Wake up time: Drastic changes required in the military medical set-up

This subject has been discussed on the blog umpteen number of times, and please be advised that the idea behind this post is not to criticize but to aid introspection.

The declaration by a medical board of an in-service incurred disability as ‘attributable to, or aggravated by service’ or ‘connected with service’, is what determines the pensionary entitlement of our men and women in uniform including whether he or she would be entitled to any kind of pension at all or not, and it also has a direct bearing on the survival of the family through thick and thin as also the right to lead a life of adequate dignity.

However, the sensitivity to this very important aspect is totally lacking in the military medical set-up, which, in a routine manner treats this issue more like an administrative and mathematical joke rather than something which affects the survival and the right to live a dignified life of our veterans and their families. It’s just a stroke of a pen – ‘Yes’ or ‘No’, and therein lies the answer whether the veteran and his family would be entitled to any kind of livelihood and facilities or not.

Direct to the point, today, to put it succinctly, it’s a pretty easy job for military medical boards. The thumb rule in use currently by the system, for most disabilities, is – if the disability had arisen in a field area, then it’s attributable to / aggravated by service, if it emanated in a peace area, then it is neither attributable to, nor aggravated by service (NANA). Needless to state, in actual terms, Regulation 423 of the Regulations for Medical Services of the Armed Forces (RMSAF) clearly provides that service in peace or field has no bearing on attributability.

So there you have it, in the ultimate analysis as to how the system is functioning, an Army Major who may be suffering from mild hypertension but is serving in say Udhampur in J&K though in an easy undemanding appointment, would be provided the benefit of ‘aggravation’ and hence disability pension because technically he’s in a field area, but a Major who may be the Garrison Engineer in a high pressure appointment and zone like Delhi or say perhaps a cardiologist in a high profile and highly demanding faculty in Army Hospital (R&R), even if suffers a massive heart attack due to excessive pressure of his job, would not be granted the benefit of ‘aggravation’ since he was posted in a peace area.

The above is how the Guide to Medical Officers (Military Pensions) issued by the office of Director General Armed Forces Medical Services (DGAFMS) deals with the subject. And it’s going from bad to worse, since while the earlier version of the same guidebook published in the year 1980 emphasized on dealing with disabilities on a case to case basis, and the one published in 2002 also provided for discretion and application of mind on a case to case basis, the supplement published in 2008 takes it all away and makes it mathematical and mechanical. To top that, the office of DGAFMS is known to issue strange letters to hospitals and boards, communications such as asking boards not to provide attributability / aggravation to diseases such as hypertension in peace areas, which is not only alien to principles of medical science but also in direct contravention of RMSAF and Entitlement Rules promulgated by the Govt of India.

What does peace and field have to do with a disability? The rigours of military service inherently involve a live link with disabilities, especially psychiatric ones and those related to the cardiovascular system. It is otiose to compare military personnel, even when posted in peace areas, with civilians. An extract of an earlier blogpost on the subject is relevant here:-

“While dealing with disabilities of military personnel, the much argued comparison with an ordinary person on the street by medical authorities is also incomprehensible. There are times when it is remarked that such a disease may also have arisen had the particular person not been in the Army and that the Army is one of the most stress-free organisations in the country. The question arises that here is a man who is 24 hours / 365 days on call, sometimes under the shadow of gun, mostly away from his family, in a strictly regimented routine, can he be simplistically compared with say a civilian employee who goes to office at 9 in the morning returns at 5, only five days a week, lives with his family, in his hometown, enjoys his gazetted holidays, retires at 60 ? !. It won’t take an expert to reply in the negative. Wouldn’t common ailments such as hypertension or IHD or minor psychiatric illnesses or psycho-somatic disorders get aggravated by even seemingly insignificant incidents at the home front such as non-performance of children in school, property disputes, sarkari red-tapism in other spheres, family problems etc ? The answer would be in the positive….”

When a person is away from his family and has no control over events in the environment, including the insensitivity of the civil administration towards the issues facing him and his kin, it hardly matters if he’s in field or peace, and many disabilities are bound to aggravate.

The archaic system of assessment of disabilities is proving to be burden on the organization, on the judicial system and is also bringing about much heartburn amongst the veteran community. When asked about the background or studies on the basis of which (regressive) changes were brought about in the Guide to Medical Officers (Military Pensions) from time to time, especially the 2008 supplement, the answer of the office of the DGAFMS has been elusive and less than satisfactory. There are no footnotes, no studies mentioned, there are no references as to how the conclusions in the said guide were reached about attributablitiy and aggravation of various diseases. For example, in the 2002 version, this was expressly mentioned in relation to heart diseases :

“…Hence no clear cut distinction can be drawn between service in peace areas and field areas taking into account quantum of work, mental stress and responsibility involved. In such cases, aggravation due to service should be examined in favour of the individual….”

