Sunday Times 2
How Lanka is taking care of patients with spinal cord injuries
View(s):It was the story of how Sri Lanka is building up a comprehensive care system for patients with spinal cord injuries that kept the eminent audience riveted at the 75th Platinum Anniversary Sessions of the Association of Surgeons of India (ASI) in Gurgaon, New Delhi, on December 17.
Dr. Narendra Pinto receiving the honorary fellowship from Chief Guest and Judge of the Supreme Court of India, Justice A.R. Dave and ASI President Prof. Santhosh Abraham at the Platinum Anniversary Sessions of the ASI in Gurgaon, New Delhi.
The signal honour of delivering the guest lecture on ‘The role of a surgeon in a developing country’ was accorded to Dr. Narendra Pinto, Senior Consultant Orthopaedic & Trauma Surgeon and former Chief Surgeon at the Accident Service of the National Hospital of Sri Lanka,. Currently, he is the Senior Orthopaedic and Trauma Surgeon at the Neville Fernando Teaching Hospital.
Dr. Pinto who is the Founder President of the Sri Lanka Spinal Cord Network (SLSCoN) and Past President of the SAARC Surgical Care Society, the College of Surgeons of Sri Lanka and the Sri Lanka Orthopaedic Association was felicitated by the ASI with an honorary fellowship which was bestowed by Chief Guest and India’s Supreme Court Judge A.R. Dave and ASI President Prof. Santhosh Abraham.
The fellowship was awarded to Dr. Pinto for his contribution to surgical services and building international and regional cooperation in surgical care, while the only other recipient of a similar fellowship at the ceremony was Prof. Abdul Majeed Chaudhry from Lahore, Pakistan.
Walking the audience through haunting memories of paralysed patients with spinal cord injuries who are on calipers, particularly the story of the little boy who was shot through the chest and was paralysed, Dr. Pinto stressed how surgeons in Sri Lanka rallied round to embark on a mission to add life to them.
In his lecture, Dr. Pinto said all aspects of prevention, curative and rehabilitation were taken into account when building a comprehensive care system for spinal cord injury (SCI) patients in Sri Lanka. In rehabilitation, the utilisation of the existing capacities of the handicapped person by the combined and coordinated use of medical, social, educational and vocational measures to the optimum level of functional ability is important. It makes life more meaningful, more productive and therefore worthwhile living. He said: “Rehabilitation can be grouped into medical rehabilitation to limit disability and socio-vocational rehabilitation to reintroduce the person to society as a differently-able person.
“Why venture into rehabilitation? It is a part of comprehensive medical care, the optimum results of surgery are affected by inadequate rehabilitation; and the surgeon who is the first contact of the patient is duty-bound and morally-bound to see to the total welfare of the patient and fit him back to society. This is why it is important for surgeons to be involved in rehabilitation.
“In our part of the world, supportive services may not be ideal or at times even non-existent. In Sri Lanka with a population of 21million, there are only 380 beds for the rehabilitation of SCI patients and those with other major disabilities. ”When considering epidemiology, according to WHO data, about 10-15% of a population in a country has a disability and of these there will also be some with severe disability. According to the National Sample Survey in India carried out in the late 1990s, 0.5% of the population was found to be severely disabled.
“When considering rehabilitation, the emphasis is on neurological disorders such as cerebro vascular accidents (strokes) and other neurological disorders, in orthopaedic surgery which involves SCI, amputees and other trauma and in paediatrics involving cerebral palsy and other anomalies. In developing rehabilitation care services for SCI patients and persons with other disabilities, it is crucial for a multi-disciplinary team comprising surgeons (orthopaedic, neuro, plastic and uro), physicians (rehab, geriatric and neuro), other medical officers, therapists (physio, occupational, speech and orthotists), counsellors, social service officers, psychologists and other paramedical staff to look after the patient.
“However, the challenges in maintaining a multidisciplinary team are bringing all under one roof, the dearth of specialists who may have to play both an interdisciplinary and trans-disciplinary role, issues that could arise over ‘territory’ of their specialties and overcoming bureaucracy and red tape in the case of public service. In Sri Lanka, we overcame these barriers by forming a network/society involving all stakeholders in health and disability care which included officials of the Health and Social Services Ministries; Specialist Associations such as the Sri Lanka Orthopedic Association, the Sri Lanka Rheumatology Association and the College of Surgeons of Sri Lanka; nursing officers; therapists; volunteer organizations; provincial organizations; and affiliations with international organisations such as the Asian Spinal Cord Network and SAARC Surgical Care Society.
“Then we set to work getting all the stakeholders under one roof thus combining all the relevant ministries, giving due recognition to each of the specialties and stakeholders, holding regular meetings and discussions, getting volunteers and philanthropists to help or assist according to their wishes within the framework of the society, getting political leadership which is essential for sustainability, giving due recognition to the relevant ministries and their officials. To overcome bureaucracy and red tape we used pilot projects and model units to launch the new projects or process.
“Along with this came moves to change the attitudes of clinicians, patients and their families, society and policy-makers while also carrying out awareness campaigns through TV and radio programmes, newspaper articles, school programmes, setting up a website and lobbying relevant authorities. Simple and cost-effective measures were used in the prevention of pressure sores, bladder care, mobilisation and wheelchair skills. We also looked at counselling and vocational training to give them a source of income, providing advice on the patients’ sexual life and on how to maintain relationships which are often neglected in our part of the world and how they could access the available resources and facilities.
“We are in the process of introducing the ‘Halfway Home Concept’, which commenced as a model project (nearing completion at the Avissawella Base Hospital premises) in which patients will be placed in a halfway home together with their family members who will be trained in their care within a specified period. All relevant supportive services will also be directed to the patients along with advice on vocational training.
“During this process, we also identified new stakeholders who included architects to design disabled-friendly dwellings, engineers to design hoists and mechanization of wheelchairs and local government officers such as Grama Niladharis who are the first responders to the community on official matters who could be of immense value in gathering data and advice in preventive measures.”
Before citing the Sri Lankan example, Dr. Pinto referring to the comprehensive care of SCI patients in a developing country said that what needs to be looked at is whether there is a chain of care in existence. Even if it exists, is it functioning? Will the patient accept the options? Is follow-up available/possible? Will he/she opt for alternative medicine? If there is a deficiency in the system, should it be ignored, and an alternative brought in or try to correct the deficiency? If you try to correct a deficiency in the system, should it be at an individual, group, professional organisation, group of related organisations, international/conventions, policy document/books, legislation or official circular level?
“The future of the Sri Lankan model lies in achieving a government rehabilitation policy which should be made into a system, implemented and monitored and not be individually-based. There should also be new curricula on rehabilitation medicine and geriatrics under various specialties while infrastructure modifications and provincial rehabilitation centres are developed. Changes should also be brought in society and the environment to make both disabled-friendly and accessible with public transport modifications to facilitate a wheelchair user to commute independently as in developed countries,” he added.