Pakistan Council of Research in Water Resources (PCRWR) has declared 12 mineral water brands in the country as unsafe for human consumption.
According to the monitoring report of PCRWR, samples of 108 mineral water brands were gathered from the markets of Islamabad, Karachi, Peshawar, Quetta, Gilgit, Muzaffarabad, Lahore, Faisalabad, Multan, Sialkot, and Tando Jam.
After testing all the samples against 24 water quality parameters, 12 brands turned out to be chemically unsafe which do not meet the standards set by the World Health Organization (WHO), International Bottled Water Association (IBWA), and Pakistan Standards and Quality Control Authority (PSQCA).
Following are the mineral water brands which have been declared unsafe by the PCRWR.
Alpha 7 star
Ziran, MM Pure, Blue Spring, Aqua Best, Blue Plus, Alpha 7 star, YK Pure, Leven Star, and Hibba contain exceedingly high quantities of sodium that is causing hypertension in public.
MM Pure and Blue Spring also contain high proportions of Total Dissolved Solids (TDS) which can result in cholera, diarrhea, dysentery, hepatitis, and typhoid while Chenab has a pH level of less than 6.5.
Meanwhile, Dista Water and DJOUR have bacteriological constituents greater than the safe and acceptable limit that is 0/100 ml, making both the brands microbiologically unsafe for drinking as well.
outlier — and not in a good way — with more than 2.5 million cases and 125,000 deaths, or about 36 deaths per 100,000 people. One of the strongest performers is Taiwan, with 446 confirmed cases and just seven deaths for nearly 24 million citizens, or 0.03 deaths per 100,000. On a per capita basis, the U.S. has 1,200 times as many Covid-19 deaths as Taiwan.
Lost in the fractious and frankly broken conversation about reopening the economy is a simple truism: containing the virus is the best fiscal stimulus. The U.S. Congressional Budget Office is projecting double-digit contractions in the gross domestic product for 2020 and unemployment rates going up to 16% this year — the highest they have been since the Great Depression. By comparison, Taiwan’s central bank expects growth to slow to about 1.5% for the year, and unemployment has “surged” to 4.1%.
To get the economy moving again, we need a functioning health care system.
A lot can be learned about handling a pandemic — and its aftermath — by looking at the health care systems in other countries. Over the past few years, we have been studying 11 countries to write a book titled, “Which Country has the World’s Best Health Care?” Taiwan was one of the countries we studied, and its successful response to Covid-19 was not a matter of luck. It was the result of careful planning and digital innovation, which the U.S. must learn from.
Taiwan could easily have had a Covid-19 disaster. It is situated less than 100 miles from China, and more than 1 million Taiwanese work in China. There is frequent travel between the two countries. As a result, Taiwan is at high risk of exposure to any novel infection that arises in China. So why didn’t it get slammed by SARS-Cov-2?
Some of the success is due to accidents of history, including the outbreak of severe acute respiratory syndrome (SARS) that began in February 2003. It generated a culture of taking infections from China seriously — unlike what happened in the U.S. The island also has a strong “face mask” culture, which the U.S. should be emulating, but isn’t.
Perhaps the most important element is Taiwan’s deliberate, systematic use of its digital health infrastructure.
The key to avoiding massive, economically ruinous lockdowns is effective testing, isolation, and contact tracing to control viral spread. Taiwan’s innovative electronic health records system made possible the country’s swift, targeted response to Covid-19. Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one.
Every person in Taiwan has a health card with a unique ID that all doctors and hospitals use to access online medical records. Providers use the card to document care episodes for reimbursement from the Ministry of Health. As a result, the card gives the ministry regular, nearly real-time data on physician and hospital visits and use of specific services.
With that data, the ministry can modify payments to reflect utilization. If physicians collectively have more office visits than anticipated or are ordering more MRI scans than budgeted, payments per service are reduced quarterly to reflect the overuse. This payment-adjustment mechanism allows the country to adhere to its annual health care budget and return information to physicians on aggregate and individual resource utilization.
When Covid-19 hit, the health card and electronic health records system were repurposed to fight the spread of the virus.
The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having Covid-19 based on their travel history. Utilization data was also employed to identify candidates for Covid-19 testing when supplies were limited. As researchers reported in the Journal of the American Medical Association, “Taiwan enhanced Covid-19 case finding by proactively seeking out patients with severe respiratory symptoms (based on information from the National Health Insurance [NHI] database) who had tested negative for influenza and retested them for Covid-19.” The availability of almost immediate data on patient visits allowed the country to efficiently identify, test, trace, and isolate cases. This has dramatically reduced Covid-19 spread without the need for extensive lockdowns.
No other country we studied had a comparably effective real-time electronic health record system, including the U.S. The U.S. has come a long with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The percentage of office-based physicians who use these systems has grown from 48% in 2009 to 86% today. They are nearly universal in hospitals as well, with utilization now at 96%.
