Special issue of Humanscape 1997; 4: 1-42

Focussing on a broad range of topics, this journal has striven to uphold standards and highlighted fearlessly our existing deficiencies.

The special issue on medical ethics is edited by Dr. Amar Jesani. The essays on this subject occupy 33 of the 42 pages and include analysis of euthanasia (Kannamma S. Raman), organ transplantation (Sanjay Nagral) and the facilities provided for health care in the public sector (Rashmi Lakshminarayana). The latter essay brings out forcefully the declining interest shown by the central government and those in most of our states in providing for the health and treatment of our poorest citizens. The table showing the availability of dispensaries and health centres in our states is especially revealing. Kerala is the only state where 90% of villages have a dispensary within two kilometres and 47% have a health centre in the same range. Contrast the figures for a state such as Maharashtra, where our rulers claim that they are enlightened. Dispensaries are avaiiable within two kilometrcs to just 22.3% of viliages and health centres in the same distance to just 7% of villages! It is a matter of considerable surprise that corresponding figures for Bihar are 25% and 31%. The data analysed in this essay demands careful study and corrective action.

Rama Baru discusses ‘philanthropy for profit’ – an apt title for an essay dealing with our private and ‘charitable’ hospitals. Whilst no one grudges the need for private hospitals to make a profit, when this is done after availing themselves of tax concessions on the basis of professed concern for the poor and through the misuse of the same high technology equipment thus imported, the failure of our regulatory agencies becomes especially worrying. Take this essay together with that by Sunil Kaul (‘ If one were to attempt a classification of quacks, it may be well to start with senior professors…’) and you are made well aware of the lack both of rationality and ethics in medical practice.

Is the solution proposed by Thomas George (eliminate the profit motive and stop private practice) feasible?

The closing section provides two accounts by the relatives of patients of their experiences with doctors. In both instances mcdica! negligence has been alleged, Navin Shah, settled in USA, discusses the role of litigation. It is a pity that the last page, entitled Human Index, has not been exclusively devoted to facts from Indian medicine. These would have proved especially effective in underlining the contents of many of the preceding essays.

The gravest show on earth: America in the age of AIDS. Burkett Elinor, Houghton Mifflin Company, Boston. 1995. 399 pages.

(This book is available at the library of the American Center, Mumbai. 362.1969792/BUR)

Introduction

This is an extraordinary account of the evolution of our understanding of the disease produced by the virus that destroys immunity in humans. It contains the fruits of seven years of research on the subject. For anyone interested in learning the truth on this disease, this is a book that must be read.

You will get some idea of the quality of what is on offer from the first and second paragraphs under ‘Acknowledgements’:

No individual ever authors a book alone. Books, like ideas in them, reflect a complex series o f interaclions, relationships and experiences that form a unique consciousness.

Three of the individuals whose influence is stamped most heavily on this work are dead. Enrique, Juan and Miguel shared their deaths with me. In doing so they offered me the profound gift of a series of lessons in fear, pain and morality, as well as the courage and grace about which so much is written. Mostly they taught me about honesty – for when your life is narrowing to fewer and fewer weeks, and to increasingly confined spaces, truth emerges from the ruins of banality with extraordinary clarity. If I no longer mince words. it is because I have learned, in the most profound way, that there simply isn’t any lime.

Truth – sacrificed to other interests

Burkett shows how easily truth becomes a casualty of competing interests; commercial, political and scientitic. She provides details on several individuals. The story of Larry Kramer– novelist and playwright, fund-raiser for those suffering from AIDS and self-appointed consciencekeeper with a genius for converting friends into opponents – is fascinating.

Her narrative of the ‘discovery’ of the AIDS virus by Robert Gallo championed by American media and politicians – and demonstration of how credit was snatched away from the true hero, Luc Montagnier of France, by Gallo; is just one of the fascinating glimpses offered by her of what went on behind the-scenes. She also describes how Jonas Salk (of the vaccine fame) provided incomplete information on his own researches on HIV in such a manner that his company’s stock prices kept moving upwards.

She tells of how Henry Heimlich (famed for his maneuver to free the airway of an ingested obstructing agent) touted the malarial plasmodium as a cure. She weaves the different threads of her narrative deeply and effectively.

Transmission of HIV virus from dentist to patient

The story of Kimberly Bergalis (in Chapter Eight entitled The immaculate transmission) is especially stomach turning. This girl, who was a virgin, had never used drugs or received a blood transfusion, when she developed AIDS. The infection was eventually traced to the removal of two of her teeth by Dr. David Acer, a homosexual dentist, two years earlier. Acer tested positive for HIV and developed AIDS. Even after this information became public knowledge, reporters continued to ask whether her hymen was intact and whether there was proof that she had never had anal penetratton. Others called her a slut and worse. On her death from AIDS, her parents were sent obnoxious letters, one of them stating: ‘Thank God the bitch is dead. She got what was coming to her.’

Capitalising on AIDS

The chapters dealing with the ‘AIDS gravy train’ shock the reader in the manner that the author fully intended. That individuals – including scientists – and corporations should do everything in their power to profit from the AIDS industry leaves us numb. Consider just some of the spheres which have spawned venality: researchers flying from one conference to another – almost always in five-star hotels in exotic locations, the biotechnology and pharmaceutical trades, manufacturers of condoms and other such accessories, AIDS and bereavement counselors, AIDS spokespersons and activists heading large Issues in MEDICAL ETHICS Vol. 5 No. 3 Jul-Sep 1997 organisations. The book is amply documented. The section listing and describing her sources covers twenty-two pages.

Conclusion

If you look for sentimentality in this book, you will be disappointed. If, however, you are searching for the facts behind the masks, camouflages and cover-ups, you’ve opened the correct volume.

Diagnosis of Occupational Diseases. Eds: Murlidhar V, Vijay Kanhere, New Delhi: Society for Participatory Research in Asia (PRIA). 1996.

Impairments, Disabilities and their assessment. Eds: Murlidhar Veena, Murkidhar V, Kanhere Vijay, New Delhi: Society for Participatory Research in Asia (PRIA). 1996.

A few years ago on a visit to the Western Coalfields Hospital at Chandrapur I was asked to demonstrate upper gastrointestinal endoscopies on patients at the hospital, all of whom were coal miners. I was surprised to find a large number of these patients suffering from severe gastritis and peptic ulcers and naturally wondered whether their exposure to coal dust could in anyway be responsible for this. I inquired with the local doctors who confirmed the high incidence of these diseases but were themselves not sure whether this could be related to their occupation. I realized how poorly equipped and trained we were as medical professional to identify possible occupational sources of disease and I am sure all of us from whichever field of medicine encounter such situations in our practice. In a sense this is a failure on our part to sensitize ourselves to a very important aspect of our patients’ problems which has major social, legal and financial implications

It is against this background that the above books written by doctors and health activists who are not full time occupational health practitioners, but are working voluntarily in the field, form an important contribution to an area in which there is very little written in proportion to the problem in India.