<![CDATA[Dr.Mahishma.K’s Newsletter]]>https://drmahishmak.substack.comhttps://substackcdn.com/image/fetch/$s_!hPAe!,w_256,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fdrmahishmak.substack.com%2Fimg%2Fsubstack.pngDr.Mahishma.K’s Newsletterhttps://drmahishmak.substack.comSubstackFri, 04 Sep 2026 04:44:09 GMT<![CDATA[The Quiet Degradation of Medical Education in India.]]>https://drmahishmak.substack.com/p/the-quiet-degradation-of-medicalhttps://drmahishmak.substack.com/p/the-quiet-degradation-of-medicalWed, 22 Jul 2026 03:16:58 GMTOver the past decade, India’s medical education system has undergone a massive structural overhaul. While the government has aggressively expanded the number of medical seats , this quantitative growth has outpaced quality control. That gap is now wide . Very wide .

The result is a system with more colleges on paper, but deeper cracks in regulation, examinations, and public trust.

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1.From MCI to NMC: New Name, Old Problems

Until 2020, the Medical Council of India (MCI) regulated medical education. For decades it was criticized for corruption, bribery for approvals, and lack of transparency.

In 2020, MCI was scrapped and replaced by the National Medical Commission (NMC) through the NMC Act, 2019. The promise was 4 independent boards, digital processes, and accountability.

What changed on ground:

- Diluted approval norms: To set up colleges quickly, NMC relaxed requirements for land, bed strength, and patient load. District hospitals were converted into medical colleges with minimal additional infrastructure.

- Paper-based assessments: Physical inspections were reduced in favor of self-declarations and document uploads. This made it easier for colleges to show compliance only during inspections.

-Corruption allegations: Within a few years, NMC faced the same accusations that plagued MCI. In 2023-2024, CBI and other agencies arrested NMC officials and consultants in cases involving bribes to clear medical college files, approve seat increases, and overlook deficiencies. Changing the regulator did not change the incentives when crores are involved in medical education. ( go google Ketan Desai to just get an idea of the problem)

2. Rules Got Relaxed In The Name of Expansion

To push seat expansion, NMC/MCI relaxed several core standards over the last decade:

1. Faculty norms: Increased dependence on part-time, visiting faculty, and residents to meet teacher numbers.

2. Hospital requirements: Lowered minimum bed occupancy and specialty departments needed for recognition.

3. Infrastructure:Reduced land requirements, especially in urban areas.

The intent was to make medical education accessible.

The outcome: many new colleges struggle with patient load- almost minimal, poor equipment, and lack of senior teachers with time to teach. When clinical exposure is weak, students graduate with degrees but with no real knowledge. Essentially a paper degree that is neither useful to the candidate nor for the country .

3.From Multiple Tests to NEET: A Change in Pattern

Before 2016, admissions were fragmented. There were multiple exams at the national level, state-level and at private university. Students appeared for 5-6 tests, paid multiple fees.

NEET-UG was introduced as “One Nation, One Exam” to bring uniformity.

How the pattern shifted:

- Before NEET: Multiple syllabi, multiple dates. Coaching existed but was scattered.

After NEET : One 720-mark paper based on NCERT, 3 hours, centralized counselling. The idea was to make merit the only criteria.

But one exam for 24 lakh students also centralized every flaw.

4. Why NEET Is Plagued With Problems and Controversies

NEET solved the problem of multiple entrances. BUT It created new ones.

The biggest issues over the last decade:

1. Coaching Dependence: NEET became a test of coaching, not schooling. Students with 2 years of intensive MCQ training have a huge advantage over those without access. This widened the gap between urban and rural, rich and poor aspirants.

2. Paper Leaks and Malpractice: From 2017 onward there have been repeated cases of leaks, impersonation, and racket busts. The 2024 NEET-UG controversy — allegations of paper leak, grace marks, and 67 toppers from a single center — led to nationwide protests, Supreme Court hearings, and re-exams. And those leaks continued year after year. Trust in the system eroded.

3. Administrative Failures: Wrong questions, errors in answer keys, website crashes during registration, and months-long delays in counselling. When there is only one exam, one mistake affects an entire generation.

4. Mental Health Crisis: With everything riding on 3 hours, the pressure is extreme. The “dropper” culture of 2-3 years became normalized. Reports of student suicides around NEET have been a grim annual feature.

5.

No Test of Aptitude: NEET tests speed and recall. It does not assess communication, ethics, empathy, or temperament — qualities that actually make a good doctor.

The Bottom Line

The last decade gave India structural change: MCI became NMC, and 20 exams became NEET.

But we also got:

- A regulator accused of the same corruption it was meant to end.

- Relaxed standards that prioritized seat numbers over training quality.

- One exam carrying the weight of an entire system and cracking under it.

Expanding medical education and access was necessary. But if expansion comes at the cost of honest regulation and fair selection, we don’t solve the healthcare crisis. We just reproduce it inside medical colleges.

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]]><![CDATA[The Mid-Day Meal Program and the Science Behind It]]>https://drmahishmak.substack.com/p/the-mid-day-meal-program-and-thehttps://drmahishmak.substack.com/p/the-mid-day-meal-program-and-theSat, 27 Jun 2026 14:45:47 GMTThe Mid-Day Meal Program was conceived with a simple idea: encourage parents to send their children to school by offering a meal as an incentive. In a country where a large population struggles to access nutritious food, this worked remarkably well.

At its core, any mass meal program is based on one basic principle: to provide a meal that is nutritious, socially acceptable, easy to prepare and store, and affordable.

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Lets see an interesting anecdote in a similar context: During the grain shortage of the early 1960s, when the government supplied wheat to the southern parts of India, it was flatly rejected.Wheat was not a culturally accepted staple in the region. The government’s aggressive push — even rolling out mobile vans to demonstrate and teach how to roll rotis — ended in failure.

This is just one example of how tricky it is to get the balance right in a mass meal program for a country as diverse as India.

The latest National Family Health Survey indicates that more than 75% of the population in India consumes eggs.When the data is this clear and concise, pushing a policy that does not cater to public preferences or practical government efforts is surely unnecessary.

Why Eggs Make Nutritional Sense at large scale

For children in school, the goal of the Mid-Day Meal is not just calories, but quality nutrition that supports growth and learning. Eggs score high on both counts.

They are a complete protein, containing all nine essential amino acids children need. They also provide Vitamin B12, Vitamin D, choline, iron, and healthy fats — nutrients that are often missing in cereal- or pulse-heavy diets. Critically, the protein in eggs is highly bioavailable, meaning a child’s body can actually use most of it. Few plant foods match that efficiency without complex combinations.

The challenge is in the replacement. Replicating the nutrition of an egg with plant-based proteins at large scale is difficult. Most plant proteins are incomplete and have lower digestibility. To match one egg, you often need larger quantities, or a careful mix of pulses, grains, and fortification. That increases cost, complicates kitchen logistics, reduces shelf life, and still may not deliver the same micronutrient profile, especially B12 and choline.

So the practical balance is to use eggs as the primary protein source because the data and nutrition support it.Many states offer Vegetarian options for the minority children ranging from chikki, made with groundnut and jaggery, to channa poda and other local preparations.

The debate over excluding a nutritious food that ticks all the boxes is rather unnecessary and a futile exercise. These efforts would be better directed toward making the Mid-Day Meal program stronger and more nutritious.

The Budget Constraint:

The real debate should be on the low budget and on how there is no fruit and vegetable in mid day meal.

Right now the per-child budget is too low to deliver the nutrition we expect

.Under PM POSHAN, from May 1, 2025, the Central government’s material cost is ₹6.78 per day for Balvatika and primary students, and ₹10.17 for upper primary students. That covers only pulses, vegetables, oil, spices, and fuel. Rice is provided separately free of cost. With foodgrains, transport, and subsidy included, the total per-meal cost is about ₹12.13 for primary and ₹17.62 for upper primary.

Since almost all states in south are already providing eggs and other subsidiaries like millet shakes, energy bars , its time they think on increasing budget allocations. This can help in providing more substantial meals one that can include fruits and vegetables.

