Posts filed under ‘Health & Wellness’

Child Mortality

Child Mortality 1

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Child Mortality 2

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Child Mortality 3

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While the info-graphics above need no explanation, for those who lack the time to enlarge the image and peruse them, am mentioning below some key take-aways :

  • 6.6 Mn children under the age of 5 died in 2012
  • The global under-5 mortality rate equals 48 deaths per 1000 births

o   In case you thought the scourge of pneumonia had been banished, think again ; it accounts for 17% of these deaths, and is the largest contributor, along with prematurity. Pneumonia is still the leading cause of deaths in 83 countries

o   Malaria is still a major killer in Sub-Saharan Africa, causing about 14 percent of under-five deaths in the region.

o   Deaths due to diarrhoea have been nearly halved in the past decade but it still accounts for a tenth of all under-five deaths. Deaths due to Diarrhoea are high in countries such as India, Afghanistan, Ethiopia, Somalia, Angola, Niger etc.

  • India, Pakistan, Bangladesh, China, Indonesia, Nigeria and China, 7 of the most populous countries, collectively accounted for half of the total number of under-five deaths globally

o   While China is mentioned among these, it’s under-5 mortality rate (at 14 deaths per 1000 births) is actually much less than that of the other nations , it features on this list die it’s large population base

o   Of these nations, the statistic is the worst for Nigeria, with an under-5 mortality rate of 124 deaths per 1000 births

In case to wish to see statistics on under-5 mortality rates or causes for a particular country, you can click on this link for causes and this link for rates.

  • Ravindra Ramavath

 

June 5, 2014 at 8:32 am Leave a comment

Molecular Diagnostics – An Introduction

Molecular Diagnostics (also known as nucleic acid based diagnostics) studies the composition of an individual’s genetic material – i.e. our DNA – in order to arrive at conclusions that have medical implications. The reason this science that is still in its infancy is hailed by many as the next frontier of medicine is that it is far more precise than previous methods, faster by several orders of magnitude – often giving results in hours vs. the weeks required by conventional tests, and can give results with far lower sample quantities. Additionally, it can sometimes give information that is simply not available from any other test.

Some kinds of molecular diagnostic tests help understand the likelihood of a patient responding positively to a particular medication, others help identify mutations that predict the probability of a healthy individual developing certain ailments in the future, yet others help conclusively identify the ailment at the root of troublesome symptoms so that the cause could be treated properly.

Basics of the science underlying the technique :

(note – those uninterested in a basic biology lesson can skip this section)

The cornerstone of molecular diagnostics is the identification of pathogenic mutations in an individual’s genetic material, i.e. their DNA.

Our DNA is made up of a sequence of pieces called genes. Each gene is made up of a series of bases (Adenosine,Thymine,Cytosine,Guanine, commonly written as A,T,C and G) in a certain order. These bases and the precise locations on the gene at which they are present are a molecular code that carries information required for making all the functional molecules – RNA and proteins – required by us. These proteins, once synthesised, are responsible for our characteristics – whether it’s the colour of our eyes and skin, our blood group, our tendency to gain weight quickly, or male-pattern baldness etc. Thus the bases and the sequence of their location on the genes are responsible for our heritable traits.

Small changes in the sequence of bases on a gene – such as substitution of one base for another, or omission or repetition of a small segment, can change the gene’s function and manifest as a difference, say in physical appearance etc. You can think of these bases on the gene as letters on this page that occur in a certain order to form words and sentences. Occasionally, a typographical error – a missing alphabet, a duplication, or a wrong substitution may occur, some do not matter much and we can still read the words and unnerstand them, but others may gargle (garble) the meaning of a word or sentence.

