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Wednesday, September 19, 2018

Why Jacob Vadakkanchery's Arrest is the Best Thing for Naturopathy, AYUSH, and the State

There is a lot of context needed here.

To begin with, Jacob Vadakkanchery is a self-proclaimed healer naturopathist from Kerala who goes around asking people to believe that modern medicine is harmful for health. His arguments are so basic and trying to respond to an argument he raised had me writing a 1200 word blog post in Malayalam explaining what science is and whether medicine is a science. He was arrested in the second week of September by Kerala police for asking people not to take Doxycycline prophylaxis (in the aftermath of the floods) under at least section 505 of IPC. Section 505 is one of those sections which exist owing to the "reasonable restrictions" over freedom of speech and expression in the interest of public order as per Article 19 of the Indian Constitution. It punishes people who spread rumors that are likely to disrupt the society unless they are based on reasonable grounds.

I, am an HIV physician and general practitioner of modern medicine. I have previously worked in a hospital where Ayurveda was regularly practiced alongside modern medicine.

Now, let us get to the matter. After Vadakkanchery's arrest, there was a discussion in my circles about how it was wrong for the state to run Government naturopathic hospitals on one side and arrest people for taking stances against modern medicine rooted in naturopathy on the other side.

Isn't it true? If you recognize natruopathy (or AYUSH) as a valid system of medicine by opening hospitals and offices for the same, are you not also paving way to firm believers in those systems to make everyday statements that insult families of cancer victims, make doctors and hospitals look like villains for providing standard care, and makes those who think question the role of scientific temper in our discourses?

Many times the prescriptions of modern medicine are directly contraindicated by the principles of alternative medicine. How is it that the government is allowing two such opposing systems to exist together? What is the government trying to tell people? Whom should a person go to when they get sick?

Here are my thoughts.

It is not the government's responsibility to tell people what to do. Actually, the government does not have any power to tell people what to do. The government's role, in a democracy, is to abide by the Constitution which is written by the people for themselves and "govern" the state. So let us leave the government out of the question.

How did we end up with such systems, though? I think the answer is simple if we try to understand what these systems are and what they represent.

Self-preservation is a fundamental drive of all living things. Humans must therefore have started thinking about the art of staying alive from the beginning. What humans also tend to do is form theories based on what they see and understand. We form theories for everything. In fact, what we call science is a continuous reforming and refining set of theories based on observations. But these theories are limited by what we can observe and imagine is happening.

Our imaginations become more accurate representation of reality when we can observe more closely and in more detail. That is how science keeps growing. The idea that there might be something that transmits diseases from one person to another was imagined by observing people living together getting the same disease one after the other even before the invention of microscope. Later, when we invented microscope, this imagination became observation. Then we moved forward imagining things which a microscope could not show us. That is how science happens.

In that spirit, Ayurveda is a science. Or to put it more correctly, Ayurveda was a science. From the set of observations that could have been made centuries ago, whatever could be imagined was indeed science at that time. AYUSH is a set of outdated imaginations based on observations that does not include all that can be observed with the state of affairs right now.

Now here is the most important sentence I am going to say. Outdated does not mean wrong altogether. If that is the case, the medicine I am practicing today in India is already out of date by a few years compared to Western world and I am completely wrong to practice that medicine. That does not make sense. It is okay to use the best of what is available. In HIV, there is a medicine called TDF which has a lot of side effects on the kidney and has been replaced by TA in the West. But it's not yet widely available in India. So, should the 1 million people who use TDF not be using TDF? Absolutely not! Oral rehydration solution is an invention that is absolutely stunning. But for simple diarrhea, drinking plenty of fluids might just be enough. So, if I do not give someone ORS when they have diarrhea instead ask them to drink plenty of fluids, am I making a mistake? No.

Similarly, AYUSH makes sense for people who do not need modern medicine and for people who cannot access modern medicine no matter what. Take a close look at the clauses I used.

"People who do not need modern medicine". A lot of conditions do not need modern medicine as a must. A simple cold with cough, a simple cut, obesity, psychosomatic illnesses.

