A criminal silence

World Hepatitis Day is celebrated every year on the 28th of July, on the birthday of Nobel Laureate Professor Blumberg who discovered Hepatitis B.  It was in 2010 that the World Health Organization made World Hepatitis Day one of only four official disease-specific world health days.  Previously an International Hepatitis C Awareness day was celebrated by the patient groups of the European and Middle Eastern regions on 1st October in 2004, but some other groups were having different dates for the same. World Hepatitis Alliance declared 19th May as the first World Hepatitis Day in association with the patient groups in 2008.  The date was finally changed to 28th July after the adoption of earlier declaration in the 63rd World Health Assembly in the month of May 2010. It was titled as the World Hepatitis Day with an aim to focus on raising awareness at the national and international level. 

Millions of people across the world have been taking part in the World Hepatitis Day, with an aim to raise awareness about viral hepatitis, and to call for access to treatment, better prevention programs and government action.  The theme for World Hepatitis Day 2015 is ‘The prevention of viral hepatitis’ with a campaign strap-line ‘Prevent hepatitis: It’s up to you’.

There are more than 400 million people living with hepatitis B and C worldwide, about 1.4 million die due to these infections every year. Unfortunately many more get infected at the same time. Prevention of further spread of the viral hepatitis is possible through better awareness, services that improve vaccinations, blood and injection safety and infection control training of health professionals. 

It is surprising that in a country like India with huge proportion of such cases, not many awareness programmes have been arranged to mark the Day.  Apart from the health secretary of Maharashtra directing health institutions in the state to organise awareness events on the day, rest of the country seems to be in a slumber including Jammu and Kashmir.  

Kashmir valley is one of the places worst hit by Hepatitis C infection, already declared as an epidemic by experts. One often reads about hundreds of positive cases in some villages of Kokernag area like Magam, Sonabarie, Sagam, Zalangam and list goes on. Unfortunately in some villages, more than 50% population has tested positive. Similarly many villages have been tested positive in Shopian, Kupwara, Lakdakh, as are some areas in downtown Srinagar.  Recent screening done in Sagam village in Kokernag has revealed more than 11% positive out of 400 samples taken.  Strangely, the results are being covered up had it not been for a dedicated journalist who broke the news. The SKIMS also collected samples in village of Sonabarie few months ago. It is alleged that the results are being covered up and not made public for unknown reasons. It is feared that more than 80% of the sample may be test positive.  Similarly it has also been alleged that SKIMS covered up the results of screening done in Zalangam village few years ago and hence those testing positive were kept in the dark and not provided with any treatment leading to complications in many.  

In spite of commendable media pressure, apart from some damage control exercises, the health authorities have completely failed to take any proper action on ground.  Tall claims were made of releasing crores of rupees for the treatment of those already infected but no one knows what happened to the money.  Recently few hundred patients from village Magam were offered treatment but nothing is being done about rest of the thousands of positive cases or to prevent people getting infected on daily basis. No work whatsoever has been done by the health department to find the reason for the epidemic or how to prevent further spread of the infection. Doesn’t it look like another scam which is being covered up? 

Since the change of the government in the state, a criminal silence has been maintained by the new health ministry.  The minister of state for health did visit Kokernag constituency   but did not care to utter a word about the ongoing epidemic of Hepatitis C. Similarly the new director health services Kashmir has either not been updated about the problem or has decided not to bother.

The World Hepatitis Day could have been used for creating awareness about spread of infection and also seek help from various national and international organisations to deal with this hopeless situation.  Instead of organising awareness campaigns, health authorities are busy stigmatising people who have been infected.  While going door to door in Sagam village few months ago, the health workers were patronising people by suggesting that screening and seeking help will affect the marriage prospectus of their daughters. Surely health workers were directed by their superiors to create fear, so that poor villagers do not demand any help.  Subsequently when a screening camp was organised under media pressure, people were hesitant to come out for screening, fearing stigma.  Allegedly another reason for cover up was that highlighting this epidemic can affect the tourist rush to Kokernag, hence poor lives are less important than non-existent tourist flow to Kokernag garden. Similarly the doctors working in the area are being discouraged to get people tested, supposedly it brings bad name to the health department.  So here are we preventing hepatitis by denying the facts for false pride…….Prevent hepatitis: It is up to you? 

