Burgeoning menace of irrational medicines / Deccan Herald Dt.27/03/2016 Hubballi Edition, Karnataka, India

<Burgeoning menace of irrational medicines Dr Chandra M Gulhati Through several gazette notifications on March 10, the Ministry of Health and Family Welfare banned the manufacture and sale of 334* unscientific cocktails of medicines called fixed dose combinations (FDCs). The FDCs are medicines where two or more drugs are combined into one pill, suspension or injection. Since each FDC is sold by many manufacturers under different brand names, thousands of products have been axed. The grounds for the ban, which took immediate effect, includes risk to patients, lack of scientific justification to combine drugs and availability of safer alternatives. Since individual ingredients of banned FDCs are available in plenty, patients can consume them separately if necessary. Thus the interests of consumers are fully protected. It took India over 35 years to realise that irrational FDCs must be weeded out to protect public health. As early as 1981, the Drugs Consultative Committee, a statutory authority comprising the Drugs Controller General of India and state-level drug authorities, had put in place voluntary guidelines as to when medicines can be mixed and when they cannot be combined. In the absence of a law, producers paid no heed and went about launching more and more FDCs to make money. Unlike in western countries, Indian drug manufacturers do not have their own research molecules, they simply copy the western medicines. Over the years, the number of fiercely-competing drug producers has reached an astounding figure of a little over 10,500, the highest in the world! With just about 1,000 basic molecules, producers resorted to introducing more and more FDCs, claiming that each cocktail to be "novel and superior to others" and worthy of prescription. Generally, patients in India are pretty reluctant to undergo diagnostic procedures such as pathological tests, X-ray test, ultrasound etc., due to the cost and consequent delay in starting treatment. For instance, a simple case of diarrhoea can have different causes, like viral, bacterial, fungal or protozoal (such as giardia). The rational approach is to get a stool-test done and then prescribe appropriate medicine. A patient usually prefers a physician in private practice who prescribes drugs without time-consuming tests. Here, pharmaceutical manufacturers offer an instant solution: A cocktail of different drugs that can tackle all possible causes even though most of them are totally unnecessary. The end result is more expenses, more side effects and still worse potential for antibiotic resistance. No wonder "Ofloxacin", once an effective drug for typhoid, is virtually useless today. The regulatory system did not keep pace with the ever-evolving medical science. The lapse was cleverly used by drug manufacturers to make huge profits by bypassing scientific principles. Till 1988, drug combinations of already approved individual agents did not require permission from the Central Drugs Standard Control Organisation (CDSCO). Even when prior approval of CDSCO was made mandatory, state drug authorities continued to issue manufacturing licences for hundreds of irrational FDCs. The result is that even today, there is no authentic, consolidated list of FDCs being sold in the country! The best estimate is that there are additional 500 or more irrational FDCs with thousands of brands in the country that need to be prohibited. Compare this with developed countries, where just over 200 rational FDCs have been approved after intense scrutiny of efficacy and safety. All such rational FDCs are already being marketed in India. In certain disorders such as HIV, tuberculosis and malaria, rational FDCs are invaluable. Therefore, the debate is not on the need for good FDCs but back-door entry of bad and harmful FDCs. In the developed countries, only one out of eight medicines consumed is an FDC, while in India, one out of every two formulations sold is an FDC. This colossal wastage of money is borne by the poor patients without realising that they are being fed with both unnecessary and often harmful combination of drugs just for profits by the pharma industry. Take the example of a cocktail of anti-epileptic drugs phenytoin with phenobarbitone. As per scientific evidence, phenobarbitone decreases the efficacy of phenytoin in most cases thus making the FDC less effective. How can such a combination be marketed? Let us examine another FDC of anti-allergy chlorpheniramine (CPM) with codeine, a painkiller and cough sedative derivative of opium. The "half life" (indicative of duration of action) of CPM is between 12 to 43 hours, while that of codeine is 2.9 hours. Thus dosing schedule of two agents does not match. In addition, side effects of the two ingredients, drowsiness and sedation, get multiplied. Finally, codeine has a huge addiction potential. Cold and cough remedies are considered worthless, except for temporary relief from symptoms, but scientifically, steam inhalation is much better and there is zero expense. A ban from the blue? Industry lobbies are claiming that the decision to ban FDCs was "sudden" and that manufacturers were not "consulted". The claims are false. On scientific issues, manufacturers need not be consulted because all of them have conflict of interest. Producers are hardly expected to suggest prohibition of their own unnecessary or harmful formulations. Drug units need to be consulted only on regulatory issues. In this respect, the health ministry repeatedly advised producers of FDCs, licensed by state drug authorities, to submit evidence of efficacy and safety by giving them an unduly long notice of 18 months. But only 6,200 brands were submitted for scrutiny and the absentee brands which never sought regularisation of their licences need to be detected, reviewed and regulated. An earlier attempt in 2007 to ban just over 200 irrational FDCs was stayed by the Madras High Court. Once the stay is vacated most of these FDCs will need to be banned as well. Even the CDSCO is not above board. It has also cleared irrational FDCs that need to be weeded out. The Parliamentary Committee on Health in its May 2012 report castigated CDSCO for its pro-industry tilt and for having cleared many doubtful FDCs. Monetary loss to producers for existing stocks, who have already made billions in the past on the very irrational FDCs now banned, can be of no consideration because after all drugs are meant to help patients, not hurt them. The present exercise is just the tip of the iceberg. * Ban on some FDCs have been stayed by the Delhi High Court till March 28. However, similar petitions for interim stay on some other FDCs have been rejected by the Madras High Court. The writer is editor, Monthly Index of Medical Specialities (MIMS) div dir="ltr" style="text-align: left;" trbidi="on">

