Andhra Pradesh High Court - Amravati
Karukola Simhachalam vs Union Of India on 28 January, 2022
Bench: Prashant Kumar Mishra, M.Satyanarayana Murthy
IN THE HIGH COURT OF THE STATE OF ANDHRA PRADESH
WRIT PETITION (PIL) NO.164 OF 2019
AND
WRIT PETITION (PIL) NO.236 OF 2021
#
WRIT PETITION (PIL) NO.164 OF 2019
Karukola Simhachalam,
s/o Nandesu (late),
Occ: Advocate, High Court of Andhra Pradesh,
Tolusurupalli Village,
Tekkali (Post & Mandal),
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 22 others .... Respondents
Counsel for the Appellants : Mr. Simhachalam Karukola
Respondent Nos.19 to 23 : Learned Advocate General
Counsel for Respondent No.18 : Learned Advocate General
WRIT PETITION (PIL) NO.236 OF 2021
Annepu Mahandhata
s/o late Karu Naidu, age 64 years
R/o 1-160, Main Veedhi, Kanithivooru,
Nandigam Mandal,
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 18 others .... Respondents
Counsel for the Appellants : Mr. M. Lakshmi Narayana
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Counsel for Respondent Nos.1 to 4 : Mr. N. Harinath,
Assistant Solicitor General
And 9 to 14 : G.P. for Medical & Health
Counsel for Respondent No.8 : G.P for Revenue
Counsel for Respondent No.15 : G.P for Environment
Counsel for Respondent No.16 : G.P for Mines
Counsel for Respondent No.17 to 19: G.P for Panchayat Raj
JUDGMENT PRONOUNCED ON: 28.01.2022
+ HON'BLE MR. JUSTICE PRASHANT KUMAR MISHRA, CHIEF
JUSTICE
AND
HON'BLE MR. JUSTICE M. SATYANARAYANA MURTHY
1. Whether Reporters of Local newspapers
may be allowed to see the Judgments?
2. Whether the copies of judgment may be marked to
Law Reporters/Journals
3. Whether Their Ladyship/Lordship wish to see the
fair copy of the Judgment?
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+ HON'BLE MR. JUSTICE PRASHANT KUMAR MISHRA, CHIEF JUSTICE
AND
HON'BLE MR. JUSTICE M. SATYANARAYANA MURTHY
% Dated 28.01.2022
#
WRIT PETITION (PIL) NO.164 OF 2019
Karukola Simhachalam,
s/o Nandesu (late),
Occ: Advocate, High Court of Andhra Pradesh,
Tolusurupalli Village,
Tekkali (Post & Mandal),
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 22 others .... Respondents
Counsel for the Appellants : Mr. Simhachalam Karukola
Respondent Nos.19 to 23 : Learned Advocate General
Counsel for Respondent No.18 : Learned Advocate General
WRIT PETITION (PIL) NO.236 OF 2021
Annepu Mahandhata
s/o late Karu Naidu, age 64 years
R/o 1-160, Main Veedhi, Kanithivooru,
Nandigam Mandal,
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 18 others .... Respondents
Counsel for the Appellants : Mr. M. Lakshmi Narayana
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Counsel for Respondent Nos.1 to 4 : Mr. N. Harinath,
Assistant Solicitor General
And 9 to 14 : G.P. for Medical & Health
Counsel for Respondent No.8 : G.P for Revenue
Counsel for Respondent No.15 : G.P for Environment
Counsel for Respondent No.16 : G.P for Mines
Counsel for Respondent No.17 to 19: G.P for Panchayat Raj
<GIST:
> HEAD NOTE:
? Cases referred
1. 1980 Cri LJ 1075
2. AIR 1992 SC 573,585
3. 1996 (8) SCALE33
4. AIR 1997 Ori 37
5. (1995) 3 SCC 42
6. 1981 (1) SCC 608
7. (1996) 4 SCC 37
8. AIR 1993 SC 2178
9. AIR 1995 SC 636
10. AIR 1984 SC 802
11. 1995 (2) SCC 577
12. AIR 1989 SC 2039
13. 1989 AIR 2039
14. 1997 (2) SCC 83
15. W.P.No.36929 of 1998 dated 20.07.2001
16. AIR 1987 AP 171
17. 1995 (2) SCC 577
18. (1995) 3 SCC 42
19. AIR 1996 SC 3261
20. AIR 1991 SC 420
21. AIR 1990 SC 630
22. AIR 1988 SC 1037
23. AIR 1987 SC 359
24. AIR 1987 SC 990
25. AIR 1993 SC 2178
26. 1999 (1) AWC 847
27. 1995 (3) SCC 42
28. 1997 (2) SCC 83
29. (1996) 4 SCC 37
30. 2010 Crl.L.J 94
31. (1996) 4 SCC 37
32. AIR 1997 M.P. 191
33. (2000) 3 UPLBEC 1969
34. AIR 2002 SC 40
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IN THE HIGH COURT OF ANDHRA PRADESH : AMARAVATI
HON'BLE MR. JUSTICE PRASHANT KUMAR MISHRA, CHIEF JUSTICE
AND
HON'BLE MR. JUSTICE M. SATYANARAYANA MURTHY
WRIT PETITION (PIL) NO.164 OF 2019
AND
WRIT PETITION (PIL) NO.236 OF 2021
(Proceedings through Physical mode)
WRIT PETITION (PIL) NO.164 OF 2019
Karukola Simhachalam,
s/o Nandesu (late),
Occ: Advocate, High Court of Andhra Pradesh,
Tolusurupalli Village,
Tekkali (Post & Mandal),
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 22 others .... Respondents
Counsel for the Appellants : Mr. Simhachalam Karukola
Respondent Nos.19 to 23 : Learned Advocate General
Counsel for Respondent No.18 : Learned Advocate General
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WRIT PETITION (PIL) NO.236 OF 2021
Annepu Mahandhata
s/o late Karu Naidu, age 64 years
R/o 1-160, Main Veedhi, Kanithivooru,
Nandigam Mandal,
Srikakulam District. ..... Petitioner
Versus
Union of India,
Rep. by its Secretary,
Health & Family Welfare Department
„A‟ Wing Shastri Bhawan,
Rajendra Prasad Road,
New Delhi - 110 001 & 18 others .... Respondents
Counsel for the Appellants : Mr. M. Lakshmi Narayana
Counsel for Respondent Nos.1 to 4 : Mr. N. Harinath,
Assistant Solicitor General
And 9 to 14 : G.P. for Medical & Health
Counsel for Respondent No.8 : G.P for Revenue
Counsel for Respondent No.15 : G.P for Environment
Counsel for Respondent No.16 : G.P for Mines
Counsel for Respondent No.17 to 19: G.P for Panchayat Raj
COMMON ORDER
Dt.28.01.2022
(Per M. Satyanarayana Murthy, J)
Since the reliefs claimed by the petitioners in W.P. (PIL) NO.164 of
2019 and W.P. (PIL) NO.236 of 2021, are one and the same and based on
identical allegations, except additional relief claimed in W.P.(P.I.L) No.236
of 2021, we find it expedient to decide both the writ petitions by common
order.
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2. Mr. Karukola Simhachalam, a practicing Advocate, claiming to be a
public spirited person for public good, filed W.P (P.I.L) No.164 of 2019
under Article 226 of the Constitution of India as public interest litigation
claiming the following reliefs:
(i) To direct the Union and the State Government are to undertake periodical
national surveys for determining the prevalence rate and new cases
detection rate of Uddanam CKD (C.K.D) and at the same time publish the
reports of the concerned survey of the authorities and subsequent
thereto into the public domain and also the activities must be given wide
publicity;
(ii) To direct the Union Of India and State Government should organize
massive awareness campaigns to increase public awareness about the
signs and symptoms of Uddanam CKD (C.K.D) and the awareness should
also be spread about the free availability of medicines at all health care
facilities in Uddanam area;
(iii) To direct the Union and state are to ensure that drug for management of
Uddanam CKD (C.K.D) and its complications including the drugs are
available free of cost and do not go out of stock at all Primary Health
Centers PHCs or as the case may be public health facilities in that
Uddanam area;
(iv) To direct the Governments that treatment should be provided at free of
cost to all Uddanam CKD (C.K.D) cases diagnosed through general health
care system;
(v) To direct the Union And the State to organize seminars at all levels which
serve as platforms to hear the views and experiences directly from the
former patients and their families as well as doctors, social workers
experts NGOs and Governments officials;
(vi) To direct the Union and State Government to ensure that both private
and public schools do not discriminate against children hailing from
CKD (C.K.D) affected families such children should not be turned away
and attempt should be made to provide them free education;
(vii) To direct the Union and State Government to appoint the food inspectors
for prohibit the food adulteration;
(viii) To direct the Union and State Government Due attention to be paid to
ensure that the persons affected with CKD (C.K.D) are issued Below
Poverty Line BPL cards so that they can avail the benefits under schemes
which would enable them to secure their right to food;
(ix) To direct the Union and State Governments should construct 500 beds
super Specialty Hospitals within the limits of Uddanam area with the
adequate dialysis Units and testing laboratory;
(x) To direct the State together with the Union Of India should consider
formulating and implementing a scheme for providing at least a
minimum assistance preferably on a monthly basis to all CKD (C.K.D)
affected persons for rehabilitations;
(xi) To direct the Union and the State Governments must proactively plan and
formulate a comprehensive community based rehabilitation scheme
which shall cater to all basic facilities and needs of the CKD (C.K.D)
affected persons and their families The scheme shall be aimed at
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eliminating the stigma that is associated with persons affected with
C.K.D patients;
(xii) To direct the state and central Government should provide the mobile
dialysis units in that Uddanam are who are the suffering with severe
CKD (C.K.D);
(xiii) To direct the Union Government may consider framing separate rules for
Uddanam Chronic Disease (C.K.D) patients and provide reservations in
all governmental Jobs.
3. Similarly, W.P (P.I.L) No.236 of 2021 is filed claiming similar relief
as claimed in W.P. (P.I.L) No.164 of 2019. However, an additional relief is
sought for, to direct the district legal service authority to sensitize the
residents of Uddanam Area (as outreach program) in coordination with
medical experts, psychologists with the assistance of government
organizations and NGOs initially for at least three years, so as to prevent
the people of Uddanam from consumption of alcohol, utilization of cashew
nut powder in foods and liquids such as tea and immediately preventing
the act of smoking raw tobacco, inside out (adda pogaku chuttalu).
4. The writ petitioner in W.P.(P.I.L) No.164 of 2019 is permanent
resident of Tekkali Mandal, claiming to be a person interested to protect
the right to life of residents in and around Uddanam area, Srikakulam
District, filed this writ petition by way of public interest litigation claiming
the reliefs stated supra, alleging that for the last two decades, lakhs were
afflicted by this Chronic Kidney Disease (hereinafter referred as „CKD‟)
known as Uddanam Nephropathy and that the issue could not be
addressed effectively by successive governments and legislative members
during the past two decades.
5. Uddanam area is a fertile, subtropical, low altitude territory, which
is well-known for coconut and cashew farms in the Srikakulam district of
the southern Indian state of Andhra Pradesh. Uddanam area that lies in
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north-coastal Andhra consists of seven mandals of Kaviti, Sompeta,
Kanchili, Itchapuram, Palasa and Vajrapukotturu, consisting for more
than 100 villages in total. By 2015, It was estimated that more than 4500
people had died in the last ten years, and around 34,000 people are
suffering from kidney diseases in this area alone. It was reported that
each family in the area had at least one person suffering from kidney
ailment. The cases had first mysteriously surfaced in the early 90s.
Symptoms included hypertension and diabetes, followed by a long
asymptomatic period, and later diagnosed with excess proteins in the
urine, decreased red blood cell count and high levels of uric acid in the
blood. The phenomenon was discussed and termed as "Uddanam
Nephropathy" at the 2013 International Congress on Nephrology held in
Hong Kong.
6. Though it has been close to twenty years since the first cases were
reported, the cause of Uddanam Nephropathy is yet to be scientifically
established. The disease is known to disproportionately affect farmers and
agricultural workers. Coconut and cashew are the main crops grown in
the area. Although the association of specific occupations with endemic
nephropathy has highlighted the issue of environmental toxins and heat
stress, the exact cause of Uddanam Nephropathy is still an
enigma," according to Georgetown University in the May 2016 issue of the
American Journal of Kidney Disease. While chemical analyses of
cultivated rice or drinking water from the endemic area have been
negative, the concern of environmental pollution with organo-chemical
pesticides and heavy metal-remnants, because this was not assessed in
these studies. In 2011, a group of researchers studied the drinking water
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sources of these villages, "the presence of phenols and mercury in
drinking water was found to be very high...Phenols and mercury, being
very toxic in their characteristic nature, are bio-accumulative. Hence the
water is found not suitable for potable purposes." But this finding too
could not conclusively term water to be the sole culprit for such a high
prevalence.
7. In 2016, The Indian Council of Medical Research (ICMR) along
with researchers of Harvard University, Andhra Medical College, Bhabha
Atomic Research Centre (BARC) and NTR University of Health Sciences
among others looked into the matter. Researchers
initially pinpointed "excessive levels of silica in water" as the cause after a
preliminary round of examination. According to the World Health
Organization, Uddanam is one of the three areas in the world with the
highest concentration of CKD after Sri Lanka and Nicaragua. In 2015, the
Minister of Medical and Health officially acknowledged that 70% of the
total kidney ailments in Andhra came from the Uddanam area.
8. It is contended that, few scientific institutions and organizations
conducted several tests of blood, urine, water and soil and opined the
reason for kidney diseases as „high level of silica in water‟, prolonged
dehydration, heat stress, anti-inflammatory drug use, gene mutations,
high pesticides use and heavy metals in water. Usage of adulterated local
made tea power with cashew nut seed coat in Uddanam area was also
suggested, which residues with high levels of Anacardic acids, which
decreases the activity of human kidney. However, exploring the cause of
CKD is still an enigma.
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9. The petitioners in both the writ petitions contends that, the disease
is intensifying quickly from village to village and it appears more in young
male agricultural workers and indigent in rural working population,
thereby, 70% of the patients die due to inadequate resources to continue
treatment, as such, several families lost their sole breadwinners. The
petitioner contends that, due to lack of systematic screening, less number
of dialysis centers, expensive treatment in private hospitals, lack of
providing free medicines, 80% patients are dying at home due to their
non-affordability to costly treatment.
10. It is contended that, Uddanam area is being de-isolated from the
State, as most of the schools in the area do not have minimum primary
facilities like supply of drinking water, poor sanitation, good hygienic
food. In addition to the devastation it caused in Uddanam area, the
kidney conundrum has also opened a Pandora‟s box for the people of this
area. With the World Health Organization identifying this area as one of
the three areas burgeoning with kidney cases, vacancies in government
offices and schools arose in this area. Many state employees who are
working in Uddanam prefer to stay in other parts of the district and are
scared to drink water here. The situation has also become difficult for
youngsters planning to get married in the future as they have to find a
girl from the same village or mandal as no one from other districts want
to marry a girl or boy from this area due to the fear that they may also
contract the disease in future.
11. It is finally contended that, sufferance of public at large in
Uddanam area due to CKD is a public issue, as right to health is inclusive
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of Right to Life under Article 21 of the Constitution of India. The
petitioners‟ requests to direct the respondents to provide good and
adequate health care to the people of Uddanam area and since the
governmental agencies are neglecting the CKD sufferers, the petitioners
filed the present writ petitions for the welfare and benefit of the residents
of Uddanam area, claiming the reliefs as stated supra.