One wonders whether the health authorities are there to safeguard people’s health or play politics with appeasement policies at the cost of poor lives.  One would have expected that the department will organise awareness programmes not only within the health department but also involve schools and other departments. It is amply clear that most people are acquiring this infection from the health facilities run by state due to lack of training of staff, poor accountability and lack of sense of responsibility.  Infection control and sterilisation practices are rare and same instruments and syringes are being used on multiple patients.  Unfortunately there are allegations that even hospitals like Government Dental College which is seat of learning for budding dentists and treats thousands of patients each day, does not follow any sterilisation procedures and same is the case with other hospitals around the state, not to speak of private dental clinics and peripheral health facilities. 

Health is a serious issue and cannot be done away with being irresponsible, may it be doctors, nurses, allied staff or health officials and administrators.  There is still time that this epidemic can be checked before it is too late. Acceptance of the problem, awareness of general public, training of staff and accountability of concerned are some of the steps required to curb further spread of this epidemic.  Creating a stigma among people just to shun away from responsibility is criminal and surely not a solution.  Let us pledge on this World Hepatitis Day to work towards controlling the further spread of hepatitis C infection as prevention is always better than cure. The state and health authorities need to take appropriate steps to help those who have already tested positive and stop further spread of infection. #worldhepatitisday 

http://www.greaterkashmir.com/news/opinion/a-criminal-silence/192736.html

AIIMS: A solution or another gimmick

We want AIIMS.  This is a common slogan from every region and district of Jammu and Kashmir these days.  I am not sure whether it is about health, politics, regional hegemony or keeping people distracted from the lack of basic health care facilities in the state.

 It has led the civil society of Jammu to unite and do whatever they can to claim the proposed AIIMS.  

Every political party is trying to take credit, doesn’t matter which region it goes to.  The Jammu faction of the ruling BJP-PDP coalition has given in writing that they will get an AIIMS for the region and the Panthers Party is marching to Delhi to demand its own.  It has also become a tool for furthering the regional divide in the state.  I wonder why people from Ladakh region are still silent. 

Similarly every district of the Kashmir valley wants AIIMS.  Social media is full of debates why it should be in south Kashmir, why not in central Kashmir and how north Kashmir best deserves it. People from Chenab valley are making similar demands.  However the question remains whether AIIMS is really the answer for poor health care delivery in the State?

 I am not against the idea at all and do believe it will help a good percentage of patients with life threatening and long term illnesses and there is a need for more tertiary care hospitals. 

What is wrong with the institutions we already have like GMC, SKIMS and the super-speciality hospital in Jammu? How do you think AIIMS would be any different from SKIMS? What happened to the four proposed medical colleges which were starting in the State? Was that promise also a political gimmick for attracting the vote bank.

 The Children’s Hospital is again in news for increased death rate of neonates and so is the lone maternity hospital for overcrowding and related issues. 

Before projecting AIIMS as the magical cure for all our health problems more needs to be done to improve the peripheral health service.  

Otherwise it is like starting a new university as a substitute for failure in primary education and replacement for primary schools. The notion that the tertiary care hospitals should treat every condition while ignoring the primary health sector, defeats the very purpose of AIIMS like hospitals.  

Would people not queue there with minor ailments like tummy ache and running nose? Would the super-specialists be able to treat those with terminal illnesses, rare diseases, life threatening conditions , organ transplants , do open heart surgeries,  cancer treatment just to name a few ? Or do you want them treating common cold, flu, itch, loose stools and subsequently turning it into another over crowded health facility.  

Hospitals like AIIMS or SKIMS are meant to treat only those patients who have been seen in the primacy care and are in need of specialist help.  Or those who cannot be treated locally and need specialist intervention for a life threatening conditions.  

That means people who are referred by the doctors from the primary care ought to be seen and treated.  We cannot have walk-in OPDs as is happening currently and then expect these institutions to deliver.  But here also we cannot blame the poor patients for queueing at tertiary care hospitals.

 If the appropriate services are made available at the primary care and referral system is streamlined, then only will it be possible to let these tertiary hospitals to work optimally and help those who actually need such kind of facility.  But are we ready for such a system, keeping in view the lack of accountability, mismanagement, corruption and nepotism? Would it cause poor patients further suffering, would they have to go from pillar to post to get referred? 

In most of the developed world, primary care system manages most of  the ailments from hypertension, diabetes, depression, anxiety, pain, asthma etcetera and people are only referred to tertiary care if not manageable locally.  