Healing fast, killing slowly / Deccan Herald Dt. 27/03/2016 Hubballi Edition, Karnataka, India

The government's decision to ban more than 300 irrational fixed dose combinations (FDC) triggered a storm in the Indian pharmaceutical market where such FDCs enjoy a sizable market share. Several firms approached the Delhi High Court seeking to cancel the order that would adversely impact their bottom line. The latest order comes nine years after a similar government attempt, which could not be executed as the order was challenged in the Madras High Court. The jury is still out. Dr Gopal Dabade Modern allopathic medicines are powerful but only when used rationally and judiciously. Pharmacology, the medical science subject that deals with the proper and scientific use of medicines, has evolved over decades and outlines how these powerful remedies should be used. If used injudiciously or irrationally, the same medicine can prove harmful. In fact, medicine is a powerful double-edged sword. It is precisely this disregard for modern medical science that has opened the Pandora's box leading to the flooding of irrational drugs into the Indian market. The news banning 344 irrational drug combinations on March 14 hit the headlines of most Indian newspapers and channels. This ban affects 1,600 brands worth Rs 3,700 crore. The media's favourite question is how were these drugs allowed and how is it that we have been using them for several years now. Before we answer these questions, we first need to know what are FDCs (fixed dose combinations), as all the drugs banned by the Drug Controller General of India (DCGI) are FDCs. When two or more drugs are combined they are then referred to as FDCs. Medical science has more to add to this. When such combinations are made the drug that has emerged as a combination is totally a "new" drug by itself. It is this simple and profound law of modern medical science that has been totally dishonoured both by drug companies and regulatory authorities, and this has led to the huge number of irrational drugs in the market. It is most obvious that both the regulatory authorities and drug companies have joined hands for these dubious activities. Now, how did these drugs get such a huge market? As the drug companies got the clearance (of course by using nefarious methods), the next step was to promote and advertise the drug using all modern marketing techniques and push the drug into the market. The "drug marketing wing" of the drug companies uses the old-age technique, "keep telling the same lie over and over again in a loud and clear fashion till the lie appears to be the truth". And the drug companies have proved often that they are very good at this. Take an example, modern medicine acknowledges that there is no cure for common cold. "Common cold lasts for just seven days if treatment is taken, otherwise it lasts for one week", goes a popular medical proverb. But drug companies sell medicines worth crores of rupees to treat it and claim that it can even be cured! The common cough-cold remedies that flood the Indian market are a combination of expectorant and suppressant, which in simple terms means that the phlegm in the respiratory tract either has to be removed by using an expectorant, and that if there is not much phlegm (only an irritating cough), the same needs to be suppressed. But our Indian drug industry makes a combination of both of them! This must be unique to India. Such a combination only confuses the body further and may even worsen the condition of patient. It is interesting to note that Codeine is a drug that is recommended for use as cough suppressant, as per medical science. This drug was used extensively to treat the irritating cough of tuberculosis when antibiotics were not available. With the advent of powerful antibiotics, the use of Codeine to treat the cough associated with tuberculosis declined but the same continued to be used for irritating cough of common cold. But Codeine is a drug of addiction and this action is potentiated when combined with other anti-allergy medicines. The so-called cough syrups have also been abused by drug-addicts, especially among college-going youths, to get a "kick". The drug companies even smuggled truck loads of these cough syrups across the border into Bangladesh, where alcohol is not permitted. So literally, drug companies became "drug peddlers". The huge promotion and sales of these irrational FDCs have even edged out Essential Medicines out of the market! For example, there are hardly any rational medicines to treat anaemia-an extremely common condition, more so in pregnant women-in the dominant private healthcare industry, while irrational FDCs to treat anaemia flood the market. There are many such instances. An expert committee headed by Dr Chandrakant Kokate, vice-chancellor of KLE University, Belagavi, has examined in detail the issue and used references from modern medical literature to check if there can be some justification in these FDCs. The panel's report can be accessed on Central Drugs Standard Control Organisation website. It is needless to mention that these FDCs do not find mention in any standard textbooks of medicines or even journals. The World Health Organisation (WHO) recognises that irrational FDCs are a great public health problem, because scant resources on health end up being used on useless and irrational medicines and this is sheer economic waste. The World Bank notes that 85% of the out-of-pocket expenditure is on private healthcare. Way back in 1975, the Hathi Committee, headed by MP Jaisukhlal Hathi, had advocated a simple but revolutionary way. It had suggested that all drugs should be manufactured by generic name only and that brand names should be weeded out in a phased manner. Unfortunately, the recommendations met the dust bin, but Bangladesh studied this report and issued the Bangladesh Drug Ordinance 1982, which saw several thousands of irrational medicines out of the market. But this gain was stifled by the powerful drug lobby. The way forward The drug companies have approached the court seeking a stay on the ban issued by the DCGI. The drug companies seem to have professionalised the art of legitimising FDCs. The drug controller may try to urge the courts that a stay should not be granted. But the drug companies have mastered the art of overcoming the ban. How do the companies do it? Very simple! Let us say when the government issues a ban for a combination of Vitamin B1+B6+B12, the drug companies just add another Vitamin B2 (Riboflavin) to this and overcome the ban. So instead of banning each and every single FDC (which in any case is impossible) the government should come out with a list of FDCs that are scientific. It should be noted that, all FDCs are not bad. WHO has a list of essential drugs (19th WHO Essential Model List of Essential Medicines, April 2015). This list which is revised every three years has totally 425 drugs of which 27 are scientifically approved FDCs. Few examples are the popular ORS (Oral Rehydration Solution) or Iron + Folic acid (for anaemia). The drug regulatory authorities should insist that only these FDCs are to be manufactured and nothing else. If not even this big exercise of banning of 344 irrational FDCs, and in spite of the huge media attention, will just be another mockery. The writer is the Karnataka convenor of All India Drug Action Network (AIDAN) What is fixed dose combination? n DCs are combination of two or more active molecules in a fixed ratio of doses. n They are important in public health and are particularly useful in the management of HIV/AIDS, malaria and TB n The WHO essential list of medicine (the 19th edition published in April 2015) has 27 FDCs, whereas the National List of Essential Medicine of India (2011) contain 14 FDCs. n But hundreds of irrational FDCs are being marketed in India under thousands of brand names. n The FDC market is estimated to be around Rs 40,000-50,000 crore, including rational and irrational FDCs Demerits of FDCs n Dosage alteration of one drug is not possible without alteration of other drug n Differing pharmacokinetics of constituent drugs n Increased chances of adverse drug effects n One of the drugs in combination may be superfluous or wasteful, ex: vitamins+iron n Higher prices by adding unnecessary drugs When are they useful n Medical rationale for the combination n Identifiable patient group that benefits n Combination has greater efficacy n The incidence of adverse reactions with the combination is lower n For antimicrobials, the combination results in reduced incidence of resistance n One drug acts as a booster n Therapy is simplified n An ingredient is intended to minimise abuse of other component n Better patient adherence n Lower cost Country FDC Single drugs India 49.6% 50.3% Brazil 33.1% 66.9% Russia 23.4% 76.6% German 16.7% 83.3% France 14.7% 85.3% China 14.4% 85.6% USA 13.9% 86.1% UK 13.9% 86.1% Japan 10.5% 89.5% (Source: IMS Health MIDAS; Total may not add up to 100% due to rounding off) Rules for manufacture and sale n After amendment of the Drugs Act in 1982, the government acquired the power to prohibit manufacture and sale of certain drugs and irrational FDCs. n A gazette notification was issued in July 1983 banning several drugs and their FDCs. Since then, the Drugs Controller General of India (DCGI) was notifying the list of banned drugs on a regular basis. n Ideally, before marketing FDCs, the cumulative toxicities and risks-benefits need to be clinically and pharmacologically evaluated. But this exercise is rarely done. n The first genuine attempt to weed out irrational and harmful combinations of drugs marketed in India was initiated by DCGI in 2007 when it directed the state drug controllers to withdraw 294 FDCs from the market. n The order could not be enforced. Associations challenged it in Madras HC resulting in interim stay. The case is still not settled. n The Parliamentary Standing Committee on Health red-flagged the menace in its 59th report tabled in 2012 n In January 2013, DCGI issued a fresh directive to manufacturers asking them to prove the safety and efficacy of FDC approved before October 2012, and all those FDCs approved by the states without the DCGI approval. n If not compliant, these FDCs were to be considered for ban. However, licences for new FDCs continued to be issued by the state

