spande72

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August 2nd 2005 - unscrupulous medical practices in India

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A wrong prescription

One day a maidservant and her child came to me. The child had been prescribed glasses at an eye camp at his government-run school.

The maidservant trusted that a government school would have arranged for a proper eye doctor. Wanting the best for her child, the maidservant went ahead and got the glasses. This was at a cost that was quite a lot for her, but good parents always want the best for their children.

Now she wanted to know why her child was unable to see properly.

I went through some tests and found that the prescription the child had been given was completely wrong. So much so, that I found it hard to believe that the person who had written it was competent.

It is well-known that children need to have their glasses prescribed with more care than for adults. Children are more fidgety, less likely to complain about vision with the glasses on, and they are more vulnerable to vision damage from wrong glasses. Indeed, because more care needs to be taken, it is sometimes necessary for a child to be seen several times just for prescribing glasses. While I recognize that a school eye camp at a government school is going to be a pretty basic affair, the prescription should at least have been in the correct direction, or a note should have been written on the prescription saying "further testing required". My impression was that the school had taken on someone who was out to make a quick buck rather than someone who had any belief in the Hippocratic principle of "do no harm".

It is an unfortunate truth that the healthcare system in India has serious problems. There are several kinds of "medical practitioners" that a patient in India needs to be wary of. These are:

1. tantriks
2. quacks
3. RMPs that work outside their area of competence
4. unscrupulous doctors

Let us look at them, one by one:

tantriks

These are the Indian equivalent of witch doctors, and they tend to claim occult or spiritual powers. Their knowledge is sometimes useful, but they can often cause great harm. There is still much faith in such people, especially in the more backward areas of India. One such documented case tells of a 3 year old girl with congenital cataracts, whose treatment at the hands of the local tantrik included applying red hot iron bars to her chest and abdomen. Such things are unfortunately not uncommon.

quacks

Patients need to be especially wary of quacks. Quacks are people without certified training, but who pretend to be registered doctors. In Delhi alone there are about 40000 of them. They far outnumber the 25000 MBBS doctors.

The way most quacks tend to get going is by working as doctor's assistants, observing how doctors do things, and then setting up their own practice in poor areas and charging much less than a real doctor would, while pretending to be doctors. In practice, they are often the first line of health care, performing first aid, or taking care of minor ailments, and refering patients to real doctors for more serious cases. But there are far too many times when their incompetence or greed puts the patient at risk.

The worst afflicted by quackery are people in poorer rural areas where genuine medical care is barely available. An excerpt from www.saaaids.org website illustrates the problem graphically:

Laxman Damor, 49, is the most popular "doctor" in the village, though he never got past the seventh grade. The way to his house lies through wheat and lentil fields and past grazing cows.

"By and large, whoever comes to me, I give them an injection," he said. "Often, tablets are better, but they want injections. If I don't give them one, they'll go to someone else. I'll lose my customer."

He is also liberal with the intravenous glucose drip, which gives a person sapped by anemia a temporary sugar surge. He charges more than $2 for a drip, in an area where people spend on average $10 a month per person for total household expenses.

A young laborer, Babu Lal, walked into Mr. Damor's courtyard, complaining of a chest cold. He had hiked several miles. Mr. Damor immediately put him on the examining table. In no time, the needle was out and Mr. Damor stuck him in the hip with an antibiotic.

Another example of blatant quackery that was in the news a few years ago concerned a "Doctor" R Gupta, who proclaimed he had a miracle cure for epilepsy. People flocked to him because they were impressed by his swanky set-up. Even the Delhi Government appointed him an Honorary Ayurveda Advisor for Epilepsy.

Bad reports came in. As a result, he was investigated by the Indian Medical Association (Karnataka Branch) who uncovered many disturbing things. For example, the BAMS degree he claimed to have was found to be an outrageous lie. He prescribed drugs in quantities that were hazardous. He used to add narcotics to the medicines he would dispense.

He was stripped of his Honorary Advisor status and hauled off to jail in the end. So it is possible to stop such things. It is not easy though - it took a special investigative team of three doctors, and several years to put him behind bars.

