Artificial Intelligence (AI) and Health Development

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Innovative Health Minister Ghulam Nabi Azad

The union health minister Ghulam Nabi Azad is bubbling with unexplored ideas to control population growth. His suggestion to postpone the marriage age and encourage television viewing in rural areas to control frequents sex are laughable. Hope he won't push the nation to the western lifestyles which is regretting now.

The Times of India writes (18 July 2009)

Going by what Ghulam Nabi Azad said on World Population Day, the idiot box isn't idiotic at all. If the rates of reproduction of TV sets head
north courtesy village electrification, human reproductive rates could head south. For, amorous couples would watch late-night shows instead of making babies. That's what you call an idea pregnant with possibilities. Power in every rural household may breed couch potatoes with suppressed libidos, but look at the bigger picture on the small screen. A one-billion-strong nation can avoid a population explosion. Poverty, inflation and crime can be vanquished. Why, as Azad suggests, Naxalites can be bloodlessly routed. Who could conceivably hope to sell misguided revolution to swelling rural masses of nocturnal TV addicts, late bloom of our healthy consumerism?

India's health and family welfare minister wasn't kidding when he said TV could reduce "80 per cent of population growth". Indeed, think of what could be achieved by busting potential baby booms through a profitable public-private partnership. When duly incentivised idiot box sales soar in a fast-electrified countryside where demand is buoyant, precipitous population decline would spur GDP growth, much to fast-growing China's chagrin. Plus we'd score over China's coercive one-child policy pushers. Our family planning mission would be infinitely superior, promoting voluntary use of televisual contraceptives. In any case, international research says TV's good for rural women, saas-bahu rona-dhona notwithstanding. Those with cable access have been found to resist spousal pressure to keep trying till they produce a male child. Admit it: Azad makes more horse sense by the minute.

The minister also wants people "awarded" for marrying late and putting off changing diapers till 30-31 years, a grand old age compared to India's early-stork norm. Accordingly, he publicly awarded a 12-year-old said to have refused wedlock. That'll win Azad a huge fan in Sharad Yadav. The JD(U) leader wants the hit TV soap 'Balika Vadhu' banned for its 'unconstitutional' theme of child marriage. Contrary to what it seems, however, creative artistes have escaped lightly. Of all the 'unconstitutional' things treason, murder, arson, dacoity, human trafficking routinely depicted on screen, Yadav wants artistic licence denied only to portrayers of toon betrothals.

Equally motivated by child welfare, Maharashtra authorities sometime ago wanted kiddies out of TV shows infringing child labour laws. Well, tiny tots may soon find themselves unemployed anyway. If TV viewers' patriotism gets fired by Azad's birth control brainwave, they might want more adult fare than 'Chak De Bachche' to compensate for night-time celibacy. Talking of entertainment suited to people of consenting age, the irrepressible Rakhi Sawant might be asked to do her bit for the country. She's providentially in the middle of an interminable reality-TV swayamvar. The agonising suspense of who'll win the finicky lady in the marriage sweepstakes is enough to make TV viewers forget about their procreative urges.

Arresting Swine Flu

Swine flu is threatening to destroy the health of nations. It is high time the WHO steps in and controls this global epidemic. Countries blame one another is of no use.

J. Gowrishankar writes in The Hindu (2 July 2009)


It was the evening of Saturday June 27, and I felt the prodromal symptoms of an incipient viral upper respiratory infection (“the common cold”) coming on. By Sunday, the infection was fully established with runny nose, sore throat and cough, fever, and the general malaise. On Monday as I am writing this, I wonder, is this the swine flu?

Known in the medical jargon as “swine-origin Influenza A (H1N1) virus” (S-OIV), the swine flu agent is a novel variant of the influenza virus to which all of humanity represents a virgin (that is, immunologically susceptible) population. Much like other viruses that cause the common cold, the swine flu agent is transmitted from one individual to another by the aerosol route. Clusters of human infections first occurred a few months ago in Mexico and then in the U.S. and several West European countries, and India has adopted the strategy of screening travellers from these countries in an attempt to prevent its establishment here. Travellers with common cold-like symptoms have been isolated and their contacts quarantined, and subsequent tests have revealed that a proportion (perhaps 20 per cent) have indeed been infected with the swine flu.

So then, do I have the swine flu? Neither I, nor any of my close contacts, have travelled abroad in the last six days (which is the maximum incubation period for the virus); but the nature of my job has put me in casual contact with fairly large numbers of unknown people who may have travelled abroad during this period. For example, I travelled by air from Hyderabad to Delhi six days ago and returned by air the next day, and I have also attended several meetings in the past week in closed air-conditioned spaces where senior officials who may likely have travelled abroad were present. Thus, there is a very small, but finite, chance that I have the swine flu.

