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"FABLE"--First Aids (FAs) for Blood Loss in Emergency--Campaign for Rural India Exploring Pharmacists.


Injuries due to road accidents cause highest rate of deaths in youth between 15 to 29 [1]. A recent comparative survey between Republic of India (ROI) and Kingdom of Cambodia shows that, road traffic deaths are two times higher in the India compared to the Cambodia (1). In general, the mortality risks are high in rural country side. This is because of health care disparities related to emergency care between urban to rural side [2]. Rural side is lacking from tertiary healthcare, diagnostic labs, advanced medical technologies and medical products apart from emergency care facilities [2-4]. This affects emergency care of traumatic injuries, leading to increased death rate in rural side.

Hemorrhage (extensive bleeding) of the traumatic injuries is the major reason for death in road accidents. For saving the lives of hemorrhage victims, immediate pre-hospital stopping of the blood loss is important [5]. Pre-hospital emergency care is scanty in rural side. As the delay occurs, hemorrhage leads to complications such as systemic coagulopathy, hematoma and stroke [5]. That can lead to long-term hospitalization. In the absence of an appropriate insurance== coverage, long-term hospitalization cause big economic burden to patients throwing them to poverty. Thus, there is a requirement of developing, new medical technologies to reduce the pre-hospital care of hemorrhage that can reduce the morbidity and mortality rate. These technologies need to be made accessible to the rural country side in a cost effective way.

It has even larger implications; it is observed that, disparity in healthcare facilities is one of the reasons for rural to urban migration [6]. As a solution, extending urban healthcare facilities to rural side is beneficial for ensuring uniform healthcare across the country [2]. However, mere distribution of imported technologies and healthcare facilities increases the infrastructure cost, and is reflected in treatment expenditure, causing huge economic burden. Price control measures are helpful for improving affordability, on the contrary is not favorable for indigenous R&D. Thus, there is a requirement of identifying alternate solutions.

One solution could be to develop newer indigenous technologies and restructuring its supply chain for improving the distribution [7]. These technologies may need to have following attributes, (1) user-friendliness, (2) affordability and (3) accessibility. The user friendliness can enhance wider usability and accessibility. Indigenous development of these products makes it affordable because of low expenditure in research, development, production and distribution of products. Subsequently, to improve accessibility, the academia (being not profit-oriented) may need to endeavor in R&D for ensuring price-control and rational-use of these technologies [7]. Training of skilled personnel in translational medicine reduces the gap between basic to applied research [8]. In India, Pharmacy profession has been instrumental in ensuring affordable public health to the rural side [9]. Their service is extendable, by training pharmacists in R&D and rational use of indigenous medical products. This alternative route of public effort, in addition to the current corporate effort, may speed up healthcare distribution across the country.

Scenario of Pre-hospital Care in Hemorrhage

In developed countries, pre-hospital hemorrhagic care after traumatic injury in accidents is immediately addressed by an expert team [10]. This team involves doctors and other paramedical such as nurse and biomedical engineer. Alternative to this team-effort, in developing countries, campaign programs are tried for saving lives. Based on the clinical experience in team and campaign efforts, new guidelines are proposed. However, both these approaches have not yet picked up in rural country side.

The latest European guidelines says [11], the emergency care personals need to provide recommendations that are evidence based, for the immediate and effective control of bleeding. In addition, appropriate interventions are essential to control tissue damage. Developing such an expert team require larger infrastructure such as tertiary care hospitals and diagnostic labs with healthcare professionals. High cost and planning is associated with such facilities; in addition require high degree of personal and professional motivation. Such healthcare facilities are available in urban country side but not in rural side of the India.