12. Mr.T. Bala Swamy, learned Government Pleader attached to the
office of the learned Advocate General represented that the basis for claim
in both the writ petitions is one and the same and adopted the counter
affidavit filed in W.P (P.I.L) No.164 of 2019 in W.P.(P.I.L) No.236 of 2021.
Therefore, the counter affidavit filed by the respondents in W.P (P.I.L)
No.164 of 2019 is taken as counter affidavit in W.P (P.I.L) No.236 of 2021,
as requested by Mr.T. Bala Swamy.
13. On behalf of Respondent Nos. 5 to 17 and 19 to 23,
Dr.K.S. Jawahar Reddy, Special Chief Secretary to Government, Health,
Medical and Family Welfare Department, A.P. Secretariat filed counter
affidavit, while admitting the sufferance of the people due to CKD in
Uddanam area and explained the steps that are taken to treat the
patients suffering from CKD.
14. The Government of Andhra Pradesh issued G.O.Ms.No.102, dated
03.09.2019 for establishment of 200 bedded super Specialty Hospital,
with Kidney Research Center and Dialysis Unit with an estimated
expenditure of Rs.50 Crores (Non-recurring expenditure) and Rs.8.93
Crores per annum (recurring expenditure) alienating land to an extent of
Ac.5-57 cents situated in Survey Nos. 253/29, 253/7A and 253/8B in
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Ananthapuram Village of Kassibuga, Palasa Manda. In addition to the
three existing dialysis centres at RIMS/GGH, Srikakulam, Area Hospital,
Tekkali and Community Health Center, Palakonda. Two more centres, one
at CHC, Palasa and one at CHC, Sompeta are started under national free
dialysis Programme and functioning since May' 2017. One more dialysis
center was established on 31.01.2019 at CHC Kaviti in Srikakulam
district. Nephrologist services are available once in 15 days at all the 6
dialysis centers. A-V fistula facility, to perform dialysis is made available
at RIMS/Government General Hospital Srikakulam, free of cost to all the
patients requiring dialysis. The Government of A.P is also providing
dialysis facility under the State Government sponsored Dr YSR
Aarogyasree Scheme.
15. Nephrologists of George Institute for Global Health, India is
conducting survey and research from 2017 in Uddanam area, on
identification, diagnosis, investigation and management of CKD. One
Special Officer was stationed at Uddanam area to monitor the activities
regularly, by George Institute for Global Health. A total of 40 clusters
(villages and surrounding hamlets) were selected for survey and
interviews and biological samples (blood & urine) were collected from
2419 villagers in that area and survey in 40 Clusters has been completed.
16. The Government of AP with a view to provide safe drinking water -
installed 6 RO Mother plants with 135 Dispensary units. Apart from that,
as a permanent measure, the Government has accorded administrative
sanction for Rs.700 Crores vide G.O.Ms.No.240, PR & RD (RWS/I)
Department Dated 16-01-2020 to provide safe drinking water with house
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connections @ 100 lped for the Uddanam area of Srikakulam District by
drawing surface water from Heeramandalam Reservoir. Orientation and
training program to Medical Officers and staff of 18 primary health
centres of Uddanam area on CKD care and identifying patients who need
specialist care for referral to higher centres for better treatment were
conducted.
17. Uddanam groundwater has lower range of total dissolved solids and
aluminum concentrations compared to Machilipatnam population of
which, shares an almost similar lifestyle, habits, and climatic conditions.
Ground water contamination with phthalates has been observed
extensively in Uddhanam area; phthalates are attributable to population
from plastic waste.
18. The Government of Andhra Pradesh with the association of Indian
Council for Medical Research, under the Ministry of Health and Family
Welfare, Government of India, New Delhi have entered an MOU with the
George Institute for Global Health, India, New Delhi in two phases. The
first phase articulates the clinical prevalence of CKD to measure affected
population and to explore community perceptions related to CKD, while
the second phase functions to determine the risk factors and progression
of CKD while analyzing residue levels of heavy metals and pesticides
through atomic absorption, so also to assess the levels of heavy metals in
blood, various aspects like cost and health expenditure, economic burden
of CKD, cost effectiveness of alternate models of CKD management and
other methodological framework.
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19. It is submitted that the Department of Public Health and Family
Welfare, Government of Andhra Pradesh has conducted the following
activities in Uddanam Area of Srikakulam District.
Initially to identify persons who are affected, Mass screening was done to
the public at large in udanam, for the age groups of above 30 years in all
the Mandals of Uddanam area and 1,01,593 people were screened from
Jan, 2017 to April, 2017 and 13093 people with abnormal tests results
were referred to CHCs in the area (CHC Sompeta, CHC Palasa, CHC
Haripuram, CHC Kavity and RIMS Srikakulam).
Two Expert teams from Ministry of Health & Family Welfare, Government
of India and Team constituted by Govt. of AP with ICMR have jointly
visited Uddanam area in Jan.2018 to study the various aspects of CKD
problem.
CHCs Sompeta, Palasa, Kaviti, Ichapuram, Barua and Haripuram are
provided with Lab Equipment and Reagents for testing CKD.
In addition to the three existing dialysis centres at RIMS/GGH,
Srikakulam, Area Hospital, Tekkali and CHC, Palakonda two more
centres, 1 at CHC, Palasa and 1 at CHC, Sompeta are started under
National Free Dialysis Programme and functioning since May'2017. One
more dialysis center was established on 31.01.2019 at CHC Kaviti in
Srikakulam district. Nephrologist services are available once in 15 days at
all the 6 dialysis centers. A-V fistula facility, to perform dialysis is made
available at RIMS Srikakulam, free of cost to all the patients requiring
dialysis.
20. Regular survey is undertaken in Uddanam Area of Srikakulam
District by the expert teams in association with George Institute for
Global Health, India, New Delhi for environmental survey by Government
of AP. Technical advisory committee meetings were held to assess the
magnitude of the problem, measures required to treat the CKD patients,
measures required to eliminate the causative factors. Progress of the
measures taken in the previous meetings is being reviewed and further
actions are contemplated in the following areas:
Regular IEC (Information Education and Communication) materials for
educating communities especially in uddanam area.
Nephrologist services are available once in 15 days at all the 6 dialysis
centers
A-V fistula facility, to perform dialysis is made available at RIMS
Srikakulam free of cost to all the patients requiring dialysis.
Regular trainings to the ANMs and ASHAS (field level health workers)
were imparted for examination of the patients.
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The required drugs and medicines are sufficiently available in the Central
Drug Stores, Srikakulam and all the Government Medical Institutions
viz., PHCS, CHCs and Area Hospitals. There are about 20 types of drugs
and medicines which are sufficiently available at Central Drug Stores,
Srikakulam for Continuous supply for the use of CKD patients as well as
general public. Government has taken steps for providing the treatment to
the CKD Patients free of cost in all Government medical institutions.
Government as a part of Welfare Measures sanctioned the CKDu /
Dialysis Pensions enhanced to Rs.10,000/- per month vide G.O.Ms.No.
103, Panchayat Raj and Rural Development (RD.,I) Department dated
30.05.2019.
21. Government also sanctioned financial assistance of Rs.5000/- to
CKD patients (Stage 3, 4 and 5) who are not on dialysis vide G.O.Rt.No.
551 HM&FW (D2) Department dated 26.10.2019. Dedicated Kidney
Research Institute is established with the support and partnership from
Indian Council for Medical Research (ICMR) and George Institute for
Global Health, India vide G.O.Rt.No.417, Dated 20.07.2017 at VIMS,
Visakhapatnam. Now, it is shifted to Palasa, Srikakulam district and
renamed as Kidney Research Innovation and Patient Assistance (KRIPA)
centre vide G.O.Rt.No.111, HM&FW(D2) Department dated 12.2.2019.
22. The Government of Andhra Pradesh determined additional risk
factors through detailed evaluation of occupational, dietary, heat
exposure and NSAIDs (Non steroidal anti-inflammatory drugs, like
Aspirin, Ibuprofen, Diclofenac, Aceclofenac etc) usage repeat eGFR and
Urine PCR estimation for identifying new incident cases of CKD at 6
monthly intervals. Systematically, validated methodological procedure will
be used to observe the heat stress in the study areas. Village level
analysis of fluoride and silica levels will be undertaken. A new project
proposal for undertaking genetic analysis of newly diagnosed patients and
family members - both affected and unaffected members to be tested. In
vitro study to be designed to examine the effect of phthalates, fluoride and
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silica on renal tubular cells. A technology assisted clinical decision
support for CKD screening and referral is facilitated through the KRIPA
centre.
23. The respondent also provided statistics from 2003 to 2019 with
regard to the measures being adopted for prevention and control of CKDs
in Uddanam area.
24. Government of Andhra Pradesh, inaugurated the CKD Special
Mobile Medical Clinics on 19.01.2017 at CHC Sompeta, and explained the
details of work undertaken in order to combat CKD in Uddanam area.
a) 6 Special Mobile Medical Clinics started CKD screening in Uddanam area
from 19.01.2017 & from 01.02.2017 started another 9 SMMC, total 15
SMMC are functioning now.
b) In Uddanam Area constituted 15 Special Mobile Medical Clinics for this
purpose for early detection of renal diseases covering total population in
the 114 high risk villages in Uddanam Area, each team consist of 1
Doctor, 2 Lab Technicians & 1 Data Entry Operator along with Semi Auto
Analyzer, Centrifuge and testing kits.
c) The Government of India has deployed a Central Team of Experts under
the Chairmanship of Dr. Sanjay Agarwal, HOD, Department of
Nephrology, AIIMS, New Delhi with their team visited the Gunupalli
Village of Vajrapu Kottur Mandal on 21.01.2017 and interacted with
public and examined the CKD Patients.
d) On 06.02.2017 ICMR Team under the Chairmanship of Dr. T. Raviraj
visited Special Mobile Medical Clinic Unit at Sompeta and visited
Borivanka village and interacted with public.
25. The respondent also furnished details about abstract of Special
Mobile Medical Clinics screening in Uddanam area from 17.01.2017 to
15.04.2017; details of referred cases of male and female from 19.01.2017
to 15.04.2017; details of below 30 years and above 30 years age group
referral to CHC‟s in Uddanam area.
26. The respondent also furnished second level screening particulars
viz, details of dialysis patients, pension amount distributed to dialysis
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patients in seven mandals. The Government also established one research
centre at Palasa of Uddanam area in collaboration with George Institute
for Global Health, New Delhi with the name „STOP CKDu‟ in Andhra
Pradesh.
District initiatives to stop CKD in Uddanam area:
Awareness camps conducted in 7 mandals, 853 villages in
Uddanam area to create awareness among the public of Uddanam
area on prevention and control of CKD through public meetings,
distribution of pamphlets, display of posters, etc.
As a district initiative, the District Collector, Srikakulam has
established 17 laboratories with semi auto analyzers for testing of
serium creatin and blood urea levels which are basic tests for
assess CKD levels of the Uddanam area public.
PHC Wise tests are conducted in the Uddanam area
27. Finally it is contended that, the State is taking every step, both to
prevent and treat CKD, more particularly in Uddanam area and that there
is no negligence on the part of the State and its officials to prevent and
cure CKD disease and requested to dismiss the writ petition.
28. Additional counter affidavit is filed by Mr. Anil Kumar Singhal,
Principal Secretary to Government of Andhra Pradesh, Health, Medical
and Family Welfare Department on behalf of Respondent Nos. 5 to 17 and
19 to 23, bring to the notice of this Court about the historical background
of the CKD of Undetermined Etiology (CKDu) and the preventive measures
being undertaken by the State Government to alleviate the suffering of the
people in the Uddanam Area and further the test and studies which are
being conducted to understand the reason behind the CKDu (CKD of
unknown origin)
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29. In the year 2003, kidney diseases were noticed in Gunupalli and
Matturu of Vajrapu Kothuru Mandal of Srikakulam District, AP. The
Medical Officers and Staff of concerned Primary Health Centre detected
25 suspected kidney cases. The Areaal Laboratory, Visakhapatnam
examined the water samples of those area and reported that the water of
those villages contains Nitrogen Nitrate and recommended for frequent
and continuation chlorination of water sources. Medical Camps were
organized at Kavity on 15-12-2006 under the Supervision of Dr. Raviraj,
Nephrologist, King George Hospital, Visakhapatnam and about 63,000
from 20 villages persons were educated on the subject. At the specialist
camp conducted 610 suspected cases were attended to, out of which 41
cases suffered from kidney diseases. The Specialist Doctors Team under
the supervision of Nephrologists of NIMS Hospital, Hyderabad visited
Uddanam Area about the cause of prevalence of Kidney diseases. The
water was found to contain silicon which may have caused the Kidney
diseases in Uddanam Area of Andhra Pradesh. Further the teams found
the following reasons were identified for the likely cause of Kidney
diseases namely (a) Personal Dietary Habits like low intake of water,
alcoholism, chewing of tobacco products, excess eating of dry fish (b)
frequently inhalation of pesticides and sprays at time of agricultural
operations and (c) Irregular and frequent usage of NSAID (Nonsteroidal
Anti-inflammatory Drugs), tablets and Analgesic drugs without
prescription of qualified Doctors. From the year 2003 to 2013 various
organizations including the World Health Organization, the Indian
Council for Medical Research, Harvard Medical College, Christian Medical
College, King George Medical College etc had conducted various studies
and tests and also created awareness among the people of the Uddanam
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area. However, inspite of the numerous studies and tests no specific
reason or cause could be identified for the CKD. So much so, this
condition was discussed and named Uddanam Nephropathy at the 2013
International Congress of Nephrology held in Hong Kong, China. This
medical condition prevalent in Uddanam is one of the 7 such instances
around the world where no specific reason has been identified for the
cause of the disease. By the year 2017 the Government had identified six
Mandals namely Kaviti, Palasa, Sompeta, V.Kotturu, Mandasa, and
Kanchali with high prevalence of CKD in the Uddanam area. A total of
167 villages fall within these 6 mandals with a population of 2,67,493.
Mass screening was done to the population in above the age of above 30
years in all the Mandals of Uddanam area in year 2017 about 1,01,593
people were screened from Jan 2017 to April.2017 and 13,093 people
with abnormal tests results were referred to CHCs in the area (CHC
Sompeta, CHC Palasa, CHC Haripuram, CHC Kavity and RIMS
Srikakulam). Two Expert teams from MOHM & FW, GOI and Team
constituted by Government of AP with ICMR have jointly visited Uddanam
area in Jan.2018 to study various aspects of CKD problem. CHCs
Sompeta, Palasa, Kaviti, Ichapuram, Barua and Haripuram were provided
with Lab Equipment and Reagents for testing CKD and the same
continues till date. In addition to existing dialysis centres at RIMS,
Srikakulam, AH, Tekkali and CHC, Palakonda two more centres, 1 at
CHC, Palasa and 1 at CHC, Sompeta were started and have been
functioning since May, 2017. One more dialysis center was established on
31.01.2019 at CHC Kaviti in Srikakulam district. Further regular sessions
with Nephrologists are available once in 15 days at all dialysis centers.
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30. Based on the tests and studies conducted thus far the following
causes have been attributed to the high incidence of CKD in Uddanam
area.
a) Tobacco usage and regular alcohol consumption
b) Extensive use of pain killers/ analgesic medications
c) Family history of CKD.
d) Heat stress due to occupational exposure.
e) Silica and Fluoride, phthalates contamination in ground water through
the exact cause has not been pinpointed it may be a combination of all
these causes and hence the Government is taking all steps to ensure that
the people in the Uddanam Area are educated about the same.
