31st October 1999
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Two wrongs never make a right
Last week saw some sabre-rattling by the Government Medical Officers Association (GMOA) largely over the provision of medical services in the northern and eastern provinces.
The doctors' trade union claims that proper facilities- or even security measures- are not provided for medical officers working in these areas and compounding the issue is the abduction of four doctors probably by the LTTE.
The government is bound to retort that no special privileges can be accorded to doctors and that they cannot be treated as elitists among other professionals. Therefore, if no such facilities are provided for other public servants serving in the north and east, then so be it for the doctors, the Ministry of Health may well argue.
But on the other hand, it is a fact that doctors working in these regions do so under appalling conditions. Perhaps they do so, not because they like it but because they have no choice.
Even so, it remains the duty of the State to provide reasonable facilities- transport, accommodation and security- for them to engage in their duties unhindered by the civil war raging in those regions.
That such facilities are not accorded to other categories of public servants is no justifiable excuse. Two wrongs never make a right. It appears that other sectors are indeed not provided these services but they have over a period of time learnt to grin and bear it because they do not have trade unions as strong as the GMOA to fight their case.
We hear periodical statements from those in the seats of power- the President, the Deputy Minister of Defence and the Minister of Health- proclaiming that all will be done to restore normalcy to the north and east, and that must surely include normalising the health services of that region.
But are the authorities sincere in those proclamations? Probably not.
The other issue which one has to of course consider is whether the inaction of the government warrants a strike that would inconvenience millions of patients in other parts of the country. That must be a moral and ethical dilemma for the doctors who insist that their demands have been granted only when they struck work.
Here they do have a point in that in the last strike by the GMOA, the President intervened and solved the dispute after some seventeen days- when it could have been done initially, preventing hardship to so many.
Of course, it is a claim of the GMOA that even the decisions arrived then- over the question of who administers the provincial hospitals- have not been implemented until now.
These are times when elections and not health issues- dominate the headlines. We hope that the GMOA is not being opportunistic in asking for their demands now.
If the GMOA says it is not being opportunistic we may believe them- after all four doctors have been abducted and their whereabouts are still unknown. But we hope the government will not wait until after elections to resolve these outstanding issues.
The government can certainly afford to wait and it may believe it could "teach the doctors a lesson" after the polls.
That may or may not be the case but those long-suffering patients cannot wait that long because for them it is verily a matter of life and death.
We don't have children
Infertility among married couples is a major medical problem the world over. For those yearning for children but not having a pregnancy, even the decision to seek medical advice can be difficult because they are anxious about facing a battery of tests.
Here's what happens when a couple says they are childless for a long period of time: Ironically the first test should be done on the male- and not the female. A 'Semen Analysis' is done where a sample of his seminal fluid is examined microscopically to determine the number of sperms, their movement and structure. Only if this test is found to be normal should the female be investigated.
The woman is first subjected to tests to see whether 'ovulation'- production of an egg- has occurred. They include measuring the body temperature, doing a biopsy of the lining of the womb or taking hormone samples.
Next, a more elaborate test should be done to see whether the 'cervical mucous'- secretions in the vagina- are favourable for a pregnancy. This is called the post-coital test (PCT) and the female has to be examined and a sample of the mucous obtained shortly after sexual activity. If all these tests are favourable then more invasive procedures will be needed to assess whether the Fallopian Tubes- the passages that transmit the female egg or ovum to the womb- are patent. This can be done through a special X-ray called a hysterosalpingogram (HSG).
A better but slightly more invasive way of assessing the patency of the Fallopian Tubes is to do a 'laparoscopy'- a procedure where a tube is inserted into the woman's abdomen through a small incision. This is not major surgery though it may require some anaesthesia and does not require an overnight stay in hospital. All these tests are available in Sri Lanka and can be arranged by a visit to a clinic at any General Hospital. They are relatively inexpensive and in a vast majority of cases will reveal the cause for childlessness. Then it will be easier for your gynaecologist to recommend drugs or any other measures to achieve a pregnancy.
Smoking: It can be cured!
Smoking tobacco has been an accepted practice for centuries though commercial production of cigarettes began only recently.
Even more recently, health researchers have become aware that nicotine, the active chemical substance in a cigarette is a stimulant of the central nervous system and that it is also very addictive.
Now, after years of research, the ill-effects of smoking are well documented.
It is related to lung cancer, other lung disease, high blood pressure, stroke and many other serious medical problems.
But the irony is that most adults who smoke are aware that it is unhealthy and would rather not do it. But they continue to smoke because nicotine is addictive.
Inhaling a puff of cigarette smoke delivers a dose of nicotine to the brain faster than it could be delivered by injection to the bloodstream.