But sharing the data — so-called interoperability between different electronic health record vendors — has lagged. Only now are we beginning to see real-time data monitoring to permit proactive interventions to improve quality of care, not only in a pandemic but also in routine care. Only recently has the data been used to give physicians timely feedback on their quality of care and resource use. It will be years before these features become integral to routine health system operations across the entire country. As Taiwan shows, however, this is a challenge of policy, not technology.
Even in the midst of the ongoing pandemic, we can learn from Taiwan. Americans share every movement and sentiment with Facebook and Google, yet we seem reluctant to allow the Department of Health and Human Services to monitor patient encounters, as Taiwan does, to track disease and determine what medical tests and treatments to order.
Medicare and Medicaid could adopt something similar to the Taiwanese health card and allow an independent third party to monitor the data. The third party could proactively identify infectious outbreaks, deficiencies in the quality of care, and other important health issues. The contract would have to strictly forbid sharing the underlying data or commercializing them in any way.
Insurers already get data based on hospital and physician claims, but only weeks or months after encounters, making the information less useful for tracking infectious outbreaks. They could use Taiwan as a model to upgrade their data systems and share the insights with public health authorities.
Such an upgrade is tremendously expensive, prohibitively so without inducement. Fortunately, the HITECH Act showed that the federal government can spur investment in electronic health records. Nearly a decade since HITECH, we have the benefit of hindsight for what went well and what went wrong. Another round of investment in electronic health record upgrades — specifically targeted to generating interoperable data that can be shared in real time with public health officials — should be part of any new stimulus bill.
Taiwan’s amazing success in responding to Covid-19 highlights ways the U.S. can improve its pandemic response. By now it is evident that we need a faster, more serious response to public health emergencies, and Taiwan’s health card offers a basis for executing such a response.
Shoring up the U.S.’s digital health infrastructure will help improve routine care in the long run while empowering us to better respond to future infectious disease outbreaks.
Ezekiel J. Emanuel is a physician, vice provost of global initiatives, professor of medical ethics and health policy at the University of Pennsylvania. He is also the author of “Which Country Has the World’s Best Health Care?” (Public Affairs, June 2020), co-host of the “Making the Call” podcast, and a member of the Biden for President public health advisory committee. Cathy Zhang is a senior research fellow at the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Aaron Glickman is a project manager in the Department of Medical Ethics and Health Policy at the University of Pennsylvania.
Two U.S. research groups have reported finding nearly 300 cases of an alarming apparent side effect of Covid-19 in children, a condition called multisystem inflammation syndrome, or MIS-C. While researchers have previously reported on the condition, the papers mark the first attempt to measure how frequently the side effect occurs and how it affects children who develop it.
The studies, published in the New England Journal of Medicine, describe children who develop severe inflammation affecting multiple organ systems after having had Covid-19, sometimes between two and four weeks after the infection. The majority of the children were previously healthy.
In one of the studies, led by researchers at Boston Children’s Hospital, 80% of the children who developed the condition required intensive care, 20% required mechanical ventilation, and four children, or 2%, died. In the second study, from researchers from New York state, a similar percentage of 99 children who developed the syndrome required ICU care and two children died. In both studies, many of the children developed cardiovascular and clotting problems and many had gastrointestinal symptoms. A high proportion also had skin rashes.
“Ours were really sick kids,” said Adrienne Randolph, an ICU physician at Boston Children’s Hospital and senior author on one of the papers, which was based on reports from 26 states.
Manish Patel, from the Centers for Disease Control and Prevention’s Covid-19 response team, said the message to parents is they should be on the lookout for fever and rash in children who have recently had Covid-19.
“I think being a little vigilant is important,” said Patel, who is an author on Randolph’s paper. “Fever, rash and I think especially in the setting of areas where you have a lot of coronavirus infections, SARS-CoV-2 infections — have a lower threshold for seeking care, I would say.”
On the whole, children appear to contract SARS-CoV-2 less often than adults and have a milder course of disease when they do.
But in late April, doctors in London alerted the world to the possibility that some children who had Covid-19 appeared to go on to develop something that looked like Kawasaki’s disease, an inflammatory condition that can attack the heart. KD, as it is called, is generally seen in children under the age of 5. Shortly thereafter, doctors in New York began to report cases as well.
In mid-May, the CDC asked doctors across the country to be on the lookout for cases of multisystem inflammatory syndrome in children.
The nearly 300 cases identified in these two studies share some similarities with KD, but there are also differences. Few of the children are under the age of 5. The average age of children in the larger study was 8; 42% of the children in the New York cohort were aged 6 to 12.
Another difference: While KD disproportionately affects children of Asian descent, MIS-C cases in the New York cohort were of all racial and ethnic backgrounds, the researchers reported.
“Among our patients, predominantly from the New York Metropolitan Region, 40% were Black and 36% were Hispanic. This may be a reflection of the well-documented elevated incidence of SARS CoV-2 infection among black and Hispanic communities,” they wrote.
