Heal-Thy India: Untold Secrets of Health Care

generation

SECTION I

CHALLENGES IN OUR HEALTH CARE SYSTEM AND SOLUTIONS

Chapter 1

INTRODUCTION TO HEALTH CARE ISSUES IN INDIA

India is a rich and beautiful country; truly God’s own country, rich in natural resources and human resources and blessed with an optimal climate. We have all the potential to become one of the best places on earth to live in. But we underestimate our potential and ignore the basic requirements for progress. One of the most important social issues neglected in our country is health care. We neglect issues concerning health care and literally end up manufacturing diseases.

In India, over the years, diseases have multiplied disproportionate to the population growth. While the population in India has only doubled in the last 30 years, doctors and hospitals have multiplied at least a hundred times. Even so, the number of existing doctors and hospitals prove inadequate. As a ritual, every year we observe the World Health Day and several other days named after diseases and organs: all stressing on treatment of diseases and rehabilitation of patients. But we keep forgetting the basic issues of health care in India. Issues like Endosulfan, Leptospirosis and Chikungunya receive attention momentarily, but the larger causal issues underlying these problems are always overlooked. I wish we had shown at least the same amount of concern in all matters of health care as we did in the case of epidemics because all diseases known to mankind, including cancers and genetic/inherited disorders are caused due to lack of precautionary measures and problems in diet, lifestyle and environment. The issues involved in Endosulfan or Leptospirosis are just the external manifestations of the pitfalls in our management of the basic issues of health care. Therefore, instead of dealing with isolated problems as and when they crop up, it is imperative for us to focus our attention and care on identifying and solving the basic problems and issues involved in health care as suggested below.

Malnutrition

Malnutrition is our biggest health problem and the real enemy of our country. Subclinical malnutrition is seen even in developed countries. But our picture is different; WHO estimates that childhood malnutrition is highest in India and it is reported that 27% of the world’s starving population is in India. Frank estimates on malnutrition may invite controversies, but it is a fact that subclinical malnutrition is considerably higher in India, as compared to developed countries, because of lack of awareness, religious and cultural barriers, as well as lack of access to a balanced diet. Malnutrition is the root cause of all infectious diseases and it is also the reason behind almost all other diseases including cancers and inherited disorders. Hence, our first enemy by any estimate is malnutrition.

Drinking Water

Another major health care issue is the lack of safe drinking water in India. Even in cities, people still depend on well water. Even small housing plots have independent wells as well as leach-pits or septic tanks, thereby increasing the risks of faecal contamination of drinking water. In crowded dwelling places and in cities, drinking water should be distributed through pipes to each household after processing it centrally, as compared to waste management, which should be decentralised and processed at the point of origin. Boiling or filtering of water or using bottled water will lead to a huge wastage of resources and invite several environmental problems. Diseases like Typhoid, Hepatitis A and the Dysenteries, which are caused by the use of contaminated drinking water, are rampant in India at a time when developed countries have eliminated them several decades ago. Today one sees such cases only from third world countries. The lack of safe drinking water in India is being capitalised by industries manufacturing the bottled water and water filters. When the developed countries have started discouraging bottled water, we are seriously promoting it. Unless and until all our citizens have access to safe drinking water, distributed through pipes in each household, we can never claim to have achieved health care.

Waste Management

The third major health care issue is poor waste management. Inadequate sanitation facilities and unhygienic surroundings pose a serious threat to our environment and health. On the world environment day, we in India should be discussing seriously on issues of waste management before we discuss global warming and ozone layer depletion. All that we do on the world environment day is hold meetings and plant some trees, which are often forgotten after that day. We casually throw away all our waste and do not manage them properly, thus providing a breeding ground for the germs responsible for several communicable diseases like Malaria, Filariasis, Dengue, Leptospirosis, Typhoid and Dysenteries. We also face other environmental issues like air and water pollution in the form of contamination of the atmospheric air with toxic gases, the water and food with toxins, bacteria and viruses. All these are signs of the absence of basic facilities in the society. There is an increasing threat to our environment from the careless dumping of electronic wastes containing heavy metals like Mercury, Cadmium and Lithium, which is the contribution of the unchecked and growing consumerism. The threat of ozone layer depletion, increasing levels of carbon dioxide and global warming are mainly caused by deforestation, but it is also linked to accumulating wastes and poor waste management. We should also realise that it is the increasing consumerism that generates more waste and promotes deforestation too.

