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RNI No. : UPENG / 2014 / 59232 A

CO M PL E T E

April 2018

H E A LT H

J O U R N A L

VOL IV, Issue V, Rs. 100

DOCTORS’ MAHAPANCHAYAT

CURBING ALCOHOL ABUSE


Contents 34 Advisory Board

Dr. A K Agarwal,

Professor of Excellence, Ex-President, Delhi Medical Council and Medical Advisor, Apollo Hospital, New Delhi

Dr Vinay Aggarwal. Member, Medical Council of India Dr. S P Yadav, Member, Medical Council of India Dr. J C Passey, Director Professor, Maulana Azad, Medical College, New Delhi Dr. Suneela Garg, Director Professor, Maulana Azad, Medical College, New Delhi Dr. H P Singh, Sr. Child Specialist Raj Kumar Gupta, Managing Director, Balaji Action Hospital & Research Center, New Delhi

COVER STORY

Volume IV Issue V April - 2018

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Curbing Alcohol Abuse 14

Editor & Publisher Amresh K Tiwary Coordinating Editor Sarvesh Tiwari Roaming Editor Dr. Manisha Yadav Editorial Team Abhigyan, Abhinav, Designer Aparna http://Facebook.com/doublehelical1 http://twitter.com/doublehelical Advertisements & Marketing Gautam Gaurav, Abhinav Kumar Email:sales@doublehelical.com All material printed in this publication is the sole property of Double Helical. All printed matter contained in the magazine is based on the information by those featured in it. The views, ideas, comments and opinions expressed are solely of those featured and the Editor and Publisher do not necessarily subscribe to the same. Double Helical is owned, printed and published monthly. It is printed at Polykam offset, Naraina Industrial Area Phase 1, New Delhi-110028, and published from G-1, Antriksh Green, Kaushambi, Ghaziabad-201 010. Tel: 0120-4219575, 9953604965. Contact us : dhelical@gmail.com Email: doublehelicaldesign@gmail. com, editor@doublehelical.com Website: www.doublehelical.com, www.doublehelical.in

World Hearing Day 2018

16

Side Effects of Stress on Oral Health

20

Aneurysm

Curbing Alcohol Abuse

38

Less Incision, More Precision

50

Treating Young Asthmatics

April 2018

3


Editorial

Curbing alcohol abuse needs to be made a priority

D

ear readers, We find it immensely satisfying every month to present to you a wide range of interesting, in-depth and analytical stories pertaining to the latest trends and advancements in the world of healthcare. We hope you would derive the same value and substance after reading the current April 2018 issue of Double Helical. These times we highlight many informative stories. This time we bring you as our cover story a comprehensive package – enriched with analysis and expert viewpoints – on the growing incidence of alcohol consumption in the Indian society has wide-ranging negative effects manifesting not only in health-related aspects but adverse social and economic conditions too. Curbing alcohol abuse needs to be made a priority in public health policy in India Alcohol consumption is a global phenomenon but it is now getting worldwide attention due to its harmful outcomes. Alcohol is classified as psychoactive substance which produces dependence. It has not only important implications on health but has social and economic aspects as well. There are a number of factors which determine alcohol consumption in a society. Social factors like cultural practices, level of development, alcohol production, distribution and marketing strategies are important factors. In India, alcohol consumption on certain religious occasions and social gathering is an accepted norm. Similarly, consumption of alcoholic beverages is prevalent in many tribal and village societies around the world. Individual factors also play a role in the pattern of alcohol consumption. Age group, gender, socio-economic factors, education, certain occupation, familial tendency, peer pressure etc are individual determinants of alcohol intake. Early age of initiation of alcohol intake leads to higher rates of diseases due to abuse, accidents and injuries. Apart from this as a special package we headlight recently held the doctors’ Mahapanchayat which out rightly rejects the proposed National Medical Commission Bill 2017 in one voice. The Mahapanchayat also rejects the recommendations of the Parliamentary Standing Committee on Health and Family Welfare thereon in their entirety as the said Bill along with the recommendations of the Parliamentary Committee are out and out anti-poor, anti-people, pro-rich, undemocratic, sponsors crosspathy through the Bridge Course, undermines the sanctity of University examinations through the licentiate examination patronizes, privatization, promotes corruption through discretionary provisions, harbors anti-federalism vide marginalization of the state and the State Medical Councils. According to Mahapanchayat, in order to provide for effective meaningful, equitable, accessible, handy and affordable healthcare

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to rural populace, Govt. of India shall ensure that the appropriation for health spending to the extent of 6% of the Gross Domestic Produce (GDP), additional rural hospital are created, care and cure facilities at the existing rural hospitals are up-dated and augmented, much desired governance is rationalized and heavily needed motivating robust policy of incentives is put into place The government must propose a strong Central Act prohibiting violence against doctors in all forms, hues, shades, matching with the enabling existing provisions in the Indian Penal Code, so as to evoke uniformity across the States in respect of its implementation and thereby extend much needed and desired immunity to the doctors while on duty from all forms of violence from any and all sources as they be and declare clinical establishments as safe zones in a real sense. As a special story Side Effects of Stress on Oral Health highlights how serious about your oral cere. If you’re feeling stressed, don’t forget about your dental health. Take the time to focus on your oral hygiene regimen, and don’t use smoking or alcohol to relieve stress. These habits are highly addictive, and they have damaging effects on your oral cavity. Instead, take proper measures to reduce stress in your life, such as eating well, exercising and getting plenty of sleep. If you suffer from extreme anxiety or depression, seek professional help. Stress and control are risk factors for periodontal disease and cardiovascular diseases. When an individual feels stressed, adrenaline and stress hormones (e.g., cortisol) are released to prepare the body for the “fight-or-flight” response. While stress is a normal part of life, excessive stress can lead to health problems and lifestyle behavioural changes (e.g., taking up or increasing smoking, increasing alcohol intake, changing dietary habits, becoming physically inactive, neglecting oral and personal hygiene) which further increase health risks. Chronic stress speeds up the process of atherosclerosis in the coronary arteries and that the stress hormone cortisol plays a role in increased periodontal destruction. Cortisol also acts to suppress the immune system, allowing bacteria to flourish in the mouth.Exercise and stress management techniques provide individuals with tools to cope with the anxieties in their lives. The most effective way to deal with stress is by correcting or modifying its underlying causes. We hope you will enjoy reading such topical stories and encouraging us with your feedback to enable us to further improve your favourite magazine Amresh K Tiwary, Editor-in-Chief


Health News

Partners’ Forum to galvanise global action for women children and adolescent health

A

t recently held the curtain raiser event for the 2018 Partners’ Forum, J P Nadda, Union Minister of Health and Family Welfare, said, “Convergence between Ministries, States and stakeholders is critical to achievements of shared goals for health of women, children and adolescents.” The 2018 Partners’ Forum, a global event will provide a unique platform for learning and exchange between countries on reproductive, maternal, newborn, child and adolescent health (RMNCH+A). Speaking at the function. J P Nadda further said that the Government is committed to collaboration for expanding universal health coverage for women, adolescents and children. Ashwini Kumar Choubey, Minister of

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State for Health and Family Welfare, Anupriya Patel, Minister of State for Health and Family Welfare, Preeti Sudan, Secretary (Health), Dr Michelle Bachelet, former President of the Republic of Chile and incoming board chair of the Partnership for Maternal, Newborn and Child Health (PMNCH), Priyanka Chopra, Partners’ Forum Champion and UNICEF Goodwill Ambassador and Dr Aparajita Gogoi, National Coordinator, White Ribbon Alliance were also present at the occasion, along with other senior officials, advocates and experts. Highlighting the achievements of the Ministry, Shri J P Nadda said that we have accelerated our progress towards our target of 90% full immunization coverage. Earlier the increase in full immunization coverage was 1% per

year which has increased to 7% per year through ‘Mission Indradhanush’. “We have launched the Intensified Mission Indradhanush (IMI), the special drive will focus on improving immunization to more than 90% by December 2018,” Shri Nadda said. The Union Health Minister further stated that India is officially acknowledged as being Yaws-free and has been validated for Maternal and Neonatal Tetanus Elimination (MNTE). Shri Nadda further said that Ayushman Bharat-National Health Protection Mission (NHPM) is a major step towards Universal Health Coverage. It will benefit around 50 crore people (from about 10 crore families) by providing coverage from secondary and many tertiary hospitalizations. Shri Nadda also


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informed the participants that to provide comprehensive primary care, the Government will transform 1.5 lakh sub health centres to Health and Wellness Centres (HWC). “The Ministry is now moving towards provision of comprehensive primary care through the Health and Wellness Centres”, he said. He further stated that in a step towards provision of comprehensive primary care, the Government has initiated universal screening of common NCDs such as diabetes, hypertension and common cancers at the sub-centre and Primary Health Centre. “This will enable the strengthening of preventive and promotive health, improve patient referral and access to secondary care services, Shri Nadda added. Shri Nadda also highlighted India’s commitment to RMNCH+A through policy and programmes, including the new school health programme and implementation of UHC that drives progress within this strategic framework. Underscoring the importance of the 2018 Partners’ Forum, Dr Michelle Bachelet said that cross-sectoral and multi-stakeholder partnerships were vital to push forward for progress on improved health at every life stage. Dr Bachelet emphasized the need for global sharing of best practices and technical expertise at the civil society, academic, private sector and governmental levels to change public discourse and lead society into adopting innovative methods to resolve issues and improve health indicators in children, adolescents and women. She introduced the 12 Success Factors case studies of best practice RMNCH+A programmes and initiatives which will be launched at the 2018 Partners’ Forum, including Intensified Mission Indradhanush. Ashwini Kumar Choubey, Minister of State for Health and Family Welfare said that quality, equity and dignity in healthcare are the core concepts addressed in the National Health Policy and that will drive progress towards achieving the Sustainable Development Goals. Shri Choubey

J P Nadda, Union Minister of Health and Family Welfare lighting the lamp at the curtain raiser event for the 2018 Partners’ Forum, Shri Ashwini Kumar Choubey, Smt. Anupriya Patel, Ministers of State for Health and Family Welfare, Smt. Preeti Sudan, Secretary (Health), Dr Michelle Bachelet, former President of the Republic of Chile and incoming board chair of the Partnership for Maternal, Newborn and Child Health (PMNCH), Ms. Priyanka Chopra, Partners’ Forum Champion and UNICEF Goodwill Ambassador

stated that by ensuring the quality of maternal and newborn care in health facilities, preventable maternal and infant deaths can be ended by 2030, as envisioned by the EWEC Global Strategy to which India is committed. Anupriya Patel, Minister of State for Health and Family Welfare, said that sanitation, hygiene and menstrual health of girls are high on Government agenda. She further stated that multisectoral collaboration is what stands out in the push for progress towards improved RMNCH+A outcomes. Gender inequalities and discrimination have clearly established effects on RMNCH+A outcomes, and these must be explicitly weaved in all discussion around women’s, children’s and adolescents’ health. Priyanka Chopra highlighted the importance of a healthy childhood with good quality health care as it sets the course for positive adolescence, adulthood and parenthood. “We need to give girls the same opportunities as boys if we want them to be healthy and successful”, she said. She further stated that across the world, girls

have become community leaders due to the support of the community. “Let’s start valuing the girl child. I hope that by lending my voice I can make a difference to their lives,” Priyanka Chopra added. The 2018 Partners’ Forum will be held in New Delhi on 12 and 13 December 2018. It will be a unique platform for learning and exchange for the alliance of 1,000 organizations to align objectives, strategies and resources, and agree on interventions to improve maternal, newborn, child and adolescent health. The Partnership for Maternal, Newborn & Child Health is an alliance of organisations in 77 countries from the sexual, reproductive, maternal, newborn, child and adolescent health communities, as well as health influencing sectors. Also present during the function were senior officers of the Ministry, representatives of PMNCH partners, as well as leading advocates, implementers and experts on maternal, newborn, child and adolescent health.

April 2018

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Health News

Swachhta Pakhwada

S

wachh Bharat Abhiyan (SBA) is not merely a programme, it’s a behavior change mission.” This was stated by Smt. Anupriya Patel, MoS (Health & Family Welfare) during the observance of ‘SwachhtaPakhwada’ at Dr. Ram ManoharLohia Hospital, recently. At the event, Anupriya Patel planted a sapling to initiate a ‘Tree Plantation’ drive in the hospital and also released the ‘SwachhtaPakhwada’ booklet. The Minister also administered the ‘SwachhtaPledge’ to the participants. Anupriya Patel stated that under the visionary leadership of the Prime Minister, NarendraModi, the programme was started on 2nd October, 2014 and since then it has become an important social movement. She further stated that to achieve the goals of sanitation and

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cleanliness, every citizen has to play an important role and understand his or her responsibilities towards sanitation and cleanliness. “It all begins with the self, then from person to the family, from family to the society and from society to the nation, and if this happens it will not take much of a time for us to transform ourselves into a clean nation”, she stated. Appreciating the efforts of the Institute, Anupriya Patel said that cleanliness activitiesshould not be limited to a ‘Swachhta Pakhwada’ but should be carried out throughout the year. The Minister was pleased to learn that the Institute has become

environment friendly by choosing solar power and looked forward to a clean and green hospital. At the function, Anupriya Patel also gave away the awards to the staff of the RML hospital for their contribution towards sanitation and cleanliness. She also awarded the winners of various competitions organized by the RML Hospital to mark the ‘Swachhta Pakhwada’. Dr V K Tiwari, Director and Medical Superintendent, Dr. Ram Manohar Lohia Hospital along with the other senior officers, faculty and staff were also present at the event.


WHO Report - World Hearing Day

World Hearing Day 2018 BY TEAM DOUBLE HELICAL

O

n the occasion of World Hearing Day 2018, an ear awareness and screening camp was organized by Ministry of Health and Family Welfare, Government of India in collaboration with Department of Community Medicine and Department of ENT, Maulana Azad Medical College; Department of ENT, Lady Harding Medical College; Department of ENT, Safdarjung Hospital and Society for Sound Hearing recently. Dr. Promila Gupta, DDG, Ministry of Health and Family Welfare,

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WORLD HEARING DAY 2018

have some form of ear morbidities. The age of the individuals varied from 21 years to 69 years. The outcome of the screening is summarized as below:Fig. 2: Morbidity pattern of the screened subjects, n=353 55 1 3 26

9 7

45

252

Normal

Wax impaction

Retracted tympanic membrane

Mild hearing loss

Moderate hearing loss

Moderately severe hearing loss

Tympanosclerosis

Dry perforation

Perforation with discharge

April 2018 11 Of the 101 individuals with ear morbidities, the gender distribution showed that 85 individuals were males (84.1%) and 16 (15.9%) individuals were females.

