‘Humanitarian’ medical council

Terna Medical College is not recognised either by Maharashtra Medical College (MMC) or the Medical Council of India, writes Manjiri Kalghati in the Indian Express (MMC Act benefits students. Indian Express Newsline, October 17,1997).

The MMC found the college deficient. It needed to ‘make vigorous attempts to improve the staff situation at the earliest… appoint qualified and eligible full-time staff in all subjects as per the deficiencies pointed out…’ It also asked the college management to give an undertaking that they would build the college building, hospital, hostel and staff quarters within two years. “Hospitals are used for the purpose of teaching on a hire basis…” it noted.

Yet the MMC has resolved that students of the Terna Medical College completing their internship in the present academic year will be registered under Schedule 3 of the MMC Act, ‘on humanitarian grounds’!

VVlPs’ medical treatment

The Delhi High Court recently raised questions on the crores of rupees spent by the central government on VVIPs for their medical treatment abroad and sought expert opinion as to whether the afflictions for which they went overseas could have been treated here.

A PTI report (VVIPs’ medical treatment. Hindu, November 20, 1997) describes the contents of an affidavit filed by the central government on medical treatment for VVIPs in foreign countries from 1991 till 1997.

The figures: Sitaram Kesri: Rs 14.18 lakh;. Arjun Singh: Rs 9.34 lakh; VP Singh: Rs 13.53 lakh; Rajendra Kumar Bajpai: Rs 12.23 lakh; Sukh Ram: Rs 22.44 lakh; CK Jaffer Sharief: over Rs 31 lakh; Ajit Kumar Panja: over Rs 56 lakh; Tarun Gogol: Rs 10 lakh; Jaipal Reddy: over Rs 14 lakh, and PV Narasimha Rao: over Rs 10 lakh.

The conditions: respiratory illness, heart disease, diabetes.

Doctored accounts

Income-tax sleuths have turned their eagle eyes on doctors. During a concerted raid on the premises of seven leading medical practitioners in Calcutta, they have made seizures worth crores of rupees in cash and kind. It is believed that these doctors had disclosed only a small portion of their actual income to dodge taxes.

Seven, of course, is not a staggering figure and the tax men would probably find that the actual number of tax-dodgers in the medical profession to be many times seven….

(From an editorial in The Times of India, October 7,1997)

Doctors withhold death certificates

Doctors at various city crematoria held back death certificates which stated that the cause of death was due to malaria, alleged Mr Ajit Panja in the court of Justice PC Ghosh of the Calcutta High Court, who was hearing a case on the extent of malaria in the state.

The Telegraph legal reporter (Telegraph, November 20,1997) describes a case filed by a Mr A Guha, advocate, demanding that the current outbreak of the disease be declared an epidemic and compensation be given to the families of those who have died of malaria in 1997.

Appearing on behalf of Mr Guha, Mr Punja mentioned that he had adequate documents to show that the government was suppressing the death toll due to the disease by instructing the crematoria doctors to keep in custody the death certificates issued by different doctors.

“In exchange, the crematoria doctors were issuing slips saying that the document is in their possession. These slips, however, do not mention the cause of death,” Mr Panja alleged.

And prisoners don’t get malaria

The same Telegraph article mentions that the state home secretary was asked by the court to submit a report interpreting the Jail Code on whether mosquito nets could be supplied to prisoners in custody.

The report clarified that there was no such bar, but said that such nets are not usually given — as there is a possibility that the prisoners may use the ropes. to hang themselves!

The report added that, on the basis of the court’s order, mosquito nets had been supplied to police station lockups, hospitals and orphanages.

HIV and AIIMS

Patients and health care workers at the All India Institute of Medical Sciences (AIIMS), the country’s premier medical institution, run a high risk of contracting HIV infection, writes Kalpana Jain, reporting on a study conducted by the Centre for Community Medicine (HIV and AIIMS. The Times of India, reprinted in’ AIDS NEXUS, September/October 1997), of 260 health care workers at AIIMS and a rural health services project in Ballabgarh, Haryana. What is happening in the peripheral areas and other hospitals should be a cause of major concern.

Some worrying statistics: 86 per cent of doctors in operation theatres and labour rooms did not take appropriate precautions against HIV — such as using gloves, masks, eye covers, boots, and aprons.

At the same time, more than 58 per cent of the doctors and almost 54 per cent of the nurses reported accidental exposure to patients’ blood or body fluids in one month. Of the exposed personnel, 35 per cent doctors and 45 per cent nurses had a break of skin.