Consumerism

The fourth and probably one of the biggest and unrecognized global health problems is growing consumerism in every sphere of life including the disease care industry. Consumerism induces people to buy, eat or consume unwanted things or undergo unnecessary procedures exposing them to overeating, physical inactivity, and stress, and finally into debt trap. The more we consume, the more will be the accumulation of waste around us, especially in a situation where there are no well coordinated or well organized waste management systems. People are deceived into buying and using most products because of lack of empowerment and the misleading advertisements promoted and propagated by celebrities. In the long run, this trend benefits only the manufacturers and suppliers of the products inside and outside the country, of whom probably USA is a major beneficiary and is presently the capital of consumerism. If we look carefully we can conclude that consumerism and lack of empowerment are the root causes of several diseases like Diabetes, Liver diseases, Hypertension, cancers and autoimmune diseases, and the consumerist forces then push people into the most expensive modalities of treatment, ignoring cheaper alternatives.

Neglectful Attitude to Health Care

As a nation, we have been ignoring health care for long and are literally manufacturing diseases. If the USA is the capital of consumerism, India is the capital of diseases like all kinds of infections (including Tuberculosis and AIDS), lifestyle diseases like diabetes, hypertension, heart attacks, and cancers and even inherited diseases. Because of our careless attitude to health care we have ended up bearing the double burden of proliferating communicable diseases due to lack of basic health needs and the alarmingly high prevalence of non-communicable disease due to ever growing consumerism, bad lifestyle and dietary habits acquired by imitating the bad trends in the USA. After manufacturing diseases in large numbers we now focus on socializing disease care facilities with a focus only on treatment and that too through specialist doctors and super specialty hospitals imitating the worst disease-care model in USA. We boast of the ultra modern treatment facilities that we have, but conveniently forget the fact that we have not achieved anything in the area of basic health care needs, cost effective basic medical care and have failed in providing human development and social security for all. To make matters worse, patients in India have the freedom to consult any doctor, bypassing all the conservative and cost effective approaches, since we do not have a health policy and a referral system. We are wasting our resources by copying all the bad trends in the American model of disease care and consumerism; at the same time we forget to emulate the good things in their basic health care. The trends in India have only helped USA to sell all their modern machines and costly medicines here.

Lack of prioritization and Holistic Provision of Heath care

We now give priority to ultramodern treatment centres at the expense of genuine health care and basic disease care facilities. We must resolve to concentrate on ensuring availability of basic health needs for every individual as the first priority in order to reduce the disease burden (as had already happened in the developed world), and to check the power of consumerist forces in all spheres of life including in treatment of diseases. Our next priority should go to popularising general practitioners and introducing a referral system to reduce ‘over-treatment’ and ‘over- investigation’. We must also remember that providing basic health care and basic disease care to all individuals is a human right or genuine health care is our right and that is the greatest health insurance to the people. We must not forget that health care and disease care are two separate issues, disease care facilities cannot sustain in the long run unless there is genuine health care and a low disease burden.

Defects in Medical Education& Basic Education

Medical education in India needs a radical change; nothing short of a major surgery will save the critically ill medical education in India. We need to modify our medical education to produce doctors capable of addressing the problems of our country which are different from those of the developed world, because we are at least 50 years behind them in terms of social health, social security and human development. These days, students go to medical colleges in India only to become specialists or super specialists and never to become general practitioners/family doctors. All this is happening since the people in the power centres of medical education have no vision on health care issues and we fail to develop a Health policy to address the various issues mentioned before. The people in charge of medical education, starting from Principals of medical colleges to the Medical Council of India should be visionaries capable of devising policies on sustainable health care. Besides making available all the health needs, we need to evolve policies on medical education, medical practice, hospitals and drug manufacturing on a war footing.

The practice of appointing our men in power centres, based on political and religious considerations should go. Instead, hand-picked people who have a vision for the nation and are honest, transparent and non-corrupt and devoid of selfish motives should occupy all the decision-making posts. Our basic education and general education also need radical change. They should focus on instilling humane values, social health and democratic principles rather than on priming them to take up professional courses. Basic education should enable the students to come out as health-conscious human beings who know all the democratic principles, know the basics of science and have a scientific approach. Democracy in India has to become stronger leaving aside the considerations of caste and religion in social issues. As a result of general education and empowerment, we should also ensure that only those individuals who are mature enough and are willing to set aside all their personal interests, should be allowed to enter politics or occupy decision-making posts to serve the people of this country.