Emergency care team is not practical in the rural India, because of the low income status of the rural side (3). Subsequently, the technologies aiming to address hemorrhage need to be effective in absence of an expert team. Medical technologies such as First aids (FAs) and advanced Point of Care (POC) systems can reduce the role of emergency care experts. It enables administration with minimum assistance or self-administration. These technologies can subsequently reduce the mortality and morbidity rate due to hemorrhage. Regarding hemorrhage, the first issue to be addressed is to stop blood loss. For a R&D roadmap, studying the military scenario may be beneficial. Such exsanguinating (heavily bleeding) wounds are common in war and military operations. Where advanced medical technologies are commonly applied to stop the bleeding. These technologies can be explored in civilian situations also. In military, blood control in hemorrhage is mainly achieved using first-aids (FAs). Availability of such technologies in civilian applications are low because of the, (1) the market fluctuations, (2) unaffordability (3) inaccessibility and (4) Lack of awareness. It is further complicated, because of the patient related factors such as variations in clotting time that affects the efficacy of the treatment [12]. This variability necessitates requirement of rational use of these technologies by trained hands. Subsequently, for improving the affordability and accessibility of FAs in hemorrhage, the pharmacists needed to be trained in principles of R&D and rational use of FAs and POCs that are in use of acute care of trauma [11-12].

The most common cause of hemorrhage in trauma is due to limb injuries, where FAs are very helpful 13=14]. This review proposes a campaign program entitled "FAs for Blood Loss in Emergency (FABLE)" with an aim to develop indigenous medical technologies with the help of academia. That involves, (1) training pharmacists with background in chemistry and biology to participate in R&D as well as (2) to train pharmacists with clinical exposure towards rational use of these advanced FAs for emergency care. Indigenous FAs need to be developed based on technology development in relation to progress in science [15]. For that, following things are important, (1) clinical scenario analysis, (2) technology landscape analysis and (3) portfolio development. Secondary to that, the "decentralization of emergency care", need to be achieved with the help of pharmacists by, providing (1) Internships in R&D of trauma-care technologies (for B Pharm and M Pharm with technology development training) and (2) Internship in Public Health (PH) in rational use of trauma care technologies (for Pharm D with clinical practice experience). Pharmacists are already [15] participating in campaign programs related to public health (PH) and emergency care [9]. The Indian pharmaceutical academic model, similar to any other international pharmacist training provides both the technological as well as clinical training [16]. Exploring this conducive environment in India is the most sorts out strategy to implement the FABLE campaign program. The combined approach of exploring FAs and decentralization of emergency care with the help of pharmacist can be used as an alternative strategy for public resource pooling to achieve affordable and accessible health-care in rural country side.

R&D of Affordable and Accessible Technologies

Clinical Scenario of Hemorrhage

Clinical scenario analysis provides required information for a suitable technology to step in into FABLE campaign. Current review is focusing on external hemorrhage from limb extremities after traumatic injuries. The recent WHO statistics shows that, traumatic injury of limbs causes external hemorrhage, ischemia, permanent disability, to even death, causing 5m deaths annually, and worldwide [17]. Globally now 12% of mortality happens as a result of accidents. In this 30- 40% is due to hemorrhage. Hemorrhage accounts for 33 to 56% of pre-hospital mortality [18]. Almost 80% of deaths during surgery happen due to hemorrhage [19]. These discussions indicate, controlling hemorrhage is important in reducing mortality due to accidents.

The hemorrhage happens due to injury of major blood vessels [20]. The traumatic injuries are classified into different types for better management. The major classifications are, (1) sever, (2) emergent, (3) urgent and (4) not-life threatening. The "severe" category is immediately life threatening and is due to chest trauma and abdominal injury, leading to breathing blockade apart from hemorrhage. The "emergent" categories are an injury that requires surgery within 6 hours to control bleeding such as that due to fracture of limbs. The "urgent" category is due to life-threatening situations emerging within 24hrs after surgery requiring immediate attention. The "not-life threatening" category is due to open fractures with chances of permanent disability such as open fractures of limb. In these cases, immediate hospitalization is the most sort-out measure. Pre-hospital care of hemorrhage helps in reducing mortality and morbidity in these cases.

