FROM THE PRESS
Lone crusader for ethics
Fighting for ethics is never simple, as a doctor from Kerala realised during his long crusade. In 2008, Dr KV Babu, an ophthalmologist practising in Payyanur, was offended by the numerous endorsements of commercial products in the media by none other than the Indian Medical Association (IMA). His plea was that an endorsement by the IMA of a particular brand of oats or fruit juice was equivalent to an endorsement made by him, as a member of the organisation. He felt that when such an action was a direct violation of the Code of Medical Ethics Regulations 2002, laid down by the Medical Council of India (MCI), it was his duty to complain to that body. However, five years down the line, the matter is still pending before the council’s ethics committee.
The MCI has delayed its decision on the issue that questions its own jurisdiction over the IMA, which has, in turn, tried unsuccessfully to expel the feisty doctor. Dr Babu has fought this battle at his own cost, spending over Rs 50,000 on trips to Delhi. He has had to file RTI applications, and write letters to the health ministry, the chief information commissioner and even the National Human Rights Commission to get the MCI to heed his arguments. Responding to the council’s view that it cannot take action against associations, Dr Babu filed complaints against all 187 doctor members of the association’s central working committee. Eventually, the MCI ruled against the endorsements and penalised two leading office-bearers.
Dr Babu, meanwhile, stands firm in his fight against his expulsion, saying: “It is law-breakers who ought to be expelled, not those who uphold the law.”
Rema Nagarajan, Cover story, The Times of India Crest edition, July 6, 2013, Available from: http://www.timescrest.com/coverstory/the-patient-doctor-10659
Serious lapses in “welfare” schemes
Twenty-three children died on July 16, 2013 after consuming a meal at a primary school in Gandaman village, near the town of Chhapra in Bihar. The meal of rice and soybean was served under the mid-day meal scheme, and was later found to contain the insecticide, monocrotophos. The media has analysed the wider implications of the tragedy and highlighted the callous manner in which such welfare schemes are being implemented.
An editorial in the Economic and Political Weekly cites a programme evaluation report, dated May 2010, by the Planning Commission that found serious lapses in the infrastructure provided and the quality of food. The tragedy has exposed several aspects of the negligence associated with the implementation of welfare schemes in the country. These include the following.
- Programmes such as the mid-day meal scheme are characterised by class discrimination. The same goes for the public distribution system for foodgrains, in which no one takes responsibility for delivering good-quality services to the poor citizen, and for infrastructure such as clinics and school buildings, which are hopelessly inadequate. Powerful local politicians and contractors embezzle the funds provided for these purposes.
- There was a woeful absence of facilities, including transport and personnel at the healthcare centres where the poisoned children were taken, right from the local centre to a public hospital in Chhapra town to the intensive care unit in Patna Medical College Hospital.
- Primary service providers, such as cooks, helpers, midwives, contractual teachers and anganwadi workers, who are employed on contract, are not even paid the minimum wage.
- Pesticides such as monocrotophos, said to have been the culprit in this case, and butachlor, are widely used in several Indian states for crops like vegetables, fruits and chillies. The used containers are left lying around and can easily harm the unwary or children, or be misused by criminals. This continues despite the fact that monocrotophos is banned in 46 countries.
Editorial, Dignity, not mere roti, Econ Pol Wkly, August 10, 2013, Available from: http://www.epw.in/editorials/dignity-not-mere-roti.html. Anant Zanane, Mid-day meal deaths: chemical banned by 46 countries is easily available in India, Ndtv.com, July 24, 2013, Available from: http://www.ndtv.com/article/india/mid-day-meal-deaths-chemical-banned-by-46-countries-is-easily-available-in-india-396260
NEET judgment in contravention of earlier SC decisions
A recent controversial judgment of the Supreme Court of India held that the Medical Council of India’s (MCI) proposed national entrance-cum-eligibility examination (NEET) is violative of Article 19(1) (g) 25, 26 and 30, under which citizens are free to practise any profession and linguistic and religious minorities are free to set up and manage educational institutions. The majority judgment of Justices Kabir and Sen held that the MCI had exceeded its powers by declaring a single-window admission process for medical colleges all over the country, and further, that since educational standards vary across the country the process will not ensure a level-playing field.
