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Right to health in India
THE LANCET
decisions were the most likely cause of the food shortage: the international community did not want to lend active support to camps that housed former Hutu soldiers or civilians who were involved in the 1994 genocide. But the presence of these men should not be used as an argument to forsake a whole civilian population. By end of February, fighting had reached TingiTingi and the refugees left the camp to continue to flee or hide in the bush.The international community must address the desperate situation of these refugees, take measures to ensure their security, and respond adequately to their vital needs. *Pierre Nabeth, Brigitte Vasset, Philippe Guérin, Brigitte Doppler, Milton Tectonidis *Epicentre, 8 rue Saint-Sabin, 75011 Paris, France; and Médecins Sans Frontières,
Right to health in India SIR—Recently I came across a landmark judgment, in which the Supreme court of India had ruled that serving and retired government employees are entitled to free medical care, including treatment at any stateof-the-art medical institute.1 This case arose from the appeals of the Punjab government challenging the state high court’s directive to reimburse costs to its employees who had undergone angioplasty at the capital’s All India Institute of Medical Sciences and the Escorts Health Care Foundation. The judges expanded the scope of article 21 of India’s constitution (right to life) and ruled that “right to health” is integral to right to life and dismissed the Punjab government’s appeal.1 Another case was an agricultural labourer who fell off a crowded train and sustained serious head injuries. He could not be admitted to a nearby government medical college (free) hospital because of shortage of beds and had to be admitted to a private hospital which charged fees for its services. In this case also the supreme court had ruled that under article 21 of the constitution government hospitals cannot deny medical facilities to seriously ill patients on flimsy grounds such as non-availability of a bed, and any patient denied of such medical facility is entitled to compensation.2 Treatments such as angioplasty, cardiac by-pass, &c, are expensive in the context of the economy of a developing country such as India. Technical innovations add to the ever increasing costs of health care, and sociopolitical changes worldwide are pressuring governments to include more benefits as basic human rights;
1032
this implies allocation of greater resources to health care. Various issues need airing in the medical community. First, we need to define health and normality, and these might be viewed differently by the various interested parties. Second, how can we measure health? Generally it is done in terms of sickness, death, and deviations from the norm such as nutritional status, biochemical indices, &c. But do these indices reflect the feelings of the community, health-care professionals, or planners? Third, what should be the components of a right to health? We know that health is influenced by several factors, such as nutrition, education, housing, environmental pollution, economy of a country and so on. But are health policies and budgets consistent with the implementation of a rights-based approach to health? Last, should health professionals be content with the role of health-care providers or should they actively associated themselves with health advocacy? In many parts of India doctors are still regarded as God-like figures, so there seems to be a moral responsibility of doctors to live up to their role, but whether one group of persons should assume responsibility for others’ welfare is debatable. I believe that these issues should be discussed so as to arrive at a basis for the right to health and health care. R K Bansal Depar tment of Community Medicine, PS Medical College, Karamsad, Pin-388 325, Gujarat, India
1
2
Bhatnagar R. Rights to life includes right to health. Times of India (Bombay). 1977, Jan 28: p 15. Prakash J. Honouring right to medical treatment. Times of India (Bombay). 1977, Jan 9: p 12.
