AIDS: On to medical management
By Dr Naveet Wig
According to estimates by the World Health Organisation, nearly 34 million people have been infected with HIV in the world. India is estimated to have 3.5 million HIV-infected people. The problem is of great concern to India since it will add a great deal to the medical, social and economic burden to an already outstretched economy. The practical approach to the management of a patient with aids is of great importance to all health-care workers (HCWs).

The demographic demon
By Dr M.L. Kataria
Most of our social, economic, health and education problems are controllable corollaries to our demographic explosion. Our political manifestos are hollow. We have lost the political will in this field since 1977. We have surrendered to the devouring demographic demon! With a helpless Centre, the remedial action lies at the grass-roots with vigorous coordination by each state.

A cloning marvel
Bull-ear cells yield calves
US researchers have succeeded in cloning four healthy calves from skin cells taken from the ear of an ageing Japanese breeding bull. A report published in the proceedings of the National Academy of Sciences describes the new technique as a decisive step forward in the cloning of animals for breeding.

Social health: a true story
Culture and tradition as medicine
By Dan Palmer

Ben McIvor's move to the big city from the native reserve when he was a young adolescent proved disastrous.

Separated from his roots among Canada's indigenous Ojibway people, the boy soon fell into a seedy world of drugs, alcohol and petty crime.

A spell in juvenile detention was simply a stopping-off point on an inevitable road to prison. A fight at a crack cocaine house in Winnipeg in 1995 left a drug dealer dead and McIvor facing nine years for manslaughter.

Now aged 32 and half way through his sentence, he has found his true identity — along with hope and happiness — with the help of a prison programme designed to reintroduce indigenous inmates to their culture.

He is not only learning aboriginal dances and prayers, to also but acquiring new skills, and can now make traditional drums and "dream catchers" — circular nets of spiritual significance which offer a link to a person's dream world.

"This is where I learned everything," says McIvor, who is now allowed out on parole and stays at a half-way house.

He has even found love, thanks to the aboriginal programme at the federal penitentiary near Prince Albert, in the prairie province of Saskatchewan. He met his life-partner Sharon at one of the cultural gatherings staged there. He is now the proud father of a baby daughter and stepfather of his wife's two children by a previous marriage.

McIvor's drift into crime is not rare among young native Canadians from the countryside who lose their way in the urban jungle.

As a boy, he was raised by his grandparents on the Sandy Bay reserve near Lake Manitoba, but when he was 12, his mother decided to seek her fortune in the city and took him to Winnipeg. "I had no choice but to go," he recalls. "It was all downhill from there."

Three-quarters of his 450 fellow inmates at Saskatchewan Penitentiary are aboriginal.

"We're trying to bring the culture back to the guys inside," explains Larry Smytaniuk, aboriginal liaison officer at the prison, who has a Metis (mixed native and French Canadian) background. Traditional culture is a way of life for those living on reserves, he says: "Without it, people get lost."

The prison helped to pioneer the programme about 10 years ago. Since then, other Canadian jails have been studying it carefully and some have introduced similar schemes based on it. "It's having a really positive effect on offenders," believes Smytaniuk.

The idea came about after native elders began visiting prisoners and talking about aboriginal culture. The inmates also began explaining to prison chaplains that their cultural and spiritual needs were not being fulfilled. "It was the offenders themselves who took the initiative," says Smytaniuk.

Many of the activities are conducted daily in the prison's cultural centre — former stables, where inmates can develop traditional crafts. A "sweat lodge" — a sort of spiritual steam bath in a teepee— has been set up, and is used by prisoners to meditate while they cleanse their bodies.

The programme also gathers inmates, their families, and elders about three times a year in the prison gym or yard for community events such as round dances, which are held to honour dead relatives. People hold hands and dance in a large circle. It was at one such event that McIvor met his present wife, who is also aboriginal.

During the gatherings, inmates sometimes meet local military veterans, who serve as role models — people who have won respect in their communities after having faced adversity in the past.

"To me, the programme brings happiness," says McIvor. "You learn you don't need drugs and alcohol to have fun."

