Defining Health & Population
The Print asks: Can a law prevent attacks on doctors or should govt address overburdened healthcare system?
Enacting yet another state-implemented central law won’t assure protection to doctors
Former secretary, Ministry of Health & Family Welfare
The protesting doctors are demanding security, which should get support from any right-minded person. But a central law will neither help nor prevent such incidents. An assault on a doctor is an assault on a public servant on duty, which is already a cognizable offence – in that the police can make arrests without a warrant. Likewise, causing grievous hurt or an attempt to culpable homicide are both serious criminal offences carrying 2-7 years in prison.
Things do not become more effective by having a central law because practically all central laws have to be implemented by the state. Police can still refuse to act or water down the charges and the investigation with a central law. Enacting yet another central law will therefore not assure more protection to doctors.
The other important thing is that the law should cover all medical staff, and not just doctors, on duty. Often, nurses, pharmacists and technicians also face patients’ or their relatives’ wrath.
A protective mechanism is required at the hospitals’ hot spots, which are mainly two — the emergency and casualty departments, and the major operation theatres.
Having an effective watch and ward system, CCTV coverage, a standard operating system for isolating caregivers and counselling them, calling the police and recording the FIR will enable a documented record to be maintained, which would place the onus on the police to act regardless of pressures.
A localised system can nip such cases in the bud. A standard protocol must be notified by the health secretaries, and shared with the doctors and the public. It does not need another law. It needs accountability.
Desh Deshantar: डॉ़क्टर, हड़ताल और इलाज | Doctor on Strike
कोलकाता के NRS मेडिकल कॉलेज में एक रोगी की मौत के बाद दो डॉक्टरों साथ मारपीट के विरोध में इंडियन मेडिकल एसोसिएशन के आवाह्न पर देशभर के डॉक्टर अपनी सुरक्षा की मांग को लेकर हड़ताल पर रहे। डॉक्टरों का कहना है कि अभी तक पश्चिम बंगाल की सरकार ने उनकी मांग पर कोई ठोस कार्रवाई नहीं की है। डॉक्टरों की मांग है कि मेडिकल प्रोफेशनल्स के साथ होने वाली हिंसा से निपटने के लिए केंद्रीय कानून बनाए जाने की जरूरत है साथ ही अस्पतालों को सेफ जोन घोषित किया जाना चाहिए और सुरक्षा की पूरी जिम्मेदारी स्थानीय सरकारों की लेनी चाहिए।
Guest: Dr. Rajan Sharma, National President, IMA, R. K. Srivastava, Former Director Health Services, GoI, Shailja Chandra, Former Health Secretary, GOI,
Anchor: Kavindra Sachan
As Alabama passes one of the most controversial abortion laws in the world, we discuss women’s right to bodily autonomy and we also take a look at abortion laws back home.
Dr. Rita Bakshi, Sr. Consultant,Infertility Specialist & Endoscopy Surgeon; Shailaja Chandra; Lalitha Kumaramangalam, Director, India Foundation; Shanti Auluck; Sapna Kedia and Sneha Mukherjee
Anchor – Barkha Dutt
Former Secretary to the Government of India and former Chief Secretary, Delhi Ms. Shailaja Chandra, in conversation with Arghya Sengupta (Research Director, Vidhi Centre for Legal Policy) and Shruti Kapila (Faculty of History, Cambridge South Asia Institute) on the challenges to building a transformative healthcare system in India and why the government doesn’t spend enough on health. Listen in to episode 5 of our ‘Standpoint’ podcast series, jointly brought to you by the Vidhi Centre for Legal Policy and the Cambridge Centre for South Asian Studies in association with The Times of India.
Source: Vidhi Centre for Legal Policy, Cambridge South Asia Institute, TNN
The National Medical Commission Bill 2017, well-intentioned and forward-looking, has unfortunately stirred a hornet’s nest. It has brought to the fore a disturbing aspect of an ongoing controversy — the activities of medical lobbies that have persistently thwarted efforts to put consumer interest above their own. Parliament needs to face some unsavoury facts.
Two lobbies are at work backing the professional interests of the allopathic community on the one hand and AYUSH practitioners (mainly ayurveda, unani and homoeopathy physicians) on the other. There are some 10.4 lakh private medical establishments with hospitals accounting for under 8 per cent of them. Most are lone practitioners running small nursing homes and clinics. Most do not possess a medical qualification. A 2016 WHO study has brought out that only 58 per cent of urban doctors had a medical degree and only 19 per cent in rural areas. Only 31.4 per cent of allopathic doctors were educated to the secondary school level and 57.3 per cent did not have any medical qualification. NSSO reports show how barring the metros and large cities, there are more unqualified practitioners than regular doctors.
