The Fight Against Malaria

Earlier this week I was in Mumbai. Monsoons in Mumbai usually mean unrelenting rain, it drizzles and then suddenly it pours and is again back to the drizzle, it never  appears to stop raining. Weatherman have been unanimous in asserting that this year so far has been one of the wettest in Mumbai in the last 5 years. While the rains have been bountiful, Mumbai has been shivering like never before-it is in the grip of an epidemic of malaria.

The evening broadcast on the television confirmed a few deaths and put the numbers affected by the disease to a few thousands, with over 800 fresh cases reported in the last few days itself. The hospitals are overflowing with the sick. In fact such is the press of patients that Mumbai Hospitals are setting up huge tents on their premises and putting additional beds to cope with the patients. Raj Thackeray the looniest Shiv Sainik has already blamed the North Indians living in Mumbai for the disease. Incredibly he believes that these people living in squalor in Mumbai are spreading the disease and the outbreak will stop if Mumbai was rid of this scourge.

Unknown to Mr. Thackeray, malaria parasite has a history, which dates back to over half  a billion years. The origin of Malaria can be traced to Western and Central Africa. About half a billion years ago the pre parasitic ancestors of the malaria parasite adapted to live in the gut of a some aquatic animals. They subsequently proliferated and evolved to live in insect larvae found in still water bodies. These insects first appeared around 150 million to 200 million years ago. During this period, certain lines of the ancestral malaria parasites achieved two-host life cycles which were adapted to the blood-feeding habits of the insect hosts. In the 150 million years since than, many different lines of malaria and malaria-like parasites evolved and radiated. The malaria parasites of humans evolved on this line with alternate cycles between human and the blood-feeding femaleAnopheles mosquito hosts.

With the advent of agriculture and human settlements, the density of the human population increased. These settlements largely concentrated along inland water bodies. Thus the mosquito population thrived feeding itself on a large and stable supply of human blood. From its origins in Africa Malaria spread rapidly across the globe and became the worst killer disease known to humans. The Chinese knew about Malaria 5000 years ago and Egyptian mummies with enlarged spleens are believed to be the remains of ancient Egyptians who died of Malaria. The disease was rampant in the Indian sub-continent 3000 years ago, Alexander the Great is believed to have died of Malaria in 323 BC, on his way to India.  The disease reached the Mediterranean about 2000 years ago and invaded Europe almost a 1000 years ago. Increasing trade and military conquests spread the disease globally and by the 18th century the scourge was at its peak with half the world’s population at risk. Poor living conditions, famine and poverty contributed to high mortality.

As the western world advanced, living conditions improved contact with the vector declined leading to a spontaneous reduction in Malaria in those parts of the world. By the middle of the 20th century Malaria had been conquered in North America and Europe. However, the fight for eradicating Malaria continues in the tropics.

As the fight against malaria accelerates the world over, an estimated USD 10 bn are being spent in an effort to eradicate it. The goal of this world wide effort is stop all malaria deaths by 2015 and finish the disease by 2035.  The fight is a global effort to improve the living conditions of people in the third world, provide effective protection (such as chemically treated mosquito nets and new generation mosquito repellents) and provide easy access to medical care even in the worst affected and remotest parts of Africa. Global pharmaceutical companies are researching the disease like never before in the hope of finding more effective drugs that can significantly bring down mortality.

Going by what I saw in Mumbai, I shudder to think how ordinary people must be coping with this outbreak in the rural areas, where healthcare services are almost non-existent. The time has now come to take up the fight against Malaria pretty much like the government has been fighting tuberculosis and polio in the country. The government’s flagship health scheme the National Rural Health Mission, must take the lead and orchestrate a nation wide initiative against malaria. A sustained effort should be made in educating people about the perils of Malaria. The government should take preventive steps such as defogging of the vector’s breeding grounds the distribution of medically treated mosquito nets and free distribution of mosquito repellents may help prevent the disease. The Primary Health Care centres must be equipped with kits needed to quickly diagnose and treat the disease. The government health workers should be able to proactively report the likely cases and the PHC doctors should be able to intervene to stymie the disease before it becomes fatal.

All this and more is possible only if there is a will. The money can be found. More than anything else we need dedicated people who feel strongly about this ancient scourge and who are willing to lead in this final battle.

The Need for Better Corporate Health

It was 7  PM in the evening in our Mumbai office. The day was winding down and it had been a hectic day for the sales people. The CEO wanted to review the sales plans and he had asked each sales person to present their targets and plans. We have a reconstituted Mumbai sales team and the CEO wanted to use the opportunity to interact with each sales person and also do a first hand assessment of the talent we had on b0ard. He was done with the junior most team members and now he was  planning to have one final round of meetings with the supervisors to share his views and provide feedback.

