Blissful Life

Category: mbbshacker.blogspot.com

  • Science is Broken Because Scientists Can’t Think Rationally

    Scihub is being sued in Indian courts by the journal industry. There are some people worried about it. But it is funny how our knowledge system works. Take this tweet for example:

    Scientific publishing sure is rigged & broken. But hoping that the very bandicoots that are getting fat from the status quo will take hints and improve the system is beyond naive. The telling lack of collective resistance from scientists too enables this perverse model to thrive. https://t.co/ye9SuxlYQM

    — M D Madhusudan (@mdmadhusudan) December 24, 2020

    The reason why journals charge exorbitantly and still get away with it is because almost all academicians publish only in those journals. And why do academicians publish in those journals? Here comes the greatest hypocrisy/logical fallacy of academicians.

    They think that publishing in “prestigious” journals bring “prestige”. They even have a way of measuring prestige without making it sound like it’s an emotional thing – impact factor. It is all part of the same logical fallacy – argument from authority. A cognitive bias that makes humans think that “authority” is right.

    The only purpose of journals in the internet age is to exude authority.

    The same purpose of universities.

    If scientists step down from their pedestals and start looking at the world without bringing in their cognitive biases (like every scientist should be doing), there can be a world where knowledge is produced and consumed with lesser hurdles.

    There definitely is a side to this where the omnipresent, omnipotent “system” is oppressing academicians and forcing them to continue with this prestige based publication. After all, scientists are humans who would rather give in to the way the world works than stand up against anything.

  • Lumbar Puncture and HIV

    Lumbar puncture is a fascinating procedure. It is cheap, it can be done in relatively remote places, and it can be learnt easily given access to enough people who need it.

    LP has an incredible role in the management of many complications related to HIV. I’ve heard stories about how there used to be 5 LPs done every day in VMH during the time when HIV was causing rampant destruction in Karnataka and India. When I was there, we would do about 5 in two weeks. Nevertheless, when a colleague asked on Twitter about CSF analysis, I thought I should write down some of the things I believe to know about Lumbar Puncture itself, especially in relation to its use in management of complications of HIV.

    The first many LPs I saw were all done for spinal anesthesia in KR Hospital. Till then all I knew about spinal anaesthesia was a friend’s description of the back ache he had post a “cool” hernia surgery because they had “poked many times for anaesthesia”. I think I hadn’t really thought about it till I was doing my anaesthesia rotation during internship. The first LP I did was also done during the same time – the “pop” and being in the space that you can learn only by doing. (If anyone thinks that all knowledge is codifiable like I do, here is what it feels like. Imagine there is a thick plastic layer laid around a piece of rusk. Imagine your needle piercing through the rusk and then splitting open the plastic layer. Now you are in the space.)

    The first time I saw an LP done for diagnostic reasons was in the medical emergency ward of KR Hospital where a young patient with some sort of neurological condition was being pinned down to the bed by 4 people and the postgraduate resident was dancing with the needle along with the squirming patient. Despite the grotesqueness of the picture, I found it incredible that 20-40 drops of a particular fluid can be so valuable in diagnosis.

    I learned the reasons when I was in VMH. There were many “spot” diagnoses we made using LP:

    1) Perceived high opening pressure in an HIV infected patient with neurologic symptoms – we send for cryptococcal antigen and it is almost certainly positive. (Always use Cryptococcal antigen test. Indian ink looks fancy under the microscope when it is positive, but is not as sensitive)

    2) High lymphocytes and proteins – you can keep your various tuberculosis diagnoses active. But even otherwise, you can’t rule out TB ever.

    3) RBCs and you can suspect sub-arachno… Just admit that you did a traumatic tap.

    But LP was mainly used for ruling out the infections. It is very simple to miss CNS infections in HIV infected patients. For example they will come with vomiting and you will examine their mouth and see oral (and possibly oesophageal) candidiasis written all over it. But rather unknown to you, they might also be having cryptococcal meningitis.

