Doctors as Humans

A few years ago, I was on a return flight from New Delhi to Paris and New York, when the chief flight attendant suddenly broke up the humming silence and asked passengers to ring the call bell if anyone was a doctor. One physician, a tall and handsome young man, quietly rang the bell and was ushered to the front of the plane where another flight attendant was in physical distress due to a panic attack.

The doctor provided the treatment, and the patient was stabilized. Just a respectful and quiet thank you from the crew at the end of the flight along with a bottle of champagne and a cache of 75,000 frequent flier miles as a token of appreciation! A good doctor in the neighbourhood is a great blessing. “Wherever the art of medicine is loved,” thus spoke Hippocrates, “there is also a love of humanity.” The ancient Greek physician (460–370 BC), regarded as the father of medicine, also gave budding doctors the oath, “First Do No Harm.” But now when healthcare has become a most essential human right, much more is expected from doctors.

Today doctors, with and without borders, are in the killing fields of Ukraine and Gaza risking their lives to save lives. During the Covid-19 pandemic doctors and medical professionals played heroic roles, working endless days and nights, to save as many people as they could from an unprecedented massive global health crisis. Unbeknown to many of us, Artificial Intelligence played a crucial role in the development of Covid vaccines and the logistics of the vaccines global distribution. Early this month, Dr. Saeed Hassapour, Director of the Center for Precision Health and Artificial Intelligence at Dartmouth College, organized a symposium that drew some of the most brilliant AI experts, physicians, and researchers including, among others, Dr. Curtis Langlotz, a Stanford Professor and President of the Radiological Society of North America, known for his work in applying AI in medical imaging, and Dr. Faisal Mahmood, an Associate Professor at Harvard Medical School, credited for his contributions to digital pathology and AI in cancer diagnosis, prognosis, and biomarker discovery.

The interdisciplinary gathering of experts discussed how AI can provide valuable insights from vast amounts of digital health data, leading to more efficient and personalized care. There was a strong emphasis upon the importance of ethical integration of AI tools into healthcare practices and the need for medical professionals to be trained on how to use these technologies responsibly and effectively.

AI algorithms can assist radiologists at every step of the imaging process; for example, providing inputs to help decide which imaging tests to order; enhancing image quality; detecting imaging problems to ensure faulty images are retaken; conducting preliminary assessment; and serving as virtual assistants for reporting observations and following up with patients. The goal is to eliminate human errors. As President Sian Beilock of Dartmouth College pointed out in her opening remarks at the symposium, researchers are developing AI tools to help diagnose colorectal cancer and identify novel biomarkers for breast cancer, offering quicker and more accurate detection to facilitate timely treatment.

Digital mental health technologies, such as web-based and mobile tools, are being developed to transform mental health care. These tools can impact mental health outcomes of users by predicting behaviours, symptoms, and engaging in interventions and therapeutic approaches based on the predicted symptoms. With its capacity to sift through massive amounts of digital health data, AI can detect patterns that are hard for humans to see, thus helping radiologists to detect subtle signs of cancer with greater accuracy and informing which course of treatment is most likely to work for a patient with a certain medical history. That is the wonderful world of IA medicine dawning upon us. But it also raises important and complex questions about security, privacy, biases, ethics, and equity.

And that brings us back to the pivotal role of doctors, and how best to educate them in the age of AI high expectations with its emphasis upon diagnostic efficiencies, superb patient management (for brand reputation and to avoid lawsuits), and humanizing the increasing impersonal healthcare delivery systems. Under their white coats, habitual smiles and calm demeanours, let us not forget doctors are people too with the same human frailties as any of us ~ families under stress, fear and hopes about growing children, divorces, addictions, and most of all the pressure to keep up professionally with Joneses.

Just think about Dr. House in the American television medical drama where Gregory House (Hugh Laurie), a brilliant and unconventional diagnostician but a person with compromised ethics and messed up life, and given to substance abuse, is unable to have steady family or friendly relationships. Although TV dramas entertain us, they do reflect social realities. The case of Dr. House may be emblematic of a larger social problem of the medical community. According to American Addiction Centers, “Few careers have such odd working hours and so many traumatic situations as those in the healthcare industry. The high levels of stress and physical pain that often come with this job open the door for numerous types of addiction,” adding that “approximately 5.5 per cent of medical professionals struggle with illicit drug abuse.”

Equally serious is the problem of the physician burnout despite radical advancement through Artificial Intelligence. In 2022, for example, 71,309 doctors gave up their profession in the USA. Medical schools and hospitals do not talk about it. Perhaps the next Dartmouth Dialogue or Symposium should be about doctors as humans. Along with the integration of Artificial Intelligence with healthcare, the foundation of medical education needs a reset. It should rest firmly on the Humanities, Medical Humanities, as someone suggested in a recent dinner conversation I had with some Dartmouth alumni and friends.

The art and science of medicine, the liberal arts, and the humanities ~ song and dance, musicals, theatre, comedy ~ go together to make a good doctor in the age of Artificial Intelligence. More than anyone else doctors need a good sidesplitting belly-laugh once in a while.

NARAIN BATRA

Source: The Staesman, 22/04/24

(The writer is the author of several books including the most recent India In A New Key: Nehru To Modi. Under the auspices of the Osher Institute at Dartmouth College, he is scheduled to deliver, on Friday 24 May, a public lecture, Superintelligence: Why We Need It. The lecture would be available in YouTube)

The journey of Mosquirix and future of Malaria

 

Malaria has plagued mankind for tens of thousands of years and the pesky mosquito, which serves as the host or vector for the disease, has killed more human beings than any other creature in existence, facilitating 400,000 deaths annually.