Supplies of protective methods were also not adequate. For instance, in the medicine wards at AIIMS, gloves and masks were available in plenty but no other protective method was available.

Worse still, laboratory workers, who face a high risk of exposure, were given almost no protective gear.

The study found out that 20 per cent the doctors and nurses did not know the correct modes of HIV transmission in a hospital.

While 74 per cent doctors and 79 per cent nurses knew that spills of blood or body fluid on areas around have to be flooded with bleach and then cleaned with cotton, only 18 per cent of doctors and 30 per cent of nurses did this.

GPs: then and now

Allopathic doctors have a propensity for prescribing medicines which may cause grievous damage in the long term. Their inability to see the individual as a whole is, indeed, a cause for concern. This is especially true in the case of children. I learnt with horror how doctors of the CGHS prescribe avoidable medication. I remember my childhood GP whose prescription used to be: plenty of rest and fluids. As the doctor knew my family and the environment I lived in, he could prescribe appropriately.

GPs of the old school have largely given way to commercially minded doctors who cater more to the pharmaceutical industry than the patient’s needs.

From Cause for concern, Pradeep Ranade, Humanscape, April 1997.

New untouchables

A donor-driven anti-AIDS programme targeted at sex workers, truck-drivers and other ‘high-risk’ groups is creating new untouchables in according to a UNI report by Ranjeet Devraj (AIDS NEXUS, September/October 1997). The worst-hit by an AIDS scare – the result of inappropriate awareness campaigns – are suspected HIV patients in the rural areas where primary health care is seriously deficient and testing facilities non-existent.

People suspected of having HIV and their families face social ostracism. A voluntary organisation, the Joint Action Council, Kannur, produced before the New Delhi press the family of a truck driver, Ranbir Singh, who died suddenly on May 21 in Chochi village in Haryana.

The family, and the whole of Chochi, has been boycotted by the neighbouring villages. Azad Singh, a former headman, was shocked by newspaper reports that described Chochi as an AIDS village. He also complained that the villagers were under pressure by the ministration to undergo HIV testing. A fact-finding team from Delhi was told by the local administration that since Ranbir Singh was a truck driver and belonged to a high-risk group, the testing was ordered because of ‘prima facie’ evidence and because of a scare among the villagers.

Sterilising the disabled

The Japanese government has revealed that more than 16,000 disabled people were forcibly sterilised over a period of decades, but has said there are no plans for an apology or compensation, writes Jonathan Watts (The Lancet, 27 September 1997).

From 1945 to 1995, 11,356 women and 5,164 men with mental handicaps or hereditary diseases were sterilised with government approval, a health and welfare ministry official acknowledged to reporters. The operations, which included vasectomies and hysterectomies on patients at public institutions, were carried out under the Eugenic Protection Law, which was abolished in 1996.

The law, introduced in 1948, was aimed at preventing the birth of genetically ‘defective’ babies. Among the categories of patients considered eligible !for sterilisation were those who were ‘retarded’ and those with epilepsy or haemophilia. A committee in each municipality, made up of lawyers, arteries, and welfare specialists, determined whether to go ahead with operations in each individual’s case.

Citizens’ groups representing women and the handicapped demanded that the government launch an investigation into the matter and apologise and compensate those who were forcibly sterilised.

The health and welfare ministry, however, said it had no intention of meeting their demands because it had ‘merely observed the law’ in allowing the operations to proceed.

No ICU, no doctors

About 100 persons have died in the a neurosurgery department of the SCB medical college hospital in Cuttack, Orissa, between April and September, 1997 because of lack of infrastructural facilities in the state’s premier medical institution (according to an report, Pharma Pulse, October 2, 1997).

Most of the cases were related to head injury. The report pointed out that there was no neuro-intensive care unit, nor the required number of qualified doctors, nurses and class four employees for the neuro ward.

The report suggested the establishment of a neuro trauma and ICU units to prevent the rising numbers of casualties in the department. Meanwhile, a public interest writ petition has been filed before the Orissa high court by the junior doctors’ association seeking judicial intervention in the matter.

Pathological conditions

The Ganeriwal committee, appointed in by the Maharashtra government committee to look at pathology laboratories in the state, has made some recommendations which, if accepted, would form the basis for the proposed Maharashtra Pathology Control Act.

