Sunday, October 26, 2014

Unlearning to relearn: a physician’s thoughts

Guest article by Dr. B.M. Hegde

The Ebola outbreak sets the context for some ruminations on life, death, disease and health

I was supposed to be a good student in school and medical school, and passed examinations with credit. In retrospect, half a century later, I feel that was not a compliment. It is only now I realise that what one learns in school is not what lasts long, and it is probably not the whole truth anyway. What one studies there is only information that is many a time doctored to suit the convenience of industry or the powers-that-be.
The label of a good student gets into one’s head. When I completed my training abroad, passing examinations there, I was fooling myself into thinking that I “knew it all”. To that extent I was also arrogant. Early on in my life, I learnt the lesson of my life. The incident is still fresh in my mind. I was called to the hospital one day at 2 a.m. to see a patient brought dead after a massive heart attack. My colleagues wanted me to pacify the relatives as they could not come to terms with this young man of 34 in the pink of his health, that too a health freak, dying so young. I found the young wife rolling on the floor wailing. When she saw me, she suddenly turned around to catch my ankle to ask me the most profound question in my life that transformed me completely. She asked me: “Why did my husband die, doctor?”
That morning was my enlightenment from my arrogance and ignorance, put together. Till that time I did not realise that I was such a big ignoramus. There is a saying: “A wise man knows he is a fool, but a fool always thinks he is wise.” That was my state of mind then. If only she had asked me, “how did my husband die, doctor,” I would have given her a textbook thesis on heart attacks. She asked me “why”, which has no answer in positive reductionist science that modern western medicine follows.
I somehow tried to extricate myself from that difficult situation by giving some solace to the wife and relatives, but her question kept troubling me. Then I went on to unlearn what I had learnt till then, to relearn again.
Later I came across the acceptance speech of the young Nobel Laureate in physiology, Charles Sherrington, in 1899 at Liverpool University where he became Professor of Physiology at 42. “Positive sciences cannot answer the question ‘why’; they can at best answer ‘how or how much, but not why’,” he said. That gave me some solace but I was still curious to know: “why” does one get sick?
That led me to various fields of human wisdom — religion, theology, psychology, spirituality, alternative medical systems, philosophy, Sanatana Dharma’s Karma Theory, sociology, and even teleology. I am still searching for answers.
The Ebola outbreak in West Africa has given me an opportunity to search for more answers. Two questions bug me. Throughout the history of disease and death, the poor, the ignorant and the deprived have suffered and died the most; the rich and the powerful escape much of the time.
In this context, two statements by leading men in this world startled me. In his book, Man the Unknown, the Nobel laureate Alexis Carrel argues that all mental patients should be put in the gas chamber as they are an economic liability on society. Bill Gates, in an unguarded moment, said that immunisation is one of the methods to control the population. I didn’t think much of it then, but now it makes sense. With vaccine-sceptics crying hoarse about vaccine-related deaths which the establishment science condemns, right-thinking people need to think on those lines.
When swine flu broke out, those who laughed all the way to the bank were drug barons. The rich always win. There seems to be a pattern in all these to agree with the biblical statement: “For whosoever hath, to him shall be given…”
Now comes Ebola that has been around on and off for some years but was confined to West Africa. This time it broke loose and is threatening to spread far and wide.
Liberian scientist Dr. Cyril Broderick wrote in the Liberian Observer that “Ebola is a genetically modified organism.” The book, The Hot Zone, confirms that infectious agents like Ebola were once developed into bioweapons by the U.S. Army, but says such research was outlawed by President Nixon in 1969. As of now there is no confirmation of the theory that Ebola is being studied for bio-terrorism.
The poor suffer and die always in nature except in the modern western medical interventions industry — which kills only the rich. The poor cannot reach that and are thus saved. History tells us that from the time of Galen almost in 127 A.D. only rich patients were dying because they could afford to pay their doctors; the poor survived, diseases notwithstanding. In 19th century London, the surgeon Arbuthnot Lane used to remove rich people’s colons as he thought the poisons from their colons were the cause of their illnesses. It only took the courage of a man like Bernard Shaw to write Doctors’ Dilemma, which forced Professor Lane to close shop. Audits today show that the medical establishment is the leading cause of death in the world, but the poor of the world escape that fate as they do not get to go near that trillion-dollar illness care industry. The biblical verse gets twisted here: “For whoever hath, to himshall not be given.”

Broken heart is real, shows study

A broken heart can feel very real for those experiencing the loss of a loved one or significant other. But for some, the emotional stress does quite literally break their heart — at least temporarily — causing symptoms that can mimic a heart attack. 

Broken heart syndrome is one of the many names for takotsubo cardiomyopathy, a rare and temporary condition where part of a person's heart suddenly becomes weakened or 'stunned' — forcing the rest of the heart to work harder. 

When this happens, the heart's left ventricle changes shape, developing a narrow neck and round bottom. 

The shape created by this bulging out earned the syndrome the name 'takotsubo', meaning octopus, in Japan where the condition was first reported. 

The condition is also referred to as acute stress cardiomyopathy and apical ballooning syndrome. 

What causes it? 

There are various theories as to what causes the condition. About three quarters of those diagnosed with Takotsubo cardiomyopathy have experienced severe emotional or physical stress prior to becoming unwell, such as bereavement. 

British Heart Foundation (BHF) says evidence suggests the sudden, excessive release of hormones — usually adrenaline — during these stressful periods causes the 'stunning' of part of the heart muscle. Interestingly, research conducted by Imperial College London in 2012 found the condition may actually protect the heart from very high levels of adrenaline. 

Professor Sian Harding, from the National Heart and Lung Institute (NHLI) at Imperial College London, who led the study, explained: "In patients with Takotsubo cardiomyopathy, adrenaline works in a different way and shuts down the heart instead. This seems to protect the heart from being overstimulated." People experiencing takotsubo cardiomyopathy will often have chest pains and breathlessness similar to those seen in a heart attack, according to the British Heart Foundation (BHF). However, the survival rate for those who are discharged from hospital after suffering from the condition is nearly 100%. Amy Thompson, senior cardiac nurse at the BHF, said: "Its symptoms can mimic a heart attack, but it causes no permanent damage to the heart — it is both temporary and reversible." 

How common is it? 

The BHF estimates that takotsubo cardiomyopathy affects 2,500 people in the UK each year. Between one and two per cent of people who are initially believed to have had a heart attack are found to have experienced the syndrome at a later date, according to Imperial College. 

Dr Alexander Lyon, a consultant cardiologist at the Royal Brompton, said that more people may be dying suddenly of the condition before reaching hospital without it being accurately diagnosed before or after their death. 

He said this can be particularly difficult with men who may have died from the syndrome. "The pathologist opens the heart, sees some signs of coronary artery disease, because in western society pretty well all adult men will have evidence of it, and so records coronary heart disease as the cause of death," he explained. 

"And with deaths in custody, we know that hearts are very often normal when examined, so this syndrome becomes relevant. It may be happening far more often than is reported." 

Who is affected by it? 

The Johns Hopkins University School of Medicine said that out of women in their research who were being examined for heart abnormalities in a catheterization lab, between five and seven per cent will be diagnosed with broken heart syndrome. 

Thompson said some studies suggest the syndrome affects women more than men. "Further research is needed to fully understand this rare condition," she added. 

Pvt sector deserts war on TB, funding down 33% since 2011

Even as tuberculosis (TB) continues to haunt the world, a new study has revealed that funding for research and development of new drugs to fight the disease is floundering. Private sector funding has declined by more than a third since 2011 as pharma companies are closing their TB research programmes.

Pfizer shut down its TB drug discovery programme in 2012, AstraZeneca in 2013 and Novartis in 2014. Meanwhile, multi-drug resistant TB is rapidly spreading with 450,000-odd new cases reported in 2012 by the World Health Organisation (WHO).

