Medical Student's Experience of Geriatrics in India: Summer 2011

India is big, crowded, and changing faster economically and socially than it can seem to keep up with.  The largest democracy in the world with over one billion people, it is completely overwhelming and exhilarating, but there is also a prevalent warmth and hospitality within the people wherever you go.  India’s history is as rich and colorful as you can get, with hundreds of different conquerors and border changes, the famous story of independence led by Mahatma Gandhi, and evidence of it all remaining in the temples, statues, and preservations of countless historical sites.  The culture is heavily influenced by religion and their daily rituals influence almost every part of the lives of the Hindu people I interacted with.  Muslims and Christians, along with Sikhs, Buddhists, Jains, Jews, and Zorastrians also are seen openly practicing their religions, and all living in relative peace and sybiosis with each other. 

The changes that the country is experiencing are palpable.  A brand new office building next to a rusty corrugated metal capped slum in Mumbai, a polished SUV on the road next too a cow, and of course the technology boom bringing western modernity into the developing world that is trying to keep up, are some of the obvious sites showcasing the new vs. the old.  Health issues are changing too- there is improvement in some public health measures, but there is still a long way to go; you’d be very adventurous to drink the tap water.  And with the large amount of people moving into the cities and greater availability of unhealthy foods, rates of diabetes and hypertension are on a dangerous incline.  But when talking to the locals about what is changing, especially from the elderly generation, you hear about the huge social changes taking place.  The breakdown of the Indian family model, which used to be comprised of a large household with all generations, is now becoming nuclear and leaving many from the silver generation without a home. 

My rotation focused on the health and social issues of the elderly population in India.  I worked with a multi-faceted medical NGO in Bangalore, the Nightingale Trust, whose realm includes home medical care, an inpatient dementia care unit, adult day care, and rural medical visits amongst other things.  I also worked with a newer NGO in Mumbai known as Silver Inning Foundation which uses social networking and media to help address multiple human rights issues and needs of the elderly.  My goals in this rotation were to learn about the health and human rights issues involving the elderly in India and compare them to the USA’s, share my knowledge and ideas with the Indian people I work with, and use my connections and what I learned in the future in some way to help address these and similar problems.

Before leaving, I had some grasp on the issues affecting the elderly.  I had heard that there were rising amounts of elderly people due to increasing life expectancy, and little infrastructure to support them.  Also I knew rates of diabetes were on the rise.  I wanted to explore the issues from a medical and human rights perspective, as are my interests.  When arriving, I found that these things were true, and more.  Again and again I heard the stories of children abandoning their parents, or moving away to the US.  There was no government support to help them finance their daily life.  Rates of depression have increased in the elderly as an outcome of the changing family structure too. 

The NGOs I worked with were helping to address these issues.  Nightingale Trust was providing home care to people in the cities and the rural areas that once had no access.  They also help underfunded people with adult daycare, abuse help lines, and sliding scale payments.  Silver Inning foundation was using social networking and media to connect elderly people with each other and with the help they needed.  They put poor people in touch with affordable old age homes, provided an elder abuse hotline, visited men’s and women’s group and provided them with information and ideas, and were constantly promoting awareness with innovative networking.  I was a part of these NGOs as an observer and short-term worker.  I think my presence benefitted the people I interacted with by sharing my knowledge of how the elderly are treated in America and by showing my support of the activities and the people in need.

I think the greatest benefit of students’ involvement in global health is the impact is has on the student herself.  I would not be the person or doctor that I am if it wasn’t for my community service and global health experiences.  My experience in India humbled me and took my breath away several times.  The family that I stayed with told me that instead of selling their printing company, they just gave it to their employers as a sign of gratitude for years of hard work.  Both NGOs I worked with were started by individuals who used all self-funding for years to keep them alive.  The fact that everything seems to work out so well in the face of so much constant chaos in India, I can only attribute to the amazing way everyone is constantly helping their fellow man.  As my rotation had a large focus on human rights, I think this observation of hospitality, selflessness, and charity made the largest impression on me. 

