Morning MEDtalks with Dr KK Aggarwal 25th September 2018

Dear Colleague

Here are two links for videos to watch. Share them with your colleagues and friends..

1. Vedic Health - A Dialogue with Ashwini Kumar Choubey https://www.youtube.com/watch?v=wdorsM5IZTQ
2. TEDx Video: Doctor-patient relationship https://www.youtube.com/watch?v=i9ml1vKK2DQ

Universal health coverage: As I understand it

Universal health coverage is the need of the hour. Two weeks back I was in Malaysia for the CMAAO Assembly, where the Malaysian Medical Association (MMA) spoke about their 40:40:20 scheme. The entire population of Malaysia has been divided into three income groups: Lower income group bracket 40%, middle income group bracket 40% and top 20 income bracket 20%. Their government has said that they would pay for and look after the lower 40% income group bracket.

That is what the Modi government has decided to do.

Under Article 21 of the constitution of India, right to health is a fundamental right and under Article 467 state directive principles, it is the primary duty of the state government to provide this as per their means and if they cannot provide, they need to enlist the private health sector under PPP model.

Under Ayushman Bharat, the government is paying for the insurance premium of 50 crore people. Everybody has a criticism that the premium is too low for five lakh insurance. But the reality is, it is not five lakh insurance, the insurance is of approximately one lakh as the packages have been capped with the maximum cap being around one lakh for tertiary care procedures. For one lakh insurance, the premium calculation is correct.

What is required is honesty at every level in running the scheme.

Being a capped reimbursement policy, chances of manipulations are lower except for billing one surgical procedure as two procedures. This loophole needs to be checked.

Once the government has divided the community into two segments the poor (under Ayushman Bharat) and non-poor (personal insurance), every hospital also can and invariably will have two categories in their establishments (general ward for Ayushman Bharat and private wards for others).

In my medical college, we were taught affordable health care under the subject low-cost healthcare and we all need to revise this topic. For example, why should I go for full hemogram in routine cases when the same information can be gathered by looking at the peripheral smear and ESR?

This scheme will promote the Make in India program of the Govt. Devices, consumables, drug, reagents and/or equipments will take precedence and their use will increase; we need to find out indigenous ways to manufacture these at low cost. Use of generics will increase; use of antiseptics may increase to cut down infection rates, which will bring down antimicrobial resistance (AMR).

The scheme will open doors for Jan Aushadhi drugs, only essential investigations, minimum cross referrals; it will also promote day care procedures.

Being a doctor means we are different and are considered demi Gods. Those who believe in it should do 10% subsidized charity by choice. The charitable rates can be reimbursed by the Ayushman Bharat schemes.

Universal health coverage is incomplete without disease prevention and harm reduction. The budgets for road safety, universal immunization, antenatal care, rural health, Swachh Bharat, environmental protection, skill development, drug development, safe water, safe soil etc. should be calculated as extension of health budget.

Harm reduction is already in the fray with elimination of mercury by 2020, sequential phasing out of Euro 4 vehicles with an aim to go for Euro 6, gradually reducing the air pollution parameters, phasing out trans fats in commercial restaurants.

A major mistake of the government is not banning tobacco from the country. The govt. is neither banning tobacco nor allowing comparatively safer electronic cigarettes in the market giving the message that conventional cigarettes are the best.

Among people who cannot afford, all those covered by ESIC, CGHS, Defence (BSF, CRPF, ITBP), PSUs, State health insurance, municipal corporations etc will automatically get excluded as they are already covered under respective schemes.

Will casual or contractual laborers be covered under Ayushman Bharat? Another major challenge would be rare diseases.

Issues such as these will keep coming up as the scheme is being implemented.

The success of the scheme will depend on the number of "no claims", amount of claims more than one lakh and percentage of disorders requiring recurrent hospitalization.

Puppies sold at six pet store companies led to campylobacter infections in 118 people in 18 states from January 2017 through February 2018, according to CDC. It can cause diarrhea, abdominal pain and fever. No deaths were reported, but 26 people were hospitalized. Samples of the bacteria showed resistance to all antibiotics commonly used to treat the infections. People with weakened immune symptoms and infants are most at risk. Out of the 118 people infected, 28 were pet store employees, and 101 people reported contact with a pet store puppy.

Campylobacter enteritis is an important cause of acute diarrhea worldwide. It is typically caused by Campylobacter jejuni or Campylobacter coli, and is largely a foodborne disease. The organism inhabits the intestinal tracts of a wide range of animal hosts, notably poultry; contamination from these sources can lead to foodborne disease. Campylobacter infection can also be transmitted via water-borne outbreaks and direct contact with animals or animal products.