He now puts his experiences to good use, visiting native reserves and warning youngsters about the dangers of drugs and crime and the rigorous of prison life. "They're so vulnerable," he observes, pointing out how some young people had a romantic view of gangs and jails, drawn from television and rap music.

"We don't go out to scare them," says Smytaniuk. "We go out to educate." — Gemini

Dan Palmer is a Canadian journalist working for the Prince Albert Daily Herald. His main concern is social health.

AIDS
On to medical management
By Dr Naveet Wig

According to estimates by the World Health Organisation, nearly 34 million people have been infected with HIV in the world. India is estimated to have 3.5 million HIV-infected people. The problem is of great concern to India since it will add a great deal to the medical, social and economic burden to an already outstretched economy. The practical approach to the management of a patient with aids is of great importance to all health-care workers (HCWs). Already, there is a lot of hue and cry because of discrimination against HIV patients by doctors. Important issues in the management of HIV-infected individuals include; staging, prophylaxis of opportunistic infections, antiretroviral therapy (ART), the prevention of mother-to-child transmission of HIV, post-exposure prophylaxis (PEP), counselling, educational and psychosocial support. Other important issues include home-care, NGO support, employment, human rights issues and the availability of antiretroviral drugs at reduced prices.

The WHO clinical case definition of AIDS (for persons above 12 years of age) includes:

(A) Two positive tests for HIV infection.

(B) Any one of the following:

1. Significant weight loss (>10% of body weight within one month) and/or cachexia and chronic diarrhoea, (intermittent or continuous) or prolonged fever.

2. Tuberculosis: disseminated, miliary, extrapulmonary and extensive pulmonary.

3. Neurological impairment preventing independent daily activities.

4. Candidiasis of the oesophagus.

5. Recurrent episodes of pneumonia, with or without etiological confirmation.

6. Other AIDS-defining conditions: such as crypyococcal meningitis, neuro-toxoplasmosis, cytomegalomegalovirus retinitis, penicillium marneffei infection, recurrent herpes zoster and multi-dermatomal and disseminated molluscum.

7. Kaposi's sarcoma

Before initiating therapy in HIV-infected patients, the evaluation includes: complete history and physical examination, complete blood count, chemistry profile, CD4+T lymphocyte counts, plasma HIV RNA measurement and tests for opportunistic infections (OI)s.

The importance of water and food hygiene should be explained to the individuals. One double-strength tablet of trimethoprim and sulphamethoxazole daily life-long is recommended once the CD4+T cell count falls below 200 cells/mm3 for primary prophylaxis of pneumocystis cariniipneumonia and for toxoplasma encephalitis. Routine tests pertinent to the prevention of opportunistic infections include chest X-ray, VDRL, tuberculin skin test, toxoplasma LgG serology, and gynaecological examination with Pap smear. Other tests like hepatitis B virus (HBV) serology, hepatitis C virus (HCV) serology, CMV serology and ophthalmological examination, when clinically indicated, may be useful in identifying HIV-related complications in certain individuals.

The viral load measures the viral burden in the blood and suggests how aggressive the disease is.

The CD4 T cell count tells us how advanced the disease is. Two HIV RNA assays are currently in use in India. These are RT-PCR assay (Roche) and the second assay b-DNA test (Chiron). The threshold of detection ranges from 20 to 400 copies of HIV RNA/ml. Data suggests that patient with low viral loads (i.e, <2500 copies of HIV RNA/ml) are at a lower risk of disease progression than those with higher (2500 to 20,000 copies of HIV RNA/ml) or very high (>20,000 copies of HIV RNA/ml) viral loads. The measurement of plasma HIV RNA levels (viral load), and CD4 T cell count should be performed at the time of diagnosis and every three to six months thereafter in the untreated patient.

CD4 T cell counts are available at few centres in India and the cost varies from Rs 600 to Rs 2000. It is recommended that all patients should have the CD4 count done to assess the disease. One viral load test costs from Rs 5000 to Rs 9000. It is beyond the reach of the common man in India. It is recommended that those who can afford and are willing to have triple drug therapy should have their base line viral load done. The routine use of the viral load in patients who can't afford ART is not recommended.

