There are hundreds of anecdotes and data to show that we are often taken for an expensive and life-threatening ride by the business complex of research, doctors, hospitals, medicines and medical equipment
"The business of healthcare delivery in the US has the same potential for graft and corruption as casino gambling and construction rackets" wrote Lisa Van Dusen in the Canadian Medical Journal in 1997. I wanted to review this statement in today's scenario.
Just as I was sitting down to write this piece, I happened to glance at a beautiful book Bottom Line Medicine by Richard K Stanzack. The author had been a registered nurse in the US medical system and he came out after getting disgusted. The amount of research he has done to write this authentic book fascinated me as he was not privy to those documents as a nurse. That might be his advantage as we doctors are being spoon-fed by company representatives who get us the best medical literature that one could hope to get in addition to the free conferences and lectures that they provide us with.
The case of the missing data is an excellent medical satire written on the lines of Sir Arthur Connon Doyle's Silver Blaze (Penguin classic 1981) in the British Medical Journal by James Le Fanu, a family physician in London. This sums up the present scenario. "Risk factor screening for major diseases such as cardiovascular disease, alcohol abuse, diabetes mellitus, raised cholesterol and breast cancer, and subsequent treatment of the detected risk factors/diseases in the The Malmö Preventive Project did not reduce total mortality in the intervention group as a whole." Malmo was the famous study which follwed the trial subjects for a very long time in Europe. "Epidemiologic data, however, consistently show a continuous, positive, linear relationship of the height of both systolic and diastolic blood pressure with the incidence of stroke and heart attack. No threshold level distinguishes those who will have a cardiovascular event from those who will not. In fact, most heart attacks and many strokes occur among persons with 'normal' blood pressures," writes Michel Alderman commenting on almost all the major studies in the field.
My own analysis of the 17 major studies of hypertension treatment with drugs, some of them followed up for nearly 20 years, showed how we are taken for a ride. There are three ways one can sell research results in medical interventions: relative risk reduction, absolute risk reduction and number needed to be treated to get that benefit. In the 17 hypertension drug treatment trials thus analysed the relative risk reduction was very impressive to sell but does not mean anything for the practising doctor on the ground. But that is exactly what is being shown in mainline journal articles and company literature. In the analysis reported in the BMJ of 18 June 2002, researchers claim clinical trials are reported with misleading statistics. The table below is theirs.
To give an example, if the statistically anticipated death in five years in a group of 1,000 research subjects with hypertension is 10 (how to estimate this God only knows) and if that is reduced to five by our treatment, the study would record that as 50% reduction in death by the drugs concerned! Very impressive indeed! The truth, however, is that there has been a statistical reduction of five deaths in 1,000 apparently healthy adults in five years by our treatment, which works out to an absolute death reduction of 0.05%-almost negligible. The latter is the absolute risk reduction. Similarly, the MRC study of mild to moderate hypertension showed that to "save one possible stroke in the next five years, we have to treat 850 healthy people with anti-hypertensive drugs for a period of five years with all the risks of adverse drug reactions!" The chart below shows the causes of death in MRFIT (Multiple Risk Factor Intervention trial) data which is self-explanatory. At the end of the day the balance sheet was that intervention was not worth it from our point of view and was a curse from the patients' point of view. The final death tally was not statistically significant.
MRFIT data after 16 years follow up of thousands of subjects on hypertension treatment
Roger Sherwin is the Chair of epidemiology at Tulane after having been at Cambridge, Johns Hopkins, etc, who was involved with most of the major studies of interventions has this to say at the end of it all. "In other words, we found that changing the "risk factors" does not apparently change the risks. This necessarily means that the "risk factors" are not as important as was thought. Indeed, it should be concluded that the "risk factors" were no such thing, at least as far as this trial (MRFIT) is concerned.
The story is similar for diabetes, cancer, and even drug interventions of AIDS! Maggie Mahar's Money Driven Medicine is another great book from where I have lifted the following lines in italics (mine) that sums up the whole book which has facts and figures with authentic cross references. "What the manifold tales, stats, and interviews illuminate is a system almost irreversibly infected by money. The story here is one of market failure, of a peculiar sector where the drive for profit demands not efficiencies and innovations, but volume and market share. That may be fine when we're talking widgets, but when it means more heart surgeries, less time with patients, more collusion with drug companies, and higher prices for less care-well, even Adam Smith would feel a little ill. But believe me, he'd think twice before summoning the ambulance."
