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Who on a shocking disclosure

The World Health Organisation - WHO last week described the findings of its study team that the ever widening gap between the haves and have-nots in the world where on one side of the scale underweight due to poverty is denying millions of people their right for good health. On the other side overweight and over-eating is causing health risk to a section of the population.

"This is shocking and needs to be corrected" says the WHO in its - World Health Report for the year 2002 released last week.

At the official ceremony held in Colombo to hand over the report to Health Nutrition and Welfare Minister P. Dayaratne. The WHO representative in Sri Lanka Dr. Kan Tun said:

The findings of the report give an intriguing - and alarming - insight into not just the current causes of disease and death and the factors underlying them, but also into human behaviour and how it may be changing around the world. Most of all they emphasise the global gap between the haves and the have-nots by showing just how much of the world's burden is the result of undernutrition among the poor and of overnutrition among those who are better-off, wherever they live.

The contrast is shocking

At the same time that there are 170 million children in poor countries who are underweight - and over three million of them die each year as a result - there are more than one billion adults worldwide who are overweight and at least 300 million who are clinically obese. Among these, about half a million people in North America and Western Europe die from obesity related diseases every year.

So it is clear that at one end of the risk factor scale lies poverty, where underweight remains the leading cause of disease burden among hundreds of millions of the world's poorest people and a major cause of death, especially among young children. The report shows that underweight remains a massive and pervasive problem in developing countries, where poverty is a strong underlying determinant.

Risk transition

Indeed, there is evidence that these risk factors are part of a "risk transition" showing marked changes in patterns of living in many parts of the world. In many developing countries, rapid increases in body weight are being recorded, particularly among children adolescents and young adults. Obesity rates have risen threefold or even more in some parts of North America, Eastern Europe, the Middle East, the Pacific Islands, Australasia and China since 1980. Changes in food processing and production and in agricultural and trade policies have affected the daily diet of hundreds of millions of people.

Three million deaths annually

The report says that while eating fruit and vegetables can help prevent cardiovascular diseases and some cancers, as part of diet is responsible for almost three million deaths a year from those diseases. At the same time, changes in living and working patterns have led to less physical activity and less physical labour. The report finds that physical inactivity causes about 15% of some cancers, diabetes and heart disease.

Meanwhile, tobacco and alcohol are being marketed increasingly in low and middle income countries. Today more people than ever before are exposed to such products and patterns, imported or adopted from other countries, which rose serious long term risks to their health. For example, smokers of all ages have death rates two or three times higher than non-smokers.

Patterns of Living

Most of the risk factors discussed in this report are strongly related to patterns of living, and particularly to consumption - where it can be a case of either too much or too little. At the other end of the scale from poverty lies "overnutrition" or, perhaps more accurately, "overconsumption".

Overweight and obesity are important determinations of health and lead to adverse metabolic changes, including increases in blood pressure, unfavourable, cholesterol levels and increase resistance to insulin.

They raise the risks of coronary heart disease, stroke, diabetes mellitus and many forms of cancer. The report shows that obesity is killing about 2,20,000 men and women a year in the United States of America and Canada alone, and about 320,000 men and women in 20 countries of Western Europe.

The report warns that if global health is to be further improved and burdens of disease lowered, countries need to adopt control policies now. It says that risks such as unsafe sex and tobacco consumption could increase global deaths substantially in the next few decades and could decrease life expectancy in some countries by as much as 20 years unless they are brought under better control very soon.

In a number of ways, then, this report shows that the world is living dangerously either because it has little choice, which if often the case among the poor, or because it is making the wrong choices in terms of consumption and its activities.

Recommended actions

To many of the main risk factors there is likely to be good agreement between the general public and public health experts on what needs to be done. In some countries, risk understanding may need to be strengthened among the general public, politicians and public health practitioners.

Recommended actions that governments can take in risk reduction have been tailored to suit high, middle and low income countries. More generally, the report makes the following recommendations:

Governments especially health ministries, should play a stronger role in formulating risk prevention policies, including more support for scientific research, improved surveillance systems and better access to global information.

Countries should give top priority to developing effective, committed policies for the prevention of globally increasing high risks to health, such as tobacco consumption, unsafe sex in connection with HIV/AIDS, and, in some populations, unhealthy diet and obesity.

Cost-effectiveness analyses should be used to identify high, medium and low priority interventions to prevent or reduce risks, with highest priority given to those interventions that are cost-effective and affordable.

Intersectoral and international collaboration to reduce extraneous risk to health, such as unsafe water and sanitation or a lack of education, is likely to have large health benefits and should be increased, especially in poorer countries.

