Is there any other profession, which has such kind of pathetic arrangement? The sufferers of such pitiable deals are doctors. An average doctors studies for decades and treats hundreds of patients for peanuts (Few hundred rupees). For one alleged mistake or just a legal interpretation is forced to pay millions for an incident, which can be merely procedural or circumstantial mistake.
Why one should be putting his/her future into such pathetic arrangements? The inspiring doctors need to think.
Large claims granted by courts are incentives for patients and lawyers for putting medical lawsuits. In an era, where people fight with their parents, brothers and sisters for money and property, it will be naive to think that idea of making money from doctor does not exist.
Now-a-days medical professionals need to not only be thorough with their medical subjects and the medico-legal implications, but also need to be careful about how courts may interpret the medical processes. What doctors think is a correct medical process, but it can be interpreted as negligence, in case of an adverse outcome. Other contributing factors that nail down medical profession are the sympathy to the patient and wisdom of hindsight, which everyone is flushed with as an after event.
Large compensations against medical profession are the single important factor can increase the cost of healthcare and demoralize medical profession. Doctors are always on the receiving end in case of an adverse outcome. Medical problems are very complex and sometimes it is difficult to judge the future course of disease as well as court interpretation of medical science, especially with retrospective wisdom by courts. Summarily doctors have to safeguard themselves from treatment as well as legal and documentation hassles.
Every case that goes to court involves lawyers and their expensive fees. Most of the time even though the doctors may be right, he has to defend himself with the help of lawyers. Law industry has been benefitted enormously because of consumer protection act at the cost of doctors.
Strangely doctor’s fee are quite low but lawyers charges and court compensations are really astronomical amounts, which are beyond any logic.
New Delhi: In a landmark order, the National Consumer Commission (NCDRC) has ordered Nagpur-based Ultrasound Scanning and Imaging Center to pay a compensation of Rs 1.2 crore to a disabled child and his parents in a medical negligence case. The firm has been blamed for misreporting of ultrasound on four occasions during pregnancy, resulting in the birth of a child with congenital anomalies. Congenital anomalies are defined as structural or functional anomalies that occur during intrauterine life. The commission held that the ultrasonology center also failed to offer to terminate the pregnancy, failing to diagnose defects at an early stage. The newborn had finger pain (complete absence), right leg below the knee and left leg below the ankle joint. The clinic – Imaging Point – was run by Radiologist Dr Dilip Ghik in Nagpur. Holding him and his clinic responsible for their failure to detect structural anomalies of the fetus at 17-18 weeks, a two-member NCDRC bench comprising Justices RK Agrawal and SM Kantikar asked them to provide for the child’s welfare, future expenses asked to pay compensation for the treatment and purchase of limb prostheses. The order said, “The amount shall be kept as a fixed deposit in any nationalized bank (preferably SBI) in the name of the child till he attains the age of majority. Parents can get periodic interest on the FD for regular health check-up, treatment and welfare of their child. It also directed the radiologists and their clinics to pay Rs 1 lakh towards legal expenses. As per the commission’s order, in October 2006, the child’s mother, who was pregnant at the time, consulted a gynecologist and obstetrician. The next month the doctor referred the patient to the imaging point for ultrasonography of the pelvis. USG Ghik and reported normally. Three more ultrasounds were done by the Ultrasound Scanning Centre. All USGs were reported as “no obvious congenital anomalies in the abdomen and spine of the fetal head”. But when the gynecologist performed an elective caesarean section and after the baby was born, the mother and all the attendants were shocked to see a “severely deformed male newborn”. The girl’s parents had alleged that all this happened due to the negligent ultrasound of the radiologist. He had prayed for a compensation of Rs 10 crore to meet future expenses. But the radiologist denied any negligence in the patient’s USG report.
Medical professionals often face a trade-off between the Hippocrates Oath that they take and the necessity of their own well-being.
Unfortunately, abusive and violent behaviour by patients or relatives or those accompanying patients has become one of the attendant risks of the medical profession. It is no surprise then that the medical fraternity has once again called upon the government to enact stringent laws and their proper implementation to curtail this kind of behaviour with the National Medical Commission (NMC) proposing that registered medical practitioners (RMPs) refuse to take on such cases.
The NMC (which replaced the Medical Council of India) is a body that regulates medical education and professionals.
The NMC’s Ethics and Medical Registration Board has issued draft regulations inviting comments from the public, experts, stakeholders and organisations on “National Medical Commission, Registered Medical Practitioner (Professional Conduct) Regulations 2022”.
Comments and suggestions on the draft proposal can be sent by June 22.
“In case of abusive, unruly, and violent patients or relatives, the RMP can document and report the behaviour and refuse to treat the patient. Such patients should be referred for further treatment elsewhere,” the draft proposal says.
“If a change of RMP is needed (for example, the patient needs a procedure done by another RMP), consent should be obtained from the patient himself or the guardian. The RMP who attends to the patient will be fully accountable for his actions and entitled to the appropriate fees,” it added.
Medical professionals often face a trade-off between the Hippocrates Oath that they take and the necessity of their own well-being. Sahajanand Prasad Singh, president, Indian Medical Association (IMA, a panel that represents doctors and their interests), said a doctor would be ethically wrong if he or she refuses treatment to someone in need. So the need of the hour is to have a central law to check such untoward incidents, said Dr Singh.
“The commission or abetment of such acts of violence shall be punished with imprisonment for a term of three months to five years, and with fine of Rs 50,000 to Rs 2,00,000,” says the Epidemic Diseases (Amendment) Act, 2020.
Former IMA president Rajan Sharma, who led a nationwide protest condemning violence against doctors in India, said without a Union home ministry law against attacks on doctors, these proposals would do very little to prevent incidents against healthcare workers.
“There has to be strong laws to deal with the rising cases of violence. The regulations made by NMC should be in tandem with the stringent laws from the Union home ministry,” Dr Sharma said.
On his part, IMA general secretary Jayesh Lele, “It’s only a draft regulation, we are going to submit our important observations to the NMC.”