The interests of all allopathic doctors, regardless of their competence, are looked after by the Indian Medical Association (IMA), a voluntary registered society with state chapters which register doctors as members and lobby with the government, resorting to agitations and strikes whenever doctors’ interests are affected. An all-India membership of over two lakh gives the IMA immense clout so that most chief ministers and even the Union health ministry avoid confrontation.
Many of the IMA’s members are single practitioners and they run their clinics with the assistance of young school dropouts engaged as helpers. They train them to handle acute illnesses and treat acute medical conditions with antibiotics, IV fluids and steroid injections. Once sufficiently skilled, these assistants set up independent practice using the prefix “doctor”. They run a lucrative business charging a fraction of a qualified doctor’s fees. When patients do not respond to treatment, they refer them to a known qualified medical practitioner who remunerates them with a 30 per cent commission.
The IMA and the Medical Council of India, both at the apex level and in their state units, are aware of what is happening. While their public position is that quackery must be stopped, covertly, both organisations look the other way. The nexus between the unqualified practitioners or RMPs (Rural not-Registered medical practitioner) is apparent from the virtual absence of action against thousands of quacks. The IMA, instead, targets ayurveda, unani and homoeopathy practitioners who hive off their business. Since RMPs are part of the business and generate referrals, action — when taken — is perfunctory.
The National Medical Commission Bill 2017 and for that matter the National Health Policy 2016 overlook this countrywide phenomenon altogether. Under law, the Medical Council of India and the state medical councils are enjoined to take action against those who practise allopathic medicine without being enrolled on the allopathic medical register. As consumer safety is at stake, this is a serious omission from a bill which seeks to replace the medical council.
The practitioners of Indian medicine also constitute another powerful lobby. The National Integrated Medical Association (NIMA) lobbies forcefully in favour of “ integrated practice”. At two national events, the prime minister publicly stated that ayurveda practitioners practise modern medicine and very few use traditional medicine. Even his observation does not seem to have had the required impact.
While the propagation of traditional medicine is publicly pursued with passion, the preponderance of treating with modern medicine is ignored. Authentic ayurveda is now confined to Kerala and western Maharashtra, other than a few government-run universities and colleges in different states. In North India, it is difficult to find even 10 practitioners of pure ayurveda excluding doctors employed by government establishments and colleges.
The development and propagation of the ayurveda system is left to a handful of committed researchers and faculty members in institutions like the Banaras Hindu University, Gujarat Ayurvedic University and Arya Vaidya Sala at Kottakkal and Amrita Vishwa Vidyapeetham in Kerala. The faculty in these institutions is worried. “If AYUSH graduates are allowed to practise allopathy, where does the status and the future of ayurveda stand? They should not be allowed to practise allopathy as otherwise the AYUSH systems will die,” lamented all faculty members I spoke to.
The new Bill must take stock of and address what the country actually needs. The first need is for thousands of community-level accredited practitioners — not full-fledged doctors — who after training should be equipped to provide the first line of care for acute conditions and to make referrals to a regular doctor within a GPS-supervised system. The realisation that neither allopathic nor AYUSH doctors will ever go to lakhs of villages — not even tehsils — must dawn on policymakers. That is precisely why a new system of community-based trained health workers (not government employees) who are enrolled on the state medical register is needed. This can only be done if the medical education law provides for it.
Second, the new Bill should promote integrative medicine enabling people to access multiple choices but available under one roof, particularly for chronic conditions or even as adjuvant therapy. The developed world has recognised that with an increase in life expectancy, chronic diseases, allergic syndromes and rare medical conditions cannot be cured — but the symptoms can be mitigated through traditional medicine. A quest for bridge courses to learn ayurveda has already begun in different countries. The new Bill should recognise the scope for integrative medicine but without mixing medical systems and practitioners.
Citizens are agitated over the mismanagement of both publicly-run and private medical education establishments. The government has done well to bring forward new legislation to replace the medical council. But unless the Bill confronts reality and addresses it, keeping consumer interest paramount, the new law will make little difference to people’s lives. The parliamentary standing committee has an opportunity to make a difference, if it shuns the rhetoric of self-interest professional groups and confronts reality.
The writer is former secretary, Department of AYUSH, government of India, and former chief secretary, government of Delhi.
Published on January 3, 2018
The Medical Bill is not as bad as IMA says it is
News that the Medical Commission Bill is to go before the Parliamentary Standing Committee has come as a relief. In its present form, the draft contains disturbing features. While it addresses many of the ills the 2016 Parliamentary committee had exposed, concerning decades-long mismanagement by the Medical Council of India, the new Act must overcome, not add to, the blunders.
