Saturday, March 17, 2018

India soon to have an essential list of diagnostic tests: AMR tests should be on priority

Dr KK Aggarwal

India may soon have an essential list of diagnostic tests along the lines of National List of Essential Medicines (NLEM).

According to the WHO, “essential medicines are those that satisfy the priority health care needs of the population and are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford.”

Having a list of essential medicines helps to monitor the costs of medicines so that the medicines included are available at affordable costs. Appropriate use of medicines listed in the NLEM promotes rational use of drugs. And, rational use of antimicrobial drugs reduces development of antimicrobial resistance.

Similarly, a national list of essential diagnostic tests would have several advantages such as facilitating therapeutic decisions resulting in improved patient care, affordable tests, reduced out of pocket expenditure and also promote rational use of essential medicines. It would also mean better regulation of diagnostic tests. These tests may be available as either point of care tests or in laboratories.

Ideally speaking, there should be no discrimination of diagnostic tests as essential or non-essential. All tests are essential.

But, if there is to be an essential list of diagnostic tests, then the first priority should be on diagnostic tests for antimicrobial resistance (AMR), a subject of immense public health concern. An essential list of diagnostic tests can be a strategy to check the rising prevalence of AMR. Rapid and correct diagnosis of infections would permit right and more targeted treatment thereby reducing overuse and/or inappropriate use of antimicrobials and in turn, the risk of antimicrobial resistance. This list should be introduced immediately and the rest can wait the bureaucracy. AMR tests should either be made free of cost or their subsidized costs should be uniform across the country.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Friday, March 16, 2018

Employing Ayush doctors in ICUs is professional misconduct

On Wednesday night, CNN-News18 broadcast a story which showed ICUs in some private hospitals in both Indore and Bengaluru did not have an accredited intensivist or a critical care physician, in charge and instead were being managed by Ayush doctors.

Employing Ayush doctors in ICUs violates the Code of Ethics Regulations as prescribed by the MCI in several ways and is a professional misconduct.

There are no ICUs in Ayush systems of medicine. Hence, their practitioners are inexperienced and/or ill-equipped in managing critically ill patients even with Ayush therapies.

Critical care medicine is a highly specialized field that requires skills to diagnose and manage life-threatening conditions in patients who may be already severely ill. Minimum standards for ICUs to be adopted throughout the country have been suggested by a committee in 2012 under the chairmanship of Prof MK Arora, Dept. of Anesthesiology at AIIMS, New Delhi as below.

Director / Incharge

·         Ideally an ICU must have a full time director or in charge, with full time appointment or at least dedicates 30%- 50% of professional time in ICU (2.1.1).
·         Senior accredited specialist in intensive care medicine with Postgraduate degree (PG) or equivalent   degree   in anesthesiology or internal medicine   or surgery   or critical care medicine.  He  should  have  formal  education/  training  and  experience  in intensive  care medicine  with preferably  5 - 7 years (full time) work experience  in intensive/  critical care medicine. Available upon request on notice in the hospital during "off duty hours (2.1.3).


·         Should possess MCI (Medical Council of India) recognized postgraduate degree in (PG) or  equivalent  degree  in  Anesthesia,  Medicine  or  Surgery  or Physicians  qualified  in intensive care medicine (
·         Should have minimum 3 years experience after post-graduation of which 3-6 months experience in intensive/ critical care medicine  (One with teaching experience  in critical care medicine is preferred (

Resident doctors (Academic or non-academic or fellows)

·         A minimum of two resident doctors must be on duty in an ICU and they must be on duty for 24 hours x 7 days (
·         One of the resident doctor must be a postgraduate in anesthesia or medicine or surgery with minimum of 3 months (preferable   6 months) full time working experience in ICU. The other resident doctor can be a trainee (Academic or fellow trainees after 1 years of training in their primary specialty and within the frame of their specialty, work in an ICU under clearly defined supervision) (
·         One resident doctor to take care of not more than five patients (

Any doctor who employs an Ayush practitioner as an assistant is responsible for his/her actions. This has been clearly stated in Regulation 7.18 of MCI Code of Ethics “In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician.”

While 7.18 does not “restrict the proper training and instruction of bonafide students, midwives, dispensers, surgical attendants, or skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians”, it does not allow issuing directions to Ayush doctors with regard to patient care in ICUs during rounds or otherwise. This would amount to training of training of Ayush doctors in critical medicine and violates the provisions of Regulation 7.10, which says, “A registered medical practitioner shall not issue certificates of efficiency in modern medicine to unqualified or non-medical person”.

