Anemia can lead to several other complications and delay recovery time

Health Care, Heart Care Foundation of India, Medicine Comments Off

Iron-deficiency and anemia are not one and the same

New Delhi, 12 April 2019: Patients with anemia who have been diagnosed with tuberculosis take longer time, and require a more intensive treatment plan, to get better, noted a new study by the central government’s Safdarjung Hospital. The study noted that three out of four newly diagnosed tuberculosis patients were anemic at the time of diagnosis of tuberculosis. There is also a need to manage underweight issues and provide counselling and health educational activities for tuberculosis patients.

Iron deficiency (depleted iron stores in the body) and anemia are often perceived as interchangeable terms. While iron deficiency is the most common cause of anemia, but the two are different. Deficiency of iron without anemia is much more prevalent than is detected. A person may have iron deficiency even if the hemoglobin is normal. The majority are unaware of their iron deficient state.

Speaking about this, Padma Shri Awardee, Dr KK Aggarwal, President, HCFI, said, “Iron deficiency anemia is the most common type of anemia, and occurs when the body doesn’t have enough of this mineral. In the absence of enough iron in the blood stream, the rest of your body cannot get the amount of oxygen it needs. What exacerbates this condition is that many people are unaware that they have iron deficiency anemia. At times, one may experience the symptoms for years without knowing what they are due to. A poor diet or certain intestinal diseases that affect iron absorption can also lead to this condition. This deficiency is usually treated with iron supplements or changes to diet.”

Some of the symptoms of moderate-to-severe iron deficiency anemia include general fatigue, weakness, pale skin, shortness of breath, dizziness, cravings for things such as dirt, a tingling or crawling feeling in the legs, soreness or swelling in the tongue, cold hands and feet, fast or irregular heartbeat, brittle nails, and headaches.

Adding further, Dr Aggarwal, who is also the Group Editor-in-Chief of IJCP, said, “Mostly, iron deficiency anemia is mild, and does not lead to any further complications, and can be corrected easily. However, if left untreated for a long time, it can cause other health problems. In pregnant women, this can lead to the birth of a premature or low-birth-weight baby.”

Here are some tips to prevent anemia.

  • Eat foods rich in iron such as green and leafy vegetables, red meat, lentils, beans, and iron-fortified cereals and breads.
  • Include vitamin C-rich foods and drinks in your diet as it will help the body in absorbing iron.
  • Avoid drinking tea or coffee with meals, as this affects the absorption of iron.

·       Include enough sources of vitamin B12 and folic acid in your diet.

The Right Prescription?

Health Care Comments Off

The amendments in Clinical Establishments Second Amendment Rules, 2019 are aimed at ensuring that patients are not conned into undergoing costly tests and diagnosis that may be totally unwarranted

The Clinical Establishments (Registration and Regulation) Act, 2010, was enacted by the central government to provide for registration and regulation of all clinical establishments in the country with a view to prescribing the minimum standards of facilities and services provided by them. On March 1, 2019, the ministry of health issued another notification that lists certain rules for further amendments in the sector.

Called the Clinical Establishments (Central Government) Second Amendment Rules, 2019, its highlights are:

  • In the Clinical Establishments (Central Government) Rules, 2012, in the Schedule in Table-(i) after the entries relating to S No I, at the end, the following notes shall be inserted, namely, “Note (i). Medical tests should normally be undertaken on the advice of a doctor.”
  • In Column 2, for the words “The authorized signatory will be liable for authenticity of laboratory test report”, the words “The authorized signatory will be liable for authenticity of laboratory test report only” shall be substituted.
  • In Column 3, for the words “wherever interpretation of lab results or opinion thereon are required, registered Bachelor of Medicine and Bachelor of Surgery (MBBS) medical practitioner is essential”, the words “interpretation of lab results or opinion thereon when required, registered Bachelor of Medicine and Bachelor of Surgery (MBBS) medical practitioner is essential” shall be substituted.

