Crisis of forest fire

(The Hindu)

 

Fighting the curse of TB

(The Hindu)

Synoptic line: The TB epidemic kills 1.8m people a year fighting it requires huge social mobilisation on the scale of the battle against HIV/Aids

(GS paper III)

Overview

 

  • According to the 2016 global TB report of the World Health Organisation (WHO), the epidemic is larger than previously estimated, with 10.4 million new infections in 2015, of which 60% were in India, China, Indonesia, Nigeria, Pakistan and South Africa.

 

  • The disease kills 1.8 million people each year more than any other disease – and drug-resistance is on the rise in many countries. 

 

  • The report also found that spending on TB this year fell almost $2bn (£1.6bn) short of the $8.3bn needed to combat the disease; this gap is expected to widen to $6bn in 2020 if funding doesn’t increase.

 

TB in India

 

  •  The incidence rate of tuberculosis (TB) in India is estimated at 200-300 cases per 100,000 population per year. As a comparison, in western Europe it is five per 100,000 per year.

 

  • Control in public health is deliberate reduction of incidence to a desired and defined level by specific interventions. Without monitoring incidence and defining the desired target, the Revised National TB Control Programme (RNTCP) is not a valid control programme, but a great humanitarian programme of free diagnosis and treatment.

 

  • India’s estimated annual TB burden is 28 lakh, 27% of the global total; our population is only 18%. Every day 1,200 Indians die of TB 10 every three minutes. The tragedy 1,200 families face every day is beyond imagination. No other disease or calamity has such Himalayan magnitude. Had control efforts registered even pass grade, we would not have become the TB capital of the world.

 

What is the disease?

 

  • Infection with TB bacilli is the necessary cause of TB, a disease that mimics other diseases, confusing doctors and delaying diagnosis. Cough and blood in sputum occur only in lung TB. For example, a young man developed headache and began making silly mistakes in arithmetic. He had brain TB and treatment cured him. Pelvic TB is the commonest cause of female infertility in India. TB can affect the lungs, brain, bones, joints, the liver, intestines or for that matter any organ and can progress slowly or kill in weeks.

 

  • In designing TB control three processes must be understood: infection, progression, transmission. Infection occurs when TB bacilli are inhaled. Bacilli may stay in the lungs or travel to other organs. Infection is lifelong, with bacilli lying dormant. This phase is “latent TB”, diagnosed by a tuberculin skin test (TST). The “annual rate of TB infection” (ARTI) is about 1%. Cumulatively, 40% to 70% of us are living with latent TB. From this reservoir pool, a few progress to TB disease, one by one, 5-30 years, average 20 years, later.
  • Progression occurs when bacilli become active, multiply and cause pathology; now we have “active TB”. Only when active TB affects the lungs do bacilli find an exit route to the atmosphere, necessary for transmission.

 

Controlling the disease

 

  • All of us, the public, health-care professionals, Health Ministry policy planners and implementers, must form a united battlefront. Beginning with schools, public education on TB and its prevention must replace ignorance and misconceptions.

 

  • Transmission and infection are ends of a tunnel. If no one spits in public places and if everyone practises cough and sneeze etiquette (covering one’s mouth and nose when coughing or sneezing), the TB affected will also fall in line.

 

  • A person with lung TB disseminates TB bacilli over several weeks. By the time treatment stops dissemination, unfortunately, all his close contacts would have been already infected. This is why TB treatment has not brought down the TB burden.

 

  • To block transmission, treatment should begin as soon as a symptom shows up. RNTCP guidelines for testing only after two weeks of cough result in the loss of precious lead time. Some 70% of people seek health care in the private sector.

 

  • As cough is a very common symptom of many diseases, doctors don’t think of TB until other treatments fail. Frustrated patients also shop around until someone thinks of TB; bingo, the sputum test is positive. While treatment is the patient’s urgent need, it will not control TB. It is like shutting the stable door after the horse has bolted.

 

  • Partnership with the private sector is essential for early diagnosis of TB. Delay in diagnosis, for which we are notorious, is a fallout of the lack of efficient primary health care. Universal primary health care, a basic human right, and a diagnostic algorithm for early diagnosis are essential for TB control. Every country that has reduced TB incidence practises universal health care.

 

  • How can progression be retarded? The biomedical method is drug treatment of latent TB. Experts recommend an age window of 5-10 years when all children must be screened with TST; those with latent TB must be treated to prevent progression. The spin-off is in getting annual data on ARTI to track the trajectory of decline. A yearly 5% reduction of ARTI is achievable. In 20 years we can be on a par with western Europe in terms of infection incidence. Active TB will also decline, but more slowly.

 

Way ahead

 

  • To outsmart TB bacilli, we must intercept infection, progression and transmission. While TB bacilli are efficient in all three, our weapons against them are blunt. Our only chance of victory is by the concerted use of all interventions biomedical and socio-behavioural. There is no glamour in this long-drawn-out battle.

 

  • Any further delay may convert a controllable disease into an uncontrollable one, because of increasing frequency of resistance to drugs against TB.

