The current big tussle on in India is the pricing of what are called “essential medicines” by the World Health Organization. No one can deny that India needs “cheap/cheaper” drugs for a host of illnesses. A National List of Essential Medicines includes over 300 formulations. And the Government of India wants to make sure that all these are available at an affordable price without sacrificing quality. An empowered committee offers a solution, which is then opposed by the Ministry of Health and the health NGOs, while manufacturers watch on because it suits them to do so. This solution looks at capping prices at the previous three-month average of the bestselling brands in each class. Here then is the crazy intersection of commercial imperatives, pitted against social emergencies, bumping into inept regulatory frameworks.
The heart of the matter is simply this: should the price of medicines be regulated at all? Yes would be the resounding answer all around the world. This is no longer a commercial space where only market forces can be allowed to act. Pharmaceutical companies have never seriously looked at the option of self-regulation. For them most times life is cheap, drugs are not.
Disease burdens are rising around the world, diseases are becoming intractable and hard to beat, therapy solutions harder to find and commercialize effectively. So the message we would like to send to the pharmaceutical majors is that we need more cooperation between them to find new molecules, bring them successfully to market and price them in such a way that the entire cost research is not put on the patient’s shoulder. We would like doctors to be on our side and not be a part of the current nexus between medical experts, academics, researchers and manufacturers. Medicines that save lives cannot be subject to the same variable that influence pricing of items that are for consumer indulgence and excess consumption ( which is another debate altogether).
The MINT has really done a number on us today (May 9, 2012). Two items have small print that calls into question the newspaper’s editorial understanding of what is going on in India in the healthcare space.
In a huge double-page article on hospital infections and bacterial resistance to them (a BLOOMBERG piece, written by foreign journalists with help from Indians and even a South African), there are statements that imply that the rampant use of antibiotics, the result of which is resistance and bacterial mutation, comes from the easy and “cheap” availability of generic brands made by Indian manufacturers. These guys have made them so affordable that they are used indiscriminately. Does this sound like an intelligent argument? The newspaper/writers are offering the view that affordability and misuse go hand in hand. This is false and unacceptable. Antibiotics are not over the counter drugs. They are prescribed by GPs/Consultants/Specialists and Super Specialists, a group of intelligent, responsible people, we hope, see the issue of misuse as their responsibility as well. Hospital acquired drug resistant infections cannot possibly be linked to this situation as the writers try to do. So the argument is that because antibiotics are cheap and affordable and because the doctors prescribe them indiscriminately, hospitals cannot really do anything to control infections that are drug resistant. Hygiene, inadequately sterilized equipment and general negligence are mentioned in passing. Poverty and cheap antibiotics do not cause bacterial mutation as the shocking statement at the end of the article states. Carelessness and irresponsibility do. The same doctors and experts who are raising the alarm in India are part of the problem. And now they need to take the responsibility to find the solution. This article under the guise of analysis is probably the worst way to fill newspaper space.
The second piece is a leader that talks about compulsory patenting and why that is not good for “innovation” . More on this later in another post.
Actually many of us are. Doctors do not have any patience with us. They do not have time to answer our foolish questions. They certainly do not have the time to reassure us that we will live a long and healthy life. They tell us to get more and more tests done. This saves them the talk time.
So on the first day when we visit a doctor she listens for a minimum of five minutes, does some perfunctory pressing and poking for another five then quickly writes down all the things that need to get tested. Maybe we did this just three months ago but if it was for another doctor it will not work for this one. So off we go to get tested all over again. This is the age of the consultant and in this age every consultant distrusts every other consultant and doctor patient communication is not part of the treatment process.
In an earlier age it was. That was the age of the generalist “family” doctor who asked a hundred questions before she took up her favorite testing tool: the stethoscope. She relied a great deal on her own diagnostic skill. She not only explained what was wrong, what was causing it, but how long it would take to get better. In between she was willing to talk on the phone or do home visits.
These doctors treated patients medically and psychologically. They were in their own way leveraging the placebo effect to great advantage. Patients trusted them, obeyed them, argued with them and truly believed that the doctor would cure them. The medicine they prescribed was more than a chemical molecule, it was a promise wrapped in goodwill.
Maybe this is an exaggerated picture but it captures well the spirit in which medical advice was given and how that empathy is completely missing in the doctor patient relationship today.
A related concept is that of patient empowerment and here you can read more about that.
Consumer food brands respond to new wellness and health trends as fast as they can, which is good. What is not at all good is what emerges as a result of this concern. One classic example is decaf coffee created to make people drink the same amount of coffee without the harmful effects of excess caffeine. We the consumer believe these claims of health not knowing that in fact there are other repercussions about which no one tells us anything. No one tells us that the sensible response to news, that something we have eaten or consumed in ‘excess’ should be to just cut the amount to acceptable levels. That should be our consistent response We need to keep a watch on anything that comes to the grocery shelf on the ‘healthier’ platform. So called ‘healthier’ versions of coffee, cheese, chocolate and a host of other food items may not necessarily be better than the ‘unhealthy’ version. Here is another example that makes the case: reduced fat peanut butter which is not healthier than the full fat version. High fat diets might even be good for us after a myocardial infarction.
