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PUBLIC HEALTH, AND THE CASE LAW

Authored by: Dr. J.P. Arya*

* Associate Professor, Chanderprabhu Jain College of Higher Studies and School of Law

ABSTRACT

Public health, which is, "Art and Science of protecting and improving the health of a community through an organized and systematic effort that includes education, provision of health services and protection of the public from exposures that will cause harm”. Public Health, Medical Ethics and Law are mainly referred to in conjunction, and frequently discussed together in this paper. This research paper explains their meaning and relationship, and how the law sees medical ethics. It then considers whether medical ethics functions in the way that the law thinks that it does. After providing a historical perspective that identifies medical ethics discourse as disjointed and fragmented, the paper continues by examining certain relevant medico-legal case law and facts that have an inherent ethical content for clues as to how they define medical ethics and its role. It also considers how medical ethics sees the law, concluding that a misapprehension by each party as to what the other does creates a mutually harmful relationship between them. India is experiencing a rapid health transition. It is confronted both by an unfinished agenda of Health hygiene, infectious diseases, nutritional deficiencies and unsafe pregnancies as well as the challenge of escalating epidemics of non-communicable diseases. The paper also emphasizes the need for public health response and suggest that Education and training in public health needs to be inter-disciplinary in content so that the pathways of public health action are multi-sectoral. The paper makes it clear that there is no legal impediment for a medical professional when he is called upon or requested to attend to an injured person needing his medical assistance immediately. There is also no doubt that the effort to save the person should be the top priority not only of the medical professional but even of the police or any other citizen who happens to be connected with the matter or who happens to notice such an incident or a situation.

Keywords: Public Health; Education and training; Medical Ethics.

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PUBLIC HEALTH AND HYGIENE IN ANCIENT INDIA

The earliest social culture in India of which we have archaeological evidence centered on Mohenjo-Daro and Harappa, chief cities of the Indus valley civilization, which flourished from about 2500 B.C. to 1500 B.C. The main characteristic of this ancient Indian urban culture was its advanced system of public sanitation. There were numerous wells, bathrooms, public baths, sewers, waterfalls and dustbins for collecting trash. Streets were laid out in regular fashion, and houses were well constructed and ventilated.1

Vedic culture is one of the oldest living religions, having evolved over a period of four thousand years. Initially it was a synthesis of the ancient religion brought in by the Aryans and the religious traditions of the Indus valley civilization. The body of literature of the Aryans known as the Veda (Sanskrit for knowledge) is the oldest scripture of Hinduism. The foundations of traditional Indian healing, called Ayurvedic (knowledge of life) medicine, rested on the ancient teachings together with a number of commentaries and later writings by healers such as Charaka, Sushruta, and Vagbhata

Ayurvedic medicine was thus based on a vast literature which included not only the Vedas and their later commentaries (the Brahmanas, Aranyakas, and Upanishads) but also a body of medical writings by many contributors, of whom two stand out as the most influential: Charaka and Sushruta. The physician included both surgery and medicine in his practice. Sushruta wrote, "Only the union of medicine and surgery constitutes the complete doctor. The doctor who lacks knowledge of one of these branches is like a bird with only one wing."

As in primitive societies and other ancient civilizations women were midwives and the possessors of drug lore, knowledge of herbs and domestic remedies. Charaka and Sushruta rarely referred to women and then only in connection with the management of women's diseases and childbirth. A considerable amount of attention was given in the Vedic and medical writings to women, including their sexuality and illnesses. In all times a woman was supposed to be treated kindly. On the other hand, although the Laws of Manu forbade adultery for both men and women, extreme penalties for the transgression were prescribed only for the woman. Bearing and raising children and running

1 Albert S. Lyons, R. Joseph Petrucelli, Medicine: An Illustrated History, Gyldendal Norsk Forlag, Oslo, Norway,1987. 75 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

ISSN 2455-4782 the household were her functions. The Laws of Manu stated, "Wherever women are honored, the gods are satisfied, but when they are not honored, all pious acts become sterile."

