Interesting . . .

Since the lastweek, The Hindustan Times has been doing a feature on the billionaire Indians. 

I found this table along with the last article on it.

To have 28 billionaires (18 in pharmaceuticals and 9 in healthcare) who made to the list by making a business out of caring for the sick and dying is a bit disconcerting to me.

I wonder if this statistics bothers anybody else . . . 

Clinical Establishment Act - Please respond

This is a post which I should have posted much before. I’m not sure about how many know about the Clinical Establishment Act 2010 which is being slowly implemented in the country. Couple of states like Assam and Orissa have already implemented it. There are many a hospital in both these states that have been closed down because of the regulations stipulated by the Act.

Recently, there was a notice from the the National Council forClinical Establishments under the Chairmanship of Director General of Health Services, Government of India inviting comments, suggestions, objections, including deletions /additions in the draft documents prepared by them from the public at large and concerned stakeholders.

I personally have much misgiving to the regulations of the Act in the present form.

1.      In a country like India which is very vast and the majority of the population (about 70%) lives in villages, it is going to be very difficult for anybody to set up hospitals in semi-urban and rural areas. The stipulations are going to be very hard to meet that setting up a hospital would hardly be a profitable venture. The other side is that even if hospitals are set up, the cost of care would be quite expensive. Almost all of us have mostly depended on small clinics or nursing homes which are run by a single doctor with the help of a nurse or by a doctor family. In fact, quite a lot of us may have knowingly or unknowingly gone to a unqualified practitioner or quack for our small medical problems. At present I live in a place where almost 95% of the population go to a quack first for treatment. They have bungled up cases where the patient ultimately died. However, nobody has been able to do anything. The only reason being that these guys are the only people who have some knowledge about medicine in remote settings. And they come very cheap. The regulations appear to be giving more importance for corporate multispecialty hospitals. This is quite protectionist in nature towards encouraging a corporate model which will ensure that healthcare is only available at a premium in the absence of an efficient public health care system.

2.      There is enough scientific evidence that family practice and nurse practioner based primary care is as efficient, and rather more people friendly than specialist doctors in full fledged hospital set ups.

3.      If you consider any of the complex clinical conditions one can think of, the primary level of care is much more important than high tech healthcare. We have examples of countries like Brazil and South Africa, where Family Medicine graduates have major role in healthcare. The present regulations would only increase costs. If you look at the regulations, the first level of treatment is going to be a Level 1 Hospital which needs to have a staffing of at least 6 for a place which do not have inpatient care.

4.      Most of our tertiary care centres are burdened with primary care. It is not uncommon for any faculty in our medical colleges who end up complaining that most of the patients that they see could have been easily managed at a Primary Health Centre or even by a Nurse Practioner. The ultimate result is that quite a many of our specialists are over-worked to the extent that they are not able to do justice to the specialised skills they’ve obtained.

If we can think of changes that can be proposed, I would propose the following –

1.      Legalising Nurse-Practioner Care: Nurses should be trained to treat simple illnesses allowed to prescribe medicines. A major need would be to allow a category of healthcentres which are entirely run by nurses who may or may not supervised by doctors. At least for populations who have poor access to healthcare, they would be a major boon. In fact, such nurse-led primary care centres have already been in existence in the country, mainly facilitated by various congregations of the Catholic Church.

2.      Provision for single doctor healthcare centres: We are all very familiar with such single doctor establishments. A 100 square feet room with a familiar friendly face to whom you ran when you had a toothache or a cold. You pay about 50 rupees and then you pay some more for the medicines and some basic investigations. The whole process took not more than half an hour. If the regulations in it's present form are accepted and finalised, the family doctor would be history.

May I encourage you to write back to the government, details of which can be found at http://clinicalestablishments.nic.in/WriteReadData/896.pdf.

The Determinants

Public health believes very much in the socio-economic determinants of health.

Many a time, we find it quite common to very good clinicians treating their patients with hardly any regard to these determinants of health. One of my teachers told me that if a clinician, however good he is, if he/she does not heed to the socio-economic factors related to his patient, he is never a good doctor.

The unfortunate part of this is that in an impoverished place like ours, although we know about socio-economic issues related to a patient, there is hardly much we can do in many cases. I’m not sure how many will remember Sabita Devi (SD). SD graced the inside cover page of our Annual Report 2012-13 (after page 16). SD’s story was one of our Human Interest Stories.