The mean incubation period is 3 days. Early symptoms include abrupt onset of abdominal pain and diarrhea. The acute illness is characterized by cramping periumbilical abdominal pain and diarrhea. Patients frequently report 10 or more bowel movements per day. Bloody stools are observed on the second or third day of diarrhea in about 15% of adults; in children bloody stools may be present in more than half of cases. Diarrhea is self-limited and lasts for a mean of 7 days. Antibiotics are not needed for most cases of C. jejuni gastroenteritis.

Newborn becomes first PMJAY beneficiary in Jharkhand. Punam Mahato has become the first beneficiary of the Pradhan Mantri Jan Arogya Yojana (PMJAY) in Jharkhand after giving birth to a baby girl at a hospital here, minutes after the scheme was rolled out by Prime Minister Narendra Modi in Ranchi. The baby was delivered by caesarean section at 1.10 pm on Sunday at the Sadar Hospital here in East Singbhum district. 24-year-old Mahato, a resident of Basurda village under Gamariah Police Station of adjoining Seraikela-Kharswan district, was admitted to the hospital on Sunday morning.East Singhbhum district Civil Surgeon, Dr Maheshwar Prasad said, her entire medical expenses would be borne as part of the scheme. The hospital has provided all the services, including food, medicines, consultation and pathological test, free of cost to the patient. The expense for the delivery was Rs 18,500, the civil surgeon said. As the baby was born through caesarian section, the mother and the baby will be kept under observation in the hospital for a week… (PTI, Sept. 24, 2018).

Doctors’ handwriting:  The Jharkhand government has mandated that all doctors of private nursing homes and government hospitals have to write prescriptions in legible, capital letters and also write down the generic names of the drugs prescribed, following the guidelines of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. This is an attempt to reduce the risk of misinterpretation in the prescriptions.

Dosing of routine antihypertensive medication in the morning or evening does not affect ambulatory BP levels, whether 24-hour (daytime or nocturnal) or clinic blood pressure levels in hypertensive patients with reasonably well-controlled BP, says the randomized crossover HARMONY trial published in the October 2018 issue of the journal Hypertension. The study participants received their usual treatment either in the morning (6 am–11 am) or evening (6 pm–11 pm) for 12 weeks, and then they crossed over to the alternative timing for a further 12 weeks. It was found that morning and evening dosing had no differential impact on the mean daytime (7 am–10 pm) and nighttime (10 pm–7 am) BP levels or on clinic BP levels. No between-group difference was observed in mean 24-hour systolic and diastolic BP. Patients should take their antihypertensive drugs when it best suits them, suggests the study.

Floods are common all over the world. Here are few safety tips.

1. Avoid driving through flooded areas and standing water. As little as six inches of water can cause you to lose control of your vehicle.
2. Do not drink flood water, or use it to wash dishes, brush teeth, or wash/prepare food. Drink clean, safe water.
3. If you evacuated: return to your home only after local authorities have said it is safe to do so.
4. When in doubt, throw it out! Throw away any food and bottled water that comes/may have come into contact with flood water.
5. Prevent carbon monoxide (CO) poisoning. Use generators at least 20 feet from any doors, windows, or vents. If you use a pressure washer, be sure to keep the engine outdoors and 20 feet from windows, doors, or vents as well.
6. Standing flood waters can also spread infectious diseases, bring chemical hazards, and cause injuries.
7. After you return home, if you find that your home was flooded, practice safe cleaning. Remove and throw out drywall and insulation that was contaminated with flood water or sewage. Throw out items that cannot be washed and cleaned with a bleach solution such as mattresses, pillows, carpeting, carpet padding, and stuffed toys.
8. Walls, hard-surfaced floors, and many other household surfaces should be cleaned with soap and water and disinfected with a solution of one cup of bleach to five gallons of water.

The average daily consumption of people who drink alcohol is 33 grams of pure alcohol a day, roughly equivalent to 2 glasses (each of 150 ml) of wine, a large (750 ml) bottle of beer or two shots (each of 40 ml) of spirits. Worldwide, more than a quarter (27%) of all 15–19-year-olds are current drinkers. Rates of current drinking are highest among 15–19-year-olds in Europe (44%), followed by the Americas (38%) and the Western Pacific (38%). School surveys indicate that, in many countries, alcohol use starts before the age of 15 with very small differences between boys and girls (WHO’s Global status report on alcohol and health 2018).

Dr KK Aggarwal

Padma Shri Awardee

President Elect CMAAO

President HCFI