October 24   2015, Saturday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal
For doctors’ cause: How important it is to ensure physicians’ wellbeing and what can be its impact on their patients

The importance of physician wellbeing was the centre of discussion among delegates at the annual General Assembly of the WMA in Moscow, which was held from 14th to 17th October. The expert panel saw the active participation of around 60 countries, stressing on how a few factors affect biological, psychological and social problems experienced by physicians such as mental illness, disabilities, occupational stress, burnout and any other chronic ailment can affect their efficiency.

As often discussed, a physician’s well-being is one of the most prominent factors contributing towards successful treatment of a patient. Although there is not much clarity on this subject, but this topic has continued to go back and forth in the discussions of the medical experts. They have spoken about how the medical industry of each country needs to focus on encouraging ongoing research on physicians’ health. Government should start supporting the conclusions based on the estimates and evidences that we already have. While it is always believed that physicians follow the nitty-gritties of a healthy lifestyle, some of them still suffer a lot of stress due to different reasons.

Reportedly, it has been observed that the highest rate of suicide is found amongst the medical professionals, especially physicians. Additionally, female doctor suicides significantly outnumber male doctor suicides.

The major contributing factors are the stress and strain one has go through in order to be a doctor and carry on in the medical profession. Due to the workload, doctors are often required to multitask. As a result, they are overworked; they get inadequate sleep and often face social isolation. The government needs to take steps and start working on framing the necessary policies that will ease up the whole crisis for physicians and in turn for their patients.

Setting all the reasons aside, physicians tend to avoid seeking help when they feel ill as they are concerned about the confidentiality of the information pertaining to them. They are seen as role models by their patients and hence, they hesitate in opening up about their health problems. To eradicate this fear of information breach and excessive burden of external expectations on them, government should ensure that the physicians get the same right of confidentiality as any other patient when seeking and undergoing a treatment. The health care system may need to provide special arrangements for the care of physician-patients in order to uphold its duty to provide privacy and confidentiality. Prevention, early assistance and intervention should be available separately from any disciplinary process for them.

WMA states the factors that hinder the well-being of a physician

• The medical profession often attracts highly driven individuals with a strong sense of duty. Successfully completing the long and intense educational requirements confers upon physicians a high degree of respect and responsibility in their communities. But, the external expectations burden them with a lot more than an individual can take, hence, leading to stress. Also, doctors, who are always looked up on as ideals and role models prioritize the care of others over care of self. Missing out on expectations often gives them a feeling of guilt.

• Working conditions, including workload and working hours, affect physicians’ motivation, job satisfaction, personal life and psychological health during their careers. Due to the extended working hours, they often miss out on required sleeping hours, which eventually leads to deterioration of their health.

• Physicians are often perceived as being immune to injury and diseases as they care for their patients. Physician who are employed by small organizations or who are self-employed may be at even a higher risk for occupational diseases and may not have access to health and safety programs provided by relatively large health care establishments. So, despite the size of a hospital or a clinic, basic healthy practices and hygiene should be adopted to help both patients and doctors.

• Postgraduate students often confront emotionally challenging and traumatic situations including suffering of patients, injury and death. Physicians may also be exposed to physical hazards like radiation, noise, poor ergonomics, and biological hazards like HIV, TB and viral hepatitis. All of this makes them more prone to the diseases, which can degenerate their health both mentally and physically

• Additionally, some postgraduate students and medical students, especially women can be victims of harassment and discrimination during their medical education. And due to their position within the medical hierarchy, they may feel powerless to confront these behaviours. This leads to the frustration building up in their minds and causing a mental outbreak

• Medical industry runners should work on potential obstacles, which restrict an ill physician from seeking care including denial, confidentiality issues, aversion to the patient role, practice coverage, fear of disciplinary action, potential loss of practice privileges, loss of performance based payment and the efficiencies of self-care.

