(In the weekly Health Matters newsletter, Ramya Kannan writes about getting to good health, and staying there. You can subscribe here to get the newsletter in your inbox.)
It always helps when there is data, data from home, particularly when there is bad news afoot. For years, experts have been warning us from inside critical care units, and researchers dredging wastewater channels for signs of pathogens circulating in the community, have warned that antimicrobial resistance is increasing. The rise of the superbugs, resistant to known and existing forms of treatment, in the last decade has been so menacing, that it threatens to put paid to any and every scientific achievement over the centuries. But mere warnings are insufficient to spur governments and people to action, match your advice with solid evidence and voila, we might hope for change. Last week, such evidence exploded on the health scenario in the country like a firecracker everyone had given up on. We were warned, but we did not take the warning seriously.
Earlier this week, the Health Ministry released the results of a survey conducted by the National Centre for Disease Control, mapping the patients treated on one to five days each at 20 tertiary care institutes across 15 States and two Union Territories between November 2021 and April 2022. Take a look at these numbers: Over 70% of the patients were prescribed antibiotics; over 50% of antibiotics prescribed have the potential to cause AMR; 55% of the patients surveyed were prescribed antibiotics as prophylaxis, or as a preventive; only 45% were prescribed antibiotics to actually treat infections; of this, only 6% were prescribed the drugs after identifying the specific bacteria. Bindu Shajan Perappadan has a good story on the numbers, do check it out for more details.
Clearly, we are doing everything wrong, leading us up the garden path to highly resistant organisms that threaten life and limb. Experts have called for rational use of antibiotics for years now, dissing its overuse and misuse among humans and animal and plant populations. The government has a written document outlining the National Antibiotic Guidelines, 2018, but obviously, it is being observed more in the breach. Tightening up monitoring and supervision of the use of antibiotics, putting in place punitive measures for overuse or misuse, and making drug availability tougher are some of the solutions that come from inside the medical community to handle this problem. The lack of newer drugs in the antibiotic pipeline is equally faulted, and doctors call for measures to amend this. Some of these points are outlined, here in an editorial in The Hindu. It is evident that urgent action is required to prevent the community from hurtling down a gorge where treatments known to man remain futile, and thus the chances of recovery are minimal or completely left to chance.
On this front, there was some hope though, also last week. As these things go, we get dealt with good cards and lousy ones at the same time. Researchers reported that a new antibiotic was identified to target a drug-resistant bacterium. Zosurabalpin was found to be effective against CRAB (carbapenem-resistant Acinetobacter baumannii)-induced pneumonia and sepsis in mouse models. Writing in Nature, Zampaloni et. al. and Pahil et. al. reported the identification and analysis of the antibiotic zosurabalpin that can kill Acinetobacter baumannii, antibiotic-resistant strains of which are hard to treat in the clinic. Dr. Zampaloni and colleagues identified a tethered macrocyclic peptide (MCP) that selectively kills A. baumannii. The compound was further optimised for efficacy and tolerability, and the fine-tuning culminated in zosurabalpin, a drug candidate.
In faith, three cheers to that, and may their tribe increase.
Last week also came, rather quietly, the government’s ICU admissions policy/guidelines. It clarified that hospitals cannot admit critically ill patients in the intensive care unit in case the patients and their relatives refuse admission.
This very crucial document also attempts to sharpen some hitherto blurry lines. For instance, when no further treatment is possible or available in a disease or in terminally ill patients, if the continuation of therapy is not going to make an impact on the outcome, especially survival, then keeping the patient on in the ICU is ‘futile care’. Further, anyone with a living will or advanced directive against ICU care should not be admitted to ICU. Besides, low-priority criteria in case of a pandemic or disaster situation, where there is resource limitation, should be taken into account for keeping a patient in the ICU. Criteria for admitting a patient to ICU should be based on organ failure and need for organ support or in anticipation of deterioration in the medical condition, the guidelines have said. It is important to be empathetic in dealing with patients or family members in these circumstances, insensitive handling of the situation might result in flare ups that do not necessarily end well for the health staff.
A long pending demand, often articulated in this newsletter, has finally fructified with the Health Ministry notifying revised Pharma manufacturing rules under schedule M to ensure quality control. The revised Schedule M prescribes the Good Manufacturing Practices (GMP) and requirements of premises, plant, and equipment for pharmaceutical products; officials say that this will ensure Indian guidelines are at par with global standards, particularly after some fraught months in the recent past where drugs manufactured in India were flagged over quality issues. A health ministry official assured that the current move would bring India’s GMP recommendations at par with global standards, especially those of the World Health Organization (WHO), and ensure production of globally acceptable quality of drugs.