The distribution of the ear morbidities showed that wax impaction was found


WHO Report - World Hearing Day

WORLD HEARING DAY 2018

LIST OF RESOURCE PERSONS IN THE CONDUCT OF SCREENING CAMP S No.

NAME

DESIGNATION ENT Consultant & Ex-Dean MAMC, New Delhi and President- Sound Hearing 2030 Director-Professor and Head, Community Medicine ,MAMC, New Delhi and Honorary Secretary General- Sound Hearing 2030

1.

Dr. A.K. Agarwal

2.

Dr. Suneela Garg

3.

Dr. Sunil Kumar

HoD, Department of ENT, LHMC, New Delhi

4.

Dr. M. Meghachandra Singh

Director Professor, Community Med. MAMC, New Delhi

5.

Lt. Col. (Dr.) Vipra Mangla

Ph.D scholar, MAMC, New Delhi

6.

Dr. Neha Dahiya

Senior Resident, Community Medicine MAMC, New Delhi

7.

Dr. Kajok Engtipi

Senior Resident, Community Medicine, MAMC, New Delhi

8.

Dr. Ruchir Rustagi

PG 3rd year, Community Medicine, MAMC, New Delhi

9.

Dr. Shraddha Deokota

PG 3rd year, Community Medicine, MAMC, New Delhi

10.

Dr. Saurav Basu

PG 3rd year, Community Medicine, MAMC, New Delhi

11.

Dr. Kavita Aggarwal

PG 3rd year, Community Medicine, MAMC, New Delhi

12.

Dr. Ruchika Juneja

Senior Resident, ENT, MAMC, New Delhi

13.

Dr. Arif K.N.

Senior Resident, ENT, MAMC, New Delhi

14.

Dr. Vishaka B.L.

Senior Resident, ENT, Lady Harding Medical College, New Delhi

15.

Dr. Sudhagar M.E.

Senior Resident, ENT, Lady Harding Medical College, New Delhi

16.

Mr. Anup Narang

Director, ALPS International, New Delhi

17.

Ms Shilpi Narang

Special Educator, ALPS International, New Delhi

18.

Mr. Sanjay Verma

Audiologist, ALPS International, New Delhi

19.

Mr. Deepak Verma

Audiologist, ALPS International, New Delhi

20.

Mr. Ashutosh Pandey

Audiologist, ALPS International, New Delhi

21.

Mr. Swadesh Mishra

Audiologist, ALPS International, New Delhi

22.

Ms. Janki Mehta

Admin. Officer-SFSH, MAMC, New Delhi

23.

Ms. Tripti

Medical Social Worker- ICMR, MAMC, New Delhi

24.

Mr. Vinay Baberwal

Data Entry Operator- ICMR, MAMC, New Delhi

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the participants varied from 21 years to 69 years. The participants were first screened for any hearing problem using screening proforma which included details of individual’s history. This was followed by ear examination by ENT specialists and those requiring audiometric assessment, were further evaluated in a separate room by audiometrists. The audiometric services were provided by ALPS International. A total of 353 individuals were screened in the camp of which 292 (82.7%) individuals were males and 61 (17.3%) were females. 252 (71.4%) individuals had normal ear and 101 (28.6%) of the individuals were found to have some form of ear morbidities. The age of the individuals varied from 21 years to 69 years. The outcome of the screening is summarized as below:Of the 101 individuals with ear morbidities, the gender distribution

Government of India, facilitated the conduct of the screening programme. It was inaugurated by Dr. B.D. Athani, Director General of Health Services; Smt. Preeti Sudan, Secretary Health and Mr. Sunil Sharma, Joint Secretary Health, Ministry of Health and Family Welfare, Government of India. As part of the screening program, 353 beneficiaries were screened. 82.7% of the individuals screened were males while 17.3% were females. The age of

April 2018 13


WHO Report - World HearingWORLD Day HEARING DAY 2018

EAR EXAMINATION FINDINGS S. No Ear Examination 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Right Ear

Normal ear Impacted wax Ear discharge Inflammation of canal walls Foreign body/ies in ear canal Fungus in the ear canal Canal atresia Dry perforation Perforation with discharge Cholesteatoma/retraction pocket Retracted TM Middle ear effusion Inflammed tympanic membrane Any other (describe) If yes; describe Tympanometry: Type of curve:

Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1

Left Ear

No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2

Yes=1

No=2

A-1/A-2/C-3/AS-4/AD -5

Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1 Yes=1

No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2 No=2

Yes=1

No=2

A-1/A-2/C-3/AS-4/AD -5

AUDIOMETRIC FINDINGS Frequency (Hz)

500

1000

2000

4000

6000

8000

Hearing Threshold Right Ear(dB) Hearing Threshold Left Ear (dB)

1

2

3

4

5

6

1

2

3

4

5

6

TREATMENT / RECOMMENDATION 1.

No action (Tick if applicable)

2.

Medication advised (If yes, please specify)

3.

Recommended for hearing aid fitting (If yes, please specify)

4.

Referred to ENT specialist for evaluation (If yes, please specify)

5.

Any other, specify

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showed that 85 individuals were males (84.1%) and 16 (15.9%) individuals were females. The distribution of the ear morbidities showed that wax impaction was found in 45 individuals

(12.7%), retracted tympanic membrane in 26 (7.4%) individuals, mild hearing loss in 5 (1.4%) individuals, moderate hearing loss in 5 (1.4%) individuals, moderately severe hearing loss in 1 (0.3%)

individual, perforation with discharge in 7 (2%) individuals, tympanosclerosis in 3 (1%) individuals and dry perforation in 9 (2.4%) individuals. All the beneficiaries screened were counselled by doctors from Maulana Azad Medical College, Delhi and Lady Harding Medical College. Audiometric assessment of the patients was also carried out and those found to be suffering from ear problems were referred for further treatment to Government hospitals in Delhi. The list of resource persons, screening proforma and photographs of the event have been attached as Appendix below.

April 2018 15


Oral Problems - Stress

Side Effects of Stress

on Oral Health

Stress can cause tooth-grinding and/or clenching of the jaw, leading to tooth damage. A common stress response is to grind the jaw during sleep. Often done unconsciously, this can be occurring during waking hours as well, it’s a kind of Para functional habit which gets worse on stress. This habit can lead to the wearing down of the teeth (attrition), as well as cracking or fracturing of your teeth…….

BY DR DEEPTI SHARMA

W

e all encounter stress in our lives, you are probably aware of what stress does to our bodies -- it can cause anxiety disorders and panic attacks, insomnia which can lead to grogginess and irritability. But stress and oral health is an entirely new ballgame for most people. Unfortunately, our mouths have just as much of a chance of being affected by stressful situations as our bodies and minds do. AFFECT OF STRESS ON DENTAL HEALTH Clenching/Grinding (Bruxism): Stress can cause tooth-grinding and/ or clenching of the jaw, leading to tooth damage. A common stress response is to grind the jaw during sleep. Often done unconsciously, this can be occurring during waking hours as well, it’s a kind of Para functional habit which gets worse on stress. This habit can lead to the wearing down of the teeth (attrition), as well as cracking or fracturing of your teeth. It can lead to a syndrome called TMD (temporomandibular joint disorder). Excessive clenching or tooth grinding

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can lead to myalgia (muscle pain) in your jaw, face, ear and head as well as arthritic changes in the joint. Canker Sores (apthous ulcers): stress initiates a breakdown in host protective factors which can lead to the development of canker sores. Canker sores are small ulcers or lesions located on the mucosal membranes in the mouth. Canker sores usually appear as a red lesion with a white or yellow center on the inside of the cheeks or lips, the tongue,


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the upper surface of the mouth or the base of the gums. Symptoms can include a burning sensation, pain, inflammation, fever and swollen lymph nodes. Canker sores are not contagious and usually go away on their own within 1-2 weeks. Dry Mouth (xerostomia): When the mouth doesn’t produce enough saliva, it can experience chronic dryness. Not only does dry mouth result from conditions caused by stress, but it is also a common side effect of allopathic drugs used to treat depression. Burning Mouth Syndrome: Psychological problems are just one of the many factors known to cause burning mouth, which is identified by a burning sensation on the tongue, lips, gums or palate. Lichen Planus: Lichen planus of the mouth is characterized by white lines, sores and ulcers in the oral cavity. Some experts believe lichen planus is a reaction to viral infections caused by stress ,it’s a chronic inflammatory condition that affects mucous membranes inside the mouth. Oral lichen planus may appear as white, lacy patches; red, swollen tissues; or open sores. These lesions may cause burning, pain or other discomfort. . TMJ/TMD: Stress contributes to temporomandibular joint disorders in many fashions. Trauma and tooth grinding are common causes of TMD, while emotional factors such as anxiety and depression can also trigger symptoms of TMJ. It refers to a variety of conditions that affect jaw joints, jaw muscles and facial nerves. TMD may occur when the jaw twists during opening, closing or side-motion movements. People with TMD may experience pain in or around the ear, headaches and neck aches, tenderness of the jaw or jaw muscles, jaw pain or soreness that is more prevalent in the morning or late afternoon, jaw pain when chewing, biting or yawning, difficulty opening and closing the

mouth, clicking or popping noises when opening the mouth, and sensitive teeth.When the body is stressed, muscles tense up. Muscle tension is a reflex reaction to stress — it is the body’s way of guarding against injury and pain. With sudden onset stress, the muscles tense up all at once, and then release their tension when the stress passes. Chronic stress causes the muscles in the body to be in a more or less constant state of guardedness. When muscles are taut and tense for long periods of time, this may trigger other reactions of the body and even promote stress-related disorders.. Gum Disease: Studies have shown that long-term stress affects our immune systems, increasing our susceptibility to infections such as periodontal disease. Long-term stress can lead to chronically elevated levels of the stress hormone called cortisol, which can weaken the immune system. When the immune system is weak, conditions are ripe for bacteria from plaque to invade the gums. More and more research is revealing a strong link between stress and gum disease (periodontal disease). Symptoms of gum disease include bleeding gums, swollen gums, loose teeth, and bad

April 2018 17


Oral Problems - Stress

flourish in the mouth.Exercise and stress management techniques provide individuals with tools to cope with the anxieties in their lives. The most effective way to deal with stress is by correcting or modifying its underlying causes.

breath. Left untreated, gum disease can lead to tooth loss. Tooth decay (cavities): Natural bacteria live in the mouth and form plaque. The plaque produces acids by interacting with deposits on your teeth from sugary and starchy foods. These acids damage tooth enamel over time which weakens the teeth and leads to tooth decay. Stress can lead to oral hygiene neglect and other detrimental behaviors such as poor diet, smoking, and alcohol abuse. Individuals who are stressed tend to consume more sugary and starchy foods, which can lead to higher incidence of tooth decay. How Do You Protect Your Teeth From Stress? If you’re feeling stressed, don’t forget about your dental health. Take the time to focus on your oral hygiene regimen, and don’t use smoking or alcohol to relieve stress. These habits are highly addictive, and they have damaging effects on your oral cavity. Instead, take proper measures to

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reduce stress in your life, such as eating well, exercising and getting plenty of sleep. If you suffer from extreme anxiety or depression, seek professional help. Stress and control are risk factors for periodontal disease and cardiovascular diseases. When an individual feels stressed, adrenaline and stress hormones (e.g., cortisol) are released to prepare the body for the “fight-or-flight” response.While stress is a normal part of life, excessive stress can lead to health problems and lifestyle behavioural changes (e.g., taking up or increasing smoking, increasing alcohol intake, changing dietary habits, becoming physically inactive, neglecting oral and personal hygiene) which further increase health risks. Chronic stress speeds up the process of atherosclerosis in the coronary arteries and that the stress hormone cortisol plays a role in increased periodontal destruction. Cortisol also acts to suppress the immune system, allowing bacteria to

SUGGESTIONS FOR STRESS REDUCTION: Exercise: Exercise promotes production of neurohormones like norepinephrine that are associated with improved cognitive function, elevated mood and learning. Exercise forces the body’s physiological systems –all of hich are involved in the stress response—to communicate more closely than usual. The cardiovascular system communicates with the renal system, which communicates with the muscular system. All of these systems are controlled by the central and sympathetic nervous systems which must also communicate with each other. The workout of the body’s communication system may be the true value of exercise. The more sedentary a person is, the less efficient the body is in stress response. Be Grateful &Volunteer: Volunteering provides many benefits to both mental and physical health. It can increase self-confidence, provide a sense of purpose, combat depression, improve


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mood, reduce stress, reduce anxiety and promote feelings of gratitude. Have Fun and be Silly: Fun activities in life may be one of the best stress relief solutions. While many responsible adults have adult-sized responsibilities that make it easy to put fun on the low end of the priorities list, letting your inner child come out to play can keep you feeling vital and happy. There are many benefits of having good old fun, so get inspired to play and relax today (even if just for a short time) and see how you feel. Eat well: The more plant-based foods the better. They help to keep your body chemistry alkaline. Meats and other heavy protein foods, refined sugars, trans fats, fast foods and processed foods all set up an acid condition in the body, and an acid system produces inflammation, and inflammation causes stress. Magnesium supplementation: To reduce stress my first and foremost recommendation is to take magnesium. But it has to be in the right form and you have to take enough of it. Magnesium is responsible for the activity of 700-800 enzyme systems that make energy, digest food, support the adrenal glands, detoxify heavy metals, relax your muscles and nerves and help you sleep well at night. Be Present in Each Moment: When you’re basing yourself firmly in the

present moment (rather than ruminating on past or anticipated stressors), you’re more open to happiness, laughter and having fun. Meditate: Meditation can give you a sense of calm, peace and balance that benefits both your emotional wellbeing and your overall health. These benefits don’t end when your meditation session ends. Meditation can help carry you more calmly through your day and may improve certain medical conditions. When you meditate, you clear away the information overload that builds up every day and contributes to your stress. The emotional benefits of meditation can include, gaining a new perspective on stressful situations, building skills to manage your stress, increasing self-awareness, focusing on the present, and reducing negative

emotions. Positive affirmations: Positive affirmations are a great tool to reprogram your unconscious and subconscious minds from negative thinking to positive. The idea is to take positive statements and repeat them enough so that they’re part of your way of thinking and seeing the world; this operates in the same way that negative self-talk does, but in a way that benefits you. By repeating calming, soothing positive affirmations to ourselves we can feed the body nourishing mental energy. (The author is owner at Dr, Sharma’s Dental Care, CMPDI Road, Shobhalok Building and Chairwomen of SSD Seva Mission and SNA Social Welfare Foundation Medical Branch, Nagpur)