• Illnesses can include mental and behavioural health problems, burnout, communication and interpersonal issues, physical and cognitive problems and substance use disorders

According to WMA, a few steps that need to be followed immediately include improved wellness promotion programs, prevention strategies and earlier intervention of symptoms in physicians. These can help mitigate the severity of mental and physical illnesses and help reduce incidence of suicide in physicians and medical students.
Breaking news
Include parents in periviable birth plan

Periviable birth is defined as that taking place from 20 to 25 weeks gestation. The first ever consensus care document on Periviable birth from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommends that when periviable (extremely premature) birth occurs or appears inevitable, clinicians should counsel parents or family on expected fetal outcomes as well as appropriate interventions. Clinicians and the family should work together to formulate a predelivery plan with recommendations for care, which may be modified based on the clinical situation. The consensus statement published in the November issue of Obstetrics and Gynecology. (Medpage Today)
Dr Good Dr Bad
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Specialty Updates
• A new study, published online October 21 in Neurology, provides more evidence that following a Mediterranean-type diet is good for the brain. The study revealed that elderly dementia-free adults more adherent to the Mediterranean-type diet had larger brain volume than their less adherent peers.

• A new study suggests that kids who regularly receive antibiotics gain weight significantly faster than their peers who do not. The findings are published in the International Journal of Obesity.

• In patients with Barrett's esophagus, low-grade dysplasia carries a substantial risk for progression to esophageal adenocarcinoma, suggests new research presented at the American College of Gastroenterology 2015 Annual Meeting.

• Taking low-dose aspirin daily could help women become pregnant, particularly those who have previously miscarried, suggested new research presented at the American Society of Reproductive Medicine Annual Meeting.

• New research suggests that physical activity could help prevent osteoarthritis. The findings were presented at the American Vacuum Society (AVS) 62nd International Symposium and Exhibition In patients with acute, nontraumatic low back pain, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up, reported a randomized study published in the October 20 issue of JAMA.

• A new study, published in Circulation: Arrhythmia and Electrophysiology, suggests that Botox may save lives when used in heart bypass surgery. Researchers noted that in the 30 days following surgery, those who received Botox injections during heart bypass surgery had a 7% chance of developing atrial fibrillation, compared with 30% in patients who received saline.

• While low maternal thyroid function during pregnancy is associated with adverse effects on offspring brain development, new research suggests that high maternal thyroid function in early pregnancy is also linked to similar effects, including lower IQ, in offspring observed at age 6. The findings were presented at the 2015 International Thyroid Congress and Annual Meeting of the American Thyroid Association (ITC/ATA) and published simultaneously in Lancet Diabetes & Endocrinology

• Being sedentary for too long during the day may be a risk factor for chronic kidney disease, suggested a study presented at the American Society of Nephrology Kidney Week 2015.

• Non-alcoholic fatty liver disease (NAFLD) was highly prevalent in morbidly obese patients who underwent weight loss surgery even when those patients did not have metabolic syndrome, suggested new research presented at the American College of Gastroenterology meeting.
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Media
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eSPIRITUAL
Why do people suffer?
1. As per Garud Puran and Hindu mythology, one of the reasons for suffering is the debts of your past birth. Your purpose of life is to face sufferings to pay these debts.

2. The second reason - your present deeds till today starting from birth. If your sum total of bad deeds is more than good deeds, they get added to your previous birth’s debts.

3. Third reason for suffering is the form of struggle, which you entertain to attain future success. Some people do not call it as suffering.

4. The last reason for suffering is that some people acquire yogic powers to take on the sufferings of others. The classical examples are Shirdi Sai Baba and Jesus Christ who were known to cure others by adding their suffering to their own account. If you see most of the Gods or holy people had suffered in their last time, be it Jesus Christ, Krishna, Buddha or Sai Baba.

Only Rishi Munis can remain alive and die at will even after they have paid for all their debts.
Legal Quote
Jacob Mathew v. State of Punjab SC / 0457 / 2005: (2005) 6 SCC 1 (iii).

“Generally speaking, it is the amount of damages incurred which is determinative of the extent of liability in tort; but in criminal law it is not the amount of damages but the amount and degree of negligence that is determinative of liability.”
Medicofinance
Estate planning

Estate planning refers to the process of transfer of one’s properties from one generation to the next generation, with a primary goal to protect, preserve and manage for the assets during your life and after death. It is generally perceived to be for the rich/wealthy people who have enough assets or valuables to leave behind for their heirs. However, estate planning is essential for all, regardless of one’s financial standing. Just analyze your assets and you would be surprised at its volume. Most of us make the mistake of not recognizing our assets, and in turn, our final estate. Estate generally includes Bank balances, cash, property, income from property, shares & debentures, jewelry, insurance policies, provident fund, recurring and fixed deposits, among other assets. Estate planning tools can be classified in two segments: During lifetime and after death.

