Cost of gaining height

You may recall that few months ago I had posted about a man who looked like a boy.He was 23 years old but had the features only of 12 years of age.His height was 123 cms and his body feature were like a small boy.He was a case of Pituitary Dwarfism. Let me tell you what happened since.

The hormone tests proved that he is having a deficiency of Growth Hormone and Male sex hormone called Testosterone.Then I took a series of Radio graphs[Xray films] to see whether his growing ends of bones had fused.In normal males it will fuse anytime between 18 and 21 years.He is 23 now,so chances are it might have fused.But fortunately the radio graphs showed it had not fused.

That meant there is a chance that he may gain in height if given injections of Growth Hormone.That was good news,but the bad news was the injections are expensive. 15 day course of injections will cost around 8000 Rupees.He may have to take such injections for several months.

The family was very poor.The patient's father was a manual labourer and have to support a large family.My first thought was not to burden them by telling them about costly injections.As he was already 23 the chances of gaining much height is very less.The hormones injected may cause the growth plate of the bones to fuse thereby preventing further gain in height.

Bur not telling their options was unethical.So I gave a long explanation which his father listened with rapt attention. From the vacant look I could realise that he did not understand much.
He put everything on my head. Saru parayunathu pole cheyyam.[Will do whatever sir say]
Now I have the added responsibility of deciding for that family.

So I decided.Let us try the medicines for 2 months and see.You tell me when you have the money ready for 15 days medicines.I will order it and give it to you directly.We can save some money by doing that.He agreed.

After a week he called me and said the money for 15 days of injections is ready.I ordered the medicine and company couriered it in my address.I taught the father how to take the injections. The money had to be send to the Company office by cheque or draft.I asked him to do that.He confessed that he do not know anything about Banks and asked me to do it for him.I did not know what to do.He just gave me the cash and left.

After 15 days he came again with his kid.There was no increase in height[ as it may take few more weeks to get the effect].Cash was ready and I handed over the medicine.
After the end of next 15 day period he called and said there is a cash shortage.They were planning to sell a piece of land,but was not able to get a good price.I asked him to come to see me with his son.

I measured the height.There was an increase of 2 cm.All of us were happy to see the increase.

He asked me for few days time to get the cash ready. I told him that a gap in therapy was not good.

Should I volunteer to give him a loan? If he asked for a loan what should I do? I was wondering.
But he did not ask for a loan.He assured me he will get the money in few days.

I know that the father was struggling hard to get money for the injection for his son. Few more months of injections may further increase his height by few centimetres. But at what cost?

How I got interested in HIV/AIDS?

In the late 1990s, I was working in a small [Government] Taluk Hopsital. HIV 'Positive' persons I saw in my practise were few and I was happy to refer them to higher centres.

Then I got transferred to a busy District Headquarters Hospital in 2001. There I could not escape dealing with 'positive' persons.
Every week the infectious disease ward will see a new 'positive' patient coming to die.
Most of them by then might have spend a fortune on magical remedies. The most infamous among them was the medicines of Fair Pharma from Kochi. For more detailed information about how one Majeed cheated poor patients and build the costliest house in Kerala click here. Now fortunately the 'medicine' is banned in Kerala by the Court after a longstanding legal battle with 'Positive' people and PUCL.

The patients in my hospital were given symptomatic treatment and left to die. Some come and die alone while the more lucky ones have a wife or mother to be with them during their last days.
I was depressed seeing all these deaths.
What can I do for them? I asked myself.
I had no experience in treating HIV/AIDS patients. In the medical college where I studied in early and mid 1990s, 'positive' persons were rarely seen. I knew a lot from the text books but practical knowledge was nil.
Those days the Government was giving lot of training in HIV/AIDS for doctors and other health care workers, but it was only about prevention.
HIV/AIDS is a death sentence. So train yourself and others how not to get it.
This was the message of such trainings. Nobody mentioned treatment. We were not trained to cope with these dying 'positive' patients.
In the developed world by the year 2000, more than 10 drugs were available effective in treating HIV/AIDS. Few were available in India too at that time. They were expensive and somewhat toxic but still they worked. And they were cheaper than the Fake medicines of Fair Pharma.
More over, HIV/AIDS patients need treatment for opportunistic infections that attack them as their immunity is low.
So when a 'positive' patient is sick, first we have to find out which opportunistic organism or organisms have infected him/her. Then give the proper treatment so that he/she becomes better. Later, ART [anti retro viral therapy] was started. Some time in severely sick patient we may have to start both treatments together.

Training myself in HIV/AIDS management, I started treating these patients in earnest. I procured medicines from drug companies directly and thus was able to give it to patients much below market rates. The stigma of buying such medicines from Drug Store was circumvented as I myself provided the medicines.

The results were dramatic. Patients in death bed about to say their final prayers were able to look after themselves with in months. Those who sticked on to the medication schedule for more than a year began working and earn for themselves.

I lost many patients too, but I tried my level best. Some came to me at a very late stage. Many could not continue the medicines because of the high cost of ART. Many by then had become social outcasts and committed suicide.