As far as the legal implications of the amended rules are concerned, the first which states that “Medical tests should normally be undertaken on the advice of a doctor” can be interpreted as follows:

  • Medical Tests: The tests include pathological, bacteriological, genetic, radiological, chemical, biological investigations or other diagnostic or investigative services, and are usually carried on with the aid of laboratory or other medical equipment.
  • The usage of the phrase “should normally be undertaken” rather than “shall normally be undertaken” makes the directive non-mandatory. It’s only an advisory, that too in normal circumstances.
  • Advice of a doctor: Doctor under the Clinical Establishments Act means an MBBS doctor. But, in Dr Mukhtiar Chand & Ors vs State of Punjab & Ors decided on October 8, 1998, the apex court said: “In our view, all that the definition of ‘Indian Medicine’ and the clarifications issued by the Central Council enable such practitioners of Indian medicine is to make use of modern advances in various sciences such as Radiology Report (x-ray), complete blood picture report, lipids report, ECG, etc. for purposes of practising in their own system.”

Now coming to the second amended rule which states that “The authorized signatory will be liable for authenticity of laboratory test report only”, it must be noted that the Clinical Establishments Act also prescribes the minimum qualification of Technical Head of Laboratory or Specialist or Authorised Signatories and says that presence of an MBBS doctor is desirable in small laboratories. This means that non-MBBS technical staff can also be hired but only for the purpose of signature and verification of the report and not its interpretation.

The third amended rule states that “Interpretation of lab results or opinion thereon when required, registered Bachelor of Medicine and Bachelor of Surgery (MBBS) medical practitioner is essential” meaning that the presence of an MBBS doctor is a must.

So, for the purpose of clinical establishments, the role of an MBBS doctor or above is most important when it comes to the question of running a laboratory. Yet, the fact remains that today doctors find themselves in the middle of a crossfire and are blamed for both under and over investigation.

In a Supreme Court judgment in the Martin F D’Souza vs Mohd Ishfaq case, Justices Markandey Katju and GS Singhvi had on February 17, 2009, enlisted six precautions which doctors/ hospitals/nursing homes should take. Two of them were related to investigations. Firstly, no prescription should ordinarily be given without actual examination. The tendency to give prescriptions over the telephone, except in an acute emergency, should be avoided. Secondly, a doctor should not merely go by the version of the patient regarding his symptoms, but should also make his own analysis including tests and investigations where necessary.

Medical tests require proper interpretation. A doctor looks at test results not in isolation but as a yardstick for treating the patient. It must be kept in mind that: (1) Lab results can turn out to be both false positive and false negative; (2)  Variations in lab test results need to be interpreted clinically; (3) Comparisons and fluctuations vis-à-vis previous reports is of utmost importance; (4) Most important is when not to do investigations. The fashion of “all test panels” are neither necessary nor in the interest of the patient; (5) Most tests usually aren’t helpful for low-risk surgery. The tests themselves are very safe, but they can cause false alarms. This can lead to anxiety and more tests adding to the cost.

Like over-the-counter (OTC) drugs which patients self-prescribe, there are OTC tests also. A classic example is the urine test for determination of pregnancy. Now the government is thinking of making HIV self-testing, where a person collects his or her own specimen (oral fluid or blood) and then performs an HIV test and interprets the result, often in a private setting, either alone or with someone he or she trusts. In 2016, the WHO published the first global guidelines on HIV self-testing.

Another field is direct-to-consumer testing. Most of the time, genetic testing is done through doctors. In direct-to-consumer genetic testing, the tests are marketed directly to customers via television, print advertisements, or the internet, and the tests can be bought online or in stores. Customers send the company a DNA sample and receive their results directly from a secure website or in a written report. Direct-to-consumer genetic testing provides people access to their genetic information without necessarily involving a doctor.

Home monitoring of blood pressure is another acceptable evidence-based testing. Apart from that, these days home inpatient care and ambulance pre-hospital emergent care is also making a dent in healthcare where primary care is done by technicians and nurses. Even in proposed wellness centres under Ayushman Bharat, the government is planning to post non-MBBS healthcare providers. All ASHA workers today are allowed to do primary investigations like malaria testing, tuberculosis testing, pregnancy testing, etc, under the National Health Programs. The Indian Council for Medical Research is soon coming out with a National List of Essential Investigations (NLEI).

A combination of self-testing OTC investigations and NLEI may just be the right mix to stop hospitals and diagnostic labs from pitching preventive health packages that a patient might not need but is often pressured into buying.

Reproduced from:, Published in India Legal, April 15, 2019:p.44-45.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA