The ageing brain- proceedings of a medico - legal seminar, Editors: C. J. Vas, Charles Pinto, Dilip Panikker, Mumbai: Bandra, Holy Family Medical Research Society. 1997. 155 pages. Price not stated.

This collection of essays was I presented at a seminar organised on April 5 and 6, 1997, by the Dementia Research and Services Group; Bandra Holy Family Medical Research Society; FIAMC Bio-medical Ethics Centre, and the Aizheimer's Disease and Related Disorders Society of India in Mumbai.

The need for a discussion focussing on medico-legal aspects of the care of patients with dementia has been felt for some time. Those working with such patients find the need for guidelines on such topics as the definition of dementia, who should be told of the diagnosis of dementia, how the stigma borne by other family members can be countered, how we can prevent relations from taking advantage of the dementing patient and how we can help individuals who have reason to fear the development of dementia in the future.

In order to clarify these and related issues, the organisers gathered a team of experts in medicine, law, administration, the social sciences and the media. Their presentations and the discussions that followed are embodied in this volume.

The first chapter consists of the inaugural address, by Dr. P.C. Alexander, governor of Maharahstra, who points to social factors that exacerbate the problems faced by the elderly-dementing patient. The number of individuals living beyond the age of 65 years doubled between 1971 and 1991 and is expected to reach 22 million by the end of the century. The joint family has almost become extinct.

Other factors: urbanisation with its attendantevils in the form of a fast pace of life, impersonal attitudes, the need for both spouses to earn (leaving ageing members of the family to themselves) and far from satisfactory and socially unacceptable institutional care.

The next section provides an orientation on the medical facts. Who is of sound mind? asks Dr Chicot Vas in this context, before going on to answer his own question, deriving the definition of dementia and how one can separate the legally competent from the incompetent. He also presents a brief review of law in India on the subject.

This review is followed by a more detailed analysis by Mr. P. M. Bakshi, former member-secretary of the Indian Law Commission. Mr.Bakshi provides comprehensive answers to such questions as who is qualified to determine competence of an individual, to whom should the diagnosis of dementia be disclosed, what is the process of determining a patient legally competent or incompetent, and who should be permitted to make decisions by proxy on behalf of individuals known to be mentally 'deficient'.

The legal and medical aspects of competence are considered in further detail by two medical experts, a retired judge and a member of the law commission. An essay by Dilip Panikker and Charles Pinto discusses issues relevant to India.

Another area concerns the medical and legal requirements that must be met before a valid last will and testament can be drawn up. The definition of a *sound and disposing mind', the steps to be taken by a doctor in determining that a given individual does, indeed, possess such a mind, and the manner in which a judge will rule on this issue are discussed in the essays by Dr. Walter Vas and Mr. Justice M. H. Kania. Essays on the medical and legal aspects of informed consent follow.

Session five deals with the power of attorney granted so that the interests of the demented person are safeguarded, how a living will may be made by a person under the threat of dementia and decision-making on behalf of the demented person.

The penultimate section deals with research on dementia (with special reference to India) and legal aspects of research in demented persons. The final section of the book provides a summary of the proceedings and recommendations made at the seminar.

The volume is attractive, well- designed and devoid of proof-reading errors. Colour photographs of speakers and panellists enable the reader to share the experiences of those fortunate enough to be in the conference hall. The text is subdivided into sections based on the actual sessions at the seminar. Brief notes on all the speakers at that session are provided at the start of each section. A summary of the presentations and discussions at the end of the session conclude each section.

The multidisciplinary approach at the seminar and close interactions between members of the medical and legal professions resulted in an outpouring of very useful information. The proceedings of the seminar provide important guidelines that will help all these working with demented individuals.- I have learnt much from this volume and strongly commend it

Sunil K. Pandya, Flat 11, Fifth floor, Shanti Kutir, Marine Drive, Mumbai 400 020

Old killer, new weapons?
Serious implications of the proposed revised national tuberculosis control programme for India. Voluntary Health Association of India, Nucleus for Health Policies and Programmes. VHAI, New Delhi, 1997. pp. 100

When the National TB control programme was set up in 1962, it was lauded as one of the few research- based efforts with epidemiological data, longitudinal studies, effficacy studies. It was devised after identifying the factors that influenced health service usage, and linked to a model of primary health care.

Yet more than 25 years later, over 14 million Indians suffer from TB, and over 500,000 die of it every year. A 1992 government study found that less than 30 per cent of diagnosed TB patients complete their drug course. Inadequate budgets, chronic drug shortages, an undue emphasis on x-ray diagnosis, poor quality of sputum microscopy, emphasis on case detection rather than cure, poor organisational set-up and support, and a multiplicity of treatment regimes, not conforming to the WHO'S standards - all of this contributed to the programme's failure.

