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Dr KK Aggarwal

From the Desk of Editor in Chief
Padmashri and Dr. B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

Dear Colleague

2nd March 2010, Tuesday

The wrong way for rural doctors

I got a commnet forwarded by Dr S Arulrhaj president Commonwealth medical assocition " though it may contradict the medico political consensus arrived at IMA HQs, it has more sense, science and logic. Kindly go through it, apply your mind and send your feedbacks to Honorable Shri. Gulam Nabi Azad, Union Health Minister of India" It was regsring aa article publisehd by the Hindu by former health minsiter Ambumani Ramdoss.

" The proposal to introduce a shortened medical course is a folly: it will aggravate the rural-urban divide and give a raw deal to villages. The proposal put forward by the Central government to introduce a shortened medical course at the graduate level to serve the rural areas will only widen the rural-urban divide and impede India's role as an emerging global power. In seeking to virtually revive the Licentiate Medical Practitioners (LMP) scheme that was available before Independence, the government has taken a regressive step. And in the process it is resorting to discrimination against rural folk, who are taken for second-grade citizens deserving medical care by a brigade of ‘qualified quacks'.

The scheme involves a three-and-a-half year course that leads to a bachelor's degree in medicine and surgery. Doctors trained under this scheme will work in rural areas. They will be trained in district hospitals. In the erstwhile LMP scheme, students were trained for around three years, awarded a diploma and asked to meet rural health care needs. It was considered a way to bridge the gap between demand and supply outside metropolitan India. The LMPs outnumbered the MBBS graduates and largely served in the rural areas. Following the Bhore Committee report of 1946, medical courses were unified into the standard five-and-a-half-year MBBS degree.

The issue is the impact of this scheme on the status of the rural Indian. In what way are rural Indians different from their urban counterparts? Do they deserve health care from medical personnel who are less qualified than those who attend to the health needs of their urban brothers? Are their well-being and lives less important than those in urban areas? This discrimination could sow the seeds of disunity and discrimination. The scheme is against the spirit of the Constitution and human rights.

The proposal is superfluous, too. Any State can introduce a short-term medical course. We do not need a centralised concept of rural service, governed by the likes of the Medical Council of India (MCI).

The need is to utilise existing personnel prudently. Today even medical colleges recognised by the MCI, numbering about 300, face faculty shortage. How is the government planning to equip the so-called rural-based institutions that will eventually churn out semi-qualified medical personnel, with faculty and infrastructure?

India has a wealth of alternative medical systems such as Ayurveda, Siddha, Unani, Homeopathy and so on, that brings in hundreds of thousands of qualified medical professionals into the health care industry. They qualify after more than four years of training. It would be easier to use this huge corps of medical manpower according to the needs of the local regions rather than create a new cadre.

Today a nurse undergoes four years of training during her or his course, whereas the proposed BRMS course is for three and a half years. The rural folk would be better off being catered to by nurse-practitioners who are more qualified than the ‘qualified quacks.'

The doctor-patient ratio in India is 1:1,700. Add to this the doctors under the traditional medical systems and the ratio comes down to about 1:700. The World Health Organisation's recommended criterion is 1:300. To reach that target, we cannot go for short-sighted and short-term measures to create a cadre of semi-qualified professionals.

We have the schemes and tools to enhance the health of our rural fellow-beings. With an exemplary scheme like the National Rural Health Mission, all that is needed is to revive and give new momentum to such schemes.

There are more than a million fully trained nurses and more than 3,00,000 Auxiliary Nurse Midwives in India. There are also more than 7,00,000 Accredited Social Health Activists (ASHAs). Then there are Village Health Nurses, Male Health Workers, Male Nurses, Anganwadi workers and so on. There is no dearth of paramedical professionals and qualified medical personnel to serve the districts and villages.

Adding one more cadre of workers who are neither here nor there will lead to state- acknowledged quackery. Already, nearly 75 per cent of India's population is treated by quacks. The proposal will only help strengthen the cause of the quacks, bestowing upon them respectability.

Already the urban-rural disparity in health infrastructure is huge. If the rural areas are catered to by BRMS personnel, it will deter qualified and experienced doctors from taking up rural assignments. It was after much thinking and cajoling that we put forward a compulsory scheme for rural service for those who desire to pursue higher medical courses. With one imprudent and rash gesture, we will do away with a good practice that was initiated with astute planning.

Ghulam Nabi Azad, my successor Union Minister of Health and Family Welfare, says BRMS personnel can be posted in Sub-Health Centres and Primary Health Centres. These already have more than enough qualified nurses who have completed four-year courses and done their practical training. So where is the need for a BRMS course that will produce medical personnel dismally equipped with only three and a half years of training?

