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At an approximate esti mate at present there are about 600,000 to 700,000 patients with diabetes in Sri Lanka and this number is likely to increase significantly in the near future. As evidence of this, for example the number of newly registered patients at the Diabetic Clinic at Teaching Hospital Peradeniya has increased by 400% during the past 10 years. Even though this phenomenon may be partly due to increased awareness of the illness by the general public an analysis of patients coming to hospital has shown that there has been a real increase in the number of patients .
The tragedy of diabetes is the presence of its complications. Blindness is 25 times more common in diabetics than in non diabetics, kidney failure 17 times commoner, heart disease and stroke twice as common and if left untreated the average life expectancy is one third less in people with this disorder.
The effect of diabetes on the community is enormous both in terms of well being of the family and cost of health care. Since the illness afflicts mainly those who are middle aged and are therefore breadwinners of the family, the family income would be affected. Regular absence from work and therefore the reluctance of some employers to employ patients with diabetes is well known. Even though fortunately attitudes are changing, still there is a certain amount of social stigma attached to this illness.
In terms of cost of health care perhaps there is no other illness which has such a financial burden both on the family and the government. As discussed above in addition to affecting the family income, the patient has to bear expenses on drugs, special foods, urine and blood sugar testing equipment and regular transport to and from hospital. Even though most patients with diabetes in Sri Lanka obtain their drugs free at government hospitals, they have to yet sustain expenses on other items mentioned previously. The expenses to the patient would drastically go up if he or she is on insulin injections particularly the newer types or more refined insulins as they are not available in most government hospitals.
The government remains the agent for delivery of diabetic care for most Sri Lankan diabetics. The human resources such as medical personnel, nurses, dieticians, pharmacists and other ancilliary staff are provided by the government. It also provides drugs and facilities for identification and treatment of complications of diabetes. Huge expenses are incurred in supplying chemicals and reagents, drugs and equipment. For example a haemodialysis (a process of removing toxic matter from the system in patients waiting kidney transplantation) machine costs between Rs. 2 to 3 million and treatment with this machine costs about Rs. 3000 per patient per day. A kidney transplant carried out in Sri Lanka would cost Rs. 300,000 at present. Similarly a Laser machine (used in the treatment of diabetic eye disease) too would cost Rs. 1 to 2 million.
It is therefore obvious that prevention of diabetes and its complications is of paramount importance. The cornerstone of a preventive strategy of any illness is the identification of the cause and methods of transmission. Unfortunately in the case of diabetes the exact cause has not been identified thereby making effective prevention virtually impossible. However certain factors that contribute the development of diabetes have been identified and attention to these factors have to some extent prevented the illness in certain communities. These factors which are genetic or environmental in origin interact to produce diabetes. In other words if one is predisposed to develop the illness in view of his or her genetic make up that person would manifest the illness when exposed to the appropriate environmental agent.
The evidence that genes play a major role in the occurrence of diabetes is derived from family studies which show a significantly larger number of patients affected in those families were one or more member has the illness. It is stated that the risk of developing the illness in an unaffected person in a family with another member is diabetic is about 30%. If it is an identical twin the chance of that person developing the illness if the other twin is diabetic is nearly 100%. However in spite of this evidence the gene that is responsible has not been identified. If it was so it would have been possible to prevent diabetes by such means as genetic counselling. Studies conducted in all three major communities in Sri Lanka have indicated a high degree of genetic susceptibility to develop diabetes.
The environmental agents that have been identified as risk factors for diabetes include diet, lack of exercise and mental stress. More recently is has been proposed that undernutrition of foetus (when a person is in the womb) too could produce diabetes in later life. Being obese (over weight) which in turn would have both a genetic and a environmental basis is an important risk factor but is not a real problem in third world countries at present. A diet which is high in calories refined sugars and fats has been shown to be an important risk factor for the development of diabetes.
It is thus evident that attention to these risk factors could appreciably reduce the prevalence of diabetes in those who are genetically predispose. In fact in the Australian Aborgines it has been shown that migration from cities to the villages had reduced the prevalence of diabetes. Even among those who live in the cities it is not difficult to adopt a traditional life style despite the social pressures that they are subjected to.
Prevention of diabetic complications too is of considerable importance both from an individual patient's point of view as well as that of health economics. It is evident that primary prevention of diabetes as described above and effective treatment would significantly reduce the occurrence of diabetic complications. However there are other correctable factors too which contribute avoidance of which would further reduce the occurrence of these complications for example in the case of diabetic eye disease two other contributory factors are smoking and presence of hypertension (high blood pressure) the occurrence of coronary heart disease, another serious complication of diabetes, is influenced by smoking, high cholesterol and high blood pressure. It has been recently shown that the development of diabetic kidney disease could be facilitated by the high animal protein diet. Avoidance of such an diet would therefore decrease the risk of kidney disease.
