Thursday, August 22, 2013

Required: Reliable TB diagnosis in private sector

There are diseases against which we humans are helpless. In many cases, only thing we can do is to prolong the inevitable death.... At the same time there are diseases – perilous ones, killing hundreds of thousands every year – we can get rid of with early diagnosis and proper medication.

If someone is dying because of illness in first category, we are completely helpless. What about people dying because of diseases in second category?

This question remembered me about a story I studied in school days. In Malayattoor Ramakrishnan’s semi-auto biographical novel – Verukal (Roots) - there is a character called Ramu who died because of Rabies. What makes this death different is, Ramu was about to see the doctor for diagnosis after bitten by a mad dog; on the way one quack advised him to go for blood testing. Blood test results were negative and he happily went back to home. After a number of weeks he started showing the symptoms of rabis and consulted a doctor. Doctor told them that, Rabies diagnosis is usually made from saliva, urine etc not blood. Had they know it earlier, Ramu might have lived for many more years.

Accurate diagnosis is the first battle against the war on any disease. If we can’t do it properly, then any amount of excellence in other fields won’t help the patient.

This rule is not different for TB too.

On 7th June 2012, GoI banned manufacture, sale, import, distribution of serology based kits (conducted on blood samples) for TB diagnosis. Problem with serology is its unreliable results. It often gives false positive and false negative results. According to a 2012 TOI report, “15 lakh TB serological tests are estimated to be done in India, with patients spending an estimated Rs 75 crore ($15 million) annually on such tests.”

By banning GoI did a fine job. However, another problem popped up. With serology based tests are out of scope, private labs turned in to Interferon Gamma Release Assays (IGRAs) for detecting TB. Problem with IGRA is, this test is for latent TB, not for active one.

What time demands is a reliable test for active TB in private sector as well.

In public sector GoI, under Revised National TB Control Programme (RNTCP), provides TB diagnosis and treatment free of cost to all patients. However in Indian medical sector government is not an all pervading force.

According to a Guardian report, “More than 70% of Indians seek first contact medical care in the private sector, and more than 50% of all TB patients in India are treated in the private sector... patients often begin seeking advice in the informal private sector (chemists and unqualified practitioners), then seek care from qualified practitioners, and eventually end up in the public sector for free treatment... while they do this, they continue to transmit the infection to others”

In such a situation, if we don’t have a reliable process for diagnosing TB in private sector...?

Delayed diagnosis will not only make it an epidemic, drug resistant but fatal as well.

Guardian report further points out that,

“TB testing practices in the private sector are completely different from those in the public sector. All over the world, sputum is the most important sample for diagnosis of lung TB... includes the traditional sputum smear test...Although not highly accurate, this test is still useful (and cheap) and should be more widely used in the private sector... WHO endorsed a new, rapid, two-hour DNA test called GeneXpert, which can diagnose TB with great accuracy and can also detect those with drug-resistance... another DNA test called Line Probe Assay... detect drug-resistance with high accuracy... liquid culture... is considered the gold standard for TB diagnosis and is the only test that can detect resistance to all major TB drugs.

DNA tests are expensive (in public sector it is subsidised to great extent) in private sector. Considering the importance of early diagnosis of TB and possibilities of transmission of diseases through air, it is very much critical to make an early as well as accurate diagnosis. Government can remove import duties on diagnostic kits and offer subsidies to private sector, if required to reduce the costs.

What time demands is right diagnosis in early stage.


For more information on TB read my earlier article – “TB - The Killer Disease and India”


1. Ban on inaccurate blood tests to diagnose TB - TOI
2. Experts question new TB test, say could lead to drug resistance - IE
3. Accurate TB tests needed in the private sector - Guardian
4. TB Facts

Opposing the statement or opposing the right to stat it?

"A Point of View: Why it can be good to give in toyour enemies" by Roger Scruton is an interesting article to read, especially in current Indian circumstances. Arguments presented in this article is equally applicable to Indians, eventhough Scruton focus on events in UK and Egypt.

