Smoking

The Indian Evidence on Tobacco Hazards

“Absence of evidence is not an evidence of absence” is a dictum which any rational individual always need to keep in mind. Presumably therefore, the absence of Indian evidence against tobacco hazards does not imply that the Indians are likely to behave differently than people anywhere in the world. We all know that the colour of blood of all human beings is red irrespective of their being blacks or white, or for that matter, Indians or Americans. Similarities aside, the fact remains that there is no dearth of Indian evidence on tobacco related harms. Obviously, the recent Parliamentary Committee Report on the subject is an act of short sightedness.

It seems that the Committee has conveniently decided to overlook the bulk of reports and research publications on the subject which have accumulated in the last few decades. The writer of this article himself has been engaged in clinical work on tobacco related disease since 1970s. One of my first paper which was published in 1982 in the international journal Thorax clearly showed relationship of lung cancer with tobacco smoking. The relative risk for smoking was reported as about three times more than in non-smokers. Similarly, higher risks were reported in the publications from Mumbai for several different types of cancers.

Cancer Registry Reports from India have regularly appeared which clearly show a significant relationship of cancers with both cigarettes and bidis. Most significant are the important Reports published by the Ministry of Health and Family welfare, Government of India which summarize the Indian evidence. A 2008 Report “Bidi Smoking and Public Health” was entirely devoted to bidi smoking. Only god can help if we continue to harp on the “lack of evidence’.

It is important here to understand that the cause and effect relationship in medicine is established on basis of multiple studies which are necessarily not possible to undertake in experimental laboratories. It is different from the experiments conducted in basic science laboratories. For causal relationship of diseases, one has to rely heavily on clinical and epidemiological data. Factually, these two types of studies constitute the core of medical research which represents factual relationships. From public-health view-point, it is more important to demonstrate clinical and epidemiological relationships with risk-factors than the experimental relationships. In any case, there are enough analytical studies and biochemical laboratories to show the presence of a large number of cancer-producing chemical in tobacco and their cancer-producing effects on experimental animals.

While Indian evidence on tobacco hazards including the cancers is substantial, there is far greater evidence from the American and the European continents. I must lay stress on the fact that factual information on disease causation is quite universal. It is quite true that there may be small differences in disease relationship in different countries. Some of the clinical risks and disease manifestations may vary depending upon local cultural, socio political and economic factors. But the basis facts in science remain the same. Why only cancer? This is also true for other diseases like asthma, hypertension,  diabetes and everything else. Factually speaking scientific research is universal in its application. We must not trivialize the issues by limiting the scope of research findings to a particular region on a country. We must also remember that we heavily rely on the Western data for most of cancer related research including on its diagnosis and treatment. It is irrelevant that the International companies have their own motives. That they have. But we also need to keep the health interests of the Indian people in our minds.

Cancer is not just one disease- it is a general terms for a large number of different diseases with similar a characteristic of relentless progression to early death. Cancers of lung, blood and brain have different rates of progression than cancers of tongue, mouth and jaws. Nonetheless, all forms of cancers will result in permanent disfigurement and disability. Interestingly, the only other commonality between most cancers is the relationship to tobacco which remains as the root cause. Undoubtedly, tobacco is the strongest cancer providing consumer product. There can be no greater truth than what was said by the WHO Director General, Dr Gro Brundtland:  “A cigarette is the only consumer product which when used as directed kills its consumer.”
The same sentiment was truthfully  echoed by Anne Edwards by Philip Morris, the major multi-national tobacco company:  "What I think is clear is if someone came to us with a cigarette today and said, hey, here is a new product, I'm going to bring it to market.  Would it be allowed in the market anywhere? No, it would not. It is a very harmful product" (on Sex, Lies and Cigarettes)

Tobacco is also responsible for a large number of non-cancer diseases. It can be easily listed as the number one cause for a majority of heart attacks, strokes, chronic respiratory diseases and general ill health.  In women of child bearing age, tobacco is responsible for infertility, prematurity and low birth weight of new born babies, and abortions.

Smoking is not just injurious for a smoker. It damages the health of non-smokers who live in the company of smokers. This is a type of second hand or passive smoking which is directly related to cancers and other diseases. Such relationship which was first shown amongst non-smoker wives of smokers from Japan, has been also reported from a large number of other countries.

The only valid argument which the Committee has put forwards is related to the loss of jobs for b­­idi workers and tobacco farmers. A large number of studies are now available which show that the overall economic loss from tobacco related hazards is far more than the revenue loss from tobacco. A number of remedies including alternate crops have been suggested in several reports to compensate for the losses of farmers. Undoubtedly, the health is the most crucial issue and tobacco-control forms the core for National Disease Control Programmes of Government of India. One cannot lose sight of the fact that the Government of India is signatory to the International Frame Work Convention on Tobacco Control. The country is committed to undertake several mandatory steps to reduce consumption and production of tobacco.