 

Questin To outsmart the disease, India must intercept infection, progression and transmission. Comment.

Is active euthanasia the next step?

(The Hindu)

Synoptic line: It throws light on the issues associated with active and passive euthanasia.

(GS paper III)

Overview

 

  • Supreme Court in Common Cause v. Union of India categorically refused to confer a right to “active” euthanasia. The administration of a lethal drug by a physician, as well as by a patient (when supplied the drug by a physician), falls within the meaning of active euthanasia.

 

  • The administration of a lethal drug by a physician even with the consent of a patient constitutes culpable homicide punishable under the Indian Penal Code. When the drug is being administered by the patient herself, it is suicide under Section 309 of the IPC, which punishes an attempt to commit suicide.

 

Active and passive euthanasia

 

  • The court does, however, permit physicians to withhold or withdraw life-sustaining treatment, both from patients who have consented to this and from those who are incompetent to do so. This is what the court calls “passive euthanasia”. The use of the terms “active” and “passive” has been criticised by the Indian Council of Medical Research in a publication released this month defining terms used in end-of-life care. Using passive euthanasia to describe the withholding or withdrawal of treatment wrongly suggests that there is something unnatural about the process. Instead, such withholding or withdrawal ought to be seen as allowing death to take its natural course. The court also sees it this way, despite its use of the term “passive euthanasia”.

 

  • In fact, this is why the court permits “passive euthanasia”, while not extending the same recognition to “active euthanasia”. In the eyes of the law, the distinction between committing a positive act (administering a drug) versus withdrawing treatment (taking a patient off the ventilator) is one that has significance. As Justice Chandrachud says, in active euthanasia, the act of the doctor “causes” death. In passive euthanasia, “death emanates from the pre-existing medical condition of the patient which enables life to chart a natural course to its inexorable end”.

 

  • Although his opinion recognises that the moral, ethical and philosophical debate on this issue has criticised the act/omission distinction, he concludes that judicial restraint demands that only Parliament and not the courts take a final call on legalising active euthanasia.

 

Ruling in favour

 

  • In Common Cause v. Union of India, the Supreme Court expounded the basis of its 2011 ruling in Aruna Shanbaug v. Union of India, which permitted “passive” euthanasia, including “involuntary” passive euthanasia for mentally incompetent patients, in certain terminal cases. Ruling that Article 21 of the Constitution guaranteed the “right to die with dignity”, the court also issued interim guidelines to enforce individuals’ living wills in case of future incompetence.

 

  •  Aruna and Common Cause have incorporated the judicial APD evolved primarily by U.K. courts. In popular discourse, APD has become shorthand for an apparently axiomatic ethical and legal dichotomy between “killing” and “letting die”. But the ethical and jurisprudential underpinnings of the apex court’s rulings logically dictate that the right declared in Common Causeextends to “active” euthanasia in carefully circumscribed circumstances.

 

  • Overall, judges and commentators recognise that in the context of euthanasia, ceteris paribus, there is no legally intelligible difference between deliberately “doing” (active) and “not doing or stopping to do” (passive) something that leads to death. Nor is there any articulable reason why “withdrawal” (as opposed to “withholding”) of current treatment isn’t an illegal “active” decision that hastens death from the underlying cause, much like a lethal injection that also accelerates imminent death. To quote Lady Hale of the U.K. Supreme Court in Nicklinson v. Ministry of Justice, “Why does active assistance give rise to moral corruption on the part of the assister (or, for that matter, society as a whole), but passive assistance does not?

 

  • As a result, APD is a morass of legal fictions about intentionality and the “ultimate” causation of death, which don’t withstand scrutiny. More importantly, it may unjustly deny a recognised fundamental right to those who need assistance to access it. A tragic U.K. case showcased the dangers of treating APD as an axiomatic rule that overrides legitimate requests to exercise the right. Diane Pretty, while mentally competent, was in the terminal stages of incurable motor neurone disease, which left her completely paralysed from the neck down.

 

  • Faced with the prospect of progressive suffocation as her breathing and swallowing muscles failed, Pretty required assistance to effectuate a dignified and bearable death in a manner and time of her choosing. To be clear, these inherent contradictions in APD are the inevitable outcome of fragmented rule-making by courts hamstrung by the lack of a comprehensive and coherent legislative and policy framework. APD is an elaborate and flawed judicial construct arguably necessitated by overarching policy concerns, namely, potential for abuse by unscrupulous individuals; the spectre of criminal prosecution of benign doctors and families; and the exercise of judicial restraint on a sensitive issue that warrants legislation embodying the democratic will.

 

  • These dilemmas fall within the realm of Parliament, which must act to resolve them. As Justice D.Y. Chandrachud notes, “the meeting point between bio-ethics and law does not lie on a straight course,” and these complex issues “cannot be addressed without the legalisation and regulation of active euthanasia” (emphasis added).
  • By emphatically erring on the side of self-determination and recognising passive euthanasia with certain safeguards as a fundamental right, Common Cause signals that APD’s days are numbered. Whether couched as “dignified death” or “bodily autonomy”, there is no reasonable basis for negating the right vis-à-vis a patient whose circumstances warrant assistance to exercise it

 

Why it should not be the case?

