Pithy Loquacity

Category: Medicine

  • Drug marketing and dichotomy


    When I began my practice following residency I became aware of the cesspool that medical and associated profession have become. Each day was (is) a learning experience. Not that one is completely unaware of the ground realities- but first hand experience is humbling.

    I was reading a blog post by Jim Sabin wherein he comments on an article on “Drug promotional practices in Mumbai: a qualitative study” in the Indian Journal of Medical Ethics (April-June 2007 issue) and surmises

    All of the issues described in Mumbai are present in the U.S., but in India the pharmaceutical practices are more brazen. Federal and state regulatory capacity is significantly less in India than in the U.S. Perhaps more important, organizations – medical schools, hospitals, medical societies, and more – currently have less capacity to push back against commercial forces than comparable institutions in the U.S.

    But the Indian media is sinking its teeth into the issue of commercial corruption of medical decision making (see, for example, “Are your drugs boosting your doctor’s lifestyle?” in yesterday’s Times of India here). The same ethical drama is playing out globally, just with different timing.

    the ground reality and the extent is so so much worse that it is mind boggling. and to be frank the medics/doctors are ending up being bit players.

    Pic from offside.com
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  • On Generics and Drug affordibility in India.

    I had previously written about compulsory licensing of expensive anti cancer drugs in India and the expected benefits to the patients. Just after this news came out, there was reaction from the Govt. sources  stating that no they had no plans for such measures as cancer was not an “epidemic or national emergency”.
     
    There is an interesting interview with Ranjit Sahani, country president of Novartis in India  who is arguing for better IP protection and pointing out that generics do not solve the issues as they remains out of bound to most of the patients.

    But here, generics alone do not solve the issue. Generic versions of Glivec are far too expensive for the poor in India. Furthermore, generic-makers in India have yet to come forward with an access program for generic imatinib mesylate (Gleevec’s generic name). For example, in India the cost of a one-year treatment with generic imatinib is $2,100, or 4.5 times the average annual income. Even our critics recognize that generic versions of Gleevec are not the solution for the poor in India. This is why approximately 99% of patients on Gleevec receive it free. There is no market for Gleevec in India…

    You can read the whole article here. (via Pharmalot).

    He also discusses the issue of epidemic and national emergency as regards to HIV and Diabetes

    There continues to be some ambiguity around what constitutes an epidemic situation. In 2007, India reported 2.5 million HIV infections, a prevalence rate of 0.36%, with less than 15% of HIV-positive people receiving [antiretroviral] treatment. That said, India has about 60 million diabetic patients [30 million diagnosed and another 30 million undiagnosed]. By sheer volume, wouldn’t that constitute an emergency? If examined carefully, limited cases would qualify as a national emergency, an epidemic, for example. HIV and cancer by the very nature of these illnesses are an emotive issue, which is why they get the volume of publicity.

    Most Indian practitioners are aware of the huge disease burden in our country and the dismal situation here but the figures he quotes is sobering.

    He also talks of differential pricing of drugs but I think it will be hard to put in practice or prevent misuse. Another point he makes ( naturally being a pharmaceutical seller) that the price of drug is fraction of the total cost of treatment.

    Despite a significantly higher cost for the private sector, an analysis of the cost structure shows that the amount spent on medicine is a fraction of that spent on diagnosis and doctors’ fees.

    I feel that were it not so, the number of patients completing their treatment/ patient compliance will go down even more. The fact is physician compensation/procedure costs are also rock bottom. For example where in world you get a cholecystectomy for Rs 3000/- or an abdominal ultrasound for Rs 300? Unless the economic condition improves the return on medicines will remain around the present levels.

    Interesting read over all.

  • Compulsory Licensing for breast cancer drugs in India?

    Stated briefly; in general  the treatment of breast cancer in India at present is suboptimal. I was reading a book regarding evolution and changes in management of breast cancer and what struck me was that we are still stuck in last decade. Most of the patients present very late in disease process. Breast cancer screening is practically non existent. A number of tests which have become routine like ER and PR status are not available even in teaching government hospitals leave alone general hospitals. And not everyone can afford to get it done from private centers given the cost. This problem extends to post operative period as well with a number of patients unable to afford tamoxifen for the long duration prescribed. In this context it is apparent that majority of patients cannot afford more recent and advanced drugs available.

    There is this article in today’s Economic Times.

    NGO to seek compulsory licensing of cancer drugs- Pharmaceuticals-Healthcare / Biotech-News By Industry-News-The Economic Times

    NGO to seek compulsory licensing of cancer drugs.

