Depression in Kashmir: In The Heart

Kashmir is a picturesque valley wedged between India, Pakistan and China. I trained and later worked as a psychiatrist at the only psychiatric diseases hospital of the valley which is based in the capital city of Srinagar. I remember the walk-in clinics, where at times we had up to 300 patients waiting eagerly to have few minutes with a psychiatrist despite the huge stigma associated with mental illness. The number of people seeking help for emotional problems grew exponentially after the armed conflict started in 1989. One of our studies reported the lifetime prevalence of exposure to the trauma of about 59%[1]. A recent survey by Medicines Sans Frontiers (MSF) reported that about half of the population is suffering from some kind of mental illness, with 50% women and 37% men suffering from a depressive illness[2].  During my research on PTSD patients, depression was again the most common comorbidity in more than 80% of the study sample[3].

One can argue that the diagnostic criteria as suggested in the ICD and DSM may not fully hold true in the local cultural context for the diagnosis of depression or even other disorders.   Asking the golden question, ‘How is your mood?’ usually gets a blank response.  People often talk in the context of ‘heart’ when talking about their emotions and feelings, rather than the mind. Typically, someone with depression would come saying, ‘My heart is not good’, usually pointing to their chest.  I remember asking, ‘How is your heart?’ more often than ‘How is your mood?’ Even the people from middle class and educated backgrounds would find it hard to discuss mood.  The same is true about anxiety disorders with palpitations and other somatic symptoms often being taken as a symptom of physical illness. http://www.rcpsych.ac.uk/pdf/VIPSIG_Depression_around_the_world.pdf

People usually do not come to the doctor with an idea that they will get treatment for depression or even that they may be depressed. It is usually the physical symptoms like tiredness, pain, palpitations, memory difficulties, medically unexplained symptoms, and weakness in limbs and headaches that bring them to the doctor.  Conversion symptoms are the most common presentations to the A&E department, typically a teenage girl not able to talk, move a limb or being unresponsive. This has a great cultural significance and is protective. If a woman reports feeling low to her husband, she would hardly be taken seriously and probably get told off for being lazy. However, when someone reports pain or physical symptoms, it is often taken seriously and considered a valid reason to seek help from a doctor. 

Depression and other mental health problems form the biggest group of illnesses and burden of disease in the local population. With such a variable presentation of symptoms, patients often go to all kinds of specialists, quacks and faith healers. This results in unnecessary costs, inadequate or wrong treatment and, at times, iatrogenic harm.  There is a need for training doctors and other health professionals in better identification and treatment of depression and other mental health disorders.  There has been some awareness both among the doctors and the general public in seeking right help for mental health problems.  Finally, medication still remains the sole therapeutic modality, keeping in view the lack of allied professionals like psychiatric nurses, psychologists and therapists. 

http://www.rcpsych.ac.uk/pdf/VIPSIG_Depression_around_the_world.pdf 

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[1] Margoob, M. A., Firdosi, MM, Banal, R., et al. (2006). Community prevalence of trauma in south Asia: Experience from Kashmir. JK-Practitioner, 13(Supplement 1), S14-S17.

[2] Medicine Sans Frontiers (Doctors without Borders) ‘’Kashmir Mental Health Survey 2015’’ https://www.msfindia.in/sites/india/files/research_summary.pdf

[3] Firdosi MM, Margoob MA. Socio-demographic profile and psychiatric comorbidity in patients with a diagnosis of Post Traumatic Stress Disorder–A study from Kashmir Valley. Acta Medica International. 2016;3(2):97-100

Depression: Let's Talk

The theme of the World Health Day 2017 is “Depression: Let's Talk”, which is being celebrated on the 7th of April 2017.  According to the World Health Organization (WHO) estimates, the number of people living with depression has increased by more than 18% between 2005 and 2015.  More than 80% of this disease burden is among people living in low- and middle-income countries.  Globally, it is estimated that more than 300 million people suffered from depression in 2015.  Nearly half of these people live in South East Asia, China and India to be specific. As per WHO estimate, around 56,675,969 people suffer from depression in India, which is 4.5% of the total population. The same report suggests that depression is responsible for 10,050,411 years lived with the disability which is around 7.1% of the global burden of disease. Depression is ranked as the single largest contributor to global disability.  Depression is also the major contributor to suicide deaths which is close to 800,000 annually. However, when it comes to the allocation of resources and funds to tackle this global epidemic and disability, depression or mental health, in general, is usually not a priority for the policy makers.

Kashmir is not foreign to the concept of psychological problems and many reports have been published in the last year alone about the high prevalence of depression and other mental health problems in the local population. The number of people seeking help for emotional problems grew exponentially after the armed conflict started in 1989.  One of our studies reported the lifetime prevalence of exposure to the trauma of around 59% with most people having suffered directly or indirectly from some traumatic incident. A recent survey by the Medicines Sans Frontiers (MSF) reported that, about half of the population is suffering from some kind of mental illness, with 50% women and 37% men suffering from a depressive illness.  During my research on PTSD patients, depression was again the most common diagnosis in more than 80% of the patients.  Another study published by Action Aid India showed a high prevalence of depressive illness, anxiety disorders and other mental health problems.

The burden of disease more so in the female population is huge although we do not have actual numbers. The number of patients coming to the hospital is just the tip of the iceberg and many more do not seek help or aren’t aware that they can be helped. The awareness about depression and other mental disorders has improved overtime; however, there is still a lot of stigma associated with visiting a psychiatrist. I know of cases where families would not allow members to seek help for emotional problems fearing they would be judged by the society which at times, is true. Some families still prefer for their children to be in prison than in a psychiatric hospital and some go as far as paying to get their loved ones locked up.

Depression can present in various forms and I believe that the Western criteria set by the WHO or the American Psychiatric Association (APA) to diagnose depressive illness, are not always applicable to our population. The core symptoms of depression are low mood and lack of interest in pleasurable and day to day activities.  When we talk about mood, and expressing it in words, apart from some highly educated people, most are not aware of what it means. Hence asking someone, ‘how is your mood?’ does not apply. Most of us think in terms of ‘Heart' and something not right with it. ‘Meh Haz dil pareshan (My heart is sad)', ‘meh haz weanijih rawan (my heart is missing beats/palpitations)', are the classical statements one hears when talking to someone with depressive symptoms in our cultural context. It is one of the reasons why people suffering from depression end up visiting cardiologists and at times undergo expensive and unnecessary investigations, when in reality nothing is wrong with their heart or its proper functioning.