One recommendation is that an MBBS degree should be mandatory for teaching DMLT students at government hospitals. Another is that the minimum qualification for running path labs will henceforth be an MBBS degree. The committee also suggested doing away with private courses.

For years now, there has been an exponential rise in the number of path labs, increasingly run by under-qualified personnel, throughout the country. Accreditations are non-existent and the quality of services and testing are dubious. Rackets between path labs and GPs in fleecing patients for unnecessary investigations are not at all uncommon.

In the circumstances, the need for regulation is most urgent. The department of science and technology has identified the need for strict regulation in haematology, immunology, microbiology and histopathology. National guidelines for regulation of labs will then be easier for states to follow. There is need for standardisation throughout the country.

Still, the recommendations of the Ganeriwal committee reveal undue bias. The very composition of the committee is apparently lop-sided with a majority of them being MD pathology, which explains their favouring the MBBS criterion.

While one can grant that an MBBS running a pathology lab is better qualified and can render qualitative testing and offer suggestions, it is illogical to expect an MBBS alone to teach DMLT students. It is the biochemist who is better qualified than an MBBS when it comes to teaching lab technology.

Scrapping private institutes running DMLT courses is another quixotic move, especially since they have been there for the past 25 years. This clearly shows a demand-supply gap that the university-conducted courses have failed to meet.

Ideally, path labs will need to be graded according to the range of services they offer An MD pathology or MBBS can only officially be allowed to head such labs. DMLT lab technicians must be allowed to work only in such labs, not to open shop. Finally, a cut-off period must be given. to under-qualified personnel manning present labs to fall in line with the proposed requirements.

(From: Regulating path labs. Express Pharma Pulse, October 30, 1997, editorial)

Uninformed ‘consent’

0n Friday July 4, 28-year-old Padma Bhupati developed complications during sterilisation surgery at Strihitakarini, a well-known health organisation in Mumbai. She died the following Monday at a private hospital, writes Sandhya Srinivasan (Humanscape, December 1997).

An investigation by Lokshahi Hakk Sanghatana, a Mumbai-based democratic rights organisation, concluded that Padma was the victim of negligence; she also could not have given informed consent to the surgery.

Padma was not told about the operation’s risks. She was new to the city, unable to speak the language, and without her husband; she could not have understood the implications of the surgery. The clinic’s consent form bears little resemblance to the government format. Nor has it been signed by a witness.

As for the surgery, the sketchy operating records give little idea of Padma’s condition during and after the operation. They do mention that “it was found that the patient had a respiratory arrest.” Then, ‘within a few seconds, it was found’ that her heart had stopped as well. “For this to happen the patient must have already been in a critically anoxic state by the time the respiratory arrest was detected,” says Dr Sunil Pandya of the Forum for Medical Ethics, “because the heart stopped a few seconds later.” This crucial failure appears to be responsible for her death.

Strihitakarini’s representatives point to the Rs 45,000 they paid to Punamiya hospital. “Normally people wouldn’t do what we did, but we are more concerned,” said Dr Vidyalakshmi Taskar, chief medical officer.” Her husband didn’t even have to pay for the cloth to cover his wife’s body!”

Aiding and abetting

Two years after an alleged nexus was exposed between criminals and a depart-section of doctors attached to the government-run JJ group of hospitals, Mumbai, the government has set up a committee to probe the charges, reports Prafulla Marpakwar (Doctor-criminal nexus at JJ hospital Indian Express Newsline, December 5,1997).

The five-member committee, which is to submit its report in three months, has been directed to examine seven years’ records of the admission, treatment and discharge of criminals, and decide whether or not they were necessary.

In 1995, a section of doctors was reported to be helping criminals booked under the Terrorist and Disruptive Activities (Prevention) Act by admitting them for treatment. At least four criminals thus admitted were either discharged or fled when they were granted bail. All of them were admitted by Lekha Pathak, honorary professor and head of the department of cardiology.

Following the report, the Maharashtra Medical Council found prima facie evidence to initiate an inquiry as to whether Pathak used her professional knowledge to shelter prisoners in the ICCU, and whether her clinical skills were used to misguide the judiciary.

Commission report in the morgue

Ten years after the Lentin Commission submitted a comprehensive report on the deaths of 14 people following administration of contaminated glycerol at JJ hospitals, Mumbai, the state government is yet to take action, writes Prafulla Marpakwar (Lentin report on JJ deaths in cold storage, lndian Express Newsline, December 1,1997).

