetime,” points out Zarina.

In the Foundation’s Health & Nutrition vertical, another key achievement has been the training of 1,156 Swa Raksha Mitras (SRMs), community health workers covering 471,000 people. “With only 6.5 doctors per 10,000 Indians, frontline health workers with paramedical training can make life-changing impact on health and hygiene. We train Class VII pass women from the community and put them through rigorous training on health and life skills,” says Zarina.

The foundation has also screened over one lakh people and provided close to 15,000 high quality spectacles and carried out over 2,000 free cataract surgeries through the Mobile Medical Unit. There are plans to conduct 70,000 such surgeries in the next five years.

FIELDING THE FARMER

As the Foundation expanded its work to the Agriculture and Livelihood vertical, many lives improved. Like that of Chandrakant Pawar, who co-incidentally reminds us of Mohan Bhagwat, a character portrayed by Shah Rukh Khan in the film Swades. Just as Mohan relocates from USA to his village to use his education and skills to improve the lives of villagers, Chandrakant has found it more satisfying to work in his village. A diploma holder in agriculture, Chandrakant came to Mumbai in search of a job but city life took its toll on him. Things changed when he enrolled for the Swades Training Programmes. He became a farmer by choice, migrated to Pashti village and managed to turn two acres of barren land into a patch of green through multiple agriculture techniques. He’s now a role model in his village and promotes agriculture as a lucrative career option. He dreams of teaching every child the joy of farming and hopes to start a wave of reverse migration.

The Foundation has worked with 12,000 farmers, training them on new farming technologies that enhance their yield at low costs and turn their small farms into lucrative businesses. Farmers follow the System of Rice Intensification (SRI) methodology whereby the management of plants, soil, water and nutrients help increase productivity. Around 1,400 farmers have successfully adopted this technique, which will extend to 4,500 farmers by March 2016. In the next five years, the programme will encompass 100,000 farmers. As an income generating effort, over 14,000 trees including high value cash crops like mango and cashew have been grafted and 35,000 new plants for horticulture have been distributed. Besides farming, cattle breeding and dairying are also being promoted.

SANITATION FOR SURVIVAL

The Foundation is a catalyst in most service including sanitation and undertakes various initiatives to aid community members overcome the sanitation barriers. One key initiative is a SwachhtaRath, a toilet prototype mounted on a vehicle that goes from hamlet to hamlet motivating people to end open defecation and adopt good sanitation practices. Over 45 days, the rathas travelled to 2,000 villages in the six blocks. Actual toilets were also constructed in public places so that people could use them and get accustomed to them.

While interacting with the villagers, the Foundation realized that they were not motivated to use sub-standard or make shift-toilets. This insight led to the building of aspirational toilets that are bigger in size, with tiled walls, proper doors and ceiling. This ensured over 99% usage.

Till date, the Foundation has built 3,240 toilets and will complete building 8,000 personal toilets this year, impacting more than 40,000 people. To put it in Ronnie Screwvala’s words, “We have buy-in for each service. For the toilets and sanitation, we’re paying a certain percent, the villages are paying a certain amount, and there is a grant that’s covering the remaining part of the cost. The locals have their skin in the game.” Each household contributes Rs. 4,500- 5,000 towards the construction of the toilet and takes part in the construction activity in the form of Shramadan.

Besides that, Swades Foundation has brought sufficient potable drinking water through taps every rural household by creating 751 water structures, thereby impacting 86,169 villagers. This year, 509 water structures are being built to impact 1,00,118 individuals.

EDUCATION YES, BUT IT MUST EMPOWER YOU TO FULFIL YOUR DREAMS!

The Swades Foundation believes in a joyful, empowering education focused on enhancing livelihood and creating socially and environmentally conscious citizen who are catalysts for change. They are convinced that a good education broadens horizons and creates choices for the child to achieve her/his dreams.

The Foundation has undertaken various unique and innovative initiatives to achieve their goal. While career counseling might not be a mandate in city schools, the Swades Foundation makes sure that all their students in the rural community undergo this process. “We ask children what they want to be and not what their parents want them to be. We allow them to think and orient them towards their career choices,” said Zarina.

Swades Foundation has built around 469 libraries in primary and secondary schools. Every school also has a Library Management Committee managed by the students.

Teaching too has been redefined; rote teaching is replaced by joyous teaching. Teachers are encouraged to think critically, and they undergo training in classroom management and positive discipline. Till date 2,000 such teachers have been trained. With this, teaching becomes enjoyable, and the experience is enhanced by math kits, learning kits and well stacked libraries housed in the Community Learning & Resource Centres (CLRC). Computer literacy and English literacy help well equip students.

Around 1,900 bicycles have been distributed to students who live five kms away from schools, while 1,000 deserving the students have been given scholarships. For senior students, the Foundation provides linkages to higher education, and wherever required, career counseling and vocational training are made available. The Foundation has already reached out to 37,000 students and plans to impact 200,000 students in the next five years.

PHILANTHROPY TAKES AN ENTERPRENEURIAL ROUTE

To a large extent, the Foundation owes its success to Community Mobilization, with community acting as catalysts of change, empowering people and orienting them towards livelihood programmes. Social Workers are in charge of 10 Gram Panchayats. They create awareness about cleanliness and hygiene in the village across all blocks.

Additionally, social workers create empowered institution like Self Help Groups (SHGs) in every village. To make its members self-reliant, SHGs have been linked to banks, government programmes and NGOs. The Foundation has strengthened 1,681 SHGs till date, and the agenda for the next five years is to create 11,830 SHGs.

In order to train local talent, the Foundation signed a Memorandum of Understanding (MoU) with IL&FS for providing vocational training and employment to 10,000 youth in the next four years. Likewise, a MoU with ICICI Foundation has been signed for skills training for unemployed youth. The aim is to train 3,000 youth over three years, creating an employment opportunity of Rs 1 lakh per individual.

White collar jobs have also been provided through a rural BPO. In the coming months, an entrepreneur cell will be launched in colleges in the six blocks Swades works in, to motivate students to re-migrate to the villages. The villages too are slated for a new look as initiatives like eradication of plastic-bags and other environment friendly projects are being introduced.

Focusing on women empowerment and gender sensitization, the Foundation has tailored Livelihood Programmes whereby uneducated people including women earn an income. A plan has been chalked out to create 10,000 Rural Entrepreneurs in cashew-processing, mushroom-farming, backyard poultry, stitching and agarabatti-making, of which nearly 40 percent will be women. These entrepreneurs are already undergoing training through a pilot project. The target is to clock revenues of Rs 50 crore by 2015-16, and then scale it up to Rs. 165 crore three years later. Through these programmes, the Foundation hopes to guide philanthropy in India towards an entrepreneurship-led model.

Already many have learnt the craft of the business. Take the case of Sharmila Jadhav from Faouji Ambawade village, where most men work in the army. With just seventh standard education and three daughters to take care of, Sharmila had no choice but to wait for her husband to send her money to run the family and pay for the children’s education. She decided to start a small business and approached the Foundation team who guided her to start a poultry business. She began with 100 chickens and expanded it to 400. Sharmila aims to be a poultry farmer, brand her business and improve the infrastructure. 

SWADES, THE WAY AHEAD

With a Rs 100 crore budget annually, Swades Foundation has been expanding circles of access and connects with the rural communities through a team of 300 full-time staffers, apart from 1,300 volunteers and numerous partner organizations working on projects ranging from drinking water to education to health, Swades Foundation touches 500,000 people’s live every day in multiple ways. Let’s hope in the next five years, Swades Foundation impacts one million rural lives and sets an example through its model scalable villages for others to emulate.