The common symptoms for someone suffering from depressing in our cultural context are tiredness, difficulties with memory, stomach problems, aches and pains, headaches, back pain, weakness in arms and legs, inability to move an arm or leg, episodes of loss of consciousness, weight changes, irritability, tearfulness, and suicidal thoughts. People usually do not come to the doctor with an idea that they will get treatment for depression or even that they may be depressed.  It is usually the physical symptoms like tiredness, pain, palpitations, memory difficulties, medically unexplained symptoms, and weakness in limbs and headaches that bring them to the doctor.  Conversion symptoms are the most common presentations to the casualty department, typically a teenage girl not able to talk or move her arms or legs or being unresponsive.  This has a great cultural significance and is protective. If a woman reports feeling low to her husband, she would hardly be taken seriously and probably be told off for being lazy.  However, when someone reports pain or physical symptoms, it is often taken seriously and considered a valid reason to seek help from a doctor. It is important then to be mindful, when going to the doctor repeatedly and not getting better, even after undergoing multiple treatments – one should strongly consider depression or an anxiety disorder as a possibility of on-going poor health.

Hence if you are suffering from symptoms as mentioned above or someone in your family is, please do consider depression and seek help. Depression is a treatable condition at a much lower cost than one would spend visiting various specialists and undergoing costly investigations.  Sometimes your psychiatrists or doctor may request tests like thyroid function and blood sugar which can be associated with depression.  People who suffer from long term physical health conditions like diabetes or heart disease are at an increased risk of developing depression than rest of the population.  Treatment of depression is necessary in such patients as it can affect the physical health condition adversely and worsen the outcome.  In people suffering from diabetes, treatment of depression helps with better blood sugar control.

One cannot blame the general public for not knowing where to seek help as it is not always easy to make sense of the symptoms.  It becomes the duty of every doctor to identify depression, treat it if they can and refer if they feel it is beyond their capability or area of expertise.  Unfortunately, at times people are put through unnecessary investigations and even invasive tests, deliberately or unknowingly when the problem lies somewhere else. Some female patients typically suffering from vague pain symptoms are advised to have surgeries like removal of the uterus which not only deprives the woman of an essential organ but in long run, makes her depression and pain symptoms worse. It is an open secret that there is an epidemic of such unnecessary surgeries and even young girls who have even not conceived are deprived of their womb.  This can only be stopped when people are aware about their symptoms.  It is therefore imperative that patients seek a second opinion and rule out depression before going under the knife.

Lately, there has been a surge in the number of people, including doctors writing about depression, its causes, suicide and other mental health issues.  This may seem a harmless enough exercise to most people, but when doctors who are themselves uninformed write about such issues in a manner that causes more harm than good, the results can be devastating.  Many articles have been published which instead of informing, misinform the general public and increase the stigma already attached to depression and suicide.  Sadly, some have even gone as far as to suggest that depression and suicidality are due to a lack of willpower and go on to sermonise with threats of hell and wrath of God.  People who suffer from depression and suicidal thoughts are already under tremendous pressure from the illness and need treatment, not threats.  They need support and empathy.  To call people suffering from depression and suicidal thoughts as weak-willed or cowards or idiots is not only derogatory but deeply shameful and inhumane.  Such articles and misinformation can trigger or even push someone over the edge by worsening their feelings of guilt and putting them through shame.  Let's reiterate again that depression and other mental health problems are clinical conditions, mostly treatable and at times curable.  Like diabetes and high blood pressure, people suffering from depression need medicine and other help on an ongoing basis.  Hence it is better to seek the right help at the right time to reduce the disease burden and improve the quality of life.  Doctors have a huge role to play in reducing the stigma, identifying those suffering from depression and providing the right treatment.  The media houses also have a huge responsibility to check that what is printed is not misleading and ask expert opinion before publishing in public domain.

http://www.risingkashmir.com/news/dark-side-of-depression 

Dignified rehabilitation of orphans, widows and destitute

Kashmir valley has witnessed numerous disasters, both natural and manmade leading to an environment of insecurity.  This has changed the dynamics of social interaction creating a sense of urgency and uncertainty.  Poor and downtrodden have been the worst victims of this conflict, though every section of the society has been affected in one way or another.  The ongoing conflict has led to huge loss of life leaving behind orphan children and widows in dire poverty and state of helplessness.  This is further complicated by the indifference of the State, with blatant refusal to take any responsibility for the care and upbringing of these poor children.  In any civilised society, the State would have introduced systems and checks so that all these vulnerable people are supported and provided necessary access to basic amenities of life.  It is no exaggeration that the State has failed in performing this crucial duty and has condemned this vulnerable group to infinite misery.

The society stepped in, to fulfil the role of a guardian and a provider for these poor children and widows, but was the response timely, adequate and dependable?  Kashmiris became well known for their resilience and helpful attitude towards people in distress.  The response seems, by and large, adequate during the crisis phase.  But the question to think about is; are we able to maintain the momentum in the long run?  Do we stop visiting the widow’s cottage after few days of mourning?  Do we think who is feeding and protecting the vulnerable children?  The initial response is usually driven by emotions which ultimately fades off and hence does not last long.  As a society, after witnessing so much of death and destruction, probably our hearts have hardened - a common phenomenon in conflict zones.  People become indifferent to the ongoing suffering, as a means of carrying on and coping otherwise, the mourning never ends.  But can we afford to forget those who are worst hit by same violence?  What about our duty and social responsibility?  This may come across as a conflicting argument but on one hand we have countless NGOs and on the other there is not an adequate response from the society to look after those in need.  Have people lost faith in all institutions including those who look after the weaker sections of the society?  With more than 200 000 orphans and thousands of widows, have we done enough to help?  Have we left children in these institutions and are happy with few donations around the Holy Month?  Do we know how the widows struggle to raise vulnerable orphans in unfriendly times and circumstances? 