Public Health and hygienic measures were different in various periods of Indian history. For instance the public baths and highly developed water systems during the early Indus valley civilization. It is difficult to ascertain when hospitals were first begun. Among inscriptions dating from the third century B.C. by Asoka, the great ruler of the Mauryan dynasty, are statements that hospitals had been established, some for humans and others for animals.2

King Duttha Gamani, a century later than King Ashoka the Great, is said to have listed among his good deeds the founding of eighteen hospitals for the poor. Certainly the account of Megasthenes, ambassador from the eastern Greek Seleucid king (inheritor of a segment of Alexander the Great's empire) suggests that there were hospitals for the rich and royal in the great city of Patliputra.(Patna).

Charaka –Samhita has described Ethics in details and summarized all the attributes of a good hospital, including location in a breezy spot free of smoke and protected from the sun, smells, and objectionable noises. Details of equipments needed were described even to the extent of proper brushes and brooms. He also discussed an appropriate food supply and the availability of drugs, privies, and cooking areas. The medical personnel should be clean, well-behaved, and able to wash and care for the patients. The well-being of the ailing was also considered, with provision for attendants who could distract the patient by recitation, conversation, and entertainment. The hospital that he pictured was easily a model for all to emulate in any time. 3

COLONIAL LEGACY OF PUBLIC HEALTH POLICY

Probably the first document of ‘public health policy’ in British India was the 1863 report of the Royal Commission on the sanitary state of the British army in India.4 Concern about threats to the

2 Koshambi DD,The culture and civilisation of ancient India in historical outline, New Delhi Vikas Publication, 1970:160. 3 Chattopadhyay D, Science and society in ancient India. Research India Publication, 1979, p. 22. 4 Harrison, M. (1994). Public Health in British India: Anglo-Indian Preventive Medicine 1859-1914. Cambridge, UK: Cambridge University Press.

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ISSN 2455-4782 health of the Indian Army, particularly after the rebellion of 1857, motivated a wide-ranging inquiry into health conditions in the country. The fierce famines of the 1870s and 1890s caused both mass mortality and huge migration; it was fear of unrest and social disruption that caused the colonial state, belatedly, to take some interest in famine relief and public health.5 Institutions of public health—hospitals, health centers, medical research laboratories, pharmaceutical production facilities—were amongst the new colonial institutions that appeared in South Asia, along with the railways, the telegraph and new forms of land tenure and law. If some historians have subsequently allowed the pendulum to swing far in the other direction, seeing medicine as only a tool of colonial power and domination over Indian lives and bodies, this tends to concur with the views of C.A. Bayly namely that what we need to understand is the ways in which Indians engaged with, appropriated, criticized and adopted colonial health institutions.6

The policy shifts in public that began in the later 19th century, around the time of the late-Victorian famines, had lasting and important consequences for the future of public health policy in India. Perhaps contradictory, legacies of this period stand out for their significance in shaping the conditions of possibility for public health policy in India: the first is institutional, the second, ideological. Colonial public health policy was inherently limited and self-limiting; it focused on keeping epidemics at bay, responding to crises and not much more. A crucial institutional innovation came in the 1880s7 when much of the responsibility for local health and sanitation was devolved to partly elect local government bodies, a responsibility shared by the 1920s with provincial governments.

Indeed, one of the most notable features of the expansion and dissemination of ideas about public health in the 1930s, particularly in the context of present-day development policy, is the importance of international standards, information, and models. The Rockefeller Foundation, for instance, had extensive involvement in establishing small scale health projects in India, China and beyond. The discussions of the League of Nations Health committee were widely reported in India, and the League’s expert committees on minimal standards of nutrition, for instance, provided new

5 Drèze, J. (1988). Famine Prevention in India. London: LSE. and Hodges, S. (2004). ‘Governmentality, population and the reproductive family in modern India’. Economic and Political Weekly 39(11), 1157-1163. 6 Bayly, C.A. (2008). ‘Indigenous and colonial origins of comparative economic development: The case of colonial India and Africa’. World Bank Policy Research Working Paper, 4474. 7 Jeffery, R. (1988). The Politics of Health in India. Berkeley and Los Angeles, CA: University of California Press. 77 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

ISSN 2455-4782 ammunition for nationalist critiques of the colonial state8. Indeed, in the 1930s the Government of India was held to account, to some extent, by having to report to the League of Nations on the progress of health and welfare in India.

