By SOMALARAM VENKATESH, MD
“It has always been science versus fundamentalism, not science versus religion.” Abhijit Naskar, Biopsy of Religions: Neuroanalysis Towards Universal Tolerance
On February 3, 2020, the luxury cruise ship Diamond Princess docked on Japanese shores and was promptly quarantined with 3711 people on board, because a passenger who had disembarked at Hong Kong two days earlier had tested positive for SARS-Cov-2, or also known as COVID-19. Passengers & crew members were either repatriated or hospitalized in Japan over the next 4 weeks. In total,, more than 700 of them were found to be infected with the virus. This was a unique opportunity – a Petri dish in a ship, if you may – for epidemiologists and virologists to study the disease and the virus.
At the beginning of this global pandemic, health care professionals and policymakers used data from the Diamond Princess experience and inferences thereof, such as infectivity & death rates, as a supplement to the observations from Wuhan. They used the data to derive models on how the pandemic will play out in the rest of the world. Later, after widespread devastation in Iran, Europe, & the United States, and after relative containment in Taiwan, South Korea & Singapore, experts have access to larger datasets & a variety of scenarios to help develop disease virulence predictions and control models.
So far, authorities in the Indian subcontinent appear to copy strategies of other countries to combat the spread of the pandemic. The curves of exponential ascendency of COVID-19’s spread across countries appear identical in nature, except in a few where health care response is more regimented. Yet, there is speculation about the virus’s survival in India’s climatic conditions: Indians may have a better “innate resistance” and the impact of compulsory the BCG vaccination in most Indians may have some effect on the expression of the disease in the country. Therefore, it may be worthwhile for India to study the actual transmission, clinical expression, and outcomes of the disease in her own population and design responses to the pandemic based on those studies.
That is to say, we must find our own Diamond Princess before we find our Wuhan.
By SOMALARAM VENKATESH MD
With a stated intent of bringing social justice and financial relief to hundreds of thousands of patients undergoing coronary angioplasty in the country every year, the Government of India capped the sale price of coronary stents in Feb 2017. Stent prices fell by as much as 80% with this populist move, seen as anti-trade within the industry circles. It is tempting for a practising interventional cardiologist to look at two years of this government control on medical device prices in a market economy.
Before price-capping, angioplasty patients were indeed getting a raw deal. There was no uniformity in price among stents of similar class/generation made by different manufacturers. The cost of the only bioabsorbable stent then available in India, to the patient, was 200,000 Indian Rupees (a little under USD 3000), whereas the US or European-manufactured (“Imported”) drug eluting stents (DES) would cost anywhere between INR 85,000 to 160,000. Stents manufactured within India (“Indigenous”) were cheaper. The real cost of manufacture or import was hidden from public view. It was left to the eventual vendor, with alleged involvement of the user hospitals, to determine the Maximum Retail Price (MRP). It was speculated that a huge margin was worked into it, and the profit was split between manufacturers, distributors, and hospitals. Allegedly, some unscrupulous physicians received kickbacks for implanting these devices. Even in government-run hospitals, foul play was suspected.
By a single stroke of the pen, Prime Minister Narendra Modi government slashed stent prices substantially. The bioabsorbable stent cost, to the patient, was capped at INR 60,000 (< USD 1000). Bare metal stents (BMS) and Drug-eluting stents (DES) were capped at INR 7500 and 30,000, respectively. The government seemed to have done its homework: these figures were arrived at from industry-supplied figures on manufacturing or import costs. The cosy network of coronary stent food chain was set on fire with this move: with sudden diminution of profit margins, it was feared that multinational companies would cut Indian workforce; stent distributors & vendors (especially small vendors) were expected to be wiped out or cut in size; doctors worried that with low profitability, multinational stent manufacturers would exit the country or at least, stop importing newer technologies; and hospitals feared revenue loss.
Following this, Industry and Hospital-chain representatives are said to have had series of discussions with the government. Rumours were that the Central Government was arm-twisting traders and that it would relent and raise price limits after these ‘talks.’ The National Pharmaceutical Pricing Authority (NPPA) promised a price revision, one year after the price cap. Meanwhile, some multinationals informed the government that they would withdraw some of their ‘top-end products’ from the Indian market, citing financial nonviability, obviously to put pressure on the government. The Bioresorbable Scaffold from Abbott actually disappeared from Cath lab shelves.