Indian Journal of Medical Ethics

FROM THE PRESS

Why medicines cost so much ...

According to a report prepared by the National Institute for Health Care Management, a non-profit research foundation in the United States, increases in the sales of the 50 drugs that were most heavily advertised to consumers accounted for half the increase in drug spending in 2000. The spending increase was not from an increase in drug prices but from an increase in number of prescriptions of the 50 drugs. The Food and Drugs Administration is now reviewing whether it should change the rules it enacted in 1997 that made it easier for medicines to be advertised on television. The drug companies objected, saying that their own studies showed no such link. Also, the benefits of advertising, such as encouraging patients to seek treatment which they had ignored, were being ignored. The heavily advertised drugs include those for arthritis, and for lowering cholesterol.

Melody Petersen: Increased spending on drugs is linked to more advertising. New York Times. November 21, 2001.

. . . which also explains which drugs sell best

Different brands of the erectile dysfunction drug sildenafil citrate introduced by leading pharmaceutical companies, have emerged as the block-buster drugs among different pharmaceutical products launched during the last nine months of 2001.

Special correspondent. Erectile dysfunction drugs among top 10 in India. Asian Age, December 4, 2001.

Dangerous x-ray machines

Excessive hazardous radiation from x-ray machines has now attracted the attention of the Supreme Court which issued notices to the centre, all state governments, the director-general of health services and the Atomic Energy Radiation Board (AERB). A public interest litigation filed by J P Sharma has sought a direction for the implementation of the safety code. MR Sharma's counsel, Anis Suhrawardy, said that flagrant violation of the code on radiation from x-ray machines was jeopardising public health.

Mr Suhrawardy told the court that the AERB had on December 13, 1986, issued a safety code with regard to medical diagnostic x-ray equipment and installations and followed it up with detailed safety measures required to be taken for these machines. But, due to wilful breach of these norms by various hospitals and diagnostic clinics, people throughout the country were suffering from hazards of radiation emission, the petition said. "As per a conservative estimate, over 50,000 diagnostic x-ray units are added every year."

Citing various scientific data, the petition claimed that the effect of such radiation would be ionisation of the cells in a human body, which could lead to a series of radio-chemical and bio-chemical reactions, resulting in or causing grave damage to important bio-molecules such as proteins and DNA.

Such damage could further lead to inhibition of cell division, chromosome aberrations, gene mutation and even cell death, the petition said. "It would be seen that the uncontrolled radiation received by a human being for a long time is capable of leading to diseases like blood cancer, skin cancer mostly on hands, shortening of life span, impotency in males and infertility in females." The authorities which have been entrusted with enforcing the radiation protection rules and the provisions of the safety code, have left the public at the mercy of the offending clinics, the petition said.

Times News Network. SC issues notices to Centre, State, on harmful radiation from x-ray machines. The Times of India, November 24, 2001.

The medical councils

When the president of a body, that is cranked out to be the central regulator of the medical profession in the country, is himself discovered to be corrupt, it says something about the state of the profession today. In a recent case, the Delhi High Court was confronted with evidence that the Medical Council of India (MCI) was in danger of fast becoming the Medical Corruption of India. Therefore, the court removed the president of the MCI with immediate effect on charges of his having misused his position for monetary gains. So disturbed was the court by the evidence at hand that it directed the CBI to inquire into the charges against the gentleman and ordered the MCI to hold fresh elections within three months.

The court's concern is perfectly justified considering the seminal role the MCI is supposed to play. Under the Indian Medical Council Act, 1956, the MCI is meant, among other tasks, to maintain uniform standards of medical education, to recognise or de-recognise medical qualifications of medical institutions in India and abroad, and to register all the qualified doctors in the country. These functions it is expected to discharge through regular monitoring, inspection and interaction on the ground. The sheer scope of the MCI's powers invests it with enormous responsibilities, especially at a time when the medical profession in the country has come under a cloud for its lack of commitment, faltering standards and general venality. Given the rush to set up medical colleges, given the frenzy with which young students vie for the limited seats in the medical colleges of the country, it is exceedingly easy for corruption to raise its head in organisations like these, which ultimately are only as good as the people who run them. The president of such a body, in particular, plays a 'pivotal role', as the court put it, and must be an individual above suspicion.

Interestingly, in early September, the Bombay High Court in another significant ruling, held that accredited members of the press shall be permitted to attend inquiry proceedings conducted by the Maharashtra Medical Council (MMC) to probe misconduct of medical practitioners. The issue cropped up in a case filed against a surgeon of Bombay Hospital for misconduct, in which the MMC found the doctor guilty but allowed him to get away with a warning. Allowing representatives from civil society to sit in at these hearings will make them more transparent and effective, given the tendency for professionals to display leniency towards each other, at the expense of better medical practices. The two cases should go some way in making the teaching and conduct of medicine in the country a little more accountable to the people it is meant for. Before physicians can heal others, they need to heal themselves, it seems.

Editorial. Medical Corruption of India. Indian Express, November 26, 2001

Blinded by cataract surgery

Gurcharan Singh went to the free eye camp near Yamunanagar for a cataract operation, hoping to see the world with a new eye. According to him, he ended up without sight and without an eye, after the doctor concerned 'gouged it out' to conceal an operation gone wrong. While the doctor who did the operation denies the charge, a preliminary medical inquiry confirmed that Gurcharan lost his eye after the surgery. It is silent on whether his eye was also removed. Five other farmers from surrounding villages who went to the camp in September - ŠŠincluding Gurcharan's uncle Pritam Singh - say they have lost vision in the eyes operated upon, like Gurcharan. At least one of them, Banwarilal, from village Amloha, also alleges that his eye was gouged out. The operation was carried out by a private eye surgeon from Get Well hospital, Radaur, Dr H R Gutain, who organised the eye camp and performed the surgeries himself. Says Gurcharan, "We were taken in by the promises made by the doctor."

