A doctor has been arrested in Madhya Pradesh’s Chhindwara after a toxic batch of Coldrif cough syrup allegedly caused the deaths of 18 children across two states, exposing alarming lapses in drug quality control.
Strangely enough, when the drug manufacturer and the drug controller are responsible for the quality of drug, the doctors are the one who is arrested. Does that imply that doctors should now stop expecting justice from courts and Government?
The whole process appeared flawed from the root. Blame for the poor quality of drugs manufactured is passed on the prescribing doctor.
Even for complexities of medical science and uncertainties of the outcome, blame can conveniently be passed on doctors due to application of average wisdom.
This strange kind of justice delivery has unmasked the everyday struggle of the doctors in the present era. The unjustified arrest just for prescribing a medicine has depicted the plight of doctors- being undervalued and demonized, forced to work as a sub-servant, irresponsible policing, blackmail by goons and vulture journalism-all have become an accepted form of harassment. This incident has unveiled the despondency, moral burden, and injustice that doctors work with.
Hammurabi 5000 years ago, was not even at the doorstep of medical science, but he promulgated some rules. It is difficult to say whether he was naive or brilliant enough to make it more mathematical. He fixed heavy prize for saving lives and used to cut the hands of physicians for death or untoward incident. But he was still wise enough to pay heavily if life was saved. After thousands of years, with some scientific advancements, our regulation has remained more or less similar in basics. It is still based on principles of revenge and punishments. Now clearly knowing well the limitation of medical science and the uncertainties and complexities of human body in better way, it still remains somewhat unfair to doctors. In other words, it has not attained enough evolution and maturity.
Hammurabi at the start of civilization believed that doctors needed to be punished in case there was poor prognosis. He failed to understand the complexity of human body and the limitations of medical science, most of which was unknown at that time. By an application of average wisdom, doctor can be easily blamed for poor outcome, because he is always a common link between treatment and poor prognosis. Stricter punishments were imposed to regulate medical profession, even when the medical science was not even developed enough to deal with most of diseases. Children are always taught in school that medical profession is a noble one. But they are never told, about the cruelty this profession has faced since ancient times. Almost universally, the earlier work or contribution of a doctor to society is not taken into account. Even for complexities of medical science and uncertainties of the outcome, blame can conveniently be passed on doctors due to application of average wisdom.
Hammurabi’s Codex specified the harshest form of deselection of health providers possible. If the physician erred through omission or commission, his fingers or hands were cut off, immediately stopping his practice. Therefore, a single mistake can undo all the good work of past or the future good work that could have been accomplished.
Problem here is that who can differentiate with certainty the real cause of sufferings of patient, a poor prognosis or a mistake. Such harsh regulatory systems will dissuade other good people joining the profession, again resulting in further inhibition and flourishing of profession for the good. Obviously, harsher penalties will discourage a physician surplus.
Today the global system of medical regulation, is becoming somewhat similar, to those ancient regulations in terms of punishment and revenge. Differential payment system for health care also resembles the Code of Hammurabi in some respects. And this is even though now we are very well conversant with the known uncertainty and complexity of the human body and despite cognizance of the poor prognosis in many disease states.
Fear factors of injustice to doctors and impact of present legal complexities is already at par with that of Hammurabi’s era.
A doctor has been arrested in Madhya Pradesh’s Chhindwara after a toxic batch of Coldrif cough syrup allegedly caused the deaths of 18 children across two states, exposing alarming lapses in drug quality control. Of the total deaths, 14 were reported from Chhindwara alone, A special team from Kotwali police arrested Dr Soni from Rajpal Chowk in Chhindwara late Saturday night after the FIR was registered against him, the SP said.
Here doctor who prescribed was arrested, whereas who manufactured the cough syrup is primarily responsible.
What is the role of ‘Drug regulator’ and ‘drug quality regulator’ in such cases?
Do they carry any accountability or responsibility?
Strangely doctors are invariably the easy scape-goats. It is time to treat pharmaceutical malaise. The rise in “falsified and substandard medicines” has become a “public health emergency.” A surge in counterfeit and poor-quality medicines means that thousands of patients a year are thought to die after receiving shoddy or outright fake drugs intended to treat ailments. Most of the deaths are in countries where a high demand for drugs combines with poor surveillance, quality control, and regulations to make it easy for criminal gangs and cartels to infiltrate the market.
If deep investigations are not done in such cases, poor quality medicines will continue to be marketed and doctors would be held responsible for the adverse reactions and deaths. Strict regulations for quality of pharmaceutical agents are need of the hour.