Careers in the education field / Deccan Herald Dt. 3/3/2016 Bangalore Edition, Karnataka, India

Careers in the education field dire NEED The educational sector is need of good, qualified educators in varied capacities. In order to be effective, one needs a sound academic footing, avers Rajashree Srinivasan Education is so closely associated with people's lives that every individual in the society holds a view about it. However, one begins to recognise the complexity when we discuss the specific problems facing public education in India such as differential access to schooling, problems of infrastructure, lack of quality teaching, children's learning problems and so on. While there has been several reforms to revive various aspects of the education sector, there is still a need to develop people to address the challenges that the sector currently faces. Additionally, the sector needs good talent to enter to help develop innovative responses to specific field realities. Contribution in these areas require capable, knowledgeable, conscientious reflective practitioners and thinkers, who can take up responsibilities ranging from classroom teaching to policy analysis. This entails a systematised engagement with relevant body of knowledge and experience that brings to fore ideas of quality, quantity and the purpose of education. Any improvement in public education depends on the people who are working in this system. Several educational schemes and projects in India in the last two decades such as the DPEP, RMSA, setting up of District Institutes of Education and the provisions of RTE have highlighted important dimensions such as classroom pedagogy, learning materials, assessment and teacher communities. These experiences have pointed to the need to develop knowledgeable personnel to make informed decisions to support initiatives on the ground. Many paths Teaching at schools requires a teacher certification qualification such as BEd, DEd or a BElEd, while teaching at teacher education institutions requires an MEd, which is a two-year teacher-educator preparation post-graduate level. There are various ways that one can contribute to the education sector aside from being a teacher. Education has several aspects that need attention and serious study such as curriculum design, policy, education of teachers and design of learning materials. There is a need for specialised personnel to contribute to these various areas and the growing opportunities in the above areas signal that the government institutions are no longer the sole players but have found significant participation from civil society organisations, private organisations, international organisations, independent consultants and researchers. Examples of non-profit initiatives in the area of education include Digantar and others. Further, an increasing demand for people in the education sector it needs over five lakh teachers in the public schools to fulfill the RTE norms. Additionally, vacancies in the government teacher education institutions are over 50 per cent. In attempt to bridge the gap, there are thousands of NGOs working towards the improvement of education and health and several corporates are getting involved as well through their CSR initiatives. Good fostering A good education programme attempts to foster perspective, knowledge, attitude, ability and experience by offering courses in the areas of curriculum, philosophy and sociology of education, child development, research and policy. Besides an understanding of educational theory and practice, a good Master's programme should provide opportunities to do theory-based practicum and field-related projects. This gives graduates capabilities to plan independent educational interventions. It should also foster group work, form humane relationships and have a deep commitment to human wellbeing. The wide range of themes such as curriculum, pedagogy, text book and teaching learning material development, assessment, early childhood education could be of interest to academic personnel working in the DIETs, SCERTS and other government run institutions, who wish to strengthen their knowledge and capabilities in the above mentioned areas. Employees of NGOs engaged with design and implementation of interventions, those working on policy issues and other areas will benefit immensely from these programmes. The MA programmes are an inviting space for teachers who wish to enhance their understanding of teaching-learning processes or aspire to work in other non-teaching areas of education. Those individuals who have a Master's degree in the foundational areas of education such as philosophy and sociology, along with a teacher certification and a MA Education degree are eligible to teach foundational courses in teacher education colleges. Those who wish to be researchers can later enroll for the MPhil and PhD programmes or join educational projects in research institutions. There are various institutes in India that offer these programmes like TISS, Jamia Millia Islamia and Ambedkar University. It is hoped that such programmes develop informed professionals who can confidently respond to the educational situations and work towards ensuring quality in the context of universalisation of education. (The writer is faculty member, Azim Premji University)

