ANNUAL CONFERENCE OF KGMOA-2012 AT CALICUT

Respected president KGMOA, Chief Guest and other dignitaries on and off the Dias, KGMOA members and their family

First of all I place on record my deep sense of gratitude to the office bearers of KGMOA for inviting me to deliver the key note address. I congratulate you on arranging such a grand function.

Ever since I was invited I am worried about the content of my talk. Even today I am doubtful of my role. As a person working in another health stream for over 25 years, I can only submit my observations.

We know that heath sector in Kerala has advanced so much during the last decade or so. This is evident both in medical education as well as in health service. Be it in infrastructure, patient care, service benefits etc. But how well all these have percolated to the public at grass root level is still a question mark. Perception of the common man on health scenario is different. Their expectations are always high. We are no where near to that. And often we see the reactions of these.

The two branches of Health Dept namely Medical Education and Health Service are not working complimentarily. That is one huge problem we face. All the district hospitals where there is no proximity to med college are working like a huge establishment. But in districts where there is a medical college the district hospital is not developed like that. We both blame each other. Truth is entirely different. We never thought of complimenting each other.

Here we have to think of referral system. But what I see is that both at Medical Education level and Health Service level this is being opposed. Nobody come with a solid proposal or approach it with sincerity. The reason is not known to me.

I feel that we should bring the family practice to the forefront. If there is a referral system we can do this. The primary care level can concentrate on family practice. This will give us an opportunity to prepare the disease registry across the state. This will help us to plan the approach both at preventive and treatment aspects. Secondary level should be empowered to deliver the standard of care they are expected to. Tertiary level should be the teaching institution for treatment of patients referred from secondary level, teaching and research. The present load should be released from Medical colleges.

There is a growing concern that the public health activities are not taken seriously now. Once three tiers Local Self Government came many of the PHC were put under gramma panchayath or block panchayath. What happened after that I don,t know. But it is alleged that immunization, sanitation etc are not properly cared for. Every year we are getting new epidemics and thousands of people are affected. This creates a heavy burden on health system. But no concrete solution is being developed. There should be comprehensive approach, a combined act where medical college can also contribute to conduct field study and look for solutions. Field work in the health sector should be revived.

Another problem is the shortage of staff in the rural areas. Whatever steps the Govt. is taking we have problem in getting people to work at periphery. The latest is the CRS. I talked to many interns regarding this. They are not enthusiastic in pursuing CRS. One problem is our attitude to bonded labour. Most important is many of them do not understand the importance of working in rural areas. We are always promoting a specialized practice and our children are also not different.

It is important that we should create a cadre for rural service. They should be offered better incentives including a PG seat. Most important is that the system should recognize their service for future incentives too, that is giving them placement of their choice. In that case we can abolish CRS and only those who are interested will come for rural service.

I am sure that there are some positive initiatives in this line. There is a plan to start family medicine specialty in Medical colleges to give training in that line. Govt also is considering the system of cadre development during MBBS itself as practiced in AFMC. Initial discussions are started on developing the referral system in health sector. Only thing is that our approach also should be proactive and we should be able to give positive feed back on all hot issues in health sector in our state. We only can improve it. I thing KGMOA the largest service organization of doctors in the state can take initiatives in this line.

Thank you

Inaugural address-Diagnostics &Surgicals Dealers Association-Annual meet

Corporate social responsibility means taking proactive steps to help others, rather than just make money. In this era of Social Innovation, businesses can do many things by investing in local communities, improving labor practices, greening supply chains, and generally giving back. Businesses are beginning to be in the business of doing social good as well. Many companies shift to incorporate environmental, social, and welfare-based themes into business plans and products, and look to increase both profit and human development.

As surgical firms your first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use your products and services. In meeting their needs everything you do must be of high quality. You must constantly strive to reduce the  costs in order to maintain reasonable prices. Customers' orders must be serviced promptly and accurately. The suppliers and distributors must have an opportunity to make a fair profit. You are responsible to the employees, the men and women who work with you throughout the world. Everyone must be considered as an individual. We must respect their dignity and recognize their merit. They must have a sense of security in their jobs, and must provide competent management, and their actions must be just and ethical. We are responsible to the communities in which we live and work and to the world community as well. We must be good citizens--support good works and charities. We must encourage civic improvements and better health and education. We must maintain in good order the property we are privileged to use, protecting the environment and natural resources. Business must make a sound profit. We must experiment with new ideas. Research must be carried on, innovative programs developed and mistakes paid for. New equipment must be purchased, new facilities provided and new products launched. Reserves must be created to provide for adverse times.