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31

Miracle drug for Ebola - ctd...

Miracle drug for Ebola - ctd...

In a follow up to the previous post ( see Miracle drug for Ebola) one of the American researchers has been declared cured of Ebola. It remains to be seen whether the cure was spontaneous or due to the administered drug.

Liberia to receive Zmapp drug to treat Ebola virus

In a new development, Liberia is likely to try out an experimental drug 'ZMAPP' for the current Ebola outbreak without the requisite human trials.  Read the previous post for more information.

Link for current post: Liberia to receive Zmapp drug to treat Ebola virus

Miracle drug for EBOLA

Two health care professionals suffering from EBOLA virus infection were miraculously saved by an experimental drug. Importantly, the drug, known as 'ZMapp' , had only been tested in animals till now! Talk about miracles.

You can read the whole story here:  http://edition.cnn.com/2014/08/04/health/experimental-ebola-serum/

"Lung dialysis"

Some things are beyond belief, though clearly plausible - as the following example illustrates.

     A male patient in the US suffering from cystic fibrosis underwent a double lung transplant followed by failure. He was posted for re-transplant but was told that his carbon dioxide levels were too high. However, his physician, who was a well read man and in contact with the bioengineering world decided to go in for something out of the ordinary. A sort of a mini ECMO machine had been developed a few years earlier, for removing carbon dioxide from the lung. Known as the Hemolung RAS, it functions by removing carbon dioxide from and adding oxygen to blood just like a dialysis machine. As it was not approved by the FDA, emergency approval was taken within 24 hrs and the patient put on the machine. Lo and behold, he improved, the carbon dioxide levels reduced to acceptable limits and he was taken up for retransplant!

Some salient points:

1. Cystic fibrosis is a sort of death sentence in general practice in India with only symptomatic treatment available
2. This patient underwent double lung transplant not once but twice
3. Emergency approval applied for and recieved within 24 hours!! (Seems like some sort of dream)
4. As the machine was not available in the US, the doctors incharge personally acquired it from across the border i.e. Canada
5. The patient remained for 20 days on the machine
6. The machine was not recommended for use by any professional society

Lessons:

1. Out of the box thinking is the key
2. Be uptodate in one's field
3. Persistence and perseverance are essential

The full article can be read here: http://medicalxpress.com/news/2014-07-patient-implanted-hemolung-lifesaving-lung.html

Thanks to Dr.Ajay Handa for updating me on this.

Withdrawal of Life Supports?

Life Prolonging Treatment : The Right to Refuse?

(Legal and Ethical considerations)

            In medical parlance, a life prolonging treatment refers to all treatments which have the potential to postpone the death of patients suffering from incurable and terminal illnesses.  These conditions may include advanced cancers, failures of organs such as the lungs, heart, kidneys, liver or others and progressive, end stage neurological illnesses.  Advancements in modern technology have made it possible to sustain lives of such patients for several days, weeks or sometimes years with treatments involving cardiopulmonary resuscitation, artificial respiration, cancer chemotherapy, dialysis, artificial nutrition, hydration and other multiple drugs. 

The subject has raised a whole lot of new questions and dilemmas in not only the medical and legal  circles but among the general public all over the world.  Media has often extensively covered and discussed such examples.  Legal and medical literature is replete with opinions and judgments on such questions and cases involving legal interventions.  Most such examples have emanated from the West, although there have been a few instances in India.  With a rapid expansion of techno-medical scenario promising almost moon to every individual, the demands of people to live long have also increased. But the costs are tremendous and there are wider gaps in availability of resources, expertise and manpower, infrastructure, awareness and knowledge in providing life prolonged treatment.  This has posed a huge burden on the shoulders of medical practitioners, health professionals and policy makers. 

Even more basic than all other considerations is the core issue of medical judgement and its legal sanctity to provide life prolonging treatment.  It is a curious turn of events that medical practitioners tend to look to law for each of their action.  No citizen, much more so a medical doctor can afford to ignore law.  But medical judgements cannot always be surrogated to legal justifications especially since the law is other silent or ambiguous on most of the issues related to prolongation of life.