As the meeting with the Managers got underway, one of our most experienced sales person, Alvin started feeling a little uncomfortable. Alvin is 36 years old and is a veteran in the industry. He has been working for us for close to 3 years now. Alvin started sweating profusely, was breathing in great gulps and was clearly distressed. He complained of tightness in the chest, heaviness all over and seemed to be unable to keep his eyes open.

As Alvin collapsed no one seems to know what to do. Someone got him down to a car and they rushed him to the nearest hospital. The Mumbai roads were as usual clogged and it took them at least 45 mins to reach the hospital. During this time, there was no one who could provide first aid and everyone prayed that nothing should happen to Alvin before they reach the hospital.

Scary isn’t it? But this is how most offices in India are. There are hardly any provisions for managing an untoward incident in the office. There are no trained personnel, who can provide basic life support till help arrives and there are no emergency protocols defined or practiced, which may help in managing a medical emergency at the work place.

There is no denying the fact that work place health is amongst the most neglected in most corporates in India. With increasing levels of work stress, sedentary lifestyles late nights and weekend business parties, corporate India today offers a lifestyle, which is fast paced and quite deadly. Coupled with pressures at home with nuclear families and live in helps being the norm, life for most people in big cities is a roller coaster and this is taking a gradual toll on everyone’s health.

Lifestyle diseases including cardiac diseases, diabetes and hypertension are catching their victims young and often by surprise and corporate India is just not equipped to handle this.

It is imperative that corporates start paying serious attention to the health of their employees. Annual health checks must be mandatory and should be taken a lot more seriously than now. It would also help if the companies could hire the services of professional counselors, who can interact with the employees regularly and shepherd them through periods of heightened stress either at work or home. There is no harm or shame in having shrinks at the workplace to help employees cope with a crisis that may be lurking round the corner. An organisation must maintain a health register of all its employees detailing their existing conditions, their risk factors, lifestyle choices, allergies, emergency contacts, family physicians et al. This information should be maintained and updated on an annual basis and should be immediately available if required.

It would also be a good idea to train  a few employees in Basic Life Support techniques. I would recommend at least 1 trained person per 50 employees would be a good ratio. Everyone should know that they need to call in case of a medical emergency at the work place. Hospitals in Delhi usually help train employees and they rarely charge a fee. While, I worked in the hospitals, we made a special effort to organise these trainings. Yet, I recall, we struggled to get corporates to allow to conduct these. Most corporates looked upon these as a waste of time and a kind of marketing activity for the hospital happening on their premises.

It would also help if the corporates had a clearly defined emergency protocol and people identified who would coordinate the medical evacuation. In Alvin’s case, we rushed him to the nearest hospital. As luck would have it, this hospital did not have a cardiologist in the emergency, it did not have a cath lab, a 3 D echo any other kind of emergency cardiac support. While, they managed Alvin as best as they could and stabilised him, we were plain lucky that Alvin was not having a heart attack. Investigations later revealed that Alvin suffered from hypertension and had a deranged lipid profile. We also knew he smoked like a chimney, loved alcohol and led a wholly sedentary life. He was under immense work pressure, spent more than 3 hours commuting from Thane everyday and was trying hard to juggle personal and professional life as best as he could.

For him this was a warning sign. His body is protesting against constant neglect and abuse. For the corporate too it is a big red light. We should have known about Alvin’s medical condition in advance. More importantly we should have been better equipped to handle the kind of medical emergency we faced all of a sudden.

This unfortunately is not just our story alone. It is happening all too often in many organisations. We need to sit up, take notice and try to create a healthier and medically better prepared workplaces.

To protect the privacy of the employee, I have changed his name.

The Apollo Clinics-The Perils of Franchising Healthcare Services in India

I came across a piece co-authored by my former colleague Ratan Jalan in ‘Marketing Health Services’ (Eye on The Indian Market, Spring 2009 edition)of the prestigious journal of the American Marketing Association. I have known Mr. Jalan since he hired me to work for him at Apollo Health and Lifestyle Ltd., many years ago and hugely respect his scholarship and knowledge about the business of healthcare in India. However, I must confess that I do not quite agree with Mr. Jalan’s portrayal of the opportunities in franchising healthcare services in India and his conclusions about Apollo Health and Lifestyle’s successful franchising of the Apollo Clinics.

Apollo Hospitals is one of the largest chain of hospitals in India. It has in its network more than 41 hospitals and manages over 8000 beds mostly in the secondary and the tertiary healthcare space.  I met Ratan in the year 2001, when he was setting up Apollo Health and Lifestyle, which was to get into franchising of the Ápollo Clinics, the primary healthcare services chain, which were supposed to complement Apollo’s large secondary and tertiary care network. These clinics were envisaged as a franchised operations, supported by the Apollo Hospitals group. They were to leverage Apollo’s excellent brand equity and knowledge about the healthcare in India and help franchisees run a profitable enterprise.