Voluntary organisations commonly known as Non-Governmental organisations (NGOs) started by like-minded people in various parts of the state became a norm and society at large has assumed these NGO’s to be solely responsible for ever increasing numbers of orphans and widows.  With time, we have even lost track of the actual number of NGO’s operating in the state and their modus operandi. Was there any method in the response?  It seems the response from society mirrored the chaos and conflict.  There is no uniform plan, policy or guidelines under which most of these organisations operate.  Should there not be a uniform code of practice and coordination among such various organisations? Having fewer organisations could deliver a more uniform level of care, better utilisation of resources and real accountability.  Is there any monitoring process?  Surprisingly, there is no such body or organisation in the State to make the NGOs accountable.  Ideally, it is the responsibility of the state to have an independent organisation or commission which should have the power to take on any unscrupulous NGOs.  This would also mean collaboration between various organisations and equitable distribution of resources depending on actual need and not merely chance.  Unfortunately, we have got an excess of such organisations in some areas with no help available in other places.  Would it be possible to create such a body in the voluntary sector which could formulate a uniform framework and various NGO’s could sign in to work and collaborate?  Can the smaller organisations merge with few bigger ones and create a uniform platform?  But that would demand serious understanding and humility to even ponder on the idea.  As a society, we have to create the checks and balances and it becomes imperative that the civil society takes charge to create the accountability process.

That said voluntary sector has played the main role in the rehabilitation of orphans and widows.   Some reports suggest there are more than 700 orphanages operating in the State. How are the orphanages doing? There is no standard against which the performance can be monitored.  With more than 200 000 orphans and thousands of widows, surely these NGOs have done a commendable job in making vulnerable children safe, housing and feeding them and providing them with basic amenities.  At least, they have provided a dignified alternative when the State has completely failed.  There are also allegations that some are using orphanages to keep their own businesses going and some have more staff than children being looked after.  Are we really happy to let these children grow up in orphanages?  Can we think of fostering or adopting them?

One cannot claim that NGO’s are immune to whatever is happening in the society.  As the number of such organisations has crossed all reasonable limits, many people have raised questions about their credibility and there are allegations that it has become merely business. This puts genuine and credible organisations in a difficult position and they have to keep defending themselves, wasting their time and valuable resources.  There is no simple answer to this problem.  Corruption is rampant in the society and it would be too ambitious to claim the NGO’s are somehow protected from this menace.  Unless there is some accountability and people are held responsible for their actions, it is impossible to weed out the fraudulent.  The civil society will have to rise above small differences and come up with a solution for this so that the genuine organisations are able to function and in the process the vulnerable are not neglected. 

The response of the society does seem ambiguous and at times critical towards the people who engage in social work.  Keeping in view the uncertain political situation in the state, most people have been struggling with the challenges of everyday life.  This has meant that only a handful have been actually left to fend for these orphans and widows.  At some level, we have unrealistic expectations from those who work in and run NGOs.  We want them to work for nothing and rather be super-humans.  But the reality is they have their own families to raise and look after.  Some may have enough resources and time to work for free, but most cannot afford to do so.  Then how do we make this sector attractive to credible and hardworking people?  We need honest people with real qualifications and passion in social work to take charge.  It is time to reason with compassion than just respond with emotions.  We have to devise methods for improving the sector than mirror the chaos around.

Work needs to be done towards building trust in voluntary sector so that more people choose to join hands.  There is a need for educating the masses about the magnitude of the problem and how their engagement can benefit the needy.  It does not have to be only monetary help but time, resources, expertise and knowledge is as important. We have a network of Auqaf committees in every nook and corner of the State, which can be engaged to spread the message e.g. by organising workshops and debates at various places. This again requires some central organisation and network for coordination.

It is evident that overall we do not have much zeal for charity or social service attitude though we may like to think otherwise.  NGO’s and orphanages are predominantly run by men when the vulnerable are mostly widows and orphan girls.  Involvement of women in such activities would mean better outcome bringing in traits of compassion, dedication and empathy.  Keeping in view our sociodemographic profile, men usually work and there are so many educated females with time on their hands who can take on the good cause.  But who is going to make that happen, are we too patriarchal a society or it is a general lack of interest? We need to encourage the involvement of women in such activities and make it easy for them to do so.  Involvement of women in voluntary sector would also help educate the children and youth to take on social work and create a more charitable society.  It would also help the widows living in their homes who may otherwise feel vulnerable and find it hard to trust strangers, particularly men.

We are also not sure about the actual numbers of widows and orphans who are suffering in silence.  Apart from few estimates by some international charities, there is no credible local register.  Here again, the state has failed to do its duty.  To formulate a proper long term plan, numbers are important, so are the estimates of current resources and people involved in such work. Organisations like J&K Yateem Foundation have tried to work beyond the concept of orphanages and expanded work in the community by helping widows, arranging marriages for poor girls, scholarships for  poor children for education, to name a few.  But a single charity or few charities cannot work everywhere and reach every destitute. It is the time that some order is restored in this sector and a mechanism devised so that NGO’s link and cooperate.  Sharing ideas and resources can make a big difference in how the help reaches the needy and those who deserve it most.  It would also increase the accountability and cut out those who are using voluntary sector for personal gains.

In the age of information technology and the internet, it is not difficult to have a database and link remote areas and organisations together.  It would help to keep track on performance, easy auditing, monitor the movement of children through the system, and compare performance and share resources etcetera.  The society has produced so many engineers and IT specialists who can bring in their experience and help to build the necessary infrastructure.  I think it is time for such professionals to come forward to help their society especially those who are weaker and worst hit by the ongoing conflict. Every professional can bring in the expertise from respective fields to make this possible.

Finally, it is hard to argue that there is something like an ideal social response. We as a society are going through a difficult phase in our history and whether we have fared well in looking after our orphans and widows will always remain debatable.  But certainly we can do better with same resources if we leave our differences aside and come together as a family.  We all need to be social workers, advocates and offer whatever we are good at. We have to inculcate the culture of compassion, social work and helping others, in our youth and coming generations.  It is time to reflect and act, as no action is too small, and after all, every little helps.

 ©EHSAAS, J&K Yateem Foundation 

http://www.risingkashmir.com/news/dignified-rehabilitation-of-orphans-widows-and-destitute 

Suicide, hidden epidemic

No country in the world is free from suicide.  As per World Health Organisation (WHO), suicide was the fifteenth leading cause of death in 2014, accounting for 1.4% deaths worldwide. More than 800,000 people die of suicide every year with many more attempting suicide, of which 75% occur in low and middle-income countries.  Although suicide occurs throughout the lifespan, it is the second leading cause of death among 15-29 year olds after road traffic accidents. 

The highest suicide rate of 44.2 per 100,000 of the population in the world has been recorded in Guyana followed by the Republic of Korea at 36.8 per 100,000 of the population.  Saudi Arabia has the lowest reported suicide rate of 0.3 per 100,000 of the population.  The South East Asia has the highest suicide rate in the world with a regional average of 17.1 per 100,000 of the population.  Sri Lanka has the highest suicide rate of 29.2 per 100,000 of the population while Indonesia has the lowest suicide rate of 3.7 per 100,000 of the population in the region.  India has the second highest suicide rate at 20.9 per 100,000 of the population in South East Asia.  