A historical perspective on the political culture of public health in India suggests that one of the most striking contrasts between the late-colonial period and the period after independence lies in the extent to which the Indian political elite concerned itself with questions of public health. The instrumental argument, that it has not been in the ‘interests’ of India’s elite to prioritize public health—given their easy access to high quality, urban curative health services—is indisputable; but interests can come into being and unravel through political discourse and as a result of political mobilization. In the first half of the 20th century, the Indian political elite was deeply concerned with questions of public health, engaging in more or less paternalistic attempts to educate, and uplift the health of, the Indian population; after independence, as responsibility for health resided increasingly with the developmental state, the culture of public discussion and voluntary activity in the field of health and hygiene witnessed a slow increase.

A public health professional would likely focus on preventing health problems from occurring, by implementing health education programs, developing health policies, regulating health systems and conducting health research. This is in contrast to clinical professionals – doctors and nurses – who focus on treating people after they become ill. Public health professionals also work to eliminate health disparities among all groups in society.9

PUBLIC HEALTH ACHIEVEMENTS IN POST INDEPENDENT INDIA

The subsequent history of public health policy in India after 1947 exhibited many signs of de- politicization, the example of Kerala showed that this was not universally true. The post- independence years have witnessed moves by a range of groups to make health, once again, a

8 Amrith, S. S., Decolonizing International Health: India and Southeast Asia, c. 1930-65. Basingstoke/New York Palgrave MacMillan, 2006.

9 Talks about Public Health by Dr. W. Douglas Evans, Professor of Prevention and Community Health & Global Health at The George Washington University School of Public Health and Health Services.

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ISSN 2455-4782 subject of public debate. Such groups seek to turn the promise of the right to health care into properly political demand for its provision. This is most notably the case of the Jan Swasthiya Abhiyan (People’s Health Movement), which declares that: We reaffirm our inalienable right to and demand for comprehensive health care that includes food security; sustainable livelihood options including secure employment opportunities; access to housing, drinking water and sanitation; and appropriate medical care for all; in sum—the right to Health For All, Now!

Health is wealth. In recent years, India appears to have finally internalized this old adage to apply the much-needed and long-awaited focus on the health of its citizenry.

In 2005, former Prime Minister, Dr. Manmohan Singh stated, “We recognize health as an inalienable human right that every individual can justly claim. So long as wide health inequalities exist in our country and access to essential health care is not universally assured, we would fall short in both economic planning and in our moral obligation to all citizens.”

Post-independence India’s most noteworthy achievement, in the public health arena, has been the decrease in death rates (mortality). In 1951 the at-birth life expectancy was around 37 years which increased to nearly 65 years by 2011.

In terms of infant mortality, there has been improvement between 1951 and 2000, such that the number of deaths in the youngest age group has fallen to 70 from 146 per 1000. Similar trends were observed from 2001 to 2006 with regards to maternal mortality, that is, 254 rather than 301 maternal deaths per 100,000 births. However, in both instances the total number of women and young children dying in India – partially due to the population growth – continues to be among the highest in the world. Some disease-fronts where significant results have been achieved include malnutrition,leprosy, cholera, malaria, tuberculosis (TB), and HIV.10

The reduction and control of diseases, as is evident from the data available in the public domain, owe much of their success to several government health initiatives as well as non-governmental organizations. Latest national-level, and ambitious, health initiatives announced by the Indian government include ‘Healthcare for all by 2020′ and distribution of free medications for all, especially to its lowest-income economic group (nearly 200 million people).

10 Dr. Poonam Kuruganti, Health care achievements of post-independent India, health care site, Feb., 2015. 79 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

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The biggest challenge for India is the dual fight of containing a ‘developing’ country’s health concerns while a flare-up of ‘developed’ world disorders are at its doorstep. On one hand India is combating basic health concerns such as malnutrition, low immunization rates, hygiene, sanitation, and infectious diseases. On the other hand, environmental pollution and lifestyle choices such as alcohol consumption, smoking, and high fat diet are set to increase the incidence rates of hypertension (high blood pressure), cardiovascular (heart) disease, diabetes and cancer to almost epidemic levels.

