October 25   2015, Sunday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal
The dangers of excessive alcohol consumption

Excessive alcohol consumption and under-age drinking are issues common to almost all countries, including India. The problem of excessive alcohol consumption is plaguing the entire country and if appropriate measures are not implemented, the number of deaths caused due to alcohol-related causes will continue to rise at a high pace. Alcohol consumption is a critical challenge and is often the root cause of various social and economic problems. It is the cause of death of over 2.5 million individuals every year (almost 4% of all deaths worldwide), and the third leading risk factor for poor health globally, accounting for 5.5% of disability-adjusted life years (DALYs) lost. In a country like India, which is home to 1.27 billion people and records one of the highest drinking and driving deaths yearly, stringent laws and checks are a must.

The urgent need to raise awareness about the evils of alcohol consumption has been brought up by most National and International bodies during their annual meetings. The World Medical Association (WMA) recently during its General Assembly meet issued a declaration, which focuses on reducing excessive alcohol consumption and framing new policies for harm reduction.

The WMA Statement stresses on the following:

• Chalking out various effective alcohol harm-reduction policies and measures that will target overall alcohol consumption by imposing some legal and regulatory measures

• Innovating new health and social policy interventions that will target high-risk drinkers and other vulnerable groups and the resulting harms

• Strengthening weak alcohol policies and prevention programs that are ineffective at protecting health and safety, and preventing harm

• Bringing in international public health advocacy and partnerships to strengthen and support the ability of governments and civil society worldwide to commit to, and deliver on, reducing the harmful use of alcohol

• Educating and encouraging health professionals in preventing, treating and mitigating alcohol-related harm, using effective preventive and therapeutic interventions

The World Medical Association has taken a leadership role to encourage and support the development and implementation of evidence-based national alcohol policies by promoting and facilitating partnerships, information exchange and health policy capacity building.

In addition to this, WMA suggested priorities in the development of policies and legislative responses related to alcohol in the countries. These include:

• Increase alcohol prices, through volumetric taxation of products based on their alcohol strength, and other proven pricing mechanisms, to reduce alcohol consumption

• Regulate access and availability of alcohol by limiting the hours and days of sale, the number and location of alcohol outlets and licensed premises, and the imposition of a minimum legal drinking age

• Governments should tax and control the production and consumption of alcohol, with licensing that emphasizes public health and safety and empowers licensing authorities to control the total availability of alcohol in their jurisdictions

• Public authorities must strengthen the prohibition of selling to minors and must systematically request proof of age before alcohol can be purchased in shops or bars

• Restrict alcohol marketing to prevent the early adoption of drinking by young people and to minimize their alcohol consumption

• Impose regulatory measures range from wholesale bans and restrictions on measures that promote excessive consumption, to restrictions on the placement and content of alcohol advertising that is attractive to young people

• Increase public awareness of harmful alcohol consumption through product labeling and public awareness campaigns.

• Social marketing campaigns to educate the public about harmful alcohol use. Encouraging drink driving policies and regulating health-warning labels on alcohol products, mandated by an independent authorized body.

• Key drink-driving deterrents should be implemented like strictly enforced legal maximum blood alcohol concentration for drivers of no more than 50mg/100ml, supported by social marketing campaigns and giving power to authorities to impose immediate sanctions

The WMA also recommends that medical and social workers should be trained and provided with adequate resources to prevent harmful use of alcohol and treat people with alcohol dependence.
Breaking news
Non Invasive FFR: To place or not to place the stent

Noninvasive FFR takes a standard set of CT angiography images acquired in the usual way: It segments those images and creates a 3D model of them. Then, through computational fluid dynamics (a complex data analysis that requires supercomputers), it simulates conditions of hyperemia in that heart and with that amount of myocardium that's perfused by the vessel to come up with pressure and flow data that mimic the invasive data. These data are presented in exactly the same way, such that an FFR CT ≤ 0.8 is likely to indicate ischemia, whereas a higher one (> 0.8) is unlikely to be hemodynamically significant.
Dr Good Dr Bad
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Specialty Updates
• The first randomized trial for fecal transplant has shown mixed results. In one of two treatment centers, fecal microbiota transplantation prevented further Clostridium difficile episodes in patients with recurrent infection, but in another center, there was no difference between transplantation and placebo. The study results were presented at the American College of Gastroenterology 2015 Annual Meeting.