Anti-HIV drugs are called antiretroviral drugs. Till date, there are 15 drugs approved by the US Food and Drug Administration (FDA) for use in HIV-infected adults. These include 10 reverse transcriptase inhibitors *(RTIs) and five protease inhibitors (PIs). Of the 10 RTIs, seven are nucleoside RTIs (NRTIs) i.e zidovudine (ZDV), didanosine (ddi), zalcitabine (ddC), stavudine (d4T), lamivudine (3TC), abacavir (ABC) and adeovir (ADV). Three non-nucleoside RTIs (NNRTIs) are nevirapine, delavirdine, and efavirnez. The five PIs are saquinivir, ritonavir, indinavir, nelfinavir and amprenavir. (Most of the drugs are available in India.)

(To be concluded)

Dr Wig is a faculty member at the AIIMS, New Delhi. (His name was wrongly spelt as Navneet in an earlier article).

The demographic demon
By Dr M.L. Kataria

Most of our social, economic, health and education problems are controllable corollaries to our demographic explosion. Our political manifestos are hollow. We have lost the political will in this field since 1977. We have surrendered to the devouring demographic demon! With a helpless Centre, the remedial action lies at the grass-roots with vigorous coordination by each state.

Our health-care manpower norms recommended by the Mudaliar Committee (1961) of 1/1500 doctors, 1/5000 nurses and health workers and 1/10,000 pharmacists and lab technicians are not even half way through. (In the USA the doctor-nurse population ratio is 1/500-600 and 1/150-200 respectively).

We have less than 50 per cent hospitals bed strength of the recommended strength of one bed for 1000 people, against eight to ten beds in developed countries.

Our annual outturn of about 15,000 doctors, 5,000 ayurved experts, 500 hakims and 5,000 homoeopaths is grossly inadequate. The doors of professional teaching institutions are slammed even on the otherwise eligible aspirants due to the limitation of seats. Why must the state continue to hold the reins tight? Why not liberally privatise all systems of professional education? The state should only prescribe and monitor a uniform curriculum and academic quality.

Social, mental and spiritual well-being, the other dimension of good health, is far from satisfactory. More than half the nation is struggling below the poverty line. Suicides by farmers because of indebtedness, poverty and state apathy were never heard of during the pre and post Independence era. Not even during the worst of droughts!

Social evils have flourished. The crime-rate during the last decade has increased considerably. The rate of strikes by all categories of workers has gone up. These are surface ripples of deeper social, mental and spiritual waves of disharmony, discontent and disruption.

We resolved to reach a goal. We have not reached it. But we are more than half-way through. Let us not despair. We are slow. Let us resolve again to reach it by 2025. We must take strides longer but surer.

We need to review our present three tier system of health-care from above — the Centre, the state and the individual. Let us turn it upside down and start from below upwards — the individual, the state and the Centre. One Prime Minister candidly, though helplessly, lamented that only 25 paise of an allotted rupee from above trickles down to the individual for whom it is meant.

Constitutionally, health is essentially a State subject, with concurrent Central involvement in several aspects. India is a vast country. The decentralisation of most functions is unavoidably necessary for their prompt implementation. Therefore, while the Centre may deal with the national health policy and goals, drug policy and price control, disaster and crisis health-management and epidemic control, the coordination of certain national level health-care projects, the higher education and research policy, the international health policy and conferences, the allocation of the statewise share of health budget, etc, the nitty gritty of most health-care functions should remain within the domain of the state.

The process of decentralisation should trickle down even in the state down to the parishad and panchayat levels that should deal with health-care in toto, assisted by the primary health centres and sub-centres.

Primary health is the individual’s concern. It is a life-long discipline. It has to be observed from "womb to tomb". It needs to be stressed, infused, encouraged and nurtured by the family, the school, the panchayat and the parishad. Health-care should evolve as a movement from the grass-roots level.

Health education, as a definite subject, should form an essential curriculum from the nursery level to the higher secondary level. All the so-called national health-care projects should start from individual homes and panchayats.

Only 20 per cent of India's population living in cities and towns is consuming 80 per cent of all health-care resources at the cost of 80 per cent living in the rural areas and slums. This lop-sided health-care must be rectified. This is possible only if all the curative, diagnostic and promotive health-care facilities are already privatised in major urban areas and the state deals with mostly preventive health-care projects.

