Health Adda 2022
Spurious Drugs, Lives and Our Reputation
The news of 66 children falling ill and dying in Gambia (West Africa) allegedly after consuming cough syrup preparations manufactured in India was deeply disturbing.
Death of children in large numbers was bad enough. That they died possibly due to a spurious drug was terrible. And that the drug was manufactured in India and exported to that country where this tragedy occurred was deeply disturbing.
The contaminant in the 4 brands of cough syrup is suspected to be diethylene glycol, or DEG. Toxicity was suspected to have caused kidney failure.
The pharmaceutical industry in India has been a success story of sorts, standing shoulder to shoulder with some of the best international medicine manufacturers, supplying affordable therapies to many parts of the world.
As we piece together the bits of news that appeared in the press, the following questions continue to disturb:
Can we claim impunity for allowing an Indian company to export a medicine to another part of the world and then not take responsibility if they were spurious and caused deaths there? Do we then admit that our ability to monitor our products is compromised, and yet we are OK with permitting them to be exported?
The official note being put out that those batches of cough syrup from that company were not allowed to sell in India but were allowed to be exported to Gambia smacks of double standards. Are we setting different prices for lives of children in India and those from Gambia?
What about our quality and standards? Some Indian companies maintain high international standards, Could the tar rub onto them? And how does the common man know which ones he can trust?
Should we be concerned about our claim to be counted as a develop(ed) nation?
I do not recall any medicinal product in recent years being manufactured in a developed part of the world and sold elsewhere that could cause this kind of disaster.
A recent review in Indian Journal of Pharmaceutical Sciences estimates that 12 to 25% of Indian medicines for exports failed to meet standards (substandard, contaminated or spurious); the figure could be much higher for medicines manufactured for local sale.
Last but not the least, there is a pattern in crime called recidivism, another name for repeat offenders. It appears that the company in question had been hauled up several times for poor manufacturing standards and even deaths in India. And we closed our eyes as it was not for our children!
(Regret the country named in print media as Ghana)
Two-Way Patient Doctor Relationship
Doctors are sometimes accused by disgruntled patients as being unsympathetic, brisk, rude, unprofessional, unscrupulous, money-minded and many more.
The range of behaviour and attitudes of the patient sitting across the table can be equally varied in spectrum, complexity and taxing!
Indian cities offer the well-to-do patient a wide range of doctors to consult. Hence if the barriers of fees and waiting time can be overcome, most patients go on to collect a few or at times, several opinions.
An anxious young mother had brought her smiling 12-year old son for abdominal pain and had proudly said that she had consulted 18 doctors, all the very best in town, in the last fortnight alone. Not knowing how best to react I had asked in a bemused tone which of the 18 prescriptions she had tried, to which she had said that she had not followed any one!
A “second opinion” is a good thing. The situation however gets tricky when having collected several prescriptions of several doctors without telling one what the previous had advised, the patient decides by himself which of the medicines he takes from one prescription, and which from another, which medications he takes from the cardiologist’s prescription and so on, often not able to trust or put his faith on a single doctor for comprehensive continued guidance.
Many medications can have interactions, and the patient not disclosing the true picture can sometimes land him and the doctor in trouble.
Some patients obviously seem to suffer from an innate ability to trust, but expect the doctor to go out of his way and take deep interest in his welfare. If professional equation is sought, why then the disappointment or annoyance if the doctor refuses to share his personal number or refuses to take a call in an emergency in off-duty hours?
With the rapidly evolving transactional nature of the doctor -patient relationship, old-world values such as trust, faith and empathy are beginning to fall by the side.
Politeness, courtesy, professionalism, and appropriate medical care are to be expected from a doctor. No excuses. The problem arises however when one starts expecting the additional factors of “empathy”, “kindness” and “personal attention” to come on as a free add-on even if they misbehave with the care-givers, just because they have paid a bill.
Patients as well as doctors belong to the human race and have their varying shares of imperfections, and any interaction will unfortunately always remain a 2-way process.
Seat-belts for Back Seat Riders
The “health related” news that shook most of us up last week was undoubtedly that of how the two front seat passengers escaped death in a high speeding high-end car crash while the two back seat passengers died instantaneously.
This fateful road traffic accident caught much media attention partly due to the high-profile passenger who died in the crash being Mr Cyrus Mistry, erstwhile chairman of Tata Sons and a young business tycoon in his mid-fifties, and partly because the car that crashed was a high-end Mercedes known for its high manufacturing and safety standards.
The question that kept cropping up repeatedly is why did the two back-seat occupants die while the front seaters (driver and partner) managed to escape, and the answer is pointing to the only variable: SEAT BELTS!
The front seaters were wearing seat belts, while the back-seat passengers were not, and it is being speculated that when a car travelling at high speed suddenly crashes and comes to halt, those not wearing seat belts are flung in front against the front seats, steering wheel dash board or wind screen as they have nothing to restrain them.
Wearing seat belts for front-seaters has been mandatory in India now for quite a while, and thanks to checking by traffic police, most drivers and front seat passengers have come around to accepting and implementing the practice. Many of us however did not pay much attention or follow seat-belt rules while sitting at the back.
Most developed nations follow strict seat-belt protocols for backseat passengers in their countries. This unfortunate accident has served as a harsh reminder that seat belts are essential for protection, not just for front seat, but for back seat passengers too.
There are over 150,000 annual road traffic accident (RTA) fatalities in India, which works out to around 1200 accidents per day. Research shows that helmets for two wheelers, and seat-belts for car-passengers are the first and main lines of defense, the latter reducing fatality rates by 50%. Air bags are less important and work when the body is restrained by seat-belts.
