Published in IJCP September 2019
From the Desk of Group Editor in Chief
“In the path of wellness, one health will be My priority this year”
September 10, 2019 | Dr KK Aggarwal
     


Dear Colleague

On September 5, I took over as the President of CMAAO for the year 2019-20 during the 34th CMAAO General Assembly held in Goa.

Here are excerpts from my speech delivered on the occasion.

“Coming to a General Assembly of CMAAO, the confederation of 19 National Medical Associations in Asia and Oceania feels like homecoming and a reunion of family as it resonates with my philosophy of life as a student of Vedic literature.

Vasudhaiva Kutumbakam” is a Sanskrit Vedic saying from the Rig Veda, considered the oldest of our ancient texts, which means “the whole world is my family.”

The complete verse from Rig Veda is as under:

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Ayam nijo paro veti ganana laghuchetasam,

Udaracharitanam tu vasudhaiva kutumbakam

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The English translation of this is “for narrow-minded people, things belong to him or others, but a person with a broad mind does not differentiate. For him the universe is a big family, so everybody belongs to one family where everything is shared.”

Most religions also propound the same philosophy.

Carl Gustav Jung, the Founder of Analytical Psychology, classified this under the category of archetypal experience of “Unus Mundus”, which is Latin for “one world”.

“Vasudhaiva Kutumbakam” imparts the basic message of unconditional love and oneness of the soul. Without the soul, a person would be like an outcast.

“I am not my physical body, as I know, once my body dies, nobody wants to touch it” (Adi Shankaracharya in the Bhaja Govindam). Such is the significance of soul that the wife who all her life has loved her husband does not even want to touch his body after the soul has left (Bhaja Govindam Sutra 3).

“Vasudhaiva Kutumbakam” (the whole world is one family, where you and I carry the same spirit) together with another saying “Ekam sat viprah bahudevanti” (truth is one and the wise may call it by different names) forms the basis of Vedanta.

The six “Maha-vakyas” or the “Great Sayings” are the essence of the teachings of the Upanishads. “Tat Tvam Asi” or “You are that” is one of the six “Maha-vakyas”. It comes from the Chandogya Upanishad in Samveda and signifies that the consciousness present in you is similar to the consciousness present in me. And, if the same consciousness lies in you, me and others, this means that we are part of the same family.

So, if the aforesaid is true and if the whole world is one, then it is also true that the same consciousness is also present in the environment, plants, animals and birds. This is in harmony with the concept of One Health, which recognizes that the health of the people is connected to the health of animals, plants and the environment that we all share.

“Yatha pinde tatha brahmande, yatha brahmande tatha pinde” is another Vedic Saying from the Yajur Veda, which means that as is the microcosm, so is the macrocosm. To put it simply, “as is the individual, so is the universe; as is the universe, so is the individual”. In relation to health and science, this denotes that the human body is a replica of the universe.

So, in the path of wellness, “One Health” will be my priority this year.

Coming back to CMAAO, since it was established in 1956, the objective of CMAAO has been to promote academic exchange of information on health issues and also to cultivate ties of friendship between member medical associations.

Dr Gro Harlem Brundtland, the first woman Prime Minister of Norway and former Director-General of the World Health Organization (WHO) wrote in the European Journal of Public Health in 2005, Public health challenges are no longer just local, national or regional. They are global. They are no longer just within the domain of public health specialists. They are among the key challenges to our societies. They are political and cross-sectoral. They are intimately linked to environment and development. They are key to national, regional and global security.”

As an organization, we too share several public health challenges such as vector-borne diseases such as dengue, malaria; air pollution; communicable and non-communicable diseases (NCDs); antimicrobial resistance (AMR); tobacco use; HIV/AIDS, to name a few.

Violence against doctors and inequity in health are few other issues that are a concern. Attaining universal health coverage, which is affordable, accessible, available, appropriate and accountable, still remains a distant goal for many of us.

All these have a bearing on the socioeconomic progress of our countries. Therefore, it becomes our collective responsibility to make certain that these issues are prioritized. Some of these issues are global concerns and we should try to solve them as a family and set an example for the world. In the event of any outbreak or public health crisis, we can share our health models besides knowledge and experiences of a similar situation.

I will briefly touch upon few such issues:

THE CHALLLENGES

Antimicrobial Resistance

Antimicrobial resistance (AMR) is a major global public health threat. Common infections such as typhoid, pneumonia, tuberculosis and gonorrhea have become difficult to treat. It is now clear that only an intersectoral collaboration and action will help to contain the spread of AMR and its further emergence.