The World Health Organisation’s (WHO) recent decision to endorse a vaccine for malaria, clinically known as the RTS,S vaccine and colloquially called Mosquirix, was a massive milestone in the campaign to eradicate the disease. Malaria has plagued mankind for tens of thousands of years and the pesky mosquito, which serves as the host or vector for the disease, has killed more human beings than any other creature in existence, facilitating 400,000 deaths annually.

Early evidence of malaria exists dating back to 2700 BC with the disease said to have contributed to the decline of the Roman Empire, the weakening of indigenous populations during the colonisation of the Americas, huge losses for British forces during the Revolutionary War, and the death of thousands of American forces in the Indo-Pacific during World War Two. Recognising the deadly toll of malaria, most Western countries successfully eliminated the disease by the 1950s. This was largely done through supply-side interventions that reduced the prevalence of mosquitos in those regions.

However, malaria still devastates large parts of Africa and Asia, with Sub-Saharan countries in particular, accounting for the vast majority of cases and deaths. Mosquirix could provide those regions with a potential, albeit limited, lifeline though challenges prevail in terms of administration, production, and complimentary antimalarial interventions.

Why is Malaria more prevalent in some regions over others?

Dr Prakash Srinivasan, an Assistant Professor at Johns Hopkins School of Public Health and expert on malaria vaccines, tells indianexpress.com that “Western states, with developed economies, have been able to eradicate malaria carrying mosquitos due to improved sanitation and other control measures like insecticides and drugs.” However, just because malaria isn’t currently prevalent in those regions, doesn’t mean that the situation will remain that way. Many strains of malaria have developed immunity to insecticides and, according to Srinivasan, “with global climate change, countries are getting warmer, and it is possible that malaria can re-emerge without proper control measures.”

Unlike in Europe and North America, countries in Asia and Africa have a long way to go before eradicating malaria. According to Srinivasan, there are a number of reasons why malaria has not been eradicated in Africa and Asia, ranging from logistical challenges to the evolution of the disease and socio-economic factors that hinder intervention.

For now, however, the problem is primarily centred around Africa, which accounts for 94 per cent of global malaria cases. This is partially because mosquitos thrive in tropical climates, where the heat and humidity increase the lifespan of the mosquito which gives the disease time to metastasise.

Malaria is primarily transmitted by Anopheles mosquitoes, which develop faster in the temperate waters found in the tropics. Given that the disease likely originated in Africa, Srinivasan also claims that mosquitos evolved in tandem with humans and thus are more resilient in those regions. Srinivas says humans have actually developed a greater resistance to the diseases in Africa. “African adults are probably bitten by several malaria-carrying mosquitos over the course of their lifespan,” he explains. “Most of them develop some sort of antibodies that protect them which is why children under the age of five, who don’t have those antibodies, are particularly vulnerable.”

Countries in Africa also have lower standards of living and poor sanitation conditions. This prevents them from implementing control measures like the use of mosquito nets, pesticides, and rapid treatment. Once the symptoms of malaria appear, it can take under 24 hours for the disease to kill its host and without access to healthcare, people in poor countries are particularly vulnerable. Lack of proper sanitation measures also mean that those countries have inadequate water management techniques, which in turn, provides breeding grounds for the mosquitos.

According to Srinivasan, because malaria is seen as a “tropical disease,” there is little impetus for industries and the governments of developed economies to research a vaccine. “Unlike Covid,” he says, “the malaria vaccine has been in trials for over 25 years.”

However, in terms of net investment, relatively little has been spent on eradication because it poses less of a risk to developed economies. Countries that have achieved at least three consecutive years of zero indigenous cases are declared malaria-free by the WHO. Thus far, only 11 countries have reached that benchmark. However, globally, the elimination net is widening. In 2019, 27 countries reported fewer than 100 indigenous cases of malaria compared to six countries in 2000.

Mosquirix

“The World Health Organization’s recommendation of RTS,S/AS01 for use as a complementary malaria prevention tool is a historic milestone in vaccine development, scientific innovation for malaria and long-term public-private partnerships,” says a representative of the Bill and Melinda Gates Foundation.

However, Srinivasan was quick to clarify that while the WHO has endorsed the vaccine, it has not yet approved it. Produced currently by GlaxoSmithKline, Mosquirix is still a long way away from being found at doctors’ offices or in pharmacies. “What the WHO has done is give a strong recommendation for its wide-spread use,” says Srinivasan, adding that the final approval will still come from regulatory agencies of respective countries.

Although researchers knew that the vaccine was effective in clinical trials for many years, questions remained surrounding its suitability in real world settings. However, since 2019, Mosquirix, has been administered to approximately one million people in Malawi, Kenya, and Ghana, three countries with high rates of malaria. The efficacy of the vaccine in those settings ranges around 30 per cent which is modest compared to vaccines designed to prevent diseases such as polio and Covid, but nonetheless significant.

When asked why this was such a seminal moment given the context of the Covid vaccine being developed so quickly and efficiently, Srinivasan explains: “First, because parasites are far more complex pathogens, malaria in particular codes for around 5000 proteins in its genome so the challenge is what do you target. For Covid in comparison there are only a handful of proteins and only one major protein on the surface. Also, the parasites have multiple forms. There are forms that are found in the red blood cells which cause the disease but there are also forms that are found in the saliva, found during the reproductive phase and so on.”

