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Burp!

Eureka!

A mousetrap for cancer!

Baffled? Take it easy. An Australian Nobel Laureate, a British Neuroscientist, and a group of Dutch researchers usher us into a new world of medical research

EDITOR’S NOTE Three sides to a story!

B Volume 1 Issue 6 | December 2012 Editor Ravi Deecee Deputy Editor Sanjeev Neelakantan Assistant Editor Dipin Damodharan Senior Reporter & Research Assistant Sreekanth Ravindran Senior Reporters Lakshmi Narayanan Prashob K P RESPONSE TEAM Coordinating Editor Sumithra Sathyan Reporters Tony William Shalet James Neethu Mohan Design & Layout Kailasnath Anil P John

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4 FUTURE MEDICINE I December 2012

urp! Eureka! And a mousetrap for cancer!

These cryptic clues to newer strides in the global healthcare sector may seem unrelated to each other at first glance. But the big picture tells a different story. Scientists have made a great start in understanding the complex nature of our immune system, finding newer ways to strengthen it against countless agents attacking the body’s defence mechanism.

From a wide variety of bacterial and viral diseases to cancerous growths and the suspended animation of man between life and death, the sentinels of the global medical and scientific research community are constantly engaged in identification of key genetic or cell sources that hold the key to the mysteries of the immune system.

Immunology is not just about maintenance of the internal environment. The external environment is just as crucial. That’s what we deal with in the first part of our Cover Story, featuring Nobel Laureate Dr Barry James Marshall. Dr Marshall, along with fellow Australian Dr Robin Warren, had identified the Helicobacter pylori bacterium, the real culprit behind ulcers. This is your opportunity to learn more about something as simple as the body’s “burp” factor from Dr Marshall.

The second part of the Cover Story is about the revolutionary “communication” technique of renowned British neuroscientist Dr Adrian Owen, who knows how to uncover the cognitive powers of a patient in a vegetative state. This discovery of the “consciousness” of such patients is a first in cognitive neuroscience.

Well, that sums up the “Eureka” element of our Cover Story. That leaves us with the mousetrap for cancer.

Well, there has to be some element of suspense. So, say cheese and walk into the trap.

The edition also includes the second instalment of our special health package (on “Wellness”). Enjoy reading and wish you a Merry Christmas and a Happy New Year!

Moving is the best medicine. Keeping active and losing

weight are just two of the ways that you can fight osteoarthritis pain. In fact, for every pound you lose, that’s four pounds less pressure on each knee. For information on managing pain, go to fightarthritispain.org.

CONTENTS

18

COVER STORY New strides in healthcare From the wonderland of science, we bring you three breakthroughs that can change your world in ways previously unimagined. Nobel Laureate Dr Barry James Marshall is working on an oral vaccine that can fight the influenza as well as the ulcer-causing bacteria called Helicobacter pylori. British neuroscientist Dr Adrian Owen has opened a communication link with patients in a vegetative state. And a group of Dutch researchers are banking on mice models to unfold the whole mystery behind cancers and tumours

50

SPINE CARE Dr Arvind Kulkarni

Wellness Special The pursuit of happiness

73 47

Female Foeticide

Sonia Bhalotra

Fitness

Dr Mini Mary Prakash

33

What is wellness? Is it just a state of mind?

Or is there something more to it? Wellness experts tell us the meaning of good living and suggest many simple and effective ways to improve the quality of life

14

Food alert Malnutrition problem Malnutrition is a child killer in India, says Nisha Malhotra, a social scientist and instructor of Economics at University of British Columbia. Spreading awareness can make a huge difference

6 FUTURE MEDICINE I December 2012

P62-69

Specialty Hospitals We introduce you to a select group of specialty hospitals in Kerala that is giving a new face to healthcare with community-driven initiatives

55

Public Health

32

Acne Management

54

Safe abortion

16

Surgeon Speaks

60

Dental Care

76

Sexual Health

Dr Mathew George, TISS

Dr Divya Ramkumar

Dr Jitendar Kumar Sharma

Dr S Sudheendran

Dr Ravi R Hebballi

Dr A Chakravarthy

December 2012 I FUTURE MEDICINE 7

MEDICAL DIGEST

Triple therapy for the heart MUMBAI: Soon, people suffering from heart troubles can avail of a new therapy. For the first time in India, an Indian-American surgeon will offer a triple therapy - a combination of angiogenesis, stem cells, and bypass surgery.

Dr Mukesh Hariawala is set to introduce the “natural bypass” in Mumbai’s Jaslok Hospital in the first quarter of 2013. The surgery involves spontaneous development of new blood vessels in the heart by laser stimulation and subsequent injection of patient’s own stem cells, harvested from the bone marrow.

Monitoring medical services to the poor MUMBAI: The Maharashtra government has

constituted a four-member committee for monitoring and inspection of medical services provided to the poor and economically weaker sections by hospitals registered under the Mumbai Charitable Act. The committee will be headed by the Joint Charity Commissioner. The Assistant Director of Health Services will be the Member Secretary, while the Chief Medical Officer, or any representative from the municipal corporation, and the Assistant Sales Tax Commissioner will be the members, according to a government resolution.

Every three months, the committee will conduct inspection of the accounts of the respective hospitals to look into their expenditure on indigent as well as economically weaker patients. The committee will examine the case history of the patients to check the authenticity of entitlements to free or subsidised care and also see whether the expenditure incurred on the tests conducted on them could be justified.

The inspection committee will submit its reports to a high-powered panel headed by the Additional Chief Secretary (Health).

8 FUTURE MEDICINE I December 2012

Dengue outbreak in Europe STOCKHOLM: Europe is experiencing its first sustained transmission of dengue fever that has infected more than 1,300 people. The Portuguese Health Ministry reported 1,357 cases as of November 11.

Of these, 669 were confirmed cases and 688 are probable cases, the Stockholmbased European Centre for Disease Prevention and Control (ECDC) said in a statement.

Some 25 patients from mainland Portugal, Britain, Germany, France, and Sweden have been diagnosed with dengue after returning home from visits to Madeira, a Portuguese island. The dengue fever outbreak in Madeira began in early October.

While no deaths have been recorded so far, ECDC stressed that given the high number of visitors to Madeira, “the outbreak is large and constitutes a significant public health event”.

Spread by one of four viruses transmitted by the Aedes aegypti mosquito, Dengue causes high fever, headaches, itching, and joint pains. At an advanced stage, it can lead to haemorrhaging and death.

TB population highest in India NEW DELHI: At 25 lakh, India has

the highest tuberculosis (TB) patient population in the world, followed by China, which has nine lakh TB patients, according to a report of the World Health Organisation. The report, titled ‘Global Tuberculosis Control 2011’, says that the WHO registered 8.8 million cases of TB last year, of which 2.5 million patients were from India. Since India is becoming the diabetes capital of the world, the threat of a TB epidemic looms even larger.

Occurrence of TB in people with diabetes is three to four times more than in nondiabetics.

Change in the structure of HIV

Minister’s alarming diagnosis NEW DELHI: Union Rural Development

Minister Jairam Ramesh has said that the public health system in the country has ‘collapsed’. He noted that even poorer countries like Bangladesh and Kenya have superior health indicators.

In a candid assessment of the country’s health sector, Ramesh said in New Delhi, “Today, the single most important reason for rural area indebtedness is the expenditure on health. We all know that the health system in India has collapsed. India is a unique country in the world, where 70 per cent of the health expenditure is private expenditure,” he said at the Hindustan Times Leadership Summit last month.

In many parts of India, he said, the public health system simply does not exist. On the other hand, he said, countries all over the world are debating the issue of increasing public spending on health to improve the social indices.

BANGALORE: A study conducted by Bengalurubased Jawaharlal Nehru Centre for Advance Medical Research says that over the past one decade, a notable change had occured in the characteristics and structure of human immunodeficiency virus (HIV) in India.

The newly-found virus is more dangerous than the previous one. It multiplies within a small time when compared with the other virus. Commonly found in blood, it can damage the immunity power of the patient within months and cause death.

Scientists state that there are three to five varieties of HIV. The study was conducted with the support of the All India Institute of Medical Sciences, Mumbai, YRG Centre for AIDS Research and Education, Chennai, and St John’s National Academy of Health Sciences, Bengaluru. More studies on the virus are underway.

December 2012 I FUTURE MEDICINE 9

MEDICAL DIGEST

DHA targets medical tourism

US to face doctor shortage WASHINGTON: The US will need about

52,000 new primary care doctors as the population grows and ages, says a study.

Research published in the Annals of Family Medicine estimated that most of the doctor shortage will be caused by the rising US population, but this change is also likely to be associated with the new law in the US, being hailed as “Obamacare”, by which many more Americans will get medical insurance. As the US population will swell up by 15.2 per cent by 2025, to serve the expanded populace, new physicians will be required. Ageing adults will create the need for an additional 10,000 physicians in that period. The Affordable Care Act (Obamacare), however, will require another 8,000 physicians, a three per cent increase from the current workforce of US physicians.

The Association of American Medical Colleges has estimated that the US will be short of more than 91,000 doctors by 2020 — 45,000 in primary care and 46,000 in surgery and medical specialties — as more Americans age.

10 FUTURE MEDICINE I December 2012

DUBAI: The Dubai Health Authority (DHA) has been instrumental in developing and implementing plans, policies, and legislations towards fostering the best model of healthcare. Currently, DHA has more than 15 primary health care centres. In addition to building new facilities, one of DHA’s goals is to strengthen its medical tourism initiative in line with the instructions of Shaikh Hamdan Bin Mohammad Bin Rashid Al Maktoum, the Crown Prince of Dubai.

With a newly-appointed Director General at the helm, DHA will continue to work with all the stakeholders to tap into the potential of the medical tourism sector. Speaking to Gulf News, Eisa Al Haj Al Maidour, the Director General of DHA, said that the global revenues from medical tourism are estimated at $30 billion and Dubai is wellpositioned to take a share of this market.

Obamacare on the way WASHINGTON: The Department of US Health and Human Services has said that it is putting in place provisions that would make it illegal for insurance companies to discriminate against people with preexisting conditions, enable consumers to compare health plans, and encourage employers to promote employee wellness.

“The Affordable Care Act is building a health insurance market that works for consumers,” said Health and Human Services Secretary Kathleen Sebelius.

While Republican Presidential nominee Mitt Romney and GOP congressional candidates had made repeal of the law a major part of their campaigns, the President defended the law he himself referred to as “Obamacare”.

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MEDICAL CONFERENCE

Fourth international meet on medical negligence

Looking at advances in Oncopathology PUNE: The Fourth International CME (Continuing Medical Education) on Oncopathology (OncoPath CME) will be held at Pune on January 5 and 6, 2013. Many world class international pathologists from the USA, Canada, and India will take part in this conference. The most interesting feature of this meeting is Digital Pathology. The cases will be presented in Digital Pathology format.

OncoPath CME is the only pathology meeting in India which presents the pathology glass slides in digital format.

The digital slide replaces the need of microscope and allows pathologists to view slides at any desired magnification in real time. There will be short courses in OncoPath CME, giving participants a brief review of the disease entity along with latest updates in diagnostic and therapeutic fields. They are designed for the practising pathologists and postgraduate students. A variety of topics will be presented by international speakers.

12 FUTURE MEDICINE I December 2012

THIRUVANANTHAPURAM: The Fourth International Conference on Medical Negligence and Litigation in Medical Practice, and the Fourth International Conference on Recent Advances in Forensic Sciences, Forensic Medicine and Toxicology will be organised in January 2013 at Kovalam. The conference will offer a futuristic view of newer domains and cover a wide array of topics, including medical negligence - what it is and how to avoid it?; Litigation in medical practice - civil and criminal implications; Recent advances in forensic medicine and toxicology; Narco-analysis, brain mapping, DNA finger printing, Sexual assault - date rape; Recent changes in medical laws, Medico-legal aspects of practice of surgery; Anaesthesia; Obstetrics and Gynaecology; Medicine; Legal remedies; Medical ethics; Role of consumer courts; and research in forensic odontology.

The scientific contributions would be in the form of Plenary, Invited, Oral, and Poster presentations. There will also be a best poster competition.

child & maternal health Nutrition

Malnutrition is a

child killer An unmet millennium development goal, child nutrition is a subject of national shame. What’s the best way to address this chronic health issue? Nisha Malhotra, a social scientist and instructor of Economics at University of British Columbia, says the absence of nutrition as a subject in school education systems has only worsened the scenario. The problem is not just limited to the poverty-stricken. Even parents from well-to-do families are ignorant about nutrition. So, the best way to address this issue is to include lessons on nutrition in the school curriculum

By Dipin Damodharan Why does child malnutrition persist in India?

We haven’t been able to address any of the issues pertaining to malnutrition, though our economy has been doing well. Anaemia among woman of childbearing age is a serious issue. After talking to people at anganwadi centres, I realised that there is a constant shortage of iron-folic acid tablets and other 14 FUTURE MEDICINE I December 2012

supplements needed by pregnant woman. Childhood diarrhea is highly prevalent and we need to address this issue by providing clean and safe water and improving the sanitation conditions.

Information on nutrition needs to be disseminated at the time of antenatal care, childbirth, and vaccinations. And the biggest issue of all is having enough income to be

able to afford food in the first place. Be it the public distribution system, food stamps, or cash transfers, we, as a country, need to figure out how to make food available for the starving population and make this a priority issue.

About Nisha Malhotra Brought up in Bangladesh, Thailand, England, and India, Canada-based Nisha Malhotra is an instructor of Economics at University of British Columbia. A Master Graduate in Economics from Delhi School of Economics and a PhD in Economics from University of Maryland (College Park), US, Dr Malhotra’s areas of study include population, gender and health, maternal and child health in Asia (mostly India) and Africa. She has also worked with the Indian Council of Research on International Economic Relations (New Delhi) and the World Bank (Washington DC).

Extensive nutrition intervention, aimed at educating families about proper infant feeding practices, is the need of the hour. This should be done at multiple levels. The subject of nutrition should be an integral part of primary and secondary education How serious is the problem of child malnutrition?

A malnourished child is more likely to fall sick and less likely to survive. There is strong medical evidence to prove that malnutrition at an early age leads to lower intellectual development and coronary heart disease during adulthood. Also, current research shows that women who were malnourished as a child are more likely to be shorter in adulthood, which may result in low birth weight of their child and increase their vulnerability

to sickness.

What should the government do?

Extensive nutrition intervention, aimed at educating families about proper infant feeding practices, is the need of the hour. This should be done at multiple levels. The subject of nutrition should be an integral part of primary and secondary education. Provide clean and safe water.

Improve sanitation conditions. Most importantly, try and fix the public distribution system so that poor children do not starve.

What’s the level of awareness among masses about nutrition?

Interactions with women who have attained motherhood and scrutiny of the National Health Survey will reveal that parents are not wellinformed about nutrition, especially about semisolid (mushy) foods and the need for variety. The nutritional value of green leafy vegetables cannot be compensated by mere consumption of grains. I am also a product of the Indian education system and I don’t recall learning about nutrition in school, other than my home science class. Even that did not give much detail on a complete healthy diet.

We, as a country, under-consume fruits and green leafy vegetables. Given that most are vegetarian, it becomes even more important to consume iron-rich food combined with other food items that makes iron absorption easier. There are detailed government guidelines on nutrition, but they do not reach the affected families.

Dissemination is a serious constraint.

How is the child feeding practice related to malnutrition?

The Indian government and the World Health Organisation recommend that children, after the age of six months, should be given breast milk and solid or semi-solid food like boiled rice, daal and vegetables and fruits.

A large number of children under the age of one are not getting enough solid foods. Mothers think that breast milk is enough, but children after the age of six months need to be fed a variety of semi-solid food. Children who stay on breast milk alone beyond six months of age without solid/semi-solid food, including two to three food groups (different varieties like fruits, vegetables, milk products, lentils, grain), are more likely to be stunted (shorter) or wasted (underweight and undernourished).

Moreover, I find that on the whole, nutritional practices for children in India are truly appalling.

Even at the age of 10 months, 17 per cent of infants are not given anything other than breast milk, and among the 10-month infants who do consume complementary food, only half get the food from sufficient (three or more) food varieties and sufficient number (three or more) of times.

December 2012 I FUTURE MEDICINE 15

SURGEON SPEAKS Dr S Sudheendran

Inspiration to become a surgeon

Maintain equality in treatments

I never dreamt of becoming a surgeon at the beginning of MBBS. Just like other boys of my age, I enjoyed the colours of life during my college days. One day, towards the end of my final year, my professor had called me for assistance in the operation theatre. As the house surgeons were on leave, there was no other option before me. I was not aware of the intricacies of surgery at that time. And I never thought that this surgery (on a young boy) will prove to be the turning point in my life. When the patient’s relatives learnt that the surgery was successful, their nerve-wracking moments ended in joy and jubilation. Being a witness to this life-saving event, I got drawn to surgery automatically.

Memorable surgical experience

I became a liver transplantation surgeon in 1998.

As in the case of any other surgeon, my first surgery proved to be a stepping stone to a great career. It injected a great deal of inspiration into me. There’s another surgery that’s close to my heart: in 2007, I had performed a surgery at Amrita Institute of Medical Sciences on a comatose liver patient.

