Dr.P.K.Sasidharan writes:
Source: facebook
Dear all,
I am thinking of writing a series of messages on how to deal with Covid 19 and similar epidemics in future:
Let me tell something about me before I tell anything more about Corona virus issues. I have 40 years of clinical practice, studying at Calicut Medical College, which was, and still is, a museum of all varieties of diseases, and then working as faculty in the Medicine department for four decades. Initially, it was a museum because our college was the sole referral center for the entire north and central Kerala, we got patients from seven districts. This status remained so till recently when several other medical colleges came. Now there are four other medical colleges in and around Calicut city- seen as a great progress indeed! Mind you, population has only doubled in the last four decades and during this period, hospitals, hospital beds and doctors have multiplied at least 15 times. Now all the hospitals are overcrowded- We never had any floor patients in the 1980s. Still Calicut Medical College continues to be a museum of all diseases, in fact now all the medical colleges have become so in India, because diseases are increasing all over India disproportionate to population growth; This is because we have been systematically ignoring social determinants of health and are literally manufacturing diseases and then to cater to the ever-increasing patient load we keep on building more treatment centers. It is a dangerous vicious cycle we need to break to deal with an issue like corona virus!!
Having trained at Calicut for my MBBS, and studying there with the intention to become a good GP, which was the only objective of all students those days: I could develop some basic insights into clinical medicine and diagnostic skills; that too since we had talented clinicians as our teachers who could inspire us to learn the magic of clinical skill, which some people now consider as intuition. I realized that general Medicine would give me the maximum opportunities to use fine-tuned clinical skill. But unfortunately, in spite of securing the highest marks from Calicut university, I had no chance of getting MD General Medicine- due to the disparities in marking system between the two universities in the state. Therefore, with the marks that I got, I joined Paediatrics with a plan to do DCH, but after a year we won the case for introducing entrance exam in Kerala, citing the disparity in marking, and wrote the first PG entrance exam in Kerala. Before the results came out I could appear for the all India test for MD Medicine in the prestigious PGI- Chandigarh, which we were told as beyond our reach, but Dr.Lulu Mathews of Paediatrics who retired as the HOD, who was then a tutor in Pediatrics, told me that I would certainly get if I had attempted. Me and two other classmates went to write the PGI entrance exam and to the surprise of all I got selected for MD Medicine. Before the results of the first entrance exam in Kerala came, I joined PGI-Chandigarh for MD Medicine. Those days super specialization boom had just started and all my batchmates at PGI came there with an intention to go for one or another DM course, thus I also decided to do one, my choice was then Nephrology and took Nephrology as my thesis topic. My first posting was in emergency department and then to Internal Medicine under the Nephrology team, a unique arrangement for students to learn properly, headed by Dr.Chugh and Dr.Vinay Sakhuja. During my rotation in different departments at PGI, I started getting an urge to specialize in each one of them, While in Neurology I thought of becoming a neurologist, then I thought of becoming a cardiologist when I was doing my rotation there, later thought of pulmonologist and then gastroenterologist and so on- my dream started wandering here and there-there was no one to guide anyway- genuinely I could not fix my mind to any one branch- every branch was equally important to me- I could not find a dividing line between any of these- and then I realized that my cup of tea is General Medicine and my passion was for teaching. No other department gives more opportunity than Medicine for teaching. Hence soon after completing MD, I said goodbye to PGI and my immature plan for a DM Nephrology, in spite of the fact that a DM from the most prestigious PGI Chandigarh was the dream of cream students, and it remains so even now. I came back and joined the Department of Medicine, (in fact this was my dream during my MBBS days – seeing those teachers who inspired me – since my ambition was to become a teacher and since I loved to practice clinical skill- the most powerful tool for a doctor- but ignored to the core now). There I worked for more than 30 years as a faculty- Our department used to manage all diseases known to humankind, all varieties of infections, including the two killer diseases HIV and TB, all nutritional disorders, lifestyle diseases, heart attacks, strokes, all anemias, ITP, hemophilia, venous thrombosis, sickle cell disease and hematological cancers and whatnot. I started working there as a lecturer (those days tutor), then as Assistant Professor, associate professor, and finally professor and was head of the department for 8 long years. I was in charge of Hematology and Hemato-oncology as well and built up that division with 40 beds by the time I retired and was an active member of the Indian Society of Hematology too. I was into social work as an organization leader of the teacher’s association and later of the Association of Physicians of India and Hypertension society of India as well.