(Source: IJCP)
Industry News
India 2nd most optimistic in biz optimism: According to the Grant Thornton International Business Report, India ranked second after Ireland in terms of the business optimism. The survey found that 86% Indian businesses are optimistic about an increase in revenue compared to 83 per cent last quarter. They are also positive about profitability with 69% respondents expecting a rise in the profits. However, only 52% Indian businesses were optimistic about rise of employment. (Business Standard - PTI).

Global speed bumps on India's growth highway: Poor global demands might slow down India’s growth. In October, IMF forecast the world economy would grow 3.1% this year, down from its July estimate of 3.3% growth. For next year, it cut the growth forecast to 3.6%, from 3.8% earlier. As recently as April it expected the world economy to grow 3.5% this year. As flagged by IMF in its October edition of the World Economic Outlook (WEO), the world faces lack of aggregate demand, leading to an output gap in major economies. This is visible from the growing gap between gross savings and gross investments. (Business Standard – Krishna Kant)

Funding slowdown for startups: Late-stage funding for me-too start-ups is drying, leading to consolidation in many segments following a period of excess initial-stage funding in the past 18 months. This trend, say venture capitalists (VCs) and investment bankers, is set to continue. Some segments that were the toast of the town are now too overheated to consume. The money, founders say, is difficult to come by and VCs have changed tack, shifting to early-stage investments. VCs now demand to see tangible progress before any further funding is made available. (Business Standard – Patanjali Pahwa & Kalpana Pathak)

Issues faced by startups in attracting talent and retaining it: The findings of the Athena study ‘Startups – The changing trends’, which covered more than 250 entrepreneurs across sectors, all of them founders or co-founders highlight the challenges involved in attracting talent and retaining it. The major findings: Almost 55% of employees are leaving their jobs to work for startups. 38.9% and 27.8% of startups felt that hiring at middle and senior level respectively was a critical and time consuming task. Better salary standards, bigger brands and job security were some of the major reasons cited for candidates moving to MNCs. (The Economic Times- Brinda Dasgupta)
Inspirational Story
Remain gracious in the face of rudeness

There was once a newspaper vendor who had a rude customer. Every morning, the Customer would walk by, refuse to return the greeting, grab the paper off the shelf and throw the money at the vendor.

The vendor would pick up the money, smile politely and say, 'Thank you, Sir.'

One day, the vendor's assistant asked him, "Why are you always so polite with him when he is so rude to you? Why don't you throw the newspaper at him when he comes back tomorrow?"

The vendor smiled and replied, "He can't help being rude and I can't help being polite. Why should I let his rude behavior dictate my politeness? "
eWELLNESS
Drinking coffee prevents Parkinson’s disease

Nicotine present in the tobacco has been used for its medicinal value for quite some time for diseases like Parkinson’s disease and ulcerative colitis. A study from University of Miami School of Medicine, USA, now has shown that people from families prone to Parkinson’s disease are less likely to develop the disease if they drink coffee on a regular basis.

Both coffee and nicotine have a link with dopamine in the brain. Dopamine is a chemical that decreases in patients with Parkinson’s disease. It is possible that people who are going to have Parkinson’s disease have lower levels of dopamine. Those with low levels of dopamine may be more likely to enjoy caffeine.

Parkinson’s disease is caused when brain cells that produce dopamine die. The disease is progressive, affecting about one percent of people older than 65. Symptoms start out with shaking and can progress to paralysis. There is no cure, although a number of drugs can make symptoms better for a time.
eMEDIPICS
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Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
MTNL Perfect Health Mela 2015.

Pls click here for details
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eMEDI QUIZ
How often should you have a Pap smear?

A. Once a year after puberty.

B. Once a year after either turning 21 or having sexual intercourse for the first time.

C. Once a year after age 21 and every two years after 30.

D. Once a year if you’re not in a monogamous relationship.

E. Once a year unless you’ve been vaccinated against the human papillomavirus (HPV). Then screening is not necessary.

Yesterday’s Mind Teaser: When should you have your first cholesterol screening?

