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mardi 18 février 2014



This was the story told to me by a good friend of mine in Indonesia.
He was recently at the class reunion from his High School Graduation, most of them now financially successful businessmen.
There were 12 of them; my friend probably was the fittest of them all, being dedicated to exercise and sports ever since his university days. Nine out of the 12 were either overweight or obese, a rate which rivals that of most corpulent countries such as USA, Mexico or UK and Australia!
While discussing health matters, my friend was told by a businessman: I just had a first class check up and also a PET CAT scan. To the query why they were done, it was said that they were done to make sure everything was all right. He had high cholesterol and high blood pressure and of course was overweight as well.

 My good friend began wondering, what is the need for all these tests? If the tests are done to see whether things are all right or whether things have already gone wrong, why not prevent from things going wrong? He asked himself. But the other gentleman was insistent and suggested that my friend contact the private hospital in Jakarta which offered these very modern technologies.
Why not prevent these diseases? My friend queried. Indonesia is blessed with abundant healthy food and why not eat well and healthy, fresh food, not preserved food or fast food, fruits and vegetables that are all available easily and cheaply. Usually the well off in Indonesia find they don't have time for eating well, even with myriad of household helpers they have at their disposal. Add to that high percentage alcohol drinks such as Whiskey, Gin and Cognac!
Another rich Indonesian businessman told me that he had gone to Singapore and ordered a 1000 USD bottle of wine and he couldn't tell the difference between that and a regular 20 dollar bottle of wine!

The gathered most of whom were in their early 50s, very rich by Indonesian standards who had made their money by hard work and manipulation, had one more thing in common: High Cholesterol and High Blood Pressure.
It is not a pattern unheard of in these emerging economies. People, who have been lucky in this upsurge of economy, make a lot of money, but the surging economies do not have prevention programmes and making money out of the ill health is also part of the surging economies. It is easier to get an expensive MRI scan in Bangalore, if you can pay cash for it, than be able to see a General Practitioner and no doctor wants to be one!
My friend told the gathering, I do exercise every day, and I don't smoke or drink, enjoy each and every meal and try to make sure that it is freshly prepared or not preserved.
He spends his well-earned money on good food for himself and not wastes it on 1000-dollar bottles of wine in Singapore in the company of European chefs who know epicurean fools when they see one, with other upstarts from the newly rich Singaporeans.

In addition to the futility of doing expensive tests looking for diseases which are entirely preventable, what about qualified people who can interpret these results, especially in light of the fact that many of the measurements are unique to the Asian population.
Poor doctor patient communication is not unique to the west but equally prevalent in Asia as well, if not more so. I will once again give the example of my friend who had to do some tests at the request of his insurance company.
The Doctor called him in and with a serious face told my friend, many of the results on these tests and measurements are wrong and I will need to send you a Cardiology Consultant to sort it out.
What are the measurements that scared the GP doctor?
My friend has a BP of 95/60 mm Hg, has a pulse rate of 60/min and on his electrocardiogram and CXR a suggestion of an enlarged heart!
But the GP doctor forgot to ask an important question, do you exercise? Instead he suggested that my friend exercise minutes a day at least three times a week and that he eat more vegetables and fruits.

My friend was flabbergasted! He walked out in disgust. He discussed this with me, I retook his BP and pulse and confirmed what I had known ever since we had been friends: My friend exercises up to 90 minutes per day, mountain biking, uphill biking, basketball, jogging, walking, strengthening exercises and swimming. In the past year alone I had been present when he ran the Bali Marathon and also the Singapore Duothlon, in both events placing very well in his age group.

While I was studying Medicine in London, I had the chance to attend Radiology sessions at Brompton Hospital for Chest Diseases and vividly recall a certain Dr Simon with his large hearing aid of that time conducting excellent teaching sessions. To us the students he would put up an X-ray and ask us questions, it was enlarged!
And we were told that the x-ray had belonged to one of the greatest marathon runners ever, Emil Zapotek of then Czechoslovakia!  I was lucky to have been exposed to such excellent teaching at the hospitals of London that all that information is still available at the tip of my memory!

