Locost: Low-Cost Standard Therapeutics

When I was an undergrad I was involved with a student group called UAEM (Universities Allied for Essential Medicines) that tried to pressure universities to cater their research policies to developing country needs. Part of our activities involved pressuring Columbia to play around with its patenting and licensing policies. Generally when a researcher at a university discovers a promising new chemical that might treat some disease, the university patents the chemical, giving itself ownership for 20 years. Since it usually doesnt have a large enough research budget to conduct all the safety and efficacy trials needed for FDA approval, it then licenses the chemical to a private pharmaceutical company, which does the rest of the work. In exchange, the company is usually the sole producer and distributor of the medicine for the remainder of the 20-year patent period, paying the university royalties from its sales.

This neat arrangement is usually sad for poor people, because the company's monopoly allows it to charge super high prices as a payoff for its research and development work. Part of UAEM's mission it to try to get universities to put more pressure on the pharma companies to relax their patent enforcement, especially in developing countries.

We had some success during my last year in school, as Columbia decided it would start trying a policy called mandatory sublicensing. The basic idea was this: if a government or ngo or someone complained that a company was not making a drug available at a reasonable price in their country, the university would reserve the right to issue another license to a producer who would only produce and sell for "humanitarian" uses.

This confused me at the time, as I had never heard of a pharmaceutical producer that wasn't a profit-making company, and wasn't sure who these humanitarian entities would be. At some point last year I was talking with another friend from UAEM, who realized that UAEM did a lot of clamoring for allowing more companies and producers to make and sell drugs in developing countries, but we didn't really have a clear idea of who these producers would be.

Which brings me to my point: When I was at Prayas, I was in touch via email with a man named Chinu, who helped me with the medicine pricing FAQ I was writing. He had written a book called "A Layperson's Guide to Medicines", which helped consumers understand issues like quality control, medicine pricing, branded vs. generic, research policies, etc. He ran an organization called Locost, which in addition to making helpful resources and engaging in pharmaceutical policy advocacy, actually produces essential medicines and sells them with little mark-up to NGOs working with the urban and rural poor in India. Eureka! This was just the type of producer referred to in the Columbia policy.

What was particularly cool was that at both Vivekananda Girijana Kelyana Kendra and Chinmaya Organization for Rural Development, the hospitals and OPD clinics stocked Locost drugs.

(OPD Clinic at CORD with Locost drugs)

Thus I encountered the organization at all three NGOs I visited, and thought that this kind of impact deserved its own post. Here is their website for anyone whose interested:

http://www.locostindia.com/

Kokilaben Dhirubhai Ambani Hospital

[May 17th, 2010]

After leaving VGKK, I went to Mumbai for a few days to stay with relatives. One of my relatives is a dietician at a very famous and high-tech Mumbai hospital called "Kokilaben Dhirubhai Ambani Hospital." This is what Indian's refer to as a "corporate" hospital, and is actually owned by Reliance Industries, a huge cell-phone and communications and pretty much everything else conglomerate.

http://www.kdah.in/index.html

My relative was nice enough to use her sway to arrange a tour for me. My tour guide usually gives tours to donors and famous people, so it was surprising he consented to giving a tour to lil' ol' me. However, it also meant that I had to be very polite and tactful in the questions I asked, so I probably didn't get all the information people might want.

For people moving from place to place, India is full of many of its own internal culture shocks. After a few lengthy trips in the country, I had pretty much gotten used to the drastic differences in wealth/culture/lifestyle from region to region, but my culture shock from VGKK Tribal Hospital to Kokilaben was unavoidable. The lobby was enormous with plush chairs, TV screens, air condition, information help desk, check-in counter, gift shop, etc. There were separate check-in counters for patients with insurance and those that paid out-of-pocket, and both counters had enormous computer screen registrations. The demographics of the patient population was wealthy, with many foreigners coming for medical tourism (I actually feel like this is the best term to describe my trip. Alas, its already taken, so I'll have to settle for "public health tourism").

