March 29, 2017
The Lower House of the Parliament passed the new Mental Healthcare Bill 2016 on Monday. The Upper House had already passed the Bill in August last year.
· It clearly spells out clearly government’s responsibility.
· It decriminalizes attempt to suicide.
· It has made the mentally ill eligible for insurance cover etc
The Bill has some very good provisions (as above) and it has been enacted by the Parliament, it suffers from some fundamental inconsistencies and poor drafting. Submissions have been made in detail to the Hon’ble Health Minister by the Indian Psychiatric Society.
Some of the fundamental problems with the Bill are as mentioned below
1. Definition of mental illness: Mental illness is defined as “substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgement, behavior, capacity to recognize reality and ability to meet ordinary demands of life”
· This definition is at variance with that of National Mental Health Policy.
· As per the definition, even serious mental illnesses like Depression and Delusional Disorder cannot be considered as mental illnesses. Common mental illnesses like Panic Disorder, Obsessive compulsive disorder also cannot be considered as mental illnesses, whereas these illnesses can be very disabling. Hence, the provisions of the act can benefit only a small portion of people with mental illnesses (PMI).
· The act states that all PMI should be admitted as “Independent” as per Section 65(2). How can this be possible? A person who suffers from grossly impaired judgement and not able to meet ordinary demands of life will be in no position to seek voluntary admission.
2. Mental Health Establishment Section 2(1) (P): As per the definition, even a general hospital psychiatric unit (GHPU) will be deemed to be a Mental Health Establishment and therefore needs to be registered as such.
· Singling out mentally ill in this fashion goes against the vision of National Mental Health Policy, which envisages full integration of psychiatric services in mainstream medicine.
· As per the definition, practically all hospitals will be deemed to be Mental Health Establishments because mental illnesses and physical illnesses frequently coexist. For example, a person who gets into a hospital for Diabetes may have Depression and will need psychiatric treatment.
· It will not be possible for the State mental health authority to regularly monitor all hospitals and other establishments
3. Mental Health Nurse Section 2(1)(q): As per the definition even a nurse with diploma in general nursing is mental Health Nurse and can be registered as a mental health professional (Section 55). A mental Health professional can admit patients and send them on leave. A Psychiatrist who had undergone rigorous training for 10 years is sought to be equated with person with 3 years training in nursing! Giving responsibilities to people who have no adequate knowledge and skill will create havoc in mental health care service.
4. Advance Directive (Section 5): It is almost impossible for a common man (Future Psychiatric Patient) to determine what treatment he should have or should not. Psychiatric knowledge is limited even in medical graduates.
5. Nominated Representative (Section 14): In our country, family members take the major responsibility of caring for mentally ill. Bringing a third party into the decision making process is against the culture of our country. Even the WHO Mental Health Act and Convention on the Rights of Persons with Disabilities (CRPD) advocate culturally consistent laws for member states.
6. Section 18(1) (3) Not Consistent with section 2(1)(s). 18(1)(3) section states that every person should have access to mental health care, whereas section 2(1)(s) even excludes people suffering from common mental illnesses and even some serious mental illnesses.
7. State Mental Health Authority: In our country, we have one psychiatrist for more than 3 lakh people. This small number of psychiatrists is shouldering enormous responsibilities. Psychiatrists who are experts in the field are not adequately represented in the State Mental Health Boards. At least 4 psychiatrists including 2 private psychiatrists should be included as members.
8. Central Mental Health Authority: At least 4 psychiatrists as above should be included as members.
9. Electro Convulsive Therapy (Section 94(3)): This is a treatment NOT a punishment as depicted in films. It is lifesaving in certain psychiatric conditions. High voltage current is directly applied to the chest without anesthesia in cardiac emergencies. Surgeons routinely apply electric current to burn tissues during operation to stop bleeding. Why special restrictions are placed on psychiatrists? It would be in the best interests of patients if treatment decisions are left to specialists.
10. Community Care: The bill deals with institutional care. Provisions for Community care are not there in it at all.
The Bill is studded with errors. For example:
· In the index at the beginning of the Bill “Mental Health Commission” is mentioned. There is NO Mental Health Commission in the Bill.