April 2018 19


Concern - Aneurysm

Aneurysm BY DR.RUPINDER SINGH BAWEJA

A

n aneurysm is an excessive localized enlargement of an artery caused by weakness in the arterial wall. Aneurysms may remain silent or rupture, causing serious problems and even death. An aneurysm can occur in important arteries such as those supplying blood to the brain, and the aorta; the large artery that originates at the left ventricle of the heart and passes down through the chest and abdominal cavities. The pathophysiology of an aneurysm (how it develops) is straightforward, although the causes are less well understood. Most aneurysms do not themselves cause any symptoms. Even if an aneurysm does not rupture, however, a large aneurysm may obstruct circulation to other tissues. An aneurysm can also contribute to the formation of blood clots that then obstruct smaller blood vessels, potentially causing ischemic stroke or other serious problems. If an aneurysm has remained undetected, the first sign of it could be when there is a complication - in particular, a rupture - with symptoms resulting from this rather than the aneurysm itself. A number of risk factors are known to be associated with the development of aneurysms, and the same factors also affect the chances of a developed aneurysm then rupturing. However, it is not fully understood why the artery wall weakens in the way that it does to cause an aneurysm. Some aneurysms, though less common, are present as an artery defect at birth (congenital). The majority of people living with an aneurysm do not suffer any of the complications like severe chest and/or

20 DOUBLE HELICAL

back pain leads to heart attack and headache Managing the risk factors is important, however, because all of these possibilities are serious. Sudden extreme headache - if a brain aneurysm leads to subarachnoid hemorrhage (a kind of stroke), the main symptom is sudden extreme headache; often so severe that it is unlike any previous experience of head pain.Other symptoms - with any aneurysm rupture there may be pain, low blood pressure, a rapid heart rate, and lightheadedness. Endovascular coiling is a minimally invasive technique, which means an incision in the skull is not required to treat the brain aneurysm. Rather, a catheter is used to reach the aneurysm in the brain. During endovascular coiling, a catheter is passed through the groin up into the artery containing the aneurysm. Not all aneurysms need to

be treated and your physician may elect to closely observe your aneurysm. There are two main treatment options for patients who need to have their aneurysm treated.like Open surgical clipping and Endovascular therapy coiling. The open surgical clipping is performed by a neurosurgeon who will make an incision in the skin over the head, make an opening in the bone and dissect through the spaces of the brain to place a clip across the aneurysm where it arises from the blood vessel. This prevents the blood flow from entering the aneurysm. Most elective patients spend 2-3 nights in the hospital and then will go home on light restricted activity for 1-2 months after surgery. There have been considerable advances in open surgery techniques. Many neurosurgeons can now perform mini craniotomies, or eye brow incisions to clip an aneurysm. In select


Concern - Aneurysm

patients a small incision is made over the eyebrow. A small two inch window is then made in the bone over the eye and through this incision a small clip is placed across the opening of the aneurysm. These patients usually spend 1-2 days in the hospital after surgery and then go home. Patients are usually on light restricted activity for 1-2 months after surgery. However, it is still an invasive procedure and takes longer to recover from than a coiling procedure. Endovascular treatment is performed by a neuro interventional surgeon who may be a neuro radiologist, neurosurgeon, or neurologist that has completed additional training. Studies have shown that patients with a ruptured aneurysm tend to do better in the long term after a coiling procedure. A coiling procedure is performed as an extension of the angiogram. A catheter is inserted into a vessel over the hip and other catheters are navigated through the blood vessels to the vessels of the brain and into the aneurysm. Coils are then packed into the aneurysm up to the point where it arises from the blood vessel, preventing blood flow from entering the aneurysm. Most elective patients will go home the next day after surgery and are back to normal activities the following day. More than 125,000 patients worldwide have been treated with detachable platinum coils Additional devices, such as a stent or a balloon, may be needed to help keep the coils in place inside the aneurysm. Stent assisted coiling involves permanently placing a stent in the vessel adjacent to the aneurysm to provide a scaffolding of support that keeps the coils within the aneurysm sac. Balloon remodeling involves temporarily placing a removable balloon adjacent to the aneurysm while coils are positioned in the aneurysm. There have been considerable advances in endovascular techniques over the last few years and the field continues to evolve. Most notable is the use of new flow diverting embolization devices. These devices

22 DOUBLE HELICAL

are similar to a stent in that they are placed into the main vessel adjacent to an aneurysm. These devices divert flow away from the aneurysm and provide scaffolding for healing of the vessel wall to occur. Over time, the aneurysm disappears. Such technology allows doctors to treat many aneurysms that were previously considered untreatable or that were considered to be high risk by other methods. There are many other new devices that are becoming available as well, such as newer that are easier and safer to deliver, as well as stents that can bridge two vessels. Both open surgery and endovascular methods are effective. The best treatment depends on a number of factors like whether your aneurysm has ruptured, it has size, shape and location. Like all medical decisions, the best treatment option should be made with specialist. Until recently, most studies on the surgical clipping and endovascular treatment of brain aneurysms were either small-scale studies or were retrospective studies that relied on analyzing historical case records. The only multi-center prospective randomized clinical trial - considered the gold-standard in study design -

comparing surgical clipping and endovascular coiling of ruptured aneurysm is the International Subarachnoid Aneurysm Trial (ISAT)1 . The study found that, in patients equally suited for both treatment options, endovascular coiling treatment produces substantially better patient outcomes than surgery in terms of survival free of disability at one year. The relative risk of death or significant disability at one year for patients treated with coils was 22.6 percent lower than in surgically-treated patients. The study results were so compelling that the trial was halted early after enrolling 2,143 of the planned 2,500 patients because the trial steering committee determined it was no longer ethical to randomize patients to neurosurgical clipping. Long-term follow-up will be essential to assess the durability of the substantial early advantage of endovascular coiling over conventional neurosurgical clipping for the treatment of brain aneurysms. It is important to note that patients enrolled in the ISAT were evaluated by both a neurosurgeon and an endovascular coiling specialist, and both physicians had to agree that the aneurysm was treatable by either technique. This study provides compelling evidence that, if medically possible, all patients with ruptured brain aneurysms should receive an endovascular consultation as part of the protocol for the treatment of brain aneurysms. Although no multi-center randomized clinical trial comparing endovascular coiling and surgical treatment of unruptured aneurysms has yet been conducted, retrospective analyses have found that endovascular coiling is associated with less risk of bad outcomes, shorter hospital stays and shorter recovery times compared with surgery. (The author is Associate Consultant Neuroradiology Sri Balaji Medical Institute, New Delhi)


Special Coverage - DOCTORS’ MAHAPANCHAYAT

DOCTORS’

MAHAPANCHAYAT BY TEAM DOUBLE HELICAL

T

he recently held the doctors’ Mahapanchayat out rightly rejects the proposed National Medical Commission Bill 2017 in one voice. The Mahapanchayat also rejects the recommendations of the Parliamentary Standing Committee on Health and Family Welfare thereon in their entirety as the said Bill along with the recommendations of the Parliamentary Committee are out and out anti-poor, anti-people, pro-rich, undemocratic, sponsors crosspathy through the Bridge Course, undermines the sanctity of University examinations throughthe licentiate examination patronizes, privatization, promotes corruption through discretionary provisions, harbors antifederalism vide marginalization of the state and the State Medical Councils. According to Mahapanchayat held on 25th March, 2018 at Indira Gandhi Indoor Stadium, New Delhi, in order to provide for effective meaningful, equitable, accessible, handy and affordable healthcare to rural populace, Govt. of India shall ensure that the appropriation for health spending to the extent of 6% of the Gross Domestic Produce (GDP),

24 DOUBLE HELICAL

additional rural hospital are created, care and cure facilities at the existing rural hospitals are up-dated and augmented, much desired governance is rationalized and heavily needed motivating robust policy of incentives is put into place. Dr Ravi Wankhedkar, National President, Indian Medical Association, the government must propose a strong Central Act prohibiting violence against doctors in all forms, hues, shades, matching with the enabling existing provisions in the Indian Penal Code, so as to evoke uniformity across the States in respect of its implementation and thereby extend much needed and desired immunity to the doctors while on duty from all forms of violence from any and all sources as they be and declare clinical establishments as safe zones in a real sense. Clinical Establishment Act: Dr Vinay Aggarwal, Former National President, IMA, the government must incorporate through appropriate amendments in the Clinical Establishment Act so as to

provide for to the effect whereby the stabilization clause is modified to first-aid, single doctors establishment is out of the ambit, purview, and jurisdiction, a single window registration, standard treatment guidelines are designated as advisory in nature, composition of CEA Committee to exclude police personnel and chargeability to be made in accordance with the market forces but in a transparent and accountable manner and to remove police personnel from CEA Committee. Capping on Compensation: Dr R N Tandon, Secretary General, IMA, said, “There is a capping of compensation for any national calamity, railway accident, plane accident, sterilization death in the public sector, on the similar lines a capping of compensation is a must claimable from a doctor not based on the income of the patient as the chargeable fee by the doctor is not based on the patient’s income for it is not open for him to discriminate the patient on the basis of the income hence the computation of capping on compensation claimable from a doctor ought to be on the basis of the


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compensation package as is depicted in the Drug & Cosmetic Rule regarding the death or injury during the drug trial.” PCPNDT Act: Dr Ravi Wankhekdar, said, “The Govt. of India through prompt, urgent and immediate amendments in the PCPNDT Act must evoke the concept and operation of graded punishment, no penal provision for clerical errors the stipulated six month’s training and certification thereto for doctors with MBBS qualification to be prospective in operation and effect and exemption to non pelvicultrasonologists from other procedural formalities except registration of the machine.”

evidence based substantiation of the cardinal principle of mensrea and the prosecution shall be strictly in accordance with the guidelines laid down by the Hon’ble Supreme Court in its Pronouncement in the Jacob Mathew Vs. Union of India Case, and by incorporating the desired and appropriate amendments in the code of criminal procedure and Indian Evidence Act in accordance with the recommendations made by the Medical Council of India under the initiative of Indian Medical Association

Dr. A.Marthanda Pillai, Chairman, Action Committee, IMA, said, “The Govt. of India explicitly makes it loud and clear that there shall not be criminal prosecution of medical professionals in absence of the

1: All the speciality organizations of India stand with Indian Medical Association under the banner of FOMA in fighting NMC in its current form. We appeal to the Government to address our concerns and demands.

RESOLUTIONS OF IMA FEDERATION OF MEDICAL ASSOCIATIONS (FOMA)

2: All the treatment guidelines and protocols under Clinical Establishment Act should be through FOMA RESOLUTIONS DOCTORS

OF

SERVICE

1. An All India Medical cadre, “Indian Medical Services” will be the answer to the unequal health status of Indian states. This empowerment of medical profession will go a long way in taking Public Health Services closer to people. We demand establishment of Indian Medical Services. 2. Uniform pay scales throughout the country is the legitimate right of the medical profession. We demand implementation of uniform pay scales for service doctors across the country. 3. We condemn adhoc contractual appointment of doctors in Government Service for a meagre salary. We demand abolition of contractual appointments.

April 2018 25


Special Coverage - DOCTORS’ MAHAPANCHAYAT

RESOLUTIONS OF IMA - MEDICAL STUDENTS’ NETWORK 1 No Bridge Course At present MBBS is the basic qualification to practice modern medicine. This highly scientific degree is acquired after rigorous training for 5 and a half years in 14 subjects. Training of AYUSH doctors through bridge course of much shorter duration to allow them to practice modern medicine will be highly unscientific and usually detrimental to public health. It is also a big injustice to MBBS students who are undergoing a rigorous training module. Hence the medical students of this country reject bridge course in any form to safeguard scientific standards and Public Health. We unanimously urge to withdraw bridge course in modern medicine in any form. 2 Exit Exam Medical students during the MBBS

26 DOUBLE HELICAL

course have exams in 14 subjects comprising of more than 47 exams including theory ,clinics and viva. More than 50 internal exams are also conducted as part of MBBS course which is regulated by Medical Council of India and approved by the Government of India. All the exams which are conducted in very highly standardized format and they are held by universities which are both competent and approved. Admission to all medical colleges are regulated by common entrance exam conducted by government hence we fail to understand how is single new exam could be standard enough to surpass all the existing ones. The students in ChhatraSansadurged strongly to withdraw licensing exam in any form .Uniformity could be made in current exams of MBBS if required. Students decided to fight with all means if exit exam is unilaterally imposed. 3 Federal structure of NMC


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5 Strike It is decided by the ChhatraSansad to declare indefinite complete medical shutdown from April 2nd if national medical commission is not withdrawn. All medical colleges will be closed and medical students will boycott classes and exams on the call given by Dr Ravi Wankhedkar, National President of Indian Medical Association. RESOLUTIONS OF CHHATRA SANSAD INDIRA GANDHI INDOOR STADIUM, NEW DELHI- 24.03.2018

Federal structure of India ensure that all States get representation and hence opportunity to address the peculiar needs of each region. Lack of adequate representation will deprive them of this opportunity. Hence ChhatraSansad has resolved to ask the government to make sure that all States get due representation in any medical regulatory authority. 4 The cost of Medical Education The cost of Medical Education is the most disturbing factor in NMC. There is complete commercialization of Medical Education which is taking away the chances of lower socioeconomic class who are excellent in academics. The bill has failed to control the cost of Medical Education in the country. Government should regulate fee structure so that poor students could get access to medical education irrespective of socio economic status and region of dwelling.