I wasn't allowed to take pictures and unfortunately did not take notes, so the following details might be slightly off. From what I remember, the hospital had roughly 750 inpatient beds, and saw a large number of out-patients in various clinics. I was first brought to their emergency room, where they had about six beds and one room devoted to emergency trauma operations. Emergency patients were only brought in by the hospital's ambulances. They were not dispatched through emergency called to government lines, but only if the hospital's own emergency line was called. There was apparently constant communication between the ambulance crew and the emergency room staff while the patient was in transit. There were no patients in any of the beds while I was there, but I think one was on his way.

I then got tours of a bunch of radiology devices, such as MRIs, CAT scans, etc. They have cute additions like painting the ceiling with pretty murals so patients feel relaxed. I also got a tour of their massive radiation oncology machines, of which they have two. From the high-tech perspective, they seemed probably better equipped than a lot of American hospitals. As far as recruitment power, I think they basically tapped people from other famous hospitals in India, and many of them came, so their physicians were probably pretty excellent at their jobs. I briefly met a famous infectious disease doctor who does a lot of travel medicine work. It was funny to imagine Indians consulting travel medicine physicians, as most Americans make travel med appointments before coming to India.

The most interesting part of the whole tour had to do with room categories. It is obvious that there are going to be issues of access in expensive corporate hospitals in which patients need to either have a lot of money. But what was really interesting was that patients paid different rates for their rooms, creating an internal division of patient class. There were shared rooms, single patient rooms, deluxe rooms, super-deluxe rooms, and luxury suites. Patients in these different classes also paid different rates for some of the services, although the tour guide said all medicine prices were the same, because there was some law against elevating prices past the Maximum Retail Price. The shared rooms were already in much better shape than any of the previous hospitals or clinics I'd been in, but the luxury suite was insane. It had an ultra-comfortable patient bed and room on the top floor with a window view, as well as a personal waiting room for visitors, which had its own couches, TV, fridge, and other amenities. I asked as politely as I could about differences in quality of care for these classes, and the tour guide assured me that everyone received the same care, with differences only in comfort. But it was pretty clear that the luxury patients (who were often famous people) received much more attention from nurses and staff than patients in lower categories, and constant attention itself likely leads to different quality outcomes.

The government District Hospital in Chittorgarh, Rajasthan (see previous post) was also in the midst of constructing a luxury ward of a few beds. This ward had air-conditioning, as well as amenities like storage closets and nice bathrooms. Dr. Narendra at Prayas was against this in principle, likely for the same concerns about quality of care discrepancies. The number of different classes at Kokilaben took this to a whole new level. It kind of made me finally realize that the "corporate hospital" label is really not synonymous with US "private hospitals".

Nonetheless, it was heartening to see patients receiving high quality care in India. In a sense, it is nice that some Indians have enough money to keep such hospitals running, keeping health professionals in the country and decreasing the brain drain. Then at least doctor availability becomes a national distribution problem rather than a international one. Also, larger public health perspective and moral principles aside, if my family member was in an emergency and I had the money, I would bring them to Kokilaben.

Late Posts

I haven't written a substantial post for about a month, but I've seen a lot since then. I'm going to break stuff up topic-wise in different posts, adding the date of when they should have been written.

Anemia and Starvation

The sheer amount of malnutrition-related anemia I saw while at VGKK was frightening, so I'm getting more interested in nutrition and food security issues. This BBC article was pretty interesting, and completely depressing. It's called "Diet of mud and despair in Indian village."

http://news.bbc.co.uk/2/hi/south_asia/8682558.stm

Besides all the rest of the heartbreaking stuff, note the mention of the changing poverty line. Recently the Indian government decided to use better standards to define the poverty line, and percentage jumped from the mid-20s to a little less than 40%. Apparently even these standards aren't as stringent as international poverty line standards, which would make the number even higher.

