Opinion: Stop attacks on medical facilities in conflict zones

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Médecins Sans Frontières / Doctors Without Borders -

Hospitals and clinics have been on the frontline of this conflict, with tragic results for patients and healthcare. For many people, seeing a doctor or getting to a hospital too often involves a dangerous journey involving landmines, roadblocks and crossfire. Fighting and everyday violence continue to take a terrible toll on ordinary people, while even basic medicines and treatment remain out of the reach of many.

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Govt mulls new norms to ease kid­ney do­na­tion

New Delhi: The Cen­tre has come out with draft guide­lines that aim to de­ter­mine cri­te­ria for re­ceiv­ing a kid­ney from a ca­daver donor, in or­der to bring in greater trans­parency and tackle il­le­gal kid­ney trade while pri­ori­tis­ing pa­tients in ur­gent need of re­nal trans­plant. As per the pro­posed norms, pa­tients re­quir­ing a kid­ney trans­plant will be reg­is­tered cen­trally by hos­pi­tals through an on­line process. The reg­is­tra­tion will be ap­proved by a kid­ney ad­vi­sory com­mit­tee af­ter eval­u­at­ing the need for trans­plant. Once ap­proved, pa­tients will be put on the “ac­tive” or “pri­or­ity” list, based on spe­cific guide­lines. At present, kid­ney do­na­tion is a le­gal maze, with the big de­mand-sup­ply gap driv­ing a black mar­ket. Es­ti­mates by Or­gan Re­trieval Bank­ing Or­gan­i­sa­tion (ORBO), which func­tions un­der ‘end stage re­nal dis­ease’, main­te­nance dial­y­sis is an ac­cept­able and rea­son­ably good alternate ther­apy; so for ma­jor­ity of such pa­tients, trans­plant is not con­sid­ered an emer­gency pro­ce­dure AIIMS, say 1-1.5 lakh pa­tients re­quire kid­ney trans­plants in In­dia, whereas only 3,5004,000 re­ceive it. How­ever, ex­perts say th­ese es­ti­mates are much lower than the real de­mand be­cause a lot of cases are ei­ther not di­ag­nosed or not reg­is­tered on time. The Na­tional Or­gan and Tis­sue Trans­plant Or­gan­i­sa­tion (NOTTO), un­der the aegis of the health min­istry, will main­tain the registry of pa­tients in need of trans­plants. The draft guide­lines, made pub­lic by the health min­istry on Fri­day seek­ing pub­lic com­ments within a fort­night, also stated that pa­tients on a given city’s wait­ing list will get the first pri­or­ity. “If no re­cip­i­ent (is) el­i­gi­ble in city wait­ing list, then al­lo­ca­tion will be done to state and then to other states in the ROTTO (Re­gional Or­gan and Tis­sue Trans­plant Or­gan­i­sa­tion), and then to other ROTTO na­tion­ally,” the draft said. Though some states like Tamil Nadu have al­ready con­sti­tuted such com­mit­tees, kid­ney do­na­tion from ca­dav­ers is largely un­reg­u­lated across the coun­try. So far, there were no cen­tral guide­lines to mon­i­tor such do­na­tions. “This ini­tia­tive re­flects our com­mit­ment to pro­mote or­gan do­na­tion in the coun­try. We will fi­nalise th­ese gui- de­lines af­ter we re­ceive var­i­ous sug­ges­tions and com­ments on th­ese draft guide­lines. Once fi­nalised, th­ese guide­lines will go a long way in pro­mot­ing or­gan do­na­tion in the coun­try,” health min­is­ter J P Nadda said. He added that an agree­ment with state gov­ern­ments and health­care in­sti­tu­tions will be signed in due course to en­sure im­ple­men­ta­tion of the guide­lines. The draft guide­lines also sug­gest that re­cip­i­ents be aged be­low 65 years. It also rec­om­mends that pa­tients go for main­te­nance dial­y­sis wher­ever pos­si­ble and be on it for more than three months on a reg­u­lar ba­sis be­fore be­ing con­sid­ered for trans­plant. It has been sug­gested that pa­tients who no longer have dial­y­sis ac­cess be ur­gently listed. Be­sides, pa­tients with end stage re­nal dis­ease who are un­likely to get a donor with a neg­a­tive cross-match will also be given pri­or­ity. For the full re­port, log on to www.time­sofindia.com