Preamble BRIDGE COURSE How a person with 6 months of bridge course could be equated with a MD doctor who has studied for 8 long years..!! Who will be responsible for his mistakes..?Being an unskilled person will he be under the ambit of negligence?There is no exit test for bridge course..!!Unfortunately these bridge course half baked unskilled persons are being brought in the name of rural people. Our question is why second class healthcare for rural poor people? What is assuarance that these unskilled people will really serve rural areas only? EXIT EXAM We have to pass on 14 subjects and 42 examinations in theory, clinicals and viva to become MBBS doctors. All our exams are University exams. By creating an additional exit exam what does the government want to prove? FEDERAL STRUCTURE OF NMC State Representation is being marginalised in NMC. Right to vote and Right to Contest is being sabotaged by NMC.An entire body and Chairman should only be elected. Atleast 51% members should be elected. RESOLUTIONS 1: No bridge course in any form to AYUSH and non doctors is acceptable. 2: No EXIT exam in any form 3: Withdraw NMC Bill.

April 2018 27


Special Coverage - OBSERVATIONS OF IMA

OBSERVATIONS OF IMA ON THE PARLIAMENTARY STANDING COMMITTEE BY TEAM DOUBLE HELICAL

T

he PSC (PARLIAMENTARY STANDING COMMITTEE) on Health & F.W in its report presented to the Rajya Sabha on 20th March 2018 and laid on the table of Lok Sabha on 20th March 2018 amongst other things have made their observations clause wise in regard to the NMC Bill 2017. The Committee has desired a greater clarity on the definition of the word Medical institution� under Clause 2 (i) to ascertain the institution it refers to specially in the context if the medical institution is to mean the medical college then the degrees are not conferred by the medical colleges but by the examining universities to which the medical colleges are affiliated. However, the definition of the word modern medicine as included in the proposed Bill has been totally subverted when it comes to prescribing the bridge course to be availed by the State Governments as a part of

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capacity building for the purposes of rural healthcare service which is dichotomous. Composition of the NMC: The Committee has altered the proposed composition of the National Medical Commission by increasing its number to 29 including the Chairperson, other than whom there would be 6 Ex-officio members that would include the President of UG Education Board, the President of the PG Medical Education Board, President of the Medical Assessment and Rating Board, the Director General Health Service and Director General of Indian Medical Council Research, and one person to represent the Ministry of the Central Govt. not below the rank of Secretary/ Additional Secretary. In addition, there shall be 22 parttime members of the Commission of which 3-Members would be appointed from 3different fields including management, law, medical ethics,

health research, patient’s rights, advocacy, science & technology & economics. 10 Members to be appointed on rotational member from among the nominees of the States and Union Terr. in the Medical Advisory Council for a term of 2 years in terms of the manner as may be prescribed and 9 Members to be elected by the Registered Medical Practitioners from among themselves from such regional constituencies and in such manner as may be prescribed. The composition as proposed by the Committee still does not give it a national, representative and a democratic character in as much as the representation of the State continues to be marginalized, universities do not find a representation and more so the representation of each state through a registered medical practitioner is not provided for. The nominee of the state has been evoked in an ex-officio


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manner in States where Health Sciences Universities are there and in States where there are no Health Universities, the Vice Chancellor of the traditional University with which the maximum number of medical colleges would be the ex-officio nominee of the state. As such the right of the State to have its nominee stands curtailed by the ex officio representation provided for. More so, the Vice Chancellor of the Health Sciences, State Universities necessarily need not be a person possessing modern medicine qualification. Likewise the Vice Chancellor of a traditional university would be a man from any general faculty like Art, Commerce, Science, Social Science, Home Science, Education, Engineering & Technology or any other Faculty. As such, the change which has been proposed by the Committee to the composition to the National Medical Commission is

totally “cosmetic� in character wherein but for a small augmentation of number nothing else is provided for. Composition of the Search Committee: The composition of the Search Committee as included in the proposed Bill has been changed to the extent that the Chief Executive Officer of NitiAayog in the name of the conflict of interest has been deleted. 2-Experts from the part time members have been included to be nominated by the Central Govt. in the manner as may be prescribed. The core issue is the desirability of a selected Chairperson of the Commission and the other autonomous Board which is totally disputable primarily on the ground that a selected person is not only going to be a salaried officer and thereby a public servant within the scope & meaning of Section 21 of the Indian Penal Code but also would be subjected to the disciplinary jurisdiction by the disciplinary authority and feasibility of

such a person being autonomous in operation and effect is nonexistent. As such, the concept of a selected full time Chairperson and Chairmen of the Autonomous Board itself is an antithesis to the desired concept of autonomy. Secretary of the Commission: The Committee, in regard to the Secretary of the Commission, has only suggested that he/she shall not be the Member Secretary of the Commission. However, the core objections on the proposed inclusion in the NMC Bill 2017 remain as they are specially in the context of the Secretary of the Commission being appointed by the Govt. of India and not by the Commission and the mandatory requirement of the said Secretary possessing PG qualification in modern medicine has been given a go-bye whereby the Secretary of the Commission necessarily would not be a person possessing modern medicine PG qualifications. Conflict of Interest: The Committee has only suggested the cooling period to be of 2-years with reference to the Members of the Commission and Chairperson after the completion of their term not taking up any assignment with a private medical institution/college whose cases they might have dealt while in office, but the provisio where by the Govt of India is vested with doing away with the said prescribed embargo has been maintained whereby the proposition made by the committee is nothing short of an eye wash. Appellate Jurisdiction : The Committee has proposed that the Appellate jurisdiction which in the proposed Bill is vested with the Central Govt. in respect of the decisions of the NMC has been done away with by proposing the constitution of a Medical Appellate Tribunal comprising of a Chairperson, who would be a sitting or retired Judge of the Supreme Court or a Chief Justice of High Court and 2 other members. One of the members should have a special knowledge in the

April 2018 29


Special Coverage - OBSERVATIONS OF IMA

medical profession / medical education and the other member with an experience in the field of health administration at the level of Secretary to the Govt. of India. The remedy that has been proposed by the Committee is more dreadful than the disease itself. Chargeable fee: The Committee has proposed that fee charged by all unregulated Private Medical Colleges and the Deemed Universities be regulated atleast for 50% of their seats. As such, the Committee has carved out a new Clause of Private colleges and Deemed universities where the fee is unregulated. In reality, there cannot be private college or Deemed university where the fee can be unregulated in the context of statutory mechanism that has been prescribed arising out of the pronouncement of the Hon’ble Supreme Court. As such, by the suggestions made by the Committee the resultant outcome is that the recommendation is redundant and infructous. The quorum and frequency of the

30 DOUBLE HELICAL

Medical Advisory Council: The recommendation of the committee prescribing 50% of the members as the requisite quorum and minimum 2 meetings of the Medical Advisory council is a well intended suggestion. Centralized Counseling: The recommendation of the Committee to the effect that autonomy to universities/ and medical institutions as per the provision of the respective Acts should also be given permission to conduct common counseling for the vacant seats after the national and state level counseling to be done on merit basis from the candidates who have qualified NEET so as no vacant seats remain. This by itself is going to undo what has been gained out of centralized counseling and will give a free hand to the private universities to have their own game plans executed.

Licentiate Examination: The proposal of the Committee that the Licentiate examination be integrated with final year MBBS examination and be conducted at the state level by itself is counterproductive in as much as that it would transgress the authority and jurisdiction of examining university because the final MBBS examination would be the licentiate examination to be conducted by a designated authority at a state level other than the examining/ affiliating university by itself untenable. The suggestion by the Committee pertaining to inclusion of other medical institution established by a separate Act of Parliament in the common pool of counseling for the PG admissions is well intended. Autonomous Boards: The


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composition of the autonomous board has been altered in regard to its number from 3 to 5 with inclusion of an elected member thereat. However, even by the said proposition, the said Board does not gain a representative character and inadequacy of the number continues to the limit and desired optimal performance. The recommendation of the Committee, that the Ethics and Registration Board shall be headed by a Retd. Judge of the High Court but would not be a ex officio member of the NMC is paradoxical. It being proposed in the name of the said Board to be autonomous of the NMC is superfluous because the Appellate jurisdiction has not been explicitly provided for. 1. Inclusion of Family Medicine: The suggestion of the Committee that medical colleges running PG Course in medical and Surgical specialties, Pediatrics and Obs& Gynae shall have to establish PG courses in Family Medicine. However in absence of a Department of Family medicine as a must at the UG Level, the proposed mandate is illusory as it would never fructify. 2. Functioning of MARB: The recommendation of the Committee that the modalities of assessment should be based on an outcome based model rather than emphasis on infrastructure, staffing and process which is misleading to the extent that the outcome based assessment cannot be at the cost of infrastructural assessment as infrastructure has a big role to play towards generating the desired outcome. 3. Levying of penalty: The recommendation of the Committee on the said count to the effect that an alternative provision be made for warning, subsequent reasonable monetary penalty followed by adequate time to address the deficiency and in case the lacuna persist a provision for de recognition for a certain period, subject to adequate checks and balances although sounds as if instilling

confidence in reality is inoperable for want of an explicit clause for withdrawal of recognition for a specified period or permanently is not provided for in the proposed Bill and what is not included in the parent Act cannot be given effect through subordination legislation. 4. Screening Test: The recommendation by the Committee that a foreign citizen who is enrolled in his country as a medical practitioner in accordance with the Law, may be permitted to practice medicine and surgery sublet to qualifying the screening test meant for foreign medical graduates. It is pertinent to note that the screening test contemplated under Section 13 of the present Indian Medical Council Act would cease to exist on the day the NMC Bill is promulgated would result in repeal of the said Act making screening nonexistent. The proposed Bill not providing for the screening test makes

the suggestions by the Committee non operable and thus superfluous. 5. Bridge Course: The suggestions made by the PSC, the Bridge Course as proposed in the NMC Bill 2017 should not be mandatory but the sTates can avail the same as a part of capacity building exercise for the professionals of other pathies and have broadened the ambit thereto to the professionals of pharmacy, nursing and have kept it open ended by ending it the word “etc”. As such, the suggestions so made is nothing short of endorsing, legalizing and validating “quackery”, whereby the half baked professionals liberally granted permission to practice medicine would be playing with the health of the poor and gullible and make a mockery of the so called effective healthcare delivery system aimed at welfare of the people ending up in causing vulgar ill-fare. The clauses of the Bill that have been adopted by the Committee as it is, the observations of the IMA on the said count stand as they are as the said concerns remain unmitigated. In conclusion, summary and nutshell it can be inevitably concluded that the recommendations of the PSC are totally cosmetic in nature and illusory in character and thus end up in serving no public cause.

April 2018 31


Special Coverage - Appeal to Prime Minister

Appeal to Prime Minister

I

n a letter written to PM Narendra Modi, the doctors under IMA baner has appeal to understand their genuine difficulties and provide commensurate solutions. According to Dr Ravi S. Wankhedkar, National President, IMA, we are the modern medicine doctors of India. Thousands of our medical students join us in this appeal. All speciality organizations, Junior Doctors Organizations, Service Doctors organizations are also part of this appeal. We have serious grievances in the way medical profession and Health Care is being governed. We appeal to our PM to understand our genuine difficulties and provide commensurate solutions. NATIONAL MEDICAL COMMISSION BILL 2017 :• Registration and practice of modern medicine by Ayush doctors or other categories of non doctors is a direct threat to patient care and patient safety. This illegitimate empowerment is unacceptable in any manner and form. • Promote and protect Ayurveda in its pure form. • Restrict the quota of private medical college managements to 15% of the total seats. Enable the State Governments to regulate the fee of

32 DOUBLE HELICAL


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85% of the seats. • Increase the representation of Registered Medical Graduates, Health Universities and the State Governments to the level currently available in MCI in tune with the concept of federalism. EMR Board should be headed by a well experienced modern medicine doctor who had been a care giver. Law and ethics are entirely different disciplines. A Judge as the head of EMR Board is inappropriate in a position which determines ethics and etiquette of the medical profession. Moreover such an appointment transforms this platform into one that is prone for litigation. VIOLENCE ON DOCTORS Mindless violence on doctors has

become an everyday affair. We are thankful that you have condemned the same. There is an urgent need to bring a Central Act against this violence and provide safety and ambience in our hospitals. Hospitals need to be declared as safe zones to protect the legitimate interest of the patients. NO CRIMINAL PROSECUTION No medical negligence case could be deemed as a crime because of absence of ‘mens rhea’ or the criminal intent. As a corollary criminal prosecution under 302, 304, 304 A is an injustice. This medieval practice should be discontinued in a civilized society. CONSUMER PROTECTION ACT Consumer Protection Act converted patients into consumers. CPA has opened floodgates of litigations

against doctors. There is an urgent need to cap the compensation on a well reasoned and structured formula. PC PNDT ACT Minor clerical errors have sent doctors to jails. There is a need for graded punishment as per the gravity of the offence. CLINICAL ESTABLISHMENT ACT Bring in amendments in the Act to make CEA friendly to the Clinical Establishments. The ambience to practice medicine has rapidly deteriorated. Legislations insensitive to the concerns of the medical profession will take us nowhere. It is for these burning reasons that we appeal to PM Modi to address our difficulties and provide just and timely solutions.

