HEALTH TRIBUNE Wednesday, June 7, 2000, Chandigarh, India
 
Management and medical services
By Dr R.P. Sapru
T
he ills of medical care provided by government institutions in the country have been the subject of comment by all segments of society at one time or another, often giving vent to personal experiences. It is, therefore, that a recent academic analysis of the ills of the medical profession, especially at the PGI, Chandigarh, presented by Prof Satya Prakash Singh is worthy of note. Professor Singh says: "The opportunity cost to the medical professionals, should they stick by government institutions like the PGI, is high. Consequently government hospitals are losing good doctors to the private sector.

Proactive heart-care
By Dr Harinder Singh Bedi
S
troke is a condition in which the blood supply to a part of the brain is suddenly and seriously impaired resulting in injury to the brain. This may be due to the clogging of a vessel, causing an ischaemic stroke, accounting for 80% of all strokes, or bleeding from a ruptured vessel, a haemorrhagic stroke. The brain is an extremely complex organ that controls various body functions and damage to a part of the brain leads to the loss of function of the area supplied by it. If the blood flow to the region that controls the leg is cut off, it will result in muscle weakness, causing a limp.

Health-care in Armed Forces
Soldiers! you are in safe hands
By Maj-Gen (Dr) Jaswant Singh AVSM
I
t is usually said that the Army Medical Corps (AMC) deals with a young and healthy population that too in a limited number. So, the health-care-delivery system is streamlined and has no hiccups. To put the record straight, it may be mentioned that we have about 11 lakh service officers and soldiers and correspondingly 70 lakh dependents and ex-servicemen. Besides that, we cater to the paramilitary forces the ITBP, the BSF, the Rashtriya Rifles, the police and the civilians in operational areas. To this figure, about 60,000 ex-servicemen are added annually with no corresponding increase in manpower or finances.

 
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Management and medical services
By Dr R.P. Sapru

The ills of medical care provided by government institutions in the country have been the subject of comment by all segments of society at one time or another, often giving vent to personal experiences. It is, therefore, that a recent academic analysis of the ills of the medical profession, especially at the PGI, Chandigarh, presented by Prof Satya Prakash Singh is worthy of note. Professor Singh says: "The opportunity cost to the medical professionals, should they stick by government institutions like the PGI, is high. Consequently government hospitals are losing good doctors to the private sector.

Painful experiences of the user public, of inadequacy and poor quality of service in government hospitals, long waits and harassment at the hands of the personnel are some of the reasons for dissatisfaction of the users. Promptness of service and a caring attitude in private clinics is the main reason that encourages people to seek private medical help even by persons who cannot really afford the cost of such treatment. The agency cost due to the pursuit of self-interest by the employees, particularly by the top management, is too high and that leads to inefficiency.

The real threat to the government or public sector originates in the private motive of the persons who man the government or public sector and make decisions on their behalf. The real privatisation of a public sector or government organisation begins when its management starts to think in terms of its self-interest at the cost of the organisational goals. The worst happens when the management uses the organisation for its own sake. This is the extreme form of agency cost responsible for the deterioration of an organisation.

The change of ownership per se does not increase organisational efficiency or effectiveness. Privatisation is not a matter of ideology, or of procedure either; it is a consequence of market mechanism and the underlying real forces that determine the supply and demand. Economists have known since long that the conditions for self-interest motivated market mechanism to maximise social welfare are too stringent to be applicable in the real world of market distortions. Such systems ignore the interest of the poor and the weak and, most importantly, of future generations.

The obvious lesson for the government hospitals is then to develop a system of accountability, and reward and punishment" (paraphrased verbatim except the italicised portions.)

There can be no disagreement with Professor Singh on the diagnosis or the treatment of the disorder. Therefore, one can only be grateful to the good professor for having yet again brought to light what many others have said in the past. That is not to say that the matter does not bear repetition; in fact it does, for the powers that be are unwilling to read the writing on the wall.

What this writer would, however, like the Professor and others like him, who have the larger interests of the nation at heart, to consider is whether the diagnosed disorder(s) and the recommended treatment are in anyway unique to the situation in the PGI or merely a reflection of the general disorder that afflicts our society? Are these arguments not applicable with equal force to the very same university to which Professor Singh belongs, and indeed to any other university, public sector industry, public administration or any other public institution in the country? As this writer wrote in these columns almost a year ago, our socio-political thinking pursues a somewhat warped and completely mistaken belief that social empowerment can be speeded up by downgrading quality even if such a policy be pursued only for a short period of time. Experience has already demonstrated that in spite of the best possible intentions such policies create aberrant centers of power that will not permit any roll-back of the so-called temporary measures.

