Mind, Market and Heart Care
Late Solomon Victor, M.S., M.S. MRCP, FRCS, FRCS, FRCP, FAMS
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
2. Insurance
3. Socioeconomic factors
4. Consumer protection
5. Infrastructure
6. Procedures
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
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).
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).