The report was prepared by Treatment Action Group (TAG), a New York based health policy think tank. It pointed out that while $9.8 billion was needed to fight TB during 2011-2015 according to a Global Plan prepared by experts in 2011, the world spent only $1.99 billion by the end of 2013.

India spent around $7.6 million in 2013 on TB research according to the TAG report. The highest spender was the National Institute of Allergy & Infectious Diseases of US which invested over $158.8 million, followed by the Bill & Melinda Gates Foundation which spent $147.9 million.

New drugs are needed because current drugs require a six-month course increasing chances of patients not finishing it and thus relapsing, explained Mike Fricke, author of the TAG report. Also, new drugs are essential to fight the growing incidence of drug-resistant TB.

"There is a great need for shorter treatment regimens using fewer numbers of pills. The current regimen requires six months of treatment... making it difficult for many patients to finish therapy. For drug-resistant TB, there is an urgent need to develop safer, more tolerable drugs. Many of the drugs used to treat drug-resistant TB are decades old and carry severe toxicities including hearing loss, psychosis and peripheral neuropathy," he told PG Times.

According to the TAG report, the onus of developing new treatments for TB is now falling more on public funding. Over 60 percent of global TB research is now done under public funded programs in research institutions and universities.

India is one of the more severely TB-affected countries with about 2.8 million TB patients including 55,000 multi-drug resistant TB cases.

Why is the private sector deserting this war? They do not see much profit in TB drugs because this is a disease most widely prevalent in middle and lower income countries, says Amit Sengupta of the Jan Swasthya Abhiyan, a health activists' network in India.

"Thirty seven percent of the global pharma market is in the US while India's share is just 2%. Big Pharma prefers making and selling drugs needed by the richer countries for ailments like heart diseases, cancer, depression. They don't want to spend money on drugs and vaccines for TB or malaria which afflict millions of poorer people," he said.

Each year 3 million of the nearly 9 million people who get TB are never reported to national TB programs and don't receive a diagnosis or treatment, says Frick. This deficiency in the healthcare system is also weighing on Big Pharma's mind.

"TB affected communities will be asked to pay twice - first to fund the research behind new drugs and then again to buy those drugs back from the same pharmaceutical companies that benefited from public financing," Frick said.

Total funding needed to fight TB = $9.8 billion (2011-15)

Actual funding = $1.99 billion (till Dec 2013)

Share of TB Research Funding

Public: 59%

Philanthropic: 25%

Private: 15%

Multilateral: 1%

Friday, October 24, 2014

PG Times launches free mini Mock Tests

Keeping in view the upcoming PG entrance exams, PG Times has come up with a unique concept of free online mini mock tests.
  • In order to help thousands of PG aspiring medicos get a seat of their choice, PG Times has launched free mini Mock Tests on its website. 
  • Ten questions (including image-based questions) will be published daily based on all the subjects asked in different PG medical entrance exams. 
  • Questions will be framed simulating the latest NBE-based All India Pattern.
  • Students can attend these free tests to get an idea of their preparation.
  • No registration is required to take the tests. 
  • The test would remain online till a new test is published. 
  • Candidates will get the correct answers and their scores immediately after completing the test.

PM announces Rs 175 crore relief for Kashmir’s flood-hit hospitals

Prime Minister Narendra Modi on Thursday met various groups of flood-affected people here to understand their problems and listen to their suggestions on the rehabilitation process following the recent floods.
These included delegations from chambers of commerce and industry, social organizations and NGOs, civil society organizations, transport operators, tour and travel operators, fruit growers, dealers and horticulture institutions, educational institutions, youth organizations, religious communities and political groups, according to an official statement.
The Prime Minister said that a common thread running through the interaction with all groups was the suggestion that affected people should be given help directly. He said this request would be seriously considered. For instance, he said, it could be considered that assistance for rebuilding houses could be given directly to bank accounts of beneficiaries.
Over and above the special central assistance of Rs 1000 crore that was announced during the Prime Minister’s visit to Srinagar in September, Narendra Modi announced Rs 570 crore assistance for housing. He said six major hospitals in the state of Jammu and Kashmir were in poor condition and required immediate intervention. For this he announced assistance of Rs 175 crore.
The Prime Minister assured the people of Jammu and Kashmir that the entire nation stood with them in the rebuilding process, after the floods.

Monday, October 20, 2014

Keep the student in you alive, says PM Modi at AIIMS convocation

The 42nd convocation of AIIMS was a memorable occasion as for the first time the premier institute initiated the tradition of presenting lifetime achievement awards to medical professionals associated with it.
Prime Minister Narendra Modi, who gave away the lifetime achievement awards to former senior faculty members of AIIMS who have contributed immensely to the development of the institution and also to medical science in the country, advised the passing out graduates to keep the student in themselves alive.
"Keep the student in you alive. These people whom I have honoured today with the lifetime achievement awards, they belong to the age group of 70-80 years. But if you meet them, you will find that they are very much aware of the latest developments of medical science, not because they need patients but because the student in them is still alive," said Modi.
Reminding the award winners of their days at the institute, Modi said, "You had so many people to turn to here in your institute to solve your problems and satisfy your curiosity. There was always someone who would protect you and take responsibility for what you do and you were aware of that. But today from a four walled closed classroom you will be entering a huge classroom.
"The moment, people especially those belonging to the medical profession fraternity feel that their learning period is over, I fell they stagnate and get stuck in all kind of obstacles. The student mindset keeps the life alive and the moment we stop to learn, we should realise that we have taken a step towards death," he said.
Modi further said that when he had come to the function, a gentleman said that people are astounded by his energy.
"I say there is nothing to feel surprised about. People from medical science fraternity are present here and they know that the urge to learn something new and do something new every time fills us with energy and zeal," he said.
Six persons who were honoured with the lifetime achievement award include Prof GP Talwar, Founder Director of National Institute of Immunology (NII), Dr JS Guleria, former Dean of faculty and former head of department for general medicine at AIIMS, Professor PN Tandon, Founder President of the National Brain Research Centre (NBRC) and also former President of Indian National Science Academy. Tandon had founded the Neurosurgery department of AIIMS.
The lifetime achievement awards were also given to Dr Sneh Bhargava, eminent radiologist and former director of AIIMS, Dr IK Dhawan, Former Head department of Surgical disciplines who initiated the renal transplant programme in India and P Venugopal, founder chief of Cardio-thoracic centre and former Director AIIMS. He also did the first heart transplant in India and is known as the doyen of cardiac care in India.
Venugopal said, "It feels great. I had joined this institute as an undergraduate in 1959. We have lived for the institute and getting a recognition and honour at our own institute is the biggest achievement.
As for Talwar, it was a very emotional moment. "I spent 27 years here in AIIMS. This honour has put new chains of binding and I feel my love for the institute renewed," he told PTI.
Tandon found the initiative very endearing and encouraging as he said, "It is a sort of symbol for the younger generation to see what the people associated with it have contributed to the Medical Science of our country.
"As our Prime Minister said we owe gratitude to this country and its people who have invested on us," he said.
Text of Prime Minister Narendra Modi’s speech at the 42nd Annual Convocation Ceremony of AIIMS, New Delhi

मंत्रिपरिषद के मेरे साथी डॉ. हर्षवर्द्धन, मंचस्‍थ सभी महानुभाव और आज के दिवस के केंद्र बिन्‍दु वे सभी डिग्रीधारी जो आज इस कैंपस को छोड़ करके एक नई जिम्‍मेदारी की ओर कदम रख रहे हैं।

मैं आप सबको हृदय से बहुत-बहुत शुभकामनाएं देता हूं।

मैं कभी अच्‍छा स्‍टूडेंट नहीं रहा हूं, और न ही मुझे इस प्रकार से कभी अवॉर्ड प्राप्‍त करने का सौभाग्‍य मिला है। इसलिए मुझे बहुत बारीकियों का ज्ञान नहीं है। लेकिन इतनी समझ जरूर है कि विद्यार्थी का जब Exam होता है, उस हफ्ते बड़ा ही टेंशन में रहता है, बड़ा ही गंभीर रहता है। खाना भी जमता नहीं, बड़े तनाव में रहता है। लेकिन आज एक प्रकार से वो सारी झंझटों से मुक्ति का पर्व है और आप इतने गंभीर क्‍यों हैं?

