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Our Heritage

Its important for everyone to where is he going to, from where he stands today. But its equally important to know, where he has arrived from.

Mind, Market and Heart Care

Late Solomon Victor, M.S., M.S. MRCP, FRCS, FRCS, FRCP, FAMS

Picture
Agony  & Ecstasy
While  we  celebrate the Golden  Jubilee  of   our association,  we   can    be justifiably  jubilant.  Today, there is no need for patients in  India to  knock at  the doors of centres  abroad for cardiovascular and thoracic surgical treatment. There is a  boom  in  the  number of cardiovascular procedures. However, there  is cause for concern. Equitable access to heart care is becoming an ever recedingdream1 2 •  Even in a developed nation like U.S.A, about 40 million Americans live without health insurance. In India, about 400 million people live in poverty earning less than  2 dollars a day. There  is no social  or health security. While humankind is struggling to find the ideal way to live together,  evolving  means  and  measures for common good, eschewing selfish gain, there is growing inequality relating to  health  care  among nations and within  nations.  While there is intense focus on economy, world trade and  globalisation, the  poor  are  getting poorer, bereft of bare necessities for living including access to basic health  care, leave alone  heart care.

Warfare  and  welfare
Almost  all nations including India  are spending, at least about  ten times more on warfare than  health  care. Expensive weapons of  mass  destruction are  being accumulated by virtually all nations, with the excuse of need  for  defense. Individually, every human being wants peace,  harmony and  prosperity. But individuals are  helpless against collective  madness. Rabindranath Tagore,  our  Nobel  laureate expressed this succinctly;

'Man is kind, men are cruel". One hopes that the voice of  the  masses raised  against war  and  terror worldwide recently,  will lead eventually to one world  and  human harmony. The  legitimate revolt against terrorism however, is not matched by efforts to curb scourges which terrorize humans; poverty, hunger, lack of housing, illiteracy,  unemployment, and  inaccessible health  care.

Market forces
There  is enough for  everyone's need;  but  not  for everyone's greed,  cautioned Mahatma Gandhi. Every "ism"   has  been  exploited to satisfy greed, forgetting humanism. In capitalism, market  economy  is projected as being fair and lovely, benign and beneficent. Corporate culture has  not  proved benevolent. The  goodness of market  economy expected  to trickle  down  to the  poor has not helped  the economically disadvantaged, at the international, national, institutional and individual levels. The blind  pursuit of materialism has neither  made  the affluent  happy nor the poor comfortable.

Who  moves the  market? In the  final  analysis it is influenced by  and manipulated by  a few  hundred persons. This is strange in the background of advoc cy of  democracy. Life  revolves around the dally announcement of the  value of currencies. But  the fallacies  of these  figures have  not been  discussed and remains a mystery.  Heart  care is adversely affected  by the market economy.

Heart  care and  Economy
When  our association held a rare symposium on economics of heart  care,  professor Gujral,  in his own inimitable manner questioned the value of saving a few hundred rupees by modifications in surgical techniques, while lakhs are wasted on  equipments and infrastructure relating  to heart care.

Today the  escalating cost of heart  care is related  to the following:

Factors  influencing cost of cardiac care

1. Ethics
  • Humanity
  • Nation
  • Industry
  • Institution
  • Individual

2. Insurance
  • Type
  • Managed care

3. Socioeconomic factors
  • World
  • Nation
  • Institution
  • Family

4. Consumer protection

5. Infrastructure
  • Land;  Building;  Equipment
  • Professional/ paramedical services
  • Maintenance

6. Procedures
  • Drugs
  • Devices
  • Techniques

Yesterday & Today
Gone are the days of Schweitzer, Mayo brothers and Gopinath. Ross  did  not  patent the  homograft or autograft. Gone  are  the  days,  when a grateful patient gave fruits, food or a product of his labour such as hand woven fabric. Today,  in  the  unfortunate event of a patient getting myocardial ischaemia, the  precious savings of the  family  get wiped out  in a few  days  of intensive care, leaving  no funds for justifiable imaging, catheter and surgical interventions. Unjustifiable investigations and interventions add to the misery. There is a risk of the treatment proving worse than endurance of  the  disease. The  'medical litany' of Sir  Robert Hutchison is more  relevant to the present  scenario:

'From inability to leave well alone;
From too much zeal for the new and contempt  for the old; From putting knowledge  before wisdom,  science before art,
cleverness before common sense;
From treating  patients  as cases; and
From making the cure of a disease more grievous  than its
endurance,
Good Lord, deliver us'

Solutions
Instead of lamenting over the current scenario, let us consider practical  ways and  means of moving towards accessible  heart care for all at least by 2020. 