    It might be difficult to treat cryptococcal meningitis because Flucytosine is not something you find easily in India and therefore you are stuck with Fluconazole and Amphotericin B and good luck to you if you plan to give the latter in peripheral venous lines. (I’m not sure if the liposomal variety of Amphotericin B doesn’t cause as much phlebitis). But cryptococcal meningitis is a diagnosis you do not have to miss, if you are doing LP.

    It is a messy thing, but it is a life saving diagnosis. I’ve seen one patient die during the treatment, even though we were doing regular therapeutic lumbar punctures to reduce the intracranial pressure. But I’ve seen almost everyone else survive (including the case where I had to take PEP). I’ve also heard a very inspiring story from Dr Ramakrishna Prasad about a patient whom everyone else had given up on, coming back to life after switching over to the liposomal variety.

    A (thankfully) much rarer thing is HIV CSF escape syndrome. Hearing about this for the first time is when I realized which peak of the Dunning-Kruger effect I was on. You see, the blood brain barrier is a real thing. And not all of the HIV drugs cross this barrier the same way (paradoxic?). And therefore there are patients who can have no virus in their plasma, but if you do a CSF viral load test you will have a real surprise waiting.

    A not so uncommon thing which can be diagnosed through CSF is neurosyphilis. I always have to read the guidelines three times about when to use a VDRL test and how much to rely on it, but this is a test that we used to do as a protocol while doing an LP in HIV infected.

    Things like gadolinium enhanced MRI are becoming more useful than CSF analysis in diagnosis of things like tubercular meningitis. But from what Dr Rahul Abraham once told a group of us about his experience with MSF in Bihar, lumbar puncture will remain with us till the end of the HIV pandemic.

  • Public Lives of Doctors?

    Social media has made our private life public. Facebook, Instagram, even WhatsApp (through stories) thrive on users generating engaging content. Often this content is snaps from daily life. A picture is worth a thousand words, yet can be generated in a second. Image centered social media platforms rely on this to keep themselves going.

    What about doctors (and other professionals) on social media? Is it any different for them? Should it be any different?

    This post has been triggered by the #MedBikini hashtag. Here’s one tweet that reveals what happened:

    This journal article considers social media posts where MDs hold alcohol, wear inappropriate attire, and give opinion on controversial social topics as “potentially unprofessional.” How would any of these adversely affect the care we give to patients? 😳 #MedBikini pic.twitter.com/G1iBuqtX8n

    — Ronnie Baticulon (@ronibats) July 24, 2020

    I will not spend a lot of time discussing this particular paper or the twitter response to it. But I will discuss sections from two of the references in this paper.

    A council set up by American Medical Association to address the subject of Professionalism in the Use of Social Media, included this paragraph in their report:

    Though there are some clear-cut lapses in professionalism that can and have been made online by physicians (such as violations of patient privacy or confidentiality, or photos of illegal drug use), there are many more situations that fall into a grey area.  Examples include photographs posted online of an inebriated physician, or sexually suggestive material, or the use of offensive language in a blog.  Any of these actions or behaviors would be considered inappropriate in the hospital, clinic, office, or other setting in which a physician is interacting with patients or other health care professionals in a professional manner.  However, whether physicians must maintain the same standards of conduct in how they present themselves outside the work environment is a more open question.  Physicians certainly have the right to have private lives and relationships in which they can express themselves freely, but they must also be mindful that their patients and the public see them first and foremost as professionals rather than private individuals and view physician conduct through the lens of their expectations about how an esteemed member of the community should behave.  Thus physicians must weigh the potential harms that may arise from presenting anything other than a professional presence on the Internet against the benefits of social interactions online.

    It is this particular paragraph that have been used when creating criteria for “potentially unprofessional” things in papers that followed. One of them has a section like this:

    Within the clearly unprofessional group, binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act violations were the most commonly found variables. Examples of binge drinking included pictures of residents lining up 5 pints of beer in front of 1 dinner plate, doing “keg stands,”and making comments about being drunk or hungover. Examples of sexually suggestive photos included simulated oral sex, female residents in bikinis with hands pointing to their breasts, and a female resident simulating intercourse with a large cannon. Profanity was also encountered, as was a link to a racist cartoon.

