For the last ten years, Majeed, a 45-year-old father of four school-going children from Kerala’s Palakkad district, was forced to live a secluded life, hiding his face from the world. The reason: the man had cancer affecting the left side of his lower jaw that resulted in a jaw tumour so large, it is rarely found in medical literature. Thankfully, Majeed’s life changed for the better a few days ago when a team of 12 surgeons at Kochi’s Amrita Institute of Medical Sciences (Amrita Hospital) removed the humongous deformity – weighing a whopping five kilos and measuring 20 x 15 x 10 cm – in a surgery that lasted 12 hours.
The tumour started growing on Majeed’s lower jaw in 2008 and protruded out to the left. The dense collection of bone and fibrous tissue led to a grotesque appearance of his face and enormous difficulty in swallowing and speaking, in addition to the social stigma. From being a social activist loved by all for his willingness to people, he became a recluse and stayed confined to his house. He and his family became dependent on the benevolence of others even for basic needs of life, as he could not go to work and people began making fun of his appearance.
Majeed was treated at a reputed cancer centre in Kerala where a part of his jaw was removed. However, there was a recurrence of the disease two years later and he had to undergo yet another surgery. He did well for a few years, but developed the disease on the other side of the jaw three years ago. Since the disease was extensive and reconstruction difficult, he was suggested palliative chemotherapy. Despite continuing with chemotherapy for several cycles, the swelling on his face continued to enlarge, making his life unbearable. That is when Majeed heard of a similar surgery done at Amrita Hospital, and decide to visit Kochi for treatment.
Said Dr. Subramania Iyer, Chairman and Professor, Plastic Surgery and Head & Neck Surgery, Amrita Institute of Medical Sciences, Kochi, who led the team of surgeons: “Majeed underwent a PET CT scan to determine the extent of the spread of the disease. Since it was found confined only to the jaw, we had extensive discussions with our tumour board and considered curative treatment for the patient. Majeed and his family decided to go for surgery despite being advised that the results may not be very good in the long term regarding disease control or having a good cosmetic and functional outcome. This is one of the largest ever reported lower jaw tumours of its kind. The huge mass was leading to grave complications. If the condition had persisted, Majeed would have found it impossible to use his mouth.”
The removal of the tumour as well as reconstruction of the lower jaw was a great challenge. Surgeons had to carry out the procedure without endangering Majeed’s life. It involved detaching the tumour from the skull bone and keeping the reconstructed jaw in place. The tumour’s removal was complicated due to its huge size and the involvement of the entire lower jaw. The amount of blood loss was a cause of worry, but this was controlled by temporarily blocking blood vessels to that part of the face.
Said Dr. Subramania Iyer: “The tumour including the entire remaining lower jaw was removed. Reconstruction had to be meticulously planned. Micro-surgical transfer of Majeed’s leg bone was carried out to construct a new lower jaw. The patient regained the function of normal eating and talking within a span of three weeks after surgery. The surgeons reconstructed his lips and he was discharged. Majeed’s tumour has been removed fully and he has been started on chemotherapy for the next two months to prevent it from coming back.”
After the successful surgery, patient Majeed said: “Because of this huge deformity on my face, my whole life had collapsed. I began staying indoors as people would be repulsed by my appearance and make fun of me. It is a huge relief to get the tumour off my face – it is almost like a second birth. If the tumour would not have been removed, my life would have been in danger as the cancer could have spread to other areas including my lungs. My tumour has been removed completely. I am truly grateful to the doctors of Amrita Hospital for enabling me to lead a normal life.”
India is currently suffering from a multi faceted burden of disease — the unfinished agenda of infectious diseases; the challenge of non communicable diseases (NCDs), linked with lifestyle changes; and the emergence of new pathogens causing epidemics and pandemics. NCDs and injuries together have overtaken infectious and childhood diseases in terms of disease burden in every state of the country, posing a new challenge to public health.
NCDs today account for 61.8% of all deaths in India, followed by communicable diseases (27.5%) and injuries (10.7%). While infectious and associated diseases made up majority of disease burden in most of the Indian states in 1990, this was less than half in all states in 2016. The health system of India is largely geared to address only acute disease as of now, and there is a need to change this tendency to include the rising pattern of non-communicable diseases.