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]]><![CDATA[ANTI- MICROBIAL RESISTANCE(AMR)- A TICKING TIME BOMB ?]]>https://drmahishmak.substack.com/p/anti-microbial-resistanceamr-a-tickinghttps://drmahishmak.substack.com/p/anti-microbial-resistanceamr-a-tickingWed, 19 Nov 2025 07:10:08 GMTA couple of months back,a patient in Hyderabad was found to have developed resistance to 15 antibiotics including a few drugs in reserved category ,the news astonished the doctor community.However this is not an isolated incident and the number of such cases are increasing at a steady pace.Tuberculosis strains which are extremely drug resistant have now troubled our country since a few years.This is called as Anti microbial resistance.
AMR occurs when bacteria,fungi,viruses and parasites change over time and they no longer respond to the medications.As resistance for the existing antimicrobial drugs keep increasing , a bigger problem will emerge.There are very few newer drugs in the pipeline,as the development of newer antimicrobials takes a very long time not to mention the huge amount of money that the research will need. Thus,this will ultimately make treating the infections harder.It increases the risk of infection spreading at a more faster rate, leads to an emergence of more severe form of illnesses and deaths too.
A study done by Lancet recently showed alarming results due to antimicrobial resistance globally,more so in Asia and Africa.It is estimated that aleast 1.2 million people died in 2019 as a direct result of antibiotic-resistant bacterial infections.The study ,covering 204 countries and territories also found that antimicrobial resistance (AMR) is now a leading cause of death worldwide, higher than HIV/AIDS or Malaria.

“Previous estimates had predicted 10 million annual deaths from antimicrobial resistance by 2050, but we now know for certain that we are already far closer to that figure than we thought” - these were the observations made in a recent study.

Hence AMR is now considered as a ticking time -bomb.Although it’s a global risk - studies clearly pointed out to a more significant risk in low income group of countries as compared to others.

India with one of the highest incidences of bacterial infections in the world like typhoid, cholera, pneumonia, tuberculosis, etc, remains highly vulnerable.As we struggle to keep these infections under control since many decades especially Tuberculosis , the emergence of AMR hampers our efforts in this and will potentially wipe out all the gains we made in these areas.

WHY AND HOW DOES IT HAPPEN?

Antimicrobial resistance will naturally occur over long periods of time, wherein organisms adapt and change to survive against the antimicrobials i.e natural selection.However due to multiple causes this process is speeding up at a much faster rate.
One of the commonest reason for this is overuse and misuse of antimicrobials.Self medication of antimicrobials without an expert advice is one of the most important causes for this along with clinical misuse of drugs,i.e lack of restraint on the part of health care professionals in using drugs that leads to sometimes an overzealous use of drugs.This will in turn speed up the process of drug resistance.
This usage of antimicrobials is however not limited to humans alone.Animals especially livestock are given the same antimicrobials - sometimes as growth supplements and preventive measures.With the usage of same antimicrobials in both humans and animals and ultimately the transfer of these to humans via food consumption,it produces a cumulative effect.
The other important reason is the use of pesticides and chemicals to get higher yield of crops. All these pesticides do contain antimicrobial substances and they in turn contaminate the soil ,water and air .The presence of these in the environment will lead to development of newer resistant antimicrobials.Along with these the effluents from pharmaceutical manufacturing units and bulk drug manufacturers contain antibiotic-laden effluents and they are discharged as sewage without treating them.



Recognising all these,the World Health Assembly adopted a Global Action Plan on AMR in May 2015 to tackle this serious crisis.As part of this in 2017, the Indian government released the National Action Plan (NAP) to tackle the issue of AMR in a multi pronged approach. The strategies of this action plan is to improve awareness among the health care community and public on antimicrobial resistance,to enhance the surveillance of AMR in the country ,to reduce the incidence of infections in the country by effective implementation of the existing disease control and prevention programmes like malaria and TB programmes(as part of this for effective implementation,government combined several disease control programmes,inter sectoral coordination was strengthened), to optimise the use of antimicrobial agents in humans,animals and food and to promote AMR control activities.


A number of legislations and amendments were introduced by government to help achieve these objectives .The Drugs and Cosmetics Rules of 1945, was amended to regulate the overuse of 24 antibiotics and other drugs through over-the-counter sale without prescription by the pharmacies.Schedule H1 drugs can now be sold only with a valid prescription by a registered medical practitioner and a warning to this effect is printed on the label in a red border box.Along with this pharmacists must also file details of the patient, co-ordinates of the prescribing doctor and the name and dispensed quantity of the drug in another register, the records too will be frequently inspected by the officials in the drug control department and these need to be maintained for a minimum of three years.In January 2020, the Government of India also introduced legislation aimed at limiting harmful antibiotic residues released by pharmaceutical manufacturing plants.All these have been a step in the right direction in our fight against AMR.However as with many other legislations in our country , effective implementation has become the major problem.

(contd..)
IMMEDIATE ACTIONS

In our country the presence of a very active system of informal healthcare practitioners(RMP,non traditional practitioners etc) poses a difficult challenge to limit the overuse and misuse of antimicrobials especially in lower social economic groups and in semi urban and rural areas. Comprehensive workshops for the informal healthcare practioners on AMR ,the need for judicious use of antimicrobials should be conducted periodically.This will significantly bring in a much needed awareness among large sections of population.
Our existing pharmacy/drug dispensing system doesn’t need more legislations but what it will need very urgently is a through change in its workings.The over the counter sales needs to be strictly regulated,the concept of “Prescription is a MUST’ for the procurement of drug needs to be brought in.Only with this can we truly make an effective surveillance of resistance patterns in different parts of the country to plan our counter measures.It will also significantly reduce the self medication habits in people.Along with this a strict implementation of existing drug laws for tamper proof packinging of drugs,effluent treatment prior to release into the environment and finally a strict adherence to WASH strategy( antibiotic-free animal feed, and antibiotics fed to animals should be different from those consumed by humans) is needed to tackle AMR.
Lastly, even with limited resources,we are one of the very few countries in the world to have a developed an indigenous vaccine(Covaxin) to fight this pandemic(Covid-19).This has given a much needed boost and inspiration to pursue research in medicine in our country.At a time when WHO has expressed its deep concern about the lack of efforts in the global community to develop newer antimicrobials, it might be India’s time to put efforts in producing newer antimicrobials.
While the government needs to tackle the implementation of an effective policy in stopping AMR raising at a rapid rate, it is of utmost importance for every one of us to remind ourselves the dangers of antimicrobial resistance and to Say NO TO SELF MEDICATION OF ANTIBOITICS. Self awareness will not only be the first step but it is a major step to tackle this imminent danger.

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]]><![CDATA[Maternal Mortality In India - What The Numbers Don’t Say]]>https://drmahishmak.substack.com/p/maternal-mortality-in-india-whathttps://drmahishmak.substack.com/p/maternal-mortality-in-india-whatMon, 26 Dec 2022 13:01:52 GMTMaternal Mortality Ratio (MMR) is defined by the WHO as the annual number of female deaths from any cause related to pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy for every 100,000 live births. Although the causes for maternal deaths are many, one of the commonest causes remains hemorrhage during pregnancy or abortions. Some of the other causes are conditions like high hypertension (pre-eclampsia) leading to sometimes seizures during pregnancy (eclampsia), sepsis, embolism and complications from difficult labor and unsafe abortion practices. Some pre-existing conditions like cardiac diseases, severe anemia, etc in the mother too lead to maternal mortalities. Most of these deaths are preventable with timely interventions and access to skilled health care personnel and infrastructure. Along with the medical conditions, child marriages leading to teenage pregnancies, lack of knowledge on contraception, no spacing between pregnancies, poverty leading to anemia, gender discrimination leading to unsafe abortion practices all contribute to maternal mortality.

In 2020, the global maternal mortality ratio was 152 deaths per 100,000 live births, up from 151 deaths per 100,000 live births in 2019.The WHO through Sustainable Developmental Goals (SDG) aims to reduce the MMR to 70 by 2030 .While some countries like the USA and the UK have already achieved those targets individually with a ratio of 35 and 5 respectively, as per reports from the Gates Foundation, India stands at 103 deaths per 1 lakh live births whereas Sub-Saharan Africa still has a very high burden of 302 deaths per 1 lakh live births.