In terms of my professional career, experiences like this rotation benefit me greatly.  I am entering into a residency in Internal Medicine that focuses on helping a diverse and underserved population, and the more experience I get with other cultures and pathologies, the better I can treat each individual.  It also shapes my goals and reiterates my desires to help all people, regardless of class, race, and borders.  I will be more of an advocate for the elderly after interviewing and assisting so many in India.  And I will be much more mindful of human rights issues with the elderly such as abuse, lack of support and a home, depression and loneliness.  Also, I made a lot of connections with doctors and activists in India, and I have no doubts that we can continue to work together in the future.

In my time in India I worked in two large cities, visited rural sites surrounding them both, and traveled to 5 cities total.  I aimed to get as much possible out of my short time there and I think I succeeded.  The NGOs I worked with showed me a comprehensive view of the health and human rights issues affecting the elderly in India.  Most of the medical problems were similar to what we see here.  Diabetes is on the rise, mostly due to the influx of people into urban areas, and the availability of food, unhealthy food, in the cities.  Also with urbanization come many sedentary jobs leading to lack of exercise and obesity.  Other common things are common, such as hypertension, asthma, COPD, dementia, depression, and cancer.  Dementia is receiving growing attention, and the prevalence is increasing due to the increase in life expectancy and increase in awareness. 

When I explored the Indian people’s perception of health care in their country I was surprised at how little people complained, which was much less than I feel we do here in America.  I found myself looking for problems, asking leading questions to get to the bottom of it.  What I found is that most people say they get medical care when they need it, and at not too high of a cost.  Very few people have insurance, and there is no Medicaid or Medicare equivalent for the destitute and elderly.  However with the lower cost of health care due partly to the lack of insurance companies, most people get what they need.  I asked, “What if you get cancer?  What if you have diabetes?  What if you’re the poorest poor?”  Most of the responses were basically that if you have chronic diseases there are schemes available to help, and that there are good government hospitals that are free to the poor.  But when I got to the bottom of it I noticed that people were not getting the primary care they needed.  Indians would rather treat themselves at home, with naturopathic or Aruvedic medicine or an antibiotic they picked up at a pharmacy without a prescription, than go to a doctor.  With this pattern comes many late presentations of disease.  This problem is sure to get worse with the increasing levels of diabetes, and this does not seem to be being addressed as of now.

Having soaked in the sites, sounds, smells, and tastes of a country as large and busy as India gives me a great perspective on the rest of the world.  Almost 1/6^th of the world’s people are on the subcontinent, and I have gained confidence after living how that huge chunk of the world lives.  Like any time I leave the USA, I am reminded of the incredible luxuries that we have here.  Potable water, roads that aren’t littered with garbage, potholes, cows, and unbelievably bad traffic, and decent access to health care.  Also my freedom as a woman and as an American are something I take for granted.  I was disappointed to see women not usually being treated as equals, and I constantly heard about the corruption of the government with attitudes of hopelessness to change.  But I will never forget the kindness I and incredible selflessness I witnessed by my mentors, my hosts, and even strangers in India.  Also there is great beauty in everything in India, from the temples, the delicious food, and the smells of jasmine and incense burning.  This global health experience has enriched my education in medicine and human rights, and also personally enriched my life.  

By Robin Reister

Medical Student

MEDI 7003 Reflective Essay

UTHSCSA

Forget yourself for others, and others will never forget you.

4th Annual National Essay Competition 2011 : World Elder Abuse Awareness Day (WEAAD)

On occasion of 6^th Annual World Elder Abuse Awareness Day (WEAAD) 15^th June 2011 Silver Inning Foundation a NGO working with senior citizens and their family members in association with INPEA (International Network for Prevention of Elder Abuse) Indian Chapter through Development, Welfare and Research Foundation (DWARF) and 'Little Things Matter Initiatives' (LTMI); SSS Global; FESCOM (Mumbai) ; 1298 Senior Citizens Helpline, Mumbai; AISCCON  & Harmony for Silvers Foundation will be commemorating Elder Abuse Awareness Day from on May 20^th to June 20^th 2011 . It has taken the initiative to create awareness among civil society and Government to eliminate elder abuse at both micro and macro level.

SILVER INNING FOUNDATION invites an Essay of maximum 2000 words in following category and topics:

1)    For all age group:

Can Elder abuse be prevented, if not eliminated? If yes how? If no why not?