Qualities of a surgeon

Dr S Sudheendran, who works at Kochibased Amrita Institute of Medical Sciences, is Kerala’s first liver transplantation surgeon. He has completed 166 transplantations so far, with a success rate of over 80 per cent. He is the third Indian surgeon to conduct more than 100 liver transplantations. In an interview with Future Medicine, this socially committed surgeon talks about the need to bridge the rich-poor gap while providing quality healthcare As told to Lakshmi Narayanan

16 FUTURE MEDICINE I December 2012

He should be confident, dedicated, and wellversed with each and every procedure. He should give confidence and hope to patients. He should be aware of the changes in the healthcare sector. And lastly, a surgeon should be well-prepared to take on new challenges.

Role of ethics in a surgeon’s life

Medical ethics are basically guidelines that enable the maintenance of a good surgical and clinical life. It brings about a perfect rhythm between a patient and a doctor. Strict adherence to medical ethics will only result in more confidence and faith in a doctor and his treatments.

Quality of healthcare in India

The healthcare sector mirrors a country’s development. The rich-poor gap shouldn’t affect the quality of treatment offered to patients, especially those from humble backgrounds. Hospitals should provide all modern facilities to safeguard the lives of patients. Hospitals and doctors should maintain equality in treatments. Every hospital in the country should follow uniform standards in terms of diagnosis and treatment.

COVER STORY - NEW STRIDES IN HEALTHCARE Dr Barry Marshall & Helicobacter pylori

Image of Helicobacter pylori created by Luke Marshall

Burp!

It’s the

Helicobacter!

By Sanjeev Neelakantan & Sreekanth Ravindran

18 FUTURE MEDICINE I December 2012

Honoured with the 2005 Nobel Prize in Medicine for identifying the causative link between a bacteria and asymptomatic infections causing peptic, gastric, stomach and duodenal ulcers and cancer in people across the world, Australians Dr Barry James Marshall and Dr Robin Warren challenged a universally accepted perception that such serious disorders are a result of spicy food intake, stress, or excess acid in the system. While many people around the world still do not know much about the bacteria Helicobacter pylori, Dr Marshall, in a candid, exclusive interaction with Future Medicine correspondents, gives a wholesome perspective on the bacterial infection and the available treatments for the benefit of all

Dr Barry James Marshall; Photo: Frances Andrijich

T

he pathogenesis of the twin human problem of neglect and ignorance has never been so miserable. A majority of the river and water systems across the globe are turning into breeding pools of disease, death, and decay. So, what’s so new about it, one may ask? There’s more: even the life support systems,

particularly in Asian, South-east Asian, and South American countries, have been degenerating at a steady pace for quite some time now. Key in a social, economic, or political issue of your choice in an internet search engine, and the statistics of human decadence just go on and on into millions of webpage links. For now, December 2012 I FUTURE MEDICINE 19

COVER STORY - NEW STRIDES IN HEALTHCARE Dr Barry Marshall & Helicobacter pylori

let’s take a look at how much we have learnt about the positives of good living. Here’s an oft-heard self-pitying sentiment on something as simple, common, and serious as being aware of one’s daily food intake, “I shouldn’t have had that spicy food. It will cause gastritis and land me in ulcer troubles.” A lot of people in this part of the world still say that at least once a day, without realising the real nature of the microscopic problem within the body – colonisation of the protective mucous lining of the stomach by a bacteria called “Helicobacter pylori”, harboured by more than 50 per cent of the world’s population as of today.

Helicobacter is a spiral-shaped bacterium commonly found in the stomach. The bacteria’s shape and the way they move allow them to penetrate the stomach’s protective mucous lining, where they produce substances that weaken the lining and make the stomach more susceptible to damage from gastric acids.

“Most people get the Helicobacter infection from their mother, siblings, or some other member of the family. Whenever there is poor quality water supply, especially with faecal contamination, or unsanitary conditions, we can assume that there will be bacterial contamination. If you look at the children in a family, say, for instance, in a country like Peru, where the Helicobacter infection rate may be 75 per cent of the total population, you will find different strains of the bacteria among them.

This is indicative of the fact that they are getting infected from an external source, possibly contaminated water. That’s the kind of situation we have in India as well. Helicobacter is everpresent in unhygienic water supply systems. In fact, the rate of Helicobacter infection is about 40 per cent even among people of the higher socio-economic strata, while people of the lower socio-economic groups are down with about 80 per cent infection rate. The rate is higher in farming areas (in rural hinterland),” says Dr Barry James Marshall, who won the 2005 Nobel Prize in Medicine along with Dr Robin Warren for identifying a causative link between Helicobacter and peptic/stomach, duodenal ulcers and cancers. “...But if a family is small, the chances of Helicobacter spreading among each of its members are not so high,” says Dr Marshall in an apparent reference to why the germ is becoming less common in Western countries.

20 FUTURE MEDICINE I December 2012

The real culprit

So, what about the diagnoses/prognoses on ulcers and cancers involving the usual suspects (spicy foods, stress, alcoholism, smoking, and other unhealthy lifestyle factors)? “Spicy foods can stimulate the acid a little bit. But I do not think that they can cause ulcers. On the other hand, they probably help the digestive system.

It’s just a theory of mine. It’s not proven.

Smoking, alcoholism, and other poor lifestyle conditions are secondary factors at best when it comes to ulcers. Earlier, it was thought that ulcers were primarily caused by excess acid, spicy food, and stress. So, the purpose of the treatment was just limited to control the (stomach) acid (level) and the stress. Now, we know that Helicobacter is the cause of peptic ulcers. Today, all my endeavours are aimed at the eradication of Helicobacter. Though we still give an acid blocker (to patients to prevent damage to the tissue by reducing production of stomach acid), once we eradicate Helicobacter, the natural healing process of the body would

Factsheet • About 80% of stomach ulcers and 90% of those in the duodenum, the upper end of the small intestine, develop because of Helicobacter pylori infection • Infected people need not necessarily have ulcers or develop stomach cancer • Symptoms: Gastritis, peptic ulcer disease (gnawing or burning abdominal pain), weight loss, loss of appetite, bloating, burping, nausea, vomiting, black, tarry stools Microscopic images of Helicobacter pylori, taken by Dr Barry Marshall in 1985

start off on its own. So, the focus is not so much on removal of (excess) acid in the long term. In effect, what that means is that nearly everybody with ulcers can be cured after two or three weeks of treatment through (focus on) Helicobacter.

The cure or success rate can be pegged at about 90 per cent,” says Dr Marshall.

Taking the argument on spicy food being the culprit behind peptic/stomach ulcers a little further in the Southeast Asian context, Dr Marshall says, “Let’s take a look at the Indonesians. They like spicy food very much, and they have spicy food regularly. For the record, a majority of them do not have Helicobacter in their system. And they also do not

suffer from any ulcers just because they are having spicy food.”

Discovery of Helicobacter

Dr Marshall and Dr Warren’s curiosity about the ulcercausing Helicobacter takes us back to their clinical research days in the late 1970s. Dr Marshall recounts, “I always wanted to be a clinician in general medicine, somebody who could treat all kinds of diseases like diabetes, cancer, tuberculosis etc. But when I started doing my clinical research as part of my training to investigate a bacteria, which my colleague, Dr Warren, had seen in gastric biopsies, I was curious... because the medical books held that bacteria cannot live in the stomach. I was

interested in finding out if the medical books were wrong. It was always challenging to find out something new and say: ‘Everyone is wrong, here’s the new bit of science which we

Dr Robin Warren December 2012 I FUTURE MEDICINE 21

COVER STORY - NEW STRIDES IN HEALTHCARE Dr Barry Marshall & Helicobacter pylori

have discovered’.”

What proved to be the turning point? “Dr Warren and I were not research scientists those days.

But after one year, we became very interested in this bacteria (Helicobacter), associating it with ulcers. Frustrated by not being taken seriously by my colleagues, in July 1984, in a desperate attempt to prove that this bacteria was harmful for humans, I grew it from a specimen collected from a patient with gastritis. I had conducted an endoscopy on myself first to make sure that I did not already have Helicobacter. There was no bacteria in my system. I then drank a bacterial cocktail. Five to seven days later, I suffered from nausea and vomiting. An endoscopy revealed severe inflammation (in the stomach) and colonisation by the bacteria,” says Dr Marshall.

‘We can cure you’

How have the dynamics of diagnosis and treatment changed over the years? “We can cure you. Every patient wants to hear about a correct diagnosis from his doctor. Most people may only have one ulcer episode in their lifetime, a first episode of a symptomatic Helicobacter infection.

Because we can eradicate the bacteria (Helicobacter), it’s not quite so important to do all those investigations like the expensive endoscopy. Most people would just need a diagnosis of the bacteria with serology, or a breath test, or even the stool test,” maintains Dr Marshall.

However, he adds, “I am afraid that for now, treatment of Helicobacter is not going to cure stomach cancer once you have that. Therefore, especially in China and many parts of Asia and South America, where incidences of stomach cancer are quite common, we still need to perform an endoscopy on people. But, eventually, I believe that stomach 22 FUTURE MEDICINE I December 2012

Dr Barry Marshall with a copy of Lawrence Altman’s ‘Who Goes First?’, the only complete history of the understudied practice of self-experimentation.

Photo: Adrienne Marshall

cancer cases will decline in the coming years once we succeed in eradication of Helicobacter.”

Misconception

Is there any public misconception about Helicobacter? “I don’t think Helicobacter spreads through eating or contamination of cooked food, although I have heard of speculative reports of Helicobacter infection in China just because people eat with chopsticks from the same bowl. It is just suggestive of transmission but it is unproven. So, firstly, we

should educate the vulnerable populations about the utmost need for hygiene, clean water supply and river systems. Helicobacter survives in water/river systems. It is never dormant. Once this bacteria enters your stomach, it infects you and stays active (until effective treatment),” says Dr Marshall.

Making the right choice

“Serology is the least expensive test but is sometimes false-positive.

This means that many people are unnecessarily taking antibiotics

for at least a week before undergoing such tests, or else, Helicobacter may not show up in the tests, despite presence in the system,” says the Nobel Laureate.

The other problem is that many people have Helicobacter pylori with no symptoms, Dr Marshall says, adding, the likelihood of cancer persists in patients who have Helicobacter for over 30 years or the whole lifetime. Talking about the possibility of an oral vaccine against Helicobacter, he says, it is coming in the next few years. But the exciting news is that we might also use Helicobacter to vaccinate against other infections such as influenza. “We need to mix a harmless strain of Helicobacter with DNA from a flu virus. Once you drink this concoction, the Helicobacter would make part of the flu virus as it colonises your stomach.

Then you could possibly get vaccinated against influenza and also suffer few side effects from an eradicable strain of Helicobacter which will last in your system only for a short time period. My company is already working on an H Pylori technology platform like this. The same technological parameters should be tried for vaccine development against a host of other dreadful diseases, including HIV/ AIDS.”

Frustrated by not being taken seriously by my colleagues, in July 1984, in a desperate attempt to prove that this bacteria was harmful for humans, I grew it from a specimen collected from a patient with gastritis. I then drank a bacterial cocktail.

Five to seven days later, I suffered from nausea and vomiting.

An endoscopy revealed severe inflammation (in the stomach) and colonisation by the bacteria these days. That is the dilemma in developing countries. Endoscopy is quite expensive. When subsidised, it is sometimes cheaper as compared to a breath test. Yet, non-invasive diagnosis, like the breath test, is the way ahead. It is accurate. It should be made available through hospital programmes. Breath tests cost around USD$25 in India and around $15 in China. I recommend the urea test but also the stool antigen test is nearly as accurate. For the breath test, it is highly recommended that patients do not take any medication

Personalised medicine

“With personalised medicine, we will have customised treatments with no side effects. It’s (emergence of personalised medicine) going to take another 20 years. And it will become inexpensive with the genomics industry taking huge leaps.

In India, cities like Hyderabad are

well-known for genomics research,” says Dr Marshall.

Current engagements

He says, “Currently, we are looking into all aspects of research at the Helicobacter Research Laboratory, Marshall Centre, University of Western Australia.

Helicobacter is a very interesting germ. We can do interesting work on diagnosis, treatment, genomics, evolution, among other areas.

We also run a Masters course at Marshall Centre in infectious diseases, with students from all over the world. My company, Ondek, is trying to make vaccines.

Helicobacter is quite a difficult bacteria to work with. Each experiment with Helicobacter takes at least one week. I am also interested in making diagnostic tests.”

Message to the global community

“My recommendation to governments across the world is that they should support young scientists with adequate funding because we still do not understand the complete immunology of the human body.

Community education is equally important,” says Dr Marshall.

Acknowledging the challenges of individual excellence in the domain of science and technology, he says, “Obviously, not every scientist is going to win the Nobel Prize. But they can work with governments...

For instance, with a regulatory body like the US Food and Drug Administration. Governments should ensure speedy approvals and build strong policy support systems for effective products of pharmaceutical companies, helping them bring down the cost of drugs.”

He concluded the interview with the hope that “the global communities and governments will adopt the right attitude, understand the challenges of the day, and act in earnest”.

December 2012 I FUTURE MEDICINE 23

COVER STORY - NEW STRIDES IN HEALTHCARE Cognitive Science & Dr Adrian Owen

Unearthing

cognitive powers of a ‘vegetative’ patient

By Sanjeev Neelakantan 24 FUTURE MEDICINE I December 2012

Do patients who are believed to be in an “unconscious” and vegetative state have the “ability to think”? Can doctors open a channel of communication with such physically non-responsive patients? At a time when patients in a vegetative state are considered “lost cases”, renowned British neuroscientist Dr Adrian Owen and his team of researchers have succeeded in giving medical science a whole new direction with the groundbreaking discovery of a means of establishing communication with such people with the help of technological apparatus. Dr Owen and his team recently “communicated” with a Canadian man who has been in a vegetative state for over a decade and learnt that he “is not in pain”.

How? They used a functional magnetic resonance imaging machine (fMRI) to analyse brain activity patterns in Scott Routley, a patient who sustained a severe brain injury in a car crash 12 years ago. Dr Owen says he asked Routley to imagine that he was playing tennis if he wasn’t in pain, or imagine that he was walking around his house if he was in pain. Thinking about these movements triggered activity in different parts of the brain, which could then be measured by the fMRI in real time. And that’s what helped Dr Owen “communicate” with Routley and understand that he was not in pain.

In an interview with Future Medicine, Dr Owen talks about his research on the “consciousness” or “cognitive” potential of people in a vegetative state.

Extending rehabilitative care in terms of improving cognitive responses of such patients is the long-term goal, but then we are still at the early stages of research as of today, says Dr Owen

Dr Adrian Owen

COVER STORY - NEW STRIDES IN HEALTHCARE Cognitive Science & Dr Adrian Owen

What’s your perception of patients in a vegetative state, considering that such cases are written off as “lost cases”?

Well, I think every patient is different and that is the important thing. Some of them have abilities that are simply not detectable using standard clinical examination, as we have shown. For other patients, even imaging demonstrates that they are non-responsive. So, I think this teaches us that we have to treat every patient as unique and do the best that we can to characterise any residual abilities that they may have.

What helped you evolve techniques facilitating communication with such patients?

A lot of what I do is driven by technology.

This would never have been possible even a few years ago because we did not have this sort of rapid (real-time) functional magnetic resonance imaging (fMRI) that we now use routinely in these patients. I was also helped by a curiosity about consciousness and the idea that I have had for many years that some of these patients may have residual abilities that we simply don’t know about.

Tell us about the techniques, the application processes, and the success you have been able to achieve in terms of rehabilitative care for such patients.

First, we are at very early stages and it would be wrong to assume that we have been able to add rehabilitative care for these patients.

What we are able to do is to better characterise any residual cognitive abilities that they may have. We do this with techniques like fMRI and electroencephalography (EEG). We ask patients to imagine certain scenarios (like playing tennis) and we are able to detect the responses in the brain indicating that they are “command following” even if they are not physically responding at all. In future, I do hope that this will assist in efforts towards rehabilitation (for example, rehabilitation efforts could be targeted towards those cognitive functions that are shown to be intact), but we are not at that stage yet. We are just beginning.

When did you achieve a breakthrough in understanding the imaginative potential and brain activation of such patients, making you confident of their status of being “conscious”?

Our paper in 2006 in the journal ‘Science’ was the first to establish that some of these patients (in that case, it was just one case) 26 FUTURE MEDICINE I December 2012

are actually conscious. So, that was the moment when everything changed. In 2010, we published a paper with many more patients, showing that about one in five of them were conscious. These studies told us how frequently this (cognitive response) occurs in this population.

How far are we from introducing rehabilitative care into mainstream clinical practices and what are the hurdles?

As I said before, this is not a rehabilitation technique. It is a way of discovering patients who are conscious but incapable of expressing that to their carers and clinicians. As for introducing the technique more widely clinically, we are some way off that for now because it is incredibly complicated and requires significant expertise in functional neuroimaging, statistics, neuroanatomy, and other aspects of cognitive neuroscience. It also requires a certain type of scanner that is not available in every hospital.