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The recent data released from India shows a consistent decline in MMR from 2000/100000 during 1940’s to 354/100000 in 2001 to a further decline now to 103. This significant and consistent decline shows that India is on track in achieving the target of SDG by 2030.

With a very high MMR during 1940s and 1950s, India developed an expansive system and healthcare programs to help us in reducing these deaths and in saving precious lives. Some of these programs include the National Rural health Mission, Janani Suraksha Yojna, Janani Sishu Suraksha Karyakram, Pradhan Mantri Surakshith Matritva Abhiyan etc. These programs aimed at providing good antenatal care to the mothers - regular checkups with the doctors, scans to rule out any abnormalities in the fetus, supplementation of iron and folic acid to expectant mothers and in ensuring safe delivery practices. Along with this primary objective they also helped in identifying high risk pregnancies which in turn helped to save precious lives, both of the mother and children. All these required skilled personnel and it is of no doubt that along with the efforts of doctors, the workforce of ANM’s, ASHA workers and Anganwadi workers helped enormously in reducing the MMR in India over the past few decades.

The above mentioned programs not only aimed at providing accessible and quality health care services to pregnant women and in meeting their nutritional needs, they also concentrated upon public education stressing on the importance of menstrual hygiene, spacing between kids, avoiding teenage pregnancies and also promoted contraception methods. These along with other aided programs to reduce anemia, promote girl education have all played a significant role in reducing the MMR in India over the past decades.

However, a closer look at the data available shows a distinct and a very wide ranging difference between the states. While States like Kerala(30), Maharashtra(38), Telangana(56), Andhra Pradesh & Tamil Nadu(58) performed exceedingly well including surpassing the national average(103), other states like Assam(205),Uttar Pradesh(167),Madhya Pradesh(163), Bihar(130) and even Gujrat(70) are still recording very high numbers. Although States like Uttar Pradesh (201 > 167) and Bihar (165>130) have shown a drop in MMR over the past few years, some states like West Bengal, Harayana, Uttarakhand etc have shown a rise in numbers.Covid-19 Pandemic and a delay in initiating vaccinations to pregnant women too, contributed to some rise in numbers even in well performing states.

However, the significantly higher rates in many states are a major concern to India especially in achieving the SDG target by 2030. That the "All India" average of the MMR camouflages the poor performance of some states is a fact. It is also a fact that we still frequently hear and see news of local people carrying pregnant women in labor across many miles to nearest hospitals (often crossing streams, harsh terrain). These significantly underline that the existing programs are not reaching the last mile and that these programs need to be re-evaluated and most importantly re-strategised keeping the local needs in mind.

Some programs in Telugu states like the adoption of direct cash transfers and Post Natal Kits helped greatly in increasing institutional deliveries thereby reducing the risks of maternal mortality. Safe Transport of mothers to and fro from the hospital in the name of "Talli-Bidda Express" in Andhra Pradesh from 2016 also helped in many women utilizing hospital services for delivery. The introduction of Feeder ambulances (2018) in remote areas along with establishment of specialised centres aimed at connecting the often neglected and vulnerable population to good healthcare achieved good results in Andhra Pradesh. This concept especially can be particularly helpful in reaching out to the remotest of areas. States like Kerala carry out a strict audit not just on maternal deaths but also on "near-miss" cases, this helped in identifying the causes and drawbacks. Programs and efforts which yielded good results in better performing states needs to analysed and expansion of these to remote areas and poor performing areas needs to be done on an urgent basis to bridge the gap between states.

Along with direct interventions, it is also extremely essential in looking at other areas which indirectly add to the burden of maternal mortality. Unplanned pregnancies, too early pregnancies (very young age), too frequent pregnancies are all a risk to the mother’s life. Even with extensive efforts the rate of contraception usage in our country is still less than 60% (as per NFHS-5) and these rates are much lower in low-performing states. Hence educating the public on safe contraception methods remains an essential part of our efforts in reducing MMR.

The MMR is a major indicator of a nation’s social, economic and cultural ambience. Although our country spent enormous resources in public health awareness and education, it is essentially the lack of awareness or the prevalence of some old cultural practices that are contributing to high numbers of MMR in some states. Ensuring that girl education and nutrition is given a priority, public awareness on ill effects of too frequent pregnancies is a key area that will help in reducing the numbers. With a growing population and a very wide urban and rural divide, it is very important for the government to focus on improving healthcare infrastructure and skilled personnel in remotest areas.

The southern states that are considered to be developed continue to improve their indicators and the states that are a part of the empowered action group- such as those of north east along with Bihar and Uttar Pradesh need further assistance. A constant drawback with the existing programs has always been with the beneficiaries it targets, a majority of the time, those in real need is missed because of outdated below poverty line definitions or other criteria as such and a closer look always point out to a pattern of these programs not reaching to the most marginalised communities. It is thus, of extreme importance to re-strategise our maternal benefit programs as per the local needs and problems of poor performing states to achieve our target of SDG by 2030.

A collective effort of strengthening existing maternal benefit programs, ensuring its implementation reaches the last mile, a targetted focus on low performing states and a robust public health awareness programs on maternal health, girl education and gender equality will hold the key in achieving a uniform MMR across the country.

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]]><![CDATA[ DRUG REGULATION IN INDIA ]]>https://drmahishmak.substack.com/p/drug-regulation-in-indiahttps://drmahishmak.substack.com/p/drug-regulation-in-indiaFri, 28 Oct 2022 05:49:07 GMT

A few weeks back, WHO issued a statement mentioning a cough syrup -manufactured by an Indian Pharmaceutical company -as the causal agent for the unfortunate deaths of 66 children in Gambia.To state that it led to a major embarrasement to the country and its manufacturing sector would be an understatment. It also led to a wary among the general public in India,many silently doubting whether the medicines available in India too are of poor quality. It is to be noted that this is not an isolated incident.In September, a hospital in Chandigarh reported deaths of five patients following contamination of an anesthetic drug.On investigation it was revealed that the drug used has failed the quality test.In 2020, a contaminated cough syrup resulted in the deaths of 12 children in Udhampur, Jammu and Kashmir.More than 70 people, mostly children, have died in five separate poisoning incidents related to drugs using poor qaulity solvents since 1972.Recently,a random testing at Telangana found a thyroid drug too failing quality tests.That it comes bearing a reputed company labelling but was actually manufactured by a lesser known smaller company complicates the issue.

A new WHO research mentions that an estimated 1 in 10 medical products in low- and middle-income countries are either substandard or inaccurate.The limited studies done in India about the quality of drugs too indicate a very dismal picture.A survey conducted in our country in 2016 states that 10% of all government supply drugs are substandard.Even a report by CAG mentions that one in four drugs procured by our Armed Forces Service Depot too are substandard.

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MULTIPLE PROBLEMS

When incidents like Gambia occur,there is always a similar pattern of blame game and it is not very hard to understand why.Drug manufacturing is a complex process,which often has multiples steps involving many players and sometimes different countries.Most of these drugs contain the actual medicine and some other solvents that needs to be mixed up to make the drug palatable. These multiple components are often manufactured by different companies,manytimes in different countries.Quality testing for these needs to be done individually and that comes at a price.Sometimes the drug itself is manufactured by a company but is marketed by other companies again in different countries.What complicates the situation more is each country has its own laws and benchmarks on the quality of the drugs.Needless to say,in low income countries and developing countries these benchmarks are lax or at a neccesant stage.All these create a perfect environment for counterfeit products and poor quality drugs to flourish,which inturn is costing lives and damaging the health of the people.

Last year a study revealed that 25 percent of the total drugs manufactured in the country are fake and of poor quality, which is 35 percent of the world’s total counterfeit drugs.It has ofcourse unfortunately become a very lucrative business,a business that is costing the health and lives of people. This has been a major problem since many decades not just in India but worldwide.That the Indian pharmaceutical companies have a very poor track record in following good manufacturing practice (GMP) is a harsh fact that needs to be accepted. A database by the Indian government itself mentions that more than 8,000 drugs have failed quality tests, ranging from not having enough of an active drug, to the presence of bacterial endotoxins, and to glass particles in drugs that are meant to be injected.