Embrace

Yesterday I visited the Bangalore office of Embrace, a non-profit out of the design school at Stanford that makes low-cost neonatal incubators. I heard about them when I interviewed at Stanford, and got in touch with them through a friend. They were totally impressive. You can check this link for more info:

http://embraceglobal.org/

VGKK, Karuna Trust, BR Hills

I am now in Bangalore, Karnataka. I just spent a few weeks at a place called the B.R. Hills, which is about 5 hours away from here. The hills were absolutely beautiful:
http://en.wikipedia.org/wiki/Biligirirangan_Hills

The hills are home to the Soliga tribe, who used to practice shifting cultivation back in the day. A Forest Conservation Act in the early 1970s set up the B.R. Hills as a wildlife sanctuary, and prevented a lot of the activities the tribe had been doing for a long time. They were in a pretty sad situation with little exposure to other economic activities and pretty much no education with which to integrate into non-tribal ways of life. This was pretty much the state they were in when a man named Dr. Sudarshan first saw them. He began to wander around the jungle with a medicine bag looking for tribal people, who ran away from him at first. Eventually he was trusted enough to stay in their villages, and roamed from village to village treating people. He eventually set up a hut as a home and makeshift clinic, which is actually still standing:
He also started holding informal night classes for 6 tribal children in his hut. (One of these students now has a PhD, and another has a master's degree). Since then, the hut has evolved into an enormous, beautiful campus with a hospital and school, run by the NGO Dr. Sudarshan founded: Vivekananda Girijana Kalyana Kendra. Here is a picture of the school and hospital:


The school teaches 540 tribal children at a time, through 10th grade. Above 95 percent of the tribal children attend the school, and 99% of them pass the national 10th grade standardized exams. Many of the students are now working in some capacity for VGKK, and others have gone on to further education. Unfortunately it is vacation season, so I didn't get to see 500 kids running around campus.

This internship was very different than Prayas. It was much more of a clinical shadowing experience, in an incredible variety of clinical settings. As I was not helping draft documents for policy advocacy and such, I was perhaps less useful to the NGO than at Prayas, but I did help in minor ways such as taking blood pressures and keeping patient records. One of the tribal people working for VGKK said something like "We are showing you everything now, so come back one day and help us." Here are some of the clinical settings I volunteered in:

VGKK Hospital
The hospital has a daily outpatient clinic from 9 to 5, where I spent many of my days. It has a doctor, nurse, lab technician, pharmacist, and two medical students from Mysore Medical College. It sees about 40-50 outpatients a day, and has a handful of inpatients at any given time. There were two inpatient wards, male and female, each of which had about 10 beds. All consultations are free, as are the medicines given. A lot of the medicines are purchased from an organization called LOCOST, which produces low-cost generic medicines for use by NGOs and health organizations. (Incidentally, the head of LOCOST gave me a lot of input and advice on the FAQ I wrote at Prayas!). They have an operation theatre, but the surgeon they had on staff left a couple of years ago, and they have done few operations since.

While at the hospital, I saw quite a few exotic injuries. We redressed a surgical wound for this one guy who broke his foot while running away from an attacking elephant. Another 0ld woman was charged by a bull, and was kept as an inpatient for observation. I also saw a non-venomous snake bite on a guys foot, which had evolved into a large and nasty infected wound, as he didn't seek treatment for a few weeks. Another woman with a similar wound was now on crutches.

There was a few sad trauma cases: a car crash occurred at a temple up the road, and a woman came in with a concussion and deep gash on the top of her head. The driver of the vehicle's lower lip was split completely in two. They stitched the woman's wound while a free Karnataka state ambulance arrived, which took both patients to a bigger hospital in a nearby down.

For the most part though, the patients have had normal complaints of fever, diahrrea, vomiting, cough, etc. As expected, there were more infections than one would see in the US. One interesting note is that they check under the lower eyelids of almost all the patients for signs of anemia. Also, the prevalence of tobacco smoking was remarkably high among men in the area, and there was an inpatient with COPD. For very complicated things, VGKK generally refers to the nearest tertiary care hospital at Mysore Medical College. This is a public hospital, but still has some fees, which makes some of these patients unwilling to go.

Mobile Medical Clinic

Every Friday and Saturday, VGKK sends out a mobile medical clinic to surrounding villages, which is basically a jeep loaded with medicines for minor ailments. I went out with the medical students to various villages, where they held informal consultations with sick people, and gave them appropriate medicines. Some villages had only 2 or 3 patients, others had more than 20. If necessary, there were also home visits.

