MEDICARE
'The aim is to save lives'
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In medicine, doctors in developing nations, including India, usually ape the West. An article in a foreign journal becomes a touchstone and then a norm, unless it is torn asunder by some path-breaking discovery. Therefore Indian physicians and surgeons who are academics prefer to publish their essays in foreign journals. As the resource base of medical institutions in the West is large and the accounting practices as well as the patient data recording system have been refined over time to meet the needs of research, data from these institutions are accepted almost blindly, even in India where medical database is still a far cry from the legally tight data systems in the West (where negligent doctors may be taken by aggrieved patients
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GOUTAM GHOSH
HOW is it that you were invited to ACTS 2004 and what was the response of the participants at the meet?
The ACTS 2004 was a meet on advanced cardiac techniques in surgery to focus on developments that had not been reported in academic journals. The modified technique of LV aneurysm (weak wall that leads to a ballooning) repair was widely appreciated, though I have my reservations about whether the technique will sway practitioners in the West. You have watched scores of left ventricle (LV) repairs so far, and you know it is difficult but not impossible to replicate. Some of my peers are doing it in India. It is different in the U.S. The pressure to find another way to operate is low in the West because insurance companies cover the cost of surgery and hospital stay. In addition a surgical technique would need peer and Food and Drug Administration (FDA) approval before it is considered applicable on human beings. It is easier to fix a left ventricular assist device (LVAD) and keep a patient waiting for transplant than to attempt something difficult even if it enhanced a patient's longevity and improved the quality of life. In the U.S., there is a circularity of dependence between the insurance sector, research-and-development by firms, and the supply of health care. Each sub-system in the U.S. supports the other. So there is no pressure on the surgeons to innovate, no pressure on them to do what Dr. V.S. Ramachandran, the cognitive psychologist, did to take care of the phantom limb problem.
What was your compulsion to modify the Dor procedure? (The procedure was first reported by Dr. Vicent Dor of Monaco who used a circular patch to repair the LV.)
I have been doing coronary bypass surgery since 1986 as a Surgical Unit Resident. I was part of a team that did 6000 operations since I joined a Chennai-based corporate hospital as a DNB (Diplomate of the National Board) candidate, and personally I have done 5000 operations since 1997. I have seen how the LV function deteriorates over time despite coronary artery bypass grafting. Many patients who had their coronary artery stenoses (blocks) bypassed came back with severely failing heart with serious LV dilatation (bulging of the LV).
As a surgeon and a physician, I realised that a circular patch had its own limitations. It would be effective if and only if the infarcted area of the anterior wall of the LV had a specific shape. Human hearts are as unique as fingerprints, so I had to find some way to give my patients the respite from a failing heart that would be cost-effective as well. LVADs cost lakhs of rupees that most Indian patients cannot afford. Unlike in the U.S. where the insurance sector funds the surgical expenses, Indian patients pay from their own pocket (unless the Chief Minister's Relief Fund, the Prime Minister's Relief Fund or philanthropists step in to cover the cost).
The mortality statistic for the reconstruction procedure is higher than the conventional CABG. How then do you justify Dor's or your own procedure?
I agree that the post-operative mortality is roughly four per cent. But consider two facts. Even in the U.S., nearly 2000 patients have cardiac transplants each year, but the transplant waiting list increases by 70000 each year. With medical management (with drugs alone and changes in one's lifestyle, by following the cardiologist's dicta to the letter) the survival rate at the end of three years is 35 to 40 per cent and at the end of five years is about 20 per cent. So 60 to 65 per cent of the end-stage patients would die within three years after their end-stage cardiac failure is confirmed.
But when failing hearts are reconstructed, between 85 to 90 per cent of the patients are reported to be alive at the end of three years. There are a significant number of patients who have been alive much longer after the procedure. Experience therefore favours the procedure, provided one is confident of doing it.
As the meet was a continuing medical education programme, do you think the surgeons in the West will try to practise your procedure?
I have already answered that. For the scientific community, two things are important — immediate results and long-term results. The immediate impact of the LV reconstruction procedure is good but it is difficult to follow up patients in India, especially those who come from far-off places. Even when we instruct them to keep us informed, patients don't when they are well. So I am unable to generate data required by medical journals in the West. Cardiologists in VHF are convinced that the procedure works, but outside this institution my peers are still sceptical. But this procedure is not the final solution to the disease. Genetic engineering research is going on with stem cells from bone marrow being injected into the damaged myocytes (damaged cells of the heart). The body on its own cannot regenerate myocytes, but stem cells can. The question is, can the stem cells replace the damaged myocytes?
There is no doubt that mind affects the body. We hear of sudden deaths from shock. Sages in India could control their heartbeats and could bring it virtually to a stop. If the heart were controlled purely by the autonomic nervous system (the nerve system that is supposedly beyond the control of our will), how could this happen? You can stop breathing for more than a minute if you wish to. Sages have also shown that cleanliness is not restricted to external aspects of the body. Internal cleanliness is more important than whether you take three baths a day, dress well and coat your body with perfumes. It is your internal cleanliness — your style of living, thoughts, habits and many more — that decides the health of your body's subsystems.
E-mail the writer at: goutam@thehindu.co.in
(Next week: Dr. Solomon Victor's views on the evolution of the human heart)
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