"People who cannot access modern medicine". When I was working with SVYM near Mysore, I became acutely aware of this. For populations of about 20,000 there simply is no surgeon available. The two obstetricians who are in different towns in the taluq have to coordinate with each other to ensure that when they take a Christmas vacation with family, the 20 ladies who are expecting do not suffer. Do not even ask me about how the on-call system of doctors could run. AYUSH practitioners are a luxury for rural Indians. MBBS doctors - an Utopia.

This is the context where AYUSH and modern medicine do not just exist together, but are forced to work together.

These are not the only reasons though. There is an element of human touch that goes missing in medical practice now. This leads to people seeking comfort from people who give that touch. Homeopathic medication might be placebo. But if placebo is the only medication that works for a particular condition, and if modern medicine practitioners are not able to give that placebo, then why not homeopathy? If in one 30 minute visit to an ayurvedic practitioner I can get relief from my headache, my grandmother's knee pain, and my child's cough, why will I visit someone else? Where is the modern medicine family doctor?

It is in this context that government opens its own naturopathic centers. This context, though tiny by definition, includes a large population of our country. Therefore, it is very important that we define this context well and nurture the continuum of care when there is a change of context. For example, a pre-diabetic who was being managed with lifestyle changes by an AYUSH practitioner will need a modern medicine consultation when they become a full-blown diabetic. At that point, it must be possible for the AYUSH practitioner to understand their limitations and refer them to the modern practitioner. At the same time the doctor at the modern medicine end must be sensitive about the context the patient is coming from and be willing to accommodate and include the system that the patient has easy access to in their prescription.

This is not happening now and cannot happen as long as practitioners of different systems do not understand their strengths and weaknesses and are not willing to collaborate on behalf of the patient. Where there is no trust and understanding, there cannot be collaboration.

When people like Jacob Vadakkanchery go about stating ill-based arguments against vaccine and doxycycline, they need to be stopped, arrested if need be. If they are not stopped, it would be ignoring all that human beings have achieved in the pursuit of science.

Only when the enmity ends can people begin to learn about each other and understand each other's strengths. The enmity can end in only one way. AYUSH will have to accept that their role is in a limited context. They will have to learn their limitations and refer patients to modern practitioners before it is too late. And modern practitioners will have to understand the issues in their practice and make use of AYUSH practitioners.

This is not a natural collaboration. It needs to be forged into place. Some organizations like SVYM may have been able to do it successfully. But it is in the best interest of the state to enable this collaboration to emerge at a national level. Pitching one against the other is not going to work. And that is where Jacob Vadakkanchery's arrest is the right thing to do.

What to do with BM Hegde though?

Sunday, September 9, 2018

Healthcare With Smartphones?

Imagine this. You are a 36 year old lady working as maid in two houses, not supported by an alcoholic husband, and mother of two school going children. Your husband had a wart on his genitals and now you have it too. It is not particularly bothersome, but you are not sure what you should do about it either.

You think it would be a good idea to go to a hospital, but which hospital? Which doctor should you meet? Would they judge you? Do they charge too much money? Is it going to hurt? Whom do you even ask these questions?

Enter our app.

You will be asked a series of questions in your own language. The questions get more and more specific as you answer them. They will also be read out to you in case you can't read. By the time you have answered about 10 questions, the app knows what your problem is.

The app has been fed with a well designed set of protocols/algorithms that need to be followed in each situation. It has a curated collection of resources (hospitals, clinics, labs, lawyers, etc) which are guaranteed to give you quality care without judging you or making you feel uncomfortable.

The app might suggest you to get over the counter paracetamol for a fever it thinks is not serious. But for your wart it is suggesting that you consult a dermatologist near you.

You can book an appointment with her through the app at a time convenient to you. Your data will be passed on to her with your consent. Later at the clinic you can start from where you stopped.