Usually, every problem related to health is called medical malaise, but that is a misnomer. In fact, health care comprises tens of different industries. Complex interplay of various industries like pharmaceutical, consumable industry and other businesses associated with health care remain invisible to patients. Various important components for example pharma industry, suppliers, biomedical, equipment, consumables remain largely unregulated. Collective malaise of all these is conveniently projected as medical problems as blame is conveniently passed on to doctors, as they are only visible component of mammoth health business. Rest all remain invisible, earn money and doctors are blamed for the poor outcome of the patient, as doctor is the only universal link that is visible with patient. By an average application of wisdom, it is easier to blame doctors for everything that goes wrong with patient.
In routine, if patient gets fake or low-quality medicines and does not get well, gets side effects, doctor will face harassment. Whereas people involved and industry will be sitting pretty and make money.
The government on Sunday also suspended Dr Soni from service. He has been attached to the health department regional officer in Jabalpur, as per an order.
MP Chief Minister Mohan Yadav on Saturday said strict action will be taken against those responsible.
The Tamil Nadu drug control authorities, in their report dated October 2, declared the Coldrif syrup sample (Batch No SR-13; Mfg: May 2025; Exp: April 2027) manufactured by Sresan Pharmaceuticals, Kancheepuram, as adulterated because it contained diethylene glycol (48.6% w/v), a poisonous substance “which may render the contents injurious to health”.
Following the report, the Madhya Pradesh Food and Drug Administration issued instructions to stop further sale and distribution of Coldrif statewide and immediately seize any available stock for investigation under the Drugs and Cosmetics Act, 1940. It also ordered that other products manufactured by Sresan Pharmaceuticals be removed from sale pending testing.
The Tamil Nadu government on Friday banned Coldrif following reports of deaths in Madhya Pradesh and at least three similar fatalities in Rajasthan due to suspected kidney infections.
The paradox – ‘if they have such exuding love for stray dogs- why such love and compassion cannot be extended to other animals?’
A very strange paradox exists, when the situation boils down to animal love. Very recently Supreme court passed a very desirable verdict about rehabilitation of street dogs. Such an order is of great necessity to common man, when children playing in streets are being mauled, attacked and bitten every day. Hundreds dying because of rabies and dog bites. The silent killer still remains the infective nature of dog faeces, which pollutes underground water, environment and air with pathogenic bacteria.
Till now Courts have also upheld animal rights but failed to formulate and implement policies to ensure safety of humans from these violent strays. Government has not made out any policy to safeguard public from such attacks nor have courts come up with any solid guidelines, which can save public, children, women and older people from such bites.
After the court verdict, a hue and cry are raised by a breed of ‘Dog Lovers’. This section has not taken any responsibility for the inconvenience to public and death of children due to dog bites, but they have forced the court to review decision. These are people who in reality are unaffected by stray animals because they are celebrities and often self-congratulate themselves for projecting themselves as animal lovers.
Now the question about the paradox starts- ‘if they have such exuding love for stray dogs, why such love and compassion cannot be extended to other animals?’
Billions of chicken are slaughtered every second.
Billions of goats, cattle and lambs are killed mercilessly every minute.
Everyday millions of pigs are killed, and various dish are prepared.
Fish (not countable) are caught and usually gasps – very cruel for a while before being killed.
Leather is collected from animal skin—very cruel
Even monkeys are caught and relocated- no court has stopped it.
It is difficult to understand this kind of differential love for stray dogs. If relocation of stray dogs is cruelty, then killing all other animals is bigger one because none of animals are actually doing any harm. They all are being held for financial reasons.
So clearly, we need to look at the financial implication and output of all these animals.
Chicken are killed and they make a big business.
Goats, lamb, pigs and cattle again give good money when they are raised and killed for meat.
Stray dogs produce financial output only when they bite. Anti rabies serum is used and is expensive. It will be good to compare data of use of Anti Rabies Serum in India and other countries. It can contribute to pharma-industry in some manner.
Court can also have data on this issue, if they take the financial factor into consideration.
Basic question still remains the same-
If it is animal love- why only stray dogs? Why others are being slaughtered? Why this kind of racial discrimination is being done. Surely it is not animal love.
What are financial benefits of having huge population of stary dogs in the community? The dogs which are mauling children, biting common people and hunt in packs in residential areas.
Hope court take a decision and keep other animals in mind while deciding on love for stray dogs.
SUGGESTION: the Government, NGOs and people who claim to be “animal lovers” should create shelters to save strays “as well as people”. It should be mandatory that all the dog and animal (stray or pet) droppings are properly collected and disposed of. This single step can do wonders as it will reduce infections, people’s suffering, save lives and eventually reduce use of antibiotics. A rationale mind will appreciate the danger due to strays and can initiate proper steps rather criticizing above said facts in the name of animal rights. An animal has no sense of responsibility, so rights should be limited accordingly.
