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| Friday, 19 April 2002 |
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Health care severely affected due to the war - SLMA President The President of the Sri Lanka Medical Association Dr. Preethi Wijegoonawardena speaking on the health care services in the country in his presidential address said, "I hope that the peace efforts of the government would succeed in arriving at an acceptable solution to the war, because this civil unrest which has devastated our country in the last two decades has caused severe setbacks in the health care services and health standards of people in some parts of the country.
The function was held last month in Colombo, amidst a large gathering of medical professionals and foreign invitees. Here are some highlights from his speech. Look back with pride We look back with pride, that from the time of the great kings, we had a health care system of a high standard. Even at that time it was the duty and responsibility of the rulers and of the state, to care for the health of the people. Kings practised medicine The existence of a system of hospitals in Medirigiriya, Mihintale and Polonnaruwa has been proven. The physicians in ancient times were highly respected professionals, and the art of healing was sometimes embellished with royal lustre by kings who practised medicine. In this context, names of king Buddhadasa (362-409 AD) and king Aggabodhi (766-772 AD) standout. There have also been many Buddhist priests who have been physicians who earned great respect. Physicians worked day and night There is evidence that physicians worked day and night, and there were no time constraints for them to attend to the sick. It did not surprise me when I read that there were physicians who visited homes to treat the sick. Ravana wrote medical books The epic Ramayana describes that Ravana is said to have been well versed in medical lore. He represented Lanka at a medical conference and it was on his return journey from India that he met Seetha. He was also the author of medical books. The majority of medicinal plants used in India at that time are the same as those currently used in Sri Lanka. Surgery performed in ancient times Ruins of hospitals have been excavated at Mihintale and these have the same basic plan according to historians and archaeologists. This is a vast topic by itself. I will not attempt to dwell on it due to time constraints, but I must say that during that period there had been an advanced medical system, where even surgical procedures have been performed. Western medicine begins The Portuguese who had a meagre learning in medicine followed by the Dutch and then the British period saw a gradual introduction of the western system of medicine, and the establishment of hospitals from small beginnings to what they are today. Local system of medicine 'fantastic' Uragoda's (History of Medicine in Sri Lanka) provides extremely interesting details and valuable insight into this period of time. It is recorded therein that the Portuguese praised the local system of medicine and described it as bordering on the 'fantastic'. In recent times the health care system of our country has improved rapidly, especially the period before independence and after independence. Unfortunately the civil unrest that has devastated our country in the last two decades have caused severe setbacks in health standards in certain areas of the country. Another disturbing feature is that the public and the private sector still remains apart though there are attempts for one to complement the other. The annual health bulletin of 1999 records tremendous strides that have been achieved in the field of health in Sri Lanka. The vital statistics documented from the post-war period up to the late 90's clearly indicate the progress. Inequities in health services A major proportion of the health expenditure is utilised by the patient care services. In 1999, it was 63 per cent of the total health care expenditure. While community health services, utilised only 12 per cent. The remaining 25 per cent were for general administration and staff services. The achievement of an acceptable standard of health for individuals and populations is hampered by unequal access to medical care and preventive services, inefficient health care systems, rising costs - especially in tertiary care hospitals and the rapid growth of the physician workforce, its maldistribution and its inappropriate generalist/specialist mix. The future: High tech medicine in the new millennium We scientists should look at the challenges we face in the rapidly advancing world of medicine. Technology in the diagnostics is advancing by leaps and bounds. From Cat-scans to MRI to thallium scans etc. Robotic cardiac surgery is gaining popularity in Germany and will soon spread to this part of the world. Using computers to improve quality of care is becoming mandatory in many parts of the developed world. Cloning is a hot topic in the medical world and the debate goes on, on the ethics and principles of cloning. The first human embryo has been cloned. Now that all one hundred thousand genes that make up the human genome, have been deciphered, the next question for genomics is 'What do to with the genes'. Now it is the new science of proteomics, that is, which proteins the genes encode and to decipher how these proteins function to direct the behaviour of a cell or organ and what role they play in disease. Proteomics, it appears is destined to change the face of biomedicine in the future. There are plenty of arguments on the potential benefits and risks of Xeno-transplantation. DNA profiles are used in criminal cases. What are the worrying implications for justice and civil liberty, if our genetic identity becomes the property of the state? They are talking of artificial intelligence and the human brain. This is said to be a combination of computer science; the creation of machines that can think. The first human cloned baby is probably on its way. What is the meaning of: What is to be human? Which, until now involved at the very least the mysterious melding of two different person's DNA - the meaning will shift forever, along with our understanding of the relationships between parents and children, means and ends, and beginnings and ends. The debate goes on as to how much man should tamper with nature particularly regarding reproduction. Fierce debates about abortion and euthanasia will turn tame and transparent, compared with questions that are likely to arise from human cloning. Bio terrorism is another issue which is plaguing the entire world and we medical scientists have to be sensitised to be aware and alert at all times to all aspects