This was said by experts in public health assembled at the two-day International Public Health Conference held at the Amrita Institute of Medical Sciences during November 02 -03, 2018. The event has brought together dozens of experts from the government, NGOs, global health bodies and the corporate world to discuss the challenges facing public health in India, including universal health coverage, cancer, cardiovascular disorders, dengue, snake bites, oral health, diabetes, and mental health.
Said Dr Vijaykumar, Chief of Public Health and Community Medicine, Amrita Hospital “India’s public health situation is problematic, with underfunded and overcrowded hospitals and inadequate rural coverage. This is despite increasing demand due to the growing incidence of age and lifestyle-related chronic diseases. The Indian healthcare sector today witnesses 50% spending on inpatient beds only for lifestyle diseases. In addition, the country has 65 million diabetes patients, among the highest in the world. This has resulted in the rapid development of super-specialty hospitals to combat lifestyle diseases. The rapid growth of the private health sector has come at a time when India’s public spending on health at 0.9% of GDP is ahead of only five other countries in the world – Burundi, Myanmar, Pakistan, Sudan and Cambodia. Only 33% of Indian healthcare expenditure in 2012 came from government sources. Of the remaining private spending, as much as 86% was out-of-pocket. Over 40% of all patients admitted in Indian hospitals have to borrow money or sell assets to cover their medical expenses, and 25% of all farmer patients are driven below the poverty line by catastrophic healthcare costs.”
Talking about the most pressing diseases impacting public health in India he added: “While the biggest killer of Indians in 1990 was diarrheal disease followed by ischemic heart disease, today this order has got reversed. Lung diseases have also grown rapidly among the Indian population. Chronic obstructive pulmonary disease (a group of lung conditions that cause breathing difficulties) has climbed the charts to become the second deadliest killer of Indians today, up from number 5 in 1990. Diarrheal diseases, cerebrovascular disease, lower respiratory infections and tuberculosis, in that order, remain the other four leading causes of death of Indians today. While the per person disease burden dropped in the country by 36% from 1990 to 2016, major inequalities remain among the states, with the burden varying almost two-fold between them. Child and maternal under-nutrition is still the single largest risk factor in India, responsible for 15% of the total disease burden in 2016.”
The experts recounted the enormous challenges in improving the overall public health in India. Dr Prem Nair, Medical Director, Amrita Hospital opines: “India is presently in a state of transition – economically, demographically, and epidemiologically – in terms of health. Apart from the high disease burden, other challenges in improving public health include low government expenditure on health, the shortage of human capital in the healthcare industry, lack of private-public partnership, absence of an organized health system, inefficient public health workforce, non-usage of modern technology by public health system, and lack of access to marginalized populations.
The experts also deliberated upon the ways to meeting these challenges. Said Dr Ashwathy, NCD expert, “Investing more in health as well as disease prevention and health promotion should be the topmost priority. The government expenditure on health should increase to at least 2.5% of GDP by 2025. The existing government healthcare infrastructure needs strengthening to improve the process of service delivery. The emerging epidemic of non-communicable diseases needs to be addressed. India has one of the lowest densities of health workforce in the world, including physicians (7 per 10,000 population) and nurses (17.1 per 10,000 population), as against the global average of 13.9 and 28.6, respectively.”
The experts said that while Ayushman Bharat Yojana is a big step in public health and a harbinger of change, the road to universal health coverage will not easy in a country like India. It depends on how fast and how well can the government evolve this scheme with the changing and emerging healthcare needs of Indians.
Said Dr Vijayakumar: “Ayushman Bharat signals a shift of focus of the government from particular diseases and reproductive and child health to comprehensive primary healthcare. There is heavy involvement of the private sector in this scheme. Yet, several issues remain. The program is being launched without much preparation and there is lack of focus on reform of the broader healthcare system. Package rates under Ayushman Bharat for various procedures and interventions are deemed too low by private hospitals. It caters to only inpatient expenditure, while outpatients and medicines are not included in the program. Without effective and comprehensive primary healthcare, pouring money into hospitalization at the secondary and tertiary level will only lead to an increase in overall health expenditure.”