It is a common belief that MDRO’s (multi-drug resistance organisms) are found and generated in hospitals, but in recent times this may not be entirely correct. Resistance bacteria are present in community and present in our home environment. This trend is dangerous as millions of people are losing battle to antimicrobial resistance (AMR) and MDROs every year. AMR alone is killing more people than cancer and road traffic accidents combined besides economic loss. To combat AMR, it is important to find causes of generation of MDROs and how they enter human body and community environment. Therefore, it is important to realize the contribution by all the following four important factors: humans, animals, food and environment.
Prevention of MDROs and AMR in India is a challenge. India has been referred to as ‘the AMR capital of the world’. While on one hand, emergence of newer multi-drug resistant (MDR) organisms pose newer diagnostic and therapeutic challenges, on the other hand India is still striving to combat old enemies such as tuberculosis, malaria and cholera pathogens, which are becoming more and more drug resistant. Factors such as poverty, illiteracy, overcrowding and malnutrition further compound the situation. Lack of awareness about infectious diseases in the general masses and inaccessibility to healthcare often preclude them from seeking medical advice.
Easy availability of over- the- counter (OTC) drugs, leads to self-prescription of antimicrobial agents or administered without any professional knowledge regarding the dose and duration of treatment.
Pharmaceutical industry has caused tremendous rise in the amount of chemical waste. With the lack of strict supervisory and legal actions, this waste reaches the water bodies and serves as a continuous source of AMR in the environment.
Another important challenge could be the use of antimicrobial agents as pesticides and insecticides in the agriculture industry. Farmers use antimicrobial agents to protect their hard-earned field and animals from pests and rodents. They are unaware about future consequences and impact on environment.
AMR in milk and food animals has been another big challenge. Gram-negative bacilli with extended-spectrum β-lactamases (ESBL) have been isolated from milk samples and poultry. Enterobacteriaceae isolated from fish and Salmonella species from broiler were isolated.
AMR in environment; Antimicrobial-resistant bacteria have been reported from different water sources of India. The major sources are the pharmaceutical waste waters and hospital effluents that are released into the nearby water bodies without adequate treatment.
In large rivers of India, multiple inlets with varying concentration of drug-resistant bacteria have been found. ESBL producers among Gram-negative bacteria isolated and E. coli isolates found from north as well as south Indian rivers.
To combat AMR, there are many steps possible at communityand Government level. Antibiotic stewardship plans for healthcare settings, promoting further research on the drivers of AMR, judicious use of antibiotics, strict vigilance of over the counter(OTC) antibiotics, control of hospital effluent plants, monitoring waste water discharges from pharmaceutical companies, regulation of use of antimicrobial in food and milk animals, improving agricultural practices and educating masses at community level about AMR.
Saif-Ali- Khan transported in auto- Primitive Ambulance retrieval system
An index case can be made, and important conclusions can be drawn of the analysis regarding Mr Saif Ali Khan case- A celebrity icon– resident of big city Mumbai- got near fatal trauma. Important point to ponder is that How he was transported to hospital? A servant went and arranged for an auto-rickshaw. He was lucky enough as he did not required oxygen or his vitals were stable. If a person like Mr Saif could not arrange or did not opt for life saving Ambulance, what can a common person expect- to be transported especially in smaller cities or remote areas. Night emergencies like heart attack, stroke, pneumonias or even severe trauma permit few minutes and need interventions at the earliest. Such situations are life-threatening and unforgiving. Not all problems of the health care can be neglected by just passing the buck to doctors. Health care delivery requires much more efficient systems, that common man can trust in time of need. Even if the retrieval system exists in Mumbai, why family of Mr saif could not depend upon that?
Whatever the situation, calling an Ambulance was not considered as first responder in this case. Ambulances are not merely transport vehicles. They are equipped with oxygen, ventilators or lifesaving drugs and more importantly with a doctor or paramedic who can actually save life in those critical moments.
As systems in our country come out of slumber only after a celebrity or VIP is involved, it is an opportunity to look at the retrieval aspect and improve upon availability of the timely safe transport of critically unwell patients. A lot of improvement can be made by making Mr Saif’s as an index case.
The issue of patient safety has been gaining increased traction year on year and the issue is in right direction. Hospitals, doctors and administration need to vigorously address shortcomings and strive toward minimum errors and desired goals of safety. Patient safety is of paramount importance; therefore, it is a serious issue. It should be achieved by good groundwork and not by sensationalizing and mischaracterizing the real basic issues, transparent safety culture, adequate number of staff and resources.