Wrong medicine, MCI / 20/03/2016 Deccan Herald Bangalore Edition, Karnataka, India

Playing with lives: Nothing can be more tragic for a nation which doesn't trust its own doctors Wrong medicine, MCI |||||||||||||||||||||||||||||||||||||||||||||||||||||||||| Some thing immediate and drastic is called for if medical education needs to be back on track in the country. The Medical Council of India, whose mandate it is to ensure quality medical education and proper facilities in medical colleges, has utterly failed to carry out those functions. A first attempt at this, done in 2011, failed to take off. A Parliamentary Standing Committee has rightly and thoughtfully made out a case for corrections. |||||||||||||||||||||||||||||||||||||||||||||||||||||||||| Dr K M Shyamprasad The Parliamentary Standing Committee on Health and Family Welfare has submitted a detailed and erudite report to the Rajya Sabha on the functioning of the Medical Council of India (MCI). The report not only highlights the malfunctioning and corrupt practices of the council, but also the inadequacy and redundancy of the IMC Act in achieving the objectives of the council, in-terms of producing adequate number and quality healthcare professionals required to deliver appropriate healthcare in properly regulated healthcare system, reaching all its people. The question is, has the failure in the functioning of MCI and the prevalent corruption led to the poor quality of medical doctors? The MCI is the major regulator of medical education in India and it also prescribes a code of ethics for medical practitioners. While there are a number of rules and regulations for establishment of medical colleges and maintenance of standards of medical education, it carries out very limited evaluation of the implementation of these standards and guidelines. The MCI is not involved in any standardised summative evaluation of the final product - the medical graduate- emerging out of new or old medical colleges. This final evaluation, and therefore the final quality of every graduating medical student, is left entirely to the medical colleges and universities to assess and establish. The MCI's code of ethics, too, is flouted everywhere by practitioners who do unnecessary treatments, prescribe inappropriate drugs under the influence of pharmaceutical companies and exchange all kinds of referrals for commissions. The MCI has only a small Ethics Committee to deal with some complaints against medical practitioners that are mostly referred to it from State Medical Councils. Between 1963 and 2009, the committee has been able to take up cases against only 129 doctors (see website under the Indian Medical Register section) and many of these are still not disposed. Thus, there is no robust quality assurance system in place when a fresh graduate enters the system and starts practising. There are no further pressures on him or her to adhere to quality standards. It is public knowledge now that with increasing number of medical seats being available for high prices in private medical colleges, the quality of students at the point of entry, too, is being compromised. A few years ago, as chairperson of an inspection committee of a private medical university, I had an opportunity to look at the school leaving marks of students admitted in the college. The highest mark obtained by any student was around 65%. By comparison, in the same region, to get into a premier liberal arts college, the cut-off mark is well above the 90% or even 95%. This puts a strong case for a common entrance examination test for the country, but this needs to be conducted well, without any vested interests and without any scope for corruption. With quality/merit being pushed aside for the sake of financial gains at the time of admission, no serious evaluation of the quality of teaching and imparting skills or of the graduate being produced by this system, and no quality assurance mechanisms in place for practising doctors, one can only conclude that quality has been hugely side-lined in the increasing commercialisation of medical education and medical practice. Meanwhile, private medical colleges/universities have developed their own screening and admission procedure which is primarily monetary based. The majority of the seats are allotted for a capitation fee of up to Rs 50 lakh and more in some colleges and yes, this is for undergraduate education! This capitation fee is exclusive for the yearly tuition fee (as determined by legally constituted fee fixation committees) and other expenses that have to be paid through the five years' duration of the course. We have heard parents' accounts of identifying and contacting agents/brokers through newspaper advertisements who ensure a medical seat for a sum of money. Brokers for different states are spread out in the country, so brokers for Maharashtra and Karnataka can be found in Delhi. The medical colleges may themselves openly state the price of a seat. Fall in standards As private medical colleges currently outnumber government medical colleges, one clear implication of this trend of "sale" of medical seats is that there may be large numbers of students entering the system who may not be up to the required academic standards. Medical course is intellectually very demanding, and a student who is not capable of grasping the subject is often pushed up in his career by the private medical colleges and deemed universities for a price. The MCI regulations provide very detailed guidelines on the curriculum, skills and competencies, and how these should be assessed by the institutions, but the MCI has no mechanism in place to conduct any evaluation of the final graduate or of the curriculum as it is being implemented or taught, especially the skills that is being imparted. Thus, there is no meaningful evaluation of the actual implementation of the MCI's detailed guidelines