I give below two real case examples for you all to consider:

      

            

                The legal considerations as well as the medical opinions guiding the judgements and actions of doctors are yet in an evolving phase in this country on the issue under discussion.  It is therefore, worthwhile to look into examples available elsewhere.  Most of the Western medical associations have come up with more clear guidelines to help doctors to decide action.  The British Medical Association has laid quite comprehensive recommendations on several issues with respect to decision making on ‘withholding’ or ‘withdrawing’ life prolonging treatment.  Needless to say that the guidelines can only act as an aid in the process of decision-making rather than form a protocol of action.  A doctor is essentially guided in his action by the primary goal of medicine i.e. to benefit the patient by restoring or maintaining the patient’s health.

                One of the most contentious subject is related to the decision of patients to refuse a life prolonging treatment.  The law generally gives the right to an individual to decide and choose an option.  One is however faced with two different scenarios i.e. in case of a dying patient who may have the capacity to make and communicate decision vis a vis a patient who does not have this capacity (for example because of altered or impaired consciousness).  In other words, a patient may be either competent or may have lost the competence to decide.  Our discussion here refers to only the adults since babies, children and several other groups may not legally possess this competence at all.

                Legally speaking, an adult has the full competence to make decisions unless there are doubts on grounds of mental incapability or misconception of reality.  In a famous trial in U.K. (reg. MB (Medical Treatment), in 1997), the Court has rejected the decision of a patient since he believed that his blood was poisoned because it was red.  The mere observation that individual’s decision appears irrational or unjustified to others cannot be taken as evidence of lack of mental capacity.  But doubts may arise if the decision is contrary to the previously expressed wishes. 

                The right to refuse treatment is firmly established in British Law.  This had been reasserted in other cases including St. George’s Health Care, National Health Service Trust vs S (etc.).  Interestingly, the right of refusal was upheld even in a psychotic patient who held erroneous views on several matters but was considered as correct with respect to refuse amputation of his gangrenous foot.  In the United States too, the Supreme Court in the Cruzan case as well as several other cases had cleared expressed the principle that an individual has the constitutional right to refuse treatment even if this may result in his/her death.  This right has been reiterated in several other judgements even where the patients did not have life threatening illnesses.

                Another important issue which has emerged in terminal care is the concept of ‘advanced directives’.  Several sick patient like to leave written (or even verbal) directives expressing their wishes and desires regarding resuscitation and terminal care.  A ‘Do Not Resuscitate (DNR)’ directive by a terminally ill patient is not an uncommon practice in Western medicine. 

                Most ‘advanced directives’ have got legal sanctions and several judgements of the courts are available on the issue.  In U.S.A., the courts and legislatures have recognized this  legal tool of “advance care planning”.  Following the patient self-determination Act (1990), the hospitals are required to inform patients of their right to refuse medical treatment and to make advance directives.  These directives can be considered at par with the expressed desires of people for example the will regarding inheritance of their properties, wishes to donate eyes and body organs after death, or the method of their funerals and last rites. 

The real dilemma is for the doctor looking after a patient who has left a DNR or ‘refusal to get treatment’ order.  The competence of such an advance directive is always challengeable.  On the other hand, providing treatment against the expressed wishes of a patient may also land the doctor in trouble.  The Medical Associations would therefore, recommend that wherever genuine doubts exist about the validity of an advance refusal, the doctor should act in favour of giving at least emergency treatment and buy more time to decide in consultation with the family and the colleagues.

                Undoubtedly, the debate on the issue and the dilemma faced by the caring doctors are bound to continue.  No final protocol can be made for the doctors to act.  They need to follow the existing cultural and medical practices of the land.  Nonetheless, more individuals are likely to assert their rights in refusing life prolonging treatments.  The core philosophy in terminal care remains – Exit with Dignity.

Resource References

1. British Medical Association.  Withholding and withdrawing life-prolonging medical treatment. London, BMJ Books 1999.
2. Emanuel LL, von Gunten CF, Ferris FD.  The Education for Physicians on End-of-Life Care Curriculum, EPEC Project.  The Robert Wood Johnson Foundation, 1999.
3. British Medical Association and the Law Society.  Assessment of Mental Capacity: Guidance for Doctors and Lawyers. London: BMA, 1995.
4. Cassel CK, Foley KM.  Principles for care of patients at the end of life: an emerging consensus among the specialities of medicine. New York Milbank Memorial Fund, 1999.
5. Meisel A.  The right to die, 2^nd ed. New York: John Wiley and Sons, 1995.

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31

How to Handle Chronic Diseases

How to Handle Chronic Diseases?

Diagnosis of a chronic disease is the first and almost an inevitable shock which one receives during the adult life. There is a stage of doubt and denial in the beginning. Sooner, however, the reality needs to be faced as a part of life.  An early recognition and acceptance is always good for the long-term management and prevention of later complications.