Health Economics

Every one of us, especially those in administration, should be aware of the basics of health economics. We need to be aware of the fact that the health of an individual is the manifestation of healthy social and economic reforms. Needless to say that we need to introduce economic and social reforms to achieve all the objectives mentioned above. Every person who earns money should give his share for social security and human development. Everyone should in turn get all basic health needs from the administration. The evil of gross inequitable distribution of wealth ought to be corrected by all possible measures. We must focus more on providing social security and human development, which can only be achieved when we get rid of our money-mindedness. But the paradox is that it is the lack of social security and lack of human development that instil money mindedness in our people. Lack of social security and human development makes every Indian work only for earning money without any other larger social objectives in mind. In that process some become successful and accumulate all the wealth and deposit it as dead investments making it unavailable to others. The creativity of the people in nation building is stunted due to this narrow minded objective generated by the lack of social security. To avoid wastage of resources and to raise more resources for providing basic health needs and social security, we need to root out corruption. For this the most important step is to insist that all transactions be made transparent by using only cheques and debit cards, which will wipe out corruption, black money and counterfeit notes. India is a rich country; it only needs effective management to achieve all the objectives mentioned earlier. We must also remember that health cannot be achieved and maintained in compartments, be it in a body or in a society. Someday, the problems in health care will spread venom to other parts of the human body or society. Therefore we should work with social concern and should act locally while thinking globally; after all, we are social beings (social animals). Naturally, this involves cooperation of all citizens and of all the departments in the government. In other words, all ministers must be health ministers in a certain sense. In the following essays, I will try and elaborate on the issues I have highlighted above.

CHAPTER 2

LEPTOSPIROSIS EPIDEMIC IN KERALA (2011): A POINTER TO OUR HEALTH CARE MISMANAGEMENT

In spite of the better health care as compared to the rest of India, Leptospirosis is a serious health problem in Kerala especially in the Malabar region. It has remained unchecked over the last several years. In the medical college where the author works, every year some 600 to 700 cases of Leptospirosis are treated. Every year around 50–60 patients succumb to the illness, accounting for a mortality rate of nine to ten per cent. Last year’s trend also has not been different as the number of cases increased during August–September. Those who succumbed to the illness had severe complications like renal failure (kidney failure) and Acute Respiratory Distress Syndrome (ARDS). Incidentally, in a matter of one week there were 70 cases, all of them succumbing to renal failure and thrombocytopenia (low platelet count), resulting in 18 cases of mortality, inviting media attention. The unexpected increase in the number of cases was due to the disappearance of rain, resulting in a sudden increase in the number of patients. In addition, cases from the neighbouring districts of Kannur and Kasaragod also have been coming this year due to some local issues in patient management in those places. An increase in the number of cases was expected because, every year, soon after the end of heavy rains, the epidemic strikes when people move around and work in contaminated wetlands or stagnant water. This was not a new issue for the doctors working in our institution. The only difference was that the media had taken up the issue last year, but unfortunately it all ended up just by fixing the blame on someone or the other, and the higher authorities shirking the responsibilities. People seem to run away from the reality that everyone is responsible and that the actions needed have to be collective involving all sections of people and departments, and that the actions necessary to contain the disease have to be directed primarily at the basic unmet health-needs.

The fact is that, to tackle the issue effectively, we need to create awareness, make relevant laws and bring forth reforms in health and economic policies and implement them with a vision for the people and their future. This can only be possible with active involvement and participation from all sections of people and all the departments of our government like health, public works, police, water authority, education, finance, law, revenue, Local bodies, NGOs etc. Common sense is sufficient to understand the point that focusing only on the patients and hospitals will not constitute an effective solution. Unfortunately, the focus of attention of the media as well as that of the government is just hospital-centred. In the present scenario, in the absence of involvement of other departments, the health department alone can only plan and execute actions to be taken in the hospitals and medical colleges for the treatment of these patients. In any case there is no point blaming each other because all of us are responsible for the present situation. There is no point fixing the blame on the present government too: the present government and all the previous governments are responsible for the lack of vision and for the gross negligence, which let things happen like this.

Why Leptospirosis?

In general all diseases anywhere in the world occur among the marginalised people. Leptospirosis is primarily a disease among the more marginalised people. The whole of India is marginalised in terms of basic health needs. Lack of proper waste disposal, malnutrition and bad lifestyle together are responsible for this disease and the high mortality associated with it in our society. Food waste is not properly disposed off or processed, instead it is thrown all around which allows rats to proliferate; infected rats will spread the germs through their urine into the soil. These organisms will remain active in moist soil or stagnant water in areas which are not exposed to direct sunlight. This happens during monsoon, especially soon after the rains when there is a stagnation of water and when the people resume their work or are actively moving around. The people who work in these areas are likely to get the infection; the organisms enter through minor abrasions or wounds on the skin when it comes in contact with the contaminated soil or stagnant water. Infection occurs also because of the fact that the affected people are unable to resist the growth and multiplication of the organisms inside their body due to their poor immunity. Poor immunity is the result of widespread malnutrition, which is compounded by the bad lifestyle habits of the people, making them more susceptible. The bad lifestyle habits among the affected people are alcohol intake, smoking, grossly unbalanced diet, overeating and lack of exercise. All these make them more vulnerable to developing liver or kidney damage, which is common in Leptospirosis. The same are the causes of other diseases as well that lead to increased susceptibility to all infections and to higher mortality.