To quote an example Johnson & Johnson started in 1800s as a small unit producing dressing materials. Through hard work they could reach a level that today they are the leaders in manufacturing surgical equipments, sterilizing products, cosmetics and baby products. In their growth they had to face unethical competition which they survived. 7 patients died of taking Tylenol and they had to with draw the whole stock. Not only money but the reputation also was at stake. Later this was found to be a tampering at retail level. Sale of the competitive products went up and it was proved to be an unethical competition. Such things should be avoided.

Many firms now use the amount for charities to give kick backs. This is another unethical way of making money. This creates a nexus between corporate, doctors and paramedics. This practice definitely exploits the poor patients.

Dear friends in corporate sector you are permitted to make profit, but a portion of it should be given back to the society we represent. More over profit making path should be clean and ethical.

DR C RAVINDRAN,28/01/2012

Disaster Management Workshop on 07/04/2011

Disaster Management Workshop- Inauguration

Al-Shifa Hospital,Perinthalmanna,07/04/2011

Dear Chairman, Faculty & Delegates,

I am extremely privileged to take part in this wonderful workshop.I thank the organizers for inviting me today and I would like to place on record my appreciation for planning and conducting a workshop on such an important topic. I always have the feeling that nursing education, when compared to all other medical disciplines, has innovative practices and deal with more common problems.

When we think about disaster, we will have the vivid pictures of Tsunami, Gujarat earth quake and recent happenings in Japan. Disasters are becoming more frequent. We are living amongst hazards every day, if we count the man made one apart from natural calamities. It is said that 60% of globe is prone for earth quake and 68% are prone for draught. There is concern over the increasing incidences of hazards with the changing life styles.

What can we do? Inspite of repeated threats are we prepared to face any disaster? Probably today you are deliberating on this. Disater prevention is the best way. But many a time it is not possible. Then disaster preparedness is the one we must think of. In this doctors, nurses, other paramedics and volunteers have definite role. We are not prepared to learn from our past experiences and not able to improve the culture of learning. It calls for nationwide learning on Disaster Preparedness, responses, preventive measure and community education. We have to create a culture of prevention and culture of safety.

Nurses, being the key members of the health care team have a vital role to play in handling the situation with competencies at the site of disaster and in the hospital. Establishing centres for conducting training programmes and preparing panel of-Nurses Disaster Team who would spring into action with other organizations during such situations. Nursing Institutions should assume leadership roles in training Nursing personnel and paramedical staff including the grass-root level workers. The main stress should be on topics like Disaster Magnitude, mapping health resource inventory and inventory of disaster prone areas.

Western Kentucky University has a nursing elective course called The Role of the Nurse in Disaster Management. They started this course in January 2005, only a few weeks after the Indonesian tsunami disaster on December 26, 2004. This was after seeing the images on television and became acutely aware of how important nurses were going to be in the recovery efforts over the next months and years.

Disasters require managers to make quick decisions, and management science provides a framework for decision making and control. Modern disaster management includes pre-disaster planning and preparation, as well as crisis management. All too often, the foundation functions of management are forgotten during a crisis and the system produces more chaos than was already present.

Dear friends, this is a beginning. More and more nursing schools should join you and you should be able to initiate Nurse Disaster Team. Ministry of Home Affairs, GOI has a National Disaster management programme.750 crores are earmarked for Kerala in the next 5 years. Naturally we can utilize their help and expertise. I wish you good luck in your endeavor.

Thanking you once again

Keynote Address at STF Meeting in Kannur Medical College

Keynote Address

 STF Meeting on 10/03/2011 at Kannur Medical College.

Respected Chief Guest, STF Chairman, members, faculty and students,

It is indeed a pleasure to be here to attend the STF meeting..I am thankful to the state task force for considering me for this key note address. I want to emphasis the point that I always endorse RNTCP and whenever possible propagate its message.

Today in India RNTCP is a lifestyle. At least for the thousands of health workers involved in this programme, it indeed is a life style. We fought hard for one and a half decades to cover the whole country, to save millions of life, to reduce poverty and to alleviate sufferings. Now we know that all the 662 districts in the country are covered by RNPCP.