It is often forgotten that poverty can only be alleviated by creating more wealth or financial muscle, not less. The poorer a nation is, the greater (not less) is the need for the more efficient utilisation of limited resources as well as the maximisation of productivity. The pursuit of quality in all walks of life is the only mantra for serious efforts to improve the quality of life of the the poorest segments of society. Our own recent history lends support to this argument.

Having then diagnosed the ailment and provided a framework for effective treatment, it seems necessary to offer the prescription to all walks of life and not merely to the medical profession. The repeated efforts to politicians and social scientists at making exhortations demanding selfless service from doctors is completely out of place in the real world. The slogan touches the heart of everybody, for there is hardly anyone who has not, sometime or the other, had the need for medical attention for himself or a close relative or a friend. Politically, therefore, the subject is a gold mine that helps to divert the attention of the people from the real issues. The stoning of the devil is an effective means for letting out pent up emotions. That is what organised bandhs' burnings of effigies and flags, doctor-bashing and other similar activities do. As with religions mired in the past and unable to cope with the present, let alone the future, emotive exhortations are excellent material for mass hypnotism, especially when the purposive advancement of human welfare is not on the agenda. Politicians are past masters at it, but it becomes a cause for worry when academicians join in.
Dr Sapru, the eminent cardiologist, is also a Doctor of Philosophy.


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Proactive heart-care
By Dr Harinder Singh Bedi

Stroke is a condition in which the blood supply to a part of the brain is suddenly and seriously impaired resulting in injury to the brain. This may be due to the clogging of a vessel, causing an ischaemic stroke, accounting for 80% of all strokes, or bleeding from a ruptured vessel, a haemorrhagic stroke. The brain is an extremely complex organ that controls various body functions and damage to a part of the brain leads to the loss of function of the area supplied by it. If the blood flow to the region that controls the leg is cut off, it will result in muscle weakness, causing a limp.

Stroke is a leading cause of death in India after heart attack and cancer. Though we do not have a proper database, we can take a sobering lesson from the following American statistics. Every 53 seconds someone in the USA has a stroke, someone dies of a stroke every 3.3 minutes; 6,00,000 Americans will have a stroke and 1,60,000 of them will die. About 4.4 million stroke survivors are alive today and stroke costs the country between $30 billion to $ 40 billion per year. Far worse than its mortality rate is the morbidity as it leaves two out of three victims disabled for life. People think it is something which happens to the aged and yet nearly a third of the patients are under 60 years of age.

Unlike cancer and heart disease, which are extensively publicised, public knowledge on strokes is negligible. Strokes are an important cause of death afflicting approximately half a million people in developed countries. Most of us know the risk factors that lead to heart disease such as high cholesterol and high blood pressure and diabetes. Stroke shares many of these risk factors in fact, the two diseases coexist quite often. The modifiable risk factors are: high blood pressure, cigarette-smoking, diabetes, high blood cholesterol and lipids, physical inactivity, obesity and the presence of heart disease.

The following grim statistics were discussed at the 25th International Stroke Conference in new Orleans recently: In 1999 alone, there were 7,50,000 full-fledged strokes and half a million transient ischaemic attacks (TIAs) or ministrokes. The ministrokes are a greater concern because they may at times be ignored by the patient. They are the harbingers of a deadly stroke and timely treatment affords dramatic relief.

The cause of a ministroke is, generally, the temporary interruption of the blood flow to the brain. The symptoms last from a few seconds to 24 hours. They do not themselves cause permanent neurological damage but are the precursors to a major stroke. They need a quick diagnosis and treatment as well as appropriate follow-up to prevent future injury.

Ministrokes are often underdiagnosed. The National Stroke Association (USA) study showed that 2.5% of all adults aged 18 or older (about 4.9 million people) have experienced a confirmed TIA. An additional 1.2 million Americans over the age of 45 have most likely suffered a ministroke without realising it. Though we do not have reliable data for the Indian population we must learn from these figures. These findings clearly show that if the public knew how to spot the symptoms of a stroke, especially ministrokes, and sought prompt medical treatment, thousands of lives could be saved and major disability could be avoided.

The problem is that the symptoms of a ministroke may be subtle and temporary. The symptoms to watch out for are:

* Trouble in seeing in one or both eyes.

