Tuesday, August 31, 2010

Making use of traditional remedies for treating infertility

Infertile couples in India will often resort to using traditional medicines . Many will go to temples and take a prasad or tie a holy thread to help them to have a baby. Not only does traditional medicine have a long history in India, it has also helped many couples with unexplained infertility to have a baby, which means it has an established track record of success !

However, many modern IVF doctors make fun of these "remedies". They believe these are useless, and will often discourage a patient from adopting these.

It's not smart to do this. A good doctor respects a patient's beliefs, and understands that different people have different world views - and there is no one right way of looking at things ! After all, IVF specialists and Western medicine do not have a monopoly on the truth !

The important thing is to work together with the patient, so that the doctor and patient form a team. An open approach will give the patient permission to confide in her doctor as to what alternative medicines she is taking - and will also teach open-minded IVF doctors that other systems of medicine can also help women to have babies ! In fact, it can be quite a humbling ( and eye-opening ) experience when patients who have failed IVF get pregnant after doing yoga or taking siddha medicines !

Some of these traditional beliefs are harmful ; while many are helpful . A good doctor will study these beliefs; research them; and encourage patients to make good use of the helpful beliefs.

After all, all doctors will acknowledge that the placebo effect is very powerful, and works in real life , even when we do not understand how and why it does. A clever doctor will make good use of the placebo effect by selecting his patients carefully.

This is where the importance of an open mind is so critical. Using a blended approach can provide the best results. We can use modern technology to define what the medical problem is and then select patients who can benefit from simpler ( and much less expensive) alternative medicine approaches. Thus, while young patients with unexplained infertility are likely to benefit from these options , those with blocked tubes will just end up wasting their time if they do so !

One major benefit of these traditional medicines is that they are much less expensive than IVF. However, a major problem is that they are very poorly researched and results are often now well documented. This means that quackery flourishes in this field, and traditional medicine doctors make all kinds of tall claims as to how their medicines help to open blocked tubes and improve low sperm counts. This is very unfortunate, as they end up giving traditional medicines a bad reputation.

Also, do not forget that modern medicine is also riddled with false beliefs , which can be equally harmful. An excellent example of this is the over-diagnosis of TB in infertile women by using PCR technology on endometrial samples. As a result of this mindless unthinking approach, thousands of infertile Indian women without TB are needlessly forced to take 9 months of toxic TB medicines to "treat their infertility " !

The simple answer is that there is no simple answer - patients need to intelligently use a combination of modern and traditional medicines to find the right answer for themselves !
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Libraries, doctors, patients and information therapy

In an ideal world, doctors would be able spend as much time with the patient as he needed. They would understand the patient's personal beliefs and preferences; empathise with his worries and concerns; educate and inform the patient about his treatment option; and draw up a treatment plan which the patient was happy with.

Sadly, in real life, the only kind of people who are going to get this type of care today are billionaires who own their own hospitals. Today, most doctors are just too busy to be able to even talk to their patients for an uninterrupted ten minutes ! When they are young, they are rushing from clinic to clinic , trying to grow their practise . When they are senior, they have so many patients who have lined up to see them, that they just cannot devote the time needed.

As a result of this busyness, the first casualty is often patient education. Because doctors are not able to spend enough time with the patient, they are often not able to explain how they plan to fix the medical problem. As a result of this breakdown in doctor-patient communication, patients often have unrealistic expectations from their medical care - and if something goes wrong, the doctor is the one who bears the brunt of the patient's anger and resentment.

This is why patients now often spend hours on the internet, trying to educate themselves and learn as much as they can about their medical problems. While this is very good, the reality is that the quality of information on the net leaves a lot to be desired - and patients often get confused or misled by unreliable websites, making a bad situation even worse !

This is why librarians can be such a useful source of Information Therapy ! Librarians are information specialists, who have been trained to search for and retrieve high quality information.

In fact there are many reasons why librarians can do a better job at dispensing information therapy than doctors can !

They are trained professionals, who are expert at taking an interview with the patient, to determine what his information needs are. Because they are not medical professionals, they are able to provide objective, reliable information with no vested interest ! In fact, the information provided by an expert medical librarian is often better than that provided by a doctor. Unlike a surgeon who is quite likely to push for surgery, a librarian has no conflict of interest or hidden agenda and is quite happy to present all possible options, without any bias !

Equally importantly, patients are often more comfortable talking to librarians, who are seen to be non-threatening peers who encourage questions and take delight in providing high quality answers ! Doctors, on the other hand, can be quite intimidating - and most patients are very reluctant to ask their doctors questions, even when they are completely confused and do not understand what is going on !

Even better, librarians can help patients to make sense of the information they retrieve, because they are taught how to rate the quality of information. While patients will often get lost on the net, librarians can help them to judge how good the quality of the information is, based on a number of objective criteria. Of course, whether this information then can be applied to the individual patient is something which only the patient ( and his doctor) can decide ! Thus, while a surgeon may pooh-pooh a medical treatment option ( because he would rather do surgery than prescribe medicines !), a librarian can help the patient to explore all the available alternatives, with an open mind. Also, librarians do not use medical jargon to obfuscate the information they provide. They ensure that the patient understands the information - and because librarians are also lay-people, they are often much better at speaking the same language the patient does ( unlike doctors, many of whom do not seem to be able to communicate with their patients in simple English !)

There are many advantages of using this combination approach !

It fosters and encourages team work in medicine, and allows patients to get the benefit of multiple perspectives !
It keeps doctors honest, as they know that patients will be counter-checking the information they give them
The information is provided by information specialists, which means it is reliable, and current
Interestingly, doctors can also learn from the information which librarians provide. It's not going to teach them about medicine, but will teach them how to explain complicated medical concepts to their patients , and help them improve their communication skills
It can also help doctors to keep updated, if they have an open mind. Thus, these information searches are likely to teach them about alternative medicine options , which they would not otherwise be aware of
This kind of partnership can save the doctor time. He can focus on providing the medical care, because he is confident that the information needs of his patients are being met by trained professionals
It also helps the patient to be more confident that they are getting the best care , and will help them develop more trust in their doctor, because they have verified the information he has provided using independent sources provided by the librarian.
This approach will also help to reduce the difficulty patients often encounter when they search for medical information on the internet, because the librarian will make sure the information is authentic and current !

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Monday, August 30, 2010

Why are Indian doctors such bad businessmen ?

I know lots of doctors, but most of them are not very good at handling money. The fact that they got into medical college means they are bright and must have been in the top of their class, but most of them have very little business sense. Why is this so ?

Even though every clinic is a small business, most doctors have no exposure or training in business management . While they are very hard working and intelligent, they are often not good at managing other people or building teams.

Sadly, most of them are not willing to learn . One of the occupational hazards of being a doctor is that because they did so well academically, many of them they think they know it all , and cannot be taught anything. How sadly mistaken they are ! If you do not know what you do not know, how will you ever learn new stuff ?

Most doctors do not have role models they can emulate. Doctors are often intensely political and competitive. They are secretive and not willing to share what they have learnt with their colleagues - which means that most doctors have to make their own mistakes in order to get ahead.

Most doctors are in solo practise, which means they are stuck thinking small most of their lives. In their first decade of practise, they are so busy trying to attract patients, they they often lose sight of the big picture. By the time they become more mature, they are already ready to retire !

Sadly, giving cuts has become the norm today and most doctors are so used to taking shortcuts in order to build their practise, that they lose sight of basic customer service principles. This means that rather than spend time and energy keeping their patients happy, they waste a lot of it networking with colleagues who refer patients to them . Because these colleagues think the same way they do, there is very little attention paid to growing the business ethically.

Some senior doctors take a perverse pride in the fact that they are not interested in earning money ! They consider medicine to be a service profession and feel that earning money is below their dignity . They will often look down ( or pretend to do so ) upon doctors who are richer than they are.

Most doctors do not use technology cleverly. While they are often aware of the latest gadget and gizmo in their own specialty, they are often not smart enough to use technology for managing their clinic , growing their practise or marketing themselves.

