Spurious Drugs, Lives and Our Pride

The news of 66 children falling ill and dying in Ghana (West Africa) allegedly after consuming cough syrup preparations manufactured in India was deeply disturbing.

Death of children in large numbers was bad enough. That they died possibly due to a spurious drug was terrible. And that the drug was manufactured in India and exported to that country where this tragedy occurred was deeply disturbing.

The contaminant in the 4 brands of cough syrup marked in Ghana and consumed by the victims is suspected to be diethylene glycol, or DEG. Toxicity was suspected to have caused kidney failure. 

The pharmaceutical industry in India has been a success story of sorts, standing shoulder to shoulder with some of the best international medicine manufacturers, supplying affordable therapies to many parts of the world. 

As we piece together the bits of news that appeared in the press, the following questions continue to disturb: 

Can we claim impunity for allowing an Indian company to export a medicine to another part of the world and then not take responsibility if they were spurious and caused deaths there? Do we then admit that our ability to monitor our products is compromised, and yet we are OK with permitting them to be exported? 

The official note being put out that those batches of cough syrup from that company were not allowed to marketing in India but were allowed to be exported to Ghana smacks of double standards and makes one cringe. Are we setting different prices for lives of children in India and those from Ghana?

What about our quality and standards? Some Indian companies maintain high international standards, Could the tarry paint rub onto them? And how does the common man know which ones can he can trust? 

Should we be concerned about our claim to be counted as a develop(ed) nation? 

I do not recall any medicinal product in recent years being manufactured in a developed part of the world and sold elsewhere that could cause this kind of disaster.

A recent review in Indian Journal of Pharmaceutical Sciences estimates that 12 to 25% of Indian medicines for exports failed to meet standards (substandard, contaminated or spurious); the figure could be much higher for medicines manufactured for local sale.

Last but not the least, there is pattern in crime called recidivism, another name for repeat offenders. It appears that the company in question had been hauled up several times for poor manufacturing standards and even deaths in India. And we closed our eyes as it was not for our children!

Advertisement

Medical Etiquette

It is intriguing that many bright medical students who have scored high marks in college do not turn up into becoming successful popular doctors.

Delivering good gratifying medical care involves not just knowledge, skills and ethics but two other vital components that are often overlooked: empathy and medical etiquette.

Medical etiquette is simply good proper behaviour that is expected of physicians and nurses when dealing with patients. Simple, etiquette is usually not given much importance during medical training in this country and is hence often found woefully lacking in our professionals. Consequently, do not be surprised to meet a top-notched specialist with a string of degrees below his name, who may forget the etiquette of offering you a seat when you enter his chamber, and continue talking on the phone.

A resident doctor, who comes to train with us to become a superspecialist, is often grossly deficient in etiquette. In the busy and crowded OPD, I see him often examining a female patient in the presence of 10 unrelated spectators. In the ward, I see him doing an ascitic tap (drawing fluid from the abdomen) without putting screens around to ensure privacy. Another common gaffe is barging into the private cabin of a patient without an announcing knock or a “please may I come in?”.

While etiquette may not decide life and death, what it does decide is whether the patient feels comfortable, cared for and treated with dignity. It also determines whether he would like to come back and be regular with follow up, ,or go to another doctor.

Doctor’s etiquette requires that he is punctual, is dressed appropriately and is well mannered with his patients; a medical doctor imbibes it party from the environment at home and his culture, from the grooming he has received from his teachers, and from his  emotional intelligence.

Medical training in many countries has focussed too strongly on information gathering, subject knowledge, and skills, while neglecting the three vital “human” aspects : communication, empathy and etiquette from the curriculum.

It is hardly surprising then that many patients are dissatisfied with their care-givers,

Disgruntled Relatives Push a Young Doctor to Suicide

The tragic death of a young female doctor by suicide last week due to coercion by angry relatives of a patient who had died under her care, has stunned the medical profession and society.

From press reports I gathered that Dr Archana Sharma was attending to a female patient who had bled massively from the uterus following childbirth, and whom she was unable to save.

Agitated relatives had accused her of negligence, had barged into the local police station, and then gone on to filed a charge of “murder”. The police had obligingly cooperated, leaving the female doctor helplessly alone and deeply hurt.