The clinical entity of athlete’s heart has been defined with increasing precision using a variety of techniques. Henschen is credited with the first description in 1899, using only a basic physical examination with careful percussion to recognize enlargement of the heart caused by athletic activity in cross-country skiers.5 Henschen concluded that both dilatation and hypertrophy were present, involving both the left and right sides of the heart, and that these changes were normal and favorable: “Skiing causes an enlargement of the heart which can perform more work than a normal heart.”5
You see, how a small piece of critical information, the exercise habits of my good friend, was missing from the GP doctors’ questions and he comes to the wrong conclusions! And gives an entirely erroneous and incongruous advice!
So the machines however sophisticated, in these emerging economies cannot replace the lack of sophistication in the knowledge of the doctors!
It is absolutely normal and to be congratulated that my good friend in his early 50s has such an excellent cardiovascular profile: lower BP and slower pulse and extreme capacity of the body for exercise.
Yesterday while watching BBC world news, amidst the carnage of Syria and Central African Republic, there was an elegant advertisement to invest in Indonesia!

I thought to myself, how far removed from the reality are these images! 238 million people, most of who are yet to get themselves out of poverty, with a very narrow band of very wealthy businessmen and corrupt politicians, a country where the medical care to the needy is poor, on par with other poor countries like Laos and Cambodia. And like any other emerging economy, has up to date machinery so that a rich businessman can order for himself a PET CT scan, a luxury even by western standards!
Imagine an American or British or Australian, however rich he is, going to a doctor and asking them, perhaps even persuading them to do a PET CT scan because he has been told that it can detect diseases? No insurance company would allow the reimbursement and most self respecting western doctors would refrain from ordering an unnecessary, incongruous test.
There are many other very cheap ways to measure whether your body is inflamed and whether or not you are susceptible to a future heart attack or stroke.
Very simple and inexpensive!
If you smoke, your chance of a heart attack or stroke is increased!
Weigh yourself, measure your height and calculate your BMI, i.e. weight in Kg divided by height in meters, squared. If you are not a weight lifter or a marathon runner, if your BMI is over 23 kg/m2 then your chance of heart attack or stroke is increased, if you are an Asian; your chance of diabetes is increased in most Asians, especially in Asian Indians.
Two simple tests both of which will tell you about inflammation in the body: CRP and Cholesterol. If they are elevated, the idea is not to take Statin medications and continue your gluttonous eating habits but modify it to suit your race and ancestral eating habits.
Even after these expensive tests, the local doctors will tell you the same thing; Eat less and Exercise More, that is why the rich patient is there in the first place. Very few doctors in the West or the East are equipped to advice the patient on HOW TO EAT LESS and HOW TO EXERCISE MORE. It is almost as senseless as telling a poor Indonesian: Earn More and Spend Less. What the poor Indonesian wants to know is: How can I do it?
I decided to check up, pardon the pun, of the prices for these tests done by a popular hospital in Jakarta in Indonesia. For those of you criticising the American System of health care, they cost far less to a patient in the USA if they are ordered when it is needed.
The following set of tests taken together will set back an Indonesian a nice tidy sum of 1500 USD or more! Cash is preferred thank you!

 Includes the following examinations: this is the best money can buy, but cheaper alternatives are also available. What does it say about the mentality of prevention of the Hospital? The message here is the more money you are willing to part with, more tests we can do for you. Whether or not it would prevent anything is dubious!
    Doctor Examination (General Practitioner, Internist, Neurologist, Ophthalmologist, ENT, Dentist, Cardiologist (EKG, Treadmill), Obstetric and Gynecologist (female))
    Test: Eye Examination (Auto refractor, Tonometry, Fundoscopy, Ishihara test), Audiometry, Spirometry
    Radiology: Thorax AP/ PA, Panoramic, Mammography Digital (female), Abdomen US (Complete), MSCT 256 Angie Coronel Contrast + Calcium Score, MRI-MRA 3T Head Non Contras
- Complete Blood Count
- Diabetic Screen: Fasting Blood GLUCOSE, HbA1c (Glyco Hb)
- Liver Function Screen: BILIRUBIN, Protein, SGOT-SGPT, Alkaline Phosphatase, Gamma GT
- Kidney Function Screen : UREUM, CREATININE, URIC ACID
- Hepatitis B Screen : HbsAg, Anti Hbs, Anti HCV Screening
- Thyroid Hormone : T4 Total, TSH Sensitive
- Serology : VDRL-RPR, TPHA
- Tumour Markers : CEA, AFP
    Complete Urinalysis
    Stool Routine Analysis
    Consultation by Nuclear Medicine
    Pap’s Smear by Obgyn.(female), PSA-Prostate (male)
    Health Report

