Preventive healthcare packages are targeted at everyone right from age two. While diagnostic tests are necessary to find what made you unhealthy, screening is often unnecessary and harmful. Raj Pradhan collates advice from sensible doctors
Abhijit Patil's (name changed) toddler son suffered from frequent recurrence of high fever. The recommended blood tests for malaria, typhoid and jaundice did not lead to a diagnosis. This led to additional tests like chest X-ray, blood culture and TB test at the Hinduja Hospital in Mumbai. A second opinion with another paediatrician, who ordered another set of tests, also drew a blank. But what perplexed Abhijit was that both doctors arrived at diagonally opposite views based on the same reports. One of them came up with some sensible advice: "Stop reading the Internet for tests to be done and the interpretation of lab results. It will mislead you. Also, there is just no end to the number of tests that can be done." His son got well, with time, without any treatment. Our body takes over and fights out any minor issues without need for any medication. Diagnostic tests are a necessary evil in today's world, especially when someone is unwell. It is the way to find out what is wrong inside our body and zero in on the drugs which would work. But when some leading hospitals offer 'screening packages' for kids starting from the age of two, it's time to pause and think. Does anybody need to spend on mindless screening? Clearly, if you are being urged to sign on for a screening package, hit the pause button.
On 16th October, The Times of India carried an article that said, "Annual health check-ups don't necessarily save lives, says a new Cochrane review of medical trials. Be it overall deaths or deaths specifically from killer diseases such as cancer and heart ailments, the review said the check-ups don't make much of a difference." It echoes exactly what the learned Prof BM Hegde has been writing in his columns in Moneylife.
Scared into Taking PHPs?
High stress levels, junk food intake, sedentary lifestyles all add up to make preventive healthcare programme (PHP) an easy sell for doctors and hospitals. So people like Abhijit—well educated, net savvy, financially stable and over 40 years—are ideal targets for hospitals and diagnostic centres hawking health check-up packages. Do you really need to go through a day of blood tests, X-rays, CT scans and consulting to confirm that you are healthy? Often, the doctors who interpret the results come up with faulty conclusions and start a person on a wrong, sometimes damaging, medication. After a day-long health package at a five-star hospital in Mumbai, S Basu (75) was started on medication for tuberculosis at the consultant's private clinic. Another doctor in the same hospital had recommended an invasive laproscopic biopsy which also turned out to be completely unnecessary. Are you setting yourself up for needless medication through annual check-ups?
Indus Health Plus runs TV ads on Marathi channels that say, "30% of total global deaths occur because of cardiovascular diseases. In India, four people die of a heart attack every minute. Five out of 100 Indians carry a gene mutation that almost guarantees the development of heart disease. Diabetes kills two Indians while stroke and cancer kill one each every minute. In 2008, more than 35% Indians who died of a heart attack, cancer or diabetes were in their productive years (age 35-60)." Isn't this fear-mongering? The ministry of consumer affairs (MCA) ought to be monitoring such advertisements, but fails to do so. But it got Abhijit to quickly sign up for the plan, with the added bonus of getting a discount if he used a certain bank's credit card (this makes it fear-mongering plus a nexus for commissions).
Indus Health Plus also had examples of seemingly healthy people who discovered heart blockages and tumours during these check-ups. It offered different kinds of memberships. Gold or silver cards carry added benefits such as discounts on consultations, diagnostic tests, medicines, etc. Indus is just one example. Thyrocare bombards you with messages and mailers about the world's largest thyroid testing laboratory they have set up in India. Vitamin B12, Vitamin D tests, sugar, liver, lipid profile and other tests are part of the package. But listen to what the US Preventive Services Task Force (USPSTF) says. The evidence available so far is insufficient to recommend for or against routine screening for thyroid disease in adults. But once you are fearful and have the cash to spare or are part of a corporate health plan, you are more than likely to take the test.
Even Shiv Sena leader, Uddhav Thackeray's, heart condition was converted by some into an opportunity to hardsell PHPs to people. The fact that the finance ministry has made PHP eligible for tax savings (of up to Rs5,000 as part of the Rs15,000 under Section 80D) has spelt happy days for medical marketeers in a segment that is already galloping at 13% every year. Abhijit was paying Rs9,000 for mediclaim covering his family. After spending Rs5,000 on PHP, he was close to the 80D limit. It means that if you are in highest tax bracket and spend Rs5,000 on PHP, it will save you Rs1,500 in taxes. For Abhijit, it was like buying term insurance. He thought that if he is healthy, the money 'wasted' on PHP is good news. Is he correct? Or should he listen to Prof Dr BM Hegde, cardiologist and former vice chancellor of Manipal University, who says, "If there is no symptom, never ever see a doctor. PHP is very dangerous. When there are symptoms (can even include headache), then see a doctor. Prevention in true sense, he says, is about promoting your health, improving your immune system."
