Iodine deficiency
By Dr R.J. Dash
Iodine is an essential micronutrient for plants, animals and humans. The thyroid gland of man and animals produces two hormones — thyroxine (T4) and tri-iodo-thyronine (T3), utilising the iodine present in blood. Iodine also helps in the regulation of the thyroid hormone secretion. Independently, it helps never cell growth in foetal life.

Suicide: a psycho-legal profile
By Dr Vij, K.
Suicide is defined as the intentional taking of one's own life. This definition, however, does scant justice either to the complexity and variability of the suicidal phenomena or to their profound ethical, philosophical, social and clinical implications. Traditionally, society has felt that it was necessary to assign blame for every death, either to God (natural/accidental) or to man (homicide/suicide).

Hospital waste: a curse
By Artur Hertle
Delhi's population is growing. This means that resources and services— food, water, housing, transport — have to be provided for more and more people. These people also need more hospitals, to take care of them, when they fall ill. One of these hospitals is the "Holy Family Hospital", a general, charitable hospital run by the Delhi Catholic Arch-Diocese.

Doctor, have you an e-mail?
By Dr O.P. Sharma

You are taking a round of your hospital. There is a message saying that you have an urgent e-mail from Kuwait duly signed by the doctor in-charge of the hospital.

The clinical situation involves a neuro-surgeon in Kuwait, with a six-week history of illness that started with fever, leucocytosis, an increased sedimentation rate and abnormal liver function tests. The report further states that the patient has lately developed leukopoenia, that is primarily neutropoenia. Most recently it has been reported that he has developed mouth ulcers which are infected.

The management of the case needed the involvement of multiple disciplines of Medicine. The mail, therefore, was referred to Prof V. K. Kak, Director-Principal, Government Medical College, Chandigarh, himself, a renowned neurosurgeon and an enthusiast of computers and internet, who, after consultation with colleagues, sent the report of the patient to Mayo Clinic at Rochester, Minnesota (USA). Dr Ayalew Tefferi of the Division of Haematology at Mayo Clinic was kind enough to give his valued opinion which was passed on to the hospital concerned in Kuwait.

Whizzing along internet, such clinical messaging lets doctors consult on tough cases, speed up test results, chat among themselves and even talk to their patients.

Medicine, in the new millennium, is all set to make a huge leap forward by the increased access and extensive use of information technology and electronic databases.

Doctors practising at far-off places can use mailing lists—the type provided at Indmedica, to seek opinion on their complicated cases from colleagues worldwide. In this method, all queries from registered users are reviewed by a "Moderator" before being posted via E-mail to list of registered members. Indmedica has the world's second largest Ophthalmology mailing list wherein more than 560 doctors discuss their difficult cases almost daily. The viewers can see the archive of various discussions on the website. They include Dr Amod Gupta, Dr J.S. Saini and the author. E-mail can also be a very useful tool for patient-physician communication. Test results could be transferred through e-mail. They can print the information and study it at their leisure, rather than calling up a doctor again and again to check whether the reports were ready or receiving a hurried telephone call from the physician's assistant that the reports could now be collected.

Doctors need to reorganise their practice so that at least routine communications with patients might take place by e-mail. They should offer this facility to patients and local practitioners for rapid response to any queries or anxieties they may have and to avoid delays caused by the post and the telephone system. This would save time, improve the accuracy of communication and enable physicians to practise medicine to the greater convenience and satisfaction of their patients.

Internet can provide vast amounts of information, but the material available is variable in quality. We were the first to create India's premier medical website with prime focus on India for the benefit of medical professionals and the public alike. (www.indmedica.com). The web features the information that has been written personally or selected (after studying it online) and considered reliable so that patients can access with confidence. Traditionally, it has always been the doctor who had all the information about the medical problem. The patient simply followed the orders! However, today anyone with access to internet can get information about any disease with the click of a mouse. We are now entering an open society with information available to everyone—the doctors as well the patients. This, in fact, is a great boon to the common man, who needs to be empowered with all the relevant information about his own or his near and dear ones' medical problems. By giving him this knowledge, we are helping our country and ourselves since this person then becomes an educated partner in his own and his family's medical welfare. That is why we at Indmedica are now starting a public education section wherein anyone can ask the experts and get detailed information about a particular disease or a diagnostic procedure. This service will be available free of cost to all those who register on the website in the current month (April 2000). Thereafter a nominal fee will be charged for this service.