There are huge gaps in the reporting and documenting of suicide deaths worldwide especially in low-income countries.  It is partly due to stigma, criminalisation, lack of trained manpower and overall poor record keeping. Hence, it is probable that suicide mortality could be much higher than noted in such regions. There are at times political reasons for not documenting some deaths as suicide, for example, the frequent farmer suicides in India.  Many countries have already decriminalised suicide and India has also decided to do so with the introduction of the Mental Health Care Bill 2016. Decriminalisation of suicide has helped to reduce the stigma and enabled people to seek help.  Globally, there has been 9% decrease in the deaths due to suicide.

In India, 5650 farmers committed suicide in 2014. In the same year, more than 20,000 housewives died of suicide.  It is reported that since 1997, more than 20,000 housewives have been committing suicide every year with a peak of 25,092 suicides in 2009.  A study published in the Lancet in 2012 found that suicide rate in Indian females aged 15 years and older is more than two and half times greater than it is in same age women in high-income countries.  The suicide rate in women is highest in India than any other country in the world. 

Depression and anxiety are the most common mental disorders worldwide affecting one in ten or about 700 million people.  With better national policies and effective treatments for depression and anxiety, many countries mostly in the high-income zone have been able to prevent and reduce suicide mortality.  Moderate and severe depression, both are included in the Mental Health Action plan 2013-2020 of World Health Organisation (WHO) with a target of increasing service coverage to 20%.  Suicide prevention is an integral part of the Action Plan with an aim of reducing suicide mortality to 10% by 2020. 

For any national response to be effective, suicide prevention strategy needs to be multi-sectorial, holistic and workable within the cultural context. This includes training of manpower, early identification, treatment of common mental disorders especially depression, management of suicidal behaviours, follow-up, and management within the community settings.  Restricting access to the means of suicide like pesticides, guns and medications is very important for any strategy to work. 

With the introduction of the Mental Health Care Bill 2016 and decriminalisation of suicide in India, it is imperative that there is a national suicide policy targeting the reasons behind the high suicide rate, especially in women.  Education, training of manpower, social equality, control over social evils like dowry and forced marriages, treatment of mental health problems especially depression are some of the essential measures which need to be included. Pesticides being the number one means of suicide in India, with free availability even in remote places of the country, need strict regulation to save lives.  Finally, it is important to record data effectively and honestly which in turn will help to plan long term policies and prevention strategies. 

http://healthanalyticsindia.com/healthopinion.php?id=253 

Bullet in the Eye

It is hard to keep a count of people maimed by the purportedly nonlethal pellets.  From the skull, chest, abdomen to the precious eyes, nothing is spared.  The victims are of any gender and age, from young children unaware of what just hit them, to the older ones who probably sense that their sight has been snatched away forever.  The 32 bedded twin wards of the ophthalmology department of SMHS Hospital Srinagar had to cope with a flood of patients most of whom need urgent intervention.  The doctors and other allied staff in the department have been working without taking a break, beyond their working hours and under hostile conditions to help the fallen and thus deserve all our commendations.  The situation has been made even more difficult by the unceasing assaults and interruptions by security agencies within the hospital premises, for obvious reasons.

Due to the eye being a very delicate balloon shaped organ, the pellets not only perforate but ricochet inside the eyeball causing severe damage to the cornea, lens, vitreous, and retina thereby destroying the whole eye from within.  In some people, the pellet goes through and through completely destroying the globe of the eye. In some cases, even the optic nerve is damaged.  We have seen horrible looking X-ray images of pellet victims doing rounds on the social media, and one does not have to be an expert to know what damage pellets can do. 

Although classified as a nonlethal weapon by the Indian state, ophthalmologists of repute have unequivocally agreed that the pellet guns are very lethal, blinding most people for life. Dr Tariq Qureshi, Head of the Ophthalmology Department at Government Medical College Srinagar went on record calling for an immediate ban on the further use of pellet guns.  In the past 3 weeks, doctors at the SMHS Hospital have performed 552 operations on those injured; out of which 211 were primary eye surgeries on the pellet victims. 58 further eye surgeries were performed out of which 48 were performed by a visiting surgeon working with an NGO. The surgeries are done to keep the eyeball intact and most patients will need multiple secondary surgeries.

The local ophthalmologists perform urgent surgeries trying to salvage the eyeball with whatever facilities they have.  There is no doubt that they have developed great expertise over the years to treat such patients but one cannot claim that they are able to treat everything locally keeping in view the complexity of the damage caused by the pellets.  The assertion by the Principal Government Medical College Srinagar that full treatment is available locally and “We are equipped as per international standards” is, in reality, the misleading rhetoric of yesmanship, probably articulated to please higher-ups or possibly under political pressure.  Barring few tertiary eye centres in the whole of India, even places like AIIMS are not fully equipped to deal with such complicated injuries. I am sure our ophthalmologists are fully aware of this and have been voicing their concerns.

Treatment of the posterior chamber of eye and retina needs specialised tertiary care facilities. The valley lacks an eye bank, so how are corneal repairs even possible in such a scenario? The team of doctors which was brought from AIIMS by the state government did nothing to help with the grim situation. They parroted the state narrative to keep the media busy, thereby misleading people by creating a false sense of security.

Even if some have chances to regain eyesight with appropriate treatment, they become blind because of the deliberate and forced negligence by the authorities.  There is a sense that any whistleblowing would not be tolerated by the authorities.  The simple narrative of 'all is well' and we have everything to deal with the situation sounds out of place keeping in view that our heath sector even struggles during normalcy let alone a war like situation.  But this is not the first time medical professionals have been used to cover up political failures and state aggression. 

I am not suggesting that everyone should be referred outside the state as the treatment is prolonged and the outcome is usually not good.  The government should officially bring experts from outside the state along with the necessary equipment so that they can work in collaboration with the local ophthalmologists, treating patients and also empowering local experts with the necessary training for future cases.  The hospitals would need to be funded properly and appropriate infrastructure developed to deal with such injuries on urgent basis. There is an urgent need to start an eye bank.