Prevention
India needs to eradicate poverty, hunger, squalor and preventable diseases. Schools need to be converted into primary health care  centres. 10  Treatment of throat infections and arthralgia must be accessible in the school premises. Children should  be  informed about the dangers of smoking, negative emotions, stress, and unhealthy diet. Exercise should be encouraged. Health science  should be introduced as a separate subject  in the school curriculum, following the initiative taken  by the Government of Tamil Nadu.10 The society  must  be educated about  diabetes, hypertension, and  congenital heart  disease.

Health Insurance
A rupee from  each  Indian will  raise  1000 million rupees. We should explore  the assets of our population rather  than  harping on the  disadvantages. A rupee a week  from  everyone will  ensure social and health security for all in the event of a major ailment or accident. The  payment could be collected while issuing birth certificates and voters identity cards which can serve as social  security/insurance documents. We should not blindly  ape  the  American method of health  insurance which,  compounded by unethical practice  of medicine increases the cost of health care11•  'Managed' care meant to curb the escalating cost of health  care manages only to curb the  freedom of the  doctors. The  medical profession needs  to restore  its image  by self discipline and high level of ethics to avoid the need to be managed by  third  parties. Models of  health care delivery established in Canada, New  Zealand and  Europe are worthy of adaptation to the Indian scenario.11

Equipment
There  must  be a time  bound program integrating medical and  technology institutes with  the  industry, towards making India self  sufficient in  ventilators, imaging equipment, blood gas and chemistry analysers, diagnostic kits,   heart lung machines, hypothemia machines, balloons, catheters, and stents. This will make us less dependent on expensive imports.

Globalisation and  Commercialisation of Health Care & Medical Education

Globalisation should develop different  yardsticks to measure human harmony and  happiness, while linking all  nations in a global  village.  The growing focus  on money and market especially relating to health care and medical education should be  diverted to  humane trends.

Primary Heart  Care
The emphasis on specialised tertiary care should be complemented by availability of primary cardiac  care in the  primary health  care delivery system. The scope of primary care should be redefined. The patient  in a village should  have access to  E,C,G., blood tests intensive care, thrombolysis,  defibrillator,  X-ray, monitors, and  intensive care in the primary health  care centre.  The doctor-in-charge of the primary health  care must be a specialist (in fact a multi specialist)  in primary health care on par with specialists in tertiary care centres. Efficient transport must  be available for referrals.

Research
Indians should not ignore  fundamental and  clinical research. We have  enough cerebrum. We have  vast clinical materiaL But  we  need  more cerebellum as pointed out years ago by late Professor  Ramamurthy, a pioneer in  neurosurgery. Innovative links with biomedical engineers should result  in  production in India of equipment for research,  ranging from pipettes, to advanced instrumentation for molecular laboratories and  nanotechnology, A major lacuna in the  practice  of medicine in  India is the  lack  of emphasis on  basic interdisciplinary  research. Lack  of follow up  also hampers scientific assessment of  the practice  of medicine. Many  of the  conflicts  relating  to the  use  of drugs, devices, balloon, knife,  and  cardiopulmonary bypass can be resolved  if unbiased adequate follow  up data  are  available. It is a paradox that  our  beautiful journal is  starved of  good manuscripts despite voluminous work  in many  centres.

Surgical Techniques
We should not  blindly ape  techniques adopted in other  countries. Our  approach must  suit  our  patients' pattern of disease  and  purse.

Mind & Heart  Care
Ultimately what matters is mind; mind to make heart care accessible to alL Mind determines what  man does. There is a need to reflect on age old questions?    


Where did we come from? 
Why are we here?
Where are we going?