* Numbness or weakness in the face, the arm or the leg especially on one side of the body.

* Difficulty in walking, dizziness, loss of balance or coordination.

* Confusion and difficulty in speaking or understanding.

* A severe headache with no known cause.

A TIA precedes a stroke in more than 20% of the cases. It is actually a brief stroke that has virtually all the symptoms of a major one though it does not cause any permanent damage. But they are dramatic advance warnings: a full fledged stroke may occur! A TIA patient is 16 times more likely to have a stroke than otherwise. If you have any of the above symptoms, you must immediately see a doctor. People who ignore these symptoms in the hope that these will pass after a good night's sleep can land up in serious trouble in the form of a major stroke which could have been prevented. So TIAs are extremely important stroke warning signs. Don't ignore them! Treat them as a life-threatening emergency. Even if a full-blown stroke is in progress, treatment by clot-busting drugs (if indicated) within three hours will greatly reduce the severity of the stroke.

One of the most important causes of a stroke or ministroke is a blockage in the artery to the brain the internal carotid artery. The block is of a cholesterol plaque or atheroma. The disease is called carotid artery stenosis and it affects the artery as it courses to the brain under the muscles of the neck. It can be easily diagnosed by a thorough examination and a simple test called a carotid doppler. In this the doctor is able to look for a block by a simple scanner called a doppler which is applied over the neck. There is no injection or anaesthesia required for this test. If the block is more than 75% and the patient is symptomatic, surgery is indicated. The treatment is by a delicate but very simple and effective procedure called carotid endarterectomy.

Simply put, the doctor removes the block in the carotid artery and repairs it. It can be performed under local or general anaesthesia. During the surgery, while the artery is clamped to repair it, the blood supply to the brain may be maintained by the use of a shunt which temporarily bypasses the block. For the repair, the surgeon may use a piece of vein from the patient's own leg or a special biocompatible cloth (Dacron or PTFE poly tetra fluoro ethylene). Special magnifying loops and very fine sutures, which are not readily visible to the naked eye, are used for the repair.

The results are gratifying as the risk of developing a major stroke is reduced. Roughly, out of a population of a million people, there are about 50-100 persons who would benefit from carotid endarterectomy.

The present proactive policy towards stroke prevention evolved from several discoveries dating back to the late eighteenth century when William Osler observed that emboli to the brain originate from the heart and from the arch of the aorta and the carotid artery. This finding has since been corroborated by heart surgeons and by a large number of trials involving thousands of patients which all conclusively point to a significant advantage (in the form of reducing stroke and death) of early surgery on symptomatic patients or even asymptomatic patients with severe blocks. These trials are: the North American Symptomatic Carotid Endarterectomy Trial (NASCET), the European Carotid Artery Surgery Trial (ECST) and the Asymptomatic Carotid Atherosclerosis Trial (ACAS). Elective surgery carried out in ideal conditions with the patient (and the surgeon) in a good condition will always have a better result than surgery carried out as an emergency procedure.

You can greatly help yourself by simple ways of changing your lifestyle:

* Quit smoking.

* Reduce your alcohol intake to no more than one drink a day (if at all).

* Increase your physical activity; perform regular aerobic exercises.

* Control your blood pressure by regular medication.

* Control diabetes.

* Practise yoga.

Stroke is thus not an unavoidable certainty of life. It is not the "stroke of luck". About 80% strokes can be prevented and the morbidity and mortality associated with this killer disease can be greatly reduced by lifestyle changes, the control of risk factors and surgery where indicated.

The author is the Chairman of the Department of Cardio-vascular Surgery at the Tagore Heart Care Centre, Jalandhar.
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Health-care in Armed Forces
Soldiers! you are in safe hands
By Maj-Gen (Dr) Jaswant Singh AVSM

It is usually said that the Army Medical Corps (AMC) deals with a young and healthy population that too in a limited number. So, the health-care-delivery system is streamlined and has no hiccups. To put the record straight, it may be mentioned that we have about 11 lakh service officers and soldiers and correspondingly 70 lakh dependents and ex-servicemen. Besides that, we cater to the paramilitary forces the ITBP, the BSF, the Rashtriya Rifles, the police and the civilians in operational areas. To this figure, about 60,000 ex-servicemen are added annually with no corresponding increase in manpower or finances.

This system covers a large area from "womb to tomb", the womb of the soldier's family to the tomb of the serviceman/exserviceman. Herein include dental services as well.