There is a recurrent old argument and temptation to ask about why healthcare can’t be as safe as airline travel. There can be many apt comparisons that may be possible between aviation and health care especially taking into account the risk involved. But the doctors who treat critical emergencies, have insight looking at life and death situations directly, know that comparing both would be just an oversimplification of the real basic issues.
At most of the points, the comparison is a complete fallacy; and like comparing apples to muskmelons.
It is beyond doubt that air-industry maintains truly an impressive system which is well-designed to achieve the safety results that it does. But, the kind of comparison that some health care safety leaders make in which they compare the mortality data of acute hospital care and airline fatal accident rates is more of a word play and not so appropriate. This comparison is dangerous because it misses the key points for improvement. Such comparisons merely present over-simplified and convenient tool for the health quality experts, who themselves have never been a front-line health worker at any point of time, but still pretend to pioneer the quality in health industry. For the quality improvement the leaders need to be grounded in the reality of emergency front line medicine to be effective.
Aircrafts are engineered to be in the best possible shape before they fly. Patients, on the other hand, patients are in the worst shape when they enter the emergency of the hospital.
Medicine is by nature, a much more risky work than flying along with vulnerability to death always.
The aircrafts are required to regularly demonstrate that the performance of their critical systems meets or exceeds strict standards. If systems are not operating well the plane will not be allowed to fly.
But all the patients, (aeroplane metaphor) are already sick; doctors are expected to fly such aeroplanes, who are in crashed condition universally. Doctors do not have the luxury to replace any part. For example, when doctors treat an elderly with heart failure, chronic kidney failure and pneumonia, they try to keep them “flying” despite multiple sub optimally functioning critical systems.
In other words, doctors have to fly crashed planes always on every day basis, something that never happens even once in aviation industry.
Has any Pilot ever tried to fly a plane in which engine power is only 25 percent of normal with other systems are functioning sub-optimally and the fuel tank is leaking? What will be standard procedure (SOP) for Pilot to fly this plane? But everyday doctors try to fly such planes and they have to fly it no matter how many systems are non-functional. Moreover, doctors can be sued on some flimsy grounds in case they fail or an accident happens in an effort to keep this plane in the air. Treating a critical illness is like an effort to keep such planes in air with suboptimal functioning systems.
Obviously the comparison is a bit overzealous.
What would be chances that a fully checked plane with a trained pilot will crash after flight takes off. Now compare the chances of patient who lands in emergency, and treatment is started.
By a simple common sense, are two situations comparable?
Former has no chance (almost Zero percent) of crash whereas in a critical emergency patient, the chances of crash are 100 % to start with.
Communication of passengers to the pilot about what he should do and what he should not while flying the plane is nil. Whereas doctors are continuously bombarded with google knowledge of patients and interference by relatives and questioned about every action.
Doctors are expected to make future prediction about what can happen, how he will be able to keep the crashed plane in the air and take consent, based on few assumptions. Doctors can be harassed and dragged to courts if such predictions fail.
Airlines will always have full staff to serve promptly during a flight. The pilot will be totally dedicated to flying the plane, and will not fly without the co-pilot and crew. On the other hand, front line healthcare workers know it well the fact that patient safety incidents and errors tend to occur when they are struggling with staffing levels and feel grossly overworked.
Fatigue and overwork is too common scenario among front line healthcare staff in clinical settings.
A pilot is also only ever going to fly one plane at a time. It is not realistic for a doctor or nurse to be allocated to just one patient, but the workflow is very different, with healthcare tasks frequently interrupted with new clinical issues and emergency situations. Consequently, insufficient staffing can have an acute effect on outcomes and the ability to perform safely.
Aviation industry is too predictable and on the contrary, health care is combination of uncountable unpredictable risk factors, be it allocation of staff or risk of death or resource prediction and complexity of communication.
Aviation is more of mechanical milieu, whereas health care deals with emotion and compassion. The two industries are vastly heterogeneous, and to say that safety in medicine should follow in the path of flying airplanes, grossly oversimplifies a complex problem.
Last but not the least; health care involves lot of financial uncertainties and arrangements. Needless to say, doctors carry the blame for financial hardship of the patients, even if they are not responsible for costs. The mammoth industry remains hidden and doctors are blamed as they are the only front man visible.
Basic difference lies in the fact that patients are real living people, whereas airplanes are simply machines, whose codes and protocols are well defined and limited to within human capabilities. The importance of human contact, empathy, compassion, interact and listen to concerns, and the ability to spend adequate time with patients, should be always be the first pillar of promoting a culture of safety.