मैं कब से देख रहा था, कि क्‍या कारण है यहां! क्या, मिश्राजी, क्‍या कारण है? मैं आपसे आग्रह करूंगा कि आप अपने दायित्‍व पर उससे भी ज्‍यादा गंभीर हों - अच्छी चीज़ है - लेकिन जीवन को गंभीर मत बना देना। जिंदगी को हंसते-खेलते, संकटों से गुजरने की आदत बनाते हुए चलना, और उसका जो आनंद है, वह बड़ा ही अलग होता है। हमारे देश में, अगर पुराने शास्‍त्रों की तरफ देखें, तो पहला convocation, इसका उल्‍लेख तेत्रैय उपनिषद में आता है। वेद काल में गुरू-शिष्‍य जब परंपरा थी, और शिष्‍य जब विद्यार्थी काल समाप्‍त करके जाता था, तो उसका प्रथम उल्‍लेख तैत्रेय उपनिषद में आता है कि कैसे Convocation की क्‍या कल्‍पना थी।

वो परंपरा अब भी चल रही है, नए रंग-रूप के साथ चल रही है। मेरा एक-दो सुझाव जरूर है। क्‍या कभी हम इस Convocation में एक Special guest की परंपरा खड़ी कर सकते हैं क्‍या? और Special guest का मेरा मतलब है कि गरीब बस्‍ती में जो Schools हैं, गरीब परिवार के बच्‍चे जहां पढ़ते हैं, ऐसे एक Selected 8वीं 9वीं कक्षा वे बच्‍चे, 30, 40, 50 जो भी आपकी Capacity में हो, उनको ये Convocation में Special guest के रूप में बुलाया जाए, बिठाया जाए, और वे देखें, ये दुनिया क्‍या है। जो काम शायद उसका टीचर नहीं कर पाएगा, उस बालक मन में एक घंटे-डेढ़ घंटे का ये अवसर उसके मन में जिज्ञासा पैदा करेगा। उसके मन में भी सपने जगाएगा। उसको भी लगेगा कि कभी मेरी जिंदगी में ये अवसर आए।

आप कल्‍पना कर सकते हैं, कितना बड़ा इसका impact हो सकता है। चीज बहुत छोटी है। लेकिन ताकत बहुत गहरी है और यही चीजें हैं जो बदलाव लाती है। मेरा आग्रह रहेगा, वे गरीब बच्‍चे। डॉक्‍टर का बच्‍चा आएगा तो उसको लगेगा कि मेरे पिताजी ने भी ये किया है, उसको नहीं लगेगा। समाज जीवन में अपने सामान्‍य बातों से हम कैसे बदलाव ला सकते हैं। उस पर हम सोचें। जो डॉक्‍टर बनकर आज जा रहे हैं, अपने जीवन में अचीवमेंट किया है, मेरे जाने के बाद भी शायद हर्षवर्द्धन जी कईयों को अवॉर्ड देने वाले हैं, सर्टिफिकेट देने वाले हैं। लेकिन आज आप जा रहे हैं, बीता हुआ कल और आने वाला कल के बीच कितना बड़ा अंतर है।

आपने जब पहली बार AIIMS में कदम रखा होगा तो घर से बहुत सारी सूचनाएं दी गई होंगी, मां ने कहा होगा, पिताजी ने कहा होगा। चाचा ने कहा होगा, देखो ऐसा करना, ऐसा मत करना। ट्रेन में बैठे होंगे तो कहा होगा कि देख खिड़की के बाहर मत देखना। कोई अनजान व्‍यक्ति कुछ देता है तो मत लेना। बहुत कुछ कहा होगा। एक प्रकार से आज भी वही पल है। Convocation एक प्रकार से आखिरी कदम रखते समय परामर्श देने का एक पल होता है।

कभी आप सोचे हैं कि जब आप क्‍लासरूम में थे, Institute में थे, जब आप पढ़ रहे थे, तब आप कितने protected थे? कोई कठिनाई आई तो सीनियर साथी मिल जाता था, बताता था। समाधान नहीं हुआ तो प्रोफेसर मिल जाते थे। प्रोफेसर नहीं मिले तो डीन मिल जाते थे। बहुत avenues रहते थे कि जहां पर आप आपकी समस्‍याओं का, आपकी जिज्ञासा का समाधान खोज सकते थे। आप कभी यहां काम करते थे, आपका हॉस्‍टल लाइफ रहा होगा। परिवार का कोई नहीं होगा, जो आपको हर पल ये कहता होगा, ये करो, ये मत करो। लेकिन कोई तो कोई होगा आरे यार क्‍या कर रहे हो भाई ? किसी ने कहा होगा भाई तुम्‍हारे पिताजी ने कितनी मेहनत करके भेजा है, तुम ये कर हो क्‍या ? बहुत कुछ सुना होगा आपने। और तब आपको बुरा भी लगा होगा कि क्‍या ये मास्‍टर जी देते हैं, हमें मालूम नहीं है क्‍या हमारी जिंदगी का? लेकिन कोई तो था जो आपको कहता था कि ये करो, ये मत करो।

आप उस अवस्‍था से गुजरे हैं और काफी लंबा समय गुजरे हैं, जहां, आपको स्‍वयं को निर्णय करने की नौबत बहुत कम आई होगी और निर्णय करने की नौबत आई होगी, तब भी protected environment में आई होगी, जहां पर आपको पूरा Confidence था कि मेरे निर्णय को इधर-उधर कुछ भी हो जाएगा तो कोई तो बैठा है जो मुझे मदद करेगा, बचा लेगा मुझे या मेरा हाथ पकड़ लेगा। इसके बाद आप एक ऐसी दुनिया में प्रवेश कर रहे हैं, जहां कोई आपका हाथ पकड़ने वाला नहीं है। जहां पर कोई आपको ये करो, ये मत करो, कहने वाला नहीं है। जहां आपका कोई protected environment नहीं है। आप एक चारदीवारी वाले classroom से एक बहुत बड़े विशाल classroom में enter हो रहे हैं। और तब जाकर के एकलव्‍य की मानसिकता आवश्‍यक होती है। एकलव्‍य को protected environment नहीं मिला था, लेकिन उसका लक्ष्‍य था achievement का। और उसने अपने काल्‍पनिक सृष्टि की रचना की और काल्‍पनिक सृष्टि के माध्‍यम से ज्ञान अर्जित करने का प्रयास किया था।

जिस पल, खास करके medical protection के लोग या professional क्षेत्र में जाने वाले लोग, विद्यार्थी काल की समाप्ति मानते हैं, मैं समझता हूं, अगर हमारे मन में यह अहसास हो कि चलो यार, छुट्टी हुई, बहुत दिन बिता लिए। वही Hostel, वहीं gown, वहीं stethoscopes, इधर दौड़ो, उधर दौड़ो। चलो मुक्ति हो गई। जो ये मानता है कि आज end of the journey है उसकी और एक नई journey में entry कर रहा है, मैं समझता हूं, अगर ये मन का भाव आया, तो मेरा निश्चित मत है, कि आप ठहराव की ओर जा करके फंस जाएंगे। रूकावटों की झंझटों में उलझ जाएंगे।

