BETLA DIARY DAY 2 AND THE QUACK. . .

Combined continuation of Betla Diary 1 (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html

) and QUACKS / RMPs (Registered Medical Practitioners) (

http://jeevankuruvilla.blogspot.com/2011/08/quacks-rmps-registered-medical.html

)

After a quite night at the 'Tree House' we were up early for the elephant ride. Unfortunately, the gentle beast, named 'Anarkali' was not at all in a good mood. To make matters worse, my son Shalom decided not to mount the elephant. Therefore, it was me, Angel and Charis who made the trip. The ride was quite a bumpy one and we did not see much of wildlife - only the tracks of elephants and bison. We had a fleeting glimpse of a pheasant and a large eagle.

Having finished our time at Betla, we had decided to drop in at the quack's joints on the way back. I had promised to give a detailed description of the visit.

To start with, the quack whom we shall call RNP, is in his late 20s. He had come to me about 3 weeks back requesting me to help him out if there are any complications in his clinic. I told him that what he was doing was quite dangerous. It was a bit difficult to believe him - but he claimed that he was doing hydrocelectomies, herniorrhaphies and appendicectomies under ketamine. It seems he had worked along with one of his relatives who was a surgeon in Ranchi and had picked up quite a lot of skills. He had got hold of a degree called BIMS - supposed to be Bachelor of Indian Medical Science.

I reached his clinic at around 12:00 pm today. There were two more people in his clinic whom he introduced as his compounders. On his table was a stethoscope, a quite old edition of Hutchinson and a microscope. He had prescription pads with his name printed on them with the degree BIMS in the end. I had wanted to get photographs of the place, but later decided against it as I felt that he could get suspicious about my intentions.

More important than the clinic was it's location. Situated between the towns of Daltonganj and Barwadih - the place was very strategically located. There were hardly regular vehicle services to the region. Even if someone got sick, the nearest place where there is a good hospital is Daltonganj which is Rs. 700 away by jeep. NJH is also Rs. 700 away from this place. Maybe that is the amount RNP would charge for a day's treatment of malaria with intravenous medicines.

After about half a minute in the clinic, he wanted me to visit his ward and operation theatre. And I got the shock of my life - the ward comprised of a room which must be about 20X15 feet with dirty floors and the operation theatre comprised of a plyboard walled off space of about 6X8 feet. Funnily, he did not show me what was inside of the walled off space.

There were three patients in the 'ward'. The first patient he introduced as a patient with fever whom he was giving intravenous quinine. The second was a lady on whom he had done an appendicectomy 3 days back and the third was a young man on whom he had done a surgery for hydrocele 4 days back. There must have been a total of about 10 people in the 'ward' - bystanders of the 3 patients.

On my way out from the ward, I asked him how much he charges. He charges according to the capacity. For the appendicectomy he had charged Rs. 3000 and for the hydrocelectomy Rs 2000. For the poor people in this remote area of Latehar, he was a life saver. He may have been a life taker too. However, isn't that true with us too - qualified medical professionals?

One of my acquintances who has known RNP for the last one year told me that there have been complications - but he is such a remote area the locals think that he does quite a big service to them that they do not make much of an issue with cases that go awry. I've seen the same happen with many other quacks too - where the patient readily accept any complication that happens, with the excuse that he is a quack rather than a qualified doctor.

I'm happy to made acquintances with a 'reputed quack'. He will be definitely keeping in touch with me for tiding over his complicated cases. I'm sure that I would be able to convince him to learn about the public health aspect of conditions which we find in such rural areas. Whatever said and done, people like RNP would find more favour in the eyes of the common poor man in remote areas of the country than fully qualified clinicians like me who is too busy, too far away and too much complex sounding for the rural poor.

QUACKS / RMPs (Registered Medical Practitioners)

The first point of contact for healthcare for almost 60% of the Indian population is not a qualified doctor, but someone who has some sort of experience in treatment of diseases. For qualified medical practitioners, it is quite unthinkable to even contemplate about unqualified people practicing medicines. I used to think that quacks are a problem in only in the rural areas of the country, till I had a conversation with my dad – that was when he told me that when he was posted in Tinsukia, a town in North East Assam, there were hardly any qualified doctors. When any of us fell sick, it was to a quack we went for treatment. Of course, the quacks were more polished than the ones I see now in the villages around NJH.