While on paper India has one of the toughest laws in place for drug regulation,it is bogged down by many problems.In India the Drugs Controller General of India(DGCI) under the Central Drugs Standard Control Organisation looks after licenses, ensures the quality of drugs, approves new drugs and regulates clinical trials. But the regulation of manufacture, sale and distribution of drugs is primarily the state authorities responsibility under the provisions of the Drugs and Cosmetics Act, 1940.This dual system created multiple loopholes.Lack of information sharing between state and central boards,unchecked corruption,State-run drug testing labs in many states being under-funded, short-staffed with poor equipment are some of the loop holes that is leading to production of counterfeit products and manufacturers escaping thorough quality checks on multiple ocassions.

Drug inspectors are responsible for executing the policy and regulatory framework governing drug manufacturers.As per recommendations by Malshekar committee,there ought to be one drug inspector for every 50 manufacturing units and one for every 200 distribution retailers.However,most of the state boards and even the Central authority are severely understaffed.

At times when the Central Committe issues a ban and recall of a purticular drug from the market,there simply is no mechanism in the existing system to fully implement such an action.It is a similar situation with respect to taking punitive action on manufacturing companies producing substandard drugs.Once a raid is conducted and poor quality drugs are found,the punishment - most of the times a suspension for few months- is not in proportion to the crime committed.What is even more significant is that there is no system in place to keep a record of these offending manufacturers,so we often miss out on taking a stricter action on habitual offenders.A recently released(July) draft of the proposed new bill - The Draft Drugs, Medical Devices and Cosmetics Bill, 2022 by the Union Ministry of Health and Family Welfare failed to address the existing problems.The WHO provided "Good Manufacturing Practices" too didnt find a place in the new bill.All these point out the need for a complete rehaul of our existing drug regulation system,especially after the extremely unfortunate incident in Gambia.

Also in a globalised world with free market,a reasonable uniformity about drug quality and saftey across all the countries reduces the chances for counterfit products and poor quality drugs.Countries adhering to a common minimum guideline for drug production and quality maintaince can help in solving the problem of manufactures taking advantage of lax laws in low income countries. It is imperative to not compromise on quality of the drugs while trying to keep the cost of the drugs low.At the end,every life is priceless.

OUR RESPONSIBILITY

Our pharmaceutical sector is one of the biggest success stories of Indian economy.We are not only the biggest supplier of generic drugs but we also lead in the supply of life-saving vaccines.Around 40% of the over-the-counter and generic medicines sold in the USA and a quarter of medicines sold in the UK come from our country. We also supply around two-thirds of drugs that help to fight HIV globally. Apart from the USA,India has the most number of drug making plants(800)that are compliant with the US health and safety requirements.

In 2014, one of India's top drug regulator infamously told a newspaper: "If I follow US standards I will have to shut almost all drug facilities". In a country like India, which has the third largest pharmaceutical industry in the world and where it bears a significant responsibilty of dispensing drugs worldwide ,such statements and thoughts have no place.Not only are we responsible for the health of our own citizens but the world too is now dependent on our drug supply.We cannot let our lax laws and systems damage the success story of Indian Pharmaceutical Sector and lose that position to other countries.We especially should make sure more lives are not lost due to poor quality drugs.It is therefore pertinent to tighten up our laws and develop a thorough system for drug quality checks. Reassuring the consumers of Indian pharmaceuticals about the safety and efficacy of the drugs available in the market should be a top priority for us.A robust drug regulation and dispensing of drugs will help in acheiving that goal.

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]]><![CDATA[Tennis,Roger Federer and a lifetime of memories.]]>https://drmahishmak.substack.com/p/tennisroger-federer-and-a-lifetimehttps://drmahishmak.substack.com/p/tennisroger-federer-and-a-lifetimeSun, 25 Sep 2022 19:25:21 GMTWhen i was a little girl,my father(he is a Steffi Graf fan)used to make me watch tennis matches late into the night with my mother trying very hard to stay awake with us.As a result,i became a tennis fan.A huge tennis fan.Iam so thankfull for that now because tennis made my life richer.

By the time i started to understand the game, Pete Sampras was on his last stretch and i used to follow his matches. It was during one such match, a young man sporting a ponytail, a beaded necklace and what would later become his signature style- a headband - glided through the centre court and beat the crowd’s favourite. Roger Federer announced his arrival to the world. He entered my life.

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For the next 20 plus years, i watched him religiously, admired, like everyone else, his beautiful, beautiful game and more importantly i developed a deep respect for his demeanour- simple, very humble,gracious and always a class act.

I bunked classes, did back to back duties in hospital sometimes just so i dont miss the legend play. I relished his beautiful game, like McEnroe himself said he is the most beautiful player that tennis has ever seen.His one handed back hand is the sexiest, most dramatic thing i have ever seen. It just takes your breath away, everytime, every damn time.

Many words were used to describe his game - poetry in motion, ballet on tennis court yet no words can really do justice.We have to see and relish to truly understand how beautiful his game was, how perfect and how devastatingly easy he made it all look("Does Roger Federer ever sweat? " asked the headlines).

I was a school girl when he lifted his first Wimbledon trophy and i became a specialist doctor when he raised his last trophy up. Life moved, i became old but Federer remained a constant.Watching his matches remained a priority.

I remember exactly where i was when he lifted his French Open title in 2009.I remember not touching the newspapers when he lost the Wimbledon in 2008 by a whisker. I remember rushing to the washroom- so one can see me cry- when he lost Wimbledon 2019- again by a whisker.

I remember his chuckle in the background when Andy Murray famously told (after Murray lost the Australian Open in 2010)"I can cry like Roger, its just a shame i cant play like him". I remember him graciously saying" I would have accepted a draw with Rafa today" - when he clinched another Australian Open title in 2017.

I remember his finger wagging swag when he won his semi final at French Open, 2011(watch the highlights if u missed the live action, a thriller and an aggressive clay court action) .

I remember his face melt seeing his young kids in the player box while he waited to collect an 8th Wimbledon trophy.I remember his joyous smile and little jig to the close up camera after his 5th US Open title.I remember him stretching to catch his wife's hand when he won his 20th Grand slam.

I remember his still face, laser like focus while watching the ball.I remember him always flicking his hair back while waiting for the ball.

I remember him finishing his service games in a flash(sometimes in a minute n half).I remember him serving aces back to back. I remember his trick shots,I remember him always flicking the odd balls to the ball kids without a glance(they always go straight into the hands of the ballkids).

What i however, remember the most is the joy, thrill and sometimes the heartbreak i felt watching the legend play and do his magic.

One day when my husband asked me why do i like Roger Federer so much? I didnt have a clear answer - sure i love his game, i respect his personality deeply, i love his on and off court behaviour - a gentleman.But i just couldnt explain it, not to my heart's content.I just couldnt say what i really really felt and it bothered me.It was later on,that i read an article by Rohit Brijnath(if you have not read his articles about the mastero- go read them, they are priceless ) which made me understand my dilemma. He said "Federer was never only about winning….and what that something else was is undefinable really because beauty mostly is".

There you go.. That was it.

Beauty and Greatness can never be described, language will not do any justice. Feel it, relish it and take it to your heart.Iam happy I did that.

Tennis now, for me atleast, will never be the same. We may never see such a beautiful game again in our lifetime. In this age of instant fame and over the top excesses, it may be even harder to expect a sportsman/woman to be like him - gentle, polite to a fault, humble,intellectual and wearing his greatness lightly.To have been able to experience this, is a very valuable gift , and i now understand how much it has made my life richer.

So i can only say, thank you sir, for a life time of memories and for showing that rare divinity in sport with your talent and conduct.

You are the greatest ever.🐐

PC : Wimbledon 2022.

P.S I included this picture instead of all the other dramatic photos of him on court because he looked so dashing and also it reminds me of his deep baritone voice. ❤️

.