SD along with her husband turned up yesterday. It seems that SD’s condition had suddenly turned for the worse. She had skin growing over almost the whole of her burnt area. She was doing good. 

The family had some amount of land where they cultivated grain. The produce was quite good this year. But, that was not enough to sustain the family as there was added burden of SD’s treatment. The husband decided that he could make some extra money and therefore went as a migrant labour. But, that was a terrible decision.

The absence of her husband ensured that SD was not well taken care of. There was nobody to ensure that she got her dressings on time. And more than that, there was no one to buy food and coax her to eat well.

SD’s husband came home after about a fortnight to check out on her. SD had lost weight. The skin which covered her burnt parts of the body had started to fall off. He called Dr. Nandamani who advised them to bring her to NJH.

It was obvious. She was terribly malnourished. Investigations confirmed it. Hemoglobin of 7 gm% and Serum Albumin of 2 mg%.

We requested her to get admitted. But the family would not have any of that. I told them that they’ll need to pay only for the dressings. But, the family had worked it out. The indirect costs were too much. There was a crop to be harvested . . .

I don’t know whether SD will return back . . . If she returns, that would be another miracle . . . 

Poverty . . .

Over the last 2 weeks, we had two instances where we were exposed to the stark reality of how poverty affects families, especially when it comes to healthcare. 

I shall start with the patient who I mentioned in my previous post on obstetric care. 

We shall call her Kkd. Yes, the lady who came in with a hemoglobin of 4.6 gm% and then had a hemoglobin of 2.6 gm% more than 12 hours after the delivery. I just got news from Acute Care that the relatives were able to arrange a pint of blood; almost 24 hours after she had delivered. 

Now, the whole question was about the reason why the family never brought her for delivery to the hospital. It seems that she was taken to the place where she had her antenatal check ups as well as to the nearest district hospital. She was turned away from everywhere. 

If we had got couple of pints of blood, we would have done off the Cesarian in no time. 

I believe that it was the good Lord's providence for her that she delivered normally. And then the family could arrange one pint of blood. Most probably, that is the maximum that they can arrange. 

The whole exercise of a Cesarian section with couple of pints of blood transfused would have resulted in quite a financial strain for the family. I realized it today morning when the nurses told me that they did not have money to pay for the medicines. In fact, we had admitted her without any advance. 

The relatives had been running helter-skelter to get some decent treatment for this poor lady. The fact was that almost all of their money had been spent paying for transport. 

However, while the process of getting blood was on, one of our nurses had caught bits of their conversation and found out that they were in the process of paying a huge amount to buy blood. 

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR. 

We somehow convinced the relatives to arrange a donor and get the pint of blood for just 350 INR. I'm happy that they heeded the advice. 

However, it was obvious that the family had run out of financial resources. 

All of us have failed them. From the very beginning. 

They had gone to a doctor in his private clinic thinking that they would get the best treatment. He/She had written quite expensive iron, multivitamin and calcium tablets. Which they brought. Instead of 30 tablets for a month, they had brought one strip (10-12 tablets) which was used for 2 months. 

They never got clear advice on what needs to be done when she goes into labour. No plan . . .

And even after she got admitted . . . unless our staff overheard the conversation about the blood, they would have spend much beyond their capacity and got the blood, which many a time is of very poor quality.

To be frank, for the poor, there is nothing much left in our country. They are the mercy of anybody and everybody. The question is whether 'the haves' of our country are listening. 

Leaving alone the subject of poverty . . . if there is 2 things which could improve maternal morbidity and mortality in this part of the country which is more of a problem for the poor and marginalised, I firmly believe that it is free availability of Iron tablets along with an awareness about the intake of these tablets and the second one - undoubtedly, UDBT.

Unsung . . .

This post is just an attempt to bring to all of your notice about quite applaud-able efforts by a section of medical students and fraternity to maintain distance from the pharmaceutical industry when it came to a conference on medical research. 

It is quite well accepted that drug companies offer incentives varying from pens and letter pads to tours abroad in the garb of attending conferences. In fact, the popularity of a doctor is gauged from the number of medical representatives who visit him or her.  

I know of my colleagues who try quite a lot to keep medical representatives in good humor lest they spoil his/her practice. And when it came to research, most of the companies fall head over heels to placate doctors and their families. 