The ignorance of patients compounds the unscrupulous behaviour of quacks. The problem is elaborated in a frank article by Prof. Bilimagga and Dr Rao, some highlights of which are:

• Tablets are wrongly regarded by patients as ineffective compared with injections. The quack will go along with the view of the patient, because he can extract more money for injecting.
• Needles are reused without sterilisation (not sterilising is cheaper than sterilising). Such needles can cause and spread dangerous infections.
• Full antibiotic courses are not followed which can lead to re-infection and more resistant bacteria.
• Steroids are used in large amounts, and frequently. Steroids get quick, temporary results and helps establish the reputation of the quack. The damage such steroid use causes to the organs is well-known, and will eventually kill the patient.
• Drugs that have a strong colour are often used completely inappropriately, just because they are cheap for the quack to use, and because he can charge more for something that looks so impressive. For example, b-complex with its strong red colour, and tetracycline with its strong yellow colour are favourites for intravenous injection by quacks.
• Fake drugs are given because the quack gets them much cheaper. India has a large and thriving industry that makes fake drugs (called "spurious drugs" in Indian terminology). The fakes are packaged just like the real ones, but are sold much cheaper than the real drugs by unscrupulous traders in the Bhagirath Palace area, opposite the Red Fort. They usually have nothing of the active drug inside the pills.

Because of such dubious practices, on the whole, quacks are more of a menace than a benefit to the health of patients.

RMPs that practice outside their discipline

RMPs are Registered Medical Practitioners. But it is a bit more complicated than that, because India is unusual in that the government recognises several systems of medicine. These systems are:

• Allopathic. This is conventional modern western medicine, as practiced based on the scientific method.
• Ayurvedic/siddha. This is based on traditional medicine as practiced since vedic times. Yoga and naturopathy are regarded as complementary to ayurveda.
• unani/tibb. This is another traditional medicine, introduced by muslims into India from the 8th century onwards
• Homeopathic. This began in the late 19th century. It is a controversial system because its foundations contradict current scientific theory.

[For the record, my personal opinion is that traditional ayurvedic/unani medicines have some merit under properly experienced practitioners. Homeopathy seems to work as a placebo in my opinion, being (from what I have observed) most effective when the practitioner psychoanalyses the patient along with prescribing the homeopathic medicine. Allopathic medicine is generally the most effective of the disciplines, and should be the first method to try].

Now, people who have passed through certain government-recognised colleges in allopathic, ayurvedic/unani or homeopathic medicine are allowed to call themselves Doctor. When they set up to practice, they need to register with their state government, and they may then add RMP to their signboards.

It is quite appropriate for RMPs to provide basic medical care. Medical care within their field of specialisation is also quite appropriate.

However, many RMPs do things which are outside their registered area of knowledge. For example, many RMPs in homeopathy or ayurvedic/unani medicine mix in allopathic drugs in their medicines without the patient's knowledge. Some homeopaths in India are especially notorious for using steroids in their supposedly homeopathic pills. Many homeopathy/ayurvedic/unani RMPs also prescribe allopathic medicines outright, despite the emphatically clear illegality of doing so.

Such practioners are effectively the same as quacks - because they are pretending to be allopaths, acting outside their area of competence, and causing harm to the patient through their ignorance.

Unscrupulous doctors

Lastly, and perhaps most troubling, is the case of unscrupulous (allopathic) doctors. These are properly certified doctors who make extra money in ways that are unethical, or can even do harm to the patient. While a quack in Delhi can be dealt with by reporting him to the anti-quackery cell, a properly registered doctor who is unscrupulous is harder to deal with. By "unscrupulous", I mean doing things like:

1. unnecessary tests/scans

   A few days ago a mother turned up to have her daughter's vision problem checked at my clinic. I diagnosed it as X (I am not going to give the details, but it was an unambiguously clear case). The mother went for a second opinion to a more elderly doctor. This doctor agreed with my diagnosis, and ordered a certain type of scan. It was absolutely unnecessary to have the scan done, but I suspect the patient was somewhat pleased that some sort of action was being done (pointless though it was). The only point for the scan being done was, I suspect, because the doctor got a cut out of the charges for the scan.

   The disheartening thing for me is that I had specifically explained to the mother that getting such a scan done was pointless. I spent a good half hour making her understand what the right things to do were, and the reasons behind them.

   There are cases for which such expensive tests and scans are indeed recommended or necessary. It is the norm for doctors in private practice to get some consideration for sending patients to such centres. But telling the patient to have such tests done when the doctor knows it is pointless, just to get money out of it, is simply cheating the patient of their money.