In recent years India’s public spending on health has increased to nearly 15% of the total health- related costs of its citizenry – which is still lower than sub-Saharan Africa (40%) and affluent Europe (75%). 11

In the Budget 2017, finance Minister Mr. Arun Jaitly gave little hope to public health programmes. He was expected to be sensitive to the suffering of millions of Indians and enhance the social safety nets in the form of expansion of employment, education, health, food and nutrition. He has, instead, made some nominal increases in the rural sector and offered tax sops to the middle class. This increase in allocation appears mere tokenism when we compare it to price increases and expenditure cutbacks over last few years.12

For instance, an additional Rs 10,600 crores have been allocated for health in this budget compared to previous year. But, when adjusted against prices accounting for inflation, this allocation is not even equal to that made six years before in 2011-12. Given the severe cuts in the overall health budget over last three years, the increase in allocation this year may not be enough to maintain existing health programs. Union government spending on health is only 0.29% of GDP. The union and states’ health spending together is about 1.2% of GDP. The World Health

Organisation recommends that governments spend between 2.5% to 5% of their GDP on health.13

Thus, we can say that there has been slow but continuous progress in the health status – especially in terms of life expectancy – in India. However, there is much to be done and a continuous focus

11 Ibid. 12 Financial Express, Union Budget 2017-18 Live, February 2,2017. and https://scroll.in/pulse/828471/in-budget- 2017, March 14,2017. 14 Financial Express, op.cit. and Union Budget 2017, Ibid. 13 Financial Express, op.cit. and Union Budget 2017, Ibid. 80 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

ISSN 2455-4782 on public health is critical and paramount for India to attain an acceptable quality of life for all its residents. As is the case with other public concerns, India’s historical and regional variability adds to the difficulty of under-diagnosis and under-treated health concerns of its citizens.

MEDICAL ETHICS AND ITS IMPORTANCE

Ethics is a very large and complex field of study with many branches or subdivisions. Medical Ethics is the branch of ethics that deals with moral issues in medical practice. Medical ethics is closely related, but not identical to, (biomedical ethics).Whereas medical ethics focuses primarily on issues arising out of the practice of medicine, bioethics is a very broad subject that is concerned with the moral issues raised by developments in the biological sciences more generally. The conventional laws, customs of courtesy and the code of conduct governing the relationship of the physician with his professional colleagues are the bases of Medical ethics. In modern times medical ethics has been greatly influenced by developments in human rights. Physicians frequently have to deal with medical problems resulting from violations of human rights, such as forced migration and torture. Medical ethics is also closely related to law. More often than not, ethics prescribes higher standards of behavior than does the law, and occasionally ethics requires that physicians disobey laws that demand unethical behavior.

Ethical principles such as respect for persons, informed consent and confidentiality are basic to the physician-patient relationship. Application of these principles in specific situations is often problematic, since physicians, patients, their family members and other healthcare personnel may disagree about what is the right way to act in a particular situation. The study of ethics prepares medical professionals to recognize difficult situations and to deal with them in a rational and pragmatic manner. Ethics is also important in physician’s interactions with society and their colleagues and for the conduct of medical research.

PRINCIPLES OF MEDICAL ETHICS

Autonomy, Beneficence, Confidentiality, Do no harm/ Non-maleficence, Equity or Justice are the main principles of medical ethics and these are discussed as below:-

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(a)Autonomy: Patient has freedom of thought, intention and action when making decisions regarding health care procedures. For a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success. This includes the need to tell the truth (veracity) and to be faithful to one’s commitments (fidelity).

(b)Beneficence: The practitioner should act in “the best interest” of the patient - the procedure be provided with the intent of doing good to the patient. Patient’s welfare is the first consideration.

(c) Confidentiality: It is based on loyalty and trust. Maintain the confidentiality of all personal, medical and treatment information. Personal information to be revealed for the benefit of the patient and only when ethically and legally required.

(d) Do no harm/ Non-maleficence: “Above all, do no harm” Make sure that the procedure does not harm the patient or others in society. When interventions undertaken by physicians create a positive outcome while also potentially doing harm it is known as the "double effect." A commonly cited example of this phenomenon is the use of morphine or other analgesics in the dying patient. Such use of morphine can have the beneficial effect of easing the pain and suffering of the patient while simultaneously having the maleficent effect of shortening the life of the patient through suppression of the respiratory system.