Many are woefully financially naive. When they first start practise, they are so used to working for free that they do not think about paying themselves at all ! When they start their clinic, they treat the clinic's income as their personal income. However, this is actually the income of their business - they should only be paying themselves a salary as a CEO. The clinic should be profitable enough to pay them a salary and should be able to run without their presence ! Most doctors are so busy working in their practise , that they fail to work on their practise !

Doctors do not learn to leverage their strengths; and because they are so busy competing with each other , they do not learn to cooperate and grow the pie for their profession. They fritter away the goodwill they have earned from their patients on personal gratification. Sadly, the leaders of the profession are intensely political , and because they are so focussed on looking only after their personal selfish interests, they do little for the profession as a whole. By the time they are senior and are capable of looking at the big picture, they are thinking about retiring !

Most doctors are good at what they do, which is taking care of their patients . While this is good for their personal wellbeing, it's not good for the profession, which lacks leaders who can provide wise counsel for their colleagues and peers.

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Healing a sick healthcare system - Dr Nadkarni - full book now online so you can read it free !

This excellent book, MANAGEMENT OF THE SICK HEALTH-CARE SYSTEM - What Is Wrong - What Can be Done is authored by Dr S.V.Nadkarni, Former Dean, L.T.Med.College, Sion.
It's 139 pages long, and is packed with the wisdom of a life time of working as a surgeon and medical administrator. Dr Nadkarni has some very clever and thought provoking ideas as to what makes our present healthcare system sick - and what we can do to heal it !

Dr Nadkarni's mobile is : 9320044525; and his email id is: [email protected]. The book is available with Vora Medical Publication, Near J.J.Hospital , Signal Traffic Byculla, Tel- 91-22- 23754161, E-mail : [email protected]
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Using the internet - what Indian doctors believe

This is a guest post from Aditya Patkar, Marketing Director, Plus91.

I met a doctor socially the other day, and we had a very interesting conversation about his practice. He has published a website with the help of Plus91 Technology’s Website For Doctor's initiative , and we were discussing the merits of a doctor using the Internet for reaching out to patients.

His first worry was: doesn't this amount to advertising? Because a website is personal digital real estate, he felt this was fine, but was very uncomfortable about using social media to reach out, because he felt this was unethical. I agree that flagrantly advertising and singing praises about yourself may be unethical, but not informing people about your services is also downright unethical ! Imagine a poor patient with a brain tumour who is forced to travel miles in order to talk to a good neurologist , just because the neurologist in his neighborhood doesn't bother to let anyone know about what he does!
Doctors in India are in short supply – don’t they have a responsibility and duty to let people know about their expertise, so that it can be used more efficiently ?

We then started talking about how his website has made a difference to his practice.

a. He now could interact with his patient via the site

b. He could easily give directions to his clinics and his timings by directing people to the site , which had all the information patients needed, including a google map. This saved his patients a lot of time and energy – and his staff did not have to keep on repeating the same directions to all his new patients !

c. The website did convey that he is a serious up-to-date professional, and his patients appreciates this.

Did it get him new patients? The ability of a website to do this depends directly on the web traffic coming to the site, and because his site was fairly new, the numbers were still small, so it was hard to say if this has had a significant impact. If he promotes his website effectively, it is common sense that it is bound to help him attract new patients ! It’s always hard to judge the return on investment ( ROI) on a website , since it takes time for a website to grow ! It needs to be nurtured carefully – and doctors who do this will find this a very cost effective option ! Even one new patient can help him to recover the cost of a year’s hosting ! However, he is reluctant to spend the money to promote his website ( using a search engine optimisation – SEO - firm) , so it’s possible that his website may not help him to grow his practice, making this a self-fulfilling prophecy !

His skepticism arose from the fact that in his experience, when patients search for a doctor, they usually ask a friend or a family member for a recommendation or a referral. Patients may do research online to find out more about the doctor, but not many patients in India today use the internet as a tool to find a doctor. , However , as time goes by, this is likely to change quickly, because many people change cities when they switch jobs; and few have a family physician they can trust. It’s becoming increasingly common for urban Indian patients to use the internet to select a medical specialist to help them get the best medical care.

Social media has a very important role to play, because it is the digital version of “word of mouth” marketing. Let’s take a doctor who specializes in arthroscopic knee surgery. If all his colleagues on twitter, facebook and orkut feeds know about this, they can create a lot of buzz for him. Anytime someone asks these people about knee surgery , they will be sure to say, “Hey , why don't you go in for mini incision surgery and avoid the big scar ? I know a guy who does this and his website is …..”. Here your website becomes a tool which allows others to refer their friends to you easily. If you have videos on your website displaying your surgical skills, as well as patient testimonials, this allows you to build your prospective patient’s confidence in your expertise, and helps to enhance your credibility !

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Sunday, August 29, 2010

Why medical college hospitals should admit private patients - Chap 9 from Dr Nadkarni's book

Indian Medical Council is very ambiguous about recognizing the affording class of patient as clinical material for the students. If the hospital keeps a section where patients pay for the treatment, that section is not recognized by the Medical Council as teaching beds. One reason given by the Council is that these beds form a section like a Nursing Home and the same bed may be occupied by a medical case under a physician one day, by a surgical case for the few days and a pediatric case at yet another time. Therefore, such beds cannot be allotted to any specific branch. The argument is quite valid but if the hospital was to have paying beds in each of the wards which are allotted to the specific teacher, then these beds ought to be considered as teaching beds. In U.S.A. almost all patients do pay for their treatment and yet form part of teaching material for the medical students. Even in attached hospital of Kasturba Medical College, Manipal, all patients pay. If 25% of the beds of each teaching unit were allotted to paying patients, it would have many advantages. First, obviously the hospital will have a source of income to run the hospital and thus will indirectly help the institution to reduce the fees for the medical students. But a bigger advantage is for the students in their medical education.
A paying patient is more health conscious and more aware of his rights. His expectations of treatment are higher and in generalhe is well–informed and more easily available for follow-up. Besides he often comes with an early and possibly curable disease. Therefore, he is an excellent clinical material for the medical students. In addition and most importantly the students learn good bedside manners almost automatically. The patient being educated, health–conscious, affording, he or she is automatically treated with due respect by the student. The students do not pounce upon him or examine him roughly as they almost always do in the case of poor general ward patients. In contrast the general ward patients suffer from more advanced disease and often do not turn up for long term follow up. They form, at best, experimental material like animals. It is regrettable to say so but it is the common experience of each and sundry who have observed the plight of these patients in our country. Every clinical unit in a medical college hospital must have about 40 beds with a recognized team of medical teachers / consultants in charge as per the medical council rules. Usually each such unit has a separate ward; sometimes two units share a ward. It is suggested that all such wards should have at least 25% of these patient-beds for paying class patients. That means out of 40 beds at least 10 beds should be paying beds where the patient pays for his / her treatment. One part of the ward could be converted into rooms with extra facilities like separate toilet, a separate access and a few facilities for relatives while remaining 30 beds would be either free or partially subsidized-generally called the general ward beds. The medical students will necessarily be allowed to examine and observe the treatment of all these paying class patients and as stated above I expect the students to learn proper bedside manners and also observe the signs, symptoms and clinical picture of a relatively early disease in the special rooms in contrast to what he observes in the general ward, namely signs symptoms and clinical picture of a relatively advanced disease in a patient whom he may not be able to observe in the follow-up period. As these beds are specifically allotted to the teaching unit, there is no reason why the Indian Medical Council should have any objection to consider them as part of the teaching beds. Such a system has an added advantage of assessing the capability of the teacher to attract patients. The patients in the general ward have no choice but to come to these ‘free’ hospitals and their number does not reflect the clinical ability of the teacher. It is only a competent teacher who can attract patients in the paying class. The incompetent teacher will thus be easily exposed. There are many more additional advantages in having this system. The out-patients department, laboratory and the operation theatre, all remain closed after the morning shift. The whole hospital works only in one shift from 8.00 a.m. till 3.00. p.m. Hospital services are closed after 3.00 p.m. except for emergencies during the rest of the day and night. If paying class of patients are to be treated. in this same hospital as mentioned, it will become necessary to use the evening hours to have such pay-clinics for the paying patients. The O.P.D. the laboratory and investigative facilities will also naturally remain open during these evening hours and in order not to disturb the treatment of the poor class, the operations and procedures for these paying class patients will also have to be performed in the evening. In short, the whole hospital will have morning hours reserved for the general class of patients while the whole infrastructure will be put to full use again in the evening hours for the paying class of patients. Double utilization of the available infrastructure, and therefore the standing expenses, will be better utilized. In addition, of course, the hospital will earn a very large income from these beds and that will cover a major part of the hospital expenses. That these patients may refuse to allow the students to examine them is a common objection raised by those who are against it or have fixed ideas. But it must be remembered that it is obligatory for every patient who goes to a teaching hospital to allow the students to examine him. As per the rules of the council, a notice has to be put up prominently and even signatures can be obtained from the patients before they are admitted and any treatment is initiated. This is the practice in the western world.