Information is strength. Knowledge is power. As a doctor, I have witnessed countless situations where patients struggle because they did not know the right room number or doctor's name. What the app does is eliminate those knowledge barriers by presenting trustworthy and relevant information in a friendly interface.

The possibilities that this idea brings are endless.

It can be tied together with a call center where people who do not have a smartphone can be given service.

A subscription based service that gives discounted rates for various medical tests and consultations can be introduced.

Micro-insurance schemes cab be brought in.

Transgenders can be employed as distributors of the app to otherwise hard to reach strata. They can be given additional training to be able to work more or less like ASHAs in the community.

Otherwise hard to navigate healthcare facilities can be easily navigated. (Think of how easy google maps has made walking around an unknown city)


The bottlenecks:

Affordable healthcare providers. Whom do we have?
Government is cheap. But what about quality and comfort?

It might be possible to tie up with private companies under Corporate Social Responsibility to fund the charges at private hospitals. But the costs can become too high too soon.

An intelligent mix match of services public and private using a friendly application can solve this in my imagination.

And that is what I am working on now! Ping me if you're interested to join forces.

Saturday, September 8, 2018

Reimagining Kinnars (Hijras) as Health Workers for Reproductive & Sexual Health

Supreme court struck down section 377 a couple of days back. India is moving forward in the right direction. There is still a lot of work left to do.

We see kinnars (hijras) working on roads asking people for money. They are "strange" humans in other people's mind and when people look at them all that comes to their mind is their gender issues and sexual connotations of those.

This strangeness might be the reason why people are unwilling to give them jobs. Could we turn this around?

Reproductive and sexual health is a topic that is absolutely neglected in our education system. There is plenty of embarrassment in discussing topics related to sex as well.

What if, then, we put them both together? What if we empower kinnars by giving them training and other resources required, to go into the community and work for reproductive and sexual health? Like ASHA workers they would promote health. They can even distribute interventions like condoms.

This is a positive change in many ways:
  • The kinnars themselves gain a better understanding of health
  • This can become an income generating opportunity for them
  • The perceptions about transgender community can slowly be changed to a positive one
  • Otherwise hard to reach strata of society can be reached

Sunday, July 8, 2018

Way Forward

On 30th of June, SVYM organized a one day session on careers after MBBS at Vivekananda Memorial Hospital.

Interns and/or final year students from Mysore Medical College, Bangalore Medical College, Hassan Institute of Medical Sciences, JSS Medical College Mysore were among the ones who were in the audience.

After the SVYM video, it began with introductory remarks by Dr Chaithanya Prasad, the director of VMH.

Then Dr MA Balasubramanya talked about administrative careers after MBBS. The gist of it was that as doctors, we are already administrating. There is no running away from it. We should embrace that reality and go forward with it.

Dr Kumaran K took the audience through the story of his life in research and thereby had them thinking about how to pursue a career in research.

Dr Ravindranath motivated the audience to take up surgery as a career and showed various alternatives to the MS degree to become a surgeon - majorly about options in various other countries.

Dr RK Nair talked about his passion for emergency medicine and how to go about it as an Indian.

Good lunch in between, and then a snippet on Fellowship in HIV medicine.

Dr Dushyanth P who is the technical lead of SVYM's palliative care talked about careers in public health and palliative care.

Dr Seetharam MR and Dr Kumar GS and the audience brainstormed on the direction where healthcare is headed or should be headed.

Later the participants were taken on a walk around the SVYM Saragur campus and the interactions continued over various tourist spots in and around.


The presentations [Powerpoint, Google Drive]
Recording of Dr Kumaran's talk [Soundcloud, audio]

Thursday, May 17, 2018

First PEP - Days 7, 8, 9, 10, and so on...

Well, I lost count.

I didn't miss a single tab. But I have, as usual, missed on writing the experience.

There are indeed some highlights.

First, a house surgeon and his friend from my college came all the way to Nugu and our hospital after reading my posts. I guess I put enough philosophy in his head that he comes back and joins here later.