2. forwarding to centres that are unscrupulous

   Some doctors, (RMPs and quacks do this too) refer patients to medical centres that are unscrupulous. These places do unnecessary and expensive surgeries, and then give a cut back from what they have charged the referred patients. There are certainly cases for which a doctor will refer to a specialist, or will refer the patient to a surgical centre. But sending a patient to an unscrupulous centre known to do unnecessary and expensive procedures is again simply cheating.

3. False operations

   For example, there is a well-known opthalmologist who specialises in Y (I want to avoid identifying him). He has a huge and impressive-looking set up, and at first sight, a layman will think he is a well-respected surgeon in the field. He is nothing of the sort. Ophthalmologists know that he has false surgeries to do with Y - operations where the patient is told a procedure has been done, and no such thing has been done. I have seen evidence of this sort of behaviour from doctors like him more than once in my career so far.

One of the problems is that doctors usually will not voice accusations outside the doctor's community. Within the medical community, doctors will gossip amongst themselves and news spreads around the grapevine about who is doing dubious things. However it would be suicidal for a doctor to put such things in writing unless the doctor is very senior and well established - and even then it is so risky that it is just not done. This is because unscrupulous doctors often have wealth, contacts and are in positions of power.

This is most troubling to me because I see no way that such an endemic problem can be uprooted, other than through India generally becoming more law-abiding over time.

In the meantime, patient awareness can help. The patient needs to take utmost care in his choice of a doctor in private practice. The patient has to be sure that he has chosen a doctor or practitioner who is absolutely ethical, as well as competent. He also needs to be able to trust his chosen doctor to point him to other doctors who are known to be true to the Hippocratic principle of "do no harm".

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June 2nd 2005 - Viagra blindness - the FDA investigates

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To my dismay, viagra is regarded by most users as a "lifestyle" drug. It is often taken like candy without first taking medical advice. There may be some people taking it recreationally who are aware that mixing it with some heart drugs can be harmful, but that sort of awareness is uncommon.

More worryingly, I have been hearing warnings about blindness due to viagra use since 1998, when Dr Howard Pomeranz first alerted the eye community about it. Despite the serious nature of this side-effect, it has not yet (June 2005) been given a mention in the patient inserts for the drug, let alone spread into general awareness amongst physicians.

(Incidentally, this blindness is not to be confused with the "blueness of vision" effect on the retina, which is a reported side-effect in patient inserts. The side-effect we are now talking about is not a temporary blueness, but a blindness called non-arteritic anterior ischemic optic neuropathy (NAION)).

Only recently has this blindness hit the mainstream news, and the US Food and Drug Administration (FDA) is now investigating the issue.

The consensus at present (June 2005) by Pfizer and the FDA is that the number of reported NAION cases is very low considering the widespread use of the drug - 38 cases out of perhaps 23 million users, so that it is not a big issue.

NAION has been described as a sort of stroke of the eye. My worry is that taking a viagra pill may cause the eye-equivalent of mini-strokes, where each incident is not really noticed, but where the cumulative damage adds up over time. Perhaps NAION mini-strokes could be a called "silent killer of vision" in the same way that glaucoma is.

Another way of putting it: the vision damage done by viagra was noticed in the 38 users by the users themselves, and obviously linked with the use of the drug because they had just taken it within the last 36 hours. The noticed vision loss was sudden and dramatic, which was why they brought it to the attention of their doctors. But in a far greater number of people, vision damage may simply not be noticed or linked to viagra use. The vision loss may be "sputtering along" and only be caught at a late stage, just like is often the case with glaucoma.

While at this stage no one knows if NAION mini-strokes exist, my advice would be that anyone using viagra should at the very least have his eyes checked regularly by an ophthalmologist. In particular they should be made aware if their optic nerve cup/disc ratio is small. Pomeranz has identified a small cup/disc ratio as a major risk factor for NAION in his 2005 paper.

The bottom line is that further study is certainly needed, because it could be a very big issue.

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May 8th 2005 - the colour blind screening incident

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As an ophthalmologist, one of the things I do for a living is screen people for colour blindness. These people that I screen are applying to join a particular company. I usually do the colour vision test with the standard Ishihara colour plates. These are colour plates in a booklet, made up of coloured blobs like here.