Evelyn Beatrice Hall (aka S.G. Tallentyre) once said, "I disapprove of what you say, but I will defend to the death your right to say it". Now-a-days many people are not only opposing the idea, but the right to present that as well.

Wednesday, August 21, 2013

Analysis of Yusuf Hamied’s statement on obligatory licensing

"...I am in favour of obligatory licensing where we don't mind paying royalties to the patent holder but at least Indian companies should be able to manufacture and market essential drugs to make them more accessible in the Third World...

...There is big obsolescence in the drugs industry and new drugs are coming up all the time. But we Indians are impotent because we can't manufacture and market them...

...We don't want to encroach on the regulated developed world markets... Just leave the developing world to us so that we don't deprive millions and ensure access to affordable drugs" 

- Yusuf Hamied (Former MD and currently mentor of Cipla) said.

Statements are high on ideals. After all who can oppose obligatory licensing, for medicines in the name poor, without feeling an element of guilt?

Let’s see how far we can agree with Hamied.

Compulsory licensing

GOI have options (and exercised as well) to go for compulsory licensing in life saving drugs. This helps many Indian generic firms to manufacture those drugs and sell it (at cheap rates). Common man often see low prices; missing out the big picture of mammoth amounts invested by multinational firms in R & D. Out of a good number of formulas they tried, may a couple of them reach clinical trial. Lesser numbers will see light at end of the tunnel – reaching market.

This is a long drawn process – investing in research, affording costly failures, lengthy trails in animals, extensive clinical trials, approval process etc. Often it’s not the manufacturing expense which makes these drugs costly but accumulated investments over life cycle. For this invention, companies will get patent protection for next 20 years or so; once that period is over, others can produce those medicines. In other words, generic companies are experimenting with something which is already proved.

Why companies like Cipla are not investing heavily in fundamental R & D and apply for patents, just like Pfizer, J & J, Roche, GlaxoSmithKline, Sanofi, Abbott or Novartis? After all they are not improvised of funds.

Many of these medicines and ideas are coming straight from public institutions funded by public money. Why Cipla can't make substantial contributions (do they?) to public institutions - universities etc - and come up with new things; instead of solely concentrating on already established formulas?

Let’s take a look at his second point, "we Indians are impotent...".

We are not. Under favourable conditions, with enough funding and courage to fail, Indians too can invent new formulas or medicines. Traditional Indian medical system called Ayurveda is a case in point. Most, if not all, Ayurvedic combinations are invented by Indians. What about Ashtanga Sangraha, Ashtanga Hridayam Samhita, Ashtangahridaya, Charaka and Sushutasamhitas?

It’s a fact, we lost track in between. Apart from some names like Upendra Nath Brahmachari (who invented 'Urea Stibamine' for the treatment of Kala Azar - aka 'Visceral leishmaniasis' - way back in 1929), vaccine against rotavirus called RotaVac (recent one) we may not have much to claim in modern era. Are we really impotent by nature? or little encouragement, scarce funding, inability to digest failures, more interested in copying formulas etc made as impotent?

Leaving developing world to generic makers? 

Good idea. In short you concentrate and sell your medicines in US, EU, Japan and make money. We will sell the copies in rest of the world. Will we enter in to the generic markets of developed world? Yes, we will do that as well.

I am leaving two questions for you to answer,

I can understand if some governments are going for compulsory licensing for a number of critical life saving drugs. After all life is precious, no government can let the people die just because they can’t afford the medical bills. But is it ok for Cipla’s mentor to say that?

Will any one stop Cipla, if they are inventing a medicine for critical illness and market it at affordable prices?


This company is world's largest manufacturer of antiretroviral drugs. Around two fifth of HIV/AIDs patients may get the benefits of Cipla drugs at affordable cost. Cipla also have an important tablet, triomune - fixed dose combination of three Anti Retro Virals (Lamivudine, stavudine and Nevirapine) - to its portfolio.

It may not be possible for developed wold contries to manufacture this combination as patents for Lamivudine, stavudine and Nevirapine are with three different companies. Lamivudine by GlaxoSmithKline, stavudine - patent expired for this one in US in 2008, Nevirapine by Boehringer Ingelheim Pharmaceuticals.



