Published by:

Dr. Ajay Kumar, MD (Patna), FRCP (Edinburgh),

Organising Secretary,

APICON 2006,

Patna, India.





Honourable Chief Minister of a very important state of Bihar and a roundedly educated Engineer Statesman, Shri. Nitish Kumar, Dr. Sahai, President of the API, dignitaries on the dais, my very dear Ajay Kumar, the organizing secretary, and beloved members of the Patna State API who have a special soft corner for me in their hearts, brothers and sisters of my profession from India and abroad, members of the media, ladies and gentlemen. It gives me immense pleasure to stand before you on this momentous evening and thank God for giving me this golden opportunity to share my thoughts with you. Although there could be much better individuals than me to shoulder this responsibility, I remain ever grateful to Ajay and others in the Bihar API for having placed their trust in me to do this job. I can only assure them and you that I shall do my best, although it might not be the best.



Association of Physicians of India is a premier body of all qualified physicians (internists) in India; consequently, it has a moral responsibility to see that the highest ethical standards of professional conduct are maintained by its members in addition to helping the latter to keep in touch with advances in their chosen fields of expertise. API should also have the capacity to influence the powers-that-be to innovate medical education to suit the needs of a vast country like India where the majority still live in the far flung villages with a hand to mouth existence; many of them in inhuman surroundings! Poverty being the mother of all illnesses, these poor Indians attract all the worst diseases and disabilities that man is heir to. With the majority of us overcrowding the metropolises, there are very few to cater to the vast majority of our countrymen and women in the villages-a truly inverse care law. The Biblical saying that “He who hath shall be given” (Mathew Law) works here as well. We also have a duty to educate humane leaders like Nitish Kumar to help them in their efforts to alleviate suffering, using wisdom in our field of expertise. “Snowflakes are one of Nature’s most fragile things, but look at what they can do when they stick together”, wrote Vesta M. Kelly. Let us stick together and make the API strong.



We, therefore, have a greater responsibility to see that the health of the less fortunate in society is promoted and maintained rather than concentrating all our energies only on the quick fixes that we are trained to use when their health fails, since doctors are primarily trained to keep the health of the public. In fact, in the long run, health promotion, not disease prevention, is much cheaper than disease control. “Time has come”, the Walrus said, “to talk of many things.”…………………..”Cabbages and Kings…….,” -time has come for us to search our conscience to see if we are going in the right path or not.



Health Care Vs Medical Care:



We use these words interchangeably. This is fatal. They are poles apart. Health care in India needs only a few things which most of us are not able to participate in and many of us are not aware of! Clean drinking water for the masses would get rid of majority of hospital bed occupancy today. Three square meals a day for the poor, uncontaminated by human and/or animal excreta is the next. Smoke free house in the villages where they cook with dry leaves, twigs and cow dung cake emanating deadly carbon monoxide into the house making women die of cancer lung and heart attacks and children below the age of five of pneumonias, is the third. Delaying the age of marriage for the girl would reduce fertility significantly. This could be achieved by sending girls to school. Economically empowering village women to reduce their risk of anxiety and depression due to their husbands drinking and coming home empty handed resulting in their children going to bed on empty stomach. Last but, the most important, is to have a toilet for every house in the village and even the slums in the cities to reduce the ravages of hook worms that today take a heavy toll of pour children’s hemoglobin and thus their immune power.1



If the governments attend to these on a war footing the disease burden and the need for hospitals would come down drastically. Let us advice the powers-that-be in this regard. We owe it to the common people of this country that we, as an organization, have advised the people concerned adequately lest we should be held morally responsible for the despicable state of health care in this country.



API-Past, Present, and the Future:



This great organization was founded by a few thinking physicians in Madras in the early part of the twentieth Century. The founding President was Late Dr. Guruswamy Mudaliar, a legend in his time who taught at the Madras Medical College. Member number two was Dr. K.S.Sanjivi, an authentic human being and a great physician himself. Things changed later and the whole organization was shifted to Bombay. You could draw your own conclusions as to why this happened. From a handful of people in the beginning, API has grown into a mighty banyan tree giving shelter to many a budding physician along with some old bandicoots like me.