    Within the “potentially unprofessional” group, pictures of residents with alcoholic drinks in their hands were the most frequently encountered. There were also several polarizing political and religious comments made by residents, and 2 instances of residents holding a gun while hunting


    We get a better picture (pun intended) here of what these papers are trying to hint. With that in the background let me talk about a couple of things from my professional life that I’ve thought quite a bit about.

    Alcohol

    Alcohol is a controversial topic among doctors (because many doctors consume alcohol). I do not consume alcohol. I actively dissuade people from consuming alcohol. You could call me anti-alcohol. I have certainly been influenced by Dr Dharav Shah’s campaign against alcohol and his argument for why we should create a negative attitude towards alcohol (the way we have towards smoking) is convincing. And I consider it hypocritical for doctors to be consuming alcohol.

    There are plenty of doctors who disagree. Some of them are of the opinion that social drinking is not a problem at all. They want to draw a line between alcoholism and social drinking and want to allow social drinking without it progressing to alcohol dependence.

    There are some doctors who agree that alcohol is indeed dangerous, but do not agree with the idea that it is hypocritical for doctors to be consuming alcohol while asking their patients to abstain. This is a very important argument.

    One part of the argument is that what doctors, as professionals, give out as advice in a professional setting is not applicable to doctors themselves. That I can talk to my patient about the importance of not eating rice excessively while still eating two full biriyanis a day. That professionals need not hold themselves to the standard that they’re prescribing for their clients.

    The other part of the argument is that what doctors do in their private lives should not be dictated by their profession. Superficially it makes sense. But does it stand scrutiny?

    Firstly, does private life stay private? As we noted in the case of social media above, the notion of a private life that is wholly disconnected from public life is Utopian. What happens when something a doctor does in their private life becomes public?

    Secondly, would you apply that logic when what the doctor does in their private life is something that you find morally reprehensible? Say the doctor in their private life engages in adultery, directing pornography, or working for BJP’s IT cell (not that I find all of these morally reprehensible). Would you be comfortable saying “it is their private life?”

    This leads to the other thing that I am constantly thinking about.

    The impression that a doctor “should” make

    How should a doctor appear in front of their patients?

    The trouble starts from the first day of medical school. There is a certain way you’re expected to be dressing. There is a “smart” appearance dictated by the higher-ups in the hierarchy which usually included (for me) shaved face, short hair well combed, clean new aprons, polished shoes, and so on.

    It goes deeper. In “Be the Doctor Each Patient Needs“, Hans Duvefelt tells this:

    “Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance.”


    The point Dr Duvefelt makes is about the therapeutic effect of a doctor-patient relationship. As a doctor, you need your patient to believe in you and in turn your advice. I talked about how this complicates everything about the doctor-patient relationship in my post about consultation fees.

    The gist of the matter is that doctors might have to do things (like shaving their naturally growing beard) to appeal to the completely irrational gut-sense of their patients. Weird argument, right? I don’t like it either.

    I don’t like it that I have to feign confidence in what I’m saying even when the field of medicine is not 100% sure about anything. I don’t like it that the biases that patients make up based on the impression I leave influence their adherence to the treatment regimen I prescribe. But these are how humans think and act.

    This is exactly why people dress well for an interview. Why politicians are careful about how they’re being photographed. Why celebrities have a link with fashion. And why people put their degrees on their Twitter and LinkedIn handle.

    I hate this world.

    Unprofessional

    Last day a patient messaged me. On SMS and on Telegram. My telegram bio includes pictures of me from a long time back and also a link to my telegram channel where I post links to my own blog posts. For some reason I responded to the patient on SMS although it was easier to talk on Telegram. I am not sure what to think about it. But at that moment I was not feeling comfortable with using Telegram to talk to a patient. The reason is that I blog mostly about technology. And multiple times in the past have people assumed I know very little medicine when they find out how much I know about technology. I don’t want my patients to read my blogs.

    That brings us back to professionalism. Professionalism is defined by society’s sense of morality. And that is where bikini pictures appear potentially unprofessional and sexually suggestive images appear clearly unprofessional to some. The #MedBikini hashtag is either about stating that private lives of doctors should not matter to patients or about the idea that bikinis are not immoral, or both.