(e) Ethics Equity or Justice Fair and equal distribution of scarce health resources, and the decision of who gets what treatment. The burdens and benefits of new or experimental treatments must be distributed equally among all groups in society.

DUTIES AND RESPONSIBILITIES OF PHYSICIANS IN GENERAL14

1. Character of physician: (a) A physician shall uphold the dignity and honor of the profession.

(b) A physician shall have a good moral character; he should be modest, sober, have patience and be prompt in discharging his duty for the sick without anxiety.

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(c) Only qualified registered medical practitioner is allowed to practice modern system of medicine.

2. Maintain good Medical practice: (a) A physician should maintain confidence of patient in their care. He should try to improve his professional knowledge and skill and should not associate with any who violates the principle.

(b) A physician should participate in professional meetings as a part of continuous Medical Education programmes organized by any reputed professional academic body or authorized organizations.

The compliance of this shall be informed regularly to MCI or State Medical Councils as the case may be.

3. Duties of physicians to their patients: A physician is not bound to treat each and every patient asking his services but he should be remain ready when a call from sick or injured. However, during emergency he should attend the patient and treat him and if a patient is suffering from such a disease which is out of range of his qualification and experience then he may refuse treatment and refer the patient to another physician.

CASE LAW

1. Pt. Parmanand Katara v. Union of India and others 15

In this case Supreme Court of India observed: "There can be no second opinion that preservation of human life is of paramount importance. That is so on account of the fact that once life is lost, the status quo ante cannot be restored as resurrection is beyond the capacity of man. The patient whether he be an innocent person or be a criminal liable to punishment under the laws of the society, it is the obligation of those who are in charge of the health of the community to preserve life so that the innocent may be protected and the guilty may be punished. Social laws do not contemplate death by negligence to tantamount to legal punishment. Article 21 of the Constitution casts the obligation on the State to preserve life. The provision as explained by this Court in scores

15 Pt. Parmanand Katara vs Union Of India & Ors on 28 August, 1989; 1989 AIR 2039 and 1989 SCR (3) 997 83 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

ISSN 2455-4782 of decisions has emphasized and reiterated with gradually increasing emphasis that position. A doctor at the Government hospital positioned to meet this State obligation is, therefore, duty bound to extend medical assistance for preserving life. Every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life. No law or State action can intervene to avoid/delay the discharge of the paramount obligation cast upon members of the medical profession. The obligation being total, absolute and paramount, laws of procedure whether in statutes or otherwise which would interfere with the discharge of this obligation cannot be sustained and must, therefore, give way." Further, the court also emphasized that there is no legal impediment for a medical professional when he is called upon or requested to attend to an injured person needing his medical assistance immediately. There is also no doubt that the effort to save the person should be the top priority not only to the medical professional but even of the police or any other citizen who happen to be connected with the matter or who happens to notice such an incident or a situation.

2. Paschim Banga Khet Mazdoor Samity & Ors v State of West Bengal & Anor.16

In this case the petitioner sustained serious injuries after falling off a train. He was refused treatment at six successive State hospitals because the hospitals either had inadequate medical facilities or did not have a vacant bed. The Apex Court declared that the right to life enshrined in the Indian Constitution (Article 21) imposes an obligation on the State to safeguard the right to life of every person and that preservation of human life is of paramount importance. This obligation on the State stands irrespective of constraints in financial resources. The Court stated that denial of timely medical treatment necessary to preserve human life in government-owned hospitals is a violation of this right. The Court asked the Government of West Bengal to pay the petitioner compensation for the loss suffered. It also directed the Government to formulate a blue print for primary health care with particular reference to treatment of patients during an emergency.

