Sri Jayewardenepura: focus on family medicine

By Nirmala Abeyesekera

Professor Leela de A. Karunaratne, the visiting professor and the first academic staff member of the medical faculty and Dr. Monica Perera, senior lecturer are rightfully proud of both these unique achievements. According to these two dedicated teachers, the elimination of ragging came by as a result of Professor Karunaratne putting into practice certain interventions to prevent ragging. A research study was done at the Sri Jayewardenepura University in counselling and guidance as interventions in ragging. Subsequently a paper was published by the two doctors along with Dr. S.Sivayogan. 

In this programme the first two batches of students admitted in 1993 and '94 were counselled in small groups. The aim was to change the behaviour and attitude of the new students as it was felt that taking punitive action against errant students did not produce the expected results. Prof. Karunaratne said she talked to small groups of students about goals, values and behaviour that were appropriate to students of medicine. 

At the end of 20 sessions completed in a single semester, the whole batch met. They were asked to name and write key words pertaining to their conduct as students of medicine on the blackboard. A list of previously prepared key statements was then presented to the students who were then asked to match these statements with the key words they had written on the board themselves. The students were encouraged to compile a code of conduct for themselves. After discussion, they expressed their intention to abide by the code they had compiled. Thus, a declaration was drafted and signed by them. 

The importance of a qualified and trained practitioner of Family Medicine cannot be overemphasised in today's healthcare system. The GP is the first point of contact, and referrals made by him to the relevant specialist or hospital as and when required. As the primary healthcare giver, the GP, is a valuable source through which the message of preventive medicine could be imparted to the community. It was with these factors in mind that Family Medicine was introduced as a recognised discipline of the Medical Faculty of the Sri Jayewardenepura University.

Dr. Monica Perera said that the department of community health comprised community medicine and family medicine. The organised teaching of family medicine was first introduced to SJMF and later on at the Kelaniya University. Family medicine was taught in the final year. The course work included lectures, seminars, small group discussions and clinical appointments with selected General Practitioners. The students who sit with the GP's have to make presentations on the characteristic features of general practice, advantages of a doctor/patient relationship, effects of illness on the patient, and his closest family. 

At the model family practice centre built by the university, the students get an opportunity of learning the proper method of conducting a family practice. It commenced its teaching operations in September 1997. The clinic has around 1000 registered patients mainly from the villages in the vicinity of the university. The cost of registering a family at the centre is Rs. 50/- and a fee of Rs. 20/- is charged for every consultation. 

The centre keeps a health record of the whole family, in addition to any other information which would be useful in the care of the patient. At these clinics, the medical students who have received an insight into a GP's practice get a further "hands on" training. 

Diabetes: Why the young?

By Roshan Peiris

Diabetes in earlier years did not have a high profile as a disease because its distressing ramifications had not been understood by the public.

Today there are one million diabetics in Sri Lanka and Dr. Wijesuriya said that in fifteen years the number will double. In India there are 300 million diabetics, the highest found in any country worldwide. 

"Diabetes has been correctly called the 'Mother of all illnesses because it affects the body from head to toe . No other disease affects the entire body in this way," Dr. Wijesuriya said. "Three thousand years ago during the time of Lord Buddha and even earlier, Indian medical books mentioned this killer disease. 145 million people worldwide are affected by this disease, yet the cause is not known," the doctor said.

Diabetes occurs when the insulin hormone which is produced by the pancreas is either absent, insufficient or ineffective. Insulin is needed to transform the sugar in a person's body into energy. Unused sugar can damage vital organs such as the kidneys, heart, eyes and the nervous system.

Dr. Wijesuriya explained that basically there are two types of diabetes. Type one strikes younger people and it is more common today than it was fifteen years ago. Earlier, the doctor said, diabetes patients were those above the age of forty. Today those in their early twenties get the disease. 

Type two diabetics are those who have acquired it through hereditary reasons, again because the insulin produced by the body is inadequate or defective. This form of diabetes in not necessarily insulin dependent. Most diabetics over thirty five fall into this category.

The cause for the erratic behaviour of the insulin producing pancreas is not known at all, and hence the doctor said prevention as such is not possible. 

Diabetes leads to coronary heart disease since it has the tendency to narrow blood vessels in the entire system pre-disposing to the obstruction of blood flow in the coronary circulation, cerebral circulation and peripheral circulation such as arms, legs etc.

Dr. Wijesuriya explained why even those in their twenties are affected. Over the last fifteen years the increasing number of young people suffering from diabetes can be attributed to the open economy bringing in its wake social changes which affect the lifestyle. There is a marked change in lifestyle due to lack of exercise, fast foods, stress because of competition and the desire to make headway in jobs and this had brought this diabetic syndrome about.

The doctor said there are changes in quality and quantity of food and the timing of meals. All encourage this killer disease.There is a shift from natural to refined foods, followed by the high consumption of sugar-based products and high fat containing items such as bacon, ham, meats and sausages and the like.