Most of the pellet victims come from poor backgrounds and cannot afford to travel outside of the state.  But patients, who need further treatment, which is not possible locally, need to be referred to appropriate centres and not just any hospital for mere eyewash.  If some patients want to go outside, they should be appropriately referred rather than denying them that chance by giving vague excuses. Medical professionals cannot ignore the limits of their expertise or the facilities available, when dealing with lives and someone’s chance at seeing the world again.  If people are not appropriately guided, they end up at wrong places, where they are not only looted but harmed further.  Even if the NGOs volunteer to help, they should work under the supervision of local Ophthalmology department and referrals to them should be done by doctors.  It is important that right patients are identified for right treatment at the right time.

The use of pellet shotguns was first introduced in Kashmir in 2010.  During the 2010 unrest and subsequent years, hundreds of people received pellet injuries with eyes being a common target. Sadly, most of these poor victims were lost to follow-up. The common reason for not coming back to the local hospitals seems to be the fear of authorities. This has meant that many people who have some hope of recovery did not come back to get further treatment.  Some of them sold everything to get treatment outside of the state on ill-founded recommendations, ending up losing both vision and money. This holds true for the recently injured who are likely to face similar consequences.  There are also allegations that doctors are being forced to discharge these patients from the hospital and many volunteers helping them have been roughed up as well.

There is hardly any research when it comes to the treatment of eye pellet injuries and long-term prognosis in the local context.  A study published in 2012, reported 198 patients with pellet gun injuries attending Sheri-Kashmir Institute of Medical Sciences between the months of June and September 2010.  Another study published in 2012, included 60 patients seen at the ophthalmology department SMHS Hospital Srinagar for various eye injuries between June and September 2010.  The study concluded that the prognosis for pellet gun eye injuries remains very bad.  A study published in 2014, which looked retrospectively at the pellet gun eye cases from 2010 cohort, suggests that visual prognosis remains grim despite adequate treatment at the time of actual injury. Half of the cases were blind with visual acuity of less than 3/60.

Due to lack of a register for such patients, it is hard to know how many young blind people are suffering in silence. If this brutal weapon continues to be showered on the civilian population, we may have another cohort of ‘deliberately blinded’ people in thousands, adding to the list of half widows, orphans, and waiting mothers.  Such weapons were used by the West in the Gulf war but the world’s largest democracy using these weapons against the civilian population can only be described as shameful.  The use of such brutal weapons needs to be stopped immediately as no amount of justification makes them nonlethal under any international law.
http://www.risingkashmir.com/news/bullet-in-the-eye 

Pellet injuries - terrible fallout

During the last 3-4 weeks, an estimated 317 people have received pellet gun injuries in the Kashmir unrest, with half of them being shot in their eyes.  The two sixteen bedded ophthalmology wards in the SMHS Hospital Srinagar had to cope with around ten times the patients they have capacity for.  The use of pellet shotguns was first introduced in Kashmir in 2010.  During the 2010 unrest and subsequent years, hundreds of people received pellet injuries with eyes being a common target.

The eye being a very delicate balloon shaped organ, the pellet not only perforates but ricochets inside the eyeball causing severe damage to the cornea, lens, vitreous, and retina, destroying the whole eye from within.  Although classified as a nonlethal weapon by the police, the medical fraternity, especially the ophthalmologists, have unequivocally agreed that the pellet guns are very lethal blinding most people for life. Even after multiple surgeries, the prognosis remains grim, with majority becoming totally blind.

The local ophthalmologists are able to perform emergency surgeries trying to salvage the eyeball with whatever facilities they have, but the hospitals are not equipped to deal with the type of injury the pellets cause to the inner structures of the eye.  Concerns have been raised that treatment of pellet eye injury is not available locally, with the state being complacent; the victims are not referred to the appropriate centres outside for unknown reasons.  The valley even lacks an eye bank.  Most of the pellet victims come from a poor background and cannot afford to travel outside of the state for specialised treatment. Hence if some have chances to regain eyesight with appropriate treatment, they become blind because of the negligence of authorities. There is a sense that any whistleblowing would not be tolerated by the authorities for political reasons.

There is hardly any research when it comes to the treatment of eye pellet injuries and long term prognosis in the local context.  A study published in 2012, reported 198 patients with pellet gun injuries attending Sheri-Kashmir Institute of Medical Sciences (SKIMS-MC) between the months of June and September 2010. Another study published in 2012, included 60 patients seen at the ophthalmology department SMHS Hospital for various eye injuries between June and September 2010. The study concluded that the prognosis for pellet gun eye injuries was bad.  A study published in 2014, which looked retrospectively at the pellet gun eye cases from 2010 cohort, suggests that visual prognosis remains bad despite adequate treatment at the time of actual injury. Half of the cases were blind with visual acuity of less than 3/60.

Western literature suggests that people who lose their eyesight late in life are worse off emotionally that those who are blind from birth. Even people losing their eyesight due to medical reasons are highly likely to develop depression and other psychological problems.  This is thought due to the fear of unknown, fluctuating ability to see and rather being on an emotional roller coaster.  Losing vision is akin to a grief reaction where the loss is mourned by the person. More than 30% of people who develop blindness due to medical reasons develop depressive symptoms.

In comparison to medical conditions, people who lose their eyesight due to a traumatic injury inflicted on them, like the pellet guns, are highly likely to develop severe psychological problems. This is due to the trauma they experience and their final memory of seeing the world shattered by a pellet. The visual loss also happens within seconds of the injury, giving the individual little time to get used to the change in comparison to the loss of vision due to medical reasons. Suddenly young people find themselves blind, maimed and in pain facing a very bleak future. The uncertainty around recovery, multiple surgeries, inadequate treatment and subsequent poor prognosis further worsens the emotional health.

Such victims of the brutal blinding violence are likely to develop post traumatic stress disorder, depression and other anxiety disorders.  The sudden loss of functional life, almost negligible prospectus of future and inadequate support systems, in the long run, makes their situation more miserable. The victims get some attention in the immediate aftermath from doctors, their families and society.  But in the long run, they are forgotten and left to grieve on their own. They often become hostages in their own heads.  Sadly this is followed by stigma from their families and friends.

Apart from a lack of proper treatment in the acute aftermath, there are no support systems to help them to adjust to the change.  They not only need physical rehabilitation but also psychological rehabilitation and training so that they are able to adjust to the catastrophic change which has overpowered them without any warning.  Unfortunately, no such facilities exist in Kashmir valley. The local doctors, psychiatrists and civil society need to support the victims even after the acute phase is over, or else they may curse themselves wishing it is better to lose life than light. Counselling and rehabilitation services need to be established in all hospitals to help such victims cope with the loss of vision, life skills training and treatment of psychological problems.