Similarly, most variations are harmless, but some can make the gene faulty; for instance, a particular protein may not be produced properly, or produced in the wrong amounts or not produced at all; such variations that make the gene’s operations faulty are called mutations. These mutations are the signposts that molecular diagnostics searches for and draws conclusions from. Thus the science is based on being able to recognise and map the structure of each gene, and identify mutations in them, as well as the knowledge of those mutations that affect our metabolic processes / physiology. This is not as easy a task as it sounds as human genes have from a few hundred up to two million bases on them (yes, really !) and you have to know and locate the specific mutation that is responsible for the effect under consideration.

(For further information on structure of the DNA, you can read the following :

What is a Genome

What is DNA 

What is a gene

How genes work 

Mutations and health

What is a gene mutation and how does it occur 

Inheriting genetic conditions )

 

Some Scenarios in which a molecular diagnostic test could be used :

Therapy support and therapy monitoring :

Determining probable response rates to certain therapies and their appropriateness for use in specific patients. In doing so, molecular diagnostics enables more personalised / individualised therapies, either with the goal of minimising harmful side-effects and / or judging how well individuals will respond to a planned course of treatment and whether they should go in for it.

This DNA-based approach to treatment, known as pharmacogenomics, is already in use in combating certain cancers.  Chemotherapy is prohibitively expensive and often has extremely painful side-effects, and not all patients respond equally well to a medication or cocktail of medications; getting the combination right often involves an initial trial-and-error phase, a frustrating and physically tortuous time for the patient. In the case of certain types of cancer, molecular diagnostics can help predict a patient’s response to a medication, thus avoiding much trauma – both emotional and physical, and saving time and money.

Take breast cancer, for instance. One of the medications used to avoid a recurrence after radiation therapy or chemotherapy is the drug Herceptin from Genentech. Now about 20-30% of breast cancer patients exhibit an over-expression of the Her2/neu gene and only these patients benefit from treatment with Herceptin.  A molecular diagnostic test to check for presence of the mutation of Her2/neu gene helps identify those that would benefit from the treatment; thus it costs about Rs. 15,000-20,000 to figure out whether a treatment running into lakhs of rupees will actually benefit someone. This is the personalised approach to medicine rather than the one-size-fits-all-with-the-same-ailment approach.

 

Early Detection Testing :

Detecting the presence of pathogens through detection of their RNA or DNA.

Using a molecular diagnostic test, diseases caused by a virus – think HIV and AIDS, HPV and cervical cancer, Hepatitis B, Hepatitis C etc. – could be quickly and reliably diagnosed well before the initial symptoms appear, thus giving physicians a longer treatment window and the patient a chance of earlier treatment and earlier return to good health. In these instances, the tests checks whether the RNA of the virus (ahem, which is significantly different from our DNA) can be detected in the patient’s tissue / sputum / blood sample sent for testing.

These tests can be used to detect other pathogens such as bacteria too. Consider the traditional diagnostic tests for TB which is caused by bacteria (Mycobacterium Tuberculosis). The current battery of tests include the Mantoux tuberculin skin test, a tissue culture, a sputum test, a chest X-Ray and a blood test; in spite of conducting all of these, there is a chance of getting a false positive or false negative result when the results are available a few weeks later. On the contrary, one molecular diagnostic test can confirm not just the presence of TB but also identify the genetic mutations in the bacterium and identify the strain of the bacterium responsible for the symptoms and which drugs it is resistant to, all this within a few hours.

Valuable info indeed in this era of multi-drug resistant TB (MDR-TB), when making a fast and accurate diagnosis of the type of TB infection a patient may have is the most important step to curing a patient.

 

Predisposition testing :

Analysing the probability of an individual developing certain genetically inherited diseases.

Such tests, done for risk analysis of cystic fibrosis, breast cancer and other hereditary diseases, can help understand whether an individual has a higher probability of developing an ailment than the general population. These are not definitive tests, in that they cannot predict whether an individual will get the ailment in future, they can only tell us that an individual has a higher or lower probability than the general population does of getting the ailment. Hence, there is still a lot of debate about whether such information is beneficial for an individual or not, whether it makes them worry unnecessarily about factors which they have no control over.