But unless we have a functional peripheral health system, no matter how many AIIMS are opened up, they are likely to have the same fate as the existing hospitals. One then wonders why nothing is being done or said about the peripheral health sector. 

We often hear accounts of deaths in various hospitals leading to beating of doctors and ransacking of property.  At times professionals are randomly arrested to calm down the situation.  Anyone from a village headman to a revenue officer feels entitled to boss around and order dismissal of staff, which speaks volumes about the actual disarray in the system and lack of seriousness from the authorities. 

There is no health policy and every new government bins the plans made by previous regime like the four proposed medical colleges.  Would it not be worth reviewing the current peripheral health structure and upgrade the facilities according to the needs of the area than how influential the local MLA is?  Is it not time that all the district hospitals are upgraded so that no patient is referred to tertiary care hospitals unless there is a real need and cannot be managed locally?  

By upgradation, I do not imply constructing oversized buildings, which our ministers are good at for reasons you know better.  Upgradation means appropriate allocation of adequate resources, recruitment of staff and doctors, creation of specialised units and starting of well-equipped accident and emergency sections at every district hospital.  There are enough trained and specialist doctors in the state to fill in these roles. 

With the ongoing neglect and failure of providing basic healthcare in the state, we surely need more AIIMS like hospitals in coming years. There is an epidemic of hepatitis C in the valley which has been completely ignored by the authorities.  People are being infected on daily basis and majority have no access to any treatment.  

If nothing is done sooner, within a decade or two, there would be thousands of people with terminal liver disease who would need AIIMS like hospitals and much more. Similarly the uncontrolled use of antibiotics, fake drugs, unhealthy lifestyle, obesity, drugs and alcohol addiction, environmental pollution, adulterated food products and road-traffic accidents leading to debilitating injuries etcetera would lead to conditions which will need more specialised hospitals. 

 But if there was any political will and demand from the civil society, most of these conditions could be prevented and treated locally.  Communicable and infectious diseases like hepatitis B and C could be curbed if department of Public health  (community medicine) is utilised beyond the borders of medical colleges so that they can conduct proper epidemiological studies on local population and come up with appropriate preventive strategies based on the resources available.

To conclude it is important that people demand equitable, safe and dignified health care first at primary and secondary level and then dispute about AIIMS type of facilities and its location.  So while the politicians play with your emotions using the issue of AIIMS and new medical colleges, it is time to demand a proper upgradation and necessary review of the current hospitals and peripheral health system.  

If there is a functioning primary health system, proper referral structure and the walk-in-clinics are closed down; even the existing facilities at SKIMS can do wonders for those who actually need them.  But surely there is need for more tertiary care hospitals to cater to the growing population and a health policy based on facts and needs than whims of political parties for vote bank politics. 

http://www.greaterkashmir.com/news/opinion/aiims-a-solution-or-another-gimmick/191834.html 

The health sector in Kashmir is an organised mafia

Recently the honourable minister for health came up with another genius plan to overhaul the health department.  A three tier roster for the doctors working in the health department was proposed.  The doctors working in the department reacted sharply questioning the very basis of the plan.   The doctor bodies even threatened industrial action if the plan was forced on them.  I am still to hear from anyone if the proposal is workable and it seems that even the common sense has been kept at a distance.  I am not advocating that doctors should not work, or work less or run way from on call and night duties.  But it would be interesting to know who came up with this idea. Was it the health ministers himself or his clever advisors? Surely whosoever it was does not seem to understand the basic problems or does not care to know.

One must be either naïve or idiotic to conceive the idea of starting a shift at twelve in the midnight where by a new doctor is supposed to come in and relieve the doctor on duty.  What about the prevailing situation in Jammu and Kashmir, conflict, insecurity, poor roads, lack of resources to mention a few? Would the authorities be kind enough to explain where a lady doctor will go if she has to leave the hospital at twelve midnight?  Who would be responsible if any doctor is harmed in the process? Is there a proposal of constructing staff quarters at every hospital? Are there plans to provide transport and security to doctors when they go home?

What is the current staffing level and doctor patient ratio in the state?  Can the current number of doctors cope with this kind of rota? If a doctor has to work whole week without any break or rest, how safe is it for the patients being treated? There are only questions and no solution. This has caused further unrest in already overburdened doctor fraternity.  It seems that such orders or rhetoric is deliberate to mislead common people from the basic issue of lack of appropriate health service in the state.

