MOHSIN WALI, a renowned cardiologist presently associated with Sir Ganga Ram Hospital, was the only physician to have served three presidents of India R. Venkataraman, Shankar Dayal Sharma and Pranab Mukherjee. A Padma Shri awardee, Wali was a Fellow of the American College of Cardiology as well as the World Health Organisation. With degrees like MBBS, FIAMS, FGSI, FIMSA, MRCP, FICP, FRCP, FACC, MD, FIACM, Wali is on the Maternity and Welfare Division of the Indian Red Cross; earlier he was on the editorial board of the Indian Heart Journal. He is a fellow of the International College of Nutrition and a member of the organisations such as New York Academy of Sciences. In an interview with MOHD NAUSHAD KHAN, he said lifestyle diseases are a major threat to our healthcare.
What would you like to say to people with cardiac problems when there is severe air pollution and how its impact could be minimised?
Well, this is a very bad situation, and I would say this is the result of the negligence of decades which has led to this level of pollution. Some patients of mine who had come from Sri Lanka told me that their air quality index today was 41 while ours was average 400 today. Sri Lanka can do and we can’t do because there is no political will. People are not as concerned as they should be. Farmers are not educated. I told a TV channel that people who lift garbage in the trucks are not trained. They are untrained and unskilled labours and they do not know how important is to cover it. So there is a primary lack of education in every sphere. People are dying in manholes; they are not educated and trained as well.
Training is more important than education. Training is deficient in each sphere and this is a tragedy of our Independent India. It has not happened in one day but over the decades. I have a baby in my house who is two months old; I feel very sorry about that baby taking this bad quality air. What a crime he has done and there are millions and millions of babies throughout the country. Older people, asthmatics patients, heart patients. As you have asked about heart patients, let me tell you an ambassador came to me last year during these days and he said, ‘Doctor, I am leaving India’; he was from Switzerland. He said, ‘I am leaving India because I am reading the harmful effects of pollution on the net. It is very harmful to the heart.’ And he left India actually. So it is the reputation of the country going down when people see the hazardous impact of air pollution. Our tourism industry is suffering; our medical tourism industry is also suffering as economy of the country is suffering.
I would like to add here that one of my friends has made a device which can reduce pollution and I am running with him for the last two years from pillar to post of all the government departments. Till recently no government organisation was ready to examine his device. Even though he is not a scientist, he is a common man but the device is working and can be useful. And now we have got the NPL report that the device is clearing 88 per cent of air pollution and certain things it is clearing more than that. It is very useful and even this evening I am going to meet a very important person who will get this device examined and place before the public for use. So there is something deficient in motivation, implementation and realisation as to how important things are. China does artificial air and reduces pollution 20 times. We can also do. So it is a great country with great resources with great manpower but the things are underutilised.
What is the latest advanced research going on to cure cardiac patients and how it can be useful?
Yes, in cardiology we have advanced even in India. There is a lot of recent advancement in medicine in cardiology and recent advancement in the stents we have made. The best advancement is robotic. Robotics has revolutionised the cardiac surgery. Earlier, we used to open the whole chest now we are making a microscopic incision, removing the blockade and doing the bypass. So robotic is a great advancement in cardiology. The other advancement is that we have got Rotablator which can cut the clot in the coronary artery. It is a very high-speed revolving device. Some time there is very dense calcium deposit in the arteries which cannot be ballooned. So we have to cut them. It is like a saw moving at a very high speed. It has got 50 thousand revolutions per second which are electronically computerised controlled and then we are trying to open the arteries. Similarly, as we make bore in wood. It works in the same way. We also have angiogenesis. We make microscopic holes in the heart.
Another advancement that has taken place in the field of cardiology is in Valvular replacement which is called TAVI (Trans Aortic Valve Implantation). Previously we used to do open heart surgery; now we have a foldable valve which can be folded like a paper in pen cover and we push this through the tube and it opens when it goes inside the heart and we set it accordingly and with clips it can be fixed. It had started in France by Alain Cribier, who was a cardiac surgeon. He primarily devised it for an aortic valve that is why it is called TAVI. Now very recently Medanta Hospital and Fortis Escort hospital have started putting this valve in the second valve which is called Mitral Valve which is a very common disease in India. Another advancement is called an artificial heart. These artificial hearts can work parallel with the normal heart in a failing heart. Similar to that we developed a balloon. Suppose a person’s blood pressure is very low then we put a balloon through femoral artery in the thigh and that balloon gives a pulse-like heart pulse. So it augments the blood flow. With each weak heart pulse, it gives its own pulse; so it pushes blood ahead. So this is called Transaortic Balloon Pump.