Anuj Aggarwal, general secretary, Federation of Resident Doctors Association of India, said the RMP Professional Conduct Guidelines offers some breather for resident doctors but has some way to go.
“The guidelines give rightful exceptions to patients with life-threatening conditions, which is justified. However, it is important to consider that most of the events in which a patient’s attendants turn violent are when the patient is very critically ill. So this proposal has no role to play in the majority of such scenarios,” he said.
Dr Aggarwal said that while it is a welcome step to curb the issue of rising violence against doctors, a central law would be a better and more effective deterrent.
The government did propose a central protection act and a draft was put in the public domain in 2019 for feedback but it was put on the back burner.
Regulation of the medical profession has become a tool to oppress doctors.
Dr Manjula Arora case (NHS-UK) unmasks the everyday struggle of the doctors in present era. Being undervalued and demonized, forced to work as sub-servant to administrators and regulators are considered new normal and has become an accepted form of harassment. Fatigue and burnout are thought to be routine side effects of being a doctor or nurse. The unhindered over-regulation has left no stone unturned in spreading hatred and creating an environment of mistrust against the medical profession. Single stray or a trivial incident is projected as an example to portray poor image of medical profession as generalization and as a token of the ‘excellent’ work done by administrators and regulators. Doctors have become soft targets because of their nature of work as they deal with life and death. Any trivial issues such as semantics used by Dr Manjula Arora (in this case) were blown out of proportion and GMC finds this as an opportunity to send a strict message to the whole profession. Such incidence show that regulators and administrators can use the nature of doctors’ work to be used against medical profession to make saviours as an easy prey for punishments on the pretext of dishonesty, negligence or semantics being used as legal weapons by law-enforcers, even in case of a perceived bias. In the process of such ‘tokenism’ administrators prove their relevance to the system.
Regulation of the medical profession has become a tool to oppress doctors. Driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes- causing patient harm.
Dr Arora has been a doctor since 1988 and is of good character. She asked her employer for a laptop. For context, most employees would reasonably expect their employer to provide work-related IT equipment. She was told that none were available, but her interest would be noted for the next roll-out. Many people would interpret this positive response to mean that they would get a laptop in due course. Clearly if her employer did not intend for her to have a laptop, they could simply have said so. Dr Arora spoke to her IT department about getting a laptop and said she had been ‘promised’ one.
And that’s it. That is the entire extent of her ‘misconduct’.
One could regard her statement as a minor exaggeration, or loose terminology, or careless language or verbal shorthand over a trivial subject. But no one should consider it to amount to ‘dishonesty’ unless interpret it in biased manner.
The tribunal took a different view. They concluded that ordinary, decent people would consider her use of the single word ‘promised’ as dishonest. The tribunal further decided that this so-called dishonesty amounted to misconduct.
They also considered that the misconduct was serious.
They decided her fitness to practice was impaired, and that it was necessary to suspend her to send a message to the profession.The regulator has a difficult task. Good regulation protects patients. Poor regulation harms patients, because doctors will run away from a toxic regulatory environment.
The case of Manjula Arora, a GP in Manchester, who has been suspended for a month for supposed “dishonesty” about a laptop, was picked up by a few colleagues, and social media did its work of ensuring the pick-up rate increased exponentially. One always worries about the latest “MedTwitter” controversy. But this one has come on back of seething annoyance among many doctors about our regulator—the General Medical Council (GMC)—and its perceived bias, with cases such as those of Hadiza Bawa-Garba and Omer Karim still fresh in our memories.
Couple this with the recent Medical Workforce Race Equality Standard (MWRES) data confirming a clear association of increased referrals and convictions on the basis of racial background—or indeed country of origin as regards training—and this case lit the touch paper.
If one considers the publicly available details of the whole trial, you have to scratch your head and wonder how it got to this stage? Would this happen if the name of the individual was, for example, Michael Andrews?
The relevance of this case stood on two things—any harm to the patient population, which, to me, should be the primary aim of the GMC, and then dishonesty and disrepute brought upon the medical community.
This ruling makes it clear that there is no risk of harm to the public: “The Tribunal considered that no issues in relation to patient safety had been identified in this case. Dr Arora is a competent clinician, and there is no necessity to protect the public.” That should have ended the issue. But the complications started when interpretation about honesty came into the picture.
“The Tribunal attached significant weight to the fact that Dr Arora’s misconduct was a single incident in relation to the use of a single word, with no evidence of any other similar episodes of dishonesty before or after the event.” If you go into the details of the case, it becomes even more murky, as it’s the interpretation of a word—subjective at best— against the background of someone for whom English is not their first language. But it was deemed enough to warrant a month’s suspension according to the tribunal: “this period would send an appropriate message to the medical profession and to the wider public that Dr Arora’s misconduct, albeit relating to a single fleeting moment of dishonesty and not a planned deception.”
This raises a multitude of questions. Firstly, there is the principle that one fleeting moment of dishonesty could result in suspension. If that’s the standard, then the profession is indeed in trouble, with the GMC now making subjective judgements and being an arbiter of what is deemed to be honest or not. Where does the line get drawn? Discussions about patients or conversations about whether Santa exists or not?
Secondly, and more importantly, there is the suspicion of bias in how that law is being applied. Daniel Sokol has written a recent column which discusses the notion of doctors as the “saintly being”; the epitome of perfection at all times.Yet, within all of us exist the same prejudices and flaws as for the rest of the population. Sokol suggests that doctors have to be “scrupulously honest—in and out of work—unless the situation obviously allows for ethical dishonesty.” Yet he makes no mention of the fact that the GMC seems to apply that principle unevenly across the board. I accept that it can be difficult to see the “problem” others are complaining about, but I can assure you there are very few international medical graduates who have read about Arora’s case and not thought “I know why this has happened.”
There is professionalism, but there is humanity too, and I would propose that driving the narrative of doctors as “perfect” beings causes more harm to the doctor-patient relationship than not. What is honesty? Saying to patients that they need to wait for another 16 hours to get a bed, or holding the hand of the elderly frail lady, comforting her and saying “I am sure something will come up shortly”? It brings back the concept that being a doctor is a vocation. Constantly seeking to attain perfection is the very approach that leads to burn out, and more mistakes—causing patient harm.