Given the scenario of traumatic injury, it is important to assess the specific cases of hemorrhage. The hemorrhage can be classified based on injury into, (1) post-operative, (2) postpartum, (3) arterial, (4) venous, and (5) capillary hemorrhage. The post-operative is due to arterial and venous hemorrhage is fatal and needs immediate pre-hospital care. Depending upon the method of blood-leak, hemorrhage is classified as, (1) primary hemorrhage; in the case of bleeding immediately after an injury, (2) reactionary hemorrhage; delayed bleeding after the injury, (3) secondary hemorrhage; delayed bleeding from sepsis, (4) hematuria; blood in the urine from urinary bleeding, (5) hemoptysis; coughing up blood from the lungs and (6) hematemesis; bleeding in stomach. From the visibility of source of blood leak, hemorrhage can be classified into (1) internal hemorrhage; source not known and (2) external hemorrhage; source of blood leak is visible [21-23]. Internal hemorrhage generally occurs after collision due to the damage of the internal organs and internal large blood vessels. Wherein, the source of injury leading to blood loss cannot be seen, and it is very hard to recognize with symptoms. These wounds are generally complex with hematomas. Thus, immediate hospitalization is the best sort out way for rescue. On the other hand, external hemorrhage refers to blood coming from open wounds [24]. In both internal and external hemorrhage, rapid control of blood loss is important to refrain from morbidity and mortality [25-26].

Injury of limb extremities and external bleeding is very common after accidents as well as in war [27]. Thus, this campaign is focusing on road accidents and pre-hospital care of external hemorrhage from traumatic injuries. The campaign is entitled as "FAs for Blood Loss in Emergency (FABLE)". In the future, this campaign can also be extended to other categories of hemorrhage. The extensive bleeding in hemorrhage is due to injury of major blood vessels. Various FAs are widely explored to stop bleeding, and are very effective [28]. The nature of wounds and the source of bleeding vary on a case to case basis so is the choice of FAs. There are mainly three categories of external hemorrhage from limb extremities, (a) arterial bleeding, (b) venous bleeding and (c) capillary bleeding [29]. In the case of arterial bleeding, blood flow originates from artery, the other characteristics are the blood is red to yellowish in color; blood spurts rather than steadily flow at the exit. This is of high risk, life-threatening due to copious loss of blood in short time and is very difficult to control. The blood control is achieved by direct pressure, elevation and indirect pressure. The choice of FAs is pressure bandages followed by tourniquets. In the case of venous bleeding, blood originates from vein; the blood is blackish in color (low oxygen content), exit in a steady manner. It's also high risk injury and life-threatening due to copious loss in short time, which is difficult to control. The control is achieved by applying pressure using pressure bandages, absorption bandages and tourniquets. The third category is due to capillary bleeding. Capillary bleeding happens in superficial wound such as abrasions. Its color varies from red to blackish. In this the blood generally oozes in small amounts as opposed to flowing or spurting. This is a no life risk category can be easily controlled using pressure bandages and absorption bandages. The knowledge about the nature of injury is poor in civilian population particularly that of the rural country side. Given the clinical scenario of external hemorrhage, recent development in technology landscape is reviewed.

Recent Developments in Technology Landscape of FAs for Stopping Bleeding

Pre-hospital use of FAs to stop bleeding reduces the fatality rate and morbidity [30]. There is an increased understanding; about the limitations of current FAs and the new requirements. New emerging technologies are available addressing most of the limitations. The new FA systems are advancing to the level of point-of-care (POC) systems. The POCs on contrary to FAs are engineered simple or modular systems capable of addressing multiple aspects of hemorrhage. For example, a new POC for hemorrhage gets activated with mechanical pump by filling the air in the flap wrapped around the pre-injury area of the limb [14]. This advancement significantly enhances the self-utility of these technologies. Another example is that, new POCs are having ability to accelerate wound healing in addition to stop bleeding [22]. The other examples that can be considered in POC category are the transdermal patches, mask, fire alarm and RBC counter. From these discussions it is apparent that, these POCs provide renewed ability to solve various issues related to injury without much human motivation. Its gradual development from one generation to next generation shows that, new clinical and technological challenges are to be identified and addressed for advancing the science of these technologies. The future technologies on the one side will progress from ordinary systems to engineered systems, on the other hand new technologies that are more affordable and accessible also will find market [57].