April 2018 33


Special Coverage - DOCTORS’ MAHAPANCHAYAT

DOCTORS’

MAHAPANCHAYAT BY TEAM DOUBLE HELICAL

T

he recently held the doctors’ Mahapanchayat out rightly rejects the proposed National Medical Commission Bill 2017 in one voice. The Mahapanchayat also rejects the recommendations of the Parliamentary Standing Committee on Health and Family Welfare thereon in their entirety as the said Bill along with the recommendations of the Parliamentary Committee are out and 24 DOUBLE HELICAL

out anti-poor, anti-people, pro-rich, undemocratic, sponsors crosspathy through the Bridge Course, undermines the sanctity of University examinations throughthe licentiate examination patronizes, privatization, promotes corruption through discretionary provisions, harbors antifederalism vide marginalization of the state and the State Medical Councils. According to Mahapanchayat held on 25th March, 2018 at Indira Gandhi

Indoor Stadium, New Delhi, in order to provide for effective meaningful, equitable, accessible, handy and affordable healthcare to rural populace, Govt. of India shall ensure that the appropriation for health spending to the extent of 6% of the Gross Domestic Produce (GDP), additional rural hospital are created, care and cure facilities at the existing rural hospitals are up-dated and augmented, much desired governance


COVER STORY

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is rationalized and heavily needed motivating robust policy of incentives is put into place. Dr Ravi Wankhedkar, National President, Indian Medical Association, the government must propose a strong Central Act prohibiting violence against doctors in all forms, hues, shades, matching with the enabling existing provisions in the Indian Penal Code, so as to evoke uniformity across the States in respect of its implementation and thereby extend much needed and desired immunity to the doctors while on duty from all forms of violence from any and all sources as they be and declare clinical establishments as safe zones in a real sense. Clinical Establishment Act: Dr Vinay Aggarwal, Former National President, IMA, the government must incorporate through appropriate amendments in the Clinical Establishment Act so as to provide for to the effect whereby the stabilization clause is modified to first-aid, single doctors establishment is out of the ambit, purview, and jurisdiction, a single window registration, standard treatment guidelines are designated as advisory in nature, composition of CEA Committee to exclude police personnel

and chargeability to be made in accordance with the market forces but in a transparent and accountable manner and to remove police personnel from CEA Committee. Capping on Compensation: Dr R N Tandon, Secretary General, IMA, said, “There is a capping of compensation for any national calamity, railway accident, plane accident, sterilization death in the public sector, on the similar lines a capping of compensation is a must claimable from a doctor not based on the income of the patient as the chargeable fee by the doctor is not based on the patient’s income for it is not open for him to discriminate the patient on the basis of the income hence the computation of capping on compensation claimable from a doctor ought to be on the basis of the compensation package as is depicted in the Drug & Cosmetic Rule regarding the death or injury during the drug trial.” PCPNDT Act: Dr Ravi Wankhekdar, said, “The Govt. of India through prompt, urgent and immediate amendments in the PCPNDT Act must evoke the concept and operation of graded punishment, no penal provision for clerical errors the stipulated six month’s training and

certification thereto for doctors with MBBS qualification to be prospective in operation and effect and exemption to non pelvicultrasonologists from other procedural formalities except registration of the machine.” Dr. A. Marthanda Pillai, Chairman, Action Committee, IMA, said, “The Govt. of India explicitly makes it loud and clear that there shall not be criminal prosecution of medical professionals in absence of the evidence based substantiation of the cardinal principle of mensrea and the prosecution shall be strictly in accordance with the guidelines laid down by the Hon’ble Supreme Court in its Pronouncement in the Jacob Mathew Vs. Union of India Case, and by incorporating the desired and appropriate amendments in the code of criminal procedure and Indian Evidence Act in accordance with the recommendations made by the Medical Council of India under the initiative of Indian Medical Association RESOLUTIONS OF IMA FEDERATION OF MEDICAL ASSOCIATIONS (FOMA) 1: All the speciality organizations of India stand with Indian Medical Association under the banner of FOMA in fighting NMC in its current form. We

April 2018 25


Special Coverage - DOCTORS’ MAHAPANCHAYAT

appeal to the Government to address our concerns and demands. 2: All the treatment guidelines and protocols under Clinical Establishment Act should be through FOMA RESOLUTIONS OF SERVICE DOCTORS 1. An All India Medical cadre, “Indian Medical Services” will be the answer to the unequal health status of Indian states. This empowerment of medical profession will go a long way in taking Public Health Services closer to people. We demand establishment of Indian Medical Services. 2. Uniform pay scales throughout the country is the legitimate right of the medical profession. We demand implementation of uniform pay scales for service doctors across the country. 3. We condemn adhoc contractual appointment of doctors in Government Service for a meagre salary. We demand abolition of contractual appointments. RESOLUTIONS OF IMA - MEDICAL

26 DOUBLE HELICAL

STUDENTS’ NETWORK 1 No Bridge Course At present MBBS is the basic qualification to practice modern medicine. This highly scientific degree is acquired after rigorous training for 5 and a half years in 14 subjects. Training of AYUSH doctors through bridge course of much shorter

duration to allow them to practice modern medicine will be highly unscientific and usually detrimental to public health. It is also a big injustice to MBBS students who are undergoing a rigorous training module. Hence the medical students of this country reject bridge course in any form to safeguard scientific standards and Public Health. We unanimously urge to withdraw


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dwelling. 5 Strike It is decided by the ChhatraSansad to declare indefinite complete medical shutdown from April 2nd if national medical commission is not withdrawn. All medical colleges will be closed and medical students will boycott classes and exams on the call given by Dr Ravi Wankhedkar, National President of Indian Medical Association. RESOLUTIONS OF CHHATRA SANSAD INDIRA GANDHI INDOOR STADIUM, NEW DELHI- 24.03.2018

bridge course in modern medicine in any form. 2 Exit Exam Medical students during the MBBS course have exams in 14 subjects comprising of more than 47 exams including theory ,clinics and viva. More than 50 internal exams are also conducted as part of MBBS course which is regulated by Medical Council of India and approved by the Government of India. All the exams which are conducted in very highly standardized format and they are held by universities which are both competent and approved. Admission to all medical colleges are regulated by common entrance exam conducted by government hence we fail to understand how is single new exam could be standard enough to surpass all the existing ones. The students in ChhatraSansadurged strongly to withdraw licensing exam in any form .Uniformity could be made in current exams of MBBS if required. Students decided to fight with all means if exit

exam is unilaterally imposed. 3 Federal structure of NMC Federal structure of India ensure that all States get representation and hence opportunity to address the peculiar needs of each region. Lack of adequate representation will deprive them of this opportunity. Hence ChhatraSansad has resolved to ask the government to make sure that all States get due representation in any medical regulatory authority. 4 The cost of Medical Education The cost of Medical Education is the most disturbing factor in NMC. There is complete commercialization of Medical Education which is taking away the chances of lower socioeconomic class who are excellent in academics. The bill has failed to control the cost of Medical Education in the country. Government should regulate fee structure so that poor students could get access to medical education irrespective of socio economic status and region of

Preamble BRIDGE COURSE How a person with 6 months of bridge course could be equated with a MD doctor who has studied for 8 long years..!! Who will be responsible for his mistakes..?Being an unskilled person will he be under the ambit of negligence?There is no exit test for bridge course..!!Unfortunately these bridge course half baked unskilled persons are being brought in the name of rural people. Our question is why second class healthcare for rural poor people? What is assuarance that these unskilled people will really serve rural areas only? EXIT EXAM We have to pass on 14 subjects and 42 examinations in theory, clinicals and viva to become MBBS doctors. All our exams are University exams. By creating an additional exit exam what does the government want to prove? FEDERAL STRUCTURE OF NMC State Representation is being marginalised in NMC. Right to vote and Right to Contest is being sabotaged by NMC.An entire body and Chairman should only be elected. Atleast 51% members should be elected. RESOLUTIONS 1: No bridge course in any form to AYUSH and non doctors is acceptable. 2: No EXIT exam in any form 3: Withdraw NMC Bill.

April 2018 27


Special Coverage - OBSERVATIONS OF IMA

OBSERVATIONS OF IMA ON THE PARLIAMENTARY STANDING COMMITTEE BY TEAM DOUBLE HELICAL

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he PSC (PARLIAMENTARY STANDING COMMITTEE) on Health & F.W in its report presented to the Rajya Sabha on 20th March 2018 and laid on the table of Lok Sabha on 20th March 2018 amongst other things have made their observations clause wise in regard to the NMC Bill 2017. The Committee has desired a greater clarity on the definition of the word Medical institution� under Clause 2 (i) to ascertain the institution it refers to specially in the context if the medical institution is to mean the medical college then the degrees are not conferred by the medical colleges but by the examining universities to which the medical colleges are affiliated. However, the definition of the word modern medicine as included in the proposed Bill has been totally subverted when it comes to prescribing the bridge course to be availed by the State Governments as a part of

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capacity building for the purposes of rural healthcare service which is dichotomous. Composition of the NMC: The Committee has altered the proposed composition of the National Medical Commission by increasing its number to 29 including the Chairperson, other than whom there would be 6 Ex-officio members that would include the President of UG Education Board, the President of the PG Medical Education Board, President of the Medical Assessment and Rating Board, the Director General Health Service and Director General of Indian Medical Council Research, and one person to represent the Ministry of the Central Govt. not below the rank of Secretary/ Additional Secretary. In addition, there shall be 22 parttime members of the Commission of which 3-Members would be appointed from 3different fields including management, law, medical ethics,

health research, patient’s rights, advocacy, science & technology & economics. 10 Members to be appointed on rotational member from among the nominees of the States and Union Terr. in the Medical Advisory Council for a term of 2 years in terms of the manner as may be prescribed and 9 Members to be elected by the Registered Medical Practitioners from among themselves from such regional constituencies and in such manner as may be prescribed. The composition as proposed by the Committee still does not give it a national, representative and a democratic character in as much as the representation of the State continues to be marginalized, universities do not find a representation and more so the representation of each state through a registered medical practitioner is not provided for. The nominee of the state has been evoked in an ex-officio


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manner in States where Health Sciences Universities are there and in States where there are no Health Universities, the Vice Chancellor of the traditional University with which the maximum number of medical colleges would be the ex-officio nominee of the state. As such the right of the State to have its nominee stands curtailed by the ex officio representation provided for. More so, the Vice Chancellor of the Health Sciences, State Universities necessarily need not be a person possessing modern medicine qualification. Likewise the Vice Chancellor of a traditional university would be a man from any general faculty like Art, Commerce, Science, Social Science, Home Science, Education, Engineering & Technology or any other Faculty. As such, the change which has been proposed by the Committee to the composition to the National Medical Commission is

totally “cosmetic� in character wherein but for a small augmentation of number nothing else is provided for. Composition of the Search Committee: The composition of the Search Committee as included in the proposed Bill has been changed to the extent that the Chief Executive Officer of NitiAayog in the name of the conflict of interest has been deleted. 2-Experts from the part time members have been included to be nominated by the Central Govt. in the manner as may be prescribed. The core issue is the desirability of a selected Chairperson of the Commission and the other autonomous Board which is totally disputable primarily on the ground that a selected person is not only going to be a salaried officer and thereby a public servant within the scope & meaning of Section 21 of the Indian Penal Code but also would be subjected to the disciplinary jurisdiction by the disciplinary authority and feasibility of

such a person being autonomous in operation and effect is nonexistent. As such, the concept of a selected full time Chairperson and Chairmen of the Autonomous Board itself is an antithesis to the desired concept of autonomy. Secretary of the Commission: The Committee, in regard to the Secretary of the Commission, has only suggested that he/she shall not be the Member Secretary of the Commission. However, the core objections on the proposed inclusion in the NMC Bill 2017 remain as they are specially in the context of the Secretary of the Commission being appointed by the Govt. of India and not by the Commission and the mandatory requirement of the said Secretary possessing PG qualification in modern medicine has been given a go-bye whereby the Secretary of the Commission necessarily would not be a person possessing modern medicine PG qualifications. Conflict of Interest: The Committee has only suggested the cooling period to be of 2-years with reference to the Members of the Commission and Chairperson after the completion of their term not taking up any assignment with a private medical institution/college whose cases they might have dealt while in office, but the provisio where by the Govt of India is vested with doing away with the said prescribed embargo has been maintained whereby the proposition made by the committee is nothing short of an eye wash. Appellate Jurisdiction : The Committee has proposed that the Appellate jurisdiction which in the proposed Bill is vested with the Central Govt. in respect of the decisions of the NMC has been done away with by proposing the constitution of a Medical Appellate Tribunal comprising of a Chairperson, who would be a sitting or retired Judge of the Supreme Court or a Chief Justice of High Court and 2 other members. One of the members should have a special knowledge in the

April 2018 29


Special Coverage - OBSERVATIONS OF IMA

medical profession / medical education and the other member with an experience in the field of health administration at the level of Secretary to the Govt. of India. The remedy that has been proposed by the Committee is more dreadful than the disease itself. Chargeable fee: The Committee has proposed that fee charged by all unregulated Private Medical Colleges and the Deemed Universities be regulated atleast for 50% of their seats. As such, the Committee has carved out a new Clause of Private colleges and Deemed universities where the fee is unregulated. In reality, there cannot be private college or Deemed university where the fee can be unregulated in the context of statutory mechanism that has been prescribed

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arising out of the pronouncement of the Hon’ble Supreme Court. As such, by the suggestions made by the Committee the resultant outcome is that the recommendation is redundant and infructous. The quorum and frequency of the Medical Advisory Council: The recommendation of the committee prescribing 50% of the members as the requisite quorum and minimum 2 meetings of the Medical Advisory council is a well intended suggestion. Centralized Counseling: The recommendation of the Committee to the effect that autonomy to universities/ and medical institutions as per the provision of the respective Acts should also be given permission to conduct common counseling for the vacant seats after the national and

state level counseling to be done on merit basis from the candidates who have qualified NEET so as no vacant seats remain. This by itself is going to undo what has been gained out of centralized counseling and will give a free hand to the private universities to have their own game plans executed. Licentiate Examination: The proposal of the Committee that the Licentiate examination be integrated with final year MBBS examination and be conducted at the state level by itself is counterproductive in as much as that it would transgress the authority and jurisdiction of examining university because the final MBBS examination would be the licentiate examination to be conducted by a designated authority at a state level other than the examining/ affiliating university by itself untenable. The suggestion by the Committee pertaining to inclusion of other medical institution established by a separate Act of Parliament in the common pool