He explains that the RTS,S vaccine targets the stage of the parasite called sporozoites that are transmitted by the mosquitos. “It does so by generating antibodies to sufficient levels to prevent the sporozoite from entering the liver, the phase known as the silent phase because it doesn’t cause any clinical symptoms. Once it exits the liver, it enters the red-blood cells, causing the disease.”

The complexity of the disease makes Mosquirix ground-breaking. However, combined with the high mortality rate of malaria, the results are even more impressive.

“We should be aiming higher than 30 per cent,” states Srinivasan, but the context is relevant given that there are over 400,000 deaths annually from malaria. Even though the 30 per cent won’t translate directly into a 30 per cent reduction of deaths, it will still save tens of thousands of lives per year according to WHO estimates.

Additionally, according to Srinivasan, “getting the seal of approval goes a long way in allaying fears, especially because the current data which the WHO used as the basis of its recommendation was based on real-life evaluation of this vaccine under real-life conditions. This means that the tests were not administered in doctors’ offices but rather in conditions under which the vaccine would regularly be given, like with measles or polio.”

This in turn demonstrated that wide-spread availability could be accepted by the local populations and that bodes well for the vaccine because it shows that people understand its importance.

Challenges

Distribution will remain complicated however and given that the vaccine requires four doses spread across one year, making sure that people complete the dose will be a challenge. Additionally, there are questions over how the vaccine will be manufactured and according to Srinivasan, “licensing of this technology will be crucial, alongside distribution.”

Moreover, prevention is still more effective than treatment. Srinivasan and other experts argue that Mosquirix alone will have a limited impact unless paired with other anti-malarial strategies. Drugs and vaccines become less effective the more they are used as they give malaria parasites more opportunities to develop resistance.

Since 2000, most progress in malaria control has resulted from expanded access to vector control interventions, particularly, sleeping inside an insecticide-treated net (ITN). ITNs can reduce contact between people and mosquitos and since 2019, an estimated 46 per cent of all people at risk of malaria in Africa were protected by an ITN, compared to 2 per cent in 2000. However, ITN coverage has been limited since 2016.

According to the representative from the Gates Foundation, “while the addition of RTS,S gives countries with high malaria burden another option to consider, accelerating progress against and saving more lives now from malaria requires significantly scaling up a range of current and cost-effective tools, including improved long-lasting insecticide nets (LLINs), seasonal malaria chemoprevention (SMC) and intermittent preventive treatment in pregnancy and infancy (IPTp and IPTi).”

Another prevention tactic is the use of indoor residual spraying (IRS), which involves spraying the inside of housing structures with an insecticide, typically once or twice annually. Globally, IRS protection declined from 5 per cent in 2010 to 2 per cent in 2019, in part, because the disease was generating resistance to the insecticides. According to the WHO’s latest World Malaria Report, 73 countries reported mosquito resistance to at least one of the four commonly used insecticides in the period between 2019-2019. In 28 countries, mosquito resistance was reported to all the main insecticide classes.

Additionally, according to the report, “gaps in access to life-saving tools are undermining global efforts to curb the disease, and the COVID-19 pandemic is expected to set back the fight even further.”

Funding for malaria eradication has also decreased over the years and in 2019, total funding reached $ 3 billion against a target of $ 5.6 billion. Calling it a plateau in progress, the report states that, “in 2019, the global tally of malaria cases was 229 million, an annual estimate that has remained virtually unchanged over the last 4 years.” Progress has slowed in recent years and gaps in funding threaten to roll-back gains made since 2000, a timeframe in which malaria deaths reduced by 44 per cent.

Disruptions in the supply of anti-malarial treatment in Sub-Saharan Africa caused by Covid, could similarly have devastating effects. For example, the report finds that a “10 per cent disruption in access to effective antimalarial treatment in sub-Saharan Africa could lead to 19,000 additional deaths in the region. Disruptions of 25 per cent and 50 per cent in the region could result in an additional 46 000 and 100 000 deaths, respectively.” According to WHO global projections, the 2020 target for reductions in malaria case incidence will be missed by 37 per cent and the mortality reduction target will be missed by 22 per cent.

The Mosquirix vaccine will undoubtedly catalyse the campaign to eradicate malaria, especially amongst vulnerable populations living in Africa. However, in order for it to succeed, three main criteria must be met. First, the vaccine must be licensed to production centres across the globe, similar to how Covishield is produced by the Serum Institute of India, using a formula developed by AstraZeneca. Second, there must be parallel efforts to ramp up measures and healthcare infrastructure that will prioritise prevention and rapid treatment. Lastly, the vaccine should not deter future funding for malaria research and the global community must avoid becoming complacent in the face of this recent progress.

According to the representative from the Gates Foundation, “achieving malaria eradication will require more than the tools we have today. The first-ever malaria vaccine brings us a major step forward in our goal of developing a highly effective, all ages elimination vaccine. Additional investment in transformative tools is critical to saving millions more lives, reducing the burden on health systems and ending the disease for good.”

Written by Mira Patel

Source: Indian Express, 13/10/21

Due diligence, unsafe drugs

Good intentions alone are not enough to secure the public interest. For governments, the manner in which it is protected is equally vital. The Delhi High Court verdict quashing all notifications banning the manufacture and sale of 344 Fixed Dose Combination (FDC) drugs is a lesson in how not to administer a regulatory law. The ban on combination drugs that have little therapeutic value was undoubtedly done for bona fide reasons. However, the government could not convince the court that the ban was valid despite statutory bodies such as the Drug Testing Advisory Board (DTAB) and the Drugs Consultative Committee (DCC) not being involved in the process. There is little doubt that a number of combination drugs should be taken off the shelf. The government believes, as do many health activists, that some combinations are unsafe and/or promote antibiotic resistance, while others lack particular therapeutic value, justification or advantage. Justice Rajiv Sahai Endlaw has correctly refrained from going into the merits of the ban, and has chosen to subject to scrutiny the process by which the decision was arrived at. While concluding that the ban was invalid because the power under the Drugs and Cosmetics Act was exercised without consulting the DTAB and DCC, he has found that the government went about the process in a haphazard manner.

