As sure as Diwali is a festival of lights, sweets, gaiety, splendor & fireworks, it is also one of deafening noise, blinding light, risky fire & suspended particles. And this has direct effects on our health & environment. When the entire nation looks forward to Diwali as a celebration of life, patients suffering from Asthma & COPD (Chronic Obstructive Pulmonary Disease) begin readying there lifesavers – Inhalers, nebulizers or whatever gives them a breath of life. For these people Diwali is not a festival of light & gaiety but that of smoke, coughing & wheezing.

Fireworks are sources of some of the highly toxic inhalants produced during Diwali celebrations. Firecrackers are “power packed” with potassium nitrate, carbon & sulfur. Apart from this they also contain toxic contents like copper, cadmium, lead, manganese, magnesium, zinc, sodium, potassium, and aluminum powder & barium nitrate. When ignited, the crackers burst allowing these powerful chemicals to come in contact with atmosphere and the smoke thus generated contains increased amounts of carbon monoxide, carbon dioxide, nitrogen dioxide, hydrocarbons, hydrogen sulfide & particulate matter which worsen the quality of Diwali air. The suspended particles hog like a thick blanket reducing visibility and suffocating the atmosphere. In fact studies have demonstrated that during Diwali festival the concentration of sulfur dioxide increased by 10 times & that of nitrogen dioxide, PM10(Particulate matter of size less than 10 microns) & TSP(Total Suspended Particles) increased by 2 to 3 times. The Overall air pollution during Diwali increases by about 200 %. The biggest culprits among firecrackers are the colour sparkles (“Phuljari”), “Anar”, “Chakri”, Fire pencils, Snake tablets & “Hydrogen” bomb.

A special mention may be made of PM10. With the average PM10 charge, we inhale millions of fine particles with each breath. The larger particles( 5 to 10 microns) are filtered in the nose & throat, smaller particles (3 to 5 microns) arrive in the bronchial tube, bronchi (2 to 3 microns), bronchioles (1 to 2 microns) & in alveoli (0.1 to 2 microns) & finally in the blood. These particles can no longer be coughed up & as deposits lead in long term to inflammation, particularly in asthmatics, & also with healthy people, although they may not notice the immediate irritant effects.

When we inhale such a highly toxic and polluted air during Diwali, how can escape from its ill effects? The harmful oxides present in the Diwali fumes come into contact with the moisture while passage from the nostrils to the lungs & form acids which cause immense damage to the body.

The Diwali smoke potentially leads to development of various respiratory ailments like –Allergic bronchitis, acute exacerbation of bronchial asthma & COPD (Chronic Obstructive Pulmonary Disease), allergic rhinitis, laryngitis, sinusitis, pharyngitis, common cold, acute eosinophilic pneumonia, reactive airway dysfunction syndrome, etc.

Children, pregnant women, asthmatics & senior citizens are highly prone to these potentially harmful effects of Diwali smoke.

Here is a list of precautions that need to be followed during Diwali celebrations.

Precautions to be followed by asthmatics:

1. Stay away from people burning crackers.

2. Keep the inhalers and other medicines ready beforehand (both maintenance & reliever medications).

3. Consult your doctor and start maintenance dose of inhalers a few days before the festival & continue the same two days after Diwali.

4. In severe cases rescue medications need to be taken & if not relieved contact your doctor immediately.

5. Better do not venture out in the evening of Diwali. Stay in company of friends and family members in house.

6. If need to venture outside use masks (N95 masks have been technically recommended).

7. Consult your doctor regarding pulmonary vaccination in advance.

8. Stay away during colouring and white washing of house before Diwali because these also act as “triggers” of an asthma attack.

9. If possible plan a visit to some hill-station / ecoclean place (which is not much crowded) during Diwali festival.

Precautions to be followed by every one of us during Diwali festival:

1. Avoid /decrease the firework celebrations & play “ecosafe” Diwali.

2. Enjoy Diwali with lamp, lanterns & diyas.

3. Fireworks if carried out should be done in open grounds, away from residential areas & during fixed time limits.

We should remember that one person’s idea of fun could be an asthma patient’s nightmare. Asthma patients have as much right as us to stick around and enjoy Diwali. And ultimately for our own benefit we should not forget that “what we burn is what we breathe”, this Diwali.

The article discusses the role Public Private Mix in treatment of Tuberculosis in current scenario especially in a country like India.

Accountability is a fundamental principal of TB control.

In many countries, significant proportion of patients with TB first consult Private health practitioners.

Characteristics of poor management of TB patients in private sector:

1. Diagnosis by chest xray without smear examination.
2. Overuse of unnecessary and expensive tests.
3. Under treatment.
4. Over treatment.
5. No supervision.
6. No follow up of late patients.
7. Inappropriate monitoring of treatment by Chest Xray.
8. Inadequate treatment records.
9. No reporting.

There is no one means to achieve coordination between public and private sectors in all countries. The various approaches to strengthening the coordination between public and private sectors include the following:

1. Competition:

Well organised out patient chemotherapy, especially if provided free of charge, will attract asymptomatic cases from far and wide.

2. Exclusion:

-Exclude the private sector.
-Ban over the counter sale of anti tubercular drugs.

3. Contracting:
Public sector can contract TB control services to private groups.

4. Engagements:

-Actively engage private sector in TB care.
-In many countries, public health programmes & professional groups such as National Chest Societies, collaborate to establish standards of care that apply to both public and private sectors & revise medical colleges curricula to reflect these consensus standards.
-The following services should be made free:
*Lab services
*transportation of specimens
*referral to public sector
*free medications

5. Reporting:

Include making compulsory the following:
-Active surveillance of laboratories.
-Reporting of bacteriologiocaly confirmed patients.
-Monitoring of these patients.

Role of NGOs:

1. Educate private practitioners to adopt RNTCP (Diagnostic & treatment policies, treatment referral).
2. Provide diagnostic & treatment services to which private patients can be referred.
3. Provision of outreach workers in community for follow up of late patients.
4. Assisting in recording and reporting of cases.
5. Act as links with Chest Physicians, Paramedics, etc.

Government has recently introduces a 5 pronged programme for involvement of NGOs in RNTCP which includes the following 5 levels:

level 1: Outreach services, Education
level 2: DOT treatment
level 3: Hospital services
level 4: Microscopy centres
level 5: Model treatment services/centres

This carries a great relevance in today's scenario when we are striving hard to fight against Tuberculosis.

The take home message is involvement of all in providing health care services in tuberculosis.