Healthcare in India Glorious past-Promising

future

Dr Indu Agarwal, M.D. Observer, Pathology department

HISTORY OF MEDICINE IN INDIA

India is one of the cradles of first human civilisation, where earliest developments took place, which includes development of early medicine.

HISTORY OF MEDICINE IN INDIA

• Indian cultural history dates back to more than 4,500 years.

• The first Indian text dealing with medicine, the Atharvaveda.

• The Atharvaveda contains prescriptions of herbs for various ailments.

• The use of herbs to treat ailments later took a large part of Ayurveda, the ancient vedic text dedicated exclusively to medicine. Ayu=life, veda=knowledge: the knowledge of life.

HISTORY OF MEDICINE IN INDIA • Charaka, born 300 BC was one of the

principal contributors to the ancient art and science of Ayurveda.

• Father of Indian Medicine. • Books: Charaka Samhita

HISTORY OF MEDICINE IN INDIA • Sushruta, born 600 BC ancient surgeon • Known for his pioneering operations and

techniques. • Some of his groundbreaking procedures include

rhinoplasty, • Removal of dead fetus • Lithotomy. • Anaesthesia through herbs for his procedures. • Father of Indian Surgery. • Books: Sushrut Samhita

EARLY UNIVERSITIES

TAKSHASHILA, Founded around 5th century BCE

EARLY UNIVERSITIES

NALANDA, 5th century AD to 1197 AD.

MODERN MEDICAL UNIVERSITIES

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

• Established in 1956 and operates autonomously

under the Ministry of Health and Family Welfare. • It has been consistently ranked the top medical

college in India in terms of medical education. • Globally recognised as an institute providing

high quality but highly affordable medical care to millions of people.

Other Prestigious Medical Institutes

• CMC Vellore • Armed Forces Medical College, Pune • JIPMER, Pondicherry • PGIMER, Chandigarh • Maulana Azad Medical College, New

Delhi.

MEDICAL EDUCATION IN INDIA

• Statutory body with the responsibility of establishing and maintaining standards of medical education

• It registers doctors to practice in India

• Has the authority to recognize and derecognize any institution for any of its specialities if norms are not followed.

MEDICAL COUNCIL OF INDIA

MEDICAL EDUCATION IN INDIA

• 381 colleges recognized (MCI) for MBBS. •31,000 medical students every year. • Post graduate courses/ Residency offered in all medical specialties. • 129 Medical Colleges offering courses in M.D. Pathology in Govt funded colleges. • Admitting around 568 Pathology residency seats recognized by MCI, (another 195 seats under process of recognition).

SELECTION OF POST-GRADUATE STUDENTS.

• Students for Postgraduate medical courses are selected on the basis of their academic merit.

• (i) As determined by the competitive test conducted by the State Government or a centralized test held at the national level; or

• (ii) On the basis of the individual cumulative performance in the Medical School

• Combination of (i) and (ii)

PATHOLOGY RESIDENCY PROGRAMME

• Three year programme - full time residents •Compulsory rotations in all subspecialities. • Post Graduate students are required to maintain a record (log) book of the duties. • Participation in the teaching and training programme of undergraduate students and interns.

COMPONENTS OF THE PATHOLOGY RESIDENCY CURRICULUM

Pathology Postgraduate curriculum includes both Anatomic and Clinical pathology.

ROTATIONS • Hematology -- Clinical Pathology

– Coagulation analyser – Cytochemistry & Immunocytochemistry – Testing for Hemoglobinopathies : by the Variant HPLC machine

• Surgical Pathology

– Histochemistry and immunohistochemistry (IHC) • Renal pathology • Gastro-intestinal pathology • Head & Neck Pathology • Gynaecologic pathology • Cytopathology • Frozen section facility • Autopsy

• These are extensive training program including lectures, tutorials, journal clubs, seminars, group discussions, and pathology slide discussions, etc

PATHOLOGY RESIDENCY PROGRAMME

I Histopathology 2007 2008 2009 Surgical Pathology 7,437 7,916 8,507 Post Mortem 119 135 170 Neonatal Autopsy 06 07 05

II Cytopathology

Aspiration 2,098 2,233 2,110 Exfoliative Cytology 1,315 1,488 1,450 Pap Smears 1,892 2,069 2,371

III Haematology

Routine Haemogram 1,84,085 2,02,907 3,42,956 Bone Marrow Aspiration/Biopsy 406 392 399 Coagulation 51,564 86,299 1,09,878 Special Haematology 3900 4826 6804

IV Clinical Pathology

Urine R/E 52,758 52,863 92,137 Semen 228 232 322 CSF & Body Fluids 1,931 2,132 3,360

PROFILE OF A TYPICAL GOVT. FUNDED TEACHING INSTITTUTE

http://gmch.nic.in/pathology.htm

• To evaluate and certify candidate’s level of knowledge, skill and competence at the end of the training.