Exhortations by armchair preachers to learn oversimplified improvement examples from aviation can provoke considerable frustration and skepticism among clinicians exposed to the unique challenges, difficult working conditions and everyday complexities. Patients are not aeroplanes, and hospitals are not production lines.
Most unfortunate part is the assumption that every sick person who dies in a hospital from an adverse event is an example of a truly preventable death rather than clinicians trying their best to keep someone alive and eventually failing.
Checklists and documentation to improve systems are wonderful in mechanical areas like operative care and inserting central lines, but have limited role and can only go so far without the most important virtues of being a doctor or nurse. It means more than mechanically following protocols and doing paper work in real sense.
In health care merely providing check list and doing extra- paper work may be counterproductive for many reasons. Increase in time for voluminous documentations will consume time and forces health care workers to focus on paper work and takes them away from patient’s real issues.
Completed paper work and excessive documentation provides a false assurance of quality work, which may or may not reflect true picture of patient care. Even after full documentation, still it will be required to be carried out in a diligent manner, a task which is different from mechanical task of mere check list of other industries . Learning from other industries seems to offer a simple shortcut to anyone trying to improve healthcare, but its utility is limited only for documentation purposes and not real quality. Caring for patients is radically different from flying aeroplanes. Healthcare is unique in the intimacy, complexity, and sensitivity of the services it provides as well as the trust, compassion, and empathy that underpin it.
Merely completing protocols mechanically and excessive documentation will result in decline in quality actually. Simply importing and applying a ready-made tool will lead to situation, where quality will exist only on papers and merely reduced to a number to the satisfaction of so called ‘pioneers’ of quality.
#Kolkata-R-G-Kar-murder case has not only exposed the cruel injustice doctors work with, but also the inability of system to provide them justice. It also exposes the law-and-order issues and poor capability of enforcing agencies to provide justice to common man.
In real terms, it is not a problem for only doctors, but such poor law and order is a problem of masses and affects all common people.
Doctors working with routine injustice whole those years looks trivial as compared to cruelty inflicted on lady doctor during this incident. But strangely, still the doctors of R G Kar hospital are facing a kind of oppression and moral blackmail. They have become more insecure and unsure about whether they will get fair justice. To continue the protest for their genuine demands is getting difficult. Even when justice is still far and distant as it can be, they may face punitive action of worst kind. There is only a faint hope of real justice left although ‘token justice’ of temporary nature may be a possibility at the best.
Overall, a complex scenario for doctors. There is increasing discontentment amongst doctors because of complex and punishing system. They are supposed to see large number of patients with fewer staff and nursing support while still giving excellent care in these circumstances. And if these were not enough, the fear of courts and medico-legal cases, verbal threats, abuses, and physical assaults and show of distrust by patient and relatives further makes working difficult. Additionally, there may be bullying by certain administrative systems at places, who use pressure tactics to get their own way.
They are regulated in a way- no one else is. Judiciary, police, government agencies and every one else are not accountable for most of their blunders, but doctors are. But still- in such cases, everyone is looking at Supreme court and Government agencies, about whether they can deliver justice in such high-profile cases, when very powerful people are involved. Will supreme sacrifice of a young lady doctor be enough to shake up the system? Was it enough for the courts and powerful agencies to show and utilize their power in best manner? Was the animal behaviour of the accused has made courts and powerful enforcement agencies to get up and go beyond the “CULTURE OF TOKEN JUSTICE” and not merely catching scapegoats?
Common masses are curious about performance of Supreme court and Government agencies and expect to deliver real justice.
#Kolkata-R-G-Kar-murder case has exposed the hardship of doctors in present era. Working with routine injustice whole those years looks trivial as compared to this incident. But strangely, still the doctors of R G Kar hospital are facing a kind of moral blackmail. To continue the protest for their genuine demands is getting difficult. Even when justice is still far and distant as it can be, they may face punitive action of worst kind. There is only a faint hope of real justice left although ‘token justice’ of temporary nature may be a possibility at the best.
Doctors are the only community who face worst kind of moral blackmail from governments and courts to end protest, even in case of blatant and cruel injustice as in R G Kar hospital.
Overall, a complex scenario for doctors. There is increasing discontentment amongst doctors because of complex and punishing system. They are bound by so many factors that they finally end up at the receiving end all the time. They are under Hippocratic oath and therefore expected to work with very high morality, goodwill and kindness for the sufferings of mankind and dying patients. They are also supposed to maintain meticulous documentation and also supposed to work under norms of medical industry. They are supposed to see large number of patients with fewer staff and nursing support while still giving excellent care in these circumstances. And if these were not enough, the fear of courts and medico-legal cases, verbal threats, abuses, and physical assaults and show of distrust by patient and relatives further makes working difficult. Additionally, there may be bullying by certain administrative systems at places, who use pressure tactics to get their own way.