Similarly, international and intersectoral collaboration should be strengthened to improve risk management and increase public awareness and understanding of risks to health. A balance between government, community and individual action is necessary.

For example, community action should be supported by non-governmental organisations, local groups, the media and others. At the same time, individuals should be empowered and encouraged to make positive, life-enhancing health decisions for themselves on matters such as tobacco use, excessive alcohol consumption, unhealthy diet and unsafe sex.

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Doctor Ducking

All over the world the medical profession has found it difficult to get the young people on to regular medical checkups under preventive medical programmes.

This doctor ducking aspect on the part of the youth has been discussed by the American Family Physicians and an interesting article on the subject has been published in the AFP Report of September 2002 has been sent to us by Dr. Ranesh Wijesinghe of the Colombo South Teaching Hospital for publication.

Where have all the young men gone? Chances are they're not in your exam rooms. The boys that routinely reported for back-to-school checkups and high-school sports physicals probably haven't set foot in your office since Mom last scheduled an appointment.

Their disappearing act is a national phenomenon. Figures published in AAFP's 2000 Facts about Family Practice show a definite dearth of male patients from 18 to 24 years of age (see table).

Is this a worrisome trend - a precursor to a lifetime of doctor ducking? It's no secret that men are at least 25 per cent less likely than women to visit a doctor and are significantly less likely to have regular physician checkups and obtain preventive screening tests for serious diseases.

Or does the dip in numbers merely reflect the reality that this generally healthy population requires little more than acute care treatment with a dash of healthy lifestyle counselling on the side?

FP Report asked members of two AAFP e-mail discussion groups to weigh in on this topic - and they were all over the board in their responses. A sampling of their comments follows.

. "Considering the little we do for men this age, outside of acute care, it's no wonder that they learn that illness is the only time to see a physician. Unfortunately, most of the risky behaviours we counsel against are considered by our society to be part of the wild oats men longingly recall when they are older. Until we have something they view as useful to offer them, men in this age group will continue to be the other person in the room' when we are taking care of their family members". Shawn Griffin, M.D. of St. Joseph, Mo.

. "Men understand the importance of maintenance on their cars - I tell them to think of their bodies in the same way. They need regular maintenance exams to make sure they haven't developed diabetes or high blood pressure and to look for signs of testicular cancer". Colette Willins, M.D., of Westlake, Ohio.

"I think trying to get young males in for preventive care is a waste of time. They are generally a healthy lot, and screening for chronic health problems in this group is very low yield. Young women go in for their Paps annually, in part to gain access to birth control. Young men have no corollary. When young men seek care for acute problems a few short questions could screen for some problems. For example it doesn't take much time to ask if he smokes. If he does just give a short message asking him to quit, and add an offer to help when he is ready". Rob Renekec Md of Grandville, Mich.

. In the military all their duty folks must have a physical examination at least once every five years which may be enough for this population under discussion", David Hutcheson-Tipton, M.D., Marysville, Wash. "I disagree with the idea that these men should seek health care on a per needed basis only. My experience has clearly demonstrated the need for diabetes hypertension and cholesterol screening on a substantial portion of the Hispanic men in my community whose obesity and family histories often increase their risks of disease". Sandra Guerra Cantu, MD, of San Antonio

"I think a campaign of information about the importance of preventive medical exams is paramount and should be encouraged through employers and on college campuses. Hereditary diseases such as diabetes and coronary artery disease must be discussed with this age group if we want to start counselling that could delay the onset of the very diseases that their parents and grandparents may already have".

. "A lot of my young men come to the office for their periodic wellness exams because their wives and girlfriends encourage them to do so. Women are still the consumers of health care, so let's encourage our female patients to get their sons, boyfriends and husbands in for their wellness exams". Darlene Lawrence, M.D., of Washington.

. "A better strategy is to target those men with risk factors including obesity, homosexual or promiscuous sexual practices, drug abuse, drinking and driving, tobacco use, and a sedentary lifestyle". Evelyn Fang. M.D., of Fresno, Gulf.

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Asthma in the 21st century

Asthma is a condition which has been known to, and treated by, Physicians for more than 2,000 years.

Asthma is the Greek word for panting, an appropriate description for a condition whose predominant symptoms are wheezing and breathlessness.

The seriousness with which the disease has been regarded has waxed and waned over the centuries. In the 17th century, Thomas Willis remarked on the seriousness of the condition and the difficulties of its treatment.

