Tuesday, December 28, 2010

TB-FREE INDIA!

The Gene X-pert was apparently developed by the department of defense after the events of September 11th when biological threats became a national priority in America.It was used to analyse the DNA in potential toxins in pieces of mails.In 2008,funding from Bill and Mellinda Gates Foundation ,FIND and NIH began to assess the machine's effectiveness in diagnosing tuberculosis.
Gene X-pert as per a study published in the 'Journal' identified 98 percent of active infections because the tests look for the bacterium itself,latent infections are ruled out.
Detection of latent infections would have no significance in the indian scenario because tuberculosis is so rampant in india.
Treating latent infections could be potentially dangerous and could promote drug resistance because only twenty percent of the population harbouring the infection could manifest the disease.
Inroduction of GeneXpert technology in the national health programme would pose two-fold challenges in india.
Firstly,the cost of the investment for the infrastructure which is currently being quoted as twenty five thousand dollars with each test coming up to twenty dollars each is huge for a point of care test(compare it with the sputum microscopy)
Secondly the cost of supporting and treating all the new case-loads the tests might bring to light which the experts are calculating might be threefold would be enormous.
The multi-drug resistant tuberculosis results which would be kicked up as early as one and half hours would be another challenge,bringing with it an increased burden on the health infrastructure.
Since tuberculosis is the disease of the poor,where would the money to support such a programme come from?
Would individuals and the media care enough to make the right kind of noises to put a sustained pressure on the government and advocate for the private sectors to support such a venture?
Can we dare to dream about a TB free India in the near future?
(The facts have been picked up from an article in the New Yorker-'Deadly Misdiagnosis'

Sunday, December 26, 2010

Let me heal in His hands.....I have not had the time!!

Someone asked me how was last christmas?...For the last four years I have been away from my family during christmas.I remember last christmas like the back of my hand.Infact for the past three years or so I have spent the christmas nights resuscitating patients back to life by the grace of God.It has invariably happened that the patient and myself ,we walk out of the ACU in the morning.They blessing me and I ,thanking the Lord for the Gift of life given for Christmas.However,last christmas was unusual indeed and will not I guess, go away from my memory too soon in the future.
My cousin was struggling for life in Jaipur,the family had all but given up on him..Mr Ram Narayan Sahu(name changed),from Satbarwa,who had just had a bypass surgery ,who also had diabetes mellitus with stage four nephropathy came in with acute on chronic renal failure with gross fluid retention ,huffing ,puffing and frothing out blood and could not go for dialysis till the day-break.That was enough to keep me by his bed-side ,....he settled by the morning and so he gratefully walked to his car,bound for Ranchi.
Unkempt and ready to hit the bed I had just about reached my door when I got a frantic phone-call from my administrator ,a young single girl that five hefty men with camerras,et all,supposedly journalists were at her door harassing her.Satbarwa is a strange place where securities dissappear when problem arises.I was running across the lawn to her place and found her looking out of the mesh window and five men with camerras ,et all standing with pad and pens.Arms akimbo,I was shouting across the lawn,I wondered where it came from(my style) and what I would have done if they had turned upon me but I hardly had a choice in the matter...in another five minutes they apologised and we worked out that it was concession they were after.
Bristtling with I guess not anger,but the utter tiredness and fatigue,I walked towards the mess....I felt nauseated and my head was hammering away.
With a slight doubt in my mind ,I asked the cook not to put salt in my omelete...I had my breaker and then walked towards the hospital to get my blood pressure checked...my diastolic was 150....
I never even realised when I had crossed over from being the 'i will conquer the world mode ..to-I better look after myself mode!'
I have considerably slowed down since then,my blood pressure is down to normal ...but I realise that there is a lot more healing to be done..
the other day the sound of the loud drums in my house with the youth prancing around to the christmas carols had me quite disturbed and took me a quarter of an hour to recover....
I never fail to surprise myself!

Thursday, December 23, 2010

There it is !!