16 Paschim Banga Khet Mazdoor Samity & Ors v State of West Bengal & Anor. Cited as: (1996) AIR SC 2426/ (1996) 4 SCC 37 84 | P a g e JOURNAL ON CONTEMPORARY ISSUES OF LAW [JCIL] VOLUME 4 ISSUE 9

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COMMERCIAL SURROGACY AND FERTILITY TOURISM IN INDIA17

A case Study By Kenan Institute for Ethics, Duke University, USA; A Japanese couple traveled to India in late 2007 to hire a surrogate mother to bear a child for them. They contacted Dr. Patel in Anand, Gujarat The doctor arranged a surrogacy contract with Pritiben Mehta, a married Indian woman with children Dr. Patel supervised the creation of an embryo from Japanese father’s sperm and an egg harvested from an anonymous Indian woman The embryo was then implanted into Mehta’s womb. In June 2008, the Japanese couple divorced, and a month later Baby Manji was born to the surrogate mother. Although the Japanese father wanted to raise the child, his ex-wife did not. Baby Manji had three mothers—the intended mother who had contracted for the surrogacy, the egg donor, and the gestational surrogate—yet legally she had none.

Aruna Shanbaug case- : In 1973, while working as a junior nurse at King Edward Memorial Hospital, . She was sexually assaulted by a ward boy She has been in a vegetative state since the assault A plea for was filed in the Supreme Court by PinkiVirani , a writer and journalist. On 24 January 2011, after she had been in this status for 37 years, the Supreme Court of India responded to the plea for euthanasia. The court turned down the mercy killing petition 7th March, 2011 The Hon’ble court, while delivering its judgment, distinguished between active and passive euthanasia. Active euthanasia means killing a person through the use of lethal substance or force, and passive euthanasia means withdrawing or discontinuing medical support necessary for the continuation of life. The court rejected the plea for euthanasia for Aruna Shanbaug but legalized passive euthanasia in the country. The debate on passive and active euthanasia continued. At some point in our life, through friends, popular media or our school or college, you must have come across the term "mercy killing". The legal term for mercy killing is euthanasia and the consequences of legalising it, have over time, become a heated debate among India's intellectual, political and legal circles. The case that led to this heated debate was that of Aruna Ramchandra Shanbaug v. Union of India.18

The reason any debate around euthanasia generates such a heated discussion is because while our constitution recognises the right to life with dignity, it does not recognise the .

17 A case Study By Kenan Institute for Ethics, Duke University, USA; https://kenan.ethics.duke.edu/wp- content/uploads/2012/08/BabyManji_TN2015.pdf 18 Aruna Ramachandra Shanbaug v. Union of India, (2011) 4 SCC 454

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Therefore, a debate regarding mercy killing is just not a debate regarding the legality of such a wish, but is also a debate about the morality and ethics of such an act. With the concept of euthanasia, law enters that complex territory of medical ethics which has even divided the medical fraternity sharply in the recent past.

Passive euthanasia did not remain legalised for long in India. In Common Cause v. Union of India, it was urged that the judgment of Aruna Ramchandra Shanbaug v Union of India was decided based on incorrect interpretation of the constitution bench's judgment in Gian Kaur v State of Punjab, and therefore it was referred to a larger constitutional bench for review and final judgment. Aruna Shanbaug died in May 2015, but her case helped in shedding light on an extremely complex issue of medical ethics and law. Euthanasia is currently legal in the Netherlands, Switzerland and the United States. In our country question still stands unsolved. Will India join the list? We’ll have to wait and watch.

CONCLUSION AND SUGGESTIONS

Numerous initiatives that Prime Minister Narendra Modi has launched is Swachh Bharat Abhiyaan. This campaign has the greatest potential to transform the lives of all Indians – rich and poor. Sanitation has been the theme of virtually every government in their times. Prime Minister Rajiv Gandhi had launched the Central Rural Sanitation Programme in 1986 and Prime Minister Atal Bihari Vajpayee the Complete Sanitation Campaign in 1999. But previous government has not shown much resolve and commitment as has been exhibited by P.M. Modi. This time it feels real.