Then, I'm making good progress in my thesis work, interviewing patients about their perspectives on how they became sick. I have interviewed three patients till today. Each interview gave me a completely different story. I have even moved to Asha Kirana hospital asking permission to interview patients there.

Also, Amazon made three deliveries. My favourite book - The Emperor of All Maladies, my favourite stethoscope Dr Morepen ST 01, and Tripti Sharan's Chronicles of a Gynaecologist. (all affiliate links) 
I started managing my tasks with any.do, and it's going well till now.

Somehow, I'm on a streak!

Wednesday, May 2, 2018

First PEP - Days 4, 5, 6

Days fly by as usual. It's already day 6 and I'm wondering what I did on day 5. (I slept all day).

Day 4 - Monday, 30th April

I had general OPD duty. In essence I was jobless almost the entire day. I sat in the injection room and saw some 10 patients.

This morning I had tried to swallow the LPV/r without any water. It wasn't a very good idea as one of it got stuck to the throat and I almost had to do Heimlich on myself.

It's the day we went to Nugu and savoured garlic bread and churmuri prepared by all the ladies.
Busy kitchen at the ladies' place

Not conspicuous: Ram struggling with pepper powder in his eyes
On the way back Kishan & Suchitra ran out of petrol. So I had to empty a 1 litre bottle of water into my throat and fill petrol in it. Swathi and I went on a scooter ride after about an year today.

Day 5: May day

All I remember of this day is sleeping all day. I tried to get some useful work done after waking up in the evening. But having finished dinner, I slept again.

Ah, ah. I also sent an email to the canteen manager regarding the legality of "cooling charge".

Day 6: May 2, Wednesday

My first shift in the new ED. I spent half an hour with the new defibrillator. Skanray as they call it. Sankar Ray as I call it. Sliding out the adult pad for getting the paediatric paddles was the most interesting part. Still wondering whether the whole machine can act as an AED.

Only 3 cases came to the ED today. One of them was a lady in labour and I sent her straight to labour ward. The lady with fracture of leg? Straight to x-ray. The sad one was the man with MDR-TB, diabetes and cellulitis of a limb, had to send him to Mysore as well.

The computer network in the hospital was in partial disarray today thanks to the lightning and thunder last night. Oh, man! Yesterday there was a bolt of lightning and ear-deafening thunder right outside my window; I thought I died. One can only imagine how the poor electronics must have felt.

The thunderstorm is back tonight. I came to the hospital to finish this blog post as the power supply keeps getting disturbed in my room. And there it goes, another strike on the radio station above us. I sure will need an audiology check-up soon.

Earlier when I was in my bed, I felt my calf muscles ache. Myalgia is an early sign of acute HIV, you see. Had to brush up on the basics of acute infection. Also had to read three studies on the failure of PEP in health care workers. Seems like the right regimen wasn't chosen or there were adherence issues in most of the cases. I might also have been part of a world record by receiving PEP at around 15 minutes which I think is the earliest anyone has ever received PEP.

I might be having some minor reaction to the PEP as I feel abdominal discomfort (in the form of flatulence) and feel like the stools are coming out faster than usual. But apart from that, the pickle in the canteen is making me eat very well.

Sunday, April 29, 2018

First PEP - Days 1, 2, 3

After having done the "Perfectly Messy Prefect" series and "Jog Journal" series, I have now gotten the opportunity to start a new series - on Post Exposure Prophylaxis.

Let's start with the good news. I put a central line in a patient (that's my first time after MBBS and the first time I was confidently doing it on my own).

This patient who's been admitted with Cryptococcal antigen showing 3+ in their CSF needed lots of amphotericin for two weeks. Putting amphotericin in a peripheral venous line is okay, but it can soon lead to thrombophlebitis and both patient and doctor will have a hard time managing it. So we decided that it must go through a central line.

And it was imperative that this happened in the new emergency department that was inaugurated the same day. Dr Ram was around and his guidance is better than the ultrasound guidance he gives.