In one village, we visited the hut of a couple who had been attacked by a bear. The woman had broken her hand, and the man had a badly hurt lower back, and was lying on the floor. He had to use a rope which was dangling from the ceiling, to pull himself into a half-way sitting position. They had already gotten some treatment and x-rays somewhere, but I got conflicting reports about where. The medical student tried to convince the man that he needed further observation at Mysore Medical College, but the man was very relucant to go.

In my last two days with VGKK, we went on the mobile clinic to another region called the M.M. Hills, staying overnight. The villagers in this area seemed to be in generally worse shape than what I saw in the B.R. Hills. There was an incredible amount of anemia, so much that we ran out of ferrous sulphate about 2/3 of the way through the first day, and had to restock at a local Sub-center. One woman's anemia was so bad it was beginning to lead to heart complications. It was pretty sad to realize that the iron supplements would only help these people for a little while, but they would soon degenerate back into anemia without drastic changes in food availability. I also witnessed my very first leprosy diagnosis: a boy had been told he had a skin allergy, but the med student noticed a few signs that pointed to leprosy infection, and then the mother mentioned that he didn't feel pain when he touched burning hot surfaces. He was directed to a PHC to test for leprosy. The medical students were particularly awesome on this outing, as they walked us through almost every diagnosis. Some of the villages had more than 50 patients. I took a few blood pressures, gave an injection, and got to participate in patient examinations. I heard rhonchi lung sounds, heart murmurs, and plenty of other things that excited my geeky medical obsession. But generally, I was pretty sad about malnutrition and anemia.

Karuna Trust and Gumballi PHC
Dr. Sudarshan and colleagues also began a sister NGO in the mid 1980s called Karuna Trust, which is focused on rural development (whereas VGKK is focused on tribal development). It began as a health project in response to the high prevalence of leprosy in the rural areas at the bottom of the B.R. Hills, but has since spread into trying to provide comprehensive primary health care and development. Probably the coolest thing about Karuna Trust is that they were able to convince the Karnataka state government to allow them to take over operations of the Primary Health Center in Gumballi, at the foot of the B.R. Hills. They turned this into a model PHC, and are now operating PHCs in every district in Karnataka, as well as in five other states of India.

I visited the PHC at Gumballi, and saw what a government clinic could look like when operating at its theoretical best. The PHC has a doctor, several staff nurses, a pharmacist, lab technician, optician, opthamologist-in-training, three dental surgeons, as well as a general surgeon who visits every once in a while to do tubectomies (female sterilization). They have programs for mental health, epilepsy, TB, leprosy, and more.
Since the mid-1990s, they have been combatting mental health. They are currently treating around 350 epilepsy patients, as well as 150 general mental health patients. Every Sunday, they hold an epilepsy camp, where one-fourth of their patients come for an update and to receive new medicines. I got to see this epilepsy camp in action, and read through a lot of the case records. Some of the patients had spouses who thought they were possessed, which made their lives really sad until their medicines brought their convulsions under control. Most of the patients were no longer experiencing seizures. I also kept records during a mental health camp on a Saturday, which is held once a month. These were incredibly fascinating patients, with interesting case histories. One interesting sidenote: on the forms there was a question for the average monthly income for the patient's family: some of these were as low as 500 to 1000 rupees, which is between 10 and 20 US dollars for a month for a family. It is incredibly fortunate for these patients that they have free quality medical attention through the PHC.

The clinic is also following two leprosy patients, and 17 TB patients. (The leprosy rate has gone down dramatically since their control efforts). An optician does eyesight consultations, and they make glasses at the PHC. An opthamologist-in-training does eye consultations and cataract surgeries, and a new one rotates in every 3 months. Two volunteer opthamologists come from a private hospital in Bangalore every Saturday to do cataract surgeries and train the intern. All consultations and surgeries are free for patients. They invited me to watch last Saturday, and I got to scrub in.

