Exploring health with the wind in your face

My friend Varun Kumar recently got bitten by the community health bug and decided that he needs to  get a better understanding about what working for health really means. Being of the adventurous sort, he has decided to go on a bike ride across the country, visiting community health organisations along the way. One of his interests is in how mobile phones, which now seem present in even the most remote hamlets, can be used for health work. His corporate background is evident in his well presented maps of the proposed journey route. You can follow him on his blog  http://journeyofvarun.blogspot.com.

AlJazeera on health care in rural India

I just chanced upon this video on the state of health care in rural India by Al Jazeera English. For a network which is new to covering India they have produced a remarkably balanced report. In a span of a few minutes they give us a glimpse of India's huge burden of common yet potentially deadly infectious diseases such as diarrhoea, the worry and hardships faced by poor rural patients, the ailing government health care system, the frustrations of a doctor working for low pay in a remote area, the corruption within the system, the health movement with its activists and the private medical industry which is far away from all this reality.

Kudos Al Jazeera.

Snapshots of a doctor in rural Tamil Nadu

A few days ago the our health minister announced that that doctors will get better pay and 10% extra marks in competitive postgraduate entrance exams for every year spent working in a rural areas up to a maximum of 3 years. The proposal may not address to problem of the severe shortage of healthcare personnel in rural areas completely but it is indeed welcome news.

But what does working in a rural area actually mean? I spent two years working and taking pictures at the Tribal Health Initiative in Sittilingi in the Dharmapuri district of Tamil Nadu. Here are some snapshots.

Rural Tamil Nadu is beautiful.

This is the view from the kitchen window of the cottage I stayed in while working for two years at Tribal Health Initiative in Sittilingi, Dharmapuri District, Tamil Nadu as part of my rural service. Students from St. John's Medical College in Bangalore have to spend the first two years after graduation in one of the college's 400 recognised rural bond centres or pay Rs. 3,00,000 (Rs. 6,00,000 for the current batch).

The work is rewarding.

Apart from the three doctors and a couple of technical staff Tribal Health Initiative is run exclusively by people from the local community. Here is one of our health workers the day after the birth of her son. She was delivered by fellow health workers all of whom have grown up in the villages surrounding the hospital.  She had her baby in the sun when I came for morning rounds and we all shared her joy.

You might just get to live in your dream house.

I lived on the hospital campus at the edge of reserved forest land with a small stream a few metres away. My cottage had a small kitchenette, a shower and a high speed internet connection. (thanks to BSNL WLL technology). More than I could have asked for. Meals were in a common mess for all staff who stayed on campus.

You get chances to do surgery.

I learnt more in the two years I spent working with Dr. Regi and Dr. Lalitha than in all six years at college. One of the advantages of working in a rural hospital is that senior doctors have the time and patience to teach you unlike the competitive, hierarchical atmosphere of a city hospital.

You get chances to visit patients at home.

 

Every doctor should try this. If you visit your patients occasionally at home then you immediately understand what is making them sick and you realise that many conventional remedies are quite foolish to say the least. Practicing medicine also becomes a challenge when you realise that most patients can't read time, read labels or even begin to understand the nature of the medicines you prescribe.

You work with a dedicated, highly skilled team.

The health workers at Sittilingi are all drawn from the local villages and are predominantly from the Malavasi tribal community. I have never seen more competence and dedication. Our neonatal unit has a high success rate only because of the energy put in by our health workers in 24x7 one on one care of sick babies.

Things get scary occasionally.

A city boy like me had to get used to the occasionally enormous, allegedly poisonous spiders that used to sit nonchalantly on my cupboard door. My room was closest to the forest and a sort of immigration desk for snakes, scorpions, spiders and suchlike.

You learn about a different culture.

 

Living in Sittilingi meant I also saw a part of India I missed in the city. Pongal is one such amazing festival with anticipation building up for months before the actual date and the actual festivities being dissected for months thereafter.

You become family.

Being on duty 24x7 for a month at a stretch means you really get to bond with your staff. We worked, lived, ate and joked together and there was never a time when my inexperience and bad Tamil got them visibly  impatient. Here they pose with the newborn of another fellow health worker they helped deliver. Their pride in their work is obvious.

Come together, right now

I have just finished attending a workshop by the International People's Health University on 'Health and Equity', where for nine days we concentrated on understanding the growing difference between the health of the rich and poor, the economic and political forces that are causing this and the social movements that have arisen as a response to this. Most participants had years of experience working for health at the grassroots level and their shared stories contributed to making it the workshop a rich experience grounded in practical realities.

The course helped us link what many of us witness as local phenomena to the much more distant economic and political arena. This can be a discomforting connection at times once you realise that as an individual you are quite powerless against such distant, undemocratic institutions such as large corporations and international bodies. This was the point in the course where the answer to such an essentially political problem emerged.