A. At age 10.

B. At age 20.

C. At age 35.

D. At age 40.

E. It depends on your risk factors.

Answer for Yesterday’s Mind Teaser: B. At age 20.

Answers received from: Dr Jainendra Upadhyay, Dr K Raju, Dr Poonam Chablani, Dr K V Sarma, Raghavendra Chakurkar, Dr Avtar Krishan.

Answer for 21st October Mind Teaser: 3. Loss of overhead abduction.

Correct Answers received from: Daivadheenam Jella, Dr Poonam Chablani, Dr K V Sarma.
Humor
Never be rude to anyone

An American tourist asked a boat guy in Zanzibar, "Do you know Biology, Psychology, Geography, Geology or Criminology?"

The boat guy said, "No. I don’t know any of these." The tourist then said, "What the hell do you know on the face of this Earth? You will die of illiteracy!"

The boat guy said nothing. After a while the boat developed a fault and started sinking. The boatman then asked the tourist, "Do you know Swimology and Escapology from Crocodiology?"

The tourist said, "No!"

The boat guy replied, "Well, today you will Drownology and Crocodiology will eat you. I will not Helpology and you will Dieology because of your Badmouthology."
BIOETHICAL ISSUES IN MEDICAL PRACTICE
Defensive Medicine

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

The rate of cesarean section deliveries is growing all over the country. Obstetricians are often accused of using cesarean section to increase their income. On the other hand, issues such as increasing maternal age, precious babies, mothers’ insistence, safety and ease, parents’ schedule preferences, and preferences for doctor’s and hospital’s office hour delivery all result in increasing operative deliveries. However all doctors believe that ‘natural is the way to go’ in pregnancy. Yet operative deliveries are undertaken to avoid the smallest risk to mother or child. What do you think?

a. Is caesarean section a part of defensive medicine?

b. Do you agree to cesarean section deliveries in general?

c. Can such sections lead to complications for the baby such as prematurity and therefore, should they be always avoided?

d. If no to cesarean section, then what is the alternative?

e. Should there be definite essential requirements for cesarean section?

Adapted and shortened from: UNESCO, 2011. Casebook on Human Dignity and Human Rights, Bioethics Core Curriculum Casebook Series, No. 1, UNESCO: Paris, 144 pp.

Do write in with views and your solutions!
Breaking news
ICMR issues ethics guidelines draft for biomedical research involving children

The Indian Council of Medical Research (ICMR) has issued draft guidelines for biomedical research on children. According to the draft guidelines, the need for the study should be justified by a thorough review of literature. Also, the drugs should be tested for safety, pharmacokinetics, and at least initial indications of efficacy in adults before being tested on children. It may often be appropriate to defer pediatric testing until adult testing has reached phase 3 or beyond, when substantial data is available on the safety and efficacy of a drug in adults. Harm occurring from participating in research has been further clarified with regard to pediatric age group and must include potential harm such as "fear and separation from parents" that is usually not considered in studies involving adults in addition to physical (e.g., pain, disability, discomfort, or death), or psychological (e.g., fear, anxiety, or depression), or social (missing school etc). Harms related to the violation of privacy or confidentiality must also be considered.

ICMR has invited comments and suggestions on these draft guidelines by 15th of November. (ICMR)
MAKE SURE
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Indian Medical Association National Satyagraha for a Healthy India
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IMA Satyagraha, suggested slogans
• Writing prescription drugs by a non-MBBS is injurious to health of the community.
• Writing prescription drugs by unqualified people can be dangerous.
• Allow doctors to treat patients irrespective of patients’ income.(If compensation is not capped, we can't do this)
• When there is capping of Rs 2 lakh for a sterilization death, why not for other procedures?
• When there is a compensation of Rs 30,000/- for a sterilization failure, why not for other procedures?
• Allow us to treat poor and rich equally.
• Non pelvic ultrasound providers should be out of PCPNDT Act.
• Unless caught doing sex determination, no criminal offence shall be registered.
• If any prospective parent asks for sex determination, they should be booked under a non bailable offense.
• More patients will die if doctors are not provided protection during duty hours.
• Death does not mean negligence.
• Money spent does not mean you will get a cure.
• Including single clinic and small establishments under Clinical Establishment Act will make treatment costly.
• How can we treat patients using outdated standard treatment guidelines made by government?
• How can government decide the charges of a clinical establishment?
IMA/HSG/C-7/                              October 23, 2015
Shri Raghubar Das
Hon’ble Chief Minister of Jharkhand
Kanke Road
Ranchi – 834 008 (Jharkhand)

Respected Sir,

Greetings from Indian Medical Association!