The commission had passed strictures and recommended immediate departmental action against the then dean, R S Chandrikapure, SV Shaligram, professor and head of the department of pharmacology; medical superintendent V G Deshmukh; pharmacist AK Jamacagni, and officers of the department of industries.

It had also asked the anti-corruption bureau to hold a probe against the industries department officials.

The then health minister, Bhai Sawant, former health minter Baliram Hiray, certain and Food and Drug Administration officials were liable to be proceeded against for corruption.

The FDA officials were suspended for some time, but most were reinstated with back wages after departmental inquiries.

“Such findings make a mockery of the commission’s recommendations,” remarked a senior official of the law and judiciary department.

The commission also made observations on the staff shortage, poor working conditions, and lack of essential storage, testing, communication and other facilities. Yet today, just one or two respirators work for a hospital with more than 1,000 beds. The blood gas analyser is almost non-functional. Ten of 32 departments are without a head, and 129 of 319 posts are vacant.

Company policies on HIV

A decade after the first HIV case was detected in India, there is no written policy for HIV-affected employees, writes Manjiri Kalghatgi (Indian Express, December 2, 1997).

A recent survey reveals that over 50 per cent of the 63 representatives from seven Mumbai companies know of at least one employee who succumbed to AIDS, and one who is HIV-positive.

The survey, conducted by the AIDS Research and Control Centre (ARCON), JJ hospital, also revealed that only two of the companies provide voluntary testing or counselling facilities. Yet prospective employees are being tested on the sly, and rejected if they are HIV positive, says ARCON director Subash Hira.

No pill for the Japanese

Bizarre as it seems, a woman in Japan cannot get a legal, safe supply of oral contraceptives. She may persuade a sympathetic doctor to prescribe the medium to high-dose pill, ostensibly for some other condition. Japan bans the safer low-dose pill introduced in the US and Europe in the 197Os and used by some 80 million women throughout the world.

Japanese women’s groups have no doubt as to why their demand for a change in the law is being resisted: it would stop Japanese women from using abortion as the principal means of birth control — 3,45,000 abortions annually in the country, excluding those done by doctors but described as other operations, or the (more expensive) back-street abortions rarely reported to the tax authorities. For the medical profession, abortion represents a major source of income which it is not prepared to give up without a fight.

Health minister Naoto Kan promised to get the ban lifted by 1997. The central pharmaceutical affairs council agreed to approve oral contraceptives; the ministry’s public health council also gave its approval… But final approval has been postponed, for the fourth time.

One argument the government gave is that lifting the ban would let the birth rate would fall even further: Birth control already exists in Japan. The pill’s advocates simply want to make contraception more civilised.

(From editorial in The Economist November 1997)

Human guinea pigs

Two months after health minister Renuka Chowdhury ordered an inquiry into allegations that poor women in Delhi were used as guinea pigs to study cervical cancer, the report is yet to be submitted, writes Minu Jain (Pioneer, December 7,1997), who has reported on this continuing agitation.

Under the project, conducted in the 1970s and ’80s, thousands of women in and around Delhi were given Pap smears to identify 1,000 women with cervical dysplasia, an abnormal, sometimes self-reversing tissue growth.

Sixty-six women who developed cervical cancer after the study was over were left without treatment.

The doctors claim oral consent was taken from the women, but written consent could not be taken as the women were illiterate.

The project was conducted by the Institute for Cytology and Preventive Oncology. It began under Dr Usha Luthra, awarded Padma Shree and the Vimal Shah Oncology Award for her pioneering work in cancer research. Besides the Maulana Azad Medical College, at least eight Delhi hospitals were involved in the project.

Free care for the poor?

Acting on petitions demanding that private hospitals provide free care, as required, the Delhi high court issued show cause notices (Notices to government, Apollo Hospital, Pioneer, December 13, 1997) to the Apollo hospital and the Delhi government on a petition filed by the Delhi unit of the All-India Lawyers Union, alleging that the hospital was not providing free medical facilities to the poor in lieu of the land made available to it by the government at a nominal price. The 200-bed free treatment block lies unused because the government does not provide free medicine.

Another notice was issued to the Delhi health secretary and the medical superintendent of Lok Nayak Jai Prakash Narain hospital on a petition by a Dr Rakesh Kishore, who cited the case of an accident victim who died following refusal of treatment by LJPN hospital.