Another problem the author had observed is the injudicious use of the non-steroidal anti-inflammatory (NSAID) group of drugs, especially if it is taken during the stage of high fever. This happens mostly because of the practice of self-treatment, and in rare cases through the prescription of doctors who are unaware of the side effects of NSAID in patients with fever. If the disease is suspected based on clinical features alone, i.e. based on the symptoms and epidemiological setting, prompt treatment, avoidance of NSAID, bed rest, adequate fluid intake and a balanced diet can save the life of most patients. Doctors, who come in contact with the patients first in the periphery, must be capable of diagnosing the infections like Leptospirosis clinically and initiate appropriate therapy without any delay. This calls for good clinical skill among the doctors of first contact or the primary care doctors. Doctors who depend too much on investigations or those who fail to make good clinical diagnosis, is a serious issue now leading to delay in diagnosis leading to mismanagement and consequent mortality; it is an issue to be addressed with reforms in health policy and medical education aimed at producing doctors with good clinical skills. Unfortunately, we produce only specialist doctors nowadays; it is a fact that all the MBBS students are now lost to the society. It is a matter of serious concern that we do not transform MBBS doctors into good primary care doctors due to the absence of a health policy. A handful of good physicians (MD Medicine) seemed to be the only solace for early clinical diagnosis, but these days they are also being lost to society as they are all on the rat-race to become super-specialists by taking a DM degree – a terminology and a degree unheard of in any other country.

Reasons for High Mortality Due To Leptospirosis

In a study we conducted in our department, we have found out that the high mortality in Leptospirosis was due to the following reasons

1. Most people who died had severe malnutrition, or had an underlying liver disease. The liver disease was either due to alcohol intake or the non-alcoholic fatty liver disease seen in overweight or obese people. Overweight or obese people have fat accumulation in liver, which causes the Non-alcoholic fatty liver disease, which often goes undiagnosed till they develop some illness. Majority of our people are now overweight due to overeating and lack of exercise.

2. Coexisting malnutrition, which is often subclinical, is the reason for allowing the organism to multiply and grow in the body. We must also realize that malnutrition in one form or the other is a universal causal factor for all diseases, especially for infections, anywhere in the world, but more so in India.

3. Injudicious use of NSAID group of drugs (ex: Mefanamic acid, Diclofenac, Aceclofenac, Nimulselide, Ibuprofen) by self-medication (over the counter or otherwise) during the starting period of the illness, that is, during the early phase of the illness – the febrile period with severe muscle pain – is another unnoticed serious issue.

4. Delay in diagnosing the illness and delay in starting the specific treatment due to inadequate clinical skill among the new generation of doctors in the periphery. They wait for laboratory proof, which comes only after the patients have either recovered or died. This is a universal problem now due to the craze for specialization, and the lack of support from the government for the GPs/family doctors. We should also remember that delay in diagnosis is NOT due to non-availability of laboratory facilities or the lack of specific diagnostic kit for Leptospirosis. The fact is that people who manage this disease efficiently know very well that diagnosis is made from symptoms and signs aided by simple lab tests available everywhere. The so-called specific test becomes positive only about a week after the onset of the illness, but by this time the patient might have recovered or entered into some fatal complications. Early initiation of the specific treatment based on the clinical diagnosis is very essential to save the life of patients in any illness. However early treatment is possible only when the doctor is capable of making a clinical diagnosis based on the symptoms and signs alone. Therefore, the specific test for diagnosis does not help any patient directly, because the patient may recover or die by the time the tests yield positive results from the patient’s blood. Even otherwise no test on earth is 100 per cent sensitive and specific. Doctors who treat patients effectively always go by what is called ‘the clinical judgment’, which takes into consideration all the factors like the epidemiological setting, symptoms, clinical signs and the dietary and lifestyle habits of the patients. It is the study of the patient’s body, mind and environment together that gives proper diagnosis or clinical judgment. In clinical judgement, study of the patient’s body and its constituents, including blood and tissues make up only one third of the issues involved – no matter what tests we use; however sophisticated the tests are. All doctors should know the principles of clinical diagnosis and clinical judgment thoroughly. They should also thoroughly know the abnormalities expected in each disease with regard to simple and easily available lab tests like urine routine examination, Total blood Count (TC), Differential blood Counts (DC), Platelet count and Erythrocyte Sedimentation Rate (ESR), which are actually just an extension of the clinical evaluation of the patient. Then, a therapeutic plan should be made keeping in mind the golden words ‘first do no harm – or never make the treatment worse than the disease’, and the patient recovers. We may get the result of the so-called specific lab test utilising the most sophisticated technology, which could be positive only by this time. But even then, a negative test does not rule out the diagnosis and positive test does not always mean that the diagnosis is correct. A diagnosis should always be made on the basis of a combination of evidences and never by a single test or single physical finding alone. Unfortunately we now have a large number of doctors who fail to realize this principle because of their preoccupation with specialization or their premature entry into specialization and the consequent lack of acquisition of the basic clinical skill. This quality was routinely acquired in the past until about 30 years ago, but now as a rule, they fail to acquire it and they are now becoming slaves of investigative medicine. Such people are now occupying decision-making posts or become advisors to higher authorities. The whole society suffers in this process. I am reminded of a statement made by a great physician Pappworth, that doctors are now trained to become ‘clever educated fools’. Unfortunately, doctors of this breed are becoming more common now. They are also more influential and powerful and they occupy high positions in decision-making bodies all over India and even abroad. The voice of genuine clinicians is becoming feeble day by day, and the public face the wrath of this trend and pay heavily. Medical education needs radical changes to address this issue.