In the military scenario, already various advanced FAs or POCs for hemorrhage are available. They include advanced tourniquets, bandages like elastic adhesive bandages, absorbent bandages and blood-transfusion sets. Further, research is happening in this area for more automation to reduce human motivation. There are pharmacological agents applied as sprays that enhance clotting [31]. A biomedical device based on neural stimulation for inducing hemostasis is also emerging [32-33]. Many non-pharmacological, non-medical approaches are used to control physiological responses in Ayurveda and meditation [33]; its influence in vagal control needs to be assessed [34-35]. Stopping bleeding using various strategies in ancient books by Sushrutha is available in Indian traditional healthcare literature [33-34]. Kerala has an established traditional Ayurvedic health care heritage [33]. The applications of pressure for controlling physiological responses are famous in Kalaripayattu, famously practiced martial art in Kerala. Using hand or finger to the site against the bones which are proximal to bleeding site is used in Kalaripayattu to stop bleeding. In addition, an intervention to stop bleeding with special tourniquet knots along with turmeric powder is also traditionally practiced. These approaches can be used as a motivation for developing new technologies. These traditional knowledge and new POCs can be explored for stopping blood loss during the pre-hospital period and that can be self-administered. However, for over-the-counter delivery of medical products, products with proven safety and efficacy need to be developed and for such solutions systematic R&D need to be done.

Affordable FAs or POCs are required for rural India; for that field bandage is an example. Field bandage is extensively utilized by the military people. It contains, several layers of adsorbent cotton stuffed inside layers of gauze. This bandage absorbs large volume of blood and cause platelet aggregation leading to accelerated blood clotting [42]. The elastic bandage is an advanced form of field bandage; that in addition to absorb blood can be applied to bleeding from even head injuries [43]. Further, advanced is the case of elastic and adhesive bandage, it avoids the slippage during the application of the bandage. A recent review says that, these affordable technologies are further progressing to new generations by combining the accelerated coagulation ability with accelerated wound healing properties [44]. For rural people it is known that applying pressure against the bone using hand or finger reduces the rate of blood leakage.

New technologies are emerging exploring this principle. Certain drugs has accelerated coagulation effect at open wounds are being explored in hemorrhage [45]. Conventionally, the external limb hemorrhage is controlled by applying the emergency trauma dressing, followed by applying pressure using tourniquets, and the limb is elevated above the level of heart [46]. On the other hand, under emergency situations, the tourniquet is first applied, when other methods are inadequate for controlling bleeding. The analysis of technological sophistication shows that, new clinical observations along with developments in science have resulted in new appreciation for inducing clotting to stop bleeding. This is achieved using advanced biomaterials [47].

New Requirements of FAs for "Fable" Campaign

The new advanced FAs or POC systems [48] aiming for rural country side through FABLE campaign, need to be self-administrable, affordable and locally available. The first focus is to address hemorrhage from limb extremities. They need to be essentially biomedical technologies based on advanced biomaterials. It need to essentially ensure, reduced blood flow rate as well as accelerated hemostasis upon administration and easily removable at the hospital. The utility of these POCs varies with respect to situation. The pathophysiological situations requiring independent attention are region and type of injury, specific patient population, and procedure, type of bleeding and specific mechanism of action of agents [49]. They have to be effectively and rapidly control bleeding, contact with the surface and accelerate coagulation, reproducible and work in a reliable manner and easy to handle. Further, its manufacturing should essentially be simple and scalable, products need to be available in multiple delivery options, compatible with patient's physiology and ensure safety. Along with that, it should not cause any damage to the neighboring tissue as a result of treatment. The product should have appropriate means for improving wound healing and tissue regeneration. Overall, the upcoming technologies should enhance treatment, improve the long term outcome and reduce the overall stay in hospitals.