April 19, 2012
February 12, 2011
Old is new and the new often turns out to be not so good. As the wheel of discovery churns, revisits to known points of the medical journey are inevitable. Right now it is the whole world of Traditional Medicine (Ayurveda and Unani Tib) that is getting a good second look. But these are not the only systems to use healing herbs and spices. Tribal communities everywhere in the world have built a huge repertoire of bio specimens used for medicinal and healing purposes to this day. Forest degradation in many parts of the world is destroying this medicinal wealth. The way scientific investigation and drug discovery process is structured today means anything that falls outside the box cannot be taken seriously. Since drug discovery is funded by the big pharmaceutical companies unless they can copyright the active ingredients in these healing substances they are not going to waste their time on it.
We hear activists shouting about preserving our bio diversity and we call then nuts. But they are right.
Two promising trends are now emerging in the medical investigation of drugs and diseases: matching your genetic makeup with a molecule that will work for you (Personalized Medicine) and making mind and body linkages stronger.
Do not be surprised to see more and more scientific studies that will tell you with assurance that Turmeric (HALDI) with its active ingredient Curcumin is likely to become part of new medical formulations for several illnesses. Traditionally in India Haldi has been used as an anti inflammatory, immunity booster and in combination with Tulsi (BASIL) the most effective expectorant.
Cinnamon (DARCHINI) is the other spice under serious study.
Here are two studies that describe the benefits of Curcumin, in one case for pain and inflammation in osteoarthritis and in the other to protect and rebuild brian cells after a stroke.
April 19, 2012
March 1, 2012
More and more people are being diagnosed with a Vitamin D deficiency and more and more research is tying this nutrient to various health conditions. Children are now said to be particularly vulnerable. Breast fed infants according to this research are more likely to be D deficient since breast milk has no Vitamin D. Pediatricians must test children often to make sure that supplements are prescribed for when they are needed. Less D means less calcium and kids and pregnant mothers cannot afford to go without calcium. Medical information seems to show that there is need for around 1000 mg of Vitamin D at infancy rising to around 2000 mg into adulthood. The most critical type of D, cholecalciferol (D3) can be obtained largely from sunshine and although we have plenty of that our darker skin allows for lower absorption. For a long time no one in India wanted to accept that Indians could suffer from a deficiency of Vitamin D since the sun shone bright for so many months in this country and since so many of us worked out in the open exposed to this sun. But studies showed this to be incorrect. Awareness has grown. Doctors are more alert. Pharma companies are making sure calcium supplements now have the required amounts of D3 included.
And this is the latest status in India.
Every day there is new information on the worth and value of Vitamin D. How it inhibits inflammation. How it shrink fibroid tumors in rats.
How it alleviates menstrual cramps. How it helps seniors prevent falls. How it prevents stress fractures in adolescent girls. How it helps you to live longer. How it lowers risk of stroke
April 12, 2012
Every day is a vindication of Darwin’s theory of evolution in the world of viruses, bacteria and parasites. As we develop new drugs, they rise to the challenge and fight back by mutating. So a new cycle begins. And for right now our ‘enemies’ seem to take the advantage with greater frequency throwing us into one public health panic after another. Malaria has just announced a brand new fight. Patients are no longer responding to the newest and latest therapy.
In some parts of the world malaria, India included, is a disease we have lived with for many generations. And in India the ambition is to bring the deaths from malaria down to zero by 2015! Social tolerance for living with malaria is high. Expectation that the government will do something worthwhile low. And now comes the news that resistance to drugs is growing. India’s strategy rested on the use of artemisinin as the drug of choice and it is to this that resistance is growing. So what happen now? How soon will science yield the next solution?
February 26, 2012
Expanding the human organism’s tolerance threshold to invasive infections…this is the emerging scientific approach to countering the threat of drug resistant bacteria, viruses and parasites. And it make a great deal of sense. Boost the body’s natural ability to ‘live’ with or throw off infection. This goes beyond strengthening autoimmunity, it looks at the genetic markers that make some of us manage to not get an illness that another person succumbs to almost immediately. Worth watching what emerges in this space.
February 22, 2012
This would not be the first time that a plant based solution holds out the most promise. Now in the rain forest in Chile there lives a plant that can make bacteria breakdown their resistance to antibiotics. It is an avocado plant which the local ethnic groups have used for long as traditional medicine. In today’s world of fast bacterial mutation every traditional substance used anywhere in the world to fight infection and disease needs to be examined with close care. The plant substance has shown great potential against the most stubborn bacterium: yellow Staphylococcus.