· Section 103 quoted as emergency treatment whereas it is section 94, which actually deals with emergency treatment.
· There are many more such errors
This bill is a Legal cum Professional document. Enormous difficulties will arise in implementing the present bill. People particularly in the vast rural areas of country will be at a disadvantage in getting access to mental health care. The Indian Psychiatric Society, the premier body of Psychiatrists in our country, is prepared to sit with concerned officials to sort out the lacunae in the bill.
The Mental Health Care (MHC) Bill may end up ruining the mental health sector in the country. The MHC Bill proposes to bring the General Hospital Psychiatry Units (GHPUs) under its purview. The general hospitals mostly treat people with depression, anxiety, phobias, sexual dysfunctions, adjustment and stress disorders, etc, before any disability sets in. “If we are trying to put these everyday life events into legal framework, people will not seek treatment and some of them may even commit suicide, ultimately leaving the Bill a disaster.” GHPU attached to teaching hospitals, general hospitals, and to some major private hospitals was the biggest revolution in psychiatry in the last 50 years. It has de-stigmatized psychiatric treatment by bringing mental health care from the confines of the mental hospitals to the doorsteps of the common man.
Moreover, the MHC Bill is modelled on certain Western Bills. Various clauses in the Bill like ‘nominated representatives’ and ‘advance directives’ are completely alien to the Indian family ethos.
Dr KK Aggarwal
National President IMA & HCFI
With contributions from: Dr (Prof) Roy Abraham Kallivayalil, National Vice-President, IMA and Dr RN Tandon Hony Secy Gen IMA
With detailed inputs from: Dr Prof Brig MSVK Raju, President, Indian Psychiatric Society
March 28, 2017
Global warming may be contributing to the worldwide epidemic of diabetes, suggests a new study from The Netherlands published online in the journal BMJ Open Diabetes Research & Care. In the year 2015, 415 million adults globally had diabetes and this number is estimated to rise up to 642 million cases by 2040, an increase of almost by 55%.
Researchers from the Leiden University Medical Center attempted to investigate if global increases in temperature were contributing to the current rise in the prevalence of type 2 diabetes by negatively affecting the glucose metabolism via a reduction in brown adipose tissue activity. Data on diabetes incidence amongst adults in 50 states of the USA and three territories (Guam, Puerto Rico and Virgin Islands) for the years 1996 to 2009 from the National Diabetes Surveillance System of the Centers for Disease Control and Prevention (CDC) was used in the study.
On average, with every 1°C rise in temperature, age-adjusted incidence of diabetes was found to increase by 0.314 per 1,000 in the US. The global prevalence of glucose intolerance also increased by 0.17% per 1°C rise in temperature in mean annual temperature. Overall, warmer countries tended to have a higher prevalence of glucose intolerance.
This effect of warmer temperatures on glucose metabolism has been linked to brown adipose tissue. It has been shown earlier that colder temperatures can activate brown fat and improve insulin action and sensitivity. Therefore, it was hypothesized that warmer temperatures could have the opposite effect; decrease in activity of the brown adipose tissue could reduce insulin sensitivity and an increase in the prevalence of type 2 diabetes.
Although this study did not establish a cause and effect relationship between global warming and type 2 diabetes, the fact remains that climate change is real and is a major challenge of the 21st century, which needs to be tackled urgently. The impact of climate change are global and not limited to a particular region of the world. Climate change affects the environment and consequentially human health both directly and indirectly.
Climate change directly affects five components of the environment: water, air, weather, oceans, and ecosystems. Through changes in the environment in the form of extreme heat and cold waves, floods and droughts, typhoons, hurricanes, worsening air quality and other natural disasters, it indirectly affects human health.
Many vector-borne diseases such as dengue, Chikungunya are showing a resurgence making them more difficult and challenging to control. Moreover, they are being redistributed across the world to areas that are currently not endemic for these diseases. Not only infectious diseases, non communicable diseases (NCDs) such as heart disease, stroke, respiratory diseases, type 2 diabetes have also been linked to climate change.