It is assuaging in this context, to learn that the Indian Medical Association intends to make a song and dance of the abysmal funding for the health sector in the country. Read here: IMA to release Health Manifesto ahead of the general elections. IMA president R. V. Asokan said the main issue to be raised will be regarding the health sector was funding. “The public expenditure on health in the country is 1.1 % of the GDP. If other health determinants like drinking water are not added, it has not increased much. It has been stagnating and IMA’s main demand in the Health Manifesto will be to increase the share. The doctors’ body will press the government to increase this to at least 2.5%,” he said.
Moving on to the incredible non-communicable disease burden in the country, there is always sobering news. India registered 9.3 lakh cancer deaths, the second highest in Asia, according to a new Lancet study. Researchers found that India, along with China and Japan, were the three leading countries in Asia in terms of number of new cases and deaths, where they say cancer has become a more significant public health threat with 94 lakh new cases and 56 lakh deaths in 2019.
Saroja S. and Benedicta Isaac do a deep dive into hypertension treatment in Tamil Nadu, looking specifically at the home outreach programme Makkalai Thedi Maruthuvam launched by the State Government. In the State, a survey conducted by the Tamil Nadu Health Systems Reforms Project in 2020, put the prevalence of hypertension among the adult population of Tamil Nadu at 33.9%. The scheme aims to improve early screening of hypertension, improve accessibility to health care services and reduce out-of-pocket expenditure for patients. Home-based screening, and drug delivery at the doorstep of beneficiaries are two of the important tasks undertaken by the women health volunteers under the scheme, as we have discussed earlier in these columns. While feting the government for its inclusive public health scheme, the authors also pointed out that the government needs to actively access and assess the numbers generated as part of the scheme. Another important question is whether it is truly sensitive to the needs of the most vulnerable demographic. A more thorough framing of the problem of access to NCD screening and treatment services in the community is necessary to assess whether the needs of these groups are being met.
Meanwhile, Serena Josephine M. records that yet another STEPS survey to estimate NCD risk factors in Tamil Nadu has been kickstarted. The STEPS Survey of 2020 indicated a community prevalence of 33.9% for hypertension, 17.6% for diabetes, and control rate for hypertension (7.3%) and diabetes (10.8%) among patients put on treatment in the State.
K. Srinivas Rao and Sambasiva Rao M. do a deep dive into seven mandals of Andhra Pradesh’s Srikakulam district: groundwater contamination, stemming from decades of chemical use in coconut cultivation, is suspected to have become the insidious catalyst behind a surge in chronic kidney disease cases, in this story: A silent epidemic in Uddanam. Heart-wrenching stories about in Uddanam area, and our reporters chronicle some of them, besides examining the government response and remedial measures too.
In health care education, there was some news last week. Towards enhancing quality in medical studies through technology integration, programmes based on Artificial Intelligence and Machine Learning will be initiated shortly, Minu Bajpai, Vice-President and Honorary Executive Director, of the National Board of Examinations In Medical Sciences (NBEMS) said recently in Coimbatore. The NBEMS was in consultation with the Indian Institute of Technology-Madras, and other IITs for offering two-year programmes for medical graduates that would include one year of study in these technology institutions.
Meanwhile, good news from the Indian systems of medicine quarter too: SMART 2.0 launched for Ayurveda teaching professionals. The Central Council for Research in Ayurvedic Sciences (CCRAS) along with the National Commission for Indian System of Medicine (NCISM) has, on January 3, launched ‘SMART 2.0’ (Scope for Mainstreaming Ayurveda Research among Teaching Professionals) program to promote robust clinical studies in priority areas of Ayurveda with Ayurveda academic institutions/hospitals across the country through mutual collaboration. The scientific validation of traditional practices in ISM is a step in the right direction.
Meanwhile, doctors have complained that mental health and burnout concerns have not been addressed in the new PG medical education regulations. The recently notified Post-Graduate Medical Education Regulations, 2023 have come in for sharp criticism on its ommissions, particularly in not addressing working hours, mental health and burnout issues among resident doctors, as well as the irregularity of stipends.