Which makes me contemplate, is this the way that the swine flu will enter and establish itself in the country? That is, through an unscreened secondary carrier who had but a casual contact with the primary carrier, a traveller returning from abroad? If so, the extensive screening now being undertaken in all the international airports in India would at best serve only to delay, not prevent, its spread through the population. The factors which strongly favour such a spread are: that the H1N1 virus is highly infectious (that is, it can easily be transmitted from one person to several others); that person-to-person transmission can occur during the incubation period (that is, before the transmitting individual is even aware that he or she is infected); that every individual in the population is a susceptible host; and that the clinical features of the infection are no different from those of the common cold. The apparent means to contain its spread and severity is either by vaccination (an approved vaccine is at present not available anywhere in the world), or by treatment with antiviral drugs. The latter course of action is not also practicable in the country, given its expense and the fact that a very small proportion of patients with symptoms of the common cold are likely to be suffering from the swine flu.

It is therefore reassuring to believe that, perhaps, no national strategy of action will be needed even if one could be implemented. It is of course entirely feasible that the swine flu pandemic will progress inexorably around the world, but the fear that it would be as devastating as the influenza pandemic of 1918 may fortunately not hold true. The experience from other countries is that the mortality rate has been quite low, about two for every thousand infected, which is not very different from the rate observed for the seasonal influenza infections (although the age distribution of those suffering severe effects appears to be different, with the swine flu affecting school-age children and adults of working age whereas the seasonal flu has typically affected the very young and the very old). In our country, no deaths have so far been reported amongst those who have tested positive for the virus. In my reckoning, therefore, if we do survive the swine flu scare, it will have been because of the benign nature of the infection, not our national preventive strategy.

Ultimately, however, statistics are for populations, not for the individual. Do I have the swine flu? It is here that I become my own doctor, and my own patient. In keeping with the best traditions of academic medicine, I shall take no antibiotics (since the infection is viral, against which antibiotics are ineffective). The only concession I shall make, for the possibility that it is swine flu, is to take my blood sample now and another two weeks later, so that a retrospective diagnosis of H1N1 infection can be unequivocally established from the pair of samples by the “method of the rising antibody titre,” if that is rendered necessary.

Decisions are never easy in the face of uncertainty, I realise: not for individuals, nor for institutions, nor even for governments and international organisations. Is there likely to be an epidemic in this country, and if so how severe will it be? Is there a need for active interventions? Will a programme of mass vaccination be feasible here, and will the vaccine be safe? (An earlier experience in the U.S., in 1976, had been that vaccination against another swine-origin flu virus was associated with a 1:100,000 risk of serious neurological complications.)

The world awaits answers to these and more questions in the months ahead, but I am left to hope that my optimism above is not misplaced.

AIIMS Under Political Siege

The All India Institute of Medical Sciences (AIIMS) is one of the premier medical research and hospitals of the country. For the past 60 years, it has been painstakingly built by the leaders. Unfortunately in the last few years it has been over politicized and pushed to the fringes. This institution of national eminence should be preserved at all costs.

P. Ramachandran writes in The Hindu, 24.2.2009,
The coronary bypass surgery that Prime Minister Manmohan Singh underwent on January 24 at the All-India Institute of Medical Sciences is evidently successful as there does not seem to be any post-operative complication. His recovery is stated to be quicker than expected and, by all accounts, he should be in a position to resume his duties in about two weeks.

For Dr. Singh, who underwent a bypass surgery in 1990, this was what is referred to as a ‘redo’ bypass. Significantly, this was done on a beating heart — or off-pump as it is called — which is relatively less common than the on-pump mode where the heart is totally arrested but blood circulation is maintained with a heart-lung machine.

It is, however, an irony that India’s premier public institution for healthcare had to summon the services of a private specialty hospital for this apparently complex surgery. The fact that Dr. Ramakanta Panda, from Mumbai’s Asian Heart Institute (AHI) who led the surgery, had his grounding in cardiac surgery at AIIMS adds to this irony. Indeed, there were protests from certain quarters of the institute against bringing in “outsiders” as it would spoil its reputation. Even the decision to do bypass became controversial with some experts arguing that it was safer to do angioplasty, the minimally invasive ballooning of the artery.