    At this time the prices of anti cancer drugs is out of reach of general Indian population with prices in excess of

    Some of the drugs identified by CPPA for compulsory licensing include Genentech’s and Roche’s Herceptin (Rs 1.3 lakh i.e Rs 130,000 per injection, to be taken 10-15 times), Roche’s Mabthera (Rs 1 lakh per injection, to be taken 10-12 times) and Tarceva (Rs 48,000 for 30 tablets, dosage details not known), Novartis controversial drug Glivec (Rs 1 lakh for a month’s treatment), Astrazeneca’s breast cancer drug Arimidex (Rs 3429 for 14 tablets, to be taken for 1-2 years) and Zoladex (Rs 8,910, dosage details not known), GSK’s Hycamtin (price and dosage details not available).

    Keeping in mind that per capita income in India is about 580 $ or Rs 23,000 and the fact that health insurance is an exception rather that a norm any disease (leave alone breast cancer) will leave the entire family in penury. Despite these facts a few patients would like to go for these drugs. What I do not understand is the reluctance of pharma majors to market these drugs and at a lower price. They will be making a profit even if 20% of the patients buy their products. Or are they afraid of these drugs undercutting their high value markets back home?

    Do you think this move will be justified?

    There is a similar news piece regarding HIV drugs and Cipla. From Pharmalot.
    (updated)

  • Rectal artemisin derivative for initial control of malaria

    There is this interesting article in todays BMC Infectious disease which had my attention. the featured article says

    Rectal artemisinins rapidly reduce malaria viral load
    BMC Infectious Diseases 2008, 8:39

    Artemisinins administered as rectal suppositories, particularly artesunate as a single high dose, reduce malaria parasite load within 24 hours without serious adverse effects, offering an alternative to intravenous quinine therapy in remote areas where trained personnel are scarce.

    Don’t laugh- but my first thoughts was HOW did they manage it technically!? on reading the whole article I realized they meant malarial parasite load in people not umm… mosquitoes.
    you can read the full article here (open access abstract).

    From my earlier days i remember there was increasing resistance to artemisin derivatives and I suppose combination therapy is advised to reduce those chances.I wonder how this will have impact on drug resistance in future.

    Note: It is not viral.

    &ps- i will try to post regularly.

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  • Health ministry mulls approving foreign degrees.

    AT the present moment medical degrees earned in foreign countries are not valid in India and vice versa. Doctors  holding such degrees are not recognized as specialist here and as such cannot practice here. The government is considering a proposal to recognize specialist degrees earned abroad (‘developed countries’) for pracitsing in India in order to aid doctors wanting to come back. Read the news here from IBN live.

    The government further hopes that such a move might induce them to “reciprocate.” Fat chance of that occurring when you consider the recent trends in NHS or elsewhere ! However it will be greatly beneficial to many MBBS students who left after internship and now may want to return as specialist. 

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  • Weird way to say thanks…

    WTF story of the day-Claiming magical powers can be hazardous!

  • Dr Punching Bags

    Doctor and Patient relations may be what it is but the relation between the  doctor and the patient’s attendants is getting more and more acrimonious. Speaking from my personal experience; for every 3-4 emergency shifts that I do at least one is bound to be horrible -not in patient load terms or how critical they are-but the unpleasant interaction with the relatives or patient’s attendants. I find harassing doctors and staff on duty has become a fashion trend; like an index to show how good your  ‘connections’ are or demonstrate your political might. Incidents like these are not new or isolated from BHU doctors on strike.

    Varanasi, November 30 An indefinite strike called by resident doctors at the Banaras Hindu University (BHU) from today paralysed operations at the varsity. The doctors were protesting against yesterday evening’s attack on two junior doctors by the sons of a high-profile patient.

    This was news about 7 days back. Subsequently the residents had went back to work expecting the hospital and university authorities to pursue the matter further with Police and administration.And what happened ? Nothing! as usual. The matter is now taking the form of circus with all and sundry reminding the doctors of their duty and Hippocratic oath( Damned if you work and double damned if you do not). This is what I read in the news today-

    Posted at Friday, 07 December 2007 10:12 IST

    Varanasi, Dec 7: The resident doctors of Banaras Hindu University are on an indefinite strike to protest against the assault of junior doctor and two of his associates in the hospital.

    The doctors are demanding action against the culprits who had manhandled the medicos.

    The Resident Doctors Association (RDA) had alleged that the district administration was trying to save the influential people who were involved in the assault.

    They also alleged that no action has been taken against the accused even after 72 hours from the time when the doctors had suspended their strike to given an opportunity to the university.

    This is not a single (the hyderabad hospital)or an isolated incident. Numerous such incident must go unreported occurring daily all over the country. I wonder if this malaise is peculiar to our country or happens elsewhere as well. It is not always that the death is totally unexpected or the prognosis or gravity of situation is not known to the people involved. Only one thing is sure-  the culprit will be let off and doctors will continue to be punching bags.

