Thursday, February 21, 2013

On wrong diagnosis, wrong medication and unnecessary surgery

(for a facebook group)
These things do occur. But I think the issue is complex and there is the danger of oversimplifying the problem.
1. First, we do not know the magnitude of the problem. Except for personal experience and stories from other people, there’s no evidence of how big the problem is in Nagaland. A statement like, ‘Naga doctors often give wrong medicines’ do not hold water. A person who has had two bad experiences at the doctor’s chamber may be enough for him to make such a sweeping statement. But for each complaint, we do not know if there are a thousand cases rightly diagnosed and rightly treated. To make allegations without solid evidence won’t be right.
2. Are all such complaints truly/proven cases of medical negligence or are there gaps in communication and understanding? There will be cases where patients lodge no complaint. But how many doctors are charged of negligence, proven guilty and debarred from practice in Nagaland?
3. Lack of facilities for investigation (laboratory, radiology) constrains doctors in diagnosing diseases and their management.
4. Medical Science is not like mathematics where 1+1=2. Doctors make cost benefit analysis, bargain, and negotiate with human beings who have choices and emotions. For every headache, one cannot order a CT scan. Sometimes, the diagnosis may be more costly than the treatment. Right medicine for the rightly diagnosed disease may not work either due to poor patient compliance or body resistance to the medicine, or for other reasons.
5. Doctors are human beings and there may be different ways/styles of approaching a sickness without going off track. Some may want to boast saying, ‘your previous doctor should have done this/that’. I worked in Delhi and yes, Indians sure can show that they know better. When you visit a second doctor, the course of disease might have been changed. Also patients influence the practice of medicine. There are people who think that doctors who give more medicines are good doctors.

Having said that, doctors also need to constantly update their skills; their clinical skills but also communication skills. And we need to have respect for fellow human beings as persons and not simply as machines to be fixed. The power relation between a doctor and patient can be as unequal as a slave-master relation. In a clinical setting, the doctor can be manipulative, Mr.-know-it-all, and cold as ice. It may not be difficult for a surgeon to open an abdomen and justify later, the only intention being to thicken one’s wallet/purse. Personal link to a pharmaceutical company, diagnostic lab, or a private nursing home can turn people in white coats into vultures, making money out of others’ misery.

On the whole, there is a need for change at multiple levels. Strengthen legislation and measures to check malpractice. Provide better diagnostic facilities. Carry out research. Follow standard treatment protocol and codes of conduct. Hold CMEs to update knowledge, and trainings to upgrade skills. Go for second/third opinion. etc.

Tuesday, February 19, 2013

Looking for Naga health enthusiasts

I am looking for people (anyone but not everyone) who have concern for the state of Health in Nagaland; people who may not have background knowledge but are interested to learn, explore, and discuss. Physical suffering is a universal experience and health care is too important to be left to doctors and nurses. Medical Science is just one component of Health. Medical jargons should not put you off for there’s so much in Health beyond biology. Health is a political, economic, and social issue. Good health is a perquisite for the progress of any society. From your discipline, be it Sociology, Economics, History, Psychology, Anthropology, Political Science, Environmental Science, Mathematics, Biochemistry, etc. you can make meaningful contributions to improve health in our society. There is a need to gather health-related knowledge resources into a common think tank. Then armed with evidences, goals to achieve, and steps to achieve those goals all set; health activism in Nagaland shall rise.

Friday, February 15, 2013

Sir, some politeness please

I sat for an interview at the World Health Organization in their Delhi office. The receptionist asked if I’d like to have tea or coffee. She showed us to a room to rest and told us to feel comfortable. The security man thanked me after the security check for allowing him to search my bag. When I entered the room, the four interviewers all stood up to shake hands with me and each of them gave a self introduction of his name and what he is doing at WHO. When they asked questions, it was as though they want to learn something from me. 

Our politicians, Bureaucrats, government officers, and yes not forgetting our students' union leaders, on the other hand, behave like our new colonial masters. From big to subtle ways, they do things to show us our place; that they are at a higher level and we are inferior. It can be discriminating, oppressive, and dehumanizing. But it can also be funny. Funny when some young people who just got into civil services start to act as though they have become very powerful.