Sadoli block has been bothering me for the past two days.Today ,I shot a letter to the CMO,ACMO and the medical officer incharge of the block.Mukesh is planning a mela for Hep B awareness,immunisation and testing in the area.He called up a panchayat head in the village and was told that another person near his house had just died of jaundice a few days back.
Got talking with one of the patient's bystanders from the area and he was sharing how the previous day when he went to a visiting RMO?Quack ?from Dehradun to administer a pain injection for his old man, he observed that the so called Dr was using the old man's used syringe and needle for a little baby and another patient who came in after that. When he reprimended him ,I believe he said,-'they cannot afford a fresh one ,so never mind!'.
Waiting to see how the government goes about investigating the issue and taking some measures.

Wednesday, December 22, 2010

Perplexed!

Five of a family from Sadoli block presented with severe jaundice with cholestatic features,ages ranging all the way from five to fifty five.They turned out to be hepatites B positive and negative for Hep C and HIV.I had just about started getting perplexed and getting the point person from the Sadoli block mobilised, another young fellow from the same block but different village altogether came in with the same picture and turned out to be Hep B positive again.
Sadoli is a block in Saharanpur district in Uttar Pradesh.Our man is making a fleeting visit through the block to actively look out for more cases.These are the cases which have landed at our hospital.Are we looking at some epidemic of some sort, I wonder.Will try to intimate the CMO tomorrow after we get more details,I sincerely hope the government takes note and swoops down to the root of it all.

Tuesday, December 21, 2010

Being Thoughtful!

Ango was with me for less than a month preparing for her DNB exams.She has always been for me a little sister ,brought my way ,I believe,by the Holy spirit.I have stopped wearing a watch for the past five years and have all but given up on my phone for the last one year.I carry the latter around more for incase,but never felt the urgency to charge it.People have a way of reaching out to you in this highly sophisticated world of advanced communication.
Coming back to Ango,she would be up and alert at five or so in the morning.I would hear her rustling around her room,having her quiet time,studying,etc and invariably I would be calling out to her in the other room asking her for the time.
It went on everyday for the rest of the days she was with me.
Time plays an important role in the mornings for me.It's a precious part of the day and I normally push in the best part of my day's schedule for then.It is perhaps the most important time of the day.
Ango presented me with a lovely wall-clock the day she left.
I put the clock up on the wall from where my morning couch lies.
Even as I take frequent glances at the time,I always remember Ango and Nandu in my intercessions...not because they presented me with a clock but because they have placed themselves before my prayer couch with a piece of thoughtfulness which remains.
Jesus,during his ministry had the same knack for doing things that mattered.
May that same sensitivity be mine!

Sunday, December 19, 2010

Human rights issues in TB control.

I remember trying to convince Phoolmati Devi(name changed) to continue with her DOTS.She was an alcoholic lady in her forties with a family of twelve or more ,clustered in a two bed-room house,unwilling,uncaring and careless.After a series of visit from our boys and the doctors in turns she continued to be a potential source of infection in the middle of the village in Satbarwa.I was totally frustrated.I asked a series of experts on tuberculosis whether some way one could legally presurise her to take the medicines....everyone quoted human right issues..sounded a little confusing ...the knife could cut either ways.I got my answer in the meeting yesterday.
http://www.who.int/tb/xdr/involuntary_treatment/en/index.html. http://whqlibdoc.who.int/hq/2001/WHO_CDS_TB_2001.290.pdf.

Friday, December 17, 2010

Why is the doctor so irrational??

The New yorker apparently carried a story about tuberculosis on the streets of Darbangha in Bihar recently.
If there was a strong message to be carried from the sympossium,it was the message to ban the use of serological tests for diagnosis of tuberculosis.WHO is ,for the first time in it's history ,putting forward a negative recommendation.
We stopped using serology for TB diagnosis five years ago,but never mind-it's better late than never.
The article I believe,goes on to highlight how the doctors in Darbangha continue to order this expensive test for diagnosis of tuberculosis.The cost of the test runs up to 25 dollars.The patient is a labourer who earns around 2 dollars per day and the profit made from the twenty five dollars received ,is shared between the doctor who prescribes it,the person who imports it and the french company which produces it.
So our poor rickshawpullers on the street ,who contract tuberculosis, are making these dubious companies in Europe rich!One gentleman put forward this question-'Why is the doctor so irrational?''.
Madhukar Pai replied-'incentives! my friend incentives!'
That is ,I guess,the India story.
Dr Pai,who seems to be a faculty from the McGill university in Montreal in Canada,obviously of Indian origin, sounded almost cynical.

