Fake drugs abound, especially in low- and
middle-income countries. The WHO has recently published reports
documenting its prevalence, delineating its consequences and expounding
on possible measures to contain this pervasive problem. In 2013, the WHO
set up a global monitoring system to track drugs that were deliberately
fraudulent, failed to meet quality standards, or had not been evaluated
or authorized for market. Approximately 10% of drugs in low- and
middle-income countries are substandard or falsified. They include both
generic and patented molecules equally. The commonest are antimalarials
(19.6%), antibiotics (16.9%), and anesthetics and analgesics (8.6%).
The WHO has proposed a three pronged strategy
‘prevent, detect and respond’ to tackle this deep rooted problem. The
University of Edinburgh and the London School of Tropical Medicine and
Hygiene have developed models to predict the impact of substandard
medicines. According to this model, a prevalence of 10% of fake
antibiotics will result in 72 430 excess childhood deaths annually due
to pneumonia. Similarly, there are estimated 2.1-4.9% excess deaths due
to malaria when fake antimalarials are prevalent.
The consequences of fake drugs encompass economic
losses, social impacts and medical issues like antimicrobial resistance.
(Nature News 29 November 2017)
The Better Birth Checklist
If the misery of the poor is due to the inefficiency
of our institutions rather than the laws of nature, great is our sin.
Childbirth remains the second largest killer of women in the child
bearing age group. And the numbers do not appear to be improving much
over time.
The WHO has developed a checklist for use by birth
attendants in the 48 hours around childbirth. This was tested in one of
the largest trials done in the area of childbirth and neonatal care that
covers more than 300, 000 mothers and newborns in over two years
starting in 2014. In this study, birth attendants were coached on the
use of a checklist in 60 health centers of Uttar Pradesh, India. They
were compared to a control group where coaching was not done. After 2
month of coaching, the adherence to essential birth practices was 73%
versus 42% in the areas where coaching was not done.
Proper administration of oxytocin following child
birth was 80% in the facilities where intervention had been done
versus 21% in the control group. Initiation of breast feeding (70%
versus 4%) and skin-to-skin contact (795 versus 11%) was
also higher in centers where birth attendants had been coached.
Appropriate measurement of blood pressure (68% versus 7%) and
newborn temperature measurement (43% versus 0.1%) was also higher
in the study group in comparison to the control group.
As Atul Gawande says in his book ‘The Check list
Manifesto’ – Man is by nature flawed and inconstant. The volume and
complexity of what we know has exceeded our individual ability to
deliver its benefits correctly, safely, or reliably. Good checklists on
the other hand are precise and easy to use even in the most difficult
situations. The check lists if used judiciously in medicine can yield
rich dividends. (NEJM 14 December 2017)
The National Medical Commission Bill
The Government is all set to replace the Medical
Council of India with a new National Medical Commission (NMC). The
commission will have 25 members nominated by the Government. They will
include persons from wide ranging disciplines such as management, law,
ethics, research, consumer advocacy, science and technology and
economics. There will be only 5 doctors in the commission.
NMC has prescribed an ‘exit exam’ for MBBS graduates,
wherein after qualifying all examinations conducted under MCI, an extra
exit examination will be mandatory for getting license. NMC would also
relax criteria for establishing a new medical college. Under the Bill,
no separate permission is needed for postgraduate courses after
undergraduate recognition. Automatic increase in seats would also be
allowed, which earlier required permission from MCI. One of the critical
changes that the new law is expected to bring about is determination of
fees. While the MCI did not have any power to prescribe fees, the NMC
can frame guidelines for determining the fee for up to 40 per cent of
the seats in private medical colleges. The NMC Bill had earlier
mentioned the merger of the Post-Graduation Board and the National Board
of examination in the draft version. But the clause has been dropped
from the current version that was tabled in the parliament
In this ‘winter of discontent’ when prevailing public
sentiments about medical practice and doctors is largely unsympathetic,
doctors in India need to ponder deeply and participate actively in
defining the direction in which health care is headed. (The Hindu 25
December 2017)