People elsewhere (including Indian officers at the national level, I know) are learning how to be polite. We continue to play petty power games which are stupid and unnecessary. After all, at the end of the day, you and I are of equal flesh and blood. You fart, I fart. You might have learned to hide it but don’t you still do it sometimes, Sir?

Related post: King of the Barber's shop

Monday, February 11, 2013

Solo drive to Imphal in a fantasy F1 race

For a day in a long time, there was time to kill. The only thing to do for the day was to reach Imphal in one piece. So, I filled my tank, updated my facebook status, and drove. As I crossed Lerie gate at Kohima, I set the meter to zero to see for myself the distance between Kohima and Imphal. Left to myself with no music system in the ‘powerless-steeringed’ Bolero Invader, I tried to do what I proposed to do in my facebook status, i.e. to contemplate on the bigger questions of life. To ponder on existential question like, ‘why is there something instead of nothing?’ or ‘why did the chicken cross the road?’ But I kept searching; searching for things to click. After frequent stops, I decided to just drive; else I won’t reach Imphal before dark. 

Then I imagined if I were in an F1 race. I started on P30 (assuming that 29 cars have gone ahead of me this day) opting to start on the soft tyres. Soon I was up to P25. But frequent stops for photo shoot kept pulling me back the grid. I changed to hard compound tyres at Mao gate and refuelled. Pit stop time? 3.6 seconds stationary. What used to be the worst stretch of road between Mao and Tadubi is well repaired. But without proper nullah, will it last one monsoon? If it were last monsoon, I would have gone for the wet tyres option. Then I met an army convoy. I wished in my heart that the driving behavior of the army convoy drivers be rewarded with ringworm on their groins. From Mao to Senapati, I was travelling at an average speed of 45 kms/hr. Then I refuelled at Senapati (Samosa and Chai) and changed into Intermediate tyres. The pace picked up and I was crusing at about 60 kms/hr. 

I looked at my watch and seeing that the shadows are still short, I decided to go for a dip. I drove into the Imphal River and bathed my car. The car besides being ugly was heating up and needed to cool down. In the DRS zone near Sekmai, I recorded my best lap time of the race and reached top speed of 90 kms/hr, thereby regaining some lost positions. On reaching the city limit, I stopped pushing and 2 cars overtook me. I overtook one again in the long straight at Koirengei, but the other one (a red Hyundai i20) got away. 

When I passed through the Imphal City gate, I looked down and saw that I had travelled 123.8 kms. That is the distance between Lerie Gate of Kohima and Imphal Gate of Imphal. From P30, maybe I finished further back and did not score any championship points. But it was an entertaining race and we (as the f1 drivers would say 'We' in post race interviews instead of 'I') managed to bring it home (being alone, I was scared if the car breaks down halfway). And as wise people say, it is not just about the finishing line, but it is the journey. (Photos to be updated soon)

Thursday, February 7, 2013

To spray or not to spray?

Spray of DDT for malaria vector control is discontinued all over the world except in India particularly in the North East. The WHO has objected to its use but the Indian government has argued that Indoor Residual Spray (IRS) needs to be continued due to its effectiveness and disease endemicity in the region. Should it be continued in Nagaland? Here are some pros and cons:
  • It is effective in vector control. UMS Dimapur study shows that vectors in the State are still susceptible to DDT although resistance does exist.
  •  There is no good alternative. Long Lasting Insecticide-treated bed Nets (LLINs) are costly and difficult to procure. 
  • It is safe if technical guidelines are followed during spraying.
  • DDT is a bio-hazard. If it is sprayed outside and enters the food chain, its concentration increases through Bio-magnification. 
  • Acceptance is low. There is reluctance to have it sprayed indoor. People prefer to have it sprayed outside which is counter-productive (chases the mosquitoes inside the house). 
  • Technical guidelines are difficult to follow in the ground: Villagers ask for their share of DDT rather than having it sprayed in their houses.
 DDT will be used for a number of years to come. It is very necessary that people are made aware of the risks and benefits, and technical guidelines be strictly followed whenever and wherever used.

Wednesday, February 6, 2013

On health care in Nagaland

When Delhi tells us to sit down, we sit down. When we are told to stand, we stand. Why, because Delhi has money and we don’t. So, we implement what Delhi sanctions for, unquestionably. The State government’s allocation to health (which again is from Delhi, but which can be used for State specific needs) is so low that it can barely manage the salary of the regular employees and build a few health centre buildings each year. There’s neither political commitment nor the knowledge of what’s going on (except how to recruit grade IV staffs that we don't need, and where supply orders are).

