Letter from Chennai

DON’T MISS THE FINE PRINT

At the height of the Covid-19 pandemic, our hospital services were overwhelmed and the existing staff was unable to cope. The Tamil Nadu government recruited 3400 nurses on an ad hoc basis in May 2020, for a period of 6 months. The order clearly said ‘the appointment of nurses shall be purely temporary for the management of Covid-19 cases and shall be terminated on completion of the said period’. These nurses had completed the qualifying examination and had been selected and placed on a reserve list. They continued to work beyond the 6-month period, and on 31 March 2022, the services of 928 were summarily terminated while the others continued to work.

With the number of new patients dwindling to fewer than 10 a day in the entire state, there was obviously no need to maintain the larger number of nurses, and the government decided to terminate the services of the remaining 2472 on 31 December 2022. They are now agitating to continue in employment at least on a contract basis. A number of politicians also weighed in with demands that the nurses be retained. I believe the terms of appointment were very clear, and the nurses had no grounds for complaint. However, perhaps in response to the increasing agitation, the health minister announced on 10 January 2023 that the government was recruiting 3949 nurses for district health societies and these nurses could be taken in those vacancies.

The Bible advises charitable donors, ‘Let not thy left hand know what thy right hand doeth’. Surely the authorities were aware that they were going to recruit so many nurses anyway, and could have appointed these nurses in those vacancies, or advised them to apply for those posts, without causing them so much anxiety.

I had not heard of a district health society earlier, so I had to look it up on the website of the National Health Mission. Each district now has a district health society which will consist of the chairperson of the zilla parishad, the district collector and the chief medical officer. It is supposed to coordinate the functions of these officials in the planning, implementation and monitoring of all the state and Central health schemes. The termination of the services of so many nurses and the need for an agitation to remind the administration that they were needed anyway does not inspire confidence in the coordination of functions of different sections of the state health services.

WORLD KIDNEY DAY

In 2006, the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations–World Kidney Alliance (IFKF-WKA) got together and decided to encourage all national associations of nephrologists to devote one day every year to educate the public about the importance of the kidneys for our normal life, the ways in which they could be damaged, and what we should do to keep them healthy. I do not remember whether any particular day in March was selected for this activity, but it is usually in the second week of that month. The theme is decided by the powers that be, and we nephrologists are informed through the ISN and our local associations several months in advance, and requested to organize programmes to spread the message. The theme for 2023 was ‘Kidney health for all—preparing for the unexpected, supporting the vulnerable’.

I am sceptical about the value of such ‘days’. The kidneys were late arrivals on the scene. Many other days, such as World Diabetes Day and World Tuberculosis Day existed several years earlier. I believe a great deal of effort and money goes into these functions, and many people have some fun, and then everyone forgets about it till the next Day comes around. What we need are sustained programmes, and I believe I have done my part with the 30-year work of the Kidney Help Trust, about which I have often told you in these pages. I am firmly convinced that we as a nation will not be able to afford the treatment of end-stage renal disease in the lifetime of any of my readers, and the only solution to the problem is to prevent renal failure. I am always ready to spread this message to anyone who will listen to me.

This year I was invited to speak at two functions on World Kidney Day. I spoke on my prevention programme at both the functions. However, I wonder whether these meetings did anything to promote the prescribed theme. One was held at a large private hospital. The audience was almost entirely drawn from the patients of its renal unit and their families. We were obviously too late to help them to prepare for the unexpected loss of renal function. There was a lavish dinner provided by the hospital, obviously not the prescribed diet for the patients, but definitely their relations and the speakers relished the fare. Perhaps the hospital management paid for the food. They could certainly afford it.

The other meeting was at a government medical college, and the audience was mainly the staff and students of the nephrology department, a few nephrologists from other hospitals of the city, and some postgraduate students. What they had was a regular teaching session on nephrology, of which I am sure there is no shortage from their teachers in the college. There is never enough time for discussion after the talks. Many speakers exceed their time, chairpersons are rarely strict about this and lunch often provides an opportunity for the attendees to question the speakers and clarify their doubts. Ideally, we should have a light repast. A full stomach does not encourage cerebral activity. I found a spread which rivalled that at the private hospital. Not only that. Each of us got a badge proclaiming ‘World Kidney Day’ (actually translated in Tamil: Ulaga Siruniraga Dinam) ‘9 March 2023’ in English. We also received a plastic cut-out in the shape of a kidney, mounted on a wooden stand. I was told later that all this largesse was provided by the pharmaceutical industry.