To be fair, the Bill has taken care of three critically important drawbacks of the existing MCI Act. First it seeks to remove the stranglehold of doctors who for over 60 years have been deciding everything that affects their own professional well-being with absolutely no input from the very interests they profess to work for — the public. The 62-year-old MCI Act had given license to doctors to elect and appoint themselves to decision making positions — a situation which gave winnability precedence over professional competence and the need to confront serious public health challenges which go beyond clinical specialities.
By drastically reducing the elected element from the proposed Commission, the de-politicisation of the highest statutory standard setting body, greater transparency and responsiveness to the health needs of the country — not just of doctors — can be achieved.
Mandating an exit-exam is another progressive step in the Bill. It is of critical importance to test the proficiency of all graduating doctors through a common examination instead of relegating it to examining bodies with undulant standards. It would help reduce — might even end — the present mess created by partisan inspection systems, political interference and protracted litigation.
Yet, another plus in the new Bill is placing non-medical people on the Commission — a practice that prevails in many countries to safeguard public interest. It is essential to induct informed non-clinicians to bring balance and breadth of vision to decision making.
IMA’s vociferous rejection of all these positive strategies through mass representations by 3 lakh practitioners is nothing but an effort to sabotage the Bill; it shows how deeply embedded is the self-preservation instinct despite all the ills that exist. Comparisons with lawyers and engineers are mere red herrings; neither the curriculum nor the approval of colleges of those two professions are administered by their elected members.
The Bill has, however, got into muddy waters by alluding to the possibility of a bridge course in case a joint body of the medical regulatory councils decides to utilise AYUSH doctors to augment medical services. The mere inclusion of an intent has rung alarm bells. At two national events the Prime Minister himself has talked about the propensity of AYUSH doctors to practice modern medicine instead of using time honoured traditional medicine systems in which they have been trained. Any move to legitimise modern medicine practice by all Vaidyas, Hakims and Homeopaths would devalue the systems and demoralise genuine traditional medicine practitioners.
To even keep a window open to legitimise the practice of modern medicine by AYUSH practitioners negates the prescient goodness of the traditional medicine systems. From a public standpoint what India needs is a core curriculum for all students of recognised systems of medicine, to overcome the present ignorance and caste based divide that exists between different systems.
The writer is a former Secretary at the health ministry
A Lift? A Wall Hugging Chair? A Wheelchair that can Climb Stairs?
Options, Costs, Pros And Cons.
As one crosses the age of 70 ( and we’re both on either side of 75,) the question of managing stairs crops up regularly.The conversation also surfaces each time someone suffers from arthritis, backache or has a fracture.You ask yourself:
“ Should you just wait for that day when one of you needs support to go up and down stairs? How do you propose to manage that?”
The prospect of developing a heart condition, experiencing a sudden fracture or being unable to climb stairs for whatever reason is an unhappy one.Suppose one is stuck on the first, second or third floor without any back-up? Can this become a default situation for you or your husband,wife, mother or father?”
The children come on their annual visits and bring more “what if” questions.
“ Have you thought of one of those chairs that goes up and down along the wall?“ Have you considered a lift?”
I decided to undertake a literature survey and follow up with some field foot work.I am sharing whatever I have learnt.
Assuming neighbours and family are fully cooperative- (often they’re not,) here are your options:
Regular Lift option
1. Buying and installing a regular lift is terribly problematic once a house is built and lived in. It would entail first selecting and buying the lift.( The smallest Schneider variety for 4 passengers would be more than Rs 9 lakhs.) Depending on its capacity and type it would need space for a pit ( think of hammering away the floor inside or outside the house) a machine room, a place for the ropes and traction to be provided – not to speak of the drilling, hammering, breaking doors, windows, walls and roof which will be decided by the sort of house you live in. The company will demand that you get the preliminary civil works done and that will be costly .
Advice: On account of the high cost the conventional lift is clearly a No- No.The only way it would work is if there is enough space and FAR and some others in the building agree to share the cost.
Pneumatic Lift option.
2. The trigger to find out more about this sort of lift was running into a former colleague living in a DDA duplex flat in Vasant Kunj. We met each other after years and her first question to me was, ” Remember you talked about a lift some years ago? Well we did tons of research and installed one three years ago. It’s marvelous! I call it my rocket. It is a pneumatic lift which goes up-and-down from the first floor down to the ground floor right inside the house.My husband and I never need to use the stairs anymore because it’s right inside the house and occupies just one square meter of space.”