The issue of Leptospirosis clearly tells us that our immediate attention in patient management should therefore be directed to the above-mentioned four major issues. But how organisms responsible for Leptospirosis reach the human beings – it is an issue of improper waste disposal. The food waste thrown around is responsible for the proliferation of rats in the community.

Strategies for tackling the problems like Leptospirosis: What is to be done at the Tertiary hospital/Medical College Level?

Insufficient number of beds in the General Medicine wards had resulted in accommodating even very critical patients on the floors or corridors. Similar is the picture all over the country – what is most needed for the society is most neglected in health care and disease care. In the periphery the primary health centres and GP doctors are neglected. In all tertiary hospitals, the most neglected is General Medicine department. Projects submitted for improvement of medicine department are not considered, but projects for specialties are taken up with ease. No one seems to be interested in improving the facilities at the General Medicine department in Medical Colleges. We, at the Calicut Medical College had submitted several projects in the past for improving General Medicine and all the other basic departments. Once it was rejected with an explanation that National Rural Health Mission (NRHM) funds are available only for women and children, which was wrong information. Since the available beds are not sufficient, we had submitted another project for a separate building for General Medicine (Institute of Internal Medicine), was accepted by all but was brushed aside with the excuse that a huge special block will come up before long and the department of General Medicine will have enough space in that building. At the same time some authorities feel that an increase in the number of beds is not the solution for the overcrowding in medical wards. They feel that the patient inflow has to be reduced, but they do not know how to reduce the inflow. Some people were of the opinion that the heavy inflow was due to the private practice of doctors, which is not true at least in the case of General Medicine. In General Medicine Departments patients come basically to solve the clinical problems, which are not diagnosed yet and for the management of complicated illnesses with multisystem involvement, for which there are not many doctors in the periphery. Hence, those General Medicine doctors who were practicing privately after the hospital work, in a country where there are very few GPs, are actually blocking the heavy inflow to the medical wards by solving part of the problem by sitting in the periphery and utilizing their private time. It is also true that the unregulated private practice of medical college teachers can interfere with their academic activities and they need to balance between the two. At the same time, we need to bring out an adequate number of General Physicians in the periphery to evaluate and manage all these patients based on clinical features alone, which I seriously suspect is not going to happen in the near future. No one is trying to study the issues responsible for the overcrowding in medical wards. People, who are aware of the problems and the solutions, are not consulted for opinion these days. Instead, opinions are taken only from the specialty departments or departments which deal with the microbial organisms causing the disease. Sometimes opinions are got from Community Medicine department (Which was previously known by a better name – Social and Preventive Medicine), but never from the General Physicians of Medical Colleges or General Practitioners in the periphery who come face to face with the problems and are capable of giving more valuable and more practical information.

