Heart health and healthcare in India
Jul 2, 2021
q. How has the health care sector especially in the cardiology department changed in the 2021 pandemic?
A. We have had a tough time because the emergencies have never been over. Even in covid times we have had to cater to acute heart attacks and acute heart failures coming to the hospital. So if you look at our portfolio of work, only the OP consultations have been less but in terms of catering to emergency which is our field it has never taken a back seat at all. We have been kept busy even in this pandemic.
But certain things like screening of patients when they reach the emergency department, and how fast we can screen them for covid so that the emergency treatment for heart care does not suffer, that has been the major challenge we have faced. And since we have gone through the first wave and there we have fine tuned our ER department so that covid tests are done in one and a half hour because you must know in cardiology that time lost is muscle lost. So we never wanted to compromise on that. But initial few days we have also been sceptical in taking up the patient for procedure because it involved the doctors and our team members being exposed to the covid infection and then quarantine for 14 days and losing half of our bench strength due to covid infection. Not having our junior doctors at work because of them getting covid infection. So all these were the major challenges during the first wave.
And first 1 month we were very conservative, even giving thrombolytic injection rather than taking up the patient for primary angioplasty. But now with adequate lab staff and lab service support given by the hospital we have been able to tide over these things and we have not had any crisis because the door to needle time is probably delayed by 1 hour after reaching the hospital only to get the covid testing done by a gene expert and we get the reports within an hour.
So things have changed in the pandemic but I’d like to say that we have adapted to the change and seen that acute cardiac care does not take a back seat.
Q. What opportunities does India have in health care these days
A. The opportunities are plenty in India, especially for specialists and speciality based health care, surgeries and procedures. Even in the tier 2 or tier 3 cities, they have a huge potential for people abroad getting treatment here.
This coastal area can be called the medical hub of our country or state, because most of the renowned doctors are from this place. And if you look at the cost of surgery or procedures, even if you compare it with Gulf countries, we are hardly 20% of the cost. And if you compare with US or UK, the cost of treatment in India, even with the best setup is hardly 5% of what it costs abroad. So I think there is a huge potential.
But now due to covid, travel has become difficult, but looking at the long run, say post covid, we have a huge potential for growth, especially with people coming from abroad for medical tourism, and I think the hospitals here need to explore on those lines.
Q .what are the thumb rules for a layman to take care of his heart.
A. This is a very good question because people do now the technicalities as a professional. So what can be done to minimize cardiac care or concern. We must remember that all heart diseases, like heart blockages or coronary artery disease, the risk factors can be broadly divided into 2 big categories. Those which you can modify, or those which are under your control, modifiable risks and those which are not under your control or non modifiable risk factors. For the latter category there is nothing that you could do, say for example age.That catches up with you and coronary blocks develop due to age, you can not do much about it. Genetic factors, you have no control if your Dad, Grand Father or Uncles have. All you can do is take care that you don’t have but there is nothing you can change in your genes.
Ethnic background, some people are more prone to developing coronary artery disease and this is not under your control.
And so these unmodifiable risk factors cannot be tackled and you need to accept that all you can do is identify that you have coronary artery disease early so that you don’t develop complications.
Now the former category is everything you can do. Say for example, smoking, which you can quit. It’s never late to quit smoking. Because even if you were smoking 10 years ago, and you decide to quit today, in another 3 years your risk of developing cardiac problems is the same as a person who does not smoke which means it’s never late to quit smoking.
Same with alcohol. There has been contradictory medical evidence saying, a little amount of alcohol is good, but too much is bad. But then people never know the limit. If you are an alcoholic, no one decides what is good for you and what is bad. So it’s always better that you don’t over drink. One or two social drinks is OK, provided you know your limits.
Third is diabetes and hypertension which is really catching up in our society. You would be shocked to know that 1 out of 3 adults in India is diabetic. And slowly we are going to be the diabetic capital of the world overtaking China.
It only means that the coronary problems are going higher because 1 out of 2 diabetics will develop coronary problems in his lifetime.
Hypertension is a risk factor because 50% of us do not know we have blood pressure unless we are checked. And you develop problems due to high blood pressure only when you land up with an event. Say coronary artery disease or a stroke. And that is when you detect you are a blood pressure patient. Which is wrong. I feel that hypertension must be screened in a community and you need to pick up hypertension patients early.