Initially it was noted that in the case of FDC drugs for which manufacturing licences were granted by State licensing authorities between September 1988 and October 2012, the process was done without any approval from the Drugs Controller. When they applied afresh to the Centre, on being asked to do so, their applications were not considered by the Drugs Controller; instead, the Centre formed 10 committees. When these panels failed to consider all the applications, another one, the Kokate Committee, was formed. However, this panel went into the question whether these drugs posed a risk to consumers or lacked therapeutic value and justification. Based on its report, the Centre issued notifications banning these FDCs. In effect, the Centre seemed to have delegated its power to ban drugs to a non-statutory committee, when the Act itself provided for expert bodies through which technical aspects of administering the law were to be considered. The government ought to have been more mindful of the processes. It is possible that an appeal will be filed on the legal aspects of the judgment, but the real lesson from the episode concerns governance, and not the law alone.

Source: The Hindu, 5-12-2016

The rationale of India’s drug policy

The Supreme Court’s description last year of India’s drug pricing policy—irrational and unreasonable—is unfortunately accurate from several angles. There have been two contradictory developments over the past few days: there is now a possibility that stents (a small mesh tube used to treat narrow or weak arteries) will become a component of the National List of Essential Medicines (NLEM). And a fortnight ago, customs duty exemptions on a number of drugs were lifted. Both are instances of the juggling act any government must carry out to achieve the twin objectives—interdependent and yet often pulling in opposite directions—of enabling broad access to reasonably priced medicines and allowing the marketplace to function well enough for pharmaceutical companies to invest in innovation. No administration in New Delhi has quite managed to pull it off yet.

The chequered history of drug price control in India, in fact, shows the extent to which it has failed to maintain that balance. Two decades ago, the Drug Price Control Order (DPCO) 1995 was introduced, covering 74 bulk drugs and their formulations. The result was not quite as hoped. Half the products were discontinued after their producers exited. Indian production of something as vital as penicillin shifted to China.

Its successor, DPCO 2013, hasn’t fared much better. Since its introduction, no new investments have been seen. Instead, there has been a shift—unsurprisingly—towards non-controlled products. Consequently, as a study by IMS Health shows, the average number of incumbent brands and new introductions of drugs in the DPCO 2013 list has reduced compared to the non-DPCO 2013 list. This “strengthens oligopolistic behaviour and reduces the choice set of doctors and patients”, says the study.

State inefficiencies compound the problem. As the Justice T.S. Thakur bench pointed out last year, the cost of the drugs in the NLEM—which feeds the DPCO—remain above the maximum retail prices offered in some states (retail price margin goes as high as 4,000%), defeating the avowed purpose of access and cheap availability. In the context of the possible addition of stents to the list, this means that there is a broad range of potentially unintended consequences—from there being none of the intended control on prices to a decrease in supply and fewer introductions of technologically advanced stents in India.

The answer, however, is not to abandon any attempt at regulation. Leaving it to the market would create efficiency, certainly—but the benefits will be skewed towards pharmaceutical companies. In a context where public health and well-being is so substantially at stake—with inelastic demand and high barriers to entry skewing the balance further—to do so would be as counterproductive as the DPCO, simply in a different fashion. The US is a good example of this, with rocketing healthcare costs and the highest drug prices in the developed world leading to what is commonly understood as a healthcare crisis.

Instead, a multi-pronged approach that has the NLEM and DPCO, pared to an essential minimum and implemented with a transparency they have often lacked, as one of several tools is more likely to be effective. Overhauling India’s intellectual property rights (IPR) regime, for instance, is a priority here. In the context of the pharmaceutical industry, the courts have done well to clamp down on the practice of evergreening patents and protecting the country’s vital generic drug industry—but at the other end of the spectrum, impediments to legitimate patents have had high costs. As per an IndiaSpend (a data journalism initiative) report, on average, a patent application takes six years to get approval in India. This is unsustainable in an industry where long development cycles and multiple research dead-ends already raise costs and delay pay-offs. The soon-to-be-announced National Intellectual Property Rights Policy will, hopefully, have a positive impact here.

Expanding insurance coverage is another aspect. A Rand Corporation study, Regulating Drug Prices, shows that financing consumer price reductions via insurance has several long-term benefits over imposing price controls. But India is one of the least penetrated insurance markets in the world. As of March 2014, only 17% of the population had any health insurance coverage, as per the Insurance Regulatory and Development Authority. The raising of the foreign direct investment cap in the insurance sector to 49% last year should, ideally, introduce benefits. But so far at least, there has been little in evidence.

Successive administrations have relied for decades on price control to increase public access to medicines. The results have not been optimal. It’s time to look for a new balance.