As I have stated in these Letters on more than one occasion earlier, I do not accept invitations to meetings sponsored by drug companies. I was unaware of the provenance of this repast, walked into the dining area while discussing something I mentioned in my talk, and began eating before I felt that the meal was perhaps too rich for a medical college, and asked who was paying for all this. In his writings on this subject, Jerome P. Kassirer, famous nephrologist, speaker, writer, editor and ethicist from Boston, expressed his aversion to industry sponsorship of food and drink, and said that if he was in a similar situation and found that he was being entertained by the industry he would put down his glass and plate and leave immediately. Normally, he would enquire in advance before accepting an invitation.

I must confess that, while I feel his approach is the right one, I cannot bring myself to walk out in the middle of a meal. I feel it might be insulting to the hosts. I should have enquired in advance and declined the invitation to lunch.

What purpose would the badge fulfil? I presume the audience would know they had assembled to celebrate World Kidney Day. Perhaps it would arouse the curiosity of anyone who saw it to ask what the Day commemorates, and thereby serve the purpose of marking the day. It would have no function from the next day onwards. I must say, though, that the badge was well designed. Most such badges are attached to one’s clothes by a very blunt pin which damages the shirt or coat through which it is passed. This one had a strong magnet, no pins. The badge was placed on the shirt or coat front, and the magnet slipped under the clothes to hold it in place. No pins, no punctures, no torn clothes.

My apologies for the digression. To return to the main theme of my Letter, these two functions, and any other such which might have been organized, serve no purpose. Our target audience should be the general public. Another Kidney Day function, which I could not attend, had a famous film star, who unfortunately developed renal disease, to speak about his illness. The large crowd would have come to see and hear him, now recovered after a renal transplant, and perhaps would have learned something about his illness and how they could avoid a similar fate.

Who would attend such a meeting? Generally, people who have renal disease or have a relative or friend who has renal disease. Someone who thinks he is healthy would not waste his time attending a boring lecture about the kidneys. The film star would certainly draw thousands, but that would have to be organized on a large open ground with police arrangements to control the crowds. On this occasion admission was by invitation only.

I believe it would be better to insert a notice in some newspapers and promise a free check of the blood pressure and a urine examination for protein and sugar. A booth could be set up at a street corner or any convenient location. Each of the city’s medical colleges could perhaps have such a place within its campus, just inside the gate so that people did not have to waste time to find out where it is. Hospitals could have a table in the lobby with a prominent notice of a free test. People who attend could be given a pamphlet with some information about renal diseases and simple measures to prevent them. Medical students and house physicians could volunteer to educate any who wanted more information. It need not just be a single annual World Kidney Day. Every day could be devoted to pick up evidence suggestive of renal disease in anyone who would like to have it checked. This is by no means as good as having a community survey and testing everyone, but at least any visitor to a hospital who sees a free kidney test announced in a corner of the lobby and feels like testing herself or himself could have it done. We would do more good to the world than one lecture on one day in the year.

THE RETIRED LIFE IS NOT EASY

I wrote in one of my earlier Letters of my decision to retire from the profession. I have retired and I mean really retired. There are always people who write to me or speak to me on the telephone to say that they have consulted so and so and would just need 5 minutes to show me their reports. There are the old patients who remind me that they have been seeing me for the last 10 or 20 or 30 years and would like to see me just once more. I have been very firm. Not one word of advice to anyone. There are many more competent nephrologists all over the country and they could consult them. If they do not know whom to go to, I remind them that my former colleagues continue to run my old unit. All of them are younger, brighter, better informed, and willing to look after them.

There has to be some exception, and I have one too. I still write and speak. Not about diseases and treatment. I do not read the literature, I do not treat patients, and therefore I am not competent to write or speak about disease. However, I continue to hold strong opinions about ethics, teaching and prevention, and I am happy to speak or write on these topics. Apart from these Letters, I have been invited to write in a few other journals, and I am happy to do so. Usually this causes no special difficulties, but a recent request for an editorial proved an exception.

I was asked to state my designation and my hospital attachment. My manuscript stated, truthfully, that my designation is ‘Retired nephrologist’, and therefore I have no hospital attachment. I was told sternly that I would have to mention the institution to which I am attached. I replied that I was not attached to any institution. This elicited a stern letter that if I did not mention my designation and attachment within 5 days my editorial would not be published.

Having taken some time and used my few remaining grey cells to write the editorial, I would like to see it in print, but I cannot make a false claim of an attachment to an institution. I racked my brains and came up with a possible solution. I am attached to one of the clubs in Chennai, and my designation there is ‘Senior Member’. Maybe my editorial can be printed after all.