• Findings from the ONTRAC (Oral Nicotinamide to Reduce Actinic Cancer) trial, published in the October 22 issue of the New England Journal of Medicine, suggest that nicotinamide is associated with a lower rate of new nonmelanoma skin cancers.

• Stopping breastfeeding due to pain or physical difficulties predicted an increased risk of postnatal depression, but stopping for other reasons, such as social reasons or embarrassment, did not, reported a new study published in the Journal of Advanced Nursing.

• New research suggests that leptin gene therapy may be more effective than dieting for long-term weight loss. The findings are published in the Journal of Endocrinology. Researchers describe how injecting a gene into the brain that codes for the hormone leptin may curb overeating, leading to long-term weight loss.

• High-functioning thyroid levels, including those falling within the normal range, show an association with an increased likelihood of dementia, even after adjustment for cardiovascular disease risk factors, thus suggesting a possible target for dementia and Alzheimer's disease therapies, suggested new research presented at the 2015 International Thyroid Congress and Annual Meeting of the American Thyroid Association (ITC/ATA).

• Diabetes and hypertension are independent risk factors for developing hepatocellular carcinoma (HCC) even when cirrhosis and its common causes are taken into account, suggests new research presented at the annual meeting of the American College of Gastroenterology.

• An advisory committee to the US Food and Drug Administration (FDA) voted 10 to 4 to recommend lesinurad 200 mg once daily for the treatment of gout-associated hyperuricemia, in combination with a xanthine oxidase inhibitor (XOI).

• In women who conceive using assisted reproductive technologies, there is an association between pregnancy loss and elevated urinary concentrations of endocrine-disrupting chemicals, known as phthalates, suggested new research presented at the American Society for Reproductive Medicine 2015 Annual Meeting.

• The oral investigational S1P receptor modulator ozanimod continued to be effective for moderate-to-severe ulcerative colitis through 8 months of treatment, suggested new research presented at the American College of Gastroenterology meeting.

• Children at genetic risk for Huntington's disease (HD) have weak connections between the striatum and frontal lobe, areas known to be affected by HD, suggests new research presented at the Society for Neuroscience (SfN) 2015 Annual Meeting.
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Media
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eSPIRITUAL
Never Hurt Ego of a Person
It is a well-known Vedic fact that if you hurt the ego of a person, he will never forgive you, especially, if you have insulted or implicated him in character assassination, cast implications, financial embezzlement or in public, you call a woman as old or a man as impotent.

For example, if I hurt the ego of a chowkidar, then the next time a patient comes to the hospital gate and enquires where Dr. KK Aggarwal is, he only has to whisper, "Which Aggarwal, whose cases never survive?"

Also never hurt the ego of a person who is drunk. Under the influence of alcohol, a person loses his capacity to judge persons and situations. If you provoke him, he can be destructive and aggressive.
Legal Quote
Jacob Mathew v. State of Punjab and Anr SC / 0457 / 2005: (2005) 6 SCC 1 (iii)

“To fasten liability in Criminal Law, the degree of negligence has to be higher than that of negligence enough to fasten liability for damages in Civil Law. The essential ingredient of mens rea cannot be excluded from consideration when the charge in a criminal court consists of criminal negligence.”
Medicofinance
Trusts

A trust is an arrangement where one entrusts property to one person or an organization. The person or trustee is appointed for managing the property on behalf of the beneficiary or beneficiaries. In a trust, a person transfers his property to another person i.e. the Trustee to hold it for the benefit of certain beneficiaries. By adopting a Trust route a person can avoid the issues which arise in a Will and make a ring fenced structure to ensure that the person’s future generations are well-protected through a vehicle created by him and according to his directions.

