The whirlwind that started after a Pakistani child had her hole in the heart closed in Bangalore some time ago continues to create ripples everywhere, and rightly so. This has brought man and man together despite the fact that the politicians, for their own ends, want to keep man away from man. Pakistanis, Indians and, for that matter, the whole of mankind, are but one large family declares the Sanaathana Dharma, anyway. Rg. Veda, that embodiment of all that is good and pure, declares that this world would have people following different religions and talking different languages, but they are all brothers. One has to feed all of them equally well.
“Janaahaha naanaa dharmaneeyam, naanaa vaachasam………………”
Rg. Veda also reminds us that mankind needs to be reminded of this truth from time to time. Two imaginary rivers talk to a Sage in the Rg.Veda, thus: ”Oh! Sage, let thy resounding voice of sanity reverberate again and again for centuries to come.
Although technology has transformed this world into a small neighborhood, mankind is yet to broaden its heart to make it a brotherhood. All religions preach the same truth that God is love and man should love his fellowmen in order to love God. However, this remains only in the books even to this day. Time was when I was a boy we never knew that there are people of different religions. We all lived like brothers and sisters. Today the media reminds us, even if the politicians, for a change, take a holiday from their mechanizations, that there is a vast gulf between the people of different religions, ethnicity and what have you. The media could do a lot by ignoring minor skirmishes in this direction to prevent major communal riots and thus contribute to peace on earth.
The fanatics, who live on this hatred, take advantage of the media publicity and add fuel to the fire, keeping it burning. Most terrorists are but people who are deprived of their basic needs and kept suppressed. The rich try to keep the poor under their control if they could help it for their own gain. Little does mankind realize that hatred begets hatred and the policy of an eye for an eye would leave all of us blind at the end of the day. The media has a large share in this game of hatred the world over. If only that minority who hate others do not get any media publicity then whole game of man hating man would eventually die down. Monetary economy, run by the economists-the heartless beasts that they are, wherein competition, resulting in subconscious jealousy, leaves a bad taste in the mouth of all concerned. Just as science is not bad but there could be bad scientists, there could be bad economists although the original idea of Adam Smith about wealth was altruistic.
Today money and market forces run this world. The terrorists run a parallel black economy unbeknownst to them. Drugs, money laundering, and many other crimes are thriving on this business of hatred. Innocent but deprived youth are attracted to crime as an easy way out. Initially, these youth are forced into crime under the threat of death. After a while these misguided young men, having killed a couple of people under duress, get inured to the act. Killing no longer evokes any feelings of guilt. It is like killing a fowl or a sheep for food. Killing another man is no different. In this background the efforts of the Bangalore group of philanthropic doctors is laudable. I am also happy that some of them are my old students and it makes me doubly happy.
The media has really gone to town painting a very flowery picture of the whole game in a slightly different way. Cardiac surgery, in itself, has been painted as the panacea for mankind’s ills. A hole in the heart of a child, many times, closes by itself, if nature is allowed to function without our efforts. But a lot of other complicated congenital defects do not do so as nature, probably for reasons best known to itself, keeps it that way. With all our “so called” advances in modern medicine we have not been able to unravel the mysteries of nature fully. In the latter case of complicated cardiac defects life of the hapless victim could definitely be made much better by elaborate corrective surgery: many of the latter procedures still carry very high peri-operative mortality, though. Poverty being the mother of most, if not all, ills of man it is the poor who suffer most illnesses. I do not know of any hospital, except the one run by Bhagwan Sai Baba in India, where totally free cardiac surgery is done for the really poor. The Pakistani child was neither poor, what with the father working in Saudi Arabia and the uncle practicing medicine in Boston, nor was the hole so complicated that it could not be done anywhere else.
While there are many centers of excellence in cardiac surgery in our country, cardiac surgical help for the really needy is hard to come by. Centres of excellence live on the ignorance of the gullible public and the equally ignorant media. Right from the day Christian Bernard did the first heart transplant in 1969, till to date cardiac surgery is being made much of by the media. While technically replacing a breast bone, the sternum, is much more difficult compared to doing a coronary bypass operation, the media and the public still believe that cardiac surgery is very romantic. Heart has always been the organ of mystery and romance. Time was when people thought that the heart was the seat of human emotions. Words like kind hearted, hard hearted, large hearted, heartless, sweet heart etc. came out of that mistaken notion. The media’s romance with heart surgery comes out of similar misconception. Unless one demystifies this myth it would continue forever. A short history of cardiac surgery since the first much publicized heart transplant, would go a long way in clearing this mist.