For instance, consider the BRCA1 and BRCA2 genes that belong to a class of genes known as tumour suppressor. A woman who has inherited a harmful mutation in BRCA1 or BRCA2 is about five times more likely to develop breast cancer than a woman who does not have such a mutation.

In a family with a history of breast or ovarian cancer, it may be informative to analyse a tissue sample of a patient (sufferer of breast cancer) and identify which harmful mutations are present; then other family members can be tested to find out if they also have the same mutation and their probability of developing breast cancer later can be computed. However, while a negative result can rule out breast cancer and bring a sense of relief, a positive test result only provides information about a person’s probability of developing cancer in future. It cannot tell whether an individual will definitely develop cancer; not all women who inherit a harmful BRCA1 or BRCA2 mutation will develop breast or ovarian cancer.

Note : Common medical problems such as heart disease, diabetes, and obesity do not have a single genetic cause—they are likely associated with the effects of multiple genes in combination with lifestyle and environmental factors, in such cases, genetics has a smaller, more complex role to play. More on this and other matters in another post.

  •  Zenobia Driver

(with a lot of assistance from assorted secondary sources)

March 10, 2014 at 12:54 pm Leave a comment

Updates

On Lifebuoy colour changing handwash :

Over a year ago, we’d written about the Lifebuoy team’s efforts to change the hand-wash habits (or lack of the same) of Indians in this post.  The post called attention to one aspect of Lifebuoy’s Swasthya Chetana campaign, the ‘glowgerm’ demonstration that children were invited to take part in. This involved applying a white powder to the palms of their hands, then washing with water only. Hands were then held under an ultra-violet light and the powder glowed where dirt remained, showing that hand-washing without soap was not enough. The children then repeated the process, this time using soap, only to discover the UV light showed no trace of the powder. This countered the common misconception that ‘visibly clean’ is ‘hygienically clean’, and, in an easy-to-understand manner, drove home the message that even clean-looking hands are dirty until washed with soap.

lifebuoy colour changing handwash 2

Now they’ve used colour changes to make another point with their latest product, Lifebuoy colour changing handwash. This time, the foam turns green after ten seconds to signal that all the germs have been wiped out. Am sure that the change in the colour as they scrub will grab every kid’s attention and ensure that they don’t wash the soap off immediately but scrub for a full ten seconds, at least while the product and the effect are still a novelty. As a communication tool, felt that the hulk mascot worked well too. You can view the ad for the product here.  

 

On the frozen yogurt market :

frozen yogurt brands

One of the trends we commented upon last year was the increasing popularity of hip frozen yogurt stores which could be termed cafés in terms of their popularity as hang-out places for youngsters.

The rapid expansion of this market has seen more competitors entering, read about the entry of foreign brands including the U.S based ‘Red Mango’, Canadian ‘Kiwi Kiss’ and others here, here, here and here.

 

  • Zenobia Driver

 

December 28, 2012 at 9:54 am Leave a comment

Update

Sometime last year, we’d run a series of posts on the topic on dealing with the challenge of ‘need, but don’t want’ in the health and wellness domain – you can read the posts in the series here, here, here and here. These discussed the problem of physiological (and often, medical) need for the product, but no desire to buy from the consumer; it’s a topic that we keep thinking about and researching ourselves, while keeping our eyes peeled for information on this topic from other sources.

As we mentioned in one of these posts :

In the healthcare space, while it’s tempting to say that there is the tangible benefit of getting better and that should matter to patients, the basic issue is that all the ill-effects of ailments such as diabetes, high cholesterol or BP are typically not evident immediately, thus, the benefit of taking medication regularly and of making other lifestyle modifications is unclear to many patients. Habit change is always hard, when the reward for it is nebulous and indeterminate, it only becomes more so.

Recently, thanks to my friends R & G, I came across this TED Talk that threw more light on this subject and I just had to share it with readers of this blog. In a nutshell, the speaker says that giving people medical information in a form that they can comprehend and that helps them see the way ahead to better outcomes, can actually boost their motivation to do something to achieve those outcomes.