What startled me was the very little publicity that this conference got in terms of media coverage both print and electronic. I could only find one newspaper who reported about this.

I remember that there were 3 such stories including this, which I highlighted in my blog and it was disturbing that all 3 of them were reported in only one newspaper (each time a different one). The media falls head over heels to report misdemeanors in healthcare but remain largely mum when there are heroes who work silently without any applaud or rewards. 

And all the more when a National Conference is run without any pharmaceutical funding . .. ... 

Don't you think so? 

The Occult . . . The Paradoxes of Indian Healthcare - Part 3

India has always been associated with the occult. And you may be surprised that the myriad religions, the thousands of gods and goddesses Indian culture is associated with has nothing to do with this. Irrespective of religion, caste, economic status . . . people depend on the occult for healthcare . . . 

Today, I came across 3 patients who tried it out . . . and it's usually the case for the conditions involved. 

The first was a young boy who had an acute episode of seizures in the morning. The relatives brought him straightaway to hospital. After the seizures was controlled, the brought in one of the local exponents of black magic to throw out the evil spirit from the boy. Our staff had quite a tough time dealing with the relatives as they were quite well off. 

The second patient was not that lucky. Bitten by a cobra early morning today, the family had been subjecting him to all mumble jumble till about afternoon when they realised that he may do better in a hospital. He arrived at around 5 pm at NJH. There was no respiratory effort. There was a faint heartbeat. From our previous experiences with cobra bites, Titus commenced CPCR . . . then he realised that it may not of any use. The pupils were already dilated. 

The third patient was also a snake bite victim, a young girl with viper bite, who came in more than a day after the bite with a very bad compartment syndrome. Dr Nandamani did a fasciotomy only to find out that one part of the leg was already badly gangrenous. 

We were sure that the chances of her going into a below knee amputation was quite high. We referred the girl. 

Unfortunately, the parents were too poor to take the girl elsewhere. However, I did not want to manage a potential high risk surgical condition without the surgeon around. They promised to take the patient elsewhere next day. Sometime later that evening, I found out there was a commotion in the Acute Care where the girl was admitted. 

It seemed that the family had arranged for a 'witch-doctor' to come and do sorcery on her. I chased them out. Later, I found out that couple of my staff were also involved in arranging the witch-doctor. I called them and asked for an explanation. However, they denied any involvement. I did not have any evidence. However, later, I found out that they had initiated a discussion with few other staff on the reasons why I should have allowed them to do the sorcery. 'The doctors are anyway referring, so what is the big thing about the relatives trying out jaad-phook (black magic) for their daughter'. . . that was the justification. 

It was shocking . . . unfortunate, but true. 

The worst aspect of the use of occult is that  most of the diseases where the populace invokes the witch-doctors are clinical conditions which merit immediate medical attention . . . SNAKE BITES, SEIZURES, ECLAMPSIA . . .the major ones we're concerned about. One more disease for which the witch-doctor is consulted is HEPATITIS. However, since it is not an acute condition, we do not hear much about it. 

The amount of money that these witch-doctors make is enormous. 

Considering that modern medical facilities are very much far away in terms of accessibility, availability and affordability, it would take quite a lot of effort to turn away the common man from these money mongers. Talking about money mongers, the sadder aspect is that modern clinical practice is also very much in danger of reducing it's practitioners to money mongers . . . which is not much different from our 'witch-doctors'. More about that in my next post on the Paradoxes of Indian Healthcare . . . 

Serving along with us . . . Prayer Request . . .

It has been quite a hectic week at NJH. As we are pleasantly occupied with serving the people of this region, we've always known that we could do with more help. Of course we have new projects, in disability, RSBY and Climate Change which have been approved and we are looking at the possibility of new people joining us in the Community Health Department.

In addition, we need at least consultants in Medicine and Pediatrics, couple of people in administration, a X-Ray technician and a Pharmacist.

All over EHA, we have realised the need for more people to join us. 

Last week our Director had come out with a letter of appeal for people to consider working alongside us. 

This weekend, could I request you to help us out with prayers that more people will join us . . . I'm sure that with a bigger and committed team we can work wonders and be the 'salt and light' for this region.

Of course, we are thankful for the people we already have, but we need more . . . Please do pass this post to people who you think would be of help to us . . . 

Maybe, who knows? The Lord could be calling you to serve with us . . . 

Prayerfully, Jeevan