We would like to draw your attention, toward the matter going on with the health department of Jharkhand state. As per our information, your cabinet has decided that, doctors posted in P.H.C. have to report to the Mukhia of that area for their attendance and leave.

Similarly, civil surgeon of the district will get attendance and leave from chairman district board and the salary will be paid to above doctors on recommendation by the Mukhia and Chairman District board respectively.

You are quite aware that all state government doctors are gazette officers working in difficult conditions in comparison to other gazetted officers. You are also aware that there is acute shortage of doctors in your state as such doctors are overburdened with giving services to large no patients.

The government decision will unnecessary drag doctors in the village politics such as during medico legal cases and reports and many more things. Due to this there will be chaos in working conditions and as such the entire medical services will be disturbed.

This decision will act as deterrent for the new doctors to come and join state health services. Doctors of your state will be demoralized and the decision of your govt. is insulting to highly respected doctors.

We request you to please withdraw your above order, so that our doctors give their services fearlessly with dignity.

Thanking you and with kind regards,

Yours sincerely,

(Prof (Dr) A Marthanda Pillai)     (Dr K K Aggarwal)
National President                          Hony. Sec. General
India has one of the highest global rates of antibiotic resistance

A recent report ‘The State of World Antibiotics 2015’ has found India among the nations with the highest rates of antibiotic resistances in the world. In 2010, India was the largest consumer of antibiotics at 13 billion Standard Unit ahead of China (10 billion SU) and the US (7 billion SU). The report released by the Centre for Disease Dynamics, Economics and Policy (CDDEP) observed that the BRICS countries reported the greatest increase in antibiotic use from 2000 through 2010 – 68% in Brazil, 19% in Russia, 66% in India, 37% in China, and 219% in South Africa. Ramanan Laxminarayan, director, CDDEP, and a lead author of the study, said, “MRSA (Methicillin-resistant Staphylococcus aureus) resistance rates have remained high in India. Carbapenem resistance has been increasing overtime. Overall, India has one of the highest rates of antibiotic resistance in the world.” He further added that the use of antibiotics in pre-mixed feed for livestock in India is increasing. Use of antibiotics in the pre-mixed feed should be stopped. Surveillance alone will not help. The key is preventing intake of antibiotics in cases where they are not needed. The report emphasizes limiting the use of antibiotics through improved water, sanitation and immunisation. (Hindustan Times – IANS)
Kidney has an extraordinary ability to reduce magnesium loss in urine, and thus achieve magnesium balance on a wide variety of intakes.
The 1st car-free day in Delhi sees significant drop in pollution levels

Delhi’s first car-free day hitched a ride on Dusshera holiday that saw a large number of vehicles staying off the road and the city, which has the dirtiest air in the world, recording a dramatic dip in pollution. The Delhi government on Thursday took the first step towards cleaning the city’s air when it closed a five-km stretch between the Red Fort and Bhagwan Das Road in the heart of the Capital to cars from 7am to 12pm, emulating neighboring Gurgaon that recently started car-free Tuesdays. Data compiled by the Centre for Science and Environment showed a 59% drop in the average levels of particulate matter (PM) 10 on the stretch when compared to Wednesday. The fall in levels of PM 2.5, a result of vehicular emissions, was steeper -- from 689 µg per cubic meter on Wednesday to 265 µg/m³ on Thursday. High exposure to particulates of 2.5 microns that are fine enough to lodge deep in lungs and blood tissues can cause respiratory and cardiac problems. The WHO has declared polluted air a carcinogen. During the first car-free day, the emphasis was on creating awareness than enforcing compliance. A similar exercise is planned for Dwarka in southwest Delhi on November 22, a Sunday, when the whole day would be car free… (Hindustan Times)
Most of world’s population lack access to pain-relieving drugs