of this new man made dilemma, in a world that seems to have gone crazy. Morbidity and mortality It is sad to note that in Sri Lanka morbidity data is collected only for those seeking treatment as in - patients in government hospitals. Morbidity data of patients attending the out-patients departments of government hospitals, Ayurvedic institutions and private sector which incidentally handle 50 per cent of the outdoor community morbidity are not compiled and collected. Recommendations and reflections Considering all these facts, I would like to draw the attention of all health planners in the country, teachers of the Faculties of Medicine, that there is a compelling need to recognise the role of the family physician and the need to regard the family physician/GP as an important, integral member of the primary care health team. It is indeed time to establish a system at least similar to that of the National Health Scheme of the United Kingdom, where the GP can be incorporated into the state health service and appointed to provide health care in all parts of the country to a defined population. By these means, patients will not be admitted to hospitals without a referral other than for accident and emergency. Out patient care would be provided by primary medical care doctors working outside the hospital. It would be mandatory for such doctors to obtain general/family practice training leading to the Diploma in Family Medicine, or follow the MCGP course and obtain this qualification. It will be imperative for them to have regular re-validation in principles of general practice and earn a minimum number of CME credit in order to continue their membership. If drastic changes are not feasible just yet, we should encourage young doctors, who will not be absorbed into government service to go into general practice, after having followed a vocational training in General Practice at least for a period of two years. The College of General Practitioners had expressed willingness a short time ago to the Minister of Health to conduct such a vocational training programme for young doctors. It was also recommended by the College that these trainees in family practice should be encouraged with financial assistance and other incentives to set up and establish themselves in general practice and placement of these GPs should be adequately and widely distributed throughout the country serving its people. Such doctors would appreciate assurances that their children would be able to find placement in good schools in the nearest city. With such incentives I'm sure that there will be many young doctors with post-graduate training in family medicine opting to set up in family practice throughout the length and breadth of the country. This would accelerate the elimination of that scourge of the health care system in this country - the 'quacks'. Ayurvedic and homeopathic practitioners will then be rehabilitated and compelled to adhere to their system of medicine. If there are sufficient numbers of post-graduate trained family physicians in a state system distributed throughout the country, there will not be a need for other government medical officers to engage in part-time primary medical care which does not address the principles and concepts of family medicine such as record keeping, continuity of care, availability and accessibility at all given times, personalised care, coordination, confidentiality, and empathy. Instead government medical officers should be paid adequate compensation. Referral system could be strongly recommended if, as suggested, there is a National Health Scheme MODEL and admission to hospitals done strictly by referral from general/family practitioners and other primary community physicians. Over-crowding in wards with patients on the floor, will be eliminated to a considerable extent. Even in the private sector, consultants and specialists should strictly adhere to a referral system, which should essentially be a 'to and fro' process. More of specialists' expertise and time will then be available for the genuine needs of patients, who require adequate time, skills and opinion of a specialist. It is heartening to note that more consultants in the private sector today do insist on a referral by a family physician/GP. Which is a healthy practice accepted worldwide. Referral back to the GP is also much appreciated. ============================= Dr. Dennis J. Aloysius picks for your reading from the British Medical Journal : Smoking produces diabetic and obese children Smoke in pregnancy and produced diabetic child BMJ of Jan 2002 reports this study where it had been found that women who smoke during pregnancy can produce diabetic and obese children. BMJ report states, that a Swedish research team headed by Scott Montgomery an Epidemiologist in Stockholm, Sweeden found this out in his study using British data of about 17,000 births taken from March 3rd to 9th 1958. At birth the research team (midwives) had recorded information on smoking during pregnancy (after the 4th month) details of maternal smoking were again recorded in 1974. When the children were 16 years old the groups smoking behaviour had been again recorded. The research team had arrived at their conclusion that smoking in pregnancy can produce diabetic and obese children, after interviewing the group again at 33 years. True Risk, The Researches say Medical examinations and record reviews were conducted at ages 7 and 16 years, and a personal interview at age 33 years asked about diabetes. Among those followed fully throughout childhood and adolescence to age 33, the authors identified 15 men and 13 women who had developed diabetes between 16 and 33 years, and 602 individuals (10%) who were obese at age 33. The association of diabetes with maternal smoking specifically during pregnancy suggests that it is a true risk factor for early adult onset diabetes, say the authors. Cigarette smoking as a young adult was also independently associated with an increased risk of subsequent diabetes. Study members without diabetes, but whose mothers smoked during pregnancy, were significantly more likely to be obese or overweight by age 33 years. They suggest that in utero exposure to smoking results in lifelong metabolic dysregulation, possibly due to fetal malnutrition or toxicity, and stress that smoking during pregnancy should always be strongly discouraged. ============================= Fruits and vegetables - cancer preventives The World Health Organisation in its staff news letter of March 12, 2002, has published details of cancer preventing nutrients found in some of the common fruits and vegetables like - sweet potatoes, garlic, broccoli, papaya, grapefruit and avocado that we consume.