    I think the entire post has been devoted to the point about whether we should worry about what patients think about us or not.

    The morality of underwear pictures is something that deserves a detailed debate. I end with the following question. Are sexually suggestive images unprofessional? Why?

  • What to Make of Itolizumab?

    It is the worst of times. Science is suffering an identity crisis. The world is in dire need of science. Science isn’t used to being rushed. “It is a giant and slow churn”, said a friend once, “and spews a breakthrough once in a while”. Is it possible to make the process faster? That’s what everyone is wondering. And praying. And waiting, eagerly. Science isn’t used to getting this attention.
    “Coronil is 100% effective”, said Patanjali folks. “Favipiravir is 88% effective”, said Glenmark folks. How to know the truth? Seeking truth has never been easy. Never has it been easy for journalists, scientists, or the common person. In some sciences there are multiple truths. Is medicine one of those sciences? Can there be a single truth in medicine?
    I won’t use words like epistemology and ontology in this post. (Because I still can’t remember which is which). But the question is essentially two:
    1. Is there a single truth?
    2. Is there a way to know the truth?
    I believe medicine is a dangerous subject because of these two questions. Biology is extremely contextual. A drug’s effect on a person with any particular infection can be influenced by a thousand factors including – that person’s biology, the day, where that person is, what that person is eating, what other medicines that person is taking, the virus that infected them, all the infections they’ve had in past, other diseases they currently have, the health of their body organs, and so on.
    When there are so many things that keep changing, how do we know whether a drug is going to be useful for a person or not? Most of medicine today is an approximation. Many drugs are used because when given to n random people it worked better than it not being given. A gross measurement, if you allow me to call it. Put something in a balance and see which side is hanging lower.
    Not that medicine is all guess work. He he. There are some theories. There are some “well-known” pathways. There are some molecules which we understand. There are some we don’t. There are some drugs we know act on some molecules in some of these pathways. Sometimes we don’t understand some parts of how a drug acts, but we fill in those gaps with the “random” trials as described above.
    For example, let us take Paracetamol which is a drug commonly prescribed for fever. And the only drug that many people need during COVID (and Dengue, and many other viral fevers). We don’t know how exactly it works. But we have a rough idea on the pathways that it affects. We also have very rich clinical experience in using the drug successfully for fever.
    The reason why we don’t rely a lot on theory in medicine is that we don’t have a lot of theoretical understanding about the biology of our body. We do know a lot. But there are still so many known unknowns. And who knows how much unknown unknowns.
    We know a bit about molecules called “interleukins”. We seem to know about a molecule we call Interleukin 6. It seems to have a role in acute immune responses. It may very well make sense to somehow block IL-6 to decrease the damage that could be caused by what is called a cytokine storm (which, as it sounds, is a storm that wrecks havoc inside the body) in sick COVID patients.
    We seem to know about a class of drugs called monoclonal antibodies. These are molecules (which can be natural or artificial) that target specific kind of molecules. There are some mAbs which seem to be able to target a type of cell called CD6 cells, including Itolizumab.
    Now, here is the deal. If Itolizumab can act on CD6 and decrease IL-6 and if IL-6 has a role to play in cytokine storm in COVID, then the inference could be drawn that Itolizumab can help sick COVID patients not die. That’s the theory.
    But the problem with medicine is that theory doesn’t always work. And sometimes what presents as reasonable with our current understanding of the body sometimes becomes dangerous when we actually try it.
    As for Itolizumab, Biocon seems to have given it to 20 patients with COVID and moderate to severe respiratory difficulty. And they all seem to have survived. Of the 10 they didn’t give it to, three people apparently died. I’m sure they’re doing this study on more people at the moment.
    According to them this is “statistically significant”. I don’t have a very deep understanding of statistics. Here, let me do the math.
    The way I read it is that based on that data we can be 95% sure that if someone with moderate to severe COVID-19 ARDS takes the drug their chance odds of survival is somewhere between 0.8802 fold to 415.9060 fold the chance odds of their survival without taking the drug.
    Didn’t I tell you this is the worst of times?
    Update: Don’t look at my math. That was not the point of this post. Also, my math sucks. Here is why:
    At a sample size of 30, the power of this study is like 30% which means it is completely unreliable. I think. I don’t know.
    Update 2: As per this article, and as per my understanding of beta, if p-value is already acceptable, then it doesn’t matter whether beta is high as all that power makes sure is that we don’t miss the effect when there is an effect.
    But then, am I confusing myself because in this study the effect of the drug is protective? I am 70% sure that the power of this study is not to be worried about.
    Update 3: Maybe the contradiction is resolved if we consider this as a type S error.