 

 

  • Euthanasia has always been a tricky subject. While some deem it immoral and against the will of god, others see the act of ending the life of a person who is suffering indefinitely as a benevolent action, an almost charitable one.

 

  • Where do we draw the line between murder and an act of charity? Does the mental state of the person who is asking for death count? How do we account for depression, or losing the will to live, when there are treatments available by mental health specialists which can effectively turn a person’s life around? Where does the concept of euthanasia stand in our law and how do we distinguish between a person who has lost the will to live and one who cannot live? What is “mercy killing” and how do we differentiate it from “killing”?

 

  • The Supreme Court, in P. Rathinam v. Union of India (1994), debated the constitutionality of the attempt to commit suicide under Section 309 of the Indian Penal Code and struck down the proviso. For the first time, the right to die was included within the right to live with dignity. The debate was raised again in Gian Kaur v. State of Punjab (1996), where the courts overruled the P. Rathinam judgment and held that the right to life did not include the right to die.

 

  • The Supreme Court, in Aruna Shanbaug v. Union of India (2011), laid down guidelines for passive euthanasia and held it to be the withdrawal of life-sustaining treatment from patients who are not in a position to make an informed decision. The debate has now been furthered with the recent ruling, where the Supreme Court has held the right to die with dignity as an inextricable part of the right to life. The judgment has created safeguards to protect a person who is in a vulnerable state, and has included the creation of living wills as an acceptable mode by which the right to euthanasia may be exercised.

 

 

  • The creation of a living will allows a person to express her desire to turn off life support if she is ever in a condition where she becomes eligible for passive euthanasia. The judgment is laudable since it frees those close to the patient from the guilt of taking away life-sustaining support. It allows a person to die with dignity and respect. It has come as a part of the series of judgments that the courts have given, expanding the definition of right to life to encompass the right to privacy and dignity.

 

  • Euthanasia is an extremely contentious issue because it is a decision fraught with emotion. It is unnatural for a person to seek death. Passive withdrawal is the maximum that we may tread on this contentious path. The will to die is often a psychological issue. Life has many twists and turns, and many of us often face loss and depression which temporarily rob us of our strength to fight. If any further step is taken, it will make people suffering from mental illness vulnerable to their own minds as well as unscrupulous elements.

 

  • As of today, courts have handed us the right to choose our death in dignity, but the line has to be trodden carefully. Another step in this direction could result in “killing” as opposed to “mercy killing”.

 

Controlling the disease

 

  • All of us, the public, health-care professionals, Health Ministry policy planners and implementers, must form a united battlefront. Beginning with schools, public education on TB and its prevention must replace ignorance and misconceptions.

 

  • Transmission and infection are ends of a tunnel. If no one spits in public places and if everyone practises cough and sneeze etiquette (covering one’s mouth and nose when coughing or sneezing), the TB affected will also fall in line.

 

  • A person with lung TB disseminates TB bacilli over several weeks. By the time treatment stops dissemination, unfortunately, all his close contacts would have been already infected. This is why TB treatment has not brought down the TB burden.

 

  • To block transmission, treatment should begin as soon as a symptom shows up. RNTCP guidelines for testing only after two weeks of cough result in the loss of precious lead time. Some 70% of people seek health care in the private sector.

 

  • As cough is a very common symptom of many diseases, doctors don’t think of TB until other treatments fail. Frustrated patients also shop around until someone thinks of TB; bingo, the sputum test is positive. While treatment is the patient’s urgent need, it will not control TB. It is like shutting the stable door after the horse has bolted.

 

  • Partnership with the private sector is essential for early diagnosis of TB. Delay in diagnosis, for which we are notorious, is a fallout of the lack of efficient primary health care. Universal primary health care, a basic human right, and a diagnostic algorithm for early diagnosis are essential for TB control. Every country that has reduced TB incidence practises universal health care.

 

  • How can progression be retarded? The biomedical method is drug treatment of latent TB. Experts recommend an age window of 5-10 years when all children must be screened with TST; those with latent TB must be treated to prevent progression. The spin-off is in getting annual data on ARTI to track the trajectory of decline. A yearly 5% reduction of ARTI is achievable. In 20 years we can be on a par with western Europe in terms of infection incidence. Active TB will also decline, but more slowly.

 

Way ahead

 

  • However, this is not necessarily where Parliament should be focusing its legislative energy next. While other countries have sophisticated regimes on assisted dying, India has only just recognised a constitutional right to refuse medical treatment. The guidelines laid down by the court to govern “passive euthanasia” and advance directives until Parliament enacts legislation are unworkable in their complexity. Parliament should frame legislation to replace these guidelines after allowing doctors and patients time to have conversations about end of life decision-making and to evolve a procedure that is practicable and fair, and which takes into account the peculiarities of Indian society. Active euthanasia should follow only after learning from this experience.

 

Question What is the difference between active and passive euthanasia? How India should respond to it?