India has one of the highest burdens of AMR. It was the discovery of New Delhi metallo-β-lactamase 1 (NDM-1) in 2008, which catapulted AMR to the forefront in India.

Over the years, several steps have been taken to tackle the rising AMR crisis in the country. Most notable of these have been the setting up of a National Task Force on AMR Containment in 2010, the Jaipur Declaration in 2011, the Chennai Declaration in 2012, Red Line campaign in 2016 and more recently, the Delhi Declaration and a National Action Plan on AMR (NAP-AMR) in 2017.

In addition to the 5 priorities listed in the Global Action Plan on AMR (GAP-AMR), India’s National Action Plan has a sixth priority that deals with strengthening India’s leadership on AMR, including international, national and subnational collaborations.

The biggest reasons for the misuse of antibiotics are self-prescription and over-prescription. So, before prescribing antibiotics, always ask yourself: “Is antibiotic necessary? What is the most effective antibiotic? What is the most affordable antibiotic? What is the most effective dose? What is the most effective duration for which the antibiotic should be administered?”

Violence Against Doctors

Violence against doctors is not a new or recent phenomenon.

“No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, black mail or suit for damages…” These lines from an article published more than a century ago in JAMA (Assaults upon medical men. JAMA. 1892;18:399-400) seemed to foretell what lay ahead.

Violence against doctors is now a grim reality and health workers are at high risk of violence all over the world. Health workers may also become the targets of collective or political violence in disaster and conflict situations.

A survey conducted by the Indian Medical Association (IMA) found that 75% of doctors in India have faced some kind of violence at their work place. Another IMA study showed that 68% of incidents of violence are caused by family members, friends or other persons accompanying the patient.

Violence against health workers is unacceptable and needs to be condemned by all, especially the general public who are direct stakeholders in this.

The Government of India is drafting a legislation on violence against doctors. According to the draft bill, violence against doctors is punishable with imprisonment and fine.

Autonomy of the Medical Profession

We cannot compromise with the autonomy of the medical profession, whether in clinical practice or in institutions.

Noncommunicable Diseases

Noncommunicable diseases (NCDs), mainly cardiovascular diseases, diabetes, chronic respiratory diseases and cancer, are the major cause of death in the South-East Asia Region (SEAR). An estimated 8.5 million deaths that occur annually in the region are attributed to NCDs; one-third of these deaths are premature and occur before the age of 70 years.

These NCDs share four modifiable behavioral risk factors: tobacco use, unhealthy diet, insufficient physical activity and harmful use of alcohol. Urbanization, sedentary lifestyles and increased life expectancy are the other major contributory factors for the epidemic of NCDs.

Traditionally considered diseases of old age, NCDs are now becoming prevalent in the younger age group, thus affecting the economically productive individuals.

India too is not untouched by this. Due to rapid urbanization, India is in the midst of an epidemiological transition, moving away from a predominantly communicable to a predominantly NCD pattern.

Air Pollution

Air pollution is considered by WHO as the greatest environmental risk to health in 2019.

India is home to seven of the world’s 10 most polluted cities and 22 of 30 cities with the worst air pollution, according to the IQAir AirVisual 2018 World Air Quality Report. So, there is much we can learn from other countries.

This year, the Government of India has launched the National Clean Air Programme (NCAP) to control the rising air pollution levels across the country. The tentative target has been set for 20-30% reduction in particulate matter (PM)10 and PM2.5 levels by 2024, with 2017 as the base year for comparison.

Universal Health Care

Universal health care is the need of the hour. It ensures that all people receive the health services they need without suffering financial hardship when paying for them (WHO Online Q&A, December 2014).

Universal health care provides Affordable, Adequate, Accessible, Available, Appropriate and Accountable quality and safe health care to the public.

In India, the private sector provides 80% of health care today, while only 20% is provided by government sector. India also has one of the highest out of expenditures on health in the world, which is over 60%. Many people are pushed below poverty line on account of the high medical expenses in what has been termed as “the medical poverty trap”.

But, now India has “Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana” or the “National Health Protection Scheme”, possibly the world’s largest government funded health care program. It provides a cover of up to Rs. 5 lakhs per family per year, at any government or empanelled private hospital, for secondary and tertiary care hospitalization. The amount of 5 lakh would cover all investigations, medicine, pre-hospitalization expenses, etc. All pre-existing conditions are covered. More than 10 crore vulnerable entitled families – approximately 50 crore beneficiaries – will benefit from the scheme. There is no restriction on family size, age or gender.