In her desperation and as a vindication of her innocence she chose to end her life, leaving behind two children and her husband. In her suicide note she stated that she had done no wrong, but had been unable to save the patient.

Post-partum bleeding can sometimes be very massive and kill within minutes despite transfusion of large amounts of blood and medicines, uterine packing and rarely sometimes requiring emergency surgery. Few patients do die from this terrible unpredictable condition, in the best of hospitals even today.

This unfortunate event is a reflection of several social beliefs and practices that we need to face up to.

For one, we are getting increasingly intolerant and unaccepting of the fact that death can indeed occur in critical conditions despite the best of interventions.

Second: whenever a patient dies, our society believes that it has to be somebody’s fault! We seem obsessed to ascribe culpability and hound someone till punishment is meted out.

It is amusing to see the CCTV footage of road traffic accidents for instance; the relative is often seen running after the offending vehicle rather than attending to the victim lying on the road.

There is no space for doctors to fail in their human efforts. I wish members of the society in other walks of life, of say a place like Dausa in Rajasthan, hold themselves to such unreasonably high standards too.

Even more shocking was the role of the police who seemed be saving their backs from an unreasonable agitated mob, rather than defending a helpless female doctor being victimized and coerced.

The reason why young doctors choose not to settle in small towns and villages, should be evident by now. They flock to big towns and cities, not just for money, but for better living conditions, and better security.

I shuddered to think what I could have done had I been in her place.

The government machinery needs to take urgent corrective steps and instill confidence in young medicos if they want doctors to serve in smaller places.

Humanising Medicine

Despite significant recent advances in medical science and technology that have spiked human life-expectancy and provided a handle to control several diseases, Modern Medicine has paradoxically come under much pelting from several quarters for becoming impersonal, cold, commercial and “dehumanized”.

Most doctors agree that this charge has come to stick. And while they remain the interface with ailing and dying patients and their relatives, they have become the target of unspoken suspicion or voiced accusation for partnering with profit-makers such as the health care, pharmaceutical or device making industries.

Not unexpectedly, perspectives differ widely. For instance, “Profit” is the wonder word that forms the core value of corporates and industries. But when it comes to medical care, the word “profit” makes relatives of a patient of terminal cancer cringe!

Realizing that “trust” underpins the core foundation of any successful patient-doctor relationship, a group of doctors, psychologists and sociologists led by a diabetologist Dr Beena Bansal, are attempting to reset the balance.

“Humanising Medicine” is the name they have given to their movement. As an initial step to inject and restore “human” values back to the medical profession, they are organizing their first meeting on March 5 and 6, 2022. Visit https://HumanisingMedicine.com for details.

The topics slated for discussion includes a wide range from “How to Break Bad News”, enhancing “empathy” in our interactions, new techniques to help patients and relatives navigate difficult decisions like choosing one treatment over another, restoring focus on “quality of life” rather than using the latest technology just because it is the new fanciful chip on the therapeutic shelf, and so on.

Another crucial aspect is to listen to the voice of patients and relatives those who have found themselves on the receiving end. This platform is encouraging them to join in. In fact, it is for them to share their experience and perspectives, and shed light on which way modern medicine ought to travel.

The aim and perspective of this forthcoming event is different from the usual “jargonized” medical conferences that doctors love to attend. It could well hold a mirror and make many doctors re-orient their future paths and destinations, as they remind themselves to re-invest human values in the most challenging human profession that they have committed themselves to!

Time makes all the Difference in an Emergency

The relatively high proportion of people who suffer and emergency and do not make it alive is well related to the significant delay in appropriate treatment reaching them. Some of the common situations are:

1. Chest pain, heart attacks, cardiac arrhythmias
2. Stroke
3. Accidents, especially involving the head or neck, or when there is associated bleeding.
4. Severe Allergies; especially with breathlessness, often called anaphylaxis
5. Seizures, fits, coma
6. Difficulty in breathing
7. Bleeding from intestines or a perforation.

Others such as appendicitis, gallbladder pain, pneumonia, sepsis or cancers are of course important, but a few extra minutes may not make so much difference in the immediate outcome unlike the seven listed above.

During an unexpected emergency last week when I had a close brush with death, one of the main reasons behind my survival was TIME. Paying attention and doing things ON Time may make a lot of difference should you have an emergency.