31. The respondents also explained the steps taken by the State
Government at different levels about control of tobacco usage and alcohol
consumption, control of pain killers usage, genetic testing and early
treatment for persons with family history of CKD, heat stress, provision
for drinking water. Finally, it is stated that, the Government took all steps
including providing drinking water to the residents of Uddanam area from
Reverse Osmosis water plants. The Government is taking steps to ensure
that more families come forward to register themselves and procure
drinking water. This existing Uddanam project was designed for 40 liters
per capita per day (LPCD). The Government now proposes to upgrade the
existing facility to provide 100 LPCD. Towards this end, the State
Government has given administrative sanction for the work "providing
drinking water supply to Uddanam area of Srikakulam District" vide G.O.
RT. No. 624 dated 29-04-2020 with an estimated cost of Rs. 700 crores.
Under the scheme raw water sourced from the Hiramandalam Reservoir
will be treated in plants and clear water will be supplied to 807
habitations in the Uddanam Area. The said work is in progress and the
project related components like head works, balancing reservoirs, service
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reservoirs etc are in progress and the work is likely to be completed
within the next two years.
32. The State Government is taking all steps to ensure that the future
generation of people in the Uddanam area are not effected by the CKD.
More kidney dialysis centers will be launched as and when the need
arises. A Dedicated Kidney Research Institute is established with the
support and partnership from ICMR and George Institute for Global
Health, India vide G.O.Rt.No. 417, dated 20.07.2017 at VIMS,
Visakhapatnam. Now it is shifted to Palasa, Srikakulam district and
renamed as Kidney Research Innovation and Patient Assistance (KRIPA)
centre vide G.O.Rt.No.111, HM&FW(D2) Department dated 12.2.2019.
There are about 20 types of drugs and medicines which are used in
treatment of CKD and these are sufficiently made available at Central
Drug Stores, Srikakulam and treating hospitals for Continuous supply for
the use of CKD patients. Orientation to Medical Officers and staff of 18
primary health centres of Uddanam area on identification, referral and
specialist care was given and is being continuously given to keep them
updated with latest treatment protocols. A special officer has been
appointed by the George Institute and is stationed in the Uddanam area
to keep a daily check on the activities. Continuous education programs
are being taken up by the District machinery and people are educated
regularly about the ill effects of tobacco, alcohol and pain killers.
Provision of clean drinking water is being taken as a priority for this area
and the Government is taking all steps in that direction to prevent further
spread of CKD, and requested to issue appropriate direction.
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33. Respondent No.18 - Mr. Gopal Krishna Dwivedi, Principal
Secretary, Panchayat Raj and Rural Development Department filed
separate counter affidavit. But the allegations in the counter affidavit filed
by Respondent No.18 is nothing but reiteration of the contentions raised
by Dr.K.S. Jawahar Reddy, Special Chief Secretary to Government,
Health, Medical and Family Welfare Department, A.P. Secretariat.
Therefore, there is no need to reiterate the contentions specifically urged
by Respondent No.18, only with a view to avoid repetition.
34. During hearing, Mr. Simhachalam Karukola, petitioner-in-person
contended that, the State has failed to take necessary action to prevent
CKD in Uddanam area by taking effective steps and that, Uddanam
Neuropathy remained as an enigma and that, failure to provide effective
treatment and failure to take steps to prevent spread of CKD is violation
of fundamental right guaranteed under Article 21 of the Constitution of
India, besides violation of human rights and unless effective directions
are given to the State and Central Governments for control of CKD and to
prevent CKD providing adequate medical care, it is difficult for the people
of Uddanam area to survive for their full lifetime, sought the directions as
stated supra.
35. Mr. Posani Venkateswarlu, learned counsel appearing on behalf of
Mr. M. Lakshmi Narayana, learned counsel on record in W.P. (P.I.L)
No.236 of 2021 raised a specific contention that, unless stern action is
taken to prevent spread of kidney disease in Uddanam area, it is difficult
for survival of future generations and submitted that, the average kidney
patients in the country is 10 to 15% of unknown etiology. But, in
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Uddanam region in Andhra Pradesh, the tests revealed 66% male and
34% female are suffering from Chronic Kidney Disease and majority of the
patients were between the age group of 40 to 59 years i.e. 52%. Learned
counsel also furnished the details of serum creatine levels in kidney
patients and also assessment of stages of chronic kidney disease by way
of Glomerual Filteration Rate. Therefore, most of the kidney patients in
the State of Andhra Pradesh in Uddanam Area are in dangerous health
condition and at least to protect the future generations from kidney
diseases in Uddanam area, State Government is under obligation to take
immediate steps to prevent spread of such CKD among the people of
Uddanam area to protect the future of the residents of Uddanam area
consisting of seven mandals will become bleak and their survival after
some time in that area is doubtful. Hence, requested this Court to issue
necessary directions to prevent further spread of CKD among the
residnets of Uddanam area.
36. Whereas, T. Bala Swamy, learned Government Pleader attached to
the office of the learned Advocate General appearing for the State
respondents explained the palliative, preventive and curative steps taken
while drawing attention of this Court to various documents placed on
record to substantiate the contention of the Government and to establish
that the State has never violated the fundamental right of residents of
Uddanam area, guaranteed under Article 21 of the Constitution of India.
On the other hand, it is contended that the respondents are discharging
their constitutional duties under Article 47 of the Constitution of India by
providing necessary medical facilities to the people who are suffering from
CKD and also providing water to the Uddanam area habitants as a
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measure of prevention of CKD and ensured that the State will continue to
monitor the same by taking effective steps both to eradicate CKD at their
level, consequently requested to dismiss the writ petition.
37. No counter affidavit is filed and no argument is advanced by
learned Assistant Solicitor General on behalf of Union of India.
38. Considering rival contentions, perusing the material available on
record, the points that need to be answered by this Court are as follows:
1. Whether failure to provide adequate medical facilities or health
care for the patients suffering from CKD in Uddanam area amounts
to denial of right to life guaranteed under Article 21 of the
Constitution of India and to discharge the fundamental duty by the
State, as enshrined under Article 47 of the Constitution of India, so
also, human rights guaranteed under various international
covenants. If so, whether any direction be issued to the State
Government?
2. Whether the State and Central Governments took adequate steps
both to prevent further spread of CKD and to cure the patients who
are suffering from CKD. If not, whether any directions are required
be issued by this Court to protect the lives of residents of Uddanam
area?
P O I N T Nos.1 & 2:
39. Since, both the points are inter-connected, we find that it is
expedient to decide both the points by common discussion.
40. The grim and sad health care situation prevailing in Uddanam area
consists of seven mandals and the inadequate measures taken by the
State and its instrumentalities to prevent spread of CKD and cure the
patients who are suffering from CKD is questioned in the present writ
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petition and sought directions. The State explained the steps taken to
prevent and cure CKD in Uddanam area. In view of the specific measures
taken by the State, the Court has to examine the issue in two dimensions,
viz. (1) Constitutional perspective and (2) Human Rights perspective, to
decide whether the State is able to provide adequate health care facilities
to prevent and cure CKD in Uddanam area consisting of seven mandals.
In Re Constitutional perspective:
41. The Indian Constitution guarantees Right to Life with Dignity under
Article 21. It reads that "No person shall be deprived of his life or personal
liberty except through procedure established by law." Till 1970s the
courts, by and large, had interpreted „life‟ literally i.e. right to exist- right
not to be killed. In late 1970s, the Supreme Court expanded the meaning
to the term „life‟ appearing in Article 21. Over the years it has come to be
accepted that life does not only mean animal existence but the life of a
dignified human being with all its concomitant attributes. This would
include a healthy environment, effective and adequate health care
facilities. Today, the health care is a fundamental right to life in the
broader perspective of the „life‟ under the term „life‟ under Article 21 of the
Constitution of India.
42. Fundamental Rights are enforceable by and large only against the
State and it is the duty and obligation of the State to provide adequate
health care to its citizens. The „Right to Health‟ is inseparable from „Right
to Life‟, and the „Right to Medical Facilities‟ as a concomitant of „Right to
Health‟ is also part and parcel of Right to Life. In a welfare state, the
corresponding duty to the right to health and medical facility lies with the
State.
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43. Part IV of the Constitution lists the Directive Principles of State
Policy. These are the principles which should be followed by the State as
the guiding principles while enacting laws and policies but have
traditionally been believed not to be enforceable in courts of law. A citizen
cannot go to court for enforcing a claim which is purely based on
Directive Principles. The importance of these principles, however lies in
the fact that in interpreting Fundamental Rights the Courts can use the
Directive Principles so as to interpret these rights as much in consonance
with the Directive Principles as is possible. The obligation of the State to
provide health care facilities is set out in the „Directive Principles of State
Policy‟. The relevant provisions of the Directive Principles which cast a
duty on State to ensure good health and adequate healthcare for its
citizens are:
44. According to Article 38, State shall strive to promote the welfare of
people by securing and protecting as effectively as it may a social order in
which justice, social, economic and political, shall inform all the
institutions of the national life. State shall, in particular, strive to
minimize the inequalities in income, and endeavour to eliminate
inequalities in status, facilities and opportunities, not only amongst
individuals but also amongst groups of people residing in different areas
or engaged in different vocations. In other words, no person will be
deprived of a healthy life because he cannot afford it. The State must
provide facilities that an economically better off person can afford out of
his own pocket.
45. At the same time, Article 39 envisages certain principles of policy to
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be followed by State- The State shall, in particular, direct its policy
towards securing-
a) that health and strength of workers, men and women, and the
tender age of children are not abused and that citizens are
not forced by economic necessity to enter avocations unsuited
to their age or strength; and
b) That children are given opportunities and facilities to develop
in a healthy manner and in conditions of freedom and dignity
and that childhood and youth are protected against
exploitation and against moral and material abandonment.
46. Article 47 of the Constitution of India deals with duty of State to
raise the level of nutrition and the standard of living and to improve
public health. The State shall regard the raising of the level of nutrition
and the standard of living of its people and the improvement of public
health as among its primary duties and, in particular, the State shall
endeavour to bring about prohibition of the consumption except for
medical purposes of intoxicating drinks and of drugs which are injurious
to health.
47. To begin with, the right to health as a fundamental right grew as an
offshoot of environmental litigation initiated by environmental activists
regarding the environment issues. Undoubtedly the right to environment
was crucial because a polluted environment affects public health. A
pollution free environment as a fundamental right presupposes right to
health as a fundamental right. Logically, the explicit recognition of the
fundamental right to health should have preceded the fundamental right
to good environment. However, the development of jurisprudence in this
branch has been the reverse. The right to unpolluted environment was
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recognized as a right in the first instance and from that followed the right
to public health, health and health care. Secondly, the right to health care
has also been debated by the courts in the context of rights of
Government employees to receive health care. A number of observations
of the Court concerning the importance of these rights are to be found in
cases dealing with denial or restriction of health care facilities for
Government employees, and not to the general masses. This is the
context of judicial pronouncements on health care.
48. In one of the earliest instances of public interest litigations -
Municipal Council, Ratlam vs. Vardhichand & Ors1, the municipal
corporation was prosecuted by some citizens for not clearing up the
garbage. The corporation took up the plea that it did not have money.
While rejecting the plea, the Supreme Court held that "The State will
realize that Article 47 makes it a paramount principle of governance that
steps are taken for the improvement of public health as amongst its
primary duties."
49. In CESC Ltd. vs. Subash Chandra Bose2, the Supreme Court
relied on international instruments and concluded that right to health is
a fundamental right. It went further and observed that health is not
merely absence of sickness:
"The term health implies more than an absence of sickness. Medical care
and health facilities not only protect against sickness but also ensure
stable manpower for economic development. Facilities of health and
medical care generate devotion and dedication to give the workers‟ best,
physically as well as mentally, in productivity. It enables the worker to
enjoy the fruit of his labour, to keep him physically fit and mentally alert
for leading a successful economic, social and cultural life. The medical
facilities are, therefore, part of social security and like gilt edged security,
it would yield immediate return in the increased production or at any rate
1980 Cri LJ 1075
AIR 1992 SC 573,585
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reduce absenteeism on grounds of sickness, etc. Health is thus a state of
complete physical, mental and social well being and not merely the
absence of disease or infirmity. In the light of Articles 22 to 25 of the
Universal Declaration of Human Rights, International Covenant on
Economic, Social and Cultural Rights and in the light of socio-economic
justice assured in our Constitution, right to health is a fundamental
human right to workmen. The maintenance of health is a most imperative
constitutional goal whose realization requires interaction by many social
and economic factors."
(emphasis supplied)
50. In "Mohd. Ahmed (Minor) v. Union of India" (W.P.(C).No.7279 of
2013) the Apex Court while referring to the address of Martin Luther King
Junior that "of all forms of inequality, injustice in health care is the most
shocking and inhumane" and after discussing various principles laid
down in various judgments including "T. Soobramoney v. Minister of
Health (Kwazulu-Natal) (Case CCT 32/97)" and Niteki v. Poland
(Application No.65653/2001), concluded that the right to health or right
to adequate health care is a fundamental right guaranteed under
Article 21 of the Constitution of India.
51. The Apex Court in "Rakesh Chandra Narayan v. State of Bihar3"
held that the Government has an obligation to ensure that medical
attention is provided to every citizen in the country.
52. In view of the law laid down by the various Courts, it is obvious that
right to adequate medical facilities or health care is not only obligation of
the State under part IV and Article 47 of the Constitution of India and
also fundamental right guaranteed under Article 21 as providing medical
care is a facet of protection of right to life under Article 21 of the
Constitution of India.
1996(8)SCALE33
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53. In the facts of the judgment in Mahendra Pratap Singh vs.
Orissa State4 the petitioner, an ex-sarpanch of Pachhikote Gram
Panchayat approached the court for issuance of appropriate writ
commanding the opposite parties to take effective measures to run
Primary Health Centre at Pachhikote within Korei block in the district of
Jaipur by providing all amenities and facilities for proper running of the
said health centre. The Government of Orissa decided to open certain
primary health centres in different areas in 1991-92 subject to fulfilment
of certain conditions, on basis of demands of the local people and public
at large. The conditions fulfilled were as follows:
(i) The local people should provide minimum one acre of land duly
pledged in favour of the Panchayat Samiti for the Medical Institution
within a period of one month from the date of issue of this order.
(ii) The local people should provide permanent buildings for the medical
institutions as well as for the staff within six months from the date
of issue of this order."
54. The Court observed that great achievements and accomplishments
in life are possible if one is permitted to lead an acceptably healthy life.
Health is life‟s grace and efforts are to be made to sustain the same. In a
Country like ours, it may not be possible. To have sophisticated hospitals
but definitely villagers of this Country within their limitations can aspire
to have a Primary Health Centre. The Government is required to assist
people, and its endeavour should be to see that the people get treatment
and lead a healthy life. Healthy society is a collective gain and no
Government should make any effort to smother it. Primary concern
should be the Primary Health Clinic (hereinafter will be referred as „PHC‟)
and technical fetters cannot be introduced as subterfuges to cause
hindrances in the establishment of health centre.
AIR 1997 Ori 37
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55. In CERC vs. Union of India5, the Supreme Court was dealing with
the rights of workers in asbestos manufacturing and health hazards
related to it. The Court was dealing essentially with private employers
involved in asbestos mining and industry. To begin with, the Court noted
that the right to health and health care of a worker is a component of the
fundamental right to life guaranteed under Article 21 of the Constitution
of India. The Court observed that, Article 38(1) lays down the foundation
for human rights and enjoins the State to promote the welfare of the
people by securing and protecting, as effectively as it may, a social order
in which justice, social, economic and political, shall inform all the
institutions of the national life.