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of counseling for the PG admissions is well intended. Autonomous Boards: The composition of the autonomous board has been altered in regard to its number from 3 to 5 with inclusion of an elected member thereat. However, even by the said proposition, the said Board does not gain a representative character and inadequacy of the number continues to the limit and desired optimal performance. The recommendation of the Committee, that the Ethics and Registration Board shall be headed by a Retd. Judge of the High Court but would not be a ex officio member of the NMC is paradoxical. It being proposed in the name of the said Board to be autonomous of the NMC is superfluous because the Appellate jurisdiction has not been explicitly provided for. 1. Inclusion of Family Medicine: The suggestion of the Committee that medical colleges running PG Course in medical and Surgical specialties, Pediatrics and Obs& Gynae shall have to establish PG courses in Family Medicine. However in absence of a Department of Family medicine as a must at the UG Level, the proposed mandate is illusory as it would never fructify. 2. Functioning of MARB: The recommendation of the Committee that the modalities of assessment should be based on an outcome based model rather than emphasis on infrastructure, staffing and process which is misleading to the extent that the outcome based assessment cannot be at the cost of infrastructural assessment as infrastructure has a big role to play towards generating the desired outcome. 3. Levying of penalty: The recommendation of the Committee on the said count to the effect that an alternative provision be made for warning, subsequent reasonable monetary penalty followed by adequate time to address the deficiency and in case the lacuna persist a provision for de recognition

for a certain period, subject to adequate checks and balances although sounds as if instilling confidence in reality is inoperable for want of an explicit clause for withdrawal of recognition for a specified period or permanently is not provided for in the proposed Bill and what is not included in the parent Act cannot be given effect through subordination legislation. 4. Screening Test: The recommendation by the Committee that a foreign citizen who is enrolled in his country as a medical practitioner in accordance with the Law, may be permitted to practice medicine and surgery sublet to qualifying the screening test meant for foreign medical graduates. It is pertinent to note that the screening test contemplated under Section 13 of the present Indian Medical Council Act would cease to exist on the day the NMC Bill is promulgated would result in repeal of the said Act making screening

nonexistent. The proposed Bill not providing for the screening test makes the suggestions by the Committee non operable and thus superfluous. 5. Bridge Course: The suggestions made by the PSC, the Bridge Course as proposed in the NMC Bill 2017 should not be mandatory but the sTates can avail the same as a part of capacity building exercise for the professionals of other pathies and have broadened the ambit thereto to the professionals of pharmacy, nursing and have kept it open ended by ending it the word “etc”. As such, the suggestions so made is nothing short of endorsing, legalizing and validating “quackery”, whereby the half baked professionals liberally granted permission to practice medicine would be playing with the health of the poor and gullible and make a mockery of the so called effective healthcare delivery system aimed at welfare of the people ending up in causing vulgar ill-fare. The clauses of the Bill that have been adopted by the Committee as it is, the observations of the IMA on the said count stand as they are as the said concerns remain unmitigated. In conclusion, summary and nutshell it can be inevitably concluded that the recommendations of the PSC are totally cosmetic in nature and illusory in character and thus end up in serving no public cause.

April 2018 31


Special Coverage - Appeal to Prime Minister

Appeal to Prime Minister

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n a letter written to PM Narendra Modi, the doctors under IMA baner has appeal to understand their genuine difficulties and provide commensurate solutions. According to Dr Ravi S. Wankhedkar, National President, IMA, we are the modern medicine doctors of India. Thousands of our medical students join us in this appeal. All speciality organizations, Junior Doctors Organizations, Service Doctors organizations are also part of this appeal. We have serious grievances in the way medical profession and Health Care is being governed. We appeal to our PM to understand our genuine difficulties and provide commensurate solutions. NATIONAL MEDICAL COMMISSION BILL 2017 :• Registration and practice of modern medicine by Ayush doctors or other categories of non doctors is a direct threat to patient care and patient safety. This illegitimate empowerment is unacceptable in any manner and form. • Promote and protect Ayurveda in its pure form. • Restrict the quota of private medical college managements to 15% of the total seats. Enable the State Governments to regulate the fee of

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85% of the seats. • Increase the representation of Registered Medical Graduates, Health Universities and the State Governments to the level currently available in MCI in tune with the concept of federalism. EMR Board should be headed by a well experienced modern medicine doctor who had been a care giver. Law and ethics are entirely different disciplines. A Judge as the head of EMR Board is inappropriate in a position which determines ethics and etiquette of the medical profession. Moreover such an appointment transforms this platform into one that is prone for litigation. VIOLENCE ON DOCTORS Mindless violence on doctors has

become an everyday affair. We are thankful that you have condemned the same. There is an urgent need to bring a Central Act against this violence and provide safety and ambience in our hospitals. Hospitals need to be declared as safe zones to protect the legitimate interest of the patients. NO CRIMINAL PROSECUTION No medical negligence case could be deemed as a crime because of absence of ‘mens rhea’ or the criminal intent. As a corollary criminal prosecution under 302, 304, 304 A is an injustice. This medieval practice should be discontinued in a civilized society. CONSUMER PROTECTION ACT Consumer Protection Act converted patients into consumers. CPA has opened floodgates of litigations

against doctors. There is an urgent need to cap the compensation on a well reasoned and structured formula. PC PNDT ACT Minor clerical errors have sent doctors to jails. There is a need for graded punishment as per the gravity of the offence. CLINICAL ESTABLISHMENT ACT Bring in amendments in the Act to make CEA friendly to the Clinical Establishments. The ambience to practice medicine has rapidly deteriorated. Legislations insensitive to the concerns of the medical profession will take us nowhere. It is for these burning reasons that we appeal to PM Modi to address our difficulties and provide just and timely solutions.

April 2018 33


Cover Story - Alcohol Consumption

Curbing Alcohol Abuse The rising trend of alcohol abuse in India has grave implications on the health, mental equilibrium and social standing of those who get addicted to it.

BY ABHIGYAN/ABHINAV

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he growing incidence of alcohol consumption in the Indian society has wideranging negative effects manifesting not only in health-related aspects but adverse social and economic conditions too. Curbing alcohol abuse needs to be made a priority in public health policy in India Alcohol consumption is a global phenomenon but it is now getting worldwide attention due to its harmful outcomes. Alcohol is classified as psychoactive substance which produces dependence. It has not only important implications on health but has social and economic aspects as well. There are a number of factors which determine alcohol consumption in a society. According A K Aggarwal, Professor of Excellence, Medical Advisor, Appollo Hospital, social factors like cultural practices, level of development, alcohol production, distribution and marketing strategies are important factors. In India, alcohol consumption on certain religious occasions and social gathering is an accepted norm. Similarly, consumption of alcoholic beverages is prevalent in many tribal and village societies around the world. Individual factors also play a role in the pattern of alcohol consumption. Age group, gender, socio-economic factors, education, certain occupation, familial tendency, peer pressure etc are individual determinants of alcohol intake. Early age of initiation of alcohol intake leads to higher rates of diseases due to abuse, accidents and injuries. Alcohol consumption, determinants of its use in different populations, consequences on health and different strategies to reduce the health and social burden caused by the alcohol abuse are important issues for public health in India. Harmful use of alcohol is defined by the World Health Organization (WHO) as “drinking that causes detrimental health and social consequences for the drinker, the people around the drinker

life. In the age group of 20-39 years, approximately 25% of the total deaths are alcohol-attributable. A majority of this is due to injuries. Excessive use of alcohol kills or disables people at a relatively young age which puts a huge burden on society. Indian figures by WHO shows that per capita alcohol consumption in the age group of 15 years and above is about 4.3 liters. Most common ill-effects effects of alcohol consumption in India are liver cirrhosis and road traffic accidents. Prevalence of alcohol use-related disorders is 2.2% in India. and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes�. The adverse use of alcohol leads to deaths of millions of people worldwide every year making it a grave concern for society.

SHOCKING FIGURES As per the WHO, worldwide 3.3 million deaths result from harmful use of alcoholevery year, which is 5.9 % of all deaths. Alcohol consumption causes death and disability relatively early in

CAUSE AND EFFECTS Alcohol is a contributory factor in more than 200 diseases and injuries. There is a causal relationship between harmful use of alcohol and mental and behavioural disorders. It is an independent risk factor for noncommunicable conditions as well as injuries. Recent studies have reported the role of alcohol in infectious diseases like tuberculosis and HIV/AIDS too. Beyond health consequences, the harmful use of alcohol brings significant

April 2018 35


Cover Story - Alcohol Consumption

social and economic losses to individuals and society at large. The harmful effects of alcohol are dependent on amount, type and frequency of usage of alcohol.  Mental disorders: Alcohol consumption leads to neuropsychiatric conditions called alcohol use disorders. Epilepsy, seizure disorder, depression and anxiety are directly attributed to alcohol consumption.  Gastrointestinal diseases: Liver cirrhosis, pancreatic diseases are some examples.  Cancers: One of the most serious effects of alcohol is cancer. Alcohol is causative factor for cancer of the mouth, pharynx, laryngeal cancer, oesophageal cancer, colon and rectum cancer, stomach cancer, kidney and urinary bladder cancers, liver cancer and female breast cancer.  Injuries and accidents: Alcohol consumption is directly associated with road traffic accidents, gang violence and criminal activities. These may lead to severe injuries leading to disabilities and deaths.  Cardio vascular diseases: Alcohol consumption has negative consequences on hypertension, atherosclerosis, atrial fibrillation and stroke. Heavy drinking is a risk factor for heart diseases, stroke and diabetes.  Maternal and foetal mortality: Alcohol, if consumed by female during pregnancy, has detrimental effects on the baby. It leads to congenital deformities in foetus.  Infectious diseases: Alcohol directly weakens our immune system, thereby making human body prone to a number of infections. This is especially relevant in pneumonia and tuberculosis.  Reproductive health outcomes: Reproductive problems in females like reduced fertility. In males, it is associated with reduced sperm count and erectile dysfunction thereby causing fertility problems.  Socio economic consequences: Alcohol consumption leads to inefficiency in work and in fulfilling

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family and social relations. It is associated with loss of job, poverty, domestic violence, damage tothe one’s image in society, loss of productivity, absenteeism and earning potential. Factors affecting alcohol consumption and alcohol-related harm A variety of factors have been identified at the individual and the societal level, which affect the levels and patterns of alcohol consumption and the magnitude of alcohol-related problems in populations. Environmental factors include economic development, culture, availability of alcohol, and the comprehensiveness and levels of implementation and enforcement of alcohol policies. For a given level or pattern of drinking, vulnerabilities within a society are likely to have similar differential effects as those between societies. Although there is no single risk factor that is dominant, the more vulnerabilities a person has, the more likely the person is to develop alcohol-related problems as a result of alcohol consumption.

PREVENTION AND CONTROL MEASURES Says A K Aggarwal, “The market forces which are promoting alcohol

should be brought under legislative control. Regulating the marketing of alcohol is essential since it has important impact on younger population. Restricting the availability of alcohol can be effective. Legislations should be made and strictly enforced. Taxation policies can have huge impact on alcohol demand and supply system. Raising public awareness about the harmful effects of alcohol is essential. Innovative strategies should be used including mass media campaigns for the same. More and more counselling and rehabilitation centres should be opened for those in need all over the country. Those who recover should be integrated within the society without stigma and discrimination. All healthcare workers, social workers should be trained in counselling alcohol users.” The WHO has launched “Global monitoring framework for the prevention and control of noncommunicable diseases”. India being one of the signatory of this is committed to take measures for reduction of harmful effects of alcohol intake. In India, there is lack of a uniform law to cover alcohol production and sale across the country.


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need special care and rehabilitation. Although steps have been taken but they are not sufficient enough. Despite its negative effects on almost every aspect of life, alcohol consumption has remained a relatively low priority in public health policy in India.” To combat the problem of alcohol abuse, political will is of utmost importance. Public policies and interventions to prevent and reduce alcohol-related harm should be formulated. All stakeholders should be involved while framing the public polices and frameworks for preventing alcohol abuse. Specific care should be taken to prevent initiation of alcohol intake in early age groups like youth. Those who are affected should have easy access to services for care and rehabilitation. Certain states like Gujarat have framed legislations at the state level to curb the liquor menace. The Punjab Excise Act, which also extends to Haryana, p r o h i b i t s establishments from employing women in any part of such premises in which liquor is consumed by the public. Drunk driving is a punishable offence. Legal limits are set for alcohol concentration for breath analyzer test. The health, safety and socioeconomic problems attributable to alcohol can be effectively reduced and requires actions on the levels, patterns and contexts of alcohol consumption and the wider social determinants of health. Countries have a responsibility for formulating, implementing, monitoring and evaluating public policies to reduce the harmful use of alcohol. Substantial scientific knowledge exists for policy-makers on the effectiveness and cost–effectiveness of the following strategies: •regulating the marketing of alcoholic beverages (in particular to younger people);

•regulating and r e s t r i c t i n g availability of alcohol; • e n a c t i n g appropriate drinkdriving policies; •reducing demand through taxation and pricing mechanisms; •raising awareness of public health problems caused by harmful use of alcohol and ensuring support for effective alcohol policies; •providing accessible and affordable treatment for people with alcohol-use disorders; and •implementing screening and brief interventions programmes for hazardous and harmful drinking in health services. Dr H P Singh, Senior Child Specialist, Mother Child Care Hospital, Vaishali, observes, “There is growing incidence of consuming alcohol in teenagers which might harm their future. There are national prohibited days which are specific days when the sale of alcohol is not permitted. The government of India has established detoxification centres and counseling centers for people who

KEY FACTS • Worldwide, 3.3 million deaths every year result from harmful use of alcohol,2 this represent 5.9 % of all deaths. • The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions. • Overall 5.1 % of the global burden of disease and injury is attributable to alcohol, as measured in disabilityadjusted life years (DALYs).3 • Alcohol consumption causes death and disability relatively early in life. In the age group 20 – 39 years approximately 25 % of the total deaths are alcohol-attributable. • There is a causal relationship between harmful use of alcohol and a range of mental and behavioural disorders, other noncommunicable conditions as well as injuries. • The latest causal relationships have been established between harmful drinking and incidence of infectious diseases such as tuberculosis as well as the course of HIV/AIDS. • Beyond health consequences, the harmful use of alcohol brings significant social and economic losses to individuals and society at large.

April 2018 37


cataract surgery - Eyes

Less Incision, More Precision In the blade-free new Femtosecond laser technology for cataract surgery, the incisions heal faster and the risk of infection is minimum.

DR MAHIPAL S SACHDEV

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he clear and transparent human crystalline lens is a part of the focusing mechanism of the eye. With increasing age, the lens becomes cloudy and opaque thereby hampering normal vision. Any opacity in the crystalline lens which leads to decreased vision is called cataract or “Safed Motia”. About half the population by the age of 60 will get cataract, while around 80 per cent people will have cataract in at least one eye by the age of 70 years. Approximately 8 million people in India have hazy vision due to cataract. SYMPTOMS OF CATARACT • Hazy, fuzzy and blurred vision • Increased sensitivity to light resulting in glare & difficulty in night driving • Poor night vision, poor depth perception, e.g. difficulty in going downstairs • Frequent need to change eyeglass & as cataract develops, even high power glasses would no longer improve the vision.