In addition, the technological sophistication of new products should be robust enough to cover treatment of a wide population with wide variability in coagulation. However, this is often difficult and appropriate decision making in specific application of POCs or drugs become important [50]. For that, in the case of rural population, the FAs need to be distributed to the provider network such as pharmacies, primary clinics as these units are available in rural areas [51]. Provider network can continue the education to the rural population for reinforcing the advantage of using these FAs for saving life and organs during traumatic injury and hemorrhage [52]. Given the possibilities of technology development, it is important to know, how pharmacies and pharmacists could be explored for improving the accessibility of these technologies.

Pharmacists Role in "Fable' Campaign

Trauma Care in Rural India and Pharmacists Emerging Role

For reducing the mortality rate in traumatic injuries, in developed countries, trauma care management team is handling the prehospital ambulatory care. The trauma care management team contains clinicians, and other paramedicals [53]. They are trained to make appropriate life support; and involved in shifting the patients to a tertiary care hospital. In developing countries ambulatory trauma care team is only available in very few cities and is unaffordable to many, especially in the rural side. In rural India still the people are dependent on traditional medicine, and emergency care is a remote possibility. The lack of healthcare is a result of multiple reasons such as; knowledge inadequacy [5456] lack of health care professionals, clinics and transportation facilities [54,57-58]. In developing countries, the physicians and hospital facilities are nearly 1/10th to that of developed countries. In rural areas, accidents leading to traumatic injury raises from 5 to 27% as the time elapses from 20 to 120min. For developing new strategies, the ground reality needs to be kept in mind. In rural India, pharmacists are most trusted after doctors for medication practice.

Orienting Pharmacists for the Bigger Mission in Healthcare

In the past, the pharmacists in India were known as "compounders", were handling the medicine preparation and distribution in rural country side for long [59]. With the growth of modern medicine, the concept of medicine compounding also changed and the pharmacists are also evolved to share more medicine related responsibilities. Today, the pharmacists are trusted for ensuring optimal pharmacotherapy, therapeutic management of chronic patients, and in emergency care in rural areas. The opportunities and responsibilities of pharmacists are ever increasing and are enabling modern medicine more personalized [60-61].

Pharmacist is being expected to play more responsible role in improving the health care scenario due to their trust with doctors and patients uniformly. Service of Pharmacists is imminent in rural areas having pharmacies; due to shortage of clinics. Understanding this, at present developed countries such as Canada, US, and UK is exploring pharmacist services for various public rural health purposes. Emergency care team in UK has pharmacists specially trained for that. This is mainly because the pharmacists have training in design, development, formulation, administration as well as safety and efficacy of medicines [62]. In the rural side of these developed countries, pharmacists are trusted after doctors for prescription-reconciliation; that increases the personal care, affordability and accessibility of the modern medicines. Considering this, WHO has initiated the campaign of "seven star pharmacist"; for increasing the role of pharmacists in public health. As per this campaign the pharmacists are advised to play important role in public health as a decision-maker, communicator, teacher, caregiver, leader, researcher, life-long learner and manager. As a follow-up step, the FIP in 2000 has propagated the idea in their policy statement [63-65]. Fundamentally, growth of pharmacists to the level of "seven star pharmacist"; helps to improve the wide acceptability of modern medicine, by improving personal care, affordability and accessibility while reducing the mortality and morbidity rate.