1. Cipla Firsts - Cipla
2. Cipla chief calls for 'obligatory' drugs licenses - ET
3. Results of the ROTAVAC Rotavirus Vaccine Study in India - NIH

Tuesday, August 20, 2013

LalBagh - Through my lens, on an Independence Day

My plan was to spend that entire Thursday - India's 67th Independence day - on banks of Sharavati River near Jog Falls. However, due to rains and some other reasons I had to drop the plan and spend that day in Bangalore's famous LalBagh gardens.

Main gate of LalBagh gardens. Known as 'Red Garden' in English, LalBagh botanical garden in southern Bangalore was originally commissioned by Hyder Ali. Later his son Tipu Sultan finished the work. This Garden also contains a lake of same name.

Yellow......... Welcoming people coming to the garden

Lal Bagh Gardens are based on the designs famous Mughal Gardens

A girl looking towards the people entering to the garden

For independence day entry fees was 50 INR, including flower show. No separate charge for Cameras

Me too. There were so many camera and so many clicks. A from the Glass House 

Along with the flow of time, I am also changing. Some deep sighs from flower

Colourful India - There were many verity of flowers, multi-coloured leaves etc

Police need to learn a lot about crowd management. I agree the queue was long, but what is the point of going there if I can't spend some time looking towards it? They were blowing whistle non-stop indicating the crowd to move forward. 

Glass House in the garden was modeled on London's Crystal Palace. This was the main attraction on 67th independence day

Am I looking good?

Crowd in front of glass house. Light rains were there when I entered the garden

This may be a moment of celebration for you. But I have to sell this balloon to get something to eat. RTE is yet to reach this kid.

One for me as well.. People from all areas of life came to Bangalore city to celebrate 67th I-Day

There were many kids selling eatable items in the garden. Many street vendors came with their full family to fully utilize the tourist booms.. various snacks, fruits, juices and more.

Touching the sky...

Lake - Calm, Quiet and Beautiful

How is mu colour? Do you like?


People are trying various positions to get a good picture in camera.

Romance is evergreen, ageless, faceless and infinite. 

Pulling it down

In the middle I grow

Kemba Gowda's - this feudatory ruler under Vijayanagar is considered as the founder of Bangalore - statue 


1. Wikipedia for some textual details.

Monday, August 12, 2013

Guruvayur - Through My Lens

Selected photos from Guruvayur Temple

Melpathur Auditorium, Eastern Gate, Guruvayur Temple. Kids used to have their first public performance in this auditorium, in front of Lord SriKrishna 

Artists performing dance. Devotees used to spent night here watching dance and then woke up around 3 or 4 in the morning to stand in the queue for viewing Vakacharthu (morning pooja)

Expressions... in dance forms expressions are critical for viewer to understand and enjoy the story.

Devotees walking to and from Eastern Gate, Private bus stand and Railway station are close to eastern gate whereas Kerala RTC bus stand is close to Western Gate. From here you can reach Parthasarathi Temple and Venkatachalapati Temple as well

Audience view dance performance. I believe one need to have some understanding of a particular art form to enjoy it fully. By the way, I am also spending time on classical art for the first time. It’s good.

On stage – Live...

People watching dance performance on the stage

Devotees standing in front of Western Gate. From Here Mammiyur temple is in walking distance.

Temple pond. Now this pool is closed, one can use the pond close to Eastern gate for taking a bath.

Guruvayur is one of the most crowded temples not only in Kerala but also in India as well. You can always see a long queue for almost all things. By the way there is no special queue here

Eastern gate and flag post

There are a lot of store selling metallic items, photos, cloths, books etc around the temple. Guruvayur has one of the toughest rules for wearing dress (for both men and women) inside the temple. On top of that mobile phones, camera, are strictly prohibited inside the temple.

People standing in the queue for going inside the temple. This is a long queue where one may have to stand hours before going inside.