I knew her husband had a heart condition but the thought of going up and down in a lift inside the flat sounded a little bizarre. But then on WhatsApp she sent me three videos of this “rocket lift” in motion and I must say I was impressed. I requested for a contact number of the supplier. It took just one call to a Company named Grand Prix to have a knowledgeable agent calling at short notice.Armed with two glossy catalogues containing beautiful pictures of high end glass lifts for indoor use, he inspected the options in our house.
The first huge deterrent was the stated cost.My friend had paid Rs 12 lakhs 3 years ago.Now it would cost Rs 18 lakhs with GST and would be imported from Italy or Dubai.The lead time would be 4 months. I would also need to hive off 1 square meter from the ground floor and have a diamond cutting drill excavate two circles of cement – concrete in the roofs on the first and terrace floors to make a passage for the pneumatic lift.
The thought of explaining all this to my brother who is in Bengaluru over the phone and getting him to agree to drilling a hole in his Ground floor portion of the house, besides persuading him to let me annex one square meter of space ( howsoever unused, )was something I knew was destined o fail. In any case I did not have Rs 18 lakhs to spend on such a futuristic project, saddled with so many imponderables.
Advice: Drop the idea of a pneumatic lift unless you have complete independence to decide on its installation.But even so, at that price I would not advise it.At half the price it’s worth it!
Hydraulic lift option
3. I happened to meet someone who said “ Just install a hydraulic lift outside the house.It would be far, far cheaper, quicker and less disruptive.”
Encouraged thus, I rang “Just Dial At 22222222” (repeatedly advertised by Amitabh Bachan) and instantly got a list of suppliers. Even before I could start making my first call, two suppliers contacted me ( the telemarketers pass on your number to everyone in the field BTW,) and 2 suppliers set up time to come to the house to give a feasibility and cost estimate – on the spot.Both callers came on time, inspected the area and said much the same thing about the cost, time and installation requirements.
I contacted our architect – a conservative septuagenarian who had helped build the ground floor of my mother’s house in 1972. The firm was no longer building houses and had moved to industrial architecture.Even so his team was horrified at the idea of a hydraulic lift . But I persuaded them to at least meet one of the suppliers if not both.
Among the two suppliers one appeared more serious about sticking to timelines. He was a burly Sardar wearing a white safa. Although he had told me he had no technical qualifications, he proceeded to answer every question with complete confidence. When there were no more questions to be asked, the conversation got down to the business of asking for specifications and then the final price.It was quite reasonable- Rs 3 lakhs for 2 floors- ground to first to terrace. Converting two windows into outlet doors for the lift would be my responsibility but Sardarji undertook to provide a platforms between the lift and the door for access.
It all sounded doable but in my mind many questions still remained unanswered. How long would it take to be erected?
Suppose the Sardarji let me down midway? Suppose the whole business of breaking and converting two large windows into even bigger doors and erecting a platform above the sunshades to act as 15 and 30 feet high pathways into the lift looked or worse felt shoddy and unsafe?
After all you don’t live in a nice house to have some makeshift warehouse lift mucking up a clean and neat facade permanently! Besides I wasn’t sure that the MCD would take kindly to the contraption as it wouldn’t fit into their bylaws.
These forebodings apart, the price was so attractive and Sardarji’s enthusiasm so sincere that I too was convinced. A lift for three lakhs going all the way up to the terrace ! Imagine taking all my potted plants up in winter and down to the shaded portions in summer ! Imagine basking in the sunshine on the roof one minute and driving off to the market the next!The possibilities were enormous and very attractive.
It then struck me why not go and see a couple of lifts in actual use before clinching the deal?So I set up time to visit two homes in Rajouri garden and Jail Road after talking to the owners.Both had installed the lift for a mother and a wife both of whom were wheelchair bound needed to visit the hospital every now and then.They both expressed satisfaction. Armed with these telephonic assurances I met the Sardarji supplier at the Mayapuri metro station and was piloted by a him – he on a two wheeler and me in a car. I don’t think I would’ve found the addresses in 1000 years had Sardarji not zoomed ahead through umpteen turns and twists within rows and rows of houses.
The first house had rather a natty looking lift which was being used to transport the owner’s disabled wife from the first floor to the ground floor. The actual cabin and the pipe and trusses couldn’t be seen and the effect was of a smart but slow moving old Mumbai type lift.It was kept on a slow setting because the motor made a noise at high speed.
The second house I visited had made minimal investment and I could see the actual lift shorn of its smart interiors and cladding.It was like an open cage – sturdy without a doubt- but really quite ugly! Noisy too when the lift went up.Not noisy as it came down however.It was however safe and did its job.
I needed to sit down and work out all the details about the construction noise, cost, completion period , civil works, beautification and factor in all the appurtenances before taking a decision if I was going to pay a 30 % advance.