The writer is Associate Professor of Medicine, University of Peradeniya
Many parents worry that their infants and smaller children do not eat enough. What must you do, when the child picks at his food but is otherwise lively, cheerful and healthy?
Here are a few suggestions and some facts to take note of before you admonish your child again:
- Choosy eaters don't starve. When they don't eat much today, they will, tomorrow or the next week.
- Children usually don't eat "balanced" meals every day. But if you keep nutritious food in your home, they tend to balance out what their bodies need.
- When your child is feeling tired, sick or has a cold and refuses to eat, let him skip a meal. He will catch up later, when he's feeling better.
- "Little and often" maybe a better pattern for some children than "three meals a day".
- Children are suspicious of new foods and flavours. So, the 'special' pudding you prepare may be rejected.
- Children like the "grown up" feeling of being able to choose how much and which foods go on their plate. Encourage this habit and they will eat more.
- Many children are hungry when they get home from school, it is a good time to feed them.
- Allow children to break or spill food at the table. Trying to prevent these only makes meals more tense for the child.
- But, if your child is losing weight or is not active and lively as he used to be, see a doctor for advice.
There is a dear old friend of mine who, many years ago, taught me the benefits of a regular morning walk.
Whatever his other commitments, for the past twenty years or so, he used to get up early morning three times a week and, with his trusty walking stick in his hand, stride out along Duplication Road to take his morning constitutional. The benefits of starting the day with this type of activity are many.
In the first place, as our bodies keep getting older, the joints stiffer and the muscles less supple, the regular activity of exercising the limbs helps to keep the body's moving parts active. The onset of painful degenerative arthritis is postponed, and the aging process is slowed. As the saying goes, if you don't move it, you lose it.
Secondly, walking is very good aerobic exercise - because it puts the heart and lungs through a period of brisk physical exertion that improves the circulation and burns up harmful fats like cholesterol.
Thirdly, the energy-consuming effects of a brisk walk help to keep the weight down. As the waistline keeps expanding with advancing years, physical exercise is one of the most convenient ways of "waist disposal".
And finally, getting out on the streets in the cool of the morning when the birds are just starting to wake up and the traffic has not yet started to pollute the streets is wonderful for clearing the brain - one can walk in peace, sharing the company of one's thoughts.
My friend would tell me that he used to get his best ideas during this morning walk.
Of course, there are others who prefer to walk with a friend - their idea of enjoying the morning walk is to share the company of a friend or spouse, chatting as they walk along. As one of my busy pals told me, the evening walk is the only time that he and his wife have time together - and so they make sure that they (using the jargon of today's busy professionals!) "prioritise their schedules" to ensure that time is set aside for the daily half hour walk together.
Now the sad thing about my old friend is that he has stopped going for his usual walk.
It all started over a year ago when he "stopped for a few days".
Once you get out of a good habit, however long you have been doing it until then, it is easy to put off resuming. You can always find something more important that gives you a good excuse to put off starting again by another day - and soon the days turn into months and the months into years, and you find that you can't remember when you last took your morning walk.
Like my busy young professional friend and his equally professional wife, you have to learn to "prioritise".
You have to make an effort to keep moving your muscles and joints.
Because if you don't move it, you are definitely going to lose it - as sure as the sun rises in the early morning.
Continuing our series of articles on Medical Negligence, this week we focus on how there may be a breach of duty by a doctor in caring for his patients. Our previous article discussed the correct concept of Medical Negligence....
When a doctor cares for his patients, the process consists of several stages.
A doctor is expected to take a "history" - a description of the patient's illness, as told by the patient or his relatives - first, before proceeding further.
Then, he is expected to examine the patient carefully.
Thereafter, he should do necessary investigations on the patient.
Finally, he should prescribe the necessary treatment, or in the case of a surgeon, do surgery and follow up the patient during his recovery period.
As can be expected, therefore, a doctor may be found negligent in any one or more of these stages involved in the care of the patient.
In taking a "history" from a patient, the doctor must be able to elicit necessary, relevant facts, which the patient might not readily volunteer as the latter may not realize the significance of that information. An allergy for a drug or a particular group of drugs, for example must be queried by the doctor before administering it. The doctor must similarly inquire from the patient what other drugs, if any, are being taken by the patient as any treatment given by the doctor may interact and cause reactions. Any past illness, surgery, investigations done on the patient are all similarly relevant information.
In Sri Lankan medical practice it is common for one patient to seek a cardiologist for heart ailments, a neurologist for a headache and an entomologist for Diabetes. If all of them were to prescribe drugs oblivious to what the other specialist was prescribing, the patient will only end up as a volatile pharmaceutical cocktail. In this context, it is important for both doctors and patients to realise the importance of careful history taking.