Vegetarian diet and cancer Scientific studies increasingly suggest that a vegetarian diet help to prevent cancer. A most recent WHO Staff News Letter, dated March 12, 2002, brings more information about specific vegetables and fruits, and their anti-cancer properties, as well as tips on cooking them right. You may wish to share this information with the Health Watch readers. Sweet potato: How it combat cancer: This nutrient-dense food contains many anticancer properties. It is loaded with betacarotene, which may protect DNA in the cell nucleus from cancer-causing chemicals outside the nuclear membrane. Diet tips: Go for freshness when picking sweet potatoes - canned varieties contain less betacarotene and vitamins C and B. Naturally sweet potatoes can be enhanced with a little apple juice; or whip the cooked tubers with orange juice and season with cinnamon, nutmeg, and ginger. Garlic: How it combats cancer: Garlic's immune-enhancing allium compounds block carcinogens from entering cells and slow tumour development. Studies have linked garlic - as well as onions, and leeks - to lower risk of stomach and colon cancer. Diet tips: Add raw garlic to salads, use it fresh in marinades and sauces; rub freshly cut garlic around the insides of salad bowls and over chicken and fish fillets. Avoid dried or powdered garlic, which is less concentrated, and less effective. Broccoli: How it combats cancer: Research has revealed that a chemical component called indole-3-carbinol can combat breast cancer by converting a cancer-promoting estrogen into a more protective substance. Diet tips: Broccoli leaves actually contain more beatacarotene (i.e. pre-vitamin A) than the florets - use leaves in purees, soups, stir-fries. To preserve brocolli's valuable nutrients, steam or microwave, being careful not to overcook. Avoid garnishing broccoli with fatty cheese and creams instead, squeeze on some lemon juice or sprinkle with toasted breadcrumbs. Papaya: How it combats cancer: Its plentiful store of vitamin C works as an antioxidant and may also reduce absorption of cancer-causing nitrosamines from the soil or processed foods. Papaya contains folacin, also known as folic acid, which has been shown to minimise cervical cancers. Diet tips: Choose papayas that are at least half-yellow in the store - fully green ones were probably picked too soon and won't ripen properly. You can serve papaya in fruit salad, add it to a garlic-and-spinach pasta mixture, or just eat it on its own, letting the juice dribble down your arm. Grapefruit: How it combats cancer: Grapefruits, like oranges and other citrus fruits, contain monoterpenes, believed to help prevent cancer by sweeping carcinogens out of the body. Some studies show that grapefruit can inhibit the proliferations of breast-cancer cells in vitro. It also contains vitamin C, betacarotene, and folic acid. Diet tips: Grapefruit could be sweetened with brown sugar or a drizzle of maple syrup or honey; vanilla extract, fresh mint, and almonds also accent the fruit's flavour. Grapefruit juice will give you the antioxidants and phytochemicals that fight cancer, but it's missing in fibre that fresh, whole grapefruit offers. Avocado: How it combats cancer: Avocados are rich in glutathione, a powerful antioxidant that attacks free radicals in the body by blocking intestinal absorption of certain fats. Ounce for ounce, avocados also supply 60 per cent more potassium than bananas and are a strong source of betacarotene. Diet tips: Store avocados at room temperature until they soften. If you don't eat the fruit immediately after cutting, sprinkle on some lemon or lime juice to keep it from darkening. Add chunks or slices to salads and sandwiches or spread mashed avocado on bread. Avocado mashed could also be taken sweetened with honey. ============================= Health Watch Question Box Designer Eggs Following our lead article last week on - Designer Eggs by Prof. Narahari we had a number of calls from our readers inquiring about these eggs, and posing some questions to Prof. Narahari. We would request those readers to write to Prof. Narahari through Dr. Mrs. A. L. Godwin (Veterinary Consultant), 31, Kirimandala Mawatha, Nawala, Rajagiriya. E-mail wpsa@wow.lk Fax 869535 She will send them to Prof. Narahari, and you will be replied through this page. Sore nipples here's our reply A few mothers who are breast feeding their babies, wrote to us for advice on how to avoid sore nipples. Dr. Ranesh Wijesinghe has sent the following extract on breast feeding from an article which had been published in the American Academy of Family Physicians News Letter of March 1998, which answers the problem - Health Watch A few points for breast-feeding mothers To prevent or heal sore nipples * Make sure your baby is sucking the right way, if the sucking hurts, your baby's mouth may not be positioned correctly. * Let your nipples air dry between feedings. Let the milk dry on your nipples. * Use a hair dryer on a low setting to warm and dry your nipples between feedings. * Offer your baby the less sore of your two nipples first; your baby's sucking may be less vigorous after the first few minutes. * Change nursing positions. * If possible, position any cracked or tender part of your breast at the corner of your baby's mouth, so that it gets less pressure during feeding. * Wash your nipples daily with warm water. * Avoid bra pads lined with plastic. * Express milk until your let-down reflex occurs. This will help make your milk more available so your baby sucks less hard. * Breast-feed often to prevent engorgement (overfulness of breast). Engorgement makes it hard for the baby to latch on. (Courtesy American Academy of Family Physicians News Letter March 1998) ============================= Next issues of Health Watch will be devoted to
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A former senior WHO advisor Dr. Terrance Fernando in an article to us on this
subject says: 