This has a further advantage in that medical teachers or seniors remain available in the premises right upto evening time even upto 8.00 p.m. or 9.00 p.m. At present the seniors leave the hospital by 4.00 p.m. maximum and they are approachable only on phones thereafter. If and when private practice is allowed to these teachers outside the premises (legal or illegal) as is often the case to-day, they are busy elsewhere in their private practice and are reluctant to come to the hospital even when the situation so demands. They manage the situation by giving telephoning advice or telling the junior to go ahead and perform or advice the juniors to keep the case pending till morning. Such negligence ill also be minimized by having the paying class in the hospital because the senior doctors are readily available within the premises even upto late evening and (b) they have no external interest in terms of private patients elsewhere and, therefore, are necessarily and truyly available for the patients within the premises-whether general ward or paying class. After some years almost every doctor develops a certain philosophy and ethics of practice. Therefore, it is unthinkable that such a senior medical teacher will attend only to the paying class patients and ignore the general class patients, when both these classes of patients are in the same premises and the consultant is available there. Therefore, the general ward patients also will get better attention in this system. Even otherwise, the attention to the general ward patients i.e. poor class of patients will improve automatically, even in the out patients department because of yet another factor. At present, if the medical teacher is competent, he attracts many patients who are either very influential or affording. They seek treatment here, for various other reasons apart from cheap or free treatment, mainly because of the competance of the consultant teacher. In the present system, these affording patients attend the same O.P.D. during the same morning hours as the poor general class patients. Inevitably this influential or affording class of patients get preference over the poor and if the medical teacher is very popular, it may happen that he hardly gets time to see any general class patient. They are all seen by resident doctors or juniors and the senior teacher is consulted only if the juniors consider it necessary to show him such a case. The same thing happens in the investigation department and in the operation theatre. The rich or influential patients easily supercede the poor and the investigations and/or operations of the poor general class patients keep getting postponed for want of time to accommodate the rich or the affording. Everyone is a loser except this crooked class, which exploits the facilities meant for the poor. The senior medical teachers in the unit do not object much because their own share of influence in the society increases by treating these people. On the other hand, he has nothing to loose, as his salaries are fixed. There are a few exceptional techers who do object on moral ground to such entries of privileged class. But they are far and few between. They lose their sphere of influence in the society and remain static, irritable and generally not appreciated by anyone.
All this would be prevented if the scheme of 25% paying bedsis properly implemented. As the medical teacher will gain in actual terms as and when he treats paying class patient, he will now be more reluctant to adjust him in the morning hours and will insist on him coming during the hours of paying clinic. Therefore, the general ward patients will have the full attention of the medical teachers during the morning hours. The investigation time and the operation time being so reserved specifically for the general ward patients till 3.00 p.m. and for the paying class in the evening, there is no interference between the two classes, thus, giving indirect benefit to the general class patients. The more competent medical teacher will earn more than the teacher who is relatively incompetent. Thus, the need of 25% paying beds in a teaching hospital is so important that, in my opinion, the students, the university and or the state government should be willing to fight for it in the court of law, if the Indian Medical Council raises any objection to such a system on any ground.

Free medical treatment should be abolished . As I emphasized earlier there is nothing which is really free. When a patient gets treatment free of charge, it only means that somebody else has borne these expenses directly or indirectly. In the case of govt. hospitals, it means that every citizen is paying for the treatment of that patient through direct or indirect taxes. Besides neither the patient nor the student nor the senior medical teacher becomes aware of the expenses incurred in the treatment of the patient and thus, does not even think whether the expenses could be minimized. Therefore, it is my firm opinion that the patient must pay at least some percentage of the expenses incurred for his treatment.

Subsidising Private Medical Colleges - Chap 8 from Dr Nadkarni's book

As pointed out earlier the government has appointed a board to determine the fee structure in private colleges and to see that the fees charged are legitimate. It is not clear what principles they use but it appears that the board merely verifies the expenses incurred during the previous year and sanctions the fee pattern to meet those expenses. There are no criteria to judge the legitimacy of those expenses. Therefore, the fees are as high as two to three lacs per annum as mentioned earlier. Even after paying such high fees, the students in private colleges are greatly handicapped because their attached hospitals have very low occupancy. The patients in these hospitals have to pay for their hospital expenses. The treatment cannot be totally free. Around 50% of the burden of the expenses incurred on the patients is borne by the students and forms part of their fees. Even then, the patient himself has to pay a fair amount towards his treatment compared to the fact that they get free treatment in government hospitals. Coupled with the fact that these institutions may be having relatively poor investigative and operative facilities and less experienced teachers, the result s a great reduction in number of patients coming in these hospitals. Therefore, the number of students admitted in these colleges is very high compared to the patients available in the hospitals and the patients feel more harassed by a large number of students examining each of them. Thus, a vicious circle is established. Ultimately this results in proportionately small number of patients available to the students to observe and learn his clinical medicine. In all technical colleges, the laboratory or workshop with all equipments suffices to give the students adequate training but not so in the medical college. For medical students, a large number of patients in the attached hospital is most essential for getting their clinical experience. The lay people should realize that a medical student does not interfere with the management of the patient. But he is constantly with the teaching staff & other seniors and observes every step in the process of clinical management and even assists them as directed. This actual observation and participation in the management of the patient forms a major part of his clinical studies; I would say nearly 75% of the education in clinical methods. Therefore, the most important need of the medical students is the hospital filled with numerous patients of different kinds of diseases. The Medical Council had recommended a ratio of 1 to 10 initially i.e. 10 patients per student admitted every year. That means if 100 students were admitted per year in the college, the attached hospital must have the facility to admit at least 1000 patients. In order words, there ought to be at least 1000 patients in the hospital on an average every day. That ratio was diluted later and now stands at 1 to 7, 700 bedded attached hospital for 100 admissions per year in the medical college. Many private college hospitals do have the number of beds but not the occupants whereas the government hospitals are full or even overburdened. The total number of patients in private college hospitals could be as low as 150 to 200. it must be realized again that the hospital fully occupied is not only the need for the students but it is a bigger need for the society because the student who passes with inadequate experience because of lack of availability of patients and has only book-knowledge will obtain the same degree and will be fully entitled to treat the people at large as a student who gets adequate clinical experience. Thus the effects of bad / immature doctors coming out of the medical college are borne for the next 35 years by public at large. So also the benefits of mature doctors coming out of the medical colleges will be reaped by the public at large only. Another factor needs to be considered i.e. the government hospitals/ medical college hospitals as well as district hospitals are too overcrowded and there is a vital need to reduce this overcrowding in these hospitals so that each of the patients gets adequate attention and treatment. Besides, overcrowding hampers medical education as much as scanty patients. The best way to disperse the patients to these private medical college hospitals would be to subsidize the cost of the treatment in private hospitals equally as in government owned medical college hospitals. What I am suggesting is that the expenses of the poor patients coming to these medical college hospitals should be subsidized by the government. The subsidy can be calculated as per what is spent for a similar patient AT A DISTRICT HOSPITAL. This amount could be safely considered as the most minimum amount essential for the treatment of the patients, with no other components added.