In the present circumstances, when doctors have become doubtful about the advice for choosing medical career, some are naïve enough to spend millions on securing an expensive medical college seat. Problems faced by doctors are not only innumerable but are also so exceedingly complex that they are difficult to be analysed. Doctors feel so disgusted about the entire system that they do not encourage their children to take up this profession which until now was one of the coveted ones, there must be something going terribly wrong with the profession.
More of a law and order issue, the physical assault on doctors reflects that they are serving an uncivilized society. Such news is viewed by medical community anxiously and is definitely a poor advertisement for younger generation to take medicine as profession. The medical students need to think, why they wish to enter medical profession in such an unsupportive environment?
The painful incident of Kolkata Doctor rape and murder had unmasked the everyday struggle of the doctors in the present era. Her supreme sacrifice depicted the plight of doctors- being undervalued and demonized, forced to work as a sub-servant, irresponsible policing, blackmail by goons and vulture journalism-all have become an accepted form of harassment. Her murder has unveiled the despondency, moral burden and injustice that doctors work with.
With the evolution of medical science and medical care intertwined with medical business, braided changes in medical regulation is not an far off expectation. But reticulation of evolution to modern medicine and health care has not happened in isolation. Simultaneously there has been progressively complex emerging trends in medical business and changing patterns of health investments along with an era of corporate investments in health care has also ushered. Every one now wishes to live longer and dreams of better quality of life with support of progressive medical care. Opportunities projected by advancements in health care, have shown that these dreams can be a real possibility, in many cases. That kind of perception has given patients a hope in lieu of some money. With rich people willing to spend more, the insurance sector and investors putting money into health care, which was unthinkable few decades back in the past. This reticulation of business and health care allowed health care to be controlled in some way by administrators and investors. Away from the health providers, who actually treated the patients.
As it is no more simply treating a disease and involves many more issues. New model of medical regulation and business in health care is still not a mature process. It has emerged and progressed in just for few decades, as compared to medical treatments and systems that existed since ancient times. It is still in infancy and still has to go a long way to do real justice to every one. No one really knows how to regulate this difficult area, which encompasses life and death, deals with extremes of poverty and riches, mortality and morbidity, pain and relief , sadness and happiness, smiles and sorrows and uncountable emotions, intertwines with financial aspects. Most difficult part is amalgamation of intricacies of science with minds of patient and doctor’s skill in newly evolved milieu of financial complexities. Results are not encouraging for the medical profession.
Hammurabi 5000 years ago, was not even at the doorstep of medical science, but he promulgated some rules. It is difficult to say whether he was naive or brilliant enough to make it more mathematical. He fixed heavy prize for saving lives and used to cut the hands of physicians for death or untoward incident. But he was still wise enough to pay heavily if life was saved. After thousands of years, with some scientific advancements, our regulation has remained more or less similar in basics. It is still based on principles of revenge and punishments. Now clearly knowing well the limitation of medical science and the uncertainties and complexities of human body in better way, it still remains somewhat unfair to doctors. In other words, it has not attained enough evolution and maturity.
Hammurabi at the start of civilization believed that doctors needed to be punished in case there was poor prognosis. He failed to understand the complexity of human body and the limitations of medical science, most of which was unknown at that time. By an application of average wisdom, doctor can be easily blamed for poor outcome, because he is always a common link between treatment and poor prognosis. Stricter punishments were imposed to regulate medical profession, even when the medical science was not even developed enough to deal with most of diseases. Children are always taught in school that medical profession is a noble one. But they are never told, about the cruelty this profession has faced since ancient times. Almost universally, the earlier work or contribution of a doctor to society is not taken into account. Even for complexities of medical science and uncertainties of the outcome, blame can conveniently be passed on doctors due to application of average wisdom.
Hammurabi’s Codex specified the harshest form of deselection of health providers possible. If the physician erred through omission or commission, his fingers or hands were cut off, immediately stopping his practice. Therefore, a single mistake can undo all the good work of past or the future good work that could have been accomplished.
Problem here is that who can differentiate with certainty the real cause of sufferings of patient, a poor prognosis or a mistake. Such harsh regulatory systems will dissuade other good people joining the profession, again resulting in further inhibition and flourishing of profession for the good. Obviously, harsher penalties will discourage a physician surplus.
Today the global system of medical regulation, is becoming somewhat similar, to those ancient regulations in terms of punishment and revenge. Differential payment system for health care also resembles the Code of Hammurabi in some respects. And this is even though now we are very well conversant with the known uncertainty and complexity of the human body and despite cognizance of the poor prognosis in many disease states.