Employing Ayush doctors to take care of patients in ICUs amounts to fraud, cheating and impersonification on the part of hospital owners, medical superintendent of that hospital including other doctors, if they are aware that Ayush doctors have been employed. Moreover, this does not have the consent of the patients.

All doctors who assign them duties including those who interview Ayush doctors to hire them in their hospitals are also liable for professional misconduct.  

As per Regulation 1.6 Highest Quality Assurance in patient care: “Every physician should aid in safeguarding the profession against admission to it of those who are deficient in moral character or education. Physician shall not employ in connection with his professional practice any attendant who is neither registered nor enlisted under the Medical Acts in force and shall not permit such persons to attend, treat or perform operations upon patients wherever professional discretion or skill is required”.

As doctors, patient safety and care is our first and foremost concern.

The Govt., Association and Regulators should take suo moto cognizance of this report and take appropriate action.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Thursday, March 15, 2018

Genesis of hoax message

Dr KK Aggarwal
Recipient of Padma Shri

A message advising against the use of paracetamol P/500 because it contained a virus “Machupo” is viral on social media. This message came up one year back and is still circulating in the media.

The Machupo virus causes a hemorrhagic fever, Bolivian hemorrhagic fever, which is included in the differential diagnosis of hemorrhagic fevers. Hemorrhagic fevers may present with jaundice such as Congo hemorrhagic fever, Yellow fever, or they can present without jaundice, such as dengue hemorrhagic fever and Bolivian hemorrhagic fever.

Bolivian hemorrhagic fever is also known as black typhus or Ordog Fever. It is a highly lethal disease.

The National Drug Authority issued a clarification saying that the story of P/500 having a virus "Machupo" is false and incorrect. It said that the Machupo virus spreads mainly via spray transmission of dust particles from the feces and urine of infected rodents. The said viruses like many others cannot survive the paracetamol tablets manufacturing process.

The “100th monkey phenomenon” can explain the genesis of hoax messages and why they spread so virally and linger on amongst the masses.

“Long time back there was a monkey called Emo in a far off village in Japan. Monkeys at that time used to eat apples lying in the gardens full of dust. One day Emo by mistake washed the apple in the pond before eating. From then onwards he washed every apple he ate. The message went from one monkey to the second monkey and then to the third and so on. Many monkeys started washing apples before eating. After sometime, some neighboring monkeys from other villages also started washing their apples before eating. The day the 100th monkey washed the apple and ate it, a strange phenomenon was observed all over the country. Monkeys all over the country started washing apples before eating. The critical mass in that area therefore was 100. Once the critical mass was achieved, the information spread like wildfire to each and every monkey and everybody started washing apples before eating.”

For a wave to spread across the entire nation, or for a hoax message to go viral, it must cover one percent of the population. This critical mass of one percent, once achieved, is the reason why ideas and movements spontaneously spread among the general population. And, people start believing them to be true.

Paracetamol is a drug, which is used in almost every household and is a well-recognized name. Hence, achieving the critical mass of 1% was not difficult in this case. Such messages generate fear and apprehension, which may be baseless.

Such hoax messages should be refuted. But to counter such a viral message, at least 2% population should get the message that the earlier message is a hoax. Govt., NGOs, Associations and pharmaceutical industry should come together to dispel such hoax messages circulating as ‘chain messages’ via social media in the interest of the general public.

Spreading such hoax messages should be made a punishable offence. 

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Wednesday, March 14, 2018

India sets 2025 as deadline for complete elimination of TB in the country

India has set a target for complete elimination of TB by 2025, before the global target date of 2030 as announced by the Prime Minister Shri Narendra Modi in his inaugural address at the “the Delhi End TB Summit 2018”.

The Prime Minister expressed confidence that the Delhi End TB Summit would be a landmark event towards the complete elimination of TB. He has also asked all Chief Ministers to join in this campaign. In his speech, he acknowledged the role of frontline TB physicians and workers as a crucial part of the drive to eliminate TB and hailed the people afflicted with the disease “those patients who overcome this disease also inspire others”. He called for “multisectoral engagement and interventions” to achieve the desired target (PIB, Prime Minister's Office, March 13, 2018)

The Prime Minister launched Tuberculosis free India campaign on the occasion, to take forward the activities of the National Strategic Plan for Tuberculosis elimination (2017-2025) with its vision of a TB-Free India with zero deaths, disease and poverty due to tuberculosis. The four strategic pillars of NSP 2017-2025 to achieve Universal Access to quality TB diagnosis and treatment are “Detect – Treat – Prevent – Build” (DTPB).

The Summit has been jointly organized by the Ministry of Health & Family Welfare, SEARO (WHO South East Asia Regional Office) and the Stop TB Partnership.