56. The Supreme Court, while interpreting Article 21 of the
Constitution ruled that the expression „life‟ does not connote mere animal
existence or continued drudgery through life but includes, inter alia, the
opportunities to eliminate sickness and physical disability. In Francis
Coralie Mullin v. Union Territory of Delhi6, it was held that, right to
life guaranteed in Article 21 of the Constitution in its true meaning
includes the basic right to food, clothing and shelter.
57. The Apex Court, in Paschim Banga Khet Mazdoor Samity v.
State of West Bengal7 while widening the scope of Article 21 and the
government‟s responsibility to provide medical aid to every person in the
country, held that in a welfare state, the primary duty of the government
is to secure the welfare of the people. Providing adequate medical facilities
for the people is an obligation undertaken by the government in a welfare
(1995) 3 SCC 42
1981 (1) SCC 608
(1996) 4 SCC 37
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state. The government discharges this obligation by providing medical
care to the persons seeking to avail of those facilities.
58. In Unnikrishnan, J.P. v. State of Andhra Pradesh8, it was held
that the maintenance and improvement of public health is the duty of the
State to fulfill its constitutional obligations cast on it under Article 21 of
the Constitution.
59. In Consumer Education and Research Centre v. Union of
India9, the Supreme Court explicitly held that the right to health and
medical care is a fundamental right under Article 21 of the Constitution
and this right to health and medical care, to protect health and vigour are
some of the integral factors of a meaningful right to life.
60. In Bandhua Mukti Morcha v. Union of India10, the Apex Court
addressed the types of conditions necessary for enjoyment of health and
said that right to live with human dignity also involves right to „protection
of health‟. No State, neither the central government nor any state
government, has the right to take any action which will deprive a person
the enjoyment of this basic essential. In Virender Gaur v. State of
Haryana11, the Supreme Court held that environmental, ecological, air
and water pollution, etc., should be regarded as amounting to violation of
right to health guaranteed by Article 21 of the Constitution. In Vincent v.
Union of India12, it was held that a healthy body is the very foundation
for all human activities. In a welfare state, therefore, it is the obligation of
AIR 1993 SC 2178
AIR 1995 SC 636
AIR 1984 SC 802
1995 (2) SCC 577
AIR 1989 SC 2039
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the state to ensure the creation and the sustaining of conditions
congenial to good health.
61. The Apex Court, in its landmark judgment in Pt.Parmanand
Katara v. Union of India13, ruled that every doctor whether at a
government hospital or otherwise has the professional obligation to
extend his service with due expertise for protecting life, whether the
patient be an innocent person or be a criminal liable to punishment
under the law. No law or state action can intervene to avoid/delay, the
discharge of the paramount obligation cast upon members of the medical
profession.
62. In State of Punjab vs. Mohinder Singh Chawla14, which dealt
with right to medical treatment of Government employees, the Supreme
Court observed that it is now settled law that right to health is integral to
right to life. Government has constitutional obligation to provide the
health facilities. If the Government servant has suffered an ailment which
requires treatment at a specialised approved hospital and on reference
whereat the Government servant had undergone such treatment therein,
it is but the duty of the State to bear the expenditure incurred by the
Government servant. Expenditure, thus, incurred requires to be
reimbursed by the State to the employee. The High Court was, therefore,
right in giving direction to reimburse the expenses incurred towards room
rent by the respondent during his stay in the hospital as an inpatient.
63. Environment Pollution is linked to Health and effect of violation was
dealt in T. Ramakrishna Rao vs. Hyderabad Development
1989 AIR 2039
1997 (2) SCC 83
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Authority15, the Andhra Pradesh High Court observed that protection of
the environment is not only the duty of the citizens but also the obligation
of the State and it‟s all other organs including the Courts. The enjoyment
of life and its attainment and fulfillment guaranteed by Article 21 of the
Constitution embraces the protection and preservation of nature‟s gift
without which life cannot be enjoyed fruitfully. The slow poisoning of the
atmosphere caused by the environmental pollution and spoliation should
be regarded as amounting to violation of Article 21 of the Constitution of
India. It is therefore, as held in T. Damodar Rao and others vs. Special
Officer, Municipal Corporation of Hyderabad16, the legitimate duty of
the Courts as the enforcing organs of the constitutional objectives to
forbid all actions of the State and the citizens from upsetting the
ecological and environmental balance. In Virender Gaur vs. State of
Haryana17, the Supreme Court held that environmental, ecological, air
and water pollution, etc., should be regarded as amounting to violation of
right to health guaranteed by Article 21 of the Constitution. It is right to
state that hygienic environment is an integral facet of the right to healthy
life and it would not be possible to live with human dignity without a
humane and healthy environment. In Consumer Education and
Research Centre vs. Union of India18, Kirloskar Brothers Ltd. vs.
Employees' State Insurance Corporation19, the Supreme Court held
that right to health and medical care is a fundamental fight under Article
21 read with Articles 39(e), 41 and 43. In Subhash Kumar vs. State of
W.P.No.36929 of 1998 dated 20.07.2001
AIR 1987 AP 171
1995 (2) SCC 577
(1995) 3 SCC 42
AIR 1996 SC 3261
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Bihar20, the Supreme Court held that right to pollution-free water and air
is an enforceable fundamental right guaranteed under Article 21.
Similarly in Shantistar Builders v. Narayan Khimalal Totame21, the
Supreme Court opined that the right to decent environment is covered by
the right guaranteed under Article 21. Further, in M.C. Mehta vs. Union
of India22, Rural Litigation and Entitlement Kendra v. State of
U.P23, Subhash Kumar vs. State of Bihar (supra), the Supreme Court
imposed a positive obligation upon the State to take steps for ensuring to
the individual a better enjoyment of life and dignity and for elimination of
water and air pollution. It is also relevant to notice as per the judgment of
the Supreme Court in Vincent Panikurlangara vs. Union of India24,
Unnikrishnan, J.P vs. State of A.P25, the maintenance and
improvement of public health is the duty of the State to fulfill its
constitutional obligations cast on it under Article 21 of the Constitution.
Adequate and Quality medical care is part of Right to Health and Right to
Life: The Allahabad High Court in S.K. Garg vs. State of U.P26 was
dealing with conditions of public hospitals. The Petition had been filed
raising concerns about the pitiable nature of services available in public
hospitals in Allahabad. Complaints were made concerning inadequacy of
blood banks, worn down X- ray equipment, unavailability of essential
drugs and unhygienic conditions. The Court appointed a Committee to go
into these aspects and report back to the Court. The High Court held: "In
our opinion, the allegations in the petition are serious. The Supreme
AIR 1991 SC 420
AIR 1990 SC 630
AIR 1988 SC 1037
AIR 1987 SC 359
AIR 1987 SC 990
AIR 1993 SC 2178
1999 (1) AWC 847
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Court in Consumer Education and Research Centre and others v.
Union of India and others27, similarly in State of Punjab and others
v. Mohinder Singh Chawla and others28 Courts are of the view that the
right to health is a part of the right to life guaranteed by Article 21 of the
Constitution. It is indeed true that most of the Government Hospitals are
in a very bad shape and need drastic improvement so that the Public is
given proper medical treatment. Anyone who goes to the Government
Hospitals in the State will find distressing sanitary and hygienic
conditions. The poor people, particularly, are not properly looked after
and not given proper medical treatment. Consequently, most of the people
who can afford it go to private nursing homes or private clinics. This is a
welfare State, and the people have a right to get proper medical treatment.
In this connection, it may be mentioned that in U.S.A. and Canada there
is a law that no hospital can refuse medical treatment of a person on the
ground of his poverty or inability to pay. In our opinion. Article 21 of the
Constitution, as interpreted in a series of judgments of the Supreme
Court, has the same legal effect." Can the State be compelled to start
hospitals or primary health care centres?: No direct guidelines are
available on this issue. But somewhat similar cases are cited below In
Paschim Banga Khet Mazdoor Samiti vs. State of West Bengal29 the
Supreme Court though primarily dealing with the issue of obligation of
the State to provide emergency health care to patients made a general
observation of significance: "Providing adequate medical facilities is an
essential part of the obligation undertaken by the State in a welfare
state. The Government discharges this obligation by running
27 1995 (3) SCC 42
28 1997 (2) SCC 83
29 (1996) 4 SCC 37
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hospitals and health centres. Article 21 imposes an obligation on the
State to safeguard right to life of every person."
In Re Human Rights Perspective:
64. India joined the UN at the start on October 30th, 1945 and on
12th December, 1948 when the Universal Declaration of Human Rights
(UDHR) was proclaimed, India was a party to this. The formulation of
India‟s Constitution was certainly influenced by the UDHR and this is
reflected in the Fundamental Rights and the Directive Principles of State
Policy. Most of the civil and political rights are guaranteed under the
Indian Constitution as Fundamental Rights. But most of the Economic,
Social and Cultural Rights do not have such a guarantee. The
Constitution makes a forceful appeal to the State through the Directive
Principles to work towards assuring these rights through the process of
governance but clearly states that any court cannot enforce them. The
experience of governance in India shows that both Fundamental Rights
and Directive Principles have been used as a political tool. While the
Fundamental Rights are justiciable, and on a number of occasions
citizens and courts have intervened to uphold them, there have also been
numerous instances where even the courts have failed either because the
ruling government has steamrolled them or the court orders have been
ignored. In case of the Directive Principles it is mostly political mileage,
which determines which of the principles get addressed through
governance. Articles 41, 42 and 47, which deal with social security,
maternity benefits and health, respectively, have been addressed only
marginally.
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65. Article 25(2) of the UDHR ensures right to standard of adequate
living for health and well being of the individual including medical care,
sickness and disability, Article 2(b) of the International Convention on
Economic, Social and Cultural Rights (ICESCR) protects the right of
worker to enjoy just and favourable conditions of work ensuring safe and
healthy working conditions. The right to health to a worker is an integral
facet of meaningful right to life to have not only a meaningful existence
but also robust health and vigour without which worker would lead life of
misery. Lack of health denudes his livelihood. Compelling economic
necessity to work in an industry exposed to health hazards due to
indigence to bread winning to him and his dependents should not beat
the cost of the health and vigour of the workman.
66. When we look at "right to health" and "healthcare" in the legal
and constitutional framework, it is clearly evident that the Constitution
and laws of the land do not in any way accord health and healthcare, the
status of rights. There are instances in case law where, for instance the
right to life, Article 21 of the Constitution, or various Directive Principles
have been used to demand access to healthcare, especially in emergency
situations or references made to the International Covenants. These are
exceptional cases, and even if the Supreme Court or the high courts have
upheld some decisions as being a right, for instance getting at least first
aid in emergency situations from private clinics or hospitals, or access to
public medical care as a right, in life threatening situations, or right to
healthy and safe working environment and medical care for workers etc.,
the orders are rarely respected in day to day practice unless one goes
back to the courts to reiterate the orders. In fact, this is often the case
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even with Fundamental Rights, which the State has failed to respect,
protect, or fulfill as a routine, and one has to go to the courts to demand
them. For a population, which is predominantly at the poverty or
subsistence level, expecting people to go to the courts to seek justice for
what is constitutionally ordained as a right is unrealistic as well as
discriminatory. The mere constitutional provision is not a sufficient
condition to guarantee a right, and more so in a situation like health and
healthcare wherein provisions in the form of services and commitment of
vast resources are necessary to fulfill the right. Despite the above, it is
still important to have health and healthcare instituted as a right within
the Constitution and/or established by a specific Act of Parliament
guaranteeing the right. Ruth Roemer discussing this issue observed that:
"The principal function of a constitutional provision for the right to
health care is usually symbolic. It sets forth the intention of the
government to protect the health of its citizens. A statement of
national policy alone is not sufficient to assure entitlement to health
care; the right must be developed through specific statutes, programs
and services. But setting forth the right to health care in a
constitution serves to inform the people that protection of their health
is official policy of the government and is reflected in the basic law of
the land".
67. To take an example, government policy vis-à-vis healthcare services
has mandated entitlements under the Minimum Needs Programme
started with the Fourth Five Year Plan. Each district should have a civil
hospital in each district, a primary health centre in rural areas for each
20,000 -30,000 population (depending on population density and
difficulty of terrain) and five such units supported by a 30 bedded
Community Health Centre (CHC), a sub centre with two health workers
for a rural population unit of 2500-5000 population, and similarly a
Health Post for 50,000 persons in urban areas. But what is the real
situation? No district (except perhaps the very new ones) has a civil
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hospital (and each district did have a civil hospital even during the
colonial period!). The situation regarding PHCs varies a lot across states
from 1 per 7000 rural population in Mizoram to 1 per over 100,000 in
some districts of the EAG7 states. The villagers deprived of this
entitlement cannot go to the courts demanding the right to a PHC for
their area because such a legal backing does not exist. Further, in many
states where this ratio is honoured for PHCs or CHCs, adequate staff,
medicines, diagnostic facilities, maintenance budgets are often not
available to assure that proper provision of services is available to the
people accessing these services [MoHFW, 2001].
68. While right to health care is recognized as human right, it becomes
discriminatory because the entitlement as a right is selective and not
universal. Mere entitlements having basis only in policy or as selective
rights does not establish a right and neither can assure equity and non-
discrimination. At the global level the International Covenant on
Economic, Social and Cultural Rights (ICESCR) mandates right to health
through Article 9 and Article 12 of the covenant:
Article 9
The States Parties to the present Covenant recognize the right of everyone to social
security, including social insurance.
Article 12
1. The States Parties to the present Covenant recognize the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve
the full realization of this right shall include those necessary for:
a) The provision for the reduction of the stillbirth rate and of infant mortality
and for the healthy development of the child;
b) The improvement of all aspects of environmental and industrial hygiene;
c) The prevention, treatment and control of epidemic, endemic, occupational
and other diseases;
d) The creation of conditions, which would assure to all medical service and
medical attention in the event of sickness .
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69. Article 12 of the International Covenant on Economic, Social and
Cultural Rights states that right to health is not to be understood as a
right to be healthy. The right to health contains both freedoms and
entitlements. The freedoms include the right to control one‟s health and
body, including sexual reproductive freedom, and the right to be free from
interference, such as the right to be free from torture, nonconsensual
medical treatment and experimentation. By contrast, the entitlements
include the right to a system of health, protection which provides equality
of opportunity for people to enjoy the highest attainable level of health. It
further state „Non-discrimination and equal treatment by virtue of Article
2.2 and Article 3, the Covenant prescribes any discrimination in access to
health care and underlying determinants of health, as well as to means
and entitlements for their procurement, on the ground of race, colour,
sex, language, religion, political or other opinion, national or social origin,
property, birth, physical or mental disability, health status (including
HIV/AIDS) sexual orientation and civil, political, social or other status,
which has the intention or effect of nullifying or impairing the equal
enjoyment or exercise of the right to health. It is appropriate to stress on
many measures, such as most strategies and programmes designed to
eliminate health-related discrimination, can be pursued with minimum
resource implications through the adoption, modification or abrogation of
legislation or the dissemination of information (Vide Naz Foundation vs.
Government of NCT of Delhi30)
70. Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity. The enjoyment of the
2010 Crl.L.J 94
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highest attainable standard of health is one of the fundamental rights of
every human being without distinction of race, religion, and political
belief, economic or social condition. Health of all peoples is fundamental
to the attainment of peace and security and is dependent upon the fullest
co-operation of individuals and States. The achievement of any State in
the promotion and protection of health is of value to all. Unequal
development in different countries in the promotion of health and control
of disease, especially communicable disease, is a common danger.