The expenses incurred by patient in a medical college hospital have added components and could be broadly divided into three parts
(1) the expenses required essentially for his treatment. I have taken it to be equal to the expense incurred by the government on similar patients in a district hospital and, therefore, suggested the abovementioned level of subsidy.
(2) But the expenses of the patient in medical college hospital would rise appreciably because he is a material for the medical student to learn. The stay of the patient is necessarily increased to some extent and some of the investigations are done merely for academic purposes. As this part of expenses is entirely due to the presence of students in that hospital, it is legitimate that these expenses be borne by students.
(3) But in good medical colleges research is an essential activity. Without research there will be no progress in the science of medicine. Since certain investigations or modalities of treatment are carried out purely for the research, it is clearly understood that this component of the expenses must be given either from the institution or recovered from the research grants provided by the private industries like pharmaceuticals or by autonomous government agencies like University Grants Commission (U.G.C.) and Indian Council of Medical Research (ICMR). The interests of the patients / volunteers are safeguarded by Research Council in that the patient must gain advantage or at least must not be harmed at all and that the patient is properly informed that these investigations and treatment are being done as part of research Today the government refuses to give a single paisa to the private medical colleges as a subsidy. "Why should we spend for ‘rich’ private trusts and the ‘rich’ medical students who, in any case, want to make money?" Strangely all experts are emphasizing the role of private public partnership in various other fields, for example in road and bridge construction. Similarly government factories are constructed on the basis of BOT i.e. build, operate and transfer policy. Therefore, there is no reason why there can not be a private public partnership in the field of medical education. It is not being done to benefit the private trust or agency which is running the college. The government and the public would get tremendous advantages by such subsidy. When the poor patient gets treatment at the same cost as in a district hospital but by more qualified medical teachers, the number of patients in the hospital is bound to increase and the experience gained by the students because of availability of wide varieties of patients would go a long way to make him a better doctor. It is in the interest of the society, therefore, that the medical college hospitals are filled with patients by giving them adequate subsidy to cover the treatment expense of the poor patients.

Saturday, August 28, 2010

Subsidising medical education - is this a good idea ? Chap 7 from Dr Nadkarni's book

Now let us look into the pattern of charging fees to the medical students during their entire curriculum. When I joined the medical college in 1951 just one year after India became Republic of India, we paid Rs. 175/- per term i.e. Rs. 350/- per annum as our tuition fees. There were, of course, other ancillary fees so that effectively our term fee was about Rs. 250/- per term. The brochure then mentioned that he government subsidized the medical education to the extent of nearly 50% of the actual expenses. When my son and daughter entered the medical education somewhere in the early eighties i.e. more than 30 years later, the fees levied were exactly the same. But now they formed hardly 10% of the actual expenses incurred on medical education. Subsequently the fees were raised but the fees were most appreciably raised only after the private colleges came up. While medical colleges run by public sector are subsidized so heavily by the government, the private colleges have to bear the entire expenses as they do not get any government aid / subsidy. It is but natural that the students/parents must bear all the expenses in these colleges.

The private medical colleges took advantage of this logic and started to charge exorbitant fees and the Court had to intervene again to regulate the fees for the medical students. Now a committee is supposed to supervise and determine the legitimacy of fees to be charged to the students. It is not clear what principles are used to determine the legitimacy of the expenses and, therefore, the legitimacy of exact fees charged but the formula appears to be obviously faulty.

The medical colleges continue to charge very heavy fees, in these colleges. A medical student pays anywhere between Rs. 1.5 lac to Rs. 3.5 lac per year at present. The government too has raised the fees because of the financial pressure; yet the fees are around Rs. 18,000/- to Rs. 20,000/- per year. The students prefer government or public sector medical colleges because the training in these is qualitatively much better and not non-affording because the training is so cheap, except in the case of a few minority of the students. Naturally the students who get highest marks enter the government medical colleges while the students getting a little less marks are forced to take admission in the private medical colleges and medical colleges of deemed universities. The paradox of the present situation is that students getting very high marks get subsidized education and, therefore, in a way are supposed to be economically handicapped whereas those students who have secured marks less by a few percentage have to pay exorbitant fees and, therefore, in a way they are supposed to be belonging to the rich or economically affording class. Between students of equal caliber of intelligence, it is the rich or affording class who can provide better facilities-special tuition class and internet facility etc. to his ward, whereas it is the middle class parent who may not be able to provide such facilities and may depend on ordinary tuition classes at the most for his ward. Between them, therefore, it is the affording student who is likely to secure more marks than the unaffording student. Yet as mentioned above, it is the student who gets less marks who has to pay very high fees and the student who gets more marks pays lesser fees irrespective of the affordability of their parents and, in all probability, the affordability being quite the reverse. During my time in 1951-56, 15% of students were given partial freeship i.e. they paid only 50% of the stipulated fees, while another 10% were given full freeship; It means that they did not pay any tuition fees at all, except the ancillary fees. The criteria for giving partial or full freeship were purely economical. The parents had to submit a form and documentary proof to confirm their income and only the deserving candidates got such relief of not paying part or full fees. I myself might not have been able to complete my medical education but for the partial freeship which I obtained during the course of my education. It is ironical, therefore, that now when the fees have been raised so high, there is not a single seat with partial or full freeship in any of the colleges – government or private. Even in the government medical colleges, the fee structure, though reasonable, may not be quite so reasonable for many of the very poor students and, therefore, today, they are forced to give up the ambition of becoming medical professionals. The situation would be even worse for those who aspire to get admission in the private colleges. Thus, it can be seen easily that more and more percentage of students in medical colleges both in government & in private colleges are now belonging to the higher income group and the percentage of students from lower income group in medical colleges is steadily decreasing. Apart from the fact that deserving students are being denied the opportunity despite their merits, this has even more repercussions on the very pattern of healthcare. Both the students and teachers belonging to the rich class cannot easily think of simpler or cheaper substitutes in healthcare for the poor. They easily accept the costly modern technology as but natural and as a sign of real progress in medical management; thus contributing to the medical expenses rising by leaps and bounds. Should the expenses for medical education be subsidized at all? The subsidy in medical education is justified, if the doctors coming out from the colleges are sure to be absorbed in the national health services and that the people at large are served by them and in return they are given a reasonable remuneration.