(Source: IJCP)
Industry News
Startups may get tax incentives: Startups are the buzzword in the Indian economy and are the epicentre of economic activity. However, India is not a tax-friendly haven for startup investments and there are over 100 startups that have registered abroad. Most of the Indian startups register themselves in Singapore, the US or Hong Kong to raise capital. Sources in North Block, which houses the finance ministry, say that they have already begun consultations to give incentives to startups in the form of offering tax sops to angel investors. (Business World)

Top 5 digital marketing trends ruling India in 2015: With the second largest internet population and an Internet Industry growing at the rate of over 20%, India offers avenues for those who are planning to get into this industry. This Digital Marketing era is bigger than computer revolution of early 90s and Communication Revolution (Mobiles) in early 2000s. The top digital trends are: Mobile Apps in Daily Life, Marketing Automation, Social Conversions and Online Reputation Management (ORM), Content Marketing and Location Based Advertising. (Iamwire.com- Guest Column)

Apple Watch coming in India: The Apple smartwatch will become available in the country starting November 6 as mentioned on the Apple India website. But, there is no mention of the Apple Watch's price on the official website. It is expected that the smartwatch will start at approximately Rs 30,000 in the country. In the US, the Apple smartwatch, which is compatible only with iPhones, costs $349 for the base model. (Times of India)

Payments banks to reduce rural remittance costs: The decision by RBI to grant 'in principle' approval for eleven entities to set up payments banks, which would be directed at small savers could help transform the rural remittances market, the World Bank said in a report on Monday. The entry of new players is likely to increase competition, lower remittance costs, and extend the formal market for remittances, it said. (Times of India)
Inspirational Story
Great Attitude

Once a Bird asked a BEE, after continuous hard work, you prepare the honey....

But a man steals the honey.
Do you not feel sad?"
Then the Bee replied, Never......
Because a man can only steal my honey, not the art of making honey
eWELLNESS
Don’t ignore women’s health

Women are not diagnosed or treated as aggressively as men. Even though more women than men die of heart disease each year, women receive only 33% of all angioplasties, stents and bypass surgeries; 28% of implantable defibrillators and 36% of open–heart surgeries, according to the National Coalition for Women with Heart Disease.

Although the traditional risk factors for coronary artery disease — such as high cholesterol, high blood pressure and obesity — have a detrimental impact in men and women, certain factors play a bigger role in the development of heart disease in women.

• Metabolic syndrome — a combination of increased blood pressure, elevated blood glucose and triglycerides — has a greater impact on women than men.
• Mental stress and depression affect women’s hearts more than they do men’s.
• Smoking is much worse for women than men.
• A low level of estrogen before menopause is a significant risk factor for developing microvascular disease.
• Though women will often have some chest pain or discomfort, it may not be the most prominent symptom. Diffuse plaques build–up and diseased smaller arteries are two reasons why symptoms can be different in women.
• In addition to chest pain, pressure or discomfort, signs and symptoms of heart attack in women include: Neck, shoulder, upper back or abdominal discomfort, Shortness of breath, Nausea or vomiting, Sweating, Light–headedness or dizziness and unusual fatigue.
• Endothelial dysfunction is more common in women. In this the lining of the artery does not expand (dilate) properly to boost blood flow during activity, which increases the risk of coronary artery spasm and sudden death.
• Results of the WISE study suggest that the commonly used treatments for coronary artery disease — angioplasty and stenting — are not the best options for women with more diffuse plaques.
• Typical tests for coronary artery disease — angiogram, treadmill testing and others — are not reliable in women.
• The WISE study showed that in some women, plaques accumulate as an evenly spread layer along artery walls, which is not visible using traditional testing methods.
eMEDIPICS
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Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
MTNL Perfect Health Mela 2015.

Pls click here for details
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eMEDI QUIZ
An enzyme involved in the catabolism of fructose to pyruvate in the liver is:

1. Glyceraldehyde-3-phosphate dehydrogenase.
2. Phosphoglucomutase.
3. Lactate dehydrogenase.
4. Glucokinase.

Yesterday’s Mind Teaser: How often should you have a Pap smear?

