Monday, January 9, 2017

NEET: How do you test ethics?

As a trained medical doctor, I feel that I must say something about the recently passed legislation called National Eligibility cum Entrance Test (NEET) which will henceforth guide admission in Indian medical colleges.

It replaces the multiple tests conducted by multiple institutions and State governments with widely differing syllabi. Prima facie, this is a great thing as students don't have to study multiple syllabi and appear for multiple exams back to back and some even happening on the same day.  However, there are disadvantages too, as I have discovered by virtue of being associated with the governance of one of the Christian Medical Colleges in the country. The issue with NEET or for that matter the JEE for the IITs is that they test for pure academic merit and nothing else. Academic merit can be accumulated by enrolling in cram centers like Kota whose sole reason for existence is to produce students who can enter those hallowed gates.

However, coming to the Christian Medical Colleges, till the time they were allowed to conduct their own exams they did not only look at academic merit. In keeping with their ethos, they looked for (not always successfully of course) those who had the aptitude to go and serve in rural India, the purpose for which these medical colleges were set up in the first place. There is also another Gandhian philosophy based medical college, which similarly looked for ethics and values in their students and not just marks.

A recent NDTV sting operation brought out the horrendous fact that in Punjab many medical colleges function with the help of hired 'ghost' faculty, private practitioners hired for 2-3 days simply to help get the college its license. Now imagine being treated by doctors who are not qualified, because they went to a college that operated with this kind of faculty. After all, when we seek out a doctor for treatment, we do not typically ask which college and university they passed out from.

In professions like medicine and many others, it is simply not enough to grade a student by how many marks he or she scored. There is such a thing in medicine as the Hippocratic Oath (and equivalent honour codes in other professions).  If we only evaluate students for their academic merit without any look at their motivation, character and ethics, which we subsequently expect them to abide by, then something is surely amiss.

Sunday, January 8, 2017

Dementia - When the mind fades away

As per the estimates of the World Health Organization, the number of aging population is increasing in countries like India and dementia is going to become an epidemic among the elderly in the coming decades. Although so far, I have not known anyone personally who is or has suffered from dementia, I am aware of people in my circle of friends who have. Since dementia is generally speaking, largely seen among senior citizens and there are in my immediate and extended family (and I myself am crawling in that direction too), I though to educating myself on the subject a bit and recently did an online course on dementia.

The course with videos of patients and care givers themselves describing their slow and steady downward sided into the disease with some of those videoed showing fairly advanced symptoms and the care givers describing the stress and strain of providing care in a context that can last for several years left me quite disturbed. Looking up the recent statistics, I find that over four million Indians above 60 have the condition, which is around 3.7 percent of that population. Approximately, one out of every 16 households with an elder has someone with dementia. Yet as I look around and ask around dementia remains a neglected area in healthcare, and many families do not seek or get suitable diagnosis or treatment for dementia symptoms. Poor awareness about dementia means that elders who experience problems like forgetfulness, confusion, or difficulty doing tasks do not consult doctors. 

India also struggles with cultural obstacles to improving care for those suffering from dementia. Institutional treatment is considered a taboo in India, as children do not want to be seen as abandoning their aging parents. Many even want to conceal the fact that their parents are suffering from dementia, at times preventing the patients — and the families — from getting the care they need. Myths, superstitions and misconceptions thrive and abound and erect further barriers in addition to the ones already existing due to inadequate public health infrastructure and largely unaffordable private mechanisms of care. The course that I did left me disturbed for one particular reason. The course was designed in the UK where through the NHS and existing support groups, there exists a reasonable structure of care and even there the care givers as they gave their interviews appeared fatigued and worn out and at least one spoke of having to give up their career because the full care giving routine, would not allow for a regular job. I do not what it is like for Indian care givers with far less support and a lot of stigma and what they go through. Clearly Dementia is a condition which is probably more a social problem as much as a medical one and needs attention from that lens.

Saturday, January 7, 2017

Security Guards : Exploited Labour in the National Capital

A few weeks ago, I was staying in a nearly empty guest house with just a security guard (also doubling up as a part time housekeeper) for company. For the two or three days that I was there, he took care of me well. As I was about to leave and my taxi was at the gate, he asked if he could have a few minutes with me. He asked me if I was a doctor as he had heard. When I affirmed that I was, he rolled up his trousers, exposing an angry, swollen and very obviously infected wound below his right knee, he asked if I would prescribe him something. He told me that he was applying some ointment locally but it wasn’t working. The condition of the wound was such that it was very clearly not going to heal through application of any local ointment.

