From one doctor to another: An open letter to AIIMS director Dr Randeep Guleria

Respected Dr Guleria,

I am a medical heretic who has inherited the trait of ‘questioning’ from the pioneers of modern medicine. You of course, have become a household name, a position well deserved for guiding the nation during the worst medical tragedy in our living memory.

People look up to doctors and doctors look up to institutions of excellence. The exalted status of the Director of All India Institute of Medical Sciences that you occupy has a halo that is richly deserved. Your words are treated as the Gospel by the entire medical fraternity in the country. Your responsibility therefore, is both onerous and unenviable.

But I draw your attention to the guidelines issued by AIIMS on April 07 of this year. It took up a solitary page in the manner of a flow chart that became the Bible of Covid treatment, from specialists down to the quacks.

For management of mild cases in home isolation, the AIIMS guideline advised prescribing Ivermectin. But as on 07th April there was overwhelming medical literature against the use of this drug. In March itself, WHO had noted that “current evidence on the use of Ivermectin to treat COVID-19 patients is inconclusive”. In fact, there never was any evidence to start with. Could you have missed WHO’s guideline or been unaware of the lack of medical evidence?

In a matter of weeks, the govt and ICMR publicly opposed the use of Ivermectin. By then of course there was a mad scramble for Ivermectin, which disappeared from pharmacies and was sold at a premium. But let it pass as no great harm was done to a patient by a couple of tablets that he gulped down in a state of panic.

Inexplicably Remdesivir was also recommended for cases admitted in hospitals. This recommendation was shocking because as you would have known, there is not an iota of evidence (except some low-quality manufactured evidence which has already been discredited) to support its use in Covid. In fact, WHO had dropped this medicine from the list of Covid drugs in November last year.

As the second wave of the pandemic spun out of control, Remdesivir earned for itself a place in the hall of shame of modern medicine. Black marketing, profiteering, counterfeiting, hoarding- the drug hogged the headlines for all the wrong reasons.

You took more than three weeks to tell us that there was no evidence to support the use of this drug. Weren’t you aware of this fact earlier? As a Pulmonologist, I have reasons to believe that you would have been aware of the Tamiflu fiasco. Yet AIIMS prescribed Remdesivir under your watch.

For a majority of Indians, procuring Remdesivir became an impossible task. Such was the desperation that relatives of patients were willing to pay any price for the drug to save their loved ones- a drug that unfortunately does not work by your own admission. Dare I say this has been a medical scam with few parallels?

Even more horrific has been the advisory on the use of steroids. Though for the last two weeks we find you are crying yourself hoarse against the indiscriminate use of steroids in Covid cases, every single hospital, dispensary and physician (unqualified quacks included) from the national capital to villages have been indiscriminately prescribing steroid tablets or injections to Covid patients. This has had disastrous consequences and led to hastening the progress of the disease besides causing bacterial and fungal infections.

That steroids should not be given during the first few days of a viral infection is plain common sense in the practice of medicine. Sadly, common sense is not very common. Most medical practitioners, unfortunately, continue to blindly follow the guidelines issued by AIIMS.

The practice of medicine requires sound judgement by discerning clinicians. This has not been possible in the present war like situation. The AIIMS guideline came to be followed blindly by physicians. An unintended error, lack of clarity or a genuine mistake might not have been fatal in normal times. But under these circumstances?

What proportion of Covid deaths could be attributed to the misuse of steroids will never be known; nor the number of families who pawned their meagre possessions or sold their tiny parcels of land for a prohibitively expensive but useless Remdesivir.

I have similar reasons to flag concerns on convalescent plasma and Tocilizumab in the guideline that does not pass muster of scientific scrutiny.

I conclude by referring to the doctrine of vicarious responsibility and with wishes for AIIMS to continue the good work for which it is rightly known. With profound regards, Major General

(Dr) VK Sinha, VSM (Rtd) (The writer is Quondam- Professor & Head of Orthopaedics, AFMC, Pune. Views are personal)