Hos­pi­tals: the new killing zones

Just as doc­tors have a duty of care and re­spect to their pa­tients, so the rest of us have an obli­ga­tion to doc­tors. It is a ba­sic tenet of civilised so­ci­eties that medics should be al­lowed to care for the sick and wounded in wartime as well as in peace. The con­cept of med­i­cal neu­tral­ity was en­shrined in the first Geneva con­ven­tion more than a cen­tury and a half ago, and over those years it has of­fered count­less doc­tors, nurses and their pa­tients a de­gree of pro­tec­tion in the cru­ellest times. At­tack­ing med­i­cal fa­cil­i­ties, trans­port and per­son­nel in­ten­tion­ally is out­lawed. No one should need to be re­minded of that; yet it ap­pears that we must be – re­peat­edly. In May, the se­cu­rity coun­cil adopted a res­o­lu­tion to strengthen pro­tec­tion for health­care work­ers, the sick and wounded, and hos­pi­tals and clin­ics in war zones. The mea­sure was prompted by in­creas­ing as­saults on such fa­cil­i­ties; ac­cord­ing to the In­ter­na­tional Com­mit­tee of the Red Cross, 959 peo­ple were killed in 600 such at­tacks in 2014 and 2015 alone. It has proved fruit­less. The strikes are now so fre­quent they are in dan­ger of be­ing nor­malised. On Wed­nes­day the United Na­tions sec­re­tary gen­eral was forced, for the sec­ond time in four months, to spell out in­ter­na­tional law’s pro­tec­tion of med­i­cal ser­vices and its de­mand that the wounded and sick, whether civil­ians or fight­ers, be spared: “De­lib­er­ate at­tacks on hos­pi­tals are war crimes. Deny­ing peo­ple ac­cess to es­sen­tial health­care vi­o­lates in­ter­na­tional hu­man­i­tar­ian law.” Ban Ki-moon spoke hours after the two largest hos­pi­tals left in rebel-held ar­eas of Aleppo were bombed out of ser­vice. Physi­cians for Hu­man Rights says there were 382 at­tacks on 259 health fa­cil­i­ties in the coun­try be­tween March 2011 and June this year, killing 757 med­i­cal per­son­nel. There can be no doubt that many of those have been tar­geted. The bald num­bers fail to cap­ture the true im­pact: mur­der­ing a dozen doc­tors may cause the deaths of hun­dreds or even thou­sands of civil­ians, who are ei­ther too fright­ened to ac­cess health­care or are sim­ply left with­out ser­vices at all. Those who at­tack fa­cil­i­ties in­ten­tion­ally know that they are de­stroy­ing the mo­rale of the com­mu­ni­ties they serve. Such as­saults are in­tended to ex­ac­er­bate suf­fer­ing and drive peo­ple from con­tested ter­ri­tory. Syria is far from an iso­lated case. In South Su­dan, the Cen­tral African Repub­lic, the Demo­cratic Repub­lic of Congo, Libya and many more places, health­care work­ers are suf­fer­ing. Médecins Sans Fron­tières has been forced to with­draw from the north of Ye­men fol­low­ing the fourth at­tack against its fa­cil­i­ties by the Saudi-led coali­tion in less than a year, killing 32 and in­jur­ing 51. The US and UK are not only fail­ing to rein in Saudi Ara­bia, but con­tinue to sell it arms. And though Mon­day will mark the first an­niver­sary of the US bomb­ing which killed 42 at an MSF hos­pi­tal at Kun­duz in Afghanistan – in­clud­ing pa­tients who burned in their beds and medics at­tacked as they fled the build­ing – the or­gan­i­sa­tion still awaits an in­de­pen­dent in­ves­ti­ga­tion. In that case, as in Ye­men’s, the fa­cil­ity was tar­geted de­spite the fact that MSF had re­peat­edly given its lo­ca­tion; and the strike con­tin­ued de­spite MSF alert­ing US forces that they were hit­ting a med­i­cal fa­cil­ity. As the or­gan­i­sa­tion’s pres­i­dent ob­served ear­lier this year, four of the five per­ma­nent mem­bers of the se­cu­rity coun­cil have, to vary­ing de­grees, been as­so­ci­ated with coali­tions re­spon­si­ble for at­tacks on health struc­tures. It is im­por­tant to ac­knowl­edge pro­found dif­fer­ences be­tween cases. In Syria, at­tacks are rou­tine and clearly in­ten­tional; there is lit­tle doubt that the As­sad regime and its al­lies are cal­cu­lat­edly hit­ting the health­care sys­tem. Reck­less as well as de­lib­er­ate ac­tions can be war crimes. But it is sig­nif­i­cant that MSF con­tin­ues to share the co­or­di­nates of its fa­cil­i­ties in Afghanistan and Ye­men, to pro­tect them. In Syria, it keeps them se­cret. In all in­stances, how­ever, medics not only de­serve to work safely; they have a right to do so. States must adopt clear poli­cies for their mil­i­taries and train per­son­nel ac­cord­ingly. At­tacks upon health work­ers and their work­places should be in­ves­ti­gated and doc­u­mented thor­oughly. Where coun­tries fail to hold fight­ers to ac­count for hu­man rights vi­o­la­tions, they should be pur­sued in­ter­na­tion­ally. A ded­i­cated UN high rep­re­sen­ta­tive, as sug­gested by MSF, would help to keep the is­sue on the agenda. We must refuse to ac­cept strikes on fa­cil­i­ties and staff as aber­ra­tions or – worse – as a new rule of war, if doc­tors and the pa­tients they so coura­geously serve are to be pro­tected.

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