Inadequate number of staff is another issue to be solved: both of medical and paramedical staff in the general medical departments of all the medical colleges; to give one example – the staff pattern in the General Medicine department where the author works- it is the same as some 55 years ago. Even as the specialties were being developed, no one seemed to be interested in developing the Medicine Department. Our Medicine department alone admits 35–40% of the total inpatient load in the hospital, over which the doctors and staff have no control. We cannot refuse admissions to needy patients. While the authorities blame us for the excess admissions, they neither issue orders to avoid floor patients nor do they increase the number of beds. There are no data managers to generate data for future planning in spite of admitting 30,000 patients annually and handling another 110,000 outpatients and 90,000 emergencies, on the Medicine side every year. For HIV care alone, which is also being done under the department of Medicine, for just 4600 patients registered, we have two data managers. This is because funds are available from non-government agencies and therefore the authorities feel that data generation is required for planning. The fact is that data generation is absolutely essential for future planning and to set priorities, but we behave as if we do not believe in this fact.

What Is To Be Done At The Community Level For Diseases Like Leptospirosis?

There is no point in placing the blame on anyone in particular for these kinds of health issues, but we must realise that all of us are responsible for the present situation. The causes leading to the disease have always been there in India but so far we have not done anything to deal with them. The basic causes for diseases like this is a deadly combination of widespread malnutrition, poor waste management, and bad lifestyle habits of the individuals concerned, which is compounded by ignorance, lack of vision and lack of responsibility from the medical professionals and authorities. The issues concerned need several social and economic reforms involving all sections of people and all the departments of the government leaving aside all their differences of opinion in terms of politics or religion. Every individual – adolescent to elderly, house wives to professionals and everyone in the administration, the Local bodies, Education department, Water authority, Public Works Department, Revenue, Police, Finance department, NGOs, those in industry and business – should know what his/her role is in health care of the society. A social awakening through media and education department followed by several social interventions and economic and social reforms aimed at correcting the basic issues-to solve the unmet health needs – is of utmost priority to our society which is at least 50 years behind the developed world, in terms of providing basic amenities to all sections of people. But it is painful to note that the public and the medical professionals are closing their eyes and ears to the real issues. The authorities are focussing only on increasing the number of medical colleges and super speciality hospitals or on distributing money to the patients to enhance their vote banks. Health care and disease care are two separate issues. We have been ignoring health care and manufacturing diseases all these years. The major social issues like lack of social security and human development and lack of basic health needs in the society are responsible for all the diseases. It is only common sense that increasing the number of doctors and hospitals can never solve these problems.

The attitude of the authorities needs to change: The Medicine Department at Calicut Medical College has been reporting the problem of Leptospirosis to the people concerned; the doctors here have enough experience and expertise; we have the data compiled by our own effort without the help of data managers; the doctors here know the causes of the disease, and the actions to be taken at all levels. Doctors here are the most competent people to advise anyone on the issue and to deal with the situations arising from the illness because we have been managing 600–900 patients of Leptospirosis annually for the last several years, because we had studied the problem extensively and also because we are sincerely involved in public health activities related to such epidemics. But when the higher mortality in Leptospirosis got media attention in 2011, and when a high level meeting was called at the District Collectorate in Kozhikode, the person who was asked to introduce the problem was someone from the health services who was not even aware of the gravity of the situation or its technical details. This is because of the wrong attitudes prevailing in the administration. At all levels in the administration, the decision makers look only for our men instead of entrusting the job to someone who has studied the issue, or someone who knows how to handle the issue professionally without any vested interests. At the meeting called to discuss the issue of Leptospirosis, first it was the District Medical Officer who was asked to introduce the problem and the others who spoke were the political leaders, and then the Indian Medical Association representative who offered to run medical camps and fever clinics as a solution. After the turns of political and organizational representatives, the meeting was declared to have come to an end, after which the audience raised a few technical questions regarding management of Leptospirosis; but the Director of Medical Education who had never managed a patient with Leptospirosis answered them. In general, those at the administration now seem to think that respecting the position of individuals is more important than respecting the issues and finding the solutions. As the show was going on, I was sitting in the front with all the details and suggestions, no one seemed to notice or bother me in spite of being aware of the fact that I had come prepared to present the technical and social problems behind the issue. The District Collector, the Principal and the Director of Medical Education all knew that I was having all the material needed for a creative discussion. Before the start of the meeting the District Collector asked me what I would be discussing and I told him that the basic problems causing the disease had to be presented before such an audience and that is what everyone should be concerned about. He then suggested that what is to be done immediately to pacify the public out roar alone be discussed on that day. My intentions were sensed before the meeting and that was the reason for not involving me in the discussion. The issue was settled on that day by assuring the public that all facilities for diagnosing and managing the outbreak was available and that compensation for the affected families will be distributed. I am pained to see such an approach to all social issues related to health care in our society. After that meeting, a central team was invited to visit Kerala to find out the problem and brainstorm the solutions, which we already knew better than any of them. In fact, we are aware that things are not moving in the right direction in health care, and therefore I have been involved in health education more than medical teaching these days, which I extend to the public, teachers and the motivated students. The truth is that we are always running away from problems; we are only attempting to plug the deep holes with darkness, we are not sincere to ourselves or to the society or to the next generation. What is happening now is just the continuation of what has been happening over the past several decades in health care and there is no sign of any change in the near future, unless and until we start somewhere.