Antibiotics and possibly strong ones at that were needed, if not some minor surgical intervention to drain the pus. Not wanting to prescribe anything in a hurry, I asked him to visit a doctor knowing that the Delhi government had recently opened Mohalla clinics which were said to be functioning well. He told me that wasn’t going to be possible. On probing further, he informed me to my horror that he received a monthly salary of Rs 6,000 with no leave for a 12 hour shift , 365 days a year and if he took any leave at all due to dire necessity, he would lose a day’s wages and with his pay being what it was, he couldn’t afford that. All I could do with my taxi honking impatiently was to give him my phone number and ask him to call me the next day so that I could take a little more in depth history, if I needed to prescribe anything. He never called back, I have never returned to the guest house since and I often wonder how he is faring.

The security business in Delhi has been operating under the Delhi Private Security Agencies (Regulation) Rules, 2009. Under this Act, a security agency takes a licence for its operations, which remains valid for five years. Most of these companies have been flagrantly violating the rules and regulations of the PSARA guidelines. Week offs, insurance, perks are a far-fetched dream for these guards hired on contractual basis. Many of these guards are not even acquainted with the rights and duties made for them under the above mentioned guidelines. They have been working for the sake of getting employment which is still a dream for many, thus, encouraging agencies to hire people on wages less than the stipulated amount.

Delhi is now being governed by a government that is of and for the “Aam Aadmi” and it is time the government took note of the pathetic conditions under which security guards work. Just as ministers are busy inspecting schools and hospitals and penalizing them if they are not meeting their obligations to the poor, it is time that some one picked up the cause of these exploited security guards.

Tuberculosis : An Under reported killer

Many years ago, while visiting a village called Arogyavaram in Chitoor district of Andhra Pradesh which hosts a Christian Mission Hospital, I was shown a cottage where Kamala Nehru, the wife of Jaaharlal Nehru had once stayed decades ago. At that time, Arogyavaram a place with a salubrious climate was a TB sanatorium and Kamala Nehru a patient hoping to recover her health there.  In those days, (we are talking of the period around 1930), TB had no cure and the only treatment prescribed was a longish stay in a TB Sanatorium where it was hoped that a benevolent climate and good nutrition would aid recovery. That didn’t happen to Kamala Nehru however and she moved from sanatorium to sanatorium eventually dying in one in Lausanne in Switzerland in 1936. Exactly a decade later, Streptomycin, the first drug to be effective against TB was discovered.
Tuberculosis has been with since antiquity and has always carried with it a lot of baggage and stigma. India has its share of the disease burden with about 3 million people suffering from it at any given time and is the country’s largest public health challenge. It was a challenge in itself and then in the 1990s and beyond with the spread of HIV & AIDS, and the close association with TB in immune compromised people, it became a bigger challenge.

A bigger challenge though, which multiple advances in medicine since the discovery of Streptomycin, all those decades ago, is the fact that the duration of treatment is long( six months onwards) and many of the patients drop of the treatment radar along the way. This incomplete treatment regime has given rise to strains of multi drug resistant TB. India again has the dubious distinction of having the second largest number of drug resistant TB cases after China. The problem is not going away anytime soon.

A larger question, is the data that I have cited even correct?  According to a report published in the prestigious journal ” Lancet”, more than a million tuberculosis (TB) cases may be missing from official statistics in India as many cases go unreported and the data only captures the numbers of people reporting to health care facilities in the organized sector. But because of factors that are both economic as well as social, many patients seeking treatment for TB turn to unregulated private doctors who often do not report cases. It is also difficult to track as to how many of such people actually complete the course of treatment. Again, one has to fall back on estimates and they seem to indicate that Out of the 2.7 million individuals with tuberculosis (TB) in India in 2013, estimates show that only about 1.05 million or 39 per cent completed therapy through the government TB programme and survived for one year after treatment without experiencing a relapse, according to a report published in the Indian Express. In today’s infrastructure driven age, public health does not attract too many eyeballs. Yet TB, where India hosts the largest number of patients, has an under noticed and under reported problem on its hands.