The Apollo Clinics were well conceived. The service mix was essentially OPD consultations, a collection centre for pathology samples, radiology services (X-Ray, Ultrasound) and basic cardiology diagnostics (ECG, TMT and Echo). The clinics also had a 24 hour pharmacy and basic preventive health packages were also offered. We worked hard on the look and feel of the clinic (Ratan had Alfaz Miller design the clinic interiors), Ravi Bajaj was to do the staff uniforms, and the clinics were to hire smart and well-trained youngsters to be the face of the clinics. The consultants were to from the local areas and it was thought that Apollo Hospital’s senior consultants will also run their OPD’s from these clinics.

On the business side of things a franchisee needed to invest close to Rs. 20 MN upfront. The business plan included a fixed percentage payout by the franchisee of the revenue that he made. Apollo was to handhold the franchisee through the setting up of the clinic, purchase of medical equipment, development of the software to run the clinic, recruitment of the employees both medical and non medical, and selection of doctors. Apollo was also to provide an exhaustive set of instructions and guidelines on the management of the clinic to the franchisees and it was responsible for monitoring the quality of the services delivered at these clinics.

While on paper the model looks perfect, it has some serious infirmities.

A franchised operation by definition has to be a replication of an existing successful model. In Apollo’s case, they had nothing to show in the area of Primary Healthcare. They used to run a clinic in Mumbai, which they owned. Just about the time Apollo decided to go the franchise route, their own clinic shut shop. It was losing money hand over fist and the management decided to shut it down.

In the franchised model that was now envisaged Apollo had no financial stake. The money was to be put up by the franchisee, he was to bear all the costs including a revenue share with Apollo and it was not clear how Apollo will contribute to bringing in new patients to the clinic. It was expected that Apollo’s name itself will pull in patients. Thus the franchisee was to fend for himself as far as developing the business was concerned. Apollo could have contributed by investing in the brand ‘Ápollo Clinics’ and by forcing some of its leading doctors to run the OPD’s from the franchised clinics. Apollo made lofty promises of investing millions in the brand but just didn’t. As far as doctors were concerned, some feeble attempts were made to get Apollo doctors to attend these clinics but hardly anything materialised. The problem really was that in Apollo system the senior doctors are not paid firm salaries and they work on a revenue share model. Thus, Apollo’s control over these doctors is minimal. The senior doctors with a busy practice had no reason to sit in the newly opened Apollo Clinics, which in any case did not have any patients of their own.

The selection of the franchisees too threw up issues. The franchisees were largely businessmen with hardly any experience of healthcare. Neither did they have any particular love or passion for the healthcare business. I remember meeting and offering franchises to computer hardware merchants, aluminium dealers, a golf ball manufacturer, a real estate player and the like. All of them were driven purely by a profit motive. Some also saw healthcare as a more respectable business for their children. We sold the franchises indiscriminately, (at least in the beginning) to anyone willing to put up the money. A network was thus born that had no glue except the brand name that each franchise shared with the other.

The biggest casualty in all this was of course the quality of healthcare services that each clinic rendered. There was no uniformity as each franchisee left to fend for himself became increasingly desperate for revenue. He hired doctors on his own many of dubious quality, started offering cuts for referrals, set his own prices and started indulging in all kinds of practices that would help him get the extra money that he needed to stay afloat. As most of these franchises were not businessmen with deep pockets, they were willing to cut corners as their very survival was at stake. In-spite of all this many had to close down operations.

Apollo gradually lost control over these franchises. Since, it did not add any value to the franchise’s life he decided not to pay the monthly royalty. Many refused access to Apollo personnel on their premises and are now pretty much operating as stand-alone entities. They continue to use the Apollo name, as that is the only thing, which adds value to their operations.

Creating a franchised healthcare network is fraught with danger. Apollo failed by not first establishing a successful chain of primary healthcare centres of its own. It had no proven learnings in that space and it undertook to make money at its franchisee’s cost. It lost the trust of not only its franchisees, but also of many of its patients who certainly expected a lot better from Apollo.

Pic courtesy The Apollo Clinic website

 

Coping with Swine Flu in India

swine fluSwine flu has finally arrived in India.

So far 4 people have died and 782 people are confirmed to be infected with the virus and are undergoing treatment in designated government hospitals. The deaths have been in Pune, Mumbai and Ahmedabad, while Pune seems to be the worst hit. Strangely, school children appear to be seriously affected and many schools have shut down for a week or more.

Last week when I was in Mumbai a colleague called up in the evening. His 8 years old daughter was having a high fever and flu like symptoms. He had taken her to Max Hospital in Saket in New Delhi and he had been referred by the paediatrician to a government owned facility in Malviya Nagar for suspected swine flu. ‘The doctor did not even touch her, heard us while we explained the symptoms and promptly referred us to the government hospitals for tests. The government hospital admitted her for observation and now we do not know what to do. I fear even if my kid does not have swine flu, she is likely to catch it in the hospital’  explained my colleague Vijay Jain.