Fear factors on doctors and impact of present legal complexities is already at par with that of Hammurabi’s era
Mpox (monkeypox) is a viral illness caused by the monkeypox virus, a species of the genus Orthopoxvirus. Two different clades exist: clade I and clade II
Common symptoms of mpox are a skin rash or mucosal lesions which can last 2–4 weeks accompanied by fever, headache, muscle aches, back pain, low energy, and swollen lymph nodes.
Mpox can be transmitted to humans through physical contact with someone who is infectious, with contaminated materials, or with infected animals.
Laboratory confirmation of mpox is done by testing skin lesion material by PCR.
Mpox is treated with supportive care. Vaccines and therapeutics developed for smallpox and approved for use in some countries can be used for mpox in some circumstances.
In 2022–2023 a global outbreak of mpox was caused by a strain known as clade IIb.
Mpox can be prevented by avoiding physical contact with someone who has mpox. Vaccination can help prevent infection for people at risk.
Overview
Mpox (monkeypox) is an infectious disease caused by the monkeypox virus. It can cause a painful rash, enlarged lymph nodes and fever. Most people fully recover, but some get very sick.
Anyone can get mpox. It spreads from contact with infected:
persons, through touch, kissing, or sex
animals, when hunting, skinning, or cooking them
materials, such as contaminated sheets, clothes or needles
pregnant persons, who may pass the virus on to their unborn baby.
If you have mpox:
Tell anyone you have been close to recently
Stay at home until all scabs fall off and a new layer of skin forms
Cover lesions and wear a well-fitting mask when around other people
Avoid physical contact.
The disease mpox (formerly monkeypox) is caused by the monkeypox virus (commonly abbreviated as MPXV), an enveloped double-stranded DNA virus of the Orthopoxvirus genus in the Poxviridae family, which includes variola, cowpox, vaccinia and other viruses. The two genetic clades of the virus are clades I and II.
The monkeypox virus was discovered in Denmark (1958) in monkeys kept for research and the first reported human case of mpox was a nine-month-old boy in the Democratic Republic of the Congo (DRC, 1970). Mpox can spread from person to person or occasionally from animals to people. Following eradication of smallpox in 1980 and the end of smallpox vaccination worldwide, mpox steadily emerged in central, east and west Africa. A global outbreak occurred in 2022–2023. The natural reservoir of the virus is unknown – various small mammals such as squirrels and monkeys are susceptible.
Transmission
Person-to-person transmission of mpox can occur through direct contact with infectious skin or other lesions such as in the mouth or on genitals; this includes contact which is
face-to-face (talking or breathing)
skin-to-skin (touching or vaginal/anal sex)
mouth-to-mouth (kissing)
mouth-to-skin contact (oral sex or kissing the skin)
respiratory droplets or short-range aerosols from prolonged close contact
The virus then enters the body through broken skin, mucosal surfaces (e g oral, pharyngeal, ocular, genital, anorectal), or via the respiratory tract. Mpox can spread to other members of the household and to sex partners. People with multiple sexual partners are at higher risk.
Animal to human transmission of mpox occurs from infected animals to humans from bites or scratches, or during activities such as hunting, skinning, trapping, cooking, playing with carcasses, or eating animals. The extent of viral circulation in animal populations is not entirely known and further studies are underway.
People can contract mpox from contaminated objects such as clothing or linens, through sharps injuries in health care, or in community setting such as tattoo parlours.
Signs and symptoms
Mpox causes signs and symptoms which usually begin within a week but can start 1–21 days after exposure. Symptoms typically last 2–4 weeks but may last longer in someone with a weakened immune system.
Common symptoms of mpox are:
rash
fever
sore throat
headache
muscle aches
back pain
low energy
swollen lymph nodes.
For some people, the first symptom of mpox is a rash, while others may have different symptoms first.
The rash begins as a flat sore which develops into a blister filled with liquid and may be itchy or painful. As the rash heals, the lesions dry up, crust over and fall off.
Some people may have one or a few skin lesions and others have hundreds or more. These can appear anywhere on the body such as the:
palms of hands and soles of feet
face, mouth and throat
groin and genital areas
anus.
Some people also have painful swelling of their rectum or pain and difficulty when peeing.
People with mpox are infectious and can pass the disease on to others until all sores have healed and a new layer of skin has formed.
Children, pregnant people and people with weak immune systems are at risk for complications from mpox.
Typically for mpox, fever, muscle aches and sore throat appear first. The mpox rash begins on the face and spreads over the body, extending to the palms of the hands and soles of the feet and evolves over 2-4 weeks in stages – macules, papules, vesicles, pustules. Lesions dip in the centre before crusting over. Scabs then fall off. Lymphadenopathy (swollen lymph nodes) is a classic feature of mpox. Some people can be infected without developing any symptoms.
