The problem with Indian medical practice

Indian doctors have made tremendous progress in the 21st century and India is now being touted as a medical tourism hub.

This is very evident with significant improvements in the healthcare infrastructure and an exponential increase in modern medical facilities throughout India. While many western countries struggle with healthcare costs and others with increasing backlog for non-emergent care, India has become a destination for those seeking cheaper and more readily available fix to their medical problems.

However, beneath this euphoric developments lie significant shortcomings of Indian medical practice. Most importantly, there are great variations in the care that patients receive based on their economic backgrounds. Apart from this, there are many issues that negatively impact the delivery of proper healthcare.

An important drawback is the lack of evidence-based literature. For years, Indian medical students have relied heavily on western textbooks to learn their art. There are two major problems with this practice. One, these textbooks are not peer reviewed. They are usually written by experts; however, they are often not as accurate as original research articles. Plus, textbooks take years to get edited and published and lag behind original research. While the western world has moved away from textbooks and started relying mostly on original peer reviewed journal articles, Indian doctors continue to rely mostly on medical textbooks. Another major fault is that Indian doctors are trying to implement western knowledge of disease in a patient population with very different ethnic background and environmental influences. While it would be a blatant mistake to say that there is minimal evidence based literature about any diseases or treatments from India, it is quite obvious that we have a long way to go.

Let us take a disease called idiopathic pulmonary fibrosis. This is a very ill-defined entity even in countries where extensive amount of research has been carried out to characterise the disease.  Based on anecdotal reports, idiopathic pulmonary fibrosis is commonly diagnosed in India. But original research out of India about this disease is literally nonexistent. PUBMED is a database of scientific abstracts on life sciences and biomedical topics.

Although maintained by the United States National Library of Medicine, it is a very important resource for the entire medical world and practically any scientific article of any value published ever is archived here. A search of this database with keywords ‘Idiopathic Pulmonary Fibrosis’ and ‘India’ returns only 28 results, many of them just review articles and not scientific clinical research. A search for ‘Idiopathic Pulmonary Fibrosis’ alone returns 3835 results from around the world. While we are unable to come up with a vast body of evidence, we are quick to jump to treatments based on literature from elsewhere; without really taking into account the ethnic and environmental differences or determining if this is the same disease across the world. 

Pirfenidone is a medication that was recently tested on patients with idiopathic pulmonary fibrosis and approved for use in Europe.

Since the launch of this drug in Europe, the Institute for Quality and Efficiency in Health Care, Germany, has already published data that this is of questionable benefit in their post marketing experience. The US Food and Drug Administration is yet to approve this drug because of lack of evidence. This drug was launched in India in 2010 and per reports is being prescribed and selling like hot cakes. A PUBMED search of ‘Pirfenidone’ and ‘India’ returns two results but none of them describe any original research studies. The studies that initially evaluated efficacy of Pirfenidone enrolled patients in Japan, Australia, North America and Europe but not in India. With relative lack of evidence in local conditions, what is it that drives Indian doctors to prescribe medications or for that matter other therapies? Is it their instinct that the disease that they are treating is same as described in the western literature? Is it that their vast clinical and anecdotal experience without statistical analysis is evidence enough? Is it lack of curiosity or lack of resources to study disease characteristics and treatment options? Or is it the conflict of interest with the proliferation of the pharmaceutical industry in India and its influence on the prescriber? It would be very unscientific to assume the answer. We need a root cause analysis to address this question. Needless to say, the literature out of India that addresses this question is nonexistent.

The future is bright but there is an urgent need to emphasise the value of collecting evidence locally and implementing it correctly to the current crop of medical students across India to get there quickly.

— The author is an assistant professor of clinical neurology, Keck School of Medicine, University of Southern California, and a child neurologist at Children’s Hospital Los Angeles; the opinions expressed are those of the author and not of the institutions.