ADDRESS AT THE CONVOCATION OF THE PT. B.D. SHARMA POST GRADUATE INSTITUTE OF MEDICAL SCIENCES, ROHTAK, HARYANA
25-05-2007 : ROHTAK, HARYANA
Profile of Medicare
"Let my brain remove your pain"
I am delighted to participate in the Convocation of Pt. B.D. Sharma Post Graduate Institute of Medical Sciences (BDSPGIMS), Rohtak. I congratulate all the graduate and post-graduate students for their academic performance and the faculty members for shaping the young minds. My greetings to the Director, faculty members, scientists, technologists, government functionaries, students and distinguished guests. During the last forty seven years, the Institute has generated more than six thousand medical professionals who are playing a key role in providing quality Medicare to the needy patients in different parts of Haryana and other parts of the country and abroad. Of course PGI Rohtak every year removes the pain of the people using the best of technology and care of over 1.6 lakh outpatients and over 73,000 inpatients. I would like to present the "Profile of Medicare".
Dear Graduating students, when I see you all, in front of me, a scene of our country appears which links the new doctors and their role in the national mission. What is that scene? In our country, 700 million people live in 600,000 villages equivalent to 200,000 panchayats. We have 2020 Vision Document prepared by TIFAC, which indiates about the typical disease pattern which will be faced by the country during the period now to the year 2020. It is expected that HIV/TB combination, water borne diseases, cardiac diseases will be the predominant diseases and we have to find solutions for diagnosing and treatment. Also there are challenges for researchers for discovering molecule leading to drugs for various diseases such as diabetics, cancer, allergic diseases, inflammatory diseases, and certain type of new pattern of diseases in the tribal sector such as sickle cell disease. Many of you may take up healthcare practice in various fields and some of you may opt for research and development. The opportunities for you in the country, will be challenging equally both in the urban and rural areas. With the development of electronic connectivity and knowledge connectivity, and the spreading of health care centres and quality education we should be able to provide quality health care to our rural citizens. I am sure many of you will find working in rural areas to be really challenging.
First and foremost, it is necessary to activate all the 411 Primary Health Centres and 85 Community Health Centres. Tele-medicine, in combination with PHCs and CHCs will bring the best possibilities in diagnostic and treatment from urban to rural areas. Another area which is knocking at our doors is preventive healthcare. Some of you may participate in the research, development and use of vaccines against HIV, malaria and even against the cardiac diseases. There are several other avenues such as application of stem cell therapy for many ailments like treatment of heart failure and diabetics. Students should be aware of such developments taking place in the country and elsewhere. I have selected the topic for discussion ?Removing the pain is God?s Mission.?
Tradition of Research and Vision
Recently, I met Dr. Charles Cummings, of the Johns Hopkins University Board and his team. I asked him, a question which was in my mind, ?Dr Charles, What made Johns Hopkins a world class medical research institution in addition to its cherishing societal missions?? His answer was, ?it is due to a great tradition, and it started with a number of visionaries simultaneously with value system, focused missions and the nature of working together. The most important aspect is the research, research base and the quantity of clinical data added everyday. Teaching-research-teaching cycle has become an important component of quality growth of Johns Hopkins. This tradition continues even now?. Indeed it is a great message from Dr. Charles. I am sure, every medical institution in the country should imbibe this culture that comes out of research tradition, leading to the results of the research reaching the people in the form of medi-care, medicines or vaccines. I recall, one of the leading institutions in Hyderabad L.V. Prasad Eye Institute has set a tradition of providing quality eye care particularly with social commitment of 1:1. 1:1 implies one free eye care service for every paid eye care service provided by the Institute. Also, they have a tradition of excellent research in Ophthalmology and they are spreading the mission to various parts of the country particularly their research in stem cell which has led to the restoration of eye sight to over 300 patients with burn affected eyes.
Health status of India
India has made considerable progress in its health status since its Independence and particularly during the last fifteen years. At the time of Independence, the life expectancy of our people was less than thirty years. Between 1991-2006, the life expectancy of our people has gone up from 58 to 64.35 years, infant mortality has come down from 87 to 60 per 1000 live births and population growth rate has decreased from 19 to 14 per thousand. Still, IMR is very high. We have to bring infant mortality to less than 10 per thousand.
I would like to briefly talk to you on some of the diseases and actions proposed and future need. Our experiences will definitely be shared with the third world developing nations in order to provide healthcare for all.
Drug for faster cure of tuberculosis
The entire country has been brought under the Revised National Tuberculosis Control Programme (RNTCP). This will ensure that maximum number of Tuberculosis cases are detected every year and brought under direct surveillance. The medical community must ensure that at least 80% success in fully curing the disease is achieved within the year. If this regime is followed continuously for over ten years our tuberculosis load will come down to less than ten per one lakh of population. It is essential to work faster on the development and clearance of new drugs which are in the pipeline. Educational and research institutions should also participate in this mission.