TB is a preventable and curable disease. Yet, India has the highest burden of TB patients, including drug resistant patients in the world. MDR-TB is a public health emergency, not only for patients but also for doctors, who are at risk of acquiring the infection from their patients.

Recognizing this public health emergency, during my tenure as National President IMA, we had launched “GTN” as IMA End TB Strategy, where G stands for GeneXpert test (sputum diagnosis), T for Trace (contacts) and Treat. N is to Notify the disease at Nikshay (mandatory).

Every sputum should be tested with GeneXpert test to not only diagnose TB, but to also detect rifampicin resistance. Rifampicin resistance indicates primary MDR TB. Rifampicin resistance should be confirmed before starting ATT. The prevalence of MDR TB is more than 2% in primary TB cases.

All contacts of patients with infectious TB should be traced, screened and if required, treated with a full course of ATT. Early detection means early and better treatment, which will prevent further spread of TB. 

WHO has defined a household contact as a person who has shared the same enclosed living space for one or more nights or for frequent or extended periods during the day with the index case during the 3 months before starting the current treatment. While, a close contact is a person who is not in the household but has shared an enclosed space, such as a social gathering place, workplace or facility, for extended periods during the day with the index case during the 3 months before commencement of the current treatment episode (Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries. WHO 2012).

Every doctor should register with Nikshay and report every TB case at

We stand alongside the Prime Minister, in his initiative to eliminate TB from the country by 2025. 

I appeal to all doctors to participate wholeheartedly towards this end.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Tuesday, March 13, 2018

Allahabad High Court directs state govt. to improve medical facilities in govt. hospitals

Dr KK Aggarwal and Ira Gupta

In a recent judgement, the Hon’ble Division Bench of the High Court of Allahabad has issued directions to the State Government, UP for improving the medical facilities in the Hospitals maintained by State Government. These directives were issued in response to two writ petitions filed before the High Court in the matter of Sneh Lata Singh & Others vs State of UP & Others, PIL No. 14588 of 2009 and in Raj Kumar Singh vs State of UP bearing PIL No. 65217 of 2008. The Chief Secretary, Lucknow was directed to ensure supervision and compliance to these directions of the Hon’ble High Court.

In the matter of Sneh Lata Singh & Others versus State of UP & Other, the complainant asked for reimbursement for medical expenses, as well as compensation for physical suffering relating to a pregnancy-related complication (vagina fistula) due to incompetent care provided to her at a govt. hospital. Simultaneously, the writ petition also highlighted various shortcomings in the hospital, notably poor infrastructure, staff shortage, unaccountability and apathy, underutilized funds.

The second petition, Raj Kumar Singh vs State of UP, was filed by a social worker and Editor of Weekly Newspaper, who asked the court to make it mandatory that all District Private Hospitals and Nursing Homes should display qualification and designation of Paramedical staff. The petition filed by him also asked for an inquiry into MTPs being done by Hospitals and Clinics without being registered the Medical Termination Pregnancy Rules 2003.

·         Immediate steps shall be taken to fill in existing vacancies of Medical, Para Medical and other attending staff at various levels

·         Necessary supply of quality medicines to all Medical Care Centre at different levels must be ensured.

·         Similarly availability of requisite apparatuses, instruments, operation theatres and other medical requirements as per status of Medical Care Centres be maintained and continuous maintenance should be ensured

·         For medical care of women, especially pre-natal and post natal treatment, lady Doctors and supporting lady Para Medical and Nursing Staff be recruited and their availability be maintained.

·         Director General Vigilance shall constitute special teams at District level to find out Medical Officers of State Government who are engaged in private practice or running Hospitals, Nursing Homes or attending or providing treatment to patients in such private Hospitals etc. Said teams shall also investigate into cases of radio diagnosis and pathology test from private institutions and establishments, in respect of patients who are under treatment at State Medical Care Centres.

·         Team shall find out reasons for non conduct of radiodiagnostic or pathological services by Govt. institutions.

·         Wherever private Radiodiagnosis and pathology tests are found as conducted from private hands, encouraged by Govt Medical Staff, appropriate action including criminal and departmental shall be taken against them.

·         It shall also be ensured that all Govt Officials should avail Medical Care services from Hospitals run and maintained by Govt.

·         Whenever any High level officials, political Executives or other dignitaries go for treatment, Medical Officer on duty, by roster, shall attend him and there shall be no special VIP treatment.

·         If medical care is obtained in Private Hospital etc., Govt must not reimburse the same.