But what Delhi plans for us may not be the best for Nagaland. Each political ministry wants to achieve quick and popular results during its time, in order to return to power in the next election. In health care, the present ministry is more interested in projects and programs than in general health services. Likewise, donor agencies like Gates Foundation, World Bank, Global Fund, etc. are more interested in vertical health programs. But just as we cannot survive on fast food like coca cola and Bingo, we need to think beyond quick fixes. We can pay honorarium/incentive to a volunteer and orientate him to get a job done for us (a lot of that is going on). But without structures and processes, that may not be sustainable. In health care, we cannot get a task done, pack our bags and leave.

A time has come for us to put our thinking caps on our heads and put shoes on our feet. As doctors, administrators and managers, we need to go beyond biology to understand the social and political factors which determine health. We need to study the cause of the cause of ill health. First, we need to arm ourselves with the knowledge of what works and what wouldn’t work. Maybe a lot of health programs today are planned and designed in front of the computer screen. The experience gained in the field cannot be bought with money or gained from a university. We need to gather that resource into a common think tank. Next, we need to analyse, debate, and discuss. We will thereby get a clear picture learning how to make head and tail of the health care system; and have a clear vision and goal for the future. Next, we need to lobby, argue, and persuade; armed with evidence and elaborate plans.

Two examples to wind up. In implementing JSSK, as there is constraint in delivering services, paying of money directly was finally approved. Not about the initiative itself, but this is an example that negotiations can be done based on local conditions. Captain Jack Sparrow said in the Pirates of the Caribbean that the code of the pirates is not a sacred text that pirates need to obey. It is more of a guideline, he said. Most of the health activities in the State are program based and each program has guidelines. But they are not sacred books, and we must constantly see how far we can negotiate or adapt them to our context.

Second example. If we have these four things together, I believe our health services (in availability of medicines) will be much improved:  State Essential Drugs List, State Treatment Protocol (which we already have), State Drug Procurement Policy, and state of the art State Drug Testing Laboratory. We can make all essential medicines available in adequate quantity, procured without much corruption, and cheaply but constantly quality tested, and used rationally as per treatment protocol.

In a book recently published by London School of Public Health and Hygiene called ‘Good Health at Low Cost’, 3 major observations from countries and states which have good health services are that they have ‘continuity’, ‘leadership’, and ‘political will’. We have continuity unlike the politicians and can give sustained effort for long term endeavours. It takes just one or a handful of strong leaders for those countries, e.g. Bangladesh. And we need to generate political will.

I wrote this on the morning of quarterly review meeting of Chief Medical Officers and Medical Superintendants of all Districts and District I was preparing my presentation on monitoring and supervision reports. I read it out to the Principal Director and he likes it and asked me to publish it in the local newspapers...I couldn’t get time to present it during the review meeting. Before publishing, it will require editing, for which I don’t have the time now.

Saturday, February 2, 2013

Zero Bulb Ideas (4): Power Back-up Plan

‘Don’t watch movies on television’, my sister advises, ‘you will not be able to complete a single movie’. That is the situation of electricity supply in the great Capital city of Kohima. Very few works get done in offices because most of the works are done in the computer. Stomachs grumble because of half cooked rice. This happens because like movie watching experience, halfway through cooking in electric rice cookers, power goes off and not many cooks have mastered the technique of cooking the later half through a different source (firewook or LPG). It has been heard that the Power Minister and a handful of other big shots are on a Generator/Inverter buying spree to power their houses. Rumours are heard that someone has an Inverter which can run a saw mill. Also gossips are heard that if the present government returns to power, they are going to project in their action plan for the next financial year to procure Inverters for each household. Electricity will be supplied for a few hours daily for people to charge their batteries. Meanwhile, people buy Inverters in sizes proportional to the thickness of their pockets. The poorer ones go for Chinese-made emergency lamps. The poorest go for candles and pinewood. After all, no Naga wants to stay in the dark because we have proclaimed ourselves to have come From Darkness To Light (Ephesians 5:8).

Zero Bulb Ideas is a series featuring whacky ideas of a noodle-headed nincompoop.