Healthcare in Our Country

One recent morning while I was gloating about our country’s claim to be seated among the developed powerful nations of the world, my car stopped at a traffic signal and a dirty starving man begged me for some money to eat a meal. While parting with a tenner, I asked him what made him beg. He said he had been a small farmer in UP, but had lost his land, home, money and living, trying to provide treatment to his son who had been stricken with cancer for two years.

Treatments have improved and many diseases are now curable, but they have come at huge costs that continue to spiral. And when a loved one falls prey to disease, emotions compel us to go to the last post to save his or her life.

Administrators view healthcare sector as a graveyard for government investments. A government hospital does not fetch money on a regular basis, unlike manufacturing industries, housing, liquor or tobacco businesses. And the political benefits of cutting red ribbons of hospitals before elections do not match the grandeur of inaugurating “large buck” projects.

Our planners and politicians, who are handicapped with visions limited to 5 years, have therefore found it prudent to pass the onus of caring for the sick and ailing, to private players. And industrialists, property dealers, liquor barons, brick kiln owners and their likes have responded by building hospitals, with profit in their eyes and philanthropy on their lips!

Business gurus argue that Health Care is after all an industry (why get emotional about it?) growing at 13% pa, and a safe bet to invest in. To meet the demands of this industry, a new breed of “health care professionals”, have come up. If you ask one such honcho what he did before joining a corporate hospital, don’t choke, if he tells you that he sold automobiles or insurance!

The norms that they have brought with them are those of any other industry: impressive-looking infrastructure, elegant ambience, modern equipment, predictable service with smiles, reputed doctors and of course, good publicity.  And they wait eagerly for returns that their investments would bring, called “ROI”.

This breed has created new jargon. Their efforts start with increasing “foot falls” (people visiting the facility), that hopefully lead to increased “conversions” (people undergoing procedures or admissions that really bring in the mullah), and a positive P and L bottom line.

Private hospitals cater to 70% of the country’s health needs and have sometimes done well, wringing in technology and advances ahead of government hospitals (liver transplant and robotic surgery being two examples).

But they come at a price, and occupy the space that our planners have created for them.

The next morning, I looked around for the destitute at the traffic lights, clutching a Rs 100 note in my hands, to make small amends for having joined the healthcare industry, that had robbed him of all he ever had and made him a beggar!

Food Fetish in Medical Descriptions

Strange as it may sound, doctors have an obsession for food items when describing body parts, organs or even human excrements.
It often starts with the relatively innocuous description of kidneys as bean-shaped organs and the human brain as walnut shaped, that most students of biology are familiar with.
But they soon go on to use “café-au-lait” marks, salmon patches, and cherry red spots to describe different types of skin lesions that tell tales of diseases from a brown nevus or angioma or bleeding spots.
And when doctors, who by the way derive their professional origin from butchers, delve inside the human body while cutting up corpses during autopsy, they resort to food items to describe what they see. If the liver shows alternating red and white stripes as in early cirrhosis the description goes as “nut meg liver”. If the intestine shows a central narrowing due to a cancerous tumour, an “apple core lesion” seems to depict it best.
Familiar fruits are most commonly used to describe the size and shape of tumours and swellings: from “ berry like” small ones, to “lemon” sized bigger ones, to “orange” shaped yet bigger ones and then on to “melon” shaped large tumours. References to our familiar fruits mango and coconut are however conspicuously absent as most writers of modern medicine have been of British or American origin.
When doctors start peeping into the stomach or other organs through the endoscope, this food-based description takes yet another turn. Scattered erosions of the stomach are described as “salt and pepper”, polyps as “pea-like” and a gastric antral vascular ectasia as “water melon stomach".
“Bunch of grapes” is a common descriptive term used for large varices (dilated blood vessels) located in the stomach or rectum, while “cherry red spots” help depict if they are in imminent risk of bleeding. “Curd like” or “cheese like” white patches suggest fungal infections of the food pipe while “cauliflower” lesions depict large cancerous growths in the gut.
When an abscess forms in the liver as often happens in amoebic infection, the reddish brown liquefied content is described as “anchovy sauce”.
Radiologists are not far behind in this race. Apart from the “apple core” lesions of luminal cancers, the swollen pancreas in auto-immune pancreatitis is likened to a “sausage” and shadows in the lungs to seeds of millet to castor, depending on their size.
But the most nauseating description is of human excrements. It is “rice water” stools in cholera, “pea-soup” stools in typhoid and “currant jelly” stools in intussusception.
It could be hazardous to have a doctor over for dinner. If you see him getting too chatty with guests, make sure you keep him well away from this topic the entire evening, should you want your guests to eat well rather than retch and scamper to the wash-room when food is served.