Most of these scanners are used purely for research and are not available for general clinical use.

Tell us about the plan to make EEJEEP (a jeep equipped with experimental equipment) an international project for people in a vegetative state.

EEG is considerably cheaper and more portable than fMRI. We have developed a system using EEG that can detect consciousness at the

been covered under your study so far and how promising is their cognitive response?

We have probably seen close to 100 patients in the last five years and one in five of them (approximately) shows good signs of having residual consciousness.

So, in the majority of patients, we see nothing, but in a significant minority, we do see a cognitive response.

Is there any other research body in the world that has taken a similar initiative to help those in a vegetative state?

Not to my knowledge. My work is funded, in part, by the McDonnell foundation in the USA. So, in a sense, they are certainly contributing to helping these patients. My main funding comes from the Canadian government through a Canada Excellence Research Chair Program, which has enabled me to reach my recent goals, and previously, I was funded in the United Kingdom by the Medical Research Council.

What’s your message to those who have challenged your theory of a patient being in a “conscious” state?

bedside in some of these patients.

The entire system is portable and we travel from patient to patient in the so-called EEJEEP. This is certainly a technology that I can easily imagine scaling up to be more internationally available. The EEG technology is widely available and affordable, and through my international collaborations, we are now doing this in several countries. However, it is important to realise that this is still a complicated scientific challenge involving significant expertise that is not as widely available as would be necessary for this to happen everywhere. That is to say, it will

not be available for every patient for some time.

What are the challenges on the research front and how do you plan to take the research forward?

I don’t really have time to go into great detail about my future plans. We are concentrating on making this technology more widely available, seeing more patients, developing the EEG to allow real-time communication, and much more. You will certainly read about it in the scientific literature.

How many patients have

They are wrong. We have now published numerous studies in peer reviewed scientific journals demonstrating that some (albeit rare) patients may be conscious and able to communicate information by modulating their brain activity, yet be entirely physically non-responsive at the same time. When those people who challenge this are able to show me a single UNCONSCIOUS patient who can answer questions in the scanner (such as “does your sister have a baby or not?”), then I will be happy to debate the significance of my findings with them. I have presented data to support my findings. Similarly, they need to present data to refute my findings.

December 2012 I FUTURE MEDICINE 27

COVER STORY - NEW STRIDES IN HEALTHCARE Cancer Imaging Tool of Hubrecht Institute, the Netherlands

A mousetrap for cancer

By Sanjeev Neelakantan

How did you arrive at the idea of surgical implantation of imageryenabling windows into the bellies of live mice and how did you carry out this procedure?

There’s a new window to understand cancer cell formation and metastasis (spread of primary tumour/cancer to other/distant parts of the body). Pioneered by Dr Jacco van Rheenen and his colleagues at Hubrecht Institute for Developmental Biology and Stem Cell Research in Utrecht, the Netherlands, a real-time imagery-enabling window system, surgically implanted into the bellies of live mice, is a first in understanding the outgrowth of the metastatic process in abdominal organs like the liver. In an interview with Future Medicine, Dr Jacco and his research associate Laila Ritsma, MSc, focus on the factors enabling better comprehension of the process of metastasis through the mice-enabled technique 28 FUTURE MEDICINE I December 2012

For the visualisation of tissue and cells, light should penetrate tissue. However, skin and other tissue are not translucent. Therefore, researchers surgically exposed the tissue of interest. Instead of surgically removing the skin and the abdominal wall in between the microscope and the organs of interest, we implant a small frame with a glass window in the skin and abdominal wall, which gives a direct view onto the abdominal organs. The concept of implanting an imaging window into a mouse to be able to see the underlying tissue is not a new concept; there were such windows to study, for example, the breast, the brain, and the skin. However, none of these windows permitted to study the abdominal organs, like, for example, the liver. Since we

wanted to study the outgrowth of the metastatic process, which can be done in the liver, we decided to design a window that would allow us to image abdominal organs like the liver.

We implanted the window into the skin and abdominal wall of the mouse, using a purse-string suture to securely fix the window in the mouse.

What are the accepted clinical diagnosis procedures in relation to various types of cancer as of today and how different and efficacious is this window imaging system?

Our finding concerning the liver metastasis formation cannot be directly translated to the human situation. More research is required before this can actually be translated to patient treatment.

Moreover, our imaging technique involved genetic labelling of cells, which precludes the use of our technique in the clinic.

How has this enabled you to understand tumour metastasis in a better way?

It is increasingly appreciated that only a small percentage of cells within a tumour drives its growth and spread, and that the behaviour of these cells change over time. Most techniques image fixed and dead tissues, and, therefore, provide a snapshot of a large number of cells, lacking crucial information on the history of the individual cells that provide growth and spread. In the last few years, these populations of cells have been studied by imaging individual cells in primary breast and skin tumours in living animals. These studies showed how tumour cells behave when they escape from the primary tumour by entering the circulation and spreading to distant sites such as the liver. However, what happens once cells arrive in the liver is predominately a black box, because imaging techniques to visualise these cells in abdominal

Dr Jacco van Rheenen organs over a time span of weeks did not exist yet. Using our new imaging technique, we can now open this black box and study the mechanism of the formation of liver metastases in much more detail.

This is really exciting since the real-time visualisation of tumour growth show that tumour cells are much more dynamic than what we thought, based on the static images, and often leads to surprising findings.

What do you intend to achieve through this research technique? What do you do after observing the cancer cell formation and movement process?

We are currently using this window to study the molecular mechanisms behind cancer

progression and metastatic development and how these processes can be stopped using chemotherapy. For example, we want to know how tumour cells survive chemotherapy and cause recurrence; what characteristics do the cells have that remain alive after chemotherapy, and how do they manage to grow a new tumour.

What cancer/tumour studies have you undertaken so far?

Have your findings given a new dimension to cancer research?

It is assumed that cell movement is only important for the early phases of metastasis, where cells have to escape from the primary tumour site and spread to distant sites. Since the tumour cells of patients that present themselves December 2012 I FUTURE MEDICINE 29

COVER STORY - NEW STRIDES IN HEALTHCARE Cancer Imaging Tool of Hubrecht Institute, the Netherlands

in the clinic with metastasised tumours have already spread to distant sites, it is thought that inhibition of tumour cell movement does not prevent the progression of metastasis. However, in mouse models, we show that cell movement may facilitate this progression. Thus, in addition to targeting tumour growth, cell movement may potentially be an interesting therapeutic target for certain subtypes of colorectal cancers. However, further research is required to determine the extent to which this data can be translated to humans and other tumour models.

How can you translate the success of the mice model into human trials?

The genetic heterogeneity, that characterises colorectal cancer, as well as the genetic background of each individual cancer patient can influence the metastatic process. Indeed, it is currently impossible to predict which patients with stage II colorectal carcinoma will develop metastases and which will not. While the model that we have used is, as all other metastasis models, an abstraction of a highly complex reality, it does provide us with the first ‘live insight’ into the dynamics of liver metastasis development. Critics will say that our model may not be representative of all metastatic (colorectal) tumours, but vice versa, the model may certainly be representative for a subpopulation of such tumours. To fully understand the heterogeneity of the metastatic process, one would need to develop spontaneous metastasis models from many different freshly resected patient tumours and/or in different spontaneous genetically

Imaging technique pioneer Dr Jacco van Rheenen was originally trained in a variety of imaging techniques during his PhD with Dr Kees Jalink at the Netherlands Cancer Institute. He was among the first to optimise imaging and develop software to quantitatively measure FRET (Fluorescence Resonance Energy Transfer) on confocal microscopes. During his PhD in the lab of Dr Jalink and as part of his post-doctoral

30 FUTURE MEDICINE I December 2012

engineered mouse models prone to colon cancer development.

Are there other imaging techniques that have been introduced by Hubrecht Institute?

Our window was the first new imaging tool introduced by the Hubrecht Institute.

How is metastasis a more serious condition than the primary condition of cancer itself?

Most patients die because of metastasis, and not because of the primary tumour. The primary lesion can usually be removed from the body by a surgeon. However, once the tumour has spread, the cancer cells might be everywhere, and they are usually difficult to detect and, therefore, difficult to treat. Usually, these metastases go to organs like the liver, or the bone marrow, in which it is difficult to remove these metastases. Also, it is impossible to remove too many metastases, because too little normal tissue would remain to keep a patient alive.

What are the achievements of the scientific community in metastasis research?

It is becoming clear that tumours and metastases are much more heterogeneous than was anticipated. For example, cancer stem cells, the driving forces behind tumour growth, have recently been found in a number of cancers.

Current research focusses on how to eliminate those cancer stem cells to treat patients. research in the lab of Dr Sonnenberg (Netherlands Cancer Institute), Dr Jacco used several microscopy techniques to study lipid signalling in tumour cells. In order to broaden his scales, he obtained a KWF fellowship to do a post-doctoral research in the United States in the lab of Dr John Condeelis. While there, he extended his imaging experience by imaging mammary tumours intravitally, including two-photon microscopy, and became an expert in the field of intravital FRET imaging. In 2008, he was appointed as group leader at the Hubrecht Institute, where he utilises his imaging techniques to visualise the metastasis cycle of mammary tumour cells in living animals. In 2009, he was awared a VIDI grant and a research grant from the Dutch Cancer Society.

COSMETOLOGY

Acne: What to do

and what not to do

What is Acne?

Acne is a chronic inflammatory disease of the pilosebaceous units (oil glands) with seborrhea (excessive oiliness), comedones (black and white heads), papules, pustules, nodules, and cysts. The eruption usually occurs on the face, back, chest and arms, and is commonly found in adolescents.

Both sexes are affected, but it tends to be more severe in males.

The androgens act on the sebaceous glands at puberty and leads to increased secretion of sebum. The dead cells, bacteria, and sebum form a plug at the outlet of the pilosebaceous follicle leading to “pimples”. Severe Acne leads to severe scarring and causes significant psychological distress.

Resolution is seen in the early twenties, but it may persist longer in some.

What affects Acne?

Diet: This is a commonly asked question. Though until recently, it was argued that diet has no role in Acne, now we cannot dismiss the association between the two. If a 32 FUTURE MEDICINE I December 2012

patient notes an association between a certain dietary factor and Acne severity, it might be worthwhile to avoid the same. Foods with high glycemic content and dairy products have been found to aggravate Acne.

Environment and occupation: Hot and humid conditions and occupations dealing with oil can cause an aggravation.

Medications: Certain medications, like steroids, contraceptive pills, antituberculosis and antiepileptic medication, can cause a flare.

Other factors: Premenstrual flare is common. Emotional stress can also aggravate Acne.

What to do?

Acne must be treated early to avoid scarring and prevent psychological trauma, especially to teenagers.

Patient must be told that the problem will persist for a few years and that they can get a good control over lesions with proper treatment.

• The face must be washed three to four times a day with soap and water.

• The scalp should be cleaned, preferably with an anti-fungal shampoo once or twice a week.

• All greasy cosmetics must be avoided. Cosmetic use is to be limited to necessary social engagements. Preferably, use water-based cosmetics.

• Do not squeeze pimples! It leads to severe scarring.

Treatments available: Medical: Choice of therapy depends mainly on the severity, extent, and the type of lesions. Various topical medications, like benzoyl peroxide,

Dr Divya Ramkumar Dermatologist & cosmetologist

antimicrobials like clindamycin, clarithromycin, and erythromycin, and retinoids like tretinoin and adapalene, are available. Topical preparations of azelaic acid, nicotinamide, and salicylic acid are also being used. Depending on the severity, a patient may be prescribed oral antibiotics and retinoids.

Surgical: Different procedures are done for faster resolution of Acne lesions (along with medical therapy) and for scars. The procedures include comedone extraction, evacuation (suction followed by incision and drainage for papules, pustules, and cysts), intralesional steroids for nodulocystic lesions, cryoslush , chemical peeling with glycolic acid, salicylic acid, yellow peel (tretinoin peel) etc. Chemical peels are also useful for the post-inflammatory hyper pigmentation and for scars.

Intense pulsed light (IPL) and various other light therapies and photodynamic therapy are gaining importance in Acne management.

The modalities adopted for scar therapy are microdermabrasion with aluminium oxide crystals, or with the newer diamond tip, chemical peels, subcision, punch excision, and closure, or incision, and elevation, dermabrasion, use of fillers, and the newer laser therapies. Currently, fractional laser with either the CO2 or the Erbium YAG are the treatments in vogue with limited downtime and minimum side effects, giving good cosmetic results.

Patient education is of utmost importance in Acne management.

Dr Divya Ramkumar, MD, works with Sun Medical and Research Centre & Carewell Clinical Centre in Thrissur, Kerala

WELLNESS SPECIAL THE ART OF WELL-BEING

Well, well, well, how well are you?

Dr Halbert L Dunn, the father of the wellness movement, defined high level wellness for an individual as an integrated method of functioning, which is oriented towards maximising the potential of which the individual is capable.

It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning

By Sreekanth Ravindran

34 FUTURE MEDICINE I December 2012

F

rench chemist and microbiologist Louis Pasteur, famous for the discovery of Rabies vaccine, overturned his own germ theory while in death bed and concurred with fellow countryman and physiologist Claude Bernard on the importance of balance in the body’s internal environment. “It’s not the bacteria or the viruses themselves that produce the disease, it’s the chemical by-products and constituents of these microorganisms, enacting upon the unbalanced, malfunctioning cell metabolism of the human body, that, in actuality, produce a disease,” Pasteur had observed, adding, “Bernard was right, the germ is nothing - the milieu (the environment within) is everything. It is the terrain what matters and not the germ.”

The meaning of wellness cannot be restricted to absence of diseases. Broadly, it refers to a state of overall well-being of an individual, encompassing variables such as physical, emotional, social, intellectual, spiritual, environmental and occupational comforts. The World Health Organisation defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease, or infirmity. Dr A Sreekumar, Chairman and Founder of Wellness Solutions, a wellness clinic in Kochi, Kerala, says, “A fine balance between exercise, relaxation, healthy food and supplements is the key to wellness or optimal health in the modern, fast world and future nano world. Though right eating, exercising, and good sleep play an equal role in the prevention of infections and diseases, a good sense of self, a loving support network, and the potential for continued personal growth are also important to our overall well-being.”

Though humans may never be able to assume control over the factors (genetic, environmental, or immunological) causing illness, there are many ways to ensure wellness. While the concept of “wellness” is one of the latest and emerging departments of modern medicine, it has always been an integral part of Ayurveda since time immemorial. Dr P K Warrier, the Managing Trustee and Chief Physician of Kottakkal Arya Vaidya Sala, explains: “Ayurveda

primarily looks at the patient rather than the ailment.

This is done by ascertaining the ‘Dosha Prakriti’ of the patient and by utilising the clearly classified herbal armamentarium to bring back the vitiated humoural status of the patient back to its normal status.”

Dr Sreekumar agrees with Dr Warrier. “We should strive to keep our terrain clean. Our terrain is nothing, but our own body and its internal environment, nothing external. Keep it strong for a healthy body and mind. This will, in turn, help us in keeping the external environment healthy and good,” says Dr Sreekumar.

Social Wellness

Man is a social being. Therefore, more than anything, the need for social wellness is paramount.

After all, the life of every human being depends on his/her interactions with society. Dr Pradeep Gowda, a clinical psychiatrist based in Bengaluru, is a researcher on “Genetics, Alcoholism, and Society”. He opines, “Social wellness is the positive influence of a society on an individual’s mental and physical health.

In actual terms, it is a measure of one’s health based on the number of close/personal friends he/she has.

Social wellness directly depends on the quality of time an individual spends with his/her fellow beings and the peaceful, harmonious nature of his/her relationships.”

Several research studies across the world have revealed that the magnitude of health risks increases with social isolation. “In medical terms, social isolation can be linked to heart disease, depression, or any other behavioural disorder. It is a major reason for the growing incidence of mental disorders in our society,” Dr Pradeep adds.

Physical Wellness

The famous Malayalam proverb ‘Chumarillengil Chitram Varaykkan Pattilla’ (You can’t paint, if you don’t have a wall to do so) stresses upon the need to maintain absolute physical wellness throughout one’s lifetime. Put it simply, without physical wellness, December 2012 I FUTURE MEDICINE 35

WELLNESS SPECIAL THE ART OF WELL-BEING

of worries. Dr Gowda asserts, “Life is nothing but a series of unexpected events. While some events are favourable, others could be unfavourable. Hence scientific management of emotions is required whenever we encounter unfavourable events. By managing one’s emotions in a scientific manner, one can prevent emotional issues from acquiring the shape of chronic disorders that can significantly reduce life satisfaction.”

Intellectual Wellness

no human goals are achievable. Healthy eating habits and direct or indirect body workouts are essential for development of an optimal physical wellness system in one’s life. Dr Sreekumar points out, “Prevention is better than cure. It is one’s responsibility to maintain a healthy lifestyle by giving maximum importance to a healthy diet and proper exercises. It will give you a well-toned body, enable you to maintain a high self-esteem and selfconfidence, and always keep you on a determined life path.”