A combination of factors, which significantly included the lack of the expertise in the AIIMS in the surgical procedure that Dr. Singh’s condition demanded, led to the situation that has cast it in a poor light. The decline, which many believe is irreversible, has happened over a period of time. The reasons lie in politicisation of the institution and the deeply entrenched attitudes of sections of the faculty that have bred nepotism, favouritism and sycophancy at the cost of merit, academic excellence, specialised medical skill and professional ethics.

Dr. Singh’s 1990 surgery was a triple bypass, in which three arterial blockages were bypassed with one arterial and two venous grafts. In 2004, he underwent angioplasty in Delhi on one of them which had narrowed and a stent was put. Angiography done on January 21, following the Prime Minister’s complaint of chest pain, indicated that there were five blockages — three old and two fresh — which required cardiovascular intervention, not excluding surgery. The medical question that arose was: should it be angioplasty or bypass? The latter would mean a redo bypass. The crucial decision essentially rested on the Prime Minister’s health panel headed by K. Srinath Reddy, an AIIMS cardiologist who was the personal physician of P.V. Narasimha Rao.

The Prime Minister’s healthcare is governed by the ‘Blue Book’ for VIP security and a separate healthcare manual that sets out details. The latter specifies that the AIIMS is the designated unit for ‘finitive’ care (inpatient hospital care beyond emergency treatment). But it also says the best available medical care in the world be provided, thus giving full freedom to take Dr. Singh, or get any person from, anywhere including abroad.

“In my opinion,” says Dr. Reddy, “angioplasty would have been risky. Also it would have had very short-term benefits and a lot of restriction on his travel, etc. Surgery, despite the so-called initial risks, would give much better long-term results. And knowing Dr. Panda’s surgical results, I was in favour of surgery.”

“The earlier bypasses were 19 years old and the 2004 stent too had re-blocked. When the stent is re-blocked, the chances of success with angioplasty are less. It could again get re-blocked in 6-12 months,” points out Dr. Panda. Also there was narrowing inside the stent. “Both these put together, the probability of his coming back within six months was fairly high. That’s why we decided on surgery where the risk is less,” he says. When Dr. Singh and his family were informed of the various options, the Prime Minister too opted for surgery.

Bringing in Dr. Panda was entirely Dr. Reddy’s decision. “I wanted to get a person who has excellent redo experience, a person who has extensive beating heart [surgery] experience, a person with extensive redo on beating heart experience. And Panda is the one who scores on all three counts,” he says. Apparently some surgeons in Delhi, including Naresh Trehan of Apollo Hospitals, did offer their services. “For me it was very clear,” says Dr. Reddy. “We [at AIIMS] do a lot of redo bypass for valves and other things but coronary redo rates are 2-3 per year, whereas Panda does 2-3 per week. And most of his redos are on beating heart whereas even some of the best centres of the world do it on-pump. And beating heart definitely has this advantage of less bleeding and less damage to the tissue,” he adds.

The mortality rate even for the first bypass at the AIIMS is four per cent as compared to 0.3 per cent at the AHI. The only person with comparable statistics is Dr. Bruce Lytle from Cleveland Clinic with whom Dr. Panda has worked.

Though Dr. Singh had the option of getting operated on in Mumbai, he preferred the AIIMS. Dr. Panda, of course, would have been more comfortable in his own environment. “The PM has high respect for AIIMS. Every time he has needed medical attention he has insisted on AIIMS,” says Dr. Reddy. All his past surgeries have been done at the AIIMS except for the left wrist carpal tunnel syndrome when an anti-reservation agitation was going on at the AIIMS. He was then taken to the Army Research and Referral Hospital but it was AIIMS doctors who operated on him.

With Dr. Singh having decided on the AIIMS, it became imperative for the institute to cooperate with Dr. Panda. But there were apprehensions about the extent to which it would cooperate given the increasingly evident institutional politics. Following the constant feud between Health Minister Anbumani Ramadoss and the former AIIMS director and cardiac surgeon P. Venugopal, the pro-Venugopal and anti-Venugopal factions of the Cardiothoracic Vascular Surgery (CTVS) faculty had, in fact, hardened in recent times. Indeed, as was feared, the divisive politics did raise its ugly head. While the CTVS head, A. Sampath Kumar, well aware of the institute’s limited expertise, promised all support, he could do little to prevent his detractors from raising the outsider bogey.

Though the AIIMS supported the operation with its team of cardiologists, anaesthetist, radiologist, laboratory personnel, associated equipment, and the overall supervision of Dr. Kumar, it sharply brought into focus its lack of higher level capability and skill. This has reinforced concerns of declining standards of academics and healthcare in AIIMS that has been evident for nearly two decades, which the recent flight of talent to the private sector has only accentuated.