Eclipse of Hepatitis C

A hugely positive note with which 2015 is signing off on the medical front is the revolutionary treatment of Hepatitis C that is set to transform the lives of 12 million Indians and several fold more across the world. Around 1-2% of Indians harbour this chronic viral liver infection, most of them unknowingly and many coming to know of it when they have already developed liver cirrhosis or liver cancer. Treatment over the last 3 decades has been either unusually difficult, with weekly injections of interferon, or impossible (due to weakness or low platelets precluding this form of therapy).
Three oral “miracle” drugs have burst into the world’s therapeutic arena, and what could not have been better is that this treatment is now available in India at less than 1% of the international price!
Sofosbuvir is the prime new anti-viral medicine for treating Hepatitis C that was discovered and launched in USA and Europe by Gilead company at the prohibitive cost of US$ 1000 (Rs 60,000) per tablet to be taken daily for 3 to 6 months, amounting to Rs 1 crore for a full course of treatment. It is now available in India for Rs 400 per tablet.
Sofosbuvir needs to be taken with another supportive drug for better results, called Ledipasvir (for genotype 1, 4 or 6) or Daclatasvir (for genotype 2,3) that also reduce treatment duration to just 3 months. Last week, the latter two drugs also became available in India at affordable prices. The total cost of treatment with these oral regimes is approximately Rs 50,000 over 3 months, with a very high (more than 90% chance of cure) and with hardly any side-effects.
The news has been quick to spread across the world where the treatment cost by original international branded medicines is still upwards of Rs 1 crore. This has led to a huge surge of “medical tourism” with plane loads of patients from across the globe, streaming into India to reap the benefit.
Hepatitis C has been painfully difficult and expensive to treat for 20 years with weekly injections of Peg-Interferon along with a weak anti-viral tablet called Ribavirin given for for 6 to 12 months. Almost every patient who has taken this therapy has felt miserable with adverse effects such as fever, weakness, falling blood counts, anemia and depression.
And in addition to the high cost (Rs 1.5 to 3 lac) and several months of ordeal of treatment, relapses have been frequent: the virus often reappearing quickly on stopping treatment. For specialists, meeting such patients who had invested a lifetime’s savings and endured a year’s tribulation but missed achieving a “cure” has been helplessly humbling.
Hepatitis C had its moment of public recognition when the well-endowed silverscreen celebrity Pamela Anderson of Baywatch fame got diagnosed with it. The sensational manner in which she contracted it made it even more popular: she had shared the needle for a skin tattoo with her boyfriend, Tommy Lee, who had carried the infection. The gossipy tale went further to her litigating against him for concealing the information, but as often happens there, they finally united by wedlock!
All this is soon poised to become history as treatment becomes simple and easy.

Coping with Midlife Crisis

When a 57 year old well-established doctor suddenly decided to quit his stable government job of 25 years, 8 years ahead of his retirement age, change his career path, move to a new town, buy a swanky car, many were taken by surprise.

When a lady of 52 years, decided to leave her career of 15 years as a school-teacher, to dive into her passion of Hindustani classical music, her friends and family were taken aback.

When a 40 year-old successful industrialist running a health care industry suddenly deciding to leave his corporate life and take to spirituality and social service, his colleagues were stunned.

Many men and women, usually between 35 and 65 years, often show a change of mood, or surprising behaviour, that smack of mid-life crisis. It was described first by Elliot Jacques in 1965, and since then been recognised the world over.

The common symptoms and signs include:
1. Change of job, often giving up one that had been going smoothly for years, and taking up a more challenging one.
2. Making new friends, often younger, and dropping old ones
3. Splashing on a new car, youthful dresses, a luxury trip
4. Mood changes such as snappiness, low feelings or unexpected joviality
5. Asking questions on meaning and purpose of life, looking back and assessing one’s achievements, wondering if life should have been lived differently
6. Picking up new hobbies. Several people take to photography, music, theatre, social work or art at this age.
7. Impulsive decision making such as changing partners, filing for divorce or having an affair.
8. Obsession with health and fitness
9. Increase in alcohol consumption

While researchers recognise that some people demonstrate such strange behaviour during the middle years of their lives, there is much speculation on the reasons behind it. Some people seem to be seeking a break from that monotonous life when their children leave the nest, freeing them of their daily parenting responsibilities. Many, on the other hand, look to fulfilling their dreams and aspirations in the evenings of their lives before the dusk of old age sets in.

Middle age brings with it change in moods and behaviour. Depression is common, manifesting often as those strange questions that keep popping up: “What have I done in life?”, “What am I living for?”, “What did I wish to achieve and where have I reached?”, “What are the things I still want to do before hanging up my boots?”.

These are indeed difficult questions that can make anyone shift uncomfortably in bed, but what is funny, is that they seem to crop up at this age, often making people feel low, or paradoxically in some, emboldening them to do strange things.

Depression and confusion may require a few sessions with a professional or a trusted colleague. Meditation, healthy food and exercise certainly help.

Midlife crisis is however not inherently a bad thing. On the positive side, it helps people to wake up and realise their unexplored potentials and goals before they walk into the sunsets of their lives. For many then, it can serve as a midlife course-correction than a crisis.