The lack of restrictions on access to antibiotics and their irrational use, non-standardized microbiology laboratories, use of antibiotics in animal husbandry and fisheries, and lack of sanitation are leading to widespread antibiotic resistance in India, and there is a danger of the country slipping back into the pre-antibiotic era. The situation can become alarming considering that the crude infectious disease-related mortality rate in India is 416.75 per 100,000 persons, which is about twice the prevalent rate in United States (World Bank data). There is also a 15-times greater burden of infectious diseases per person in India than in the UK.
This was said by experts in antimicrobial resistance (AMR) from India and abroad who are in Kochi to participate in the two-day ‘International Conference on Antibiotic Stewardship and Infectious Diseases,’ to be held at Amrita Institute of Medical Sciences on October 27-28, 2018. They highlighted the importance of ‘Antibiotic Stewardship,’ which means a combination of practices to rationalize antibiotic use through the right dose, right drug, right duration, right frequency, right patient and right indication. Rationalizing the use of antibiotics is essential to reduce the burden of infectious diseases, the experts said at the event, which saw the participation of ten prominent international speakers from the UK, the US and South Africa.
Said Dr. Sanjeev K Singh, Medical Superintendent, Amrita Institute of Medical Sciences, Kochi: "Over-consumption of antibiotics is rampant in India. A recent study in Kerala has found that 89% of all doctors prescribe antibiotics on daily basis. Hence, when a patient suffers from, say, symptoms of upper-respiratory infection, diarrhoea or vomiting – which usually indicate a disease that is viral in nature and therefore should not be treated with antibiotics – the patient gets prescribed a course of antibiotics. It therefore comes as no surprise that India consumes the highest volume of antibiotics in the world.”
He added: “Internationally, the spread of antibiotic resistance is high too but the access to antibiotic drugs is controlled and a third party monitors their use and consumption, leading to rational practices. An Antimicrobial Stewardship Program along with good Antibiotic Prescription Practices (GAP) is an effective strategy for optimization and rationalizing the use of antimicrobials. All healthcare professionals in India need to be educated on rational antibiotic prescribing. This, along with effective patient education to not take antibiotics unnecessarily, can help optimize the use of antimicrobials in Indian hospitals. Such optimization is urgently needed considering that as many as 90% of the estimated antibiotic resistant deaths in the world come from low and middle income countries. However, the challenge is that, presently, there is a lack of data regarding infection control practices in Indian hospitals and their hygiene and sanitation is poor. There is also an absence of standardization around these aspects in hospitals across the country.”
Added Dr. Arjun Srinivasan, Associate Director, Healthcare Associated Infection Prevention Programs, Centers for Disease Control and Prevention, US Dept. of Health: “Antibiotic resistance poses an urgent threat to health of the world. The loss of effective antibiotic therapy threatens to make once-treatable infections deadly again and jeopardize the delivery of modern medicine. One of the best ways we can preserve the power of life-saving antibiotics is to improve the way we use them, a concept known as ‘antibiotic stewardship.’ Its goal is to ensure that everyone gets the right antibiotic when they need one. Improving access to effective antibiotics as well as the way we use them will require partnerships between the public and private sectors, as well as engagement from patients.”
Said Dr. Alison Holmes, Director of the NIHR Health Protection Research Unit at Imperial College, London, and Public Health England: “Individually and collectively, we all have responsibility in preserving the effectiveness of antibiotics, which means we must use them wisely and that we must also reduce the need for antibiotics by maximizing action to prevent infections from occurring.”
Talking about the challenges of early and accurate diagnostics of infectious diseases, Dr. Sanjeev Singh said: “The results of traditional bacterial cultures and antimicrobial susceptibility testing, which may take up to several days to obtain, remain one of the major barriers to providing optimal therapy. Currently available lab parameters like the white cell count and C Reactive Protein are non-specific. These surrogate markers may not lead to definitive treatment, but rather an empirical treatment. Advancements such as rapid diagnostics, the syndromic approach which uses multiplex Polymerase Chain Reaction (PCR) to rule out infections, better diagnostics for virology, and the use of better markers like procalcitonin can help in the early detection of infections.”