Then there is cardiac transplant which was started by Christiaan Neethling Barnard. Various centres are doing it. Even in Sir Ganga Ram Hospital at least five to six per year we are doing cardiac transplant. It can be done more, depending on the availability of the heart. We are fighting with the environment of advancement by spending millions of dollars for a disease which we can be prevented with half an hour exercise every day. So this is a diversion of energy to a wasteful expenditure or an expenditure that can be saved. Be it cardiac disease or hypertension, both are preventable. So we have to emphasise on it right from the school level. When we were children, we had fields and plenty of places for other activities but nowadays we hardly find enough space for physical activities. We used to exercise in the first period which was compulsory. This is vanishing. Cycling is also vanishing. These days people hardly do any kind of physical activities. They don’t walk, do no exercise, no games. So this lack of exercise combined with stress, sleep deprivation and two white enemies, salt and sugar are creating all these problems. These problems are 100 per cent preventable.
What are the challenges before the healthcare industry and what according to you should be done to meet those challenges?
Challenges before the healthcare industry are too many. We are a spectrum of society, starting from very poor to very rich. Affordability is an important challenge for all people. Earlier doctors used to charge very less; now it is very high. There was less disease and people became less sick as compared today. We are having mineral water in our hand, a lot of sanitation but still more people becoming sick when there is a lot of medicines and antibiotics and so on. Life expectancy has increased but the health index has come down. Now, we have coronary artery disease at the age of 20 which is called juvenile coronary artery disease which was never there before.
We used to take more food earlier but we used to earn the meal. Earn the meal is my slogan. You have to eat a meal only when you have done enough exercise for the meal taken earlier. Otherwise, we have no right to overeat. Cost cutting, rural healthcare is a very big challenge because India lives in villages. The primary healthcare has not been revamped. There is poor infrastructure. The reason is doctors and nurses cannot live there without minimum facilities. Everybody is moving to the referral hospital which is again a big challenge.
The increasing cases of cancer. You might have heard that difference between smokers and non-smokers has vanished. It is now 50-50. Previously it used to be 30-70 or even less, 20-80. Now everybody who is a non-smoker is smoking the bad air.
Before this interview started, a patient came; he was done open heart surgery in 2010; after two months he was again subjected to stenting. They did not bypass the other artery. They could have bypassed the other artery at the same time. This case is an example of lack of education.
Previously in the 80s, we were talking about brain drain; now there is no brain drain; we have the brain gain. Our doctors have come back and have started working in private hospitals. They are getting good affordable patients who can afford. Educational and awareness problems. People in rural areas do not have education about cleanliness, sanitation, water problems in Kolkata; it is arsenic. Doctors are being watched by the government and they should be watched. I say very easy explanation for this. You don’t need to be watched by the government; you watch yourselves. Do introspection of what you are doing is correct. If you are doing introspection, nobody can harm you.
A headache patient is prescribed MRI and a brain tumour patient is prescribed MRI. Why a headache patient is spending Rs 90,000. He may have headache because of some eye problem, sinus or ear problem or even stress. This simple thing was taught to our generations; it was called either bedside manners or clinical medicine. So the clinical medicine is fading which is another problem. And experimental and investigative medicine is creeping in. That is why the expenditure on medical is increasing. It is so because from the West a theme came which is evidence-based medicine. Suppose I think you have tuberculosis, I get your X-ray and get your sputum test. Then it is called evidence-based medicine. Suppose some a doctor is treating the same patient and he is treating the patient without doing these tests. It is called clinical medicine. So many a time there is no resources we have to apply our wit, our clinical judgement as the judge writes to the best of his wisdom and experience. Similarly, a doctor has to apply his best wisdom and judgement while writing a prescription. That art is under the threat of either being sued or under watch.
Till three decades back no doctors were sued; they were worshipped like God. Now no patient treats a doctor like ‘Bhagwan’. If a patient I have treated just a short while ago has gone happily, it is well and good; but if he dies then the same people would have cursed me without realising how serious the patient was.
We have to do enough investigation because of the fear of being sued. The evidence-based medicine has surpassed the clinical medicine. Insurance is very less in India. In America everybody walks in, he throws the card on the counter and he does not bother about anything no matter how many tests are done or so. A patient has no concern because the insurance pays for it. Then it is the duty of the insurance company that the patient gets the right treatment. Here 80 per cent out of the pocket expenditure. We have good infrastructure but the even distribution of medical infrastructure is not there.
What according to you are the basic difference between Obamacare and Modicare?
Narendra Modi was very impressed with Obamacare. The Modicare launched in India is the biggest scheme in the world. People are debating that from where the money will come for this scheme and how it will be implemented. The basic difference is here the person for which this scheme is selected and made for a population based on a registry (Ayushman Bharat Scheme) of poor people. In America, this is not that case. The second is we have to revamp the medical infrastructure while in America it is already there. These are two major differences. The other may be cover of insurance and so on. And most of the hospitals already existing will be included here. This is a good scheme and India needed it for a good time. The good result will come but it will take some time. Maybe after 10 years we may have the good side of it. At least a sense of security has come in the minds of the people.
The third problem is the GDP difference. India spends a paltry 1.2 per cent of its GDP on the healthcare sector while the USA spends almost 21per cent of its GDP on the healthcare sector. And the GDP spent in India is just over 1 per cent and in America is different. This is a very big difference. The fourth is that in America if a person has got fever, he goes to the doctor on day one but in India, one goes to the doctor when it becomes severe and chronic. So the running cost of the treatment here is increased to five to six times for the same patient who could have been treated very early. I have worked in American, UK and Canadian setups and I know the difference. In vaccination too we have started now and they started decades ago. Another major difference is the demographic difference and racial difference. Both the schemes are good but it depends how it is implemented on the ground and how it serves the purpose.