What worries me, though, is the sheer size and the unwieldy annual conferences that we host where most, if not all, people are concerned more with fellowship and sight seeing rather than in the scientific agenda. Too many didactic lectures make life miserable for the minority that chooses to savour the intellectual feast. There is ample scope to make it manageable with less pomp and show and spending less money. I also feel that we could have cheaper delegates’ fee for the juniors who might not be earning big money like some in the corporate sector of the fee-for-service system. There is always a small minority in any conference that gets lost in politicking for the future elections and other perks that go with the offices. The next concern is about the elections that we have these days; they would make many of our crafty politicians look like pigmies. The Chief Minister could learn a thing or two from medical politicians. One example would suffice.



When Dr. K.S.Sanjivi, a pioneer in NGO movement in co-operative medical care, through his innovative VHS (Voluntary Health Services) hospital in Adyar in Chennai and a man who resigned from Madras Govt. Service at the fag end of his career on principles, had to contend with only a few votes when he contested right royally for the President’s post a few decades ago. All he wanted people to know was that he was member number two of the API. He was a giant. Not electing Sanjivi as its President would remain the greatest blot on the organization. API would have honoured itself by electing such a son of India for the top post! Sanjivi’s life reminds me of the old saying of Winston Churchill: “It is better to deserve than to get.” How true?



API must strive to put Continuing Personality Development (CPD) on line for every member to keep updated regularly. With new knowledge pouring in at a phenomenal rate of 7% per month (most of it is only noise), it is imperative that a scientific organisation like the API should take the wheat from the chaff , noise from the signal, and offer the best to the novice who is in danger when he/she, all by himself/herself, gets into the thick jungle of medical literature of mostly dead wood interspersed with rose and teak woods in some corners. When we look at the future we have to keep in mind all the above points and try to change for the better. I am not, for minute, blaming any one but the system. After all change is life and stagnation is death. Let the API live as long as the Sun shines on this planet, continuously changing en route. I dare not predict the future but hope for the best, as man lives on hope, anyway.



The Quiet Art of Medicine:



Bedside medicine, the bedrock on which most of our generation was raised in the medical schools of our times, is fast changing into the western system of hi-tech investigation-based euboxic medicine.2 This is sad for both thinking doctors and their patients. While sophisticated prospective computerized studies have shown the great value of bed side medicine and the doctor-patient relationship with the need for a placebo doctor to provoke the patient’s immune system, we seem to go in the opposite direction. Texas Heart Institute Journal in its November 2005 issue had an editorial on Hyposkillia –lack of bed side skills-which according to that editorial is killing American medicine. Next editorial is on Stethoscope song originally written in 1848 by Oliver Wendell Holmes Sr., an American essayist, physician and poet. American cardiologists are reminded to relearn the skills of bed side auscultation!3,4



William Osler, in his farewell address to Johns Hopkins, goes to say: “Cultivate, then, gentlemen, such judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening the human heart by which we live.” What a statement of the truth? It is the human heart that we have to retain as physicians in our daily work, which is called the art of medicine. “Art” wrote Henry David Thoreau “is that which makes another man’s day”. Art of medicine should be such that it should endeavour to make the patient’s day. Let us rededicate ourselves to develop the skills needed for these qualities of head and heart on the bed side. They are the ones that heal the patient and not the other interventions that we embark on. Imperturbability and equanimity (aequanimitas) are the two hall marks of a good physician according to William Osler.5





Deep down the Medical Science is very shallow:



The conventional research in medical science, better called statistical science, is all reductionist and is based purely on the bio- medical model of the human body that runs on its electrochemistry. The future predictions based on statistics are unpredictable, full of “butterfly effects.”6 We are trying to medicalise the whole population, if one were to believe that almost 90% of the population, by the age 40, will have at least one “so called” risk factor qualifying for drug intervention. With the kind of drugs at our command the future of mankind looks really bleak!7 Intervening in symptomatic patients is a different cup of tea altogether.

Drug treatment of healthy people with mild hypertension, when viewed differently, shows the darker side. The MRC trial of mild hypertension, for example, showed that to save one person from stroke in the future we will have to treat 850 people unnecessarily with drugs!8 One could only imagine the plight of those 850 people taking antihypertensive drugs for life. Apart from the serious long term side effects, those drugs also make patients to lose their right to “life, liberty and pursuit of happiness.”