Furthermore, to increase "Computer and internet literacy" in the people in general and among medical professionals in particular, Indmedica has held a large number of workshops around the country to demonstrate to patients and the doctors the basic aspects of computers and internet and how internet can be used to access information-relating to health-care. The doctors and the patients have been able to participate and gain hands-on experience. There has been some resistance from those on the +45 age groups, but on some occasions, elderly people have been found more keen to learn about the new technology and the benefits from global exposure. The Indian Institute of Quality Management, Ministry of Information, Government of India and Indmedica are now jointly organising a series of workshops on computer and internet for medical professionals around the country—the first joint workshop scheduled for April 29 and 30 at Jaipur.

We use internet extensively to search literature and look out for competent doctors round the globe. However, we have realised that there is very little reliable information available on Medicine in India on the net. We can retrieve information on the leading cardiologists in New York, but we cannot help a user to find the names and addresses of cardiologists in Amritsar or Jalandhar! We, have therefore, decided to correct this situation by putting up our own Doctor's Directory at www. indmedica. com which has now become the most important resource material for doctors in India.

The website also presents clinically focused summaries of medical meetings, CME programmes, expert-written interactive lectures and an extensive image library to help physicians deliver state-of-the-art patientcare. The latest information about medical equipment, medical dental pharmaceutical nursing college admissions and medical job opportunities for professionals of all specialities (dental surgeons, pharmacists and paramedical staff) is available. It is no surprise that Encyclopaedia Britannica's editors have selected Indmedica as one of the best on internet when reviewed for quality, accuracy of content, presentation and usability.

Dr O.P. Sharma is a renowned eye specialist based at Chandigarh. Once a National Professor, he has been running India's premier medical web Indmedica dot com on internet for three years now.

Iodine deficiency
By Dr R.J. Dash

Iodine is an essential micronutrient for plants, animals and humans. The thyroid gland of man and animals produces two hormones — thyroxine (T4) and tri-iodo-thyronine (T3), utilising the iodine present in blood. Iodine also helps in the regulation of the thyroid hormone secretion. Independently, it helps never cell growth in foetal life.

A variety of health problems occur due to iodine deficiency. These are the enlargement of the thyroid (goitre), cretinism and mental retardation. Subtle iodine deficiency affects the woman's ability to have a pregnancy, increases foetal loss, and leads to a lack of concentration, poor memory and sluggishness.

Over a quarter of the world's population in 118 countries faces problems of iodine deficiency. Of them, 655 million persons have endemic goitre, 5.7 million cretinism and 26 million brain damage.

Every year 60,000 still births, abortions and infant deaths occur within days of delivery owing to iodine deficiency.

Sluggishness is an important cause of losses in effective man-hours, industrial growth and economic stagnation in many developing countries. Iodine deficiency constitutes the world's major cause of preventable mental retardation ranging from mild intellectual blunting to overt cretinism.

When the availability of iodine is low, the thyroid gland grows bigger and bigger with the good intention of capturing any iodine that circulates in blood. Iodine deficiency is the major cause of endemic goitre, accounting for over 90% of simple goitres. People exposed to the intermittent supply of iodine develop nodular goitre. Without meeting iodine deficit, if the goitre is surgically removed, it invariably recurs. Neck irradiation for lymphnode malignancies, radiation exposure following nuclear accidents and even repeated X-Rays of the neck increase the risk of thyroid cancer in subjects with iodine-deficient goitres. Follow-up studies of the Chernobyl nuclear plants disaster have confirmed the risk of thyroid cancer from a nuclear accident.

Iodine deficiency during reproductive age may cause inability to conceive, particularly when associated with a decrease in the thyroid function. Higher rates of pregnancy loss and, most importantly, mental retardation and various neurological manifestations in the newborn are well-known sequelae of iodine deficiency.

While iodine deficiency early in pregnancy accounts for neurological cretin that occurring later in foetal life and continuing through out infancy leads to a profound decrease in thyroid functions, resulting in a myxodematous cretin. Both these forms of cretin are seen in the sub-Himalayan belt. The administration of iodised oil injections during pregnancy substantially reduces the risk.

In our country, endemic goitre is largely because of iodine deficiency with an overall prevalence of 21%. The Himalayan goitre belt includes Jammu and Kashmir, Punjab, Haryana, UP, Bihar, West Bengal. Sikkim and the north-eastern seven sister states. Many pockets and tribal areas in the country have a high prevalence of endemic goitre.