January 25, 2012
The problem intensifies, throwing up alarming ramifications and is a discussion point at the World Economic Forum at Davos, that starts today. So what happens if we go back to a time before penicillin was invented? Cataclysm is the word used to describe such a situation in today’s context. As drug resistance continues to grow this will remain the next frontier of medical research. But there are many experts who now question the direction this research is taking. Should it be to be more and more aggressive with bacteria that continue to mutate and fight back in a very clever way or should scientists be looking at a more covert guerrilla approach which would be to trick them into destroying themselves? Along with this is the suggestion that the new solutions must also work to keep the symbiotic relationship between the human organism and benign bacteria. So far this has not always happened.
April 7, 2011
Today’s news on antibiotics is alarming and not really news. Misuse/overuse of antibiotics, of which we are all guilty, has led us to a situation where serious illnesses which could once be cured with the right antibiotic, have now become life threatening because the bacterium has stopped responding to the antibiotic. Multi drug resistant TB is a prime example here. And now there is a water-borne bacterium that falls in the same class.
This is not intended to be a medical piece. This is to say that we need to know more about these matters so that we can do better for ourselves and help our doctors make better decisions. Curing bacterial infection through use of antibiotics is like pitting two contestants against each other in a boxing ring. Once each gets a measure of the other, the weak becomes strong and vice versa. Irregular, frequent and unwanted use of antibiotics leads to the body building an immunity against a particular strain
The World Health Organization has released a survey on antibiotic misuse. The survey results are impressive to read but are they going to change the current mindset of doctors and patients? Doubtful.
Viruses and bacteria are both good at mutation and as the strains change, older drugs become ineffective. To find new vaccines and new antibiotics is a race pharmaceutical companies run every day. Each year we are introduced to a new vaccine for an old disease. Every year the sceptics among us ask why so many injections. Every year a new fear syndrome rises to consume more and more of us. Autoimmunity, that big weapon we once wielded to such good effect is no longer as strong and solid as once it was. Are we eating wrong? Are we living wrong? If only global medical authorities and experts could find a way to reduce drugs in our lives and tell us more about healthy lifestyles and foods that can cut our reliance on medicine.
The current pharmaceutical commercial establishment shows no willingness to see us as people to be protected. We are all just waiting to become patients to be cured.
Outright lying is no longer possible because there are too many watch dogs around. But leaving a few unpleasant facts out, sliding around some uncomfortable issues and then weighing in with some heavy emotional hooks, would be some of the ways advertising plays around with a subject that requires careful, truthful, clear and unbiased communication at all times.
In countries where Rx drugs are permitted to do direct to consumer communication, the advertisement is filled with small print (not sure whether readers actually go through it all) and words of caution. OTC advertising and health claims by branded health products have some amount of self-regulation in place. Largely because in these mature markets consumer knowledge levels are high, their trust a highly valued element, their activism at a well-developed stage, with litigation often the first option exercised. Not so in India.
Rx advertising is NOT ALLOWED, here but what should be regulated and is not, is communication about the superiority of one headache pill over another AND even more, products targeting children. Particularly annoying are the ‘advertorials’ that look and sound like serious sensible pieces of communication but are in fact even more devious because the space is bought and the content monitored to again say the same thing, leaving out just as many hard negatives.
There is a good strong line between asking third parties to comment on products that have clear health benefits and the claims the company makes on it own with a pretend doctor wearing a stethoscope! Health advertising is guilty of overemphasis, lying by omission and over emotionalizing issues that need rational explanations and scientific evidence. The ‘health’ platform leverage has increased in direct proportion to the increase in consumer health consciousness. But when too much razzmatazz is thrown in and the tone brought down to a ‘consumerist’ level, the scientific/emotional balance is lost and the communication becomes not just superficial but spurious. The most recent, almost funny example, is that of an air conditioner manufacturer advertising ACs that actually provides you with some Vitamin C – not that the process is explained in the advertisement. This miracle AC also kills off ‘germs’ since it has an ‘antimicrobial’ filter. Again no explanation of how this happens is available. So am I expected to switch to this brand on the back of the full-page waste of time?
Research into meditation and what it can do for a variety of brain conditions is ongoing. And as this body of knowledge builds, new experts are likely to emerge to tell you how best to meditate. However, new paths should be explored ONLY if traditional ones fail to deliver. In the case of meditation this is not true. Meditation is linked to the practice of YOGA. And its value has always been considered to be very high. The word YOGA means union and the intended union is between the body and the mind, the physical and the mental. Setting aside the spiritual and psychic aspects the essence of yoga is quite simple: attend to your body before you do anything with your mind. There are several schools of Yoga and experts have modified techniques to suit their own purpose. Largely though the essence has not been diluted or destroyed. At the end of the day, you are your own teacher in the most important ways. An expert can show you the moves but can do no more for you. You practice, you achieve, you excel and you arrive!