Malaysia has its B40:M40:T20 scheme, wherein the entire population of Malaysia has been divided into three income groups: Top 20% (T20), Middle 40% (M40), and Bottom 40% (B40). The Malaysian government has announced a free national health scheme for the B40 group from this year.

SUCCESS STORIES

Nevertheless, many of our member countries have successfully met some public health challenges. These achievements should not only inspire us to accomplish these goals, but also to help each other to attain them.

Let me share with you few of these success stories.

  • Emergency medical teams (EMTs) provide timely emergency medical care and transport in emergencies. As the first responders, they constitute an important part of the health care delivery system. In July this year, Thailand became the first in WHO SEAR to get WHO classification for its EMT. This classification makes Thailand EMT, the 26th team in the international roster of WHO classified, internationally deployable medical teams (http://www.searo.who.int/about/administration_structure/hse/Thai_first_SEAR_EMT_WHO_classified/en/, July 31, 2019).
  • Bangladesh, Nepal and Thailand (along with Bhutan), have become the first countries in WHO SEAR to achieve Hepatitis B control, with less than 1% prevalence of hepatitis B among 5-year-old children. All four countries have consistently recorded over 90% coverage with hepatitis B vaccine doses provided during infancy for past many years (SEAR/PR/1714, July 26, 2019).
  • Elimination of malaria in Sri Lanka. The elimination of malaria in Sri Lanka is a public health success story that is almost 8 decades in the making. The country reported its last case of measles caused by an indigenous virus in May 2016 (SEAR/PR/1712, July 9, 2019).  

    And, the mantra for this success: “If we learned of a case of malaria we would search for the patient’s house and trap the infected mosquitoes in the surrounding areas. We had to spend days, sometimes weeks in the jungle, without passable roads”. The anti-malaria campaign made a paradigm shift from mosquito control to parasite control. “That’s how we differ to other countries. We have gotten rid of malaria by eliminating the parasite, not the vector...” (http://www.searo.who.int/srilankadefeatsmalaria.pdf?ua=1, September 2016)
  • China’s war on pollution: Like many other countries, China too has been battling air pollution since the infamous “airpocalypse” in Beijing in 2013, when PM peaked at 35 times the WHO recommended limit. The strategies adopted are: New standards and targets for air pollution levels; revisions to China’s Environmental Protection Law designed to increase penalties for polluters and repeated government inspection campaigns, coupled with heavy fines for violators. Although the battle is far from being won, air quality has improved. The average level of PM2.5 in the 50 most populous Chinese urban areas has dropped by nearly one-third, from 71.2 mg per cubic meter in 2013 to 47.9 in 2017.
  • The Singapore Civil Defence Force (SCDF) provides round-the-clock emergency medical services (EMS) in Singapore for all types of life-threatening emergencies. SCDF operates a fleet of ambulances, “fast response paramedics” on motorcycles as well as first response fire-bikers in a ?re-based system activated by a centralized dispatching. Dispatchers are predominantly ?re?ghters, but also include paramedics and dispatch nurses. The ambulance service is staffed by salaried personnel, provided free of charge, and is publicly funded. In 2018, SCDF handled more than 1,87,000 emergency medical service calls amounting to 500 calls daily in 2018 (https://www.channelnewsasia.com/news/singapore/scdf-will-no-longer-take-non-emergency-patients-to-hospitals-11393350, Mar 29, 2019).  

    This year, the Indian Council of Medical Research (ICMR) has launched ‘Mission DELHI’ (Delhi Emergency Life Heart-Attack Initiative), an emergency medical service under which a pair of motorcycle-borne trained paramedic nurses would be the first responders for a person suffering heart attack or chest pain. The pilot project is linked with Centralized Ambulance Trauma Services (CATS) and has been launched in a radius of 3 kms (1.8 mils) around All India Institute of Medical Sciences (AIIMS), a premier tertiary care hospital in New Delhi.
  • Japan has universal public health care: All Japanese citizens are required by law to have health insurance. Medical treatment in Japan is provided through universal health care. The health care system in Japan provides free screening processes for certain diseases, infectious disease control and prenatal care. Thirty percent of the medical costs are borne by the Japanese citizens and the remaining 70% by the government.     

    The four characteristics of Japanese universal health insurance coverage system as mentioned in the website of the Japan Ministry of Health are:
  1. Covering all citizens by public medical insurance
  2. Freedom of choice of medical institution (free access)
  3. High-quality medical services with low costs
  4. Based on the social insurance system, spending the public subsidy to maintain the universal health insurance coverage.
  • India has become a preferred medical tourism destination today. Millions of patients from abroad have so far availed the best medical facilities in India. A medical tourism report considering data for the year 2015-16 suggests that a majority of Indian medical visa was issued to patients from Bangladesh, followed by other regions such as Afghanistan, African countries, other Asian countries, Iraq and Nigeria. Sri Lanka, Kenya, Pakistan and Commonwealth of Independent States (CIS) countries also rank among some of the leading nations from where a maximum number of patients come to avail the best medical facilities in India.