2)    For School Students - Class 5^th to class 10^th:

Grandparents are the best Friends

3)    For Students - 1^st year College to Post graduation :

Youth are important link towards Elderly friendly society       

What is Elder Abuse?

Elder abuse is an under-recognized problem with devastating and even life-threatening consequences. Elder abuse is often defined as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an ‘expectation of trust’ which causes harm or distress to an older person.

Types of Elder Abuse:

1. Physical abuse
2. Sexual abuse
3. Emotional or psychological abuse
4. Financial or material exploitation
5. Neglect
6. Abandonment
7. Self-neglect

All of us know that we will be elders one day and join the ever increasing percentage of senior citizens in the global population! And yet some of us continue to show gross indifference and disrespect to our elders in our own families and in the society! Each of us might have countless reasons, logics and excuses for this behavior but this could be due to a combination of many problems. Let us try to put into a right perspective these various problems and what we could do to keep our elders happy.

Remember, by helping our elders stay physically fit and mentally happy, we are only helping ourselves and our future. If we fail to give proper care and respect to our elders at home now we will get the same ugly treatment from our children later on in our lives!

World Elder Abuse Awareness Day 15^th June ,programme aims to increase society's ability, through various programmes to recognize and respond to the mistreatment of older people in whatever setting it occurs, so that the latter years of life will be free from abuse, neglect and exploitation.

Prizes:

The First (1^st) best in each category will be given Prize of Rs.500/- by Indian cheque only, to each 1^st winner and Certificate.

The Three (3) best essays in each category will be given Certificate each and their essay will be published on Blogs: http://peopleforsocialcause.blogspot.com/ ; http://silverinnings.blogspot.com/  and best Ten (10) in each category, with India postal address will be given Participation Certificate.

  

All the essays will be property of and used by Silver Inning Foundation as database/Talk / Reference / Lecture / Book/ Paper presentation for its strategy to Tackle Elder Abuse and issues of Elderly. The verdict of management of Silver Inning Foundation & Silver Innings for selection of best essay will be final.

Silver Inning Foundation consists of a dedicated team of professionals contributing to the cause of the elderly. Silver Inning Foundation conducts seminars, camps, lectures, awareness modules, advocacy, networking, Dementia management services and also has support groups for home based advice. At Silver Innings we are working towards creating Elder Friendly World where Ageing becomes a Positive and Rewarding Experience.

The Last date for submission of Essay is 20^th June 2011.

Email your essay with complete Postal Address, Telephone Number and Date of Birth on or before 20^th June 2011 to info@silverinnings.com and copy to silverinnings@gmail.com . Only soft copy by email i.e. email entries will only be accepted for this competition.

The winners will be announced online by email after 15^th July 2011. For further information please call on Tel no. 09987104233 – Monday to Friday 10am to 5pm.

Terms and Condition:

• Essay should not be more than 2000 words
• Essay should only be in English language
• Essay should be sent by Email only (soft copy only)
• No hard copy will be accepted
• It’s open to all Indian Residence / POI / NRI
• People from other country can also participate, but they will not be part of competition and they will be given virtual participation certificate.

This Programme is supported INPEA (International Network for Prevention of Elder Abuse) Indian Chapter through Development, Welfare and Research Foundation (DWARF) and 'Little Things Matter Initiatives' (LTMI); SSS Global; FESCOM (Mumbai) ; 1298 Senior Citizens Helpline, Mumbai; AISCCON  & Harmony for Silvers Foundation

Together, we all have the power to prevent elder abuse

My World…  Your World…Our World…Free of Elder Abuse

Forget yourself for others, and others will never forget you.

Her victory marks a milestone in the domestic workers’ struggle in India

Papamma, a Elderly domestic worker in Bangalore, took her employers to court and managed to receive a favourable judgment. This is a historic victory for perhaps the most vulnerable segment of unorganised workers, made possible by the support of a trade union, a dedicated team of advocates and a labour officer who adjudicated objectively.

With the upcoming International Labour Conference later this year, there is a buzz about a new legal international instrument providing ‘decent working conditions’ to domestic workers globally. However, as of now, laws benefiting unorganised workers in India, including domestic workers, are few, and the sad reality is that even these most often remain on paper. 

