How India can provide healthcare for all
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7693 (Published 12 November 2012) Cite this as: BMJ 2012;345:e7693
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Dr Devi Shetty, the eminent heart surgeon who has been carrying out pioneering service, succinctly highlighted the ways in which India can provide health care for all.
Unknown to many, advanced, technology-driven medical practices are thriving in India leading to significant wasteful expenditure.
An example is thermography-based breast scanning devices for diagnosing cancer.
A systematic review done in New Zealand concluded that there is insufficient evidence showing that thermography provides benefit to patients as an adjunctive tool to mammography or to suspicious clinical findings in diagnosing breast cancer1.
"It is vital that we offer our patients correct information with supporting statistical, scientific, reproducible evidence so that they and their physicians can make informed decisions regarding their health.", Dr.Belinda Scott, Managing Director and Breast Surgeon, Breast Associates, Auckland wrote in an accompanying editorial in the same issue of the New Zealand Medical Journal.
The American Cancer Society (ACS) stated that no study has yet shown that thermography is an effective screening tool for finding breast cancer early. "It should not be used as a substitute for mammograms", ACS cautioned2
"There have been no randomized trials of thermography to evaluate the impact on breast cancer mortality or the ability to detect breast cancer. Small cohort studies do not suggest any additional benefit for the use of thermography as an adjunct modality for breast cancer screening," the US National Cancer Institute stated clearly3.
Thermography device has been in use in the Apollo Hospital Ahmedabad India since 2010. A query to the hospital on the usefulness of the tool did not elicit any response.
Scientific reviews have shown that as a screening tool, thermography gives too many false positives4. That means all those patients will have to undergo further tests such as mammography. Currently, the device is a good example of technology driven medical practice.
In spite of well known deficiencies, a few private hospitals in India have already purchased No Touch Breast Scan imaging system, which is a thermography-based device.
"To make it comfortable for women to undergo check-up of breasts for detection of cancer, the Brihanmumbai Municipal Corporation (BMC) plans to buy 'no-touch' scan machines.", The Times of India reported on November 8, 2012.
The health committee chairman of BMC announced the civic body's plans to buy the machines so that women "do not have to experience awkwardness while going through physical examination of breasts or pain while scanning through a mammography machine." the paper added.
"The ‘no touch’ breast scan machine, developed in the USA by UE LifeSciences and installed at private facilities in Thane, Pune and Ahmedabad, is likely to cost the BMC up to Rs75-80 lakh. It gives the report in 20 minutes along with details such as the size, nature and location of the cyst." The Daily News and Analysis (DNA), another Mumbai daily, reported on November 8, 2012.
It appears that there was no critical evaluation of the equipment and its known limitations. Those involved got carried away by the advantages of the technique as advertised by the vendor.
They may not know that probably only a handful of these units have been sold in USA itself 5, 6
There is a need for critical appraisal of such expensive tools before they are purchased. Such reviews must include the experience in using the device internationally. India has the expertise in relevant fields to make the technical assessment.
It is inappropriate and unethical to spend scarce resources on fancy equipment where its benefit to users has not yet been proved.
Competing interests: None declared
Dr KS Parthasarathy, Former Secretary, Atomic Energy Regulatory Board, India
AERB, 302, Mangal Prabha, Sector 9, Nerul 400706, Navi Mumbai, Maharashtra, INDIA
REFERENCES
1. Amita Fitzgerald and Jessica Berentson-Shaw Thermography as a screening and diagnostic tool: a systematic review The New Zealand Medical Journal, 09 March, 2012 VOL 125, No 1351
2. American Cancer Society Mammograms and other breast imaging procedures
http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestd... (Accessed on November 19, 2012)
3. National Cancer Institute Thermography
http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofession...
(Accessed on November 19, 2012)
4. Guilfoyle CM, Collett AE, Christoudias MK, Barrio AV, Frazier TG Does Infrared Thermography Predict the Presence of Malignancy in Patients with Suspicious Radiologic Breast Abnormalities?
https://www.breastsurgeons.org/presskit/docs/ASBrS_press_conference_2012...
