Personal Viewpoint

The city of Delhi where I practice, is choked with traffic, population and ambulances ferrying patients. Everywhere, there is a turmoil. It should raise red flags, but everything goes on in a routine manner. Hardly anyone with influence asks hard or troubling questions. Priorities are different. There is a catastrophic failure of systems which we never created in the first place. However, let me confine myself to heart matters. Heart and brain strokes are occurring in younger and younger people. That creates scare as well as opportunities; genuine and of undesirable greed. People want to find out their risk and take precautions for early detection and prevention. Fear and anxiety permeate in young upwardly mobile professionals with work-related targets and ambitions. Over period of time, cardiologists of my generation gained skills and knowledge to tackle heart attack scares and actual events in an evidence-based graceful manner (we had our financial motives and failures too). However, there occurred birth of a parallel system of pseudo-science, quick-fixers and hoodwinkers also which gradually gained strength. For quite some time, mainstream medicine of heart matters has not succeeded in winning hearts and minds of patients. Every day, our near and dear ones are falling prey to heart attacks. That provides an opportunity to medical professionals as well as to charlatans. Every day on my way to work, I am barraged with tonnes of hype about heart health benefits of using different edible oils, food items, heart scans, discounted medical tests, concession fortnights, bill-boards of hospitals announcing world class care for heart attack detection and treatment in the neighbourhood and of course about innovative health insurances. I do not want to be judgemental or lose objectivity. However, there are sources who have an agenda that they are trying to advance. Pseudo-experts making tall claims or disseminating semi-false information on YouTube videos and other platforms are not uncommon. Why are we vulnerable to half-truths and fake news and why is it so hard to get rid of it? Half-truth achieves success because it delivers hope and promises attractive, easy and ready-made solutions to subjects troubled by heart disease. Tell me something I desperately want to hear or believe and your success is guaranteed. Who is worried about critical scrutiny in this world of commerce and quick-fix solutions? In addition, more worrisome are large well-organised anti-truth and anti-evidence forces including sooth-sayers, fortune-tellers, supplement manufacturers and alternative medicine purveyors. Human beings have a near infinite capacity to deceive other fellow beings and sometimes themselves. There is active or passive support of political, social and fake scientific establishments to this canard of half-truths or blatant lies. Most people who can change destiny of the populace are far more interested in astrology or unproven indigenous science than real medicine. Dubious claims by self-styled experts for financial gains are weakly criticised by real medical establishment in closed doors with desperate wringing of hands. By contrast, real medical community, truth be said, often only can deliver, at best, a far more nuanced perspective, offering tentative hope for more modest success. Even worse, sometimes real medical news dashes the hope of people who are desperate for happy miracles. No wonder people turn to fake claims. Vast majority of literate but scientifically unsophisticated people are vulnerable to its promises and hopes and are susceptible to countless swindles and unproven diagnostic techniques or therapy, often promulgated by famous, telegenic or eminently presentable scoundrels and half-baked self-declared cardiologists. The medical establishment does not have time, resources or inclination to repudiate or validate or endorse every major hype. It is paradoxical that the Indian society whose rise on the world scene has been linked with major achievements in science and technology, is so sceptical and suspicious of real evidence-based medicine.

Despite all this, there are the cold facts to ponder. 60% of Indians die prematurely due to heart attacks, South Asians (read Indians) are more prone to heart attacks than rest of the world. Their longevity and event-free survival are poor compared to the Western or Caucasian population. We have been weaponised by research but unwilling or reluctant to use those tools and weapons because of ignorance, prejudice and financial constraints in equal measure. In the developed world, deaths due to heart attacks and stroke are decreasing at a steady pace but are rising constantly in this part of the world. It is estimated that in very near future, every third adult will die of heart attacks despite National Health Policy 2017 reiterating its goal of reducing premature heart attacks by 25% by 2025. The society is unhealthy both because of common risk factors as well as not believing in real medicine.

Statins are cholesterol lowering drugs which reduce chances of first heart attack in vulnerable subjects, prevent recurrence of heart attack in those who have experienced heart attack in the past, Evidence also proves prolonging survival in certain groups of patients. These are reasonably safe and inexpensive drugs which are being grossly under-utilised. There is no need to over-state the benefits or gloss over real benefits or potential harm in high risk subjects. Statins are not miracle drugs. For some people they are lifesaving, for others they are not. However, there is a strong lobby of hardliners out there to malign this whole science with anecdotal adverse effects. Statin denial and statin fear is actively promoted. In its place, there is pitch for worthless or harmful dietary supplements. The diversion of patients away from evidence-based therapy by advocates of unproven dietary supplements instead of statins must be vigorously opposed by physicians. Similarly, the claims that cult diets can reverse heart disease have no scientific basis and represent a danger to public health.

The best way of arresting ongoing heart attack or preventing it in those with imminent danger is by unclogging the affected heart artery by balloon catheters and stents. Stents are tiny scaffolds that keep heart arteries open. This method of treatment has saved millions of lives. This sub-speciality is called interventional cardiology which is growing leaps and bounds in this country and penetrating smaller cities. Public in general, however, is suspicious of this modality of therapy. Agreed that all is not well with this branch of medical science. What is ailing interventional cardiology in the country? I approach the subject with some trepidation, discomfort and hesitancy. I insist that doctors who perform the procedure have adequate training and that the hospitals where the procedures are performed have sufficient experience and adequate facilities. I would be happy to recommend a patient to a local community hospital with some experience in the procedure rather than delay the treatment because of transportation to a bigger tertiary care hospital. However, I fail to see how everyone would benefit by widespread proliferation of primary angioplasty (unclogging heart arteries by devices) by novice operators at inexperienced centres. There should be some reasonable safeguards to protect patients from being victims of a system that sometimes ruthlessly exploits patients for financial gains. Quality of implantable devices is another important issue. There is competition between locally manufactured versus imported stents. Both these have excellent quality with some exceptions. Price is now government-regulated and same for both varieties. Stents from multinationals have more efficacy evidence and safety data. That point should be acknowledged without grudge. Our safety standards are not that high. We should have an open mind; but not that open that our brains fall out. Why is it a bad thing to insist that the manufacturers continue to study the device against best in the class available in the market? Time and again problems with devices and drugs have popped up years after approval. Interests of industry, hospitals, and physicians would often converge but the patient’s interests are supreme. No doctor intentionally delivers substandard care, or performs procedures solely for the sake of money, or engages in fraud. However, there are subtle pressures for some preferential use. The patient’s interest should be ahead of “Be Indian, Buy Indian” philosophy. We are part of a global village.

Above are the random thoughts of somebody who has practiced in this city for four decades. Stating facts as I perceive is not a tirade against individuals, establishments, society or the powers that be. It is merely another perspective. Every man is under obligation to contribute his or her two cents

The author declare no conflict of interest.

No funds were received for publication of this article.