When regular smokers abstain, they experience "withdrawal symptoms"- irritability, increased appetite, sleep disturbances- and a powerful desire to smoke! Because smoking is socially acceptable (thanks to the vigorous advertising campaigns by cigarette manufacturers which portray the habit as glamorous) most people are comfortable admitting that they smoke.
This has created a ready market for numerous products and people offering ways to quit.
But the success of all of these methods depends finally on the motivation of the smoker and nothing else.
An accepted form of treatment is called 'aversive conditioning' where the technique of rapid smoking is used.
The smoker sits in a closed room and puffs quickly on a cigarette as frequently as once every six seconds until he feels ill and is unable to take another puff.
This feeling of illness becomes associated with smoking and an aversion to cigarettes develops.
But, be warned, this is not a 'do it yourself' method and without medical supervision can be dangerous!
The other popular method is the use of a nicotine gum which contains a high level of nicotine which is released as the smoker chews.
Research suggests that this approach does improve a smoker's chances of long term abstinence but a draw- back is that the brain is yet being conditioned to nicotine.
However the physical illnesses related to smoking will of course be eliminated.
However, what most smokers require is a drug that would eliminate that powerful craving for a cigarette.
There is some hope on this aspect too: Clonidine, a drug used to treat high blood pressure is being researched for a possible role in treating cigarette addiction.
There is no magic pill as yet to quit smoking overnight but smokers should realise that five years after a smoker quits, he is virtually at no more risk than a non-smoker for all the vulnerable illnesses- provided there is no permanent harm to the body already.
Measles-it is not that serious
Cholera is over but there is a Measles epidemic sweeping urban areas presently. As it too affects mostly children, parents are often anxious when they discover their child has the illness. Here are some facts that would be helpful.
Is Measles a deadly disease like Cholera? Unlike Cholera, it is a relatively harmless disease and will resolve even without medical intervention except in a very small percentage of cases which can develop complications.
What causes Measles? Measles is caused by a virus. It is probably the most infectious of the common childhood fevers.
What are the early symptoms? The earliest symptoms are fever with a cough and cold and probably a sore throat. This is followed by a typical Measles rash which appears about two weeks after infection.
Other signs such as redness of the eyes and characteristic 'spots' inside the mouth may also be seen and they will be easily recognised by a family doctor.
When is the disease infectious? Measles unfortunately is most infectious in the two to three days before the appearance of the typical rash.
Therefore, by the time the rash is seen a patient could infect many others as the infection is carried by minute 'droplets'.
Is Measles never a serious illness? No, complications can occur but are very rare.
They include pneumonia, encephalitis and meningitis when the infection enters the lungs, brain or brain coverings respectively.
If a measles patient continues to be ill he should certainly seek medical advice.
Is there a vaccine against Measles? There is a vaccine against Measles and it is given to children now combined with vaccines for other illnesses.
The local MOH office will offer details regarding vaccination against measles.
The bone of contention is calcium
Females Age Old Revised
Children 1 to 10 800 mg/day 1000 mg/day
Adolescents 11 to 18 1200 mg/day 1600 mg/day
Adults 18 to 50 800 mg/day 1100 mg/day
Post menopausal 1500 mg/day 1500 mg/day
By Dr. Sisira Siribaddana, MBBS, MD Endocrinologist & Physician
Bones are the basic support system protecting our vital organs and act as a reservoir for calcium - the most abundant mineral in the body. In fact 99 percent of the calcium in the body is found in our bones and teeth.
Beginning in the 40s or later, reabsorption of existing bone starts to exceed formation of new bone, resulting in loss. Age-related bone loss is influenced by both genetic and environmental factors.
The higher calcium requirement for post menopausal women is due to a combination of less efficient calcium absorption from the gut and poor calcium reabsorption from the kidneys.
Treatment of post-menopausal women with oestrogen results in better absorption and retention and lowers the daily requirement to 1200 mg/day.
The average intake of calcium by women between the ages of 40 & 65 varies from 450 to 650 mg/day. Thus the average calcium intake for these women should generally be increased by 100%.
The recommended daily allowances (US-RDA) of calcium aregiven in the table.
Certain factors are linked to the development of osteoporosis or contribute to an individual's likelihood of developing the disease.
Many people with osteoporosis have several risk factors, but others who develop osteoporosis have no identical risk factors.
Following are the risk factors that you cannot change;
GENDER: Your chances of developing osteoporosis are greater if you are a woman.
Women have less bone tissue and lose bone more rapidly than men, because of the changes involved with menopause.
AGE: The older you are, the greater your risk of osteoporosis. Bones become less dense and weaker as you age.