Whole-body CT Imaging
PHP is an emotional-sell that began in Western countries and is now spreading like wildfire among India's newly affluent with high-paying corporate jobs. The argument that something may be wrong inside your body which you may not know makes PHP an easy sell. Prof Dr Hegde, says, "Going for screening when one is healthy could be very, very dangerous. Medicine is not a hard science. It is a statistical science where averages are equated with normality. We have no definition of 'normal' in medical science. When average is normal, false positives and false negatives are 50%. Now imagine your position when you go for a heart check-up. You will certainly end up on the angiogram table if not on the bypass table!"
The question is: What is 'healthy'? Wellness initiatives like quit smoking, regular exercise, yoga, etc, are undoubtedly crucial for leading a healthy lifestyle; but who is really 'healthy'? One Moneylife reader says, "The problem with visits to a doctor is that they almost always find something wrong. And, the definition of 'healthy' has narrowed to the degree that no one fits into the 'healthy' category. Once you are diagnosed with a condition, no matter how minute and questionable it is, your insurance premium increases. Should you need to come off a group cover and get individual coverage, you could be denied or the premium loaded."
False Positive and False Negative
A false positive is when your tests throw up something that leads you to further treatment, a biopsy or a procedure that may be unnecessary. A false negative is when your diagnostic tests or health package miss out a crucial test, giving you the false impression that you are healthy, when you may, in fact, need treatment.
The key is in getting the right diagnosis. For example, a CT coronary angiography is a sensitive investigation and a wrong interpretation can put you through needless trauma. Dr Shreedhar Archik, consultant orthopaedic surgeon with Lilavati Hospital (Mumbai) says, "People reach old age of, say, 80 years because they are healthy. Often, we find them taking anti-cholesterol and blood thinning medicines without really needing it. Complications from drug usage (containing statins) lead to muscle pain. They are roaming around searching for a cause when it is not there. PHPs often suggest investigations to earn revenue. It is easier for hospitals to do 50 health check-ups than a complicated surgery; there is no risk of getting sued."
The grey areas from test results need doctors with expertise. Dr Archik adds, "One patient had back pain. The radiologist saw a lesion of 0.8mm. I spoke with the patient about family history of cancer, enquired about symptoms and decided to just keep it under observation with no action. Another interpretation could have led to bone scan, PET scan and so on. This is how PHPs can lead to rise in malpractice. An X-ray may reveal a small stone which may be totally asymptomatic. Why take it out without any reason? Some centres may suggest series of other tests and lead you to a wrong path."
Dr Anant Phadke, leader of the People's Health Movement in Maharashtra, has started the Lokayat Medical Centre in Pune managed by a socially-oriented doctor under expert guidance. According to him, "The sensitivity (ability to detect the abnormality) and specificity (ability to recognise/spare the non-diseased) of stress-ECG (electrocardiogram) for detection of ischemic heart disease (IHD) is between 55% to 70% and 75%-95%, respectively. If the prevalence of IHD in the community is 3%, out of 1,000 persons undergoing the test, 21 will be true positives, nine will be false negatives (labelled 'normal' although they have the disease) and 145 will be false positives (shown as having IHD when they don't). Those testing positive end up undergoing further tests to rule out IHD, including expensive and invasive angiography. Alternatively, if the physician relies on the test result alone, s/he may advise a lifelong treatment to a person who does not have IHD!"
Dr Phadke is clear that stress-ECG should be employed as a screening test only in high-risk groups or in a subset of persons who have suggestive symptoms. Even in pilots or railway drivers, the test must be done only if the results are going to be followed-up with an angiogram, since 80% of positive stress-ECG results turn out to be false positives after angiogram.
Dr Phadke says this is part of standard medicine textbooks but scientific principles are violated under commercial pressures. He says that other examples of virtually useless screening tests are: pre-operative ECG and chest X-ray in low-risk individuals, serum PSA (prostrate-specific antigen) as a test to detect prostate malignancy, mammogram as a test for breast cancer for women even below 50 years of age.
False negative occurs in tests for malaria or blood culture, if it is done when temperature is not elevated or other reasons. Typhoid tests may throw up false negatives, unless done after nearly week of fever. Many adults and some children living in metros will test false positive for mantoux TB screening test, but do not really need treatment. If given medication, there can be significant debilitating side-effects.