I enjoyed my stint at RNTCP. I had good support from STO’s office, by all medical colleges,DTOs, WHO consultants and workers. The staff of RNTCP unit was an enigma to me at that time. With negligible help from most of the departments the few workers of RNTCP showed immense potential and an untiring resolve which really was a motivating factor for me. The extraordinary commitment and dedication shown by the programme’s large contingent of NGO workers, who work with the patients to make DOTS services available and accessible even in the most remote corners of India is an extraordinary feat.

I thought that the doctors were a little hesitant to accept DOTS. There were many doubts, most of them irrelevant and baseless. Private practitioners were more suspect.

. I felt that those who are criticizing DOTS are those who are not practicing it. It is very simple, involve in the programme, start practicing and then try to find out the defects. Programme is flexible and any genuine doubts can be addressed. For that all of us especially doctors should believe that DOTS strategy is cost-effective and is today the international standard for TB control programmes. To date, more than 180 countries are implementing the DOTS strategy. RNTCP has consistently achieved treatment success rate of more than 85%, and case detection close to the global target.

It is important that to maintain the success there should be committed workers. Job satisfaction and job stress are two important parameters which decide the motivational level of these workers. I have tried my level best to focus on these parameters during my tenure. Each stratum of workers needs different scale to assess their motivational level and different strategy to improve that. When I look back I feel that I had fairly an easy journey and I particularly remember my colleagues who earnestly put in their effort to make my life easier.

In 2009, the Programme reached the key milestone of 70% case detection and 85% cure of new smear positive patients. This milestone was reached by the concerted hard work of thousands of committed TB workers both within and outside government system, and they deserve hearty congratulations. The ultimate goal of the programme remains a “TB-free India”, with reduction of TB burden till it is no longer a major public health problem in India. From 2010, the programme will seek to achieve universal access of TB care for all. This means early and complete detection of all TB cases. All health providers who undertake evaluation and treatment of a patient with tuberculosis must recognize that they

are assuming an important public health function that entails a high level of responsibility to the community, as well as to the individual patient. Hence the need of a strong public private partnership in TB controls efforts.

TB control efforts in the last decade in the country have been tremendous and the achievements of RNTCP make us, quite correctly, very proud. Of paramount importance is the sustained political and administrative commitment to the cause of TB control, quality supervision and monitoring of the programme at all levels and effective partnerships with other sectors including NGOs, private sector health providers, patients and community.

While maintaining the current status, the prime task for the next decade is to achieve the

Millennium Development Goals (MDGs) and related Stop TB Partnership targets for TB control. Meeting these targets requires a coherent strategy that enables existing achievements to be sustained, effectively addresses the remaining constraints and challenges, and underpins efforts to strengthen health systems, alleviate poverty and advance human rights.

RNTCP is essential in order to maintain the international standards for the management of TB cases. It is necessary that professional bodies endorse the International Standards for TB Care (ISTC) and pledge that all health care providers shall give care to their TB patients as per these Standards. The Indian medical practitioner community should commit to provide the best possible care in managing patients with tuberculosis, in accordance with international guidelines and standards and ensure rational use of first and second line anti-TB drugs.

RNTCP is building partnerships with civil society organisations and other sectors to reach out to larger sections of society through them. In addition, the MDR-TB management needs to be scaled up under the RNTCP DOTS PLUS strategy while promoting rational use of second line anti- TB drugs in the country. An important component of this is the scaling up of laboratory capacity to diagnose MDR-TB. In the longer term, the success of new diagnostics, drugs and vaccine, currently under research and development, will determine the pace of TB control efforts globally and in India.

New Initiatives and Future Plans

1.Role of Medical Colleges in RNTCP Training

In India, out of the 286 medical colleges as on 30^th October 2009, 273 medical colleges are involved (formation of core committee, DMC and DOT Center) under RNTCP’. State OR Committees have also been constituted under the STF of each state in most of the states to facilitate, process and refer the selected OR proposals from various medical colleges in the state to the Zonal or Committee. STF in Kerala is one of the best state units and all medical colleges in the state are enrolled. Every three months STF meeting is held in one4 of the medical colleges and review the programme for the quarter.This gives an opportunity to analyse the strength and weaknesses and to plan for the future. Kerala also has two DOTS PLUS sites and is achieving good outcome in managing MDR TB.