Healthy development of the child is of basic importance; the ability to live
harmoniously in a changing total environment is essential to such
development. The extension to all peoples of the benefits of medical,
psychological and related knowledge is essential to the fullest attainment
of health. Informed opinion and active co-operation on the part of the
public are of the utmost importance in the improvement of the health of
the people. Governments have a responsibility for the health of their
peoples, which can be fulfilled only by the provision of adequate health
and social measures.
71. "Everyone has the right to a standard of living adequate for ...
health and well-being of himself and his family, including food, clothing,
housing, medical care and the right to security in the event of ... sickness,
disability. Motherhood and childhood are entitled to special care and
assistance." - Universal Declaration of Human Rights, Article 25.
72. "States Parties shall ensure to women access to specific educational
information to help to ensure the health and well-being of families,
including information and advice on family planning. States Parties shall
eliminate discrimination against women in health care to ensure, on a
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basis of equality of men and women, access to health care services,
including those related to family planning; ensure appropriate services in
connection with pregnancy. States Parties shall ensure that [women in
rural areas] have access to adequate health care facilities, including
information counseling and services in family planning" - Convention on
the Elimination of All Forms of Discrimination Against Women,
Articles 10, 12, and 14.
73. "States Parties undertake to eliminate racial discrimination and to
guarantee the right of everyone, without distinction as to race, colour, or
national or ethnic origin, to equality before the law, the right to public
health, medical care, social security and social services." -Convention on
the Elimination of All Forms of Racial Discrimination, Article 5.
74. "States Parties recognize the right of the child to the enjoyment of
the highest attainable standard of health and to facilities for the
treatment of illness and rehabilitation of health." - Convention on the
Rights of the Child, Article 24 In the 1977 World Health Assembly
member states pledged a commitment towards a health for all strategy,
"the attainment by all citizens of the world by the year 2000 of a level of
health that will permit them to lead a socially and economically
productive life." (AL Taylor -Making the World Health Organization Work :
A legal framework for universal access to the conditions for Health,
American Journal of Law and Medicine, Vol. 18 No. 4, 1992, 302). At the
International conference which followed in 1978 at Alma Ata this was
converted into the famous primary health care declaration whereby
Governments would be responsible to the people to assure primary health
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care for all by the year 2000. Primary health care is "essential health care
which is to be universally accessible to individuals and families in the
community in ways acceptable to them, through their full participation at
a cost the community can afford" (WHO, Primary Health Care, 1978, p. 3)
- Alma Ata Declaration on Health For All by 2000.
75. "Health and development are intimately interconnected. Both
insufficient development leading to poverty and inappropriate
development can result in severe environmental health problems. The
primary health needs of the world‟s population are integral to the
achievement of the goals of sustainable development and primary
environmental care - Major goals - By the year 2000 eliminate guinea
worm disease; eradicate polio. By 1995 reduce measles deaths by 95 per
cent; ensure universal access to safe drinking water and sanitary
measures of excreta disposal; By the year 2000 [reduce] the number of
deaths from childhood diarrhoea by 50 to 70 per cent" - Agenda 21,
Chapter 6, paras. 1 and 12.
76. "Everyone has the right to the enjoyment of the highest attainable
standard of physical and mental health. States should take all
appropriate measures to ensure, on a basis of equality of men and
women, universal access to health-care services, including those related
to reproductive health care. The role of women as primary custodians of
family health should be recognized and supported. Access to basic health
care, expanded health education, the availability of simple cost effective
remedies should be provided" - Cairo Programme of Action, Principle 8
and para. 8.6.
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77. "We commit ourselves to promoting and attaining the goals of
universal and equitable access to the highest attainable standard of
physical and mental health, and the access of all to primary health care,
making particular efforts to rectify inequalities relating to social
conditions and without distinction as to race, national origin, gender, age
or disability" - Copenhagen Declaration, Commitment 6
78. "The explicit recognition of the right of all women to control all
aspects of their health, in particular their own fertility, is basic to their
empowerment. We are determined to ensure equal access to and equal
treatment of women and men in health care and enhance women‟s sexual
and reproductive health as well as Health." - Beijing Declaration, paras.
17 and 30.
79. "Women have the right to the enjoyment of the highest attainable
standard of physical and mental health. The enjoyment of this right is
vital to their life and well-being and their ability to participate in all areas
of public and private life. Women‟s health involves their emotional, social
and physical well being and is determined by the social, political and
economic context of their lives, as well as by biology. To attain optimal
health - equality, including the sharing of family responsibilities,
development and peace are necessary conditions." - Beijing Platform for
Action, para. 89.
80. "Strategic objective - Increase women‟s access throughout the life
cycles to appropriate, affordable and quality health care, information and
related services - Actions to be taken: Reaffirm the right to the enjoyment
of the highest attainable standards of physical and mental health, protect
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and promote the attainment of this right for women and girls and
incorporate it in national legislation; Provide more accessible, available
and affordable primary health care services of high quality, including
sexual and reproductive health care; Strengthen and reorient health
services, particularly primary health care, in order to ensure universal
access to health services; reduce maternal mortality by at least 50 per
cent of the 1990 levels by the year 2000 and a further one half by the year
2015; make reproductive health care accessible to all no later than 2015;
take specific measures for closing the gender gaps in morbidity and
mortality where girls are disadvantaged, while achieving by the year 2000,
the reduction of mortality rates of infants and children under five by one
third of the 1990 level; by the year 2015 an infant morality rate below 35
per 1,000 live births. Ensure the availability of and universal access to
safe drinking water and sanitation." - Beijing Platform for Action, para.
106.
81. "Human health and quality of life are at the centre of the effort to
develop sustainable human settlements. We commit ourselves to the
goals of universal and equal access to the highest attainable standard of
physical, mental and environmental health, and the equal access of all to
primary health care, making particular efforts to rectify inequalities
relating to social and economic conditions, without distinction as to race,
national origin, gender, age, or disability. Good health throughout the life
span of every man and woman, good health for every child are
fundamental to ensuring that people of all ages are able to participate
fully in the social, economic and political processes of human settlements.
Sustainable human settlements depend on policies to provide access to
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food and nutrition, safe drinking water, sanitation, and universal access
to the widest range of primary health-care services; to eradicate major
diseases that take a heavy toll of human lives, particularly childhood
diseases; to create safe places to work and live; and to protect the
environment. Measures to prevent ill health and disease are as important
as the availability of appropriate medical treatment and care. It is
therefore essential to take a holistic approach to health, whereby both
prevention and care are placed within the context of environmental
policy." - Habitat Agenda, paras. 36 and 128.
82. International law apart, as discussed earlier, provisions within the
Indian Constitution itself exist to give the people of India right to
healthcare. Articles 41, 42 and 47 of the Directive Principles enshrined in
Part IV of the Constitution provide the basis to evolve right to health and
healthcare:
Article 41. Right to work, to education and to public assistance in certain
cases: The State shall, within the limits of its economic capacity and
development, make effective provision for securing the right to work, to
education and to public assistance in cases of unemployment, old age,
sickness and disablement, and in other cases of undeserved want.
Article 42. Provision for just and humane conditions of work and
maternity relief: The State shall make provision for securing just and
humane conditions of work and for maternity relief.
Article 47. Duty of the State to raise the level of nutrition and the
standard of living and to improve public health: The State shall regard the
raising of the level of nutrition and the standard of living of its people and
the improvement of public health as among its primary duties and, in
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particular, the State shall endeavour to bring about prohibition of the
consumption except for medicinal purposes of intoxicating drinks and of
drugs which are injurious to health. Thus social security, social
insurance, decent standard of living, and public health coupled with the
policy statements over the years, which in a sense constitutes the
interpretation of these constitutional provisions, and supported by
international legal commitments, form the basis to develop right to health
and healthcare in India. The only legal/constitutional principle missing is
the principle of justiciability. In the case of 10 "The courts are much more
aware of and attentive towards their obligation to implement socio-
economic uplift programmes and to ensure decent welfare for all. The
state has a duty to all citizens to adhere to that part of the Constitution,
which describes the directive principles as „fundamental‟ to the
governance of the country. The courts have therefore been using the
directives as an instrument to determine the extent of public interest in
order to limit the extension of fundamental rights. In doing so they have
upheld a number of statutes on the grounds of public interest, which in
other circumstances may have been nullified." With regard to healthcare
there is even a greater need to make such gains because often in the case
of health it is a question of life and death. As stated earlier, for a small
part of the working population right to healthcare through the social
security/social insurance route exists. This means that such security can
be made available to the general population too. That a few people enjoy
this privilege is also a sign of discrimination and inequity that violates not
only the non discrimination principle of international law, but it also
violates Article 14 of the Constitution, Right to Equality a Fundamental
Rights.
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83. With regard to the question of justiciability of international law, like
Britain, India follows the principle of dualism. This means that for
international law to be applicable in India, it needs to be separately
legislated. Since none of the international human rights treaties have
been incorporated or transformed into domestic laws in India, they have
only an evocative significance and may be used by the Courts or
petitioners to derive inspiration. Thus on a number of occasions many of
these human right treaties ratified in India, have been used by the Indian
Courts in conjunction with Fundamental Rights. International law has its
importance in providing many principles but in India‟s case, there is
substantial leeway within our own legal framework on right to health and
healthcare. The emphasis needs to shift to critical principles as laid down
in the directive principles. This is the only way of bringing right to health
and healthcare on the national agenda, even as the support of
international treaties will play a role in cementing this demand. In view of
various international convention referred above health and healthcare are
human rights and India as one of the signatories to conventions is under
obligations to proceed adequate healthcare.
In Re Right to Health and Healthcare:
84. Health and health care are now being viewed very much within the
rights perspective and this is reflected in Article 12.
85. „The right to the highest attainable standard of health‟ of the
International Covenant on Economic, Social and Cultural Rights.
According to the General Comment of the Committee for Economic, Social
and Cultural Rights states that the right to health requires availability,
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accessibility, acceptability, and quality with regard to both health care
and underlying preconditions of health. The Committee interprets the
right to health, as defined in Article 12.1, as an inclusive right extending
not only to timely and appropriate health care but also to the underlying
determinants of health, such as access to safe and potable water and
adequate sanitation, an adequate supply of safe food, nutrition and
housing, healthy occupational and environmental conditions, and access
to health-related education and information, including on sexual and
reproductive health. This understanding is detailed below: The right to
health in all its forms and at all levels contains the following interrelated
and essential elements, the precise application of which will depend on
the conditions prevailing in a particular State party
(a) Availability. Functioning public health and health-care facilities, goods
and services, as well as programmes, have to be available in sufficient
quantity within the State party. The precise nature of the facilities, goods
and services will vary depending on numerous factors, including the State
party's developmental level. They will include, however, the underlying
determinants of health, such as safe and potable drinking water and
adequate sanitation facilities, hospitals, clinics and other health-related
buildings, trained medical and professional personnel receiving
domestically competitive salaries, and essential drugs, as defined by the
WHO Action Programme on Essential Drugs.
(b) Accessibility. Health facilities, goods and services have to be accessible to
everyone without discrimination, within the jurisdiction of the State party.
Accessibility has four overlapping dimensions:
Non-discrimination: Health facilities, goods and services must be
accessible to all, especially the most vulnerable or marginalized sections of
the population, in law and in fact, without discrimination on any of the
prohibited grounds.
Physical accessibility: health facilities, goods and services must be
within safe physical reach for all sections of the population, especially
vulnerable or marginalized groups, such as ethnic minorities and
indigenous populations, women, children, adolescents, older persons,
persons with disabilities and persons with HIV/AIDS. Accessibility also
implies that medical services and underlying determinants of health, such
as safe and potable water and adequate sanitation facilities, are within
safe physical reach, including in rural areas. Accessibility further includes
adequate access to buildings for persons with disabilities.
Economic accessibility (affordability): health facilities, goods and
services must be affordable for all. Payment for health-care services, as
well as services related to the underlying determinants of health, has to be
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based on the principle of equity, ensuring that these services, whether
privately or publicly provided, are affordable for all, including socially
disadvantaged groups. Equity demands that poorer households should not
be disproportionately burdened with health expenses as compared to richer
households. Information accessibility: accessibility includes the right to
seek, receive and impart information and ideas concerning health issues.
However, accessibility of information should not impair the right to have
personal health data treated with confidentiality.
(c) Acceptability. All health facilities, goods and services must be
respectful of medical ethics and culturally appropriate, i.e. respectful of the
culture of individuals, minorities, peoples and communities, sensitive to
gender and life-cycle requirements, as well as being designed to respect
confidentiality and improve the health status of those concerned.
(d) Quality. As well as being culturally acceptable, health facilities, goods
and services must also be scientifically and medically appropriate and of
good quality. This requires, inter alia, skilled medical personnel,
scientifically approved and unexpired drugs and hospital equipment, safe
and potable water, and adequate sanitation. (Committee on Economic,
Social and Cultural Rights Twenty second session 25 April-12 May 2000)
86. Universal access to good quality healthcare equitably is the key
element at the core of this understanding of right to health and
healthcare. To make this possible the State parties are obligated to
respect, protect and fulfill the above in a progressive manner: The right to
health, like all human rights, imposes three types or levels of obligations
on States parties: the obligations to respect protect and fulfil. In turn, the
obligation to fulfill obligations to facilitate, provide and promote. The
obligation to respect requires States to refrain from interfering directly or
indirectly with the enjoyment of the right to health. The obligation to
protect requires States to take measures that prevent third parties from
interfering with article 12 guarantees. Finally, the obligation to fulfil
requires States to adopt appropriate legislative, administrative, budgetary,
judicial, promotional and other measures towards the full realization of
the right to health. States parties are referred to the Alma-Ata
Declaration, which proclaims that the existing gross inequality in the
health status of the people, particularly between developed and
developing countries, as well as within countries, is politically, socially
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and economically unacceptable and is, therefore, of common concern to
all countries. States parties have a core obligation to ensure the
satisfaction of, at the very least, minimum essential levels of each of the
rights enunciated in the Covenant, including essential primary health
care. Read in conjunction with more contemporary instruments, such as
the Programme of Action of the International Conference on Population
and Development, the Alma-Ata Declaration provides compelling guidance
on the core obligations arising from article 12. Accordingly, in the
Committee‟s view, these core obligations include at least the following
obligations:
(a) To ensure the right of access to health facilities, goods and services on a
non-discriminatory basis, especially for vulnerable or marginalized
groups;
(b) To ensure access to the minimum essential food which is nutritionally
adequate and safe, to ensure freedom from hunger to everyone;
(c) To ensure access to basic shelter, housing and sanitation, and an
adequate supply of safe and potable water;
(d) To provide essential drugs, as from time to time defined under the WHO
Action Programme on Essential Drugs;
(e) To ensure equitable distribution of all health facilities, goods and
services;
(f) To adopt and implement a national public health strategy and plan of
action, on the basis of epidemiological evidence, addressing the health
concerns of the whole population; the strategy and plan of action shall
be devised, and periodically reviewed, on the basis of a participatory
and transparent process; they shall include methods, such as right to
health indicators and benchmarks, by which progress can be closely
monitored; the process by which the strategy and plan of action are
devised, as well as their content, shall give particular attention to all
vulnerable or marginalized groups.
The Committee also confirms that the following are obligations of
comparable priority:
(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and child
health care;
(b) To provide immunization against the major infectious diseases occurring in
the community;
(c) To take measures to prevent, treat and control epidemic and endemic
diseases;
(d) To provide education and access to information concerning the main health
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problems in the community, including methods of preventing and controlling
them;
(e) To provide appropriate training for health personnel, including education on
health and human rights.
87. The above guidelines from General Comment 14 on Article 12 of
ICESCR are critical to the development of the framework for right to
health and healthcare.