In countries like England and Sweden, highly subsidized medical education may be fully justified as their entire health care system is nationalized. But in our country, where the student has a total freedom to select his field of practice-even go out of the country to the greener pastures in the foreign countries-the subsidy coming from the tax payer's money cannot be justified. Alternatively some provision has to be made to recover the entire subsidized fund with interest, if and when, the doctor leaves the country or enters into private business (I have deliberately used the word business instead of practice). Therefore the question of subsidy in medical education has to be very carefully looked into. The best solution for this is easy availability of educational loan at fairly low interest rate, say 6% which can be repaid by the student after he enters into regular professional field. Certainly some students-to the extent of 15% and 10%, from the poorer sections of the society-deserve partial and total free ship respectively as was the practice in the fifties and the sixties. The government would be fully justified in compelling these students to serve in the public sector for a stipulated period-say 10 years on a subsidized salary. On the other hand, the insistence of the government of compulsory service in the public sector by each and every student does not appear to be justifiable, if he/she is paying fully for his/her education. Similarly the fee of only Rs.18,000/- to Rs. 20.000/- in government medical colleges versus average fees of Rs. 2,00,000/- in the private colleges is too weird as explained above. At least 50% of the students getting admission in government/municipal colleges belong to high/very high income families. A few of them could buy the hospital. For example if the son of Ambani or Godrej or Kirloskar secures 98% of marks and gets admission in G.S. Medical College (K.E.M.) in Mumbai or B.J. Medical College in Pune, he pays the fee of only Rs. 18,000/- but the son of the poor accountant or head clerk working in his own office who secures 92% marks pays a fee of Rs. 2 lacs, if at all he aspires to become a doctor. The question of proper subsidy to proper students will be correctly approached and this paradox will be totally abolished, if the fees in the government colleges are also raised on par with the private colleges and, therefore, the subsidy is totally abolished. Now subsidy should be given only on the basis of the economic status of the family in two or three grades ot students in all colleges, government or private. The students with family income of Rs. 75,000/- per month or more will pay full fees. those whose monthly income ranges from Rs. 60,000/- to Rs. 75,000/- per month may get 25% subsidy. The families with income between 40,000 to 60,000 will get 50% subsidy. Those below this income up to Rs. 25,000/- per month may get 75% subsidy. and those below Rs. 25,000/- p.m. will get full freeship. These figures are mentioned somewhat arbitrarily but the actual figures could be worked out very easily taking into consideration family liability and their capacity to pay for the education OF THEIR TWO CHILDREN ONLY. The government need not consider even remotely the financial burden of the family beyond two children as in Singapore. In short the pattern of subsidy would ensure that the poor should get 100% subsidy, lower middle class may get 75% and the middle class may get 50% For the highest strate, there is no need to give any subsidy irrespective of which college he joins, government or private. Such subsidy, therefore, will be available to the students whether he joins a government college or private college or a deemed university college. The subsidy means that an equivalent amount will be paid to the respective colleges by the government so that their budget is not disturbed. Every student who gets subsidy will have an obligation to serve in government service or in public sector for a reasonable number of years as per the subsidy he has received or else he will have to return the amount of subsidy with interest to the government. A large number of doctors will then become available to serve the poor at various primary health centres or other public sector health care organizations. Otherwise the government will receive back the money they had spent on these students-money which can be now re-used for future students.

Admission to Medical College - Chap 6 from Dr Nadkarni's book

The pattern of selection for entry into medical colleges was supposed to be only by merits. But this principle of admission only on merit was diluted by the political decision of giving reservation for the scheduled cast and scheduled tribe to the extent of 16%. Initially the constitution accepted this special reservation only for 20 years to be replaced later by criterion of pure merits. However, the politicians thought it fit to extend this reservation perpetually. Not only that, on the recommendation of Mandal Commission, another 33% of other backward class were given reservation based on their castes. Constitution prohibited the ratio of reservation not to extend beyond 49%. However, there was a lacuna. The percentage of reservation could be increased even beyond 50% by any state provided such an extended reservation could be approved constitutionally by Central Government. Thus, the states like Tamilnadu increased the percentage of reservation well beyond 49%. The admissions in the respective reserved category however, must be only on merits. However, a minimum of 45% marks had to be obtained in 12th standard examination in physics, chemistry, & biology (P.C.B.) to be eligible for admission. It was reduced further by another 5% for reserved categories. Naturally, the students getting admission under reserved categories scored much lower than in open merit category students, and in the category of scheduled tribes & nomadic tribes students are admitted even today with marks as low as 40%. Immediately after independence, the number of students getting first class i.e. 60% marks was very small and the last student getting admission on merits would have secured as less as 52% marks. The minimum qualifying marks of 45% was justified in those days. Pattern of examination for S.S.C. and H.S.C. changed and students started scoring very high marks. Later, only the marks obtained in P.C.B. only (Physics, Chemistry, Biology) were considered and low scoring subjects like languages and maths were excluded while considering merits, and the percentage sored --- higher. Patterns of examination for S.S.C. and H.S.C. changed further and objective assessment was introduced, so that the students nowadays secure more than 80% in aggregate & above 90% marks in P.C.B. and yet some of them are unable to get admission on merits in the public sector medical colleges. Even then minimum qualifying marks remained at 45% in H.S.C. (i.e. 12 th standard)-that too in P.C.B. only-not the grand total. Full advantage was taken of this lacuna by the private medical colleges. They kept some reservation quota for foreign students, local students, trust students etc. and charged exorbitant additional amount as donation from students seeking admission under such categories, as long as they secured 45% or more marks in P.C.B. at 12th standard. Fortunately the Court’s intervention stopped all such so-called 'quotas' and the court directed the private colleges to admit all students purely on merits. Donations / Capitation fees were prohibited. However, now a new problem propped up. The marks obtained in the very same state as in maharashtra in different zones like Marathwada, Vidarbha, Pune and Mumbai differed a great deal, and comparison became difficult. So this difficulty was overcome by restricting the admission of the students of a particular zone to the medical colleges in the same zone.

But meritorious students from other regions who wanted to enter into the medical colleges of Pune and Mumbai protested and the Courts had to accept their grievances. Court ordered that atleast 25% of the students from other regions must be accepted in the medical colleges anywhere within the state. In addition similar applications were made by the students from other states and again the Supreme Court ordered that an additional minimum of 15 % admission must be reserved on an all India competitive basis. Looking into all these aspects of comparison of merit between different zones in the same state and between students from all states of country, (CET) had to be started in all states. CET was also justifiable because of another reason. The question papers for H.S.C. i.e. 12th standard were set up taking into consideration the average intelligence and capacity of all the students taken together. Passing percentage of H.S.C. is usually 70% or more and kept at that level all the while. Hence, the bright students get 90 to 95 percentage marks without much difficulty with this set of simple questions. Therefore, it was necessary to test the differential merit of these bright students for their selection in professional colleges and a relatively difficult question paper was in order. In addition there are several boards like I.C.S.E., C.B.S.E. which conduct their own 12th standard examination. Thus, taking into consideration all these aspects, CET was perfectly justified. Now the students passing H.S.C. have to appear yet again for Common Entrance Test for Medical or Engineering or any other branches of professional studies. It was presumed that there will be only one common test for one state and may be yet another one by Central Government for an all India selection. But private medical colleges took advantage of this new criterion and decided that they will have a separate CET for private colleges. The University Grant Commission has in addition created another extremely fallacious entity called ‘deemed University’. Originally the principle for considering any institution as 'deemed university' was that the institution has such a high standard far above the standard in the University of the area that they could examine their own students as per their own high standard and confer its own could not degrees. University which in any case had only an average standard could not interfere. But the rules governing deemed University are so fallacious that many new institutions with hardly any standard or reputation could fill in the forms and submit some data as required by the University Grant Commission and could obtain the status of ‘deemed university’. Thus, there are many medical institutions which have obtained the status of deemed university. They can decide the merit criteria and decide the pattern of admissions on their own. The deemed universities conduct their own CETs. Therefore, a student today has to appear for not less than 5 to 6 CETs and run from pillar to post to seek admission in one or the other college, if he wants to enter the medical profession. Needless to say that there have been number of complaints, with solid proofs, about partiality and corruption in these CETs conducted by private medical colleges or by deemed universities. Professional colleagues have authentically mentioned the cash they paid for their ward to secure adequate marks in C.E.T. and get admission. Actually there is no reason why the result of CET conducted by the state and/or CET conducted centrally on an all India basis, should not be acceptable to each and every medical institution, whether it be private medical college or deemed university or for that matter even Armed Forces Medical College.
That would obviate the need of multiple CETs that the students face today. Ordinarily such one common CET would effectively curb the corruption and malpractices practiced by these private bodies.

The question of admitting 15% students on an all India basis could also be resolved suitably. After all, health is a concurrent subject. The central government as well as the state government have a role to play in creating the health care structure. The desire of students from any part of our country to seek admission to any medical college anywhere is also fully justified. But why reserve 15% seats in every college as per the present supreme Court’s order? It would be much simpler for the central government to create 15% of centrally administered medical colleges in all states, and admit all students in these colleges only, on the basis of All India Common Entrance Test. There is no need even to create more colleges. Central Government can take over 15% i.e. one out of seven colleges in all the states and run them through central government funds. In case the municipal corporation as in Mumbai or Pune decide to have medical colleges from its own budget without the assistance of the state government or central government, such institutes definitely have a right to have certain percentage of seats reserved for the students of the city, say about 25% to 33% of the total seats. Similarly if any region / district decides to have a medical college and is willing to support such a college financially, if would be able entitled to have 25% to 33% regional reservation. Instead of reservation based on caste and tribes or religions, the regional reservation as mentioned above would go a long way in creating balanced growth of medical facilities in various parts of the country.