He added: “Despite the rising antibiotic resistance, I do not believe that the world will enter the post-antibiotic era due to improvements in technology and the use of rapid diagnostics. If indeed, such a state is reached, then measures like good hygiene practices, safe disposal of waste, vaccination for vaccine preventable diseases and good infection control practice can aid in treatment.”
The Amrita Institute of Medical Sciences instituted an Antibiotic Stewardship Program four years back, which has led to significant reduction in the use of high-end antibiotics. “We have achieved reduction of Colistin prescription by 74 %, Linezolid by 86%, and Dorpenum and Ertapenum by 34 and 38%, respectively. Mortality has been reduced by 24% and cost-benefit because of implementation of our Antibiotic Stewardship Program is Rs 2.3 crore in a year. In addition, the Healthcare Associated Infections have dropped significantly for ventilator Associated Pneumonia (64%), Blood Stream Infections (34%), Urinary Tract Infections (23%) and Surgical Site Infections (32%),” said Dr. Sanjeev Singh.
Amrita Institute of Medical Sciences is also playing a key role in the implementation of Kerala Antimicrobial Resistance Containment Plan along with the Indian Medical Association. It has till now trained 122 trainers and is going to run capacity building in all 14 districts of Kerala over the next six months.
One out of every five students in Kerala in the age group of 12-19 suffers from psychological distress, with its severity ranging from mild in 10.5% of students to moderate (5.4%) and severe (5%). Studies across the state have also revealed the prevalence of physical abuse (75%), emotional abuse (85%) and sexual abuse (21%) among school-going adolescents, which are prime factors in triggering mental illnesses. This was said by Dr. Dinesan N, Professor, Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, at a workshop on mental health problems among young people.
According to WHO, 10-20% of all adolescents worldwide (youngsters between 10 to 19 years) experience mental disorders. Half of all these mental illnesses begin by the age of 14 years, and three-quarters by the age of 20 years. Suicide is the leading cause of death among 15-20-year-old youth. The burden of depression has increased by 67% between 1990 – 2013; by 2025, it is projected to rise by another 22.5%.
Dr. Dinesan N said: “Most of the time, youngsters are not able to cope with stress and use a variety of coping mechanisms like substance abuse. In Kerala, the prevalence of alcohol among adolescents is found to be 15% (23% in boys and 6.5% in girls), with prevalence increasing with age. The prevalence of tobacco use is 6.9%, and the mean age of onset of use is 14 years. Bullying, depression, substance abuse, and suicide are major challenges facing today’s youth.”
He added: “Adolescent depression is on the rise, but most of the time, it goes undetected with symptoms like irritability, anxiety and poor performance in studies. Traumatic events in early childhood, frequent migration, negative life events, educational setbacks, early relationship problems and stress at school and family are all linked to depression among children and adolescents. Early identification and treatment are the key to improving the mental health and quality of life of such patients.”
Talking about suicides among youth, Dr. Dinesan N said:“Suicide is the second leading cause of death among youngsters in the age group of 15-29 years. About 78% of global suicides occur in low and middle income countries. Ingestion of pesticides and hanging are the most common methods to commit suicide among young people. The link between suicide and mental disorders is well established, but in adolescents, suicide mostly occurs on an impulse.”
Dr. Dinesan N also highlighted the menace of substance abuse among today’s youth, which is on the rise, with 40-70%of adolescents in India exposed to some form of substance abuse before the age of 18 years.“Addiction to drugs at an early age leads to many high-risk behaviors like gambling, stealing, fighting and other antisocial activities. Parents, teachers and friends of children facing substance abuse need to help enhance positive self-esteem among them and be supportive. It has also been found that the increased need for gadgets and technology in adolescents has given rise to impulsivity and reduced ability to concentrate. Children unable to delay gratification is predictive of low performance in later life.”
Talking about the importance of inculcating a spirit of resilience in today’s adolescents to overcome mental illnesses, Dr. Dinesan N said: “Resilience is the ability to successfully cope with the various challenges and opportunities in life. It does not mean that individuals do not suffer emotionally when faced with a life circumstance; it means they are able to apply competencies which they have learned to deal with challenging circumstances. By doing that, they are developing new skills which they will be able to apply in future situations. Having supportive relationships and an ability to manage emotions and ask for help contribute to resilience.”
A Donor-Recipient Meet involving families of organ-donors and recipients of the organ donation and their families was conducted at the Amrita Institute of Medical Sciences. The Hon. Health Minister of Kerala, Smt. K K Shailaja , presided over the function. Administration teams from local bodies who helped with the organ donations were also present.
Fr. Davis Chiramel , President, Kidney Foundation of India, Fr. Reju Kannampuzha, Asst. Director, Little Flower Hospital, Dr. Prem Nair , Medical Director, Amrita Institute of Medical Sciences and Dr. Subramania Iyer K., Head, Dept. of Head and Neck Surgery, Amrita Institute of Medical Sciences spoke at the event.
Speaking on the occasion, Hon. Health Minister Smt. K K Shailaja said: “Caring and interdependence among members of the society as well as proper communication and awareness are the basic factors that can encourage organ donation in Kerala. We have seen an increase in the number of complaints regarding organ donation recently. In the past 1-2 years, our statistics have shown a decline in organ donation numbers. Though the numbers for organ donation for live donors through informed consent have grown, there has been a marked decline in organ donation from brain-dead donors. To counter this, the process of regulating organ donations from brain dead donors has to be made speedy.”
Dr. Prem Nair, Medical Director, Amrita Institute of Medical Sciences, added: “The aim of this donor-recipient meet was to send out a positive message to the society that concerted efforts from everyone can encourage organ donation and help save several lives through this noble deed. This message is especially important since the organ donation drive in Kerala is at its lowest ebb in recent years.”
Said Dr. Subramania Iyer K, Head, Dept. of Head and Neck Surgery, Amrita Institute of Medical Sciences: “This Meet was very much needed because the instances of organ donation after brain-death have been very low in Kerala for the past few years. The main reason is several unnecessary and unhealthy misconceptions raised and publicized through social media regarding brain death. To counter this, the government brought in more stringent criteria for declaration of brain death. But this has not helped to improve the situation, as the general willingness of all concerned to encourage and facilitate organ donation has not picked up.”
The 29-year-old Arunraj, a donor, hailed from Ambedkar Colony in Vengoorkara, Angamaly, Ernakulam. Son of Mr. Rajan and Ms. Seetha, he was working as contract employee at Cochin airport. He was socially involved in activities related to DYFI. Arunraj became brain-dead after being involved in a road accident, and was being taken care of at the Little Flower Hospital, Angamaly. He was identified as a potential organ donor and his family consented for the same. His heart was transplanted to a patient in Chennai, liver to a patient at Amrita Institute, pancreas and one kidney to another patient at Amrita institute, other kidney to a recipient at Kottayam Medical College and both hands to a 49-year-old lady at Amrita Institute. All these transplanted organs and patients are now doing well.
This organ donation which saved five lives becomes noteworthy in today’s context, since it was made possible by the efforts of numerous agencies. Foremost, was the willingness of the donor family which was catalyzed by the efforts of family friends and social activists. The role of the Little Flower Hospital was another helpful factor.
The local body administration, from the ward member to the municipal chairperson and Angamaly MLA and the Kerala Network for Organ Sharing (KNOS) were involved throughout. The stellar role played by the office of the Kerala Health Minister in mobilising the government doctors’ support for certification and transfer of the organs, as well as sustaining the motivation of the family to tide over the delay in the release of the body was noteworthy.
During the meeting the mother of the donor Arunraj, his father and his brother were felicitated by the Hon. Health Minister and the recipients. All persons and institutions who helped to make this organ donation were felicitated for their role. The role of the Hon. Health Minister and her office in streamlining the process was also highlighted.