However, whether this can be successfully done in a private consultation that lasts all of three minutes is an arguable issue!
In examining the patient, similar care should be exercised. A doctor is expected to examine the patient as a whole, and not only the system to which the patient refers his complaints - because an illness affecting one system may cause complications in another system. Failure to do so would make the doctor negligent.
Now, this is an issue for controversy. Doctors in this country are often accused of performing a cursory examination on patients related to his symptoms and prescribing treatment.
At least on paper, this is wrong and would amount to negligence but, specially in the state sector where a doctor is expected to examine and treat fifty to a hundred patients, a complete "physical" for every patient would create absolute chaos in government hospitals. A competent doctor, through learning and experience, overcomes this problem by acquiring the skill to quickly examine only the relevant areas of the body to which the complications of a disease may be referred.
But this,of course, is not a defence in the private sector where a doctor is duty bound to examine a patient carefully here, he cannot complain that there were too many patients, for he always has the option of limiting the number of patients he treats!
Next: Negligence in investigating a patient and in treatment.
Sunday February 22 (Today): Sri Lanka Medical Association National Seminar on career guidance for junior medical officers, at Lionel Memorial Auditorium, Wijerama Mawatha, Colombo 7, from 8.30 am. onwards
Speakers: Dr. D. N. Athukorala (President, Sri Lanka Medical Association) Dr. Lakshman Fernando (Obsterics and Gynaecology), Dr. S. D. Atukorala (Pathology), Dr. E. K. Rodrigo (Psychiatry), Dr. N. G. Aturugama (Radiology), Dr. N. Goneshanthan (Surgery), Prof.
Anoja Fernando (University Teaching) Dr. Nalini Rodrigo (Anaesthesiology), Dr. Lalith Wijerathne (Rheumatology), Dr. V. Jeganathan (Management), Dr. H. M. S. S. D. Herath (Community Medicine), Dr. Dennis Aloysius (General Practice), Dr. L. B. L. de Alwis (Forensic Medicine), Dr. W. Ratnayake (Otolaryngology), Dr. Maxie Fernandopulle (Paediatrics), Dr. Charith Fonseka (Opthalmology) and Dr. Sarath Gamini de Silva (Medicine)
Saturday February 28: Inaugural annual sessions of the Population Association of Sri Lanka at the Sri Lanka Foundation Institute, Colombo.
The Sunday Times invites doctors, medical faculties and associations of medical professionals to inform us of professional events to be included in the MEDICAL DIARY in this page. Address your letters to:
The Medical Page
C/o The Sunday Times
P. O. Box 1136
Colombo.
Newspapers have reported and authorities later confirmed that the intake to Medical Faculties is to be increased from its present 880 per year to about 950.
By all means, we must encourage more opportunities being afforded to students to become doctors. Certainly, Sri Lanka has one of the higher doctor-population ratios in the region and the country could do with more medical personnel.
But, whatever increase there is, it should be a planned programme that makes more provision for training and teaching and ultimately employment. More importantly, such increases should not be at the behest of Ministers and politicians hungry for votes at the next election.
At present, many, if not all of the six medical schools in the country are overburdened with work, under-staffed and their administrators complain of a lack of adequate resources.
Clinical teaching facilities for medical students have not improved greatly despite the ever increasing number of trainees, and there are, more often than not twenty or more students crowded around a patient's bedside. The patient suffers, but so does the student, and the quality too of the medical graduate produced.
Then, when the doctor finally graduates, he or she is told by the Health Ministry that he cannot be guaranteed a job in the state sector. Why? Not because the country has an excess of doctors, but because the state health infrastructure cannot absorb all graduates because its expansion has not kept pace with expansion in university education.
Needless to say, the newly passed-out doctors begin their career clutching at each other's throats, fighting for places in the merit list and organising protest marches against foreign medical graduates, who are of course, also citizens of this country. Is this the way to enter a noble profession? Most certainly not, but this is what happens when medical schools are set up at the whims and fancies of politicians. And, as far as we know, the latest increase in the intake of medical students is also politically motivated.
All this will only result in more chaos and crisis in the health sector. Finally, a poor patient somewhere, will suffer.
Yes, Sri Lanka needs more doctors. But that does not mean they can be mass produced by the stroke of a pen that increases the medical school intake. So, if more doctors are being produced, it is high time for the Ministers and Ministries of Health and Higher Education to realise that it must be done properly. Or, not done at all, because little learning is a dangerous thing, especially in the practice of medicine.
Continue to Plus page 9 * Kala Korner - By DeeCee
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