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]]><![CDATA[INDIAN WOMAN’S HEALTH – 75YRS ON!]]>https://drmahishmak.substack.com/p/indian-womans-health-75yrs-onhttps://drmahishmak.substack.com/p/indian-womans-health-75yrs-onTue, 13 Sep 2022 14:51:28 GMT“YOU CAN TELL THE CONDITION OF THE NATION BY LOOKING AT THE STATUS OF ITS WOMEN” – PANDIT JAWAHARLAL NEHRU


As we celebrate 75years of independence, now is probably a good time to look back and assess the progress we made pertaining to the health of half our population. Did we achieve significant progress in the field of women healthcare? The answer to that question will never be a very simple one especially for a country as wide and diverse like ours. Hence, before coming to simplified conclusions and passing judgements we need to understand where we were 75years back and what work we did in all these years.

Woman and her health 75years back…

For many years now some experts and historians have been putting forward their opinions to whitewash the sins of British rule in India. One among them is an opinion that the British brought with them the concept of western medicine ,helped establish hospitals in India and gave good quality medical care to our citizens including women.

However Indian civilization always had a concept of “Science of Life” and has been passed on from generation to generation in what we now call as Ayurveda. The presence of documented and well acknowledged books like Charaka Samhitha and Sushruta Samhitha too conclusively prove that the concept of healthcare was part of Indian civilization. It was however the Portuguese who first brought their concepts of modern medicine.

The East India Company established dispensaries and hospitals initially to cater to its citizens serving here and some Indian men with rank. For a longtime these hospitals didn’t cater to Indians as first priority, more so for poorer sections and women. The only exception to this was the setup of lock hospitals where Indian women – many of them having been forced into prostitution - were treated for venereal diseases to safeguard British serving men. From as cruel a practice as this ,it took some very forward thinking individuals like George Kittredge, P.H Cama who came forward to establish exclusive women and children hospital in our country and encouraged Indian women too to pursue careers in medicine. At a time when even their male counterparts were not treated with respect brave women like Dr.Anandibai Joshi, Kadambini Ganguly, Dr.Jirahad, Dr.Scudder pursued their careers which brought medicine closer to Indian women and children.


As India became a feeder economy for Britain for nearly two centuries - its citizens were living in the most inhuman conditions. The patriarchal society allowed for a lot of cultural practices which in turn contributed to the poor health of women. The practice of Sati, Polygamy, Child marriages, lack of knowledge/aversion to family planning, female foeticide all lead to a precarious health status of Indian women.It was only with the intense efforts by many social reformers like Raja Ram Mohan Roy, Savitribai Phule, Ramabai Ranade, Ishwar Chandra Vidya Sagar, Periyar and the fervor of national movement at later stages that gave rise to reforms in civil society. The legislative reforms – Abolition of sati, Widow Remarriage Act, Child restriction Act - caused a change in both the status of women in society and in their health.

By the time India was free from foreign rule, like every other sector, healthcare especially among women were in shambles.According to the 1951 census, only 18.33 per cent people were literate and a mere 8% of the women population were literate, and overall life expectancy was just 32 years in women. Sex ratio was 945females/1000males.The infant mortality rate (IMR) was 145.6/1000 live births while maternal mortality ratio (MMR) in the 1940s was as high as 2000/100,000 live births. There were only 50,000 doctors across the country and only 725 primary healthcare centres covered an area of over 3,287,263 square kilometres.

The task of rebuilding the nation was mammoth for our first post freedom leaders. With a poor economy ,our health budget was never sufficient to cater to the needs of our fast growing population. Nevertheless we made significant improvements in health care sector especially focussing on women reproductive health.



THE LONG , BUMPY ROAD ...


Eventually, by setting up a separate Health Survey ,Planning Committee and by the introduction of Five Year Plans, much needed health care programs mainly concentrating on increasing the life expectancy of women and on their reproductive health were drawn up and implemented. Several significant initiatives were launched at a large scale catering to women’s health. We should also remember here that our first Health Minister for Independent India was a woman -Amrit Kaur - who worked tirelessly for 10years to lay down the foundations of healthcare system in free India.

From the first five year plan launched in 1951 to the last plan in the year 2017 – various aspects of women health were given focus of attention and appropriate nation wide health schemes were launched to achieve our targets. Efforts were put into establishing community health centres at various levels and establishing a network of trained personnel who can carryout the healthcare activities among women, young girls and children. As a part of this, grass root system of infrastructure and trained persons were developed from 1950 and this underwent many changes as per the need of our country. It was around 1950 and 1960 ANM(Auxiliary Nurse Midwife) were trained and used to carry out healthcare activities predominantly in the field of reproductive health of women and in the welfare of children. In 1975 the setting up of Anganwadi workers were established as part of ICDS to combat malnutrition. Although majority of their work was concentrated upon the nutritional requirements of young children. Their work also included to educate the families on family planning, child growth and especially to bring awareness in teenage girls on health and hygiene.

Along with these, the National Health Mission was launched – a scheme which underwent multiple changes since 2000’s, initially as separate entities for urban and rural areas, now has been brought under one head - in 2013. It is under this scheme, ASHA workers were trained and brought to work as Community Health workers.
Over the years ASHA workers along with ANM’s and Anganwadi workers developed into a robust system of community healthcare services – where they acted as first port of call for any health related issues specially among deprived populations. Their services were used in a wide ranging of health promotion actives beginning with antenatal care for women, distribution of iron and folic acid medication to pregnant women, taking the women for deliveries at hospitals, care of the newborn, encouraging and getting the families to get a family planning option of their choice, immunizations and in controlling of other diseases like tuberculosis via DOTS program testing and medication etc .They also worked for specific disease control activities like Tuberculosis, Malaria and HIV in particular etc. It is no doubt that with an extensive door to door to campaigns and screenings we were able to stop the spread of infections that were rampant in pre independent India and we are also now looking at declining trends of HIV infections among women in India.
In spite of a low doctor to population ration , this intricate and complex system of multiple community health care workers carrying out a variety of healthcare activities, awareness programs for women, we have been able to achieve significant results in reducing the maternal and infant mortality rates, fertility rates, and increased the life expectancy of women over the decades. (Table 1)


Efforts were also taken to increase institutional deliveries as opposed to home deliveries which was the norm then(this lead to unhygienic deliveries, increased maternal and child deaths) Janani Suraksha Yojna was started in 2005 to promote institutional deliveries ,as a aprt of this cash incentives were provided to mothers. Some pro-active state administrations like our Telugu states are giving post natal kits which aid in taking care of the newborn baby and mother in addition to the direct cash transfer incentives. This brought about a significant rise in institutional deliveries in public hospitals. The percentage of women having institutional deliveries rose to 88.6% as per NFHS5 (2021)from a mere 26% in NFHS1(1992-93).

Due to the neglect of women and girl child in our society, their nutritional status has always been poor. Special schemes were launched which concentrated on improving the nutritional status of pregnant and lactating women and girl child – these included the ICDS which concentred on the nutrition of adolescent girls, pregnant women along with children. Programs were aimed at tackling anaemia in our country with Anemia Mukth Bharat and Poshan Abhiyan.

Along with these several other schemes were started to end social issues related to women which aid in improving the health status of women in the country. A strict PNDT(prenatal diagnostic techniques)Act was enacted in 1994 which prohibited pre delivery gender reveal. This was further amended in 2003 to PCPNDT bringing in preconception gender reveal under punishment too. This significantly reduced the declining sex ratio in our country.Programs like Beti Padav Beti Bachav too provided awareness on female literacy and to end female infanticide.



TABLE:1

FUTURE ...

The biggest challenge for our country now is a twin problem i.e one containing a 'developing' country’s health problems and a second one being the flare-up of 'developed' world disorders which are at our doorstep. On one hand India is combating basic health concerns such as malnutrition, low immunization rates, hygiene, sanitation, and infectious diseases. On the other hand, environmental pollution and lifestyle choices such as alcohol consumption, smoking, and high fat diet are set to increase the incidence rates of hypertension (high blood pressure), cardiovascular (heart) disease, diabetes and cancer to almost epidemic levels.

Although we have made significant improvements in healthcare indices of women ,it is an accepted fact that the pace of our improvement is not up to our desirable level. As health is a state subject, some states worked proactively to achieve our targets and have shown significant improvements while some states are still lagging behind. The failure to tackle social issues in some states too have contributed to poor improvement of health status in women and girls.

