VOX POPULI

Medical practice in Delhi (1)
Ten to twenty per cent of Delhi’s fresh medical graduates leave the country without even attempting to obtain further qualifications here. Others trickle out after having completed their post-graduation. Even medics who scale great heights continue to say their prayers looking westward. Some even change their field of work to reach El Dorado.

This migrant is rampant not because access to the US is easy for the medico. Far from it. Even for the lucky few who have got their passports stamped and the air tickets in their pockets, the ordeal is far from over for there are the hospital interviews. And then, one is never sure of getting a residency of choice or even getting one at all. The fields offered are predominantly non- surgical and in the black- dominated areas where the white person fears to tread.

The odds are, indeed, heavy. And yet, the mass exodus continues. The reasons become clear when one takes a look at the scenario back home. For a young doctor trying to get established, the struggle is hard in India. Here, a young doctor has two broad options: he can either join a public sector organisation such as a teaching hospital or establish lucrative private practice.

Doctors who join public sector institutions do have an aura. One can aim at setting up an ethical practice and at least hope for some research facilities. But often the journey is arduous, against a strong hierarchy where yesmanship, not merit, is the key. Recently, the head of surgery of a prestigious government hospital passed away. His juniors swore by his surgical expertise and dedication. When he died his bank balance was a mere Rs. 3,000.

Even the working environs are far from conducive. For resident doctors, basic facilities like drinking water and clean toilets are scarce. Recently, the water supply of a major hospital in the heart of Delhi was found to be polluted with sewage, leading to an epidemic of jaundice among the doctors working there.

Naturally, the majority want to do private practice. Competition in the private sector is fierce, which does not always allow ethical practice. Cuts and commissions are quite common and it is important to be a member of a doctors’ clique.

Transmission of hepatitis B (2)
A large number of people at Sirsa in Haryana were found to be infected by hepatitis B. Investigations showed two quacks practising in this area, using a single syringe each for all their patients without boiling them or changing their needles.

There could be any number of such areas where deadly diseases, easily acquired through infected needles and blood, are spreading in the absence of stringent mechanisms to prevent the reuse of unsterile syringes and needles.

Even qualified doctors are not sure of the quality of needles and syringes being used by them. Former president of the Delhi Medical Association, Dr. Vinay Aggarwal, says: “It is very difficult to know whether the syringes being used by us are recycled or genuine.” Disposable syringes and needles, which should be destroyed after the first use, are in wide circulation.

A study conducted in Calcutta by the All India Institute of Public Health found that 56% of the disposable syringes and needles being sold were contaminated! The samples used in this study were obtained from the supplies departments of major Calcutta hospitals and private nursing homes. The samples had come from eleven leading manufacturers. Eight of the forty-eight samples did not have the date of manufacture or expiry stamped on the packages.

Although rules exist for the destruction of syringes and needles after their initial use, there seems to be no system for preventing expired and infected needles from being sold again.

Recycling AIDS among patients and rag- pickers (3)
Shahid and Habibulla - brother and sister aged eight and ten years - are proud of the fact that they earn much more from scavenging than their mother. Every morning at 4 a. m. they join several others at the King George Medical College (KGMC) in Lucknow. Each of them goes through garbage dumps outside the emergency and private wards and fishes out disposable needles and syringes, not yet destroyed, which have ended up in the garbage bin. A day’s collection fetches them thirty to forty rupees from a agent in Daliganj.

Shahid’s hands are pricked all over. He dismisses this casually. He has never heard of AIDS, hepatitis or any other health hazards. He knows nothing about what happens to the stuff they deliver. There are scores of children participating in this predawn activity near all the major hospitals in Lucknow. "It is common knowledge," says Dr. N. C. Mishra, former head of the department of surgery at KGMC. "The reports are very disturbing, indeed," said Dr. Asha Mathur of the department of pathology, KGMC. "It is not only syringes. Even catheters and plastic urine bags are being recycled in Lucknow. This could result in a disaster." Dr. Sanjeev Kumar of the department of surgery, KGMC, calls it an organised racket every doctor in the city knows about. Yet nothing is being done about it.

Another senior professor who insisted on anonymity, was more forthright. "Why only urchins? Even the wardboys and sweepers in the hospital recycle the used syringes and needles by selling them off at the drug stores outside the KGMC gate." Dr. Malini Gupta (not her real name) admitted that herkabari gives triple the amount for the non- damaged syringes than that for damaged syringes.