  2. Co-ordination of TB-related and HIV/AIDS Training with the National               AIDS Control Organization.

This is another area where RNTCP has shown good progress especially in identifying and treating tuberculosis among HIV infected. There is a reasonably well managed network for coordinating the activities of DMC and ART clinic.

  3. Managing Information for Action (MIFA)

  4. Training in Advocacy, Communication and social Mobilization

ACSM is an important component of RNTCP. ACSM strategy has carefully addressed the communication needs and interventions as per the programme objectives. Prior to 2006 (before achieving full coverage of the country under DOTS), focus of ACSM was as per the implementation status of DOTS in the states. It focused on restricted use of mass media, however, decentralized planning and implementation has been central to all ACSM initiatives.

The goal of ACSM is to support TB control efforts for:

• Improving case detection and treatment
• Adherence.
• Widening the reach of services
• Combating stigma and discrimination.
• Empowering people affected by TB,
• Mobilizing political commitment and resources for TB.

        5. Practical Approach to Lung Health (PAL)

This is a comprehensive plan to prepare treatment protocols for common respiratory illnesses and to make available mostly used drugs in all peripheral health institutions. This will standardize treatment at national level at the same time provide free and comprehensive health care to all needy persons across the country.

        6. Engage all Health Care providers

This is another area of focus where in all health care providers are bought under single umbrella and to entrust them with public health activities including TB control

        7. IMPAC t –Indian Medical Professional Association Coalition against TB

This enables all professional associations to endorse health programmes like RNTCP so that the members of the body can work together to achieve the desired outcome.

        8. Enable and Promote operational Research

For the future of health system we need quality research, both epidemiological as well as clinical. It is our duty to find out operational research areas and involve in quality research.We need to formulate newer and rapid diagnostic methods, newer drugs and treatment protocols.

            Dear friends, it is our duty to see that RNTCP and DOTS are practiced by all doctors, both in Governmental and corporate levels. We use this opportunity to pledge our commitment to TB control activities in the country.

Thanking You, Good bye.

Inaugural speech

CME in Obstetrics & Gynaecology

05/03/2011

Respected chairperson, faculty members and dear delegates,

I am extremely delighted to be with you today for the inauguration of this CME. I am happy that you have organized a wonderful CME on complimentary topics which probably students may not be exposed to, even though they have to study those things.

I am wondering how you are managing these academic activities. A hospital attending to24000 normal deliveries per year  and almost 25-30% of this figure in the form of caesarian sections, it really is a herculian task. It is not that easy to find time for classes and discussions. But being an academic institution we have to. With proper planning and time management you can do it, I am sure.

The science and art of providing quality health care to women has made tremendous strides in recent years. In the subspecialties

of Obstetrics and Gynaecology, recent advances in laboratory techniques and in clinical diagnostic, surgical and laparoscopic skills have improved the prevention and early detection of disease. New frontiers have been established in Maternal Fetal Medicine, Reproductive Medicine and Gynaecological Oncology. Maternal request for elective Caesarean delivery is always a clinician dilemma. The litiginous nature of our society has resulted in record indemnity subscriptions by Obstetricians and Gynaecologists. It is time to ponder on the absurd situation in which the Obstetrician is placed when deciding on a patient’s request for an elective Caesarean delivery for non-medical reasons. Another Obstetric issue that constantly perplexes clinicians is the issue of which test to use to screen for chromosome abnormalities in pregnancy. The plethora of tests, both ultrasound and biochemical, that can be used in the first and second trimesters of pregnancy are clearly evaluated. Another much debated area is cervical cancer screening which has been shown to decrease the incidence of invasive cervical cancer.

Another point to mention here is the lack of an advanced unit for managing infertility. I understand that this subspecialty has grown much faster than any area of Gynaecology. With so many accomplished clinicians we could not establish a modern infertility clinic. I am not ignoring the contributions of individuals in this field. But the next aim of this department should be to establish a laparoscopy unit and infertility clinic. I am sure you can do that and that will definitely bring more glamour to the Dept.

First Day As Principal, Medical College, Calicut

Article for the Souvenir of State Task Force of RNTCP-Kerala State

What RNTCP gave me?