लेकिन अगर आप एक बंद classroom से एक विशाल classroom में जा रहे हैं। विद्यार्थी अवस्‍था भीतर हमेशा रहती है। जिन लोगों को आज सम्‍मानित करने का सौभाग्‍य आज मिला, 70-80 साल की आयु वाले सभी हैं। लेकिन अज उनसे आप मिलेगा तो मुझे विश्‍वास है, आज भी medical science के latest Development के बारे में उनको पता होगा। इसलिए नहीं कि उनको किसी पेशेंट की जरूरत है, इसलिए कि उनके भीतर का विद्यार्थी जिंदा है। जिसके भीतर का विद्यार्थी जिंदा होता है, वही जीवन में कुछ कर पाता है, कर गुजरता है। लेकिन अगर यहां से जाने के बाद इंस्‍टीट्यूट पूरी हुई तो विद्यार्थी जीवन भी पूरा हुआ। अगर ये सोच है तो मैं समझता हूं कि उससे बड़ा कोई ठहराव नहीं हो सकता है। विद्यार्थी अवस्‍था, मन की विद्यार्थी अवस्‍था जीवन के अंत काल तक जीवन को प्राणवान बनाती है, ऊर्जावान बनाती है। और जिस पल मन की विद्यार्थी अवस्‍था समाप्‍त हो जाती है, मृत्‍यु की ओर पहला कदम शुरू हो जाता है।

अभी मैं आया तो वो सज्‍जन बता रहे थे, कि लोगों को अचरज है, मोदीजी की energy का। अचरज जैसा कुछ है नहीं, आप लोग medical science के लोग हैं, थोड़ा इतना जोड़ दीजिए, हर पल नया करने की, सीखने की इच्‍छा आपके भीतर की ऊर्जा कभी समाप्‍त नहीं होती है। कभी energy समाप्‍त नहीं होती। आपकी स्थिति कुछ और भी बनेगी, जब आप hostel में रहते होंगे, OPD में आपको कई पेशेंट को डील करना होता होगा। कभी दोपहर को दोस्‍तों के साथ मूवी देखना तय किया है तो मन करता था कि OPD ऐसा करो निकालो। हमें सिनेमा देखने जाना है। मैं आपकी बात नहीं बता रहा हूं, ये तो मैं कहीं और की बात बता रहा हूं।

आपने पेशेंट को कहा होगा ये खाना चाहिए, ये नहीं चाहिए। इतना खाना चाहिए, इतना नहीं खाना चाहिए। लेकिन जैसे ही आप मेस में पहुंचते होंगे, सब साथियों ने मिलके स्‍पर्धा लगाई होगी, आज तो special Dish है। Sweet है, देखते हैं कौन ज्‍यादा खाता है। ये सब किया होगा। और वही तो जिंदगी होती है, दोस्‍तो। लेकिन आपने किसी को कहा होगा, ये खाओ, ये मत खाओ। तब जा करके अपनी आत्‍मा से पूछा है, मैंने उसको तो ये कहा था, मैं ये कर रहा हूं। इसलिए सफलता की पहली शर्त होती है। कल तक की बात अच्‍छी थी, किया, अच्‍छा किया। मैं उसको appreciate करता हूं। लेकिन आने वाले कल में, मैं कैंसर का डॉक्‍टर हूं और शाम को धुंआधार सिगरेट जलाता रहता हूं और मैं दुनिया को कहूंगा कि भाई इससे कैंसर होता है तो किसी को गले नहीं उतरेगा। ऊपर से हम एक उदाहरण बन जाएंगे- हां यार, कैंसर के डॉक्‍टर सिगरेट पीते हैं तो मुझे क्‍या फर्क पड़ता है।

इसलिए मैं एक ऐसे व्‍यवसाय में हूं, मैं एक ऐसे क्षेत्र में कदम रख रहा हूं, जहां मेरा जीवन मेरे पेशेंट की जिंदगी बन सकता है। शायद हमने बहुत कम लोगों ने सोचा होगा कि क्‍या एक डॉक्‍टर का जीवन एक पेशेंट की जिंदगी बन सकता है? आप कभी सोचना, आपका हर मिनट, हर बात, हर संपर्क पेशेंट की जिंदगी बन सकती है। कभी सोच करके देखिए, बहुत कम लोग हैं, जो जीवन को इस रूप में देखते हैं। मैं आशा करता हूं, आज जो नई पीढ़ी जा रही है, वो इस पर सोचेगी।

उसी प्रकार से, हम डॉक्‍टर बने हैं, कभी अपनी ओर देखें - क्‍या आपके पिताजी के पास पैसे थे, इसलिए आपने पाया? क्‍या आपके प्रोफेसर बहुत अच्‍छे थे, इसलिए ये सब हुआ? क्‍या सरकार ने बहुत बढि़या इमारत बनाई थी, AIIMS बन गया था, इसके कारण हुआ? आप थोड़े मेहनती थे, इसलिए हुआ? अगर यही सोच हमारी सीमित रही तो शायद जिंदगी की ओर देखने का दृष्टिकोण पूर्णता की ओर हमें नहीं ले जाएगा। कभी सोचिये, यहां पर जब आप पहले दिन आए होंगे तो एक ऑटो-रिक्‍शा वाला या टैक्‍सी वाला होगा जिसने आपकी मदद की होगी। बहुत अच्‍छे ढंग से यहां लाया होगा, पहली बार दिल्‍ली में कदम रखा होगा, बहुतों ने। तो क्‍या आज स्थिति को प्राप्‍त करते समय आपकी जीवन की यात्रा का पहला चरण जिस ऑटो ड्राइवर के साथ किया, या उस टैक्‍सी वाले के साथ किया, क्‍या कभी स्‍मरण आता है?

Exam के दिन रहे होंगे, थकान महसूस हुई होगी, रात के 12 बजे पढ़ते-पढ़ते कमरे से बाहर निकले होंगे, ठंड का मौसम होगा और एक पेड़ के नीचे कोई चाय बेचने वाला बैठा होगा। आपका मन करता होगा, चाय मिल जाए तो अच्‍छा हो, क्‍योंकि रात भर पढ़ना है। और उस ठंडी रात में सोये हुए, उस पेड़ के नीचे सोये हुए उस चाय बेचेने वाले को आपके जगाया होगा, कि चाय पिला दे यार। और उसने अपना चेहरा बिगाड़े बिना, आप डॉक्‍टर बने इसलिए, आपका Exam अच्‍छा जाए, इसलिए, ठंड में भी जग करके कही से दूध लाके आपको चाय पिलाई होगी। तब जा करके आपकी जिंदगी की सफलता का आरंभ हुआ होगा।

कभी-कभार एकाध peon भी, कोई paramedical staff का बूढ़ा व्‍यक्ति, जिसके पास जीवन के अनुभव वा तर्जुबा रहा होगा, उसने कहा होगा, नहीं साब, सिरींज को ऐसे नहीं पकड़ते हैं, ऐसे पकड़ते हैं। हो सकता है, classroom का वह teacher नहीं होगा, लेकिन जिंदगी का वह Teacher बना होगा। कितने-कितने लोग होंगे, जिन्‍होंने आपकी जिंदगी को बनाया होगा। एक प्रकार से बहुत बड़ा क़र्ज़ लेकर के आप जा रहे हैं।

अब तक तो स्थिति ऐसी थी कि कर्ज लेना आपका हक भी था, लेकिन अब कर्ज चुकाना जिम्‍मेवारी है। और इसलिए भली-भांति उस हक का उपयोग किया है, अच्‍छा किया है। लेकिन अब भली-भांति उस कर्ज को चुकाना हमारा दायित्‍व बन जाता है। और उस दायित्‍व को हम पूरा करें। मुझे विश्‍वास है कि हम समाज के प्रति हमारा दायित्‍व अपने profession में आगे बढ़ते हुए भी निभा सकते हैं। आप अमीर घर के बेटे हो सकते हैं, गरीब परिवार के बेटे हो सकते हैं, मध्‍यम वर्ग के परिवार के बेटे / बेटी हो सकते हैं, लेकिन क्‍या कभी सोचा है कि आपकी पढ़ाई कैसे हुई है? क्‍या आपके फीस के कारण पढ़ाई हुई है? नहीं, क्‍या scholarship के कारण हुई है? नहीं।