The HOT study was stopped prematurely since the death rate in the treated group outnumbered those among the controls.9 The arbitrary nature of defining “normality” of blood pressure could be seen in the excellent book “Disease Inventors”, by a German, Professor, Jerg Blech. The cut off point keeps dropping by the day, naturally to net more and more people under that label. Now even the reading 120/80 is said to be hypertension! We still refuse to believe there is land as we see nothing but sea.

While the physiology of organ function depends on the mean capillary pressure, we do not know what happens to the mean capillary pressure when we reduce the arterial pressure arbitrarily? Some times the raised pressure might even be a compensatory mechanism. The first, and, to my knowledge, the only proof that lowering blood pressure helps is the article published in JAMA in 1967.10 This was a placebo controlled study. The patient numbers were small. Even among them a significant percentage of the treated group dropped out because of side effects. Despite this big statistical lacuna, the results were based on the intention-to-treat analysis. There has never been another placebo controlled study for obvious reasons, as we have been selling the idea that it is unethical to leave mild-moderate hypertensives alone with only life style changes, although, by default, the Australian study did show that nearly 40% of the control group did become normotensive on TLC, changed diet, cessation of smoking and alcohol, exercise, weight reduction et cetera. 11,12

Long term drug treated and “well controlled” hypertensives showed significantly higher death rate compared to their normotensive cousins in society! 13 Long term follow up of medically intervened healthy people’s group showed higher “all cause” mortality compared to their controls.14 All these and more would prove Goethe right when he said that “ man is absolutely certain when he knows little, with (more) knowledge doubts increase.”. With more knowledge in human physiology we will have to embrace the science of non-linearity and chaos. Raised cholesterol as an indication for drug treatment in the healthy segment of the populace is another huge hoax in medicine but, I need not go into it here as people have already done that earlier.(www.thincs.org) A study of the elderly in France showed that those with the highest cholesterol levels lived the longest. 15

“That, that is is,” wrote Shakespeare in the Twelfth Night.

.



Time and again studies have shown that time evolution in a dynamic human system does not depend on minor changes in the phenotype alone. Doctors have been predicting the unpredictable future of the hapless patients using these screening techniques that have become a big business these days. Death can never be predicted with any degree of certainty even in seriously ill patients; leave alone by screening for any thing. Cancer biology also tells us that some cancers could kill themselves as time evolves. But the scare and the dread of knowing the screening result, be it true or false positive, could kill the victim!16



Evidence Based or Evidence Burdened Medicine?

“They are ill discoverers that think there is no land, when they see nothing but sea."

Sir Francis Bacon

The oft repeated statement that the incidence of coronary artery disease is going up exponentially in the immigrant population (as also in others) needs further scrutiny. Is it just a statistical anomaly or a real increase needs to be seen?17 In our reductionist bio-medical model of diseases we use coronary artery blocks and coronary artery disease synonymously. Many people could have blocks in the epicardial vessels without any evidence of coronary artery disease; elegantly shown in the studies of Vietnam and Korean War casualties!18 Many of those that have innocent blocks could be provoked to have coronary artery disease by our precocious labeling them. Evidence based medicine can not assess the gravity of frightening patients about fatal diseases and doctors predicting their unpredictable future course. Many of these youngsters could eventually suffer the ravages of the Ulysses" syndrome.19

“Evidence-based medicine (EBM) has been defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." Intuition and individual clinical experience are deemphasized and decision-making based on evidence is stressed. Although there have been some concerns about whether there is sufficient evidence to guide many of our clinical decisions, about what represents the best available evidence, and about the authoritarian voices of the EBM movement, it should be our goal to make the most informed medical decisions on behalf of patients.” writes Howard Bauchner.20 With newer studies showing the mind as the major player in the causation of coronary artery disease, one wonders why the authors are still harping only on the time honored “risk factor hypotheses” of fat, blood pressure, diabetes etc.21 The latter could all be the genetic clusters in such individuals rather than being the cause of one another! The conventional fat hypothesis has led to the burgeoning business in anti-cholesterol drugs that seems to have only changed the label in the death certificates without changing the date!22, 23, 24 Too much drugging for lowering patient’s blood sugar and blood pressure have both been counterproductive to say the least.25, 26

The economic status could also be contributing to the incidence of coronary disease. Coronary artery disease also follows the rule that poverty is the mother of most ills. Barker’s hypothesis could be working in those precocious CAD patients that were born to abject poverty. Therefore, if future studies are being planned to study the reasons why precocious coronary disease occurs, if at all it does, the above mentioned suggestions could be incorporated there to make it more evidence based and authentic. We seem to be absolutely certain about the risk factors in coronary disease as we know very little about its causation.27 “Man is absolutely certain when he knows very little, with knowledge doubts increase” said Goethe. Recent evidence points to the role of life style modifications with a special stress on tranquility of mind as the best insurance against precocious coronary disease as also in the management of established CAD. That needs to be incorporated in the evidence based management strategies of CAD.28, 29, 30

"Facts do not cease to exist because they are ignored."