Sardarji had no place to offer except his own “office” which was in the heart of the industrial area. I followed him through the worst kind of metallic chaos coupled with deafening sounds of clanging metal, trucks dumping wares and dust and lethal fumes everywhere.We entered the factory- a large enclosure where it was impossible to make out what was gong on behind mountains of cylinders, poles lying alongside massive craters of iron scrap. Sardarji simply toodled up a rickety iron ladder which had 6 inch slats which perhaps qualified it as a “staircase”.He beckoned me to follow him with nothing to hold on to except the step above.I grasped each step above my head and climbed the 10 rungs up to his “office”. It was more akin to a metal machaan supported by a couple of angle irons. Sardarji’s spry father sprinted up and joined the discussion.Never having seen my house he too had a deft and convincing reply to every point I raised.I returned home all set to start on this project no matter what it took.But then it struck me that at least I should have a word with the tenants downstairs as the din the lift installation would entail could be insufferable.
Luckily we ran into each other late that night as I took our dachshund for her last pee under the lamppost. The couple had just returned after a late dinner and listened to me patiently.I told them my plans and requested them to put up with a lot of noise for a few days.They were unperturbed. They had no objection- except to enquire why I needed a lift in the first place!
“What is wrong with you? Why can’t you climb a few stairs?”Coming from complete outsiders it was a bit of a revelation- was I becoming unnecessarily paranoid with no plausible reason except to have a back up for a future emergency of unknown origin and uncertain timing?Had I overlooked some other option which would be less invasive and disruptive?I put the hydraulic lift idea on pause.
Electric Chair options
4. The next step was to look at the possibility of installing a chair like what dentists and doctors provide in their basement surgeries.This time I asked Google and sure enough found a company called Vin Grace and rang them up! A woman named Suchitaa answered. She sounded helpful and efficient and her answers were concise but knowledgeable.She gave the time and cost figures including for delivery and installation with the confidence that comes from having dealt with scores of customers.She came the next morning accompanied by a small wheelchair and an attendant. Wearing a smart winter coat and boots, she slipped into the wheelchair in a trice and was wheeled downstairs step by step and pulled back upstairs but facing downwards. At every step the attendant would let go and the wheelchair remained glued to the spot until a command was given by the attendant which decided what the wheelchair had to do- move ahead or stay put.It would cost Rs 3 lakhs plus GST of 5 %.
Having demonstrated the feat that this wheelchair could perform the well heeled lady went on to suggest that the wall clinging ( dentists’/ doctors’ chair) would suit our needs better as the wheelchair could not be self propelled.It would cost Rs 1 lakhs for each flight up and a separate chair would be needed from each landing up to the next.But having demonstrated everything and taken me through some impressive catalogues even Suchetaa proceeded to ask, “Why do you need anything right now? Why do you want to spend that kind of money when there is no apparent urgency?I can supply and install whatever you need in 24 hours flat. Right now I strongly advise you to use your legs!”
Advice: If someone is immobile the wall climbing chair is just the ticket.It’s not disruptive and installation takes a few hours.
Summary of Findings
- The regular lift idea is strictly avoidable if you are installing it in a built up house.It is just too costly and will need permissions, approvals and a license-all huge deterrents.
- A pneumatic lift is unaffordable and the 4 -5 month wait for it to be customized and installed negates the undoubtedly attractive idea of something sleek and user friendly.
- The hydraulic lift will work but you have to have immense time, energy and motivation ( plus money ) to get a really finished job.If breaking doors and windows is involved you might lose a lot of sleep and neighbors goodwill besides you might end up with an ugly eye sore which could disturb the aesthetics of the house howsoever much you beautify the exterior and interiors.That’s not part of the supplier’s responsibility so remember it’ll be your additional cost.
- A wall hugging chair is doable, affordable ( if you really need it )and can be ordered in a matter of a few days ( if not 24 hours as promised by Suchetaa of Vin Grace.This chair can carry one person up and down each flight.It’s safe, will work for sure and is the answer for someone who is unable to climb stairs but not an invalid ( as sitting down, getting up unassisted is required.
- The stair climbing wheelchair is an option if either the staircase itself or other inmates of the building restrict your erecting rails along the wall or the bannister. But this stair climbing wheelchair is also costly at Rs 3 lakhs plus; what’s more,it needs a trained attendant to give the command to move step by step. Although the battery lasts for years and the average maid can learn to operate it, it requires breaking her in to give her confidence.That depends on individual willingness to learn.
Please God let you and me not need any of these alternatives!But it’s good to know there are so many options which are available should the need arise!