Pharmacists Role in Campaign Based Programmes

The term public health (PH) aims for activities related to improving healthcare; that pharmacists are always involved in. The PH training for orienting the pharmacists towards "seven star pharmacists" initiates at undergraduate level in many academic curriculum around the world [66-67]. This is widely practiced in many acclaimed Indian pharmacy schools in all public pharmacy schools and private institutions such as Amrita School of Pharmacy; Amrita University [68] and Annamalai University [69]. The student bodies such as International Pharmaceutical Student's Federation (IPSF) is part of PH and supported WHO campaigns related to TB, HIV-AIDS, Tobacco related to world health day over 50yrs [70]. Recently, pharmacists are widely campaigning for antibiotic stewardship. The Indian Pharmaceutical Association (IPA) and Commonwealth Pharmaceutical Association have joined hands with IPSF on "TB fact card project" during the year 2005-2006 [71]. There is a greater degree of voluntary leadership effort the pharmaceutical student community of the country is showing. Currently as per the curriculum, Pharmacists with clinical pharmacy training such as M Pharm (Pharmacy practice), Pharm D, Pharm D PB and B Pharm with clinical pharmacy and hospital pharmacy training are being recruited for clinical pharmacy services in various hospitals. Certificate programs on specific disciplines or campaign programs can make pharmacists jobready. This campaign based training can be a potential approach for enabling "health for all" mission in rural India.

Emerging Trend in Curriculum Scope for Campaign Programmes

The pharmaceutical program of Republic of India (ROI) is entering into a new phase after the introduction of Pharm D program by Pharmacy Council of India (PCI) [71]. The Pharmaceutical program in ROI has two distinct faces, giving (1) training in pharmaceutical technology through B Pharm and M Pharm and (2) training in clinical pharmacy practice through Pharm D, B Pharm and M Pharm. The specialization in pharmacy education starts after a thorough learning phase about various aspects of pharmaceutical profession at undergraduate level (initial 4yrs). The pharmaceutical technology development training contains physical, chemical and biological concepts about design, development, formulation and practice of medicines. In addition, training for pharmacist is given to supply chain management and its rational use. The medicines are expressed in terms of "percentage impurity" not on the basis of "purity of substance", thus the activities are highly regulated and documented and its rational use need to be mentioned. Pharmacists are trusted to reduce the deviations from their professional responsibility and oath. The Pharm D program is aimed to enable clinical practice for pharmacists to ensure rational use of medicines. In fact, emergence of clinical practice by pharmacist has the history back to that of modern medicine. The era ahead is full of opportunities for pharmacists. In a short span of less than 10yrs, the new clinical pharmacists are expected to be participating in emergency clinical scenarios along with doctors to improve medication practices that can help in reduction of mortality and morbidity rates. Apart from optimizing the medication regime the clinical pharmacists are participating in patient counseling, helping the modern medicine more personalized. This is being reflected in increased hiring of clinical pharmacists in leading hospitals. The country is looking for "seven star pharmacists", and their increased role is in enabling the affordability and accessibility of treatment, while ensuring safety and efficacy. Even though, the clinical practice has become full-fledged, the old practice of flexibility in choosing between the industries or clinical practice is going to continue for some more time. Thus, several B Pharm and M Pharm graduates, who are clinically trained, will be still choosing for clinical practice in secondary or tertiary care. To ensure their services, on the long run they need to be trained towards the requirement of seven star pharmacist. The Pharm D program will soon be leading the hospital pharmacy and medication optimization in major hospitals this will enhance the patient confidence in such hospitals. On the other hand, the community pharmacies continue to be the same for some more time, mainly guided by the prescriptions and over the counter (OTC) medication. The current academic focus is to provide required clinical experience to the pharmacy practicing students with required research background for the rational use of therapeutics. Further, for campaign programs more tailored learning related to specific campaign need to be given.

"Fable"--First Aids (FAs) for Blood Loss in Emergency Care Campaign for Training Pharmacists in R&D and Rational Use of FAs