Dubious pathology laboratory (4)
Dr. Bharat Shah, consulting nephrologist, P.D. Hinduja Hospital, says: ”I can never be comfortable relying on test reports done at labs outside my hospital because most path labs in the city (nearly 70 to 80%) do not have proper equipment, technology or personnel. Also the medium that is used and the conditions under which the tests are carried out are never right...”

Mahendra Ojha, hospital planning and health consultant, concurs. “In the absence of any regulation and licensing by the authorities, hundreds of labs are mushrooming in the city, (Mumbai has over 1,500 labs) without even meeting the basic standards. But we do not seem to realise the gravity of the situation...”

Path labs, Ojha reveals, have become major money making rackets with businessmen now entering the line. Since no doctor can function today without a pathologist’s report, this branch of health care has become a high revenue generating field. “The profit margins range from 100% to 300% on any given test.”

Food and Drugs Administration Commissioner Anil Lakhina admits that in the absence of any legislation, the quality of investigations just falls by the wayside.

Where ignorance is not bliss (5)
A study in Chennai shows that the national drug policy relating to malaria is hardly being followed by many medical practitioners.

Of the more than 1,000 questionnaires sent to doctors in government service and private practice, only a handful were returned for analysis.

As many as 20.6% of doctors studied did not know that primaquine could not be administered to pregnant women. Five per cent of doctors came up with the shocking opinion that blood could be donated by patients with malaria.

Nine percent of doctors thought that malaria was rare.

Should a patient with AIDS be ostracised? (6)
The decision by Tata Memorial Hospital, Mumbai, to treat a staff doctor suffering from AIDS has driven a wedge in the hospital staff. Whilst one section calls it an unnecessary risk, the other says that it’s the least they could do for an ailing colleague.

Colleagues suspect he must have acquired the infection from one of the many patients he attended to during his ten- year- long service in the hospital.

A surgeon with the Head and Neck Department, the doctor is now languishing in near- isolation in the septic room of the Intensive Care Unit. Not many doctors, paramedics and conservancy staffers are willing to go anywhere near this room.

Doctors requesting anonymity pointed out that even if bare traces of HIV virus are diagnosed in a patient, he/ she is immediately transferred to the designated government hospitals. They ask: “If this doctor can be treated here, why are others shunted out?”

HIV- AIDS: the unkindest cut (7)
In a recent bizarre case, the employee of a nationalised bank was barred from entering its premises when he was found to have tested positive for HIV. When he insisted to attending to his duties, the bank referred the case to the district collector, who, in turn, entrusted the case to the police who went on to issue an arrest warrant. It is only after officials of the AIDS control project intervened on his behalf that he was able to continue work.

Especially ironic is the outcome in a project aimed at setting up a rehabilitation centre for HIV- positive patients on the premises of a leprosy hospital at Kukutpally. This was vehemently opposed by the inmates, themselves suffering from leprosy.

Breach of confidentiality ostracises an entire village (8)

Chochi, better known as ‘AIDS village’ under Jhajhar tehsil in Rohtak district of Haryana, where Ranbir Singh died of the virus, is facing serious social alienation and humiliation. It is not just the future of Ranbir’s three daughters that is in jeopardy but that of the entire population of 4,500.

Surrounding villages have isolated Chochi in fear of an epidemic. It is almost impossible for the villagers to escape from the stigma of living in an AIDS village.

A move is afoot to set up a high- level committee of experts from the Indian Council of Medical Research to investigate the unethical behaviour on the part of doctors in the hospital and disclosure of the blood status in utter disregard of the direction of anonymity.

Dr. D. R. Gaur, head of the Department of Community Medicine, bemoaned the fact that no proper guidelines or training have been provided to face a situation such as that in Chochi. "We have only clinical information which, too, is confusing when we have to deal with people. The social aspect is missing in the entire campaign and I am confused about how to reach out to the people."

HIV- AIDS continued (9)
A study of seven industries in Mumbai by researchers from Yale University and the local AIDS control centre reveals widespread suspicion that AIDS can affect the company’s business or production. There is also a feeling that the presence of individuals testing positive for HIV mean bad publicity for the company. This has led to the emergence of a ruthless streak where, on the one hand, some companies openly test prospective and current employees for evidence of infection by HIV and, on the other hand, other companies secretly obtain information on the HIV status of their employees through blood donation drives. Infected employees are either fired, asked to retire early or moved to a location within the factory where there is hardly any contact with co-workers.

It is estimated that 0.5 - 2% of all factory employees are HIV- positive. Inevitably, the industries in the city will soon be feeling the impact of the epidemic.

No company has a formal, written policy on HIV/ AIDS in the workplace. Prevention activities, if conducted at all, are one- time occurrences that have little impact on the employees.