So, smoking, alcohol, blood pressure, diabetes and cholesterol. These are controllable risk factors which people should be aware of so that the burden of coronary artery disease comes down in our community.
Q. Are there any health care models India can emulate
A. It is very difficult. If you look at the healthcare system of the world each country works on a different model. I have had the opportunity of knowing the US health care system quite closely. In UK or US, healthcare is the responsibility of the government. They can afford to do so because they spend a huge amount of their GDP on the health care sector. You compare it with our country, we are nowhere at their level. UK spends 15% of their GDP on health care, US spends 10% of their GDP on health care. In India it is less than 0.5% being spent on health care. You must also know that our population is 10 times that of the US and 50 times that of UK. So to just copy a model from one of the developed countries and implement it at ground level is going to take 25 or 30 years to see that we get the same amount of health care like developed countries, spending a minuscule amount from the overall GDP. There are some positive aspects of various other health care models like if the government in our country is going to take care of health care, it is going to be fantastic. If you are going to spend a certain amount on tax, it is imperative that the government look after you because if you are not healthy then you are not going to pay tax. That is how the US Government looks at it. They spend a small amount on health care but get a large amount from you as tax, so it is the responsibility of the government to look after you. But since the government health sector is underdeveloped or does not have the capability of taking care of modern health care facilities, the burden has fallen on private health care.
Now what happens with private health care is they are not funded by the government, it is funded by individuals or big corporate setups who look at health care as a service but also want it to be a break even model to cater to society.
So the cost factor adds up in the private health care sector which otherwise might have been much less in India if the government had invested in the public health care model. Even for basic health care, the public model is inadequate to meet the standard of health care. There is no point in having a primary health care center with no basic facilities. You need at least the basic testing facilities in our primary health care center.
And it is sad to say that 75 years post independence the Indian government health care center is not geared up to provide the basic minimum health care to the citizens. Because people in power have not looked at health care as a priority.
It’s very simple for the government to upscale the public health care system, which is not a huge investment given the GDP of our country. It is probably the lack of vision or inadequacy to recognize health care as a priority. Now there are various other sections such as industry or water supply which is being looked at on priority. Probably because of covid the government has woken up to upgrade its system because you do not have a choice. You cannot get health care beds overnight. It is looking at government and district hospitals to be upgraded, oxygen supply to be implemented, ventilators, increase of beds, personal to be employed. A hospital requires more than just doctors. You require nursing staff, second grade or third grade employees to look after a patient. The government should look at health care as an employment generating sector where they can employ a lot of people. Receptionists, counsellor, nurses, paramedics and doctors. A lot of doctors can be incorporated in the government sector provided they are paid well.
In UK a lot of doctors want to do family practice, because there is less risk than a specialist. But a family doctor is paid as well as a specialist. So there is no discrepancy in terms of the NHS medical care. The gap between a specialist and a generalist is not so huge even if the specialist is paid more.
So in India you get a lot of super specialist because it is lucrative in terms of income. Of course there is a lot of hard work to be a super specialist and to succeed. But we have less number of generalists and family physicians who can cater to 90% of the population.
We do not require so many super specialists, because out of 100, the super specialist role is only 10. But you require a lot of generalist and family physicians to cater to a huge population.
So in India’s health care sector, in the tier 2 or tier 3 cities are overloaded with super specialists and the rural towns are devoid of even a generalist. So you have a huge population, inaccessible to health care with inadequate primary health set ups. Whereas you have all the super specialists, corporate hospitals, lined up in tier 2 or tier 3 cities looking at economically breaking even, catering to a smaller population.
So you have to bridge the gap. And the policy makers need to look at spending more and strengthening the public health care sector so that investment comes up and a lot of people get employment in this sector.
Q. How does irregular eating habits affect the heart?
A .We need to look at 2 aspects. One is the quantity of food the other is the quality of food. So far as the heart is concerned you need to take in limited quantity taken at frequent intervals like for a diabetic person. Rather than having big meals full of nutrition once a day, you need to split your food components into saturated and unsaturated, lots of leafy vegetables, fresh fruit intake, less of ghee and fried foods and non veg taken in smaller proportions compared to vegetables.