another 11 million new HIV infections, or will they heed the advice of Merson and colleagues to more actively evaluate the potential benefits of selftesting? The aim of screening for HIV is to identify individuals who are at high risk of infection rather than infection per se. Individuals who have a positive result require additional confirmation of the result. In much of the world, the only available screening measures for HIV has been the signs and symptoms of AIDS, or, in symptom-free individuals, a prognosis based on their present or past risk behaviour. Even with truthful answers, the specificity and sensitivity of such assessments are low. With the advent of self-testing for HIV, there will be fewer false-positive and falsenegative results, and silent carriers of HIV who come to know their status will be able to consider ways to prevent further transmission and avoid untimely death. Innovations take time to diffuse through societies, 4 and when first presented, criticism is common. But over time, after opinion leaders have voiced their support, the innovation becomes accepted by society and previous resistance becomes but a distant memory. Perhaps the same will happen with personal screening for HIV, with fingerstick blood, oral fluids, or urine tests available in the privacy of one’s home. Once such screening measures become commonplace and people recognise that HIV can be avoided,5 another vital option will exist to help to prolong life and limit transmission of HIV. Ralph R Frerichs Depar tment of Epidemiology, School of Public Health, University of Los Angeles, Los Angeles, CA 90095, USA
1
Personal screening for HIV revisited SIR—In 1994, personal screening for HIV infection was first suggested as an important public-health measure for developing countries. 1 Since then, although the value of such testing has been disputed,2 WHO estimates that the prevalence of HIV has increased from 11–12 million to 22·6 million. Rather than heeding the urgent need for action, the debate on self-testing for HIV continues. Now, after much deliberation, Merson and colleagues (Feb 1, p 352)3 endorse rapid selftesting for HIV, and suggest that individuals who use the tests will become active partners with healthcare providers in confronting the disease. But the question remains: will health officials worldwide wait for
2
3
4 5
Frerichs RR. Personal screening for HIV in developing countries. Lancet 1994; 343: 960–62. Merlens TE, G Davey Smith, Van Praag E, et al. Home testing for HIV. Lancet 1994; 343: 1293–95. Merson MH, Feldman EA, Bayer R, Stryker J. Rapid self testing for HIV infection. Lancet 1997; 349: 352–53. Rogers EM. Diffusion of innovations. New York: The Free Press, 1995. Frerichs RR. HIV winners and losers. Epidemiology 1995; 6: 329–31.
DEPARTMENT OF ERROR MODY genes and mutations in hepatocyte nuclear factors—In this commentary published on Feb 22, p 516, reference 11 came from J Clin Invest 1997; 99: 582–91. Gallbladder polyps: when to wait and when to act —In this commentary by R A Boulton and D H Adams (Mar 22, p 817), the figure should indicate that patients with small polyps and complications factors should be referred for cholecystectomy.
Vol 349 • April 5, 1997
decisions were the most likely cause of the food shortage: the international community did not want to lend active support to camps that housed former Hutu soldiers or civilians who were involved in the 1994 genocide. But the presence of these men should not be used as an argument to forsake a whole civilian population. By end of February, fighting had reached TingiTingi and the refugees left the camp to continue to flee or hide in the bush.The international community must address the desperate situation of these refugees, take measures to ensure their security, and respond adequately to their vital needs. *Pierre Nabeth, Brigitte Vasset, Philippe Guérin, Brigitte Doppler, Milton Tectonidis *Epicentre, 8 rue Saint-Sabin, 75011 Paris, France; and Médecins Sans Frontières,
Right to health in India SIR—Recently I came across a landmark judgment, in which the Supreme court of India had ruled that serving and retired government employees are entitled to free medical care, including treatment at any stateof-the-art medical institute.1 This case arose from the appeals of the Punjab government challenging the state high court’s directive to reimburse costs to its employees who had undergone angioplasty at the capital’s All India Institute of Medical Sciences and the Escorts Health Care Foundation. The judges expanded the scope of article 21 of India’s constitution (right to life) and ruled that “right to health” is integral to right to life and dismissed the Punjab government’s appeal.1 Another case was an agricultural labourer who fell off a crowded train and sustained serious head injuries. He could not be admitted to a nearby government medical college (free) hospital because of shortage of beds and had to be admitted to a private hospital which charged fees for its services. In this case also the supreme court had ruled that under article 21 of the constitution government hospitals cannot deny medical facilities to seriously ill patients on flimsy grounds such as non-availability of a bed, and any patient denied of such medical facility is entitled to compensation.2 Treatments such as angioplasty, cardiac by-pass, &c, are expensive in the context of the economy of a developing country such as India. Technical innovations add to the ever increasing costs of health care, and sociopolitical changes worldwide are pressuring governments to include more benefits as basic human rights;
1032
this implies allocation of greater resources to health care. Various issues need airing in the medical community. First, we need to define health and normality, and these might be viewed differently by the various interested parties. Second, how can we measure health? Generally it is done in terms of sickness, death, and deviations from the norm such as nutritional status, biochemical indices, &c. But do these indices reflect the feelings of the community, health-care professionals, or planners? Third, what should be the components of a right to health? We know that health is influenced by several factors, such as nutrition, education, housing, environmental pollution, economy of a country and so on. But are health policies and budgets consistent with the implementation of a rights-based approach to health? Last, should health professionals be content with the role of health-care providers or should they actively associated themselves with health advocacy? In many parts of India doctors are still regarded as God-like figures, so there seems to be a moral responsibility of doctors to live up to their role, but whether one group of persons should assume responsibility for others’ welfare is debatable. I believe that these issues should be discussed so as to arrive at a basis for the right to health and health care. R K Bansal Depar tment of Community Medicine, PS Medical College, Karamsad, Pin-388 325, Gujarat, India
1
2
Bhatnagar R. Rights to life includes right to health. Times of India (Bombay). 1977, Jan 28: p 15. Prakash J. Honouring right to medical treatment. Times of India (Bombay). 1977, Jan 9: p 12.
