FUTURE MEDICARE SYSTEM

Prof. B. M. Hegde
Vice Chancellor
Manipal Academy of Higher Education
Manipal - 576 119

“Men are disturbed not by things which happen, but by the opinions about the things.”
Epictetus; First Century Greek Philosopher.

Modern medicine has become prohibitively expensive. It is going to be still more so with newer technology invading medical diagnosis and management more and more. Most of these technologies have not been audited and some of those that were inadvertently audited did not come up to the expectations of their promoters and, in some instances, have even caused more harm than good.1 It is estimated that around 80% of the world population have not been availing the modern medical facilities! Around half of the rest who have even free access to modern medicine would prefer to have an alternative system, if available, even in the industrialized west. The reasons for the disillusionment are protean2, but the lack of medical humanism is one of the foremost.

Oregon state in the USA realized, to their dismay, that one bone marrow transplant in a terminally ill cancer child would cost as much to the taxpayer as looking after the health needs of one thousand pregnant women through pregnancy and delivery, as also the health needs of the baby for the first year of life. Recently, they enacted the Oregon Law that bans bone marrow transplants for terminally ill cancer children at the taxpayer’s cost. This did create trouble in the beginning but, eventually, many other states have followed suit. This could give one an idea of the magnitude of the financial load of covering every citizen with all the hi-tech stuff even in the rich nations. Most of these techniques only make life appear longer making the patient a slightly better cripple.

Let us not bother to look at the scenario in the poorer countries for the purposes of this paper. Suffice it to quote the recent WHO document (WHO 2002) that shows that if the people of the poorer nations were to get clean drinking water, it would bring down two million deaths per year and prevent half a billion serious illnesses. Obviously our priorities are skewed very badly. The western pharmaceutical industry, however, is trying to push the costly, many times unproven, drugs and technology3 into the third world, where even today the common man does not have access to clean drinking water, three meals a day with food uncontaminated by human and/or animal excreta, and a toilet to avoid the deadly hookworm infestation of children!

Need for a new paradigm in medical care:

Robust circumstantial evidence goes to show that the 80% of the world population that does not have access to modern medicine lives using their intuition in times of need and get benefit from many other time-tested alternative systems of medicine, many of them being much more ancient compared to the modern medical wisdom. One of them, the Indian system of Ayurveda, is much more ancient, having survived the discouragement in the recent past even in India. We now have unequivocal data to show that Ayurveda is the mother of most other systems, notably the modern medical system.4 Present day modern medicine originated in the Nile Valley five thousand years ago as sorcery, witchcraft, magic and mumbo-jumbo. Present day “much of the news and advertisements of health education with which we are bombarded are designed to heighten our worries, not soothe them; many drug companies play upon our tendencies toward hypochondriasis.” Wrote Herbert Benson in his celebrated book Timeless Healing.5

In its onward journey through Arabia and then Greece, it came under the spell of Ayurveda taken to Greece by the army of Alexander, the Great. There are two authentic works to support this hypothesis. India in Greece is an excellent treatise written by a great Greek scholar, E. Pococke, who lived in India for years. He wrote this book in 1832 AD. Another authoritative book is the one on Ancient Indian Medicine written in 1936 by Late Prof. P. Kutumbiah, MD, FRCP., who served as the Professor of Medicine both, in Vellore and, later, at the Madras Medical College.

This apart, the popular belief about the eradication of the only scourge of mankind, smallpox, needs a major change to get at the truth. Dr. T.Z.Holwell, FRS, was a Fellow of the London Royal College of Physicians. He spent twenty years in “The Bengall Province” of the Raj to study the Indian system of vaccination and its effect in preventing small pox. After twenty years of prospective controlled studies, he concluded, in his report to the Royal College, submitted in the year 1767 AD, that the Indian system of vaccination, which existed for “time out of mind,” with a type of attenuated small pox virus, was ninety per cent effective in preventing small pox deaths and had very little side effects. This report, in its original shape, is still available in the archives of the College library. It can not be Photostatted but is in the Internet as a Revised Version. Surprisingly, it survived the great fire in the library some years later. Holwell favored permitting the anecdotal experience of Edward Jenner to be used freely in view of the Indian experience of antiquity! He pleaded with the President and Fellows of the Royal College to recommend to the King the free use of Jenner’s unproven method in view of his solid proof from Indian vaccination system. Rest is history known to all.6