According to Dr Sreekumar, a strong mind resides only in a strong body, and for maintenance of a strong body, one requires the right plan of action. “Proper vitamins, proteins, and minerals should be made essential ingredients of our regular diet. Physical activities should target cardiovascular endurance (the ability of the heart and lungs to function together to provide the needed oxygen and fuel to the body), increase muscular strength and body flexibility. It is also advisable to conduct routine health checkups and tests for diabetes, cholesterol etc at regular intervals,” he adds.

Emotional Wellness

“A scientific man ought to have no wishes, no affections... a mere heart of stone,” observed Charles Darwin, a naturalist who propounded the Theory of Evolution. Was he hinting at complete control over emotions? Well, that may be next to impossible.

Yet, emotional wellness, closely connected to social and physical wellness, is all about pursuing a life of complete emotional satisfaction. Studies conducted on the human mind says that the more we approach our mind in a scientific manner, the more mature we become. However, psychiatrists are of the opinion that unless we train our minds, it is impossible to guard oneself against the burden 36 FUTURE MEDICINE I December 2012

Wellness gained through creative pursuits or intellectually stimulating activities is called “Intellectual Wellness”. According to Dr Gowda, intellectual wellness has nothing to do with one’s academics or progress reports. “It is all about expanding one’s knowledge and skills outside the academic environments by challenging one’s own mind with intellectually stimulating activities.

Generally, people who have high intellectual wellness have low social wellness as they are supremely self-absorbed, or self-obsessed,” says Dr Gowda.

Occupational Wellness

Today, people are very much aware of the occupational hazards at workstations, and given this increasing concern for a hospitable work environment, business magazines and newspapers across the world have been regularly doing news features on the top employers, or best companies, that have been extending a promising package of healthcare, including fitness centres within the office premises, to show that they too are conscious of the well-being of their employees. Such incentivepacked policies are also helping the corporate players in effectively tackling the stress factor and low output issues. Dr E Shaji Raj, a wellness expert, says: “If someone is passionate towards what he does, he wouldn’t feel any stress at the workplace.

On the flip side, he would be able to maintain a fine balance between work life and leisure time, and build better relationships with colleagues.”

Spiritual Wellness

The Oxford English dictionary defines spirituality as “the quality of being concerned with religion or the human spirit”. Like other concepts of wellness, spiritual wellness is an important part of human life. “Though the meaning of spirituality may appear to be different from individual to individual, it is generally considered to be a search for understanding the purpose of human existence or coming to terms with one’s true goal in life. Real spirituality emphasises on shedding one’s own ego.

Spiritually inclined individuals can always help others maintain peace in life,” says Dr Gowda.

WELLNESS SPECIAL Interview - Dr A Sreekumar

Wellness ≠ luxury Wellness = necessity

Dr A Sreekumar, an ENT surgeon-turned-wellness expert, founded Wellness Solutions at Kochi in Ernakulam district of Kerala in 2002. In one decade, this centre developed an entirely new concept of wellness management by integrating modern medicine with Ayurveda, Naturopathy, Homoeopathy, and Yoga techniques, improving the overall wellness quotient of thousands of people, including several patients suffering from cancer, diabetes, heart diseases, and HIV. In an exclusive interview with Future Medicine, Dr Sreekumar observes that wellness is not a luxury, but a necessity for all, as it aims to improve the quality of life from a holistic point of view

By Sumithra Satyan

How do you define “wellness” and what is its importance in today’s fast-paced world?

Wellness can be defined as a state of optimal physical, mental, social, and spiritual health. The world is ever evolving and the speed of evolution is getting faster and faster. Today, given the fast pace of life, we should realise the basic fact that our internal body mechanism remains the same as it has been since millions of years of human existence, despite all the changes we have brought about in this universe.

We should adopt appropriate measures to sustain our life in the changing environment.

Wellness is, in fact, about sustaining our health all the time under any circumstances.

conventional preventive and curative medicine has failed to offer solutions. Nutrigenomics and Pharmacogenomics are paving the way for new trends that aim at personalising preventive and curative healthcare, rather than restricting us to disease-oriented care.

How can we maintain our “wellness” in a fast-paced life?

Proper exercise, relaxation, and nutritious food are essential to achieve wellness in the modern world. Apart from these, a good sense of self, support from social networks, and the potential for continued personal growth are equally important.

What are the milestones achieved by Wellness Solutions?

We have conducted hundreds of free medical camps and seminars in different parts of Kerala and other parts of India, creating awareness about the concept of “wellness”. Now, we have branches in Trivandrum, Trichur, Chennai, and Bengaluru.

We have tie-ups with wellness centres in Goa, Mumbai, and Kolkata, and Malaysia. Our clientele is more than 100,000 and we have full-fledged programmes for schoolchildren and corporate employees.

What is the significance of ‘gene expression’ when we talk about wellness?

The human genome project had been completed in 2003, and the epigenetic research that followed revealed a stunning reality, that an individual is the expression of his/her genes.

About 99.9 per cent of human genes are the same. Only 0.1 per cent difference in expression makes every individual unique and only one per cent of this 0.1 per cent is bad. This bad expression can cause various diseases, and that’s where

Tell us about your transformation from an ENT surgeon to a wellness expert?

I have been inspired by impressive developments in the West and works in the area of wellness, especially by Prof Ian Brighthope. Medical care might have improved life expectancy, but then, I am of the opinion that proactive and personalised healthcare is the need of the hour.

What is your vision on wellness?

Tell us about your future plans as well.

Wellness is not a luxury. It’s a necessity for every one of us.

The concept includes prevention of diseases, cure, achieving longevity and quality of life.

I want to set up wellness centres all across India.

December 2012 I FUTURE MEDICINE 37

WELLNESS SPECIAL Punarjanis Life Sciences, Chennai

Rejuvenation of

the body and mind

Being physically and mentally well is undoubtedly the most essential thing in life. More than any modern medical or scientific discipline, the ancient science of Ayurveda encapsulates the whole concept of wellness, enlisting simple ways of rejuvenating both life and life systems. The treatments are so effective that they can make a person undertaking traditional therapies sense a rebirth of the defence mechanism against the ever-present threats of poor lifestyle and viral or bacterial diseases. Do you think your system is badly in need of a rebirth?

Step into a new life at Chennai-based Punarjanis Life Sciences

A

Bureau

cknowledging Ayurveda as the master among all health sciences, Punarjanis Life Sciences has evolved its very own concept of health and wellness for all by strict adherence to the ancient practices of holistic healing. The Ayurvedic treatment styles at Punarjanis emphasise upon the ultimate aim of all ‘shastras’ (sciences) - enlightenment.

According to the shastras, the body is made up of 72,000 ‘Nadis’ (channels or meridian), which are inter-connected by six ‘Shakthi Chakras’ (spinal energy centres) and three knots. The multitude of treatments offered at Punarjanis is based on these shastras.

Punarjanis is famous for the pulse reading diagnosis method. By feeling the pulse of a patient, doctors can diagnose his/her disease, its character and etiology, the environment where they live, and the diseases they are vulnerable to. This method was quite popular during the ancient times. “By a single touch, experienced physicians can diagnose the disease. Within every human being, there is a divine energy called ‘Kundalini’. In Japanese, it is called as ‘Ki’, and in Chinese ‘Chi’. Treatment is possible only when the Kundalini of a

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patient interacts with the Kundalini of the physician. By their touch, word, or look, they can infuse ‘Prana’ into a patient, thereby removing the negativity of their subtle body,” says Dr E Shaji Raj, the Chairman and Chief Physician of Punarjanis Life Sciences and an expert in pulse reading.

Dr Shaji Raj does not prescribe any bottled medicines or medicines available across the shelf. Instead, every patient is prescribed a combination of herbs as medicines on the

Dr E Shaji Raj, Chairman & Chief Physician, Punarjanis Life Sciences

Prakash Chari, CEO, Punarjanis Life Sciences

At Punarjanis, patients suffering from the most chronic ailments are being treated. The fact that they are being completely cured is something to be proud of

basis of his/her body constitution. “At Punarjanis, patients suffering from the most chronic ailments are being treated. The fact that they are being completely cured is something to be proud of, since we have been able to achieve success in areas where modern medicine has failed,” says Dr Shaji Raj.

Panchakarma

Panchakarma is the main treatment offered by Punarjanis. The other wellness packages include rejuvenation therapy, ‘kayakalpa’ treatment for body immunisation/longevity treatment, beauty care treatments, and spine, neck, and body pain care treatments. The rejuvenation therapy includes ‘dhanyamla dhara’ (pouring of a herbal concoction on the patient’s body), ‘snehapanam’ (intake of medicated oil), vomiting, purging, oil ‘dhara’ (pouring of oil on the body), ‘sirovasthi’ (retention of medicated oil on the head for a certain period), ‘vasthi’ (application of herbal oil, or extracts, through the rectum), and ‘njavara’ treatment (body massage with a special type of rice mixed with medicated milk). This therapy rejuvenates the mind, body, and soul.

Kayakalpa treatment is a traditional form of treatment. It reduces the ageing process,

arrests the degeneration of the body cells, and improves the immunity of the system. The kayakalpa treatment includes body massage, dhanyamla dhara, snehapanam, vomiting, purging, oil dhara, sirovasthi, sneha vasthi, ‘kashaya vasthi’ (herbal decoction enema), njavara treatment, ‘karnapooranam’ (exposure of the ears to medicated fumes), ‘nasyam’ (administration of medicated oil through the nose), medicated steam bath, ‘thalapothichil’ (application of medical paste on the head), etc in accordance with the procedures mentioned in Ayurveda texts. This treatment is recommended for those under the age of 60.

Beauty treatments include application of herbal medicines on the face, herbal cream massage, intake of herbal medicines, snehapanam, medicated steam bath, purging, oil dhara, etc. It improves the tone and texture of the skin and helps one maintain a good body shape.

Spine, neck and body pain care treatments include body massages, sneha vasthi, kashaya vasthi, oil dhara, sirovasthi, njavara treatment etc.

Wellness specialties at Punarjanis • • • • • •

External and internal purification of the body Gaining body flexibility Physical, mental, spiritual, and sexual wellness Effective pain management Rejuvenation and relaxation from stress Treatments and medicines are designed specifically for each patient

Spreading wings to future healthcare

Ayurveda is becoming more popular because of the growing incidence of lifestyle diseases. However, Ayurvedic treatments are becoming more expensive. Therefore, it is imperative for treatment centres to bring down the costs for health and fitness programmes so that all classes of society can have an easy access to wellness initiatives. “We are planning to do some projects for children suffering from cerebral palsy. We will provide affordable treatment for such patients. We are also in the process of establishing our branches in other parts of the country,” says Prakash Chari, the CEO of Punarjanis Life Sciences.

December 2012 I FUTURE MEDICINE 39

ECO TALK

Beware of the watery grave

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he inveterate, irresponsible lifestyle habits of the human collective pose a grave threat to our eco systems. Be it household garbage or industrial waste, a sensible method of disposal still eludes us. That’s just one side of the problem.

The real trouble begins once this waste mixes with valuable life systems such as the very source of our water supply. Today, water pollution is one of the most serious environmental concerns.

Most of us may think that water pollution is something that is limited to the contamination of water bodies that can eventually be put through

40 FUTURE MEDICINE I December 2012

George Scaria Proprietor, H²O Care

the process of purification.

What causes water pollution?

We need to use water every day, both in our industries as well as our homes. We get water from groundwater sources, rivers, and lakes, and most of the water we abuse finds its way back to one or more of these water bodies. The used water from agricultural and industrial sites as well as from households together generate sewage, or waste water. If sewage is allowed to flow back into water systems without treatment, it will lead to pollution. The polluted water bodies harm all

forms of life - humans, animals, and plants. Water also gets polluted due to surface runoff from industries, agricultural land, and urban areas.

This runoff water then flows directly through storm water drains into larger water systems without any treatment.

Sewage disposal is a major problem in developing countries, aggravating the already existing twin problems of poor sanitation and hygiene in large areas through bacterial and viral contamination of vital water sources.

Well, the situation in developed countries is not any better since people there often flush pharmaceutical and chemical products down their toilet, adding to the chemical load of wastewater and sewage.

On the other hand, the direct causes of pollution are oil spillages and dumping of waste in streams, rivers, and oceans. Some of these pollutants (cardboard, foam, Styrofoam, plastic, aluminum, glass, and so on) take a very long time to degrade. For example, foam takes 50 years, Styrofoam takes 80 years, and aluminum takes 200 years, while plastic can take 400 years!

Ways to prevent water pollution

While we should see to it that the government is stringent about their policies related to sewage treatment plants and methods, there are many things that we can carry out individually to prevent water pollution. Given below are a few ways to prevent water pollution: • Toxic products like paints, automobile oil, polishes and cleaning products should be stored and disposed of properly. As a matter of fact, it is better to use non-toxic products for the house as far as possible.

Also, never dispose of such products through your toilets and sinks.

• Dispose of your trash in a proper manner and cultivate recycling habits as far as possible. Non-degradable products should not be flushed down the toilets, for they can end up damaging the process of sewage treatment.

• Refrain from throwing litter into streams, lakes, rivers, or seas.

• Try using environment-friendly household

products like toiletries, soap-based household cleaning material, and washing powder as far as possible.

• Try using natural fertilisers and pesticides as far as possible, or at least do not overuse them. Also, do not overwater gardens and lawns. This will prevent the flow of pollutants into water systems due to runoff.

• Automobile oil should be re-used as far as possible. At the same time, it is important to maintain automobiles in good shape to prevent leakages.

• Actively conserve water by turning the tap off when you do not need running water.

Apart from preventing water shortages, it lessens the amount of water that needs to be treated.

• Avoid buying packaged drinking water as far as possible. The best policy is to carry a bottle of water when you step out of the house. This way, you can avoid and overcome the problem of plastic disposal.

Well, it will save you some money as well.

So, do you think you can contribute towards environmental detoxification? Well, together we can make a big difference.

December 2012 I FUTURE MEDICINE 41

NEWS FROM THE WEB Multiple sclerosis

Nano success in mice model A nanoparticle made from an easily produced substance, approved by the US Food and Drug Administration, has stopped the attack of multiple sclerosis on the immune system in a mice model

Chemical structure of a nerve growth factor (NGF) protein molecule.

This signaling protein is important for the growth, maintenance, and survival of certain nerve cells

H

ere’s a medical breakthrough enabled by use of nanotechnology.

A biodegradable nanoparticle is said be the perfect vehicle to stealthily deliver an antigen that tricks the immune system into stopping its attack on myelin and halt a model of relapsing remitting multiple sclerosis (MS) in mice, according to a report in Northwestern University’s website.

The new nanotechnology can also be applied to a variety of immune-mediated diseases, including Type 1 diabetes, food allergies, and airway allergies such as asthma.

In MS, the immune system attacks the myelin membrane that insulates nerves cells in the brain, spinal cord, and optic nerve. When the insulation is destroyed, electrical signals can’t be effectively conducted, resulting in symptoms that range from mild limb numbness to paralysis, or blindness. About 80 per cent of MS patients are diagnosed with the relapsing remitting form of the disease.

The Northwestern nanotechnology does not suppress the entire immune system as do current therapies for MS, which make

42 FUTURE MEDICINE I December 2012

patients more susceptible to everyday infections and higher rates of cancer.

Rather, when the nanoparticles are attached to myelin antigens and injected into the mice, the immune system is reset to normal.

The immune system stops recognising myelin as an alien invader and halts its attack on it.

“This is a highly significant breakthrough in translational immunotherapy,” said Stephen Miller, a corresponding author of the study and the Judy Gugenheim Research Professor of Microbiology-Immunology at Northwestern University Feinberg School of Medicine, Chicago. “The beauty of this new technology is it can be used in many immune-related diseases. We simply change the antigen that’s delivered,” Miller was quoted as saying by a news report on Northwestern University’s website.

“The holy grail is to develop a therapy that is specific to the pathological immune response, in this case the body attacking myelin,” Miller added. “Our approach resets the immune system so it no longer attacks myelin but leaves the function of the normal immune system intact.”

The nanoparticle, made from an easily produced and already FDA-approved substance, was developed by Lonnie Shea, professor of chemical and biological engineering at Northwestern’s McCormick School of Engineering and Applied Science.

“This is a major breakthrough in nanotechnology, showing you can use it to regulate the immune system,” said Shea, a corresponding author. Miller and Shea are also members of the Robert H Lurie Comprehensive Cancer Center of Northwestern University.

The paper will be published in the journal ‘Nature Biotechnology’.

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HEALTH STUDY Crime & ADHD

ADHD medication may help in stopping crime Criminal tendencies of those suffering from attention deficit hyperactivity disorder (ADHD) can be curbed if they are on ADHD medication, says a new study

A

health study conducted in Sweden shows that the possibility of commission of crime by older teens and adults with attention deficit hyperactivity disorder (ADHD) is much less while they are on ADHD medication. ADHD is the most commonly diagnosed behavioural disorder in childhood. It affects about five per cent of school-aged children. ADHD is diagnosed much more often in boys than in girls.

The study analysed some of the commonly used ADHD drugs and its impact on patients.

Drugs like Ritalin and Adderall, among others, that curbs hyperactivity and increases attention, remain vital beyond the school-age years and wider use of these medications in older patients might help in curbing crime.