In an era when economic and political decisions made by big businessmen and our politicians have a large influence on both our individual health as well as the health of the communities we belong to, the only protection against bad, corrupt decisions is community organisation. If communities come together from the street to the global level in order to monitor the decisions our leaders make, only then we can protect ourselves from the decisions that are detrimental to our health and lives.

What do I mean by community organising? This video says it much better than I ever could.

Kutti Thambi Chinna Doctor

He died five hours ago.
A small boy of three.
Looked so still and limp.
His family wailed.

His house is a few fields away.
His aunt works in our hospital.
He was born here.
He died at home.

He had a fever.
He vomited for three days.
His mother took him to a
Local traditional practitioner.

Our ambulance was called.
He stopped breathing before it came.
Tha held the mother.
And both were disconsolate.

His name is not tomorrow.

Poem in a car

Imagine if this poem was fashionable.
And was found in a book of fashionable poems.
Read by fashionable people in fashionable cars.

Then the name of this fashion will be
Fair fashion. And it will be fashionable to be fair.

To be fair one would need to look at the paper
On which this fashionable poem was written.
And wonder whether the paper is fair as it is
fashionable.

Who cut the tree to create a fashionable poem's paper?
Whose tree was it anyway? Does she read
fashionable poems?

Who sat in the car in which the fashionable poem was read?
Should we wonder whether the car is fashionable as it is fair?

Who mined the earth to create a fashionable car's body?
Whose earth was it anyway? Was he ever in a fashionable car?

Lousy T design idea

Public policy quacks

Another interesting presentation at ARSICON 2007 was one by Dr. Meenakshi Gautham on her study on the treatment of reproductive tract infections by informal medical practioners in the Tehri Gharwal region. I won’t attempt to summarise her findings here. I will only concentrate on the finding that almost all the practioners had no concept of the infectious etiology of urethral and vaginal discharge yet almost all prescribed antibiotics for such symptoms. When the actual rate of infection was calculated among symptomatic patients who were prescribed antibiotics it was found to be quite low (3-5% if I remember right). Most patients who got antibiotics did not need them.

These practioners were using a different theoretical framework, a traditional humoral understanding of the body to explain their patient’s symptoms. However they then proceeded to use antibiotics which have been developed using a modern biomedical framework. Since a formal medical education was inaccessible to them due to reason of money and language they had no means understanding this biomedical framework and this in turn made their prescription practice excessive and dangerous. Although it was not brought out in the study, they were possibly also aware of the fact that prescribing more antibiotics meant more profits and more incentives from pharmaceutical reps.

The traditional humoral understanding of the body is common sense knowledge in the region where they lived and worked. Most informal medical practioners learn what drugs to prescribe by careful observation of other doctors and it is hence not unnatural that they attempt to fit such observations into the theoretical framework in which is most familiar to them. They invest antibiotics which properties of ‘heat’ and ‘cold’ just like traditional medicines.

What I found interesting was the parallels that can be drawn between such a scenario and that of doctors writing health policy at state and national level. A large number of doctors in government committees are super-specialist clinicians with years of experience operating within the modern biomedical framework. Modern medical education ensures that even those who have spent years seeing patients from poorer, rural communities have no theoretical basis for understanding the social, cultural, economic and political realities of their patients. Those with post graduate degrees in Community Medicine don’t fare much better. It is quite likely that the surgeon mentioned in my previous blog entry might sit on a committee looking into ‘Tribal Health in India’.

Most assumptions on which policy is then based stem from common sense and years of observation. We have already seen how this can be a dangerous practice, since a large number of observations do not automatically mean that one has even begun to understand even the basics of the underlying phenomena. Indeed the resultant policy prescriptions produce results that seem similar to those of informal practioners. A lot of money gets spent, a few people get better and a large majority remain as they are.

If we are to ensure that policy decisions are made on rational grounds then we need to ensure that those making such decisions have both a deep theoretical and practical understanding of the social and political reality they are attempting to affect. Given the choice we would not entrust our bodies to a surgeon if we realised that he either didn’t have the necessary theoretical understanding of the human body or the requisite amount of practical experience. Policy interventions which affect the lives of millions of people deserve no less.

Novartis, drop that case!

In August 2005 I had written two articles on this blog on the rewriting of the Indian patent laws using the controversy surrounding Gleevec, an anti-cancer drug by Novartis to illustrate the issue. Under the new patent regime, large pharmaceutical companies could take out product patents which would allow them to monopolise production of new drugs and increase prices.

In January 2006, Novartis' patent application for Gleevec was rejected on the grounds that the drug was a new form of an old drug and therefore was not patentable under Indian law. This enabled patients with certain cancers to access the drug at a price of around Rs. 9000 ($200) a month as opposed to a price of 1,15,000 ($2600) which was the price of the drug elsewhere.