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  • Barenaked medicos.

    barefoot doctor from sinophilia.orgImage from www.sinophilia.org

    The proposal for compulsory rural service by graduating medicos has long been in the pipeline. It is already being implemented by some states with variety of carrots and sticks attached. In a move by the parliament all newly minted doctors will be required to spend one year in rural areas in compulsory manner. They will not be accompanied by any support staff as per the proposal. Students are certainly not happy about it

    “How can you extend the already long five-and-half-year tenure of the course? With this one-year mandatory rural service and the post-graduation after that, the total medical education becomes of nearly 11 years,” said Anil Sharma, spokesman of the resident doctors’ association (RDA) of AIIMS.

    One thing I can say for sure- the amount of ill will in general population towards medicos is increasing. Do your think the targeted population will be benefited? I wouldn’t bet on it. forum discussion at IBN

    As for our esteemed Minister- this is what he had to say

    “the MBBS degree was not being extended by a year. The students were only being asked to do a year of rural service.”

    “This is not a new scheme, as compulsory rural service was in force in the country 30 years ago. Even now, this is in practice in states like Kerala and Maharashtra. This will be only a temporary scheme for a few years to bring down the infant and maternal mortality rates in rural areas”

    It is not just the health minister who is of this opinion. Even the mandarins at the planning commission see medicos as cheap plug for the gaping hole that health services is in India; especially in rural areas. In trying to make amends they plan to offer Medicos as the sacrificial goat at the electoral altar. So what do the esteemed gentlemen (&ladies)  propose? well-

    The Planning Commission has made a strong case to make a few years of public service compulsory for all graduates from government medical colleges.

    This should be at least three years, the apex planning body has recommended in the draft Eleventh Plan that aims to improve government’s health care services to the public.

    The idea is to enable students who get state-subsidised education to contribute to the society by serving the tax payer for a few years. The Commission has also recommended that the pay structure of doctors should be improved. read the news here

    You might notice that the proposed posting is just for students from government medical colleges. I am sure that the rules will be tweaked in future to include those passing out from private colleges and also provide an escape route for “political proteges.” It will be further tweaked to ensure that the brightest and the most selfless suffer the most.

    The commission further notes –

    Sources said quoting various national sample surveys that people do not go to public health facilities because medical and para-medical staff, diagnostic services and medicines are not available there. The scene is pathetic in some states. As per a recent government survey, Bihar and Jharkhand have just 0.48 health care professionals per 1,000 people, while the norm is 2.25/1,000 people.

    I mean they had to do a sample survey for that! Any medical student knows that the country has been unable to achieve goals for public health set 60 years back!

    update I see that the issue has already been well covered by catscanman

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  • Home remedy for breast lump

    Sometime back a patient presented in emergency with complaint of bleeding from an ulcer in breast and severe backache. As is typical she was referred from community health center in nearby town coming to us at 2:00 A.M. She appeared not to be worried about the lump in her breast or the multiple swellings in her axilla and other areas in her body ( she had metastasis and satellite nodules as well) but about the bleed from her ulcer. The surprising thing was that she is from well to do family and quite educated. In fact she did consult a doctor three years back who had advised mammogram and FNAC which had been inconclusive. She was asked to undergo a biopsy which she found bothersome and turned to home remedies/ ayurveda/ unani for treatment till now.

    The sad part is that even her relatives are under the impression that she is fine. Her appetite is good; hasn’t lost weight hence must be healthy. “Doctor just give her some glucose (i.v. fluids) and blood and she will be fine” is what they say.

    This is not the first time i have seen case of terminal cancer, but to go this way without trying is sad.

    In our hospital (and i suppose in India in general) a large proportion of patients of Breast cancer present very late in the disease process. Mostly this is due to lack of awareness and access to medical facilities. The patients comes to the doctor only when the lump or discharge is noticed by friend or family member and forced to seek medical care. there is astonishing amount of ignorance and shame associated with the disease. This is the case not just in cancer but even more so in gynecological malignancies. I find patients are much more prompt in seeking care for abdominal or respiratory complaints.

  • Separating Conjoined twins

    A 2 year old girl with eight limbs undergoes surgery in Bangalore. Read the news from bbc

    Lakshmi was born two years ago on Diwali in Araria village in Bihar. Although the people of the village treated her as a re-incarnation of Goddess Lakshmi, for doctors she was an ischiopagus conjoined twin.

    Update: The operation was successfully completed in 27 hours. Read the rest of the story with photos here

    reupdated: Lakshmi is doing fine following surgery further news

    Lakshmi is deemed fit enough to go home following surgery. She may require further surgery later to enable her to walk properly.
     

    “Lakshmi has recovered adequately with no significant problem during her process of recovery. Her parents are keen to take her home and medically she can do so,” Dr Sharan Patil, who headed the team that performed the rare surgery on Lakshmi on November 6, announced at a news conference.

    the full story.

    Further news