Travelling in the Narmada Valley ..

What did you do when the poor
suffered, when tenderness and life
were dangerously burning out in them?

Apolitical intellectuals
of my sweet country,
you will have nothing to say.

A vulture of silence
will eat your guts.
Your own misery
will gnaw at your souls.
And you will be mute
in your shame.

-Otto Rene Castello.
Guatemalan poet who was killed by the Guatemalan army on March 19, 1967.

Explaining Why Not

The Master was known to side with the revolutionaries even at the risk of incurring the displeasure of the government.

When someone asked him why he himself did not actively plunge into social revolution, he replied with this enigmatic proverb:

“Sitting quietly doing nothing.Spring comes and the grass grows."

Quoting Paul Farmer

This man has the most fascinating collection of quotes. These are my favourites.

“I will define what I conceive medicine to be. In general terms, it is to do away with the suffering of the sick, to lessen the violence of their diseases, and to refuse to treat those who are over-ministered by their diseases, realising that in such cases medicine is powerless."
- Hippocrates
“The Art”

“For if medicine is really to accomplish its great task it must intervene in political and social life. It must point out the hindrances that impede the normal social functioning of vital processes and effect their removal.”
-Rudolf Virchow

“Our system is one of detachment: to keep silenced people from asking questions, to keep the judged from judging, to keep solitary people from joining together and the soul from putting together its pieces.”
-Eduardo Galeno
“Divorces”

A Worker's Speech to a Doctor

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.

The pain in our shoulder comes
You say from the damp: and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?

-Bertolt Brecht

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.

Neevu Engleesh Daktara?

Language in Medicine

One wonders why the study of language is not a more integral part of the study of medicine. Especially here in South India where it is not uncommon to encounter over six to seven languages in a single morning at the OPD.

The presumption is that all Indian doctors are natural born linguists. This is true to a certain extent with most of the senior doctors who seem to be able to take a basic history in a fair number of languages. Often however the interaction merely consists of a few basic questions and recycled advice. Real conservation in which the doctor can relate to the patients is difficult and requires a fair amount of experience and skill.

The people who feel the language barrier the most are the medical students and junior doctors who suddenly find themselves in possession of a fair amount of medical knowledge and absolutely no way of adequately communicating this to the people to whom it matters the most, the patients.

In this era of globalisation the issue of language and communication is all the more relevant. Large scale migration, especially to the cities ensures that at least in the urban setting doctors will always have to deal with patients from a multitude of linguistic and cultural backgrounds.

Miscommunication is at the heart of the recent rise in the number cases of litigation against doctors by irate patients and carers who feel that there expectations and rights have been betrayed. Obviously the most glaring forms of miscommunication occurs when the doctor and patient do not share a common language and have no means of overcoming this barrier.

In this context a more organised approach to the challenge of producing multilingual doctors is the need of the hour. The assumption that doctors will pick up language 'on the job' needs to be reevaluated and alternate approaches need to be looked at.

The teaching of languages has undergone a radical transformation over the last fifty years. Most Western universities have language laboratories where new and innovative methods of acquiring language ability are being explored. The challenge is for the medical profession to incorporate these advances in its effort to provide better and more effective care.

Celluloid Medicine

The other day I was browsing through old issues of the BMJ at the British Council Library when I came across a study on whether screening films that portrayed doctors realistically helped medical students develop emphathy. The article contained the following lists.

Most useful films for medical education

1. The Doctor (1991)
2. Arrowsmith (1932)
3. The Citadel (1938)
4. Not As A Stranger (1955)
5. Pressure Point (1962)
6. Whose Life is It Anyway (1981)
7. Miss Evers Boys (1997)
6. The Interns (1962)
9. Critical Care (1997)
10. And the Band Played On (1993)

Best portrayal of doctors in films

1. Red Beard (1965)
2. The Hospital (1971)
3. Article 99 (1991)
4. State of Emergency (1993)
5. Miss Evers Boys (1997)
6. The Elephant Man (1980)
7. Panic In The Streets (1950)
8. Spellbound (1945)
9. Death And The Maiden (1994)
10. Guess Who's Coming To Dinner (1967)

The Characteristics of a Physician

The introduction to Harrison's Principles of Internal Medicine has this beautiful excerpt from he first edition of the book in which the original authors aim to sum up the essential physician. The current edition apologises about the seeming chauvinism of the original text and reminds us that women physicians were still an oddity back then. I thought a little affirmative action was indicated so here's a re-edited yet continuingly gender biased version of the same.

The Characteristics of a Physician

No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of suffering she needs technical skill, scientific knowledge and human understanding. She who uses these with courage, with humility and with wisdom will provide a unique service for her fellow human and will build an enduring edifice of character within herself. The physician should ask of her destiny no more than this, she should be content with no less.

Tact, sympathy and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs and disturbed emotions. She is human, fearful and hopeful, seeking relief, help and reassurance. To the physician as to the anthropologist, nothing human is strange or repulsive. The misanthropic may be a smart diagnostician of organic disease, but she can scarcely hope to succeed as a physician. The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining rogue. She cares for people.