Another group performing classical music

Elaphants – Elaphants are very much part of the temple. More than 70 elephants are already there in Guruvayur’s stable (aka ‘Aanakotta’). Temple also has an athletic tournament for elephants – annual race

Giving some bathing lessons?

Elephants participate in festivals, Shiveli etc. During ‘shiveli’, a Priest holding Lord’s idol sitting on top of an elephant do rounds across the sanctum

Devotees walking through the sides of the temple. Even though this temple is known as SriKrishna temple, presiding deity in Sanctum sanctorum is Vishnu

How to reach Guruvayur?

By Road
You can reach Guruvayoor from Thrissur, Palakkad, Mannarkkad, Perinthalmanna, Pattambi, Kochi, Calicut, Kunnankulam etc by bus. From Guruvayoor Kerala RTC stand you can get buses to Pollachi, Madurai, Bangalore etc as well.

By Rail
Guruvayur Railway Station lies in Thrissur-Guruvayur Section. Two passenger trains from Guruvayur Railway Station to Ernakulum Jn; two others to Thrissur Railway Station every day. Overnight express train to Chennai Egmore via Ernakulum Junction, Thiruvananthapuram, Madurai, Trichy every day. Government is planning to start one more train service to this station from Southern Kerala.
Thrissur Railway Station is the nearest major station. From here you can get many trains for other major cities of India.

By Air
Cochin International Airport is the nearest airport. Calicut International Airport can also serve Guruvayur very well.


1. Wikipeida

Thursday, August 8, 2013

Parvez Rasool & Playing eleven: Why this hue and cry?

For last couple of days I was thinking about Parvez Rasool - lower middle order batsman and off spinner - hailing from Kashmir. He was selected to Indian team for recent Zimbabwe tour; but didn’t make in to playing eleven.

There may be many others who suffered similar fate. What made this young cricketer’s case different is the blatant criticism from various fronts.

Omar Abdullah tweeted "Did you really have to take him all the way to Zimbabwe to demoralise him?? Wouldn't it have been cheaper to just do it at home???".”Really disappointed that Parvez Rasool hasn't been given a game in Zimbabwe. Come on BCCI give the young man a chance to prove himself."

From Shashi Taroor- "Greatly disappointed that Parvez Rasool not playing today. Bizarre selection. Could easily have rested Jadeja&Raina for Rasool&Rahane". "What's the point leading 4-0 if you can't give every member of the touring team a chance to play at least once by reshuffling the deck now?"

Their primary arguments is - India won first four matches in the ODI series so they could have played Parvez in the last one (India won last match as well).  Many others were also commenting on similar lines. Several others took it to the next level and made it Kashmir issue by giving political overtones.

Why people are taking this as a political issue? It is good to hear that a person from Kashmir became part of Team India. In last Ranji season he scored 594 runs and took 33 wickets. Selectors took him mainly because of this performance and 7 wickets in an innings against Australian team visiting India.

But, who should be there in playing eleven is the discretion of Captain and team management, isn’t it? Shall we force them to take him in because he is from Kashmir? They may have a number of reasons as well - feel good factor, spreading sporting spirit across J&K, consideration for J&K etc. But then the same rules are applicable for people from insurgent hit NE India, Maoist hit Central -East India etc. What about people from SC/ST/OBC/OEC etc? Shall we compel BCCI and team captain to take them to playing eleven because they are so and so or because they are from so and so places?

You can say “wasn't it good to include him at least in the last match?” Probably yes. But again, it's captain’s decision. Team selection should be based on the strategy of team management and captain. It should not have anything to do with Parvez being from Kashmir or not.

In the absence of any discrimination he suffered because he from so and so place there is no need to make this hue and cry, especially by politicians. He played well in Ranji, he made it to Team India as well – without any political games. If he is going well in the coming months as well then there is no doubt that he will become part of playing eleven.

Wishing him all the best, may he be able to reach the top echelons of Indian sports.



Monday, August 5, 2013

Mid-Day Meals - Master cooks and edible foods

Shashi Tharoor, Minister of State, Human Resource Development today said, on the request of the MHRD, the Ministry of Tourism has agreed to provide training to selected cook-cum-helpers as master trainers through Hotel Management Institutes and the Food Craft Institutes (FCIs) - Mid-daymeals to be prepared by master cooks – BS

This may make the food tastier. However, the million dollar question is - How government will ensure the quality and edibility of food distributed through MDM (mid-day mean) system?

