Indian Medic

One of the most striking aspects of practicing medicine in a developing country like India is the whole wide range of medical conditions we get to see. Not only diseases like Polio and Whooping cough which are termed exotic in the developed nations but also their share of scourges in the form of modern epidemics of diabetes, hypertension etc which were hardly seen when India was just a farming nation. We see and study the whole spectrum of diseases even though major international textbooks limit the diseases that have been already eradicated from most of the world to a page or two at the most.

Having been trained in India, in a General hospital I have been intimately aware of the battle we have been raging with Polio with guidelines provided by the WHO. It’s a matter of disgrace for my peers and me that India is one of the four countries that have yet to eradicate polio while the rest of the world has succeeded in doing so. The other countries in the list are Pakistan, Afghanistan and Nigeria. These four countries are described as Endemic for Polio while there are a few more countries with importation Polio problems. It can be argued that it is because of the abundance of the wild poliovirus in these regions, three of which abut geographically. But there is more to this saga than that.
India was one of the signatories to the WHO declaration in 1988 to eradicate polio by the year 2000, which was later extended to 2005. Even though we have stepped into 2007 the goal still eludes us.

Polio is not a killer disease. If you are lucky enough it will pass you as nothing more than a flu, but one in 200 cases develop Acute Flaccid Paralysis which on resolution lead to atrophy of muscles and residual paralysis. There are three types of Polio viruses of which Type 1 causes most epidemics. The Vaccines currently being used to immunize children against polio are of two types OPV and IPV.

OPV or Oral polio vaccine is the weapon that is being primarily used to battle polio in India. Following is the salient features of the Eradication strategy
1) Routine Immunization - Three routine OPV doses should be received by infants at ages 6, 10 and 14 weeks.
2) National Immunization days - Conducting Pulse Polio Immunization (PPI) programme by providing additional OPV doses to every child aged <5>
3)Surveillance of acute flaccid paralysis (AFP) to identify all reservoirs of wild poliovirus transmission.
4) Mopping Up- intensive house-to-house, child-to-child immunization campaigns are conducted over a period of days to break the final chains of virus transmission.
Add to this Ring Immunization in which when a case of polio is detected all children less than 5 years of age within a radius of 5 km are immunized within 48 hours.
When all this is added up, an average Indian child may receive upto 20 doses of OPV by the time he turns five. The Eradication strategy has made a tremendous difference in bringing down the incidence of Polio from almost 40,000 in 1981 to 300 in 2006. Still it has not succeded…

One of the most purported reasons for the apparent failure of the eradication strategy is the non-maintenance of the Cold chain. Cold chain is essentially the series of machines employed in keeping the OPV at the recommended temperature of 4 degree Celsius, which includes Walk in freezers the district levels to small refrigerators at PHCs and the ubiquitous Ice box taken into the field. More often than not, it is failure to maintain the highly sensitive OPV at the specified temperature that causes it to lose potency and eventually leading to ineffective immunization. Introduction of Vaccine Vial monitors or blue indicators on the vial itself, which indicate if the vaccine is viable or not has rectified the above said problem to a certain extent. (see inset picture)

The other major argument is over the choice of the vaccine itself.

OPV or Sabin vaccine has been selected as the mode to eradicate Polio for a variety of well-established reasons. It is cheap (which goes a long way in its favor), easy to administer (just two drops in the infants’ mouth are enough), it produces Systemic immunity as well as local intestinal immunity (which prevent re-infection from wild viruses), antibody production is quick and the person excretes the vaccine virus, which infects other people propagating Herd immunity. Thus, it is also useful in controlling epidemics.
The points that go against it are stringent storage conditions required as mentioned above and the small but potential chances of Vaccine induced paralysis since a live virus is being administered.

The counterpart of OPV is the IPV (Inactivated Polio Vaccine) or the Salk vaccine, which though not popular in India has its own merits and demerits. It is a costly vaccine, difficult to manufacture and administer (given Subcutaneous or Intramuscular), gives only systemic immunity and does not prevent reinfection, also no role in epidemic control. The good part is however is that being a killed vaccine there is no risk of vaccine induced paralysis, is easy to store, has a longer shelf life and is hundred percent effective after the second dose. In addition, it can be combined with the DPT vaccine ( Diphtheria, pertussis and Tetanus) and given as a quadruple vaccine without changing the current National immunization schedule.

Most of the countries that have successfully eradicated polio have done so with the help of IPV or a combination of OPV and IPV. Considering that the cost factor is one of the major determinants in the usage of OPV alone in India, experts say that the mass administration of IPV may work out cheaper than the 20 doses of OPV that an average child gets. The current National immunization schedule is as follows -

Geriatric medicine in India is the least known form of medicine. Becoz no one practices it, because no one gets trained in it. Presently the focus of the health administration is still on decreasing the IMR (infant mortality rate) to less than 30 per 1000 live births which right now, in India, is 54.63 per 1000 live births. It is one of the factors in determining the PQLI - Physical quality of life index in the country. PQLI is determined by the follwing
- IMR
- Life expectancy at age 1
- Literacy rate

If you notice, Life expectancy is also a determinant and presently the Life expectancy in India is 64.71 years (male: 63.9 years female: 65.57 years). That is pretty ok, so it will be a while before Geriatric medicine training is introduced into the mainstream health education. However, I am basically writing this post to string together my experiences with the elderly population.