for UG/PG medical education. The yearly so called "surprise" inspections count the staff and look at their degrees and experience without any cross-checking of facts with their own data base. These "ghost faculty" are gone the moment the inspectors leave the town. Students are left with teachers who are inexperienced to cover the syllabus, which is antiquated. There are no faculty training programs organised either by the MCI or the medical institutions. Teachers are also moving from one college to the other looking for higher emoluments. This creates further instability to the teaching-learning process. There is an overall shortage of trained and professor-level teachers in the country which is known to our authorities but they turn a blind eye when approving new medical colleges. Post graduate medical education is another Pandora's box. Without a postgraduate qualification, a medical doctor cannot earn big money and hence the admissions cost crores of rupees. The training is dubious to say the least and lacks uniform standards. A great disservice is being done to the country's healthcare delivery system through a corrupt MCI. Apart from the poor quality of graduates, the distribution of medical colleges in India has led to disparity in quality and access to healthcare in different regions/states. For instance, Pondicherry, with a population of 2.4 million people, has 10 medical colleges, including a Central government and a state government medical college. In comparison, the eight states of the north-east have around five medical colleges. (The writer is a cardiothoracic surgeon and former vice-president of National Board of Examinations, New Delhi.) what parliamentary standing committee report says UNDERGRADUATE EDUCATION n The MCI has failed to address the separation between the medical education system and the health system in the country. The medical education that is imparted to a graduate doctor is only for basic treatment and if he is not competent enough to do even that, there is basic problem in the system. n The health ministry should have a role in fixing the fee n The existing system of the graduate medical education has failed and total revamping is needed n The training of MBBS doctors should be in primary care centres and secondary hospitals including district level hospitals. n If a unitary Common Entrance Exam is introduced, the menace of capitation fee will be tackled in a big way; there will be transparency in the system and students will not be burdened with multiple tests n Young doctors should not only have practical skills but also have a lot of soft skills including ethics. n Common exit test for MBBS doctors n Move swiftly towards removing possible roadblocks to the Common Medical Entrance Test including legal issues and immediately introduce it dh graphics/ G Balaji Nangali INDIA'S DOCTOR PATIENT HOSPITAL SCENARIO n In India, every allopathic doctor serves 11,528 persons n In private medical college, the fee ranges between Rs 12-13 lakh that poor but meritorious students cannot pay. n World Health Organisation suggests 1: 1000 doctor-patient ratio MEDICAL EDUCATION n No. of medical colleges (in 2014-15): 398 n No. of MBBS seats: 46,456 n No. of MD/MS seats: about 25,000 TEACHING n Acute shortage of teaching faculty n There is need for a re-look at the retirement policy of teachers and work out a re-employment policy. n Shortage of doctors derails both access to and quality of health care n There are 20,306 hospitals having 6,75,779 beds n There should be separate UG and PG Boards for the regulation of UG and PG medical education POST-GRADUATE EDUCATION n The PG education should be governed by a body like National Board of Examiners n Should have common entrance and exit test at the PG level too MEDICAL COUNCIL OF INDIA n Medical Council of India was established in 1934 under the Indian Medical Council Act, 1933. n MCI's main function is to establish uniform standards of higher qualifications in medicine and recognition of medical qualifications in India and abroad. n The UPA government amended the Indian Medical Council (IMC) Act, 1956 through the Indian Medical Council (Amendment) Ordinance, 2010 n The MCI was superseded for one year and a Board of Governors was notified to perform the function of the Council n The ordinance was extended by several times, but the lawmakers did not favour the National Commission for Human Resources for Health bill that the UPA government proposed as an overarching regulatory body. n The NCHRH bill was introduced in the Rajya Sabha on December 22, 2011 and was referred to Department related Parliamentary Standing Committee for examination and report. n The Committee recommended on October 30, 2012 that the ministry may withdraw the bill and bring a fresh bill addressing the apprehensions of the stakeholders. n As the council was to be reconstituted within 3 years from the date of the supersession, it was reconstituted in November, 2013 Standing Committee on MCI n There is too much power concentrated in the MCI which has failed to create a transparent system of licencing of medical colleges n The current system of inspections is flawed and opaque. This opaqueness means these inspections give enormous scope for money to exchange hands. n The committee recommends setting up of an autonomous accreditation body, mandated to assess and accredit institutions in medical education n No reason why a retired specialist at the age of 60 cannot be re-employed as a teaching faculty on a full time or part time basis. n The Committee was informed that for a PG seat, capitation fee ranges from Rs 1-1.5 crore due to which it is impossible for the meritorious ward of an honest person to become a PG doctor n Merger of the DNB and MD/MS programme n Existing norms governing allotment of PG seats on the basis of the bed strength and number of PG teachers be rationalised

