Medicine Matka

Being Healthy is Not a Lottery

Category: Alternative Medicine

The Tragedy of The Intelligent

I recently interacted with a highly intelligent lady with carcinoma breast who believes that the only way to manage the disease is with alternative therapy.

I don’t really want to argue with the choice she has made – if you intelligently decide to follow a line of treatment, assuming of course it is done with the full knowledge of all data available, then so be it.

Her tumor is growing and she wants to compare its progression / regression. She has been doing so with successive breast MRIs and when I was asked to look at the breast MRIs, my first reaction was, Why…. why would someone do breast MRIs for comparison when the standard of care is PET/CT, given that she has metastatic breast cancer with bone involvement?

The answer I received was that she was scared of effects of the radiation from PET/CT.

And I felt sorry for her. She was misinformed and making bad decisions based on some delusional understanding of the ill-effects, if any, of radiation.

Diagnostic radiation has been around since 1895. In the last 120 years, there has been no data and I repeat no data that links diagnostic radiation to cancer. We are not talking of 10 or 20 or 30 years…this is 120 years. All the hype that comes in the newspapers and lay press is from extrapolation of nuclear blast data, which is unscientific and has no basis.

And even for a moment, assuming that diagnostic imaging related radiation does cause mutagenesis with the possible chance of cancer, this would take 20 odd years to manifest, by which time this 55 years old lady would have been 75.

I may have sounded mean, but I actually blurted out the fact that it was unlikely she would be alive for another 20 years and hence not doing a PET/CT was really just a completely rubbish decision.

Sometimes I feel it is best to not know a lot and to have some faith in modern medicine and data and clinical judgement calls. Ask the right questions, but also accept facts and management directions when presented by people who do know perhaps a little more.

Informal Medical Workers (Quacks) Providing Healthcare – The Challenge

I am always conflicted when people talk about alternative medicine practitioners. When those trained in alternative medicine start practicing allopathy and caring for patients, or when there is talk about integrating them into the mainstream, the uneasiness grows even more.

There is no question there is a significant shortage of doctors / healthcare workers in India. We have 1 doctor per 1700 people instead of 1 per 1000 as mandated by the WHO for low income countries, with 80% of the doctors clustered in cities and urban areas, which worsens the already bad patient:doctor ratio in the rural areas. To add to this, the primary healthcare centres are short-staffed with rampant absenteeism, and this is not getting any better.

A large number of viral and bacterial diseases are self-limiting and would heal irrespective of whether there is a doctor or not. Doctors make a difference in trauma, acute emergencies (appendicitis, etc) and infections that need active management. Chronic diseases can be controlled, but very often doctors really just provide support systems that can also be managed by others under supervision or with training.

To that end, nurse practitioners have made quite a difference in the management of both acute and chronic conditions, so much so, that a nurse practitioner-managed ICU has the same results as a resident-managed ICU.

There is no nurse practitioner program in India, with a denial from the Health Minister in 2015, changing to a positive commitment in June 2016. The nursing council has created a 2-years curriculum as well, with the hope that they will get a green signal soon to implement this.

With the larger healthcare problem in mind, the Government of India (GOI) at various times has tried to introduce programs that train people to manage basic health care issues, like the Bachelor of Science (Community Health), which have met with strong resistance from the Indian Medical Association (IMA) and a variety of other medical stakeholders. The general fear is that given the state of the law in India, these health workers will start calling themselves doctors and and practice advanced medicine, even though not trained to do so, eventually to the detriment of the patients.

Proposals to allow practitioners of homeopathy and ayurveda to practice allopathy after a one year course have also been met with strong resistance.

Wading into this mess, is a new paper in Science, by Jishnu Das and Abhijit Chowdhury titled “The impact of training informal health care providers in India: A randomized controlled trial” that describes an experiment where formal training was given to a group of informal health workers (quacks), with a monitored control group that was not given training, with outcomes compared to those of doctors in the public sector.

Outcomes for trained informal healthcare workers

These graphs show that even with just a 56% mean attendance, the trained informal workers managed cases more effectively than those who were untrained and closed the gap with those in the public sector. While this could partly be because the public sector doctors also probably need skill upscaling, the fact remains that most diseases can be taken care of by simple training of health workers.

Priyanka Pulla, in The Wire, wrote about this study in 2015, when it was first started, (http://thewire.in/14683/india-is-training-quacks-to-do-real-medicine-this-is-why/). The Liver Foundation in Kolkata has been conducting this training. The caveat is that once trained, to allay the apprehensions of the IMA, MCI and other “doctor-based” stakeholders, these health workers are to stop using the prefix “Dr”.

In a utopian world, that would be the perfect solution. But, in a country where we can’t even stop two-wheeler riders from riding on the wrong side of the road and beating up traffic policemen, where an aromatherapy healer with some rubbish diploma also starts calling herself “Dr” with impunity, that really seems to be a tall-order.

Therefore, while the study has shown that training “quacks” improves outcomes, practically, we would be legitimising quackery, hoping these workers will agree to a demotion from being “doctors”, while in reality they would likely use the training to add another diploma acronym (DLFT, or something like this) to enhance the “Dr” prefix.

Perhaps the nurse practitioner solution is the best. Nurse practitioners would be able to provide basic healthcare in under-serviced areas, work under the supervision of doctors and most importantly, would not suddenly start calling themselves doctors.

Like I said at the beginning…I am quite conflicted. We have a huge healthcare problem that needs to be solved and yet solutions that don’t involve doctors or seek to legitimise those who have entered the system surreptitiously or illegally, leave me with quite some unease.

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