Chronic diseases often referred to as non-communicable diseases, together pose a major health-care crisis in the 21^st century.  A bane of modern life-style and longevity of life, the crisis has attracted a global call for action for different governments and international agencies including the UN General Assembly thus bringing the NCD agenda to the highest level of attention.  Considered in the past as ‘life-style diseases’ or ‘a punishment of the rich’, they are even more common and burdensome amongst the poor, and in the developing countries. 

Chronic diseases include a host of different diseases of which the four major groups (cancers, diabetes, chronic cardiovascular diseases and chronic respiratory diseases) account for priority action at the international level.  India has included chronic mental disorders and chronic renal disease also in its ambit for its Control Programmes.  It is now estimated that one or the other chronic disease (or diseases) is/are likely to afflict almost every individual beyond the age of 60 years.  What the governments do for their control at the national and the international levels is a subject of policy and planning.  What the individuals can do to safeguard the health and cope with the burden is an issue of interest and understanding for all of us.

Living with NCDs is a fact of life . How to happily live and cope with a disease depends upon an individual’s personal perceptions and understanding of the disease as much as on the medical facilities available for its treatment.  The natural history of chronic diseases is variable from slow for most of the illnesses to rapid progressive for others.  Fortunately, most of them are compatible with a normal life span and style with modifications here and there.  For example, diabetes, hypertension, ischaemic heart disease, asthma and mental disorders can be effectively managed with regulated dietary alterations, regular medication, avoidance of precipitating factors/ triggers, and rehabilitative measures. On the other hand, diseases such as cancers, chronic obstructive lung disease, chronic heart, brain, kidney or liver failures are bound to progress sooner and later culminating into a premature fatal end.  With appropriate managements, the progress of most of these disorders can be delayed and life span prolonged.  More importantly, the ‘quality of life’ can be significantly improved.

It is also an accepted fact that the chronic progressive diseases as above reach an end stage in their natural history when curative treatments have little to offer. Only about 5 percent of us are going to be fortunate to die a sudden death, the rest are destined to be bed ridden from a chronic end-stage disease  for variable periods before the final exit This is the stage for palliative-care i.e. symptomatic management of troublesome complaints ( intractable pain, breathlessness, sleeplessness, severe anorexia, vomiting, gastrointestinal upsets etc.)  Unfortunately, several of the symptom-relief medicines are also likely to be detrimental for other organ functions and survival.  As a classical example, the powerful opioid drugs used for relief of most of the complaints as above, may result in fatal respiratory depression.  This ‘rule of double-effect’ is acceptable in specific situations, of course with a multitude of medical, procedural and legal implications.

Preventive steps are most important for the individuals to undertake.  Four important risk-factors which are common to most of the NCDs (i.e. tobacco smoking, obesity, lack of physical activity and alcohol intake) have been identified the world over.  Unfortunately, the prevalence of these factors is quite high – physical inactivity is almost universal in India.  Obesity is partly contributed by physical inactivity and partly by the intake of unhealthy diet.  High intake of sugars, fats and salt is responsible for several of the ill health effects.  Incidentally, the risk factors have a significant social, economic and cultural background.  The behavioural changes required for their control and avoidance are difficult and slow.  Nonetheless, it is important to minimize their occurrence for a meaningfully, healthy life.

The bottom line of living and coping with chronic disease is to accept its occurrence and win it over with the available armament.

It is worth remembering what was said almost four centuries ago at the dawn of modern medicine – ‘Acute disease is an act of God; of chronic diseases the patient himself is the author” (Thomas Sydenham). 

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000

Patient's Partnership in Disease Management

Patient’s Partnership in Disease Management

Dr. Surinder K. Jindal, M.D., FCCP, FAMS, FNCCP
(Ex-Professor and Head, Department of Pulmonary Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh. India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D, Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com          Website: jindalchest.com
Email: skjindal@indiachest.org

                There is no better example of mutual trust and belief in a relationship than that between a doctor and a patient.  This is a relationship of a wide spectrum which resembles that between the parents and the children on one hand, and between the seller and the consumer on the other.  It extends from compassion, responsibility and empathy to consumerism, business and (sometimes) confrontation.  Moreover, the relationship is neither permanent nor obligatory.  It is a partnership which succeeds best when both the partners are mutually responsive and responsible.  One cannot just rely on the doctor alone to get the positive results.  Similarly, the doctor must not assume the role of “Mr Know All” and “Mr Do All” whenever managing a sick individual. 