The hospitals would need to be funded properly and appropriate infrastructure developed to deal with such injuries in future. For now, the state has a responsibility to fund their treatment in appropriate centres across India or even abroad if needed.   Finally, the use of such lethal weapons needs to be stopped immediately as no amount of justification makes them nonlethal.

http://healthanalyticsindia.com/healthopinion.php?id=221 

Ramadan and Corruption

A few decades ago, while filling the board examination forms for 12^th class, we were asked to pay five rupees extra by the clerk in our school.  One of my friends initially refused to pay but agreed on a condition that he will be provided with a receipt for the five rupees.  Many of us at the time thought his reaction was odd and uncool.  Trust me he was not poor and could have paid it easily.  Many years later, the same friend stormed the Vice Chancellors office at the University of Kashmir as money was being demanded by the examinations section for his marks sheet.  While he was trying to meet the VC, the police guards kept laughing at him and made him wait for hours, but he did not give up and made it through.  Did he achieve anything better by living a principled life in a corrupt society?  

When it comes to corruption in our state, we have accepted it in all forms possible.  It is no longer a taboo, but usually a path to success and respect in the society.  Those who do not play by it are often labelled as dry, eccentric or commonly ‘Khowshikh’.  Corruption has become the backbone of our black and white economy.  Without any exaggeration, it’s morally, socially, culturally and religiously accepted.  Paying in cash or in kind is not the only forms of corruption our society suffers from, but sufarish, crony-capitalism, phone calls, VVIP culture, yesmanship, and who’s who are few other examples and the list goes on.

One could assume that during the holy month of Ramadan when we fast to control our inner self, discipline our evil side and live like true Muslims, there would be an automatic end to the corrupt practices in offices, on the roads, in hospitals, and one can’t be but naïve to believe that.  The files do not move from table to table, as the so-called weight is missing and some prefer to delay it after Iftar, like somehow taking bribes on a full stomach makes it Islamic.  We spend hours in mosques when we are being paid to work somewhere else.  Some even completely give up work as it seems to them that they can’t take bribes during the holy month, so why to bother. Do we stop taking the salary?

I remember a revenue official, who was religious and practising Muslim from his outlook.  He had even sent one of his sons to a religious school to become Hafiz-e-Quran. He demanded five thousand rupees bribe from a poor father for the issuance of a backward area certificate.  The irony, it was Ramadan, he was on his prayer mat, giving the final verdict that nothing less than five thousand rupees will do- Allah-u-Akbar, leaving the humble guest bewildered.  I am not taking a dig on religion or religious practices, I am just trying to make a point that we have religiously accepted corruption and it is no longer a sin for us, although most of us have heard that ‘both the receiver and giver are buying a ticket to hell’.

During my college days, one of our friends wanted to get married.  One Friday, we ended up in a mosque in the heart of Jammu city to meet a Mufti.  His sermon was mesmerising and many people were in tears.  When we disclosed the purpose of our visit, to my surprise, the Mufti gave a long discourse how youth should marry by their own choice even in secret, than to convince us to get families on-board.   Without much persuasion, he agreed to perform the Nikah, though I was expecting he may object as there was no representative from the girl’s side.  He even arranged witness on her behalf.  How much will he charge? In my naivety, I replied that it is up to us.  Not convinced my friend blurted the question.  Respected Mufti shocked us by saying that the matter is complex and would cost a minimum of five thousand rupees.  Subsequently, he started demanding more money, and when finally he completed the formalities, he refused to hand the papers, brazenly asking for money first.  I will leave you to judge the moralities here.  The point being it was for money; he went ahead, gave a sermon and did not bother to even question what was happening, and such examples are ample in our neighbourhoods.

Any doctor will tell you how during the MBBS training, they are also taught the holy business of corruption from the day they enter the academic section. There is a surplus charge for everything and within few months the whole idea seems normal and rather essential.   When I started working as a doctor, my salary was not being released.  It was only after my friend pointed out if I had met the Madam.  He further advised me to gift a dress to her from my wife’s wardrobe as he had done the same.  I met the madam, made peace with her and henceforth my salary was always on time.  She was even saving my income tax and when I told her that I want to pay than to produce fake certificates; she was surprised and rather laughing on my judgement.  On a positive note, one of the cashiers in the directorate of health services office works honestly and he categorically refused to take anything.  But by that time, I had gone into the default societal mindset aka ‘corrupt-mode’ and now I felt that he should take some chai-pani from me.  So how does one protect oneself in not getting indoctrinated into this business of the give and take and normalisation of corruption, which has essentially taken over our society as cancer?   

I came across a recent Facebook update; talking about how in a government higher secondary school in Islamabad (Anantnag), students need to pay to sit exams. “Students are shortlisted as per shortage in their school attendance, on the instructions of administration, which is reportedly constituted of few clerks, teachers, and lecturers, who have been posted in the same higher secondary school for past 10 to 12 years.  These students are barred from submitting the examination form on the basis of a shortage of attendance, and then charged a bribe of Rupees 500 to 1000 from each of them.  This has been a practice for years now and nobody can even complain as no one wants to put his career at stake.” Further the update mentions, “I don’t have a sum of rupees 500, and I can’t ask my parents for the same; these people have asked to arrange the money before Eid, or they will cancel the admission.  I have asked my cousin to lend me the sum, and I shall return his debt after Eid from my Eidhi.” The other fellow with disgust replied, “They don’t even stop it in Ramadan; they pray- I see them going to the mosque every day but- of what use- they are a bunch of wolves.”  Hopefully, the director school education will do something about it, as he stands informed from the social media already.

These are just a few examples and one can write an encyclopaedia.  As a rule, we all are corrupt unless proved otherwise.  The fact remains that may it be education, health, other civil services, recruitment, and even religious services, unfortunately, corruption is a norm than an exception.  It has reached a level where the more corrupt are seen as role models and people work hard or pay for such jobs or posts, may it be civil service, police or revenue. Similarly, when it comes to postings within the departments, there is a defined rate for plush postings.  People who are honest are the odd man out and posted to places considered punishment by the mainstream.  Hence, an honest engineer would be posted to civil secretariat or an honest police officer to an airport, as the means of extra income are limited in such places. The corruption starts top down and no one is allowed to challenge it.

