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Monthly Archives: July 2008

 

Yesterday, a dear friend forwarded a chain mail he had received. The mail referred to the magic effects of ‘chelation therapy’ in the treatment of coronary blocks and spoke about ‘bypassing the bypass surgery’. Expectedly, there were tall claims and some miraculous anecdotes about how this wonder cure is the panacea to all people with blocks in the coronary arteries. Thanks Uday, for asking me to clarify the scientific truth about this form of treatment.

 

My first instinct was just bulldoze the forwarded mail and tell my friend that chelation therapy was a big fraud. But then I thought that a question coming from a medical colleague (Dr Uday Thanawala is a well-respected gynecologist from Mumbai) deserved more than rhetoric and hence this detailed proposition.

 

Evidence-based medicine requires that rigorous experiments in the laboratory and painstaking clinical trials are conducted to establish both the effectiveness as well as safety of a drug or a process. The end result of this arduous process is what is accepted by the scientific community and delivered to the suffering patients. Modern medicine has progressed in leaps and bounds during the last century and continues to do so in 21st century purely on the basis of these scientific endeavors.

 

Often there are sensational stories: the thalidomide disaster and the Vioxx controversy are examples where checks and balances in drug development are either insufficient or deliberately flouted resulting in a compromise on safety. Barring these, the process of developing scientific treatments for diseases is largely effective.

 

Coronary artery disease (CAD) is a modern epidemic especially in 21st century India. By 2015, India will have over 60 million CAD patients1. Three treatment options exist: medical therapy, angioplasty or bypass surgery. Each of these treatments has advantages and disadvantages. More importantly, each has its own place in modern medicine. For example, a patient with critical block in the left main coronary artery is best treated with bypass surgery, because medicines alone or angioplasty alone are both less safe and less effective than surgery in this situation in most cases. Similarly, someone with extremely advanced disease with too many blocks (‘diffuse disease‘) is perhaps best left alone on medication because bypass surgery is not so effective in such a situation. The decision to choose one form of therapy over others is guided by the same processes of clinical trials like in the development of drugs.

 

Chelation therapy is touted as a form of medical therapy which effective even in cases where bypass surgery is advised. Is this claim scientific: let’s examine.

Through the 1960s to 80s there have been several small clinical experiments involving this therapy in patients of coronary blocks. Uniformly, the trials have all involved small number of patients and have drawn no firm conclusions about the effectiveness of this treatment. There was one large retrospective study2 of 2,870 patients which concluded that chelation therapy benefited patients with cardiac disease, but without comparing people did and did not receive the same treatment. To date there has been only one significant trial where people underwent coronary angiography first, received chelation therapy and then underwent coronary angiography again to check whether the treatment worked. Here3, Hopf demonstrated in 16 patients so studied, chelation therapy had no effect on coronary artery disease.

In the American Heart Journal (2000), Ernst reviewed all available scientific trials on chelation therapy and concluded that “Given the potential of chelation therapy to cause severe adverse effects, this treatment should now be considered obsolete” In spite of all this, the American College for Advancement in Medicine (ACAM – founded in 1973 as the American Academy of Medical Preventics) has been promoting chelation therapy in the USA.

 

In India, there is no such organized body but several centers are administering this treatment to patients. There is no scientific proof as to how chelation works and no warnings on the side-effects. These centers play on the patient’s hope of somehow avoiding coronary bypass surgery. No initial snapshot of the severity of patient’s problem is documented in the first place. After the entire course of treatment costing more than a lakh of rupees, there is no cross-check whether the blocks are gone. Most of these centers also prescribe symptomatic treatment for heart blocks so at the end you never know what’s really happening underneath. Most centers discourage patients from going back to conventional cardiologists lest they should have check angiograms and the truth discovered!

 

The other danger of this form of therapy is the false reassurance. During and after the chelation therapy, if a critically needed bypass surgery is avoided by the patient, he runs the risk of heart attack or death while fondly hoping to avoid the same!

 

Chelation therapy has no scientific basis or proof of efficacy and safety. Due to huge insurance impact and with activists snapping at the heels of the authorities, the National Center for Complementary and Alternative Medicine (an arm of National Institutes of Health, USA) is conducting a nationwide study to see if chelation therapy can be a safe and effective heart disease treatment.