Time ripe to modernise our education system

Time ripe to modernise our education system By Manika Ghosh The higher education system in India seems such a paradox. On the one hand, it has a hallowed past, having world class universities like Nalanda and a robust presence in the world of scientific knowledge and philosophical elucidation. Education was seen both as a means to make a living as well as make a life. On the other hand, the present is witness to a colossal growth in numbers with a steady and sure decline in focus and quality. Whether one blames the colonial hangover, regional frictions, deficient leadership, chaotic administration, insufficient regulations, or apathetic faculty. There is no denying the lackadaisical handling and spread of higher education in our country. India has the largest spread of higher education institutions in the world with 740 universities, 39,671 colleges including 46 Central universities 342 state universities, 227 state private universities, 125 deemed to be universities and 39 `institutions of national importance'. India also has the world's third largest student enrolment in higher education. But in absolute terms, she has one of the poorest GER (gross enrolment ratio) hovering around 12-15% compared to 20% in China and around 75% in the US and Australia, prompting the Ministry of Human Resource Development set 30% GER target by 2020 - an ambitious albeit a ludicrous goal. It would mean increase in students' enrollment from the current 18.5 million to around 40 million, requiring additional 10,000 technical institutions, 30,000 colleges and around 500 universities, along with massive infrastructure, staff, funds and administrative machinery. It certainly promises higher accessiblity to aspiring millions but mere enhanced GER does not augur national development or excellence. It is worrisome that we continue to face the ignominy of having failed to produce world class university yet. While no Indian university features among the first 100, a city like Hong Kong has three, ranked at 24, 35 and 46. It is needless to say that for India to surge ahead as a knowledge economy and achieve the aspired development index, quality and excellence in higher education is a matter we can ill afford to ignore. In fact, all stake holders regard the need for ensuring quality in higher education. However, quality is a relative term, compared against a set standard, and therefore often difficult to define. Recently, a three-day 'National Conclave on Academic Quality in Higher Education' was jointly organised by Christ Institute of Management (CIM) and Internal Quality Assurance Cell (IQAC) of Christ University Bengaluru at Lavasa, Pune. The conclave provided an invaluable opportunity for free flow of rich ideas among scholars, researchers and administrators. According to Kennedy Andrew Thomas, Director, IQAC, Christ University, "The conclave was a serious attempt at engaging an assembly of experts who have the special authority and power to influence higher education to identify the pivotal issues of Indian higher education. It aimed at synergising conflicting ideas, produce workable solutions and present effective alternatives to the existing policies of Higher Education that could be adopted by institutions for quality enhancement." The deliberations that ensued in this congregation threw light on several bureaucratic malfunctioning, provided important suggestions and questioned the very process of assessing higher education institutions in the country. Some of the major issues brought out as the 'Lavasa Declaration' is worth pondering on. Rating of institutions For one, it was felt that rating of institutions presently undertaken by several accreditation bodies erroneously follow the Western model focussing merely on physical aspects like infrastructure and human resources. These parameters alone cannot be taken as the definitive quality markers for any institution. Indian institutions not only nurture a very diverse kind of demography, the structure of the higher education system is quite unlike that of the West. Therefore, the process of quantifying quality needs to look at the Indian ethos in education coupled with certain socio-eco-political realities. Concerted efforts are required for developing indigenous quality standards. Presently, the curricullum adhered to in almost all our institutions of higher education are prosaic and archiac, reeking of the British era. Ever since the start of the first English education college at Serampore near Calcutta in 1818, millions of Indian youths have been educated in the same fashion. It was reiterated that curricullum should match the changing times and be devised enriching the campus experience of the learners in its entirety including cognitive, emotional, and spiritual domains of learning.

YouTube helps in learning surgical techniques: Study / Deccan Herald Dt.05/03/2016 Bangalore Edition, Karnataka, India

YouTube helps in learning surgical techniques: Study Many experts are using streaming online media such as YouTube to learn new surgical techniques, researchers, including one of Indian-origin, say, reports PTI from Washington. A survey of American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members found that most of them had used online streaming media (YouTube) at least once to learn a new technique and most had used those techniques in practice. For the study, Anita Sethna from Emory University School of Medicine in US and colleagues surveyed 202 AAFPRS members. The most popular ways to stay current with technical and nontechnical findings included meetings, journals and discussions with colleagues, the study found. However, 64.1% of respondents said they had used online media at least once to learn a new technique, especially for rhinoplasty and injectable procedures, and 83.1 per cent had used those techniques in their practice, researchers said. Less experienced surgeons were more likely to have used online streaming media than more experienced surgeons, they said. "The enthusiasm is not unbridled, however. The internet's ease of access has raised concerns regarding the quality of these sources," researchers said.

Women who suffer violence may develop blood vessel disease / Deccan Herald Dt.05/03/2016 Bangalore Edition, Karnataka, India

Women who suffer violence may develop blood vessel disease Washington, PTI: Women who experience physical violence in adulthood may have an increased risk of developing heart and blood-vessel disease, a new study has warned. "Both society and the health-care sector need to be aware of the importance of exposure to violence and its impact, not only on social well-being, but also on women's long-term health," said Mario Flores, from the National Institute of Public Health in Mexico. Worldwide, violence against women is a critical problem. It is established that experiencing violence can cause depression, substance abuse and other disorders in women, its possible effects on heart and blood vessel disease are a new area of study, researchers said. In the new study, researchers found that women who had experienced physical violence as adults were more than one and a half times more likely to have narrowing of the main blood vessels in the neck that carry blood to the brain, compared to those who had not experienced violence. This narrowing is an early sign of increased risk for stroke. A leading cause of death and disability, a stroke occurs when the blood vessels to the brain either become blocked by fatty substances or burst, preventing blood flow to the brain.