“There is a perception that ADHD is a disease of childhood and you outgrow your need for medicines. We’re beginning to understand that ADHD is a condition for many people that really lasts throughout their life,” said Dr William Cooper, a paediatrics and preventive medicine professor at Vanderbilt University in Nashville, Tennessee, US. While Dr Cooper has conducted research on ADHD, he had no role in the new study.

Data shows that about five per cent of children in the United States and other Western countries have attention deficit hyperactivity disorder, which can cause rash behaviour and difficulty in paying attention.

Many youngsters are given medication to help them sit still and focus in school. Some

44 FUTURE MEDICINE I December 2012

people have symptoms in adulthood. It’s well known that individuals with ADHD have much higher rates of criminality and drug abuse than people without ADHD. The study was conducted in 16,000 males and 10,000 females aged 15 and above. For comparison purposes, researchers matched each ADHD patient with 10 similar people without the disorder from the general population. The findings were as follows: • More than 37 per cent of men with ADHD had committed at least one crime during a four-year period, as compared to just nine per cent of men without ADHD. For women, the crime rates were 15 per cent with ADHD and two per cent without it.

• Use of ADHD medicines reduced the tendency of committing a crime by 32 per cent in men and 41 per cent in women.

• The crimes were mostly burglaries or thefts. About 4,000 of more than 23,000 crimes committed were violent. ADHD medication use reduced all types of crime.

The research results compared ADHD and criminal situations in Sweden and other Western countries. The Swedish Research Council, the US National Institute of Child Health and Human Development, the Welcome Trust and other agencies paid for the research. ADHD medicines may help people organise their lives better and reduce impulsive behaviour.

FROM THE OT Largest bilateral kidney tumour

PVS Memorial Hospital creates medical history PVS Memorial Hospital of Kochi, Kerala, has created a special space for itself in the annals of medical history with the surgical removal of a 30 centimetre-long bilateral kidney tumour weighing six kilogrammes. The tumour was removed through bench surgery and autotransplantation

T

By Shalet James

wenty-eight-year-old Sumi Joseph, a the kidneys, something that would have resident of Chingavanam in Kottayam made Sumi dependent on dialysis or renal district and nursing assistant at a private transplantation. hospital, had been suffering from abdominal “One of the major risks involved in the discomfort since 2007. Upon diagnosis, two removal of a large tumour is a sudden, lifetumours weighing three kilogrammes each threatening haemorrhage. Luckily, for the were found in both of her kidneys. past five years, God saved her. It was a very Initially, Sumi had undergone treatment major surgery done in two stages. Opening at the private hospital where she had been the chest and abdomen took around 10 studying. Later, she hours for one side. was sent to Belgaum Under the surgery, in Karnataka for CT we had to take out evaluation. Though a the kidney, cool it large bilateral renal mass with HTK solution, was detected, no surgical resect the tumor mass, treatment was offered and reconstruct and due to the complexity autotransplant it with involved in surgical ventilator support. removal.

Thankfully, just as we had hoped, the Sumi’s hopes surgery turned to be a shattered when many grand success,” said Dr hospitals backed out Abraham. from the surgery because of the high risk factor.

Sumi had luck But last August, when on her side. A major The bilateral renal mass that was Sumi and her family part of the surgical removed surgically knocked on the doors expenses was taken of PVS Memorial Hospital, Senior Urologist care of by the hospital management. Very large Dr George P Abraham rekindled her hope of kidney angiomyolipomas are rarely reported recovery. “The CT scan showed a large bilateral in the medical literature. “To the best of our angiomyolipoma. During our discussion with knowledge, we have removed the largest Sumi, we openly talked about the complexity angiomyolipoma till date. We had performed and risks involved in the surgery. We offered bench dissection and autotransplantation bilateral nephrectomy, bench surgery, and using flower vase incisions for the first time. autotransplantation. We explained to her It has never been reported in the medical field the whole process and consequences of the till date,” said Dr Abraham. surgery and then decided to go ahead only The other doctors involved in the surgery after obtaining the consent of the patient and were Dr Krishnamohan, Dr Thampan, Dr the management,” said Dr Abraham.

Avinash, Dr Datson George, Dr Jisha Abraham, Since it was a large bilateral renal and Dr Das, Dr Nisha, Dr Jithesh, Dr Jacob, and mass, there was a high risk of losing both Dr Felix of the anaesthesia team.

46 FUTURE MEDICINE I December 2012

FITNESS

Dr Mini Mary Prakash Chief Clinical Dietitian, PRS Hospital, Trivandrum

Diet for the

working class

T

he working class is prone to both communicable and non-communicable diseases.

Unhealthy eating habits, irregular shifts, and long working hours make them vulnerable.

We can prevent, postpone, or delay non-communicable diseases like hypertension, diabetes, coronary artery disease, cancer etc by following a proper diet. A balanced diet rich in antioxidants can prevent many diseases and disorders, such as high cholesterol, obesity, acidity, diabetes etc.

Too much cholesterol in our blood can raise the risk of a heart attack, or stroke. High cholesterol levels are generally seen among those who skip their breakfast. To start with, the working class usually skips breakfast because of a fast-paced lifestyle. If we consume a carbohydrate-rich breakfast, then HMGCoA, an enzyme in our body, will increase and cholesterol synthesis will reduce. When breakfast is skipped, the enzyme level decreases, and automatically, the liver produces more cholesterol to compensate. Most of

14 FUTURE MEDICINE I December 2012

the cholesterol in our body is made by liver. The rest comes from our dietary intake. Trans fat found in vanaspathi, chips, and fried items also increase cholesterol levels.

High fibre intake also helps in reduction of cholesterol. Fibre acts as a sponge absorbing cholesterol in the digestive track and carrying it out of the system. All fruits, vegetables, whole grains, oats bran, nuts, citrus fruits, beans etc are rich in fibre. Examples of a balanced breakfast are ‘Puttu-Kadalai’ (steamed cylindrical rice cake layered with coconut, eaten with chick pea curry), ‘Dosai-Sambar’ (a fermented pancake and a mixed vegetable curry), ‘Appam’ (another type of fermented pancake) and egg curry etc. Each one should limit consumption of coconut and oil. Only half kg oil should be used for cooking and five coconuts be consumed per person in a month.

Contrary to popular belief, nuts are among the healthiest natural foods.

However, too much of anything is bad.

Nut consumption in excess can lead to indigestion and weight gain.

FITNESS Dr Mini Mary Prakash

About 20-30 gm or a handful of nuts per day are/is enough for a healthy diet. Nuts are rich in MUFA (monounsaturated fatty acids), antioxidants, calcium, magnesium, potassium, and choline.

Choline helps in preventing fat deposit in liver.

Fats present in nuts and seeds are a combination of MUFA and poly unsaturated fats (PUFA).

MUFA reduce bad cholesterol and increase good cholesterol levels.

Obesity is another health problem. If the food intake is higher than required, then obesity occurs.

Cutting sugar, oil, coconut, and fried foods help reduce weight. If we have two ‘vadas’ (a fritter-type snack) (500 kcal) daily, then it will cause to increase two kg wt/month. Due to its easy availability and taste, most of us have these food items daily.

Instead of vada, take oats porridge, vegetable soup, nuts etc. They are healthy options.

Water is another nutrient the working class often misses. If we don’t drink enough water, our stored fat won’t burn. So, try to drink two to three litres of water per day (minimum) to reduce weight.

The key to build stamina and energy is to stay active throughout the day. If you cannot find one hour in the morning for exercise, you could break it up in smaller segments - one in the morning and the other in the evening. Do keep in mind that being active throughout the day helps burn calories and keeps you healthy both at home and office. The dietary modifications serve as a guide for the obese to make healthy food choices. The daily diet plan should have an energy deficit of 500-1,000 kcal in general. If we deduct 500 kcal from our present diet, we will lose two kg wt in a month.

Acidity is another chronic health problem among the working class. Frequent eating causes lifestyle changes and work-related stress. The stomach normally secretes acids (HCL) that are essential to the digestive process. This acid helps in breaking down the food during digestion. When there is excess of acid produced in the stomach, it results in a condition known as acidity. Heartburn, dyspepsia, bloating, nausea etc are the common symptoms.

Simple eating can help you get rid of this trouble.

Eat a wholesome diet rich in fresh fruits, especially papaya and pineapple. These fruits are high in digestive enzymes such as papain and bromelain that aid digestion. Include vegetables, grains, and high fibre foods. Use asafoetida, cumin, and mint in your daily cooking for their carminative properties (improves digestion and relative gas and colic).

Cabbage juice is particularly good for heartburn.

It has a strong taste, so blend it with some other vegetable juice.

Avoid drinking water between meals as it dilutes the digestive juices produced in the stomach. Eat 48 FUTURE MEDICINE I December 2012

regular small meals throughout the day to avoid over-burdening the digestive system.

Change your eating habits, do not eat on the run.

Eat slowly and enjoy your food. Avoid fried foods, spicy foods, high fat meals, and food containing caffeine (coffee and tea) as these are acidic in nature.

Protein-rich foods are immuno boosters. Boost up your proteins by eating fish, lean meat, low fat diary products, nuts, pulses, and dals (soyabean, rajmah etc). Vitamin C boosts immunity and also acts as an antioxidant. Amla, citrus fruits, tomatoes, green leafy vegetables, lime juice etc are rich in vitamin C. Get more vitamin A and carotene as they help in maintaining the health membranes lining your skin and internal organs. They will be your first line of defence against bacterial, parasitic, and viral attack. Dark green, yellow, and orange vegetables, such as carrot, sweet potatoes, apricots, mango, and fish liver oils are rich in Vitamin A. Vitamin E too has similar health benefits. Nuts, apple, green leafy vegetables, whole grains etc are sources of Vitamin E. Zinc-rich foods are also good for immunity. Good sources are nuts and whole grains. Do not forget essential fats like omega-3.

They are best obtained from nuts, fatty fish, and sea foods.

Probiotics and prebiotics boost immunity. They play an important role in rejuvenating the digestive system by enabling better absorption of nutrients and strengthening immunity. Yoghurt, curd, bananas, and onions are good sources. Honey also helps in improving immunity. So, try to use honey in limited amount, instead of sugar. Small changes in diet can make big difference. So, plan your diet with healthy choices.

SPINE CARE Dr Arvind G Kulkarni

An ideal prescription for success of spine care on a mass scale Dr Arvind G Kulkarni heads the Mumbai Spine Scoliosis and Disc Replacement Centre as a Consultant Spinal Surgeon at Bombay Hospital, Mumbai, one of the oldest and largest hospitals of India. He has vast experience in spinal surgery, having trained in some of the top spinal centres across the globe, such as KEM Hospital Mumbai, National University Hospital Singapore, Westmead Adult & Children’s Hospitals, Australia, St George Hospital, Australia, and Toronto Western Hospital and Hospital for Sick Children in Canada. He is one of the pioneers of Minimally Invasive Spinal Surgery in India. He introduced ‘Micro-Endoscopic’ techniques using the MetrX system for the first time in India in 2007. He is also one of the pioneers of Artificial Disc Replacement. He has performed the first Artificial Disc Replacement (ProDisc-L) in the country, a feat recognised by the Limca Book of Records. His special interests are Minimally Invasive Spinal Surgery, Deformity Correction, Artificial Disc Replacement, etc

By Prashob K P Tell us about the latest techniques and solutions available in the specialised field of minimally invasive spinal surgery.

‘Micro-Endoscopic spinal surgery’ is a specialised revolutionary technique with which routine spinal surgeries are performed using a key-hole. The most common spinal afflictions are disc herniations (slipped 50 FUTURE MEDICINE I December 2012

disc), lumbar canal stenosis, and spinal instability. Generally, an open surgery is done to tackle most of these conditions. However, with the microendoscopic techniques, the objectives of the surgical procedure are achieved without any significant collateral damage to the soft tissue (muscles and ligaments), or the bony skeleton.

Tubular retractors with diameters of

16 mm, 18 mm, and 22 mm are passed through the key-holes to perform the procedures based on the indication of surgery. Apart from the elegance and cosmetic appeal, this technique has several advantages. The scar is miniscule (1.5-2cm long) and appears like an ordinary scratch. Since there is no muscle or bony trauma, the contours of the back are well-preserved. The dependence of the patient on pain-killers for the wound site pain is absolutely minimal as compared to an open surgery. In fact, patients do not express any experience of wound site pain after a few hours of surgery. Since the tissue trauma is so minimal, there is no stress on the patient’s metabolic functions, unlike after a big open surgery that is associated with significant tissue trauma. Most of these patients are elderly with accompanying baggage of associated conditions such as diabetes, hypertension, heart issues, etc and a swift and painless procedure such as this makes a big difference in terms of their recovery. In obese patients, the surgery makes a monumental difference. Obese patients are associated with wound-healing problems. In these patients, a long incision is otherwise needed to reach depths of 7-8 cm (to reach the spine). The entire procedure can be done using a keyhole in these patients (lots of patients with this condition are obese because they do not walk as a result of pain and hence accumulate weight). The blood loss with this procedure is minimal. The patients are made to walk within a few hours after surgery and can go home the very next day. A water-proof dressing is applied so that the patient can take bath as early

as he/she wishes to.

Can you give us the specifics of the artificial disc replacement procedure you have pioneered?

The first Pro-Disc-L (AO Synthes) artificial lumbar disc replacement in India was performed by us at Bombay Hospital in 2008. It is an FDAapproved prosthesis and has polythene (ball) over metal (socket) configuration. The artificial disc allows motion in all planes. The rationale for disc replacement is as follows: spinal fusion (excision of the inter-vertebral disc and welding of the vertebrae abolishing motion) has been the standard of care for unrelenting back pain secondary to disc degeneration. Though spinal fusion has stood the test of time, it has some concerns. Post-operative recovery is relatively slow; non-union, bone-graft site morbidity and instrument-related problems are observed in a certain percentage of cases. Though the incidence of adjacent level degeneration (increased stress on the adjacent inter-vertebral disc) following spinal fusion remains unresolved, biomechanical and kinematic investigations demonstrate increased load and movement adjacent to fused segments. For a long time, there was no alternative between taking chronic medication and undergoing a spinal fusion operation for the diagnosis of degenerative disc disease in the absence of central canal or foraminal stenosis.

Disc replacement is an option for such patients with chronic back pain who meet the selection criteria. The benefits of motion preservation and December 2012 I FUTURE MEDICINE 51

SPINE CARE Dr Arvind G Kulkarni

protection of adjacent levels from non-physiologic loading make prosthetic replacement of the disc a potentially attractive choice.

How affordable are these treatments considering that the techniques involve highend, cost-intensive equipment?

Once you make an investment and buy the minimal access equipment, there are no recurring costs involved – it is usually a one-time investment.

In the long run, the costs are actually cheaper as compared to an open surgery for the patient. The reasons are several – lesser stay in the hospital, less dependence on medication, early return to work, etc. Our recent research shows that the costs borne by a patient undergoing a minimal access surgery, when compared with open surgery, are much less in the event of a post-operative complication. Artificial discs are expensive and basically, the patient pays for the technology.

However, like anything else in the world, once the awareness and the volumes (number) of disc replacements increase, the costs will come down automatically.

Does India have the medical and scientific expertise to pioneer innovative treatments for the spinal injury-induced paralytic patients on the lines of the Miami Project to Cure Paralysis?

It is not difficult to organise for the expertise – we have the brains. The problem lies in developing an infrastructure. How many dedicated comprehensive spine care centres do we have in India? First of all, we have to change our mindset. Most of the investments in healthcare in India are profit-driven. Unfortunately, spine injury-paralysis treatment is low on priority. At the same time, a lot of money, perseverance, and patience are necessary to develop such centres.

The government, or someone from the corporate sector, must take an initiative to fund such investments.

Is there a lack of mass awareness on availability of effective treatments for spinal injuries?

Yes. There are several reasons for the same. Although back pain is extremely common in society, there is meager understanding of the subject in our routine curriculum during MBBS. There is no stress on understanding the basics of spinal 52 FUTURE MEDICINE I December 2012

functioning, spinal disorders, and treatment options during basic training. Let alone basic MBBS training, spine training is very basic, if not almost absent, during MS (Orthopaedics) courses in many university hospitals in the interiors.

Unless the doctors are trained, awareness about the importance of spine care will not percolate down to the general population. The other important reason is scare. Spine surgery was and is still considered dangerous, leading to some kind of neurological weakness. This is because of ignorance of the newer understanding of the subject and treatment options. Now, we have specialised spine surgeons devoted to spine care, enhancing the success rates as well as safety of the surgical treatments.

Can patients undergoing disc corrections or replacement hope of leading a normal life?

Yes, of course. The emergence of newer technologies and deeper understanding of spinal functioning in the last few years has revolutionised the field of spinal surgery. Optimal treatments decided on a case-to-case basis, keeping in mind the pathology, the radiological findings along with patients demands and expectations, yield longterm results. One of the common goals of minimal access spine surgery and artificial disc replacement is ‘re-establishment of normal anatomy and physiology’ of the spine. While minimal access surgery achieves goals of surgery with least collateral damage to the muscolo-skeletal structures, artificial disc replacement maintains

programmes of the Centre or states?