88. In 1943, a committee known as "Bhore Committee" under the
Chairmanship of Joseph William Bhore was appointed to conduct
health survey and development of public health. It laid emphasis on
integration of curative and preventive medicine at all levels. It made
comprehensive recommendations for remodeling of health services in
India. The committee submitted its report in the year 1946 making
several important recommendations both as short-term and long term
measures.
89. Some of the important recommendations of the Bhore Committee
were:
1. Integration of preventive and curative services at all administrative levels.
2. Development of Primary Health Centres (PHC) in 2 stages:
1. Short-term measure - one Primary Health Centre was suggested for
a population of 40,000. Each PHC was to be staffed by 2 doctors,
one nurse, four public health nurses, four midwives, four trained
dais, two sanitary inspectors, two health assistants, one
pharmacist and fifteen other class IV employees. The first was
established in 1952. Secondary health centres were also envisaged
to provide support to PHCs, and to coordinate and supervise their
functioning
2. A long-term programme (also called the 3 million plan) of setting up
primary health units with 75 - bedded hospitals for each 10,000 to
20,000 population and secondary units with 650 - bedded
hospital, again regionalised around district hospitals with 2500
beds.
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3. Major changes in medical education which included 3 months training in
preventive and social medicine to prepare "social physicians".
4. Abolition of the Licentiate in Medical Practice (etc) qualifications and their
replacement by a single national standard Bachelor of Medicine and
Bachelor of Surgery (MB BS) degree.
5. Creation of a major central institute for post-graduate medical education
and research: which was achieved in 1956 with the All-India Institute of
Medical Sciences (AIIMS).
90. The proposals of the committee were accepted in 1952 by the
government of independent India. Though most of the recommendations
of the committee were not implemented at the time, the committee was a
trigger to the reforms that followed.
91. Based on Bhore committee recommendations, few States in India
enacted Public health laws. In our State, the Andhra Pradesh (Andhra
Area) Public Health Act, 1939 (for short "Act No.III of 1939") was enacted
specifying the measures to be taken at different levels, which is inclusive
of public health, establishment of local authorities, water supply,
drainage, sanitary and food control etc.
92. According to Section 9 of the Act No.III of 1939, a local authority
shall, if so required by the Government, include the post of a Health
Officer in its establishment schedule.
93. According to Section 17 of the Act No.III of 1939, every local
authority may, and if the Government so direct shall, provide or arrange
for the provision of a sufficient supply of drinking water for consumption
by the inhabitants of the area within its jurisdiction. The local authority
shall, so far as may be practicable, make adequate provision for securing
- that the water-supply is continuous throughout the year, and that the
water supplied is at all times whole-some and fit for human consumption.
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A local authority may also provide or arrange for the provision of a
sufficient supply of water for other domestic purposes or for non-domestic
purposes.
94. Section 18 of the Act No.III of 1939 obligates the local authority to
execute water work. Section 19 permit the Government to divert water
from water-main belonging to a local authority.
95. According to Section 20 of the Act III of 1939, the Collector of the
district, or any other officer appointed by the Government in this behalf,
may cause inquiries to be made in any local area or part thereof, with a
view to ascertaining-
(a) whether the source of water supply for such local area or part is
contaminated from any cause against which effective means of protection
can be taken, and
(b) whether the provisions of any additional source or sources of
water-supply is necessary for such local area or part.
(2) The Collector or other officer aforesaid may, after taking into
consideration the result of such inquires, by notice, direct that any source
of water-supply be cleaned, improved repaired or otherwise protected
from contamination, or that such additional source or sources of water-
supply be provided, as the case may be.
Thus, it is the obligation of the Collector to monitor water supply in
the entire district and issue necessary direction from time to time.
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96. In the present case, one of the reasons for CKDu is finding Silicon
and other chemicals in the water being consumed by the residents of
Uddanam area, which consisting of „7‟ Mandals. So far, no steps were
taken by the Collector in terms of obligation imposed upon him by Section
20 of the Act No.III of 1939. But at the Government level, certain
Government Orders were passed for establishment of water purifier plants
and took certain steps to establish Reverse Osmosis water plants to
supply water to the residents through Kiosks. Though CKD is prevailing
in Uddanam area for the last three decades, the Collector did not take any
action in this regard.
97. Chapter XII - Sections 108 to 115 of the Act No.III of 1939 deals
with „Food Control‟. Section 108 deals with „prohibition of sale of unsound
food‟. Section 109 deals with „punishment for contravening provisions of
Section 108, through others‟. Section 110 deals with „flesh of dead animal
not to be consumed.‟ Section 111 deals with „importing meat into local
area‟. Section 112 deals with „power of Heath officer to enter premises
used for wood trade‟. Section 113 obligates the health officer to deal with
carriers of disease handling food‟. Section 114 prescribes „investigation of
diseases caused by milk or dairy produce‟. Section 115 specifies
„inspection of dairy by Health officer.‟
98. As per the allegations in the counter, one of the reasons for CKD in
Uddanam area is consumption of alcohol, tobacco, pain killers and dry
fish. Though few reasons were traced during scientific investigation by the
authorities, local authorities did not exercise its power available under
Chapter XII of the Act. Thus, the District Collector and Local authorities
failed to act in accordance with the provisions of the Act No.III of 1939.
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99. Where does State of Andhra Pradesh stand today vis-à-vis the core
principles of availability, accessibility, acceptability and quality in terms
of the State‟s obligation to respect, protect and fulfill?
100. To sum up from the, healthcare infrastructure, except perhaps
availability of doctors and drugs is grossly inadequate. Then there are the
underlying conditions of health and access to factors that determine this,
which are equally important in a rights perspective. Given the high level
of poverty and even a lower level of public sector participation in most of
these factors, the question of the State respecting, protecting and fulfilling
them is quite remote.
101. Besides this environmental health conditions in both rural and
urban areas are quite poor, working conditions in most work situations,
including many organized sector units, which are governed by various
social security provisions, are unhealthy and unsafe. In fact, most of the
cases based on Article 21 of the Fundamental Rights and relating it to
right to health have been cases dealing with working conditions at the
workplace, workers rights to healthcare and environmental health related
to pollution.
102. Other concerns in access are the question of economic accessibility.
It is astounding that large scale poverty and predominance of private
sector in healthcare co-exist. This contradiction reflects the State‟s failure
to respect, protect and fulfill its obligations by letting vast inequities in
access to healthcare and vast disparities in health indicators, to continue
to persist, and in many situations get worse.
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103. Related to the above is another concern vis-à-vis international
human rights conventions‟ stance on matters with regard to provision of
services. All conventions talk about affordability and never mention free of
charge services. In the context of poverty this notion is questionable as far
as provisions for social security like health, education and housing.
Access to these factors socially has unequivocal consequences for equity,
even in the absence of income equity.
104. Finally there are issues pertaining to acceptability and quality. Here
the Indian states like Andhra Pradesh fails totally. There is a clear rural-
urban dichotomy in health policy with urban areas enjoying
comprehensive healthcare services through public hospitals and
dispensaries and now, preventive inputs and in contrast rural areas with
poor curative services. This violates the principle of non-discrimination
and equity and hence is a major ethical concern to be addressed.
105. In view of the catena of perspective pronouncements of Apex Court
and various High Courts, healthcare or right to life is not only guaranteed
under Article 21 of the Constitution of India, but also obligation of the
State to provide health under Chapter-IV of the Directive Principles of
State Policy, besides protection of Human Rights. The State is under
obligation to protect the life of a citizen, both under Constitution and
under International Covenants, being a party to several international
covenants on human rights. Any amount of failure to provide adequate
health facilities or failure to provide proper healthcare to the citizens of
the State would amount, not only negation of fundamental right but also
human rights. Therefore, the State is under obligation to monitor the grim
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situation in Uddanam constantly area and take every step to prevent
spread of CKD in Uddanam area.
106. Keeping in view the law laid down by various Courts and Rights of
Citizen, we would like to examine the issue based on the material
produced.
107. To substantiate the contention that the State and its
instrumentalities failed to take necessary care, more particularly, to
prevent further spread of disease and treatment of patients suffering from
CKD, petitioners placed on record Bulletin issued by World Health
Organization on 03.10.2017. Word Health Organization in its report
observed that an unknown number of people living in this area have a
chronic kidney disease of unknown etiology, a disease that mostly affects
farmers and agricultural workers. This condition was discussed and
named "Uddanam nephropathy" at the 2013 International Congress of
Nephrology held in Hong Kong, China. Unpublished cross-sectional
estimates from Uddanam suggest that the prevalence of chronic kidney
disease of unknown etiology is between 40% and 60% (T.Raviraju, Dr,
NTR University of health sciences, personal communication, August
2017). This range is nearly three times higher than the national
prevalence of 17.2%. As of 2015, it was estimated that more than 4500
people had died due to chronic kidney disease in the last ten years and
around 34,000 people had kidney diseases in Uddanam Area.
108. Another Bulletin of World Health Organization also lending support
to the case of the petitioners that causative factors were not detected by
the Government till date.
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109. Dr.T.Raviraju, Dr.NTR University of Health Sciences along with
other team of Doctors submitted a report about high prevalence of CKD in
Uddanam area specifying the test conducted etc, which are narrated in
the petition. Similarly, other documents annexed to the petition
clinchingly established that several tests were conducted by different
institutions Like ICMR, WHO, Harvard University, but could not detect
the actual cause for CKD in Uddanam area, but few reasons were
mentioned in the counter, which we extracted in the earlier paragraphs.
Though, research institute was established, as on date, no causative
factor was detected finally. Therefore, unless the investigation process is
continued till the cause is detected for CKD in Uddanam area, it is
difficult to manage the situation and provide health care to the residents
of Uddanam area for effective control and treatment to cure the disease,
so also palliative treatment. Therefore, the State has to make every
endeavour to continue the investigation to detect the causative factors for
prevalence of CKD in Uddanam.
110. The respondents to substantiate their contention that they have
taken necessary care and continuously monitoring the situation, placed
on record certain material along with their counter and additional
affidavit of respondent Nos.5 to 17 and 19 to 23 and 18. The respondents
explained the steps taken at every stage, the respondents placed on
record G.O.Ms.No.102 Health, Medical and Family Welfare (D1)
Department dated 03.09.2019, whereby the State accorded administrative
sanction in principle for establishment of 200 bedded Super Speciality
Hospital with Kidney Research Centre and Dialysis Unit at Palasa in
Srikakulam District with an estimated expenditure of Rs.50.00 Crores
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(Non-recurring expenditure) and Rs.8.93 Crores per annum (Recurring
expenditure) and sanctioned regular posts of Medical Superintendent
(Addl. Director)-1, CSRMO-1, Administrative Officer-1, Senior Assistant-
2. The State also sanctioned contractual services of Nephrologist-2,
Urologist-2, Vascular Surgeon-1, Specialist Doctors (Gen.Physician-4,
Gen.Surgeon-2, Anesthetist-4, Radiologist-1, Pathologist- 1, Micro
Biologist-1, Biochemist-1), Gen. Duty Medical Officers-12,
Nutritionist-1, Staff Nurses-60, Project Manager (Research Lab)-2,
Research Scientist-2, Senior Research fellow-2, Junior Research fellow-
2. The State also sanctioned certain posts on outsourcing basis viz.
Junior Assistant-cum-DEO-4, Reception-cum-Registration Clerk-4, OT
Assistant-4, Dialysis Technician-10, Laboratory Technician-4, C arm
Technician-4, Social Worker-2, Supporting Staff (Class-IV)-20, Security
Guards-6, Ambulance Driver-2.
111. This is a step forward to treat the patients, who are suffering from
CKD, but not a preventive measure taken by the State. It is only a
curative measure. The respondents placed on record report emphasizing
the need to provide Reverse Osmosis water plants etc. and G.O.Ms.No.240
Panchayat Raj and Rural Development (RWS-1) Department dated
16.01.2020 is placed on record in support of it. State accorded permission
to the Andhra Pradesh Drinking Water Supply Corporation to take up
Drinking Water Supply projects covering all 13 districts of State of
Andhra Pradesh to ensure supply of potable drinking water in rural and
urban areas by obtaining funds by way of loans from various sources viz.,
Public Sector Scheduled Banks / NABARD / Government contribution /
External Aiding Agencies / Public Private Partnership mode / Hybrid
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Annuity Mode etc., duly identifying fully sustainable sources in
consultation with Water Resources Department with estimated cost of
Rs.12,308 crores. For Uddanam, an amount of Rs.700 crores were
sanctioned, whereas for East Godavari, West Godavari, Guntur,
Prakasam, YSR Kadapa an amount of Rs.3960, Rs.3670, Rs.2665, Rs.833
and Rs.480 crores were sanctioned respectively.
112. The way forward to supply potable water, State issued
G.O.Ms.No.624 Panchayat Raj and Rural Development (RWS-1)
Department dated 29.04.2020 to take up drinking water supply projects
at various places and issued e-procurement tender notice No.02/2020-21
dated 18.06.2020 calling tenders for "providing Drinking water supply
scheme to Uddanam area of Srikakulam District". In response to the
tender, a bid was received and finalized in favour of Megha Engineering
and Infrastructures Limited. At best, the entire documentary evidence
produced by the respondents would show that the department is making
every endeavour to provide potable water to the habitants of Uddanam
area besides other areas. Similarly, G.O.Ms.No.194 Panchayat Raj and
Rural Development (RWS.II) Department dated 23.03.2017 was issued
sanctioning Rs.1730.30 Lakhs under SDP grant for providing safe
drinking water through Reverse Osmosis Plant to Uddanam area and to
ST habitations in ITDA area of Seethampeta Mandal of Srikakulam
District.
113. These documents established that the Panchayat Raj Department
has taken steps to provide potable water, but the project is not yet
completed as per the material produced by the respondents.
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114. The State issued G.O.Rt.No.417 Health, Medical and Family Welfare
(D) Department dated 20.07.2017 for setting up as dedicated Kidney
Disease Research Institute at Srikakulam in partnership and 50%
financial support of ICMR with an expected amount of Rs.5 Crores per
annum for three consecutive years. The pleadings further disclosed that
the research centre was established for conducting research on Kidney
disease in Uddanam area, but it is only for three years, which is already
expired by 20.07.2020, it is not known whether the research centre is
continuously conducting scientific investigation and research to find out
the reasons for Kidney disease in Uddanam area. Therefore, the action
taken by the State is for the limited period of three years. During this
period, nothing is worked out to find out the causative factor for kidney
infection to the residents of Uddanam area as per the material on record.
Therefore, mere establishment of research institute for three years did
serve no purpose, but the State has to continuously conduct scientific
investigations establishing necessary research institute and taking help of
NGOs including Indian Council of Medical Research, Word Health
Organization, Department of Nephrology, AIIMS, New Delhi, but no such
attempt is being made by the respondents as on date and failed to detect
the cause for CKD in Uddanam area.
115. One of the contentions of the respondents is that the State is
providing pension to the Kidney affected patients at the rate of
Rs.10,000/- per month by G.O.Ms.No.103 Panchayat Raj and Rural
Development (RD.I) Department dated 30.05.2019 and also providing
pension to the Chronic Kidney disease patients, who are not on dialysis
vide G.O.Ms.No.551 Health, Medical and Family Welfare (D2) Department
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dated 26.10.2019. Thus, the respondents are providing financial aid to
the victims of CKD for extension of their lifetime for some more time
without starvation. However, the amount being provided by the
respondents is not sufficient to treat the Kidney patients at the advanced
stage. Instead of providing such pension, it is appropriate to provide
super speciality treatment to the Kidney patients at their door step. But
the State did take no such step till date.