Finally, if the role of the GMC is to protect the public from “single moments of untruth,” as this destroys the view among the public that doctors are saints (although I am pretty sure the public don’t see doctors like that in modern life), then there needs to be a discussion of that concept, of the overreach into personal lives, and of where the line is drawn as regards the GMC’s intrusion and inordinate application of that principle. I would suggest the role of the regulator should be for the rare circumstances when there is an interest in behaviour not being repeated or where it cannot be dealt with effectively by an employer.
I work with the GMC closely these days, and I find it immensely frustrating to see such cases as they undermine some significant hard work that is being done by individuals who are determined to change the narrative that the GMC is biased. I would encourage all concerned to look into this case, review it, learn from it, and offer support to Arora. There is a lot of work in hand to repair the damage from the Bawa Garba case, and this case could reinforce those sentiments, which we must avoid.
The intention may once have been for doctors to be Superman, but modern times and the foibles of individuals only permit a Batman. It’s worth remembering neither of them work to harm the public.
It has become a common practice to advertise health products or therapies that claim to be panacea for all ailments enhance immunity, to increase power and health by creating an impression on minds on various platforms. Instead of producing scientific evidence, such products and therapies are sold under disguise of natural therapies or alternate medicines. Needless to say, the objective evidence or global neutral trial for the claimed efficacy or about real side effects is always missing.
Companies have created huge fortunes based on circulation of such pedagogic narratives and social knowledge. But in real sense, these are actually chemical and have biological actions and reactions. Chemical derived from natural sources can have side effects and contain impurities. Global neutral trials to validate effects and side effects remain an urgent need of the hour for all health products.
Suffering for the common public is immense. Doctors’ sincere warning had no effect rather they were called as medicine mafia. Unfortunately false beliefs like local religious figures can cure cancer and kidney diseases cause they could communicate with invisible spirits and gain knowledge. Unsurprisingly the cranks have been wrong and innocent patients suffer. Doctors objecting to elevation of crank theories were painted as western medicine agents, or nattering nabobs of negativity.
Here is an example of the folly of following fringe theories.
A 52-year-old homemaker from Dum Dum had to undergo a few rounds of dialysis and was put under intense critical care for a renal failure, triggered by ‘fish bile poisoning’. The patient had ingested raw fish bile for four consecutive days as a treatment to cure her diabetes prior to being rushed to Manipal Hospitals Kolkata with acute abdominal pain. Doctors at the Salt Lake hospital found the patient had low blood pressure and was in a state of shock. Initial reports showed a significant derangement of liver and kidney functions. It led doctors to treat common causes of liver and kidney injuries or drug induced organ damage. When further tests didn’t match with these diagnoses, the team started looking for a possible cause. The patient then revealed she had ingested bile of Rohu fish for four days to control her diabetes. “Consuming fish bile causes acute kidney and liver injury with the need to go for long term dialysis. This patient had to be put under dialysis within 72 hours of admission,” said internal medicine and critical care consultant. She was discharged from hospital after a month.
The clinical presentation of monkeypox resembles that of smallpox, a related orthopoxvirus infection which has been eradicated. Smallpox was more easily transmitted and more often fatal as about 30% of patients died. The last case of naturally acquired smallpox occurred in 1977, and in 1980 smallpox was declared to have been eradicated worldwide after a global campaign of vaccination and containment. It has been 40 or more years since all countries ceased routine smallpox vaccination with vaccinia-based vaccines. As vaccination also protected against monkeypox in West and Central Africa, unvaccinated populations are now also more susceptible to monkeypox virus infection.
Whereas smallpox no longer occurs naturally, the global health sector remains vigilant in the event it could reappear through natural mechanisms, laboratory accident or deliberate release. To ensure global preparedness in the event of reemergence of smallpox, newer vaccines, diagnostics and antiviral agents are being developed. These may also now prove useful for prevention and control of monkeypox.
Key facts
Monkeypox is caused by monkeypox virus, a member of the Orthopoxvirus genus in the family Poxviridae.
Monkeypox is a viral zoonotic disease that occurs primarily in tropical rainforest areas of Central and West Africa and is occasionally exported to other regions.
Monkeypox typically presents clinically with fever, rash and swollen lymph nodes and may lead to a range of medical complications.
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases can occur. In recent times, the case fatality ratio has been around 3-6%.
Monkeypox is transmitted to humans through close contact with an infected person or animal, or with material contaminated with the virus.
Monkeypox virus is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding.
The clinical presentation of monkeypox resembles that of smallpox, a related orthopoxvirus infection which was declared eradicated worldwide in 1980. Monkeypox is less contagious than smallpox and causes less severe illness.
Vaccines used during the smallpox eradication programme also provided protection against monkeypox. Newer vaccines have been developed of which one has been approved for prevention of monkeypox
An antiviral agent developed for the treatment of smallpox has also been licensed for the treatment of monkeypox.
Monkeypox is a viral zoonosis (a virus transmitted to humans from animals) with symptoms very similar to those seen in the past in smallpox patients, although it is clinically less severe. With the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination, monkeypox has emerged as the most important orthopoxvirus for public health. Monkeypox primarily occurs in Central and West Africa, often in proximity to tropical rainforests and has been increasingly appearing in urban areas. Animal hosts include a range of rodents and non-human primates.
The pathogen
Monkeypox virus is an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family. There are two distinct genetic clades of the monkeypox virus – the Central African (Congo Basin) clade and the West African clade. The Congo Basin clade has historically caused more severe disease and was thought to be more transmissible. The geographical division between the two clades has so far been in Cameroon – the only country where both virus clades have been found.
Natural host of monkeypox virus
Various animal species have been identified as susceptible to monkeypox virus.. This includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates and other species. Uncertainty remains on the natural history of monkeypox virus and further studies are needed to identify the exact reservoir(s) and how virus circulation is maintained in nature.