A. Once a year after puberty.
B. Once a year after either turning 21 or having sexual intercourse for the first time.
C. Once a year after age 21 and every two years after 30.
D. Once a year if you’re not in a monogamous relationship.
E. Once a year unless you’ve been vaccinated against the human papillomavirus (HPV). Then screening is not necessary.

Answer for Yesterday’s Mind Teaser: B. Once a year after either turning 21 or having sexual intercourse for the first time.

Answers received from: Dr Avtar Krishan, Dr Jainendra Upadhyay, Dr Bitaan Sen & Dr Jayashree Sen, Dr Poonam Chablani, Dr K V Sarma, Daivadheenam Jella.

Answer for 23rd October Mind Teaser: B. At age 20.
Correct Answers received from: Dr Jainendra Upadhyay, Dr.K.Raju, Dr Poonam Chablani, Dr K V Sarma, Raghavendra Chakurkar, Dr Avtar Krishan.
Humor
Nobel Prize

A man is driving down a country road, when he spots a farmer standing in the middle of a huge field of grass. He pulls the car over to the side of the road and notices that the farmer is just standing there, doing nothing, looking at nothing.

The man gets out of the car, walks all the way out to the farmer and asks him, "Ah excuse me mister, but what are you doing?"

The farmer replies, "I'm trying to win a Nobel Prize."

"How?" asks the man, puzzled.

"Well I heard they give the Nobel Prize to people who are outstanding in their field."
BIOETHICAL ISSUES IN MEDICAL PRACTICE
Defensive Medicine

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

The rate of cesarean section deliveries is growing all over the country. Obstetricians are often accused of using cesarean section to increase their income. On the other hand, issues such as increasing maternal age, precious babies, mothers’ insistence, safety and ease, parents’ schedule preferences, and preferences for doctor’s and hospital’s office hour delivery all result in increasing operative deliveries. However all doctors believe that ‘natural is the way to go’ in pregnancy. Yet operative deliveries are undertaken to avoid the smallest risk to mother or child. What do you think?

a. Is caesarean section a part of defensive medicine?

b. Do you agree to cesarean section deliveries in general?

c. Can such sections lead to complications for the baby such as prematurity and therefore, should they be always avoided?

d. If no to cesarean section, then what is the alternative?

e. Should there be definite essential requirements for cesarean section?

Adapted and shortened from: UNESCO, 2011. Casebook on Human Dignity and Human Rights, Bioethics Core Curriculum Casebook Series, No. 1, UNESCO: Paris, 144 pp.

Do write in with views and your solutions!
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Breaking news
WCD Ministry Issues Model Guidelines for Foster Care

The Union Ministry of Women and Child Development has issued Model Guidelines for Foster care. These guidelines have been developed through a consultative process involving representatives from States/UTs, Non-governmental organizations, civil society, academicians, experts and organizations working on alternative care. The Model Guidelines on Foster Care detail the procedures, roles and responsibilities of stakeholders, along with various aspects related to the implementation of the foster care program in the districts. These Guidelines have been strengthened by providing additional formats for preparing case study of the child, application form for the foster carer/parents to apply, tools for counselling before and during the process to the child, the foster carer/parents and the biological parents of that child, if available. The IEC material for supporting the foster carer/parents on helpful tips, the rewards and challenges of a foster parent, and a summary card on steps on becoming a foster carer are also covered in the model foster care guidelines.

