The Tribune, Chandigarh, India

December 1 is World AIDS Day
Tell HIV-positive donors the truth
By Dr J.G. Jolly

The concern about the safety of blood supply was highlighted when HIV was linked to transfusion therapy. AIDS exerted the greatest influence on blood banking. The future of blood banking, will in large measure, be shaped by our responses to the community’s perception of safe blood supply. There is no doubt that the AIDS epidemic played a role in stimulating research and advancement in blood banking as a result of which the transfusion programme received considerable impetus during recent years.

However, the lengthening dark shadow of AIDS across the four corners of the world has made the discerning people among us, be they doctors, social workers or caring compassionate, intelligent citizens, sit up in horror and wonder at the fate of mankind if we failed to find, in the foreseeable future, effective medicines to check the hitherto seemingly incurable disease which has been compared by some prophets of doom to ‘‘the harbinger of Dooms Day’’. This may not happen. This is our hope, for human ingenuity and mind know no limits. They rise to the occasion.

In at least one area of problems relating to AIDS, medical personnel engaged in tackling and curing the disease are faced with an acute dilemma. It has moral, ethical and legal dimensions.

The dilemma is: Should a donor of blood, who is found to be HIV-positive — infected — be told or not told that his blood sample betrays his fatal infection?

So far, the policy followed by doctors and blood banks has been to follow the guidelines laid down by the Government and keep the donor ignorant about the results of the test. There may have been some logic behind this refusal to divulge the results of the tests to the donor.

(The intention may have been to spare him the agony of knowing the hopelessness of his situation). But the problem needs to be looked at afresh. The question is: Should we continue to maintain a veil of secrecy on the fact that the donor is a potential victim of the dreadful AIDS?

As one weighs and contemplates the consequences of hiding the truth, one is forced to conclude that, other things being equal, it is desirable that nothing should be hidden from the donor though one should do everything possible to let the truth dawn on him as gently and sympathetically as possible.

If the donor realises that he may infect other people, including his acquaintances, friends and kith and kin, he can be persuaded to take steps to avoid infecting them. We should not forget that AIDS spreads in geometrical proportion and once it infects an individual, there is no knowing as to how many other people may become its victims.

Another point that merits our attention is: Would not the doctor or the agency that detected the infection in the donor’s blood but deemed it fit to keep him ignorant about it, be accountable for his intentional lapse? He could be questioned on legal and moral grounds for not revealing the truth to the donor who remained blissfully ignorant about what was wrong with him.

The policy of secrecy which has been practised so far needs to be amended and revised. We should change the rules which bind our hands. Secrecy is worse than truth. Rules and policies should be such as can be adjusted to the changing scenario.

In view of the above-mentioned fact, the entire issue is being viewed with concern and the matter relating to the current policy of the health authorities is being debated exhaustively on the following lines:

Experts in this field view with utmost concern an aspect of the National HIV Testing Policy relating to blood transfusion safety, which, inter alia, directs that any blood unit from a donor testing HIV-positive should simply be seen as ‘‘suspected’’ blood, and thus ‘‘discarded’’, without tracing back the donor for subsequent tests or for informing him about the state of his being a potential AIDS risk.

These experts consider that such a proposition is not without serious implications involving crucial issues of moral, ethical, professional and even legally tested significance. To wit, if the donor remains ignorant of his being tested HIV-positive:

a) he is precluded from taking steps for his treatment;

b) he is likely to pass on the infection to members of his family and others who may come in close contact with him;

c) he may donate his blood again elsewhere which may be used in the absence of test facilities or in any grave emergencies without making use of such facilities even if they exist;

d) he may sue such transfusion personnel, if he happens to discover his condition later, for keeping him in the dark and leaving him unprotected.

Such potential realities tend to negate the very idea of transfusion safety.

The current trends in ensuring the evolution of a well-organised plan of action for awareness among the community as well as essential steps in maintaining the desired transparency and management of AIDS should include the following points:

(1) The exaggerated and frightening figures reported in the media periodically remain unchallenged by official agencies and non-governmental organisations. Such a situation results in avoidable scare instead of alertness on the part of all concerned. The release of periodic statistical information by the Central health authorities appears to be the answer to the problem.

(2) Making AIDS a notifiable disease seems to be an essential prerequisite for minimising harassment to the HIV-positive individuals as well as patients by the police and the health authorities.

(3) The indigenous production of HIV-testing kits will ensure economy and provide an appropriate scientific answer to the variation of the strain which is being encountered in this field.

(4) Vaccine trials: Some reports have appeared about the trial of an AIDS vaccine in the country without appropriate authority from the Drug Controllor. Such trials should be banned forthwith. Similarly, the experimentation of drugs, whether from the modern system of medicine or from indigenous systems, should not be allowed unless these have been approved by the appropriate authority.

(5) The disclosure of the positive HIV status of the donor needs to be enforced strictly. Maintaining secrecy from the blood donor is a retrograde step and it results in the avoidable spread of the disease.

(6) The look-back policy: AIDS patients, giving the history of earlier blood transfusions, through which they might have contracted AIDS, should be provided the opportunity to know the status of the donors whose blood had been transfused to him. Such a look-back policy will be helpful in checking the spread of AIDS through the donor to others.

(7) The increasing incidence of tuberculosis, venereal diseases and oral ulceration has a close association with AIDS. These should be carefully looked for in all such patients.

(8) The problem of the window period giving negative results for HIV and the legal aspects of this variation should be understood clearly.

(9) The care of orphans born to HIV-positive parents needs a very sympathetic and organised dispensation.

(10) The status of the haemophilics and thalassaemics who receive repeated blood transfusions requires periodic checks for the HIV status to evaluate the transmission of the disease from the donors to the patients.