Outbreaks
Human monkeypox was first identified in humans in 1970 in the Democratic Republic of the Congo in a 9-year-old boy in a region where smallpox had been eliminated in 1968. Since then, most cases have been reported from rural, rainforest regions of the Congo Basin, particularly in the Democratic Republic of the Congo and human cases have increasingly been reported from across Central and West Africa.
Since 1970, human cases of monkeypox have been reported in 11 African countries – Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Cote d’Ivoire, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan. The true burden of monkeypox is not known. For example, in 1996–97, an outbreak was reported in the Democratic Republic of the Congo with a lower case fatality ratio and a higher attack rate than usual. A concurrent outbreak of chickenpox (caused by the varicella virus, which is not an orthopoxvirus) and monkeypox was found which could explain real or apparent changes in transmission dynamics in this case. Since 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality ratio of approximately 3%. Cases continue to be reported until today.
Monkeypox is a disease of global public health importance as it not only affects countries in West and Central Africa, but the rest of the world. In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats and dormice that had been imported into the country from Ghana. This outbreak led to over 70 cases of monkeypox in the U.S. Monkeypox has also been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021. In May 2022, multiple cases of monkeypox were identified in several non-endemic countries. Studies are currently underway to further understand the epidemiology, sources of infection, and transmission patterns.
Transmission
Animal-to-human (zoonotic) transmission can occur from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals. In Africa, evidence of monkeypox virus infection has been found in many animals including rope squirrels, tree squirrels, Gambian poached rats, dormice, different species of monkeys and others. The natural reservoir of monkeypox has not yet been identified, though rodents are the most likely. Eating inadequately cooked meat and other animal products of infected animals is a possible risk factor. People living in or near forested areas may have indirect or low-level exposure to infected animals.
Human-to-human transmission can result from close contact with respiratory secretions, skin lesions of an infected person or recently contaminated objects. Transmission via droplet respiratory particles usually requires prolonged face-to-face contact, which puts health workers, household members and other close contacts of active cases at greater risk. However, the longest documented chain of transmission in a community has risen in recent years from six to nine successive person-to-person infections. This may reflect declining immunity in all communities due to cessation of smallpox vaccination. Transmission can also occur via the placenta from mother to fetus (which can lead to congenital monkeypox) or during close contact during and after birth. While close physical contact is a well-known risk factor for transmission, it is unclear at this time if monkeypox can be transmitted specifically through sexual transmission routes. Studies are needed to better understand this risk.
Signs and symptoms
The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.
The infection can be divided into two periods:
the invasion period (lasts between 0-5 days) characterized by fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, myalgia (muscle aches) and intense asthenia (lack of energy). Lymphadenopathy is a distinctive feature of monkeypox compared to other diseases that may initially appear similar (chickenpox, measles, smallpox)
the skin eruption usually begins within 1-3 days of appearance of fever. The rash tends to be more concentrated on the face and extremities rather than on the trunk. It affects the face (in 95% of cases), and palms of the hands and soles of the feet (in 75% of cases). Also affected are oral mucous membranes (in 70% of cases), genitalia (30%), and conjunctivae (20%), as well as the cornea. The rash evolves sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid), pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off. The number of lesions varies from a few to several thousand. In severe cases, lesions can coalesce until large sections of skin slough off.
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases occur more commonly among children and are related to the extent of virus exposure, patient health status and nature of complications. Underlying immune deficiencies may lead to worse outcomes. Although vaccination against smallpox was protective in the past, today persons younger than 40 to 50 years of age (depending on the country) may be more susceptible to monkeypox due to cessation of smallpox vaccination campaigns globally after eradication of the disease. Complications of monkeypox can include secondary infections, bronchopneumonia, sepsis, encephalitis, and infection of the cornea with ensuing loss of vision. The extent to which asymptomatic infection may occur is unknown.
The case fatality ratio of monkeypox has historically ranged from 0 to 11 % in the general population and has been higher among young children. In recent times, the case fatality ratio has been around 3-6%.
Diagnosis
The clinical differential diagnosis that must be considered includes other rash illnesses, such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-associated allergies. Lymphadenopathy during the prodromal stage of illness can be a clinical feature to distinguish monkeypox from chickenpox or smallpox.
If monkeypox is suspected, health workers should collect an appropriate sample and have it transported safely to a laboratory with appropriate capability. Confirmation of monkeypox depends on the type and quality of the specimen and the type of laboratory test. Thus, specimens should be packaged and shipped in accordance with national and international requirements. Polymerase chain reaction (PCR) is the preferred laboratory test given its accuracy and sensitivity. For this, optimal diagnostic samples for monkeypox are from skin lesions – the roof or fluid from vesicles and pustules, and dry crusts. Where feasible, biopsy is an option. Lesion samples must be stored in a dry, sterile tube (no viral transport media) and kept cold. PCR blood tests are usually inconclusive because of the short duration of viremia relative to the timing of specimen collection after symptoms begin and should not be routinely collected from patients.
As orthopoxviruses are serologically cross-reactive, antigen and antibody detection methods do not provide monkeypox-specific confirmation. Serology and antigen detection methods are therefore not recommended for diagnosis or case investigation where resources are limited. Additionally, recent or remote vaccination with a vaccinia-based vaccine (e.g. anyone vaccinated before smallpox eradication, or more recently vaccinated due to higher risk such as orthopoxvirus laboratory personnel) might lead to false positive results.
In order to interpret test results, it is critical that patient information be provided with the specimens including: a) date of onset of fever, b) date of onset of rash, c) date of specimen collection, d) current status of the individual (stage of rash), and e) age.
Therapeutics
Clinical care for monkeypox should be fully optimized to alleviate symptoms, manage complications and prevent long-term sequelae. Patients should be offered fluids and food to maintain adequate nutritional status. Secondary bacterial infections should be treated as indicated. An antiviral agent known as tecovirimat that was developed for smallpox was licensed by the European Medical Association (EMA) for monkeypox in 2022 based on data in animal and human studies. It is not yet widely available.