After the Chikungunya epidemic (a viral fever transmitted by mosquito bite) in Kerala, Virology institute was set up in Alleppey, the epicentre of this disease. Now with Leptospirosis, what institute will be set up in Kozhikode is a genuine question, because we are known only for knee-jerk reactions and not for thoughtful actions with a vision for future and priority based resource utilisation. If Chikunguniya is due to mosquito proliferation, which in turn is due to improper waste management, naturally we should focus first on correcting this problem. It is difficult to digest how a virology institute can solve the problem of Chikungunya. The problems related to Chikungunya are already known to all of us. There is nothing new to discover. If it is a General Hospital or an Institute for Internal Medicine, which will contain more beds for the patients, they can at least have a comfortable treatment and a torture-free hospital stay. All the patients admitted to General medicine (around 30,000 patients annually) come with genuine problems requiring admission. At any time we have 400–500 critically ill patients, admitted in the 13 medical wards, which have just 300 beds, arranged with very little space left in between beds. Many patients have to be accommodated on the floor in between these crammed spaces. The maximally overcrowded wards in government medical colleges and government hospitals have been neglected like the poor people in the periphery, and the situation has come to a state now that we have marginalized the departments working for severely marginalized people and this is the situation in all the government medical colleges. The country will progress only when we start working for the marginalized sections.

(The above articles expose the issues in health care and disease care. Due to the Leptospirosis- outbreak we were sanctioned five ventilators within a week after the meeting mentioned above, from NRHM funds, and people were made to believe that the issue had been addressed properly).

CHAPTER 3

MALNUTRITION IN INDIA, WHAT IS BALANCED DIET AND GOOD LIFESTYLE?

Why malnutrition in India?

Malnutrition in simple terms mean lack of a balanced diet. Many have the wrong belief that malnutrition is not a major health care issue in India, or even if they consider it as a major issue, what they discuss would be the issue of starvation because the absence of starvation is often equated with adequacy of nutrition. In reality malnutrition is the most major and the commonest health care issue in India, it is the most important enemy of India – the enemy within – it is several thousand times more dangerous than the only imaginary enemy outside India. The severity and extent of malnutrition and its relation to social security and human development is also not recognised and we resort only to costly short cuts when it comes to issues of malnutrition. The prevalence of malnutrition is so high because of two major reasons 1) no one knows what actually a balanced diet is, and 2) the society is not adequately empowered to get it everywhere. Without a second thought one can confidently state that malnutrition is as high as 90 per cent or even more in India. Even in developed countries, in spite of all the richness, plenty of resources and society-friendly policies they have, people there suffer from malnutrition in the form of obesity due to overeating, and micronutrient deficiency resulting from voluntarily omitting some essential items of food or by ending up eating the wrong food. One can imagine the extent of malnutrition in India where the available resources are poor, people are not empowered and the society is totally unaware of what constitutes a balanced diet. The gravity and extent of malnutrition in India is unimaginably high and needs urgent attention. Obesity is also a kind of malnutrition because it predisposes to diseases, and also because obese people just eat excess calories often ignoring the quality of diet. They eat everything that is tasty in excessive quantities from their choicest food items but are not necessarily getting a balanced diet; accidentally in that process, the obese rich people might get some essential items as well, and may be relatively better protected against infections, as compared to the grossly malnourished people who do not have access to a balanced diet. Even if people eat a balanced diet in excess quantity and become obese, then also it should be identified and treated as malnutrition. This is because obesity itself can lead to several diseases, more so when the diet is not balanced. It is also very obvious that the obese people in India develop diseases earlier as compared to their western counterparts who are more likely to eat a better quality diet, though in excess quantities. People living in developed countries have higher chances of getting all the items of a balanced diet due to better social security and human development, which their home countries focus on. Their dietary habits and the social support systems they have, allow them to take most of the essential components and they finally end up eating a healthier food as compared to us. The traditional Indian diet was balanced, but we have moved away from the traditional Indian habits and imported only the fast food culture from the west, without acquiring the goodness of their diet. Thus, even the rich people in India now get the wrong diet and therefore the overall health status of the obese people in India is worse than their western counterparts. Unlimited consumerism is now rampant all over the world, which is being promoted by the celebrities, without any checks and controls, that make people obese by eating more without adequate exercise