Suggested New Classification of Diseases:

To understand the new paradigm one needs to classify human diseases based on the treatment needs thus.7

• Emergency Medicine…………………………..10% of the sick population.
• Minor illness syndromes……………………..…35% ----ibid
• Doctor-Thinks-You-Have-a-Disease……….....15% ----ibid
• Patient-Thinks-He-has-a-Disease………….......10% ----ibid
• Neoplasias………………………………...…..10% --- ibid
• Chronic Degenerative Diseases…………......….10% --- ibid
• Iatrogenic Diseases………………………...…..10% --- ibid

Classified like this most of the diseases, where modern hi-tech medicine, with all the glittering array of diagnostic tools, the expensive interventions and drugs are of utmost need, fall into the first category of emergency diseases. The new specialty of emergency medicine in the west is the most welcome timely step in the right direction. Rather, it heralds the need for the paradigm shift, referred to earlier. It is here that the advances of modern medicine could make a dent in improving the lot of the suffering humanity and, possibly, also in preventing avoidable deaths. In the emergency set up even the unproven technology could be justifiably used in extreme situations.

Time has come for a proper audit of the present use of hi-tech medicine under all the illness situations classified above. I strongly feel that in the non-emergency situations we need not (possibly, should not) resort to hi-tech modern medical help. We could easily put together an inexpensive method of managing most of those 90% illnesses using a judicious mix of the best in many useful alternative systems of medical care.8 Rarely in some of those situations, like the neoplasias, modern medicine could be used in conjunction with scientifically tested alternatives, to reduce the cost and the intolerable side effects of chemotherapy and radiation. The two mentioned above have not shown themselves in very good light so far.

Many of the newer, yet to be tested but, much hyped, chemo-therapeutics are prohibitively expensive for the poor. These methods of cancer management have not made a significant dent in total cancer deaths. Cancer deaths have still to level off before showing a tendency to come down. This could be contested using statistical methods known to modern researchers, though.

There are excellent remedies for the control and/or prevention of the major class of minor illness syndromes, that cause the largest sick absenteeism in productive fields everyday, in Ayurveda as well as other alternative systems. Some of them have been tested by the modern medical methods already. The powerful anti-viral properties of Indian spices, mainly garlic, ginger, and pepper have been studied in the leading western laboratories. More than all that is the thrust in Ayurveda of methods to keep the healthy well. These health-promotive strategies are the backbone of Ayurveda.

“Swasthasya swastha rakshitham.”
[Keep the well healthy]

This is the most important slogan in that system and there are many methods of health promotion based on life style changes, food habits, exercise, yoga, meditation (making the mind tranquil), and also certain herbal remedies to slow the ageing process. Time does not permit me to dwell into the useful methods in many other systems of health care delivery people have been using down the ages.

Unfortunately, quacks and unqualified people have brought disrepute to most of those systems.9 It is because those methods have not been scientifically evaluated before being let loose on the gullible public. This must stop forthwith! The reader could be surprised to know that the ancient school of medicine of Shushruta needed a much longer period of training to be a doctor that most modern medical schools today. The students studied human anatomy in much greater detail for much longer time to achieve perfection! All these need to be looked into before we jump at the new bandwagon of other systems. What I am advocating is not too many systems to be used concurrently. The best brains in the various systems will have to put their heads together to evolve a new system, the complementary system of medical care, that has a scientifically judicious mix of the best in all those systems along with the emergency hi-tech care for a wholistic medical care delivery system that could economically do most good to most people most of the time.

There was an audit of the effect of modern medicine in the USA about two decades ago. Whereas 59% of the improvement in human health and fall in disease incidence there could be attributed to improvement in sanitation, improved nutrition, better education, decent housing, economic empowerment of the masses, and healthier life style avoiding tobacco and alcohol, only 3.4% of the change could be due to modern medical claptrap! One needs to repeat this in many other countries to get a better picture that might motivate even the skeptics to agree to the paradigm shift.