The website of the Union Health Ministry provides details about the NRHM. Thousands of crores of rupees are being invested in the rural health sector under the NRHM to strengthen rural infrastructure. As Health Minister, in order to supplement the NRHM, I initiated a proposal for a one-year compulsory rural posting for each MBBS doctor after the internship. This faced stiff resistance from medical students. A committee under Dr. Sambasiva Rao was formed to deliberate on this issue around the country and give their recommendations. Finally, the recommendation was that anybody who aspired for a post-graduate degree should undergo a one-year compulsory rural posting. Unfortunately this recommendation came at the fag end of my tenure. Had this been implemented, every year we would get nearly 30,000 fully qualified doctors working in Rural Health Centres.

The need is to start more medical colleges in areas such as the northeast, Bihar, Uttar Pradesh, Madhya Pradesh and Jharkhand. The country has nearly 300 colleges, of which 190 are in Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and Gujarat. Uttar Pradesh, with a population of 19 crores, has only about 16 colleges. Bihar, with a population of nine crores, has eight. Rajasthan with an eight-crore population has eight and Madhya Pradesh, with a population of eight crores, has 12. If the State governments open medical colleges in all the districts, we can have nearly 600 medical colleges, rolling out nearly 75,000 MBBS graduates a year.

We have another huge health resource pool to tap from: doctors trained in Russia and China. Their services can be utilised in the rural areas.Many doctors settle abroad. The government should take steps to prevent this drain by offering them attractive remuneration, avenues to train and upgrade knowledge and due recognition.

One school of thought favours admitting two batches of medical students in each institution every year – in the morning and in the afternoon. Clinical sessions could be alternated. By resorting to the double shift, we can double the number of medical graduates using the same infrastructure and faculty. This can be followed for medical, dental and nursing courses. This was accepted by the MCI for post-graduate courses when I put forward the suggestion that accommodates one more student per professor within the existing system, given the infrastructure available. Earlier one professor could take in only one postgraduate student; now one professor can take in two students without compromising on the quality of medical education, thereby doubling the intake of students to postgraduate courses, leading to optimum use of the existing resources and infrastructure.

My suggestions in a nutshell are here. Make one-year rural posting compulsory for all MBBS doctors after internship. State governments should start medical colleges in every district to create more medical graduates. Increase the number of medical graduates and post-graduates using the existing infrastructure and faculty. Focus more on the northern and northeastern States. Expand and invest more in the National Rural Health Mission. Start government-run nursing colleges in all districts. Public-Private partnership ventures can be initiated, using the district and sub-district government hospitals for the purpose. Preference should be given to students from rural areas for admission to the MBBS courses, and it should be stipulated that the graduates work for five to 10 years in rural areas. The harmonization and utilization of doctors who have been trained in Russia and China, who have undergone seven-year MBBS courses, to fit into the rural programmes could help. The utilization of doctors from traditional systems for specific needs and programmes could be planned. Anyone who wants to join a post-graduate course in a government college should have done a minimum of three years in a rural posting."

Dr KK Aggarwal
Chief Editor

News and Views

Could exercise be a new strategy to revert some patients with atrial fibrillation?

A small preliminary study suggests that in some patients it may be possible to revert atrial fibrillation (AF) to sinus rhythm (SR) with exercise and avoid direct current reversion (DCR) and concomitant general anesthesia. The authors suggest that a larger multicentre randomized trial is warranted to confirm or refute these initial results and if correct identify those who might benefit.

Excess stroke, MI, and death seen with carotid stenting

In patients with symptomatic carotid stenosis, stenting was associated with a higher rate of stroke, death, or procedural myocardial infarction than endarterectomy, results of a randomized trial showed. The International Carotid Stenting Study (ICSS) findings, reported in two papers by a team led by Martin Brown, MD, of the Institute of Neurology at Univeersity College in London, were published online by Lancet Neurology.

A case for tPA in unwitnessed strokes

Because many strokes occur when the patient is alone, with no one to verify when it began, recombinant tissue–plasminogen activator (tPA) – approved for use within three hours of stroke onset – is often withheld. But the lack of a witness is not an insurmountable barrier, according to Demetrios J. Sahlas, MD, of McMaster University in Hamilton, Ontario.

Predicting prognosis and treatment response in a subset of pancreatic cancer patients

Specific chemical modifications to proteins called histones, which are found in the nucleus of cells and act as spools around which DNA is wound, can be used to predict prognosis and response to treatment in subsets patients with pancreatic cancer, a study by researchers at UCLA’s Jonsson Comprehensive Cancer Center has found.

Pre–pregnancy, obesity and gestational weight gain influence risk of preterm birth

Researchers at Boston University School of Medicine’s Slone Epidemiology Center and Boston University School of Public Health have shown that pre–pregnancy obesity and gestational weight gain are associated with an increased risk of preterm birth in African American participants from the Black Women’s Health Study. This study currently appears on–line in Epidemiology.