Unlike other nutrients such as iron, calcium, zinc or the vitamins, iodine does not occur in sufficient concentration in natural foods. Small quantities of iodine are present in vegetables and drinking water. Deforestation and soil erosion increase the loss of iodine from the soil. Desalinated sea water and seafoods (prawns, fish crabs, snails, etc.) have higher quantities of iodine.

Soils from mountain ranges such as the Himalayas, the Alps and the Andes are areas devastated with frequent floods; these are iodine deficient. Hence, ground or surface water in these areas are iodine sufficient. The contamination of sea water by industrial and other organic wastes have significantly reduced iodine availability in our sea foods. Dietary iodine supplementation has, therefore, become essential for all of us.

IDD have been successfully managed by salt iodisation programme in North America and Europe beginning in the 1930's. In Asia, iodisation of salt was initiated in 1960's but the programme gained momentum in the 1980's. China has successfully implemented a programme covering 300 million people and has now expanded universal salt iodination to the whole country.

We adopted a policy for the universal iodination of salt in 1984 and currently have covered over 500 million people in the endemic regions.

A project has been successfully carried out under the aegis of the Rajiv Gandhi Foundation for making iodised salt available in Madhya Pradesh in 1996. An International Council for the control of IDD (ICCIDD) operating through WHO and UNICEF at the global, regional and national levels has the ambition of eliminating IDD by end of the year 2000, which appears improbable.

India, like many other countries in the world, uses potassium iodate for the iodination of refined salt in modern salt iodisation factories in Gujarat and Rajasthan. The level of iodisation at the production level is 30 mg/kg salt, aiming at providing an individual 300ug of iodine in 10g of salt consumed.

After privatisation, iodised salt production has increased to nearly 40,000 tonnes but this is still short of the targeted need. At the peripheral level, however, the consumption of iodised salt and the iodine content of the salt consumed widely vary.

Iodine being a volatile substance is rapidly lost from the iodised salt when it is kept open, near a fire place and/or is added while cooking.

A fresh packet of iodised salt should be obtained every month, stored away from the fireplace and added to food items after cooking to maximise iodine availability from the salt mixture.

The implementation of universal salt iodisation programme has a few reservations. The fear of harmful effects of iodine is totally unjustified. The use of iodised salt by people with iodine-sufficient status produces no harm. Iodised salt should, however, be avoided by patients with thyrotoxicosis and those who experience a relapse of thyrotoxicosis following effective drug treatment. "A stitch in time saves nine": thus goes a saying implying that an action taken in time benefits people at large. The Universal Salt Iodisation Programme is one such step to protect humanity from the major maladies caused by iodine deficiency.

Dr R.J. Dash is the Head of the Department of Endocrinology at the PGI, Chandigarh. He is the seniormost Professor in his discipline in the country.

Suicide: a psycho-legal profile
By Dr Vij, K.

Suicide is defined as the intentional taking of one's own life. This definition, however, does scant justice either to the complexity and variability of the suicidal phenomena or to their profound ethical, philosophical, social and clinical implications. Traditionally, society has felt that it was necessary to assign blame for every death, either to God (natural/accidental) or to man (homicide/suicide).

If God was the responsible agent, nothing more needed be done. But if man was to blame, there must be punishment for the guilty.

Legal requirements regarding the responsibility for death have changed considerably in recent years. The importance of God as the responsible agent has receded into the philosophical background. Both accidental and natural deaths may be investigated with great care, and responsibility is frequently assigned to some correctable circumstance. With regard to suicide, society's attitudes have become more tolerant, but these are still ambivalent and contradictory.

Judicial attitudes have turned away from assessing guilt and enforcing punishment toward protecting suicidal persons when possible and toward efforts at caring for compensating the surviving victims of suicide deaths.

Degrees of suicide

There might logically be various degrees of suicide as there are various degrees of homicide.

1. First-degree suicide: deliberate, planned, premeditated self-murder.

2. Second-degree suicide:impulsive and unplanned; under great provocation or mitigating circumstances.

3. Third-degree suicide: sometimes called "accidental" suicide. This occurs when a person puts his or her life into jeopardy by voluntary self-injury, but where we infer that the intention to die was relatively low because the method of self-injury was relatively harmless, or because provisions for rescue were made. The person was actually "unlucky" to die.

4. "Suicide under circumstances which suggest a lack of capacity for intention, as when the person was psychotic or highly intoxicated from the effects of drugs, including alcohol.

5. Self-destruction due to self-negligence: for example, such self-destructive behaviours as chronic alcoholism, reckless driving, ignoring medical instructions, cigarette smoking, and similar dangerous activities. In general, such deaths are not at present classified as suicide.