    The high quality hospital infrastructure, latest technology, affordability, world class treatment, less waiting time, a large English-speaking population are some of the USPs that make India a hotspot for medical and wellness travel destination. India is already on the tourist map. Last year, the Indian Government launched a dedicated health care tourism portal to streamline the travel and to promote medical and wellness tourism.

PATH TO WELLNESS

The theme of this General Assembly is “Path to Wellness”.

Traditionally, health care has focused on treating diseases and not preventing them. But, with the escalating incidence of lifestyle diseases, health care is now shifting from sickness to wellness care.

Wellness is not just for the sick, it applies to healthy people too, who have no evident or overt disease, yet may be unwell due to depression, anxiety or other such conditions.

Wellness is defined as “the sense that one is living in a manner that permits the experience of consistent, balanced growth in the physical, spiritual, emotional, intellectual, social and psychological dimensions of human existence.

This means that wellness takes care of the overall quality-of-life and well-being and not just physical health.

My Formula of 80 to Live up to 80 Years without a Lifestyle Disease

All the major lifestyle disorders share modifiable risk factors; so, instead of advocating a lifestyle for individual disease, patients should be advised a common lifestyle, which will prevent all lifestyle disorders.

Keeping this in mind, I have devised a ‘Formula of 80’, which I teach and recommend to all my patients. They are evidence-based and as most recommendations are to keep the values below 90, I have chosen the 80 as the number common to all risk factors so that it is easy for patients to remember.

Here is my Formula of 80 to live up to the age of 80:

  • Keep your lower (systolic) blood pressure, LDL “bad” cholesterol, fasting sugar, resting heart rate and abdominal circumference all below 80.
  • Keep the lung functions and eGFR above 80.
  • For this, walk 80 minutes a day; brisk walk 80 minutes a week; walk with a speed of at least 80 steps per minute; for cardiac walk, achieve 80% of target heart rate.
  • Keep the levels of PM1, PM2.5, PM10 and noise pollution all less than 80.
  • Do not take alcohol and if you take and there is no contraindication, limit it to less than 80 mL (40% 80 proof whisky) a day or less than 80 grams a week.
  • Eat in moderation and variety with no more than 80 grams of caloric food or 80 mL of caloric liquid in one meal. To reduce insulin resistance, adopt to low refined carb diet 80 days in a year.
  • To shift from resting sympathetic to para­sympathetic mode, do 80 cycles of parasympathetic breathing (slower and deeper breathing).
  • To reduce the harm of vitamin D deficiency, sit in the sunlight for 80 days a year.
  • Donate blood 80 times in lifetime.
  • To reduce chances of AMR by 80%, avoid self antibiotic medication and ask yourself before prescribing an antibiotic: is it necessary?
  • Do not start tobacco and if you take, then quit; if you cannot stop, switch to less harmful
    non-tobacco alternatives or you will end up coughing out 80K Indian rupees on treatment.
  • With this there are 80% chances you will not get a heart attack. And if you still get it, ask for 80 mg aspirin and 80 mg atorvastatin.
  • And if you get an angiography and your blockage is less than 80% or FFR is more than 0.8, you do not need an intervention.
  • With this there are 80% chances you will not have a sudden cardiac arrest. AND even if you get a sudden cardiac arrest, there are 80% chances that some bystander will give you compression-only CPR and revive you by using the Formula of 10 (within 10 minutes of death, at least for the next 10 minutes, compress the chest of the victim effectively and continuously with a speed of at least 10 ´ 10 = 100 per minute).

I add another today to this list, “For the success of CMAAO let us give 80 seconds every day to the CMAAO and share one idea with me to make this year, one of the most vibrant years in the history of CMAAO”.

I welcome you all to India.

Atithi Devo Bhava (vfrfFknsoks Hko:) or “The guest is God” has been a tradition for us in India for centuries.

This mantra is from the Taittiriya Upanishad, Shikshavalli I.11.2 that says: matrudevo bhava, pitrudevo bhava, acharyadevo bhava, atithidevo bhava. It literally means that treat the mother, father, teacher and guests as God.

I bow before all our International and National guests present on the dais and off the dais and seek your blessings and good wishes.

And let us all clap 80 times for them.

Long Live CMAAO!

Long Live IMA!