And more important is how you utilize your calorie intake per day so that you don’t increase intake. These are some of the aspects you need to look into. And if you binge eat it is not good for your heart. Because it increases obesity, increases bad cholesterol and increases the risk of diabetes. So binge eating should be avoided.
Q .What are the first aid steps taken for a heart attack.
A. The common public should be aware of the emergency steps before a person with a heart attack or a suspected cardiac problem reaches the hospital. You must realize that most of the deaths due to a heart attack happen in the first 3 hours and sometimes much before a person seeks medical attention. Most of the deaths are not due to the heart attack but due to heart beating problem. It is very important to know the symptoms of a heart attack, which is excruciating pain which the patient has never experienced before, radiation of pain to the left hand or to the jaw, heavy chest as if someone is choking you, or profuse sweating, vomiting or abdominal discomfort.
So these are some of the alarming symptoms that a person has got a heart attack. There are very few things a doctor can do when called outside a hospital. So you should have people to help you, to measure your pulse, BP, whether the patient is breathing properly or not.
It is important that 2 things are restored. One is respiration and the other is heart rate. You require someone to give the cardiac massage or take care of ventilation by mouth to mouth resuscitation so that you can rush him immediately to first aid medical attention. Once you are sure that these things are done, you require to take an ECG to check for heart attack. Now if he has all the symptoms but ECG does not indicate heart attack then you have more time to rush him to the hospital to do a electrocardiography or to consult a specialist. If the ECG shows that he has got a heart attack you should reach a cardiologist so that you can take an angiogram or be treated for angioplasty so that you don’t waste time. All this should be done in the first 3 hours, the golden period after an attack. Here the damage to heart muscle will be minimal. And the patient assumes normal lifestyle within a week or ten days of time. If you delay this by 48 hours most of the muscle is dead and the benefit of these procedures are minimum. So it is very essential to have him treated in the golden period and shift him to the cardiac center as early as possible, so that appropriate treatment can be carried out by the cardiac team.
Now what can be done outside the hospital is that you can give Aspirin 350 mg to be chewed, and for the pain you can give Sorbitrate which is to be kept below the tongue and you can repeat it at a gap of 5 minutes so that the patient becomes pain free. So these are some of the emergency steps that can be taken outside the hospital by a common citizen so that they can be aware of what to do before a person is moved to a hospital.
Q. Can a person help himself during a heart attack?
A. If the patient is conscious, if he has only pain and his vitals are stable, he can rush to the nearest pharmacy for aspirin and then call for help. So the emergency medicines can be taken by the patient himself because the aspirin should not be swallowed, it should be chewed because the content of Aspirin goes into blood circulation within 5 minutes if you chew the tablet rather than swallow. If you swallow the tablet it will take blood levels almost three hours to reach a peak, so that the platelets that block the blood vessels are inactivated rapidly. So you must chew the aspirin or Sorbitrate because it gets absorbed by the oral cavity below your tongue.
Whereas if you swallow, it goes to the stomach and is absorbed by the intestine which takes about 3 hours.
So this can be done by the patient itself provided he is haemodynamically stable, in the sense that his blood pressure and heart rate are normal. And more importantly he must call for help because he would require someone to move him to the hospital to take an ECG or meet a specialist because he cannot drive himself. You never know when you can have a rhythm disturbance and collapse while driving and land up with an accident. So call for help and have someone drive you to the place of cardiac care.
Q. Sometimes due to hectic schedule, people are not able to exercise. So does walking between chores or climbing the stairs at home work as a substitute for exercise?
A. Yes, definitely. It is important to have exercise as part of your daily schedule. Keep sometime for our selves doing religious activity or praying so that you will be mentally at ease despite your daily schedule. You can have exercise as part of your daily schedule. Now people get up and rush to the offices because we are now tuned to a corporate culture. We have lost those days where we could have a morning walk or meet your friends over a cup of tea in the morning. In that case you can exercise at the office. So that the concept od exercise is not lost, it can be done anywhere. In fact if you go to bigger companies, they all have a gym at the workplace. Productivity comes if you are healthy. If you are not healthy then you are not productive. So it is important to exercise at the workplace. Don’t take the lift, climb the stairs so that you burn calories. You can run up the stairs to burn more calories. Keep walking. It burns alot of calories. Spend 20 minutes minimum 5 times a week on exercise so that you do not put on weight. It is important to reduce abdominal fat rather than on the full body.