It is heartening therefore when the law is actually applied, giving these workers their due. This happened recently to Papamma, a domestic worker in Bangalore who was paid a pittance during her long years of service -- 1978 to 2007. Worse, she was discharged abruptly with no provision for retirement. In her words: “I came with empty hands and I left (after 31 years of working) with empty hands.”

A trajectory of her employment shows Papamma received a wage of Rs 60 for 22 years, for eight hours of work a day spanning the entire gamut of household chores from washing clothes to cooking and shopping for vegetables. In 2003, her wages were raised to Rs 500. (Incidentally, the minimum wage for domestic workers was notified for the first time in 2004 -- Rs 2,279 for an eight-hour day.)  In 2007, before she was unceremoniously dismissed during the last six months of her employment, and following repeated demands, Papamma’s wages were grudgingly raised to Rs 1,500. Even this fell short of the legal minimum wage for that year (2008).  

Papamma’s case illustrates the predicament of the domestic worker. Verbal agreements govern working conditions; there is no formal record of employment, only oral undertakings given by the employer that are often retracted later; demands for better wages are met with promises of future settlement which never materialises. 

In her employers we see a not-uncommon feudal attitude which manifests in the belief that the domestic worker does not require a weekly day off or extra payment should her workload increase because of guests. And the notion that the occasional help extended when she falls sick, or providing her children school uniforms justifies non-payment of a higher (adequate) wage. 

In Papamma’s case we also see loyalty towards her employers that ultimately soured when they refused her employment after a bout of illness. 

These were the circumstances that led Papamma to seek legal recourse. 

The favourable conclusion of Papamma’s case is a rare example of a domestic worker getting justice from the courts. An instance, perhaps, of institutions coming together to work the way they are meant to -- the trade union that provided Papamma a forum, a dedicated team of advocates (from the Alternative Law Forum), and a labour officer who adjudicated objectively.

According to one of the litigators for Papamma, Maitreyi Krishnan, a major reason for the case’s success was Papamma’s persistence; in her experience, due to the vulnerabilities of their situation, many domestic workers don’t see their battle through. Papamma went to the court or to the lawyer’s office whenever required in the course of the litigation which carried on for one-and-a-half years. Secondly, and perhaps equally important, was the support of the Karnataka Domestic Workers Union. 

The union was registered in 2003 by Sr Celia who had been working with domestic workers for a number of years. During that time she became convinced that true empowerment of domestic workers would only come about through their unionisation. She believes that any organisation, no matter how well-meaning, will only ‘work for’ and ‘speak on behalf of’ the workers. In the case of a non-worker-headed organisation, the workers become the beneficiaries and are therefore dependent on what is provided to them. There is a difference when those who are actually the ones suffering speak about their own situation, Sr Celia says. As a union, they can represent their own case. 

A worker asking for her own rights is different from a human rights activist asking for her rights. There is a sense of empowerment and dignity that does not come through social service, however well intended.

In Papamma’s case, there was a body she could take her grievances to and avail of the support of union members. Initially, this took the form of going with her to the employer’s house. There the employer did not even speak with them, instead he complained to the police about the visit. Papamma, in turn, filed a complaint at the local police station about her wage grievances. They took no action. She then went to the police station, accompanied by some union activists. When the police sub-inspector did not grant them an audience they sat outside the station until he gave in. The police then called the employer to the station where the sub-inspector suggested he pay Papamma a minimal amount of money so that she would not create any further trouble for them. Papamma turned down the employer’s offer as it was far less than what she had been promised. The police told her not to confront the employer and that the appropriate forum for her was the courts. Members of the union went with Papamma to court to attend the hearings.

Krishnan believes it also helped to have a good labour officer hearing the case. In the order that followed a well-researched case, not only were back wages granted but hefty compensation equalling the amount of back wages as well as overtime for all the Sundays Papamma had worked. Stating his reasons, the judge observed in his ruling that the employer was an educated senior citizen and that his lack of awareness about the law showed he had failed in his duty. 

Papamma herself does not appreciate the verdict much. She points to her home: an unlit small two-room house in a Lingarajpuram slum. An asbestos sheet forms the roof. The only furniture is an assembled double bed with a thin sheet covering its hard surface, and a plastic chair. Papamma says they wanted to use the money that was promised by her employer to carry out basic structural improvements to the house. The compromise amount she finally got would not serve this purpose. Further, at the age of 65, she would have to continue working.