Today in India RNTCP is a lifestyle. At least for the thousands of health workers involved in this programme, it indeed is a life style. We fought hard for one and a half decades to cover the whole country, to save millions of life, to reduce poverty and to alleviate sufferings.

I was attracted to RNTCP in the year 2000 when I was working in Alappuzha. I had the opportunity to be associated with the RNTCP unit of Alappuzha Medical College. Next year I was invited for the launching of RNTCP in Calicut district. When I was posted back to Calicut in 2002 I took over as core committee convener of Calicut Medical College. The staff of RNTCP unit was an enigma to me at that time. With negligible help from most of the departments the few workers of RNTCP showed immense potential and an untiring resolve which really was a motivating factor for me. The extraordinary commitment and dedication shown by the programme’s large contingent of NGO workers, who work with the patients to make DOTS services available and accessible even in the most remote corners of India is an extraordinary feat.

I thought that the doctors were a little hesitant to accept DOTS. There were many doubts, most of them irrelevant and baseless. Private practitioners were more suspect. At this point I have worked out my plan. I have decided to take up the mission of propagating the scientific basis of DOTs. I was immensely helped by few of my friends especially my colleagues and the WHO consultants etc.

The task was cut out. My job was to tell others to believe the facts. Any criticism is acceptable within the framework. I felt that those who are criticizing DOTS are those who are not practicing it. It is very simple, involve in the programme, start practising and then try to find out the defects. Programme is flexible and any genuine doubts can be addressed. For that all of us especially doctors should believe that DOTS strategy is cost-effective and is today the international standard for TB control programmes. To date, more than 180 countries are implementing the DOTS strategy. RNTCP has consistently achieved treatment success rate of more than 85%, and case detection close to the global target.

In 2007 I was appointed as State task force chairman. I just made a decision to manage by participation. Every body should be given some role in RNTCP programme. The STF meetings were planned frequently and it was decentralized. Every three months we will meet in one of the low target colleges. Their strength, weakness and opportunities were exposed to them and naturally their attitude towards the programme changed immediately. Our aim was to start RNTCP core committees in all the 18 medical colleges. I am sure that almost all the colleges were brought in to the mainstream. All of them were motivated to start DOTS centre and Microscopy centre. Man power was provided where ever necessary.

Another area where we could contribute during my tenure was operational research. It later was mentioned in one of the subsequent NTF meetings as ‘Kerala Model”. We could motivate the faculty to submit about 11 OR proposals, out of which 7 were approved by ZTF. We could get fund approval for many PG theses during that period.

What RNTCP gave me? I always felt that RNTCP is a model programme of health intervention, a unique one for the whole world. Being an active worker, eventhough for a brief period, I enjoyed my job. I got due respect and immense help from all around me. It was really a capacity building exercise for me. In other words it was a job enrichment period for me. For my masters in Business management I took up one aspect of RNTCP to prepare my thesis. The study on human resource management in RNTCP was a challenge to me and an eye opener too.

There is a rapidly growing realization that human resources for health are crucial to the delivery of the services focused on the human development goals and the reforms in service needed to achieve them. Clearly reforms in services depend upon having the right people in the right place at the right time to deliver accessible, effective and affordable services. The performance of health care systems depends ultimately on the knowledge, skills and motivation of the people responsible for delivering the services. It is essential to have adequate staff with right skills, knowledge and attitude to successfully implement and sustain RNTCP. More over there should be regular efforts for capacity building such as training, retraining, reviews and appraisals. RNTCP is one programme where all these are properly taken care of. It is our duty to see that the work force is able to deliver the services at the highest level. There are minor problems leading on to stress at work But during the core committee meetings, state task force meetings and subsequent training sessions problems are discussed and solutions are suggested.

It is important that to maintain the success there should be committed workers. Job satisfaction and job stress are two important parameters which decide the motivational level of these workers. I have tried my level best to focus on these parameters during my tenure. Each stratum of workers needs different scale to assess their motivational level and different strategy to improve that. When I look back I feel that I had fairly an easy journey and I particularly remember my colleagues who earnestly put in their effort to make my life easier.

Dr C Ravindran MD,DTCD,MBA

Professor of Pulmonary Medicine & Dean

Medical College, Calicut

Former Chairman, STF-Kerala

Member, Governing council, TB association of Kerala

ravindranc@calicutmedicalcollege.ac.in