EXAMINATIONS

EXAMINATIONS THEORY PRACTICAL

MINIMUM PASSING 50%

Post Doctoral Certificate Courses (1 year) 1. ONCOSURGICAL PATHOLOGY • Gujarat Cancer and Research Institute, Ahmedabad. • P.D. Hinduja Hospital, Mumbai • Doctors' Diagnostics Center & Research Institute, Trivandrum

2. LABORATORY MEDICINE • Safdarjung Hospital, New Delhi • Anand Institute of Lab Medicine, Bangalore • Doctor's Diagnostic center, Thiruvanthpuram 3. RENAL AND TRANSPLANT PATHOLOGY • Institute of Kidney Pathology, Disease and Transplantation, Ahmedabad • Post Graduate Institute Of Medical Education &Research, Chandigarh • Histopathology Department, Sanjay gandhi Post Graduate Institute Of Medical Education &Research, Lucknow

4. NEUROPATHOLOGY • PGIMER, Chandigarh • All India Institute of Medical Sciences, New Delhi

5. DERMATOPATHOLGY • Department of Pathology, AIIMS, New Delhi

6. CARDIOVASCULAR AND PULMONARY PATHOLOGY • Seth G.S. Medical College and K.E.M. Hospital Mumbai 7. AUTOPSY PATHOLOGY • Grant Medical College, Mumbai 8. GASTROINTESTINAL AND HEPATIC PATHOLOGY • TN Medical College, Mumbai 9. HEMATOPATHOLOGY • Maulana Azad Medical College, New Delhi • All India Institute of Medical Sciences, New Delhi 10. OPHTHALMIC PATHOLOGY • Department of Pathology LVPEI., from Jan 2010

Post Doctoral Certificate Courses (1 year)

FURTHER TRAINING

• Fellowship (2 years) in Tata Memorial Hospital, Mumbai – Surgical Pathology – Hematology

• Senior Residency (3 years) in most academic institues.

PATHOLOGY SOCIETIES • Indian Association of Pathologists and

Microbiologists (IAPM) • International Academy of Pathology-Indian

division (IAPID). • Indian Society of Haematology and Blood

Transfusion (ISHBT). • The Indian Association of Practising Pathologists

(IAPP). • Indian Society of Colposcopy and Cervical

Pathology (ISCCP).

• Indian Journal of Pathology and Microbiology (Indian J Pathol Microbiol)

• Indian Journal of Hematology and Blood Transfusion

• Indian Journal of Clinical Pathology. • Indian Journal of Forensic Medicine and

Pathology.

PATHOLOGY JOURNALS IN INDIA

HEALTHCARE INDUSTRY IN INDIA

HEALTHCARE INDUSTRY IN INDIA

Indian Healthcare system

PUBLIC PRIVATE

• The Private Sector

– Offer high level care of global standards – Indian hospital services sector generated revenue

over 45 billion US dollars in 2012 and is this figure is rapidly rising-'booming'

– The cost of medical care is very reasonable compared to other countries

– India is the world's 3rd largest producer of generic drugs

– These medicines are made available at a very low costs.

HEALTHCARE INDUSTRY IN INDIA

Subcenters • First contact between community and healthcare • One ANM and one male health worker • Skills to cover •essential health needs

Primary health centers • First contact between village community and MO • 14 paramedical staff • Referral center for 6 SCs. • Integrated curative and preventive healthcare.

Community Health Centers • Four specialists - surgeon, physician, gyne and ped + paramed • 30 inpatient beds • Diagnostic facilities • Referral center for 4 PHCs.

RURAL HEALTH CARE SYSTEM

Sub-District Hosp • Take referral cases from SCs, PHCs and CHCs • Provide emergency neonatal and obs care. District Hospitals

• Secondary referral level resp for a district • Comprehensive secondary health care

THE COMMONWEALTH OF BAHAMAS AND

ITS HEALTHCARE SYSTEM

• The Bahamas have a total population of 347,176.

• Birth rate: 17.81/1000 • IMR: 23.21 deaths/1,000 live births. • Life expectancy at birth of 69.87 years • Bahamas territory encompasses 180,000 square

miles of ocean space. • In terms of GDP per capita it is one of the richest

countries in the Americas.