  • Moral Determinants of Health? How is it Different from Social Determinants of Health?

    There is a viewpoint in JAMA published under the title: “The Moral Determinants of Health” a couple of weeks ago.
    I went through it and don’t claim to understand it fully. But because there is a draft I’m working on about health as a fundamental human right, I think I understand what the author was meaning to say.
    Social Determinants of Health (SDH) are things like gender, race, caste, occupation, etc which directly influence someone’s health. According to WHO:
    The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
    Where is the space for moral determinants when the definition of SDH includes a catch-all phrase “wider set of forces and systems shaping the conditions of daily life”?
    I think the space is at a meta level.
    Take race. Race, and racism are social determinants. But whether a society accepts racism and whether they want to change are moral determinants.
    What is a society’s moral stance towards the inequities within it? That is what moral determinants are.
    For example, when it comes to COVID-19 and lockdown/quarantine, the social determinants are things like job security, government policy on lockdown, migrant status, etc. The moral determinant is the collective moral maturity to take into account such SDHs when doing things. Whether the government feels the need to consider daily wage workers when declaring lockdown. Whether people feel the need to pay their maids even when they can’t come for work. Whether people consider it okay to isolate and discriminate against people infected with COVID. These are moral determinants.
    That’s why the author of the article mentions “right to health” multiple times. Right to health can be mistaken for a social determinant. It is a governance policy. A law. Something that can be included in the Constitution.
    But no. Right to health is not really a social determinant. Having the right to health holds no meaning. Right to health is a moral determinant. It is only when people understand “right to health” through the moral compass within and appreciate the meaning of what it means when someone has a right to health, that right to health becomes meaningful. That is when people will become ready to make the sacrifices required to ensure health for all. Sacrifices like giving up the luxuries of capitalism, paying higher taxes, waiting for one’s turn, and so on.
    The reason why my post on health as a fundamental right is still pending is the same. I couldn’t find a compelling reason to convey the moral argument behind right to health. It is dependent fully on whether people want to care for others or not. This is a fundamental moral argument. Should all people be equal? The proportion of people who justify inequalities in the society (either through economics, history, politics, or whatever) is the measure of how bad moral determinants of health are in that society.

  • Double Standards – Patanjali vs Glenmark; What is the Point of Ayurveda?

