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.

Sajeev.

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

References

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.

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?

Cipla 

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.

Sajeev.

References

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

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?

B...a...m...b...o...o... 

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 

 Sajeev.

Reference

1. Wikipedia for some textual details.

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

Sajeev.

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.

References

1. Wikipeida