I urged other Physicians to take up the challenge of HIV. I conducted lectures in the IMA[Indian Medical Association]. I told them that it was ,we the modern medicine doctors, who are making the 'positive' persons go to Quacks like Majeed [Fair Pharma]. As we are not ready to take care of them, they are helpless. Unscrupulous persons squeeze out the last penny from them giving false hopes.

That made some difference. Few of my colleagues started taking up such cases.

By 2003-2004, things started changing in a positive direction for 'positives'. ART drugs became cheaper. India became one of the biggest manufacturer and exporter of cheap generic HIV drugs. Govt of India started giving ART drugs free of cost at selected centres. Kerala Government followed suit.
The emphasis in training of health care workers shifted from prevention to treatment. From a 'death sentence' HIV/AIDS became projected as a chronic manageable disease needing lifelong medication like Diabetes.

Now a 'Positive' person comes to my clinic every other day. Most of them are old patients coming for follow up. A newly detected 'positive' person is seen once or twice a month. Most of them are taking the free ART drugs from Medical Colleges. Some who can afford [and is afraid of perceived stigma at Govt centres] take medicines from me.
Deaths occur but only rarely.

I cherish the sight of happy faces and healthy bodies of all those positive persons. That sight make my life meaningful.

A Study in Contrast

The other day two of my patients were boys who presented so differently.Their stories were a study in contrast.
The first boy came along with his anxious parents.Both of them were school teachers. The boy was around 14 years and appeared healthy.
' What brings you here?' I asked.
' His urine is frothy'.The mother said.Is he having a kidney problem? They were very anxious as a classmate of their son had Kidney disease.
I examined him in detail and could not find anything wrong.Then I asked for a series of tests of urine and Blood and that too were normal.
I reassured the parents and send them off.


The other' boy' came with his father.They were from a village 30kms away. They came with a reference letter from a Local doctor.The ' boy' looked as if he is about 12 years old. When I looked down at the patient file in front of me I was shocked to see the age written as 23.Was it a clerical mistake?I asked the father about the boy's age.Yes it is 23. I read the reference letter.Yes he was referred to me to find a reason for his short stature.
I examined him. His height was 123cm and weight 24 Kilograms. He did not show any features of puberty. He had no hair growth over face, chest, armpits or genitalia.
His penis was small and testicles rudimentary. His voice was like that of a 10 year old child. It seemed as if his body got stuck at 10 years for the last 13 years.
'When did you notice that there is something wrong in your son?' I asked the father.
He told me that once a doctor told him the boy had problems and need many tests to find out the cause,but nothing was done.
Why those tests were not done?
Money was the major problem he said apologetically. 'Also I was sick for several years.So there was nobody to take him to distant City to do the tests.' He added.
He is probably a case of ' Pituitary Dwarfism'. It is an abnormality rarely seen in children.They stop growing early or growth is very much delayed. This is caused by deficiency of Growth hormone . Such children may have deficiency of other hormones also.This may result in lack of sexual maturity as seen in this boy.
Early diagnosis in the childhood is important. Treatment with Growth Hormone Injections usually makes a big difference.But it have to be given before adulthood.By 18 to 20 years the bone plates fuses and further growth is not possible.
Treatment with sex hormones may help this 'boy' to mature.But he will never gain height. He could have gained height if treatment was started when he was around 15 or earlier.
Such contrasting tales I see in my practise regularly. India is full of such contrasts. Over anxious literate and well off parents who know many things and is afraid of all known and unknown diseases attacking their children on the one hand,and the illiterate poor rural folk who accepts everything that is given to them as destiny on the other hand.
India is a land of
Luxury,opulence and high education on one side
and
poverty,illiteracy and ignorance on the other side.

When will this huge divide go away?

Who profits from illness?

The other day I was travelling with an Indian guy settled in US.He is a retired person aged about 60 years.He has been in US for last 35 years. He had come to India for attending a marriage of one his nephews.After the customary lamentations about the 'dismal' situation in India our chat turned to the subject of health care in USA.
He said recently he had to do an emergency surgery for Piles in USA and it cost him about 20000 US dollars. I first thought I heard him wrongly.In India for 20000$ a person can replace both his knees and do a coronary bypass surgery.I asked him again and he said Yes the bill was for twenty thousand dollars.He also added that his Insurance Company payed only 6000$.He is paying the rest from his pocket in instalments.
Then I said the doctors in US must be having handsome earnings as the patients have to pay so much. He said only a few docs have good savings. He revealed that his son is a Doctor and is still paying off his debts incurred while studying even though he passed out 5 years ago.
So who profits from the illness among common people? May be Insurance companies,Drug Companies,Corporate Hospitals etc. Is there any way out so that quality health care is easily affordable to all?

Life and Death

Recently the doc on duty in the Hospital I work did a heroic resuscitation of life.An 85 yr old lady bedridden with chronic lung disease and Crippling arthritis suffered a massive heart attack and went in to a Cardio respiratory failure.He along with the nursing team revived the lady with all the equipments and medicines available.The lady survived for another five days only.Those 5 days made a huge hole on the pocket of the family.With no medical insurance they had to suffer a big financial burden.
With most patients here paying from their own pocket such heroic measures of resuscitation often do more harm to the family than good.But who is to decide to what extend resuscitation should go on?