In spite of multiple programs that have been launched, re-launched again making changes for better implementation, we are still some distance behind in achieving basic health care indicators in the field of women health. India stands at a rank of 120 out of 186 countries in MMR, the latest reports of NFHS-5 confirm that more than 50% of women (15-49years)in our country are suffering from anaemia. News of lack of hospital staff in remote areas, pregnant women being carried upon by people to reach nearby hospital still come up every now and then, and there is no doubt that these incidents do not have any place in a developed society that India oneday aspires to be. It is therefore necessary to implement the existing programs that cater to basic health care in women to the very last mile.

On the other hand with the advancement of living conditions in the society we now have to focus on providing care for women with respect to non communicable diseases like hypertension, diabetes, osteoporosis, prevention of stroke,cancer and mental health which are posing as the next epidemic.The access of healthcare to women other than reproductive health is still at an incessant stage in India. A recent study in AIIMS, Delhi analysing the patient profile in OPD revealed that a very less number of women come forward to avail services as compared to men. This of course is the pattern in all of India especially in the rural sectors.The concept of regular health care checkups,menstrual hygiene awareness, screening for breast and cervical cancer, is still at a significantly low level.

Although programs have been launched by the government regarding menstrual hygiene awareness , it is an established fact that to this day this is one of the reasons for significant number of young girls to drop out of school. As we are trying to provide good infrastructure at schools, some states like Andhra Pradesh launched a program called ‘Raksha’ in 2018 where sanitary pads were provided at subsidized rates. These are much needed initiatives that need to be expanded and implemented across country.

With several reports saying that the number of cases of breast and cervical cancer are increasing at an alarming rate in India, the recent survey results from NFHS-5 showed shocking results that less than 1percent of women have undergone screening for breast cancer and less than 2% of women underwent screening for cervical cancer. The most shocking fact from the study was that a mere 0.9% underwent screening for oral cancers, this inspite of an extensive awareness program that the government has mandated for viewing to public at entertainment shows.
It needs to be an immediate focus of attention to get women to access healthcare for overall well being and not just for reproductive health. Plans need to be drawn upon for regular screening of women for non communicable diseases like osteoporosis(1 out of 3 women),hypertension(23% of Indian women),diabetes(13.5% of Indian women) as they are turning in to new epidemics in our country along with cancer screening . With India now having a higher burden of cervical cancers globally, Immunization of young girls with HPV vaccine which significantly reduces the risk of cervical cancer needs to be incorporated into the existing National immunization Program as an immediate priority.

Over 75years we as a country made significant progress in the field of women and young girls health . From a time when the sex ratio was significantly lower to now - females are being outnumbered by males for the first time since independence - we have come a long way. However, to achieve our aspiration of being a new superpower ,it is extremely important to tackle the problems of a developing nation like malnutrition, anaemia, reproductive healthcare on one hand and on the other to laydown the foundations for an improved public healthcare system that can tackle the problems of a developed world for its women.

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]]><![CDATA[DOCTORS AND THE ALARMING RATE OF SUICIDES]]>https://drmahishmak.substack.com/p/doctors-and-the-alarming-rate-ofhttps://drmahishmak.substack.com/p/doctors-and-the-alarming-rate-ofThu, 18 Aug 2022 04:05:17 GMTSuicide is a global phenomenon and more than 7lakh people die due to suicide every year.According to the 2019 World Health Statistics, there are 10.6 suicides per one lakh people every year, however in India,the rate is as high as 16.3.Studies from across the world indicate that suicide rates among doctors are higher than in the general population, with the risk of suicide being 2.5 times higher among medical students and doctors.Those in the age group of 24 to 37 years continue to remain the most vulnerable group.Even though there are no proper studies in India that compare suicide rates among doctors with that of the general population ,several reports do confirm that the scenerio in India too is no different.Between 2016-2018 while 3100 professionals comitted suicide in the age group of 18-30years,Central Governement mentioned that a majority of them are doctors.Along with this,the report also mentioned that more than 12000 students comitted suicides during the same period ,however there is no proper data on the number of medical students.It is to be noted here that suicide incidents in medical colleges are unfortuantely a common occurance , that is receiving less importance.

COMPLEX ISSUES

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While everyone agress that the stress of being a doctor and studying to become a good doctor is one of the chief cause that is pushing doctors and medicos towards suicide,the reasons to this are multifactorial and complex.Due to poor doctor - patient ratio in our country, the stress on doctors especially among junior doctors is enormous.Each doctor on an average day attends to not less than 200 patients in a span of 6hours in government hospitals.This enonormous patient load combined with poor infrastructure in hospitals,absence of decent facilities(rest rooms,wash rooms,canteens) for duty doctors,lack of sleep due to extremely long working hours(24-36hours shift) is pushing many young doctors into depression.The concept of mental health is still a stigma in our society and this in medical field especially remains a completely hushed topic.The idea that a doctor should thrive under pressure,should remian "strong" is further preventing doctors to seek help. Harrassement continues to be a common cause for doctors to take the extreme step- harrassement, both in the form of bullying from senior staff,sexual harrassement of female doctors and physical assaults from patients and their kin.The onset of Covid pandemic further caused extensive damage to the morale of the doctors, especially of the junior doctors, who are the first line soliders - extremely long hours,lonely living,fear of the pandemic and poor facilities contributed to the loss of many doctor lives.

Along with these issues, policies of the governement too are sadly to be blamed for the loss of bright doctor minds in our country.With less number of seats available for speciality and superspeciality courses, the competition is enormous , multiple attempts to get into their preffered choice of specialities,extremely poor salaries for the MBBS graduates including in private sector are all contribuiting to the poor mental health of the doctors.It has almost become an established practice in telugu states to not credit salaries for resident doctors for months on end.Some of them had to go on a strike due to non payement of salaries during pandemic.There is also that unfortunate harrassement of a doctor(who ultimately lost his life to a heart attack)during pandemic all because he asked for basic PPE.While these doctors slogged through pandemic and saved many lives,society carried on with their lives and did not look at their plight.This struggle for survival -with poor/no salaries while their counterparts in other professions are well settled- is also a major driving force for young doctors to attempt a suicide.

Taking care of our "warriors"

"Behind every suicide there are many more people who attempt suicide"

To attend to this, associations like the IMA(Indian Medical Association) have taken some steps to ensure doctors are mentally healthy; through its Doctors for Doctors(D4D) programme, IMA organised self-help awareness workshops and 24/7helpline.In 2019, the association alos released a mental health guideline for medical students.It is extemely important to include facilities of counselling and therapy in medical colleges and hospitals where doctors can seek help.It is also imperent for the governmnet too to include psycological counselling in medical cirriculum to train young doctor minds.Over the years,governement strongly adopted a strict "No Ragging policy" that yielded good results,it is now time to look at establishing a "saftey net" to shield doctors from harrassement in all forms - physical abuse from patient's kin, bullying, sexual harrassement from senior faculty etc. The lack of grievance redressal system is one of the major reasons for many harrassement incidents in medical colleges to remain under the carpet,these are ultimately leading to the unfortunate loss of lives.

Succesive governements brought in many changes to medical education over the decades yet none showed good desired results.While elections were conducted without any halts during pandemic ,entrance examinations and counselling were postponed putting many doctors and students future at risk.As the cost of becoming a doctor raises exhorbiently every year,many especially the middle class are forced to study in foreign shores where the standards of medical education are poor.These lapses need to be plugged immediately by increasing the seats proportionate to the population,bringing the cost of medical education down and by laying down rules on basic salary especially for MBBS doctors.

Pandemic made the society and government to laud the doctors as "warriors" but if the governement and society wants to proctect its warriors it needs immediate plans and actions to primarly improve the working conditions of the doctors(avoiding long work hours),establishing better infrastucture to ease the work load and more importantly it needs to establish a safety-net system to shield and help doctors from harrassement and mental problems.