Any suggestion from you in terms of services and affordability in healthcare?
The medical profession should be kept out of greed because greed is creeping in. It is so because there is a change of setup in the medical education. Our profession starts with medical education. When I was a medical student, the fee was Rs 300 per quarter. These days it is quite high and private colleges charge even more. So a doctor who spends crore of rupees he will not settle for Rs 20 as fees. This is a very unfortunate side of the story. The cost of medical education has multiplied. There is also a lack of good faculty. Our generation doctors; they are few who have acquired bedside manners and clinical knowledge from their seniors which no book can teach. They use tech in the ward in the evening. Earlier there was continuous education climate.
Until 2000, our medical education was like a Gurukul which is not there now. It should come back because it would have good faculty, good teachers, respect for teachers and a sense of togetherness. “Bedside teaching” and “Clinical method” has vanished. There is great deterioration in the whole medical education and even medical system. You might have never heard of MCI doing bad things but you can hear now. Matters are in the Supreme Court. Why the deterioration has taken place. Ye deemak kyon lagi. The termite has crept in all systems but here it means a life of yours and mine. I used to tell my staff that I am treating a life, not a patient. So the termite in the medical system is endangering our lives. The concept of dealing a patient as a life has gone. When we think that we are dealing with life then we will realise the value and treat accordingly.
One big difference is that earlier people who took to this profession had in mind to serve mankind; now that concept has also gone. When doctors are treating patients like business patients, doctors are treating them as commodities. They treat them as consumers and the patients say will sue you if don’t discharge your duty. The tag of a noble profession has gone and now it is no nobler.
What’s your take on India’s performance in medical tourism?
India has been performing before this term medical tourism came in. Lots of patients were getting operated here and we have the best doctors here. Abroad it is a well-known fact that Indian doctors are the best in the world to the extent that our Indian doctors withdraw 100 per cent then the health system of many countries will collapse. But the same doctors who work here, they don’t get the climate to discharge the same duties because there they are very sincere bound by the rules. Here the element of fear is vanishing.
The reason for success in our medical tourism is that here we have no queues for the VIP patient from abroad. They get the best of the treatment and one more factor is that we are cheapest. People have a lot of faith in Indian doctors. Again if we start treating medical tourism only as business or we start creating different rates or slots then the thing will not survive for a long time.
Foreign patients come here and if they do not get the kind of services they aspire for, if they are cheated and not treated properly then it may not go a long way. Let me give you an example, I was shopping in London with our former Prime Minister Mr V P Singh. He used to take me along every weekend when he used to go to London and America for treatment. In one of the stores in London, there was a girl and she was picking up a decorating bawl which was priced at one pound. She was picking it and after seeing it kept it back and repeated it many times. Probably she was not having enough money to buy it. That to me gave a great lesson that a foreigner even if he spends one rupee or pound he thinks many times that how much he is spending. And they audit what they spend; not like we that we don’t care to throw Rs 500 notes and forget. If medical tourism wants to survive in India then my message for them is that they should genuinely be economical to our visiting patients; they should be honest, friendly and should give them the correct opinion. In case if the operation is not required then tell the patient that operation is not required. Because after some time they will start auditing the Indian medical system. If these qualities are there, it will bloom.
Our corporate hospitals should make less profit but they should try to get more numbers. My father used to say when I was a child that I am selling some commodities only because the turnover should be great. Not that I should have great profit. At the same time, the welfare of the employee of the hospital should also be taken into account. This I learned from Sir Richard Branson of Virgin Atlantic from his lecture in India and the only thing I picked up from his lecture is that he said that over and above the passengers I care for my staff. So at the same time, at corporate hospitals we are short of nurses and doctors; unless the corporate hospital is taking enough care of the staffs, the blooming of the medical tourism will not take place. A very important observation I am making while moving around from a government setup to a corporate setup. Also, every hospital should avoid touts.
As you have already talked about robotics, my next question is on artificial advancement in India in healthcare as compared to the rest of the world?
Well, artificial intelligence, also called machine intelligence, in medicine, cannot substitute artificial intelligence in Judiciary in the same way. For research, it can be very useful. When we have to pool the data device methods, select antibiotics select a procedure. But when treatment comes, the robotics is the only dependable way of artificial intelligence and there are four types of robots (Da Vinci Surgical robot, Gamma Knife, Drones-self driving cars can be used for driving trolleys and the Heart Lander). The most important for heart surgery, for abdominal surgery, prostate surgery and vascular surgery and for brain we are doing Gamma Knife that can be reinforced with artificial intelligence. The reason for artificial intelligence is to reduce human error. Artificial intelligence has a great future in medicine especially in research and it should be taken as a positive node for the medical profession. It has very little scope in clinical medicine.