THE HINDU EDITORIAL : JUNE 19, 2018
THE HINDU EDITORIAL : JUNE 19, 2018
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Heart of the matter
Over the last few days a storm has been raised following publication of an article in The Hindu (June 12, 2018) based on a leaked WhatsApp message from the head of the National Organ and Tissue Transplant Organisation (NOTTO) claiming that foreign patients who are waiting for a donor heart transplant are being prioritised over Indian patients by private hospitals in Chennai. This article has angered many. Unfortunately, amidst the din, the basic concepts of organ donation, allocation and transplantation have been completely lost.
Tamil Nadu’s advantage
A forward thinking bureaucracy, committed non-governmental organisations and a willing political dispensation took up promotion of cadaver organ donation as a must-have in Tamil Nadu around 10 years ago. This was primarily in response to a widely publicised and unrelated kidney donation racket unearthed in the late 1990s. The initial kick-start and continuing efforts have made Tamil Nadu the undisputed leader in organ donation in India. Thousands of lives have been saved through organ donation.
Many southern States have successfully emulated Tamil Nadu’s road map and have developed organ donation programmes on their own. The uptake of the concept of organ donation, however, has been disappointing in north India. This has led to a steady stream of patients from north India to travel to the south for a cadaver donor organ as their chance of getting a timely transplant in their own State is close to zero. While the organ donation rate in Tamil Nadu is over 10 times greater than most of the northern States, there is a lot of work to be done to achieve the West’s donation rates.
Every country goes through an evolution process in terms of organ donation, and this is different for each organ. Kidney transplantation has been practised in India for over 25 years. There is public confidence in the procedure, and it is not surprising that there is a massive waiting list for cadaver kidney transplants. On the other hand, liver transplant as a treatment option for liver failure remained an esoteric idea in India until 10-15 years ago. The results of liver transplantation in India were poor in the early stages. That has changed in the last 10 years. With increasing success, an increasing number of patients who need a liver transplant are getting waitlisted. So there is no real possibility of a foreigner getting a cadaver liver or kidney in India, as there will always be a patient to whom a donor liver or kidney, irrespective of its characteristics can be matched. Among 2,100 liver transplants performed by our group in south India over the last nine years, not a single foreign patient has been transplanted with a cadaveric liver.
Cardiac and lung transplantation have been the last to develop in India. Until five years ago, results of heart and lung transplantation were dismal in India. Many doctors would have been reticent to put their patients forward for transplantation even if they would have benefitted from the treatment. However, over the last two-three years, results have improved significantly with the influx of talented and trained surgeons. But the number of patients being assessed and listed are still fewer in comparison to those listed for livers or kidneys. Waiting lists for heart transplantation are still small, and in such a situation while a donor liver or kidney can be immediately matched to a suitable Indian patient, this is not always possible for a heart or lungs.
This is where the claim for utilising the organ for a foreign patient comes in as otherwise the organ would be wasted. Even though occasional abuse of the system may be a possibility, it is important to point out that even with the current practice of allocating an organ to a foreigner when there is no suitable Indian patient, one-third of all hearts and lungs are still not being used due to “lack of a suitable recipient”. As public and physician confidence in the success of heart and lung transplantation improves in India, the waiting list of Indian patients will increase and it will be possible to match every organ to a suitable Indian patient. Once that stage is reached, there will not be even a remote possibility of a foreigner getting an organ.
An additional issue with heart and lung transplantation is the strict criteria for size and quality and the very tight timeframes within which these organs should be transplanted. While a kidney can be preserved for 12-18 hours and a liver for 8-12 hours, hearts and lungs should be transplanted within six hours, otherwise outcomes are likely to be poor. So while sharing of livers and kidneys across the country is possible, it is very difficult as far as hearts and lungs are concerned, considering the size of our country. In the absence of a viable and accessible air ambulance service to transport organs, feasibility will depend on the timing of the donation and the flight schedules of commercial airlines. Remember, most organ donation procedures happen in the night as logistics permit. So, at least for hearts and lungs, exceptions notwithstanding, sharing is feasible only by adjacent States.
Fine-tuning the process
What can be done to improve the situation? The government can decide that no foreigners can receive a cadaver donor organ in India even if it means that an organ is wasted due to lack of a suitable Indian recipient. But this may be an extreme step as local governments and corporate hospitals are still very interested in medical tourism. Another option is to develop a system of zonalisation across the country (like in the U.S.) so that more efficient sharing of organs across States is feasible, possibly with the development of a publicly-funded air ambulance service. This will significantly benefit transplant programmes in government hospitals.