                The issue that a patient needs to participate and cooperate in almost any plan of medical management is undebatable.  A prescription is meaningless unless effectively utilized by the patient.  It is a common knowledge that most people do not follow the treatment instructions in toto.  This is perhaps inherent in human nature.  Yet we often tend to blame the prescription or the physician for any unfavourable outcome of an illness.  Endless examples of such experiences can be counted.

                The issue of treatment compliance is best understood in case of de-addiction programmes.  Compliance can hardly be expected on the mere advice to quit alcohol, a habit forming drug or tobacco consumption.  Every one may want a magic medicine to get rid of a habit causing distress.  But success can be achieved only with a prolonged and arduous programme involving the whole family.

                Certainly, people do understand that a psychiatric disorder or a drug dependence problem is difficult to treat especially because the patient himself/herself is not fully competent and involved.  Let us take more simple examples of an acute infection and a relatively chronic illness such as pulmonary tuberculosis.  As per several assessment studies, more than 80 percent of people will faulter on either the dose or the duration of prescribed drugs.  It was the realization of this very fact that led the World Health Organization and also the Government of India to adopt the strategy of Directly Observed Therapy, Short Course (DOTS) for tuberculosis where each treatment dose is required to be put in the mouth of the patient in front of a drug-provider.

                Patient cooperation is important in not only taking the medicine, but also in following other instructions.  Any number of bottles of cough mixtures and expectorants or strips of antibiotics will do no good to a patient of bronchitis or asthma who continues to smoke, irrespective of medical advice.  Similarly, anti-diabetic and anti-hypertensive drugs will not serve the purpose unless dietary precautions are taken.  Most patients with musculo-skeletal and joint problems cannot fully benefit without recommended exercises and weight reduction.  Unfortunately, many of the ancilliary recommendations are difficult to follow, but do play a crucial role in treatment plans.  Quite often, the non-drug factors may determine the success or failure of a treatment.

                Another important area where patient’s active participation is required is his/her appreciation and understanding of the disease, anticipation of future complications, progress of illness and limitations of treatment.  While most diseases are treated in one or the other way, only a few are cured.  Many of the illnesses require life long treatments and remain controlled while others continue to progress, irrespective of treatments.  It is the last group of diseases which is difficult to understand.  Treatment in these cases is aimed either at palliation or in somehow reducing the pace of progression.  There is a constant dilemma whether to treat or not to treat such patients, especially because treatments are associated with several other problems.  There is no easy way to wriggle out of this dilemma.

                We always like to involve the patient and/or the family in treatment decisions.  This however is not necessarily a successful strategy all the time.  This is even more so in case of relatively unfamiliar illnesses.  People may know the ifs and buts of asthma, tuberculosis, diabetes, hypertension or cancer.  But how many can really appreciate problems such as emphysema, cardiomyopathy, fibrosing alveolitis or motor neurone disease which may relentlessly progress to death, sooner or later?  Patient’s ability to understand depends upon innumerable factors such as age, sex, education, occupation, religion, race and so on.  Further, the explanation given by doctors are interpreted differently by different people.  Generally, people would tend to translate all advice as per their own beliefs and conveniences.  There is almost always a lack of clear understanding.

                Patient’s interpretation of medical advice is quite personal for not only the serious and progressive disorders but also for other common problems such as anxiety, depression, allergies or infertility.  There is never a direct correlation between what is advised and what is understood.

                Lastly, the limitations and problems of treatment as required to be accepted.  Quite often, the treatment effects are unexpected.  There is no treatment which is one hundred percent effective and safe.  Even a highly effective drug in most patients may not show its useful effects in a few.  Similarly, a very safe drug may well prove to be risky in some.  It is a common knowledge that some patients may show allergic or hyper-sensitivity reactions to an otherwise innocuous drug.  Same holds true of a complications following a surgical procedure.  The issue of unexpected effects and reactions is always a sore point with patients.

                On the other hand, many treatments are administered with full knowledge of their side effects and toxicities.  Several kinds of surgical operations are done and medicine (such as corticosteroids and cytotoxic drugs) given in spite of their known problems.  Such a decision is obviously made in being the best (or better) of the available options.  The problems ensue when the opted solution starts causing problems.  Factually, no patient can appreciate the unforeseen problems of a treatment in spite of being told in the beginning.  Yet, the explanations require to be given.

                To summarise, the patient continues to remain as an important and responsible partner in managing his/her disease.  Unfortunately, the disease belongs to him/her alone.  The patient needs all the attention and empathy of a doctor.  But neither the doctor, nor anyone else can own the disease.  Although the treatment is given by the doctor, it belongs to both.  A doctor is more of a counsellor or a facilitator than a proverbial god.  He/She needs to always keep in mind the very ancient saying – I treat, He cures.

               

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31