1. Save the EMERGENCY numbers on your cell phone: Hospital emergency ( at least 2), Ambulance services, Doctor (your personal one), a critical care expert, apart of course that of the police and fire services.
2. Share these numbers with each member of the household as well as neighbors…don’t keep them to yourselves alone.

When I suddenly lost consciousness due to a cardiac arrest, each second could matter. As I was not in a position to call anyone (was unconscious), my wife had the presence of mind to call 3 numbers…that ensured.

It might well be possible or necessary for others to call on your behalf.

• Keep the home address save on your smart phone, preferably with a location indicator on Google map. It makes it much easier for the ambulance to reach home than trying to give verbal instructions all the way.
• Keep money at home, in case you do not use credit cards
• Informing relatives and explaining things to them should wait till the above emergency issues have been lined up.
• Try not to bargain with doctors when they are trying to save your life. I have seen some people wanting to have a detailed discussion and seek endorsement of distant relatives, when each second could matter
• Make sure that you have an ADEQUATE Health Insurance policy, preferably a cashless one. Make sure you declare all your health issues when you take your policy…don’t hide facts like diabetes, hypertension so that they do not become reasons for rejection.

Do these today please, and do not postpone till tomorrow, as you never quite know when it could become necessary.   

Do Patients’ Expectations and Attitudes vary? East vs West

One may argue that if body organs and illnesses have common patterns of afflicting the human race, why should responses, reactions, expectations and attitudes between Indian and Western patients be so different.

• In the West, particularly in Western Europe, patients fiercely uphold their right to know the diagnosis. If it is a cancer, the patient is often the first and only one to acquire that information. They often demand to be told explicitly what he is suffering from, the stage, the treatment options and the likely options. The doctor is bound to share this with the patient directly in most instances.

In Oriental cultures, such as India and Japan, the family often assumes the role of the guardian cum care-giver and very often requests the doctor not to divulge the “C” word or break the bad news to the patient, fearing that he may be unable to bear the blow.

The patient’s right to information and decision making all too commonly shifts from the patient to the “responsible” relatives, the doctor often finding himself trapped in an awkward position of having to lie to the patient if he is asked a straight question.

In a survey conducted in Japan several years ago, 80 % of respondents did not want a “bad” diagnosis or poor chances of survival to be told to their elderly relatives…something quite like India. While the figures may have moved marginally, responses in India have remained similar.

• Confidentiality about a patient’s clinical details is often a very strictly guarded and valued aspect of care in the West. The French president Francois Mitterrand was solely privy to his diagnosis of prostate cancer that he hid from the public and family for over 10 years. His  long-time personal physician kept it a secret too , but provoked a furore a decade later by revealing in public, and got sued for violating professional ethics.

India is quite a contrast: the doctor is bombarded by questions or phone calls about the diagnosis, status and details of reports, not just by a “care-giver” relative, but friends, in-laws, office colleagues, bosses and even neighbors!

Assuming that these questions sprout from genuine concern, most doctors usually do share some updates. But “confidentiality” is usually not on top of the list of our virtues.

Marking the door with a red cross of those who had tested positive during COVID times might have served public health, but plunged an individual’s sense of privacy and confidentiality to very low levels!

Several colleagues who have practiced medicine in developed Western countries find the transition back to India difficult. What makes it so, are not the diseases, but our social and cultural responses. Will discuss some more next week.

Making Patients Active Participants in Treatment

The overwhelming majority of patients are quite accustomed to playing the passive role in treatment. When they have a symptom, they go to a doctor, get a few tests done if advised, take the pills or injections, and think no more!

If asked what the doctor diagnosed or what line of treatment he suggested, they are usually blank.

This “passive” approach does not work well in long-haul treatments where the patient and family has a significant role to play.

Take for instance the wide range of “life-style disorders” such as fatty liver, diabetes, hypertension, obesity and heart disease. If the nurse measures the height and weight, and calculates the Body Mass Index (a measure of how much one weighs for his height), he merely comes off with a figure not learning what it means, and what he needs to correct.

Studies have shown that engaging patients to discover themselves, could help convert them into “active” stakeholders. If each clinic provided a facility to assess a patient’s anthropometry (height, weight, body composition, BP) and the patient was asked to read off the BMI value on  chart provided, he would immediately get to know if he was off the mark.

