Troglodytes of the medical world

By Aamir Amin

A troglodyte, according to the Oxford Dictionary, is a person who is deliberately ignorant or old-fashioned.

Another definition, which is more faithful to the original etymology stems from a rather crude synthesis of two Greek words ; trōglē meaning “hole” and dyein meaning “to go in, dive in” ; and is meant to be used for “a primitive individual who lives inside a cave”.

That said, it should not come as a surprise to anyone reading this that there are certain doctors in Kashmir who “live inside a cave”. No, it is not a cave in the ground like the ones at Burzahom, nor a cave once inhabited by rishis and sufis on a scenic mountain side near Pahalgam, and neither is it a cozy little gujjar hut that one would certainly like to visit, rather it is a dark cave filled with Lovecraftian horrors in which the only sound you can hear is that of bones crackling beneath your feet.

A metaphorical location, this cave is hidden in plain sight and sustained by the ignorance of the people who dwell therein ; a population of doctors who refuse to change with changing times.

At some point in their careers, just about all medical professionals are placed at the threshold of this ‘cave’ as a test. Some enter into it willingly, explore a little and are able to leave just in time before their curiosity gets the best of them, while others remain trapped inside forever in what appears to be an ideological limbo.

These are the same doctors who would not think twice before dismissing a morbidly diabetic patient sneaking in a big, white chunk of peer sahab’s glucose-loaded tobruk with his daily morning tea, as something trivial and perhaps even helpful with the treatment process (I kid you not, this is a true story).

These are the same doctors who exude a sense of entitlement, disrespect paramedics and feel threatened by competent juniors. These are the same doctors, who, in spite of little to no evidence for the use of excessive vitamin-C or zinc supplementation beyond the recommend dietary allowance (RDA) for a patient with COVID-19, will continue to prescribe high-doses even for mild cases.

In fact, the latest COVID-19 Treatment Guidelines given by the US National Institutes of Health (NIH) have noted that zinc supplementation has not been shown to have clinical benefit and may even be harmful.

Long-term use can result in copper deficiency with subsequent reversible hematologic defects (i.e. anemia, leukopenia) and potentially irreversible neurologic manifestations (i.e. myelopathy, paresthesia, ataxia, spasticity). In addition, oral zinc can decrease the absorption of medications that bind with polyvalent cations.

As for vitamin-C, the Panel notes that there is insufficient data either for or against its use. But, consider this as well ; for a relatively needy family suffering from COVID-19, the cost of adding high-dose vitamin C and supplemental zinc to their daily treatment regimen is nothing less than a violation of the principles of ideal medical practice, especially the maintenance of a feasible cost-benefit ratio.

The lack of antimicrobial stewardship in Kashmir, on the other hand, is not the only putrid niche expanding within this troglodyte infested cave, but it is by far the most disturbing.

Rampant abuse of over-the-counter (OTC) antibiotics like Azithromycin, Ciprofloxacin, Amoxicillin, etc. for something as trivial as a sneezy, snotty nose by the local population, along with careless over-prescribing by medical practitioners who refuse to acknowledge the ‘super-bug’ crisis, has set up an impending (or, as some would argue, existent) threat of multidrug resistant microorganisms in Kashmir – and this is a battle we are bound to lose.

Some parents, fearful that their children might contract COVID-19 from sick relatives or friends, have been administering zinc and antibiotics on a prophylactic basis to them.

Do we not realize the future implications of pumping perfectly healthy children with antibiotics ? If culture and sensitivity tests (C&S) were to be performed on the Kashmiri population en masse, one would reckon that the shocking drug resistance profiles would set in motion the necessary chain of events to introduce a drastic transformation in both health policy and practice, almost to the point of revoking the OTC label of many drugs.

What do our hospital antibiograms reveal ? How many hospitals in Kashmir follow local antibiotic policies ? Or rather, how many hospitals even have a functional antibiotic policy ?

When it comes to testing the safety and efficacy of pharmacological agents, randomized, double blind, placebo-controlled trials are considered to be ‘gold standard’ by scientists worldwide.

It matters very little if your neighbourhood doctor chacha, someone’s wise old grandmother, the local kandur or even the trustworthy goor thinks that drinking kehwa or ginger-garlic tea will protect him or others against COVID-19.

As long as there is no reliable evidence in their support – these ‘home remedies’ simply do not work. It is nothing short of a sin for a medical professional to either support or worse, encourage irrational beliefs and practices – ever more so the ones that have no bearing on established medical science.

Doctors must play a role in dispelling medical myths and untruths, be it something as simple as resisting the urge to share unscientific though attractive messages and posts on WhatsApp or social media, which add to societal confusion rather than clarity.

The scientific method, which is the foundation stone of reliable modern scientific knowledge and the enemy of the ‘troglodyte mindset’ , implores us to seek out the truth beyond our personal opinions, fears and values – both cultural and religious.

Medical education is based on teaching doctors how to think critically – especially when it comes to information relating to factors that can significantly influence patient morbidity and mortality.

Every once in a blue moon, internationally recognized medical bodies, reputable organizations and associations, streamline their efforts to publish guidelines based on new or emerging medical data. It is our responsibility as doctors to stay constantly updated with this information.

Why, then, do so many of us refuse to dive in and extract these pearls from the ever-expanding sea of medical knowledge ? How many of the concerned professionals are aware that the ESC has recently updated its guidelines on the management of STEMIs ? Or that the ACOG guidelines for gestational hypertension and pre-eclampsia have been revised this year ? Surgery too has leaped into a futuristic era of minimally invasive and robotic techniques with fewer and fewer complications.

Not so in Kashmir – with its many talented professionals embroiled in discussions on Kashmiri politics. Despite the numerous achievements of this sector, an immuno-compromised person with bone or lymph node metastases inadequately responsive to radiotherapy or chemotherapy, with a presentation admittedly beyond the local surgical skill set and dexterity, has to consider travelling far and wide to the rest India and abroad to seek out the necessary treatments, even during these challenging times.

Thus, putting themselves at a much heightened risk of infection and subsequent morbidity.
‘Health for all’ is dynamic and absolute. It entails no wastage of time in celebrating what people already have access to in Kashmir or, for that matter, wallowing in the misery of what they lack – but in pursuit of discovering new ways of improving and filling in the many gaps in service delivery.

It is just as important to eschew and unlearn outdated information, as it is to learn about the new and outstanding developments taking place across the world. At the end of the day, our beloved Valley is only as good as its advancements in healthcare and education.

(Aamir Ahmad Amin is a Final Year medical student at Khwaja Yunus Ali Medical College (KYAMC))