Does all this mean that doctors should close shop and go hunting? Never ever! Doctors were needed in the past; they are vital today and will be relevant for all times to come as long as there are patients. How do the two statements that I have made above go hand in hand? A recent study in the British Medical Journal showed that even in major surgical procedures it is the placebo doctor effect that was important to the extent of nearly two-thirds of the times. This brings back to memory the famous quotation from Oliver Wendell Holmes that the "two most powerful drugs that medicine ever discovered are the two kinds words of a good doctor." Good doctors are the need of the hour.
Even a major event like total myocardial revascularization (like bypass surgery) study "showed that those that had the surgery got relief from pain but also those that were told that they had a successful surgery but never had any surgery done had equally benefited from pain. Moreover, at the end of five years the sham operation group's blood supply had become normal on scanning," wrote Roger Laham, one of the researchers and the director of angiogenesis laboratory at Harvard. The study did show that the operation was more of a sham and what worked was the faith in the doctor that assured them that their operation was a success." Most of our interventions, including surgery in many areas, have not been shown to do good to our patients. How are the patients relieved of their troubles after the interventions? They were relieved because they believed in their doctors and had faith in them. They survived inspite of interventions but because of their doctors.
This boils down to spirituality in medicine. Spirituality has nothing to do with religion. On the contrary, spirituality is simply sharing and caring. James F Peabody was a great doctor at the Mass General Hospital and wrote this note in 1927 that became the major motto of that hospital even to this day. He said that "patient care is caring for the patient." That is true spirituality. After all who heals the sick?
A great surgeon like Michel De Bakey, who died recently at the ripe old age of 96, who could innovate major surgical feats during his life at Baylor would have accepted the fact that he could only stitch the wound but could never heal the same. The scientific proof of that statement of mine, if such a proof was ever needed, could be guessed from this question. Could any surgeon, including Michel De Bakey, make a great operation heal in a dead body? Healing occurs in a living body only. What then is the difference between the living body and that of the dead? The dead do not breathe! Breath (spires in Latin) is the root of the word spirituality according to our cave dwelling ancestors. The latter thought, in their wisdom, that there was one difference between their living brethren and the dead ones. The dead did not breathe. They surmised, very scientifically compared to our epidemiological science that breath entered the body at birth and left the body at death. They wrongly drew the wrong conclusion that breath was God and the word spirituality thus connects to God and religion.
That is the conclusion of all our studies in modern medical science today. "Passion makes some of the best observations but, draws, many times, most wretched conclusions" wrote John von Neumann years ago. Our research has made some wonderful observations but we have drawn wrong conclusions from those studies. Let us change the science of medicine from the reductionist science of linearity that we discussed above to that of the future science of chaos and holism as was elegantly shown by Professor David Eddy, a former professor of cardiovascular surgery at Stanford converted to a mathematician, to get at the right holistic science for medicine in his ground-breaking research work which could be accessed by readers on www.archimedesmodel.com.
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also editor-in-chief of the Journal of the Science of Healing Outcomes, chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former vice chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London. Prof Dr Hegde can be contacted at [email protected])
While private developers primarily target luxury, high-end and upper-mid housing segment, it is the housing requirements of the lower middle-income and lower income groups that are grossly neglected in India
Indian cities fall short of planned housing for low income and economically weaker households, resulting in a perennial and an ever-growing housing shortage, alongside compromised living conditions. Whilst this is detrimental to the planned growth of cities, it also gives birth to the demography of “less than equal citizens” forced to live in substandard clusters of slums, says a report.
In a report, “Affordable Housing in India”, real estate services firm Jones Lang LaSalle (JLL) India, said currently the country falls short by 26.5 million housing units. “Indian developers are primarily targeting luxury, high-end and upper-mid housing segment, with value housing being used only as a ‘saviour’ in the low phases of real estate cycles,” the report said.
According to estimates of the technical group constituted by the ministry of housing and urban poverty alleviation (MHUPA), during the 11th Five-Year Plan, the total housing requirement in Indian cities including backlog by end-2012 will be to the tune of 26.53 million dwelling units for 75.01 million households. If the current increase in backlog of housing is maintained, a minimum of 30 million additional houses will be required by 2020, the report added.
Availability of affordable housing in adequate numbers is one of the greatest necessities of urban India today. As per the 2011 Census, the country had a population of 1.21 billion, out of which, 377.10 million or about 31.2% lived in urban areas. The housing stock in urban India stood at 78.48 million for 78.86 million urban households, according to the census data.