At the Manipal Medical centre (which is much more of a Meat market than a Medical centre), all the things included in Doctor Examination would cost less than 100 usd. MRI would cost another 100 usd
Add another 100 dollars for all the other laboratory tests mentioned, so the cost of these tests are 350 dollars maximum, doctors would be given 150 dollars for their work but the foolish but rich Indonesian businessman is paying 1500 dollars for the tests with of course a Health Report. As mentioned, the health report reflects the expertise of the doctor and as seen in the case of my friend, you may be referred for further tests and consultations.
You can spare all these. Come and see your classmate who graduated with you from High School, the humble man of Bogor. Listen to him, soon you would be spending your money to buy clothes that fit a thinner and healthier you, rather than paying into the coffers of the hospital making money for its investors!
Of course, there is a whole philosophy of who should be screened for what disease. In this case illustrated above, the only indication for screening seems to be MONEY, having money and willing to part with it.
My good friend, the humble man of Bogor has this to say:
Knowing my exercise schedule like I do, I think I am healthy enough, I don't feel anything, no signs of any sort of a medical problem, My BP is as 90/60 and the pulse is 60 per minute, blood cholesterol is not high and I eat well,
During my days of working with poor people of Jamaica, I learned a deep lesson, I told my friend.  It is foolish to go around trying to detect diseases among people when there is not enough knowledge to follow it up and offer adequate treatment. In the above case what if the PET scan, which is usually used to FOLLOW up treatment of Cancer with chemotherapy or radiation therapy in the west, what if, it lights up on a spot? What is the next step?

The West already wastes a lot of money on unnecessary tests and it is a pity that developing countries like Indonesia should copy these bad habits rather than copy habits of countries in the developing world, which are extremely good at prevention of diseases or adopt programmes that have been successful in the poorer countries. Several wonderful programmes in various parts of the world come to mind.
The following paragraphs are official criteria for screening for diseases. Urban Indonesia now competes well for Lifestyle associated diseases, such as Diabetes, Hypertension, Heart Diseases. Lifestyle associated diseases are prevented, not by tests and not by medications, but listening to good lifestyle related advice from such notably healthy Indonesians such as my friend, the Humble Man of Bogor!

When the prevalence of preclinical disease is low, the positive predictive value will also be low, even using a test with high sensitivity and specificity. For such rare diseases, a large proportion of those with positive screening tests will inevitably be found not to have the disease upon further diagnostic testing. To increase the positive predictive value of a screening test, a program could target the screening test to those at high risk of developing the disease, based on considerations such as demographic factors, medical history or occupation. For example, mammograms are recommended for women over the age of forty, because that is a population with a higher prevalence of breast cancer.
What criteria should be considered for an effective screening program?
  Life-threatening diseases, such as breast cancer, and those known to have serious and irreversible consequences if not treated early, such as congenital hypothyroidism, are appropriate for screening.
  Treatment of diseases at their earlier stages should be more effective than treatment begun after the development of symptoms. For example, cancer of the uterine cervix develops slowly, taking more than a decade for the cancer cells to progress to a phase of invasiveness. During this preinvasive stage, the cancer is usually asymptomatic but can be detected by screening using the Pap smear. Treatment is more effective during this stage than when the cancer has become invasive. On the other hand, lung cancer has a poor prognosis regardless of the stage at which treatment is initiated. Early diagnosis and treatment appear to prolong life little more than therapy after symptoms have developed. Screening to detect early stage lung cancer using currently available techniques would not be beneficial.
  The prevalence of the detectable preclinical phase of disease has to be high among the population screened. This relates to the relative costs of the screening program in relation to the number of cases detected and to positive predictive value. The expenditure of resources on screening must be justifiable in terms of eliminating or decreasing adverse health consequences. A screening program that finds diseases that occur less often could only benefit few individuals. Such a program might prevent some deaths. While preventing even one death is important, given limited resources, a more cost-effective program for diseases that are more common should be given a higher priority, because it will help more people. 
In some cases though, screening for low prevalence diseases is also cost effective, if the cost of screening is less than the cost of care if the disease is not detected early. For example, phenylketonuria (PKU) is a rare disease but has very serious long-term consequences if left untreated. PKU occurs in only 1 out of every approximately 15,000 births, and if left untreated can result in severe mental retardation that can be prevented with dietary intervention. The availability of a simple, accurate and inexpensive test has lead many states, including New York State, to require PKU screening for all newborns.
  A suitable screening test must be available. Suitability criteria includes adequate sensitivity and specificity, low cost, ease of administration, safe, imposes minimal discomfort upon administration, and is acceptable to both patients and practitioners.

There must also be appropriate follow-up of those individuals with positive screening results to ensure thorough diagnostic testing occurs.