Aldous Huxley.

Pills Thrill but Could Kill!

All our drug studies have major flaws. Firstly, a chemical molecule is discovered in the laboratory and then this is checked for its potency, toxicity, and other dynamic features using an animal model. The animal data is then extrapolated to man and preliminary studies are done on volunteers. If all these are uneventful, the final phase of drug development, the controlled study is mounted. In addition, all the controlled studies are done for not longer than five years before the drug is let lose on the gullible public. Usually one single drug at a time is tested under ideal settings, while in real life situations a single drug is rarely ever, if ever, prescribed. The ideal situation obtaining in controlled studies is rarely seen in patient care setting. Occasionally, the last step is even given a go by before letting patients have the drug with disastrous consequences as had happened in the case of Milrinone.

Many of the unforeseen side effects occur only after five years when the drug has been given to millions of people. Similar is the fate of surgical interventions and many other medical interventions. Swan-Ganz catheter, that used to be routinely used in the intensive care set up, was found to have resulted in at least 100,000 deaths in the American hospitals in one year! 31

Sexed-up Studies:

Research funds drying up from independent sources more and more studies are done with industry sponsorship. Most of them have strings attached, the new breed of CROs in the third world is another cause for anxiety. Positive reports having better chance of publication, the sponsors, many times, indulge in data dredging, in addition. Occasionally, companies get doctors to create diseases to sell drugs. It is a multibillion dollar business anyway and market forces influence research in this area very significantly. Academic medicine seems to be on sale these days with doctors and researchers being offered lavish gifts by the companies. Even the textbooks are written with drug company money! Final blow comes from researchers trying to confuse the doctors with complicated statistical methods when the data are not convenient to their mentors. One only has to read the editorial in the Lancet on the influence of drug company money in medical education in the US as also the one in the New England Journal same year 2000 entitled “Is Academic Medicine for Sale?”32, 33 John Cleland systematically deciphers the long term effects of small dose aspirin in healthy people in the British Medical Journal in 2002, to show how the good effects sold to the public are the result of sexing up the real data. 34

The present scenario:

SSRIs and Cox2 inhibitiors are not the only culprits in making man miserable. Let us survey the other common diseases and their drugs. Type 2 diabetes has been a history of failures, while the drugs lower the glucose levels complications set in, sometimes more vigorously in the tightly controlled sugar status. In a paper entitled-Treatment and Mistreatment of Type 2 diabetes- Prof. Leif Groop stated that no treatment thus far has been able to change the inevitable course of this disease; diabetes is far more heterogeneous than thus far thought of, therefore treatment should be custom built for the individual patient, a sagely advised followed for “time out of mind” in Indian Ayurveda. Unfortunately, in the reductionist science that we follow the individual patient does not exist. Only bits and pieces exist.

Rheumatoid arthritis drugs, present controversy notwithstanding, lower the pain, yet mortality and morbidity remain frightening. Pincus discusses this and says "RA trials paint a rosy short term picture, while patients’ status deteriorates over the long term." Anderson et. al have shown that while anti-hypertensive drugs lower blood pressures, yet survival and mortality rates worsen compared to non-hypertensives. Recent IOM report in America showed that modern medicine is the leading cause of death in that country followed by cancer and heart attacks. Most conventional medical treatments are not helping the majority of people taking those most of the time! Many Americans are seriously harmed by modern medicine while more than 200,000 die annually because of modern medical interventions, drugs and all.