इन व्‍यवस्‍थाओं का विकास तब हुआ होगा, जब किसी गरीब के स्‍कूल बनाने का बजट यहां divert हुआ होगा। किसी गांव के अंदर बस जाए तो गांव वालों की सुविधा बढ़े, हो सकता है कि वह बस चालू नहीं हुई होगी, वह बजट यहां divert किया गया होगा। समाज के कई क्षेत्रों के विकास की संभावनाओं को रोक करके इसे develop करने के लिए कभी न कभी प्रयास हुआ होगा। एक प्रकार से उसका हक छिन कर हमारे पास पहुंचा है, जिसके कारण हम लाभान्वित हुए हैं। और ये जरूरत थी, इसलिए यहां करना पड़ा होगा। क्‍योंकि अगर इतने बड़े देश में medical profession को बढ़ावा नहीं देते हैं तो बहुत बड़ा संकट आ सकता है, अनिवार्य रहा होगा। लेकिन कोई तो कारण होगा कि समाज के किसी न किसी का हक मैने लिया है, तब जाकर आज इस स्‍तर तक पहुंचा हूं। क्‍या मैं हर पल अपने जीवन में उस बात को याद करूंगा कि हां भाई, मैं सिर्फ डॉक्‍टर बना हूं, ऐसा नहीं है? ये मेरे सामने आया हर व्‍यक्ति किसी न किसी तरीके से योगदान दिया है, तब जाकर मैं इस अवस्‍था को पहुंचा हूं। मुझ पर उसका अधिकार है।

मैं नहीं जानता हूं, जो लोग यहां से पढ़ाई की और विदेश चले गए, उनके दिल में यह बात पहुंचेगी कि नहीं पहुंचेगी। कभी-कभार, अपने profession में बहुत आगे निकल गए और निकलना भी है। हम नहीं चाहते हैं कि सब पिछड़ेपन की अवस्‍था में हमारे साथी रहें। लेकिन कभी हम भी तो यार दोस्‍तों के साथ छुट्टी मनाने जाते हैं। कितने भी पेशेंट क्‍यों न हो, कितनी भी बीमारियों की संभावना क्‍यों न हो, लेकिन जिंदगी ऐसी है कि कभी न कभी उसकी चेतना अगले 7 दिन, 10 दिन अपने साथियों के साथ बाहर जाते हैं। कभी-कभार ये भी तो सोचिये कि भले ही बहुत बड़ी जगह पर बैठेंगे, लेकिन कम से कम सब साथियों को ले करके साल में एक बार पांच दिन, सात दिन दूर-सुदूर जंगलों में जा करके, गरीबों के साथ बैठ करके, मेरे पास जो ज्ञान है, अनुभव है, कहीं उनके लिए भी तो कर पाएं। मैं सात दिन, 365 दिन करने की जरूरत नहीं है, न कर पाएं, लेकिन ये तो कर सकते हैं। अगर इस प्रकार का हम संकल्‍प करके जाते हैं तो इतनी बड़ी शक्ति अगर लगती है। समाज की शक्ति से बड़ी कोई शक्ति नहीं हो सकती है। हम एक समाज के बहुत चेतनमंद ऊर्जा है। हम क्‍या कुछ नहीं कर सकते है इस भाव को लेकर अगर हम चलते हैं तो हम बहुत बड़ी सेवा समाज की कर सकते हैं।

कभी-कभार मैंने देखा है, सफल डॉक्‍टर और विफल डॉक्‍टर के बीच में आपने अंतर कभी देखा है क्‍या? कुछ डॉक्‍टर होते हैं जो बीमारी के संबंध में बहुत focused होते हैं, और इतनी गहराई से उन चीजों को handle करते हैं, और उनके profession में उनकी बड़ी तारीफ होती है। भाई, देखिए इस विषय में तो इन्‍हीं को पूछिए। consult करना है तो उनको पूछिए। लेकिन कभी-कभार उसकी सीमा आ जाती है।

दूसरे प्रकार के डॉक्‍टर होते हैं। वे बीमारी से ज्‍यादा बीमार के साथ जुड़ते हैं। यह बहुत बड़ा फर्क होता है। बीमारी से जुड़ने वाला बहुत Focused activity करके बीमारी को Treat करता है, लेकिन वो डॉक्‍टर जो बीमार से जुड़ता है, वो उसके भीतर बीमारी से लड़ने की बहुत बड़ी ताकत पैदा कर देता है। और इसलिए डॉक्‍टर के लिए यह बहुत बड़ी आवश्‍यकता होती है कि वह उस इंसान को इंसान के रूप में Treat कर रहा है, कि उसके उस पुर्जे को हाथ लगा रहा है, जिस पुर्जे की तकलीफ है? मैं नहीं मानता हूं कि वो डॉक्‍टर लोकप्रिय हो सकता है। वह सफल हो सकता है। डॉक्‍टर का लोकप्रिय होना बहुत आवश्‍यक होता है, क्‍योंकि सामान्‍य व्‍यक्ति डॉक्‍टर के शब्‍दों पे भरोसा करता है।

हमें भी अंदाज नहीं होता है। हम कहते है तो कह देते हैं कि देखो भई, जरा इतना संभाल लेना। बहुत पेशेंट होते हैं जो, उस एक शब्द को घोष वाक्‍य मान करके जिंदगी भर के लिए स्‍वीकार कर लेते हैं। तब जा करके हमारा दायित्‍व कितना बढ़ जाता है। और इसलिए हमें उस डॉक्‍टर समूहों की आवश्‍यकता है, जो सिर्फ बीमारों की नहीं, बीमारी की नहीं, लेकिन पेशेंट के confidence level को Build up करने की दृष्टि से जो कदम उठाए जाएं। और मैं नहीं जानता कि जब आप पढ़ते होंगे, तब classroom में ये बातें आई होगी। क्‍योकि आपको इतनी चीजें देखनी होती होगी, क्‍योंकि भगवान ने शरीर में इतनी चीजें भर रखी हैं, कि उसी को समझते-समझते ही कोर्स पूरा हो जाता है। सारे गली-मोहल्‍ले में Travel करते-करते पता नहीं कहां निकलोगे आप? इसलिए ये बहुत बड़ी आवश्‍यकता होती है कि मैं इस क्षेत्र में जा रहा हूं, तो मैं एक समाज की जिम्‍मेवारी ले रहा हूं। और समाज की जिम्‍मेवारी ने निभाने के लिए हम कोशिश कर रहे हैं।

हमारे देश में by and large, पहले के लोग थे, जो रात में भी मेहनत कर करके रिकॉर्ड मेंटेन करते थे। और वो पेशेंट की history, बीमारी की history, कभी-कभार भविष्‍य के लिए बहुत काम आती है। आज युग बदल चुका है। Digital Revolution एक बहुत बड़ी ताकत है। एक डॉक्‍टर के नाते मैं अभी से दो या तीन क्षेत्रों में focus करके case history के रिकॉर्ड्स बनाता चलूं, बनाता चलूं, बनाता चलूं। उसका analysis करता चलूं। कभी-कभार मेरे सीनियरों से उसका debate करूं, चर्चा करूं। science Magazines के अंदर मेरे Article छापे, इसके लिए आग्रही बनो।