An article in The Hindu analyses how this latest verdict has gone against the principles laid down in the earlier judgments of the apex court. In the Unnikrishnan case of 1993, a constitution bench had stated that education “can neither be a trade or business, nor can it be a profession within the meaning of Article 19(1)(g). Trade or business normally connotes an activity carried on with a profit motive. Education has never been commerce in this country.” In 2002, an 11-judge bench had declared: “Inasmuch as the occupation of education is, in a sense, regarded as charitable, the government can provide regulations that will ensure excellence in education, while forbidding the charging of capitation fee and profiteering by the institution. Since the object of setting up an educational institution is by definition ‘charitable’, it is clear that an educational institution cannot charge such a fee as is not required for the purpose of fulfilling that object.”In yet another judgment in 2005, a seven-judge bench had stated: “Holding of such common entrance test followed by centralized counselling or, in other words, single-window system regulating admissions does not cause any dent in the right of minority unaided educational institutions to admit students of their choice.”
Dhananjay Mahapatra, SC’s NEET logic contrary to constitution bench rulings, Times News Network, “July 22, 2013, Available from: http://timesofindia.indiatimes.com/india/SCs-NEET-logic-contrary-to-constitution-bench-rulings/articleshow/21228499.cms
Malnutrition deaths in outskirts of Mumbai
Within the short period of April to June 2013, 171 children in the age group of 0-6 years have died in the tribal belt of Maharashtra, including Shahpur, Jawhar and Mokhada talukas, very close to Mumbai. During the same period last year, 184 children had died, 141 of them in the age group of 0-1 years. Of the 171 children who died this year, 131 were in the age group of 0-1 years and 40 between 1 and 6 years of age. In 2013, 173 children in the area have been diagnosed as “severe acute malnourished” and 3403 as “moderate acute malnourished.”
After 258 deaths attributable to malnutrition had occurred in Jawhar tehsil in 1992, the government had set up special projects for the tribal areas of the state. Over Rs 2118 crore has been spent on these projects over a 21-year period. The Thane zilla parishad is said to have a budget thrice the size of that of the state of Kerala and five times that of Goa.
Government health officials attribute the problem to the geographical nature of the region, early marriages, malnourishment of mothers, poor awareness about family planning practices and superstition.
Indavi Tulpule, an activist of the Shramik Mukti Sanghatana, an advocacy group, says, “The government needs to starts looking at malnutrition as a symptom of a larger developmental malaise affecting this region and work holistically with [a] multi-pronged approach. Land is being diverted from agriculture and food crops on the one hand and on the other, people simply have no work. Even if you ignore the problems in the public distribution system, this means their capacity to buy food is compromised, resulting in hunger and malnutrition.” The administration has an ethical responsibility to prevent the country’s children from starving to death. Furthermore, when this occurs so close to the metropolis, remote location and backwardness can hardly be a justification for neglect.
In Rajasthan’s tribal belt, where one-third of the children in the age group of 0-3 years were found malnourished and 80% anaemic, district officials have declared an incentive scheme. A reward of Rs 100 is to be given to government health workers who bring in a malnourished child for treatment. Officials say this will be in addition to a payment of Rs 135 being made, per day for 10 consecutive days, by the health department to the parents of a child admitted to a centre for malnourished children. The new scheme will include auxiliary nurses, midwives, anganwadi workers and asha sahayoginis.
Small steps of this kind may show serious intent, but a major overhaul of all such schemes is essential.
Yogesh Pawar, Maha shame: 171 children die of malnutrition in Thane, DNA, July 30, 2013, Available from: http://www.dnaindia.com/mumbai/1867404/report-maha-shame-171-children-die-of-malnutrition-in-thane IANS. In Rajasthan, rewards for spotting malnourished kids, The Times of India, July 13, 2013, Available from: http://timesofindia.indiatimes.com/city/jaipur/In-Rajasthan-rewards-for-spotting-malnourished-kids/articleshow/21052458.cms
Government eases compensation norms in clinical trials
After drawing flak from the clinical trials industry for its reforms relating to compensation for participants who suffer adverse events during trials, the government has amended its own revised guidelines. Uncertainty regarding the fallout of the earlier reforms is said to have thrown the clinical trials industry into the doldrums, causing an estimated loss of about Rs 900-1200 crore over the last six months. The revised guidelines had stated that participants who suffered death or injury would have to be compensated even if these events were not necessarily the consequences of the trial. Under the new guidelines, a participant will be awarded compensation only if the death or injury is proved to have been caused by the trial. These modifications have been recommended by the Drug Technical Advisory Board and accepted by the health ministry. Further changes include the following.
- Medical management will be provided only in case the injury is due to activities related to the clinical trial, “as the free medical management may create undue influence for the patient to enrol in a clinical trial.”
- The period for reporting serious adverse events and fixing the quantum of compensation has been extended from 21 to 30 days.
- The deadline for an independent expert committee to establish the cause of death during a trial has been increased from 30 to 60 days.