THE BAHAMAS

CIA world fact book

PUBLIC HOSPITALS AUTHORITY

Referral centers (Hospitals) •Princess Margaret Hospital, Nassau •Rand Memorial Hospital Freeport

Sandilands Rehab Center

Emergency Medical services

Family Medicine Clinics

Population of

347,176

• Princess Margaret Hospital is a non-profit public funded facility built in 1952.

• PMH is a comprehensive Healthcare system, providing primary, secondary and tertiary health services. It is the premier referral centre in the country.

• The institution is continuing to develop as an Academic / Teaching Hospital.

THE PRINCESS MARGARET HOSPITAL

INTERESTING CASE

Interesting Case History • 36 YO immunocompetent female with high grade fever

for 3 weeks • Fatigue and weight loss • Night sweats • Signs: O/E: Splenomegaly Lab investigations: • Anemia (Hb: 10.3 gm/dL) • Pancytopenia (WBC: 2100/micL, platelets: 85,000/micL) • ESR: 70mm/hr • Biochemical tests normal except eleveted serum globulin

4.2 g/dL.

Blood Smear

• Peripheral blood smear showed decreased cell counts.

• No immature or atypical cells were seen.

MGG 100X Parasites and Vectors 1 (1): 25

MGG, 100X Centers for Disease Control and Prevention's Public Health Image Library (PHIL)

Leishmaniasis

• Leishmaniasis is caused by protozoan parasites belonging to the genus Leishmania. The parasites are transmitted by the bite of a tiny (2–3 mm) insect vector, the phlebotomine sandfly.

• 1-2 million new cases per year worldwide. • Epidemics occur periodically in tropical regions

of world; increasing infections in HIV+ patients.

GEOGRAPHICAL DISTRIBUTION OF DISEASE

Visceral leishmaniasis

Cutaneous leishmaniasis - new world Cutaneous leishmaniasis - old world

LIFE CYCLE OF Leishmania donovani

• Cutaneous: (Localised and Diffuse): Most common form, Skin sores or ulcers usually form on exposed areas, such as the

face, arms and legs. These usually heal within a few months, leaving scars.

• Mucocutaneous : The lesions can partially or totally destroy the

mucous membranes of the nose, mouth and throat cavities and surrounding tissues.

• Visceral leishmaniasis: Most serious form, aka kala azar, is characterized by high fever, substantial weight

loss, enlargement of the spleen and liver, and anaemia. If left untreated, the disease can have a fatality rate as high as 100% within two years.

TYPES OF DISEASE

• The diagnosis can be confirmed by: – Microscopic examination – Culture and molecular analysis (mostly PCR assays)

of tissue aspirates (cutaneous and visceral leishmaniasis)

– Biopsy smears, scrapings, or slit skin smears (cutaneous leishmaniasis)

– Serology (visceral leishmaniasis) – Leishmanin (Montenegro) skin test (cutaneous

leishmaniasis).

DIAGNOSIS

Bone marrow aspirate, MGG, 100X Centers for Disease Control and Prevention's Public Health Image Library (PHIL)

Bone marrow core biopsy, H&E stained, 40x magnification

Skin lesion, H&E stained, 40x magnification

Am J Trop Med Hyg 2011

Skin lesion, H&E stained, 40 X magnification

• Cutaneous Leishmaniasis may be misinterpreted as sarcoidosis, foreign body reaction, granulomatous rosacea and even granuloma annulare.

PITFALLS

• Cure rates are high with the proper medicine. • Death is usually caused by complications (such as other

infections), rather than from the disease itself. • Complications • Bleeding (hemorrhage) • Deadly infections due to immune system damage • Disfigurement of the face

Prognosis

TREATMENT • Medicines called antimony-containing compounds are the main

drugs used to treat leishmaniasis. These include:

• Meglumine antimoniate • Sodium stibogluconate

• Other drugs that may be used include:

• Amphotericin B • Ketoconazole • Miltefosine • Paromomycin • Pentamidine

• Plastic surgery may be needed to correct the disfigurement

caused by sores on the face (cutaneous leishmaniasis). • Prevention through mosquito control.

References

• WHO • UNICEF • CIA World factbook • MCI • International Monetary Fund. Retrieved

2013-04-16. • American Journal of Tropical Medicine and

Hygiene. 2007 Jul; 77(1): 95-98 • American Journal of Tropical Medicine and

Hygiene. 2011 vol. 84 no. 4, 562-565. • Parasites and Vectors 1 (1):25.