If used for patient care, tecovirimat should ideally be monitored in a clinical research context with prospective data collection.
Vaccination
Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness. Evidence of prior vaccination against smallpox can usually be found as a scar on the upper arm. At the present time, the original (first-generation) smallpox vaccines are no longer available to the general public. Some laboratory personnel or health workers may have received a more recent smallpox vaccine to protect them in the event of exposure to orthopoxviruses in the workplace. A still newer vaccine based on a modified attenuated vaccinia virus (Ankara strain) was approved for the prevention of monkeypox in 2019. This is a two-dose vaccine for which availability remains limited. Smallpox and monkeypox vaccines are developed in formulations based on the vaccinia virus due to cross-protection afforded for the immune response to orthopoxviruses.
Prevention
Raising awareness of risk factors and educating people about the measures they can take to reduce exposure to the virus is the main prevention strategy for monkeypox. Scientific studies are now underway to assess the feasibility and appropriateness of vaccination for the prevention and control of monkeypox. Some countries have, or are developing, policies to offer vaccine to persons who may be at risk such as laboratory personnel, rapid response teams and health workers.
Reducing the risk of human-to-human transmission
Surveillance and rapid identification of new cases is critical for outbreak containment. During human monkeypox outbreaks, close contact with infected persons is the most significant risk factor for monkeypox virus infection. Health workers and household members are at a greater risk of infection. Health workers caring for patients with suspected or confirmed monkeypox virus infection, or handling specimens from them, should implement standard infection control precautions. If possible, persons previously vaccinated against smallpox should be selected to care for the patient.
Samples taken from people and animals with suspected monkeypox virus infection should be handled by trained staff working in suitably equipped laboratories. Patient specimens must be safely prepared for transport with triple packaging in accordance with WHO guidance for transport of infectious substances.
The identification in May 2022 of clusters of monkeypox cases in several non-endemic countries with no direct travel links to an endemic area is atypical. Further investigations are underway to determine the likely source of infection and limit further onward spread. As the source of this outbreak is being investigated, it is important to look at all possible modes of transmission in order to safeguard public health. Further information on this outbreak can be found here
Reducing the risk of zoonotic transmission
Over time, most human infections have resulted from a primary, animal-to-human transmission. Unprotected contact with wild animals, especially those that are sick or dead, including their meat, blood and other parts must be avoided. Additionally, all foods containing animal meat or parts must be thoroughly cooked before eating.
Preventing monkeypox through restrictions on animal trade
Some countries have put in place regulations restricting importation of rodents and non-human primates. Captive animals that are potentially infected with monkeypox should be isolated from other animals and placed into immediate quarantine. Any animals that might have come into contact with an infected animal should be quarantined, handled with standard precautions and observed for monkeypox symptoms for 30 days.
Violence against doctors has become a serious issue in India. But problem is a global one to some extent. The underlying basic reason for the omnipresent malaise is the altered doctor-patient equation globally and growing mistrust in the saviours. The mistrust is propagated by opportunist medical industry, media and law industry for their selfish motives as doctors are shown as front men for the failures. Poor outcomes are projected because of medical errors and mistakes. Every death is thought to be because of negligence rather than a natural complication of the disease. Because of the instigation and poor law enforcement in favour of doctors, the response of lay public to these unfortunate incidents has become extremely erratic and out of proportion. As Governments remain more or less indifferent, and doctors have become punching bags for inept health systems. Law industry has been enormously benefited financially due to medico-legal cases against doctors. Media has sold their news items not by good ground work, but by sensationalizing and mischaracterizing the real basic issues, airing one single incident as generalizations. An atmosphere of mistrust has been generated against medical profession. Administrators and Industry have put themselves on higher pedestrian by selectively projecting the genuine failures and mistakes of doctors. Local goons have blackmailed doctors over genuine complications and the natural deaths occurring in hospitals. There is a little token action by police after routine incident of violence against doctors.
Consequently violence (legal, verbal or physical) against doctor has acquired an epidemic proportion, omnipresent world-wide. As a result, medical business has thrived whereas medical profession is suffocated and art of medicine has been dying a slow gradual death.
But in Israel, doctors seem to be united against this menace and their associations are actively pursuing the issue.
Doctors in Israel to Protest Violence against Medics
The strike was called after family members of a patient who died at a Jerusalem hospital on Monday attacked medical staff and caused significant damage to the intensive care unit after they were informed of his death.
The union said the hospitals and clinics would operate on a weekend schedule for 24 hours on Thursday, offering reduced services.
Staff at public hospitals and clinics will strike on Thursday to protest violence against medics, the doctor’s union announced Tuesday.
The Israel Medical Association, announcing the strike, called for a police presence in every emergency room, and said hospitals and community clinics needed improved security systems. The association also urged a change in legislation so that an attack on medical staff would be viewed with the same severity as an attack on a uniformed police officer. The chairman of the Israel Medical Association, Prof. Zion Hagay, said that Thursday’s strike would be just the start of action taken by the medical establishment if changes were not made to protect workers.
“We have long announced that we will not accept any more incidents of violence in the health system, and it has unfortunately become a real epidemic,” Hagay said at the start of the association’s meeting on Tuesday evening. “The lives of doctors must not be abandoned, and this initial strike is only a warning.”
“As long as the Israeli government does not immediately take the necessary steps to increase the personal security of medical staff, we will not hesitate to increase it.There has been no announcement from the nurses’ union on whether they will be joining the strike.
The strike comes in the wake of violence at the Hadassah Medical Center in Jerusalem after a patient died there on Monday.
An initial investigation found the patient died after taking an overdose, police said, without giving further details.
Relatives of the man arrived at the hospital and were notified of the patient’s death.
After they were given the news, a number of the patient’s relatives broke doors and windows in the unit, damaged the nurse’s station, computers, and equipment, and attacked staff. Two members of staff were lightly injured, requiring medical treatment.
Police said they arrested an East Jerusalem resident in his twenties on suspicion of being involved in the violent clash at the medical center.