Christian Bernard wanted to be the first cardiac surgeon to do the transplant, although he had nothing to do with the technique himself. His erstwhile chief, Norman Shumway, and, to a certain degree, that father of British cardiac surgery, Sir Russell Brock, were the ones to be remembered for that innovation. The much-harassed government of South Africa in 1969, having lost all its credibility in the world community because of its apartheid policy, gave all encouragement to Bernard to go ahead. An ideal recipient, Dr. Blaiberg, with intractable heart failure, was on the threshold of death, despite all the known treatments at that time.
The reason why Shumway did not perform heart transplant in 1969 was that the prevailing wisdom then was that for a transplanted heart to survive and take in the recipient the donor heart must be taken from a living donor. For obvious reasons living heart donors were difficult to get. For Bernard, who had picked up the method from his boss and itching to do one first, South Africa’s Groote Schoore Hospital was heaven.
He was literally poaching for a donor in the wards. Fortunately for him there was a nineteen-year-old boy admitted with head injury sustained while diving in the swimming pool. The boy had a massive sub-dural haematoma and remained unconscious despite the clot having been removed. After a week’s coma Bernard was pestering the neurologist, Raymond, to declare this boy brain dead. In the absence of a definition of brain death at that time (not that it is perfect now) and being a humane neurologist having seen many unconscious people come back to life even after weeks, Raymond refused all kinds of pressures on him. Bernard was getting restless and thinking he might lose this golden opportunity, used his political clout with the government to get Raymond declared “friend of the communists”, a label that would get Raymond and his family deported within hours from South Africa of 1969. Having achieved his aim of sending Raymond away for good (he retired to his native Australia) Bernard got the heart removed very easily and did the first heart transplant. The transplant technique was nothing great and the operation was successful. However, the recipient, Blaiberg was anything but better. The world did not know the truth. The media were given “sexed up” photographs of the patient swimming days after the operation, while, in truth, the photographs were taken with a swimming pool like thing constructed around the patient’s bed in the intensive care unit.
The media went to town with all kinds of half-truths and falsehoods. The world leaders started praising Bernard and the government of South Africa gave him millions of dollars to go round the world to lecture about his great feat. South Africa could come out of its untouchability to a great extent because of this and Bernard became filthy rich. Let us not go into more details, as it will expose more skeletons from the cardiac surgical cupboards of such over ambitious surgeons. Not surprisingly, in the next one-year sixty-four heart transplants were performed in 24 countries around the world. Most, if not all, recipients, of course, met their maker soon after the operation, with a transplanted heart in situ. India did rank fourth in 1969. Credit and genuine praise must be given to Prof. P.K.Sen, who did that operation in Bombay, as he did admit that the operation was successful but his patient died. He did neither get that kind of money nor did the poor chap, an excellent and very devoted scientific cardiac surgeon that he was, get any media publicity of the type we see today. He disappeared from the scene when he retired without even a mention in the media.
This brings to mind the famous saying of Aristotle: “ Truth could influence only half a score of men in a century, while falsehood and mystery would drag millions by the nose.” In most heroic surgeries, the real hero is the poor patient who submits himself to the surgeon.
Rheumatic fever is the greatest curse on the poor children of this country even today. This is a minor clinical syndrome in children, which “only licks the joint but bites the heart.” It starts as a simple infection of the throat with an ordinary germ-the streptococcus-that might present clinically with sore throat, fever and, sometimes, mild joint redness and swelling, awkward limb movements (chorea) and malaise. Many times these minor symptoms could be absent and the whole infection of the throat by this germ might go unnoticed until after a few years, ranging from a couple of years to twenty years, when the victim could develop signs and symptoms of the involvement of the heart. This process makes the body’s immune cells, that had learnt to kill the sore throat germ streptococci years ago, mistake the cells of the heart to be their enemy and attack them mercilessly-an intriguing way how our own body becomes the victim of our army (immune system cells)-horror auto-toxicus. This remains an enigma even to this day despite lots of work being done by Dr. Bywaters and his colleagues at the Red Cross Hospital in Taplow, England. They have stopped their work now as the problem disappeared with better living conditions for the poor in that country. Rheumatic fever is rarely seen in that country now where it was as common before the1950s as in India today.