Till date, sweeping streets and ending open defecation have occupied media center stage. But equally critical to Swachh Bharat are access to piped water; well-functioning drainage, sewage and solid waste management in all cities and villages; elimination of ponds in which stagnant water collects and serves as host to bacteria and mosquitoes; instilling greater appreciation of cleanliness in all its aspects among the masses. Indeed, taking the campaign to its logical conclusion would require replacing slums with more spacious housing having piped water delivery and modern sewage facilities

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There are several benefits of Clean India Campaign that India can get if it becomes success like (a) There is great improvement in public health, (b) Our country can enhance its tourism (c) People can prevent many diseases (d) We can have a more happy and healthy society (e) We can attract global players to invest in India (f) It will lead to better life to our upcoming generations (g) We can build a better eco-friendly environment (h)We can reduce cost of maintenance (i) It is a good method to give back to society (j) If Clean India Campaign becomes reality every Indian can feel proud of it.

Hence, the need for maintaining right cleanliness, sanitation and hygiene in any community cannot gainsay. It is perhaps the most basic step towards keeping diseases at bay. Poor hygiene and cleanliness is one of the worst enemies of young children. The fact that diarrhoea and malnutrition are two leading causes of under-5 deaths in India substantiates this. It is therefore imperative to have sanitation and hygiene intact, both at personal and community level, to improve health of the masses.

Medical profession is considered a noble profession and the doctors have been always compared and equated next to God. The word noble means that a doctor should have qualities like compassion, caring, giving, sharing, concern, helping, etc. A doctor is supposed to treat a person irrespective of caste, creed, religion, financial status, or social esteem. His sole concern is and should be to remove the miseries of the suffering patients.

His sewa or service should be selfless and not oriented towards publicity. To provide that and to get a complete satisfaction of the job a doctor needs a proper infrastructure, basic money and a proper security.

The point of ethics is being more comprehensive than the law has a practical implication on medical malpractice and judicial remedies available against it. Legal recognition of medical malpractice is confined to violation of a specific law, criminal nature of malpractice and admissibility for compensation. For instance, compensation can be sought only if harm and loss are demonstrated. Whilst malpractice not resulting in loss and harm does not qualify as unethical conduct inviting the penalty on the doctor. There is an interesting relationship between the law and ethics. Since autonomy and self-regulation are not merely ethical principles but are backed by law, the self-regulatory code has legal value and significance. Once specific clauses are accepted by the

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ISSN 2455-4782 profession as part of a self-governing code, they acquire legal validity. Aggrieved patients can haul up professionals erring against such clause, before the court of law. Medical Council in our country and to a lesser extent even in the countries of their origin (Western Europe) have shown inadequate efficiency in the stringent implementation of self-regulation by doctors. Patients and public organisations have ample scope under the law for making them respect their legal obligations.

One of the questions always raised is that doctors do not go to villages. Going to villages is like going to the border by a military person as in a village the doctor invariably will have to go and live without his family as the village cannot provide the type of infrastructure, schooling or college which a doctor may like his children to have. The Government should do best endeavours in the direction to providing such facilities to villages.

Nobleness of profession means doctor has to be sincere in his actions and thoughts and not necessarily adopt and live a life of a sanyasi or vairagi. As he is only supposed to follow what he or she preaches to the community like not smoking, regularly exercising, doing morning-evening walks and practicing meditation to lead a healthy life style. The other suggestion is to allowing commercialization of the rural services. Today cold drinks and junk food is reaching the rural areas without any problems. Executives are being posted by these companies left and right in these areas. Once the health services are commercialized doctors will be posted by these commercial houses in the rural areas without any problem.

Today no car or vehicle can go on the road without insurance. If the same law is made compulsory for the human body; the private sector will jump in opening district health centres all over the country to care for the health of the life assured public.

The other need is to promote basic primary care through naturopathy, homeopathy and Ayurveda, which does not require sophisticated infra structure, technologies and hospitals. Mohalla Clinics is also one of the praiseworthy initiatives taken by the government of Delhi. In this way we can certainly promote public health.

Further, the growing public-health threats of non-communicable diseases, including those caused in part by unhealthy behaviors such as smoking, poor diet or lack of exercise, have raised the question of the extent to which public-health authorities should interfere with personal choices on health.

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Participation, transparency, and accountability are a significant ethical matter. It is the process by which decisions are made is as important as the outcome of the decisions. In the area of medical research, much attention has been devoted in recent years to strengthening systems for informed consent and community oversight. Once such systems are in place, the next step should be to develop mechanisms for evaluating their effectiveness.

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