·         However, if there are some kinds of diseases or ailment, treatment /cure whereof is not available in Government Hospitals, and for that purpose, treatment in private becomes necessary, this condition may be relaxed but in such contingency, Govt must ensure that for similar ailments and deceases if suffered by common poor people, arrangement should be made for their treatment also at Government expenses in such Private Medical Care Institutions.

·         State Government shall ensure transportation of patients to Trauma Centres.

·         Whenever vehicles are stopped for any reason including traffic signals, people must stop the same in a single line ensuring clear passage for ambulances and fire brigades etc.

·         Traffic Police Force including other Police Personnel shall ensure clear passage, proper parking of vehicles, non-encroachment of roads. Local Traffic Police people, if any congestion is caused, should be held personally responsible. Any damage suffered by injured/serious patients due to obstruction in smooth passage for ambulances etc. must be held a criminal liability including of traffic persons

·         Responsibility shall be fixed upon the residents and persons running commercial activities without providing parking space, by imposing heavy penalty etc.

·         Provision restricting purchase of new vehicles and registration thereof unless person(s) purchasing vehicle have parking place at their residences.

·         State Government shall also take immediate steps for providing dedicated corridors for movement of vehicles of essential service as an honor of fundamental right to patients and injured people to get quickest medical services and travel on road without any obstructions and also to ensure other essential services to be carried out without obstruction.

·         Special Committees at District and Block levels be constituted on permanent basis which may have participation of common people and members of society to monitor proper functioning of Medical Care Centres

·         Free food to patients and their attendants shall also be ensured in all State run Medical Care Centres

·         Fields, lawns etc. maintained in medical colleges, hospitals attached to medical colleges and other Government hospitals shall not be allowed to be used for any celebration or function like marriage ceremony of non- residential staff etc.

·         In no case any unregistered hospital or clinic (MTP Act) shall be allowed to function. Any laxity shall be treated personal responsibility of the concerned CMO.

·         State Govt shall also ensure that in no case funds allocated for Medical Services remain unutilized and unspent. Funds allocated for welfare of Medical Services, if are not spent, it means that requisite service to that extent has been denied.

·         Any authority in State Government if finds expedient, may approach this Court by filing an application for clarification/modification of this order

We have been repeatedly raising almost all of these issues at least for the last three years and have written to the govt. to address these deficiencies in health care delivery. The rising expectations of the patients is a major factor accounting for the widening gap and the distrust between doctors and their patients. When the expectations of the patients are not met, they may sometime resort to violence.

Self-regulation is the answer to this conundrum. Each one of us must work and carry out our duties and responsibilities wholeheartedly and with all sincerity. If we do not self-regulate, then the govt. will and it will do so with penal provisions. 

If the govt. will not regulate, then the courts will do so. And if the govt. fails to comply with the orders of the court, it may find the govt. in contempt of the court.

Health is a state subject. Therefore, all govts. should take note of these directions of the Hon’ble Allahabad High Court and implement them in their states.

Such matters should suo moto be taken up by the govt. if not the govt. then the High Courts in the interest of the general public.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

Monday, March 12, 2018

Trial by media: Is it just and fair?

Media has a great role in shaping the opinion of the society and how people perceive events that take place. It’s no longer just a medium of communication. Media can pronounce a person “guilty” simply by changing the perception.

This is what happened in the coverage of actor Sridevi’s death last month in Dubai, when the media conducted a trial and gave a verdict, even while the post mortem report was awaited. Several theories on what caused her death were making the rounds. Her death became a topic for discussion for almost everyone.

She was 54 years old and according to her family had no history of heart disease. The subtext changed quickly from sudden cardiac arrest to multiple plastic and cosmetic surgeries to diet pills to stress of her celebrity status to alcohol to even discord in her relationship with her husband and depression arising thereof. Her ‘suspicious’ death was also labeled as a possible homicide.

An autopsy may not take place on the same day of the death. Autopsy includes gross examination, blood tests, viscera analysis and histopathology. All these take time.

All these theories came to naught when following the completion of post mortem analysis, Dubai police headquarters stated that the death occurred due to drowning in her hotel apartment's bath tub following loss of consciousness.

Media even ruled out cardiac arrest.

The fact is even drowning death cannot occur without cardiac arrest. Drowning death can be seizure or arrhythmic unconsciousness leading to gasping, aspiration of water and death while taking a bath in the tub or falling down in the tub. In the first case, the person will be in the bathing dress and in the second, the person will be fully dressed up.  

In medicine, there is always a way of differential diagnosis and until a final diagnosis is reached, it’s not right to speculate.

An unfair media trial creates wrong perceptions, myths and generates fear and apprehension such as multiple cosmetic surgeries may lead to a heart attack.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA