Golden Jubilee Annual Conference of Indian Association of Cardiovascular?thoracic Surgeons

Mission towards healthy hearts?

I am delighted to participate in the Golden Jubilee Conference of the Indian Association of Cardiovascular - Thoracic Surgeons. My greetings to the organizers, surgeons, doctors, medical scientists and technologists, pharmacologists, distinguished guests and all the participants of the conference for your health and happiness. Cardiac care is a vital health care area for Indian community. Indian Association of Cardiovascular-Thoracic Surgeons has to provide leadership in bringing smiles in the faces of cardiac patients. In this gathering I would like to discuss on the ?Mission towards healthy hearts?.

1. Cardiovascular cases ? a scenario

As per one of the studies, only 8% of the world population has access to heart surgery delivery systems. Out of the 6.5 lakh surgeries taking place in a year, 4.5 lakhs are performed in USA alone, only 2 lakhs are performed in the rest of the world. In India fifty to sixty thousand operations are performed every year, whereas possibly 2.5 million people may need heart operations in India. Another observation is that the occurrence of coronary artery diseases in India is taking place between the age group of 35 and 55, whereas in thewestern world, it generally occurs after 55 or 60. The main reason for this in India is attributed to the urban life style and intake of rich food having high cholesterol. It is also found that the occurrence of Cardiovascular cases is 4% in rural area as against the 10% found in big cities in India. Whereas the world statistics says that the incidence is only 3 to 4%. A research is essential for establishing the reasons for occurrence of heart ailments among Indians at a young age and also the reduced occurrence of the disease in rural areas. The results of the study will assist in national planning for combating the heart ailment. This also shows that the urban life and the facilities come at the cost of deteriorated environment detrimental to one?s heart and life. The PURA- Providing Urban amenities in Rural Areas ? would overcome this draw back and establish that the Urban comforts can be brought to the rural areas without the drawbacks associated with the rural life styles.

2. Characteristics of the Indian Population

It is reported that Indians are genetically three times more vulnerable to heart attacks wherever they are than Americans and Europeans. My Doctor friends say, Rheumatic heart disease, which leads to heart valve destruction, is peculiar to the Indian community. This arises out of poverty and poor socio-hygienic living conditions of our population, which results into rheumatic fever in young age, leading to one in every thousand child suffering from Rheumatic heart ailments in later years. You may like to discuss this situation and possible solution in this conference. In India over hundred and fifty thousand children are born with congenital heart diseases every year. Out of these 85% of them have risk of life before any treatment reaches them, approximately, 40% could be saved if timely diagnosis and proper pre-operative preparation of the child is done. Pre-operative preparation and the surgical intervention are time sensitive and vary with the time of detection of the ailment. Due to lack of timely detection and Medicare is not reaching the children leads to high rate of mortality. With the present estimates only one percent of the 1.5 lakh children are saved after proper medical intervention. I would suggest the remedy for this situation lies in screening and detection of the child, right at the birth, so that the parents can be advised about the state of the child, when he or she leaves the hospital. I was told this type of screening is presently available only in big hospitals like AIIMS, Narayana Hrudayalaya and other few big hospitals. I would recommend, that it becomes a routine medical practice with all the hospitals in the country dealing with childbirth and childcare.

The health care study 2020 has given possible diagnostic, preventive methodology with focus on early and periodical diagnosis, improvement in socio-hygienic conditions and better nutrition including pre-natal nutrition. At this point of time I would like to share with you two case studies that took place recently about which some of you will be familiar with.

3. Case studies

(a) Tripura Example: In October 2002, I inaugurated the Care Hospitals telemedicine units at the G.B. Pant Hospital, Tripura, and I interacted with patients at different centers where I came across a 13 year old boy from Kailashar, Tripura. His parents are farm laborers and even a tiny peace of land they own was sold to provide medical treatment to this boy before CARE hospital diagnosed the problem of this boy. This boy was suffering from chronic Rheumatic heart disease with severe mitral stenosis. His heart ailment was noticed three years ago, when he complained of breathlessness and chest pain. He was also coughing blood and lost weight, according to his elder brother Ismail Ali. Doctors at Agartala found that his condition was serious and needed specialized treatment which was expensive. He discontinued his studies as he couldn?t take the strain of walking down to the school or even play around with the other kids. He was taken to the CARE Hospital at Hyderabad, and was treated by Dr. B. Somaraju and Dr. Raghava Raju who carried out the balloon dilatation. The entire treatment and travel expenses were borne by the hospital. The boy?s condition is being continuously monitored and he is doing fine. He has also started going to school.

(b) Mumbai Example: I would like to narrate another incident. A Rickshaw puller?s son Bholu Gupta was born without a heart valve medically known as Tricuspid Artesia. Due to this defect, his lungs would always be filled with blood and he would find it difficult to breathe or even suck milk or water. Such children are commonly known as blue babies and unless operated upon early in life have very short life span. The suffering of the child and the plight of the poor parents were brought to my notice by a compassionate citizen. I referred the case to the doctor friend. The CARE Foundation made arrangements for the child and parents to come to Hyderabad and stay for the treatment that took more than a month. The boy when brought was severely malnourished and even infected with tuberculosis. The state of the art intravenous nutrional therapy was given to the child to make him withstand the surgery. A team of surgeons led by Dr M Gopichand and Pediatric Cardiologist Dr K Nageswara Rao successfully bypassed the flow of deoxygenated blood directly to the lungs. The boy will however, have to undergo two more rounds of surgery later over the next three years for a complete correction of his genetically inherited structural abnormality in the heart. He will grow normally thanks to the correction made now and there will be no disability or danger of fatality. Gratified and contended, the boy and parents have left to their native place in eastern Uttar Pradesh.

There are many such cases in our country. The Indian Association of Cardiovascular ? Thoracic Surgeons may like to create a system through which such treatment will become available to all the needy patients in the country. In this connection I appreciate the services rendered by Narayana Hrudayalaya at Bangalore, who have undertaken to perform heart operation free of cost to all those children with congenital heart ailment brought to them before the completion of one month of age.

4. Possible Solutions

The occurrence of Cardiovascular disease is increasing rapidly, particularly in the Indian community. Multi-dimensional solutions are available for management of the diseases based on my discussion with experts. The solutions include medicinal treatment using Statins, which lowers the cholesterol in the blood by reducing the production of cholesterol by the liver. Statins block the enzyme in the liver responsible for making excess cholesterol. However one has to be careful about the side effects and take adequate precautions while treating the patients. The second is through angiography and angioplasty using stents. If the heart blockage is severe, valve defect and death of cells in the heart due to less blood supply etc., surgical intervention will be necessary. What are the future promises for treating the hearts?

(a) Stem cell therapy for future heart ailments

Newer knowledge emerging out of research on stem cells from abroad and India has to be taken note of and studied. Drawing of tens of thousands of stem cell - immature cells that are capable of transforming themselves into almost any kind of tissues from the suffering patients and inject them into the heart to stimulate heart repair. In one case, it is reported that the pumping efficiency has increased from 25% to 40% over a period of four months. In 2003, successful stem cell procedures that resulted in measurable boost in blood pumping capacity have increased substantially in many countries across the globe. This holds a big promise for effective heart repair for ailing people.

(b) Experience in stem cell:

During my visit to various laboratories, I happened to see the beginning of stem cell research for different purposes including brain research. I would like to share with you an important stem cell research application in the field of cardiology. When I met Dr.P.Venugopal,Director, All India Institute of Medical Sciences (AIIMS) a famous cardiovascular and thoracic surgeon, he told me about his experiences. He said in one of the cardiac diseases, where conventional medical and surgical treatment were ineffective because of the affliction of the heart muscle, use of autologous bone marrow stem cells implantation into the diseased heart muscles had been applied in order to improve the function of heart muscle. This kind of application of this procedure is the latest and very few cases have been done in the world, the first time in India. This is expected to open new frontiers in the treatment of patients for regeneration of heart muscles, thereby giving new hope for the patients suffering from end stage heart disease. When we are progressing with stem cell research, it is essential to create a regulatory mechanism regarding the production of stem cell through embryo generated either from human foetus or through cloning in the laboratory. I am of the opinion that use of embryo for stem cell production in any form should be banned.

(c) Life style intervention

There is a need to propagate the importance of appropriate food habit and life style among the urban population to combat the situation of increased occurrence of heart ailment. Hospitals in the country should take proactive steps to counsel their clients in a family atmosphere for ensuring reduction in this number in the years to come. Another feature which has been noticed is that there is a competition, between cardiologists and surgeons in treating heart cases. The ideal practice should be to provide only the minimum essential treatment instead of going in for surgical intervention as a routine management of the disease. It has been reported that the repeated occurrence of heart ailments is caused by diet, smoking, and lack of exercise and uncontrolled diabetes. All these factors can be controlled by an appropriate life style intervention. I have seen the change of life style pattern practically taking place in Global Hospital and Research Center, Mount Abu with the constant care of Brahma Kumaris. There was a joint project of Defence Institute of Physiology and Allied Sciences (DIPAS), DRDO and the Global Hospital and Research Center for studying the effect of "holistic lifestyle intervention" on the patients suffering from Coronary Artery Diseases during the year 1997-98. The project involved both Control Group and the Experimental Group. The Control Group was subjected to conventional treatment whereas the Experimental Group was supported by an intervention involving low fat, high fiber vegetarian diet, aerobic exercises and meditation. This three-dimensional psycho-physiological mind-body approach in treating heart patients of the Experimental Group resulted in dissolution of angiographic plaque and improvement in microcirculation of blood in heart muscles of the patients. The treatment was also supported by participation of spouses and other family members of the patients, leading to a unique family system approach to Medicare. When I conducted the first review of the project, I found that nearly 60 people had reported positively about their well being and their clinical reports showed remarkable improvement. When I visited the hospital again after two years, nearly 400 patients gave us a joyful presentation about their experiences. It was an experience of great happiness to see the patients presenting their medical records, showing us how this unique way of treatment has given great relief to their hearts. The conflict between cardiology, psychology and theology still persists, but this experiment has given a new thrust and a lasting cure for heart patients. The message I would like to convey is that through the integration of medical science, physiology, health care, psychology and spirituality, a native Indian knowledge system in combination with allopathic systems may emerge. Through a total lifestyle intervention you are purifying the human minds and promoting peace. How can we radiate this fragrance of peace to the entire nation and the world?

5. Actions needed for effective heart care

I would like to share some thoughts, which will enable availability of adequate number of cardiologists to our remote areas, provide cost effective Medicare to our rural masses and provide an opportunity to exchange valuable treatment information among the cardiologists and cardiac surgeons.

(a) Training policies:

In our country of billion, we are producing only around 30 cardiologists a year. This is totally inadequate for meeting our demands in this area. There is an urgent need to review the policy enunciated by the Indian medical council regarding the training of doctors in cardiology. They should consider opening the medical education like in England where royal college recognizes various hospitals through Britain and thousands of young people undergo training in surgery and medicine and appear for FRCS examinations. Only the best ones clear the examinations. Such opportunities should be provided to our young doctors to enter the training programme in large numbers in India without restricting the number of seats, as is the practice now. This aspect, I will be discussing with Indian Medical Council and Ministry of Health and Family Welfare for the evolution of a training and examination scheme, which will enable provision of adequate number of cardiologists for the country. Your Conference may also give certain recommendations.

(b) Indigenisation of health care products:

The cost of open heart operations are very high, since all the health care products including consumables are imported. There is a need to produce the medical instruments and consumables indigenously to bring down the overall cost of the operation. In this co-operation of the surgeons is very essential to encourage the Indian health care industry by using these products whenever they are available as preferred products. Some of the products available in the market are indigenous suture materials, which are a huge cost factor for heart operation and the indigenous stent for angioplasty. We should follow the example of Brazil, where the doctors will not use the imported items, if Brazilian products are available in the market. This approach will encourage the indigenous industry to improve their products, which will eventually become a competitive exports business.