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]]><![CDATA[MATERNAL DEATHS - A DISMAL PICTURE AT DISTRICT LEVEL]]>https://drmahishmak.substack.com/p/maternal-deaths-a-dismal-picturehttps://drmahishmak.substack.com/p/maternal-deaths-a-dismal-pictureTue, 26 Jul 2022 03:10:06 GMTMaternal Mortality Ratio (MMR) is the annual number of female deaths from any cause related to pregnancy or its management (excluding accidental or incidental causes) during pregnancy/childbirth or within 42 days of termination of pregnancy for every 100,000 live births.The recent data released from India shows a consistent decline in MMR from 2000/100000 during 1940’s to 354/100000 in 2001 to a further decline now to 103. This significant and consistent decline shows that India is on track in achieving the target of Sustainable Developmental Goals(SDG) of the U.N(i.e.to reduce the MMR to 70 by 2030).

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However,beneath this number lies a very different picture...Since some years,there has been a discussion on how behind this consistent decline of our MMR(national average)there lies a vastly different picture.Well performing states like Kerala(30), Maharashtra(38), Telangana(56), Andhra Pradesh & Tamil Nadu(58) with better average than the national average(103) are camouflaging the poor averages of other states like Assam(205),Uttar Pradesh(167),Madhya Pradesh(163), Bihar(130) and even Gujrat(70).That the "All India" average of the MMR camouflages the poor performance of some states is a fact.This is further reiterated now by the findings from the first ever mapping of India's maternal deaths at district level.

This mapping showed Arunachal Pradesh — and not Assam as per the government surveys — has the country’s highest MMR of 284 and Maharashtra reported the lowest (40). While according to SRS (2016–18), only Assam (215) has a MMR of more than 200,this study however pointed out that five states have MMR of 210 or more.In the district-level assessment based on Health Management Information System(HMIS) of the Ministry of Health & Family Welfare (MoHFW) about 130 districts have reported above 200 maternal deaths per 100,000 live births,i.e 20% of the Indian districts are having a very high MMR.

Maternal mortality ratio (MMR) in 448 of India’s 640 districts(districts as per 2011 census) are higher than the target set under UN Sustainable Development Goals (SDG), as per this mapping.It clearly demonstrated that while Southern part of the country fared better(68 districts had MMR<70) followed by Western region(46),North,East and Central regions of India had much work to do in achieveing the primary targets of MMR.

Along with such wide inter-state differences,there is also the presence of huge within-state inequalities. For instance, the state of Karnataka as a whole falls in the category of 70–139, but several of its districts have an MMR above 140. Similarly,Tamil Nadu, Kerala, Andhra Pradesh, and Telangana also have some districts with MMR above 140, despite all four states falling in the category of MMR below 70 at the state level.

WHY IS THIS STUDY SIGNIFICANT ?

Till now, India monitored maternal mortality using information from the periodic sample registration system (SRS). We did not have reliable routine information on maternal deaths for smaller states and especially no district level data is available.This has been a major hurdle in local-level health policy and in planning to prevent avoidable maternal deaths.

With this mapping,for the first time, there has been a credible data in not just identifying the well performing and poor performing states,it also clearly identified the "hotspots" of high MMR that are spread across the country(including in well performing states). Like for example, only Assam from the North-eastern region was in the lime-light for higher maternal deaths, but with this study, it has been learned that the entire North Eastern region is facing a similar problem and needs policy attention.It also showed that there are problems even with the well performing states that needs immediate attention.

FURTHER ACTION

An expansive system of health care workers (ASHA,ANMs) and programs like National Rural health Mission, Janani Suraksha Yojna, Janani Sishu Suraksha Karyakram, Pradhan Mantri Surakshith Matritva Abhiyan etc. helped us to reduce our country's MMR over the decades.But the implentation of these programmes in economially and scoially weaker sections of the society,in rough terrain areas have always been an area of problem.It is now imperent to draw up plans based on local needs especially in high MMR hotspots.

Most of the time access to quality healthcare during emergencies is a major problem in remote areas.The introduction of Feeder ambulances (2018) in remote areas along with establishment of specialised centres aimed at connecting the often neglected and vulnerable population to good healthcare achieved good results in Andhra Pradesh. States like Kerala carry out a strict audit not just on maternal deaths but also on "near-miss" cases, it helps in identifying the causes and drawbacks.Programs and efforts which yielded good results in better performing states are to be analysed and expansion of these to remote areas and poor performing areas needs to be done on an urgent basis.Continuation of this mapping of data from districts is very crucial in the road ahead as it helps in identifying the problem area and inturn helps to implement plans which are locally feasible.

If access to emergency healthcare is a problem in some of the districts of the well performing telugu states then harsh terrain and poor infrastructure is the reason for a very high MMR in the North-Eastern part of our country.In other areas, social issues like wanting of a "boy child",lack of awareness on family control ,safe delivery practices are the reasons for these areas being hotspots for high MMR.Although the problems with our healthcare programs have been staring at as for a very longtime,this recent study and data have conclusively shown us that it is time to re-evalaute and change our policy making on an urgent basis. It is an essential need to have a micro-level healthcare policy and planning.For a country which is as diverse and vast like ours,problems are unique to each area and thus only with micro-level policy,multi-pronged approach(public health awareness programs on maternal health, girl education and gender equality) and implementation(locally targetted healthcare programs,robust healthcare facilities in rural & remote areas) can we as a country achieve our target of lowering MMR.

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]]><![CDATA[RISE OF HYSTERECTOMIES IN INDIA -Dr.Mahishma.K]]>https://drmahishmak.substack.com/p/rise-of-hysterectomies-in-india-drmahishmakhttps://drmahishmak.substack.com/p/rise-of-hysterectomies-in-india-drmahishmakSun, 19 Jun 2022 03:44:44 GMT                    Average Age of women undergoing hysterectomy in India is 34 years!!!

"removing uterus/reproductive organs at a young age is stealing a women's life"

Hysterectomy is  the surgical removal of the uterus. It may also involve removal of the cervix, ovaries , Fallopian tubes , and other surrounding structures.It is done as a treatment for conditions like fibroids,endometriosis,carcinoma,chronic pelvic inflammatory disease,abnormal uterine bleeding, prolapse, etc. Hysterectomy, after Caesarean delivery, is one of the most common surgical techniques performed in women.Nine out of every ten hysterectomies are performed for noncancerous conditions that are not life threatening but they have a negative impact on quality of life.

While there was a high incidence of hysterectomy rates in the developed countries in the past,these rates are slowly decreasing.In USA the rates have reduced to 6 in 1000 women today from a high of 10.6 in 1000 in 1975.They are much lower in Italy(3.7/1000 women) and Norway(1.2/1000 women). However hysterectomy rates in India are at a very high rate of 17/1000 ,i.e 17 out of 1000 women undergo hysterectomy - almost twice higher than USA.

Recent data from National Family Health Survey(NFHS-5) revealed startling information especially with respect to the telugu states.While the Overall National rate for hysterectomy in India is 11% (>45years of age women) and 3.2 percent in younger women(15-45years of age),these rates are more than twice as high in telugu states.The rates of hysterectomy among younger age group is as high as 8.7% in Andhra Pradesh and 8.2% in Telangana. The next highest state (Bihar) is having a rate of 6% , suggesting a huge difference of 2-3% at the top of the table and 2.5 times higher rate  than the national incidence.

WHY IS THIS HIGH AND RAISING ?

The notion that "that surgery is a permanent solution for women-related problem" is a major cause for such a  high rate of hysterectomies in India,especially in younger women.The focus of women health in our country is predominantly on safe obstetric care, there has been little to no focus on gynecological morbidities and in health education of gynecological care for women.This, coupled with a patriarchal society's opinion that "a uterus is of no use following the birth of children" created an environment of complete ignorance about common gynecological problems among women and the various treatment options-other than surgery- that are available.

Majority of the women including those who are well educated and working class do not completely understand/know about the various complications and side effects that can result from an early age hysterectomy. One of the most serious complication is early menopause.Those who undergo hysterectomy at an extremely young age attain menopause too early-early by atleast 10years[normal age of menopause is 46.2yrs in India,which is much less when compared to western countries(51yrs)].This early menopause,sometimes in theirs 30s and early 40s leads to multiple health problems in women that vary from abonormal vaginal discharge,painful urination,genital prolapse,mood changes etc.