Finally, the question remains, why these students wouldn’t become corrupt on their way up.  If corruption is systemic and being practically taught at homes, in schools, offices, and mosques, why are we pointing fingers at each other when it comes to other social evils of no significance? Why do we blame our daughters for natural disasters?  Does this mean that we as a society have become so rotten that our noses have given up smelling the putrefaction? Others may not have as much integrity as my friend and even he is struggling to keep his head above the water in a toxic environment. The ball is in our court and we cannot blame others for our downfall.  The money which pays for the Sehri and Iftar cannot be from unfair means, nor do the times spend in the mosque when one is supposed to be working.  And please let us not fool ourselves that taking a bribe after Iftar or Ramadan is approved.  Are we starving for sixteen long hours for nothing? 

http://www.risingkashmir.com/news/ramadan-and-corruption 

Festivity not Radicalisation

By eating in secret, pulling down the curtains on restaurants, taking bribes after Iftar, a woman covering up in Hijab or playing spiritual records than Bollywood songs in the buses, is not hyper-religiosity but simply a mark of respect towards the holy month of Ramadan. Those who fail to understand this and blame all such acts on radicalisation should see a mirror. This does not mean that people will change forever, or not sin or a woman may again give up her headscarf. But let's respect the essence of this holy festival and not mock those who try to observe it.

Also, those of us living in the West may fail to understand that the Ramadan is like a festival and there is a change in overall societal mood. The children are excited and elders in humility. Those who believe seek forgiveness and refuge. Those in ill health seek to get well.

PS: The teacher has every right to suddenly wear an Abaya and remove it as well. This is a simple act of respect for the Holy month and nothing more. She may choose not to use it later or may continue wearing it, but let there be no coercion or denigration for what one does of their own free will. The school should have apologised to her than to those who are making hue and cry.

©Mudasir Firdosi 

Tale of a Doctor

I was lost for words. He sounded desperate, helpless and fed-up.  He wants to serve his people to the best of his expertise but has become a victim of an unhealthy health care system, losing his skills with every passing day.  Though he never thought of leaving his home, he is even considering moving out of the valley.  As he narrated his ordeal, I kept thinking of hundreds of sincere doctors in his shoes, who want to alleviate the suffering of their community but are rendered unworkable by a corrupt and badly run health department.  This is how the story unfolds.

After completing his MBBS, he decided to become a child specialist. While training as a paediatrician, he would often feel helpless seeing the pitiable state of neonatal care in the Valley.  You may recall the headlines of hundreds of neonates dying not that long ago.  There is not only lack of infrastructure and equipment but also a dearth of trained professionals like neonatologists and allied specialists.  With this in mind, he decided to become a neonatologist. He left valley joining a specialist centre for a period of 3 years.  That meant leaving his family and a few months old son at home. He missed his son’s babbling and the first steps.  Whenever he would visit home, his son would refuse to play with him, taking him for a stranger.

While in the far off land, he used to dream day and night that once back; he will serve his people by starting a new era of neonatology in the Valley.  He would often talk about the feats he was able to do in a properly run system, how even a few hundred grammes premature neonate, is saved by right equipment and professional help. But once back, things did not work as planned.  He gathered that health authorities are more interested in the head count than competence and training of a professional.  He was even not posted to a place which caters to children, nor has any equipment or infrastructure to allow him to do his job.  Probably he is just supposed to collect his salary at the end of the month.  Who cares about neonates or their worried parents? Moving from pillar to post, requesting and pledging the top officials in the department, he went unheard.  Why would a highly trained professional, who declined job offers from across the world, be posted in a place where he will even forget his basic training? ‘Kareh Najjar Badasteh Gilkar’.  Let me remind you that J&K was awarded for the best healthcare in India.  You are free to believe.

Keen to serve and learn, he visited many health care facilities across the valley and interacted with his colleagues to understand how to work.  But apart from disbeliefs, he did not achieve much.  It became clear to him that postings and transfers are not done using any method, taking into consideration the qualifications or the training of the doctor or need of a particular area. It is usually based on who knows whom, sufarish, crony capitalism or the mood of the official at the time.  No one thinks of the poor patients or the doctor in question.  It does not matter if practically an unqualified person is treating you.

Many buildings along the national highway have been named as Trauma Hospitals. Interestingly, there is no trained doctor to manage trauma.  Glorified load-carriers driven by untrained personnel are called as ambulances.   A room, named as the neonatal intensive care unit, has a warmer, weighing machine, and zero number of support staff.  He also came to know that a brilliant surgeon was transferred from a district hospital to a far-flung village, not because of his inefficiency but being upright who was trying to do good for his patients.  A dermatologist was forced to manage complicated pregnancies and then blamed for the adverse consequences.  There are hundreds such examples of a square peg in a round hole.

 He came to know that wounds are being stitched with bare hands, putting both the doctor and patients at risk of infections like hepatitis C and B.  When he suggested asking patients to buy gloves from the market, he was advised that “the vigilantes from the revenue department will be dispatched within a jiffy on the directions of the local henchman, to cut doctors to size".    Who is at fault here, administration or the civil society is for you to judge.  I am not advocating patients should buy anything when the healthcare is allegedly free.  But who pays the cost for the treatment of rampant hepatitis C cases? Unsurprisingly, some do ask medical representatives to supply gloves and other equipment, as hospitals are always in shortage.  Whom would you blame for the alleged doctor –medical representative (MR) nexus?

A consultant friend was encouraging him to join his native district.  When they met last, he found his friend distraught.  His friend had been lobbying to procure some equipment for the hospital, with intensions that a maximum number of patients will benefit from the latest technology.  He was warned by a class fourth employee from the administration that he is a non-entity and should refrain from defaming the hospital.  Trying to improve the facilities is taken as defamation; some would say it as progress.  When he mentioned his plans (rather dreams) of starting a neonatal intensive care unit (NICU) to his colleagues, having trained in latest technology including use of high-end ventilators, there was a loud laughter, whether on him or his naivety, one cannot be sure.   

Finally, he reached back to Srinagar rather dismayed.  While lost in his thoughts, he boarded a bus.  He had thought that buses are obsolete now and probably not many people use them.  Within no time, there were more people standing in the middle than those apparently seated, and more people hanging by the doors than those trying to stand relatively straight, and sandwiched in the middle.  He thought, contrary to popular belief as our leaders often claim, most are still economically deprived and socially unprivileged.  How can people afford healthcare if boarding such unsafe is a norm?

