Standard Treatment Guidelines: Protocols for 220 diseases remain on paper

The STG norms have neither been notified by the Centre nor enforced by the states which decided to adopt the central act.

Published: 30th May 2020 10:35 PM  |   Last Updated: 30th May 2020 10:35 PM   |  A+A-

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Express News Service

Surabhi Tyagi, 28, a teacher in a private school in Hapapur village in Barabanki district of Uttar Pradesh had a close shave last year when complications during her Caesarian Section nearly killed her.

She had excessive blood loss and severe infection during the procedure in a small nursing home in Barabanki after which she was referred to the King George's Medical University in Lucknow—one of the biggest government-run health facility in the state.

Surabhi spent nearly a month in the hospital last September before being discharged. The family, however, is now relieved that both she and her baby girl are okay despite the long the ordeal.

A little investigation into her case reveals that the C-section that was carried on her may have been completely unnecessary—a problem that has been vastly acknowledged in the country but barely addressed.

“My pregnancy had been absolutely fine without any issue but days before my due date, the gynaecologist-obstetrician I was seeing told me that I had a very narrow pelvis and won't be able to give birth to a baby naturally,” Surabhi says.

“She then asked me to choose a day when the C-Section could be performed. Her words had filled us with so much fear that we went ahead with the surgery despite reservations.”

Both Surabhi and her husband Manoj Tyagi, who has worked for the doctor in the past, however, did not want to push a case of negligence despite the unimaginable trauma they suffered.

Now, they do not even want to name the doctor for the fear of retribution.

The problem that the couple faced, however, is faced by millions of patients routinely in the absence of standard treatment guidelines—which means that doctors in India are free to suggest drugs, surgeries or procedures for a medical condition at their whims and fancy.

Dr Neelam Pandey a Lucknow based activist doctor who has not gone through Surabhi’s case fully pointed out that a large number of hysterectomies and C-Sections like various other procedures are absolutely farce but are carried out routinely in India due to the complete lack of a regulatory framework for the healthcare sector.

“This is because there are no specific standards for doctors specifying under what circumstances can C-Sections or hysterectomies be performed.  Millions of women—like other patients who are treated unduly—suffer quietly in multiple ways due to these procedures performed on them unnecessarily but who cares?” she rued.

Once the Clinical Establishment Act was promulgated in 2010 with an aim to introduce rules for the first time to govern India’s healthcare providers, hopes had risen that the country will soon see doctors stick to STGs, the systematically developed protocols to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.

But even after STG were specified for over 220 diseases three years later when the rules under the Act were partially made—they have just remained on paper, much like the Act itself, as they have neither been notified by the Centre nor enforced by the states, including UP, which decided to adopt the central act.

“Ideally, STGs should be norm and in 10-15 % cases where the doctors can not adhere to them due to specific condition of the patient they should justify the deviation but that looks still looks like a long way,” said Dr Abhay Shukla, the national co-convener of the Indian chapter of People’s Health Movement.

Dr Sanjay Nagral, a surgeon in Mumbai who is chairman of the Forum of Medical Ethics, has also worked in the UK in the past.

“There, like most other developed countries, doctors can not prescribe even an antibiotic outside the defined protocols for every condition,” he said. “But here you go to a doctor with a simple cold, 10 doctors will prescribe 10 different medicines either because of their choice or under the influence of the pharmaceutical companies.”

And its patients who bear the brunt in multiple ways.

Suresh Rani, a resident of Ghaziabad, had felt uneasiness in stomach and dizziness one afternoon in October, 2012. Her son, Rohit Goyal, a software engineer took her, then aged 59, to a private doctor but despite his treatment she did not feel better.

Next day, she went to Kailash hospital in adjoining Noida where at first she could not get any treatment because of the absence of a gastrointestinal doctor but the next day got admitted on the insistence of the doctor.

“There she did various tests on her including MRI and told us that she had brain stroke. Then they shifted her to the ICU and started treating her for stroke even though her indications were totally different,” said Goyal.

“What she actually had was electrolyte imbalance but the doctors were on the wrong path since the beginning. After realising that they had messed up the case—they raised her Sodium levels five times the safe limit within a day and that damaged her brain permanently.”

She spent nearly a month in the ICU during which the family spent about Rs 10 lakh on the treatment.

But in this period she developed Extra Pontine Myelinolysis and Central Pontine Myelinolysis — the conditions in which normal functions of the brain are badly damaged — and has been almost a vegetable since then.

Goyal appealed to the UP state medical council, Delhi Medical Council and the Medical Council of India seeking justice but every time these bodies ruled in the favour of doctors and the hospital.

He has now approached the National Consumer Disputes Redressal Commission seeking a compensation of nearly Rs 50 crore and the case is under trial.

“My wife and sister had to quit jobs to take care of her and we could not have a second baby—we have suffered so much but not as much as even a warning was issued to the doctors,” he says. “We had to go to a consumer forum now because there is no other platform where we can put forth our grievance.”

The hospital meanwhile pointed out that the patient was discharged from the hospital with “stable vitals” and the UPSMC, DMC and the MCI following their investigations had not found any negligence or wrong treatment by the hospital.

“Since the matter of Mrs. Suresh Rani is subjudice before Hon’ble NCDRC, any comment or discussion regarding the same is not appropriate at this stage,” the management of the hospital told this newspaper via an e-mail.

Authorities at both the Centre and in UP know what the problems are but shift the responsibility on each other.

“The STGs had been published long back—its for states to adopt them as health is a state subject,” Union health secretary Preeti Sudan had told this newspaper in February this year.

UP health minister Jai Pratap Singh, in an interview with this correspondent earlier had said that the state had been trying hard to enforce the CE Act and its provisions but needed to take “everyone along.”

Dr Shukla meanwhile pointed out what the Centre needs to show is the leadership but that is what is missing.

“Has the Centre left states to grapple with the current Covid-19 pandemic because health is a state subject? It does take the lead where it wants to but hides behind excuses on other occasions. Why can't it at least notify these guidelines along with minimum standards of operationalisation for hospitals?,” he asked.

Dr Nafis Faizi, who teaches community medicine at the Aligarh Muslim University underlined that if lack of STGs was a massive problem for patients requiring hospitalisation services, its absence is equally problematic in OPD.

“Lack of STG based prescriptions lead to therapeutic anarchy in OPD with drug overuse in private settings and underuse in public settings,” he said adding that lack of these guidelines has facilitated massive misuse of anti-biotics in India over the years which has now resulted in a big public health issue of antimicrobial resistance.

(The author has received support in the form of a grant from Thakur Foundation, USA to report a series related to the Clinical Establishment (Registration and Regulation) Act, 2010.)

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