Huge gaps in ovarian cancer research / Deccan Herald Dt.5/3/2016 Bangalore Edition, Karnataka, India

Huge gaps in ovarian cancer research Miami, AFP: Ovarian cancer, often called the "silent killer", is poorly understood by researchers and often does not even originate in the ovaries, a US panel said Wednesday. With no cure in sight, no reliable early screening tests and a lack of effective treatments for the cancer, the National Academies of Sciences, Engineering and Medicine called for a series of steps to close what it said were "surprising gaps in the fundamental knowledge about and understanding of ovarian cancer." Ovarian cancers kill about 14,000 women each year in the United States, where some 21,000 women are diagnosed annually with what is the nation's fifth most common cancer. "Ovarian cancer is not a single disease. Indeed, it is a constellation of sub-types," said Jerome Strauss, chair of the committee that authored the 377-page congressionally mandated report. "And these different types of cancers have different origins in the reproductive tract." Experts have found that "a substantial proportion of carcinomas labeled 'ovarian' may actually originate outside the ovary," such as the fallopian tubes, said the report. Early symptoms of ovarian cancer may include bloating, pain while urinating or abdominal discomfort; but often, no early symptoms are detectable. About two in three women who are diagnosed with the cancer learn of it only once it is already advanced and has spread beyond its initial site. Fewer than 30 per cent of women who receive these late diagnoses will survive beyond five years. Overall, fewer than half (46 per cent) of all women diagnosed with ovarian cancer live for five years. But there are research opportunities "that, if addressed, could have the greatest impact on reducing the number of women who are diagnosed with or die from ovarian cancers," said the report. These include placing a priority on research into high-grade serous carcinoma (HGSC), the most common and lethal subtype of ovarian cancer. A better understanding of the range of other subtypes is also needed, the report said. Women with mutations in their BRCA1 or BRCA2 genes are known to face a higher risk for ovarian cancer -- along with breast cancer. But genetic testing and counseling for families at risk has not been "universally adopted," said the report. "The committee discussed this at length and really recommended that women with ovarian cancer have genetic testing beyond just BRCA1 and BRCA2," said Beth Karlan, director of the women's cancer program at Cedars-Sinai. "And that this testing also be discussed with their family members -- what we call cascade testing -- so that their sons, daughters, sisters and brothers can also find out if they are carriers of these genes and would also be at risk." But since most women who get ovarian cancer have no family history of it, the report also called for a fresh effort to understand the risks of developing ovarian cancer, "including hormonal, behavioral, social and environmental factors." Another challenge involves the relative rarity of ovarian cancer. Although it is the seventh most common cancer in women worldwide, clinical trials may enroll fewer participants than breast cancer trials, for instance, so researchers must design trials "that are information-rich in terms of molecular characterisation and metadata so that clinically useful conclusions can be drawn quickly from smaller study enrollments," said Strauss.

Eating broccoli may lower liver cancer risk: Study / Deccan Herald Dt.5/3/2016 Bangalore Edition, Karnataka, India

Eating broccoli may lower liver cancer risk: Study Washington, PTI: Including broccoli in your diet may protect you against liver cancer, as well as aid in countering the development of fatty liver, a new study has claimed. Scientists have previously reported that eating broccoli three to five times per week can lower the risk of many types of cancer including breast, prostate, and colon cancers. The new study found that including broccoli in the diet may also protect against liver cancer, as well as aid in countering the development of fatty liver or nonalcoholic fatty liver disease (NAFLD) which can cause malfunction of the liver and lead to hepatocellular carcinoma (HCC), a liver cancer with a high mortality rate. "The normal story about broccoli and health is that it can protect against a number of different cancers. But nobody had looked at liver cancer," said Elizabeth Jeffery from University of Illinois in US. Consuming a high-fat, high-sugar diet and having excess body fat is linked with the development of NAFLD, which can lead to diseases such as cirrhosis and liver cancer, researchers said. "We called this a Westernised-style diet in the study because we wanted to model how so many of us are eating today," said Jeffery. Researchers wanted to find out the impact of feeding broccoli to mice with a known liver cancer-causing carcinogen. They studied four groups of mice; some of which were on a control diet or the Westernised diet, and some were given or not given broccoli. "We wanted to look at this liver carcinogen in mice that were either obese or not obese. We did not do it using a genetic strain of obese mice, but mice that became obese the way that people do, by eating a high-fat, high-sugar diet," said Jeffery. The study shows that in mice on the Westernised diet both the number and the size of the cancer nodules increased in the liver. But when broccoli was added to the diet, the number of nodules decreased.