Obstetrics and maternity services: Recently I learnt reliably that two Army officer brothers decided to get their wives operated upon or delivered in civil hospitals or nursing homes. They genuinely felt that their wives deserved better obstetrics care not feasible in service hospitals). They shelled out about Rs 20,000 to Rs 25,000 each on caesarian section deliveries.. On the contrary, their third brother, also a Captain, in spite of persuasion to follow them, decided to have his wife's caesarian section done in the Command Hospital, Chandimandir, and paid a paltry sum of Rs 29. Fortunately, things went on well for all the three ladies. It is a different matter why all the three decided not to deliver normally but to undergo caesarian section!

Cancer hospitals: Life expectancy is rising and naturally a larger number of serving and retired men are getting afflicted by cancer. The cost of chemotherapy, radiotherapy and cobalt therapy is exorbitant at times unaffordable. It is understandable to treat the serving man at the Malignant Diseases Treatment Centre (MDTC), Pune and the sub-centre in Delhi. But for retired personnel, we have to resort to outside agencies, though life-saving treatment is being provided in Services hospitals.

Heart ailments are increasing both in service and after retirement. It is a matter of great satisfaction that military hospitals (the Cardiothoracic Centre at Pune and the R.R. Hospital, Delhi Cantt) are carrying out coronary artery bypass graft (CABG) successfully. Nearer home, our cardiologist, Col Nikhil Kumar at the Command Hospital, Chandimandir, is carrying out angiography and angioplasty successfully in collaboration with a local heart centre, thus saving a lot of money and discomfort or dislocation for patients.

The Research and Referral Hospital (Delhi Cantt): This premier research and referral hospital of the Army, a 720-bed super-speciality institution, is now fully functional. It is equipped with the state-of-the-art diagnostic and therapeutic equipment such as MRI, spiral CT scanner, DSA, SPECT gamma cameras colour doppler, ultrasound, a modern cardiac cath and interventional laboratory, a linear accelerator, brachy therapy and gamma knife, the neuronavigation system and holmium laser. The hospital is routinely performing laparoscopic surgery, renal transplantation, bone marrow/stem cell transplantation, joint replacement, open-heart surgery, including coronary artery bypass surgery, and coronary, non-coronary interventions in a large number of patients. Some of the latest procedures being performed at this hospital include deep brain stimulation for Parkinsonism, the implantation of permanent cardioverter defibrillator, occluder devices for congenital heart diseases and endovascular interventions.

This hospital treated about 100 tertiary referral Kargil patients with complex injuries with excellent rehabilitational foresight.

Practical large service hospitals should have satellite-section hospitals where, besides medicines, laboratory, x-ray and basic physiotherapy facilities are provided. It will go a long way in improving the lot of retired personnel and dependants. This is possible and desirable in Chandigarh and Mohali. The process has begun.

Medicines cause a major financial strain. Fortunately, all medicines prescribed for indoor patients are provided. The problem is there for the outdoor clientele. Let us accept that our resources even though augmented by canteen profits, are short of the requirements. We are sure that our commanders at all levels, will manage things well. As for the quality of medicines, the myth that the Armed Forces get second-grade drugs is entirely baseless. In fact, we have an inbuilt testing system not heard of in civil life where any particular batch of medicines is put through biochemical tests and, if found unfit, is discarded. I heard another myth today from a senior Brigadier. The medicines for senior officers were superior! They have no way to get superior medicines as there are no separate medical stores.

Surgical operations: Some specialised centres have been established. For example, joint replacements are being carried out at the Orthopaedic Centre, Army Hospital, Delhi Cantt, and the Military Hospital Cardio-Thoracic Centre (CTC), Pune, for Heart and Chest Diseases. Recently, at my behest, a retired Colonel, in his mid-seventies, underwent hip replacement successfully at the Army Hospital, Delhi Cantt, by spending only Rs 30,000 as the cost of joint-prosthesis as against Rs 1,50,000 he was asked to deposit at the PGI, Chandigarh. Even that amount was reimbursed by the Army Group Insurance Section.

Though my aim was to highlight the fact of cost-free medical treatment in Service hospitals for serving or retired personnel and their dependants, I would hasten to add that more funds are required for medicines and the latest equipment for still better service. The soldier gives his all, including his life. Does the nation look after his needs including medical charges?

The General has been a consultant surgeon to the Army. He has retired as the Director of Medical Services, Western Command. He is a practising surgeon based at Chandigarh.


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