Our country has also made significant contributions in developing drugs that are critically required for India. One of the achievements comes from a laboratory of the Council of Scientific and Industrial Research (CSIR). CSIR lab has developed a new therapeutic molecule for Tuberculosis. This molecule has shown the potential to cure TB in around 2 months, as against the standard treatment of 6 to 8 months. This breakthrough is very important. After completing the pre-clinical studies, the molecule transformed into a drug called Sudo-terb is undergoing clinical trials in humans. This development has been done as a public-private partnership involving the Lupin, the three CSIR Laboratories, namely, Central Drug Research Institute, Indian Institute of Chemical Technology and National Chemical Laboratory, and the University of Hyderabad. It is hoped that the drug will be in the market soon after the clinical trials. In addition to the above, there is also a need to develop a more effective vaccine against tuberculosis. The combined action of surveillance, detection and disciplined treatment have to work together to ensure faster cure of existing cases. Prevention of future cases has to be achieved through R & D efforts of developing new breed of vaccine and medicines. The collaborative action is needed between healthcare personnel, academicians, doctors, researchers and the pharmaceutical companies both in the private and public sector to accomplish this mission.
Incidence of Malaria has reduced from 22 lakh to 18 lakh in the period 1998-2006. However, the death cases has increased from 644 to 943. I understand that the conventional medicine used for treatment of Malaria namely Chloroquin has become resistant to Falciparum which causes cerebral Malaria. CEMAP (Centre for Medicinal and Aromatic Plants, Lucknow) in partnership with a Pharma company has developed and produced a drug named Arteether from Artemisinin which has been found to be an effective cure for cerebral Malaria. I understand that this drug is being exported to over forty countries. Also, Ranbaxy has acquired a malarial drug molecule and they are progressing towards clinical trials. This will also be available in the market soon. This will be another important milestone in the treatment of Malaria.
Over the years, I find that in spite of our efforts there is no rapid reduction in the occurrence of Malaria cases in the country. We have not succeeded in creating a vaccine so far for Malaria. However, Italian scientists have recently found a bacteria that lived symbiotically inside the pest. They claim that such bacteria could potentially be genetically altered later to attack the Malaria parasite when it reaches the Mosquitoes. The bacteria is called ?Asaia? which is found throughout the mosquito body. It is said that instead of spraying chemical and biological pesticides, we could use the symbiotic bacteria that is passed on and you do not have to spray every year. Now, I would like to present HIV /AIDS control.
Today in our country, all age groups put together have an incidence of 5.7 million HIV cases. 163 out of 611 districts in the country have a high proportion of HIV cases. The scientific community had a very important mission of determining the genetic nature of HIV that will lead to its cure. The genetic nature when studied had some surprises. The retro virus is RNA based and not DNA based. Most retro viruses have only three genes, whereas the HIV virus had nine genes, with 9200 base pairs. With this understanding of the genetic nature, a number of drugs have come in at least to control HIV in as it is where it is condition. This intervention extends the life of HIV affected persons. The typical drug which has been developed and produced abroad is AZT, based on DNA synthesis. It halts the spread of the disease. Another medicine found is INDINAVIR with equally good results. A foreign University has tried a combination of AZT-INDINAVIR and 3TC, for some patients, which gave unique results fully suppressing the HIV/AIDS virus. Of course research is continuing. I am sharing this with the young students, to convey that there is a possibility of controlling HIV and extending the life of patients. However, the cost of the medicine was so far prohibitive. Indian companies have already brought down the cost of first line treatment to an AIDS patient from nearly Rs 5 lakhs to Rs 12,000, per year. Similarly, the cost of second line treatment has also been brought down through the development of medicines such as Viraday a substitute for Atripla from Rs 5 lakhs to Rs 4,500/-, per month. Even this reduction does not make the drug affordable to the common man in our country. Medical community assembled here should make use of these medicines so that further cost effective methods can be evolved.
Development of Anti HIV Vaccine
Apart from the HIV control protocol, the most important mission for the country today has to be the prevention of the spread of HIV further. There is no other way other than developing and leading to production of an effective anti-HIV vaccine.
Phase one clinical trials of an imported Adeno-Associated Virus based HIV vaccine was initiated at the National AIDS Research Institute, Pune in early 2005. Thirty volunteers were enrolled in the study and given HIV vaccine. The follow-up study has been completed in January 2007. The vaccine has been tolerated well by volunteers and safety is good. Immunogenicity studies were carried out during the follow up. Results have been decoded and analyzed after follow up. Phase two trials with prime and booster vaccine is being planned. Another vaccine is undergoing phase-I trials at the Tuberculosis Research Centre for the Modified Vaccinia Ankara (MVA) based vaccine developed from the Indian HIV-1 sub type C virus genes. This vaccine has been developed by Indian Scientists in collaboration with a US company under the ICMR-NACO-IAVI programme. These two anti-HIV vaccines have to be completed with a time bound mission mode, as it is very important for India?s HIV control programme. It is also essential to take up a third fully indigenous anti-HIV programme as a collaborative work between educational institutions like PGI Rohtak, research laboratories and traditional medicine practitioners. The chances of any one of the three vaccines cleared for use may take sometime. Nationally, the anti HIV vaccine is a very vital requirement. We have to launch time-bound programme. Atleast one anti HIV vaccine has to come in before 2010.