The important ..and the very important!!

I remembered Nirmal Bhuiya yesterday while attending the international sympossium for TB in Delhi.Nirmaljee was our DOTS provider.He volunteered to become one after his daughter who had tuberculosis was cured under the programme in Satbarwa.As I rave about it often,the DOTS providers in Satbarwa were one of the wonders of the world.Their dedication and perseverence and commitment to the cause of DOTS was phenomenal.That was before the government renumeration made it a paid service.These simple villagers pursued the cause of DOTS at considerable costs to their livelihood...paying at times out of their pocket for the transport and things and the government renumeration was not even forthcoming.
Nirmalji contracted tuberculosis one day.He had quietly come into the clinic,had enrolled in and was about to go home when one of the TB workers up-dated me about things.I sat and talked to Nirmaljee for a while,some words of encouragement and promised to visit him at his house.
We made a trip to the village in Dhawadih ,around twenty of us ,after the clinic at around seven at night.Nirmalji had gathered some of the villagers who were extremely hospitable and insisted we visit their houses as well.What struck me was the absolute material poverty.There was a few pots and few pans in the kitchen.Nirmaljee's wife was at the fire cooking some kind of gruel.The three children were hanging around and the mud-house they lived in had two rooms one of which had no roof.There were no animals,nothing.The villagers had pulled in a charpoy where they made some kind of seat for us.
Under the starlit night we sat,we sang some songs for the villagers,we gave him the few gifts we had brought along...and we prayed with them.
The government TB division were asked for some stories for awards to be given for individuals who were into community DOTS.With great joy in our hearts we gave Nirmaljee's story with the hope that it would be a source of inspiration for the community at large and also an incentive for a man so much richer in attitude inspite of the circumstances that surrounded him.
We waited..we waited..and one fine day we received an intimation that his award had been cancelled since it did not give the right kind of message to the public at large!Yesterday reciprocality was one of the aspects of ethics discussed by WHO.

Tuberculosis-GenXpert /MDR/Rif.............right to life!!

Was on and off for the sympossium conducted by the Bill and Melinda Gates foundation and FIND on tuberculosis in ICGEB in Delhi.It was on diagnostics and with the current onslaught of GenXpertMDR/RIF being endorsed by WHO the mood in the TB world is upbeat no doubt.However,in one of the presentations on ethics some points were highlighted which were rather disturbing.I,being a clinician working in a relatively rural set-up where MDR is rampant would naturally have a single question in my mind and that would be-how is it going to effect my patients with MDR?I came back totally discouraged by a few points put forward by a speaker who was discussing the ethical aspects of the tests in hand.
He was putting forward the options that lay before the government of India.I thought the cost of the infrastructure would be a case in point but what was on discussion was the dramatic increase in case load,without a back-up of proportionate treatment facility which could have moral and legal implications for the government.
The options put forward were to use the GenXpert only for diagnosis of TB and not for detecting drug resistant cases in the national programme.Sounds morbid to say the least!
To me the options sounded like deprivation of right to life either ways..
Someone suggested in one of the presentations that in India tuberculosis is so rampant that one could very well put Isoniazid in the drinking water for community prophylaxis....
There were experts come in from all the world over,there was but one presentation to be made by the RNTCP to put forward the visions of the programme and the big man had deputed someone else to speak on his behalf..he was apparently busy with a meeting conducted for another programme where he seemed to hold responsibility.Questions came as one would expect it to come for a programme that has an implication for the mass in our country.....there was defensiveness for response and the questions had not even started!
Does the government even perceive tuberculosis as a major threat to public health in the country at all.There is so much of hue and cry made out of calamities that happen off and on where a few lives may be lost whereas this killer disease which is killing and compromising the quality of lives of millions of Indians continues to be a side issue.
As one of the speakers rightly put it..methods to interrupt transmission may be the key to the backbone of control of tuberculosis in India.
We might after all have to put isoniazid into our drinking waters!!