Yes. This is extremely necessary. A lot of backs and necks can be saved. The spine is an integral and key component of the human body. Disability resulting from spinal ailments is quite common, affecting work and activity. Back pain is the most common reason for sickness absenteeism worldwide. An initiative such as this would bring focus on spine just as all other major specialties.

What’s the incidence of spine injuries in India and how many of these cases have attained success?

We do not have statistics on this. However, based on my experience, I can say that it is quite common. Most of these are a result of road traffic accidents (two-wheelers) and falls from construction sites. Unfortunately, most of these patients are young and come from poor economic backgrounds. It is universally well-known that the partially paralysed patients have a potential to recover following a spinal injury as compared to completely paralysed patients, provided early surgical intervention is done.

spinal mobility.

What are the challenges in the field of spine care as of today?

The most significant challenge is creation of awareness among people that spine problems do have excellent solutions.

Although there are spine specialists in the major cities, such as the state capitals, the two-tier cities and towns lack expertise. This issue needs to be taken into consideration and more training centres and fellowship opportunities should be provided. We also need to develop special spinal physiotherapists and develop rehabilitation centres for spine care, especially the spinal injury patients. The other challenge is to make treatment options affordable to the majority of the population.

Are Indian spinal treatments at par with the global standards?

In the major cities, yes. The only area where we lack is research and development.

In terms of technology, we are slightly behind the global standards. In terms of expertise, we are as good as the global standards.

Is there a need for inclusion of spine care as a special initiative in the health

An accomplished spine surgeon Dr Arvind G Kulkarni

is an invited faculty at most of the national spine conferences and workshops.

He has made various national and international podium presentations. He has numerous scientific publications in high-impact journals to his credit. He has also contributed to chapters in textbooks. He is in the Editorial Board of Indian Journal of Orthopaedics for the section on spine.

He has done clinical research in various fields – morphometric study of Indian skeletal structure and size in relation to the application of implants; craniovertebral index and its application; innovative treatment of neglected high-degree scoliosis; spinal tuberculosis etc. He was awarded the International Spinal and Spinal Cord Spinal Injury Best Paper Award in 2012. He was awarded the Association of Spine Surgeons of India’s Best Publication Award in 2005. He has been awarded the Scoliosis Research Society (USA) Global Outreach Award twice in 2004 and 2005. He has been a recipient of the Korean SICOT Award in 2008.

December 2012 I FUTURE MEDICINE 53

ABORTION

Right to Life:

No shortcut to

safe abortion

U

S-based Guttmacher Institute has released a report entitled “Abortion worldwide - a decade of uneven progress”. It says that the worldwide abortion rate has fallen by 17 per cent, from 35 to 29 per 1000 women of childbearing age, resulting largely from a reduction in safe abortions in Eastern Europe, where abortion is legal. However, the abortion rate decreased less in areas where the procedure is still illegal and, therefore, remains unsafe. The developing world is now ahead with 29 abortions per 1000 women of childbearing age as compared to 26 in the developed world.

Worldwide maternal mortality due to abortions remained static, at 70,000 deaths per year. Most deaths still occur in sub-Saharan Africa (38,000) and south-central Asia (24,000). This tragic and unnecessary toll follows from an unchanged rate of unsafe abortions: 14 per 1000 women of childbearing age, currently at 20 million annually.

Thus, somewhere in the world a woman dies every 8 minutes because of an unsafe abortion.

Additional barriers to safe abortion include the procedure’s high cost, a deficit of trained physicians, and lack of confidentiality (consent being needed from a family member).

Improving sex education and access to effective contraception methods can reduce the rate of unwanted

54 FUTURE MEDICINE I December 2012

pregnancies and the need for unsafe abortions. Expanding reproductive services can extend health coverage and the quality of post-abortion care. Abolishing legal restrictions on abortion can not only make the procedure more accessible, less costly, and safer, but will also fulfill a basic human right for women worldwide.

India implemented the Medical Termination of Pregnancy Act in the year 1971, followed by introduction of additional rules in 1975. As per the Act, no place shall be approved for conducting an abortion unless the government is satisfied that termination of pregnancies may be done therein under safe and hygienic conditions; and the following facilities are provided therein: • An operation table and instruments for performing abdominal or gynaecology surgery: • Anaesthetic equipment, resuscitation equipment, and sterilisation equipment; • Drugs and parenteral fluids for emergency use.

It is appreciable that patient interest groups raise an uproar whenever abortion is denied to Indian citizens staying abroad - a practice which measures the value of life differently in different countries.

However, it is equally important to ensure that abortions taking place in our own country, where it has been legal for decades, are performed with highest possible safety so that unsafe abortions do not add to maternal deaths. In recent times, two important systemic changes have impacted the Indian healthcare system positively: the NABH accreditation, which assesses

Dr Jitendar Kumar Sharma Member, Faculty of Health Sciences at University of Adelaide, Australia

healthcare facilities in terms of patient safety and quality of care; and the Clinical Establishment Act, which evaluates healthcare facilities in terms of governance robustness to ensure public and patient good. It is desirable that these two systemic models have specific considerations for facilities that are engaged in providing abortion services. These specific considerations may include adequacy of staff, availability of drugs, continuity of care to the patient, safe clinical practices, and social counselling. Being a country known for having a legal system for abortion, it would be politically and socially obligatory to ensure that abortion as a procedure is practiced in highest safety, considering the unsafe abortions mushrooming in unidentified and unknown settings.

It would also be desirable that international organisations engaged in healthcare provide a base for a uniform maternal and child health law that upholds equal right towards abortion, care during pregnancy, childbirth, immunisation and family planning, irrespective of nationality or place of residence.

Dr Jitendar Kumar Sharma has served as Hospital Administrator for a number of years at Sri Sathya Sai Institute. Later, he served as a consultant to the World Bank and the World Health Organisation in the division of medical devices. He is part of the Faculty of Health Sciences at University of Adelaide, Australia, and Advisor to Health Technology Innovation Centre of the Indian Institute of Technology, Madras. He has authored many research papers and two books

PUBLIC HEALTH

Dr Mathew George Assistant Professor, TISS

We need a

robust public health system

The basic goal of public health practice has been to prevent the occurrence of illness in a population through organised community efforts and not mere treatment of the ailing ones

H

ealthcare in India is currently a $65-billion industry and targeted to achieve $100 billion by 2015. This implies that there is tremendous growth not only in the quantity of healthcare but also in terms of quality. This is obvious from the growth of pharmaceuticals, laboratories, and other allied sectors.

Is this a good trend? Is this a sign of progress? If so, progress for whom?

What does this mean to the health of the population, or public health?

Public health is a discipline and a profession that emerged in the post-war years. Having achieved prominence, it is a discipline that has immensely influenced medicine in terms of knowledge, though, at times, hindered growth of the former. The relationship between medicine and public health is unique in its own way. The uniqueness is borne out of the fact that when public health of a nation is good, then the country needs very little medical care. It is through public health surveillance that a nation will know about its burden of disease, which may aid in planning its medical care. Thus, the growth of healthcare needs to December 2012 I FUTURE MEDICINE 55

PUBLIC HEALTH Missing Links and Challenging Pathways be cautiously viewed, taking into consideration the implications of it on public health. Public health aims at ensuring the health of a population through organised community efforts, with medical care at the core. Only in recent times did the term “healthcare” emerge as a category which mistakenly gives an impression that it is capable of ensuring public health. Moreover, in the field of public health, there has always been a tug of war between those proposing a social model and arguing that the health of a population is determined mainly by factors other than medical care and those who propose a medical model, where medical care is the most important determinant of the health of the population.

One of the reasons for this is the fact that public health as a discipline emerged from the discipline of medicine and, therefore, has a biomedical focus, wherein public health practice historically progressed from a social model approach that addresses issues of overcrowding, water supply, and sanitation to prevent diseases of cholera, TB and so on.

Public health: A discipline and a profession

When it achieved the status of a modern discipline, C E A Winslow in 1920 defined “Public Health” as the “art of preventing disease, prolonging life, and promoting health and efficiency through organised community efforts”.

Thus, the basic goal of public health practice has been to prevent the occurrence of illness in a population through organised community efforts and not mere treatment of the ailing ones. Historical evidences across countries, both Western and the East European, shows that medical care per se has not been significant in organised community efforts at a time when public health among those populations was poor.

The improvement was mainly due to improved standard of living, especially diet and sanitary conditions. This again raises the above mentioned questions more critically; whether the growth of

56 FUTURE MEDICINE I December 2012

healthcare helps in achievement of public health goals? If not, then why is it that a nation fails to invest in public health instead of investing in healthcare?

Public health across the globe

It is important to examine public health movements across the world. The most acclaimed historical analysis of the public health situation that resulted in the first Public Health Act of 1848 was in England, when Edwin Chadwick identified the sanitary conditions of the working population as a strong determinant of several infectious diseases. It is claimed that the idea of sanitary movement owes to the French Public Health Movement, which started slightly earlier and tested its theories during the cholera epidemic of 1830s. In Paris, thanks to the concerns of public hygienists, the sanitary movement later became the sanitary revolution. It brought about improvements in solutions to the problems of overcrowding and disposal of solid and liquid wastes. This growth of public health had parallels in these two countries in terms of approach, though Britain could formalise a better system than the French and make it part of the administrative system.

The United States took up public health slightly later than the two countries, partly because it was a newly-formed state then.

That only helped the US in avoiding several shortcomings France had faced. It is fascinating to note that even the US, which is too liberal as a state, proposed for a state-level intervention in sanitary measures, water supply, and other determinants of public health. For the US, even in the early 20th century, collective public health action was considered a routine function of the state. These included, along with the earlier interventions of quarantine and nuisance removal, aspects of sanitation, water supply, and food protection. With these public health movements, the US could reduce TB deaths in the country from 200 per 1 lac population during 1900

to 60 per lac population by 1940, even before the initiation of antibiotics. Countries like Sweden, the erstwhile USSR, Germany, and others had public health movements alongside nation-building efforts. It is important to note that the state(s) had played an important role in actualising these movements, which happened much before the introduction of medical care.

Public health in India

From the above experiences, it is obvious that understanding the social determinants of various health problems has helped in developing effective, successful strategies for improvement in public health. India as a country failed to have a public health movement of this kind, partly due to the colonial rule till the mid-20th century, a time when medical care attained popularity and significance across the world.

Public health in India hovers around debates on provisioning of medical care and the question of access and quality of medical care.

It is because of this that the linkage between medical care and public health becomes important. This becomes obvious when we examine the kind of public health problems our country is facing, viz. TB, Malaria, and malnutrition on one hand, and problems like accidents, cardiovascular diseases, diabetes, and cancer on the other, along with the re-emerging infections like Dengue, Japanese Encephalitis and so on. This is usually described as dual burden within the public health parlance, but there is more to it.

As mentioned earlier, India as a country failed to have a public health system in place, either within the state, or outside. Whenever there is talk of building a public health system, the focus gets restricted to vaccination and health education, while the core components of public health, like water supply, sanitation, and food supply, remain unattended. On the other hand, in the process of improvements in science, technology and development, our country faces the problems of accidents and pollution of various kinds, including radiations and the most dreaded solid waste (hospital and electronic wastes). Take the case of any city in India, be it the bigger metros, or the tier II cities, the failure of a traditional public health system is there for all to see. The victims of this failure are mostly the poor and the migrant labourers. The natives too are among the affected parties.

Way ahead

It is in this context that the growth of the

healthcare industry needs to be analysed. There should be an architectural correction in the administrative structure with clear demarcation of the functions of public health and healthcare.

This is possible with a better understanding of the concept of public health through identification of linkages between the health of a population and its living and working conditions. This implies an improvement in the provision of traditional health determinants like water supply and sanitation, along with modern determinants like accidents, lifestyle diseases, and pollution. This (task of evolving an all-pervasive public health system) cannot be left to the common people. It should be a state-directed public health system that is competent enough to address both old and new problems by developing an evidence base on disease profiles and linking it to the prevailing social determinants. This will not only improve the overall health of the population but also give a new, meaningful direction to the growing healthcare sector.

Dr Mathew George is Assistant Professor, Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai. Email: mathewg@ tiss.edu Disclaimer: Views expressed by the author are personal November 2012 I FUTURE MEDICINE 57

FOCUS Columbia Asia India

An ethical multispecialty set-up A multispecialty set-up with core specialties of internal medicine and subspecialties, general surgery and subspecialties, obstetrics and gynaecology, paediatrics, emergency care, diagnostics, and critical care, Columbia Asia India is an integral part of India’s secondary healthcare network. A fully-owned subsidiary of Kuala Lumpur-based healthcare chain Columbia Asia with nine hospitals under its aegis, Columbia Asia India’s mission plan is centred on providing the best care services to the urban and semi-urban centres. It has been able to achieve several milestones in terms of clinical values and medical practices over the years. Columbia Asia’s core strengths and specialties define the hospital chain’s immediate as well as ultimate goal of optimal patient care. The hospital has spread its wings across many urban cities in India. As of today, it has many facilities in metros and tier-1 and tier-2 cities, including Bengaluru, Delhi, Kolkata, Patiala, and Mysore. Its hospital at Hebbal in Bengaluru is one of the busiest hospitals in the metro. Columbia Asia’s recipe for growth has been simple. Instead of building huge super-specialty hospitals with 250-300 bed facilities in prime residential areas of metros, it has been concentrating on setting up 100-bed secondary care hospitals in tier-1 and tier-2 cities. In an interview with Future Medicine, Dr Nandakumar Jairam, the Chairman and Group Medical Director of Columbia Asia India, talks about the group’s core strengths 58 FUTURE MEDICINE I December 2012

we mobilise doctors from other Columbia Asia hospitals or appoint locums to ensure appropriate patient care.

What kind of research activities do you undertake? Do you have any clinical trial and drug development programmes?

We do not have any drug development programmes. We do have clinical research and trials, which are done strictly as per the government’s regulations and international standards. We only do phase 3 and 4 trials.

Dr Nandakumar Jairam, Chairman and Group Medical Director of Columbia Asia India

How does your hospital chain bring synergy to the operations and ensure exchanges with renowned specialists?

Our doctors are busy in their respective hospitals.

However, we do share manpower wherever prudent as long as it does not compromise care and it does not impair the function of the doctor’s practice.

Bureau

What have been the milestones set

by Columbia Asia in terms of clinical values and practices and what are your guiding principles?

We believe in establishing world class standards for the practice of medicine in an ethical environment. Evidence-based practices with adherence to well-established guidelines will help us achieve this.

What are your core strengths and specialties and what defines your goal of optimal patient care?

We are a multispecialty set-up. We have the core specialties of internal medicine and subspecialties, general surgery and subspecialties, obstetrics and gynaecology, paediatrics, emergency care, diagnostics, and critical care. Based on the local need, we do tweak the specialty mix.

How many patients do you receive on a daily/annual basis and how do you intend to enhance patient access to specialty care?

This varies from hospital to hospital. In Hebbal, our busiest hospital, we see more than a thousand patients in the outpatients (department) on busy days.

How do you attend to the shortage of medical and paramedical staff?

We have managed to staff our hospitals adequately. Hence, most often, we do not have this issue. However, we do face shortages of medical officers and registrars close to the entrance examinations. Even at such times, December 2012 I FUTURE MEDICINE 59

DENTAL CARE

Maintain good oral hygiene, or else…

Dr Ravi R Hebballi Consultant Oral & Maxillofacial Surgeon

the tongue are some of the dental problems that can cause bad breath. Just using a mouthwash to cover up bad breath will only mask the odour and not cure it. A dental visit is very important if you suffer from bad breath.

Gum disease

Gum disease, also known as periodontal disease, is one of the main causes of loss of teeth among adults. It could also be due to the long-term effects of plaque deposits on your teeth. If you do not remove plaque, it turns into a hard deposit called tartar (or calculus) that becomes trapped at the base of the tooth. Plaque and tartar irritate and inflame the gums. Bacteria and the toxins they produce cause the gums to become infected, swollen, and tender. Bleeding gums most often indicate gum disease. Regular dental checkups along with maintenance of good oral hygiene will help in preventing gum disease.

Mouth sores or ulcers

Tooth decay

Tooth decay, commonly known as a tooth cavity, is the most common problem one faces today. Tooth decay occurs when plaque, the sticky substance that forms on teeth, combines with the sugars of the food we eat. The best way to prevent tooth decay is by maintaining good oral hygiene. Brushing twice a day, flossing daily, and regular dental checkups help avoid decays. Tooth decay, if neglected, can cause infections in the mouth and thereby cause pain, swelling, and discomfort to the patient and may cause loss of the tooth or teeth eventually.

Bad breath

A sizeable number of people today suffer from bad breath (halitosis), which can be very embarrassing. This can result from poor dental health habits and may be a sign of other health problems. It can also be due to the types of foods you eat and other unhealthy lifestyle habits. Studies have shown that people with persistent bad breath have an underlying dental condition. Gum disease, tooth decay, oral cancer, dry mouth, and bacteria on 60 FUTURE MEDICINE I December 2012

There are different types of mouth sores. They can be really troublesome. Canker sores are a common form of mouth ulcer. They may occur with viral infections. Canker sores may also be linked to problems with the body’s immune system. The sores may occur after a mouth injury due to dental treatment, aggressive tooth cleaning, or biting the tongue or cheek. They can also be triggered by emotional stress, lack of vitamins and minerals in the diet, menstrual periods, or hormonal changes.