Recent months have seen an increased wave of attacks against medical teams and facilities across the country.
In November, nurses at Haifa’s Rambam Medical Center held a strike for several hours in protest of a violent incident in which staff members were beaten and threatened by the family of a dying cancer patient.
Earlier the same month Rambam said it had to forcibly remove dozens of people who gathered outside the facility after a victim of violence was brought there for treatment. According to hospital officials, riot police were called to the scene to prevent the crowd from entering the hospital.
And in Beersheba, four people were hurt and 19 were arrested in a massive brawl outside Soroka Medical Center that included gunfire.
In 2017, in one of the most severe cases in recent years, a man burned 55-year-old nurse Tova Kararo to death at the Holon clinic at which she worked.
Nurses already heldmultiple strikes this year and last year over severe staff shortages during Covid, which resulted in additional state funding.
A doctor and three nurses at Rambam Medical Center in Haifa were assaulted last month by relatives of a cancer patient. Staff were beaten and threatened by the family of the patient, who eventually died, The Times of Israel reported.
Chairwoman of the National Association of Nurses, Ilana Cohen, said at the time that if the government did not take action to fight such violence, “we’ll hold a strike throughout the entire health care system.”
“War has broken out here,” Benny Keller, the head of Rambam’s security, told the Kan public broadcaster Wednesday, according to The Times of Israel.
“Two or three times a week, the hospital turns into a battlefield between warring clans.”
India features a mixed-market health system where chronically low investment in public health systems has led to the proliferation of private care providers. In last few years, a bevy of apps and service aggregators have starting operating brazenly in the country, pushing aggressively for tests and surgeries and delivering drugs, often advertised by Superstars and Celebrities. Patient often zigzags between health providers with unclear referral pathways, and ends up receiving questionable quality of care that may typically neither be safe nor affordable.
Online health aggregators are nothing more than sophisticated commission agents. The medical business model thrives on advertisement and commission. Government rules prevent doctors from advertising or soliciting for surgeries, but these companies live on advertising. Any doctor or hospital can get advertised through these companies. In lieu of some money, anyone can be declared as the best and hence misguidance to the patients cannot be ruled out. The flow of patients to a health care facility can be enhanced by financing the advertisements and not by actual quality work and results in increasing medical business manifold. They do not contribute to much needed medical infrastructure and merely redirect patients to existing facilities. They may at the best be able to become facilitators of the process that attract patients by advertisements and result in skyrocketing cost to patients. Any of the Hospitals and doctors can be projected as the best, who tie up with these online aggregators in lieu of some money. Therefore the misguidance as well as increased costs is the two main drawbacks of such a lucrative arrangement of this new medical business. They charge hospitals and doctors for advertisements ( sending more patients) and patients for channelizing them. In the resulting Zig-Zag path, patients are treated more on the basis of advertisements that are many times aired by our ‘Filmy Superstars’.
The health service aggregators have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against the values and ethics, which healthcare delivery is supposed to be.
The damage caused by the unchecked presence of health service aggregators online is snowballing into a major healthcare crisis which the Union and state governments can ill afford to ignore. Instead of becoming a part of the solution, they have added to the problem by pushing aggressively for tests, surgeries and healthcare services without any medical requirement or prescription.
There are plenty of such apps which advertise about doctor consultations, quick surgeries and direct-to-consumer laboratory tests.
This is where the trouble begins.
In one case, the healthcare aggregator suggested surgery for constipation. The mention of surgery scared the patient, who then approached a hospital where they advised him to improve his diet.
For a kidney stone issue, a healthcare aggregator suggested a laser surgery to a patient without consulting a urologist. The laser surgery was done and the stones got stuck in his pelvi-uretery junction of the kidney-uretery track. He became aware of it two weeks later when he had severe pain in his flank, because of which he walked in to a hospital after the app refused to acknowledge his concerns.
In all of these cases, the apps charged almost double the existing rates for surgeries. For a piles operation, in a general ward, a hospital charges between Rs 50,000-70,000, inclusive of medicines in a patient without co-morbidities. The apps charged between 1.25 lakh to 1.5 lakh, while the national public health insurance scheme Ayushman Bharat rates for such surgeries begin at Rs 10,000.
Ads are being run by online health service aggregators in newspapers and all kind of media.
For removal of kidney stones, hospitals charge Rs 50,000, while the apps charge upwards of Rs 1 lakh, while on the government’s Ayushman Bharat scheme, it is Rs 33,000.
Circumcision is priced at Rs 60,000 by the healthcare aggregators, when hospitals charge Rs 10,000 for a surgery such as this and it is Rs 3,000 for those availing it using Ayushman Bharat.
Their modus operandi? The healthcare aggregators have tie-ups with certain departments in certain hospitals, where after the app does the diagnosis, a doctor on their payroll is sent to the hospital to perform the surgery. After the surgery, the doctor walks away without any care and the patient is left at the hospital until he gains consciousness. At which point, if there is any immediate post-operative care, the nurse concerned does it based on the instructions of the doctor who left. Then the patient checks out.
A fee is paid by these healthcare aggregators to these hospitals for use of the premises for the surgery. In most cases, they approach smaller hospitals where either the top administration turns a blind eye towards these activities. Sometimes, the doctor who performed the surgery may not be on their rolls, but that from a healthcare aggregator.
“The health service aggregators have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against what healthcare delivery is supposed to be,” said Dr Jagadish Hiremath, CEO of ACE Suhas Hospital in Bengaluru.
Government rules prevent hospitals from advertising or soliciting for surgeries, pointed out Hiremath, but these companies live on advertising.
Such health care aggregators are feeding off hospitals and they need to be regulated. “If you remove the advertisements, these companies don’t exist. They have no physical presence except for a few labs or clinics,” he added.