Management of Cardiac Diseases
Multi-dimensional solutions are available for management of the diseases based on my discussion with experts. The solutions include medicinal treatment using Statins, which lowers the cholesterol in the blood by reducing the production of cholesterol by the liver. Statins block the enzyme in the liver responsible for making excess cholesterol. However one has to be careful about the side effects and take adequate precautions while treating the patients. The second is through angiography and angioplasty using stents. I understand that very soon we may have bio-degradable stents. The next generation stents may be nano-stents. If the heart blockage is severe, valve defect and death of cells in the heart due to less blood supply etc. surgical intervention will be necessary or it may lead to treatment using stem cells.
Non-invasive treatment for Coronary Artery Disease
Today, I find that cardio vascular treatment moving towards a totally non-invasive treatment using EXTERNAL COUNTER PULSATION (ECP), a truly non-operative, non-pharmaceutical, safe and effective treatment which is being used in many countries. In India also a few centres have come up. This is a ripe area for research of the faculty members and students of PGI Rohtak. Now, I would like to discuss promotion of three dimensional life style approach for health-care.
Promotion of 3-D Life Style Approach for Healthcare
The discovery of genes and the nature of chromosomes through the human genome project, as you all know, has led to the conclusion that each human being, has nearly about 30,000 genes. The most challenging programme is the proteomics programme, which calls for characterization of proteins from every gene. This will lead to Research and Development and production of genetically engineered drugs and can open a new field of pharmaco genomics and customized medicine. These advanced drugs and other medical interventions can definitely improve the quality of medicare available to patients considerably. However, experimental evidence shows the importance of a favourable lifestyle for realizing long term disease free life.
I would like to present the experience of one such life style intervention. I happened to visit a number of hospitals to see the healthcare delivery systems. During my visit to hospitals, I found that doctors tend to focus their attention on treatment of body ailments to reverse pathology to physiology. It was realized that the success rate of such treatment is only partial. A group of Indian scientists had an opportunity to experiment the concept of mind-body complex approach for therapy on breast cancer patients, when the psycho-neuro, immunological axis was demonstrated to significantly influence the prognosis of these patients. Another experimental evidence of this concept emerged from a study, we had initiated at the Defence Research and Development Organization (DRDO) in collaboration with Global Hospital Research Centre at Mount Abu in Rajasthan, on the regression of Coronary Artery Disease (CAD) through a 3 dimensional life style intervention. It included (a) low fat high fiber diet (b) regular aerobic exercise of walking and (c) meditation. The study clearly demonstrated that lifestyle intervention resulted in regression of Coronary Artery Disease (CAD) as evidenced by the disappearance of plaque in angiograms. Every individual has an inherent ability of spiritual potential which lies dormant. If we invoke this potential, we can definitely enhance the process of healing and improve the quality of life of patients.
Such a three dimensional approach to health care will be a significant evolution of health care philosophy and can be applicable for the treatment of diseases including HIV/AIDS, cancer, diabetes and many other chronic diseases. This life style approach is not only less costly but also provides a sustainable solution for improving the quality of life of individuals.
Human disorders can be classified into three broad categories. They are genetic disorders, disorders due to cellular function deficiency and disorders arising out of certain pathogens. I recommend intensive research for developing and producing cost effective treatment regime for the above categories of disorder through :
(a) Gene therapy and gene chip research
(b) Stem cell research and
(c) Combination vaccine and pathogen specific antibiotics
This could lead to cost effective and safe treatment for the needy and improve the quality of life of mankind on this planet. PGI Rohtak can be a partner in some of these research areas.
Recently, there was a meeting of cured heart patients, their doctors and a few social workers. One important point emerged during the interaction was that the relationship between the patient and doctor extends to patients? family. This in turn, transmits effective messages from one family to another family on advice to prevent diseases, necessity of periodic checks, the dietary habits and the need for life style changes including exercise for good health. Actually, I believe this good contact between the doctor and patients is very valuable. I request every doctor graduating from PGI Rohtak to play the role of a teacher in advising every family on disease prevention and methods to lead a healthy life in addition to his or her regular medical responsibilities.
Giving quality health care through continuous acquisition of knowledge, upgrading diagnosis and treatment, providing care and counselling particularly to the unreached should become the life time mission of each one of you graduating from PGI Rohtak. Thus, you will contribute effectively to the mission of developed India 2020. Above all, by giving your best to healthcare, you will in turn, lead a happy life because ?giving? is the 'happiness'.
My greetings to all the members of PGI Rohtak and my best wishes to the students and faculty members of this institute.
May God bless you.
Five Point Oath for Medical Professionals
1. We the medical professionals realize that we are in God?s mission.
2. We will always give part of our time for treating patients who cannot afford.
3. We will treat at least 20 rural patients in a year at minimum cost by going to rural areas.
4. We will encourage the development of quality indigenous equipments and consumables by making use of them and assisting in enhancing the quality and reliability of the products.
5. We will follow the motto "let my brain remove the pain of the suffering humanity and bring smiles".
Dr. A. P. J. Abdul Kalam