On the other hand, the states must concentrate on the primary health centres and sub-centres for rural and slum areas (over eight lakh villages and slump but hardly 500 major cities and towns).

We should aim at a PHC for every 10,000 and a sub-centre for every 5000 rural and slums population. The present norms of a PHC for 1.2 lakh people and a sub-centre for 10,000 people are grossly inadequate. Ideally, primary health-care should be available within 2 km from the consumer’s residence.

Each PHC should be a mini 25-50 bed rural hospital. It should be staffed and equipped to tackle medical and surgical emergencies, including gynaecological and obstetric procedures. It means that the support services should include the facilities of X-ray, ultrasound and ECG and a well-equipped clinical laboratory. Even the best of the existing PHCs is a mere apology.

The central and state budges for health-care never crossed the 2-4 per cent limits of the total outlay at any time. A big share goes to urban areas and tertiary care institutions. The rural and slum population, which have the maximum health problems, get the least. Let us not forget that that we are a labour-intensive country. Our work force constitutes one third of our population. About 14 per cent of our work force in farms and factories is not at work at any given time because of illness. It is time we diverted our attention to the grass-roots levels, as recommended by the Bhore Committee (1946), which is gathering dust in some obscure archives.

According to Nobel laureate Amartya Sen, low per capita income is not necessarily a barrier to good health. As basic medical care at the grass-roots levels is labour-intensive, low wage economies have low medical costs, and can achieve higher health results through good economic organisation at lower grass-roots levels. Good health, according to him is an integral part of good development. Kerala, despite average economic growth, could achieve a rapid reduction in the mortality and morbidity rates and population growth owing to heavy public spending on health and education. These investments yield high dividends in the long run.

The 21st century philosophy of an open and free market to cater to the total needs and wants of society depicts its socio-economic developments. The marketing of health-care services is an important index of the advancement of its science, technology and art of management. It is also an index of the prevailing culture and civilisation.

The health-care equation in the twenty-first century has shifted from "disease-patient-doctor" to "providers-consumers-tax payers". It will not be possible to deny this fundamental human right for a long time.

The new century will contribute considerably to the concept of international orientation to community health and one world health. The whole world is now a global village. This concept is not new to India. We believed and lived it from the Vedic times, from the days of ayurveda, Dhanawantari and Charaka. Let us run fast to make up the backlog of miles to go and promises to keep, from the twentieth century into the twenty-first century, and relive our traditional motto: May all be healthy.

(Concluded)

A cloning marvel
Bull-ear cells yield calves

US researchers have succeeded in cloning four healthy calves from skin cells taken from the ear of an ageing Japanese breeding bull.

A report published in the proceedings of the National Academy of Sciences describes the new technique as a decisive step forward in the cloning of animals for breeding.

The researchers scratched the bull’s ear to remove skin cells which were transferred to a nutritional solution and kept in the laboratory for several months. They then removed the nucleus, containing the cell’s genetic information in the form of DNA, from each of the cells and injected it into the egg cell of a cow, the nucleus of which had likewise already been removed.

Finally, the egg cells were implanted into the wombs of several cows. Four of the cows gave birth to healthy calves.

The successful experiment conducted by Dr Xiangzhong Yang and his colleagues at the University of Connecticut is beneficial in several aspects, announces the article prepared for the journal.

Skin cells taken from the ear of a breeding animal are far more accessible than cells which have to be removed from reproductive tissue, such as the udder used in the cloning of Dolly, the sheep.

Another new and very promising development is the length of time the cells were able to survive in the laboratory before being put to use as part of the cloning procedure.

The time spent in the lab allows researchers the opportunity to alter the genetic make-up of the cells.

One aim of the research is to employ cloned breeding animals in the mass production of sought-after proteins. As the journal noted, production of such proteins could lead to significant progress in the manufacture of pharmaceutical drugs.

Cloning expert Mario Capeechi, from the University of Utah, said in a comment that a realistic scenario would involve animals being used as factories to make human antibodies, a development of considerable potential advantage to pharmaceutical science. — DPA