The New York group estimated that the majority of MIS-C cases occurred about one month after the peak of Covid-19 cases in the state. They estimated that between March 1 and May 10, two of every 100,000 people under the 21 years of age who had laboratory-confirmed SARS-CoV-2 virus developed MIS-C in the state. The infection rate in people under the age of 21 years was 322 in 100,000 over that period.Trending Now:
An editorial written by Michael Levin, from the department of infectious diseases at Imperial College London, said there have been roughly 1,000 pediatric cases of the condition reported worldwide to date. He suggested more are likely going unrecorded, because case definitions require evidence of prior Covid-19 infection.
“There is concern that children meeting current diagnostic criteria for MIS-C are the ‘tip of the iceberg,’ and a bigger problem may be lurking below the waterline,” Levin wrote.
The Covid-19 pandemic has pushed telehealth — the remote provision of health care resources, tools, and consultation, usually via digital technologies — from the backwaters of medicine to its leading edge.
Though novel to some health care providers, and considered impractical by others, telehealth will likely endure — and become even more appealing — after the Covid-19 pandemic has faded away. We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health.
The changes that have made possible the wider use of telehealth appear to be temporary. For instance, health insurers, who once declined to fully reimburse virtual visits to physicians, nurse practitioners, and other health providers, are now making exceptions expressly tied to the nature of the pandemic. Yet research and theory from the social sciences on institutional change would predict that there may not be a clear-cut return to “normal” once this crisis is over.
The adaptation to Covid-19 has realigned the power and positions of physicians, nurses, insurance companies, hospitals, and telehealth startups in providing health services to different communities. Providers are establishing new policies and automated systems around triage, virtual visits, and infection control that may become taken-for-granted work routines going forward. Such practices may be laying the foundation for opportunism in the expansion of telehealth markets above and beyond their value in treating disease and saving lives by allowing compensation for unnecessary visits.
For some time, technology companies have sought to disrupt the health sector with algorithms and other patient-centered digital innovations. These companies are now rushing to consolidate their positions before the opportunities presented by the pandemic abate.
Some providers and hospitals, attracted by potential reductions in cost and in potential improvements in patients’ health outcomes, were early adopters of virtual visits and other telehealth technologies. With the emergence of Covid-19, providers who had once been prudently looking for an evidence-based way to add value to their practices have been pushed into rapidly developing telehealth strategies to keep their practices afloat. Academic medical centers that had previously piloted telehealth as a strategy to expand their referrals or to decrease readmissions are now leveraging this infrastructure to more intentionally maintain contact with patients who have been seen in their outpatient offices.
There’s no question that the expansion of telehealth could be a force for good. These changes may save lives during this crisis by keeping patients out of health care settings where exposure to Covid-19 may be high. In the post-pandemic era, they could provide greater access and convenience for some patients. But they could also worsen health disparities down the road if not implemented carefully.
In its earliest days, one of telehealth’s missions was to ensure greater access to health care services by populations that otherwise would go without proper or timely care and consultation, such as those who are incarcerated or who live in rural areas. Now it is being used as a tool to supplant in-person visits and expand patient markets, partly in response to consumer demand for convenience and efficiency. This emphasis on expanding patient markets and responding to well-resourced consumers’ demand may put marginalized groups with poor health, no health insurance, or few digital resources at risk.
A market-driven, consumer-centered vision of telehealth could have negative implications for marginalized groups that already face discrimination during in-person medical encounters. Marginalized racial and ethnic minorities are more likely to report discrimination within health care settings, influencing their willingness to trust providers and seek medical attention early.
Discrimination and mistrust could be magnified in virtual doctor-patient encounters, in which patients may not feel they can fully communicate and providers may be less mindful of guarding against implicit bias based on attributes such as race, ethnicity, or educational status.
The potential for racism and class bias to be encoded into telehealth algorithms is also worrisome. Predictive tools are imperfect — although they may be able to predict average patterns across groups, they can neither fully account for the complexity of individuals nor incorporate subtle variables that may assist in the identification and treatment of disease. While doctors misuse of these algorithms is mitigated by clinical judgement and training, a patients’ uninformed use of such algorithms in lieu of seeking professional medical advice could be harmful. This is particularly true of patients who belong to social groups underrepresented in algorithmic data.
Hospitals, insurers, policymakers, and health care professionals must carefully consider how the telehealth policies and routines they implement might have durable — and potentially harmful — reverberations. Research into the costs and benefits of specific telehealth applications at the individual and population levels is essential.
Institutional policies created during this pandemic will have long-lasting consequences on health disparities. We must work to ensure they are net positive.
Matthew Clair is a sociologist and assistant professor of sociology at Stanford University. Brian W. Clair is an orthopedic surgeon at Lahey Hospital and Medical Center in Burlington, Mass. Walter K. Clair is a cardiologist, professor of medicine at Vanderbilt University Medical School, and executive medical director of the Vanderbilt Heart and Vascular Institute.