Letter from Mumbai

The Impending Corona Virus Epidemic

The first patients harbouring the corona virus (since named Corona Virus 2019 or Covid-19) were identified in Wuhan, China in December 2019. (It is of historical importance to note that Wuhan, capital of the Hubei province, dates back 3500 years and once served as the capital city of China. It has been reputed over centuries for its arts and intellectual scholarship.)

Since February 2020, we have patients in Kerala even as increasing numbers of patients have been identified in South Korea, Japan, Vietnam, the Philippines, the United Arab Emirates, Hong Kong, Taiwan, Malaysia and Thailand. Further afield, similar patients have been identified in Europe, the UK and the USA.

We are no strangers to epidemics. The ravages wrought in India by cholera, plague, influenza and other widespread diseases and lessons learnt from them have been adequately documented.

The pioneering work by such individuals as Waldemar Haffkine, Nasarwanji H. Choksy, Acacio G. Viegas, Nusserwanji Surveyor in Bombay (present day Mumbai) and others in Calcutta (present day Kolkata) and Madras (present day Chennai) during the plague epidemic at the turn of the 19th century coupled with records of the various stages of the epidemic by officers of the Indian Medical Service and other health officials have left us considerable information of the steps to be taken to minimize morbidity and death. We also have notes from other countries, notably the UK, dating back centuries.

It is to be hoped that we shall utilize the lessons learnt from the past in dealing with the current epidemic. Let me list some of them.

1. We need a single, authoritative agency to make and implement decisions, issue guidelines and public notifications. This must include clinicians, epidemiologists, immunologists, virologists, experts on vaccines and clinical pharmacologists from our eminent teaching institutes.

We have a pool of talent in our country in our reputed public sector medical colleges and hospitals. Institutes such as All India Institute of Medical Sciences, New Delhi; Postgraduate Institute of Medical Education and Research, Chandigarh; Christian Medical College and Hospital, Vellore, the National Institute of Immunology, the Indian Institute of Science, Bengaluru, the National Institute of Virology in Pune and the Department of Virology at the National Institute of Mental Health and Neurosciences, Bengaluru are of vital importance.

The resources of the Indian Council of Medical Research, Department of Biotechnology and allied agencies must be tapped.

It is crucial that members of this agency are chosen strictly on merit and this committee remain free from bureaucrats, administrators of our national institutes who do not belong to the fields noted above and politicians. It must be provided facilities to interact with the WHO; Centre for Disease Control, Atlanta, USA, leading medical centres and other similar agencies worldwide. This agency must speak with one voice and through a single spokesperson so that information is not polluted by confusion. It is important to record every proceeding of this agency and the basis for decisions made by it.

2. Since health is a subject to be dealt with by individual states, it is crucial that each state sets up expert agencies along the lines outlined in the paragraph above. Once again, it is important to keep proven merit as the only criterion for inclusion of members. Each state agency must liaise with those in other states and that in Delhi for optimal functioning. These state agencies must be empowered to act in their respective states.

3. Preventive, diagnostic and therapeutic regimens need to be developed. They will evolve with experience. Appropriate tests will have to be designed and made available at all public health centres, clinics, hospitals and laboratories. It will be important to change course, at times rapidly, when unforeseen events or development of novel methods of treatment make this necessary. We will have to impose restrictions on travel. Situations that may lead to spread of the disease, isolation of ill individuals and measures to keep relations, neighbours and friends of patients from contracting the disease will also need attention.

4. We must take care not to apply blindly rules and regulations laid down decades or centuries ago. Times have changed. We have better facilities, drugs and measures for controlling disease.

5. It is especially important to keep all sections of our people informed, preferably on a daily basis, of the extent of spread of disease, measures being taken to prevent further damage and steps that each individual must take to minimize the risk of infection. Explanations go a long way in avoiding major unrest as was seen in Poona (present day Pune) during the plague epidemic that led to the murder of ICS (Indian Civil Services) officer Charles Rand.

6. At present it appears that a vaccine to augment immunity and the ability to combat the corona virus may serve as an important method to prevent spread of the disease. Agencies with a proven record for producing such vaccines must be alerted immediately and put to work. The great vaccine producing centres of yesteryear such as the Haffkine Institute in Mumbai; Central Research Institute, Kasauli; Pasteur Institute, Coonoor have, unfortunately, been allowed to fade. They need to be revitalized and restored to their original glory.

7. As always in matters of health, we must concentrate on the care of the poor. They form the majority of our population.

While we hope that the epidemic will be nipped in the bud, it makes good sense to follow Lord Baden-Powell’s motto for the scouts: ‘Be prepared.'

As we gird our loins to combat the virus, I wonder how well our poorly funded health services will cope. Despite the many voices emphasizing the low budgetary allocations for health in Central and state budgets, decade after decade, there has been no corrective enhancement of funds. Our primary care health centres remain in an abysmal state.

National Award For Work in Fostering Medical Humanities

Dr Apoorva Pauranik retired as Professor of Neurology and Consultant Neurophysician from the Mahatma Gandhi Memorial Medical College (MGMMC) and the affiliated Maharaja Yeshwant Rao Holkar Hospital (MYH) in Indore, Madhya Pradesh.

