Increasingly there is a consensus on people’s right to quality health care, including access to information and counselling services. Among the organisations which have spoken of health and human rights are the International Planned Parenthood Federation and the 1994 International Conference on Population and Development. A recent court order in Delhi banned strikes by hospital employees, citing the need to protect patient’s rights to health care. Professional organisations such as the Indian Medical Association have held continuing education programmes for their members on the rights of people in custody, on how medical professionals should respond when confronted with evidence of torture, and so on.
However, as our health care system is faced with a growing number of people with HIV and suffering from opportunistic infections, the national media is beginning to report instances of human rights violations in this context. Some groups such as sex workers and truck drivers have often been subjected to compulsory HIV testing without pre-test and post-test counselling. Hospital patients who have been tested without their consent have sometimes committed suicide when confronted with the results of the test. Women in labour have been refused entry into maternity homes and have even been forced to deliver their babies on the roadside.
In several instances the view is expressed that people’s individual rights can be given a back seat to protect the public’s health. The argument is that halting transmission of the virus depends on our identifying and isolating those with HIV. Such an approach actually further increases people’s vulnerability to HIV/AIDS.
The fact is that public health interests do not conflict with human rights. There is need to understand the complex relationship between the public health perspective of preventing disease transmission and the human rights perspective which calls for reducing vulnerability, stigma and discrimination.
Currently, HIV screening and diagnostic services are available at a limited number of facilities in the public sector. Guidelines for HIV testing require pre- and post-test counselling to be provided, as also confirmatory tests in the case of a positive result. The second phase of the National AIDS Control Programme envisioned that each district would have one voluntary counselling and testing facility.
However, many reports indicate that private sector health care institutions are carrying out routine and universal HIV testing — not for screening or diagnostic purposes but in order to know the patient’s HIV status. People testing positive for HIV are either denied care or referred to other facilities. Needless to say, this is done without pre- or post- test counselling – so the first casualty is the principle of taking a patient’s informed consent to being submitted to any medical procedure. Doctors argue that they need to know their patients’ HIV status before they undertake even minor surgical procedures so as to protect themselves.
Universal testing without consent is conducted along with another routine – and unethical — practice. These test results and the patient’s other identifying information are available for anyone to read. No precautions are undertaken to conceal the identity of the person whose blood sample is subjected for HIV testing. Similarly in hospital wards there are instances when a patient’s HIV status is noted in bold letters and so that everyone including attendants of nearby patients is aware of this information – in a clear breach of confidentiality.
It is generally agreed that universal precautions need to be followed in health care settings to prevent transmission of infections. In many health care settings providers are either not aware of universal precautions, or they simply ignore such practices.
Invariably this is a problem caused by providers’ attitudes, not scientific realities. Take the case of obstetric care. A number of reproductive tract infections can be spread from patient to provider or to subsequent patients if the basic principles of asepsis are not followed. Hepatitis B and HIV are two infections that can be transmitted by the reuse of contaminated sharps, specula and gloves. Since many patients are asymptomatic, it will not be possible to know as which patients have infections. For this reason universal precautions must be followed regardless of the person’s known or suspected infection status. In this context one also needs to understand the importance of proper disposal of hospital waste.
In India , most deliveries are still conducted by traditional birth attendants or ‘dais’. Several training programmes have been conducted in the past and currently to upgrade their skills so that they can conduct clean deliveries, recognise complications early and refer them to other services. Unfortunately, most training programmes do not provide training on the use of gloves for conducting deliveries. Dais are at high risk of exposure to HIV transmission as they come in contact with blood and placenta. Also, gloves are not provided with most disposable delivery kits.
It is imperative that health care providers in both public and private settings be oriented to respect people’s rights with special reference to HIV/AIDS. It is of no use to blame doctors and paramedics as this is a problem born out of ignorance. They must be educated properly.