These Guidelines however do not cover Pre-adoption Foster Care as in such cases Guidelines Governing Adoption of Children, 2015 will apply. These Guidelines may be adopted or adapted as per the requirement of the State/UT. (Press Information Bureau)
MAKE SURE
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Indian Medical Association National Satyagraha for a Healthy India
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IMA Satyagraha, suggested slogans
• Writing prescription drugs by a non-MBBS is injurious to health of the community.
• Writing prescription drugs by unqualified people can be dangerous.
• Allow doctors to treat patients irrespective of patients’ income.(If compensation is not capped, we can't do this)
• When there is capping of Rs 2 lakh for a sterilization death, why not for other procedures?
• When there is a compensation of Rs 30,000/- for a sterilization failure, why not for other procedures?
• Allow us to treat poor and rich equally.
• Non pelvic ultrasound providers should be out of PCPNDT Act.
• Unless caught doing sex determination, no criminal offence shall be registered.
• If any prospective parent asks for sex determination, they should be booked under a non bailable offense.
• More patients will die if doctors are not provided protection during duty hours.
• Death does not mean negligence.
• Money spent does not mean you will get a cure.
• Including single clinic and small establishments under Clinical Establishment Act will make treatment costly.
• How can we treat patients using outdated standard treatment guidelines made by government?
• How can government decide the charges of a clinical establishment?
The apex consumer court has asked the Centre to ensure presence of some officials at every hospital handling cases of Central Government Health Scheme (CGHS) to answer queries of patients and to provide toll free enquiry number in this regard.
An evaluation of the Rashtriya Swasthya Bima Yojana (RSBY) has concluded that the government-financed health insurance scheme had little or no impact on medical impoverishment in India. (Times of India)
Survey for Monitoring the National Noncommunicable Diseases Targets

The Indian Council of Medical Research (ICMR) will be the nodal agency for surveillance of non communicable diseases (NCD) in the country NCD. It has been allocated budget to undertake a national level survey for monitoring the national Noncommunicable Diseases targets during 2015-2016. The survey will generate country/national level estimates of key NCD related indicators (risk factors and health system response) identified in the national NCD monitoring framework for the year 2015, create a central and regional pool of resources (protocols, standard tools, training manuals etc.) to support conduct of similar surveys at state level, and strengthen capacities for monitoring of NCDs at national and sub-national level. The population to be surveyed includes both male and female, residing in urban and rural areas in face to face interviews. The points to be assessed are key behavioral risk factors, physical measurements, laboratory assessments and health facility assessments for national systems response. (ICMR)
Geriatrics Society Offers Alternatives to Beers Drugs

The first-ever list of alternatives to the drugs deemed by the Beers Criteria to be risky for elderly patients is now available. Dr Todd Semla, PharmD, from Northwestern University in Chicago, who cochaired an American Geriatrics Society (AGS) panel that updated the Beers Criteria gave an overview of the updated criteria and the list of alternatives here at the American College of Clinical Pharmacy 2015 Global Conference. The update was published online October 8 in the Journal of the American Geriatrics Society, along with a guide for the use of the updated criteria and the list of alternative medications. (Medscape)
Living near airports is injurious to health

Findings are based on a study of the 12 largest airports in California in the US suggest that people who live within 6 miles of an airport are at higher risk of health problems. Air traffic congestion, which leads to aircraft spending more time idling and taxiing on the tarmac, is responsible for extra pollution, mainly from carbon monoxide. Periods of air traffic congestion accounted for a 17% increase in hospital admissions for asthma and a 9% increase in heart problems. Older people and young babies were at most risk. The findings are published in the Review of Economic Studies. Two thirds of people with asthma find air pollution makes their asthma worse, which increases their risk of a potentially fatal asthma attack.
Med school enrollment in the US hits new high

As per the Association of American Medical Colleges (AAMC), the number of people applying to medical school increased by 6.2% for 2015, which followed a 3.1% jump the previous year. A total of 52,550 people applied to medical school in 2014 for enrollment in 2015; of those, 38,460 were first-time applicants, an increase of 4.8% from the previous year. Medical school enrollment for 2015 was 20,630, an all-time high and an increase of 25% since 2002. Darrell Kirch, MD, the AAMC's president and CEO, said, “One goes back to the notion of service; there aren't many forms of service more clear, direct, and gratifying than caring for patients. The other reason is that medical schools have not remained in an ivory tower; they're changing what they offer to students. These last two decades have seen more change in the way we teach, the tools we teach, and our embracing technology.” (Medpage Today)
WHO advisory groups recommend pilot implementation of first malaria vaccine