The heart is the seat of final assault in rheumatic fever, some times years after the forgotten streptococcal throat infection. Germs are not man’s enemies. They are our friends. They attack man only when man lowers his immune guard. In the case of children in the poor homes the immune guard comes down because of bad nutrition, damp homes, appalling living conditions etc. The west has been able to eradicate rheumatic fever completely because of better living standards for their masses. We need to do the same since rheumatic heart disease, the final assault of the man-germ fight, is the biggest curse on our poor masses. Large numbers of these children, with deformed heart valves, go from pillar to post with advanced heart failure when a simple corrective surgery with or without artificial heart valves would make life tolerable to these poor souls.
But there are no heart surgeons who would be interested in the poor valve victims as the procedure is expensive and the patient is too poor to pay. Most surgeons and hospitals would be interested in operating on the rich and the middle class for coronary artery blocks and congenital defects. In the latter case, in addition to money, the hospital gets free media publicity. Recently, Tenet Hospital in Redding, California, had to close its cardiac surgical unit after being investigated by the FBI following a complaint by a priest that unnecessary heart surgeries were done there. The FBI found that more than half the coronary surgeries done there were done for money even without any indications. The hospital has now settled the suit out of court by paying $ 54 million, the largest ever payment in health area in America. However, Tenets’ other units in America are under scrutiny by the FBI. This happened last week. If that were the case in the US one could imagine the percentage of unnecessary operations in India! I do not know if the Indian media ever got scent of that important news! Many leading world leaders in cardiology had called earlier for closing some of the cardiac centers for the good of humanity. Prof. Tom Treasure in London and, my former chief, Nobel laureate Bernard Lown of Harvard, are the two who voiced their concern much earlier.
Real Altruism in cardiac surgery for the poor:
What the media needs to know is that in any third world country today the biggest load of cardiac surgery that really helps the dying patient is the surgery of the common post-inflammatory valve disease, rheumatic fever included. This being a disease of only the poor it rarely gets media attention. The valve surgery of the sophisticated hi-tech variety is today very expensive. No hospital, which is there to make money, could even think of doing such procedures free. To cap it most, if not all, patients with valve disease are really from the lowest economic strata of society. They get the disease because they come from that background, in the first place. Industrialized west, with good food and basic hygienic facilities, has been able to eradicate this scourge totally. I had seen, as a student in London, some of the great cardiac surgeons doing simple operative procedures to relieve the valve disease burden in many of the victims. I could mention two such surgeons, who are still alive, Jack Belcher and Marvin Sturridge, who have pioneered simple closed heart widening of the mitral valve to relieve the obstruction to the onward flow of blood in the left heart, even in the presence of minor damage to other valves, thereby relieving most symptoms of the victim easily. Thomas Holmes Sellers and Tubbs were the other leaders in England, while Michel De Bakey led the American surgeons in this area.
Today’s hi-tech trained surgeons are not able to do that. They avoid doing such simple procedures citing “scientific” reasons that in the day of open-heart surgery it is unscientific to do closed procedures. Their cardiology colleagues are itching to open the valve without surgery using the balloon catheter. The latter procedure could only be done in ideal cases, which are very, very rare. Dr. Jack Belcher and Marvin Sturridge would repeat the closed procedure if needed many times over and keep the patient going for decades! The closed procedure could help such poor patients even now. But who would listen? Market forces run the world. The present market forces encourage surgeons to go for open procedures. Each open procedure involves disposables alone worth thirty thousand rupees for the industry. In the bargain, the poor valve disease patient does not get either.