I remember quite well the chamber to which we used to go when I or my brother used to fall sick. My father later told me that the ‘doctor’ whom we used to consult was in fact an apprentice to a former army doctor. Of course, we used to get better after the treatment from the quack. With the present state of medical care in the country, they have become a sort of ‘necessary evil’.

There have been enough efforts taken at various levels to involve quacks in the evidence based management of cases. The Revised National Tuberculosis Control Programme, the Acute Flaccid Paralysis Programme etc. are few national level programmes who have tried to involve them. We had tried to involve them in helping them find out danger signs whereby they would be able to refer patients to hospitals at the earliest. Unfortunately, the response from them have been quite disappointing.

However, the saddest story in the medical care sector of the country has been the overwhelming commercialization of the pharmaceutical industry, which is unblatantly interested only obtaining profit by hook or crook. A related post (

http://jeevankuruvilla.blogspot.com/2011/08/pharmaceuticals-in-india.html ) to this is the proliferation of unethical combinations of medications which are very freely used by quacks and doctors alike. Unfortunately, the pharmaceutical industry has been well supported by quacks in increasing the market of medicinal preparations and more so for the unethical combination preparations. Among the quacks they have also found brother-in-arms to combat the cost effective generic preparations.

What makes quacks so popular? There are quite a lot of things which we need to learn from the quacks. One of the major aspects which make them quite endearing to communities, especially in the rural areas is their ready availability for service. It is quite common to see them moving around in our nearby villages in cycles or mopeds with a bag filled with all the necessary implements, medicines including injections. The bag which they carry around with them has given them the name ‘jhola chap’ to such doctors in our part of the country.

Now imagine a patient coming to my emergency. The present system is that the nurse would first take the vital signs, and then inform a doctor – it takes some time for the doctor to come, most of the time it would need an admission. And with that come the costs - which bring us to the next advantage with the quack. They take their payment any time and in any kind, which is very difficult to obtain in the present system of treatment in any hospital of the country.

The next point is something which is quite an important aspect which needs to be noted by every qualified medical professional. That is the ability to communicate – clearly, logically and in a language which the patient can comprehend. We have very little time for our patients. Each of our patients are cases and beds. The humanity and identity of the patient vanishes the time they enter our ivory towers.

The last point is the treatment of demand which most of the quacks readily obliges. This makes them quite popular. I never took this aspect quite seriously until I met a quite senior medicine consultant in a mission hospital in the South of India. I was shocked to find quite well looking people in the emergency lying in the beds in the emergency ward taking intravenous fluids. I enquired about this – when she told me that many people came to her for i.v fluids for strength. It was a bit difficulty and when I enquired about the ethical part of it – she told she knew that there was not much of a evidence in giving i.v fluids for no reason, but that was what the villagers wanted. She took over the hospital when it was really going down – she struggled for the first two years. Later, just to make ends meet, she started to slowly oblige the villagers' demands for specific treatments. And within no time, she was quite popular. At the end of the visit, I felt she looked more of a quack than a qualified medicine consultant.

Except the last point, I strongly feel that the rest of them are major learning points for modern medical practitioners. By the way, I recieved an invitation to visit one quack and his practice in a nearby village. I've heard that he managed to even do surgeries - herniaplasties and hydrocelectomies... I happened to meet him during my break at Betla (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html). Please watch out for a blog on the interactions with him.

BETLA DIARY, Day 1

It was only couple of days back that we took a decision to take a break from hospital work for couple of days and be at the Betla National Park which is only about 15 kms as the crow flies, but about 40 kms away by road. It was the first park in the Indian subcontinent where a tiger census was done sometime in the 1910s. However, over the years the number of tigers have come down from to technically 8, but practically one which was sighted sometime in January 2011.


We arrived after a hurried day for me at the office. We had finished our selection process for the nursing school over the last couple of days. I had barely any time to pack, but my sweet better half had ensured that all my essentials were taken. I had hired one of the outside vehicles for the trip rather than take a hospital vehicle.

The drive was uneventful. The scenery was superb after the regular rains we had over the last couple of months. It was so pleasant to see the Auranga river full of water.


