Must Reads: Medical Nemesis

I've been reflecting recently on some of the books I've read as a medical student apart from our volumnious textbooks and I think it would be interesting to start a series on this blog about essential additional reading for any medical student particularly in the Indian context.

I think the hands down winner for Most Influencial Book is Medical Nemesis: The Expropriation of Health by Ivan Illich simply because it humbles you. In an atmosphere where doctors are becoming sickening self-congragulatory about the increasing use of technology in medicine which enables us to intervene and control bodily phenomena like never before, Illich reminds us that medicine, just like everything else has is limits beyond which is cannot hope to do good. Here is a sample.

Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine the damage appears as iatrogenesis. Iatrogenesis is clinical when sickness and death result from medical care; it is social when health policies reinforce an industrial organisation which generates ill health; it is structural when medically sponsored behaviour and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other and aging or when medical intervention disables personal responses to pain, disability, impairment, anguish and death.

The book was first published in the 1970's and is sadly almost unknown among medical circles today. I have still not found a bookshop in India that stocks it though it is available on amazon.com. I myself had to fall back on the time honoured technique of photocopying the only remaining library copy. Read it.

The social context of Indian medicine

I'm currently posted in Chamrajnagar, a rural district in South Karnataka and am practising in a social setting that gives me a lot of food for thought ..

Indian medical practice is largely based on clinical research conducted in the West. Most of the internationally recognised standard texts are by North American or European authors. The teaching methodology used here is largely an outdated, didactical approach which was imported here in the 50’s and 60’s when a large number of medical colleges were set up post independence.

However the social context in which our system is embedded is radically different from the one on which our system is based. While the Westernised elite are more likely to demand and have access to health care it is the poor, who are in an overwhelming majority who really require good, relevant health care. This is because poverty is intrinsically linked to sickness, a large component of which is preventable or easily curable.

It is quite evident that a majority of doctors respond to this difference between theory and reality with a range of practical modifications which range from the simple and obvious to the highly sophisticated. However they still exist only at the level of individual endeavors and as yet there is no large systemic acceptance and addressal of our unique reality.

Doctors in India are also handicapped in their understanding of the social context in which they practice for two reasons: One is that since entrance to medical colleges is highly competetive and students from private schools have an enormous advantage during entrance exams, doctors as a group come predominantly from upper class, upper caste backgrounds whereas a majority of people in real need of health care come from lower class, lower caste backgrounds. The second reason is that since admission to medical college is open to students only from science streams in India, doctors complete their education with only a miniscule component in social sciences as part of their Preventive and Social Medicine syllabus which exists more for namesake than anything else. Hence they are ill equipped to analyse, research and act upon any problem that is not quantitative and out of the realm of pure science.

It is this lack of understanding of social context that has prevented modern Indian medicine from being truly relevant in rural India, where the medical need is immensely greater than in urban areas. The crying need of the day is for Indian doctors to move out of the biomedical paradigm and become anthropologists, communicators and true practioners of revelant social medicine.

Pixels

Thanks to Snake Anthony I have finally managed to put a whole lot of my pictures online on Flickr. Check them out here.

A mere two Israeli generations ago

"In Germany first they came for the communists
and I did not speak out-
because I was not a communist.

Then they came for the Jews
and I did not speak out-
because I was not a Jew.

Then they came for the trade unionists
and I did not speak out-
because I was a Protestant.

Then they came for me-
and there was no one left
to speak out for me."

-Pastor Martin Niemoller (1892-1984)
A leader of the church's oposition to Hitler.

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.