The World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) and the Malaria Policy Advisory Committee (MPAC) jointly recommended pilot projects to understand how to best use a vaccine that protects against malaria in young children. The vaccine, known as RTS,S, is the first vaccine for malaria and acts against P. falciparum. It requires four doses for a child to be fully protected and therefore requires additional contacts with the health care system. The first three doses are given one month apart followed by an 18-month pause before the fourth dose. Without the fourth dose, children had no overall reduction in severe malaria. It offers no protection against P. vivax malaria, which predominates in many countries outside of Africa. The malaria vaccine may complement the proven malaria preventive, diagnostic and treatment measures. (WHO)
Hospital administrators, physicians, and other healthcare personnel should start taking greater advantage of video technology by filming medical procedures, argue three researchers in an editorial published in the BMJ. "Healthcare can benefit from the power of cameras to improve accountability," write Martin Makary, MD, MPH, professor of surgery and health policy and management, Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. "In an era where 86% of nurses report having recently witnessed disruptive behaviour at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement too," they write. (Medscape)
List of Notifiable Diseases
 
1. Cerebrospinal fever
12. Tuberculosis
2. Chickenpox
13. Infectious Hepatitis (Hepatitis A, B, C, D & E)
3. Diphtheria
14. Epidemic Influenza (Including Swine Flu (H1N1), Bird Flu & Seasonal Influenza)
4. Leprosy
15. Whooping cough
5. Cholera
16. Viral encephalitis
6. Measles
17. Hemorrhagic fever (Including Dengue)
7. Plague
18. Malaria
8. Rabies
19. Tetanus
9. Scarlet fever
20. Poliomyelitis
10. Smallpox*
21. AIDS
11. Typhoid/Enteric fever
22. Chikungunya
23. Any other disease which the Government may from time to time by notification declare to be a notified disease for the purpose of this part either generally throughout the state or in such part or parts thereof as may be specified in the notification.

*Small Pox globally eradicated in the year 1980, but continues to be a notifiable disease.
IMA JIMA
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GP Tip: Fluid intake

Fluid intake depends upon the body weight. Never instruct your patients to take a lot of fluid. 30 ml/kg is the adequate requirement.

(Source: IJCP)
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Readers column
Dr. Aggarwal, Sir, emedinews sounds like a wonderful way to start the day. I love to be a part of it! Dr Kalpesh
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Press Release
IMA urges the government to withdraw plans to start a Bachelor of Science in Community Health

The Indian Medical Association strongly objects the Government move to start BSc Community Health course under the National Board, to man sub-centers and empowering them to prescribe medicines.

Speaking about this issue, Padma Shri Awardee Dr A Marthanda Pillai National President and Padma Shri Awardee Dr K K Aggarwal Honorary Secretary General and President Heart Care Foundation of India in a joint statement said, “Sub centers are the cornerstones of disease prevention activities and implementation of national health programs and not primarily meant to provide curative service except home remedies. The staff pattern in the sub center consists of one male and one female multipurpose health worker (JPHN/JHI/ANMs). The job description of these staffs is family welfare services, immunization, awareness, household visits, data collection regarding disease prevalence, and coordinating other national disease control programs. These staffs currently work under the supervision of a medical officer posted in PHC. For this purpose there is no need for a more qualified workforce. Posting the proposed BSc (Community Heath) graduates in sub centers will be a wrong human resource management”.

At the Sub Centre level, a more suitable workforce would be an ASHA worker with basic primary education and training. So the concept of posting paramedics at sub centers will be a gross waste of human resources and will be counterproductive for the purpose they are meant. The policy proposal on this is not based on ground reality and is conceptually wrong. The deployment of over qualified staff at sub centers will only increase the attrition rate. Entrusting the newly proposed BSc (Community health) graduates to manage very sensitive areas like child health within the health system may even worsen the situation. To leave the health of children and adolescents in the hands of ill-equipped personals is detrimental and may nullify the results of years of hard work that the country has put into reducing child mortality and morbidity

Moreover, if the Government’s intention is to produce health workers to work in sub centers, then why should such courses be conducted by the National Board of Examination (NBE). In fact the NBE conducts postgraduate courses and not even undergraduate courses in modern medicine. Allowing these graduates to be registered under Medical Council will set a wrong practice.

IMA therefore, urges the Government to desist from the move to start BSc (Community Health) course.
Digital IMA