Aaron Wildavsky in 1977 said: “Most of the bad things that happen to people are at present beyond the reach of medicine.” In the same book Lewis Thomas questioned concerning the major issues like cancer, heart attack, hypertension, stroke, diabetes, arthritis and peptic ulcer, the following: “For many of these illnesses, do we possess a decisively effective technology for cure or prevention, directed at a central agent or mechanism, comparable to the treatment, say, of pneumococcal lobar pneumonia with penicillin?” His answer was that “It does not look like the record of a completed job, or even of a job more than half begun, when you run through the list,” In essence a reflection of failure. The story seems to be veering round to Heinemann’s thinking that drugs in large doses seem to cause diseases that they are supposed to control. Recent reports about one of the beta-blockers in the long run causing higher strokes in hypertensives, and pain killers causing heart failures comes close to this thinking. Incidentally, the name pain killer is very apt; while it removes the pain it could kill the patient.35

The moral of the story is that we seem to have built our modern medical buildings on quick sand using the bricks of reductionism and linear mathematics both of which do not have any relevance to human dynamic system. Our controlled studies are seriously flawed, to say the least. No one wants drug companies to close shop; on the contrary, the powerful drug companies could listen to sane advice and try and mend their ways and be more transparent for the common good of mankind. Medical science should learn from quantum physics and try and take the right road to success. Change is a part of life and change is science. Blind faith in our methods is close to being unscientific.



Need for a paradigm shift:

There is an urgent need for a paradigm shift in medicine if society has to really benefit from us. Many years ago, an article of mine in the Proceedings of the Royal College of Physicians of Edinburgh did have the same caption-need for a paradigm shift, but there were no takers!1 In emergency care we have no other choice than to follow the modern medical quick fixes, although there are warning signals that all is not well even in that area. In all chronic illnesses, I feel, our treatment does more harm than good, if one carefully audits the outcomes. Many a divine intervention in the apparently healthy population has similar outcomes.

A good example is the Philadelphia-Ontario bypass audit in the immediate post myocardial infarction period. This is not surprising at all, as time evolution in a dynamic system is not dependent on minor changes in the initial state in the human body. Correcting those changes need not (will not) result in better outcomes in the long run. "Butterfly effect" of Edward Lorenz takes over. The altered state (lowered BP or Sugar) might result in catastrophic changes elsewhere, if one understands non-linear mathematics that the human body follows. Aristotle wrote that “truth can influence only half a score of men in a century while falsehood and mystery would drag millions by the nose.” This is more than true in the case of modern medicine. Plato, in his celebrated book, The Republic, refers to his teacher Socrates’ efforts to change society when, at that time in Greece, injustice was justice and justice was the convenience of the powerful. Socrates did not succeed, though. I am only trying to indicate the inherent drawbacks in our system lest people should be taken for a costly ride!

Lucien Leape of the Harvard Medical School in his excellent article, Errors in Medicine, published in 1994 in the prestigious Journal of the American Medical Association,36 gives a very graphic description of all the errors that we have been committing. This has been updated recently by Barbara Starfield in her excellent article in the same journal in the year 2000, which reiterates the same, adding many more glaring dangers to the list already given by Leape.37 To date; I have been able to trace more than seven thousand articles showing the mistakes of modern medicine in the best western journals.

Nearly 2,25,000 people have died in one year in the US alone due to iatrogenic diseases. Of these 1,40,000 has been exclusively due to adverse drug reactions. In addition, 79 million people had to be treated on out patient basis for serious drug reactions costing a total of $80 billion in doctor and prescription bills in one year. There have been three million injuries due to medical interventions in a year with 44,000 to 98,000 deaths annually. Nosocomial infections alone caused 80,000 deaths in one year in hospitals. One hundred million people suffer from chronic debilitating illnesses partly due to medical interventions. These figures look horrible if one takes into consideration the relatively small population of US. The sad story does not include the escalating costs of modern medicine.

One of the reasons why this sordid drama unfolds in that country is the heavy advertisement for screening the apparently healthy people for all kinds of abnormalities. However, all the audits of screening efforts have shown that screening healthy people could be one of the most dangerous activities in society. Time evolution in the human system does not follow linear laws of predictability. The screening industry is the biggest money spinner in medicine. A very recent editorial by Richard Smith in the prestigious British Medical Journal entitled “The Screening Industry” bares the true picture in all its ramifications. Screening probably is the main source of the above sickening numbers mentioned earlier.38 If doctors confined themselves to cure the sick rarely, comfort them mostly, but to console always, they would be doing a great service to the public. When doctors try and intervene in healthy segments of society problems start. Sir William Osler, a celebrated brain in medicine in the last century, was right when he said: “patient doing well do not interfere.”