To see how far can they push the human body seems to be the abiding behavior pattern for all viruses. The human organism responds, often throws off the attack and ‘immunizes’ itself against that particular virus. In some critical instances the bully not only wins but wages a life and death battle with the human body. HIV is the perfect example. The real viral threat to our health is potential of viruses (bacteria) to mutate and survive. There appears to be an aggressive native intelligence at work here. The very simplicity of the structure of the virus makes it attack differently and survive stubbornly. Even when antivirals work it is like setting up a line of defense and keeping it armed forever. You let your guard down and you are under attack again. And should the virus mutate in the meantime the effective antiviral becomes useless. Viruses vary in small but dangerous ways. Take flu for instance. So many strains and they all need their own vaccine. Vaccination is like putting the body in training to recognize and destroy viruses. But as the viruses increase so do the vaccine with no end in sight.
Research is focused on how to build more defenses plus how to arrest life threatening viral attacks. Break the chain, stop the advance, etc.
So can we build more natural immunity or strengthen our natural defenses in any way? Does this have no role to play in the whole human versus virus story? Is auto immunity of no relevance? Is diet and lifestyle no important in this context? What about the role of stress and viral attacks? ‘Fighting fit’. This phrase was never more relevant than in the context of the fight against new and mutating viruses. To end on a naive note: is there potential for actually learning to live more comfortably with viruses?
MAN AGAINST VIRUS: A Brief History
Doctors in India use an early version of vaccination against smallpox, introducing small amounts of dried pus from smallpox sores into the skin of healthy patients.
Lady Mary Wortley Montagu introduces smallpox variolation—direct exposure to dried pus or sores—to England, having witnessed it in Constantinople. Although variolation carries a 2 to 3 percent risk of death, the practice spreads through Europe.
Benjamin Jesty, an English cattle breeder, is credited with performing the first vaccination in history. Jesty had long known that dairymaids didn’t get smallpox. He guessed it was because of their exposure to cowpox, a similar disease in cows. Jesty inoculated his wife and children with cowpox, protecting them from smallpox for years.
Edward Jenner, a British physician, publishes the first scientific report of a vaccination experiment using cowpox.
Louis Pasteur invents a vaccine for rabies. It was the first to use a laboratory-weakened strain of the target virus, rather than a related virus like cowpox, to induce immunity.
A Dutch biologist named Martinus Beijerinck searches for the cause of a disease killing tobacco plants. He passes sap from infected leaves through porcelain filters so fine that bacteria can’t get through. Yet the sap can still cause healthy tobacco leaves to wilt. He argues that the disease is caused by a tiny agent smaller than a bacterium.
Oxford biologists Howard Florey and Ernst Chain discover how to produce large quantities of antibiotic and test it on humans. Industrial-scale production of penicillin soon begins.
American virologist Wendell Stanley reports that penicillin and other antibiotics have no effect on viruses.
Interferons, antiviral proteins produced naturally by infected cells, are discovered. They are hailed as a potential miracle drug but prove to be risky and unreliable as an antiviral.
William Prusoff of Yale University discovers idoxuridine, the first effective antiviral. It fights herpes by interfering with the assembly of new virus genes. Approved in 1963 by the FDA, it can only be used topically for herpes infections in the eye because of dangerous side effects in other parts of the body.
After screening thousands of compounds for antiviral activity, scientists get a hit: a compound called amantadine proves effective against influenza. It is approved in the late 1960s.
The World Health Organization launches a campaign to eradicate smallpox, which still kills some 15 million people a year.
Researchers discover a broad-spectrum antiviral, which can work against a number of viruses. Known as ribavirin, it is now mainly used against hepatitis C. It’s not widely prescribed because it can cause anemia and other side effects.
Acyclovir, an antiviral for herpes viruses, is discovered.
The last known death from smallpox occurs. In 1980, WHO declares its eradication campaign a success. Three decades later, stocks of smallpox still remain in American and Russian laboratories, and there are suspicions that some stocks of virus are unaccounted for. If smallpox were to emerge again, doctors would have no antiviral drug to combat it.
Scientists discover the first antiviral effective against HIV. Known as AZT, it is later joined by a number of other drugs.
AZT-resistant strains of HIV are discovered. Doctors soon begin prescribing cocktails of several different antivirals to slow the evolution of resistance.
Gilead Sciences researchers discover a new antiviral for influenza, marketed as Tamiflu.
Scientists report influenza viruses that are resistant to Tamiflu. Since then, resistant strains have spread around the world.
Vertex Pharmaceuticals and Merck win FDA approval for highly effective new antivirals for hepatitis C, which infects 170 million people worldwide.