Friday, August 2, 2013

Vellore – City of 1806 Uprising, CMC and VIT

Jalakandeshwara Temple - Outer entrance
I was tired of wasting weekends by watching television programs. Western Ghats areas were off the limits because of heavy rains; Krishna river area was also under the threat of flooding; not enough leaves were available for North/ West Indian destinations. What to do? Where to go? Unexpectedly, I got an old map from cupboard, along with a paper listing out the attractions in Vellore. At an earlier instance I cancelled the trip due to some personal reasons, so why not revive the plan now?

Vellore – History

Vellore, HQ of district with the same name is located on the banks of River Palar in the Southern Indian state of Tamil Nadu. This city at various times in history came under the rule of Pallavas (of Kanchipuram), Medieval Cholas, Later Cholas, Vijayanagar, Rashtrakutas, Carnatic and British before finally joining with Indian Union.

Vellore Fort was built during the time of Chinna Bomma Nayak (subordinate of Vijayanagar). In 17th century Vellore came under Nawabs. After Nawabs, administration passed through various hands before finally settled under British in 19th century. During British rule Tipu's family and Vikrama Rajasinha (last king of SriLanka) were held as prisoners here.

Vellore fort also witnessed the massacre of Vijayanagara royal family of Emperor Sriranga Raya; and the uprising against British in 1806 (51 years before the first war of Indian independence)

Sri Lakshmi Temple (aka Golden Temple) constructed using about 1500km of with an estimated expenditure of 300 crores is located around 8km away from Vellore bus terminus.

Towards Vellore - Hosur, Krishnagiri, Ambur and then Vellore

My first plan to go in a bus leaving Bangalore on Friday night. Later it became clear that, going in night may not be a viable plan. Vellore is around 210 plus hours from Bangalore – neither far enough nor close enough. So finally I decided to go in Saturday morning.

Who wants to wake up early in the morning that too in a holiday? So am I. Finally around five in the morning I left the room and boarded a bus to Shantinagar.

In Bangalore, Tamil Nadu government operate buses going to Chennai and rest of Tamil Nadu from ShantiNagar, Andra Pradesh State RTC also operates from here, Kerala RTC operates from Mysore Satellite Stand. Private buses operate from various parts of city like Majestic, Madivala, Kalasiplalaya, Shantinagar etc. Karnataka RTC operates mainly from Majestic, Shantinagar etc.

First bus I saw in the line was going to Chennai. Vellore is located on Chennai route. So I checked with conductor about Vellore (stress on‘ll’). He replied, “Velur?” Hmm... I am not sure whether ‘Vellore’ (no stress on ‘ll’) is same as Vellore (emphasis on ‘ll’). So I moved towards the end, searching for another official. Finally I found one and he resolved my problem – Both names designate the same city. So I went back to the first bus and sat comfortably on a side seat in second row. Wow!!! no one else were there in the bus!!! When it would start? Would they be ready to with only one passenger? After a while six more adults and two kids came in and we started our journey at 6.40am.

Bus was going too slow, as if its movement was hurting the bitumen coated NH7. Familiar sceneries repeated on both sides; in between I slept as well. In between when I woke up we were entering Hosur bus stand. We picked up some 10 – 15 people from here and proceeded towards Vellore. Krishnagiri, Ambur and finally Vellore. We traversed around 210+ kilometre in four and half hours!!!

After having dosha (aka Dosa) and tea from a hotel located inside the stand, I walked towards main road in search of a bus to Vellore Fort. By the way, both Dosha and tea were good (so as the cost). Boarded No.1 bus and reached fort with in some 15 minutes.

Jalakandeshwara Temple

Inside the mandapa
Crossed fort entrance and walked towards Jalakandeshwara Temple. There are a couple of playgrounds on the other side. Kids were playing cricket there. Madapa made of stone (with elaborate engravings of various episodes from puranas) was standing on the left side, just after the gate of out temple wall.