The same principle could be applied even to the different communities. The reservation on the basis of religion, caste and creed is not only strictly against our constitution but it has additionally created a lot of resentment and animosity amongst different castes. The recent examples of Mina Vs. Gujjar in Rajasthan and the agitation for Maratha reservation which is creating apprehension amongst the other backward classes in Maharashtra, are the latest examples. It is ironical that during the period of independence movement, our leaders blamed the British rulers of adopting a policy of 'divide and rule' by creating electorates on the basis of religions. Gandhiji had to fight and use all his power of pursuation to oppose separate reservation for scheduled castes and persuade Dr. Ambedkar against such a move by the British. Pune agreement between them is very famous. Yet it is ironical that our present leaders are increasingly supporting such reservations on the basis of caste and our new politicians are willing to extend them even to Muslims and Christians, thus creating severe resentment and conflicts between various castes and religions. The reservation on the basis of castes has not given any advantage to the poor. On the other hand, only a few privileged people in these various castes are reaping the maximum advantage out of it.

Even in U.S.A. Dr. Martin Luther King Junior and many other protagonists, the uplifters of the blacks in America, did not ask for reservation but instead created opportunity in education and other infrastructure facilities for the blacks and thus brought them up to the level of the whites. Those who have already been benefited by policy of reservation can contribute along with the state or central government or along with N.G.O.s to create educational and other infrastructural facilities including the medical educational and service facilities, with percentage of seats reserved for their own communities (again say 33%). These efforts by community itself to uplift the other members of their own community will not cause any animosity and are likely to benefit the poor much more than the ever expanding reservation system prevalent at present. It may be noted that minority colleges created by minority religions like Christian, Jain, Muslims etc. do have such a facility of reserving the seats for the members of their own religions and they have not caused much resentment in the society. It would be the golden day when the reservations based on castes are totally abolished and replaced by such efforts by various communities and N.G.O.s to uplift the members of backward communities. However, such reservations should not exceed 25% to 33%.

Admissions are now based on marks obtained in the C.E.T. provided the student gets a minimum of 45% in P.C.B. in his 12th standard examination. One adverse effect of this system is that the students totally or near–totally ignore their 12th standard examination and remain satisfied with obtaining the minimum of 45% marks in P.C.B. in that examination. It is also illogical that languages and mathematics are totally ignored. Obviously this omission was done as demanded by the parents who have now developed a habit of complaining of ‘stress’ or ‘tension’ for their wards. Language is a means of communication and those who cannot communicate well can never become good medical professionals. Similarly the modern advances in the medical knowledge have made it more a science, less an art and the students have to be mathematically precise in their clinical practice after they graduate and start practising. Modern equipments are now mathematically derived and the student who does not have a mathematical attitude is likely to fail in treating properly, the complexities in cardiac, renal and such other diseases. Besides, examination is a test to know how much the students have absorbed out of what is taught to them. Therefore, if languages and mathematics are taught, his ability to absorb these subjects also must be a part of examination to decide his merits compared to the others. Therefore, marks obtained in languages and mathematics must also be considered while deciding the merit at 12th std. and CET must include questions in these subjects too.
To keep the minimum qualifying marks at 45% in the present days is ridiculous. This is one of the reasons why undeserving students are able to manipulate and get admission in private medical colleges or under reservation category as long as they can obtain more than 45% marks in PCB in the 12th standard. It is tragic that many of these students are not able to complete the course at all and I have seen many parents suffering huge financial loss-despite their poverty-in trying to make their-ward a doctor and getting frustrated after 7 to 8 long years. Such a tragedy among scheduled tribes and such a corruption among the among influential and wealthy parents in CETs would be avoided, if the minimum qualifying marks are made 55% in aggregate and 70% in physics, Chemistry and Biology. As at present, the minimum percentage could be 5% less for all catagories having reserved seats. So, the minimum would be come 55% in aggregate and 70% in P.C.B. It could be safely presumed that candidates getting less than these percentages are not safe to be entrusted the task of caring for the sick.

Also merit need not be decided only on the basis of CET. Merit can be best decided by taking into consideration
a) the performance in 10th standard;
b) the performance in the 12th standard and
c) the performance in the common Entrance Test
If all the three examinations were taken into consideration, a chance freak lower performance by a particular student in CET would affect him less, as his average performance would prove to be better. Similarly the corruption is likely to reduce, as it is not so easy to use the corrupt methods in all the three examinations.The comparision of 10th and 12th standard marks could be done on percentile basis. Properly re-calculated percentile basis removes most discrepancies. It is the best method universally adopted by developed nations.

In short, having considered the present pattern of selection of students for medical education from the 12th standard, I would suggest the following important steps.
(1) Admission should be purely on merits. The merit is decided based on CET examination, provided the candidate gets a minimum 55% marks in 12th standard overall, and/or 70% in P.C.B. The merits need not be decided only by the performance in CET. It would be better to consider the performance of the students at various levels from his 10th standard to 12th standard. At least overall marks in 12th standard, corrected by percentile
method should be considered to 50% extent & CET would make up the other 50%
(2) The omission of certain subjects like languages and mathematics while considering the candidate for medical admission is faulty. The performance in all the subjects must be considered and therefore these subjects ought to be part of the CET also, if overall marks of 12th standard are not to be taken into account.
(3) The minimum qualifying percentage of marks for eligibility to enter the (medical) professional colleges must be raised from the present 45% in PCB to a minimum of 70% in PCB or 55% marks overall. (5% less for all 'reserved' catagories.)
(4) Despite some criticism and adverse publicity, I still believe that S.S.C., H.S.C. and CET or equivalent examination conducted by different Government Boards are still the most impartial examinations conducted in the state. Hence, there
should not be multiple CETs. Only one common entrance test conducted by the boards appointed by the government is not only sufficient but be made absolutely compulsory for all colleges whether government, private or colleges of the deemed university. Central government would be the only other body to conduct their CET on an all India basis. As stated above, if the central government takes over 15% of the colleges from all the states and itself administers them, these students will get
admitted to the Central Government Medical Colleges. Thus, admission to the rest of the colleges in the state will not be hampered, delayed or interfered with because of the so called 'central quota' as is happening today.
(5) Reservation on the basis of caste should be totally abolished. However, regions or communities willing to conduct their own medical colleges with their own expenses should
certainly be allowed to reserve some percentage of seats but not more than 33% to the students of their regions or the students of their particular community. In short, reservation should be based on region or community, provided the region or community takes the responsibility of running their own medical colleges and hospitals.

Premature Ovarian Failure ( POF) and Infertility

Premature Ovarian Failure (POF), also known as premature ovarian insufficiency, primary ovarian insufficiency , premature menopause and primary ovarian failure, hypergonadotropic hypogonadism, is the loss of ovarian function before the age or 40. hypoestrogenism. POF affects 1% of the population.

On an average, in a normal woman the ovaries will produce eggs until the age 51, which is the average age of natural menopause. In some women, the ovaries stop functioning much earlier. This is called premature ovarian failure. Most women with POF will have irregular menstrual cycles. Initially, these are light or infrequent; and soon stop completely. The age of onset can be as early as the teenage years but varies widely. If a girl never begins menstruation, this is called primary ovarian failure. The age of 40 was chosen as the cut-off point for a diagnosis of POF. This age was chosen somewhat arbitrarily, as all women's ovaries decline in function over time.

POF is diagnosed by finding abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. On ultrasound scanning, the ovaries are small ( atrophic) with a very low antral follicle count. Women suffering from POF usually experience menopausal symptoms, which are generally more severe than the symptoms found in older menopausal women. The symptoms vary from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience hot flashes, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness and vaginal dryness.