From a larger perspective, however, the judgment is unprecedented in Karnataka: that someone from the most disadvantaged even within the unorganised sector managed to access the formal legal system and receive a favourable judgment. The fact that Papamma ultimately got a compromise amount, not what the judge ordered, is today’s reality. If she had not gone to court she would not have got even this amount. The judgment is an important step towards recognising that domestic workers too are workers with enforceable rights.

When the minimum wages notification for domestic workers in Karnataka was first passed in 2004 there was a lot of deliberation between the government, labour advocates and civil society about implementing the law. This was because the notification did not provide for implementation mechanisms such as regular inspections and regulations for the maintenance of wage registers by the employer. The labour commissioner of the time suggested that in a scenario of non-payment, if just one claim was filed before the department the successful outcome of the case would have “a multiplier effect”. He suggested that news of the case would spread and serve as a strong deterrent to employers who failed to pay adequate wages. Perhaps Papamma’s case will serve as just such an example.  

By Anuja Mirchandaney a legal researcher and freelance writer with the Alternative Law Forum, Bengaluru. Her primary interest is in research and writing on socio-legal issues.


Source:  http://infochangeindia.org/livelihoods/features/papamma-s-victory-marks-a-milestone-in-the-domestic-workers-struggle.html

Forget yourself for others, and others will never forget you.

SC denies plea for enhanced punishment for Bhopal gas tragedy accused

The Indian Supreme Court, on May 12, 2011, threw out the curative petition filed by the Central Bureau of Investigation (CBI) seeking enhanced punishment for top officials of Union Carbide, the multinational at whose Bhopal plant an accident led to a massive leak of poisonous gas that killed over 4,000 people instantly and disabled many thousands more.

The deadly leak occurred on December 4, 1984. Compensation for the victims, negotiated by the Government of India, was paltry by any standards and has been hotly contested for more than 25 years by groups fighting for the victims. In a 1996 judgment, the Supreme Court diluted charges against the accused from Section 304 (II) of the Indian Penal Code (culpable homicide not amounting to murder) to Section 304 (A) (criminal negligence). In 2010, a Bhopal court convicted seven accused who were sentenced to two years in jail. All seven secured bail immediately. The then Union Carbide Chairman Warren Anderson, also accused in the case, was declared a fugitive in 1992.   

The sessions court verdict and sentence was criticised strongly by civil society and the media, and a group of ministers was set up to look more closely into the matter. The GoM recommended stricter punishment for the seven officials. The CBI filed a curative petition against the light punishment and sought direction from the SC for framing of charges against the accused for culpable homicide not amounting to murder that carries a maximum imprisonment of 10 years (curative petitions have only been allowed since 2002). 

A five-judge bench including Chief Justice of India S H Kapadia dismissed the CBI’s petition saying it was based on a “wrong and fallacious plea”, and filed after 14 years. It said there was not enough reason to build a case of culpable homicide. “The materials produced do not meet the requirement (for homicide),” Kapadia said.

However, the court said that its 1996 judgment in no way prevented the trial court from framing charges under the stringent provisions of the Indian Penal Code. 

It said the Bhopal sessions court was free to examine the charges against the accused and decide, if the evidence available so warranted, that they could be tried for a more serious offence such as culpable homicide not amounting to murder. The SC bench clarified that the 1996 judgment was based on evidence presented before it at that time, and it was wrong to assume that it was binding on the trial court when additional facts and material were forthcoming.

On May 13, a day after the SC judgment, the Indian government said it would ask the CBI to move the sessions court in Bhopal for an early hearing of its revision application and appeal filed by the Madhya Pradesh government for stricter punishment for the accused. 

Source:  http://infochangeindia.org/environment/news/sc-denies-plea-for-enhanced-punishment-for-bhopal-gas-tragedy-accused.html

Forget yourself for others, and others will never forget you.