COVID-19 is very much with us still, in varying numbers in different States and competing for lung space with the flu and other seasonal bugs. Here is a compilation of stories from over the week, on the subject:
January 4: COVID-19 cases in country recorded at 4,423
Karnataka to soon direct doctors to focus on targeted treatment of comorbidities
With increasing COVID deaths, Karnataka Health Department asks TAC’s opinion on suitable clinical protocols for patients with comorbidities
Karnataka Health Department issues precaution guidelines to healthcare facilities
Siddharth Kumar Singh says INSACOG data shows low COVID-19 sample collection from Telangana
Afshan Yasmeen’s story on NIMHANS research automatically qualifies for the tailpiece this week, even if you got this far with ‘mindful scrolling’. Mindless scrolling seems to be an affliction of the times, and while not much attention is paid to it, experts at NIMHANS say it can disturb the quality of cognitive processing. Evidence suggests that it takes an average of 23 minutes to fully restore attention following a digital distraction, says Manoj Kumar Sharma who heads SHUT Clinic at NIMHANS.
The review article titled “Scrolling Mindlessly: Emerging Mental Health Implications of Social Networking Sites” was published in the Journal of Public Health and Primary Care. Dr. Sharma told The Hindu that this habitual behaviour could lead to decreased productivity, increased stress, and a sense of detachment from the present moment as attention gets divided among countless digital distractions. “Thoughtless scrolling can disrupt face-to-face conversations, causing isolation and lowering the quality of relationships. Evidence suggests that it takes an average of 23 minutes to restore attention following a distraction fully,” he said.
The other one this week taps on the age-old joke of a doctor’s handwriting. This week, Satyasundar Barik reports that the Orissa HC directs doctors to write post-mortem reports and prescriptions in capital letters or in legible handwriting. Badly written medico-legal documents are affecting the judicial process as it is very difficult to read those and come to a definite conclusion, complained the HC. Consequently, it told doctors to write either in capital letters or legibly, if in cursive. The issue came to the fore during the hearing of a case regarding the granting of ex gratia in a snakebite death. The post-mortem report was not legible. So, it’s not enough if you are a great doctor, you’ve got to have great handwriting too. It’s better to start at the beginning, but reinforce the importance of a good hand for a good doctor in medical schools at least.
From the Health page
If you have a few moments, perhaps you can tarry at these stories:
Christianez Ratna Kiruba writes on how conflict and violence frustrate the delivery of health care in Manipur, ravaged by sectarian violence.
Sayantan Datta asks: Could sisal leaves make sanitary napkins more sustainable in India?
Chetan Makam makes a convincing argument: The blood management system needs a fresh infusion.
WHO axes medical aid delivery to north Gaza in absence of security guarantees.
Rescuers race against time in search for survivors in Japan after powerful earthquakes leave 78 dead
Bringing you more health news published across our bureaus:
K. Umashanker reports: Anganwadis workers in Andhra Pradesh stage novel protest as strike enters 27th day.
V. Raghavendra says: Andhra Pradesh Health Minister promises to resolve issues faced by govt. doctors soon.
Rajulapudi Srinivas reports how with the Anganwadi workers’ protest, the attendance of children and pregnant women plunged in Centres across Andhra Pradesh.
Soibam Rocky Singh notes: Delhi HC tells Health Ministry to fix timelines for organ transplantation process.
Delhi LG V.K. Saxena orders CBI probe into ‘fake’ tests prescribed by mohalla clinics, according to sources.
Kannada organisations condemn Maharashtra government health scheme that offers benefits Marathi speakers in Karnataka.
Operation Amrith to check antibiotics abuse in Kerala.
DPR for organ transplant institute in Kozhikode to be ready in two months.
Kerala Government committed to increasing nursing seats.
Kerala Government ignoring medicine shortage in govt. hospitals, alleges Opposition Leader V.D. Satheesan.
Maharashtra closely monitoring COVID-19 situation, says Ajit Pawar.
Satvika Mahajan writes: MHA orders probe into ‘spurious’ drugs case.
Recruitment of doctors to be completed by January 20, says Tamil Nadu Health Minister.
Lack of awareness, poor adherence to ARV main causes of rabies deaths; pet animals major source of infection in T.N.
Nephrologist’s book on cardiovascular and renal diseases in elderly launched.
Software to track antenatal women, newborns upgraded in Tamil Nadu.
New buildings for government hospitals in Ambur, Vaniyambadi will be ready this year, says Tamil Nadu Health Minister.
Telangana’s Maha Lakshmi scheme aids healthcare access for women.
Shiv Sahay Singh reports: Calcutta HC directs SSKM Hospital to file report on scam accused availing medical facility.
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