Reading his measurements on a chart, and finding his value in the “red zone” prompt him to ask “what should my ideal weight be? how much off the range am I at present? What should I do to get back to the green zone?”.

And even more importantly, to ask the question, “What is the risk if I remain in the red zone?” This is the concept of HEALTH PROMOTION, where the patient gets educated as well.

Thanks to technology, there are enough gadgets available now that could tell your heart rate, rhythm, blood pressure, blood glucose, body composition and so on.

Patients are however clearly divided on two lines: some who use them too often and turn hypochondriacs, or the other who do not bother to learn at all!

I was disappointed when a friend of mine died of COVID recently after being in ICU for over 2 weeks. Both his otherwise well-educated gown up children rang up to ask “what is a ventilator?”. Worse, the son wanted to take the “body” home for a few days, completely oblivious of the risk it could pose to relatives and neighbors!

Awareness about health issues is no longer a matter of curiosity or general knowledge, but a necessity…and each person needs to play an ACTIVE role in it.

Faith, Facts and Future

Faith leaders have played a crucial role in society, in anchoring a set of beliefs and values, when the world has seemed to change too much and too quickly.

The recent death of the Hindu saint, Sri Kapil Dev Das and nine others, of COVID infection after attending the Kumbh Mela in Haridwar, was indeed sad. Death of saints deprives the world of deep religious knowledge, immense spiritual prowess and charismatic leadership.

Faith and Science have however had a long history of sitting uneasily together. Ever since Christians in Europe were called upon to choose between the Book of Genesis (Faith) or Charles Darwin’s theory of evolution (Science) regarding how we humans came to be born the relationship has had its ups and downs.

With COVID raging this year and on advice of scientists, the Pope cancelled the traditional Easter celebrations and gatherings in the Vatican this year; this not only helped followers to practice a muted ritual but also absolved them of any feeling of guilt for flouting religious tradition.

Faith, tradition, rituals and customs form a part of every culture and provides “character”, and meaning, to otherwise mechanical lives. They provide that much needed sense of “belonging” and purpose making followers bond together as a group to share similar beliefs and values.

Regardless of our following of religion or politics, it is becoming increasingly difficult to escape from the real-world evidence of damage that the small SARS-Co-2 virus is causing to our lives, nation, economy and future.

And we are once again at crossroads being called upon to choose  “faith” that requires us to believe first, or “science”, where we are required to see first, and firm up our beliefs based on them. It is time we shunned the “this alone in this form” approach and learnt to accommodate science and evidence as a part of evolving religious or political beliefs. 

What we choose to believe needs honesty too. Even astrologers require exact data (date, time and place of birth) to make accurate predictions. How then can public health experts or scientists provide forecasts based on inaccurate data of numbers infected, disease and deaths?

In the last month, each one of us would have come across one or more seriously ailing relative or friend unable to get a hospital bed or oxygen. Some would have died, and we would have heard their relatives recounting harrowing experiences in crematoria or burial grounds. Haven’t we all cringed at the pictures of our hometowns appearing on international media showing long lines of lit pyres.

Two international science journals, The Lancet and Nature, in their issues this month, have highlighted the importance of accurate data (reporting) to understand the magnitude and nature of the problem as a pre-requisite in planning and strategizing our COVID response.  Manipulating data to cushion us and give us a sense of comfort, could be a disservice at this crucial stage as honesty is indeed the need of the hour.

It is time we lived up to our reputation of being the pharmacy of the world and ramped up our own vaccination program to protect our citizen. If Americans did not hesitate to say “America First” should we not expect our leaders to say (and also do!) “India First” ?

How is technology changing healthcare?

In my last column, I discussed how technology is changing healthcare, and focused on the impact it is having on doctors and patients. The effects of technology are however stretching far beyond to other aspects of health care as well.

Clinics and Hospitals

One cannot think of any modern health care facility today without computers, and their role is expected to grow exponentially.  Most good hospitals have already started keeping patient’ s clinical data, visit and progress records, investigations, bills and payment details in computers.  It makes data retrieval easy. The patient need not carry heavy files and x-ray plates in briefcases or suitcases any more. Also, it is much more easy to pull out all the reports and clinical details by the doctor during consultation, some of which the patient may have forgotten to bring.