भारत के लिए बहुत अनिवार्य है दोस्‍तों कि हमारे Medical Profession के लोग, अमेरिका के अंदर उसका बड़ा दबदबा है। दुनिया के कई देश ऐसे हैं, कि गंभीर से गंभीर बीमारी हो, अस्‍पताल में आपरेशन थियेटर में ले जाते हों, लेकिन जब तक वो हिन्‍दुस्‍तानी डॉक्टर का चेहरा नहीं देखते हैं, तब तक उनका विश्‍वास नहीं बढ़ता है। यह हमने achieve किया है। By and large, हर पेशेंट विश्‍व में जहां भी उसको परिचय आया, कुछ ऐसा नहीं यार, आप तो हैं, लेकिन जरा उनको बुला लीजिए। ये कोई छोटी बात नहीं है। लेकिन, हम Research के क्षेत्र में बहुत पीछे है। और Research के क्षेत्र में यह आवश्‍यक है कि हम Case history के प्रति ज्‍यादा Conscious बनें। हम पेशेंट की हर चीज को बारीकी से लिखते रहें, analysis करते रहें, 10 पेशेंट को देखते रहें। हो सकता है कि धीरे-धीरे 2-4 साल की आपकी इस मेहनत का परिणाम यह आएगा कि आप मानव जाति के लिए बहुत बड़ा Contribute कर सकते हैं। और हो सकता है कि आपमें से कोई Medical Science का Research Scientist बन सकता है।

मानव जाति के कल्‍याण के लिए मैं समस्‍याओं को Treat करता रहूं, एक रास्‍ता है, लेकिन मैं मानव जाति की संभावित समस्‍याओं के समाधान के लिए कुछ नई चीजें खोज कर दे दूं। हो सकता है, मेरा Contribution बहुत बड़ा हो सकता है। और ये काम कोई दूसरा नहीं करेगा। और आज Medical Science, आज से 10 साल पहले और आज में बहुत बड़ा बदलाव आया है। Technology ने बहुत बड़ी जगह ले ली है, Medical Science में।

एक जमाना था, जब गांव में एक वैद्यराज हुआ करते थे, और गांव स्‍वस्‍थ होता था। गांव बीमार नहीं होता था। आज आंख का डॉक्‍टर अलग है, कान का अलग है। वो दिन भी दूर नहीं, बाईं आंख वाला एक होगा, दाईं आंख वाला दूसरा होगा। लेकिन एक वैद्यराज से गांव स्‍वस्‍थ रहता था और बायें-दायें होने के बावजूद भी स्‍वस्‍थता के संबंध में सवालिया निशान लगा रहता है। तब जा करके बदले हुए समय में Research में कहीं न कहीं हमारी कमी महसूस होती है। Technological development इतना हो रहा है, आप मुझे बताइए, अगर Robot ही ऑपरेशन करने वाला है तो आपका क्‍या होगा? एक programming हो जाएगा, programme के मुताबिक robot जाएगा जहां भी काटना-वाटना है, काट करके बाहर निकल जाएगा, बाद में paramedical staff हैं, वहीं देखता रहेगा। आप तो कहीं निकल ही जाएंगे।

मैं आपको डरा नहीं रहा हूं। लेकिन इतना तेजी से बदलाव आ रहा है, आपमें से कितने लोग जानते हैं, मुझे मालूम नहीं है। एक बहुत बड़ा साइंस, जो कि हम सदियों पहले जिसके विषय में जानकारी रखते थे, बताई जाती थी हमारे पूर्वजों को, वह आज medical science में जगह बना रहा है। पुराने जमाने में ऋषि-मुनियों की तस्‍वीर होती थी, उसके ऊपर एक aura हुआ करता था, कभी हमको लगता था कि aura अच्‍छी designing के लिए शायद paint किया गया हो। लेकिन आज विज्ञान स्‍वीकार करने लगा है कि aura Medical Science के लिए सबसे बड़ा input बन सकता है। Kirlian Photography शुरू हुई, जिसके कारण aura की फोटोग्राफी शुरू हो गई। Aura की photography से पता चलने लगा कि इस व्‍यक्ति के जीवन में ये Deficiency है, शरीर में 25 साल के बाद ये बीमारी आ सकती है, 30 साल के बाद ये बीमारी आ सकती है, ओरा साइंस बहुत बड़ी बात है, वो develop हो रहा है।

आज के हमारे Medical Science के सबसे जुड़ा हुआ Aura Science नहीं है। Full Proof भले ही नहीं होगा, पर एक वर्ग है दुनिया में, विदेशों में, जो लोग इसी पर बहुत बड़ा काम कर रहे हैं। अगर ये Aura Science की स्‍वीकृति हो गई तो शायद Medical Science की Terminology बदल जाएगी। एक बहुत बड़े Revolution की संभावना पड़ी है। हम Revolution से डरते नहीं है। हम चाहते हैं, Innovations होते रहने चाहिए। लेकिन चिंता ये है कि हम उसके अपने आप के साथ मेल बिठा रहे हैं कि हम उन पुरानी किताबों को पढ़ें, क्‍योंकि हमारे professor भी आए होंगे, वो भी वही पुरानी किताब लेके आए होंगे। उनके टीचर ने उनको दी होगी। और हम भी शायद प्रोफेसर बन गए तो आगे किसी को सरका देंगे कि देख यार, मैं यहीं पढ़ाता रहा हूं, तुम भी यही पढ़ाते रहो। तो शायद बदलाव नहीं आ सकता है।

इसलिए नित नूतन प्राणवान व्‍यवस्‍था की ओर हमारा मन रहता है, तो हम Relevant रहते हैं। हम समाज के बदलाव की स्थिति में जगह बना सकते हैं। उसे बनाने की दिशा में अगर प्रयास करते हैं तो मैं मानता हूं कि हम बहुत बड़ी सेवा कर सकते हैं। आप एक ऐसे Institution के Students हैं, जिसने हिन्‍दुस्‍तान में अपना एक Trademark सिद्ध किया हुआ है। आज हिन्‍दुस्‍तान में कहीं पर भी अच्‍छा अस्‍पताल बनाना हो, या Medical Science में कुछ काम करना हो, कॉलेज अच्‍छे बनाने हो तो लोग क्‍या कहते हैं? पूरे देश के हर कोने में। हमारे यहां एक AIIMS बना दो। और कुछ उसे मालूम नहीं है। इतना कह दिया मतलब सब आ गया। उसको मालूम है AIIMS आया, मतलब सब आया।

इसका मतलब, आप कितने भाग्‍यवान हैं कि पूरा हिन्‍दुस्‍तान जिस AIIMS के साथ जुड़ना चाहता है, हर कोने में कोई कहता है, पेशेंट भी चाहता है कि यार मुझे AIIMS में Admission मिल जाए तो अच्‍छा होगा, Students भी चाहता है कि पढ़ने को यदि AIIMS में मिल जाए तो exposure बहुत अच्‍छा मिलेगा, Faculty अच्‍छी मिल जाए, बहुत बड़ा जीवन में सीखने को मिलेगा। आप भाग्‍यवान हैं, आप एक ऐसे Institution से निकल रहे है, जिस Institution ने देश और दुनिया में अपनी जगह बनाई है। ये बहुत बड़ा सौभाग्‍य ले करके आप जा रहे हैं।

मुझे विश्‍वास है कि आपके जीवन में माध्‍यम से भविष्‍य में समाज को कुछ न कुछ मिलता रहेगा और “स्‍वस्‍थ भारत” के सपने को पूरा करने में आप भी भारत माता की संतान के रूप में, जिस समाज ने आपको इतना सारा दिया है, उस समाज को आप भी कुछ देंगे। इस अपेक्षा के साथ में आज, जिन्‍होंने यह अचीवमेंट पाई है, उन सबको हृदय से बहुत-बहुत अभिनंदन करता हूं। मेरी शुभकामनाएं हैं, और मैं आपका साथी हूं। आपके कुछ सुझाव होंगे, जरूर मुझे बताइए। हम सब मिल करके अच्‍छे रास्‍ते पर जाने की कोशिश करेंगे।