In most patients with POF , the cause cannot be determined. Some cases of POF are attributed to autoimmune disorders, others to genetic disorders such as Turner syndrome and Fragile X syndrome. Radiation treatments for cancer can sometimes cause ovarian failure. Family history and ovarian or other pelvic surgery earlier in life are also implicated as risk factors for POF.

Serum follicle-stimulating hormone (FSH) measurement can be used to diagnose the disease. Two FSH measurements with one-month interval have been a common practice. Because the eastradiol levels in patients with POF are low, the FSH levels are very high. The typical FSH level in POF patients is over 40 mlU/ml (post-menopausal range). Many women get confused with their FSH levels. They feel that the high FSH is the cause of the POF; and if this can be treated, then their problem with get solved. The fact is that while it’s very easy to suppress the high FSH level back to the normal range by using estrogen tablets, this will not help the patient with POF to grow eggs or to have a baby.

A new and more reliable marker for ovarian function today is the blood test for checking the AMH level. The diagnosis can be confirmed by checking the AMH level, which is very low in patients with POF.

Often the diagnosis comes as a rude shock – both to the patient and the doctor. Most young women have irregular periods because of another disorder called PCOD, which is much commoner. Many doctors assume that a young woman with irregular periods have PCOD, as a result of which the correct diagnosis of POF is often missed for many years. The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further. In addition, many women who are affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives, which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive.

Currently no fertility treatment has been found to effectively increase fertility in women with POF. While some women with POF can and do become pregnant on their own, this is unpredictable and uncontrolled. Medically, the best treatment option is the use of donor eggs. While it can be very difficult for young women to come to terms with the fact that they may have to use donor eggs to have a baby, the good news is that this option has a very high success rate in patients with POF. Other options include: embryo adoption; childfree living; and adoption.
Patients with POF have low estrogen levels and this can result in painful sex ( because of lack of vaginal lubrication); as well as osteoporosis. Hormone replacement therapy ( HRT) with estrogens and progesterone can help to deal with these problems very effectively. However, while HRT can help women with POF to have regular cycles, it will not help them to have a
baby !

Many women find this very confusing, because they feel that if the medications can help them to have regular periods, they should be able to help them to have a baby as well. Sadly, the woman with POF has no eggs left in her ovaries, which means we cannot help her to grow these.
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Friday, August 27, 2010

War on your health - the medical mafia

This is a guest post from Dr Leo Rebello. Food for thought !

Dr. Leo Rebello

This is an abridged version of the Chapter of eponymous title from

Dr. Leo Rebello’s inspiring book “World without Wars”.

The book nominated for Peace Nobel may be ordered from eBay

Dr. Leo Rebello resides in India and may be contacted on [email protected]

Also see his popular website : www.healthwisdom.org

Our modern world is not only crazier than we think, but crazier than we can possibly imagine. This can be proved by the following examples:

(a) The Court in Minnesota orders a parent to poison her 13-year-old boy with chemotherapy as it believes chemo is the only treatment for cancer that works (parental and child rights be damned).

(b) London-based epidemiologist Malcolm Law says that all those above 55 years be put on toxic blood pressure drugs, regardless of the health status of the person. He says that the “polypill” (containing statin) would be an effective way to cut the number of heart attacks and strokes in the UK. [1]

(c) Massachusetts Senate passes a law allowing mandatory vaccinations of all citizens and a $1,000 / day fine for those who refuse. It also legalizes health care "interrogations" of citizens, forced entry into their homes, "involuntary transportation" of people into quarantine camps, etc.

(d) Soy protein is contaminated with a toxic chemical solvent Hexane that’s a byproduct of gasoline refining. Hexane (a lethal neurotoxin) is found in soy protein that’s used in infant formula, protein bars, and other soy products.

Austrian investigative journalist, Jane Burgermeister, filed a lawsuit in Vienna (in July 2009) against the companies (Baxter and Avir), which are preparing the vaccine against the resulting pandemic on the grounds that they are preparing a global genocide designed to substantially reduce the world's population. [2]

This sinister agenda goes back to the Rockefeller family, which had supported the Nazi's racial agenda and which today controls virtually 100% of the US bioengineering industry, as well as the UN.

As part of the Population Control Pogrom, various wars, in the name of Health, are waged against you. Like the carpet-bombing of Iraq, Afghanistan and Pakistan, vaccines, drugs, carcinogens, steroids, statins, anti-retrovirals, antibiotics, aspartame, fluoride and other chemicals are pumped into you. More people are killed in normal times, in hospitals – by devils called doctors -- than all the war casualties put together.

Under the Model State Emergency Health Powers Act, upon the declaration of a “public health emergency,” public health officials can: * Force individuals with “infectious disease” to undergo medical examinations. * Force persons to be vaccinated, treated, or quarantined for infectious diseases. * Control public and private property during a public health emergency, including nursing homes, other health care facilities, and communications devices. * Mobilize all or any part of the “organized militia into service to help enforce the state’s orders.” * Impose fines and penalties to enforce their orders.

The arrogant medical scientists instead of educating the parents what causes genetic disorders are trying to create artificial sperm and artificially inseminate a woman. But they won’t inform that junk food, drugs, tobacco, alcohol cause a loss in sperm quality in the first place. They will also keep mum that after a hundred years of medical domination, they have yet to create a single cure for anything: Cancer, diabetes, heart disease, depression, Alzheimer's, kidney stones or a thousand other health conditions.

These ‘sickos’ who cannot think beyond insane profits, have also turned pregnancy (a natural phenomenon) into a disease -- evidenced by the way pregnant women are rushed into hospitals for all sorts of poking, prodding and blood testing. There is no willingness in modern medicine to simply let pregnancy, childbirth or fertility happen naturally. It's all about intervention and profits.

It is high time, says Robert Butts that we can solve any high profit problem by deprofitising the problem. But the septuagenarian committed to Water Cure and Salt Treatment [3], like several others, does not understand the cloak and dagger Laws of the Pharmaceutical Industry.

The governing principles of the medicine mafia

1. By last count, the medicine mafia has produced some 30,000 diseases.

2. ‘Pharma Industry’ was artificially created and strategically developed over an entire century by the same investment groups that control the global petrochemical and chemical industries.

3. The huge profits of this industry are based on the patenting of new drugs. These patents essentially allow drug manufacturers to arbitrarily define the profits for their products.

4. A key strategy to accomplish this goal is the development of drugs that merely mask symptoms while avoiding the curing or elimination of diseases.

5. They expand their market by continuously hoodwinking the patients. For example, Bayer’s pain pill Aspirin is now taken by over 50 million healthy US citizens under the illusion it will prevent heart attacks.

6. Another key strategy is to cause new diseases with drugs. For example, all cholesterol-lowering drugs currently on the market are known to increase the risk of developing cancer.

7. The known deadly side effects of prescription drugs are the fourth leading cause of death in the industrialized world. [4]

8. Prevention and root cause treatment of diseases decrease long-term profitability; therefore, they are avoided or even obstructed by this industry.

9. To protect the strategic development of its investment business against the threat from effective, natural and non-patentable therapies, the pharmaceutical industry has – over an entire century - used the most unscrupulous methods, such as:

(a) Withholding life-saving health information from millions of people; for example, Vitamin C is available in fruits, vegetables and herbs in plenty and it can prevent and cure cancers without any costly intervention.

(b) Discrediting natural health therapies. The most common way is through global campaigns that spread lies about the alleged side effects of natural substances used for millennia. Or lies of homeopathy being placebo, etc.

(c) Banning by law the dissemination of information about natural health therapies. To that end, the ‘Big Pharma’ has placed its lobbyists in key political positions in key markets and leading drug export nations.

10. Pharma business is the biggest con in human history. The product “health” promised by drug companies is not delivered. Instead, the “products” most often delivered are the opposite: new diseases and frequently, death of millions.

11. The survival of ‘pharma’ is dependent on the elimination of effective natural health therapies. Yes, these traditional and natural therapies have become the treatment of choice for millions of people despite the combined economic, political and media opposition of the world’s largest investment industry.