Q. Why did you make medicine your chosen field of study and career path. What aspects of medicine drew you into the specific area that you chose.
A. I am basically from Mangalore and in those days there was a competition to get into either medicine or engineering, 18 or 20 years back. They were the 2 mainstreams of higher education. Less stress was given to commerce or commerce related activities, which I think today has taken a forefront. Today people don’t want to choose medicine at all because they don’t see it as a lucrative profession. But in those days it was not a priority in choosing a career and since I was from this place and I got good academic credentials both in PUC and CET, so I got into Kasturba Medical College and it was close to my house. That is one of the reasons why I chose medicine as my career. I was inspired by good doctors in this part of the country. But you need a few qualities to become a good doctor. One is knowledge about the field and upgrading yourself to the changes that happen. What happened 20 years back no longer holds true today. In medicine what we learned 5 years ago no longer holds true today. So I like this field because it kept me on the move. Unless you are adequately tuned to the changes of the world, you don’t stand a chance to succeed in a medical career today.
Next is to care for fellow human beings. You need to have some element of sympathy or empathy towards your patient as well as towards society. Also your ability to take the decision at the right time makes a lot of difference for your patient.
Q. What should one do to avoid covid-19
A. Things that are easier said than done. This infection is spread by droplets from person to person contact. It is very difficult to know who a carrier is. So we need to follow the 3 universal rules termed as SMS (Sanitizer, Mask, Social Distance).
One is sanitizer usage. So that you take care of hygiene. Second is mask, so you have less chance of contracting an infection from another. If both wear a mask, the chances of infection is less than 1% to 2%. If we don’t wear a mask, chances are 40-60%. Third is social distancing because the infection cannot be spread by the organism. It is spread by people carrying covid from one place to another. The organism does not survive more than 24 hours if there is no one to carry it. So social distancing, maintaining 6 meter gap between healthy people also is a good practice. So that the chain of infection is broken.
People forgot all the rules after they came out of the first wave and we had a lot of political, religious and social events which have triggered the second wave. It is the responsibility of the citizens to see that we combat this infection by sensible, simple measures of sanitization, wearing a mask and social distancing.
It is not a killer disease. The mortality rate due to covid is very less. The mortality of patients getting infected, becoming seriously ill is 0.1% to 0.4%. If you look at other contagious diseases, the mortality rate is high. So to say it is not a serious infection. Though people who become serious develop death or mortality is very fast. But that number to the number of people getting infected is very small. If we maintain these simple rules the number of people getting infected becomes very less. Those who fall sick can be adequately looked after by the health car system that is in place.You don’t want healthy, asymptomatic people to rush and fill hospital beds. Only high risk patients who require oxygen, ventilators should visit health care centers. So that you can have adequate channeling of available resources to those people who are in need of such facilities.
Q.How can health care create equitable growth?
A. Health care is never looked at as essential either by the government or by the people. How many of us go for health check ups. Unless you fall sick people do not want to go to the doctor. People do not have the concept of health care checking or getting tested for issues. All of us only go to the hospital when we fall sick. So thats not a good angle to look at it.
Above 40 anybody who has a family history of heart disease or diabetes at least needs to see what the risk is. Dont we take insurance at a young age. But do we really look at screening ourselves for probable risk factors at a young age. The answer is no. We must see that people remain healthy so that they contribute not only to themselves but to family society and the nation.
So if you look at equitable health care growth, it should have received priority long time back. Because our country has a very young population who contribute to the growth of the nation. People above 60 do not earn they do not pay taxes. If you look at the tax bracket of our country it is sad to say that 3% support 97% people. So only 3% are in the high income bracket who support all projects growth of the nation infrastructure, government spending. Why is it not possible to see that our young population who contribute to the growth of the nation also look after themselves well. Sad to say we have young people with diabetes heart disease.
If you look at the statistics 1 out of every 4 person dying due to heart disease is less than 40. And this would be an earning member of the family. And that is sad. If you can prevent this you can increase his growth potential he survives longer he contributes better to his family country and society. The thinking needs to be changed in some of our young software engineers who earn well in their 20s and 30s and think their career is over by their 40s. Which is not the right way to approach it. We need to see that it is a test match and not a 20 20 innings.