Source: Mint epaper, 18-02-2016

Aug 05 2015 : The Times of India (Delhi)

`Happy hormone' can kill cancer tumours, discover Kol-born scientists

Prithvijit Mitra & Sayan Mazumder TNN

Kolkata:





A 14-year study by two Kolkata-born scientists has led them to discover that dopamine -known as the happy hormone -can also kill tumours, putting them on the verge of one of the most significant medical discoveries ever.Trials on mice have been successful, say researchers Partha Dasgupta and Sujit Basu. If human trials succeed, cancer cure will get significantly cheaper -a chemo course costs lakhs, while a vial of dopamine comes for just Rs 25.
Dasgupta is an emeritus professor with Chittaranjan National Cancer Research Institute and Basu, a professor at Wexner Medical Centre, Ohio State University. Like penicillin -said to be the biggest medical discovery in history -the cancer-killing property of dopamine was discovered almost by accident, when the duo was carrying out random tests to analyze the hormone.Dopamine is a neurotransmitter that helps regulate movement and emotions. The duo says it also starves cancerous tumours of blood, causing them to shrink and eventually vanish. “Tumour cells multiply rapidly, making them swell very fast. We concluded that if the growth of blood vessels can be checked, tumours will stop growing and disappear. In animal-model experiments, we observed that dopamine acted very well on cancerous tumours, effectively countering vascular endothelial growth factor (that helps tumours grow),“ said Dasgupta.
But dopamine fluctuation could lead to serious disorders like Parkinson's disease. “We need to know more about its efficacy in the long-run,“ said oncologist Gautam Mukhopadhyay .
For the full report, log on to http:www.timesofindia.com

A doctor and his love for a neighbourhood

In Chintadripet, he is known as the physician who provides free consultation to poor patients.

One afternoon, a group of men met Dr. M.Venugopal at his Sundaram Clinic on Mangapathy Street, Chintadripet, requesting him to attend to a patient, who was too ill to visit the clinic. The men explained that the patient was bleeding and was at his house on Swamy Naicken Street, not too far away from the clinic.

The doctor hesitated, but changed his mind and went with the men.

The patient’s body had gone cold indicating that he might have died at least an hour ago.

Once Dr. Venugopal declared him dead, the gang demanded that he give a death certificate on the spot. Some of the gang members waved bundles of currency notes in front of him, while the others threatened him with knives.

Dr. Venugopal did not give in to their demand and when they realised that no degree of threat would make the man change his mind, the gang let him go.

Later, he learnt from the police that the deceased was a retired chief superintendent of the Madras Zoo and that it was not a natural death. The former government official had been ruthlessly stabbed, as many as 16 times. A property dispute had caused the murderous attack.

This was in 1972, and 43 years later, sitting in the same clinic, Dr. Venugopal recounts various other unforgettable events and incidents that had taken place at the clinic. The clinic, which recently celebrated 50 years, also has unforgettable memories for many poor residents of the neighbourhood. Over the years, the doctor has maintained a ‘no-charge policy’ while attending to poor patients. If the treatment went beyond consultation and basic treatment, he would refer the patient to government hospitals. Dr. Venugopal’s forefathers settled in the locality in the 18th century as textile merchants and were zamindars during the colonial era. They had rows of handlooms shops at Chitadripet, where a group of weavers made cotton clothes for the British.

In fact, the Mangapathy Street, where the clinic is located was named after his grandfather, Goday. A. Mangapathy. “Though he has shifted to Anna Nagar, his heart still is Chintadripet and he continues to practise at the clinic,” says S. Vivekanda, a resident of Chintadripet.

Though from a business family, Dr. Venugopal had to struggle in the initial days as his father had suffered losses in business. Scholarships saw him through school and college: he studied at Pachaiyappa’s Higher Secondary School and qualified in MBBS from MMC.

After completing medicine, he joined the Chennai Corporation as chief medical officer in 1967 and served the civic body till 1978.

Later, he worked as chief health officer at the Government Boys High School in Chindatripet for five years. Simultaneously, he started the Sundaram clinic (in memory of his mother Sundara Rajamma) in 1965.

“I was keen on having my own clinic as it would help the locals get timely treatment. As I have my own house here, I converted a portion of it into a clinic,” says Dr. Venugopal.

He supplemented his income by working as consultant for various hospitals. Around 50 patients visit the clinic in Chintadripet every day.

Patients come from as far as Ambur, Vellore, Walajabhad, Tirupathi, Sulurpet near Gummudipoondi, Thiruvannamalai and Kancheepuram.

For patients who can afford a fee, Dr. Venugopal charges Rs. 100 for a consultation, but for the poor residents of Chintadripet, the tradition of free treatment continues.

Keywords: Dr. M.Venugopal, Sundaram Clinic

Write prescriptions in CAPS: Health Ministry to doctors

Fear of misinterpretation due to doctor’s illegible handwriting may soon be a thing of the past as government is set to make it a norm for physicians to prescribe medicines “preferably” in capital letters.

The Union Health Ministry will come out with a gazette notification under the Indian MCI Regulations which will mandate doctors to prescribe medicines in capital letters in a “legible” manner and also mention the generic names of the drugs.

“The Health Ministry will come out with gazette notification under the MCI regulations. Under this, the prescription should be legible and preferably written in capital letters along with the names of the generic drug prescribed,” a senior Union Health Ministry official told PTI.

Sources said that the notification is likely to be issued by the Ministry within a week’s time.

However, the senior health ministry official said that there would no penalties or punishment for the doctor as such for not writing in capital letters.

“Like all other MCI regulations, this too will govern the doctors,” the official said.

Health Minister J.P. Nadda last year in Parliament had agreed with concerns of some MPs that illegible prescription by doctors may lead to serious implications and even death in certain cases.

“The central government has approved to amend Indian Medical Council Regulations, 2002, providing therein that every physician should prescribe drugs with generic names in legible and capital latter and he/she shall ensure that there is a rational prescription and use of drugs,” Mr. Nadda said.

K.K. Aggarwal of Indian Medical Association (IMA) said this will help decrease prescription errors and it is a cheaper alternative to electronic health records.