I spent approximately half an hour there. Next destination was actual temple. When I was about to walk towards inner temple gate, one guard closed half door. He made an elaborate expression, which in simple words can be translated to “why you wasted your time outside?” Subsequently, he went inside and started blowing his whistle asking people to go outside. After coming this much distance I was not ready to go back without entering inside the temple. Hence I walked in using the other half of that big gate and took a quick look. Where is the sanctum? Well it was on another side. I quickly walked towards sanctum and got a quick look of deity, from a distance.

Vellore Fort 

Fort wall and Moat

A police training camp is occupying a substantial portion of the fort. After taking a round, I reached in front of ASI Museum - nothing much to see, in fact nobody was there in the premises other than person-in-charge.

After watching the fort moat for a while I took the stairs to reach the top of fort’s outer wall. Next one hour went in that way. Many couples were sitting there, in shades, enjoying their private moments with partners. A little bit further, two horses were viewing the city arteries through holes in the walls. 3-4 eagles were drawing big circles in the sky.

View of Vellore City

It’s the time to move on. There was a big part located outside the fort walls. I walked in diagonal direction reached the other end. Roads were busy; buses were going in both directions; People were eagerly standing in the bus stop; at a distance, in fort, Indian flag was flying high.  

I sat on the shades of a big tree for some time. A mid-aged person, probably in his early fifties, was sitting some 10 metres away was constantly looking towards me. In between he was walking here and there before finally coming back to the shades.

Vellore City

Sky is not the limit
Another 15 minutes. Finally I told bye to Vellore fort and started walking towards the bus stop. That guy was also following me, at a distance. This time, he was looking towards me and talking to somebody else on phone. Suddenly a bus came and I boarded the same. Well, that guy too is walking towards the bus (but he didn’t get in). Was he checking the destination of the bus? Is he planning to follow the bus in another vehicle? I don’t know.

After spending some more time in the city, I went to new bus stand and boarded a direct bus to Bangalore. Without describing the road side sceneries of Krishnagiri – Bangalore stretch in NH 07 this travelogue won’t be complete. Here, in every 100 metres there is a granite quarry. I don’t know how long those granite hills will last. Will consumers appetite for granite, last so long that, there may not be any more hills at all? Probably yes.

Before midnight I reached Bangalore.


How to reach Vellore

By Road,

Vellore is connected by road with mojor cities like Chennai, Coimbatore, Bangalore, Tirupathi, Salem, Chittoor, Hosur, Nagercoil, Cuddalore, Kurnool, Trichy, Thiruvannamalai, Kanyakumari, Madurai, Tirunelveli, Kanchipuram, Dharmapuri, Erode, Tirupur, Palakkad, Krishnagiri etc. City has two bus terminals: the Town Bus Terminus (opposite the fort and near CMC Hospital) and the Central Bus Terminus (Near Green Circle).

By Rail,

Vellore has three main railway stations - Katpadi junction, Vellore Cantonment and Vellore Town. Vellore-Katpadi Junction, 5 km north of CMC hospital is a major one Chennai-Bangalore line running to Chennai, Bangalore, Tirupati and Trichy. Direct rail links are available to Vijayawada, Tirupati, Bhubaneswar, Nagpur, Bangalore, Bhopal, Mumbai, Mangalore, Tiruchchirapalli, Bilaspur, Korba, Patna, Ernakulam, Trivandrum, Kanyakumari, Shirdi, Kanpur, Gaya, Dhanbad, Jammu Tawi, Madurai, Bhilai, Gwalior, Chennai, Howrah, New Delhi, Coimbatore, Guwahati, Thiruvananthapuram, Kozhikode, Jaipur etc. Vellore Cantonment is connected to Tirupati, Chennai, Arakonnam etc.

By Air,

City has an airport near Abdullapuram but not of much use. Nearest international airports are Chennai (130 km) and Bengalore(200 km); the nearest domestic airport is Tirupati Airport (100 km).

Standing on the Fort wall