This did not seem to concern the government - till the HIV pandemic woke the West up to the fact of HIV- related TB, and the possibility of multi- drug resistant

The Revised National TB Programme focusses on a very different perspective from the earlier programme. The Directly Observed Treatment programme, which worked to control TB among poor people in urban USA, is going to be implemented "in the deserts ofRajasthan...(and) the forests ot'Gadchirolli", in an effort to bring the disease "under control". The programme will be supported by international grants and 'soft loans' from the World Bank.

It was following stiff criticism of this new approach that the Voluntary Health Association of India commisioned the Nucleus for Health Policies and Programmes to prepare a rejoinder to the draft RNTCP. Assisted by an authoritative advisory committee, Debabar Banerji prepared a position paper on the proposed revised programme focussing on DOT.

The paper was circulated to a number of organisations dealing with the subject - including the World Bank, which actually responded by coming to India for a meeting with the group.

"Serious implications..."presents a succinct overview of the TB control programme in India - its epidemiological basis and link to a people-based health service, problems with its implementation, and international initiatives. A short description by the government of the current and revised strategy is followed by the authors' critique, and their alternative plan for action.

The bibliography is followed by a series of annexures that delineate the process that followed the critique. In March 1996, key institutions and scholars were contacted for their comments; the text of those who responded is reproduced, along with comments from the authors; the minutes of a meeting with the World Bank/ WHO is described, along with the Bank's correspondence on those minutes.

Finally, there is the Indian government's official memorandum on a national coordinating committee to plan, implement and evaluate the revised programme.

This package provides a useful picture of the issues involved in theTB control programme.

Short notes
The Marathi publishing house Granthali released two books by doctors last month.

In Manoos navache jagane (A living called human being), plastic surgeon Ravin Thatte details the personal influences of the philosopher Dyaneshwar. DrThatte said he wrote the book in response to the several questons about life and death which surrounded me" while working as a doctor.

In Aushadh ani aapan (Medicines and us), Sharadini Dahanukar maps the history of modern medicines, their making and side-effects.

Corporate charity and public health
The January 1998 issue of Medical - Issues, the bulletin of the Medical Action Forum, discusses the implications of corporate houses being asked to adopt primary health centres: Can they do it, and what will the government do if the compnay closes down after a year? Why should health care be considered charity? Who pays ultimately for that care? And can such moves make a difference without altering the basic causes of poor health?

The author notes that a corporate house which is accused of polluting its environment has offered to look after the local district hospital.

'Health care as corporate charity'. Medical Issues. 2 (1). 1998. 11.

Human rights and HIV/AIDS
The mission of public health cannot -L succeed if it results in human rights violations. People working in the field must be aware of the possibility of such violations. For example, do the rights of the individual to receive treatment overrule those of another to privacy?

Public-health workers and affected communities need a fuller knowledge of human rights principles and a framework for their application.

This is provided in Human rights and public health in the HIV pandemic. The authors cover the origins of human rights law, moving from the UN charter to the International Covenant on Economic, Social and Cultural Rights in 1976, then describing the relationship of public health and human rights, the principles of autonomy, cooperation, consent, confidentiality, privacy and discrimination in the public-health response to the HIV epidemic.

They also propose a seven-step framework for reviewing and evaluating the human rights questions raised by any proposed public-health policy or programme. Some of the steps described are: defining the medical and epidemiological .facts at issue, examining the strenghth and efficacy of the public health benefit, ensuring that it targets the desired population and has minimal impact on others, and evaluating it for its impact on human rights.

One of the issues raised is: is it the least restrictive option that can achieve the desired objective? The process is applied to some current public health issues.

Gostin Lawrence O, Lazzarini Zita:Human Rights and Public Health in the AIDS pandemic. 1997. Oxford University Press. Delhi.

Health and human rights
The HIV/AIDS pandemic was one of the motivating forces behind the efforts to link people's health status with human rights issues. The first part of this special section, carried over two volumes, carries a historial perspective to the pandemic, and touches on some of the social determinants of infection in various groups: women, homosexuals, injecting drug users, the deaf community, and the poor in general.

Gruskin S, Mann J, Tarantola D, co- editors: HIV/AIDS and human rights. Health and Human Rights, Part I: the roots of vulnerability. 2 (4).

Reproductive health matters
The international women's health movement is the theme of this issue of Reproductive Health Matters.

Among the topics covered: a history of the movement, reports from various countries, features including one on female infanticide in Tamil Nadu, policy issues, commentaries (research questions on HIV transmission, eugenic sterilisation), and a round-up of news in research, law and policy, and service delivery.

A short bibliography of publications on the international women's health movement includes the FIGO (International Federation of Obstetricians and Gynaecologists) recommendations for the study of ethical aspects of human reproduction, available through FIGO at 27 Sussex Place, London NW1 4RG, UK, e-mail secret@figo.win-uk.net.

Reproductive Health Matters.The International Women's Health Movement. Number 10, November 1997.