(Thats me on the left in the picture)

Three dental surgeons also rotate in every 15 days, and operate a mobile dental clinic, where they are able to do consultations and minor operations. They consult out of the mobile clinic in the PHC parking lot, and drive it out to villages every few days.
The pharmacy was well stocked at Gumballi, which is more than many government clinics can say. They are provided to patients as a fixed nominal cost of 15 rupees for all medicines, whatever the quantity or relative expensiveness. They also have a well-equipped laboratory for tuberculosis sputums, blood sugar measures, urine analysis, and more. They have a trained staff nurse who performs many of the deliveries, people cultivating a medicinal herb garden, and a rangee of other activities that have gotten too numerous to keep listing. In summary, the PHC is incredible.

There was also a group that did health education teachings in villages in the block. They go to villages for 2 days at a time. On the first day, they parade around and get a lot of attention. Then they put on street plays and sing songs about water quality, infectious diseases, nutrition, and more. They did a demonstration for me and another volunteer at the PHC, singing songs and dancing. We were supposed to go out to a village, but they were asked not to by the government because Gram Panchayat (Village-level) elections were taking place.
B.R. Hills Sub-Center
This was a government clinic sub-center about a 2 km walk from VGKK. It is one of five subcenters attached to the PHC at Gumballi. It serves 8 tribal settlements and 2 non-tribal settlements in the B.R. Hills, for a total population of 2,383. There is one ANM on staff, who was actually trained at VGKK's nursing school. There are an average of 20 patients per day, mostly for minor ailments. There used to be about 2-3 birth deliveries per month, but the Karnataka state government is trying to get all deliveries to happen at the hospital level now. They favor squat delivery of babies rather than lying down, as it is believed to be less dangerous for the mother.

Karnataka has a pretty remarkable compensation system in place to try to reduce maternal mortality. (I think this is Karnataka-specific, but its possible the NRHM is trying to implement this in other places. I at least didn't hear anything about it when I was at Prayas in Rajasthan). A family will get 500 rupees if their home delivery is supervised by a healthcare provider, 700 rupees if the delivery happens at a hospital, and 1500 rupees if she gets a C-section. If the mother comes regularly for Ante-Natal Care check-ups, she will get 100 rupees before delivery, and 1000 rupees after. This benefit system is only in place up to 2 babies, as they do not want to encourage overpopulation. For a female baby, 100,000 rupees will be given to the mother when the daughter reaches 18 years. This is to discourage female infanticide, which has led to some pretty gross boy/girl ratios in a lot of states of India. (Girls are seen to be less economically useful, as the family will have to marry them off and pay a dowry). The ASHA system from Rajasthan is in place here, with 1 ASHA for every 2 or 3 villages.

The ANM at the SC did immunizations, which VGKK helped out with. We followed one of the VGKK health workers to some of the villages, where he visited the houses of people who were due for vaccination and reminded them to go. There was also a mentally ill patient who had TB, who had been coming irregularly for his TB medications. The health worker and the guy's father scolded him, and he promised to come the next day.

VGKK was also up to a bunch of other cool projects, such as training tribal people in honey processing and the sustainable harvesting of non-timber forest products. They are partnered with a biodiversity conservation organization called ATREE (Ashoka Trust for Research in Ecology and the Environment), whose B.R. Hills field office is actually run by one of the first 6 students in Dr. Sudarshan's hut in the 1970s. He is now working on his PhD.
http://www.atree.org/
Part of their mission is to do research on the ecological sustainability of the Soliga tribe's way of life, so that the tribals will be given more flexibility by the forest conservation act.

I'm now back in Bangalore. I'm going to visit relatives in Mumbai for a few days, then off to my last NGO in Dharamsala. This trip has been incredible so far.

More indians with access to mobile phones than toilets!

So a recent UN report on sanitation says that India has more mobile phones users (45%) than people with access to toilets or sanitation facilities (31%):
http://www.hindustantimes.com/News-Feed/india/India-has-more-cell-phones-than-toilets-UN/Article1-531449.aspx
I'm curious to know the amount of overlap, or people with mobile phones and no toilets. From my experiences over the last few weeks, I think it might actually be a decently high number. I downloaded the pdf of the report, but havien't finished reading it yet. If I find the overlap number, I'll edit this post.