Psychosocial problems are common in children with dental fear

Children and adolescents with severe dental fear often come from families with a turbulent background. It is also more common that they have had counselling contact with a psychologist. These are the conclusions of research carried out at the Sahlgrenska Academy at the University of Gothenburg, Sweden.

Short–Term radiation therapy successful for breast cancer

An intense three-week course of radiation therapy is just as effective as the standard five–week regimen for women with early–stage breast cancer. (Feb. 11, New England Journal of Medicine)

Hot Pepper: Painkiller

Scientist at Barrow Neurological Institute at St. Joseph’s Hospital and Medical Center have discovered a new category of painkillers, called TRPV1 antagonists.These drugs block the transient receptor potential vannilloid–1 (TRPV1) channel, which is the same receptor responsible for the sensation of hotness from hot peppers. However, clinical trials have revealed that TRPV1 antagonists cause hyperthermia–– a dangerous, fever–like rise in body temperature.

Women with gout at greater risk of heart attack than men

Women with gout are at greater risk of a heart attack than men with the disease, indicates research published ahead of print in the Annals of the Rheumatic Diseases.

Intense Sweet Taste

New research from the Monell Center reports that children’s response to intense sweet taste is related to both a family history of alcoholism and the child’s own self–reports of depression.

Taspoglutide may reduce sugar levels when compared with or added to other treatments

Results from five late–stage clinical trials show that its experimental diabetes drug taspoglutide reduced blood sugar levels when compared with or added to widely prescribed treatments. The drug met the main goal of studies comparing it to insulin glargine injection, exenatide injection and sitagliptin, as well as trials where it was combined with metformin and against placebo.

Conference Calendar

18th Annual Conference of INASL (Indian Association For Study of The Liver)
Date: March 12 – 14 , 2010
Venue: Bhubaneswar, Orissa, India
Email: scb_gastro_dept@hotmail.com; inast.2010@gmail.com

Quote of the Day

I have been driven many times to my knees by the overwhelming conviction that I had nowhere else to go. (Abraham Lincoln)

Diabetes Fact

Sulfamethoxazole + Trimethoprim when used together with Glibenclamide can cause hypoglycemia (both drugs are protein–bound)

Public Forum (Press Release)

Turmeric can prevent heart failure

Traditional Indian turmeric prevents heart failure, lowers cholesterol, prevents cancers and gall stones and augments scar formation in a wound, said Dr K K Aggarwal President, Heart Care Foundation of India and Editor eMedinewS.

Studies from the University of Toronto’s Cardiology Division and published in The Journal of Clinical Investigation have shown that Curcumin, an ingredient in the curry spice turmeric, when given orally to a variety of mouse models with enlarged hearts (hypertrophy), can prevent and reverse hypertrophy, prevent heart failure, restore heart function and reduce scar formation.

In the studies, curcumin was given to rats, who then got surgery or drugs designed to put them at risk of heart failure. The rats that received curcumin showed more resistance to heart failure and inflammation than comparison groups of rats that did not get curcumin.

Curcumin treatment also reversed heart enlargement. Curcumin short–circuited the heart enlargement process, though it’s not clear how it did that.

The healing properties of turmeric have been well–known. The herb has been used in traditional Indian medicine to reduce scar formation. For example, when there is a cut or a bruise, the home remedy is to reach for turmeric powder because it can help to heal without leaving a bad scar.

Curcumin has come under the scientific spotlight in recent years, with studies investigating its potential benefits for reducing cholesterol levels, improving cardiovascular health and fighting cancer.

As an herb, turmeric should to be taken 300 mg thrice–daily with meals. It has useful actions like antioxidant, anti–inflammatory, anti rheumatic; lowering cholesterol, anti cancer and prevention of gall stones. It is also found to be useful in situations like dysmenorrhea, dyspepsia, HIV, muscle soreness, peptic ulcer disease, scabies and uveitis.

Curcuminoids, act as free radical scavengers. They also inhibit leukotrienes and synthesis of prostaglandins. The anti–inflammatory activity has been claimed to be comparable to NSAIDs (such as indomethacin).

Curcuminoids lower blood lipid peroxides, decrease total cholesterol and LDL cholesterol, and increase HDL cholesterol. Turmeric has also been claimed to inhibit platelet aggregation.

Question of the day

What is the management of intractable distal ulcerative colitis (UC) not responding to medical therapy?

Generally patients with ulcerative colitis (UC) with relatively localized distal disease can by and large be controlled with medical treatment. They do not need a surgical intervention. But, surgery is indicated in such patients who have not responded to medical treatment and continue to have debilitating symptoms. Either a conventional proctocolectomy with ileostomy or a restorative proctocolectomy and ileoanal pouch anastomosis should be done in patients with distal UC, which is the standard procedure in more extensive disease. Most surgeons have recommended against performing a more localized resection that includes only the diseased segment of colon and rectum in these patients as it is associated with a high rate of proximal extension requiring reoperation.

eMedinewS Try this it Works

Look under the tongue

Looking under the tongue should be a consistent part of the routine oral examination. It can pick many early cancers.