Around three-fourths of the world's population have no access to any pain-relieving drugs according to a report ‘The Global Crisis of Avoidable Pain: The Negative Impact of Drug Control on Public Health’. Most people in late stages of cancers and/or enduring severe forms of acute or chronic pain do not have access to pain relieving medications, despite them being included in the WHO Model List of Essential Medicines. The large majority (99%) of the world's supply of morphine is consumed by just 17% of the global population with consumption primarily concentrated in the global north. The report says, “States must recognize they have an obligation under international law to ensure equitable access to controlled medicines for their populations. This obligation has equal importance as drug control measures to reduce illegal diversion. There should be a review of the 1961 and 1971 drug conventions' schedules in light of scientific evidence of the medical benefits of controlled substances, including cannabis.” The report was released by the Global Commission on Drug Policy (GCDP) on Monday… (Times of India – Rupali Mukherjee)
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IMA Digital TV
GP Tip: Relieving reliance on nasal sprays

Patients with chronic sinusitis often become dependent on nasal sprays. To ease withdrawal from these sprays, tell patients to buy a saline nasal spray and use two puffs in each nostril four times a day. This helps break the rebound effect of nasal sprays, provides nasal irrigation, and assists with behaviour modification.

(Source: IJCP)
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Readers column
Dear Sir, Very good Coverage. Regards: Dr K Sharma
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Press Release
IMA demands amendments to the PCPNDT Act

The PNDT Act came into being with the purpose of improving the altered sex ratio in India. It was further amended PCPNDT Act to regulate the technology used in sex selection. The Act banned preconception and prenatal sex determination. Its intent was to curb the actual act of sex selection and female feticide by regulating the use of ultrasound technology.

WHO in its recent publication has clearly declared that restricting technology was not the way forward and there is a lot that still needs to be done in this direction.

Despite the Act having been in existence for over 20 years, the altered sex ratio in India has not changed. Instead, the act has had two major negative consequences:

In its current form, the implementation of the PCPNDT Act has deprived the community of life-saving and essential ultrasonography which has now become an extension of clinical practice for all specialties globally, being a well-known non-invasive, cost-effective and accurate diagnostic tool.

The current PCPNDT Act has made it extremely difficult for ultrasound clinics to ensure complete enforcement. Doctors and other medical professionals are being put to extreme hardship while performing routine and essential scans. Due to this, many qualified doctors are opting not to do PNDT scans, thus creating a shortage of experts trained in ultrasonography.

Speaking on this issue, Padma Shri Awardee, Dr A Marthanda Pillai – National President and Padma Shri Awardee, Dr K K Aggarwal – Honorary Secretary General and President HCFI in a joint statement said, “As the PCPNDT Act has not resulted in the improvement of the falling sex ratio, social rather than medical interventions will be required to handle this issue effectively. The Act is being used to punish doctors for minor offences such as clerical errors in the filling of forms, thereby resulting in doctors being prosecuted and ultrasound machines being seized and sealed. Collectively IMA has put together some amendments which are required to solve this crisis”.

IMA demands the following amendments:

• The Act needs urgent modification to allow unambiguous and easy interpretation. The “Rules” need to be simplified and implemented uniformly across the country, and adhoc changing of rules by each local authority should be strictly prohibited. New rules must be logical and should apply to the entire country only after due discussion with the representative bodies. Time should be given for implementation of the new rules.
• The Act is to be directed only towards Obstetric Ultrasound and not any other applications of ultrasonography. The word “Offence” under this act has to be clearly defined. The word Offence should only mean the “actual act of sex determination or female feticide”.
• All other clerical/administrative errors should be classified as non-compliance (and not an offence). Strict penalties can only be imposed for the actual act of sex determination or female feticide and not for other errors. There is a need to redefine “what amounts to sex determination” as mere evidence of clerical error does not amount to sex determination. “Imprisonment” rules should be for the offence (of sex determination or female feticide) & not for non-compliance.
• Inspections should be conducted yearly instead of every 90 days. No NGO can conduct “raids” on doctors’ premises and there should be no impediment to doctors doing their practice during inspections.
• Ultrasonologists should not be restricted to working in only two centers.
• The doctors should have the right to report on those seeking sex determinations and action must be initiated against them immediately.
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