If a mouth sore lasts more than two weeks, it is advisable to see a dentist and rule out serious causes.

Tooth sensitivity

Tooth sensitivity is tooth discomfort in one or more teeth that is triggered by hot, cold, sweet, or sour foods and drinks, or even by breathing cold air.

The pain can be sharp, sudden, and shoot deep into the nerve endings of your teeth. There are many factors that may lead to sensitive teeth, including brushing teeth too hard, tooth decay near the gum line, recession of the gums, gum disease, cracked teeth, and also ageing of teeth. This sensitivity can be treated and it is better to seek a dentist’s advice.

Dr Ravi R Hebballi is a Consultant Oral & Maxillofacial Surgeon based in Bengaluru, Karnataka

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FOCUS KIMS, Thiruvananthapuram

C for care, C for courtesy, C for competence, C for compassion...

Keep It Moving Sincerely

With a fine fusion of the cardinal principles of holistic care and hospitality with the three-pronged approach of courtesy, compassion, and competence, Thiruvananthapuram-based Kerala Institute of Medical Sciences (KIMS) offers a wide range of services, from anaesthesiology, urology, cardiology and cardiac surgery, oncology, child and adolescent psychiatry, dental, clinical, oral and maxillofacial surgery, endocrinology, diabetes, gastroenterology, hepatobiliary, pancreatic and liver transplant surgery, nephrology, critical care, dermatology, cosmetology, ENT, laryngology, foetal medicine, neurology, and obstetrics and gynaecology to orthopaedics. Other than a centre in Ernakulam, KIMS has presence in Saudi Arabia, Qatar, Bahrain, Oman, and Dubai as well. In an interview with Future Medicine, Dr M I Sahadulla, the Chairman of KIMS, says the basic objective of the hospital chain is to evolve a single point model where all possible kinds of treatments and care services can be made available

By Tony William What inspired you to get into the field of healthcare?

During vacations, I used to take my relatives to hospitals for various treatments.

That’s when I got a firsthand impression of the awful situation in our hospitals. Once again, when my father died in a medical college after being bedridden for about two weeks, I realised the need for care in our healthcare system in the truest sense of the 62 FUTURE MEDICINE I December 2012

word. All these experiences motivated me to set up a hospital where quality healthcare for the general public could be provided with easy access and affordability. Today, KIMS is a multi-super speciality offering a wide range of services. The most important wing at KIMS is the intensive care department. We have a dedicated team for child as well as adult intensive care. We are proud to say that in Kerala, the search for the best intensive care

unit naturally leads to KIMS. What importance do you give to wellness treatments?

Wellness is the sign of a health conscious generation. It is highly effective in terms of disease prevention. We have received a very good public response to programmes like adult vaccination.

Travel medicine, too, is a part of wellness treatment. Depending on the climatic conditions of the place(s) you visit, you can take preventive medicines and vaccinations like meningitis vaccine, influenza vaccine, yellow fever vaccine, malaria prevention tablets, etc. Wellness is related to the overall well-being of an individual. So, apart from the focus on vitality of the body and disease prevention, we have special programmes on weight reduction, dental health, and exercise, among other issues concerning an individual’s mental and physical fitness. There is no doubt that prevention is better than cure.

What do you have to say about the criticism that healthcare has turned into an industry?

Before criticising, you must take note of the positives in the healthcare sector. Would you recommend poor treatment for your relative when you have access to proper, quality healthcare? A given treatment may be a little expensive, but what matters is that a life can be saved. Though health is a service, every component of this service comes from an industry. So, naturally, it becomes expensive. How efficiently can we deliver a service must be the topmost concern.

What’s your take on medical tourism?

Promoting medical tourism is good not only for the healthcare sector of the country, but for the whole economy. However, we have to change our attitude towards foreigners in terms of good hospitality. After all, they are contributing to our economy in many ways. Actually, it is because of our strengths in medical tourism that we (KIMS) have been able

to find enough funds for our corporate social responsibility (CSR) initiatives. We have a blessed landscape here and well-trained doctors too. So, in my opinion, medical tourism has a vast scope here. Lack of proper governmental support in this field is quite unfortunate.

At KIMS, Thiruvananthapuram, we have an international care centre. Most of our patients are from the Maldives, Arab countries, and the US. Last year, we received about 45,000 international patients. While it is Ayurveda that attracts these patients to Kerala, we lack cleanliness and hygiene.

For instance, foreigners are very wary of blood transfusions from here. At KIMS, we have Australian as well as Indian accreditation.

Be it our laboratory, blood bank, emergency room, or gynaecology department, all of them have accreditations.

What about KIMS’ CSR initiatives?

From the beginning itself, we have been helping weaker sections of society who do not have an access to quality healthcare. In a year, we spend at least Rs 2.5 crore for CSR programmes and organise free or subsidised care.

Under the ‘Hrudaya Spandanam’ scheme, we conduct surgeries for poor patients. At the same time, one should acknowledge that all heart diseases are not curable. Last year, we carried out 100 free cardiac surgeries.

Patients from across Kerala have benefited from this scheme. A screening committee under the leadership of Padmashree Prof Dr G Vijayaraghavan, the Chief of Cardiology at KIMS, ensures transparency in the right selection of deserving heart patients.

We also have a scheme called ‘Guruvandanam’. It is a social initiative under the aegis of KIMS Department of Orthopaedics and KIMS Charitable Trust. Under the scheme, retired school teachers are provided proper treatments, especially knee replacement surgeries which otherwise cost about Rs 2 lakh. This year, we hope to help about 100 retired school

Dr M I Sahadulla, Chairman, KIMS

teachers who are suffering from Arthritis and knee pain. We have conducted 40 knee replacement surgeries so far.

The ‘KIMS Touch A Life Foundation’ aids cancer patients undergoing treatment at KIMS Pinnacle Comprehensive Cancer Center. We have also been giving free renal dialysis occasionally for the poor patients.

What are your future plans?

By next year, we will add 300 more bed facilities at KIMS, Thiruvananthapuram. We will open a liver dialysis unit soon.

Some specialists have already joined us. We also plan to expand our centre in Ernakulam. We will be opening two more hospitals in other districts of Kerala. We had made a proposal in this regard during the recent Emerging Kerala Global Connect Conclave. We are awaiting the government’s sanction. Because of the delay in governmental sanction for projects in Kerala, we are also thinking of setting up a hospital in Bengaluru.

In the Middle East, we have five day care centres and two hospitals as of today. We would like to establish ourselves as a single point where all possible treatments and care services can be offered to patients. That is our vision.

December 2012 I FUTURE MEDICINE 63

FOCUS Jubilee Mission Medical College and Research Institute, Thrissur

Community-driven Affordable Reliable Effective

Jubilee Mission Medical College and Research Institute, popularly known as ‘the poor man’s hospital’, is a multispecialty healthcare and medical education institution seeking to provide holistic healing solutions on a mass scale and generate a responsible resource pool of care-givers Bureau

W

Mgr Raphel Vadakkan, Director 64 FUTURE MEDICINE I December 2012

ith the motto “Service with Love”, Jubilee Mission Medical College and Research Institute came into being in the year 1951 under the patronage of the late Bishop of Thrissur, Rev Dr George Alapatt, in the heart of Kerala’s cultural city. It made a humble beginning as a small dispensary that served the non-surgical needs of local people. In 1952, the hospital expanded its facility to four rooms with 20 beds and the assistance of two retired part-time doctors and two nurses of the Holy Cross Congregation. In due course of time, patients’ trust and confidence, coupled with the sacrifice, dedication, and determination of the management, helped the dispensary in growing from strength to strength and establish the Jubilee Mission Medical College and Research

Institute.

Today, this is a 1450-bedded multispecialty hospital with world class facilities for treatment of all kinds of diseases.

Jubilee Mission has presence in the medical education sector as well through its medical college, college of nursing, school of nursing, and an array of allied health science courses. Jubilee Mission’s School of Nursing was started in the year 1966 and the hospital got recognition from the Indian Medical Council (IMC) for Compulsory Rotatory Residential Internship in the year 1971.

Jubilee Mission Medical College and Research Institute

is one of the best healthcare institutions in the state for cleft lip and palate surgery, and treatment of snake bites and burn injuries.

With diligent capacity expansion, this institution has managed to upgrade its profile from super specialty to multispecialty. It opened up new horizons of healthcare within the reach of the common man with the creation of the departments of Cardiology and Nephrology in the year 1998. In the successive years, the hospital set up departments for Urology, Gastroenterology, Neurology, Neuro Surgery, Endocrinology, Gastro Surgery, etc. The Burns Treatment Unit and Charles Pinto Centre for Cleft Lip and Palate Surgery are among the hospital’s milestones.

In the year 2003, following recognition by the MCI as a teaching hospital, Jubilee Mission Medical College and Research Institute opened a medical college and a college of nursing. Managed by the Jubilee Mission Hospital Trust, the medical college is a selffinancing institution affiliated to University of Calicut. “Excellence in all fields of healthcare and promotion of quality health education, training and research are our chief objectives. We are doing our best to make Kerala a hub of best medical care. While implementing policies, we are guided by the needs of society.

After all, we are respected only because of our dedication and commitment towards society,” says Mgr Raphael Vadakkan, the Director of Jubilee Mission Medical College and Research Institute.

This ‘poor man’s hospital’ is supported by Mary Maids,

an organisation of housewives attending to the needs of poor patients on a weekly basis, Jubilee Fraternity, a group of local residents that serves as an advisory body, Sahrudaya Blood and Eye Society, which conducts free eye and blood grouping camps on Sundays, St Joseph’s Helpline Group of Social Workers, which helps outpatients, and Nanma Counselling Centre, respectively.

Mission of holistic care

The hospital management is planning to expand its areas of operation to ensure availability of more reliable, effective, and affordable treatments for all classes of society irrespective of their economic disparities. To keep up its mission of holistic healthcare, the hospital has been following an action plan that gives medical students an enlightening learning experience through rural service; ignores the concept of patient to doctor and emphasises on the new concept of doctor to patient; focusses on provision of quality treatment at affordable rates; facilitates medical insurance facilities for all; hopes to make Kerala HIV-free; delivers healthcare for old patients at their doorstep; understands the need for free dialysis for kidney patients; educates patients on proper hygiene, water sanitation, and waste disposal; aims to achieve cent per cent blood literacy (i.e., knowing the blood group and encouraging people aged above 18 to donate blood at least twice a year); and establish counselling centres with the help of experienced, retired citizens.

December 2012 I FUTURE MEDICINE 65

FOCUS Azeezia Medical College, Kollam

Redefining tertiary care

Well-known for providing quality healthcare through its general specialties, super specialties, and super specialty clinics, Azeezia Medical College Hospital in Kollam district of Kerala is setting new benchmarks of excellence in the field of tertiary care

M Abdul Azeez, Chairman, Azeezia Group of Institutions 66 FUTURE MEDICINE I December 2012

S

et up by the Podikunju Musaliar Memorial Charitable and Educational Trust in Meyannoor village, about 18 km from Kollam Town, Azeezia Medical College Hospital is a tertiary care institution redefining the meaning of outreach and qualitative healthcare at affordable costs.

The 500-bedded hospital has well-qualified, experienced doctors engaged in a wide range of multispecialty and super specialty disciplines, enabling it to take on new challenges in the field of healthcare.

These specialty departments are equipped with stateof-the-art gadgets and equipment that can effectively aid doctors in making quick diagnosis and prescribing timely treatments for the entire spectrum of diseases, starting from minor issues such as cold and fever to ailments as serious as cancer.

With each passing day, the hospital is adding newer facilities, sensing the urgent need for a holistic approach towards a host of complex diseases. The hospital has an excellent mix of consultants and academicians to deal with any kind of medical situation or emergency. The hospital’s services cover general specialties, super specialties, and super specialty clinics.

General specialties: The general medicine and general surgery departments attend to the problems of patients of any age group following proper evaluation. From general paediatric complaints and complex diagnostic problems to cases requiring general surgery, the departments have expertise in multiple fields, including minimally invasive surgery, hepatobilary and pancreatic surgery, thoracic and thoracoscopic surgeries, endocrine and breast surgery, vascular surgery, and cancer surgery. The general specialties section has four surgical units. It provides round-the-clock emergency care for traumatic and non-traumatic emergencies.

General as well as laproscopic surgeries are done

in operation theatres that have a stainless steel wall panel system. A well-equipped surgical ICU caters to the needs of post-operative patients.

The department of obstetrics and gynaecology helps patients through psychoprophylaxis (antenatal classes). Entonox, Epidural, T.E.N.S., and water births are offered accordingly to individual needs.

The hospital also has a continuous electronic heart rate monitoring (CTG) system matching international standards. Post-graduate trained resident obstetricians monitor the condition of both the mother and the child round the clock, under the guidance of senior consultants.

Patients faced with high-risk pregnancies because of their diabetic condition, or high blood pressure, or heart disease, or previous pregnancy losses, need not worry. The hospital has highly trained obstetricians and a neonatal intensive care unit.

Other subspecialties within general specialties: Paediatrics: Expertise is available for correction of major congenital malformations in the neonate.

Highly specialised facilities exist for management of emergencies and complex surgical problems in infants and children. This department also conducts paediatric bronchoscopy, cystoscopy, laparoscopy, and thoracoscopy, both diagnostic and therapeutic.

Dermatology: The hospital has facilities for cutaneous surgery for skin and nail diseases, allergy skin testing cryotherapy, electrocauterisation and chemical peels. Cosmetics dermatology is becoming an integral part of the

management of clinical dermatology.

So, in addition to chemical peel in treating hyper pigmentation of face, the hospital conducts microdermabrasion to treat scars resulting from acne, chickenpox etc.

A patient is not required to admit himself/herself for this kind of treatment.

The department also treats hyperhidrosis (excessive sweating) of palm and axillae with local injection of Botox, which is also effective in treating wrinkling on forehead (frown lines) or near eyes (crow’s feet).

The department is ever-ready to meet the challenges of sexually transmitted diseases. AIDS patients are also provided care by the department with assistance from other specialists. The hospital has excellent supporting facilities related to microbiology, clinical pathology, biochemistry, histopathology with immuno- fluorescence studies, nuclear medicine, and nerve conduction studies to help in diagnosing and treating different dermatological and sexually transmitted diseases. The hospital also treats leprosy patients.

The departments under the super specialties section comprise cardiology, radio diagnosis, urology, nephrology, neurology, neurosurgery, tuberculosis and chest diseases, maxillofacial surgery, and surgical oncology.

The super specialty clinics deal with infectious diseases, infertility, diabetes, cosmetology, palliative care, nutrition, and dentistry.

The emergency wing of Azeezia Medical College Hospital

is offered a 24-hour support by all specialties. This wing handles a wide range of acute medical and surgical emergencies, polytrauma and paediatric cases. The hospital has Advanced Life Support/ ICU ambulances, supported by a dedicated team of medical and para-medical staff. The hospital has a regular Basic Life Support and Advanced Cardiac Life Support Training Programme as well.

Azeezia Pharmacy is well-stocked with FDA-approved drugs of high quality. The strategically located IP pharmacy, based on the Herman Miller Model, directly distributes medicines to the in-patients and counsels patients at the time of discharge.

Azeezia Medical College Hospital truly believes in the age-old adage, ‘prevention is better than cure’.

Towards this end, Azeezia Wellness Lounge offers a wide range of health check packages for all age groups. These packages have been specially designed to meet diverse requirements. The packages available at Azeezia Medical College are Executive Health Checkup, which includes complete haemogram, urine analysis, diabetic profile, kidney function test, liver function test, ECG, and chest X-ray; Complete Heart Care Checkup, which includes ECHO, TMT, Dietetic Advice etc; Diabetic Care Checkup, which includes spot urine microalbumin test, ultrasound abdomen test, eye test, and diet advice; and Well Lady Executive Checkup, which includes Pap Smear test, blood calcium test, evaluation of all physical parameters, and gynaecological consultation.

FOCUS Bharath Cardiovascular Institute

Into the heart of the matter Bharath Cardiovascular Institute is one of the comprehensive centres in the state that can cater to all kinds of surgical needs, irrespective of the age of patients, in the whole spectrum of cardiovascular disease. It is the state’s first successful key hole heart surgery centre and one of the only two centres in Kerala doing Endoscopic (Vein) Conduit Harvesting for bypass Bureau

B

harath Cardiovascular Institute is a Diagnostic and Interventional Cardiology multispecialty centre functioning under is a sensitive area covering services such the aegis of Bharath Hospital, a super as Transthoracic and Transoesophageal specialty hospital based in Kottayam district Echocardiography and Color Doppler; of Kerala. The main objective of this cardiac Holter Monitoring; Treadmill Stress Testing; institute is to provide high quality, affordable, super-specialised care.

The management of Bharath Cardiovascular Institute has equipped the centre with all modern facilities required for proper, quick diagnoses and treatments. The institute, which meets the highest standards of quality, safety, and reliability, has a well-qualified, experienced team of eminent medical professionals.