Currently Novartis is suing the Indian Government in order to have the patent decision overturned so that it can sell Gleevec at the same price in India as in other countries. If Novartis wins the case and succeeds in getting the provision of Indian law changed to resemble patent laws in wealthy countries, it could mean that fewer and possibly no generic versions of newer drugs will be able to be produced by Indian manufacturers during the first 20 years after discovery of a drug and India will no longer be able to supply much of the developing world with cheap essential medicines.

Sign a petion to demand that Novartis drop its case against the Indian Government.

Read more about the issue at the Medecins Sans Frontieres site.

The Gleevec Story: Part 2

This is the second part of the article. See below for Part 1.

The pharmaceutical industry and other ancillary industries which depend on modern allopathic medicine make only a weak pretense at being anything but profit making entities. This is fine as long as the physician acts as the intermediary between them and the patient, determining objectively when a patient really needs a particular pharmaceutical product.

However what has dramatically changed over the last two decades or so is that with the advent of globalisation and the birth of the multinational corporation, pharmaceutical companies find that in addition to stupendous profits, globalised trade also allows them to wield enormous amounts of power to influence international and local trade policy as well as the decision making capabilities of healthcare institutions and individual doctors. Time and again they have used this power to further their interests even when their decisions have adversely affected people’s access to essential medicines.

The only effective tool to influence a profit driven corporation is one that reduces profit. The need of the hour is to build a strong consumer movement which can protect itself through effective mechanisms that put pressure on big pharmaceutical corporations. World over it has been shown that when confronted with resolute consumers determined to ensure fair marketing practices, corporations have rarely risked profit endangering bad publicity and in many cases have backed down.

Doctors everywhere have a clear choice ahead of them. Whether to side with corporate bodies and become in effect corporate doctors with six figure salaries and a full range of pharmaceutical sops but no power to stand up against a corporate decision or whether to side with their patients and demand that people’s needs are put before profits, a position which guarantees a lower pay scale, more work, greater freedom and a fuller sense of job satisfaction.

This is a choice that our current system of medical education which is conspicuous in its silence about ethical issues and a strong economic and political understanding of the pharmaceutical industry leaves us ill-equipped to make.

The Gleevec Story: Part 1

This is the first part of an article which I wrote for Raw Nerves, our nascent college newsletter. The second part is soon to follow.

On April 17, 2001 a new drug called Gleevec was officially announced by Novartis, the second largest drug company in the world. Gleevec or imatinib which is its pharmaceutical name works by interfering with the pathways that signal the growth of tumour cells. Overnight the drug revolutionised the treatment of CML (chronic myeloid leukemia) as well as GIST (gastro intestinal stromal tumours). The scientific community was greatly excited by the development of such signal transduction inhibitors and there was hope that soon similar drugs could be used to treat various other types of cancer.

Imatinib turned out to be extremely good news for the 24000 patients who are diagnosed with CML every year in India. As per existing patent laws in India, which allowed patenting of the manufacturing process but not the final product, imatinib was soon produced by nine different generic manufactures and was made available to patients at Rs. 9000-12000 per month. This was in glaring contrast to the Rs. 1,20,000 per month which was the cost of the branded Gleevec sold by Novartis.

In 2004 things took an ugly turn when Novartis managed to secure from the Patent Controller an EMR (Exclusive Marketing Right) for Gleevec. Almost immediately the Madras High Court was forced to order six of the generic manufactures of imatinib to stop production based on a case filed by Novartis. The decision spelled death for a majority of CML patients who could not afford the Rs 1,20,000 for the branded Gleevec.

To make matters worse in December 2004 the Central Government tried to push through a piece of legislation known as the 3rd Patent Amendment Bill in order to meet India’s commitment to the World Trade Organisation’s TRIPS Agreement which required that we amend our patent laws to allow for product patenting. Such a law would make EMRs like the one granted to Novartis standard practice for any new drug and would prevent people from accessing cheaper generic versions.

Health activists around the world were quick to recognise the potentially disastrous implications of the amendment and organised themselves under the banner of the Global Campaign against the Indian Patent Amendment. Protests were organised in Europe and North America as well as throughout India.

After many modifications the final version of the Bill was finally accepted by the President on 7 April 2005. The Bill ushered in a product patent regime in India but allowed generic manufacturers like those of imantinib who had made “significant” investment to continue production after a “reasonable” royalty has been paid to the patent holder such as Novartis. Such vagueness of the terminology can be easily exploited in favour of the patent holders. In many cases generic manufacturers were reluctant to restart production fearing lawsuits from the patent holders or unreasonably high royalties.

Under the new law, if the next signal transduction inhibitor drug which works against another form of cancer was discovered, then the patent holder, in most cases a large pharmaceutical corporation will have the exclusive right to market it for the next 20 years. In the presence of such a monopoly they will be able to get away with exorbitant prices.

The story of Gleevec highlights a growing phenomenon in modern day medical practice. That the health of our patients can be adversely affected by trends in globalised trade and that in order to safeguard our patient’s health doctors will have to understand and be active participants in a worldwide movement to counter the ill effects of globalisation.