6. "Justifiable" suicide: for example, the self-destructive action of a person with a terminal illness. This last category is of considerable current interest to philosophers, theologians and social psychologists.

Sections 306 and 309 of the IPC

Section 306 of the Indian Penal Code deals with "abetment of suicide". One committing suicide places himself or herself beyond the reach of the law, and necessarily beyond the reach of any punishment too. But it does not follow that it is not forbidden by the Penal Code. It is very much indeed. Section 306 punishes abetment of suicide. Section 309 punishes an attempt to commit suicide. Thus, suicide as such is no crime, as indeed, it cannot be. But its attempt is: its abetment too is! Suppose A and B conspire to procure B's miscarriage, and A procures arsenic, which he gives to B, which she takes and dies. Here, A could only be held liable as an abettor, but if A had himself administered the poison to B and thus caused her death, he would have been guilty of culpable homicide.

Section 309 of the Penal Code deals with an attempt to commit suicide". The law esteems the lives of men as not only valuable to the possessors, but as also valuable to the state which protects them—and for the protection and amelioration of which the State exists. It, therefore, rightly claims to prevent persons from taking their own lives, as much as it prevents them from taking the lives of others.

This right has been claimed by the State at all times, though the nature of its interference has, from time to time, varied. At the present time, it is a recognised doctrine of criminal jurisprudence that though the State should impose posthumous disabilities in case of suicide, it should certainly punish those who attempt to commit it.

It may be said that the policy of punishing an attempt, where the completed act goes, unpunished, might encourage those who make the attempt to make it successful. But this has not been the experience of jurists who have found the provisions, as existing, both salutary and deterrent.

The fact that an attempt to commit suicide is made criminal shows that in the eye of the law suicide is not necessarily the outcome of deranged intellect; it maybe a crime committed by a person in his sober senses. And this is the view of medical men and many psychologists.

There can be no doubt that persons are often driven to commit suicide owing to poverty or distress, loss of honour and fortune: while others are driven to self-effacement under the impulse of religion, as witness a case of sati, and of those who starve or torture themselves to death to attain nirvana, or supreme beatitude by absorption in the Divine essence.

In England, suicide is presumed to be an act of insanity and so in such cases the official verdict is couched in the formula—"committed suicide while temporarily insane". However, as said earlier, suicide is not necessarily the outcome of deranged intellect and, therefore, it remains to be seen how far this verdict is successfully carried keeping in view the modern developments plagued with dehumanising attitudes.

Here, I must stress that in order to attract the provisions of this section, the "attempt" must form a part of the "intention" of the individual to be charged with as the word "attempt" connotes some conscious endeavour to do the act. This may vividly be explained by a simple illustration. A man wrote a "suicide note" and turned on the gas. However, the concentration of the releasing gas was low. After waiting for sometime, the victim became bored and lit a cigarette. There was an explosion causing severe burns of which the victim died. The certificate was suicide as the connection between the original suicidal intention and the eventual death was direct enough to justify it.

Dr Vij is the Professor and Head of the Department of Forensic Medicine at Government Medical College, Chandigarh. He is equipped with a degree in Law also.

Hospital waste: a curse
By Artur Hertle

Delhi's population is growing. This means that resources and services— food, water, housing, transport — have to be provided for more and more people. These people also need more hospitals, to take care of them, when they fall ill. One of these hospitals is the "Holy Family Hospital", a general, charitable hospital run by the Delhi Catholic Arch-Diocese. It was founded by the "Medical Mission Sisters" in 1956 and has since then been offering its services — modern Allopathic Medicine, traditional Ayurveda and Homeopathic systems — to the public. Free medical treatment is offered to poor, deserving people coming to the hospital. Furthermore, comprehensive health care is provided for the slum dwellers of Nehru Place, where doctors provide maternal and child healthcare, ante-natal care, immunisation and medical care. Under a "school health programme" school children are examined and treated. Measures for the control of tuberculosis are also applied.

Yet hospitals do not only "produce" health, but also, as a "by-product" a lot of waste. This waste can be unsafe, as it can be contaminated with bacteria or viruses. So what is to be done with it? The German Embassy was able to help out: it financed an incinerator in which the infectious waste can be disposed of more safely. This incinerator was inaugurated on January 13th by the Minister of the German Embassy, Mrs Ute-Banerjea- Komers.

Thanks to the incinerator, waste is no longer a problem for the "Holy Family Hospital". So it can now deal even better with other problems: health- problems!