Study of comparative anatomy and  physiology of the  heart  points to a supreme intellect  with  a master of social welfare,  truth and  justice,  while  drawing our attention to the order  and  harmony in the universe. India is poised for a mighty take off into tremendous development and  scientific progress. She  also  has  a wealth of philosophical and cultural background dating back to five milleniums. India can provide a model  for equitable heart care.  An  ideal   role  model has  been established by Sri Sathya Sai Baba. Equitable health and heart care needs to  become a  countrywide,  nay worldwide mass movement. Members of our association can be the moving force.

"0 mankind, I bind you together with one objective. The welfare of man

Toil together with mutual  love and good will" Rig Veda


" What you do not want done to yourself do not do to others" Confucius


 "Do not do unto others, what is hateful to you" Judaism

"Do unto them as you would have them done to you" Christ

"Those which ye spend   for good  to .. . .orphans and the needy and the wayfarer, and whatsoever goodye do, La! Allah is Aware of it" Holy Qur'an

Sourced From Google: I]TCVS 2004; 20: S38-S41


References:

1.  Victor S. Concerning health  for all humanity. AustralAs 1 Cardiac Thorac Surg 1993; 2: 155.
2.  Victor  S. A dream for  the  decade (editorial). Indian  1 Thorac Cardiovasc Surg 1989-90;  6: 1.
3.  Victor S,  Kabeer M. KISS approach to open  heart surgery.  Indian ] Thorac Cardiovasc Surg 1989-90; 6: 20-6.
4.   Victor S, Kabeer M, Nayak VM. KISS approach to cardiac surgery. Ann  Thorac Surg 1996; 62: 1890-1.
5.  Victor S,  Nayak  VM, Kabeer M. Cardiopulmonary bypass;  keep it simple  and  safe. AustralAs] Cardiac Thorac Surg 1993; 2: 44-5.
6.  Victor S, Kabeer  M, Manohar M, Nayak  VM. Should  surgeons and anaesthesiologists auscultate? Texas Heartinst] 1999; 26: 160.
7.  Victor S, Kabeer  M. Venting and  deairing without roller pump. Ann  Thorac Surg 1993; 55; 807.
8.   VictorS,  Kabeer M. Is systemic cooling  essential for open  heart surgery? Ann  Thorac Surg 1999; 50: 334-5.
9.  Victor S,  Kabeer M.  Single drain  (pleura, pericardium mediastinum) after open heart operations. Ann Thorac Surg 1991;51; 345-6.
10.  Victor S, Kuganantham P, Sankkaran R. Health Science for School Children, The Heart  Institute, Edition  I, 2004, Chennai, India. (ISBN  81-900682-5-3).
11.  Victor S. A doctor's dilemma. The Hindu August 25, 2001: 3
12.  Victor S. Are we here by Chance  or Choice? Bhavan's], 2002; 49:151-155.
13.  Victor S. Science & Technology Leading to Origin of Humankind. Proceedings of the symposium on Science, Technology, Origin of Humans and Theology, Science and Technology Centre  and Science
14.  Victor  S. Science  &  Sensibility (Preface)   Proceedings of  the symposium on Science, Technology, Origin of Humans and Theology, Science and Technology Centre  and Science City, Chennai,  August 21, 2003.
15.  VictorS, Nayak VM, Raveen R. Evolution of the ventricles (Guest Editorial). Tex Heart Ins] 1999; 26: 168-75.
16.  VictorS, Nayak  VM. Evolutionary anticipation of the  human heart (Arnott demonstration lecture. The  Royal  College  of Surgeons of England)  Ann  R Coli Surg Eng 2000; 82: 297-302.
17.  VictorS,  Nayak VM, Raveen R. Gladstone M. Bicuspid evolution of arterial and  venous atrioventricular valves.  ] Heart Valve Dis 1995; 4: 78-87.
18. Victor S, Nayak VM. The  evolution and genesis of supraventricular waltz  and duet. Indian] Thorac Cardiovasc Surg 2002; 18; 84-94.
19.  VictorS,  Nayak VM. Every heart beat is under neural  command; an  hypothesis relating to the  cardiac rhythm. Heart  Lung  and Circulation 2003; 12: 11-17.
20.  Bta; The  Cosmic  Order.  Ed.  Khanna M.D. K. Print  world (P) Ltd., New Delhi and  Indira  Gandhi National Centre  of the Arts New  Delhi 2004. (ISBN  81-246-0252-2).    

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