Dealing with Hemorrhoids and Community Health Provider (CHP)

THE NATIONAL MEDICAL COMMISSION ACT, 2019 [NMC Act 2019] by providing for Community Health Provider (CHP) has brought new hope to Indian population facing acute shortage of doctors but there is a darker side of it as well. Common recto-anal problems for instance, hemorrhoids has already been treated by under qualified practitioners with tall claims but fuelling further complications.

It will be interesting to be seen if the Act aiming to bridge the gap between supply- demand of doctors actually proves a boon for the most common ailments of the people.

Section 32(1) of the NMC ACT provides for licensing of Community Health Provide (CHP) for practicing medicine at mid level. Such licensed CHP shall have to meet the eligibility criteria of the Regulations framed under the NMC Act, 2019. As on 20.10.2021, the official site of National Medical Commission (NMC) displays “Rules and Regulations are in the process of being framed till then the Rules and Regulations of IMC Act, 1956 will prevail as per Section 61(2) of the NMC Act, 2019” Meaning, what will be the eligibility criteria of these CHP is yet not clear.

Nature of Hemorrhoids

Hemorrhoids has plagued the humankind since time immemorial and it is estimated that 80% of the population is affected by this health condition at some point of time or other. It is said the emperor of France, Napoleon Bonaparte, suffered from hemorrhoidal disease. On the day of the decisive battle at Waterloo, Napoleon was in pain because of a severe case of thrombosed hemorrhoids, which impaired his battlefield conduct.

Various reputed science Journals and Reports by Medical fraternity have published guidelines for treating hemorrhoids. These guidelines are although not regulations under some specific ACT but without having an adequate knowledge of these publications wrong counselling is likely to occur. The relaxed eligibility for licensing of CHP and hurried move of the NMC to bridge the gap of demand- supply of health care professionals can cause detriments to many common ailments including hemorrhoids. While a qualified doctor can treat hemorrhoids just with a restricted diet plan others can worsen the case.

Current Public Approach towards Medical Fraternity

The “God on Earth” notion about doctors and medical practitioners has taken a plunge during recent time and public has resorted to violent activities against there saviours on pretext of many accusations against. Some of which had vaild concerns but others being frivolous. Violence however in any case cannot be justified.

Violence against doctors have been a shocking reality and its seriousness was most felt during last two years of covid pandemic. As per an interview of IMA Secretary Jaywant Lele, during  2020 alone about 300 incidents of assault on doctors and medical practitioners were recorded in India. The violence increased in the second wave of Covid with complaints about the lack of proper treatment. Harsh reality is that some 750 of doctors and practitioners lost their lives in 2020, and 700 in 2021 in course of serving people during pandemic . IMA secretary highlighted that showering  healthcare workers professionals with petals at one hand beat them up on the other is despicable dichotomy.

With growing violence in the backdrop, the IMA across India worked with black badges/ribbons in June 2021 to emphasize their ‘Save the Saviours’ appeal, demanding a definite legal recourse for violence against doctors.

How do Doctors Treat Hemorrhoids?

Treatment of hemorrhoids by doctors in a clinical office setting Or outpatient center and a hospital involves certain procedures that include the following:

A.Office treatments Procedures

Rubber band ligation– Under this procedure doctors do treat bleeding or prolapsing internal hemorrhoids. A special rubber band is placed around the base of the hemorrhoid. This band cuts off the blood supply and eventually the banded part of the hemorrhoid shrivels and falls off. In the process scar tissue is formed in the remaining part of the hemorrhoid that prompts shrinking of the hemorrhoid. The entire procedure requires a specialized doctor.

Sclerotherapy- Under this procedure, the doctor injects a solution into an internal hemorrhoid which causes scar tissue to form. The scar tissue so formed cuts off the blood supply often shrinking the hemorrhoid.

Infrared photocoagulation– Under this procedure the doctor uses a special device that throws infrared light at an internal hemorrhoid. In the process heat is created by the infrared light and it causes scar tissue to form. Again this scar tissue cuts off the blood supply leading to eventual shrinking of hemorrhoid.

Electrocoagulation- Under this procedure, the doctor uses a medical device that sends an electric current into an internal hemorrhoid. In the process the electric current causes scar tissue to form cutting off the blood supply and eventual shrinking of the hemorrhoid.

B. Outpatient Center or hospital Procedures

Hemorrhoidectomy- Under this procedure, the surgeon doctor, performs a surgical operation to remove external hemorrhoids Or, prolapsing internal hemorrhoids. It is usually resorted to the cases which do not respond to other treatments.

Hemorrhoid stapling- Under this procedure the surgeon uses a special stapling device to remove internal hemorrhoid tissue and push a prolapsing internal hemorrhoid back into the anus.

What Research Reports Record about Treating Hemorrhoids?

According to a Research work titled “Guidelines for the treatment of hemorrhoids” and published on Science Direct there is work flow of the procedures which is to be adopted. The conclusion part of the work marks the following:

The management of hemorrhoids involves confirmation of the diagnosis, meeting the needs and expectations of the patient, and to master the various treatment alternatives, or at least, to be aware of their indications and limitations.

Medical treatment should always be proposed in first intention, which may be sufficient for acute events and in cases of grade I and II hemorrhoids.

Instrumental treatment is recommended in case of failure of medical treatment or immediately for grade III localized prolapses for which rubber band ligation should be preferred.

Surgical treatment should be offered in the event of failure of both medical and instrumental treatment, or immediately for advanced prolapse. The patient should be reliably informed of the surgical alternatives and be able to participate in the choice of technique, the final decision depending on the surgeon.

Postoperative pain (POP) should be prevented by the systematic implementation of a pudendal block and multimodal use of analgesics. Elective routine outpatient surgery is possible provided that the patient’s safety can be assured.

American Family Physician website too lays down a meticulous diagnosis and corresponding suitable procedure for the treatment of the hemorrhoids. It emphasizes that without proper diagnosis, the measure taken could deteriorate the case instead improving on. Science Direct also marks that in many of the cases the actual problem may not be the hemorrhoids so treating with conditioned mind can lead to other complications.

Way Forward With Community Health Provider

Hemorrhoids is a common problem but without meticulous diagnosis, trying to treat could lead to several other complications and a simple problem may further into immensely harmful to patient. Cases have been reported wherein, underqualified practitioners have worsened the cases of hemorrhoids and given that as a common problem, large no. of hemorrhoids cases arise in rural areas, go unreported.

The NMC Act, although provides for bridging the gap of inadequacy of doctors by CHP licensing to eligible persons but the eligibility has not been defined yet. India is a country of Rules and Regulations, where rule of law and constitution prevails but it has been seen that despite 2000 Acts in the country, effective enforcement of the statutes is far fetching reality and instead benefitting the masses they have harmed more.

Provision of CHP under NMC ACT is a controversial subject and flags have been raised by the medical fraternity citing the flawed implementation of similar & Prior statutes in Chhattisgarh and Assam. Now it remains to be seen how CHP eases out the some of the common ailments of people. And, if they actually turn out to be saviour or earn the ire of masses on account of apprehended incompetency.