Chandra's corner - February 2019

Dr PH Chandrasekar

Wish each of you a warm, happy and productive 2019. My best wishes and hopes for 2019 and beyond for ID in India – a) less antimicrobial resistance via improved hygiene/sanitation, better stewardship and due recognition of ID specialists in all sectors of public health, b) better judgment among physicians, notably ID clinicians to avoid “antibiotic-cocktails” for ‘just in case’ infections and c) increased ID research and academic productivity in all medical institutions.

During rounds, I came across a hand transplant recipient. Life’s lessons for ID specialists are frequently through cases, provided we have our senses open and are willing to receive. This man had lost his right hand in an industrial accident, with subsequent successful hand transplant. Tacrolimus was used to prevent graft rejection; unfortunately after some years, he developed metastatic squamous cell carcinoma of skin, a dreaded not-so-uncommon complication of tacrolimus. I was consulted for management of his pneumonia in the intensive care unit. As usual, he was on multiple antibiotics. Pneumonia, of course, was from metastatic cancer and against the objections of the ICU physicians, after many discussions, antibiotics were discontinued (stewardship!). In order to use an experimental immunotherapy protocol for management of metastatic skin cancer, administration of tacrolimus had to be stopped. Prior to discontinuation of tacrolimus, he was advised to have the transplanted hand removed. Hard to believe, the semi-functioning transplant hand, at the request of the patient was amputated, so the patient can stop taking tacrolimus and receive cancer immunotherapy. I was astonished. I had to sit down during rounds to digest this information. Life indeed is precious, and the extent we go to extend our lives! Who am I to judge?

Keeping with my interest in transplant, I wish to mention an article from Kolkata, India in the New York Times (Dec 16, 2018) titled, “Organ Donation’s Burden in Women”. Data presented were eye-opening. About 90% of organ transplants in India are living donor transplants while in the US, nearly 60% of organs transplanted are of cadaveric origin. As per the author, Sohini Chattopadhyay, cadaveric donation rate in India is abysmally low because of cultural misgivings, mistrust in health care system arising from reports about organ trafficking and absence of state initiatives and infrastructure to facilitate it. Nearly 75% of kidney donors and well more than 50% of liver donors in India are women. Likewise in the US, 62% kidney donors and 53% liver donors during 2008to 2017 were women. While women are dominant donors, as recipients however, they are in the minority. In India, only 19% women are kidney recipients, and 24% women are liver recipients. Indian women give more and receive far less. Why? The author proposed economics as part of the explanation. Donor surgery requires considerable time to recover, which means taking time off from work. Women who do work are paid >30% less than male workers. So, by that calculation, Indian women are cost effective donors (as they earn less) and considered poor returns on investments as recipients. The author, Sohini Chattopadhyay, “chickened” out from being a liver donor for her dad and ultimately, the author’s mother stepped in to save her husband’s life. And the mother wears her surgical scar with ease and pride.

This disparity with gender-biased healthcare in India is stunning. Present time with #MeTooMovement, is the perfect time to raise this issue. Is anyone prepared to hear?.