Other complications apart from early menopause is, with the removal of ovaries - harmone balance of estrogen(produced in the ovaries)is lost.This, studies show has an effect on conginitive function and can cause early demmentia. Early Hysterectomies also lead to osteoporosis in women leading to severe backaches,affecting daily activities and work.Some of the other problems include chronic pain- joint pains,musculoskeletal pains,sleep problems,mental health issues,weight gain,lack of stamina,etc. Studies also showed that women who had undergone a hysterectomy without ovary removal had a 13 per cent increased risk of high blood pressure, as well as an 18 per cent increased risk of obesity.Studies also showed that women below 50years of age who underwent removal of uterus or ovaries are at more risk for development of coronary heart disease.

Lack of knowledge about the above mentioned side effects due to a early hysterectomy among the population along with poor communication by the treating doctors are leading to a very high rates of hysterectomies among young women in India.

ADDRESSING THIS

The introduction of Aryoga Sree in United Andhra Pradesh saw a very high rate of hysterectomies due to rampant surgeries, most of the times those surgeries were unwarranted.Reports suggested that during 2009-10, the total number of hysterectomies in (united) Andhra Pradesh was more than a million. But when the state government initiated restrictions on private hospitals for claim benefits under  government sponsored health insurance schemes for hysterectomy, there was a fall. Surgeries dipped from 6,189 in 2010-11 to 4,943 during 2011-12.Along with the government insurance schemes, private hospitals using insurance coverages  from third party sources are conducting hysterectomies  without any checks and balances.If this needs to be regulated,a check on ethical medical practices  that limits the misuse of incentives to doctors/hosiptals is necessary.Therefore it warrants an immediate  need for a strict audit of hysterectomies at district and state levels periodically.Although NFHS-4 and 5 posed questions on hysterectomy census,the information we gathered is still only primivitive,it didint cover how many of them had their ovaries and other organs removed along with uterus- which is extremely important to understand the complications that these women might face in the future.Hence a strict vigilance and regualar audits will help us to put a stop to poor medical practices and misuse of insurance coverages in the country.It will also help us to identify women who might need further care following surgery.

While there are many other treatment options - medical,harmonal- available for most of the common gynecological problems that can be offered to patients before going to the last option of surgery ,most of the times these are not explained to the patients well.While the cost of these medicines and relatively longer time for recovery are pushing women,especially from lower socio economic group towards a quick fix surgery, medical sector too needs to take the blame for not effectively explaining to the patients the various options available especially in case of benign conditions among younger/middle aged women. This can only be overcome with the introduction and implementation of standard protocols for indications of hysterectomy with an overview committee.

With the advancement of science, even in case of many gynecological conditions which warranted a surgery before,doctors are now practicing removal of diseased parts of the uterus,while conserving the uterus itself(uterus reconstruction) in other parts of the world,our medical education too should focus on improving its graduates expertise and skill which can benifit people.

Health education is the need of the hour regarding common gynecological problems,various other treatment options available other than surgery and about the complications that arise out of early hysterectomy.A three pronged approach of strict clincial audit,SOP for hysterectomies and health education can prevent a generation of women in our country from suffering  a devasting non-communical health issues that can arise out of early age hysterectomy.

]]><![CDATA[Thyroid disorders - Iodine in diet.]]>https://drmahishmak.substack.com/p/thyroid-disorders-iodine-in-diethttps://drmahishmak.substack.com/p/thyroid-disorders-iodine-in-dietWed, 25 May 2022 10:27:00 GMT               (This article is was originally published in Eenadu -the largest circulated Telugu language newspaper on 25.05.2022 by the same author.This is a translated,unedited version by the same author)                     

       

The thyroid is a butterfly-shaped gland that sits low on the front of the neck.Thyroid gland secretes various harmones and these hormones act throughout the body.They influence the metabolism  of the body ,help in growth and development and also in maintainance of body temperature. Thyroid hormones are also essential for  neuronal development, reproduction and regulation of energy metabolism.During infancy and childhood, adequate thyroid hormone is crucial for brain development.As these harmones help in the function of the body and more importantly help in brain development during infancy,the efficient functioning of thyroid gland is very important.It is also essential to note here about the vital role iodine plays in the production of thyroid harmones in our body.A less idoine diet leads to impaired production/synthesis of the thyroid harmones.

Any abnormalities in the fucntioning of thyroid can lead to hypothyroidsim(less thyroid harmones) , hyperthyroidism(more thyroid harmones) and sometimes can lead to even carcinoma.Hypothyroidism and hyperthyroidism are common conditions with potentially devastating health consequences that can affect every age group from newborns to older age people. Symptoms can be very non specfic at the earlier stages that can make a delay in diagnosis. While newborns and children may not show any symptoms at all sometimes, some of the common symptoms noted in both children and adults include fatigue,changes in body weight,poor performance in school or work,constipation,sensitivity to cold or heat etc.

In India around 42million people suffer from thyroid disorders.One in every 10 adults are suffering from hypothyroidism and it is three times more common in women than men.More than 40 percent of pregnant women are diagnosed with hypothyroidism in their 1st trimester of pregnancy.When left untreated or inadeqautely treated it leads to an  increased risk of miscarriage, preterm delivery, and severe developmental problems in their children. Hypothyroidism at birth again when left untreated will lead to poor growth and impaired neurological functions including mental retardation in children.Of all these what is more striking is that 1/3rd of the people are not aware of their condition and thus they do not seek the required treatment.Along with hypothyroidsm and hyperthyroidism,another common thyroid related disorder which is most prevalent in India is goitre. At present, goitre, an iodine deficiency disorder, puts around 167 million people in India at risk.

In developed countries too thyroid disorders have a wide spread prevalance, some studies point out that around 12 percent of the population in USA  are at a risk to develop thyroid disorders during their lifetime.Owing to life limiting effects of hypothyroidism at birth - screening of all pregnant women for thyroid disorders in now a universal recommendation.Many countries adopted screening of both pregnant women and newborns as a cost effective measure in treating the disease early and also to prevent mental retardation in children.Some of these countries also adopted thyroid cancer screening methods.In India while the private healthcare sector imbibed these protocols,we still do not have a universal screening program of pregnant women and newborn children at our public healthcare sector where the majority of the vulnerable population seek care.

In our country goitre caused due to iodine deficiency is a major thyroid disorder health problem.During 1980s WHO and UNICEF recognised this global health  issue and recommended food fortification of Iodine in countries where iodine deficiency is prevalant.India was among the first countries to adopt this and launched nation wide fortification of iodine in salt.In 1984, the Government took a policy decision to Iodate the entire edible salt in the country by 1992.In August, 1992 the National Goitre Control Programme (NGCP) was renamed as National Iodine Deficiency Disorders Control Programme (NIDDCP) with a view of wide spectrum of Iodine Deficiency Disorders like mental and physical retardation, deaf mutisim, cretinism, still births, abortions etc.The programme is being implemented in all the States/UTs.In 2005, universal salt iodisation was made mandatory in the country.

While this policy of fortification achieved siginificant gains in curbing goitres both world wide and in India,estimates suggest that in 2020, globally, 21 countries still have insufficient iodine in their diets. The recent data from National family Health Survey -5(NFHS-5) too revealed that there is still a long road left to curb this problem in India.An estimated 167 million people are at a risk and of these 54 million suffer from goiter and two million children suffer from cretinism as per the study.Survey pointed out that only 71 per cent of households were consuming iodized salt in adequate amount.Andhra Pradesh (83.1)recorded the lowest consumption of iodised salt among all states.States like Tripura(99.5%),Kerala (99.3%) had highest perecentages while Telangana is at 95.8%.The main reason for AP to have such low consupmtion rate is due to the use of raw sea salt by majority of pickling and canning industries to prepare products despite the ban.

These data along with the problem of a majority of population being unware about thyroid disorders points out to a significant rise in the burden of the disease.It is thus important to spread awareness to the people that helps in both prevention and early detection of the disease.Keeping in view, the importance of awareness,in 2007 at Leipzig, Germany a decision was made to celebrate every 25th day of May as the World Thyroid Day.

]]><![CDATA[Coming soon]]>https://drmahishmak.substack.com/p/coming-soonhttps://drmahishmak.substack.com/p/coming-soonWed, 25 May 2022 10:21:29 GMTThis is Dr.Mahishma.K’s Newsletter, a newsletter about Mostly about public health policy.

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