Tuesday, December 14, 2010

Meanderings of the mind!!

Sometimes it so happens that you just want to let your mind wander and keep wandering..it hasn't happened to me for sometime but I can see all the traits of a workoholic developing in me.I do my share of duty and more normally ,I do it because there is a need .I enjoy the work that I do but I don't necessarily drag myself around my work twenty four hours a day.I stuff in a lot of other things within that schedule but the last but one week I am beginning to observe myself staying longer hours at work....I leave the workplace by seven or later which is not normal for me....I need a lot of time to myself and I am quite possesive about it.
The other day my sister was having a spell of dizziness and the doctors were at it trying to get to the bottom of it and now she has a MRI in her hand which reads a 'small six into six millimetre patch in the left parietal lobe ,may be demyelination!'.
She is a non- medico and was on the phone asking me about it's implication.I kept it to myself the first day not knowing how she would take it but the next day I found myself explaining to her what demyelination meant and she was at her funniest best.She thinks it might be part of a normal finding in the ethnic population we belong to.
Her husband was at it making sure all forms of radiation sources were taken note of.He is a journalist with Tehelka which took out the controversial 'Tehelka radiation survey '.My guess is that he might be attributing it to the onslaught of environmental pollution...he might be right,we certainly don't have it in our genes...or do we???.
My sister had a word of advice for me.
Walk around with a helmet!!

Sunday, December 12, 2010

What Mathew shared today…..!

Mathew for one always surprises me with his faultless hindi.

He gave the sermon in the church and it was a powerful sermon.

Few things that I remember …

We are here on a Sunday because of the Cross and not because of Christmas.

When Mary said ‘so shall it be with me !’ to the angel ,she was fearful in the circumstances that surrounded her where the punishment for adultery was being stoned to death and being a social out-caste.

When she agreed to the virgin birth she also agreed to a lifetime of pain.

God put the burden of the salvation of the World on two young shoulders ,who went through periods of uncertainity,displacement…during this very season….

Christianity is a lifetime of intense pain which brings us to the experience of exceeding joy amidst it and is not a chocolate candy solution for everything there is.

He challenged the youth in the church ,amidst the activities of the christmas to read through the four gospels.

He cautioned us against institutionalizing christmas as netas in India do the Gandhi Jayanti...what we cannot follow we put them on a pedestal and give it our token respect.

Christianity is as much a paradox as the birth of the Master of the universe who emptied himself for the salvation of the world!

Saturday, December 11, 2010

Disadvantaged or advantaged..??

A fifty year old lady came to the out-patient accompanied by a fiesty husband with a history of having been through the DOTS-1 and DOTS-2 in the local PHC with continuing symptoms and with added features of florid peripheral neuropathy.The lady was having a tough time standing straight the first time I saw her.They were poor ,refused admission.Came back with the investigations which made my heart heavier.She had a suspicious mass in the right upper zone in the X-ray and her sugars were touching 400mg%.
She needed a CT,but that would put them back straight by two grands where they were counting the pennies for the immediate treatment.It was a saturday afternoon and it was well past the out-patient time.While the out-patient staff patiently waited,I struggled through my words to convey the news.The man looked a little indecisive and wanted his wife's opinion.The wife took the matter in her hand and very calmly made some very practical decision taking the matter and the responsibility into the collective hands of the family.She asked to be prescribed some antidiabetic and said would come back asap with the CT .These were obviously poor people from Saharanpur in UP.I was relieved to see such resilence and practicality in the face of such obvious set-back.I was just bidding the couple good-bye when the husband suddenly turned around and said,-'We will get you a gift when we come back next!'It was said with an element of joy and gratitude ...
I was absolutely taken aback and humbled...generosity of spirit in the face of adversity!...I definately have a lot to learn from the disadvantaged!

Friday, December 10, 2010

It happens sometimes...!