“Prescription errors will decrease. It will become uniform. One drug has 10 odd brands. The patients will be now able to know whether the drug is generic or not,” Dr. Aggarwal told PTI.

“In US alone, 100,000 prescription errors occur every year. India does not have any data on this. This is a cheaper alternative to electronic health records. It will take some time for doctors to get used to it,” he said.

Keywords: medical prescription, MCI, Health Ministry, JP Nadda

From the first human genome, to a “great library of life”

Geneticist Eric S. Lander, one of the principal leaders of the Human Genome Project that mapped the entire human genome in 2003, offered a rare glimpse into the genetic “library of life” being created by a global community of scientists. This veritable catalogue has already begun to help decode the genetic basis of certain cancers, heart disease and schizophrenia.

A packed audience of students, scientists and medical practitioners heard Prof Lander speak on “The Human Genome and Beyond: A 35 year Journey of Genomic Medicine at the fifth edition of the Cell Press-TNQ Distinguished Lectureship Series at the All India Institute of Medical Sciences here on Monday.

Over the last decade, genetic research has been revolutionised and the costs of genome sequencing have dropped drastically. While mapping a single human genome (as part of the Human Genome Project 1990-2003) costs $3 billion, today it costs less than $ 3,000.

This breakthrough opens up enormous opportunities to understand diseases, he said. Today, for instance, over 108 genes can be associated with schizophrenia, and particular genetic mutations can be linked to heart attacks early in life.

And yet, “we have only scratched the surface,” Prof Lander said. “Discoveries require studying huge samples for every major disease. And for that our healthcare systems have to turn into learning systems.”

The Global Alliance for Genomics and Health comprising 246 organisations in 28 countries -- including India -- is one such endeavour to create a critical mass of data.

It is imperative, however that the data remains “shareable”, said Prof Lander, who is the Founding Director of the Broad Institute (linking MIT, Harvard University and hospitals).

“But genetic data must belong to patients, who have the right to share it with their privacy protected.”

India, with the “extraordinary size of its population” is, from the genetic point of view, “the single most interesting population in the world”.

Cancer: Not beyond us

On World Cancer Day today, The Union for International Cancer Control calls the doctors, institutions and the community at large to come together and unite in the fight against cancer

It is estimated that in the next year, nine million people will die of cancer and these numbers will unfortunately only rise, if steps towards cancer prevention and control are not put in place now. This year’s World Cancer day programme focuses on taking a proactive role in the fight against cancer under the tagline “Cancer- Not Beyond Us”.

Adopt a healthy lifestyle

Recent research has shown that physical activity brings down the incidence of cancers as well. About 50 per cent of common cancers can be prevented by reducing alcohol consumption, giving up smoking, a healthy diet and regular physical exercise and that is a pretty good incentive to help in making the right lifestyle choices.

Get regular check ups

Very commonly, people are not aware of the importance of seeking care when symptoms are present, nor are they aware about recommended screening tests such as pap smears, HPV tests for cervical cancers and mammograms for breast cancers. This holds true for women across the socio-economic strata and varied educational backgrounds.There is now clear evidence that deaths due to cervical cancer can be reduced by 80 per cent in screened women. In fact, even a single screening for cervical cancer in women between the ages of 30 -40 years can bring down a woman’s risk of cervical cancer by 25 to 36 per cent. Cervical cancer can be easily prevented by a combination of HPV vaccination and regular screening. The question is how do we get women to access health care and who pays for it? Cancer is a complex disease and often needs a lot of psycho-social input apart from a multidisciplinary medical treatment.

Spread awareness

In spite of improving levels of education and economy, discussion about cancer is often considered taboo. While people would not hesitate to talk about their symptoms and the various medications they are on for their hypertension and diabetes, a diagnosis of cancer is one topic they do not feel they can talk about.

There are a lot of myths and misconceptions that surround a diagnosis of cancer – a common one is that cancer is contagious which it is not. There is still a huge stigma attached to a cancer diagnosis especially in rural areas, very often leading to the person being ostracised from society.

Get involved

As a priority, levels of public and professional awareness about cancer screening and early cancer warning signs should be improved and we would like the health sector, government and the media to be part of this important initiative.

Cancer control has to begin with cancer awareness amongst the community at large. Understanding local cultural beliefs and practices is important and screening programmes will have to factor this into their programmes to succeed.

It is ‘Not Beyond Us’ to meet the challenge of cancer control, if communities and governments realise that prevention of cancer is better and definitely cheaper than cure, if cancer awareness is given priority and screening programmes are integrated in to existing health systems. On the occasion of World Cancer Day, let us all take a pledge to fight against cancer.

Valavadi Narayanaswamy Cancer Center, GKNM Hospital, and Coimbatore Cancer Foundation collaborate to give cancer awareness talks in schools, colleges, corporate offices and others, both in urban and rural areas as part of their community oncology programmes.

Dr. Latha Balasubramani is DGO, MD, MRCOG, Consultant - Gynaec Oncology at G K N M Hospital and a trustee at the Coimbatore Cancer Foundation.