You see we are doing everything to help you is the usual refrain. Fluoridation, for example, gives you Germ Free Aqua Pura. Let us look at this claim.

Fluoridation is a practice in which a relatively small number of people, with limited scientific qualifications, are intent on fluoridating drinking water supplies worldwide with very little to no understanding of fluoride's toxicology. [5]

The worldwide ambitions of this dental lobby was revealed in November 2006 when the WHO (supported with a lot of cash from the US as well as the sugar lobby), IADR (for whom the fluoridation practice represents the gravy train for dental research) and the FDI (funded by the toothpaste, sugar, pharmaceutical and chemical industries) organized the "Global Consultation on Oral Health through Fluoride" in Geneva and Ferney Voltaire, 17-19 November 2006. These bodies (WHO, IADR and FDI) issued a declaration containing this preposterous phrase: "universal access to fluoride for dental health is a part of the basic human right to health."

Fluoride was first used in the concentration camps of WW2 to keep the prisoners subdued and sterile. If you do not believe they mean to calm us all by this method, please consider the fact that moods altering medications or calmers, such as, Prozac, are around 94% fluoride. So, a very expensive to dispose of, toxic waste, is bought by our taxes to add to the water to help our teeth.

In the mean time, more and more people die of cancer, Alzheimer’s, osteosarcoma etc, fertility is reduced lowering the birth rate. Someone who dies from smoking-induced cancer is listed as dying from cancer, not smoking. Someone who has fluoride induced cancer...cancer instead of fluoride poisoning.

Laws have been made to protect the pharma and water companies from lawsuits for mishaps or damages. Even fluorosis of the teeth (affecting approx. 78% of kids in Ireland) is listed as being cosmetic, not treatable under the NHS dental services.

Eleanore Dunn, Nutritionist, comments: All these things lead to the destruction of the probiotics, the metabolizers in our bodies that make the elements bio-available. Everything alive on the planet needs probiotics to survive. We need to focus on this issue since it is the root cause of all of the diseases. We need to clean the water with hydrogen peroxide since a virus, bacteria, pathogen or cancer cannot survive in a liquid oxygen environment. This is the cure for swine flu, cancer, AIDS, etc. and is so easy to prove scientifically. Just have them test the rainwater for probiotics as they create our hydrogen peroxide, the immune system”.

Now since they say Swine Flu is raging, let us do quick calculations. Assuming you believe the vaccine works, it turns out you would have to vaccinate 200,000 people to prevent the death of just one person from swine flu. And vaccinating 200,000 people would probably result in the harm or death of several just from the vaccine side effects. But it will mean trillions of dollars of profit.

If any further proof of ‘pharma con’ is required, this message received on 1st Sept. 2009, via email should put the nail in the coffin of the killer Pharma industry.

I am the author of the book "The Medical Mafia". [6] Among the many topics mentioned in this volume, I was revealing the ineffectiveness and dangers of vaccination. At that time, I was a practicing physician in Quebec, Canada, under the name of Ghislaine Lanctôt, and the owner of numerous medical clinics. Because of my professional status, my words weighed significantly in the public eye. The Medical Board’s reaction was immediate and strong. Its leaders demanded that I resign as a physician. I answered that I would do so as long as they could prove that what I had written was false. The Medical Board replied with a call for my expulsion.

An 11-day trial followed (1995), where I appeared without any lawyer. The arguments rested mainly on vaccination. As I witnessed the disproportionate reaction of the Medical Board, I realized that, for the health establishment, the subject of vaccination was taboo. discovered that, despite official claims, vaccines have nothing to do with public health. Underneath the governmental stamp of approval, there are deep military, political and industrial interests.

Throughout the trial, the Medical Board brought many physicians as public health “experts”. During the cross-examination of one of these, Dr. Richard Massé, I used an episode from the March 11, 1979, 60 Minutes TV show from CBS. This episode talked about the tragic and massive vaccination in USA during the 1976 swine flu outbreak.

None of the physicians at the trial took this information seriously. Since this trial, these same physicians have continued their career in public health and now hold hon’ble positions. They are the very ones who are pushing the public toward a new worldwide epidemic. This A(H1N1) pandemic is concocted and orchestrated by the WHO, and serves the same military, political and industrial interests as those of 1976.

I am emerging from a long silence on the subject of vaccination, because I feel that, this time, the stakes involved are huge. The consequences may spread much further than anticipated. Here are the most important ones:

* Compulsory inoculation of vaccines containing a deadly virus.
* Massive and targeted reduction of the world population.
* Through vaccines, possible introduction of tiny microchips for mind control.
* Establishment of martial law and police state.
* Activation of the concentration camps built to accommodate the rebellious.
* Transfer of power from all nations to a single .New World Order.

She has decided to take sanyas. She has given up her identity cards, bank accounts, insurance, driver’s license and has decided to let her Canadian passport lapse and was just released from jail. I wonder how this 66-year old lady will survive. This is how Medicine Mafia operates” wrote Thomas Victor, an Indian-American Health Activist, in Sept. 2009.

Louis Pasteur, originator of the “Germ Theory” of disease on which the concept of vaccines are predicated, recanted his entire theory on his death bed when he capitulated to his biggest critic, Antoine Beauchamp, by saying “The germ is nothing, the terrain is everything". By “terrain” Pasteur was referring to the amount of dissolved oxygen in the body. Otto Warburg won the Nobel Prize in 1931 for his discovery that no virus, no pathogen can survive in an oxygen rich environment. This finding has been massively suppressed by the pharmaceutical industry, which is the biggest con of our times and yet it has the stranglehold of “religion” on the minds of even well educated people.

Virologist Bill Deagle, MD was approached by the CIA a few years ago wanting his help to develop a weaponized flu and weaponized vaccine for population control purposes. After pouring over their documents he refused to help them and at the risk to his life became a whistleblower. [7]

How many of you know that Codex Alementarius has come into effect on the midnight of 31st December 2009, which will mean: Quality nutrients would be banned and only foods that were GMO, irradiated, hormone or antibiotic infused etc. would be available? Toxic chemicals presently banned would be allowed, and, of course, pharmaceuticals not touched at all.

Mahesh Bhatt, filmmaker, adds a new dimension to the growing rage against GM food. In the film, Poison on the Platter, he says the health hazards of genetically modified food would dwarf all catastrophes like nuclear attack, floods, cyclones and the world wars. It is bioterrorism, he emphasizes, and it has the potential to wipe out life from the planet, in its entirety. After all, he argues, everyone needs food and if that is poisoned, what could be more devastating?

Harm from GM food is not a myth, says Bhatt as he portrays the havoc wrought by the GM food supplement L-Tryptophan on American Citizens. Jeffrey Smith, author of Genetic Roulette, proves it led to scores of deaths and thousands were taken ill by the time the source of the problem was discovered.

Dr Gregory Damato gives an idea about what GM food can do to us. (a) There is no increase in yield with GM. (b) Gene insertion has unintended cascading effects. (c) One gene insertion can have more than one uncontrolled effect. (d) Decrease in fertility, very serious and deep-rooted immunological changes, and allergies. (e) A single gene insertion caused uncontrolled changes in 1016 genes of mice under experimentation. (f) The after effects were more pronounced in the third generation. (g) Emergence of newly expressed proteins with allergenic potential.

We need to wake up to fight this war on our health, now, for tomorrow may be too late.


1. http://news.bbc.co.uk/2/hi/health/8057850.stm

2. http://www.naturalnews.com/z026503_pandemic_swine_flu_bioterrorism.html

3. www.watercure2.org

4. Journal of the American Medical Association, April 15, 1998.

5. www.FluorideAlert.Org

6. www.jemesouviensdequijesuis.com/english/images/dotconnector02ghis.pdf

7. Jeff Rense interviews Bill Deagle on www.youtube.com/watch?v=5SvxwvWHTsA

Additional Resources

8. Dr. Leonard Horowitz: www.OxySilver.org

9. Dr. Leo Rebello: www.healthwisdom.org

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