But the above lines are completely missing in the 2008 supplement. Isn’t this retrograde? Has anyone questioned the office of DGAFMS as to how and on the basis of which studies was the line omitted? And when the militaries of all democracies make no distinction between peace and field and examine diseases on a case to case basis, what right did the office of DGAFMS have to impose its thought process on the future of millions of disabled veterans and also their families? Can we, and should we let a couple of officers holding key appointments decide the fate of disabled personnel and their families?

The guide is also inconsistent on various disabilities, for example, in the 2002 publication, it is stated that a regimented lifestyle in peace may adversely affect heart diseases, the same is not mentioned in the case of hypertension though it is commonly known that the factors affecting both may be intertwined.

The way how policies are handled by us in the official establishment was also highlighted earlier in yet another blogpost in the past in the following manner:-

“…Then there is the tendency to thrust one’s thought process on others in the system and on to the affected parties without deep analysis of issues. An officer wakes up one day, drafts a letter which he or she thinks is the epitome of intelligence, floats a minute sheet, gets it approved on file and viola we have a ‘policy decision’ which is imposed on others who sadly have no say in the arrangement. Or else what could explain letters from the office of DGAFMS asking medical boards not to grant attributability or aggravation to disabilities such as hypertension if the onset is not in a field / high altitude area, when on the contrary, the rule governing the issue states the below mentioned :-

‘For the purpose of determining whether the cause of a disability or death is or is not attributable to service, it is immaterial whether the cause giving rise to the disability or death occurred in an area declared to be a field service/active service area or under normal peace conditions’

So what should prevail over medical boards, the bright-morning idea of the gentleman who signed the policy letter or the rule extracted above ? It is sad but such illegal letters are prevailing over our system rather than the actual legally promulgated rules….”

The problem with us is self-righteousness, the inability to see reason, clinging on to fiefdom, not realizing the damage in the long run. I would have wanted to render a benefit of doubt to the system but there are some very glaring examples which come to mind, thankfully the veracity of which I can vouch since I personally handled them:-

1.  A soldier went into coma due to cerebral malaria and was later invalided out on the basis of ‘Opium Addiction’ without pension. The said person had not even touched alcohol in his life, and here he was, branded an opium addict. The medical establishment refused to see reason. After much struggle and after the inception of the RTI Act, it was discovered that probably his papers were mixed up with those of another patient while he remained in an MH in the north-east. With intervention of the Army HQ, he was finally granted disability pension.

2.  A Gunner of Clerical trade briefly posted in CI Ops faced an ambush like situation and thereafter used to experience flashbacks about the same. His disability pension claim was rejected by the medical board on the ground that he was posted in field area for less than 2 years. When a fresh medical board was ordered on judicial intervention, rather than recording the flashbacks, the psychiatrist simply wrote that the soldier had ‘disturbed sleep patterns’. Now there is a world of difference between the two, but based on this slipshod opinion his claim was again rejected but thankfully he got his pension later, again on directions of the Court. Till date, it seems that the military medical establishment has not realized that a stressor or a triggering event for a psychiatric disability can happen in  one single second of a person’s presence in a particular event, and length of service in field area has no role to play.

3.  Medical restrictions were imposed on a soldier that he may not be posted in a high altitude area since he was suffering from Psoriasis. He was still posted to an area beyond Leh from where he was invalided out and the remarks of the medical board were predictable – that the disability was neither attributable to, nor aggravated by service. Again disability pension was granted on judicial intervention.

4. An officer, a volunteer for OP Meghdoot, was diagnosed as a case of excessive dandruff while posted to the glacier. Afterwards he was diagnosed as a case of psoriasis. Claim of disability pension refused on the pretext that the disability was neither attributable to, nor aggravated by service. Now if this isn’t related to service conditions, what is?  

5.  A soldier diagnosed with cancer was continually posted to field and CI areas despite undergoing chemotherapy. When just about to complete pensionable service, and almost on his death bed, he was forcefully invalided out of service. Disease declared neither attributable to, nor aggravated by service though guidelines clearly provide that if a person with cancer has had an operational tenure within a window of 30 days to 5 years, he is to be granted attributability. He died 9 days later. Family pension refused on the ground that he died after invalidation. The family was then granted pension on the orders of the Court.

The list is endless. These are people who had the wherewithal to fight it out or to approach judicial fora, but countless others suffer in ignorance and silence. Isn’t it the duty of all of us, especially the serving community and senior military staff to order a complete overhaul of the system and make it more logic and medicine oriented? Other democracies are way ahead. In most countries, attributability / aggravation is the rule if it occurs in active service, while rejection is an exception, whereas in our military, it is the other way round.

Already, military personnel are not provided the benefit of protection of service and pension in case of a disability as is provided to all civilian government employees.

The issue is not clearly in open public domain like say corruption in the military, but the way disabled personnel are being treated by us is the greatest disservice to the very foundation of our armed forces in particular and society in general.

Do not keep your eyes closed. Wake up. Please.