Modern medicine is slowly becoming unpopular in the west. In the year 1997 alone 629 million people took treatment from alternative systems of medicine in the west paying from their own pockets. India should take note of this as we have one of the best systems of health care in Ayurveda, especially for chronic illness syndromes. If this could be judiciously clubbed with the emergency care methods of modern medicine, complementing each other, we could bring down the costs of medical care to almost one tenth of its present level with less danger to the public as a bonus and offer an excellent new integrated system of medical care.39

The future lies in emphasizing promotive health. We should change the present teaching in medical schools to that of patient-centred education from the present disease-centred education. We should use statistics sparingly in medical research.40, 41 One of the drawbacks of applying disease statistics to the healthy population is that the latter throws up a very high percentage of false positives, resulting in epidemiologists predicting the unpredictable epidemics. The fear of an illness could help the illness to take a firm root in a healthy person.42 Modern medicine has realized that the human mind plays a vital role in disease causation as well as its control. Hence there is a need for doctors to train themselves in human psychology and behavioral sciences. Health is one’s birth right. Diseases are only accidents. If one follows the correct rules of healthy life style, accidents (diseases) will be rare indeed! Unexplained symptoms also fall into place in this new scenario.43



Afterword:

Our war against disease and death is anything but won. World goes on, the medical fraternity notwithstanding. More than 80% of this world population does not have any touch with modern medicine! They live all the same. If things have changed in the affluent part of the globe for better it is now known to be due to better hygiene, better nutrition, health education, decreased smoking and alcohol intake, better housing, cleaner atmosphere, less crime, and not due to doctors and hospitals. In fact, recent data clearly shows that in the US, where the healthy life style changes have been the best among the fourteen industrialized countries, the disease and death statistics are the worst. US is the last but one in the list of 14 developed countries in medical care outcome! Countries with more doctors per capita and more specialists have done badly compared to countries with less doctors and significantly less specialists and sub-specialists! Japan gets the first rank for all these reasons with the best medical care outcome.36 When doctors went on strike recently in Israel asking for more money, health status improved in the public and death and disability rates fell precipitously only to come back to the normal levels when doctors came back to work!44

Our wise Chief Minister could take these lessons home to change the face of this great State of Bihar, which at one time was the leader not just of India but of the whole world. The Athenian race in Greece is said to have migrated from Athoni in Bihar. The whole European wisdom, according to this study by a Greek scholar, Edward C Pococke done in 1832 AD, came from Bihar. Our war against diseases reminds me of the American war in Vietnam and Iraq. Both of us are stuck with it for ever. But both are being fought with ulterior motives! American wars are fought to reap the oil wealth and for hegemony, our wars are fought to get more money for the drug and the technology industry.45 Today the pharma lobby is three times bigger than the oil lobby in Washington! Our efforts have been aimed at medicalising the whole population with total body scanners that measure 500 body parameters at a time.46 Imagine with 5% false positives for every parameter measured, there is no chance for a “well human being” to exist. A very good proposition indeed! That exactly is the reason why large corporates want to get into hospital “business”, in a Nobel profession whose motto; according to the father of modern medicine, Hippocrates, “is not to make money in the sick room”!



Conclusions:

“Fear not! Life still

Leaves human effort scope.

But, since life teems with ill,

Nurse no extravagant hope;

Because thou must not dream, thou need not then despair!

Mathew Arnold, in Empedocles on Etna.



This poem, in short, is the long and short of my talk today which I hope has taken you through a long journey of the life of a physician giving the two sides of the same coin, one the real side and the other the ideal. Although humans could never be perfect, they should strive towards that goal, anyway. Jesus Christ did extort men: “Let perfection be thy aim”.

Now I deem it an honour to declare this 61st APICON 2006 duly inaugurated on this day in this historic venue, where great events have occurred in the past. May the year 2006 be peaceful, happy and healthy for all the members? Let us also wish the best of everything for everyone in our vast nation as also in all the corners of the world. “Sarve Janaah Sukhino Bhavatu.” I hope and pray that we resolve in this New Year 2006 to try and do most good to most people most of the time. API has to rise like a monolith to be in the forefront of human kind’s struggle against squalor, oppression, suppression, denial, ignorance, and illness. Long live human kind on this planet with physicians assisting them to live well.



“One doesn’t discover new lands without consenting to lose sight of the shore for a very long time.”

Andre Gide.









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