(c) Telemedicine:

There are some tele-medicine models working very well in the country. One of the institutions Narayana Hrudayalaya has connected 19 remote areas with Kolkatta and Bangalore. They have treated 12,000 patients through telemedicine. The partners in this mission are Government, Private sector hospital and government hospitals. CARE Hospitals Hyderabad has a tele-medicine link between Hyderabad, Agarthala, Mehabubnagar and Delhi. These models can be replicated in different areas in the country to provide affordable, quality Medicare to our rural masses.

(d) Medical Insurance:

In Karnataka, the state co-operative department in collaboration with Narayana Hrudayalaya has come out with a scheme called Yeshasvini. In this scheme, the villagers are required to pay a premium of Rs. 5 per month. The government contribution is Rs. 2.50 per month. There are 17 lakh members in this scheme; the members are eligible to get free treatment from the best available Medicare facility in the state in 85 recognized hospitals. Presently in this scheme they have provided free medical consultation to 27,000 people and carried out 7000 operations including 600 open-heart operations in 7 months period. The monthly expenditure incurred is approximately Rs. 1.2 crores. This model can be replicated in many states for providing quality health care to the village community at an affordable cost.

(e) Database:

A comprehensive database for cardiac surgical cases is essential through Internet. Application has to be designed and distributed to all the centers, carrying out cardiac intervention. Objective of this database should be to collect the data regarding the different surgical procedures being done in the country and also the various techniques being adopted by different centers. Through this we will be able to get national averages and status of heart care. We can merge this data with international databases, which will enable us to know the specific factors influencing the disease in our country. Database can also be useful for cardiac surgeons resident training and generation of new knowledge in cardiology. I was told that the association of cardio-vascular thoracic surgeons is planning for such a database. However the success of this scheme will largely dependent on the co-operation extended by all the cardiac surgeons in providing accurate data to the network and regular updation. I would suggest this conference to deliberate on this issue and find an effective method of collection of data from our health centers. (f) Health communication: Recently, there was a meeting of cured patients, their doctors and a few social workers. One important result was discussed. The relationship between the patient and doctor extends to patients? family and doctor in medical care. This in turn, transmits effective messages from one family to another family on advice to prevent the diseases, necessity of periodic checks, the dietary habits and the need for life style changes including the exercise for good health. Actually, I believe this good contact between the doctor and patients is comparable to that of a teacher and student. I request every doctor to play the role of a teacher in advising every family on disease prevention and methods to lead a healthy life. I hope you will find time for this noble action.

6. Conclusion

We need good hearts to treat the ailing hearts, we need helping hands to remove the pain, and we need beautiful minds to give happiness to the patients. In this context, I would like to recall a poem. I would like to share with you the essence of it. When God first created the human being, it took million and millions of years to get the right shape. He went on experimenting and finally he realized the shape he wanted. Once realized, he gave life. First the man said, ?I thank you, Almighty. Second thing he did, he smiled at God. Almighty was very happy, that his creation has done two things correctly. Then, God was preoccupied for some time, later when God looked at the man and found something is missing in him. He created the fire in Milli-seconds and created Shaitan out of fire. He asked Shaitan to prostrate before the first human being that he created in his image. The Shaitan refused to prostrate. He said, ?Oh! Almighty you have created me out of fire, I am a superior creation?. The God was taken back. He thought for a while and decided to integrate the man and Shaitan into a one single system, that is the human race what we are. If we want to become close to Almighty God, let our mind and hand be kind to human beings who are suffering particularly with heart disease. That means we have defeated the Shaitan within us. The question is who will defeat whom? May God bless you to be close to God?s image and the Shaitan gets defeated. Your kindness will flow through your actions, thousands and thousands of patients will be relieved of the heart pain and they will say ?Thank you doctor? with the smile. That means you are in God?s image.

In this context, if you don?t mind, dear doctors, can you take with me a five action point oath? The doctors responded in the affirmative. The oath is as follows:

1. We the Cardiovascular and Thoracic Surgeons realize that we are in God?s mission.

2. We will always give part of our time for treating heart patients who cannot afford.

3. We will treat at least 20 rural patients in a year at minimum cost by going to rural areas.

4. We will encourage the development of quality indigenous equipments and consumables by making use of them in all our operations assuring the reliability of the products.

5. We will follow the motto ?Let my brain remove your pain and bring smiles?.

I wish you all the best.