This review proposes a campaign program for rural India, entitled "FABLE"--First aids (FAs) for Blood Loss in Emergency care. As a first step the campaign is focusing on injuries of the limb extremities. This is to save victims after hemorrhage due to traumatic injury in road accidents. Through campaign programs training can be given for clinical pharmacists on rational practice of advanced FAs, as they are already part of PH. Current pharmacy curriculum in the country supports sufficient flexibility for either R&D or clinical practice. With adequate specialized training their service can be utilized in emerging healthcare requirements. Recently, Vision 2035 roadmap is published by Government of India (GOI) [57]. It identifies biomaterials sector as a strategic sector to raise countries GDP [57]. Modern medicine has explored biomaterials for designing various new and advanced devices and several new inventions are happening in this field [57]. Engineering biomaterials [73-76] helps to improve therapeutics [77-81] and diagnostics [82]. For developing new FAs, new materials need to be developed substituting old inferior materials. Many technologies for stopping bleeding [83-84] in hemorrhage explore biomaterials. The fundamentals of biomaterials are similar to that of drug molecules. In addition, pharmacy program provides robust training in material sciences in the pharmaceutics specialization. However, more specialized short term R&D certificate programs or project based training need to be given based on specific campaigns for fitting the pharmacists into campaign based programs. In FABLE campaign R&D training need to be given to pharmaceutical technologists (B Pharm and M Pharm) on development of biomaterials and medical devices aiming to stop bleeding in hemorrhage. Similar short term clinical training is to be given for clinical pharmacists (Pharm D) interested in emergency care. Pharmacists are extensively trained in clinical practice, particularly Pharm D and M Pharm Pharmacy practice. Peer-institutes may need to take the lead role for formulating the, (1) R&D training as well as (2) clinical practice training based on FABLE campaign program. For improving the motivation to serve in rural country side, the rural internship needs to be made part of the FABLE campaign program. The FABLE campaign to serve victims of hemorrhage should be to, (1) identify the type of hemorrhage and type of treatment, (2) The process involved in R&D of these materials and technologies (3) new strategies for pre-hospital care. The demographic findings and research findings of the FABLE campaign need to be published for further improving the strategy to improve its reach to rural side of the country.

Current Proactive Policies by Government for Improving Healthcare

The Republic of India (ROI) has recently taken several proactive steps to cater world supply chain. One strategy is to empower the manufacturing sector through the "Make in India" campaign; it helps in improving the affordability and accessibility of the technologies [85-87]. This effort has already energized the manufacturing scenario, and there is a corresponding increase in foreign direct investment (FDI) [57,87]. Biomaterials and medical devices manufacturing sector is showing considerable growth over the years. Here, pharmacists can find numerous opportunities, as it requires clinically trained manpower. It is now time for the pharmacists to venture in biomedical field and develop new biomaterials and devices along with engineers for the management of hemorrhage by participating in FABLE campaign to serve rural India. This model can be explored for bigger global mission.


In conclusion, the FABLE campaign is proposed here to initiate efforts to provide affordable and accessible FAs to stop bleeding in hemorrhage after traumatic injury as a result of road accidents. The program is aimed for rural India, as the healthcare disparities are high. The campaign is planned to motivate academia for voluntary efforts to develop academic programs for training pharmacists in R&D of biomaterials and medical devices as well as in its rational use in clinical front aiming the rural population, so that, they can participate in the process of empowering rural India. The Vision 2035 roadmap and the Make in India campaign need to be appropriately explored for the said purpose. This FABLE campaign can be a model to reduce the scantiness in healthcare facilities in rural country side.


Dr. Kaladhar wanted to thank Prof. Shanti V Nair, Dean, Amrita University, Dr. Sabitha M, Principal, Amrita School of Pharmacy, Amrita University, and Prof. Chandra P Sharma, Formerly Head, BST Division, BMT Wing and acting Head BMT Wing, SCTIMST for the kind support.


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Kaladhar Kamalasanan

Pharmaceutics, Amrita School of Pharmacy, AIMS Healthcare Campus, Amrita Vishwa Vidyapeetham, Amrita University, Ponekkara, Kochi, Kerala, India

Received 16 February 2017; Accepted 11 April 2017; Published online 31 December 2017

* Coresponding author: Dr. Kaladhar Kamalasanan;
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Author:Kamalasanan, Kaladhar
Publication:Trends in Biomaterials and Artificial Organs
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Date:Jan 1, 2017
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