India's mentally ill persons still in jails

gal, abuse of the law, appalling physical conditions, and inhumane treatment of patients. They also recorded denial of any psychiatric care or treatment to such nonOn the recommendation of a medical criminal prisoners, and even that distribution of medicines was delegated to life board constituted under a Calcutta High convicts. They found cages for violent Court’s order, Ajoy Ghosh, who has lan33 without trial in for Calpatients in Alipore Special Jail, also desigyears guished nated as the Institute of Mental Health. cutta’s Presidency Jail, is to be moved to the Antaragram Psychiatric Centre for Following their report, the court declared the detention of mentally ill non-criminals treatment. Although Ghosh falls into the "criminal" category, his case reflects how in jails illegal (Lancet Sept 11, 1993 p 670). a Supreme Court declaration in SeptemPublic-spirited legal experts, human ber, 1993- that the detention of mentally rights activists, and doctors have since that ill non-criminals in jails is illegal-is only discovered implementing the : Supreme Court judgment may be much very slowly being taken note of. The Ghosh case came to light when a more difficult. Following a status report team of advocates appointed by the court from the state of Assam, the Supreme went to examine the prison conditions Court had appointed advocate Gopal : and the Association for the Protection of Subramanium as a special Commissioner Democratic Rights filed a public interest . in May last year to look at the implemenpetition demanding his release. Ghosh tation of the Supreme Court’s verdict on . had allegedly bludgeoned his brother to the detention of mentally ill persons in death in January, 1962, and the psychiaprisons. Subramanium discovered that trists had diagnosed him as a "lunatic". officials in Assam had presumed that the His trial had always been deferred Supreme Court judgment was applicable because doctors had continued to proto West Bengal alone. They were totally nounce him "unfit to defend himself". oblivious of the coming into force, since Although the APDR has secured his April, 1993, of the Mental Health Act and release after this long interval, during continued to go by the old Indian Lunacy which even the principal witness had died, Act, which became redundant. He found the court has still refused his acquittal the inhumanity of West Bengal prisons without trial. : also prevalent in Assam. Much to his The practice of lodging the mentally shock, he discovered that many "lunatics" were, in fact, sane and had been lodged ill-especially non-criminals-in prisons has been in the public eye ever since a there because of connivance between officials and others whose interests conflicted journalist Ms Sheela Barse filed a public detained the interest writ petition in the Supreme with individuals, for Court in 1989. The court subsequently instance, because of property. He set about setting the sane "lunatics" free and appointed Dr Amita Dhanda of the Indihas submitted a scathing report to the an Law Institute, and Dr R Srinivasa Supreme Court, where the hearings Murthy of the National Institute of Mental Health and Neurosciences to conduct regarding the implementation of its verdict are in progress. The situation in other a special inquiry into the state of affairs of

India’s mentally ill persons still in jails

mental health care institutions in West Bengal state, especially its prisons. The team reported widespread detention of mentally ill persons in jails in West Ben-

One-stage catheterisation for angioplasty

:

states is believed Assam.

to

be

no

better than

in :

Sanjay Kumar the

charge of attempting

Something better than zidovudine for children The standard drug treatment for paediatric HIV disease is not as good as two others. AIDS Clinical Trials Group (ACTG) 152 is a three-arm double-blind comparison of zidovudine (AZT) alone, didanosine alone (an approved alternative treatment), and combination therapy with zidovudine and didanosine. Interim analysis by an independent Data and Safety Monitoring Board, announced on Feb 6, found that didanosine alone and didanosine plus zidovudine were superior to zidovudine alone (p=00058), as measured by growth failure, new opportunistic infections, neurological or neurodevelopmental deterioration, or death. The zidovudine group also had the most side-effects. Outcomes of the didanosine and the combination regimen did not differ significantly from each other, and those arms of the study will be continued until Aug 30, as planned (not as reported in Lancet Feb 18, p 446). According to protocol co-chair Carol J Baker (Houston), "While AZT is extremely useful (70% of the patients in the AZT group had no disease progression), the other regimens were better." Patients in the zidovudine arm will be allowed to remain on zidovudine alone or switch to other therapies. ACTG 152 includes 839 children, aged 3 months to 18 years, at 62 clinical centres. All were anti-retroviral naive at the start of the trial (except for 8% who had had 6 weeks or less of zidovudine), and all had become symptomatic just before entry into the study. Half the patients were under 30 months of age, and, as expected, there were more disease progressions and deaths among the younger patients in all three trial arms. Paul M Rowe

to earn an

extra

surgical support

to

make such

a

system

: fee by going on to PTCA, Rozenman et al "widely practical". He contends that the : impose a system of instant referral to savings estimates to date do not take into : another invasive cardiologist on call at the account a myriad of indirect costs including "systems in place to ensure the quality Routinely combining diagnostic coronary: hospital to confirm desirability of combin-

catheterisation with percutaneous transluminal coronary angioplasty (PTCA) is : "feasible, safe, and efficient", conclude: Yoseph Rozenman and colleagues, after a study of 2069 consecutive, unselected patients undergoing elective or emergency angioplasty (Am J Cardiol 1995; 75:: 30-33). Previous studies have been of selected patients. Rozenman et al also say that routine combination of diagnostic and therapeutic procedures could result in a saving of about US$600 million per year in the US alone (at a cost-saving of about$2000 per procedure by the combined approach:

i

[Am Heart J 1991;

122:

50-54]).

For clinical confirmation and

to

:

prevent,

ing the procedure.

Their study showed no difference between the combined and staged groups in successful dilation, major or minor complication rates, or duration of hospital stay after angioplasty. : Since 1988, an American College of Cardiology/American Heart Association task force suggested a two-stage approach for elective PTCA, to ensure time for careful evaluation of the patient’s clinical profile and coronary pathology, and to discuss the risk-benefit with the patient. In an accompanying editorial, James A Hill (Am J Cardiol 1995; 75: 75-76) argues that not enough institutions have a mechanism for rapid consultation with other cardiologists, or ready availability of

of such a practice". He warns that a recommendation for a one-stage pro cedure should "not be mandated, nor should physicians be penalised if they feel that further discussion with either colleagues or the patient is necessary before proceeding", a reticence that reflects concern that third-party players will jump at the immediate fiscal benefits of combination, ignoring other considerations. But Rozenman and colleagues believe that benefit to the patient will make the one-stage approach the standard.

Rachelle H B Fishman

511