BODY SIZE: Small, thin-boned women are at greater risk.
FAMILY HISTORY: Susceptibility to fracture may be, in part, hereditary. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk of fractures.
Following are the risk factors that you CAN change;
SEX HORMONES: Abnormal absence of menstrual periods (amenorrhoea), low oestrogen level (menopause), and low testosterone in men.
DIET: A lifetime diet low in calcium and vitamin D.
DRUGS: Certain medications used in wheezing and convulsions.
LIFESTYLE: An inactive lifestyle and/or extended bed rest.
HABITS: Smoking and alcohol consumption, both aggravate and precipitate osteoporosis.
The foods we eat contain a variety of vitamins, minerals and other important nutrients that help keep our body healthy. All of these nutrients are needed in a balanced proportion.
In particular, calcium and vitamin D are needed for strong bones as well as for your heart, muscles and nerves to function properly.
Exercise is an important component of an osteoporosis prevention and treatment programme.
Exercise not only improves your bone health, but it increases muscle co-ordination and balance and leads to better overall health. While exercise is good for someone with osteoporosis, it should not put any sudden or excessive strain on bones.
As extra insurance against fractures, there are specific exercises to strengthen and support your back.
Currently, oestrogen and some other drugs are used for the treatment of post menopausal osteoporosis.
While foods containing calcium can be found in each of the major food groups, those from milk are the primary source of calcium. A few other foods also provide a concentrated source of calcium. Calcium from some vegetables is absorbed as well as or better than calcium from milk and milk products, but these foods have a significantly lower amount of calcium per serving.
In addition to that, some plant sources of calcium may contain substances, such as phytate, oxalate and fibre, which reduce the bio-availability of calcium.
Going 'out of mind'
The word dementia from Latin means 'out of mind', but so does 'paranoia,' this time from Greek. This is an illustration of how terms, definitions and the very concepts have changed over the years and over the centuries with increasing knowledge and understanding. 'The German psychiatrist, Emil Kraeplin (credited with the 'recognition of schizophrenia' as a distinct entity at the turn of the century), named the condition Dementia Praecox, indicating a progressive degeneration. However it is now possible to arrest this course.
Who develops dementia? To many, dementia conjures up a disease brought on by old age. Indeed, they see it as an inevitable consequence of ageing. It may surprise them to know that based on pathology and the sequence and variety of symptom appearance, it is now recognised that the dementing process may quite often precede the ageing process.
The most talked of the dementias today, Alzheimer's disease can set in as early as the 40s. Of course, the condition rapidly becomes more frequent with the passing of the years, so that the prevalence of about 5% in over 65's, rises to 20% in those over 80 years (these figures are for industrialised countries).
Another misconception is that dementia is almost by definition progressive and irreversible. May not be so. Metabolic abnormalities such as kidney and liver failure, deficiency of vitamins, especially of the B group, circulatory conditions, lack of oxygen, cerebral tumours, endocrine disorders, hydrocephalus with normal cerebrospinal fluid pressure are all treatable and possibly reversible.
The moral of the story is that one cannot write off a person on the grounds that he is dementing.
Some years ago, the common belief was that dementia was a condition of increasing memory deficit. Today the concept has been widened to include other aspects of mental functioning. Although memory loss both short and long-term would be the essential criterion for its diagnosis, the outstanding feature of dementia is distorted cognitive functioning. Lipowski (1980) defines cognition as a process involving symbolic mental operations as perceiving, remembering, creative imagery and thinking. Disturbances of congnition result in difficulty dealing with new ideas, thought impoverishment, handling abstract ideas, impaired judgement and insight, and rigidity of thinking which results in holding on obstinately to incorrect ideas. As the dementing process progresses, thinking is more and more restricted until complete disorganisation results.
Although memory and cognition suffer most, emotional changes, e.g., depression, are also seen and may indeed precede intellectual impairment. Prominent too can be a paranoid suspiciousness indicating delusional activity. Other common features are loss of interest and initiative, inappropriate behaviours and episodes of confusion and delirium. Perceptive disturbances in the form of hallucinations (visual, auditory or somatic) may occur for periods.
This picture is painful to consider, particularly when one considers this could be the final episode in a life, hitherto of ability, activity and achievement. Yet, 80% of demented people reside with their families or in close proximity.
It is clear that treatment conducted in familiar surroundings and among loved ones is both helpful and merciful. The management of a person who has dementia should be a team effort with an occupational therapist, social woker, psychologist and doctor. There are also new drugs being introduced which can slow down the dfdfproprocess. process.
Courtesy of the National Council for Mental Health "Sahanaya"
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