Doctors drive AIDS patients to quacks (10)
The failure of the medical profession to attend to patients with AIDS or offer sympathy and understanding has driven them and their relatives to quacks, with disastrous results. Not only have the patients worsened and died but the attempt at obtaining a cure results in the loss of savings made over a life time. Worse, quacks convince patients that they can marry and have children, passing on the virus to the hapless spouse and children.

Left with nothing but shattered hopes and weakened health, hounded by discrimination, Indian patients with AIDS are losing the will to live and are dying faster than in other countries.

The few doctors who are working for these patients fight a losing battle and risk being burnt out.

Maharashtra’s deputy health secretary, Arun Ghate, offered a typically bureaucratic solution. He asks patients and relatives to complain against doctors in public hospitals who deny treatment, cheerfully disregarding the fact that those already known to be flouting rules continue to flourish on account of their political connections. He also pleads powerlessness on the part of the government against erring private practitioners:

The response of an unnamed general practitioner embodies some of the common arguments offered by doctors: "I will not treat AIDS patients for three reasons - their presence brings down the image of my practice; I have no time for patients who need long- drawn treatment; and there is little point in taking on such patients when I cannot offer them a cure."

Should the HIV positive patient inform his wife? (11)
This report focuses on the dilemma of a man who has been married a month but has not yet informed his wife that he had tested positive for HIV seven years ago. He defends himself by saying that he protects his semi- illiterate wife by practising safe sex, under the rationale that he does not wish to have a baby just yet. "It is terrible when my wife pleads with me not to wear a condom since she wants a baby," he says. Instead of telling her the truth, he had told her and her family that he suffers from cancer before they got married. In an earlier, three- year relationship too he had told his girl friend that he had cancer. It was only when she insisted on marriage that he revealed the truth. Ugly scenes followed.

Like many others with HIV, he blames his parents for insisting that he marry. He has decided to commit suicide when he develops full- blown AIDS. "I do not want my illness to be exposed." He fears that his wife will be ostracised after his death.

The painful story of paracetamol (12)
Nine of eighteen brands of paracetamol have failed in recent laboratory tests specified in the Indian Pharmacopoeia and the US Pharmacopoeia, conducted by the Consumer Education and Research Society (CERS), Ahmedabad.

‘Calpol’ of Burroughs Wellcome, ‘Metacin of Themis Pharmaceuticals and ‘Crocin’ of Duphar Interfran were amongst those scoring the lowest ratings in the nine brands that passed the test.

Regulatory authorities such as the FDA must explain the role it contemplates when fifty percent of the tested brands of paracetamol - which are available without prescription - have failed to meet the standards laid down.

Toxic ‘tonics ‘ (13)
Several samples of popular ayurvedic ‘tonic’ preparations, when tested, were found to contain high levels of lead, warns the Consumer Education and Research Society (CERS) in its journal Consumer Currents. The preparations tested were Suvarna Vasant Malati Bruhat, Suvarna Malini Vasant, Suvarna Vasant Malati Rasa and Suvarna Vasant Malati. These are recommended for the treatment of weakness and debility. If one pill of some of these preparations is taken twice a day, the weekly intake of lead can be 63.2 to 74.6 mg, The lead content absorbed from these preparations is 14 to 28 times higher than the weekly permissible limits recommended by WHO.

In another published report, Professor B. N. Mishra and Dr. B. K. Mohanty showed that several ayurvedic medicines tested by them had high levels of mercury.

Another exercise in futility (14)
A cell set up by the Union Ministry of Health and Family Welfare to look into complaints against doctors has failed to take off.

The cell was set up amidst great enthusiasm by former minister of health, Salim Sherwani in March, this year. Soon thereafter, it started receiving complaints from all over the country - a total of 76 complaints in four months. The largest number have been from Delhi, followed by Uttar Pradesh. These range from complaints on negligence by doctors to those on thefts in medical stores and nonavailability of drugs.

The cell had promised strict action against doctors found guilty.

None of the sixteen states from where complaints have been received have responded to the health ministry’s move.

Officials in Delhi were deeply disappointed. "We don’t have a mechanism. If states don’t take up the complaints seriously, there is nothing that we can do as health is a state subject."

Recognition of hopelessly inadequate medical college (15)
Sitting in a makeshift office in a flat in Ghaziabad’s Pratap Vihar, R. S. Thakur, Director (Administration) of Santosh World Medical Academy, told this reporter, when he posed as a poor student wishing to join the medical college: "We charge Rs. 25,00,000 for an MBBS seat in the NRI quota. (The) maximum we can come down (is) by a lakh."