It is estimated that more than two thirds of the Americans are overweight or obese. Obesity is also becoming very common among the relatively well-to-do people in all parts of India as well. But most of the obese people in India are undernourished as well, because they are unaware of what constitutes a balanced diet or are careless and they eat only for taste and appetite ending up eating the wrong foods in excess amounts. Their diet is most often deficient in several nutrients, especially micronutrients due to inadequate intake of vegetables and fruits. Even protein-rich food items are usually deficient in the diets of most people in India due lack of awareness, lack of empowerment and some wrong concepts about diet. Thus, gross malnutrition is universal, even among the rich in India. Besides these deficiencies, and eating excess calories, the exposure to toxins is another serious problem in India, even among the affluent sections. Deficiency of micronutrients in the diet of the affluent people is primarily due to inadequacy of fruits and vegetables in their diet. In developed countries, their diet invariably contains adequate or more than adequate calories and enough or more proteins by default. In addition, they regularly include fruits and raw vegetables in their diet. Their major problem with diet is excess calories and exposure to toxins from the fast foods and preserved foods and micronutrient deficiency is rare. We have imbibed all the pitfalls in the western diet; in addition, our diet is deficient even in its basic components as well and it contains lots of toxins due to frequent use of fast foods, junk foods and deep-fried foods.

Why are we careless about Our Diet?

Lack of awareness and lack of social empowerment are the primary reasons behind a faulty diet. There isn’t any organised programme or plan to give our people the correct concept and practical tips about a balanced diet. There is no national programme, which aims at providing everyone with a balanced diet. We waste our resources – both money and manpower – in treatment of diseases, which are multiplying, and in undergoing costly treatments and procedures, which also are increasing, even when there are cheaper alternatives for the management of diseases. At the same time there are several wrong concepts, which people follow, since these are popularised by the media with the help of celebrities. People fall prey to these ill informed concepts, which are propagated for the benefit of marketing a product or procedure by the vested interests.

The consumerist forces are very active, selling wrong ideas in the name of health care. They propagate wrong myths about health care, which drive people to consume the wrong type of food, that too in excess quantities. For example, they make the rich and some not-so-rich people eat oats to reduce cholesterol. People now believe that by taking oats their problem with high cholesterol is solved forever. High cholesterol is actually not a public health problem; it is the creation of the vested interests to increase the selling of medicines for it. High cholesterol is the result of eating more and not doing any physical activity. Even doctors, who regularly check cholesterol levels, fail to check their weight/height²ratio (BMI) and enquire about their diet (quantity and quality) and exercise habits at each visit. What the people should be worried about is their weight, the body mass index and the quantity and the quality of food they eat. They should be taught to reduce the quantity of food, rather than changing their staple food (replacing wheat or oats for rice) or increasing the dose of medicines to reduce cholesterol. The consumerist forces make people even drink alcohol in small quantities, citing the reason that it protects the heart. In reality any amount of alcohol in any form is harmful to the body, but one can continue to drink in small amounts without much harm, that does not mean that the absence of problems was due to the protective effect of alcohol. People buy olive oil or sunflower oil replacing cheaper coconut oil and other traditionally used cooking oils to reduce cholesterol. People even make fried foods with these oils when the fact is that cholesterol increase results from eating foods in increased quantity and not doing any exercise. In fact olive oil and sunflower oil are more toxic than coconut oil when they are used for frying foods. Thus the vested interests and celebrities here are spreading incorrect information without any checks and controls to make people consume anything and everything, citing one or the other health tips, and finally our people, the rich and poor, all end up as patients.

To fish in troubled waters medical consumerism also works aggressively in the society and passively forces people to undergo medical procedures and investigations, ignoring more effective and cheaper alternatives, pushing them into bankruptcy, and consequently more serious malnutrition as well. The human body is probably the most complex machine that we can imagine of. When we fill much simpler machines like our car engines with the right kind of fuel, often insisting on the same brand even, because of quality concerns, why are we ignoring these simple rules while filling our own fuel tank – the stomach? Should we fill it with any damn thing? Should we eat at any hour and any food just because it is tasty, or eat to avoid wasting of food? It only needs common sense to choose the right kind of food at the right time in the right amounts. Avoid all kinds of fast foods to be on the safe side; they are for use in case of emergencies or as a last resort to avoid starvation in certain situations when we have no other choice. All the ready-to-eat foods, with prolonged shelf life, including packaged juices, health drinks and biscuits are fast foods and should be taken only by exception and not by choice. Many popular food items which children and adolescents are fond of – like biscuits, cakes, chocolates, pizza, fried chips and savoury with long shelf life come under this category of fast