Surprisingly, even in the emergency set up, although I feel that the latter definitely needs hi-tech, a comparative study of the per capita deaths of the wounded soldiers in the Vietnam and Falklands wars did show that it was marginally better in Falklands compared to Vietnam. While the American soldiers in Vietnam had the best base hospital in the nearby Saigon, the British did not have such luxury in the South American war theatre. Many a time the wounded soldiers in Falklands were left to be tended by the forces of Nature, before being attended to and, that too, not in a sophisticated hi-tech modern base hospital. One of the explanations for this disparity could be that we have been interfering with Nature’s methods of dealing with human injury with the help of the sympathetic system evolved to protect the hunter-gatherer forefather of man, from the most important danger those days of predation!

Complementary Medical Care Delivery System :

The idea of mooting this strategy is to stimulate people to think about this possibility to make medical care available to all the people of the world, rich and poor, that is not only equally effective but cost effective as well. We must take care to see that the new system is put in place after due care to see that untested, unproven, and potentially dangerous methods do not get included. The scientific methods and agencies overseeing this stupendous task must not only be highly competent, but should be equally authentic. We hear of the fraud in medical research in modern medicine almost daily, to be brushed aside lightly. With that background in view, the people at the helm of affairs must have proven track record.

There would be great opposition from the all-powerful drug and technology lobbies that literally run medical education in the west these days.10 They start brainwashing the future doctors from day one at the medical school, only to stop at their graves! It is heartening to know, though, that there are very good people even in those areas, but they are like an occasional oasis in the vast desert sand and are an endangered species, indeed. We should be able to get their help in this humanitarian venture.

With the present worldwide communication facilities the task of bringing the best people together need not be difficult. Well meaning people in the modern medical field should take the lead to bring respectability to this effort. We need to do a lot of education of the common man and the media to accept this line of thinking in the midst of the powerful and rich medical claptrap.11 The latter has a vested interest in keeping the system as it is. The present hi-tech medical care delivery system is a big business. This is the very reason why medicine has lost its heart today. The time-honoured doctor patient relationship is replaced by the doctor being viewed as the seller and the patient the buyer of medical technology, bringing in its wake the consumer movement into medicine.12 The crux of the medical scenario is the trust that the patient has in his/her doctor that provokes the immune system to heal the sick. Healing is a much larger concept than the concept of “curing” used commonly by doctors.13 Doctor only dresses the wound; the immune system heals it.14 Let us bring back the patient confidence in his/her doctor back into the medical arena for the common good, before it is lost for ever.

“No man, no author, not even the greatest, ever provide the last word on anything.
Men are vain authorities who can resolve nothing.” (II, 13)
------------------------------------------------------------------------------Michel de Montaigne.

BIBLIOGRAPHY

1. Robin ED. Death by Pulmonary Artery Flow Directed catheter. Time for a moratorium. Chest 1987; 92: 727-729
2. Steven Milloy. Science without Sense, 1997. Cato Institute, Washington
3. New Scientist, 17th september 1994, page 23
4. Ancient Indian Medicine, Kutumbiah P. Oxford University Press
5. Benson H. Timeless Healing. 1996 Simon and Shuster, Sydney
6. Hegde BM. Vaccination in India, JAPI 1998; 46 : 472-473
7. Hegde BM. Are We Barking up the wrong tree? The Cardiologist 2000:Vol. 3 No.4 :1-3
8. Coleman V The betrayal of Trust, European Med. J. 1994; :4
9. Editorial. Flight from Science. BMJ 1980; :1-2
10. Editorial. Drug company influence on medical education in the USA Lancet 2000; 356: 781
11. Austin JA. Why patients use alternative medicines? JAMA 1998; 279: 1548-53
12. Weil A. The significance of integrative medicine for the future of medical education. Am.J.Med 2000; 108: 441-443
13. Smith GD, and Ebrahim S. Data Dredging, bias, or confounding. BMJ 2002; 325: 1437-1438
14. Bernardi L, Bandinelli G, Cencetti S, et. al. Effect of Rosary Prayer and Yoga mantras on Autonomic cardiovascular rhythms: Comparative study. BMJ; 2001; 323: 1446-1449

1) ………………. Swan Ganz Catheter………………

India in Greece.
E.Pococke 1832. Oriental Publishers, NewDelhi. First Ed 1851, reprint 1972

“I know that most men, including those at ease with the most problems of greatest conmplexity, can seldom accept the most simple and most obvious truth if it be such as wpould oblige them to admit the falsity of conclusions which they have delighted ….in weaving thread by thread into the fabric of their lives.”
Leo Tolstoy.