- The “licensing authority” or Drug Controller General of India may now decide on the amount of compensation and cause of death up to two months after receiving the expert committee’s report.
Vidya Krishnan, Govt eases compensation guidelines for clinical trials, Live Mint [Internet] July11, 2013, Available from: http://www.livemint.com/Politics/fsjKnlxaH6JKm1Ep7tnGtJ/Govt-eases-compensation-guidelines-for-clinical-trials.html
Government policy moves away from family planning
“Maternal and child mortality are the major issues faced by India and not population growth. The days of high fertility rate are over,” according to SK Sikdar, the deputy commissioner and head of the family planning division, Union ministry of health. The health ministry has stated that it is “repositioning” its policy focus away from birth control towards maternal health and spacing of pregnancies. However, with a maternal mortality rate of 212 per 100,000 live births, the country has a long way to go to reach the Millennium Development Goal of 109 by 2015.
The new strategy is “completely free of taboos and coercion. We have also moved from a camp-based approach where our health workers had a target to achieve. Instead, we now have fixed-day services for women in clinics,” said Anuradha Gupta, the mission director of the National Rural Health Mission.
Activists have greeted these statements with caution. Jasodhara Dasgupta of the National Alliance for Maternal Health and Human Rights said, “We would welcome the policy by the government, but my personal experience shows the government still concentrates on target numbers more than the quality of services.” She pointed out that the burden of birth control is still borne by women, who also face the accompanying violations of human rights at many government-organised camps.
Nikita Mehta, Government shifts focus from birth control to spacing, Live Mint [Internet]. July 10, 2013 Available from: http://www.livemint.com/Politics/rulUdu59QejhnLgg80dssJ/Govt-shifts-focus-from-birth-control-to-spacing.html
Controversial tests on H7N9 flu virus
A group of researchers working on the Influenza A H7N9 virus has, in a letter to Science magazine, put before the public its case for gain of function (GOF) studies to create viruses with varied properties in the laboratory. The epidemiologists, led by Ron Fouchier and Yoshihiro Kawaoka of the University of Wisconsin, say that their earlier experiments, on the same lines, with the H5N1 flu virus had aroused a storm of protest and been virtually shut down for a year. They now want to explain to the public the nature and importance of their work in the interests of transparency. According to them, so far, research has studied “the wild-type avian A (H7N9) viruses in terms of host range, virulence, and transmission” and they are evaluating the effectiveness of antiviral drugs and vaccine candidates.”
Researchers “use several techniques to give viruses characteristics that they don’t have in nature, such as the ability to infect new species or transmit more easily through the air. Such studies are critical to understanding the sometimes subtle changes that can make a bird virus a pandemic threat.” The Fouchier group argues that traditional epidemiological testing does not enable healthcare authorities to tackle pandemics in time. However, scholars opposing the tests are very sceptical, arguing that the justification for carrying out this research is unconvincing and that the precautions outlined by the group cannot guarantee safety.
Among the characteristics given to viruses in GOF studies could be easier transmission and the ability to infect more species. These could be potentially disastrous if the viruses were to escape from the laboratory or get into the hands of terrorists, say critics.
David Malakoff, Critics skeptical as flu scientists argue for controversial H7N9 studies, Science, August 9, 2013, Available from: http://www.sciencemag.org/content/341/6146/601 Ron A M Fouchier, Gain-of-Function Experiments on H7N9, Science, August 9, 2013, Available from: http://www.sciencemag.org/content/341/6146/612.full
Survey shakes up medical teachers
According to a survey carried out recently at the Grant Medical College in Mumbai, medical students pointed to continued absenteeism, lack of clarity in teaching and ignorance of the subjects taught as the three worst failings of their professors,.
The survey covered 900 students from the first to third years. They were asked to rank their professors, from all 12 departments, on a score of 1 (worst) to 10 (best). The students were encouraged to be frank, with no obligation being placed on them to mention their names or roll numbers. The participants were the most indignant about those teachers whom they said they had never even seen on campus.
The survey was initiated by the dean, Dr TP Lahane, who said that though the college is a reputed institution, “not many of our students are able to crack the All India Post-Graduate Medical Entrance Exams.” He concluded, “This survey gives a fair idea of where the problem lies.” In the survey, the pathology and forensic departments fared the worst, while the biochemistry and anatomy departments were rated the highest. The teachers have apparently taken the survey seriously and say they intend to improve their performance. This is a good augury for the maintenance of standards in medical education which have been a cause for concern all over the country. More colleges in India should take a leaf out of Dr Lahane’s book. There are plans for a follow-up survey after six months.