Organ donation is based on public trust that due process is being followed. Currently, the donation process and organ allocation in Tamil Nadu is fully monitored by Transplant Authority of Tamil Nadu (TRANSTAN). Every organ that is transplanted, even to a foreign patient, is only done after approval from TRANSTAN. The authority of course depends on the clinical judgment and decisions of the transplant team as to the best use of each organ. The process should be made more transparent and accessible to the public. If donation and the allocation of each organ can be tracked, that will be a strong deterrent to mischief. Most importantly, the outcome of every transplant should be monitored. TRANSTAN should make it mandatory that the transplanting centre should report the outcome of the organ and the patient with updates at one week, one month and one year after transplantation.
Organ donation is a highly emotive topic. When a family agrees for organ donation, they are making a decision to be generous to some unknown person in the midst of a great personal crisis. For this to succeed, they should have utmost trust in the process of organ donation and allocation. Even in highly developed countries, donation rates drop temporarily when news of suspicious practices surfaces. In India, this is even more important as controversies such as these can break a developing programme and bring us back to square one. A reduction in donation rate will affect patients waiting for organs as each donor can save up to seven lives. The issue must be thoroughly investigated before newspapers and televisions proclaim a “scandal”. It does no good to the system and can cause immeasurable harm to sick patients desperately waiting for the call that “they have an organ”.
Delhi stand-off: Power crisis
One crisis, many causes. The immediate provocation for Chief Minister Arvind Kejriwal sitting on a dharna at the residence of the Lt. Governor might have been a run-in with the bureaucracy, but the crisis is rooted in the understanding (or misunderstanding) of the constitutional limits of the powers of the elected government in the National Capital Territory of Delhi. The Aam Aadmi Party government has a history of confrontation with the Centre on the question of who is the administrative head of a region that is less than a State and more than a Union Territory. Since the party came to power in 2015, the demand for Delhi to be given the status of a full-fledged State, allowing it among other things powers over the police, has become strident. Differences extend to the LG’s discretionary powers to appoint the Chief Secretary, with the AAP nursing a grouse that the bureaucratic cadre came directly under the Centre. Matters came to a head when Chief Secretary Anshu Prakash was assaulted during a late-night meeting in Mr. Kejriwal’s presence. Since then, officials have been in a non-cooperative mode, only attending statutory meetings, skipping what they term are “routine” meetings and not taking phone calls from Ministers. Mr. Kejriwal and his Cabinet colleagues decided on the dharna in protest, but instead of forcing a solution, they may have precipitated a crisis. Members of the BJP responded with a dharna at the Chief Minister’s residence, completing the political spectacle.
In adopting the politics of protest as part of its quest to expand the powers of the elected government, the AAP is putting governance at risk. Instead of mounting a legal challenge to the Centre’s efforts to further curtail the limited powers of the Delhi government, Mr. Kejriwal chose to respond politically. While he might like to be seen as a constitutional functionary whose hands are tied by an overbearing Centre, he is coming across as someone who is keener on a bigger fight on a bigger stage than as one eager to fulfil his constitutional mandate. The dharnas might end, but the underlying causes of the present crisis will not disappear without the Centre and the Delhi government agreeing on the terms of engagement through the office of the Lt. Governor. The BJP cannot mock Mr. Kejriwal out of politics; the Centre will have to deal with him, and work jointly with the AAP government for the welfare of Delhi’s citizens — something it has failed to do. The way to fight the AAP cannot be by placing handcuffs on the Delhi government. As for the AAP, it should learn to make the best of the system before demanding more autonomy. To push the constitutional limits to acquire more meaningful powers is fine, but it cannot be at the cost of failing to do whatever is possible within the current framework.
Meaning: State or assert that something is the case, typically without providing evidence or proof.
Example: “The Prime Minister claimed that he was concerned about Third World debt”
Synonyms: Assert, Declare
Meaning: A loud, unpleasant, and prolonged noise.
Example: “The fans made an awful din”
Synonyms: Uproar, Racket
Antonyms: Silence, Quiet
Meaning: A dead human body.
Example: He is handed a case to experiment on, just as a medical student is handed a cadaver to dissect.
Meaning: A loud unpleasant noise; a din.
Example: “The kids were making a racket”
Synonyms: Noise, Hubbub
Meaning: Not disputed or called in question; accepted.
Example: “The undisputed heavyweight champion of the world”
Synonyms: Undoubted, Unchallenged
Antonyms: Doubtful, Disputed
Meaning: Match or surpass (a person or achievement), typically by imitation.
Example: “Most rulers wished to emulate Alexander the Great”
Synonyms: Imitate, Copy
Meaning: Intended for or likely to be understood by only a small number of people with a specialized knowledge or interest.
Example: “Esoteric philosophical debates”
Synonyms: Abstruse, Obscure
Antonyms: Simple, Familiar
Meaning: Causing a mood of gloom or depression.
Example: “The dismal weather made the late afternoon seem like evening”
Synonyms: Dingy, Dim
Antonyms: Bright, Cheerful
Meaning: An arrival or entry of large numbers of people or things.