Rare diseases: Too rare to care?/Deccan Herald Dt. 4/03/2016 Bangalore Edition

Rare diseases: Too rare to care? By Dr Olinda Timms Once again, Suniti had to excuse herself from an evening of celebration with her friends. She was exha-usted and needed to take her pa-ck of medications to be fit to work the next day. While earlier she needed help to set up the subcutaneous infusion pump, these days she is able to introduce the needle bravely into her own arm. Suniti is 25 years old and living with Thalessemia; a rare inherited genetic blood disorder that produces defective haemoglobin in the body, resulting in severe anaemia. The drug infusion will remove the excess iron in her body accumulated from frequent blood transfusions. Since the diagnosis, soon after birth, Suniti's life has been all about health crises, hospital admissions and medication. She struggled through her education, and hopes she can cope with her new job. Tired with fighting for life, she pushes back dark thoughts of ending it all. For the first six years of her life, Anjali was taken to a series of doctors for muscular weakness and lung infections until she developed respiratory failure and had to be ventilated. At that late stage she was diagnosed to have Pompe disease, a rare genetic disorder that affects glycogen storage resulting in damage to multiple organs and muscles in the body. Without treatment the prognosis was poor and Anjali's parents left no stone unturned, even selling their land and borrowing from family, to provide medical care. Today she attends class 10; an ambulatory ventilator is her constant companion, connected through a tracheostomy to her lungs. Her enzyme treatment costs Rs 1.25 crore a year and supportive care costs an additional Rs 40,000 a month. Each year, Global Rare Diseases Day is celebrated worldwide on the last day of February. Also called 'orphan' diseases, they affect a small percentage of the population and are usually genetic in origin. There are around 7,000 rare diseases reported worldwide, and 50% are detected soon after birth. The WHO defines a disease as rare when it affects less than 1 in 2,000 people; the more familiar being Haemophilia, Thalessemia, Duchenne muscular dystrophy, Hirschsprung disease and cystic fibrosis. The Organisation for Rare Diseases India reports around 70 million Indians affected by rare diseases, almost one in 20 people. The ethical issues relate to the neglect of these patients, who are virtually overlooked by health services, government agencies and health insurance. There is no government policy that addresses this health need, and patients and families are left to fend for themselves. Inaccessibility of drugs Drug companies spend a fraction of R&D budget on orphan drugs (used to treat orphan diseases), as the market is small. This has resulted in insufficient approved medication for these patients; where available, they are prohibitively expensive. Enzyme drugs available today are out of the reach of most patients. With no treatment for most of these rare diseases, patients have to rely on supportive and preventive measures and given the inevitable periodic hospitalisation, costs involved are crippling. Needless to say, health insurance plans will not cover hospitalisation costs or medication for these patients. A critical factor is early diagnosis, which is a major challen-ge. Amidst the preponderance of malnutrition or infectious disease, paediatricians could easily miss rare diseases, as they could be difficult to spot. Delays worsen prognosis, limit treatment options and increase the cost of care. Sometimes the patient is moved through orthopaedics, psychology and neurology before a diagnosis is made. Genetic testing has assisted in diagnosis of patients as well as family members, although more than one test may often be required. Even here, costs range from Rs 6,000-60,000. Also, there is a desperate shortage of trained genetic counselors to guide patients through the emotional trauma of diagnosis. How can these patients claim their constitutional Right to Health in a country where the budget for health is so shockingly inadequate? While health prioritisation may seek to utilise resources where they would cover the maximum number of people, can this justify neglect of this suffering minority? Who should decide on the 'common good' and how resources should be justly distributed? Adoption of a policy to address the needs of these patients will be a first step. Most rare disease societies in the country are initiatives by survivors or families, who work with doctors, geneticists, drug companies and the government to save lives. We cannot lose sight of this vulnerable group, for, in the words of Martin Luther King Jr, 'of all the forms of inequality, injustice in healthcare is the most shocking and inhumane'. (The writer, an Ethicist in Medical Humanities, is anesthesiologist at St Johns Research Institute, Bengaluru)

Drinking water may have numerous dietary benefits /Deccan Herald News Paper Dt. 3/3/2016 Bangalore Edition.

Deccan Herald Dt.3/3/2016 Bangalore Edition Drinking water may have numerous dietary benefits Washington, PTI: Drinking more water may help you control your weight and reduce intake of sugar, sodium and saturated fat, a new US study has claimed. The study that examined the dietary habits of more than 18,300 US adults found the majority of people who increased their consumption of plain water by 1 per cent reduced their total daily calorie intake as well as their consumption of saturated fat, sugar, sodium and cholesterol. People who increased their consumption of water by one, two or three cups daily decreased their total energy intake by 68 to 205 calories daily and their sodium intake by 78 to 235 grammes, researchers said. Participants were asked to recall everything they ate or drank over the course of two days that were three to 10 days apart. Researchers from the University of Illinois in US calculated the amount of plain water each person consumed as a percentage of their daily dietary water intake from food and beverages combined. On average, participants consumed about 4.2 cups of plain water on a daily basis, accounting for slightly more than 30 per cent of their total dietary water intake. A small but statistically significant 1 per cent increase in participants' daily consumption of plain water - tap water or from a cooler, drinking fountain or bottle was associated with an 8.6-calorie decrease in daily energy intake. There was also slight reductions in participants' intake of sugar-sweetened beverages and discretionary foods along with their consumption of fat, sugar, sodium and cholesterol. "The impact of plain water intake on diet was similar across race/ethnicity, education and income levels and body weight status," said Ruopeng An from University of Illinois. "This finding indicates that it might be sufficient to design and deliver universal nutrition interventions and education campaigns that promote plain water consumption in replacement of beverages with calories in diverse population subgroups without profound concerns about message and strategy customisation," said An. The findings were published in the Journal of Human Nutrition and Dietetics.