(Accessed on November 19, 2012)
5. Cipla introduces new pain free screening technology for early detection of breast
cancer in India - ‘No Touch Breast Scan’
Press release dated March 2, 20111 from Cipla (Accessed on November 19, 2012)
http://www.cipla.com/CiplaSite/Media/PDF/Press-Releases/Cipla-introduces...
6. How a philly company fought the fda to get its breast cancer screening device cleared
http://www.flyingkitemedia.com/features/notouchbreastscan0313.aspx
(Accessed on November 19, 2012)
Competing interests: No competing interests
Dr. Shetty has given a solution but will it work in the current scenario in India if implemented? Doubtful?
Every year nearly 40 million (1) people in this country plunge into poverty because of health care expenditure. So we can make the people insured, that will be like secondary prevention. But, to really take care of the matter of concern we have to make the following changes:
a) We have to make the people aware about the primary health care. Millions of people are dying due to lack of awareness about the primary health care. Non profitable organisation like "Health Care Information For All by 2015" working worldwide in the aspect.
b) We have to improve our primary health care system.
c) We have to improve our basic needs like sanitation & hygiene, education etc.
d) Population control is of great importance
References:
1)BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7554 (Published 8 November 2012)
Competing interests: No competing interests
Dr Dev Shetty has written vey poignantly on the need for universal health care (UHC). Whilst Dr Shetty is a cardiac surgeon doing complex heart surgeries and a gentlman to provide some feasible solution for UHC, the ground realities are rather different. A fair majority of our population suffer ill health due to high deprivation index (poor social determinants of health). Unless we make more efforts to improve sanitation and hygiene (more public health), housing and employment, education and health capability (awareness), any investment in UHC can mean only one thing: simply a cosmetic improvement with people caught up in a vicious cycle of povery and ill health. It's time we take pride by bringing more social equity.
Competing interests: No competing interests
The ever-growing Indian Population defies every effort for development. The burgeoning Indian Population oversteps the resources, facilities and services of all kinds.
Competing interests: No competing interests
The choice of articles by BMJ Editors are so timely and apt it forces a Professor like me to respond to an article which delineates the plight of many patients who have to make a choice between physical death and economic doom. I will cite a case.
A merchant had six children, one of whom developed kidney failure. Renal transplantation was this child's only hope, but the father could not afford to pay for it unless he sold his house. But by selling his house he and his family would have no home or livelihood. The father thus has a moral dilemma of saving his child's life or bringing economic disaster to the whole family. The father decides to save the family and the child dies. He lives with the guilt with the slight comfort that he was able to look after the rest of the family.
This is the true picture of many families who have to make a choice between life and death when struck by illnesses. Who is to fund these citizens? Yes there are few institutions who offer services to the poor patients like the late Sathya Saibaba's Institution at Puttapurthi, in Karnataka state or many Christian Mission Hospitals who offer their services at affordable charges.
Life and living are meaningful if human dignity is respected. No human being must be allowed to die because the patient cannot afford it defies the basic tenets of democracy - food, shelter and clothing.
Competing interests: No competing interests
Re: How India can provide healthcare for all
It is true that most of the ailments (more than 90%) which are commonly occurring can be treated and can be cured at primary levels itself. But our patients prefer to have consultation with specialists or super specialist even for a simple ailment. As the specialist or super specialist cannot afford to over look any possible causes of the ailments for the proper diagnosis, the patient will be asked to do the entire realm of diagnostic tests and procedures for the proper confirmation of the disease. This will increase the cost of treatments and this is the main factor which prevents common people in receiving affordable treatments.
If a first level of screening is done at primary level for all the ailments and if the patients are referred only if necessary to a right specialty center or to a specialist from the primary levels, the treatment costs can be reduced and patients will be relieved from wandering around for the right specialized treatments in time.
So my suggestion is to introduce compulsory referral system in private health care sector in India as in the case of Govt health care sector. If referral system in private health care sector is enforced with no loop holes, the Govt funded health insurance schemes will be surely viable and will be successful at the current level itself.
Competing interests: No competing interests