We had not done our homework well on where we would stay. We had booked a room in the Jharkhand Tourism Development Corporation guest house called 'Van Vihar'. The decision was a tragedy. However, we were blessed to have the 'Tree House' of the Forest Department unoccupied and we shifted over to the same, today afternoon.

We had a quiet overnight stay at the former place. Today morning, we came down to the park entrance for an elephant ride. Unfortunately, the gentle beast was booked for the day. The mahout offered us a booking for the next day which we gratefully accepted. However, we decided to try our fortune to sight some animal by taking a jeep-ride. The only thing we spotted was few monkeys and a peacock. The guide assured us that we would definitely spot elephants if we came back in the evening. We had come down to get some time of peace and quietness. Therefore, we politely declined the offer.


Later, in the morning, we had a time of worship at the Gems mission centre. It was humbling to see very poor people come down to this place. Pastor Santosh is doing a very good work among the people in this region.


After a simple lunch at the Forest Guest House of which the 'Tree House' is a part, we had a good afternoon siesta after quite a long time. We planned to go to the museum before it closed for the day. Unfortunately, the staff had decided to close it early and we will have to postpone our visit to the museum for our next trip to the park.


By evening, quite a big horde of deer had come down from the forest to the 'Tree House'. We had a good time just watching them graze.

We wait patiently for the elephant ride tomorrow. Who know? We may see the tiger tomorrow (http://jeevankuruvilla.blogspot.com/2011/08/tyger-tyger-burning-bright.html).

MISMANAGED BURNS

LD had just finished bringing in light to every corner of the house as is the customary Hindu tradition sometime in the first week of June. The light source she used was a old tin filled with kerosene with a hole in its lid for a wick. Different places know it by different names – in quite large parts of the country it is known as ‘kuppi batti’ and is notorious for causing burn injuries. In fact during one of the conferences I attended on burns, I learnt that there is quite a large movement to abolish use of these ‘kuppi battis’ and it is not only prevalent in the Indian subcontinent but also in other South Asian countries as well as Africa and South America and is a leading cause of burn injuries in all these places.

LD must have been a bit careless. She kept the lamp on the floor and was just about to turn around when she realised that the free end of her sari had accidentally tipped over the lamp and the kerosene had drenched the tip of her sari. Within no time, her sari was on fire. LD does not remember quite well about what happened next. By the time, she came to her senses the only thing she knew was that the area below her waist has been fully burnt. Her husband later narrated that it was only because of the presence of mind of her nephew who cried out 'fire, fire' that she did not get fully burnt - quite a number of people nearby ran to her rescue and put off the fire.

But the damage was done. The family took LD to the district hospital where she was admitted for about 3 weeks. LD's husband noticed that nothing much was being done and she was not at all healing. Instead, the wounds had become a dirty yellowish in colour and was stinking. He knew he had to act fast. On his own will, he brought LD to a private practitioner in Daltonganj. He had a very interesting experience here. A junior person, an old acquintance of the family, presently working along with private practitioner warned him that the private practitioner is in fact not a qualified person and that he is more interested in extracting money from his patients. He advised the family to bring LD to NJH.

NJH has now been with us for almost 2 months. When she came, she was in quite a very sad state - with infected crusts all along the area of her burns - which extended from her waist downwards to include the perineum and the upper two thirds of both legs. As is always the case with mismanaged or neglected burns, the percentage of burns (about 25%) had increased because of the superadded infection. She has had quite a number of surgeries after admission. There have been ups and downs. Her skin grafts have taken up well. She's glad that she has ultimately come to us.

Unfortunately, to many of us at NJH, LD and her family looked well off. The family was initially paying off the bills. Then, we noticed that they were finding it difficult. We also did not insist that they pay. Suddenly, the husband came with quite a hefty amount and paid off quite a large part of her bill. Dr. Nandamani found out how this was done. LD's husband had sold off quite a good part of his agricultural land to rake up some money to at least pay some part of her bills. It was something unfortunate.

We have insisted that they do not pay anything more. However, the outstanding bills amount to something around Rs. 40,000. Similiar to MI (http://jeevankuruvilla.blogspot.com/2011/08/prodigal-son-attempt-to-come-back.html), we are looking at the option of well-wishers and good Samaritans pitching in to cover part of her treatment costs.

 

 

LD looks forward to getting back home to her village in far away Garhwa soon.