There are so many other examples of such orders since this government took charge.  Humiliating doctors seems part of the plan, should it be the senior most doctors working as Principal Medical College Srinagar or a female psychiatrist in Jammu.  Sadly the honourable health minister was seen physically pulling a doctor’s collar recently.   I wonder does law of the land permit anyone to behave like this.  In another example, it was ordered to arrest a doctor and other staff members of a hospital who had been on a picnic, probably to please the local headman.  Also hefty fines are being imposed on the staff for not doing their job, which not only speaks about lack of vision but also regressive approach to improve any system.  Is there no legal framework in that state?  Surely there must be some rules and regulations.  If someone is not attending duties properly, action needs to be taken after proper fact finding than following an appeasement policy.  As an elected representative, how can one think and behave like a dictator is amusing.

Similarly an order was passed making prescribing by generic names mandatory for doctors without thinking about how that will work on  ground. When there are no regulated pharmacies in the state, anyone can sell and buy medication, how was the policy supposed to make any positive impact and not do more harm?  If this is about fooling people, surely there are other ways to do that.  But let’s not forget health is a serious issue and how long can one fool the voters by polarising and rhetoric.  The issue of private practice by doctors is another favourite past time brought up often to cover the failings of the system without any proper alternative whatsoever. Huge threats are made in media without any action or a plan of action.

In another bizarre statement the health minister came up with the impractical idea of mandatory five year service for doctors.  Apparently he wants to pass an order to prevent any doctor leaving the state to curb the shortage of staff.  Let us not forget that Jammu and Kashmir is the only place where doctors are jobless and if he actually wants to improve the staffing levels, why not recruit?  He actually reduced the number of posts in the department by recruiting allied professionals on the assistant surgeon posts.  None of the announcements or policies made so far seems practicable and every time there is a U-turn for obvious reasons.  So apart from making some news, nothing changes in practice.

There has been too much centralisation of power and posts like Principal GMC have lost its worth and effectiveness. There are no significant decisions which can be taken locally and everything is managed from the secretariat, making sure that one has to be either a yes-man or corrupt to remain on any post. This has a significant negative effect on the delivery of health care and morale of doctors. There is no room for whistle blowers and people who strive to improve the service.   Is this the fault of our ministers and bureaucrats or top doctors in the department is open to debate?

There are often allegations that the senior doctors are hand in glove with the administration when it comes to corruption and current miserable state of health care delivery in the state.  Whenever there is a question of improving services, queries about lack of facilities, lack of manpower, the in-charge bosses always take one stand  of ‘nothing  being wrong’.  It is confirmed in writing that everything is hanky dory and there is no room for any error whatsoever. They presumably do all this to keep their bosses happy in the secretariat, either to acquire a position, remain in the chair or get further undue extensions.  Are they doing so in compulsion or not, I leave you to judge that.

The selection of doctors for various administrative posts from BMO to Director Health has always been a contentious issue. There are no set guidelines and even if there are any, surely none is followed.  Posts are allocated by a process better known to the health secretariat and the minister.  One does not have to be a genius to know how it works.  There are rampant examples of partiality and corruption.  Same people who are initially attached to department on corruption charges are later awarded higher posts.  How on earth are these officers going to be effective and upright when they are toothless and only in-charge till the ministers are happy with them?

Doesn’t it look like an organised mafia which actually does not care what happens to poor people? If there were any real intensions to help people and alleviate their suffering, surely something meaningful would have been said and done by now. The doctors involved in corruption and malpractice get away with it, so does the administrators and ministers who benefit.  Common man and an average doctor are made out as scapegoats in the process.

In a civilised set up, any representative tries to understand the shortcomings of the department first and then resolve the same. It is prudent that few expert committees are framed to review the current health infrastructure and failings to come up with appropriate recommendations which can be acted upon.  Nothing will improve by mere tactics of threats, bullying, humiliation and corruption to name a few. But as the African proverb goes, ‘a wise man never knows all, only fools know everything’.

Should the Chief Minister think about changing the health minister or keep a check on his rhetoric to save further embarrassment?  Should the civil society respond and demand some actual change? Question remains who will bell the cat?

http://www.kashmirreader.com/the-health-sector-in-kashmir-is-an-organised-mafia/