As a teacher I could inspire hundreds of students into the art of medicine but sadly many of my favorite students went for DM, which worried the teacher and social worker in me. I am sorry to say that those brilliant students of mine were literally lost to the society, some of them may be doing some research oriented works, but still the thought which lingered was – had they practiced General Medicine or worked as family doctors at least, the whole society would have been benefited in a more substantial manner as compared to the limited services they do now. This is because we do not need so many specialists, but this country needs large numbers of generalist doctors (Family doctors and Internal Medicine). Thus, I was genuinely upset about the drop out of students, who adored me, into superspecialisation – it was a painful experience for a teacher who wanted to bring out genuine doctors for the people of this country. It was painful to realize that they did not practice what I taught and they no longer considered me as a teacher too after they go into the so called super specialization- but the relief was that those who chose to practice after MD alone or without a DM are all doing wonderful service to the patients. Besides being passionate about teaching I was into research as well- I had done original researches on problems like proteinuria, cardiomyopathy, Myeloma, Typhoid, Tuberculosis, Vitamin D, SLE, Leukemias, Anemias, B12 deficiency, Polycythemia, Nonalcoholic fatty liver disease (NASH), Diabetes, Hypertension, Social determinants of health and so on – research, I still continue to do .
After retirement I still continue to work, voluntarily, in the same institution to build up Family Medicine, which became my life mission and passion after realizing that all the maladies of India can be pinned down to lack of the ‘friend – philosopher and guide’ kind of doctors in the community and lack of good primary education which is capable of converting each child into good human beings. The chance that I got now to nurture Family Medicine was the fulfillment of my unfinished journey into the medical profession.
I wrote all these not to project myself, anyway I do not stand to gain anything by projecting my achievements five years after my retirement – but I wanted to convince all that I am competent to prepare guidelines or advice governments in this crisis due to Covid19- Why I wrote all these was only to prevent the hi-tech people from calling me an unscientific person- science to me is the scientific behaviours, the logical thinking and not just use of technology to fight an organism. Use of technology is considered as science in the present-day consumerist society, technology has dominated everywhere; it rules over us. For Covid 19 the popular approach now is -Test, Test, Test, Test—- it is the only objective now- testing for what? For what purpose? What will we do after identifying the virus, is it possible to test all suspected cases, is it not important to consider what makes us vulnerable to the virus and eliminate that first?
Preventing a war by logical thinking and action alone is Science, but fighting a war, no matter what we use to fight, may be with the latest missile, or with the most modern nuclear bomb, is not Science. Sadly, people like me have no place in any committee to make strategies now. Death statistics from other countries, the consequent fear psychosis generated widely, especially among the aged and the decision makers, and the awareness that the cause of death is due to ARDS, is the basis for all the decisions in designing strategies, including the formation of the expert committees to fight Covid 19, Yes the fight is only against the virus.
To me the real virus in India is gross inequitable distribution of wealth and human resources … India is the richest nation with respect to human resources and material wealth But just 2 percent of super rich are holding 80 percent of our wealth, 90% of our allocated health budget(a meagre 1-2% of GDP) and human resources are now utilized in tertiary care in India, when it should be the opposite- that means 90% should be spent in primary care. India seems to have the highest dead investment as gold in lockers (worth Rs 75 lakh crores), we have large stretches of privately-owned unused land all over the country mostly bought by people with unaccounted money, bought as an investment. We also have the dubious distinction of having the highest number of homeless people and paradoxically the highest number of houses and flats where no one stays; we allow our people to hoard cash in secret places or allow them to build huge houses where at the most only two individuals ‘may be staying’ or are lying unused most of the time, we allow the people with money (often black money) to build huge compound walls too, worth more than cost of a decent housing, all these happen even as several millions live on foot path or slums, and when no one gets safe drinking water, but they are asked to boil it using imported fuel, or to buy costly water filters, or use the so called mineral water, in some cities like Chennai the tanker mafia decides what water you should drink – wasting money and creating environmental hazard; But surprisingly very few only knows what a balanced diet is, even if they are super rich, they are not empowered to practice good lifestyle, still all of them are told that 30 ml alcohol will reduce their heart attacks, Even more surprising is that with whatever little or more they earn, they eat to full stomach and prefers only white collar jobs and are always stressed due to lack of social security and lack of human development – this has led to a corrupt system; There is some relief now that at least there is an attempt to repair this damage- in short we have ignored all the social determinants of health and we produce diseases- then the governments are ready to spend any amount of money on repairing the organs at enormous costs; super specialty hospitals are more important than play grounds, we have more specialist doctors but no family doctors etc etc … let us eliminate these viruses too… then only our fight against Covid-19 will succeed.