The confidentiality myth

Health personnel in government and private hospitals in Calcutta have leaked the HIV status of at least four patients and blood donors, writes Amit Ukil in the Telegraph (Health staff violate HIV ‘confidentiality’, December 13, 1997). In three of the cases confirmatory tests showed the person was not HIV-positive.

In one case the information was marked on the patient’s outdoor tickets, She was refused treatment for delivery of her child at R G Kar, and was thrown out by her husband. In another case, staff at the Calcutta hospital were informed of a patient’s HIV status before he was, and he tried to commit suicide.

There is plenty of evidence that such practices are the rule, not the exception.

No incubators

A new mother and her premature baby were refused emergency admission to the Vartak Nagar municipal hospital in Thane, Maharashtra, because the hospital didn’t have an incubator, writes Vivian S in Mid-day (The cradle will fall, December 16,1997).

For the same reason, they (and another mother and child) were almost sent back from the Chhatrapati Shivaji Hospital in Kalwa.

Sources at Vartak Nagar hospital say that three premature babies died between May and December 1997, since the incubator stopped working.

As hospital authorities and the health department pass the buck, both hospitals have neither incubator nor its substitute, a radiant warmer.

On-the-job training…

In Tura, the main town of the Garow Hills in distant Meghalaya, a laboratory assistant is appointed at the civil hospital. The earlier one is transferred, although regarded as competent. Doctors in the hospital are chatting casually with him.

Where had he last worked? they asked. Not in a hospital, he replied. Then perhaps in a private clinic, they said. No, said the man, fumbling for an answer. Had he done any work in medical labs before? No, came the reply. So what was his experience, they asked in alarm. He had worked as a teacher in a primary school. But he had been appointed to the post on the recommendation of a local politician.

One would feel extremely concerned about the fate of patients who have to go through the process of getting their tests done by someone who is not just under-qualified but not qualified at all.

A lab technicians job is a sensitive and crucial post. To place people who are not qualified for the work is not just an insult to the post and the medical community but also to the patient who go to government hospitals in the hope of getting better: Will this anomaly be corrected?

(From op-ed piece, Sanjoy Hazarika, Asian Age, December 18,1997)

Miracle septuplets?

The birth of septuplets in the US sparked intense criticism from ethicists and doctors warning that fertility treatments are used indiscriminately and irresponsibly, writes Rick Weiss in the Washington Post (Peers criticise doctor of septuplets, Washington Post Service, International Herald Tribune, November 1997.)

All seven children born to Bobbi and Kenny McCaughey seem to be doing well. But multiple births beyond triplets usually are characterised by some degree of physical or cognitive disability, critics said. In most cases they can and should be avoided.

Dr Katherine Hauser said she had given Kenny the same dose of the drug that she had given her two years earlier, which led to the birth of a single daughter.

But critics said that when Hauser saw that the fertility treatment had led to the maturation of about three times the expected number of eggs, she should have withheld the addition of the husband’s sperm and tried again when a more modest number of eggs were produced.

It would have been obvious that Mrs McCaughey’s ovaries had over-reacted to the drug, said Mark Sauer, chief of reproductive endocrinology at Columbia-Presbyterian Medical Center in New York. “That’s not even a borderline call, it’s a cavalier decision.”

Ovarian over-stimulation can cause swelling and bleeding of the ovaries and severe fluid retention that can lead in rare cases to heart failure. Women carrying multiple foetuses also are at risk of potentially fatal blood clots and other complications during pregnancy and delivery, and the children often require expensive follow-up care for years.

Reproductive medicine and research in the US is unregulated and confined to private clinics. “By and large infertility treatment in this country has grown up as an entrepreneurial rather than scientific field, so many of the things doctors are doing . . . have not met the same standards of scientific scrutiny…,” said Thomas Murray, director of the. Center for Biomedical Ethics at Case Western Reserve University, who said he did not begrudge the parents’ decision to carry all seven foetuses to term.

Prison hospitals

The National Human Rights Commission has asked the Maharashtra state government to pay an interim compensation of Rs 25,000 to the next of kin of an under-trial in Kalyan district prison, Thane district, who died due to the lack of ‘reasonable, prompt and adequate medical faclities.’ The October 1997 newsletter mentions that the jail which lodges more than twice its authorised capacity of 540 has a 10-bed hospital but an absentee doctor. Laxman Somnath Varma, who had been treated as an indoor patient twice before his death, complained of breathlessness and chest pain. The compounder administered an injection but did not refer him to a central hospital in time.