Next we find over here that quantity consumed has risen sharply in the face of relevant affluence. The first thing man does when he has more money is to indulge in anorgy of eating and that too at irregular times. Any meal delayed leads to the highlighting of hunger and hence naturally larger quantities are consumed .

"We find rather regrettably that this is a classic problem affecting our school-going children. They often leave home without any breakfast and then around eleven'clock eat their tiffin which is only either bread or buns. They reach home after three pm. in most instances, ravenously hungry and tired. They unfortunately consume at once fifty to seventy five percent of the total intake for the day at once. This is a disaster and hence children are today having diseases such as diabetes which earlier only our grand-parents had. In addition, exercise is lacking especially when the child comes closest to major exams. Moreover, exercise is restricted by the parents in their anxiety that the child should waste no time and instead focus on studies," Dr. Wijesuriya said.

"Today, both parents and teachers expect children to perform like gladiators at the 'O' and 'A' levels tilting the balance so that children are sick before the exams and some suffer from diabetes as an aftermath."

Symptoms of diabetes can include acute thirst, frequent and large quantity of urine passed especially at night, and weight loss despite healthy intake of food.

The doctor said that the less common symptoms are cramp, white discharge from the vagina and the cracking of the foreskin of the penis. Finally, itching, especially in the genital areas, altered vision and non healing wounds.

A multi faceted approach the doctor recommended can be made in the following way in reducing the possibilities of diabetes.

(a) Improving nutrition of mother and child. (b) Breast feeding to be encouraged (c) Childhood nutrition should start from weaning to adulthood and sustained to manhood and womanhood.(d) Exercise to be encouraged in school and work place. (e) Natural foods to be encouraged as opposed to refined foods. (f) The educational system to be geared to the ability of the child and the child should not be forced to go in for higher education when the child is not capable. This leads to stress which can lead to diabetes or other nervous and harmful diseases. 

Dr. Wijesuriya appeals to the public to support the Insulin Bank and save a diabetic child.

Are we eating the wrong foods?

Sri Lanka is in a state of transition where nutri tional disorders are concerned. At one end of the spectrum, there is an enormous problem of low birth weight leading to childhood malnutrition. Maternal under-nutrition leaves a challenge for supervision of weight gain in pregnancy.

At the other end of the spectrum, there is a growing problem of chronic degenerative disorders such as obesity, diabetes, high blood pressure, heart disease, osteoporosis and malignancies (cancers). Some of these can be prevented; some by diet changes.

Firstly, lifestyles are changing - not for the better. The rich are over-eating and the poor are near starvation. The food consumption per capita cannot therefore be an accurate indicator of nutritional status. It is not food availability that matters. As Amartya Sen, the Nobel Prize winner has stated, there must be accessibility to essential foods.

With the free market economy all manner of unnecessary expensive items come in, which create prestigious values tempting poor children to abandon old values of natural and healthy foods. 

Household food security has certainly declined. The purchasing power of families too has declined. 50% of families do not cover their food requirements. Although the poor spend upto 70% of their income on food, there is a trend to spend on high-cost processed commercial foods due to poor knowledge of what is good nutrition.

The country spends billions of rupees on importing all manner of milk foods. Adults do not need them. A good nutrition foundation in childhood prevents osteoporosis. Obesity is partly due to excess of sweets, starchy and fatty fast foods. A new concept in infant feeding is to prevent a taste for sugar and salt. Thus some of the chronic degenerative diseases are preventable.

The UN proposes a "blue revolution" to promote aquatic fish food sources as in Bangladesh and Thailand. Fish has to be fed to children in acceptable forms with culinary skills and imagination.

Chickens are given poultry food with antibiotics and growth hormone to prepare them for an early market. The rising food allergies and wheezing problems in childhood are due to its low cost and popularity among the lower middle classes. Eggs have to be well cooked so as to avoid salmonella infections.

With more and more fast food and street food points, an accent on food safety needs reiteration.

At rural level, people must have access to potable water, not only clean but a sufficiency of water for cleansing of people and utensils. Solar exposure of water to 60F or so can kill many bacteria and mosquito breeding with dangers of Dengue and Malaria can be prevented by constant use. Our vegetables are full of pesticides. CISIR work has shown that neither washing nor cooking will rid our favourite green leaves of pesticide contamination. We only await to hear what is the toxic level in these vegetables. Until then, small home gardens, even in pots or window boxes can help in one's daily consumption of leaves. Many governments have proposed home and school gardens. But who heeds such advice with sustained commitment? 

Inflationary prices of food hit the hearts of the poor while the rich pay any price for their requirements. Governments have shown a commitment to poverty alleviation but this has not been matched with action at grass root level because they are highly politicised. 

There may have been improvement in the poverty situation but there is a widening gap between the rich and the poor. Programmes seek to relieve the consequences of poverty. They have not produced freedom from necessity. There is a feeling of deprivation because of the background of consumerism. 

This is where real values must be inculcated into the minds of children. Along with a rising culture in science, general population approaches need to be prioritised.

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