another 11 million new HIV infections, or will they heed the advice of Merson and colleagues to more actively evaluate the potential benefits of selftesting? The aim of screening for HIV is to identify individuals who are at high risk of infection rather than infection per se. Individuals who have a positive result require additional confirmation of the result. In much of the world, the only available screening measures for HIV has been the signs and symptoms of AIDS, or, in symptom-free individuals, a prognosis based on their present or past risk behaviour. Even with truthful answers, the specificity and sensitivity of such assessments are low. With the advent of self-testing for HIV, there will be fewer false-positive and falsenegative results, and silent carriers of HIV who come to know their status will be able to consider ways to prevent further transmission and avoid untimely death. Innovations take time to diffuse through societies, 4 and when first presented, criticism is common. But over time, after opinion leaders have voiced their support, the innovation becomes accepted by society and previous resistance becomes but a distant memory. Perhaps the same will happen with personal screening for HIV, with fingerstick blood, oral fluids, or urine tests available in the privacy of one’s home. Once such screening measures become commonplace and people recognise that HIV can be avoided,5 another vital option will exist to help to prolong life and limit transmission of HIV. Ralph R Frerichs Depar tment of Epidemiology, School of Public Health, University of Los Angeles, Los Angeles, CA 90095, USA
1
Personal screening for HIV revisited SIR—In 1994, personal screening for HIV infection was first suggested as an important public-health measure for developing countries. 1 Since then, although the value of such testing has been disputed,2 WHO estimates that the prevalence of HIV has increased from 11–12 million to 22·6 million. Rather than heeding the urgent need for action, the debate on self-testing for HIV continues. Now, after much deliberation, Merson and colleagues (Feb 1, p 352)3 endorse rapid selftesting for HIV, and suggest that individuals who use the tests will become active partners with healthcare providers in confronting the disease. But the question remains: will health officials worldwide wait for
2
3
4 5
Frerichs RR. Personal screening for HIV in developing countries. Lancet 1994; 343: 960–62. Merlens TE, G Davey Smith, Van Praag E, et al. Home testing for HIV. Lancet 1994; 343: 1293–95. Merson MH, Feldman EA, Bayer R, Stryker J. Rapid self testing for HIV infection. Lancet 1997; 349: 352–53. Rogers EM. Diffusion of innovations. New York: The Free Press, 1995. Frerichs RR. HIV winners and losers. Epidemiology 1995; 6: 329–31.
DEPARTMENT OF ERROR MODY genes and mutations in hepatocyte nuclear factors—In this commentary published on Feb 22, p 516, reference 11 came from J Clin Invest 1997; 99: 582–91. Gallbladder polyps: when to wait and when to act —In this commentary by R A Boulton and D H Adams (Mar 22, p 817), the figure should indicate that patients with small polyps and complications factors should be referred for cholecystectomy.
Vol 349 • April 5, 1997