This World Academy is run by Dr. P. Mahalingam, the personal physician of Bahujan Samaj Party chief Kanshi Ram and functions out of five houses on the outskirts of Ghaziabad. It survives through chronic violation of all rules.

The makeshift lecture theatres have leaky roofs, living rooms have been converted into classrooms whilst one of these houses serves as a mortuary. Each student pays Rs. 10,000 as library fee but the physiology, pathology, biochemistry shelves are barren. Anatomy has a few books, all donated. There is no campus boundary which demarcates this cluster of buildings from surrounding fields and private houses.

The college is affiliated to Meerut University and offers courses towards MBBS, BDS and degrees in physiotherapy and occupational therapy. Though the authorities say that the college is well staffed, second year students say their preclinical classes have not yet begun due to shortage of teachers.

Despite an adverse report from the Medical Council of India, the college started functioning in January 1995 after the State Health Ministry gave its sanction.

Several students said that receipts were hardly ever provided and when they were, the amount said to have been received was much less than that paid and it was scribbled in pencil on a scrap of paper.

The principal of the college, Dr. Bishnu Kumar, served as an inspector for the Medical Council of India before resigning to join here.

Doctors who advertise (16)
The lure of filthy lucre seems to be eroding the medical ethical codes as well. In Maharashtra, the state medical council is grappling with several cases of self-glorification by doctors who are ‘marketing’ themselves through advertisements in newspapers with claims of successful ‘rare’ operations, fancy fitness and weight- loss programmes or ‘guaranteed’ cures for cancer and other dreaded diseases. Far from confining themselves to their consulting rooms and allowing their good work to speak for them, doctors are increasingly taking to brash marketing methods or dubious consultancy columns and TV talk shows to promote themselves and their ‘business’.

The Maharashtra Medical Council recently cancelled the registration of a celebrity doctor who modelled for a well- known Ayurvedic tonic after he refused to apologise for such crass commercialism. Similar action has been threatened against another who appeared in a commercial for a toothpaste. The council is also proceeding against a doctor who has placed advertisements in newspapers for her slimming programmes.

Self- promotion in any form is a punishable offence under the apex Medical Council of India’s rules and the state council’s code of ethics which even bars doctors from publishing their photographs. But so rampant is the practice now that a physician even published a calendar with his name, address, degrees and pager number.

It is obvious that only strict vigil and action by medical councils can put an end to such pernicious practices. But then, going by the wall graffiti, huge hoardings and newspaper advertisements some of physicians in north India put up to proclaim their expertise, the Medical Council of India does not seem bothered by such violations of its codes and rules.

References
1.Mahendru Saurabh: The Big Apple a day, keeps doctors away.The Times of India22 June 1997 p 18.
2.Jain Kalpana: Recycled syringes are taking lives.The Times of India22 June 1997 p 19.
3.Mishra Manjari: Racket in recycled syringes, needles exposes rag- pickers in UP to AIDS.The Times of India12 July 1997 p 9.
4.Rohera Draupadi: Government proposes regulations as dubious pathology labs flourish in city.Bombay Times,The Times of India17 June 1997 p 1.
5. Staff Reporter: Few takers for drug policy on malaria.The Hindu22 June 1997 p 3
6. Sequeira Rosy: Dot with AIDS divides hospital staff. Express Newsline, The Indian Express21 June 1997 p 1.
7. Kumar Manjula G: Stigma overpowers AIDS control in Andhra.Indian Express3 July 1997 p 5.
8. Jha Shivanath: AIDS- ridden village faces ostracism. Indian Express15 July 1997 p 5.
9. Chinai Rupa: City industries rake defensive approach to AIDS.The Times of India5 July 1997 p 5.
10.Chinai Rupa: Doctors drive AIDS patients to quacks.The Times of India14 August 1997 p 1.
11.Martins Reena: Should I tell my wife? Dilemma torments HIV-positive man.The Bombay Times, The Times of India, 13 June 1997 p 1.
12. Deshpande Shirish: The painful story of paracetamol.Bombay Times, The Times of India26 June 1997 p 7.
13. Anonymous: When that tonic becomes toxic.Deccan Herald26 June 1997 p. 10.
14. Jain Kalpana: Cell on complaints against doctors fails to take off. The Times of India15 July 1997 p 8.
15. Shivani: Kanshi-backed medical college thrives in flats.Indian Express11 August 1997 p 4.
16. Anonymous: Treating doctors.The Times of India18 August 1997 p 13.