In the context of the global outbreak of mpox which began in 2022 (caused mostly by Clade IIb virus), the illness begins differently in some people. In just over a half of cases, a rash may appear before or at the same time as other symptoms and does not always progress over the body. The first lesion can be in the groin, anus, or in or around the mouth.
People with mpox can become very sick. For example, the skin can become infected with bacteria leading to abscesses or serious skin damage. Other complications include pneumonia, corneal infection with loss of vision; pain or difficulty swallowing, vomiting and diarrhoea causing severe dehydration or malnutrition; sepsis (infection of the blood with a widespread inflammatory response in the body), inflammation of the brain (encephalitis), heart (myocarditis), rectum (proctitis), genital organs (balanitis) or urinary passages (urethritis), or death. Persons with immune suppression due to medication or medical conditions are at higher risk of serious illness and death due to mpox. People living with HIV that is not well-controlled or treated more often develop severe disease.
Diagnosis
Identifying mpox can be difficult as other infections and conditions can look similar. It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible infections, and medication-associated allergies. Someone with mpox may also have another sexually transmissible infection such as herpes. Alternatively, a child with suspected mpox may also have chickenpox. For these reasons, testing is key for people to get treatment as early as possible and prevent further spread.
Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for mpox. The best diagnostic specimens are taken directly from the rash – skin, fluid or crusts – collected by vigorous swabbing. In the absence of skin lesions, testing can be done on oropharyngeal, anal or rectal swabs. Testing blood is not recommended. Antibody detection methods may not be useful as they do not distinguish between different orthopoxviruses.
More information on laboratory confirmation of mpox can be found here.
Treatment and vaccination
The goal of treating mpox is to take care of the rash, manage pain and prevent complications. Early and supportive care is important to help manage symptoms and avoid further problems.
Getting an mpox vaccine can help prevent infection. The vaccine should be given within 4 days of contact with someone who has mpox (or within up to 14 days if there are no symptoms).
It is recommended for people at high risk to get vaccinated to prevent infection with mpox, especially during an outbreak. This includes:
health workers at risk of exposure
men who have sex with men
people with multiple sex partners
sex workers.
Persons who have mpox should be cared for away from other people.
Several antivirals, such as tecovirimat, originally developed to treat smallpox have been used to treat mpox and further studies are underway. Further information is available on mpox vaccination and case management.
Self-care and prevention
Most people with mpox will recover within 2–4 weeks. Things to do to help the symptoms and prevent infecting others:
Do
stay home and in your own room if possible
wash hands often with soap and water or hand sanitizer, especially before or after touching sores
wear a mask and cover lesions when around other people until your rash heals
keep skin dry and uncovered (unless in a room with someone else)
avoid touching items in shared spaces and disinfect shared spaces frequently
use saltwater rinses for sores in the mouth
take sitz baths or warm baths with baking soda or Epsom salts for body sores
take over-the-counter medications for pain like paracetamol (acetaminophen) or ibuprofen.
Do not
pop blisters or scratch sores, which can slow healing, spread the rash to other parts of the body, and cause sores to become infected; or
shave areas with sores until scabs have healed and you have new skin underneath (this can spread the rash to other parts of the body).
To prevent spread of mpox to others, persons with mpox should isolate at home, or in hospital if needed, for the duration of the infectious period (from onset of symptoms until lesions have healed and scabs fall off). Covering lesions and wearing a medical mask when in the presence of others may help prevent spread. Using condoms during sex will help reduce the risk getting mpox but will not prevent spread from skin-to-skin or mouth-to-skin contact.
Outbreaks
After 1970, mpox occurred sporadically in Central and East Africa (clade I) and West Africa (clade II). In 2003 an outbreak in the United States of America was linked to imported wild animals (clade II). Since 2005, thousands of suspected cases are reported in the DRC every year. In 2017, mpox re-emerged in Nigeria and continues to spread between people across the country and in travellers to other destinations. Data on cases reported up to 2021 are available here.
In May 2022, an outbreak of mpox appeared suddenly and rapidly spread across Europe, the Americas and then all six WHO regions, with 110 countries reporting about 87 thousand cases and 112 deaths. The global outbreak has affected primarily (but not only) gay, bisexual, and other men who have sex with men and has spread person-to-person through sexual networks. More information on the global outbreak is available here with detailed outbreak data here;
In 2022, outbreaks of mpox due to Clade I MPXV occurred in refugee camps in the Republic of the Sudan. A zoonotic origin has not been found.
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