Rajendra Khatry. Eye camp: 2 blinded, claim eye gouged out to conceal proof. Indian Express. November 3, 2001.

Died waiting for treatment

An unidentified 55-year-old man who had been waiting for treatment near the chief medical officer's office in the government-run JJ Hospital, died allegedly due to medical negligence. According to an eye witness, Leslie Pereira, the police constable on duty, Prakash Kubde, who is attached to the JJ Marg police station, first saw the man seated on the parapet outside Ward Number 3 at 3 p.m. The police desk was installed near the ward since it is a casualty ward. Mr Pereira said, "Kubde went out for a while and when he returned he saw that the man had slumped to the floor. Kubde went into the chief medical officer Dr Shashi Pawar's office and appraised him of the matter. Plice sources say that Dr Pawar rudely asked Kubde to mind his own business. They said, "The man remained unattended on the floor for 30-45 minutes. Later, when Dr Pawar admitted him for diagnosis, he was dead. The frightened doctor then approached Kubde and urged him to issue a death after admission certificate."

Sonal Shah. Oversight by JJ hospital CMO results in man's death. The Asian Age. November 27, 2001.

Regulating ultrasound clinics

The Supreme Court has undertaken the major task of facilitating a government drive to identify clinics where sex determination tests are illegally conducted. It summoned the health secretaries of 11 major states and issued notices to five multinational concerns that supply ultrasound machines in the country.

The court asked the health secretaries of Punjab, Haryana, Delhi, Bihar, UP, Gujarat, Maharashtra, Andhra Pradesh, Kerala, Rajasthan and West Bengal to be personally present on January 29 to explain the steps taken by their states to implement the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994.

The direction was made when the court found that its orders for registration of ultrasound clinics and the prosecution of those resorting to illegal sex-determination tests were not complied with. The court issued notices to five multinationals - Philips, Symonds, Toshiba, Larsen & Toubro, and Wipro GE. They have been asked to give the names and addresses of the clinics and persons in India to whom they have sold these machines in the last five years to help the government find out whether the clinics or persons have been registered under the act. After asking the MNCs to identify the purchasers of ultrasound machines, the courts said that considering the importance of the matter, "it would be desirable for the Centre to frame appropriate rules with regard to the sale of such machines to unregistered clinics."

The bench also directed each state to provide district-wise data on ultrasound clinics as well as publicise the constitution of district advisory committes. Under the act, people could approach these committees, which could then order prosecution of the erring clinics.

Times News Network. Irked by inaction, SC gets into the act. The Times of India, December 12, 2001.

Test for HIV before treating

When 28-year-old Ramesh (names of patients have been changed to protect identity) sufered multiple injuries in a road accident, first aid was not available because doctors first wanted to check his HIV status. And once he tested positive, the private hospital he was admitted to refused to treat him. Ramesh was refused admission at another private nursing home too before landing at the Sassoon government hospital. But the delay cost him dearly. Gangrene had set in and his leg had to be amputated. Nitin required surgery for his distended abdomen. But the doctors preferred not to operate on the HIV-positive youth. Nitin is no more.

Renu died of renal failure. She was infected with HIV and such patients are often denied life-saving haemodialysis. Surajmal Jain Agarwal (who insists that his name not be changed)is the distressed father of Pawan who is on his deathbed at a private hospital. Surajmal who hails from Aurangabad, was virtually hounded out of private hospitals there, and gave up hope when a few started closing their doors on him in Pune as well. Finally, one hospital did admit his son, and after spending more than one lakh rupees, he is now resigned to the brutal fact that life is slowly ebbing out of the once strapping young lad. The National AIDS Policy, redrafted in December last year, clearly states that HIV-positive patients cannot be denied treatment at government and semi-government hospitals. But what about private ones? Several doctors and patients point out that private hospitals get away by simply pegging the treatment rates to levels which cannot be afforded by poor patients. Dr Sanjay Pujari, head of HIV medicine and consultant at Ruby Hall Clinic, admits that the HIV status of a patient does matter. For example, what would otherwise cost Rs 10,000 for a Caesarean may be pegged at Rs 30,000 in case of an HIV patient. "A simple lymph node biopsy may be charged Rs 1,000 in ordinary cases but the rate goes up to Rs 7,000 in case of HIV patients," he says.

Pujari says overcharging is one way to deny treatment to these patients and points out that most HIV-positive patients die due to secondary opportunistic infections like tuberculosis and meningitis. "Sometimes it is even difficult to provide anti-TB drugs," he says, adding that the government does not allocate funds for anti-retroviral therapy that costs more than Rs 5,000 per month." What angers several social workers is the alleged practice of HIV testing before any surgery. Says Kusum Phule, social worker at Gadikhana, an STD clinic, " When AIDS cases were first reported, there was overall panic, with doctors refusing to even touch such patients. While that may no longer be evident, what is cruel is the pre-operative HIV testing." Once a patient's HIV status is disclosed, doctors find ways to deny treatment.

Dr Nitin Bora of Kayakalp, a non-governmental organisation which works towards creating awareness on HIV among commercial sex workers, points out that doctors often try to get away by saying that their hospital does not have the infrastructure to manage HIV infection. However, since most HIV-positive patients need treatment for secondary infections like TB, no special infrastructure is required for them.

Agrees Pujari who has treated 5,000 HIV patients since 1996 and seen two die per week, "It is high time we integrated HIV care in routine care. It is normal to sterilise instrumentse and other equipment for all patients. AIDS patients can be managed within the same infrastructure."

Anuradha Mascarenhas. Private hospitals hike rates to keep out HIV-positive. Indian Express, November 24, 2001.