आपके बीच आने का मुझे अवसर मिला, मैं भी हैरान हूं कि मुझे क्‍यों बुलाया? ना मैं अच्‍छा पेशेंट हूं। भगवान करे, ना बनूं। डॉक्‍टर तो हूं ही नहीं। लेकिन मुझे इसलिए बुलाया कि मैं प्रधानमंत्री हूं। और हमारे देश का दुर्भाग्‍य ऐसा है कि हम लोग सब जगह पे चलते हैं। खैर, मुझे आप लोगों से मिलने का अवसर मिला, मैं आपका आभारी हूं।


Sunday, October 19, 2014

India has 3rd-highest number of HIV-infected people: UN

India has the third-highest number of people living with HIV in the world with 2.1 million Indians accounting for about four out of 10 people infected with the deadly virus in the Asia—Pacific region, according to a UN report.
The report by UNAIDS, the United Nations programme on HIV/AIDS, said that 19 million of the 35 million people living with the virus globally do not know their HIV—positive status and so ending the AIDS epidemic by 2030 will require smart scale—up to close the gap.
The first—ever UNAIDS ‘Gap Report’ said after sub—Saharan Africa, the region with the largest number of people living with HIV is Asia and the Pacific.
At the end of 2013, there were an estimated 4.8 million people living with HIV across the region.
Six countries - China, India, Indonesia, Myanmar, Thailand, and Vietnam - account for more than 90 per cent of the people living with HIV in the region.
“India has the third largest number of people living with HIV in the world — 2.1 million at the end of 2013 — and accounts for about 4 out of 10 people living with HIV in the region,” the report said.
It said HIV treatment coverage is only 36 per cent in India, where 51 per cent of AIDS—related deaths occur.
In India, the numbers of new HIV infections declined by 19 per cent, yet it still accounted for 38 per cent of all new HIV infections in the region.
The proportions of people who do not have access to antiretroviral therapy treatment are 64 per cent in India.
In Asia and the Pacific, the number of AIDS—related deaths fell by 37 per cent between 2005 and 2013, the report said.
India recorded a 38 per cent decline in AIDS—related deaths between 2005 and 2013. During this period, there was a major scale up of access to HIV treatment, it said.
At the end of 2013, more than 700,000 people were on antiretroviral therapy, the second largest number of people on treatment in any single country.
In India, HIV prevalence among female sex workers dropped from 10.3 per cent to 2.7 per cent but it increased in the states of Assam, Bihar and Madhya Pradesh, the report said.
A look at the HIV prevalence among sex workers:
(Source: UN GAP report)
The estimated population size of sex workers is 868,000, of which 2.8 per cent is HIV—positive. In India, HIV prevalence among women who inject drugs was nearly twice that or more than the figures for their male counterparts, it said.

Wednesday, October 15, 2014

Fighting India’s silent epidemic

ECONOMIC AND CLINICAL CRISIS: There are 2.2 million new cases and close to 3,00,000 deaths each year according to the Government of India’s TB India 2014 report. Picture shows the x-ray of a patient in New Delhi suffering from both TB and HIV.

Tackling TB requires both strengthening the public sector and engaging the private sector

Over 60 per cent of all Indians seek health care in the private sector according to India’s last National Family Health Survey. This undoubtedly makes the private sector the largest provider of health services in India. The government health system, though vast and well-intentioned, continues to be overburdened with multiple challenges including long waiting hours, an ageing infrastructure, limited funding and human resources. Even though parallel providers of health services, the absence of partnerships between the public and private sector has disastrous implications for patients and for disease control. A striking case study is that of TB.
With 2.2 million new cases and close to 3,00,000 deaths each year, TB is India’s silent epidemic. The 60 per cent of all TB patients who first go to the private sector receive care whose quality varies enormously, often leading to delays in diagnosis and no assurance of cure. As a result, a large proportion of these patients move — sicker and poorer — from one provider to another, infecting others in the process.
Treatment access and reliability

While TB can affect anybody, studies have shown that it is four times more common in people in the lowest socio-economic quintile compared to the highest. A recent systematic review found that the total costs of TB for patients and affected families on average corresponded to more than half their yearly income. This makes it a clinical as well as an economic crisis.

How can India address this crisis? Tackling TB in India requires both strengthening the public sector and engaging the private sector. For a disease like TB, early diagnosis and correct treatment are the easiest ways to reduce transmission. India needs to give every patient, irrespective of whether they go to the public or private sector, access to quick and reliable diagnosis and treatment.
 Studies have shown that TB is four times more common in people in the lowest socio-economic quintile compared to the highest 
For the government, this means that every primary health centre (urban and rural) — the first point of care for the patient — should be capable of making a diagnosis of TB and initiating treatment.
For this, diagnostic facilities need to be upgraded and clinical and laboratory staff given training. Private services could be utilised for some of these investigations in PHCs where these facilities may not be available (for example imaging studies, paediatrician opinions and rapid molecular tests). Patients should not need to travel long distances to get a diagnosis.
Ultimately, the quality of health care provided and a “satisfied client” are the most successful advertisements for the health system. At the same time, we must actively engage the private sector in a mutually acceptable way — while patients continue to remain with the individual doctor, both diagnosis and treatment could be provided free through the public sector.
Brazilian example

Here, Brazil offers an excellent example, where TB drugs are offered only by the public health system and are unavailable in the private sector. TB drugs are bought through a centralised mechanism of acquisition and distribution, ensuring drug quality.

Such a model could easily work in India if combined with effective use of technology. Each patient diagnosed in the private sector could avail drugs through the use of a paper or electronic voucher valid at designated pharmacies. This would ensure that patients receive appropriate and quality-assured drug regimens reducing patient costs. Further, it would ensure notification of all patients and help in monitoring and follow-up to ensure cure.
There is obvious reluctance in the private sector to engage with the government because of the fear of losing their patients, excessive monitoring, delayed payments, etc. Hence, we must be flexible in our approach to treatment (as long as standards are followed) and create more transparency, accompanied by use of technology to address systemic delays.
Changes in TB programme

Rapid reduction in TB burden is not possible without significant changes in India’s TB programme. It requires uniform and equitable implementation of the diagnostic, treatment, public health and social support guidelines laid down in the Indian Standards of TB care, strengthening of human resources both at the Central and State level, using novel methods of monitoring patient compliance (e.g. mobile phone based) and launching a massive public awareness campaign. Procedures for procurement and distribution of drugs need to be streamlined to ensure a constant supply of quality-assured drugs. More flexibility in programme delivery needs to be given to State and district-level implementing officers. Alongside inputs to achieve universal health coverage, social protection interventions that address out-of-pocket expenses and the food and nutritional requirements of TB patients are also critical — an innovative example is the free breakfast scheme for TB patients launched by the Chennai Corporation.

India may take a cue from China, where TB prevalence declined by half as the government invested heavily in systemic improvements, modernisation and changing approaches to diagnosis and treatment. This revitalisation of TB services led to millions being able to access timely, high-quality TB treatment which considerably reducing the number of new TB cases.
India urgently needs similar investment in the health system combined with innovative strategies to address TB and drug resistant TB.
In 2013, the World Health Organization identified 3 million missing TB cases globally of which 1 million were in India. These 1 million missing cases fall somewhere between the public and the private sector and lack access to free care. If India wishes to end its TB crisis, we must begin by providing prompt diagnosis and treatment to our missing million. Yet this is unlikely to happen unless we transform our current TB programme while simultaneously engaging the vast private sector. If we do not act now, our inaction will make us responsible for continued suffering of patients and deaths.
(Soumya Swaminathan is director, National Institute for Research in Tuberculosis, Chennai, and Chapal Mehra is an independent New Delhi-based writer.)