The key to good health is to find a good doctor, rather than rushing to experts. As Dr Hegde says, "If your family doctor is a good human being, you will live comfortably for the time you are destined in this world." He also points out that PHP is a $1.72 trillion industry with cancer screening as the biggest myth. So it is no surprise that doctors, hospitals and the media inexorably push people to sign up for PHP. Dr Hegde, a Padma Bhushan awardee and one of India's most qualified doctors, cites a few eye-popping facts.
• If an asymptomatic person having hyperglycaemia is treated with drugs, it will expedite death. Early bypass surgery increases the risk of stroke. A French study has shown that using statins (cholesterol lowering drugs) could be dangerous.
• Everybody has cancer rogue cells, but it rarely ever becomes clinical cancer. They can remain in the body for 10 to 15 years before turning into cancer. Asymptomatic cancer should be left alone. If you meddle with it, it will kill you. It is not just about prostrate cancer, but also about other cancers too.
• Severe congenital heart defects generally are diagnosed during pregnancy or soon after birth. Congenital heart disease testing needs to be done for babies and children. Heart valve issues or holes can become huge problems after some years. Many of the correctable things should be detected and treated. Prevention and cure are important to avoid sudden deaths that can happen like seen on football fields.
Diagnostics and Screening—Hustle and Bustle
Senior citizens are most vulnerable to the hardsell for PHP packages; they are quickly converted to patients or put on daily medication because modern medicine does not tell them that several minor aberrations in health parameters can be corrected by exercise and improved diet. Buying heath check-up for parents' birthday is a good marketing gimmick which shows you care. It's a ploy. Drug companies organise screening camps which use their own products. Apollo Pharmacy even has people queuing up to get instant blood sugar and pressure testing outside their shops.
Dr Sadanand Nadkarni, a highly respected former dean of LTM Medical College (Mumbai) says, "PHPs are often offered at ridiculously low price or sometimes free to attract customers. Take it with a pinch of salt. In the garb of detecting some disease, they put you on treatment. Any aberration may be called as disease." Dr Nadkarni believes that PHP may sometimes be useful in detecting cancer at the first stage but it is over-marketed to the masses and only a small percentage actually benefits from it.
Dr Archik highlights another flaw. He says, "PHPs are supposed to advise the healthy too on how to remain healthy but, in reality, doctors rarely interact with healthy people to advise them on exercise, lifestyle, diet control, work-related stress, etc." He also points out that since MRI (magnetic resonance imaging) machines cost crores of rupees, small centres tend to flog them for higher usage to cut corners/recover the investment. A good MRI requires 50 minutes with a radiologist looking at the sequence while it is happening and should not be conducted by a technician.
But here is more conclusive evidence about the efficacy of health check-ups. On 16th October, the Nordic Cochrane Centre's review published details of research which looked at 14 trials involving almost two lakh people to arrive at the conclusion. People were divided into two groups: one was invited for general health checks and the other was not. The results were varied. But a closer look at 11,940 deaths recorded in nine of the trials showed no difference between the number of deaths in the two groups. "From the evidence we've seen, inviting patients to general health checks is unlikely to be beneficial," said lead researcher Lasse Krogsboll of the Nordic Cochrane Centre at Copenhagen (Denmark), in a public statement.
Listen to Your Body—Test What Really Matters
Every doctor will have a different opinion about when to start PHPs—it can range from age 30 years to never. But ideally, it is best to listen to your body for signals. Ignorance is not bliss in matters of health and there is a fine line between bravado and stupidity; it is important to know the difference. According to Dr Nadkarni, "Regular check-up was needed for those over 60. Today, annual check-ups after 65 can be physical check-up and a few simple tests. They are: blood CBC, blood sugar, serum creatinine (kidney), serum protein and bilirubin (liver), X-ray of chest (lung) ECG, stress test (heart) and vision."
Employment Related Tests
Jobs in large companies or specific professions involving high physical activity or stress require specific medical tests as a pre-condition. Often, the tests are also to minimise a company's liability. But what about domestic help that you employ? Should you worry about them? Sometimes, ignoring their health issues is at your cost; but are you prepared to spend for it? Here are a couple of interesting examples.
Dr Archik, says, "A top executive contracted TB. He panicked and read everything about it and kept asking why him, when he travelled in a nice chauffer-driven car to a plush office. Finally, it clicked that it may be the driver had TB and he was sitting in the closed environment of an AC car inhaling the germs. He tested the driver for TB and it was positive."
Astonishingly, he also says that the doctors often have a high incidence of TB since they work in a contagious environment of hospitals all the time. "When I graduated (MBBS) from college, six colleagues already had TB. We were working day and night with no immunity. If you go to good restaurant, they may wear gloves, but your maidservant does not and may be amoebic carrier."
Uncertainty is only certainty in life and everyone's case is unique. Moneylife has always highlighted that you must not fall for marketing gimmicks in the belief that it will keep you healthier.
Costs of PHPs
The cost of diagnostic tests varies sharply and it pays to be smart about your choice. The difference can be as much as 100% to 200% and, often, involves kickbacks to the recommending doctor. Dr Shreedhar Archik says, "There is mushrooming business of agencies collecting blood and sending it to some lab who, in turn, call some free physician and pay. The quality suffers. NABL (National Accreditation Board for Testing and Calibration Laboratories) is a better option for authenticity. Every process goes through stringent quality norm with an error rate of one in a million. There is a classic man versus machine problem. Most tests are done by feeding the sample to the machine which gives the reports. One in 10 reports has something that suddenly raises suspicion. An alert pathologist will manually intervene. A good lab will have norms to handle this situation in order to be doubly sure. They may recheck the sample and look at it manually under a microscope. For instance, a platelet count of 44,000 can cause panic, but a microscope may reveal a larger platelet size and, in turn, a lower count." If you buy a PHP package online, check if they use NABL-accredited labs. These days, a child is exposed to diagnostic tests and risks even before birth. Screening for congenital heart disease, downs' syndrome and so on happens before birth. Some of these are invasive tests carrying risk factors, even miscarriage. After the baby is born, there are divergent views about the necessity of vaccines such as pneumococcal.
Do You Really Need To Test for Osteoporosis?
Older women tend to suffer from deterioration of the bones called osteoporosis. The US Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women aged 65 years or older and in younger high risk women. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. But views on this are widely divergent.
Some new studies have cast a doubt over the screening tests such as bone densitometry. According to Dr Anant Phadke, "Bone densitometry in post-menopausal women though being aggressively pushed (even in absence of appropriate standardisation for Asian, Indian population), has no value. If a 50-year-old woman has marked osteoporosis due to oestrogen deficiency, as seen on bone-densitometry, no safe and effective medication is available. Hormone replacement therapy (HRT), which is still being advised by some doctors to such women, is hazardous. Adequate dietary calcium and regular exercise are advised to all ageing people anyway. Bone densitometry as a screening test has been used to terrify women into believing that they would develop fractures and thereby made to go in for hazardous HRT. Since HRT itself has been questioned by different studies, bone-densitometry as a screening test should disappear."
Dr Shreedhar Archik, an orthopaedic surgeon, disagrees with this view. According to him, "Bone mineral density (BMD) test is done to detect osteoporosis which is known as a 'silent killer'. The first symptom of osteoporosis is a fracture that is too late for prevention. BMD, therefore, is done to detect osteoporosis early and not a test to frighten someone. HRT is prescribed by gynaecologists and the BMD test reports are usually ordered and seen by orthopaedic surgeons so it is wrong to say that it is used to frighten a woman to take HRT. Also, there are so many new drugs available which are much better than HRT and, hence, HRT is not used much now-a-days. We actually have very few BMD machines compared to the estimated patient load and are under served as per the Asian audit. So spreading such rumours is detrimental."
Dr S Nadkarni was earlier in favour of BMD, but has been rethinking his position after reading some latest articles. According to him, "Exercising is good for keeping bones healthy. BMD is popular, but what is the treatment? Giving calcium and Vitamin-D3 may not be enough. Often, it is an indication of protein deficit. Calcium is deposited on wire-mesh of protein which itself may not be there. I used to think HRT was good, but am not sure any more."
What You Really Need
We have listed the ills of preventive healthcare programmes packages which are being aggressively pushed at you, stoking your fears. So, what should be your preventive healthcare initiatives?
• Stop tobacco, drug and alcohol use
• Nutrition to maintain caloric balance
• Oral health
• Calcium intake in women >18 years
• Physical activity
• Regular exposure to the sun
• Folic acid when planning for pregnancy
• STDs and HIV prevention
• Vision, hearing, dental evaluations, fall prevention, home safety issues for elderly
• Injury prevention (loaded handgun, seat belts, bicycle helmet)
• Immunisations (if applicable)
This is all you need to stay healthy.
Source : MLF
Best Regards
Prakash Nair