    A couple of days back Glenmark made a press release about Favipiravir which made it sound like they have a “game-changer” and “magic bullet” (according to various media houses). This was based on little evidence about its benefit. There is virtually nothing in public domain that shows that Favipiravir is useful in COVID. CDSCO explicitly approved Glenmark to do this.
    But today Patanjali is receiving flak and even has been officially asked by government not to advertise a drug they name “Coronil” which has very similar “research” to back it up. In fact, a quick look at the (?) methodology puts a placebo controlled trial by Patanjali at a better position to support the claim that their drug is useful.
    Such double standards of Indian people and government.
    Is this to do with Ayurveda?
    We have no issue with Ayurveda. We have elected a government which set up a ministry for Ayurveda. In fact, this ministry was one of the first to come up with “prophylactic measures” for COVID drawing on Ayurvedic and Homeopathic medicine.
    I personally believe Ayurveda is a science stuck in the ancient past. Thereby it is no longer science. But just because there are remedies mentioned in Ayurvedic textbooks, those do not become just Ayurvedic medicines. If those are tested with modern scientific methods, they are modern medicine too.
    If not for research into Ayurvedic medicine that helps improve modern medical field, what is the point of running 250+ Ayurvedic medical colleges in India?
    Is this to do with commercialization of Ayurveda?
    Patanjali (and other companies) has been in the business of selling Ayurveda products commercially for so long. Surely, commercialization of Ayurveda isn’t a crime.
    Is this to do with private interests during a public health crisis?
    Hasn’t every damn thing we’ve been seeing in the past 6 months or so been about that? Can you name one thing which has been selflessly done for public health? If you named something, I bet it involves an individual or a group of individuals caring for the people right around them. I mean, if you see people suffering right in front of you but you are developing a solution for some others, tell me that there is no private interest in there.
    Is this to do with scientific rigor?
    Where was the question of scientific rigor in approving Favipiravir? Is any data available for that? Was evidence taken into consideration? Was it considered whether the people who generated the evidence were also the people who were going to market the drug? Has there been a peer reviewed publication?
    What makes Coronil any different from Favipiravir? Is it that Patanjali’s claim is 100% while Glenmark’s is 88%? What if Patanjali claimed 99%? What is the right number for this game?
    Is it that anything that has a name that sounds Greek and Latin is inherently good?
    Like “hydroxycholoroquine”, “azithromycin”, “favipiravir”. Is it the name?
    Is it the fact that these drugs sound “modern”? What makes some chemicals modern and some chemicals ancient? Why can’t all chemicals be just “chemicals”?
    All these are rhetorical questions that lead us to the main part of this post.
    What is the point of Ayurveda?
    What are we doing with Ayurveda? What is the role of Ayurveda in today’s world? Can we modernize Ayurveda taking the good parts and plugging out weaknesses?
    Is there a way to re-imagine Ayurveda through modern scientific methods?
    Can we apply the same standards when looking at evidence in both Ayurveda and modern medicine?
    Have we extracted, examined, and integrated all the useful knowledge available in Ayurvedic textbooks into modern medical practice already? Is there perhaps a rudimentary theoretical framework in the way Ayurveda looks at wellness and illness? Can we build on that with the technological advancements that we now have to arrive at new theories on how to think about a human body?
    I mean, is there a central theory in modern medicine? Except at the molecular level where there is DNA->RNA->Protein, what kind of dogmas do we have in modern medicine? Isn’t there a need for such dogmas?
    I’m not saying Ayurveda has a correct theoretical framework. In fact, if you go down the slippery slope, you might say that I will say that homeopathy also has the potential to provide a theoretical framework. I’m not saying that. From my limited understanding of homeopathy and dilutions, homeopathy seems to have nothing in it.
    But Ayurveda is a different beast. Ayurveda was fairly useful during its time. It has sufficient nuance in its management algorithms to qualify for a thorough analysis. All I’m saying is, perhaps there is something to extract from it. And I’m saying this from my limited experience interacting with Ayurveda practitioners.
    Nevertheless, why double standards?
    Why do we trust “modern” medical “research” by default and distrust Ayurvedic “research” by default?
    I mean, what does it tell you that a country which has no issue in pharmacies selling Ayurvedic medicine for every other condition says foul when an “innovation” is attempted for dealing with a pandemic that nobody has a clue how to handle?
    When will we stop lying to ourselves?