(Source: BMJ Open Diabetes Research & Care. 2017, Volume 5, Issue 1)
March 27, 2017
Dr KK Aggarwal
National President IMA
“Be respectful” This is what we have been taught since childhood… our traditions and culture also teach us to always be respectful towards every living being, and not just towards another human being.
The Right to Life is recognized in Article 3 of the 1948 Universal Declaration of Human Rights and Article 6 of the 1966 International Covenant on Civil and Political Rights.
The ‘Right to life’ is enshrined in our constitution in Article 21, which says “No person shall be deprived of his life or personal liberty except according to procedure established by law.” The scope of Article 21 has been expanded over the years in various judgements of the Supreme Court by adding the dimensions of right to health and medical care among other things that are essential to life such as adequate nutrition, education, etc.
The Right to life also means the ‘Right to live with human dignity’.
In its judgement in Francis Coralie Mullin vs The Administrator, Union Territory of Delhi & Ors dated 13th January, 1981, the Apex Court held: “The right to life includes the right to live with human dignity and all that goes along with it, namely, the bare necessaries of life such as adequate nutrition, clothing and shelter and facilities for reading, writing and expressing oneself in diverse forms, freely moving about and mixing and commingling with fellow human beings… Every act which offends against or impairs human dignity would constitute deprivation pro tanto of this right to live and it would have to be in accordance with reasonable, fair and just procedure established by law which stands the test of other fundamental rights…”
It’s not just the living, who deserve our respect … the dead too deserve dignity just as the living do. A dead person has the right to be treated with dignity as exemplified by the right to a decent burial or cremation. A dead person has the right to remain undisturbed and unharmed.
Section 297 of the Indian Penal Code ‘Trespassing on burial places, etc.’ has recognized it as a punishable offence and says, “Whoever, with the inten¬tion of wounding the feelings of any person, or of insulting the religion of any person, or with the knowledge that the feelings of any person are likely to be wounded, or that the religion of any person is likely to be insulted thereby, commits any trespass in any place of worship or on any place of sepulchre, or any place set apart from the performance of funeral rites or as a depository for the remains of the dead, or offers any indignity to any human corpse, or causes disturbance to any persons assembled for the performance of funeral ceremonies, shall be punished with imprisonment of either description for a term which may extend to one year, or with fine, or with both.”
Also, organs or tissues of a dead person can be harvested as defined under the Transplantation of Human Organs and Tissues Rules, 2014. For most organs and tissues, the time between death and donation is 12 to 36 hours. The approximate maximum time span between recovering organs/tissues and transplantation for the following organs/tissues is: Lung (4-6 hours); Heart (4-6 hours); Liver (24 hours); Pancreas (24 hours); Kidney (72 hours); Corneas (14 days); Bone (5 years); Skin (5 years); Heart valves (10 years).
A dead body is living as long as organs can be harvested and the dead body deserve to be treated with respect and dignity…
Vedic texts describe five different movement forces in the body: apana vayu expulses urine, stool, baby and menses; samana vayu controls the intestinal movements; vyana vayu controls the circulatory system; udana vayu controls the neurological impulses and the connection between soul and spirit and prana vayu controls the brain stem reflexes. The Soul or consciousness is linked to udana vayu and prana vayu.
According to the Chandokya Upanishad, at the time of death, the Prana Vayu (life force and respiration) merges with Udana Vayu (brain stem reflexes) and leaves the body. But this does not happen immediately after clinical death, which is defined as stoppage of heart and respiration.
Except for cornea many organs can be harvested for donation after a person has been declared as brain dead. The vital organs of the body such as the heart, lungs, liver, intestine, kidneys can be kept viable for some time, if a brain-dead person is kept on a ventilator to maintain oxygenation of organs, so that organs remain viable till they are harvested. This is because the body has normal Prana Vavy, Samana Vayu and Apana vavy. The patient will maintain blood pressure, GI functions, urinary functions and reproductive functions.
The life force resides in each one of us… This vital force is the soul, Atman or consciousness.
To summarise, a living person has a right to live with dignity so does a dead body with retrievable organs and tissues (as it is considered still a living body) and finally the fully dead body, including the mummified body or the cadaver, also needs to be treated with dignity