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In contrast to conventional cataract surgery, the innovative Femtosecond laser technology allows for the creation of corneal incisions and capsulorrhexis with computer- guided, lasercontrolled precision.


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April 2018 39


cataract surgery - Eyes

In Femtosecond laser-assisted cataract surgery, every aspect of cataract surgery is automatically programmed and monitored by the computer resulting in a safer operation and improved surgical outcome TREATMENT PLAN Surgical correction is the only treatment for cataract. Phacoemulsification with foldable intraocular lens (IOL) remains the standard surgery for cataract removal where using ultrasonic power, cataractous lens is broken down into small pieces and sucked out using a vacuum based aspiration system. A new artificial lens is implanted in its place which allows seeing clearly. ROBOTIC LASER CATARACT SURGERY Femtosecond laser technology or robotic blade-free laser cataract surgery is a leap ahead of the traditional Phacoemulsification cataract surgery

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(which is a manual technique, where the surgeon makes cuts in the cornea using a hand-held blade). Through these incisions the surgeon then inserts surgical instruments inside the eye to make a manual round opening (capsulorrhexis) around the cataract. An ultrasound probe breaks the old, cloudy lens into pieces. After removing those pieces through the incision, the surgeon inserts an intraocular lens (IOL) inside the eye to replace the natural lens. In contrast to conventional cataract surgery, the innovative Femtosecond laser technology allows for the creation of corneal incisions and capsulorrhexis with computer- guided, laser-controlled precision. The laser also fragments the cataract into tiny pieces which can then

be safely removed by the surgeon. The critical high resolution eye image mapping and measurements that are used to plan and perform the Femtosecond laser cataract surgery to exact specifications are not attainable with traditional surgery. With the use of Femtosecond laser, each aspect of this advanced blade-free cataract surgery is automatically programmed and monitored by the computer. While cataract surgeons are doing a good job now, Femtosecond laser technology introduces the ability for even the best cataract surgeons to be more consistent. It has the potential to, in the simplest of terms, help automate


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FACTS ABOUT FEMTOSECOND LASER CATARACT SURGERY: • • • •

many of the crucial steps of cataract surgery resulting in a quicker and safer operation and improved surgical outcome. FEMTOSECOND LASER ADVANTAGE  Blade-free, laser-created incisions: deliver precise cuts and is more accurate than manual blade incision The wound architecture in traditional surgery is limited by hand- held instruments and manual incisions. In contrast, the Femtosecond laser allows for computerized programming of corneal incisions. The precisely structured self-sealing incisions heal faster and minimize the risk of post-

operative infections.  Consistent circular laser-created capsulorrhexis enhances final visual outcome The first step in Femtosecond laser assisted cataract surgery is the creation of the capsular opening (capsulorrhexis) around the cataract with the help of laser. The opening in the capsule through the use of this technology is twice as strong and 5 times more accurate in size and shape as compared to the manual opening. The laser then breaks down the cataract into smaller fragments. Then corneal incisions are made with robotic precision. All these

Blade-free laser cataract surgery The actual working of the laser takes less than 1 minute Greater safety, precision & accuracy Capsular opening, laser fragmentation & corneal incision is fully automated Better visual outcome with quicker recovery

steps are performed without using any blade or needle.  Enables astigmatism correction at the time of cataract surgery In people suffering from astigmatism, the front surface of the eye (cornea) is not curved properly. The curve is irregular resulting in blurred vision. Laser-assisted cataract surgery allows for correction of astigmatism at the time of surgery.  Improved safety for the patient Femtosecond laser aims to convert the manual, multi-step, multi-tool Phaco procedure to one with lasercreated, and computer-controlled precision. The critical high resolution eye image mapping and measurements that are used to plan & perform the surgery to exact specifications are not attainable with traditional surgery. In Femtosecond laser-assisted cataract surgery, every aspect of cataract surgery is automatically programmed and monitored by the computer resulting in a safer operation and improved surgical outcome. If you need to undergo cataract surgery, opt for a centre which offers the latest technology combined with the expertise of a qualified cataract surgeon. Robotic laser cataract surgery technology is available at Centre for Sight’s New Delhi, Meerut, Agra, Jaipur, Indore and Hyderabad branches. (The author is chairman, Centre for Sight Group of Eye Hospitals)

April 2018 41


Eye Care - Vision

Keep an eye on your eyes Frequent changes in glass power may be a serious outcome of an underlying ocular or systemic disease.

BY DR SHISHIR NARAYAN

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ye sight turning weak and wearing spectacles is a pretty common thing today. It is generally no cause for alarm. However if the same number changes every six months or even earlier, then this definitely calls for some investigation.

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A clear and stable vision is a muchneeded requirement for every individual. However patients generally don’t give this issue the attention it deserves, where it may be an indication of something more serious. At all ages, it is advised to keep a regular check on your eye number.

The constant change in the power of your glasses can be a serious outcome of an underlying ocular or systemic disease. Frequent change in eye power after 40 years may indicate development of cataract and needs to be addressed. Corneal diseases like keratoconus, corneal scarring can


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Dwindling eye sight may be the effect but the underlying cause might be diabetes, hypertension, or other hereditary problems. These may cause Hypertensive Retinopathy and several other retinal diseases

lead to frequent change of glass power as well. Dwindling eye sight may be the effect but the underlying cause might be diabetes, hypertension, or other hereditary problems. It is seen that individuals with diabetes have a higher tendency to develop cataract as well as glaucoma at a younger age. The primary problem caused by diabetes in the eyes is Diabetic Retinopathy, which, if not treated in time can lead to permanent blindness. The symptoms to diagnose Diabetic Retinopathy are blurred or cloudy vision, irregular patches of vision or black spots. All these can lead to constant change in eye number. Hypertension is another big reason for the constant decline in vision. Some people suffering from hypertension don’t realize it, but it shows up in the form of regular decline in the vision or change in power of glasses. This causes Hypertensive Retinopathy and several other retinal diseases. Keeping a tab on your blood pressure can save you from the risk of developing such retinal diseases. Swelling in retina due to blockage of retinal blood vessels because of various causes like anemia, cardiac thromboembolism, carotid artery embolism etc are other major causes of changing eye power. Additionally, constant change in the eye number can be an outcome of hereditary problems too. Precautions and preventive measures which can be taken to avoid such situation are; get your eyes tested once in every 6 months, try to avoid spending too much time on computers and if you have to, it would be better to consult an eye specialist. Your diet should include fruits and vegetables, rich in vitamin A and vitamin K to ensure a healthy eye sight. Regular intake of vitamin and mineral enriched diet is very helpful for maintaining a good eye sight. (The author is Senior Eye Specialist Associated with Shroff Eye Hospital, New Delhi)

April 2018 43


Ayurveda - Skin Care

Magical Herbs Looking to protect your skin in the scorching summers? Go back to Nature that has given us wonderful herbs endowed with therapeutic and rejuvenating properties

BY TEAM DOUBLE HELICAL 44 DOUBLE HELICAL

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ant to have that perfectly glowing skin but not sure what to do about it? Well, the answer lies in your own surroundings! We often fail to realize the importance of the things that are easily available to us - the biggest example being ‘nature’ itself. Just look around and you will find that there are numerous valuable herbs and plants that have endless therapeutic and rejuvenating properties that could be a boon to your skin in the scorching heat. Here are three useful, easily available herbs that will pacify your doshas and keep your skin healthy and glowing in summers:


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TURMERIC (HALDI) Turmeric purifies blood, nourishes the skin and gives it a healthy natural glow and radiance. It has antiinflammatory, anti-aging and antibacterial properties that help reduce inflammation of skin, acne, pimples, blemishes, pigmentation, and prevent many skin ailments. It also helps heal and prevent dry skin, and slows down the skin aging process. AYURVEDIC PROPERTIES: Quality (Guna): Rough, Light Taste (Rasa): Pungent, Bitter Post-digestive Effect (Vipaka): Bitter Potency (Virya): Warm Effect on Doshas: Pacifies Vata, Pitta and Kapha HOW TO USE: To treat pimples, make a paste of one teaspoon of sandalwood powder mixed with one teaspoon of turmeric. Add one teaspoon of water to make the paste, and apply to pimples before bed. For itchy skin, apply the mixture of one teaspoon of sandalwood with one teaspoon of turmeric and one teaspoon of lime juice. Leave on for 20 to 30 minutes and rinse with cool water. Sandalwood oil can be used as a moisturizer on the face and body and is also great for massaging. Mix five tablespoons of coconut oil with two teaspoons of almond oil. Add four teaspoons of sandalwood powder, and apply the mixture to the overexposed areas of your skin. You will notice a considerable improvement in

your tan. ALOE VERA (GHRITKUMARI) Aloe Vera has been well known for centuries for its anti-inflammatory, anti-fungal, healing and cooling properties. It facilities healing of any kind - be it a skin wound, acne, burn, scald, blisters, insect bites, rashes, urticaria, vaginal infections, allergic reactions or dry skin. The gel of this plant helps to protect the outer layers of the skin, keeps the skin cool and reduces inflammation. AYURVEDIC PROPERTIES: Quality: Heavy, Oily Taste: Bitter Post-digestive Effect: Pungent Potency: Cold Effect on Doshas: Pacifies Pitta and Kapha HOW TO USE: Applying Aloe Vera gel on the skin prior to application of make-up can prevent the skin from drying. Blend the pulp of some fresh fruits with Aloe Vera gel in a blender and use it as a pack to keep the skin cool. Mix Aloe Vera with wheat germ oil or almond oil to use it as a moisturizing pack. To treat pigmentation, get a fresh leaf of Aloe Vera and split it to remove the gel. Apply this on clean skin and leave for about 20 minutes. In case of sunburn, the application of Aloe Vera-based cream acts as a protective layer on the skin and helps replenish its moisture.

April 2018 45


Feature - Child Health

Empowering Parents A digital platform – Integrated Child Health Record (ICHR) – has been launched to enable parents to track their child’s growth and vaccination

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our child’s health records will now be made available at a click of a button. India’s first ever digital platform, Integrated Child Health Record (ICHR), to keep a child’s health record, has been launched. Supported by cloud computing and mobile technology, ICHR is a revolutionary product to map a child’s health and track vaccination. ICHR is supported by first-of-its-kind mobile application to address pressing concern of parents willing to track their child’s growth and vaccination. The mobile interface will be available for both android and iOS users. The eminent scientist Samir K Brahmachari who

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was present as chief guest to launch and endorse ICHR, said; “I am happy to announce/endorse product in ICT domain by young entrepreneurs with high social value, which is aligned to Government of India’s digital vision.” ICHR provides and automates longterm surveillance of a child’s growth. It has other benefits like it will also help in early detection of obesity and malnutrition in urban and rural population respectively. It also addresses the dire need of maintaining the data centrally for research purposes. Once fully implemented, ICHR will become a potent tool in providing authentic region specific data for analysing and identifying reasons and probable solutions for both child vaccination and growth related issues. This application is all about empowering parents regarding their child vaccination and growth. This application removes the manual vaccination cards and makes the experience paperless and traceable from any part of the

world. This is the only app available in India to track the growth of premature babies both in the hospital and once they have been discharged from the hospital. This will be particularly beneficial for both doctors and parents to track the growth parameters of premature babies (Fenton Chart), not only while they are in hospital but even after their discharge up to 5 years (only app which continues from Fenton chart to the WHO chart). ”He further explained that the application can be used in both urban and rural areas to track growth parametres in children up to 5 years

and help in early detection of obesity (increasing trend of obesity as per WHO guidelines) and malnutrition. This will also help in much needed collection of data across India with regards to vaccination uptake. WHO data indicates that we have 235 million children 0-9 years out of our total population of 1.25 billion with physicians’ density of 6.49 physicians per 10000 population. We witness 7 lakh neonatal deaths every year and almost 3 lakhs of such cases are because of lack of vaccinations. These kids died due to diarrhoea and pneumonia making India rank as third lowest amongst 15 other high burden countries across the globe. Once fully implemented, ICHR will come handy in providing authentic region specific data for analyzing and identifying reasons and probable solutions for such problems. Main objective behind this product is to provide a paperless authenticated platform integrating doctors, hospitals and parents. The platform will provide automated vaccination record andwill monitor the growth schedule. Additionally, the technology is secure and HIPAA compliant. It is a cloudbased solution, which can be easily linked to hospital HIS/EMR system via HL7 or integration adaptors. There is no physical software installation needed to start using iCHR. Being on Amazon cloud, doctor can access real time patient information regarding growth & vaccination from any part of world using Internet. Oxyent Medical is the first one to bring such a technology in child health care. The company claims to provide a dedicated front end and back end team to support the users. On the pricing, Singh added that the technology is available at effective pricing. “It amounts to 1/3 rd of your monthly newspaper bill,” he said.