Dr Good Dr Bad

Situation: An uncontrolled diabetic came with hearing loss.
Dr Bad: Go for a hearing aid.
Dr Good: First get your sugar controlled.
Lesson: Lack of glycemic control shows a positive correlation with extent of hearing loss when compared to those diabetics with good glycemic control. (Source: Int J Diab Dev Ctries 2008;28:114–20)


Make Sure

Situation: A hypertensive patient on atenolol developed erectile dysfunction (ED). Atenolol was stopped.
Reaction: Oh my God! Why did you stop beta-blocker. You should have just switched over to nebivolol.
Make Sure that nebivolol is used as the beta–blocker of choice in a hypertensive patient with ED. (Source: Asian J Androl 2006;8(2):177–82.)

Laughter the best medicine

When you breathe, you inspire. When you do not breathe, you expire.

Respiration consists of two acts: first inspiration, then expectoration.


Formulae in Critical Care

Waist–to–hip ratio
Formula: Maximum abdominal circumference/maximum hip circumference.

Punjab & Sind Bank
Central Bank of India

Milestones in Neurology

Pierre Paul Broca (1824–1880) was a French physician, anatomist, and anthropologist. He was born in Sainte–Foy–la–Grande, Gironde. He is best known for his research on Broca’s area, a region of the frontal lobe that has been named after him.

Mistakes in Clinical Practice

Include drug name, exact metric weight (i.e, grams, milligrams, micrograms, and milliliters), concentration, and dosage form.

1–7 April Prostate Disease Awareness Week: Prostate SMS of the Day (Dr Anil Goyal)

Enlargement of prostate is not similar in every patient. The enlargement varies in size and shape. No two patients behave the same.

Lab test (Dr Navin Dang)

Typhidot has no FDA approval and has minimal supportive literature to prove its accuracy.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name Indication Approval Date
Amlodipine Tablets 5mg/10mg (additional indication)
1. To reduce fatal coronary heart disease and non–fatal myocardial infarction, and to reduce the risk of stroke.
2. To reduce the risk of coronary revascularization procedures and the need for hospitalization due to angina in patients with coronary artery disease.

(Advertorial section)



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eMedinewS–PadmaCon 2010 

Will be organized at Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

eMedinewS–revisiting 2010

The second eMedinewS–revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited.

Stress Management Workshop (April 17–18)

A Stress Management Workshop with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized on April 17–18, 2010.

Organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, in association with IMA New Delhi Branch and IMA Janak Puri Branch

Venue: Om Shanti Retreat Center, National Highway 8, Bilaspur Chowk Pataudi Road, Near Manesar.

Timings: On Saturday (2pm onwards) and Sunday (7am 4pm). There will be no registration charges, limited rooms, kindly book in advance, stay and food (satvik) will be provided. For booking e–mail to emedinews@gmail.com or sms to Dr KK Aggarwal 9811090206/ BK Sapna 9811796962

Stroke Update Workshop for GPs

Indian Stroke Association and International Stroke Conference is organizing a Stroke Update Workshop on March 13–14, 2010 at AIIMS Auditorium. eMedinewS has tied up with the conference for free registration for the first 200 GPs of NCR. Organizer: Dr Padma, Prof of Neurology, AIIMS, New Delhi. SMS for free registration to 9717298178 or email to isacon2010@gmail.com

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.

Readers Responses

  1. Dear Padmashri Dr. K K Aggarwal: I have really become a fan of yours by the way u r handling the e Medinews. This is one of the best way to keep yourself updated other then your field of practice. I read it daily and now I am interested in contributing. Since you are the editor and so probably there is a slight bias towards cardiology articles. I am a neurosurgeon based in Hyderabad and if u feel it is possible I would like to contribute small articles related to neurosurgery on a regular basis. I work in Nizam’s Institute of Medical Sciences, I am basically from Delhi and earlier was in Delhi. We have postgraduate students whom we train and so I am quiet upfront with academics and the latest happenings in my field. I love writing provided I get time. If there is any scope for me to write in your newspaper I will be more then happy to do so. Kindly communicate to me on this front. Once again congratulations and best wishes for your endeavour. Regards: Dr. Suchanda B, Assistant Prof. Dept. of Neurosurgery, Nizam’s Institute of Medical Sciences, Hyderabad, India.

  2. Very deserving tribute to you Congratulations! Dr Vinay Walia

  3. Sir, heartiest congratulations. We are proud of you: Dr. Pradeep Poswal

  4. Congratulations Sir for getting Padma award: Ashim