A few sentences from the transcript of the talk are reproduced below to whet your appetite, hope you actually watch the entire video after reading these.

You’re looking at things where people are actually given information, and they’re not following through with it. It’s a problem that manifests itself in diabetes, obesity, many forms of heart disease, even some forms of cancer- when you think of smoking. Those are all behaviours where people know what they’re supposed to do. They know what they’re supposed to be doing, but they’re not doing it.

……

But for as much as clinical medicine agonises over behaviour change, there’s not a lot of work done in terms of trying to fix that problem. So the crux of it comes down to this notion of decision-making – giving people information in a form that doesn’t just educate them or inform them, but actually leads them to make better decisions, better choices in their lives. 

  • Zenobia Driver

September 7, 2012 at 10:41 am 2 comments

Turning Medical Services Upside Down

When I buy a book on Amazon or Flipkart, I can see the ratings and comments by hundreds of customers. But when I need to choose a doctor, I have to rely on the inefficient and inadequate method of asking friends, with whom I may or may not want to share my ailments. This is true whether I am trying to find a GP or a surgeon. And, after seeing the doctor, there is no way for me to rate him or her even for mundane things like whether or not he shows up on time to the clinic, let alone more important comments regarding his or her approach to medical care!  In contrast, I can easily find gigabytes of information about whether the keypad of a particular laptop model becomes sticky after use.

Another point to consider: Different people look for different things from a doctor: some may want the reassurance of the (imagined) old time family doctor, while others may prefer a “just give me the facts, I’ve brought my own sugar coating” approach. Why assume that we have the same expectations from doctors while we have entirely difference preferences for the texture of our cookies or the settings on our Facebook accounts?

Much of the discussion about modernization of medicine gets stuck in technology discussion (digital versus human interface).  However, what we need is a thorough modernization of medicine inside out, seriously thinking through which aspects of medical care would benefit from more information (including customer feedback) and which aspects would benefit from more customization and personal preference being taken into account.

Industry experts focus on customer segments and behavior for FMCG consumer products, but what about customer segments for the ultimate consumer product – medical care — the one that determines our life and health?  Isn’t it about time that the medical services industry starts thinking beyond the simplistic considerations of digitization of patient records, or focus on specialized clinics versus primary care, rural versus urban customers?

 

By,

Richa Govil

(Richa shares her thoughts on rural businesses at ‘Stirring the Pyramid’)

June 4, 2012 at 9:59 am Leave a comment

Reflections on the doctor-patient interaction

Last week, I shared two interesting articles on this blog, one of which was the transcript of an interview with Dr. Eric Topol, author of the book, ‘The Creative Destruction of Medicine’. Buried in this article was a very interesting question posed by the interviewer :

Is there a possible irony that in using all this technology to “personalize” medicine you “depersonalize” it instead ?

A valid concern indeed! While the advances in science and technology make it possible to treat every individual’s physiology as unique and we now often have the means to tell apart conditions that are symptomatically similar but in fact are different diseases altogether, in all the exhilaration about the advances in medical science we tend to forget that there’s a person-to-person connect that we humans yearn for – especially when faced with bad news, and this seems to be slowly reducing.

A few years ago, a friend’s father developed an eye problem that needed surgery. It was complicated and he was referred to a surgeon well-known for his expertise in the field. The surgeon examined him, confirmed the diagnosis, scheduled the surgery and then – undoubtedly with the best intentions – blandly told him to be prepared for the worst as the operation had a high failure rate. As luck (and the surgeon’s skill) would have it, the operation was successful and the gentleman is fine now. However, his children still remember their father’s distress at hearing the news and wish it could have been presented in a gentler, more humane fashion; at that time I remember that they bubbled over in anger and resentment at the “cold, heartless” surgeon.

I’ve heard similar versions of this story from multiple people that met a thoroughly competent but not-empathetic-enough doctor/ surgeon/ other clinician. Not just those suffering from an ailment of some sort, even pregnant women that visit their gynaecologist voice a similar desire for time, information, and most of all, reassurance.