Two years ago, Dr Pauranik decided to encourage the pursuit of the humanities by medical students and professionals. Towards this end, he has set up a national award to an Indian physician who is doing outstanding work in this field. At the same time, he has also established another prize to promote medical research in Indore.

Dr Ravi Ramakantan (who retired as the Professor and Head of the Department of Radiology at the Seth GS Medical College and KEM Hospital, Mumbai) is the chairperson of the selection committee for this award.

Dr Mario Vaz, Professor of Physiology, St John’s Medical College and Head, Health and Humanities, St John’s Research Institute, Bengaluru, received the first award for his work on 2 November 2019, at MGMMC and MYH, Indore. The second award will be made at the ‘International conference on health and humanities’ in Karnataka in September 2020.

Dr Pauranik deserves applause for the practical manner in which he lauds endeavours in our country and for inculcating the spirit of humanities into medical students and professionals. We hope this will encourage teachers and mentors in our institutes of learning to augment instruction in the science of medicine with that in its art as well.

Why Are Neuroradiologists So Possessive about Interventional Radiology?

We learn of a move by neuroradiologists in some Indian medical centres to ensure that interventional procedures be performed only by them.

Such procedures include occluding intracranial aneurysms, blocking arterial feeders to arteriovenous malformations and vascular tumours and opening up narrowed or nearly occluded intracranial arterial trunks using special catheters introduced through the femoral or brachial artery.

Those in favour of such restrictions point to the need for expertise in radiology. They overlook the fact that interventional neuroradiology was initiated in a department of neurosurgery in Mumbai. Its early development was spearheaded by Dr Anil Karapurkar, a neurosurgeon. In fact, this development was necessitated by the fact that radiologists in the institute were already heavily burdened by other work and had neither the time nor the opportunity for developing this subspecialty.

They also overlook the expertise developed in the diagnosis and treatment of coronary artery disease by cardiologists. An analysis of their work and publications will show the extent of their contributions.

While is it essential to ensure that all measures are in place to ensure safety to patient and others in the interventional radiology department, eliminating clinicians trained in such procedures and possessing demonstrated expertise will be short-sighted and counter-productive.

Ameliorating the Consequences of Surgical Complications

A sword hangs over all surgeons and members of their teams as they treat patients with serious illness and in precarious states. The very nature of their operations carries the probability of complications that result in morbidity and, at times, death.

During the training of every surgeon care is taken to inculcate the need for discussing pros and cons of surgery with every patient and family. Emphasis is placed on the benefits from such efforts in terms of better informed patients who are enabled to make decisions on surgery and other forms of treatment with confidence.

Gentle but detailed explanations of the gravity of the illness and inherent risks of worsening of the clinical state prepare the minds of patients and their families and help them weather the storm, should it follow. Conveying to the family immediately after the end of the procedure what transpired during the operation and untoward incidents, if any, keep them ‘in the loop’.

As they witness the care taken by their medical and nursing attendants during the immediate and subsequent postoperative care, and as they are kept informed of the clinical course of the patient, there is reassurance that everything that is possible is being done.

Should the patient emerge unscathed from the operation and travel on the path of recovery, everyone, including the surgical team, heaves a sigh of relief.

It is when the patient shows a turn for the worse that concern mounts exponentially in the family members. This is when they need special care, frequent and detailed explanations of what is going wrong and measures being taken to restore health.

Morale crumbles when, despite great care and maximal effort, the patient inches towards death.

The relationship established between the medical team and the patient’s family is now of paramount importance. A healthy rapport will go a long way in assuaging the grief of the family. There are instances of the near and dear ones of the deceased patient consoling the surgeon and the team. ‘You have done everything possible.'

There will be occasions when, despite all care, the family of the deceased patient decides that there has been a deficiency in medical care or, worse, a malpractice. Under such circumstances, especially when the family is already burdened with the agony of loss, some are driven to seek legal action against the surgeon, the surgical team and the institution in which the patient was treated.

Legal defence of the surgeon is strengthened by the maintenance of detailed and accurate medical records on paper (including the notes made by surgeon, anaesthetist and the assisting nurse and those made during the postoperative care). It will also be necessary for the surgeon to gather together papers published in recent issues of relevant medical journals and accounts in reputed reference books supporting the need for the operation, steps taken during surgery and the course of treatment after surgery. Expert testimony by reputed surgeons in the city and country supporting the surgeon on medical grounds also helps.

Dr Keki Turel has been organizing international conferences on complications in neurosurgery in Mumbai. He enunciated the philosophy behind them simply: ‘Most neurosurgical conferences…lay emphasis on technical nuances, and how complex cases were tackled by the surgeon’s knowledge, skill and innovative methods. Very few had shown the dark side of what was attempted. Success is not built on success. It is built on failures, it is built on frustrations, and sometimes it is built on catastrophe. With the view to learn from our failures, we organized the 1st International Conference on Complications in Neurosurgery in 2017.' He has been able to get luminaries in the field from all over the world and our country to discuss freely and frankly disasters faced by them and steps taken to prevent recurrence. The intent is to learn from each other for the eventual benefit of the patient. The second such conference was held in January 2019 and the third is scheduled in March 2021. To say that these meetings have been beneficial, especially to our younger neurosurgeons and those in training, is to put it mildly.