There is no doubt most of the ailing people who are admit chronically in hospitals are about middle aged. Here I am talking about routine cases like CVE, IHD, Uncontrolled Diabetes and Hypertension and of course Cancer patients. And often instances come where there is nothing much you can do for them. I’ve come across such patients being described as ‘Gomers’ in a few Robin Cook novels. They take up hospital beds and resources that could be more effectively used otherwise. There is a solution possible for this in the form of Nursing homes and Recovery homes and such.

But there are very few such nursing homes and recovery homes in India that will take care of such patients for optimized economic disbursals. And the burden falls on mainstream hospitals. There are often scenarios played out, especially in Government run hospitals, where the doctor takes the family aside and tells them that there is nothing much they can do for their patient, so they can take him home if they wish to. There is no ‘all we can do for him is to keep him comfortable’ (as in pain relief). It’s different when a patient chooses to die in the familiarity of his home and it is different when due to lack of facilities in the hospital or due to the financial situation of the family the patient is taken home to die. Medical insurance is still in its primitive form here and government subsidies for the elderly are limited to separate Qs at railway stations and such.

This is a sore point with me becoz I lost my grandfather in exactly the same way. He was diagnosed with Carcinoma prostate and on diagnosis, his PSA levels were approximating 40 ng/ml with bone and lung mets and it was too late for any modality of treatment to be effective. He was taken to one of the better Cancer hospitals in India but after running tests and treating him for a week, the doctors promptly told my relatives to take him home, as there was nothing much they could do for him. I was 17 and a first year medical student then in the midst of exams, so I could not go visit him. But I was appalled when I learned that instead of keeping him in the hospital in pain relief, my uncle chose to bring him home. My grand father died at home, one and half months after his diagnosis amidst his family in, god - only - knows how much pain. Now after a few years of experience I realize that this should not have happened. My grandfather, 78 when he died, had been complaining of prostatism and acute body pain for 3-4 years. But as is the plight of most elderly who have to depend on their offsprings for getting them medical attention, my grandpa waited and my uncle kept dismissing it, till it was too late.

I am not sure whom to blame, the government which doesn’t make better facilities available for the elderly or my family who didn’t help him in time.

Please note, that most of all this applies to people who are not so affording, though there are the occasional odd rich examples .It’s the norm in India for the kids to look after their parents in their old age. But there are way too many people who think of it as a burden to take care of people who have practically spent their whole life looking out for you. Its only recently that people have started saving for themselves in their retirement and old age, rather than give it all away to their kids and expecting them to fend for them in their bleak years. Also more and more old age homes are coming up in cities and many of the about-to-age populace, including my mom, have decided to live there (and die) in dignity! About my mom, its remains to be seen, as it’s a constant debate between us with me saying I won’t let her!

Examining the other side of the coin, I should mention what is being done for the elderly other than separate senior citizen Qs and concessions. The hospital, where I studied, was a tertiary Government hospital meaning that most of the difficult cases were referred there from the peripheral districts outside the city. The department of Internal medicine conducted weekly clinics for Diabetes, hypertension and Ischemic heart disease, which basically consisted of a bunch of doctors refilling prescriptions of patients and ordering tests as required. The medicines were free as were the tests. And yes, there was a geriatric clinic too, which was in conjunction with other relevant departments like surgery and orthopedics, but that was mostly prescription refilling too.

However my personal brush with elderly patients happened in two particular places. The first was in the Ophthalmology department as in intern. The most common cause of blindness in India is Cataract. In my hospital an average of 40-50 cataract extractions were done a day, and it was the interns’ responsibility to get all the relevant tests out of the way before admitting the patient. That meant giving the patient a list of tests that needed to be done and making sure they went to the right departments to get blood tests and urine tests etc done. Trust me when I say that it is one of the most challenging things to explain to an elderly, illiterate, unaccompanied lady who walks leaning on a staff and is invariably hard of hearing too, the various directions to the get her tests done. Dozens of times I have wound up taking them around for their tests and ultimately depositing them in the Ophthalmology ward, which, unfortunately, was on the fourth floor with no elevators. I suppose it was one of those times that I promised myself that my mother will never suffer a lonely older age.

The other place where I came across multitudes of geriatric patients was during my rural posting, which is a three-month long stint in one of the government run Primary Health Centers or PHCs in rural areas. Apart from the Obstetric patients who came in hordes to avail the Antenatal facilities, (India does have one of the highest populations and population growth rates in the world!), the major bulk of patients were geriatric females and occasionally males. The hypertensives and diabetics aside, they invariably came with complaints of generalized weakness, body ache and joint pains. Osteoarthritis at such a grass root clinic could hardly be treated with HRT (hormone replacement therapy). We had to resort to the NSAIDs (aspirin, Paracetamol etc) along with antacids for treating their symptoms and giving them a week’s worth of calcium supplements and Multivitamin tablets which were free of course. As per protocol, we could only prescribe a week’s worth of medication, but rest assured they returned every week.
As a Primary care physician, I could not bring myself to prescribe virtually unlimited supply of NSAIDs to any patient, over and over again, for fear of giving them Gastritis or Ulcers. Initially I tried to teach them exercises to keep the joints supple but they were more interested in the painkillers.

Then there were those who demanded injections. Not for the pain but for the weakness. It’s a habit in PHCs to give intramuscular injections of Vitamin B12 to anemic patients. The illiterate patients call them ‘Strength booster shots’ or ‘Red strength shots’ as the solution is light red in color. It’s a common for patients suffering form easy fatigability to visit such clinics and demand for ‘Strength shots’. And so used are they to them that when in shortage of Vitamin B12 injections a placebo like distilled water helps as well.

I think I have been rambling too long in this post. I will conclude by saying that much needs to be desired in the practice of Geriatric medicine in India and hope that things change soon for the better.