For public health as political priority

A systemic reform of the health sector in order to meet the key objectives of equity, efficiency and quality is long overdue. In this, the Central and State governments need to make interventions intelligently, decisively and strategically so that the poor reap the benefits

How does Prime Minister Narendra Modi’s focus on population, health and subjects like public hygiene, the facilitation of toilets and ensuring preventive health through yoga fit in with his party, the Bharatiya Janata Party’s manifesto; one which promises a National Health Assurance (NHA) mission, with its aim of providing cashless hospitalisation in order to reduce out-of-pocket expenses? Why do these concerns seem contradictory? Does pursuing one necessarily hurt the other? These are legitimate questions and concerns. This must be looked at in a global context where there is discussion on Universal Health Coverage (or National Health Assurance) widening inequity in the short and medium term.
In seeking the maximisation of the health and well-being of every individual, the NHA subsumes the essentiality of access to those elements that constitute the foundation of good health — tap water (where conveyance of contamination is reduced by 99 per cent), a toilet and sewerage system, environmental hygiene, nutrition and basic primary care — and in the process, reduce 90 per cent of all morbidities and a substantial proportion of mortality. Evidence of efforts in the United Kingdom to contain tuberculosis by ensuring better housing and nutrition, the successful eradication by India of guinea worm infestation using improved water systems, or eradicating polio through improved sanitation and universal immunisation are some useful reminders of the interconnectivity between disease and environment, and between public health and clinical science.
Addressing inter-State disparities

In India, public health has been severely neglected with about 44 per cent of the population having access to tap water and toilets, 42 per cent of children being malnourished and a majority of people being treated by quacks. Setting right these issues requires an expenditure of an estimated Rs.10.7 lakh crore (recurring and non-recurring) against which the 12th Plan has allocated Rs.3.8 lakh crore. The most challenging of these is in bridging inter-State disparities, with 70 per cent of this investment required by the northern States that have restricted fiscal space, three quarters of the disease burden (preventable with effective primary health care) and weak implementation capacity, making inadequate funding not the only constraint. For example, in Bihar, 2.5 per cent of its rural population has access to tap water, 23 per cent of its people to toilets and a battered primary care system. Should such a State then invest in providing these basic services or in buying expensive care from private hospitals through insurance? What are the moral and ethical imperatives that must guide State action?

The Andhra Pradesh experience

In this regard, a review of the impact of the Rajiv Aarogyasri Health Insurance Scheme (RAS) in former Andhra Pradesh is illustrative of how the State consciously chose to abandon primary care for universal coverage of a select set of tertiary and secondary care conditions.

In 2007, RAS, a State sponsored health insurance scheme (covering 85 per cent of the population, with sum assured of Rs.1.5 per family for cashless treatment in 486 hospitals involving 938 procedures) was launched to provide risk protection against catastrophic illnesses that “have the potential to wipe out a lifetime savings of poor families.” The justification was that there was effective demand for treatment for non-communicable and chronic diseases, low investment in public hospitals and a burgeoning private sector, unaffordable to most.
RAS was perceived to be a popular programme. But there is a thin line between perception and reality. Several commentators have critiqued it as having boosted the revenue streams of private corporate hospitals without necessarily reducing health expenditures or improving health outcomes.
 Scaling-up the National Rural Health Mission’s efforts to revive the primary health-care system would be far cheaper and more sustainable than buying care from private hospitals. 
While there are no systematic evaluations to assess the impact of RAS, a recently conducted household survey in Andhra Pradesh by Access International covering 8,623 households offers interesting insights. While it showed an overall reduction in out-of-pocket expenditure and increased hospitalisation, it had limited impact in reducing impoverishment or indebtedness among the two lowest quintile groups. For example, while per capita expenditures for inpatient treatment nearly trebled from Rs.391 in 2004 to Rs.1,083 (2012) for the poorest quintile, it was down to Rs.1,174 from Rs.1,819 for the fourth quintile group. Likewise, while the proportion of those incurring catastrophic expenditures more than doubled from 1.1 per cent to 2.8 per cent and 1.2 per cent to 3.4 per cent for the two lowest quintiles, the richer quintiles faced reductions. Such wide disparities are attributed to the concentration of half the accredited hospitals in seven districts (towns) resulting in an inequitable distribution of and gross deficiencies in the supply side, making access difficult and unaffordable for those residing in backward districts.
Impact on poor

Second, 49 per cent of reimbursement was for cardiac, cancer and kidney failure (38 per cent of patients or 0.5 per cent of population), while the two bottom quintiles suffered impoverishment, premature mortality and disability due to lower respiratory infections, diarrhoeal diseases, tuberculosis (TB), ischemic heart diseases and malaria — conditions eminently preventable and treatable with effective primary care.

Besides, partaking RAS benefits implies forced hospitalisation for outpatient care, increasing the risk of hospital acquired infections and higher indirect expenditures that the poor cannot bear.
Third, the primary health-care system that the earlier Telugu Desam Party government had accorded high priority to has all but collapsed. Among 19 major States, Andhra Pradesh incurred the lowest expenditure of Central grants (National Rural Health Mission and disease control programmes) as proportional to its total health spending during 2011; 16 per cent against 31 and 28 percentages by Maharashtra and Karnataka respectively and the only State to slash its primary care budgets from 53 per cent to 46 per cent and allocate just 9 per cent for secondary care down from 12 per cent during 2007-12. In comparison, RAS was provided 23 per cent of the health budget for less than 1 per cent of the population (not necessarily poor) or 11.3 per cent of total hospitalisation. In the absence of cost containment measures and generous pricing, costs are likely to escalate further, impinging on the fiscal space of the two new States of Telangana and Andhra Pradesh. RAS reimbursement rates, say for hysterectomy, laparoscopy, appendectomy or coronary bypass are higher when compared to other schemes in the country. Prices set through negotiations with private hospitals by committees without professionals — like chartered accountants, health economists or systematic unit costing methodologies — can only be arbitrary. Further, package rates provide scope for gaming the system. In the absence of standards to measure quality and regulations to control provider behaviour and fraud, perverse incentives are created, as reflected in unnecessary diagnostics, procedures and surgeries.
RAS was a bold initiative to address the problem of impoverishment that has been partially addressed. Contrary to Tamil Nadu, which witnessed a 10 per cent shift in institutional deliveries from private to public sector, the increase in Andhra Pradesh is in the private sector, resulting in huge borrowings. Access to social determinants and the substantial load of preventable diseases like diarrhoea, TB, sexually transmitted diseases and HIV, are bouncing back due to policy neglect and mismanagement and continue to be issues requiring attention.
Policy corrections

The Andhra Pradesh story shows that lessons need to be learnt in order to reboot health policy along a more sustainable path. Scaling-up the NRHM’s efforts to revive the primary health-care system; incentivising lifestyle changes; universalising access to social determinants; revamping and embedding the primary care system within the community; increasing investments in public sector hospitals, along with improving incentive structures, employing requisite staff and upgrading infrastructure would be far cheaper and more sustainable than buying care from private hospitals for services that are available in the public hospitals at a third of the price. Private care must supplement, not substitute public care. Finally, in order to ensure patient well-being and value for money, standard treatment protocols and guidelines need to be developed; costing of procedures undertaken, monitoring systems for quality such as rates of survival, hospital acquired infections and readmissions developed and regulations enforced alongside establishment of grievance redress systems, with fair compensation and penalties against malpractice.

A systemic reform of the health sector in order to achieve the three principal objectives of equity, efficiency and quality is long overdue. This will require skilful political management and stakeholder negotiations. Governments at the national and State levels need to give up rhetoric and knee-jerk responses as substitutes for real action. Instead, they need to make interventions intelligently, decisively and strategically to ensure that solving one problem does not give rise to another. They also need to stay focussed on doing the simple things right in the first instance so that disparities reduce and the poor reap the benefits in real terms.
(Sujatha Rao was Health Secretary in the Government of India.)