PHARMACEUTICALS IN INDIA

This blog is written in the light of the article (

http://www.downtoearth.org.in/content/harmful-combo-drugs-flood-market) published in the magazine 'Down to earth'.

Combination drugs have always been a major issue in the Indian subcontinent. The major reasons for the popularity of combination drugs are quite a lot. I tried jotting down many of my thoughts on this issue which has been a bane to practicing medicine in India.

The foremost reason for the high popularity of combination drugs has been the fact that most of the doctors recieve their practical pharmaceutical education from medical representatives. I very much remember our days during internship when we had no clue on why we wrote a certain brand of iron or calcium tablets or even an antibiotic. Basically, there was a major gap between pharmacology classes in the second year and the medicines which were available in the market.

As I read through the article in 'Down to earth', I remember how one medical representative tried to convince me of the great advantages of a combination drug of diclofenac and ranitidine. Another drug - 'Dexorange' is an absolute favourite with many doctors and patients. I know couple of families who are regular customers of this tonic. Even well meaning doctors write this syrup very regularly for their patients. Very few of them realise that it's the alcohol within the syrup which makes them feel good.

The most flagrant misuse of all such combinations is most in the management of diarrhoea. I recently found out that there are companies who have started coming out with lactobacillus in ORS (oral rehydration solution) preparations. When we know that the most common cause of diarrhoea is viral - it is very unfortunate to find pharmaceutical companies trying push down all sorts of combination down the patient's throat - Ciprofloxacin+Tinidazole, Metrogyl+Norfloxacin, Ofloxacin+Ornidazole... The list is inexhaustive.

Another reason for this situation is the aggressive marketting of drugs in the Indian subcontinent and the huge profits which are at stake. The image of the generic drugs which were supposed to bring down pharmaceutical costs to quite a large extent has been badly tarnished. Generic drugs were potrayed as something sub-standard. I was shocked when my previous store keeper told me about 'unethical drugs' being kept in my store. I could not believe my ears when I realised that medical representatives had taught him that generic drugs are actually unethical drugs.

Since I started my second stinct in NJH, on many occasions I've realised that sometimes it is actually difficult to get a cheaper basic variety of a drug than a costlier 2nd or 3rd choice drug for a particular condition. A typical example was the availability of Hydrochlorothiazide (HCT). I had so much difficulty convincing my suppliers that this drug was the first choice for the management of hypertension. Couple of suppliers went to the extent of making fun at me. They told me that Losartan and Amlodipine AT are the latest medicines. A strip of 10 tablets of HCT 25 mg cost 4 rupees whereas Losartan cost 50-60 rupees. One can imagine the margin you can get from the latter. And we talk about cost effective management of non-communicable diseases.

To find out more about this is to request any doctor friend of yours to rummage through the drugs they recieve as samples. You may be surprised to find that there would be very few sample medicines which are commonly used and which are cheap. Most of them would be quite expensive medicines and there would not be enough to cover a complete course - especially when it comes to antibiotics. The game is simple - you give some of them free. Then you have buy the rest. I recently heard that this was the same ploy that the English used to popularise drinking of tea in the Indian subcontinent.

The story goes that when the English established tea estates, they found out that there was quite a lot of wastage as they only used the high quality tea dust. They somehow realised that that the low quality tea dust which was thrown out was also tasty. So, they organised free tea stalls for the local population. And as soon as drinking of tea became quite a popular past-time among the locals, the low quality tea dust was available at the cost - thereby ensuring that there was a revenue. (No idea on how true the story is. I heard it on a recent visit to Bangladesh)

Drug resistance especially with antibiotics is a major issue. Nowadays, it is very uncommon to see anyone prescribing antibiotics like septran or amoxycillin. Augmentin, Levofloxacin etc rules the roost and that too for a one day fever. A very simple medicine for urinary tract infection is Furulic Acid or Nitrofurantoin. Very few medical practitioners knows that this is the best antibiotic for community acquired urinary tract infection. In addition, there are only few companies who produce the tablet form which comes very cheap. And it is not very easy to get.

Whatever said and written, the bottomline is that the pharmaceutical industry has made a mockery of medical science in the country. I hope that the latest initiative from the planning commission will bring in some amount of control in the manufacture and sale of drugs whereby ethical preparations are available at a cost which the poorest of the poor can afford.