116. G.O.Rt.No.111 Health, Medical and Family Welfare (D2) Department
dated 12.02.2019 was issued for shifting of Research Centre at VIMS,
Visakhapatnam to Palasa, Srikakulam District along with the existing Lab
and equipment, but that would not serve any purpose.
117. In any view of the matter, details of tests conducted in the
Uddanam area disclose high prevalence of Kidney disease in the
Uddanam area. The documents produced by the respondents are
sufficient to conclude that the State intend to provide potable water in
Uddanam area to improve their health avoiding silicon deposits in the
water and the measures taken by the Medical and Health department, at
best, establishes the minimum steps taken by the Medical and Health
department to treat the patients, who are suffering from CKD in Uddanam
area and extending financial aid to the patients, who are at the advanced
stage of kidney problem. But these measures are not sufficient to prevent
CKD in Uddanam area. Even according to the allegations made in the
counter, the reasons are numerous. One such reason is occupational heat
stress. But the State did not take any steps to shift Cashew processing
units and brick kilns to the distant places so as to prevent the heat
generation from those units and such steps are required immediately to
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protect the workers working in the cashew process units and brick kilns
while directing the owners of those units to modernize their industries so
as to prevent heat generation, which seriously affect the health of the
workers in the Industry with the assistance of Pollution control board and
other concerned department.
118. The other cause shown by the respondents is that consumption of
chewing tobacco, dry fish, alcohol, pain killers and adulterated tea
powder mixed with cashew nut subsidiaries, but so far Government did
not take any steps to prevent or at least to control the sale of chewing
tobacco, dry fish and alcohol as a preventive measure for spread of CKD
among the residents of Uddanam area, as such it is imperative to take
steps to control sale of above items with the aid of different Government
departments including Food Safety Authority to prevent further spread of
CKD among the residents of Uddanam area.
119. Another major reason disclosed in the counter is the presence of
Nitrogen Nitrate, Silica, Fluoride, phthalates contamination in ground
water. Till date, no scientific investigation was done to prevent such
deposit of excessive Nitrogen Nitrate, Silica, Fluoride and increased
percentage of chromium in drinking water. Therefore, as a measure to
prevent further spread of CKD, the State has to make every endeavour to
conduct scientific investigation to find out reasons for such deposits, till
then it is difficult to control the spread of CKD in Uddanam area.
120. Thus, the State failed to take adequate measures to prevent spread
of CKD among residents of Uddanam area, which is health hazard and on
account of such sufferance, their capacity to work is drastically reduced
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and it has its own impact on the productivity in those areas and on
economy of State.
121. Therefore, in view of the law declared by the various Courts as
discussed in the earlier paragraphs, it is the duty of the State to provide
adequate medical care and failure to provide such adequate medical care
amounts to violation of fundamental right to life guaranteed under Article
21 of the Constitution of India, so also human right recognized by various
Courts and several international covenants as discussed in the earlier
paragraphs. Apart from that, it is the obligation of the State under Article
47 of the Constitution of India to provide adequate medical care to the
citizens of the State. But the State failed to take necessary preventive
measure to prevent the spread of CKD and this condition was discussed
and named "Uddanam Nephropathy" at the 2013 International Congress
of Nephrology held in Hong Kong, China. This medical condition prevalent
in Uddanam is one of the 7 such instances around the world where no
specific reason has been identified for the cause of the disease. When
such serious disease causing deaths in the Uddanam area, the State has
to make every endeavour to prevent such spread of CKD, but as seen
from the material produced by the respondents, the State miserably failed
to take steps to provide adequate medical care to the residents of
Uddanam area besides failure to take preventive measures in Uddanam
area.
122. The State did not dispute prevalence of CKD (CKDu) in Uddanam
area as narrated in the counter affidavit extracted above. But, it is
difficult for this Court to decide whether those steps are adequate to
prevent spread of CKD among the residents of Uddanam area and
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whether those steps are sufficient to palliate the pang of CKD patients
and as a measure for cure.
123. It is evident from the undisputed facts of the case based on the
pleadings that the State could not detect the causative factors for CKD in
Uddanam area consisting of seven mandals.
124. Independent medical research institute like George Institute for
Global Health, India, also took up research in Uddanam and this
phenomenon was discussed and termed "Uddanam Nephropathy" at
the 2013 International Congress of Nephrology held in Hong Kong, but
could not suggest the ways and means to prevent CKD in Uddanam area
and it was noted as one of the diseases for which causes could not be
detected and thereby, named as "Uddanam Nephropathy" at the 2013
International Congress of Nephrology held in Hong Kong.
125. From the pleadings of both parties, it is clear that, the attempts
made by the State Government to detect the causative factors for such
sufferance proved futile, but they could detect few reasons as enumerated
in the counter affidavit filed by the respondents, based on epidemiological
and statistical evidence, the suspected causative factors for CKD
Uddanam (CKDu) are as follows:
1. Tobacco usage and regular alcohol consumption
2. Extensive use of pain killers/ analgesic medications
3. Family history of CKD.
4. Heat stress due to occupational exposure
5. Silica and Fluoride, phthalates contamination in ground
water
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126. It is also an undisputed fact that the State did not take steps to
provide treatment in emergency cases, though provision for treatment in
emergency cases is an obligation of the State. Therefore, the State has to
take appropriate steps to provide medical facilities for treatment in
emergency cases, besides providing necessary budget and medical
infrastructure to the residents of Uddanam area.
127. The Apex Court in Paschim Banga Khet Mazdoor Samiti v. State
of West Bengal31 highlighted the obligation of the State to provide
emergency medical healthcare. The issue before the Supreme Court was
the legal obligation of the Government to provide facilities in government
hospitals for treatment of persons who had sustained serious injuries and
required immediate medical attention. Upon consideration of entire gamut
of law, an enquiry commission was appointed for providing emergency
medical care and the enquiry committee made certain recommendations
that were adopted by the West Bengal State Government to health
centres/Emergency Departments of hospitals in dealing with patients and
they are as follows:
1. Proper medical aid within the scope of the equipments and facilities
available at the Health Centres and hospitals should be provided to such
patients and proper records of the treatment given should be maintained and
preserved. The guiding principle should be to ensure that no emergency case is
denied medical care. All possibilities should be explored to accommodate
emergency patients in serious condition. To avoid confusion
Admission/Emergency Attendance Registers shall contain a clear recording of
the following information:
a) name, age, sex, address, disease of the patient by the attending MO;
b) date and time of attendance/examination/ admission of the patient;
and
c) whether and where the patient has been admitted, transferred,
referred; Further, there should be periodical inspection of the
arrangement by the Superintendent and responsibility fixed for
(1996) 4 SCC 37
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maintenance and safe custody of the registers.
3. Emergency Medical Officers will get in touch with Superintendent/Deputy
Superintendent/ Specialist Medical Officer for taking beds on loan from cold
wards for accommodating such patients as extra-temporary measures.
4. Superintendents of hospitals will issue regulatory guidelines for admitting
such patients on internal adjustments amongst various wards and different
kinds of beds including cold beds and will hold regular weekly meetings for
monitoring and reviewing the situation.
5. If feasible, such patients should be accommodated in trolley-beds and,
even, on the floor when it is absolutely necessary during the exercise
towards internal adjustments as referred to above.
The Enquiry Committee made certain other suggestions which were also
accepted by the state government:
A central Bed Bureau should be set up which should be equipped with
wireless or other communication facilities to find out where a particular
emergency patient can be accommodated when a particular hospital finds
itself absolutely helpless to admit a patient because of physical limitations.
In such cases the hospital concerned should contact immediately the
Central Bed Bureau which will communicate with other hospitals and
decide in which hospital an emergency serious patient is to be admitted.
Some casualty hospitals or trauma units should be set up at some points on
area basis.
The intermediate group of hospitals, viz., the district, sub-division and the
State general hospitals should be upgraded so that a patient in a serious
condition may get treatment locally.
128. Apart from directions of the government of West Bengal and the
recommendations of the Enquiry Committee, the Supreme Court made
some additional recommendations:
1. Adequate facilities should be available at the PHCs where the patient can
be given basic treatment and his condition stabilized.
2. Hospitals at the district and sub-divisional level should be upgraded so that
serious cases can be treated there.
3. Facilities for giving specialist treatment are to be increased and having
regard to the growing need, it must be made available at the district and
sub-divisional level hospitals.
4. In order to ensure availability of bed in an emergency at state level
hospitals, there should be a centralized communication system so that the
patient can be sent immediately to the hospital where bed is available in
respect of the treatment which is required.
5. Proper arrangement of ambulance should be made for transport of a patient
from the primary health centre to the district hospital or sub divisional
hospital to the state hospital.
6. Ambulance should be adequately provided with the necessary equipment
and medical personnel.
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129. The Supreme Court observed that while financial resources would
be required for the implementation of the above directions, the
constitutional obligation of State to provide adequate medical services to
the people cannot be ignored. The Court also observed that, "In the
context of the constitutional obligation to provide free legal aid to a poor
accused the Apex Court has held that the State cannot avoid its
constitutional obligation in that regard on account of financial
constraints. These observations will apply with equal, if not greater, force
in the matter of discharge of constitutional obligation of the State to
provide medical aid to preserve human life. In the matter of allocation of
funds for medical services the said constitutional obligation of the State
has to be kept in view." The Court held that it was necessary that a
time bound plan for providing these services should be chalked out
keeping in view the recommendations of the Committee as well as the
requirements for ensuring availability of proper medical services in this
regard as indicated by us and steps should be taken to implement the
same. The Court also observed: Providing adequate medical facilities is an
essential part of the obligation undertaken by the State in a welfare state.
The Government discharges this obligation by running hospitals and
health centres. Article 21 imposes an obligation on the State to safeguard
right to life of every person. Preservation of human life is thus of
paramount importance. Government hospitals run by the state and the
medical officers employed therein are duty-bound to extend medical
assistance for preserving human life. Failure on the part of a government
hospital to provide timely medical treatment to a person in need of such
treatment results in violation of his right to life guaranteed under Article
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21‟ (para 9) This case arose out of an incident in West Bengal. Other
states were not parties to the case. Also, the Committee was concerned
with West Bengal and the directions were also given by the West Bengal
Government. However, the Supreme Court observed that other states,
though not parties, should also take necessary steps in the light of the
recommendations made by the Committee, the directions contained in the
Memorandum of the Government of West Bengal dated August 22, 1995
and the further directions given in the Judgment. Thus all the directions
referred to above, would be equally applicable to other states in the
country. Besides, the Union of India was a party to these proceedings.
The Court observed that since it was the joint obligation of the Centre as
well as the States to provide medical services it is expected that the Union
of India would render the necessary assistance in the improvement of the
medical services in the country on these lines. The Court also ordered
that the Petitioner be paid Rs. 25,000 as compensation.
130. Similar, recommendations are required to be followed by the State
Government in Uddanam area to provide emergency medical healthcare to
the residents of Uddanam area to avoid death due to CKD, otherwise, it is
difficult for them to travel for more than 200 kms to reach
Visakhapatnam for medical treatment and there is no possibility of
getting treatment after travelling for such a long distance in emergency
cases.
131. One of the reasons highlighted by the State for spread of the CKD
in Uddanam area is environment i.e. polluted drinking water on account
of presence of Nitrogen Nitrate, Silica, Fluoride, phthalates contamination
in ground water. It appears that, as per the material on record, the
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Government has given administrative sanction for the work "providing
drinking water supply to Uddanam area of Srikakulam District" vide
G.O.Rt.No. 624 dated 29-04-2020 with an estimated cost of Rs. 700
crores. Under the scheme raw water sourced from the Hiramandalam
Reservoir will be treated in plants and clear water will be supplied to 807
habitations in the Uddanam Area, but construction of Hiramandalam
Reservoir takes two years. Moreover, the State Government also provided
water kios for drinking water to the residents of Uddanam area. It is the
step taken by the State Government to prevent such spread of CKD
among the residents. Though, Uddanam area is a lush green area, the
reason for presence of Nitrogen Nitrate, Silica, Fluoride, phthalates
contamination in ground water is not detected and necessary scientific
investigation is to be undertaken by the State, since one of the causative
factor is the environmental condition as healthy environment is human
right.
132. The Apex Court in Municipal Council, Ratlam vs. Vardhichand
& Ors (referred supra) held that, Healthy Environment is also a Human
Right and the Supreme Court issued the following directions:
1. We direct the Ratlam Municipal Council (R1) to take immediate action,
within its statutory powers, to stop the effluents from the Alcohol Plant
flowing into the street. The State Government also shall take action to stop
the pollution. The sub-Divisional Magistrate will also use his power under
Section 133 CrPC, to abate the nuisance so caused. Industries cannot make
profit at the expense of public health. Why has the magistrate not pursued
this aspect?
2. The Municipal Council shall, within six months from today, construct a
sufficient number of public latrines for use by men and women separately,
provide water supply and scavenging service morning and evening so as to
ensure sanitation. The Health Officer of the Municipality will furnish a
report, at the end of the six-monthly term, that the work has been
completed. We need hardly say that the local people will be trained in using
and keeping these toilets in clean condition. Conscious cooperation of the
consumers is too important to be neglected by representative bodies.
3. The State Government will give special instructions to the Malaria
Eradication Wing to stop mosquito breeding in Ward 12. The sub Divisional
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Magistrate will issue directions to the officer concerned to file a report
before him to the effect that the work has been done in reasonable time.
4. The municipality will not merely construct the drains but also fill up
cesspools and other pits of filth and use its sanitary staff to keep the place
free from accumulations of filth. After all, what it lays out on prophylactic
sanitation is a gain on its hospital budget.
5. We have no hesitation in holding that if these directions are not complied
with the sub Divisional Magistrate will prosecute the officers responsible.
Indeed, this Court will also consider to punish for contempt in case of report
by the sub-Divisional Magistrate of willful breach by any officer
133. The Court also held that the State should be guided by the
paramount principle of Art. 47 of the Constitution of India which states
that, improvement of public health should be one of the primary duties of
the state.
134. The Bombay High Court in Citizens Action Committee, Nagpur
vs. Civil Surgeon, Mayo (General) Hospital, Nagpur and Ors32, put in
detail the responsibilities of the Municipal Corporation, in marinating the
civic hospital and the other basic amenities in the city. The high court in
its order stated that,
"We cannot but emphasise that the hospitals have their own role to
play. Hospitals are the necessities of modern life and they have to
respond to the needs of any growing city. Hardly any option can be
speedy out or any excuse permissible so as to afford an alibi when
the matters concern the authorities would bestow urgent attention on
every facet of the problem of public health and effectively".
(emphasis supplied)
135. The Citizens Action Committee approached the Nagpur bench of the
Bombay High Court requesting the court to intervene as the overall
condition of the civic amenities such as roads, sanitation and public
health was deteriorating considerably. The court issued notice to all the
concerned authorities and asked them to file their say. Two fact finding
reports of the citizens were also given to the court. The court largely
AIR 1986 Bom 136
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based its finding on the reports and the affidavits filed by the citizens.
There were three hospitals that were being run by the state. Overcrowding
in all these hospitals had reached dangerous levels. Trespassers and
visitors also burdened the hospitals. Even the staff of the hospitals was
housed in poor conditions and they were living in unhygienic conditions.
The court held that as per Article 47 of the Constitution of India it is the
duty of the state to provide proper facilities for public health. The court
set up an Investigative and Remedial Measures Suggestive Committee
(I. R. M. S. C.) to look into the matter.