Keywords: World Cancer Day, Union for International Cancer Control

Feb 04 2015 : The Times of India (Delhi)

Cancer strikes more Indian women, but kills more men

Malathy Iyer

Mumbai





More Indian women than men are diagnosed with cancer every year. It is reflected in insurance statistics that show more women in our cities claim medical insurance for cancer treatment.Blame it on physiology or the stereotypical image of an Indian woman who chooses to ignore her symptoms for long, but fact is the Big C exhibits a clear gender divide.
But when it comes to cancer-related fatalities, the figures turn upside down: more men die of cancer annually than women.
In all, 5.37 lakh Indian women were diagnosed with cancer in 2012 as against 4.77 lakh men, according to the World Cancer Report. The same year, 3.56 lakh men died of the disease in comparison to 3.26 lakh women.
In the past four years, 62-65%of cancer-related insurance claims were for women while the figure for men was only 35-38%, according to data released by private insurance firm ICICI Lombard. The claims were more for cancers of the cervix and breast, which are, according to the Indian cancer registry, the leading cancer types among women.
The main reasons for the gender divide in cancer are hormones and habits. “Physiologically, women’s cells are exposed to more hormones and more hormonal fluctuations, leading to an increased susceptibility of cell dysplasia (abnormality),” said Dr Boman Dhabar, medical oncologist with Wockhardt Hospital in Mumbai Central.
He believes “oppression of Indian women” leads them to neglect their own health. “There are also socio-economic reasons such as lack of hygiene and toilets that lead to an increased incidence of cervical cancer,” said Dr Dhabar.
Dr Surendra Shastri, who heads the preventive oncology department of Tata Memorial Hospital, had another reason. “There is an increase in the incidence of lifestyle-related cancers, for example breast cancer and ovarian cancer. Moreover, better awareness and detection rates have contributed to the increasing numbers of cancer in women in India.” His colleague Dr Rajesh Dikshit, who heads the epidemiology department, pointed out that if incidences of breast and cervical cancers are removed, women have a very low and almost negligible incidence of cancer in comparison to men.
“Claims from men are usually limited to oral cavity and lungs, where the root causes are tobacco and occupational exposure to hazardous material such as asbestos and silica. We find men who suffer from these cancers come from classes that primarily stay away from taking any health insurance,” said Amit Bhandari of ICICI Lombard.
Interestingly, data for 2014 from Metropolis Healthcare, a chain of laboratories, shows how different cancer rates are among men and women (see box). Dr Kirti Chadha from Metropolis India said of the 1,151 samples that tested positive for cancer in Mumbai, 214 were of breast cancer alone. “Breast cancer is the most common or largest cancer in our country.
This is our finding from each of our laboratories across the country,” she added. There is an age difference pattern too in cancer’s gender bias. “If you look at age-wise cancer incidence, the peak period for women is 60 while for men it is 70,”said Dikshit.
A 2006 paper from Duke University in US titled, ‘Difference between male and female cancer incidence rates: How can it be explained?”, said the peak of hormonal imbalance in women is between 45 and 55, when the reproductive system ultimately stops functioning. In males, this peak is shifted to 55 and 65.

Feb 02 2015 : The Times of India (Delhi)

Obesity could lead to cancer, finds study

Janani Sampath1





Indians At Risk; Docs Advise Dietary Changes To Reduce Threat

Nearly everyone knows that obesity is a major cause of cardiovascular problems and diabetes. But what many do not know is that extra kilos can also lead to that emperor of maladies -cancer.Obesity is now pandemic and researchers have noted a statistically increased risk of developing cancers, especially that of the breast, endometrium, colon and rectum, among overweight people. Several studies including one by National Cancer Institute, USA, indicate that there is a direct link between obesity and cancer. Doctors who conducted these studies say unless obese individuals make appropriate dietary changes, obesity could soon overtake tobacco as the top cause of cancer.
The Overseas Development Institute, an independent think tank, found that Indians constitute a huge chunk of the one in three adults who are obese, a total of up to 1.46 billion across the world. Simultaneously ,a 16-year-long study published in the New England Journal of Medicine, which followed 90,000 American adults, revealed that the heaviest participants were more likely to develop and die from cancer than participants with healthy weight.
“Though there are no Indian studies on the subject, research done abroad is relevant to us as well as we are increasingly aping the West in terms of diet. The number of obese people in India has increased exponentially ,“ Rigid Lifeline Hospitals surgical gastroenterologist Dr J S Rajkumar said.
The surgeon recently submitted a paper to the Journal of Obesity and Metabolic Research exposing the link between cancer and obesity . He said though the answer to how obesity causes cancer may be different for each type of cancer, the overall explanation is that obesity triggers changes in bodily functions, which can lead to harmful cell growth and cell division.
Explaining the link, senior diabetologist Dr A Ramakrishnan said the link between obesity and cancer is insulin resistance.“Both obesity and cancer result from body losing its ability to burn fat as fuel. Obesity is linked to excess levels of insulin circulating in blood and this can stimulate harmful cell proliferation. It also increases oxidative stress levels in overweight people, increasing risk of cancer,“ he said.
Stressing on the link between obesity and breast, colon and endometrial cancer, oncologist Dr Deb Narayan Dutta of Apollo Hospitals said excess fat cells, when partially metabolised, become carcinogenic.
“In women, obesity exposes them to higher estrogen levels because estrogen is produced in fat tissue. Obese women therefore have more estrogen, which can lead to insulin resistance and the development of more fat tissue, which produces even more estrogen, making it a vicious cycle that raises the risk of estrogen-sensitive cancers,“ he said.
Dr Rajkumar said overweight people can significantly reduce the risk of developing cancer through behavioural, pharmaceutical and surgical strategies.

Jan 06 2015 : The Times of India (Delhi)

Depression is a physical ailment?