It is time we learnt our lesson from this tragedy and tightened our seat belts in the back seats too.
GERD: The new age malady
Do you get burning sensation behind your chest bone, or have sour food come into your mouth? Do you wake up at night with “heartburn” or “acidity”, and need to drink water or take antacids for relief? If this happens more than once a week, you are suffering from GERD or Gastro-Esophageal Reflux Disease, one of our modern day maladies.
GERD is caused by refluxing of acid that is normally produced by the stomach, into the food pipe or esophagus, due to malfunctioning of the one-way valve located at the stomach-food-pipe junction (GE valve).
A recent nation-wide survey from 25 centres, conducted by the Indian Society of Gastroenterology, found that 8.4% of Indians suffer from this disorder. If you are a sufferer, you have 80 million in India for company!
GERD is a lifestyle disorder, but also tends to run in families suggesting a genetic component as well. Its frequency has jumped up in recent decades replacing Irritable Bowel Disease as the commonest GI disorder.
Obesity. fatty food ( pastries, fried food, cheese, cream), chocolates, pungent spices cause relaxation of the GE valve as do alcohol, nicotine and caffeine and are notorious for causing GERD, accounting for the early morning “heartburn” often experienced after that perfect late night party.
Diagnosis of GERD is fortunately not difficult as the symptoms are quite typical. The commonest test advised is an endoscopic examination, during which the doctor examines whether ulcers have formed in the food pipe or if the lower oesophageal valve is very loose. Long standing severe reflux may occasionally cause scarring and narrowing, and sometimes lead to cancer.
Changes in life style certainly help. Regular exercise, maintenance of ideal body weight, avoiding all the predisposing foods and beverages, a small early dinner and elevating the head end of the bed, do work.
Those who can’t change their ways, prefer to take pills that reduce acid production in the stomach (Proton Pump Inhibitors or PPIs) or tighten the GE valve. They work well, but only as long as you keep taking them.
Refluxers are confronted with a hard choice of “Pleasure and Pill” or “Frugal Pauper”. Not easy!
ALCOHOL USE and the CAGE Questionnaire
In our present times of frequent social alcohol drinking, it sometimes becomes difficult for the consumer, family or doctor to recognise early symptoms of dependency.
Alcohol use disorder (AUD) as it is presently called, is the wider all-encompassing term that includes dependency, addiction and withdrawal, and by virtue of its broad range and blurred margins, sounds more acceptable as well.
Medical and mind scientists have relied on recognising patterns of behaviour and consumption, to identify ALCOHOL USE DISORDER and have created several scoring methods.
The CAGE questionnaire, an acronym, is one such, and is the easiest, simplest and most widely used interview tool. It consists of four straight questions that need to be answered with a YES or NO.
Here they are:
1. Have you ever felt you should CUT down on your drinking?
2. Have people ANNOYED you by criticising your drinking?
3. Have you ever felt bad or GUILTY about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE- OPENER)?
Needless to say, the consumer has to answer these questions honestly. Presence of a spouse or relative may help in getting accurate responses to questions 2 and 4.
If any one of the answers is YES, it is time take heed. It will be good to meet a specialist and seek help to cut down or stop.
After ingesting, alcohol is carried by the blood stream to different organs of the body. Brain is the organ where its mood – effects (pleasure, desire, relaxation, sleep, anger) find expression while its injurious effects occur more in the liver, pancreas, heart and muscles.
The effects of alcohol, both on the brain as well as its metabolism and clearance from the body, are regulated by a large number of enzymes ( Alcohol dehydrogenase enzymes and their wide range of polymorphisms) with considerable genetic variations.
Hence we often hear the stories of someone who is said to have drunk a whole bottle of whisky every day for decades and lived a healthy long life.
More often, many tolerate alcohol poorly and can develop liver damage or pancreatitis with as small doses as just a couple of occasional drinks, and find it hard to reconcile their fate with the story!
Independent India’s Healthcare @ 75 years
Three quarters of a century is a good time to pause, look back at the path we have covered so far, and take a look at the road ahead in this long and endless journey.
I am sure no one would argue that the nation’s health is better off now than when we gained independence. A baby born in India in 1947 could have expected to live for 37 years only. This life expectancy figure has gone up now to 69 years, indicating that most Indians being born now are living much longer.
While on the subject of health statistics, there are two other important indicators of progress; 146 of every 1000 infants born then used to die; that has come down to 28 now. Infant mortality rate as it is called, is an important health parameter and has shown an impressive decline. So has Maternal Mortality Rate, another important health index.
It is difficult to believe now that there were merely 19 medical colleges in India when we became independent. That meant very few doctors indeed. One cannot imagine how difficult access to modern health care must have been at the time of independence.
India now has around 400 medical colleges, producing the much- needed medical manpower. Still short, one may argue, but a 20 times jump is laudable.
Looking beyond numbers, let us see what else have changed in the health care sector. India managed to eradicate two diseases, small pox and polio.
The profile of illnesses that claimed lives in 1947 and the ones that do now are quite different too. Most deaths then were due to infections and malnutrition. Thanks to an effective immunization program and vaccine manufacturing facilities across the country, one hardly hears of deaths due to diphtheria, whooping cough, tetanus or measles these days.
The disease profile has changed to metabolic disorders now: diabetes, blood pressure, heart disease and cancers, largely due to consuming excess calories, exercising less and gaining weight.
Access to health care and affordability are the big challenges now. No denying that there are many miles to walk, but the glass can be seen as half empty or half full.
Happy 75th Anniversary!