136. The High Court of Madhya Pradesh in Hamid vs. State of M.P33
held that the citizens have right to clean and safe drinking water. The
court stated, Under Article 47 of the Constitution of India, it is the
responsibility of the State to raise the level of nutrition and the standard
of living of its people and the improvement of public health. It is
incumbent on State to improve the health of public providing unpolluted
drinking water. State in present case has failed to discharge its primary
responsibility. It is also covered by Article 21 of the Constitution of India
and it is the right of the citizens of India to have protection of life, to have
pollution free air and pure water. The court also held that the state was
liable to pay for the damages caused by the consumption of the polluted
water. Hamid Khan a lawyer filed a petition before the High Court of
Madhya Pradesh, regarding the quality of water supplied through the
hand pumps in the district of Mandla. The water being supplied
contained high amount of fluoride causing damages such as skeletal
flurosis and dental flurosis to a number of people. The High Court held
AIR 1997 M.P 191
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Under Article 47 of the Constitution of India, it is the responsibility of the
State to raise the level of nutrition and the standard of living of its people
and the improvement of public health. It is incumbent on State to
improve the health of public providing unpolluted drinking water. State in
present case has failed to discharge its primary responsibility. It is also
covered by Article 21 of the Constitution of India and it is the right of the
citizens of India to have protection of life, to have pollution free air and
pure water... The court also held that the people affected due to the
contaminated water should be treated at the expense of the State. It also
added that the State should bear the expenses of any surgery might be
required. The State was also directed to closing of hand pumps where the
water had excessive amount of fluoride and that a proper and safe
drinking water facility should be put in place.
137. The Allahabad High Court in Kamlavati vs. Kotwal and Ors34,
ordered the brick klin owners to follow the norms laid down by the
government very strictly and also ordered the government to set up a fund
for the modernization of the brick kilns as the traditional brick klins were
causing a lot of air pollution.
138. The Supreme Court in Murli S Deora vs. Union of India and
Ors35 , recognized the harmful effects of smoking in public and also the
effect on passive smokers, and in the absence of statutory provisons at
that time, prohibited smoking in public places such as,1.auditoriums, 2.
hospital buildings, 3. health institutions, 4. educational institutions,
5.libraries, 6. Court buildings 7. public office, 8. public conveyances,
(2000) 3 UPLBEC 1969
AIR 2002 SC 40
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including the railways.
139. In State of Andhra Pradesh, the local government in Uddanam area
including municipalities and panchayat are unable to take such steps to
maintain ecological balance and to prevent presence of deposits of
Nitrogen Nitrate, Silica, Fluoride, phthalates contamination in ground
water, failed to control brick kilns, cashew process units and plastic
units, which are main causes for heat stress and contamination of ground
water. Therefore, we recommend the State to undertake necessary
scientific investigation to prevent elimination of excessive deposits of
Nitrogen Nitrate, Silica, Fluoride, phthalates contamination in ground
water in drinking water in Uddanam area, as expeditiously as possible,
since it is one of the causative factors, and take steps for prevention of
heat generated from cashew process units, brick kilns to reduce heat
stress as admitted by the respondents.
140. The other causes pleaded in the counter affidavit by the
respondents are Tobacco usage and regular alcohol consumption;
Extensive use of pain killers/ analgesic medications; Family history of
CKD.
141. In view of the reasons explained in the Courts, it is the duty of the
State to sensitize the residents of Uddanam area about the ill-effects of
consumption of Tobacco and regular alcohol consumption; extensive use
of pain killers/ analgesic medication; Heat stress due to occupational
exposure and Silica and Fluoride, phthalates contamination in ground
water, by conducting necessary programmes and also conduct in-depth
study to take effective steps to save valuable lives of the residents of
Uddanam area and submit a report to the State Legal Services Authority
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to monitor the same in an interval of two months for a period of three
years initially.
142. National Human Rights Commissioner recommended National
Action Plan to operationalise the Right to Health Care. State Public Health
Services Act is enacted, detailing and operationalising the National Public
Health Services Act, recognizing and delineating the Health rights of
citizens, duties of the Public health system and private health care
providers and specifying broad legal and organizational mechanisms to
operationalise these rights. This would include delineation of lists of
essential health services at all levels: village/ community, sub-centre,
PHC, CHC, Sub divisional and District hospital to be made available as a
right to all citizens. This would take as a base minimum the National
Lists of essential services mentioned above, but would be modified in
keeping with the specific health situation in each state.
143. A set of public health sector reform/measures to ensure health
rights through strengthening public health systems, and by making
private care more accountable and equitable. The minimum aspects of a
health sector reform framework that would strengthen public health
systems must be laid down as an essential precondition to securing
health rights. An illustrative list of such measures are as follows:
1. State Governments should take steps to decentralise the health
services by giving control to the respective Panchayati Raj
Institutions (PRIs) from the Gram Sabha up to the district level in
accordance with the XI Schedule of the 73rd and 74th Constitutional
Amendment 52 of 1993. Enough funds from the plan and non plan
allocation should be devolved to the PRIs at various levels. The
local bodies should be given the responsibility to formulate and
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implement health projects as per the local requirements within the
local overall framework of the health policy of the state. The elected
representatives of the PRIs and the officers should be given
adequate training in local level health planning. Integration
between the health department and local bodies should be ensured
in formulating and implementing the health projects at local levels.
2. The adoption of a state essential drug policy that ensures full
availability of essential drugs in the public health system. This
would be through adoption of a graded essential drug list,
transparent drug procurement and efficient drug distribution
mechanisms and adequate budgetary outlay. The drug policy
should also promote rational drug use in the private sector.
3. The health department should prepare a State Drug Formulary
based on the health status of the people of the state. The drug
formulary should be supplied at free of cost to all government
hospitals and at subsidized rate to the private hospitals. Regular
updating of the formulary should be ensured. Treatment protocols
for common disease states should be prepared and made available
to the members of the medical profession.
4. The adoption of an integrated community health worker programme
with adequate provisioning and support, so as to reach out to the
weakest rural and urban sections, providing basic primary care
and strengthening community level mechanisms for preventive,
promotive and curative care.
5. The adoption of a detailed plan with milestones, demonstrating how
essential secondary care services, including emergency care
services, which constitute a basic right but are not available today,
would be made universally available.
6. The public notification of medically underserved areas combined
with special packages administered by the local elected bodies of
PRI to close these gaps in a time bound manner.
7. The adoption of an integrated human resource development plan to
ensure adequate availability of appropriate health human power at
all levels.
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8. The adoption of transparent non discriminatory workforce
management policies, especially on transfers and postings, so that
medical personnel are available for working in rural areas and so
that specialists are prioritised for serving in secondary care
facilities according to public interest.
9. The adoption of improved vigilance mechanisms to respond to and
limit corruption, negligence and different forms of harassment
within both the public and private health system.
10. All health personnel upto the district PRI level must be
administratively and financially accountable to the PRI at each
level from the Gram Panchayat to the District level. Adequate
financial resources must be made available at each level to ensure
all basic requirements of health and medical care for all citizens
144. Summing up law laid down by various Courts; Constitutional
provisions and International Covenants on Human Rights and various
recommendations made by Hon‟ble Supreme Court, we dispose of both
the writ petitions by issuing following directions to the State and Central
Governments:
1. We direct the State and Local governments of Uddanam area to take
immediate action, within its statutory powers, to stop the effluents
from the nearby cashew processing units and brick kilns into the
water bodies, as industries cannot make profit at the expense of
public health.
2. Proper medical aid and adequate health care be provided at the
Health Centres and hospitals irrespective of financial constraints to
CKD patients and proper records of the treatment given, should be
maintained and preserved. The guiding principle should be to
ensure that no emergency case is denied medical care. All
possibilities should be explored to accommodate emergency
patients in serious condition. To avoid confusion
Admission/Emergency Attendance Registers shall contain a clear
recording of the following information:
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d) name, age, sex, address, disease of the patient by the
attending Medical Officer;
e) date and time of attendance/examination/ admission of the
patient; and
f) whether and where the patient has been admitted,
transferred, referred; Further, there should be periodical
inspection of the arrangement by the Superintendent and
responsibility be fixed for maintenance and safe custody of
the registers.
3. Emergency Medical Officers will get in touch with
Superintendent/Deputy Superintendent/ Specialist Medical Officer
for taking beds on loan from cold wards for accommodating such
patients as extra-temporary measures.
4. Superintendents of hospitals will issue regulatory guidelines for
admitting such patients on internal adjustments amongst various
wards and different kinds of beds and will hold regular fortnightly
meetings for monitoring and reviewing the situation. If feasible,
such patients should be accommodated on trolley-beds.
5. Adequate facilities should be made available at the PHCs where the
patient can be given basic treatment till condition is stabilized.
Hospitals in the villages of Uddanam area should be upgraded so
that serious cases of CKD can be treated there.
6. Facilities for giving specialist treatment are to be increased having
regard to the growing need, it must be made available in all the
villages of Uddanam area.
7. In order to ensure availability of bed in an emergency at state level
hospitals, there should be a centralized communication system so
that the patient can be sent immediately to the hospital where bed
is available for the treatment required.
8. Proper arrangement of ambulance should be made for transport of
a patient from the primary health centre to the district hospital or
sub-divisional hospital to the state hospital. Ambulance should be
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adequately provided with the necessary equipment and medical
personnel.
9. Union and State shall ensure that drugs for management of
Uddanam CKD (C.K.D) and its complications including the drugs be
made available at free of cost and do not go out of stock at all
Primary Health Centers (PHCs) or as the case may be public health
facilities in Uddanam area;
10. Union and the State must organize seminars at all levels which
serve as platforms to hear the views and experiences directly from
the former patients and their families as well as doctors, social
workers experts NGOs and Governments officials;
11. Union and State Government must ensure that both private and
public schools do not discriminate against children hailing from
CKD (C.K.D) affected families such children should not be turned
away and attempt should be made to provide them free education;
12. Union and State Government shall appoint food inspectors for the
villages in Uddanam to prohibit food adulteration. They must pay
adequate attention to ensure that the persons affected with CKD
(C.K.D) are issued Household supply cards so that they can avail
the benefits under schemes subject to their eligibility which would
enable them to secure their right to food;
13. Direct the Union and State Governments should construct Super
Specialty Hospitals with adequate number of beds within the limits
of Uddanam area with the adequate dialysis Units and testing
laboratory; immediately to meet the present and future needs.
14. State together with the Union Of India should consider formulating
and implementing a scheme for providing at least a minimum
assistance preferably on a monthly basis to all CKD (C.K.D) affected
persons for rehabilitations;
15. Union and the State Governments must proactively plan and
formulate a comprehensive community based rehabilitation scheme
which shall cater the basic facilities and needs of the CKD (C.K.D)
affected persons and their families The scheme shall be aimed at
eliminating the stigma that is associated with persons affected with
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C.K.D patients;
16. State and Central Government should provide the mobile dialysis
units to the CKD patients in Uddanam area who are the suffering
with severe CKD (C.K.D);
17. Take steps to prevent heat stress generating from cashew
processing units and brick kilns, with the assistance of experts
from Pollution Control Board and take steps for modernization of
cashew units; brick kilns to prevent heat generation.
18. Take steps to reduce excessive Nitrogen Nitrate, Silica, Fluoride,
chromium deposits, phthalates contamination in ground water by
scientific methods; and ensure providing potable water to residents
of Uddanam area free from silicon and fluoride;
19. Sensitize the residents about ill-effects of chewing tobacco,
consumption of alcohol, dry fish by conducting necessary
awareness programmes and by distributing pamphlets
145. As seen from the material placed on record by the petitioners, to
substantiate the contentions of the respondents that they have taken
adequate steps to provide adequate healthcare to CKD patients, we find
that it is not adequate. When the Government is not acting swiftly to
protect the rights of a citizen guaranteed under Article 21 of the
Constitution of India, indirectly violated such right without providing
adequate healthcare to the residents of Uddanam area in discharge of
their obligation under Article 47 of the Constitution of India, we find it
appropriate to issue certain directions. As such, we framed a scheme for
conducting outreach programmes and one such programme is to monitor
the steps taken by the Government from time to time in Uddanam area
both preventive, curative and palliative measures being provided by the
State to CKD patients and to sensitize them by conducting awareness
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programmes with the help of concerned authorities about the ill-effects of
chewing tobacco, consumption of alcohol, dry fish so also to monitor the
steps being taken by the State for modernization of cashew processing
units, brick kilns to prevent generation of heat, which seriously affect the
health of workers working in those industries and to monitor the scientific
investigation being done by the State to prevent Nitrogen Nitrate, Silica,
Fluoride, phthalates contamination in ground water.
146. In order to monitor the steps being taken by the State to prevent
and control Chronic Kidney Disease in Uddanam, as a part of National
Legal Services Authority (NALSA) Resolution on 17th & 18th of march,
2018, to elaborate the activities of NALSA, there is a need to involve
hospitals with Legal Services Authority, as such, the Chairman, DLSA
Srikakulam shall constitute the following committees at District Level and
at Mandal Level Legal Services.
1. Advisory Committee
a. Chairman DLSA, Srikakulam
b. District Collector
c. Chairman, District Medical Board / Superintendent,
Government General Hospital
d. An NGO connected to the medical field
e. Environmental Engineer, Andhra Pradesh Pollution Control
Board Regional Office
f. Commissioner of Labour
g. Psychiatrist
The members of the Advisory Committee shall meet once in a
month to guide the members of the other committees for effective
implementation of Uddanam Nephropathy Scheme and implement the
directions issued by the Committee.
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2. Awareness Committee
a. A Nephrologist
b. General Physician
c. 2 or 3 Advocates
d. A social worker
e. AASHA worker
To identify the families of the victims of kidney disease and to
explain the medical treatment and facilities available to them and to
enlighten them about the causes for kidney disease due to consumption
of various types of food, alcohol, smoking and to create better
environment by themselves such as sanitation, fresh drinking water and
to conduct medical camp in the villages where people are affected, once in
a fortnight and also create awareness by going door-to-door by ASHA
workers.
3. Legal Aid Committee
a. Advocates
b. Chairman, DSLA, Srikakulam
c. Secretary, DLSA, Srikakulam
To create legal awareness of right to live in hygienic and healthy
atmosphere and related laws to enforce their rights and also to give
proper legal advice to get compensation and medical care by victims of
Uddanam Nephropathy.
4. Coordination Committee
a. Chairman, DLSA
b. Secretary, DLSA
c. Chairman, MLSA
d. Legal practitioner
To coordinate all the departments by sitting once in a month for
implementation of the Uddanam Nephropathy Scheme.
5. Monitoring Committee
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a. Executive Chairman, SLSA
b. Secretary, Finance
c. Secretary, Medical and Health Department,
d. Secretary, Revenue Department
e. Chairman, SPCB
It shall monitor the work done by the Committee by holding
meeting once in two months and give appropriate guidance for effective
implementation of the Scheme.
147. In addition to the above, the State authorities are directed to
handover the reports relating to measures taken to prevent and cure
CKD in Uddanam area every month/two months to the State Legal
Services Authority to suggest necessary measures from time to time, in
view of the directions of, National Legal services Authority to all the State
Legal Services Authorities to conduct outreach programmes to find out
core issues in the area and to attend those issues within their
limitations, which is inclusive of providing medical care with the help of
Doctors.
148. Member Secretary, State Legal Services is hereby directed to get
necessary funds from the State by taking appropriate steps and report to
Patron-in-Chief from time-to-time. The State may take help from NGOs
and industrialist and assist as part of corporate social responsibility, to
ensure, protect right to life and adequate health care and to protect
human rights of the residents of Uddanam area.
Consequently, miscellaneous petitions pending, if any, shall also
stand closed.
PRASHANT KUMAR MISHRA, CJ M. SATYANARAYANA MURTHY, J
Sp/Ksp