The bus conductor was shouting at the top of his voice to get more passengers on board. Within no time the conductor started yelling at the passengers, who were virtually hanging, to close the door. How can we close the door when there is no space inside, someone shouted back? Despite knowing everything, the conductor kept on insisting on packing more people into the bus. When the bus reached its final destination, surely many people had their backs and knees in a condition needing repair. Once off the bus, he could relate the condition of the health department to this bus in the 21^st century.  Our health system is like an overloaded bus, and those supposed to administer the department, hardly care to change it.

One would have thought that administration is paid to improve the system and not just rule and control people by punitive postings and transfers.  Isn’t it is up to the civil society to hold health authorities accountable than getting fooled by false promises of new hospitals which then fail to deliver for obvious reasons? It is time to get a proper system in place which is patient centred, professionals working as per their competence, and are held accountable for their actions.  The department needs to utilise doctors as per their expertise, encourage and reward them than to punish them for not having right contacts.  Let paediatricians look after children and ophthalmologists treat eyes, by forcing them to treat heart attacks or conduct deliveries, you will not only kill the patients but loose doctors as well.  The opening of new medical colleges or announcements of model hospitals only makes sense when right people are chosen for right jobs.  Otherwise, constructing concrete jungles only helps a few people to get rich and nothing more.  Big buildings do not make good hospitals, but the professionals working in them do.

http://www.risingkashmir.com/news/tale-of-a-doctor 

Open Debate – Is NEET good enough?

A common entrance test (CET), also called National Eligibility-cum-Entrance (NEET) test was proposed by the Medical Council of India (MCI) in 2012 for the admission to MBBS, BDS and postgraduate courses (MD/MS) in all colleges across the country.  Many State governments opposed the proposal and moved to court with the plea that NEET infringes upon their right to keep education as a State subject.  NEET was declared unconstitutional by the Supreme Court in 2013.  The private medical colleges were completely opposed to the idea as they seemed to be the biggest losers if NEET is implemented.  Recently, the Supreme Court of India ordered the implementation of NEET overturning its previous directive.  The MCI claims that NEET will improve the process of admissions, bring transparency and remove observed malpractices.  It is thought that many States do not have a robust mechanism of admissions and situation is worse when it comes to the private medical colleges.  There are often allegations of corruption and favouritism.

The aspiring candidates, medical students and doctors mostly welcomed the NEET.   On the positive side, candidates can just appear in one exam and this will save their time and money. They do not have to apply at various places and pay every time.  The allocations can be done with ease choosing their favourite colleges depending on merit.  The psychological stress of appearing in multiple examinations will be lessened.  On the other hand, the sudden introduction of the NEET meant that some candidates may be at a disadvantage due to their background or the way they were preparing for the exam etcetera.  Candidates from Jammu and Kashmir will lose the advantage of filling all the seats in the J&K Medical colleges, as non-State subjects are not allowed admission.   The fifty percent reservation for women in government colleges will also be lost in J&K.

Coming to a bigger question, is NEET the only solution to the declining standards of medical education in the country?  What else has MCI done so far to advance the medical education? It is a welcome first step towards the long awaited reforms.  It will make the life of the aspirant’s easy; avoid unnecessary bureaucracy and red tape.  The NEET is a multiple choice examination (MCQs), which is the gold standard for entrance examinations in India.  In view of the prevalent crony capitalism and corruption, an MCQ type of exam is the best option to cut down fraud and favouritism.  As there is no interview, it limits any outside interference.

Across the globe, the methods of admission, teaching and assessment have advanced keeping up with the developments in medicine and technology but India is still stuck in the early fifties of the twentieth century.  The MCI has proved to be a big disappointment due to its inability or rather inaction to reform the medical education over last six decades.  It is a shame that the MCI has not even been able to put together a proper syllabus and curriculum.  Every medical college trains and teaches, depending on the beliefs and whims of the faculty and there is no uniformity or standard across the country.

Becoming a doctor is not an easy task and apart from the academic qualifications and merit, one needs to have right aptitude and personality.  This cannot be examined by a simple multiple choice examination.  The overall personality, career goals and resilience to stand the gruelling exams and responsibility which comes with the job need to be kept in mind.  In the United Kingdom, admissions to medical colleges are done by a multistage process.  Aspirants with good grades in A-levels (10+2) are eligible to apply to the medical schools of their own choice. There is an initial longlisting process.  There is no MCQ type exam and they do not have to waste time revising and cramming the 10+2 syllabus again.  UK applicants must take one of three additional tests- the UK Clinical Aptitude Test (UKCAT), the Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT).  The candidates have to demonstrate suitability for becoming doctors by working with charities, hospitals or simply shadowing doctors, so that they can test themselves in real life situations and make an informed decision to enter the medical profession.  Such work experience is scored in the shortlisting process.

Candidates who are shortlisted are invited for interviews by the medical schools.  Interviews are a complex process of assessment (Multiple Mini Interviews-MMI) comprising of multiple stations in which various attributes of the candidate like attitude, ethics, compassion, resilience, and conscientiousness etcetera are assessed.  They are given clinical scenarios and asked to comment and give their opinion.   Interestingly there is hardly any stress on the theoretical knowledge as it is presumed that candidates have already done well in the 10+2 examinations and there is no need to assess the rote memory again.  Compare this to the MCQ type of examination.  Apart from testing the rote memory, there is hardly any emphasis on testing other attributes. While as the candidates in the UK make an informed choice to join medicine, many of our candidates sit the entrance because of social pressure.  Such candidates often become frustrated in the future leading to dangerous consequences like suicide, as there is usually no going back due to pressure from family and stigma. 

It is too ambitious to suggest switching from the MCQ type exam to this multi-stage assessment, but more needs to be done if we want to produce high quality and safe doctors. Having a common exam like NEET is a good start, but much more needs to be done if the deteriorating situation has to improve.   MCI needs to reform the curriculum and subjects taught in medical schools on a war footing.  The focus needs to shift from reading thick books and theory to practical skills, empathy, ethics and accountability just to name a few.  There needs to be a common minimum standard of doctors passing out of the medical colleges.  If the MCI is not able to deliver, then it may be better to start with disbanding the monster as recommended by the parliamentary committee.  The Committee on petitions (Lok Sabha) has already invited views/suggestions on the petition “Medical reforms in the country” which is a good start and may hopefully lead to some positive changes.  Interestingly, due to pressure from various state governments, the central cabinet passed an ordinance postponing the implementation of NEET by one year.  Only time will tell if it will be implemented or not and who’s interests will be dearer to the politicians running the country.

http://healthanalyticsindia.com/healthopinion.php?id=198