Regulation of Surrogate Parenthood in India

 The advances in human reproductive sciences have made it possible for couples and others to have biologically their own children who otherwise cannot for a number of reasons. This has given rise to the concept of surrogate mothers. Surrogacy is a method of assisted reproduction. More common form is IVF/Gestational surrogacy in which the surrogate child biologically belongs completely to the social parents. The other type is gestational surrogacy where the surrogate child is genetically related to the male parent and the surrogate mother.

India has emerged as a favourable destination for surrogacy and its Assisted Reproductive Technology (ART) industry has evolved into a 25-billion rupee business annually, with Law Commission describing it as “a gold pot”. The phenomenal rise in surrogacy in India has been due to it being cheap, socially accepted. Moreover, surrogacy has emerged as a preferred option because of complicated adoption procedures.

Foreigners including NRIs seeking surrogacy for various reasons, both medical and personal, have also contributed to the rise of the Indian surrogacy industry predominantly because of it being at least ten times cheaper than in their respective countries. No statistics exist on the number of foreign couples coming to India to have a child. But ART clinics say that their numbers have been appreciably growing.

In India surrogacy heralded with the delivery of its first surrogate baby on June 23rd, 1994, but it took eight more years to draw world attention to it when an Indian woman in 2004 delivered a surrogate child for her daughter in the U.K. Surrogacy as a medical process has matured over the years. India has become a booming centre of a fertility market, partly surreptitiously, and today there are an estimated 200,000 clinics across the country offering artificial insemination, IVF and surrogacy. They call it Assisted Reproductive Technology (ART).

There is at present no law governing surrogacy in India, eventually the activity including renting a womb (commercial surrogacy) is considered legitimate. In the absence of any law the Indian Council of Medical Research (ICMR) in 2005 issued guidelines for accreditation, supervision and regulation of ART clinics in India. But the need for legislation became pressing with ICMR guidelines being often violated and reportedly rampant exploitation of surrogate mothers and even cases of extortion.

At the instance of the Indian government an expert committee has drafted a legislation known as Assisted Reproductive Technology (Regulation) Bill, 2010 for legalizing surrogacy. The proposed legislation earlier floated in 2008 envisages legalizing commercial surrogacy as well. It defines a ‘couple’ as two persons living together and having a sexual relationship and as such, following Delhi High Court’s verdict on homosexuality, gives gays besides the singles the legal right to have surrogate babies. It also stipulates the age of surrogate mother to be within 21-35 years and limits her deliveries to five including her own children. The surrogate mother will have to enter into a legally enforceable surrogacy agreement as per the proposed legislation.

Foreign couples including NRIs seeking surrogacy in India will have under the proposed law to submit certificates that their country recognizes surrogacy as legal and also that the surrogate child after birth would get their country’s citizenship. The Law Commission of India in its 228th Report on “Need for legislation to regulate assisted reproductive technology clinics as well as rights and obligations of parties to a surrogacy,” has by and large supported surrogacy in India, but is not favourable towards commercial surrogacy. The Commission said, “It seems that wombs in India are on rent, which translates into babies for foreigners and dollars for Indian surrogate mothers.”

But according to an infertility specialist in Mumbai the Commission favouring altruistic surrogacy only may not be the solution either. “It will be very difficult to get altruistic surrogates and relatives could end up being pressured to become surrogates,” says the specialist. This could be a reality in view of poverty, illiteracy and the lack of power that women have over their own lives in India.
But many legal experts are of the view that the draft Bill is a step in right direction as it will end the present confusion and help regulate the functioning of the IVF centers and ensure quality check and accountability of ART clinics. It is expected to protect the interests of both the surrogate mother and child and help the commissioning parents to realize their dream of having their own baby more or less hassle free.

There are worries too as to what impact it will have on the society in terms of commercialization. Poor illiterate Indian women with the lure of money could be forced into repeated surrogate pregnancies risking their lives. There are also ethical and moral issues as well as the human dignity involved besides questions about the rights of surrogate mother. As such the draft legislation on surrogacy needs to be debated threadbare in social, legal and political circles as well as by the civil society before it becomes a law.

By M.L.Dhar

Disclaimer: The views expressed by the author in this feature are entirely his own and do not necessarily reflect the views of PIB or WBRi.

Source: http://www.washingtonbanglaradio.com/content/52569911-regulation-surrogate-parenthood-india

Forget yourself for others, and others will never forget you.