To deal with the crisis the Governments across the world would have set up committees, an analysis of the expert committees formed will have a common picture it would consist of one single system specialist, in this case a pulmonologist because of ARDS as the cause of death, one virologist, one pathologist, one critical care doctor and no generalist doctors. If they find that heart is also involved by myocarditis, a cardiologist also will find a place in the committee. My experience of 40 years tells me that practical tips to contain a problem like this would come only from a panel of doctors who live among patients and feel the pulse of the common man in the community setting- I mean socially committed general practitioners with insight into all aspects of social health and its determinants. But sadly, India does not have many GP doctors now. If I am asked, I would advise to have a panel consisting of three genuine GP doctors who have developed adequate insight into public health issues and one or two epidemiologists. They can get inputs and help when required from all others. In addition, there is another malady in all the places, the practice is to form a committee with only those who are branded as their associates depending on which coalition is in power. One more thing to remember here is that genuine doctors anywhere would have worked without a political identity and hence the governments would certainly be missing out genuine persons in the panel to advise them.
In continuation of previous post on the survival tactics that we can do at our end, we must remember that no virus could conquer us if we have good defense mechanisms inside the body, defense does not necessarily mean specific antibody against the virus. Sometimes when the dose of the virus or its virulence is too high we may get the infection as it could defeat our immune mechanisms, this is a rare situation, even that is not the end of our life, we would fight it and come out successfully if we do not allow our immunity to go down- to me, the way we are fighting Covid 19 is inappropriate- In Wuhan they would have made some action- In Italy they would have done something else- But India is not Italy or China- everything is different here- we need to have common sense to identify what India needs now: Is it not important to devise strategies suitable here, I wanted to associate with the state or central government in doing that, But sadly a person like me is not included anywhere as I am not in the good books of any of the political parties -may be because I have not identified openly with any of them.
At this point I will make few points on survival strategy if Covid-19 attacks us- NO NEED TO PANIC- we need to prepare ourselves to face it, the mortality is very low or nil due to the virus as such.
1) Avoid self-medication- Do not take any kind of NSAID for fever and myalgia- Say No to Ibuprofen and Mefenamic acid (Brufen and Meftal Forte)- no matter what the height of fever is- just because it is used in Italy and USA we should not be using it- I am almost certain that those who developed the cytokine surge and ARDS are people who are exposed to these agents.
2) The people who are unable to protect their body from the virus are the people who do not take a balanced diet and have wrong lifestyles. This is applicable also to the few youngsters who would have succumbed to the disease, or they would have died of some other disease which went undiagnosed in the Covid-dominated scenario. — I will give some practical tips on balanced diet to defend our body against corona virus or any other disease-using the two pictures attached here- eat always a balanced diet every time we eat- a) The major bulk of the diet should be high fiber vegetables (as sabji, salad, aviyal, thoran etc- but do not include the carbohydrate rich roots and tubers as vegetables) b) always include fresh fruits (not dry fruits or boiled banana) which will give you enough vitamin C, positively include citrus fruits, c) always include one source of protein (any one of the pulses/curd (not milk)/egg/fish (not fried)/ or meat(not fried), d) one source of carbohydrate in minimum quantities depending on the amount of our physical activities (rice/wheat/ragi/oats/tapioca/unripe jackfruit/potatoes etc)
3) Take plenty of water (2.5 liters to 3 liters per day to ensure adequate 1.5 liters) urine output
4) Avoid overeating – eat only half the capacity of stomach (see the picture)
5) Avoid fast foods and junk foods, avoid fried foods including fried fish and meat
6) Adequate rest and sleep (6-8 hours)
7) Avoid smoking and alcohol
8) Manage your stress (details later)
9) Good oro-dental hygiene (brush teeth before going to bed, rinse mouth properly after every drink or meal)
10) Find time for some kind of exercise (aerobic activity only)
11)Quarantine the vulnerable groups for the time being
(To be continued further in the coming days)
Dr.P.K.Sasidharan, MD, FICP, FRCP
Emeritus Professor, Department of Family Medicine,
Former Professor & Head, Department of Medicine
Govt. Medical College, Kozhikode
sasidharanpk@gmail.com
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