I will put a better picture of the new ED in a future post

First thing we settled was whether the artery went lateral or medial to the vein. Of course it goes lateral in the femoral canal (NAVY). And nature will never let us have easy mnemonics that apply everywhere. That means artery should go medial to vein in neck. Yet I guessed that it went lateral. Anyhow we immediately confirmed with the USG that the common carotid went medial to internal jugular. The vein was there large and compressible just below the skin.

After pressing the vein some 21 times to get the point on the skin where I had to prick, I pricked a bit lateral to that point. Yet, thanks to ultrasound I could move a bit medial and get into the vein in one go. In went the guidewire, then dilator and then the catheter itself.

Having placed the catheter, I just had to put two sutures on the clips to hold it in place. I don't know what made me choose a round bodied cat-gut. Or I do know - it was the cheapest among the suture materials that were lying around. A round bodied needle never goes easily into the skin. And the way I hold a needle, I do not get enough pressure on the tip. No matter how many times I have tried to correct it, I hold the needle wrong every time.

And the holder slipped just enough for the needle to go through my glove and make a tiny cut on the distal phalanx of my left ring finger laterally. It wasn't deep at all. Maybe one layer of skin was cut out. The direction was tangential. But it left a cut big enough for everyone to see.

And I'm also fortunate to have good colleagues who spoke sense in to me and prevented me from neglecting the prick. I removed the glove and confirmed the prick. There was no blood or anything. Yet I put the finger under running water for more than 5 minutes. And straight I went to the counselling room to get my PEP regimen.

Tenofovir 300 + Lamivudine 300 0-0-1, Lopinavir/Ritonavir 200/50 2-0-2 it would be. 5 pills a day is a lot of pill burden for a person who hasn't had a paracetamol tablet in 5 years. But I was really curious about experiencing PEP.

And within 15 minutes of the prick, I had swallowed the first set of three tablets. There was no nausea or giddiness or anything for that matter. I also got my baseline investigations done. My CBC was perfect except for high eosinophils. I do suspect there are some worms inside me. Maybe I should get an albendazole also, anyhow I'm getting bombarded my antibiotic this month. Creatinine, SGOT, SGPT everything was okay.

I woke up to alarm next day. I didn't want to wait 16 hours before taking the second dose of LPV/r. I took it at 14 hours. I had kept some Bourbon biscuits last day because I knew I would not get breakfast that early. I even had a masala dosa at around 9 am. Didn't feel much of nausea. But my bowel was irritable. I think it was irritable much before all this began. From the day we attended that marriage at Saragur town. Anyhow the masala dosa kept me asleep throughout that morning.

I had kept another alarm for 6 pm Saturday. This one was for the TDF+3TC that I had at 26th hour after the first dose. And then the LPV/r at 8 pm. I don't know if it was gastritis or nausea, but I wasn't really feeling hungry and had only an apple to eat with these.

And then it was today. I woke up at 6 (yesterday's alarm memory?) and slept again. The 7:30 alarm went off and I was actually up when Swathi called me to make sure I woke up and took the tablet. I took the next two LPV/r and went for breakfast.

Right after breakfast I left for Mysuru. Did feel nauseated in the bus that took half an hour to start. Not sure how much of that can be attributed to reading on phone screen in a moving bus. Anyhow, once sleep crept in, there was no other feeling.

At Mysuru I went with a friend to this really nice place called "Khushi". It's a home converted into a hangout cafe. There I had ragi pancake, oats with almond milk, and peanut butter smoothie all without vomiting.

On the way back to bus stand, I dropped in at KR Hospital. Went to the medical ICU to see a patient we had referred here the previous day. Also went to the casualty OT and found it the same level of activity at 2 pm as it used to have 2 years ago - an intern or first year PG struggling to put a catheter in, the ortho intern proud of the slab he put, and patients with tubes running out of various orifices.

I came back to Saragur in a sunny bus ride and was really hungry. Quickly had my tablets and then a full plate of rice and sambar. The mango pickle these days in canteen is coming closer to real mango pickle from back home.

2 from the big one and one from the small one