Partly, our frustration and distress stem from the fact that as patients or friends and relatives of patients, we want the Doctor to be everything, Superman almost. We hanker for the simple comforting relationship and degree of involvement of earlier times, but with all the benefits of better diagnoses and effective medicines that are available today; we want the caring demeanour, the reassurance, the generosity of time that an old-fashioned family doctor gave; yet we also want this person to have the skills and knowledge of a specialist, to have invested the time to be up-to-date with all technological and medical advances and to have the latest scientific facts at his fingertips. Occasionally, we meet such people, but they are rare. It’s a very fine line between doctors telling the patient as it is and being positive about the outcome to keep the patient cheerful and positive. Unfortunately our medical system does not train well for this ‘fuzzy’ part of medical care, and hence it is up to individual doctors how they deal with it.

One that does it very well is an orthopaedist called Dr. Niranjan Deshmukh at Lilavati Hospital in Mumbai. Multiple people that I know have been to see him for various back, shoulder and leg injuries and have given glowing reports of their experience. Apart from a calm reassuring manner, this Doctor also spends time with patients explaining to them why they are in pain, the cure needed, how long it will take etc. He uses 3-D images of our skeleton with the network of muscles and nerves over it to give detailed explanations of the reason for the pain, how it can be mitigated and means of preventing a recurrence.

I think it is time to acknowledge that such Doctors are the exceptions and build a system for the norm; one that is built around our needs as patients for more information to help us feel a bit more in control, for reassurance, and of course, for guidance and treatment. As Dr. Gawande says in his article, we need pit crews.

In some ways, hospitals are beginning to respond to these needs. Some hospitals address this through talk sessions that all their patients and their families can attend. Sometimes, for metabolic ailments, a doctor and a dietician work as a relay team for diagnosis and then ailment management. Additionally, one member of the pit crew could also be a trained medical counsellor, contributing the ‘time to care’ component of ‘quality of care’; someone who would help patients and their family members traverse from denial and anger to acceptance and solution-seeking, giving them all the information they need so that they can make sense of the situation – explain what’s happening, understand treatments available, sort through options etc.

Of course, one key question is that of the payer for these services and to what extent they can be rolled out in a country such as India where large swathes of underserved or un-served populace lack access to even basic medical care. Nevertheless, I think we need to push ahead on both fronts, improving quality of medical care and the overall experience and increasing access.

  • Zenobia Driver

 

May 28, 2012 at 6:19 am 20 comments

Is change afoot in the practice of medicine ?

Two articles that I came across recently got me thinking about the way medicine is practised currently and how it is going to change significantly during our lifetime.

The first is an article by noted physician, writer, and policy-maker Dr. Atul Gawande; titled ‘Cowboys and Pit Crews’, it is the text of Dr. Gawande’s commencement address at Harvard Medical School last year. In this speech he touched upon the way the practise of medicine evolved and the background to the way it is currently structured. Some fragments from the speech are reproduced below to whet your appetite, hope these encourage you to read the entire article :

‘The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves…….The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. ……We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care…..We train, hire, and pay doctors to be cowboys. But its pit crews people need………By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.’

Dr. Gawande’s speech was about the systems and a process involved in healthcare delivery, and his prescriptions were practical, though complex to implement. The second article I’m pointing out to readers is a bit more far-out (or farsighted maybe), a bit like science-fiction-meets-medicine. This article is the transcript of an interview with Dr. Eric Topol, author of the book, ‘The Creative Destruction of Medicine’, a perspective on the changes in healthcare made possible by technology and digitisation. In this interview, Dr. Topol talks about the changes possible and the extent to which personalised medicine / treatment is now available and could benefit people, also about the prevailing system which (he feels) is resisting these changes.

 

  • Zenobia Driver

 

 

May 21, 2012 at 9:35 am 5 comments

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