The other day a young man came in for screening. He passed the colour test, but raised our suspicions. Now, I personally have always been doubtful of the value of the Ishihara test when there is a motivation to pass it. Well, it turns out I was right to be so, because after further scrutiny it turned out that he was colour blind after all. He had tried to pass the test by memorising the patterns in the booklet that a person with normal vision sees. He had done a pretty thorough job at it, because his employment with an excellent company was at stake, and getting good work in India is tough. While I was sad at having to fail him, it was obviously my duty to do this for the company.

It raised some moral questions in my mind. As a doctor my conscience requires that I be ethically on solid ground. So, my actions should always be based on reasons (ie not excuses), and overall benefit to society (ie not necessarily to individuals). So I thought carefully about the rights and wrongs of this case, along with the consequences and might-have-beens. I decided to write my thoughts on the matter down here as a record for the future.

1. Firstly, was the company right in imposing a colour test?

   Well, yes. They can put whatever restrictions they like on who they want to employ. They have every right to do so. That said, there are two things that make the colour vision restriction somewhat unfair.

   1. It is a surprise disqualification after the first stage of recruitment. The company should have made it clear at the first stage of recruitment that it was a necessary requirement that the applicant have full colour vision. About 8% of of applicants were colour blind enough to fail the test, many of whom were previously unaware that they were colour blind. Since most people restrict how many companies they apply for during recruitment, 8% of applicants lost a chance to join this company at a stage that can be devastating to planning their future.
   2. Colour blindness is not a major disability. So it is illogical to turn away colour blind people unless full colour vision is a critical part of the job. Some illustrative examples:
      • Airline pilots or train drivers certainly need to be able to discern colour because it can be a matter of life or death.
      • For an artist or designer, it is not a matter of life or death, but they'd have a hard time earning a living.
      • Electricians can actually get away with mild colour blindness because they can see the difference in wire colours, and if they are having problems (eg under coloured lights) they can ask a colleague about wire colours. And when in doubt, they can use a multimeter.
      • In electronics, a colour blind person can have trouble telling the difference between green and red LEDs, or working out resistor values from the colours painted on it. But it can be worked around by, eg, testing with multimeters, or reading the labels. It is probably a bit safer to disregard the colours in such cases.
      • Then there are the vast majority of professions in which colourblindness is no big deal - eg programming, which is what this company mostly does.
      • And, finally, there are also some cases in which colourblind people do better than people with normal vision - eg some can see through camouflage better than normal sighted people, and their night vision tends to be better than normal sighted people.

   So unless there are very good reasons, a person who has the most common kind of colour blindness functions as well as a normal vision person for most jobs in my opinion.

2. Secondly, was the person being screened wrong in trying to subvert the system?

   Yes. It could have compromised my reputation, and the reputation of the place that I am working for. We have worked hard to get the good reputation that we have. As a result, if we say something, people value what we have said because they trust us. Any damage to this reputation wrongs us, and is unacceptable to us.

3. Thirdly, whose loss is it really?

   The person showed remarkable initiative and gall in his attempt to beat the system. That is a valuable asset. He was also a hard worker and desperate to get accepted and do well, since he came from a disadvantaged background. His behaviour was to some extent understandable.

   Unfortunately all this came together with a disregard of our reputation, and with dishonesty towards the company that required the screening.

   From a practical point of view, this sort of gumption probably actually makes him ideal material for grooming into becoming a company director in the Indian business environment - he would be alert and agile enough to bend the rules enough without truly breaking them to keep his company in the lead. Successful Indian companies are not saintly in their behaviour, and do best when led by gutsy people like this. So, while his behaviour was unethical, and something I disapprove of, I think (again from a practical point of view) it worked out to be a loss on the part of the company that was putting him through the screening. I think he will benefit any company he joins, despite him having done a wrong thing like this.

So, what would the right thing to do have been? The right thing, according to my way of thinking, would have been for him to calmly talk to the company about their rejection policy, pointing out that he was not informed about this requirement at the time he got to apply to them (of note is that he rejected other offers in favour of this company because he was unaware about his colourblindness and the colourblindness restriction). He would almost certainly have been rejected anyway. But maybe he would have impressed them enough by his reasoning that they would take him on regardless.

In any case, it would have been the right thing to do and better in the long run.