Example: “A massive influx of tourists”
Synonyms: Inundation, Inrush
Meaning: Use (something) to bad effect or for a bad purpose; misuse.
Example: “The judge abused his power by imposing the fines”
Synonyms: Misuse, Misapply
Meaning: The detailed organization and implementation of a complex operation.
Example: “The logistics of a large-scale rock show demand certain necessities”
Synonyms: Organisation, Planning
Meaning: Possible and practical to do easily or conveniently.
Example: “The Dutch have demonstrated that it is perfectly feasible to live below sea level”
Synonyms: Practicable, Workable
Antonyms: Impracticable, Impossible
Meaning: A person or thing that receives or is awarded something.
Example: “The recipient of the Nobel Peace Prize”
Synonyms: Beneficiary, Receiver
Meaning: Move or transfer (someone or something) to another place or situation.
Example: “It was proposed to transplant the club to the vacant site”
Synonyms: Transfer, Move
Meaning: A thing that discourages or is intended to discourage someone from doing something.
Example: “Cameras are a major deterrent to crime”
Synonyms: Disincentive, Damper
Antonyms: Incentive, Encouragement
Meaning: Playful misbehaviour, especially on the part of children.
Example: “She’ll make sure Danny doesn’t get into mischief”
Synonyms: Badness, Misbehaviour
Meaning: Arousing or able to arouse intense feeling.
Example: “Animal experimentation is an emotive subject”
Synonyms: Inflammatory, Controversial
Meaning: The middle part or point.
Example: “He left his flat in the midst of a rainstorm”
Synonyms: Middle, Centre
Meaning: Having or showing a cautious distrust of someone or something.
Example: “He was suspicious of her motives”
Synonyms: Doubtful, Unsure
Antonyms: Trustful, Trusting
Meaning: Prolonged public disagreement or heated discussion.
Example: “The design of the building has caused controversy”
Synonyms: Disagreement, Dispute
Antonyms: Agreement, Accord
Meaning: Declare officially or publicly to be.
Example: “He proclaimed King James II as King of England”
Synonyms: Declare, Announce
Meaning: An action or event regarded as morally or legally wrong and causing general public outrage.
Example: “A bribery scandal involving one of his key supporters”
Synonyms: Impropriety, Misconduct
Meaning: Used to emphasize the extreme degree of something.
Example: “He desperately needed a drink”
Synonyms: Seriously, Gravely
Meaning: Action or speech that makes someone angry, especially deliberately.
Example: “You should remain calm and not respond to provocation”
Synonyms: Incitement, Rousing
Meaning: A system of government in which most of the important decisions are taken by state officials rather than by elected representatives.
Synonyms: Civil service, Administration
Meaning: A hostile or argumentative situation or meeting between opposing parties.
Example: “A confrontation with the legislature”
Synonyms: Conflict, Clash
Meaning: (Of a sound) loud and harsh; grating.
Example: “His voice had become increasingly strident”
Synonyms: Harsh, Raucous
Antonyms: Soft, Dulcet
Meaning: Complain about something trivial; grumble.
Example: “She heard him grousing about his assistant”
Synonyms: Grumble, Complain
Meaning: A small group of people specially trained for a particular purpose or profession.
Example: “A cadre of professional managers”
Synonyms: Team, Corps
Meaning: Make a physical attack on.
Example: “He pleaded guilty to assaulting a police officer”
Synonyms: Hit, Strike
Meaning: Required, permitted, or enacted by statute.
Example: “Statutory controls over prices”
Meaning: A visually striking performance or display.
Example: “The acrobatic feats make a good spectacle”
Synonyms: Display, Show
Meaning: A long or arduous search for something.
Example: “The quest for a reliable vaccine has intensified”
Synonyms: Search, Hunt
Meaning: Reduce in extent or quantity; impose a restriction on.
Example: “Civil liberties were further curtailed”
Synonyms: Reduce, Cut
Antonyms: Increase, Lengthen
Meaning: Unpleasantly overpowering.
Example: “An overbearing, ill-tempered brute”
Synonyms: Autocratic, Oppressive
Meaning: Having or showing eagerness or enthusiasm.
Example: “A keen gardener”
Synonyms: Eager, Anxious
Antonyms: Reluctant, Apathetic
Meaning: A time of intense difficulty or danger.
Example: “The current economic crisis”
Synonyms: Catastrophe, Calamity
Meaning: Tease or laugh at in a scornful or contemptuous manner.
Example: “Opposition MPs mocked the government’s decision”
Synonyms: Ridicule, Deride
Antonyms: Friendly, Open
Meaning: Put handcuffs on (someone).
Example: “He was led into court handcuffed to a policeman”
Synonyms: Manacle, Fetter
Meaning: Freedom from external control or influence; independence.
Example: “The courts enjoy a considerable degree of autonomy”
Synonyms: Self-government, Independence
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