 

Finally, perhaps the bluff will be called and this unscientific practice will stop

 

 

References

 

1.       Indrayan A. Forecasting cardiovascular disease cases and associated mortality in India. New Delhi: National commission fro Macroeconomics and Health, Government of India, 2004

2.       Olszewer E, Carter JP. EDTA chelation therapy: a retrospective study of 2,870 patients. J Adv Med. 1989;2:197-211

3.       Hopf R. The test of alternative medicine: Chelation therapy. Zeit f Kardiology. 1987;76:2

Simple problems need simple & straightforward solutions. On the face that’s how the honorable health minister’s prescription for the ailing health of Indian rural Medical system. So, all medical students of India shall serve a one-year rural term before getting into any postgraduate specialist training. Lo and behold, all our villagers will brim with good health.

 

If the solution to this massive rural-urban healthcare disparity was so simple, why did it take so long to be thought of!

 

In all fairness to the medicos let’s examine the issue closely.

 

Unlike in the US, the average medical student enters medical school after class 12, meaning he (also could be a she, but forget about being politically correct, that’s not the issue here) is 16-17 years of age. MBBS is 5 years plus a year’s internship. Having gone through the mill, let me assure you that a majority of doctors who come out of medical school after MBBS are clueless about clinical practice. Our system teaches them how to examine patients, how to assist consultants in their surgeries and clinics, but fails to teach them how to prescribe medicines and worst of all, there is absolutely no training in interpersonal communication. A fairly large number of MBBS doctors would never have experienced how to discuss the pros and cons of let’s say undergoing HIV testing. Or how to declare to a family that a beloved one is dead.

 

Equipped with this kind of ability to practice, to deal with the illnesses of our rural kindred, look at what he is armed with. A large number primary health centers in the country function without adequate medicines, lab facilities, x-rays, nurses & technicians. In the absence of all these, how does our man diagnose the diseases? And in cases where he can, does the paper on which the prescription is written cure the patient. Remember, utter poverty prevents a great majority of patients in the villages from buying medicines.

 

If indeed shortage of doctors in rural areas is the reason for making rural tenure compulsory, why not make it universal. Why only sent PGs-in-training to the villages? This is where our honorable health minister has taken the easy way out: unlike the MBBS students, interns or practicing doctors, PGs are almost at the mercy of the authorities. If they are sent they better go, or else they won’t get the degree. Come on doctor, why don’t you send your in-service doctors to the villages? It is no secret that a large number of doctors in government service posted in rural areas are actually sitting in urban or semi-urban areas by hook or crook. Governments have realized that it is impossible to take corrective action against serving employees. Whereas PG students will have neither choice nor voice against this decision.

 

Is there an educational advantage for the PGs to be posted in villages? True, they get a closer look at the medical problems of rural India. The exposure to some of the third world problems such as rheumatic heart disease is so great in rural India that I know of doctors in US coming to India to study tropical medicine in this population. However, learning cannot happen in the absence of diagnostic aids. If clinical suspicion of disease cannot be confirmed by laboratory or imaging techniques, do you really learn something out of that case? Learning how to treat diseases merely on basis of clinical suspicion is not scientific medicine. Our rural doctors have no choice, but to allow PGs to learn this kind of medicine is certainly not on.

 

What about comparative economics? In a good number of cases, medicine is chosen as a career by the top students in the class. Having been brilliant throughout and for the six year toil, the salaries offered by most governments in the country are at best pathetic. Contrast a student who after 3 year BSc or 4 year BE earning 5-figure monthly salaries. And if there is a 2 year MBA thrown in, earnings could cross a lakh a month.

 

It is nobody’s case that a non-medical man should not earn comparatively larger amounts of money. But then, after any sort of education, most people are given the freedom to work where they want. In places where labor of any kind is difficult to obtain, financial incentives are given so as to compensate for the inconvenience caused. A PG cannot claim any of this and will become a hapless scapegoat of one more governmental scam.

 

Improvement of rural medical facilities is truly an important requirement. Invest in hospitals and well-equipped clinics in villages and towns, pay the doctors well enough and then rural medical service may improve. If building hospitals in non-urban areas is made a profitable business, private players will also come in. Strategies for these have to be thought of. But all these ideas need men of steel to think and execute. In the absence of such steel, people like the hapless PGs will suffer.