Wednesday, October 22, 2014

To treat or not . . .

As mentioned in my previous post of malnutrition, one of the major aspects that most of us doctors forget is the innate ability of the body to heal itself.

What happens if you don’t treat your pneumonia. Yes, there is a higher chance of dying and getting complications in the absence of treatment. However, there is a good chance of escaping unscathed even without medicines. Maybe, there would be delay in your getting better. Of course, there are major determinants of spontaneous healing like non-extremes of age, good nutrition, hygienic environs etc.

As public health consultants, we’ve been taught in school about risks and benefits. One of terms that helped me quite a lot was the concept of number needed to treat (NNT).

I was so happy to see a website called where one can find out more about the concept. Recently, there was a good article about it. I’m sure you’re going to get quite a few surprises about many of the traditional treatment protocols that we commonly use.

Some of my favorites . . . 

So, do check out if you really need to prescribe something about which you're not really sure about. You save a lot of money for your patient and maybe even prevent unnecessary complications . . . 

Itch, Itch, Itch . . .

Few days back, a mother brought her 10 year old boy to the clinic. Her complaint was that the boy told her that something was wrong with his private parts. I asked him what the problem was. He told that he is having severe itching and there is infected wounds filled with pus in his genital areas.

After quite persuasion, he agreed to let me examine him. His scrotum and penis was covered with pus filled ulcerated areas. There were few lesions which appeared to have healed resulting in quite bad scars in his scrotum and penis. I asked him if there was pain. He told that the pain was tolerable, but what he could not tolerate was the itching at night.

There was only one diagnosis – scabies with secondary infection. However, I had never seen this much extent of secondary infection in scabies. After advising the parents on the possible diagnosis, I got assurance from them that they would come within couple of days after I start treatment for review.

I was surprised to find the boy back after couple of days. He appeared quite cheerful. Once I was inside the clinic, I realized that the parents and his brother also had registered themselves for check-up. To my horror, all three of them had scabies over various parts of their body. And for the boy on whom I had started antibiotics, all the pustular lesions had healed and the lesions which are very typical of scabies was very obvious.

All four of them were started on topical applications to treat the scabies.

However, I was in for another surprise later that day. For the first time in my life, I saw an infant of less than 2 months of age with scabies. Of course, the mother also had scabies infestation on her body. The interesting thing was that the mother never thought of the skin lesions very seriously. Her main complaint was that the baby was crying throughout the night as if he was in pain. Little did she know that the itching was bothering the baby.

Scabies as an indication of poor personal hygiene. 

Yesterday, I was on a field visit with Prof. Haider, Professor of Birsa Agricultural University. It was very obvious during the visit to most villages that the drought has started to affect the daily activities of the villagers. Water was a precious commodity. Taking bath even once a day was a premium. The women were the worst affected.

The issue is that treatment of scabies also involves advise to take bath regularly as well as to wash all clothes, especially undergarments in boiling water. I wonder how this family is going to find enough water to do all that. 

I’m sure that I would be seeing a lot more of scabies over the next few weeks. I would also be interested to see what other diseases can a drought bring about. With an obvious issue with food security, my gut feeling is that we would be seeing an increase in the number of chronic infections especially tuberculosis.

Sunday, October 19, 2014

Immuno-compromised by Malnutrition

One of my favorite quotes is that by William Osler about the usage of medicine.

Unfortunately, almost all of us believe that medicines are the elixir of life. And when we take medicines, we want quick relief. Almost all over the country, quacks and non-qualified practioners have thrived on this and one of the major challenges in the healthcare scenario of the country is the unbridled use of medicines especially antibiotics and steroids. Of course, the pharmaceutical industry all the more promotes such usage. 

And as doctors we fail to understand the inherent nature of the body to heal itself, which is very evident by the way many of us prescribe medicines.

This becomes a major issue in poor and marginalized communities of the world as it is quite a fashionable thing to resort to medicines and injections and get well. A very dangerous trend when we look at the fact that issues of sanitation and nutrition are hardly given any serious thought.

I personally believe that in India, malnutrition is the most serious form of immune-compromised state. As medical students, we were trained to think of only HIV patients and patients on immune-suppressive medicines to be immunosuppressed. I hope to see a change in the attitude that many of our medical colleges have towards malnutrition. We don’t see many HIV patients or patients on immunosuppressive medicine, but we see so many malnourished.

In Barwadih, the population of which comprises mainly on permanent residents of the Kherwar tribe and a migrant population of people from Bihar and Munda tribals from the Ranchi plateau, we are stunned by the amount of malnutrition we see. We did a rough survey of children who come to us and it was quite alarming to find that almost 70-80% of under-fives who come to us are at least moderately malnourished. I’m sure the situation would be worse if we do a community based survey.

And I dream to do a community based survey to highlight the gravity of the problem in hard-to-reach areas. I’m sure that there are going to many determinants of this health issue which could be different from other regions.

The challenge is to find long term solutions especially in a situation where more than half of the nation’s under fives are malnourished.