“The problem is getting compounded by these discounts and offers for unnecessary medically and unwarranted testing in the name of wellness/immunity packages. It is a price war to offer maximum number of tests at lowest prices which is totally meaningless,” highlighted Malini Aisola, co-convenor of All India Drug Action Network (AIDAN)
These online health service aggregators have added to issue of illegal pathology laboratories mushrooming all over, pointed out Dr Jagadish Keskar of the Maharashtra Association of Pathologists and Microbiologists
Almost all of them have roped in big names as brand ambassadors – actor Hrithik Roshan, Amitabh Bachchan, singer Guru Randhawa, Rahul Dravid, actor Sonu Sood, actor Rajat Kapoor, Neha Dhupia, Yuvraj Singh and Randeep Hooda to talk about specific health issues and MS Dhoni.
“They have all these famous names as brand ambassadors as if they will perform the surgeries or look at your blood in a lab. This confuses the public, who are already bombarded with too much information,” quipped Hiremath.
Consumer Drug Advocacy group All India Drug Action Network (AIDAN) argued that the direct-to-consumer advertising has to stop completely. “It is too dangerous in healthcare. Aggregators are inducing demand when people are at their most vulnerable due to the pandemic. They are pushing promotions and offers on tests and surgeries and healthcare services without medical assessment or prescription,” said Aisola.
There is a danger particularly with surgeries, contended Aisola, because this could lead to bypassing medical opinions and identifying alternative treatments. When doctors, hospitals and labs associate themselves with the aggregators, there are ethical issues too, she pointed out.
The practice of doctors associating themselves with these healthcare aggregators have alarmed several doctors’ associations. Association of Minimal Access Surgeons of India (AMASI) wrote to its members stating that any member who has made such a contract with healthcare aggregators should disengage immediately failing which a member found to be in contract thereafter may be liable for disciplinary action by regulatory authorities.
They warned that any litigation arising from such practices will not be defended by the association during legal process by way of expert opinion or otherwise.
“It jeopardizes adequate clinical judgment by a trained person regarding need for surgery and decision as to the type of surgery that would be optimum for the particular patient. The apps are made for the sole purpose of making money,” said the AMASI notification.
While violence against doctors should be a concern to everyone, more so for the public, but sadly everyone in society has preferred to take advantage and reap benefit of the situation at the cost of doctors. Government has remained more or less indifferent, whereas people don’t have minimum basic health amenities and doctors have become punching bags for inept health system. Law industry has been enormously benefited financially due to medico-legal cases against doctors. Media and celebrities have sold their shows and news items not by good ground work, but by sensationalizing and mischaracterizing the real basic issues, airing one single incident as generalizations. An atmosphere of mistrust has been generated against medical profession. Administrators and Industry have put themselves on higher pedestrian by selectively projecting the genuine failures and mistakes of doctors. Local goons have blackmailed doctors over genuine complications and the natural deaths occurring in hospitals. There is a little token action by police after routine incident of violence against doctors. Consequently medical business has thrived whereas medical profession is suffocated and art of medicine has been dying a slow gradual death. Actually public needs to be concerned as the society itself is going to suffer in the long run, not realizing that people themselves are responsible for their health problems and not the doctors.
At this stage, Chief Justice of India N V Ramana on Saturday expressed serious concern over rising violence against upright and hardworking doctors and lodging of false cases against them. The show of concern is nice gesture, as problem is clearly evident to all, but merely expressing a concern at this stage is too mild a remedy. When cancer is in late stages and needs a radical surgery, applying an ointment will not work.
Chief Justice of India N V Ramana on Saturday expressed serious concern over rising violence against upright and hardworking doctors and lodging of false cases against them. The CJI said that he would also like to pay his tribute to the unending spirit of doctors, who work tirelessly round the clock for their patients. Doctors are mentors, guides, friends and counsellors. They should always remain active members of society, and solve problems faced by the people,” he said. The CJI said, “I am extremely saddened to witness rising violence against doctors. Several false cases are being lodged against upright and hardworking doctors. They need a better, and more secure, working environment. This is where professional medical associations assume great significance. They have to be proactive in highlighting the demands of doctors.” The CJI also expressed concern about the healthcare system in India and said that more than 70 per cent of the population resides in rural areas where people don’t have minimum basic amenities, forget about the comfort of corporate hospitals.
“Even Primary Health Centres (PHC) are also not properly equipped, if there is a PHC there are no doctors and if there is a doctor, there is no PHC. If both are there, there is no infrastructure. This is the situation in this country and in this scenario this type of affordable technique of detecting cancer through ultrasound at the preliminary stage is very helpful,” the CJI said.
Diarrhoea –loose motions has many causes. Bacterial, protozoal or viruses all can cause diarrhoea. Infections like cholera caused by bactweria Vibrio cholera can be life threatening. Similarly Shigella, another bacteria can be fatal occasionally, if treatment is delayed. Shigellosis is not a very common infection, and it can be treated easily, doctors say. But a delay in getting to a doctor can complicate the effects of the food poisoning. Young children and those with weakened immune systems are more vulnerable.
The Kerala health department on Tuesday (May 3) identified Shigella bacteria as the cause for the food poisoning incident in Kasaragod, which claimed the life of a 16-year-old girl and led to 30-odd others being admitted to hospital.
The presence of the bacteria was confirmed in the blood and faeces of people undergoing treatment after they consumed chicken shawarma from an eatery at Cheruvathur in Kasaragod last week. Police have arrested the owner and staff of the eatery.
While food poisoning is fairly common and can occur in a range of situations, how common is Shigella infection, what are its symptoms, and when should you consult a doctor?
Shigella is a bacterium that belongs to the Enterobacter family — a group of bacteria that reside in the intestine, not all of which cause disease in humans. It mainly affects the intestine and results in diarrhoea, sometimes bloody, stomach pain, and fever.
The infection spreads easily as it takes only “a small number of bacteria to make someone ill”, says the US Centres for Disease Control and Prevention (CDC). It is a food- and water-borne infection, and can happen when someone consumes contaminated food — like in the case from Kerala — unwashed fruit or vegetables.
The disease is easily spread by direct or indirect contact with the excrement of the patient. You can get the infection if you swim or take a bath in contaminated water.
How widespread is Shigella infection?