All these points appear to be essential and need a scientific follow up, besides a well-planned research programme.

The author is the Emeritus Professor of Transfusion Medicine at the PGI, Chandigarh, and a member of the National Blood Transfusion Council of the Government of India.

Health scenario at century’s end
By Dr G.D. Thapar

These are the best of times.
Man has reached the moon and is striving to reach other planets. He has made the rail, cars, jets, computers, FAX and Internet. He has radio and television, what to speak of electricity and airconditioners. He has those luxuries which even kings did not enjoy a century ago. He has doubled his life expectancy with the miracles of modern medicines and surgery. Serious diseases and epidemics have been conquered.

These are the worst of times.
Man has overpopulated, overcrowded and overpolluted the planet. He has denuded it by destroying forests. In a remarkable “first” in human history, he has begun to change the composition of the atmosphere by the constant release of garbage into the atmosphere in the form of greenhouse gases, the thinning out the ozone layer around the earth and increasing the harmful ultraviolet radiation from the sun.

He has steadily increased carbon dioxide concentration in the air to 2 per cent (normal 0.03%), caused global warming, raising sea level which is going to inundate large low-level areas.

The foodgrain supply has started dwindling with large populations, already more than one billion, below the poverty line. He has made himself lazy and has forgotten to walk, bringing in its train diseases of sloth. Infections have retaliated and are becoming resistant to the action of antibiotics. New serious infections have emerged and more are burking, and threatening man to extinction, because he has failed to invent a cure or a vaccine against them. On top of it all, he has amassed a huge pile of weapons of mass destruction for self-annihilation.

* * *

The fading century has been the period of unprecedented change and phenomenal progress in every field of science and technology, including medicine. During no period of history have such far-reaching changes occurred in such a short time; and the pace of change is accelerating with each passing day. We must admit that the future is overtaking us at a speed which is bewildering.

The turn of the last century saw India in the age of bullock cart, with most of the 30 crore population living in villages. The towns and cities were small; Delhi having only two or three lakh inhabitants. There were few cars, no telephone, cinemas, radio or television. The mode of transport was either one's legs or at best a bicycle. Life was simple and its expectancy just about 34 years. The death rate was high and there were not many people above the age of 55 or 60.

The spectacular advances in medicine and public health, coupled with improved standards of living, have resulted in nearly doubling life expectancy. This in effect, means that most people now live beyond 70 or 80 years. The increased life span has resulted in population explosion to almost four times ( 96 crore of divided India) within a matter of a century. This has caused the phenomenal growth of towns and cities with consequent overcrowding and its ill effects. Equally phenomenal is the growth of motorised traffic and industry which has given rise to frightening pollution. The phenomenon is global.

The antibiotic era
The remarkable extension of life span all over the world has been caused mainly by the discovery of antibiotics, the development of preventive vaccines and chemical agents against disease-carrying vectors, making it possible to prevent many infectious diseases on the one hand and cure infections on the other hand.

But something serious has happened which threatens to undermine the gains of this century.

The bacteria have developed resistance to the action of antibiotics. Animal vectors like mosquitoes have become resistant to the action of insecticides. Man has responded by developing more and more antibiotics and insecticides, to which resistance has also developed. The stage has now reached when resistance to antibiotics and chemicals is developing at a rate faster than the rate at which new drugs are forthcoming. Worse still is the emergence of new infections for which we have neither cure nor any vaccine.

The 21st century may, therefore, find us again at the mercy of infections.

Those of you who were born in the later part of this century would be spending a major portion of your lives in the next century and should prepare yourselves for this eventuality.

Fortifying your defences
The antibiotic era has produced a sense of complacency. People have started taking life for granted. Since it may not turn out to be so in the future, certain things become important. If you can't annihilate the enemy, fortify your defences so that the enemy dare not attack; and in case it does attack, the body should be strong enough to withstand the attack. Producing natural immunity to disease and fortifying our bodies with good nutrition, clean air and healthy habits will take precedence in the 21st century, just as it used to be before the antibiotic era, if we are to retain the gains of the 20th century.

Degenerative diseases of old age
The phenomenal rise in life-expectancy, coupled with family limitation drives, means that the number of old people in the community is rising at a rapid rate. The incidence of diseases of old age and degenerative disorders is, therefore, steadily rising. Hypertension, diabetes, heart attacks, paralysis, cataracts, osteoarthritis, cancers, dementia, etc, are taking a big chunk of our resources.

It also means that younger people, who are now becoming fewer as a result of family planning drives, have to carry a bigger load of the problems of the elderly. On the other hand, modern life has become very hectic for them. This fact, coupled with the breaking up of the joint family system, clearly goes to show that the old people should expect less and less assistance from the younger generations. It is, therefore, of paramount importance that today's young ensure that they remain healthy in their old age. This is not difficult provided a healthy life-style is adopted and maintained throughout life.

Stressful life
The advent of fast modes of transport, FAX, computers, e-mail and the Internet have made life fast and stressful. Coping with stress or using it to one's advantage has become important, so as to prevent it from becoming distressed and causing disease.

The world today is in a state of turbulence as a result of rapid change and demands constant adaptation to new ideas and challenges. In common with other denominators, new problems have come to challenge our health and well-being and demand new solutions and adaptations from us.

The coming weeks will be devoted to acquainting the readers with these challenges and their solutions.

Note: The Ambala-based legendary clinician, writer and health administrator, Dr G.D. Thapar, has recently produced two more informative volumes — “ Good Health in the 21st Century” and “Executive Health Manual” (S. Chand and Company, Ram Nagar, New Delhi - 110 055) for public awareness and forwarded them to Health Tribune for wider public notice. The write-up appearing above has been culled from “Good Health.....”.