This makes cross-reference easy. A cardiologist sitting in his clinic in another country can see the video-picture of a patient’s coronary angiogram, and advise him by tele-consultation.

This new aspect of healthcare delivery has stimulated several computer companies to develop new software for clinics and hospitals, and they are getting better and cheaper with time.

Payment for Healthcare

The scene in India is in huge contrast with that of developed nations, in that only 20% or less of our citizen are covered by any form of health insurance. In other words, around 80% of our patients make out-of-pocket payments for getting medical care.

This is indeed worrisome as medicines, medical procedures and hospitalizations are getting very expensive by the day.

This upward swing in costs has predictably generated two types of response. One is to try and bring the costs down both, by policy (say costs of antibiotics sold by pharmaceutical companies, devices like cardiac stents sold by device manufacturers, hospital charges for procedures etc. This is certainly imperative, as even the USA with all its wealth adopted Obamacare that Mr Trump has not been able to shake off.

The other approach to deal with increasing costs is to have someone pay for it, ie medical insurance. If one wants to go for a robotic surgery with its many advantages and safety features, it is bound to cost more– the machine is expensive, the setup is costly, and doctors who train at it expect better remuneration and so on. Hence health insurance is becoming imperative.

E-Pharmacy

Medicines that are sold in pharmacy shops are indeed expensive as they are sold by the MRP printed on them. If you were to buy the same medicines from a whole-seller, it would come cheaper as it would be shorn of the retail margin.

E-pharmacies are doing just that. They are buying medicines form the pharmaceutical houses at “outlet prices” and selling them on-line with small profit margins. This is making a lot of difference especially for those who require long-term therapy, and can help them save much on a monthly or yearly basis.

Technology is inescapable. It depends on us how we make the best of it.

Technology in Healthcare?

Even the worst skeptics will concede that if Indians are living longer these days, from an average of 34 years at independence, to 65 years now, our health care, despite its many deficiencies, must have had a role to play in it.  Wider and better vaccination coverage, oral rehydration, affordable antibiotics and, easier access to health care must have all contributed.

But how is technology changing health care, and how is it poised to change the landscape in the next five years? This was the subject of a recent brain-storming meeting in which several leading experts from multiple specialties as well as health-care professionals took part.

1. What do DOCTORs need to adapt to?

Most patients want their doctors to be knowledgeable and updated about new tests, treatments and guidelines. As it is impossible to keep pace with the exponentially expanding volume of medical knowledge, doctor’s will spend less time reading books in libraries, and depend more on tools and technology that will provide them immediate access to specific recent medical information. The transition is already occurring, and a wide range of apps and calculators available on hand-held devices are replacing the conventional ‘medical websites’ accessed through conventional computers.  It is all about quick access to latest information. The patient sitting across the table or on the other side of a video-consult camera, needs quick answers!

Technology is expected to play a greater role in medical education too. Webinars are already in fashion, and tele-discussions are likely to replace many of our conventional conferences. Internet and social media based focus groups are engaging specialists already, and not being a part of some of them is already beginning to make many feel obsolete.

2. How are PATIENTS likely to change?

Most net-savvy patients in metros are already depending heavily on technology, from searchingthe net to find out about their symptoms, disease and treatment options, to selecting an appropriate doctor they wish to consult or a hospital they wish to visit. This method is partly replacing the familiar “referral” by other doctors as well as the “word-of-mouth” recommendation by other patients.

The next thing that will happen is for patients to save time and travel, and seek consultations from doctors, either by e-mail or messaging service platforms, or by tele-consultations. Skype or one of its newer avatars, where one can have a video chat with a doctor or counselor, is already in vogue in many places, replacing a good chunk of the “conventional” face to face meetings.

Tele-consults are bound to increase, and are particularly useful for chronic health issues where one needs adjusting the dose of medications. Most busy patients will want to avoid take leave to visit a hospital or doctor for say minor adjustment of insulin dose for instance.

Devices technology is expected to grow and replace conventional lab testing in a major way. Most educated patients with diabetes or hypertension are already using home monitoring devices for measuring their parameters, and sharing these results with the doctor for appropriate medical decisions. Apps on watches that tell you calorie consumptions, calorie burned, weight, heart rate, Body mass index and other parameters are finding increasing use.