Of course, as Dr. Reddy emphasises, the AIIMS does a lot of poor patients’ valve cases and a surgeon doing paediatric surgery also does valve surgery. So specialisation, like Dr. Panda, becomes difficult. But such specialisation can come about only with more faculty and more facilities. The AIIMS is a goldmine of clinical cases and is one of the best training institutions. It can be made a high-class research and public health centre only if there is functional and administrative (including financial) autonomy and less political interference in selection and governance. Political interference is why the AIIMS is still without a director after Dr. Venugopal retired in mid-2008.

Recruitments too have been frozen for the last five years. This is a direct fallout of the highly irregular appointments made during 1993-2003. A five-member committee constituted by the Ministry in January 2007 found that no regular selections were made because of agitations and litigation resorted to by the faculty to recruitments in reserved categories. “Instead,” the committee said, “the vacancies at entry-level assistant professors were made through ad hoc selections and appointments … characterised by a series of arbitrary in-house decisions and procedural violations.” As many as 152 faculty positions were filled in this manner.

In 2001, the court dismissed the anti-reservation petition. When the regular selection process was resumed in 2003, for 170 advertised positions, 762 candidates appeared for an interview including 151 earlier ad hoc appointees and 611 others. The details of selection of 161 candidates available to the committee revealed that 131 of them were from the ad hoc pool itself. The committee found instances of highly meritorious candidates in both the reserved and general categories not being selected. “This was done primarily to regularise the ad hoc appointees … [which] was unlawful,” the committee observed.

The absence of in-house expertise at the AIIMS in many areas can perhaps be traced to the irregularly selected faculty who continue to function at the cost of far better candidates. The CTVS is, in fact, guilty of biased dispensations even earlier during Dr. Venugopal’s long term as its head since the mid-1980s, say AIIMS sources. Many capable young people — who included Dr. Panda himself — were forced to leave then. The impact of that legacy is evident now when this famed institution finds itself lacking in the necessary surgical expertise to treat the head of the country.

The less political interference means the more better for AIIMS and the public. At the earliest AIIMS must be relieved from the clutches of the government control and made totally autonomous in all aspects. The union health ministers and other political heads should not even allowed to have even a single say in the day to day running of the institution.

Increasing Mental Disorders

There are various reasons for the increasing mental disorders. One of the major factors is the negative social attitude towards the mental patients. Generally people misbehave with the mentally ill patients. The hospitals meant for these patients do not give adequate sympathy, love and care. Most of the mental patients feel better outside the hospitals. They are treated like animals in the cages. While this is the sorry state of mental health treatment in the country there is fast rise in the number of patients. Due to the severe economic crisis and lack of social support mental ill health is becoming common nowadays. The government is preparing for the worst. It must be countered with all out efforts.

WHO estimates 30 crore people globally suffer from mental health disorders
In India 15-20 crore people suffer from some sort of mental illness, the commonest being depression and anxiety syndromes, stress and psychosomatic disorders, bipolar mood disorders, schizophrenia and dementia.
1.6 of them need institutional intervention
According to WHO, at lease 3 in 4 mental health patients in developing countries receive no treatment
75% of mentally ill patients in India are treated through traditional interventions and by tantriks
8.1% of all disabilities in India are due to mental illnesses, as against 5.8% due to cancer and 4.4% due to heart diseases
India needs 32,000 psychiatrists but has 3300 trained psychiatrists, 3000 of whom are in metros
By 2020, depression is expected to become the 2nd largest illness in the world
Most countries allocate less than 2% of their health budget to mental disorders
Suicide is one of the commonest manifestations of mental illness
In India, 1.2 lakh people end their lives every year by committing suicide
4 lakh attempt commit suicide
Globally, one million people die from suicide annually
The global mortality rate is 16/100,000, or one death every 40 seconds.
In the last 45 years, suicide rates have increased by 60% worldwide
Mental disorders, particularly depression and substance abuse, are associated with more than 90% of all cases of suicide
Asia accounts for 60% of the world’s suicides
India, China and Japan account for 40% of this number
Over 71% of suicides in India are by persons below the age of 44.

The Union health ministry is getting nervous over the alarming rate of mental patients in the country. A shocking number of 13 crore Indians suffering mental disorders have shaken the ministry from its slumber. It is going to circulate a cabinet note next week to handle the rising mental disorders. It has proposed to upgrade the existing eleven mental hospitals, increase of at least 44 post-graduate seats in psychiatry, 176 M.Phil seats in clinical psychology and 220 seats for psychiatric nursing each years. The ministry envisages that 616 qualified mental health professionals would be produced from these centres. One hopes for the better situation in the coming days.