Shigella outbreaks appear to be exacerbated during pregnancy and in children under five years of age, and in those with weakened immune systems.
There are four types of Shigella bacteria that affect humans — Shigella sonnei, Shigella flexneri, Shigella boydii, and Shigella dysenteriae. The fourth type causes the most severe disease because of the toxin it produces.
But is it common for people to die of the infection?
It is not. Doctors say that the infection does not generally kill, unless the patient has a weak immune system or the pathogen is resistant to the antibiotics that are prescribed. It is a very treatable condition; if a patient reaches hospital on time they can effectively be treated using IV antibiotics.
He said that doctors usually send samples of patients with severe diarrhoea for culture to see what pathogen is causing the symptoms, in order to decide which antibiotics were likely to work the best. In the meanwhile, doctors prescribe antibiotics for the most common infections that cause diarrhoea, and they will generally work for Shigella as well.
The problem though, occurs when the antibiotics do not work because the bacteria are resistant to it.
The problem with Shigella is that it produces a lot of toxins that can affect all other organs. So, if the bacteria continue to proliferate in the body even after giving the antibiotics, it will continue to produce toxins, which can then affect the kidney, cause seizures, lead to multi-organ failure, and shock, and even turn fatal. This, however, does not happen in most cases, the mortality of the infection is less than 1%.
So if you have abdominal discomfort or an upset stomach, at which point should you start worrying?
There is no need to rush to a doctor or a hospital every time you have loose motions. However, if you have loose motions accompanied with high fever, blood in the stool, or constant vomiting such that you cannot keep any fluids down, you must get yourself to a doctor.
A person who has severe diarrhoea — which means 20 or more bowel movements in a day — must see a doctor within a day; a patient with mild diarrhoea may wait for three to four days before going to a doctor.
This is true of any diarrhoea, whether it is because of Shigella or any other reason. It is possible that the student from Kerala who died after eating the shawarma did not get medical treatment in time, he said.
What precautions should you take?
The measures to prevent a Shigella infection are the same as that of any other food- and water-borne infection. Wash your hands thoroughly before and after a meal. Wash your hands properly after a bowel movement. Ensure the water that you drink is clean and the fruits and vegetables are fresh.
“Products such as milk, chicken, and fish can get infected easily and must be kept at a proper temperature. They must also be properly cooked.
A triple burden of malnutrition – under-nutrition, micro-nutrient malnutrition, as well as overweight and obesity – is rising in India. Paradoxically, these forms of poor nutrition often have the same nutritional root cause. More nourishing freshly cooked home-foods or more natural foods are being replaced by cheaper pre-processed packaged alternatives with high levels of salt, sugar and fat that fill the stomach, but do not nourish and in fact promote ill health and disease.
India is the diabetic capital of the world, with the highest concentration of diabetics in any single country. Hypertension closely follows, leading to an overall non-communicable disease (NCD) burden reaching epidemic proportions. A major pathway leading here is the rise of overweight and obesity, as a consequence of poor diets combining with sedentary lifestyles.
Health star ratings are designed by the powerful food industry to mislead the consumer. If the government is serious about the epidemic of obesity and non-communicable diseases, the consumer needs to be cautioned about junk foods through warning’ labels, public health experts gathered at the National Conclave on Sustainable Food Systems’, organized by the Centre for Science and Environment (CSE) in Nimli, Rajasthan, said.
The government should issue a warning’ label on packaged junk foods instead of health star ratings as they are misleading and doing more harm to customers than good, health experts said on Wednesday. Health star rating is a labelling system that grades packaged foods on the scale of one to five stars.
By pushing these, the Food Safety and Standards Authority of India (FSSAI) will give license to glorify junk foods, which is the opposite of what should be done, Director General, CSE, said while leading the expert deliberation on the Need for front-of-pack warning labels on ultra-processed junk foods’. Health star ratings are designed by the powerful food industry to mislead the consumer.
Front-of-pack labelling on packaged foods was first recommended by the FSSAI-led committee formed in 2013. CSE was part of this committee. FSSAI then came up with a draft regulation in 2018, which had strict thresholds limits to know unhealthy levels based on those developed by the WHO for countries like India in the South-East Asia Region.Due to industry pressure, FSSAI came up with another draft in 2019.
The food industry was still not pleased and this draft was repealed.
From January-June 2021, stakeholder consultations were held on the labelling design to be adopted, thresholds to made applicable and nutrients to be displayed.
CSE has documented all delays and dilutions until June 2021, the organisation alleged in a statement.
The latest consultation took place in February during which it was made clear that FSSAI plans to go ahead with the Health Star Rating’.
The sole objective of the stakeholder consultations, which were heavily dominated by the packaged food industry, was to come up with a labelling system, which is industry-friendly, said Khurana, who was part of these consultations, adding that all this while, FSSAI has been insensitive to the information needs of the consumer.
He alleged that the statutory body also ignored the global best practices and evidence around it. Instead, in an orchestrated way, through the scientific panel and commissioned studies, it is now getting ready to adopt a labelling system which is considered least effective and rejected across the world, he said.
Health star ratings are depicted based on an algorithm at the back-end, which is not known to consumers, CSE said, adding that it is only adopted voluntarily in few countries such as Australia and New Zealand and only some food products carry it.
It has been rejected in several other countries as it can mislead the consumer and be easily manipulated by the industry, the CSE said.The proven best practice in front-of-pack labelling is nutrient specific warning’ labels, experts said.They have been simple and effective in discouraging junk food consumption. Several Latin American countries, Canada and Israel have already adopted warning labels.Many other countries are considering them.
Among them, the best known are symbol-based warning labels such as that of Israel. These will be most suitable for India, as it would transcend the literature and language barriers, the CSE said.We have submitted our concerns to FSSAI. It can’t allow a system that will effectively nudge the consumer to make unhealthy choices. It will mislead the consumer because of its design, algorithm and inclusion of positive nutrients in the calculation. It can’t allow relaxed limits and voluntary adoption, Narain said.
Evolution of Medical profession-Extinction of good doctors 