In this drama the media plays the negative externality game of the economists. By publicizing the romantic procedures the media adds to the burden of the poor. If the media gets a judicious view of the whole scenario they could contribute to popularizing the simple methods that could help the poor. Media will then have produced positive externality and helped the poor. India needs valve surgical set ups in the free category for many more years to come, unless the government wakes up to the real health needs of the country. In our country health care is mistaken for medical curative methods. Hospitals are thought to be the real need of the hour. Every politician worth his salt wants a five-star hospital. Studies in the west have shown clearly that more hospitals and more doctors make for lower standards of health and lower life expectancy! The real needs of the country for the masses are clean drinking water, three meals a day uncontaminated by animal and/or human excreta and, avoiding cooking smoke coming into the house. A warm clean house with a toilet would eliminate the deadly hookworms as also abolish valve disease producing rheumatic fever in children. People who endeavor to do these and save millions of lives do not get media publicity, as it does not make news value for the media. There are surgeons working in villages and with lepers. They rarely get mentioned in the media.
The media must understand the entire scenario in the medical world and try and take an altruistic but holistic view of the problem to be able to project the right ideas and views for the public and the politicians to understand. Many of the latter get their continuing education from the media only. Consequently, the well-meaning people in the media have a great responsibility to society to make life easier for all of us. To get back to the analogy of terrorism, the dynamics of terrorism is simply that the poor try to beat the hi-tech armies of the great powers with their rustic suicide bombers since they cannot afford to protect themselves by competing with the rich and the powerful. This shows how the good ideas of Adam Smith of competition to help people live a better life with more wealth are destroyed by the market forces giving place to greed to amass wealth. Terrorism is raising its ugly head to undo the damage with low-tech methods. Similarly, in cardiac surgery to do most good to most people most of the time, one needs to go low-tech and help more people. These are not crazy ideas from an idealist, but these are mundane thoughts to make life easy on the planet for the less fortunate. There are enough and more centers and surgeons to close the holes in the heart but we need people to try and help the dying valve victims in larger numbers.
More than all that, we need people to understand that better living standards would eliminate most of the valve problems. Let us do the less publicized but humane methods in medical care instead of the media savvy hi-tech but top-heavy procedures, which would reach only the rich. True inverse care law in operation. One would want better sense to prevail sooner than later in this large country of ours where basic health needs are not available to the majority today. Have a heart!
(Belle Monappa Hegde often abbreviated as B. M. Hegde (born 18 August 1938) is an Indian medical scientist, educationist and author. He is a retired Vice Chancellor of the Manipal University and the head of the Mangalore Chapter of Bharatiya Vidya Bhavan. He has authored several books on medical practice and ethics. He was Professor of Cardiology [Visiting] London University since 1982. He was Emeritus International Advisor to The Royal College of Physicians of London and Edinburgh. He was First Indian examiner for MRCP [UK] examination in the UK from 1988 to 1998. He was MRCPI examiner in Dublin since 2000 till 2009. He served as President of World Academy of Authentic Healing Sciences, Mangalore. He has been a Non Executive & Independent Director of Zydus Wellness Limited since July 29, 2009. Dr. Hegde has 47 years of teaching experience to undergraduates and postgraduates. He has been a professor of Medicine since 1973. Dr. Hegde, an elected fellow of the National Academy of Medical Sciences, has won Dr. B. C. Roy National Award in the category of an Eminent Medical Teacher, Dr. J. C. Bose Award for Life Sciences Research, PRIDE OF INDIA Award from the Pacific Association of Indians in California and many more. Dr. Hegde is Padma Bhushan awardee 2010. He is MBBS, Ph. D. [Hon. Causa], MD, FRCP [London], FRCP [Edinburgh], FRCP [Glasgow], FRCPI [Dublin], FACC [USA] and FAMSHe is also the Editor in Chief of the medical journal, Journal of the Science of Healing Outcomes. He was awarded the Dr. B. C. Roy Award in 1999. In 2010 He was honoured with a Padma Bhushan, one of India’s highest civilian awards. Hegde is visiting faculty at many universities. Email: email@example.com)
(See also earlier articles By Prof. B. M. Hegde
Do We Need More Drugs For Hypertension? In countercurrents , 17 May, 2016