The Department of Cardiology, headed by Dr Smartin Abraham, offers Diagnostic and Interventional Dr Smartin Abraham, Consultant Vinod Viswanathan, Cardiology and Cardiac Surgical Cardiovascular Surgeon, BCI Administrator, BCI Services.

68 FUTURE MEDICINE I December 2012

Cardiac Catheterisation and Coronary Angiography; Cardiac Re-synchronisation Therapy; Angioplasty and Stenting for coronaries; Angiography and Angioplasty of arteries of neck, leg, arm, and kidney; Enhanced External Counter Pulsation (EECP); Heart Failure Clinic specialising in Treatment of Failing Heart; Pacemaker and AICD Implantation; Permanent Pacemaker (Single and Double Chamber); and Balloon Valvuloplasty.

The Cardiac Surgical department offers world class treatments such as Coronary Artery Bypass Surgery, Valve Surgery, Aneurysm Surgery for aorta and blood vessels, Key Hole Cardiac Surgery, Maze Procedure for Atrial Fibrillation, Coronary Revascularisation, Transoesophageal Echocardiography etc.

Milestones so far

Within a short span of time, Bharath

Cardiovascular Institute has set many milestones. In 2010, the institute carried out its first bypass operation with 100 per cent success. It is one of the comprehensive centres in the state that can cater to all kinds of surgical needs, irrespective of the age of patients, in the whole spectrum of cardiovascular disease. It is the state’s first successful key hole heart surgery centre and one of the only two centres in Kerala doing Endoscopic (Vein) Conduit Harvesting for bypass.

The credit for these achievements goes to the dedicated team of cardiac surgeons and their support staff. “Dedication and a humanist approach towards the patients are vital features of our value system. ‘Treat patients with patience’ is our approach. That helps us in building a strong relationship between doctors and patients. That is the secret of our success,” says Dr Abraham, the Consultant Cardiovascular Surgeon at Bharath Cardiovascular Institute.

The 15-bedded multispecialty CCU has the most modern multipara monitors, pacemaker facilities, and a state-of-the art operation theatre. The Cardiac Catheterisation Laboratory has a fully digital flat panel cathlab (Latest Innova 2100 Machine), which can cater to 3D neuro and vascular interventions. It has facilities for Radial Angioplasty as well. The post-operative care system provides a 10-bedded ICU with IABP Ventilators, Continuous Cardiac Output Monitors, Haemodialysis, Non-invasive Ventilation etc. The institute maintains a hospitable environment in each of its departments, especially the cardiology ward, enabling patients to make quick recovery.

Future projects

Bharath Cardiovascular Institute is in the process of expanding its infrastructure to ensure optimal patient care. “In the near future, we will open various centres and departments for Heart Failure Surgery, Ventricular Restoration, Ventricular Assist Devices, Heart Transplantation, Implantable Heart, Hybrid lab with Transcatheter Interventions etc,” says Dr Abraham, adding that the institute is striving hard to emerge as the country’s top cardiac centre.

December 2012 I FUTURE MEDICINE 69

POLICY INITIATIVE The Central Plan

UPA Govt’s booster dose for healthcare not good enough Indians have much to look forward to in the New Year, with the Union government set to triple the healthcare spending in the 12th Five-Year Plan.

But then, these measures are still inadequate to attain the prosperity (and care) index of the progressive nations of the world

E

ven if the United Progessive Alliance (UPA)-led Central government triples the budget for the health sector, as Prime Minister Manmohan Singh said while laying the foundation stone of the redevelopment project of Lady Hardinge Medical College, New Delhi, last month, India’s healthcare spending will still be among the lowest in the world.

Promising that allocation for the health sector will be enhanced by about three times in the 12th Plan period, scheduled to begin in 2013, the Prime Minister had said, “There will be increased emphasis on factors such as nutrition, safe drinking water, sanitation, housing and education, and education of the girl child in allocations for the 12th Plan.”

Dr Singh also said that free generic drugs will be made available through all public hospitals to help “reduce the outof-pocket expenditure of the poor”. As the country is faced with an acute need for more healthcare professionals, Dr Singh stressed upon the need for better, trained human resources.

“The availability of trained human resources in the health sector remains a challenge. We need to set up more nursing and medical colleges (to increase both undergraduate and postgraduate seats) under the 12th Plan.”

India is placed at the 140th position in the World Trade Organisation’s list on healthcare spending. The country’s health indicators, too, are exceedingly low, when compared with the global standards.

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VOICES

“The healthcare sector is attracting the maximum attention today from private equity and venture capital. The investors see a huge potential, with a growing population and a highly underserved market” Naresh Malhotra, Director, Modern Family Doctor Pvt Ltd

“Health is one area which has high potential for application of e-Governance initiatives. If assessed and applied in right areas, it will bring high benefits for the common man” Praveen Prakash, Commissioner of Health and Family Welfare, Government of Andhra Pradesh

“Everybody has something to learn from somebody else. There is no perfect system to carry out procedures in the healthcare system, so countries exchange their technological advancements, and our motive is taking ICT to every hospital” Janette Bennett, Clinical Director (Asia Pacific), British Telecom Health

“We are a country where the bed-to-patient ratio stands at one bed for a thousand patients.

Private investment is the only way forward to change this scenario” Vishal Gandhi, Managing Partner and CEO, BIORx Venture Advisors Pvt Ltd

“Currently, the two most important modalities in healthcare are Ultrasound and MRI. Somebody termed the MRI as the rich man’s ultrasound.

Conversely, ultrasound is the poor man’s MRI. Both are radiation-free and growing fast ” Conrad H Smits, Senior Vice-President and General Manager, Philips Ultrasound

12 FUTURE MEDICINE I November 2012

FEMALE FOETICIDE

Where have all the young girls gone?

SONIA BHALOTRA Professor of Economics at University of Bristol in the UK

I

ndia has a long history of son preference, reflected in greater mortality rates for girls and women over the life-course, arising from their relative neglect. A marker of this is that the sex ratio in India - the ratio of males to females in the population - is unnaturally larger than one. Since the mid-1980s and most markedly since the mid-1990s, the all-age sex ratio has stabilised, but the sex ratio at birth has risen sharply. This suggests sex-selective abortion, or female foeticide. In recent research, my co-author and I estimate that nearly half-amillion girls were being aborted each year, on average, during 1995-2005. This is more than the number of girls born annually in Britain and it represents 6.2 per cent of potential female births in India (Bhalotra and Cochrane 2010).

We use the timing of the introduction and spread of prenatal sex detection technologies to show that this is a direct consequence of the availability of this technology. This result stands even after we account for trends in son preference, fertility preferences, and the increasing educational enrolment of girls in India.

The practice of female foeticide is more prevalent among relatively rich and educated families. This flies in the face of ideas about m

Gender inequality remains a huge issue in India and policies aimed at changing this are welcome. But the shocking reality is that abortion of female foetuses has been going on at an unprecedented scale with the introduction and spread of ultrasound scans in India December 2012 I FUTURE MEDICINE 73

FEMALE FOETICIDE India

better treatment of girls.

In particular, it is relevant to find out whether female foeticide represents a simple substitution, with one less girl dying after birth for every one girl that is consciously aborted before birth. We find that girls born after the introduction of ultrasound are more likely to be vaccinated and are breastfed for longer. Related, we find that the girl-boy difference in the risk of dying before the age of five shrinks (three-fourth of the gap is closed) after the introduction of ultrasound Trends in the proportion of females at birth by birth order and previous sex composition (Bhalotra and Tam 2011). (five-year moving averages). First births as well as later births in families with previous boys show no tendency for a deficit in girls to emerge with the appearance of ultrasound The technology available to detect the sex of a child backward women being enslaved in Hindu culture. These needs are before birth is improving to old customs. But it is consistent met by one son. A striking and continuously, enabling more reliable with ‘modern’ women being more novel finding of our research is resolution of the foetal image earlier receptive to new technologies and that parents conduct prenatal sex in pregnancy. At the same time, the wanting fewer children. These selection even after they have one development of smaller and more factors appear to override lower son. Our research suggests that mobile ultrasound scanners has self-reported ‘son preference’ among Indian families want two boys and increased market penetration. Their women of higher socio-economic one girl. use by rural households caught status.

In subsequent research, up rapidly, with initial uptake by After taking into account we investigated whether, after urban households. The cost of an differences in wealth and education the introduction of ultrasound ultrasound scan in India is in the among the religions, we find that technology, the ability to have region of $12, which is about one Hindu women, especially high caste only ‘wanted’ girls has led to per cent of per capita income, and women, are more likely to conduct sex selection. There is no discernible evidence of sex selection among Muslim women. A likely explanation is that, even if they have a similar preference for sons, Islam is more averse to abortion. This reconciles with evidence that the sex ratio is more balanced in Pakistan and Bangladesh than it is in India. A recent study of Canada also observes that there is female foeticide amongst Indian and Chinese immigrants, but not amongst Muslim immigrants (Almond, Edlund and Milligan 2009).

Amongst reasons that Indian families put enormous weight on See notes to Figure 1. The probability of a girl being born amongst second births falls having a son is that elderly parents sharply with the appearance and spread of ultrasound but only in families with no live with their eldest son till they previous boys (note: for second births, families with at least one boy are effectively die, at which point the son lights the families with only boys) funeral pyre, and this is meaningful 74 FUTURE MEDICINE I December 2012

mid-1990s coincided with a period of sustained economic growth in India.

While the growth takeoff is widely associated with deregulation of industry and trade, an unintended consequence is that it became easier to import ultrasound machines and, after 1994, for multinationals to start large-scale production in India. Although sex-selective abortion was made illegal in India in 1994, it has, in fact, continued since that date at See Notes to Figure 1. The probability of girl births among third births shows an an increasing pace. even larger divergence between families with and without a previous boy than While our study does this probability among second births indicates that the availability of ultrasound advertisements in rural areas highlight how scans has played a critical role in enabling small this sum is relative to the cost of a dowry. abortion of girls, it also plays a positive role in Before our study, there was considerable improving prenatal care. It would not, therefore, anecdotal evidence of abortion of girls in India, be desirable to ban the use of scanners. But once but no clear causal evidence. As there are no they are in use, it is difficult to monitor the ban direct records of the practice, sex selection is on prenatal sex detection because families and inferred from changes in the sex ratio at birth. (often unqualified) private medical practitioners Our strategy is essentially to use three decades collude in evasion of the law. of data on about half-a-million births to study The phenomenon of female foeticide touches how the sex ratio at birth changes upon the on many of the dilemmas of modern times, introduction of ultrasound. We employ a number including the ethics of scientific progress, of further statistical approaches to control for gender equality, human rights, and freedom of the role of other factors. choice. Even where preferences over child sex Strikingly, the emergence of female foeticide are relatively balanced, as in the UK, so that in the mid-1980s and its intensification in the issues of gender inequality and an unbalanced demography are muted, the ethical issues are alive. For example, the UK Human Fertilisation and Embryology Authority has banned sex selection for primarily moral reasons.

Inspired by the The scale of the problem is ominous of a Bitiya Bachao future of unmarried men at the bottom of the campaign of socio-economic distribution in India, increasing the Rajasthan violence against women, and other ills of an Patrika, unbalanced society. the Grama Panchayat of Budania, along with teachers of a government school, recently adopted fourteen girls from humble backgrounds

(Sonia Bhalotra is Professor of Economics at University of Bristol in the UK. Her research is centred upon the creation of human capital. She has active research programmes on the long run benefits of childhood health interventions, educational reform, conflict, the political economy of public service delivery, intergenerational transmission of human capital and poverty, and the dynamics of mortality, fertility and sex selection) Note: Reprinted with the permission of www.ideasforindia.in December 2012 I FUTURE MEDICINE 75

SEXUAL HEALTH

Non-consummation is a major cause for U

divorce

nconsummated relation or non-consummation means couples are either unable to have successful sexual intercourse because of fear or lacking the power to perform penetrative sex.

Sometimes, they are totally confused as to why this is happening to them.

It is one of the significant reasons for sterility or infertility (the inability of a male to deposit semen inside his wife’s vagina).

Non-consummation is often associated with men, while infertility is largely seen as an issue of women.

Both issues can be psychologically devastating for couples, and if the problem persists, they can break a marriage.

Causes for non-consummation

There may be many reasons for non-consummation. These may include: • Lack of emotional involvement • Fear of sexual act • Inappropriate advice or information from friends and family before marriage about first night and sex • Vaginismus (terrible cramp at the entrance of the vagina, which makes penetration impossible) • Lack of arousal and less lubrication for the female • Dyspareunia (painful intercourse) • Thick hymen • Erection problems or an inability to copulate • Fear of pregnancy • Sexual abuse in childhood

Complaints about nonconsummation •

Dr A CHAKRAVARTHY

A majority of women have

76 FUTURE MEDICINE I December 2012

•

• •

complained that either their partners have less erection to penetrate the vagina (erectile dysfunction) or they ejaculate outside the vagina (premature ejaculation) Some complained of having failed in vaginal penetration despite a good erection (anxiety about performance) Some patients had no erection for penetration (erectile dysfunction) Vaginismus in females leads to unsuccessful sexual intercourse

Signs of non-consummation • • • • •

Lack of desire for sex Irritating or painful experience while attempting intercourse Difficulty in insertion of penis into vagina Softening of penis while performing intercourse Ejection of semen before penetration

Major outcomes of nonconsummation • •

Marital disharmony Breakdown of marriage

Consultant In Reproductive and Sexual Medicine

• • • •

Emotional disturbance and loss of self-esteem An inability to impregnate (infertility) Use of over-the-counter medicines to boost sex life badly affects health Alcoholism

Treatment for non-consummation

A physician can come up with a treatment plan only after clear understanding of the root cause(s) of non-consummation.

Medications should be taken for erectile dysfunction and premature ejaculation. Sex therapy, in combination with pharmacological therapy, is a very effective method for treatment of non-consummation.

The ultimate goal of sex therapy is to help couples overcome nonconsummation worries so that they can lead a satisfactory sex life.

Dr A Chakravarthy, MBBS, MBA (Hospital Management), MHSc (Reproductive & Sexual Medicine), is a Consultant in Reproductive & Sexual Medicine, based in Thiruvananthapuram, Kerala

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MOTIVATION

In Mother Teresa’s footsteps

By Shalet James

78 FUTURE MEDICINE I December 2012

L

iving for the welfare of the underprivileged isn't as easy as it sounds. Here's the story of a widow who sought to render a greater meaning to her life by following the footsteps of Mother Teresa.

Almost two decades back, Uma Preman's husband succumbed to tuberculosis due to the lack of timely medical intervention. Instead of giving in to the tragedy that struck her, she stood up to the promise she gave her husband while he was still on the deathbed. The sense of loss made her understand the agony of those who are denied the basic right to proper healthcare access.

Uma pursued her dream of establishing an institute that could help the marginalised sections of society with proper information regarding access to best healthcare and financial backing for treatments. Her dream came to fruition in 1997, with the opening of Santhi Medical Information Centre at Guruvayur in Thrissur district of Kerala.

Over the past 16 years, Santhi Medical Information Centre has facilitated many free healthcare services to the needy, including 1,50,000 dialyses, 20,500 heart surgeries, and 640 kidney transplants.

Born and bought up in a middle class family in Coimbatore, Tamil Nadu, Uma had a very difficult childhood.

At the tender age of 10, she had to look after her family with whatever little money her father gave her. Uma’s father had instilled social values in her quite early on. The turning point in her life came when she turned 18. She had the great fortune to meet Mother Teresa, who taught her, “Social service could be done anywhere. One just has to look around and identify those in need.” This set her on the path of social

service.

In 1999, Uma donated one of her kidneys to an orphan, Salil. “We only live once. Life takes a whole new meaning only when we are successful in bringing happiness in others’ lives,” says Uma. “Since the kidney transplant, Salil has been with us. He is an active member of Santhi Medical Information Centre today,” says Uma. In 2010, TV news channel CNN-IBN honoured her with the ‘Real Hero Award’ for her contributions to society. A charity institution employing over 100 volunteers, Santhi Medical Information Centre has eight advanced dialysis units and two mobile dialysis units, offering about 2,000 dialyses every month. Of these, 1,000 dialyses are free of cost, while the rest are offered at a subsidised rate. Uma has also helped more than 300 kidney patients find a donor. “I am a great fan of Tamil writer, poet, journalist, freedom fighter, and social reformer Subramanya Bharathi. His words, ‘Nimrindha Nadayum Nerkonde Parvayum’, have helped me embark on a righteous path,” says Uma. Santhi Medical Information Centre has already established its presence in the Middle East. It plans to spread wings to Alappuzha, Kollam, Trivandrum, Pathanamthitta, Koothattukulam in Ernakulam district, and the Union Territory of Lakshadweep.

Santhi Medical Information Centre’s awareness and charity programmes are supported and promoted by actor-politician Sarathkumar and his wife, Radhika Sarathkumar.

Uma is now busy giving final touches to her biography, ‘Kathai Keykum Suverukal’ (Even Walls Listen To Stories).

This book, scheduled to be published in 2013, will be translated in English and Malayalam.

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