“Urbanisation has resulted in people increasingly living in slums and squatter settlements and has deteriorated the housing conditions of the economically weaker sections of the society. This is primarily due to skyrocketing prices of land and real estate in urban areas that have forced the poor and the economically weaker sections of the society to occupy the marginal lands typified by poor housing stock, congestion and obsolescence,” the report pointed out.
Developing affordable housing in Indian cities faces significant challenges due to several economic, regulatory and urban issues. Whilst the lack of availability of urban land, rising threshold costs of construction and regulatory issues are supply-side constraints, lack of access to home finance is a serious demand-side constraint, which impacts the ability of low-income groups to buy housing in the organised sector. Whilst some of these are gradually being mitigated, concerted efforts are required by multiple institutions to facilitate mass development in this sector.
During 2009–2012, real estate developers have launched projects in the affordable segment across Indian cities, with units priced between Rs5–Rs10 lakh. Several of these projects have been sold on an application model due to huge demand, with multiple takers for the same unit.
With high prices of land within the city, the low-income housing projects are being developed at “leapfrogged locations”, which offer land parcels at suitable price points for such developments. Mumbai and the national capital region (NCR) have affordable housing projects located 65 km to 75 km from the city centre. On the other hand, Ahmedabad and Kolkata provide better proximity, with projects located at a distance of 15 km to 20 km from the city centre. Bangalore, Pune and Chennai also have projects after a distance of 25 km to 30 km from the city centre, the report said.
Estimated construction costs for low income housing
Whilst price of premium residential projects are largely guided by land costs, construction costs have a significant share in the price of affordable housing. If land is acquired at a reasonable cost of Rs150–Rs250 per sq ft, an affordable housing project with basic amenities (construction cost of Rs800–Rs1,000 per sq ft) would result in a minimum selling price of Rs1,400–Rs1,700 per sq ft. Thus, construction costs form nearly 50–60% of the total selling price for affordable housing.
On the other hand, luxury housing projects in South Mumbai have construction costs of nearly Rs4,000–Rs5,000 per sq ft, which is nearly 18–20% of the selling price of Rs20,000–Rs25,000 per sq ft. Affordable housing projects get more affected by rising costs of construction than premium projects. Hence, it becomes important that costs are minimised for construction of low-income housing whilst balancing the amenities provided as well as ensuring the safety and serviceability of the built structure during its lifecycle, the report added.
According to Monitor Inclusive Markets, the loan market of Rs3-Rs10 lakh is worth almost Rs11 lakh crore or around $220 billion. Despite this, majority of the loans disbursed by housing finance companies (HFCs) are to mid-income group (MIG) and high-income groups (HIGs) in a loan bracket above Rs10 lakh. The key issue that deprives people from availing housing loans in the Rs3-Rs10 lakh bracket is the perceived high risk i.e. apprehensions of loans turning into non-performing assets (NPAs) and uneven payment patterns. As per the ministry of labour and employment, 65%-70% of the workers in urban areas are employed in the unorganised sector. Since they are paid in cash and lack formal documents of identification, address and income, they remain underserved by HFCs.
Housing loan disbursals by HFCs
The present models on which affordable housing is being created to concentrate on the ability of people to buy. This model does not guarantee that the beneficiaries of such projects are the actual needy people or speculative investors, the report said.
Maruti Suzuki's total passenger car sales in June in the domestic market increased by 23.11% to 70,977 units from 57,653 units in the same month of 2011
New Delhi: The country's largest carmaker Maruti Suzuki reported 20.30% jump in total sales at 96,597 units in June.The company had sold 80,298 units in the same month last year, Maruti Suzuki India said in a statement.
In June, Maruti recorded domestic sales at 83,531 units, compared to 70,020 units in the year-ago period, registering a rise of 19.30%.
Similarly, Maruti's exports went up 27.13% to 13,066 units last month from 10,278 units in the year-ago period, the company said.
Total passenger car sales in the domestic market increased by 23.11% to 70,977 units from 57,653 units in the same month of 2011, it added.
Sales of the company's mini-segment cars, including the M800, A-Star, Alto and WagonR, fell by 10.44% to 34,198 units during the month from 38,183 units in June, 2011.
However, in the compact segment (comprising the Estilo, Swift and Ritz models), Maruti witnessed a 39.32% jump in sales to 22,624 units from 16,239 units in the same month a year ago.
Sales of Maruti's DZiRE model increased by over five-fold to 13,741 units in June from 2,486 units in the same month last year, it added.
Maruti's mid-sized sedan SX4 sales slipped 42.78% to 408 units last month from 713 units in June 2011.
Luxury sedan Kizashi witnessed 81.25% fall in sales at 6 units as against 32 units in the year-ago month.