Another colleague in Mumbai, who was coughing and sneezing, had a bad throat and a fever decided not to come to work for a few days.  He felt that it wasn’t right for him to put others in office at risk.

These are tough calls. It is difficult for doctors to diagnose Swine Flu from the symptoms a patient presents. If the flu like symptoms are a little severe thay have no choice but to refer patients to the designated hospitals for tests, which means a patient has to visit a hospital, which has confirmed cases of Swine Flu and is therefore exposed to the disease. It is really a catch 22 situation.

In this situation the best thing to do would be to avoid going to busy public places, which are closed, particularly malls, airports, cinema theatres and yes offices and schools.

It would also help not to panic if one develops flu like symptoms. Afterall flu, that is the normal flu is a lot more prevalent than the swine flu and kills many more people every year. Mortality rate due to swine flu is still quite low, less than 7 per thousand. Statistically this is not a big cause of concern.

The government on its part must involve some private hospitals in combating the epidemic. It would help if a few private hospitals were allowed to test blood samples for the disease and admit patients in secluded wards. Large private hospitals are certainly more than capable of maintaining the records, treating the patients and ensuring that the disease remains in check. Additional testing and treatment centres will also help in instilling greater confidence in the public.

The government must also embark on a public awareness campaign. It must use mass media to educate the public about the disease, its symptoms, diagnostic procedure, treatment and prognosis. While I have noticed some advertising, it is hardly adequate.

Finally, the media must behave responsibly. In a situation like this it is indeed easy to create panic and cause mayhem by irresponsible journalism. It is the duty of all journalists to report objectively without resorting to unnecessary sensationalism and devoting too much media space to stories related to the spread of the disease.

Last but not the least, let us spare a thought for folks in the medical profession. They are at great personal risk in handling infectious patients. However, this is part and parcel of their calling. They must take all possible precautions, while providing succor and care to all those who seek their helHospital,p.

At the end of the day all of us are at risk. It is really up to us to exercise caution and help in whatever small way we can to fight the disease.

Pic courtesy http://www.flickr.com

Some names have been changed to protect privacy

The PR Story

newspaper-storiesAs I wearily settled into the cramped seat of a Spicejet flight to Mumbai this morning, I pulled out the Metro Nation a tabloid format newspaper and started flipping through the pages. Suddenly an image of my former colleague Dr. Deep Goel, the head of Laparoscopic and Bariatric Surgery at Artemis Health Institute, Gurgaon caught my attention. Dr. Goel was featured in the story along with a 200 kg Canadian patient, whom he had successfully operated upon (performing sleeve gastrectomy) and discharged from the hospital with in 24 hours. The story albeit poorly written (the journalist appears to be totally ignorant about medicine, medical procedures, surgeries et al), did manage to inform the readers about Dr. Goel’s superlative skills and about the Bariatric Surgery at Artemis.

Last week I had come across the story of a successful heart transplant in Chennai, when the donor was in Bangalore a team of surgeons from Chennai successfully harvested a heart in Bangaloreand transplanted it in a policeman in Chennai. Stories about Pakistani children being successfully treated for congenital heart diseases at Narayan Hridyalaya in Bangalore and undergoing liver transplants at Apollo Hospital in Delhi have routinely appeared in national media. Celebrities being treated at Leelawati and Breach Candy hospitals in Mumbai are also commonplace.   Continue reading

The Terror in Mumbai

taj-on-fire I am shocked and bewildered at the audacity of the terrorists in Mumbai, who are holding the country to ransom. As the gruesome drama unfolds live on television channels going berserk, one is left wondering at what might be some of the consequences of this dastardly act.

I woke up this morning to the headlines in the Hindustan Times about terrorists striking in Mumbai and having killed more than 100 people in random firing at public places including the crowded Railway Station, busy hospitals, beaches and finally taking hundreds of people hostage in the landmark Taj and Trident Hotels in downtown Mumbai. Switching on the television, brought the tragedy and horror to ones bedroom.   Continue reading

The Gay Season

gays It seems that the Gay season is upon us.

The gay rights movement seems to be generating unprecedented media attention. The courts are busy hearing petitions against a law framed in the 19th century, which proscribes homosexuality and the punishments for anyone caught in the act includes a maximum of 10 years in jail. The newspapers are writing stories about a gay couple from Israel, who have become parents through a surrogate mother who bore their child in Mumbai and a popular movie, which brings the gay question out of the closet is running to packed theatres across the country.

All this attention to an issue, which is still hardly a matter of discussion even amongst friends (forget family) is quite amazing. Gay rights activists are no longer considered pariahs and they are often seen in the media holding forth on issues that till now have been buried deep underground.   Continue reading