  • Public Health Was Always Broken, You Are Just Noticing It Now

    There is this nytimes article about how one pregnant lady who was also breathless couldn’t find appropriate care despite going to multiple hospitals. I find it nothing surprising. Our country’s public health system has never been able to provide appropriate care to people with medical emergencies (or for that matter, any health issue). Maybe now people are noticing because it comes on news.
    There is a limit to how many emergencies can be handled at a time by a small medical team. Even in tertiary care government hospitals, this “team” is a very small one. It usually includes a couple of young doctors – either doing their internship or their residency. And a couple of nurses. And a couple of janitors. It is the same whether you are talking about the ICU or the emergency room of any department. There are no mechanisms for requesting extra hands when there is a spike in cases at any moment. Crises are handled by expediting care (many a times at the expense of quality and/or completeness).
    Imagine this. You are attending to a very difficult accident victim with multiple dangerous bleeds and possible head injury and suspicious breathing. As you are assessing their breathing, another patient comes in with severe pain abdomen. The other doctor stops assisting you and goes to assess the patient with pain abdomen. And then comes in another patient who has a open fracture on both bones of one lower limb. Who on earth is going to take care of this new patient? Well, let’s say the other doctor gives a pain killer to the patient with pain abdomen and let them settle down thus relieving themselves to attend to this new patient. At that moment comes in yet another patient with a head injury. What happens now?
    It becomes worse in the ICU. You could be in the middle of a procedure and there could be a new patient coming in with lots of things to be taken care of. And another patient could crash as this is happening. There are so many things that can go wrong at the same time. But there aren’t ever enough trained hands.
    It is in such situations that doctors refuse to take patients. They know that they can’t give justice to anyone if they take in more patients, especially critically ill. This is where “referral to higher center” happens. Anything can happen, actually – misdiagnosis, unnecessary investigations, miscommunication, death, so on.
    What is the way out?
    Of course, there are a lot of things that maybe potential solutions. But I do have one idea which seems sane.
    Proper “professional” education in colleges
    Nurses can perform any intervention done in an ICU if they are trained and empowered to do it.
    Medical students should be made capable of handling cases on their own.
    In an academic institution there is no dearth of learners. If learners are properly trained and given “professional” education, they can share a lot of workload. Similarly, our country needs to stop putting the doctor at the center of everything and start allowing other professionals like nurses to do more things.
    Above all, there needs to be a culture of quality and improvement. This has to be built from within colleges. When such highly trained teams focused on quality come together, they can do debriefing, build protocols, and create Standard Operating Procedures for managing cases. They will figure out the weaknesses of the system and ask for infrastructure upgrade and many other things necessary to be done to improve the overall system.
    Unfortunately, we are stuck in “long case, short case” mode in medical education. And this is not going to help the country.

  • Glenmark Lies About Favipiravir

    I received from a friend a PDF which happened to be Glenmark’s press release about Favipiravir. The release is full of claims that make it sound like Favipiravir is a wonder drug that is going to solve COVID problems. It becomes my responsibility to refute some of these claims, considering how majority media outlets are doing what they’re best at – exaggerating an already exaggerated PR claim.
    Firstly, we have to verify the claim whether India’s drug controller did approve the drug. The way to do that is visit CDSCO’s website and navigate to approvals -> new drugs. And as per that, “Favipiravir bulk and Favipiravir film coated tablet 200mg” did in fact receive approval on 19th of June for “the treatment of patients with mild to moderate Covid-19 disease” as the 18th entry.
    I do not think CDSCO publishes details of the approval process, about what evidence they considered for approval, etc. Making these processes transparent would be useful for avoiding putting people in great danger.
    The deceptions start from the title itself. “Glenmark becomes the first pharmaceutical company in India [..] blah blah blah [..] COVID” – what does it mean to say “first pharmaceutical company in India in this context? They just want it to sound like this is the first drug for COVID.
    They then start with a bullet point about accelerated approval process which makes it sound like it was CDSCO who wanted the approval to be accelerated so that the “benefit” of Favipiravir can reach everyone. I doubt that’s what really happened.
    They then talk about “responsible medication use” and informed consent. The reality is that this informed consent is necessary because there is no way to know if Favipiravir is really useful in COVID. According to the Telegraph article, the approval was based on a trial on 150 patients. (The CDSCO website does list approval for a Favipiravir trial in May, although this was given to Cipla. Interestingly, the CDSCO website seems to be missing details of any approvals given in April (and Glenmark received approval in late April, as per them))
    In that last pdf they do share the details of the clinical trial. They say they would enroll exactly 150 patients and give Favipiravir to half of them. 75 people!
    Now, next in their bullet point they come up with the ridiculous and unsupported claim that Favipiravir shows clinical improvements of 88% and rapid reduction in viral load. In the text, they do add a citation which points to this PDF report of an observational study done in Japan. This was an observational study with no control arm or anything to compare with. The report itself states this:
      It  should  be  noted,  however,  that  this  study    only    captures    patients    who    received    favipiravir,  which  precludes  direct  comparison  of  the  clinical  course  with  those  who  did  not  receive  the   agent.   Given   that   over   80%   of   COVID-19 patients have mild disease which often improves by supportive   therapy6),   caution   is   required   in   interpreting  efficacy  of  favipiravir  based  on  the  data presented here
    And this is what is cited to support the ridiculous claim in the PR.
    I’m not going to go ahead and waste my time talking about each point made in the PDF.
    But the fact is that saying Favipiravir is useful for treating COVID is as correct as this claim by Patanjali:

    #WATCH We appointed a team of scientists after #COVID19 outbreak. Firstly, simulation was done&compounds were identified which can fight the virus. Then, we conducted clinical case study on many positive patients&we've got 100% favourable results: Acharya Balkrishna,CEO Patanjali pic.twitter.com/3kiZB6Nk2o

    — ANI (@ANI) June 13, 2020

    —
    Conflict of interest disclosure: I have 2 shares in Natco pharma worth about 1000 rupees the last time I checked.

  • What is a “Normal” Human?

    Under the JK Rowling tweet about “erasing the concept of sex“, I found an interesting article: You Can’t Be a Feminist Without Acknowledging Biological Sex.
    It brings up an interesting point:
    The existence of people born with Syndactyly, for example, does not mean that humans don’t normally have 10 fingers and 10 toes.
    I think this is at the heart of the debate. What is “normal” and what is not.
    There is a wonderful TED talk by Aimee Mullins titled “The opportunity of adversity” (coincidentally, I had blogged about it 10 years and 2 days ago)

    In it she brings a view of “disability” that should make anyone question the concept of normal.

    Humans tend to call as “normal” what is “common”. If 99% of people look and act in one way that is what most people call “normal”. But “normal” has a connotation that is completely different from “common”. The opposite of “normal” becomes “abnormal” – something to be corrected, something that shouldn’t have been. And that’s why the word “normal” creates all kinds of problems.
    This has disastrous consequences. People with mental health issues are stigmatized against taking help because they get labelled “abnormal” by people who lack experience in understanding the spectrum of human existence. What is uncommon isn’t abnormal. It is just uncommon.
    Let’s come back to the case of fingers. Do humans “normally” have 10 fingers or “commonly” have 10 fingers? What makes 10 fingers normal? Since we are using scientific terms like “syndactyly”, let us also take a step back and look at the science of evolution. The way life evolves is through random genetic changes. All the diversity on earth (including human species) is the result of millions and billions of “mistakes” during cell division. Is there, then, anything abnormal about having a genetic makeup that causes a visible change in appearance from one’s parents? Aren’t there a lot of genetic differences between every individual on the planet (many of which perhaps don’t cause visually apparent differences)? What is the rationale behind arbitrarily calling some set of human characters as “normal”? “Common”, sure! But “normal”?
    Let us take a human being born with 10 fingers. What if they lose a finger in an accident? Do they become abnormal? Sure they have lost a finger and probably a lot of functionality associated with that finger. You could call them “disabled”. But watch the Aimee Mullins talk above again. Calling them “abnormal” creates unintended alienation. See how labeling people is a very hard thing?
    That is the context in which saying biological sex can have only two normal values – “male” and “female” – creates problems.

  • More Than a Word: Neo-Colonialism in Today’s Vocabulary. | BMJ Global Health blog

    “Resource-limited settings” is a term that I’ve to now reconsider.

    I have used it in the past to talk about Vivekananda Memorial Hospital. But when I think about it from the perspective that this article brings, VMH was the most resource rich hospital I’ve seen. Sure, there may not have been a ventilator ICU or a neurosurgeon. But the lack of such materials had always been compensated by other invaluable resources – dedication of staff, community level mobilization, and holistic approach to healthcare.

    How can we measure “resource richness” of a facility only along the dimension of medical devices available in that place?

    More Than a Word: Neo-Colonialism in Today’s Vocabulary. | BMJ Global Health blog