London: PTI





Depression may not be a mental or emotional condition but actually a result of inflammation caused by the body's immune system, scientists say .George Slavich, a clinical psychologist at the University of California in Los Angeles, has spent years studying depression, and has come to the conclusion that it has as much to do with the body as the mind.
“I don't even talk about it as a psychiatric condition anymore. It does involve psychology , but it also involves equal parts of biology and physical health,“ he says.
Research has shown that healthy people can be temporarily put into a depressed, anxious state when given a vaccine that causes a spike in inflamma tion, `The Guardian' reported.
A family of proteins called cytokines sets off inflammation in the body, and switches the brain into sickness mode. Both cytokines and inflammation have been shown to rocket during depressive episodes, and in people with bipolar disorder -drop off in periods of remission.
Another researcher Turhan Canli of Stony Brook University in New York believes infections are the most likely culprit behind inflammation and goes as far as to say that we should rebrand depression as an infectious, but not contagious, disease.
However, infection is not the only way to set off inflammation. A diet rich in trans fats and sugar has been shown to promote inflammation. Obesity is another risk factor. Carmine Pariante, a psychiatrist at Kings College London, believes that in five to 10 years, there may be a blood test that can measure inflammation in people with depression.

The risks that diabetes poses for the eyes — and what to do about it

Diabetic retinopathy often has no early warning signals. But when it comes, vision could get blocked completely

Diabetes has emerged as a public health problem globally, more so in developing countries like India. According to projections made by the World Health Organization, the number of people with diabetes in India will rise to 79.4 million in 2030. It was 31.7 million in 2000.

Diabetes affects the eyes, among other parts of the body. However, vision-threatening complications occur when it affects the retina, causing diabetic retinopathy. Sankara Nethralaya in Chennai has been running the Sankara Nethralaya Diabetic Retinopathy Programme for nearly a decade. Major epidemiological studies done under the programme, have thrown up some salient findings.

In people aged above 40 years and living in urban areas like Chennai, nearly one out of four have diabetes. The situation is better in rural India, where among those aged above 40 years, one in 10 has diabetes.

Among those with Type 2 diabetes, nearly one in five in urban and one in 10 in rural India has diabetic retinopathy. Diabetes is more common in upper middle and upper socioeconomic classes. However, once a person has diabetes, everybody has the same chances of getting retinopathy.

Young males with suboptimal glycemic control, hypertension, anaemia and microalbuminuria (kidney damage) are at particular risk. The most significant risk factor among both rural and urban populations is duration of diabetes: the risk is 6.5 times more for those who have had diabetes for more than 15 years. People who get it before 40 have double the risk of developing retinopathy and sight-threatening retinopathy than those who develop it after 40.

Visual impairment occurs in 4 per cent of those with Type 2 diabetes. Diabetic retinopathy is the second most common cause of visual impairment. Cataract is the most common cause.

At the time a person is diagnosed with diabetes, one in 10 would have the kidneys affected (nephropathy) or the nerves (neuropathy). But one in 20 will have retinopathy. Obesity increases the risk. Pot belly, what is clinically called central obesity, increases the risk by two times. Diabetic retinopathy is more common among diabetics who take low-fibre diet (20 per cent) in comparison to those who take a high-fibre diet (15 per cent).

Genetic factors contribute to increased risk while some offer protection. Probably such genetic factors are what offer some protection against retinopathy.

People with suboptimal glycemic control (HbA1c>7) have a higher risk of diabetic retinopathy and those with poor control (HbA1c >8) of sight-threatening retinopathy. There is evidence to show that blood sugar control in the initial years of diabetes offers long-term protection against retinopathy. Abnormal serum lipids (especially serum cholesterol and LDL cholesterol) have a significant role in diabetic macular edema, which involves the swelling of the central part of the retina that results in blurred vision.

People with a combination of suboptimal control (blood sugar, blood pressure and lipids) have a higher risk of both retinopathy and sight-threatening retinopathy. Nearly one in three diabetics with suboptimal control will have retinopathy. In those with early kidney damage (microalbuminuria) the risk doubles. If he has advanced damage (albuminuria) the risk is six times more. In a person with diabetes who also has anaemia, the risk of developing retinopathy is two times more.

Framingham risk assessment scores which take into account age, smoking status, lipid levels and hypertension give a 10-year risk profile of cardiovascular disease. If a person has a high risk score, the chances of his developing sight-threatening retinopathy doubles as compared to people who have low risk.

Abnormal sleep patterns are related to neuropathy and nephropathy. Recent evidence suggests that sleep apnea is related to the severity of retinopathy.

Type 2 patients should have their eyes screened at the time of diagnosis and at least annually then. Children and adolescents with Type I diabetes should undergo dilated fundus photography five years after diagnosis and at least annually then. Both Type 1 and 2 diabetics need an eye examination soon after conception and then early in the first trimester. Thereafter the doctor recommends follow-up based on the severity of retinopathy.

Diabetic retinopathy often has no early warning signals. Blurred vision may occur when the macula, the central part that provides sharp vision, swells from the leaking fluid. This makes it hard to read or drive. As blood vessels bleed, there will be specks of dark spots or clouds, floating in your vision. Sometimes bleeding might be of a severe nature, blocking vision completely: this often happens during the sleep. Even in advanced cases, the disease may progress asymptomatically. Hence, regular eye examinations are important for people with diabetes.

Mild cases need no treatment. Regular examinations are critical. Strict control of blood sugar and blood pressure levels can reduce or prevent diabetic retinopathy. In advanced cases, treatment is needed to stop eye damage from diabetic retinopathy, prevent vision loss, and potentially restore vision.

(Dr. Raman is a Senior Consultant with Sankara Nethralaya, Chennai. November 14 marked World Diabetes Day.)

Keywords: Diabetic retinopathy, diabetes health risks, World Diabetes Day