April 2018 47


Health Check - Hemophilia

Dangerous Disorder

With the alarming increase in the number of people suffering from haemophilia in the country, the need of the hour to take appropriate initiatives for establishing infrastructure and providing good quality factors for the management of the disease BY DR MANISHA YADAV

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ccording to a study conducted by the World Federation of Hemophilia (Annual Global Survey), almost 50 per cent of the world’s hemophilia population lives in India and almost 70 per cent of PWH (People with Hemophilia) do not have adequate knowledge or access to treatment. The risk of death from the lack of basic knowledge and untreated hemophilia is very high. Hemophilia is a genetic and lifethreatening bleeding disorder. Even

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with a minor injury or cut, in hemophilia patients’ blood does not clot normally due to the absence of clotting proteins called Anti-Hemophilic Factors (AHF). If not taken care, recurrent and prolonged bleeding into joints and muscles can lead to permanent disability and bleeding from the sensitive organs can lead even to death. The only possible treatment is infusion of life saving drugs AHF, which are costly and neither produced nor readily available in India (1 unit of Factor costs around Rs. 10-12 and at any bleeding episode a person needs 500 to 2,000

IUs in one shot which amounts to an expenditure of Rs 5,000 to Rs 20,000 on an average.) With the network of 80 Chapters spread across the country, Hemophilia Federation India (HFI) aims to reach out to more and more PWH and provide quality care, affordable treatment, educational & psycho-social support and economic rehabilitation. The HFI has so far been able to identify more than 16,000 hemophiliacs across the country out of estimated 1.2 lacs (1 in every 10,000 population). According to Meenakshi Lekhi,


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Member of Lok Sabha, said, “Health is a sate subject but the support of the Central Government too is necessary to achieve healthcare objectives. I am happy that our Government has finally decided to waive off the customs duty on Anti Hemophilia Factors. This will make the product fairly easy to obtain.” She emphasised the need to develop a unified management system for severe haematological disorders. She added, “We are trying to get haemophilia patients sanctioned for benchmark disability or under a special category of disability.” Considering the issue of haemophilia in women, she hinted about launching a project investigating bleeding disorders in women” Discussing the current state of haemophilia in India, Dr Kanjaksha Ghosh, Expert, Haemophilia Federation of India, said, “At present, only 15% of the total hemophilia population has been identified in India and the rest remains undiagnosed. There are about 16000 patients registered with us, however, we suspect that the number of people suffering from hemophilia in India could be ranging seven times more than the current registered patients.” The event aimed at generating sensitization on hemophilia for the policy makers both at national and state level. Recently held daylong session saw representation of senior officials from Ministry of Health and Family Welfare state secretaries of health, mission directors, eminent doctors, hematologists,

physiotherapists and hemophilia caregivers from various medical colleges and hospitals of the country. Talking about the disease management in Delhi region that focuses on providing treatment to patients in their vicinity, Dr Alok Srivastava, Professor, Department of Haematology, CMC Vellore said, “In Delhi, there are 2000 registered patients suffering from hemophilia and the state is also witnessing cases coming from other states as they do not have basic facilities and management care in their region. Through this initiative, we are proposing to build more “hemophilia care centres” in regions which would create effective mechanism for diagnosis, treatment and bringing timely comprehensive

care for haemophiliacs within their reach. We are committed to provide the treatment accessible and provide stateof-the-art facilities for the patients.” While talking about the state of hemophilia in the country and the need of the hour to take appropriate initiatives in collaboration with the government, Dr. Kanjaksha Ghosh added, “We thank the government for their support in establishing infrastructure and providing good quality factors for the management of disease in some parts of the country. However, we need to address this issue at a national level and thus, we would request government intervention at a macro level by means of funding, expanding infrastructural support, making free factors available and building trained workforce to control blood related disorders including Hemophilia”. According to a study conducted by the World Federation of Hemophilia (Annual Global Survey), almost 50 per cent of the world’s hemophilia population lives in India and almost 70 per cent of PWH (People with Hemophilia) do not have adequate knowledge or access to treatment. The risk of death from lack of basic knowledge and untreated hemophilia is very high.

April 2018 49


HealthTrek - Asthma

Treating Young Asthmatics Asthma is the leading cause of chronic illness in children. It can begin at any age but most children have their first symptoms by age five. So, an early diagnosis is important BY DR JASMEET K WADHWA

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hildhood asthma is a condition that is underrecognized, underestimated, under-treated and responsible for considerable morbidity among children between one to four years of age group. Asthma is a chronic inflammatory disorder of the airways, characterized

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by recurrent, reversible, airway obstruction. Airway inflammation leads to airway hyperactivity, which causes the airways to narrow in response to various stimuli, including allergens, exercise, and cold air. Children with recurrent cough, wheezing, chest tightness or shortness of breath may have one or more forms

of asthma. If left untreated, asthmatic children often have less stamina than other children, or avoid physical activities to prevent coughing or wheezing. Sometimes they will complain that their chest hurts or that they cannot catch their breath. Colds may go straight to their chest. Or, they may cough when sick, particularly at


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If left untreated, asthmatic children often have less stamina than other children, or avoid physical activities to prevent coughing or wheezing. Sometimes they will complain that their chest hurts or that they cannot catch their breath night. Asthma has multiple causes, and it is not uncommon for two or more different causes to be present in one child. Asthma is more than wheezing. Coughing, recurrent bronchitis and shortness of breath, especially when exercising, are also ways that asthma appears.

For some children, severe asthma attacks can be life-threatening and require emergency treatment. Signs and symptoms of an asthma emergency in children under five years old include gasping for air breathing in so hard that the abdomen is sucked under the ribs and trouble speaking because of restricted breathing.

Investigating childhood Asthma Studies have found that amongst the unlabeled asthmatics, cough and other mild symptoms of asthma are predominant whereas wheezing and shortness of breath are more common among the labeled ones. In India, studies determining the prevalence of asthma in school children have been

April 2018 51


HealthTrek - Asthma

reported but no study has been done to determine the factors for under diagnosis of asthma. Thus, we planned to study the under-diagnosis of asthma in school children and its related factors using questionnaires and pulmonary function tests. A cross-sectional study was carried out on 1000 school children studying in three public schools of Delhi and Haryana between 10 to 17 year age group over the period of one year. It aimed in studying under diagnosis of asthma in school children and its related factors. Questionnaires including details of medical, social, environmental factors precipitating asthma were filled by the parents and class teachers. Pulmonary function test (PFT) was performed. Based on questionnaires and PFT results, children were grouped as labeled and unlabeled asthmatics. Cough was found to be equally prevalent in both the groups while wheezing and shortness of breath were independent and significant factors associated with getting a physician diagnosis. General physical and systemic examination was done, followed by pulmonary function test. Peak expiratory flow rates were measured by Mini-Wright peak flow meter in standing position. Best of three measurements was taken. Children who had asthma-like symptoms were subjected to spirometry examination. In conclusion, we found that asthma is more likely to be missed or under diagnosed in children presenting with cough without wheezing and shortness of breath. Tricky diagnosis Wheezing, coughing and other asthma-like symptoms can occur with conditions other than asthma, such as viral infections and so diagnosing asthma in young children can be really tricky. And this is the reason why it may not be possible to make a definite diagnosis of asthma until the child becomes older. Diagnosing the precise cause of asthma is sometimes difficult because two or more causes may be present in one child. Unfortunately, there is not a

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single test that provides all the answers. An allergist/immunologist has specialized training and experience to determine if a child has asthma, what is causing it and accordingly what treatment plan should be developed. It is also important to understand what triggers the symptoms in a particular child, and what (including medications) can make them go away. For this purpose an understanding of the family history of the child and the analysis of the environment (such as smoking or pets) is useful, so your physician may ask. For many children under age five, asthma attacks are triggered or worsened by colds and other respiratory infections. It may be noticed that a particular child’s colds last longer than they do in other children, or that signs and symptoms include frequent coughing that may get worse at night. Moreover, infants may need extra attention during the diagnostic process because asthma symptoms can be caused by many things in this age group, some of which need very different therapies. When an infant has asthma symptoms, it is sometimes

called reactive airway disease. What triggers Asthma in Children The two most common triggers of asthma in children are colds and allergens. After infancy, allergies become particularly important, and therefore asthmatic children should have an allergy evaluation to help diagnose and manage their asthma. Avoiding the allergens to which your child is allergic may help improve his or her asthma. If the child is older than 5 years, he or she may be asked to perform pulmonary function testing to learn how air flows in his or her lungs. Other tests that your physician may discuss with you include measures of inflammation, a chest x-ray and tests for some of the less common causes of asthma-like symptoms. Managing asthma in children The most important part of managing asthma in children is to gain knowledge on how and when asthma causes problems, besides how some of the triggers can be avoided and the use of medications. The causes of asthma and best treatment for one child may be quite different than for another. To understand this phenomena an


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The most important part of managing asthma in children is to gain knowledge on how and when asthma causes problems, besides how some of the triggers can be avoided and the use of medications bronchiolitis when describing episodes of wheezing with shortness of breath or cough in infants and toddlers (even though these illnesses usually respond to asthma medications).

allergist can help develop an asthma management plan, and moreover, it is wise to share it with other caregivers. The plan outlines what medications to take, and when and how to increase the doses or add more medication, if needed. It also includes advice about when to call the physician. An asthma management plan puts the patient in control for detection and early treatment of symptoms. Inhaled medications come as metered-dose inhalers (sometimes called pumps), nebulizer solutions (delivered as a mist by a machine) and dry powder inhalers. However, it is important to learn how to use the type of medications prescribed for a child, or they might not work well. Asthma medications include inhaled rescue medications (quick-relievers) to treat symptoms and long-term controller medicines (inhaled as well as oral) to control inflammation that commonly causes the asthma. If a child’s asthma is more than a rare minor problem, a controller medication will probably be prescribed. For older children and adults, doctors can use breathing tests (lung function tests) such as spirometry or peak flow

measurement. As the child gets older, these tests may be used to help pinpoint an asthma diagnosis and track the progress of treatment. Generally, children under age five aren’t able to do these tests. Not all children have the same asthma symptoms, and so these symptoms can vary from episode to episode in the same child. Possible signs and symptoms of asthma in children include frequent coughing spells, which may occur during play, at night, or while laughing or crying, chronic cough, less energy during play, rapid breathing (intermittently) complaint of chest tightness or chest hurting, whistling sound when breathing in or out -- called wheezing, see-saw motions in the chest from laboured breathing. These motions are called retractions, shortness of breath, loss of breath, tightened neck and chest muscles and feelings of weakness or tiredness While these are some of the symptoms of asthma in children, the doctor of a particular child should also evaluate whether any illness complicates the breathing of that child. Many pediatricians use terms like “reactive airways disease” or

Understanding symptoms There are many risk factors for developing childhood asthma. These include nasal allergies (hay fever) or eczema (allergic skin rash), a family history of asthma or allergies, frequent respiratory infections, low birth weight, exposure to tobacco smoke before or after birth and may be being raised in a low-income environment. This is also important to know why the rate of asthma in children is gradually increasing. Some experts suggest that children spend too much time indoors and are exposed to more and more dust, air pollution, and secondhand smoke. Some of the suspect that children are not exposed to enough childhood illnesses to direct the attention of their immune system to bacteria and viruses. Many children with asthma develop symptoms before age five and so an early diagnosis is important. There are a number of conditions that can cause asthma-like symptoms in young children. Treatment of Asthma in children improves their day-to-day breathing while reducing asthma flareups which further help reduce other problems caused by asthma. (The author is well known Consultant Pediatric Pulmonologist, New Delhi)

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HealthTrek - Life-saving vaccines

Life-saving vaccines BY DR POONAM KHETRAPAL SINGH

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hildhood asthma is a condition that is underrecognized, underestimated, under-treated and responsible for considerable morbidity among children between one to four years of age group. Asthma is a chronic inflammatory disorder of the airways, characterized by recurrent, reversible, airway obstruction. Airway inflammation leads to airway hyperactivity, which causes the airways to narrow in response to various stimuli, including allergens, exercise, and cold air. It is imperative that every child, adolescent and pregnant woman in the

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WHO South-East Asia Region receives the life-saving benefits vaccines provide. Whether to maintain the Region’s polio-free status and protect against the resurgence of maternal and neonatal tetanus (MNT); to achieve the Region-wide quest to eliminate measles; or to control ongoing challenges such as rubella, diphtheria, hepatitis B or human papillomavirus, immunization is the most cost-effective way to protect individuals, communities and countries against a range of lifethreatening and disabling diseases. But to leverage vaccines’ full, lifesaving potential, every child, adolescent

and pregnant woman must be reached and the highest possible coverage attained. To that end, Region-wide progress has been substantial. At present, seven Member countries’ routine immunization programmes have achieved more than 90% coverage with three doses of the basic diphtheria, tetanus and pertussis vaccine. Almost half have achieved 95% coverage of both doses of measles-containing vaccine. These are significant achievements. Region-wide, each Member country should ensure all vaccines reach at least 90% of the population at all times. Doing so will save countless lives,


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April 2018 55


HealthTrek - Life-saving vaccines

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S achieve herd immunity against vaccine-preventable diseases, and ensure newly introduced vaccines have optimal impact. There are several ways to achieve this target. First, each Member country should make immunization a national priority and secure sustained, high-level political commitment to strengthening national immunization programmes. Second, individuals and communities should be given the means to fully comprehend the value of vaccines and appreciate that immunization is both their right and responsibility. Third, sustainable financing models should be developed to support national immunization programmes, leveraging partnerships at the national, regional and global levels. And fourth, Member countries should increase their research capacity, with particular focus on increasing coverage and equity and evaluating the effectiveness of different delivery, supply and communication strategies.Alongside routine immunization strengthening, supplementary immunization activities (SIAs) play an important role. Over the

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past 14 months alone, 113 million children received the measles and rubella vaccine as part of mass campaigns in Bangladesh, India and Indonesia. Those vaccines will have lifechanging impact for each one of those children. SIAs carried out in Indonesia in 2015 and 2016 were meanwhile critical to protecting hundreds of thousands of women and neonates from MNT and achieving national (and regional) elimination of the problem. In acknowledging the value of SIAs, Member countries must take full advantage of them to strengthen routine immunization programmes and help build the infrastructure needed to

achieve at least 90% routine coverage. Doing so will not only provide life-saving protection to millions of children, adolescents and pregnant women, but will also help achieve universal health coverage – a key Sustainable Development Goal.As World Immunization Week begins, obtaining society-wide buy-in to that outcome is crucial. Immunization is, after all, a political and social compact – one between citizen and state; individual and community. Being protected together means honoring that compact and reaching every child, adolescent and pregnant woman in the South-East Asia Region with the life-saving benefits vaccines provide. WHO’s South-East Asia Region comprises the following 11 Member States: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and TimorLeste. (The author is WHO Regional Director for South-East Asia)


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Health News

The Hon’ble Vice President of India, M Venkaiah Naidu addressing the 8th convocation ceremony of PGIMER and Dr. Ram Manohar Lohia Hospital at New Delhi

The Hon’ble Vice President of India, M Venkaiah Naidu awarding the degrees at the 8th convocation ceremony of PGIMER and Dr. Ram Manohar Lohia Hospital at New Delhi recently. J P Nadda, Union Minister of Health and Family Welfare is also seen along with other dignitaries

J P Nadda, Union Minister of Health and Family Welfare addressing the 8th convocation ceremony of PGIMER and Dr. Ram Manohar Lohia Hospital at New Delhi 58 DOUBLE HELICAL


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