This has been a mad week end indeed!
With all the students and the consultants away for the examination week ,I was supposed to be the lone doctor managing the medical out-patient which has an average of eighty to ninety patients,I actually ended up seeing my usual thirty patients (don't ask me how ? we have not solved the mystery as yet),second call for the emergencies in medicine ,as well as consultant incharge of the wards and the acute care unit with another resident doing the hands on.
Yesterday evening,a patient with a broncho-pleural fistula went into an acute episode of traumatic pneumothorax following a tube block-he was a hefty man to boot who already had a chronic kidney disease,it was a frightening three hours with us almost losing him but somehow we got the better of the pneumothorax with my heart in my throat even as we flailed around with the patient.Thanks to the few colleagues around who were such a rock I thought I would collapse on the spot.Just as the calm was setting in and I was trying to mentally go through the event ,I suddenly remembered that I had kept my food on the hot-plate and had been heating the water to boot and that was three hours ago...My flat is a little more than a hundred metres away.I was not only sprinting ,I was frantically praying that my flat had not caught fire by then.The hot-plate was miraculously switched off,I did have the presence of mind after all,but the room where the water was getting heated was full of steam...it could have been a bath!I put the switch off ..thanked the lord for small and big mercies.
The next day saw my colleague back on duty,gracefully offering to take on the tougher bit,seeing my ordeal.......it was lunch time before the hunger pang reminded me that I had forgotten to eat my dinner and my breakfast...the food was happily cooling it's heel on the hot-plate!

Wednesday, December 8, 2010

Tuberculosis and HCH!

Started organising the TB work in HCH.
It's a mammoth work with hordes of multi-drug resistant tuberculosis patients.Trying hard not to think too hard about the challenges that are going to come my way once I get started.It's amazing just how much of involvement each of these individual would need.Have roped in Mukesh from CH to help me out.He already has an extensive field experience in tuberculosis.
Started off with preparing my colleagues and getting a register started with the patient details.Have segregated a room in the out-patients that is going to serve as the clinic on wednesdays.We will need a lot of grace from the Lord even as we get deeper into the work.Today I met a patient who was well into the third year of the drug,having lost his family to the disease,being supported by the hospital entirely.
There are a lot of patients who are potential MDRs.
A huge number of cases are from the adjacent Saharanpur district of UP.
A month back,one of the patients walked into the OPD with government drugs in a loose paper which looked nothing like the RNTCP drugs.Yesterday ,the Hindustan Times had an article on spurious drugs which were confiscated from the government stores in UP.I wonder how they are going to compensate the population who have been victims of the drugs used.
Sometimes,I think all of India's administrative problems would be solved if corruption could be taken care of.It is just everywhere and it is frightening that in most places in India it is a norm.
Some of the challenges that would come my way would most probably be
patient compliance,
Cost of the drug,
XDR,
Infection control,
Drug tolerance,
Difficult topography,
Psychosocial problems,
government net-working....
and this could just be the tip of the ice-berg!

Friday, December 3, 2010

'Fazal tera hum par prabhu..raham tera hum par....'

One of our seniors was visiting from abroad.
While speaking in one of the devotions,he was reminding us how fortunate we were to start off a day's work with the morning prayer.He asked us if we were aware of it.
Having worked in a mission hospital for most of my adult life it is a norm but for me every day,a good time of corporate worship with devotion before the work starts off continues to be precious.I remember during my post-grad days running to the chapel early in the morning to sit on the cold cement ground of the ODC chapel to listen to the nursing students singing those melodiously beautiful Malyali and Tamil songs ,not that I understood too much of it ,but it used to be ethereal.Even now in HCH,the OPD staffs lead the worship to some out of world worship songs accompanied by beautiful indian and western instruments.Songs like 'Fazal tera hum par prabhu,reham tera hum par'...so typically folkish and heavenly ,has the ability to export us to another world alltogether.
Today was one of those days.It was the world disability day.
The pastor announced in the morning chapel that at ten sharp the siren would go off and wherever we were we should take a minute to remember the disabled of the world in our prayers.We in the OPD were attending to our patients when the siren went off...it was a tremendous privellage and a great joy to stop for a moment..explain to the patient about the significance of the day and to pray together for these very special people who have made our lives fuller and more meaningful by just being around.