Osler, more than a century ago, recognized one of the most important aspects of the asthmatic process, inflammation of the air passages. In the late 19th century, an American Physician, Oliver Wendell Holmes described asthma as a 'slight' ailment which promotes longevity.

Oliver Wendell Holmes could not have been more mistaken. Approximately 150 million people worldwide suffer from the disease, which makes asthma the commonest chronic non-infectious disease in the world. Nearly 180,000 people die from the disease each year.

The majority of them in the productive age group. In the United States of America, death rates from asthma have doubled since the early 1980s to 5,000 a year, in spite of the availability of the best medical facilities in the world. Most significantly, the incidence of asthma in many countries has doubled every decade. In the US, the number of new asthma patients has risen by over 60% since the 1980s, and in Western Europe, by 50% during the past decade.

In Sri Lanka in 1990, 80,000 cases of Asthma were treated in government hospitals, with nearly 300 deaths. In 1999 163,000 cases of asthma were recorded with nearly 970 deaths. In general, approximately 1 in 10 children and 1 in 7 adults suffer from asthma. Sri Lanka is estimated to have nearly 1 million asthmatics and the prevalence of asthma among children in Sri Lanka is estimated to be between 2% to 8%.

Clearly, the incidence, morbidity and mortality of asthma is increasing the world over. But, why? This ominous trend is especially worrying because it comes at a time when morbidity and mortality from many diseases, especially infectious diseases (with the exception of Tuberculosis) is decreasing and comes at a time when we think we have a fairly sound understanding of the pathophysiology of asthma and its treatment. What is going wrong? Is asthma really becoming more prevalent or are we simply better at diagnosing it? Is the nature of the disease changing i.e. Is it becoming more virulent?

Do modern lifestyles have a part to play? Is it atmospheric pollution, design of houses, junk food, air-conditioning or loss of the ozone layer? Could widespread immunization with live viral vaccines have a part to play? Most important of all, are we managing asthma properly?

Asthma is a chronic inflammatory disease of the air passages (tubes) in the lung. To understand inflammation, a minor burn on the skin is a good analogy. The cardinal signs of inflammation are calor (Heat), Dolor (Pain), Rubor (Redness), Swelling and loss of function. All these processes of inflammation happen inside the asthmatic airway.

Until about 30 years ago, the treatment of asthma mainly consisted of treatment of its symptoms i.e. the wheeze, cough and breathlessness. This was easy, since many drugs like ephedrine, theophylline and salbutamol which are all symptoms relieving drugs, were good at making the narrowed air tubes, bigger - but there was something fundamentally wrong in this approach. The narrowed, spastic air tubes, the wheeze, the cough and the breathlessness are all symptoms of the underlying, untreated inflammation.

If only the symptoms were treated, the underlying inflammation was bound to become worse resulting in worsening of the symptoms, needing bigger and bigger doses of symptom relieving drugs. In other words, the patient would keep increasing the dose and frequency of the symptom relieving drugs until he reaches a point where maximum doses of the drugs are unable to control the symptoms, resulting in the uncontrolled inflammation erupting with such ferocity that the severity of the attack could well kill the patient.

Thus the myth about patients dying with inhalers in their hands, the deaths being attributed to overdose from the inhaler medication. It was not the inhaler that killed the patient, but the uncontrolled disease whose symptoms the medication was no longer able to control. It has been convincingly shown that regular use of symptom relieving drugs like salbutamol does indeed result in the disease becoming more uncontrollable.

The modern day management of asthma is quite different. It stresses the importance of avoidance of trigger factors (e.g.: Animal dander, moulds, tobacco smoke, stress, cold air, certain drugs and food additives, to name a few) and the importance of controlling the underlying inflammation of the airways with anti-inflammatory medication.

In fact, the first line management of any form of mild, moderate or severe persistent asthma is the regular use of anti-inflammatory medication, with symptom relieving drugs like salbutamol being used only on an as required basis, but never on a regular basis. This is only logical, as this form of treatment attacks the root cause of the symptoms, namely inflammation. It is now recognized that asthma is a chronic disorder with progressively developing chronic airway inflammation leading to recurrent episodes of cough, wheezing, breathlessness and chest tightness.

Numerous clinical studies have shown that any type of asthma more severe than mild, intermittent asthma is more effectively controlled by intervening to suppress and reverse inflammation with anti inflammatory drugs (Preventers) rather than by trying to treat only the symptoms with bronchodilators (Relievers), which would only result in the disease becoming more and more unmanageable with the passage of time.

Recently, another class of drugs, inhaled long acting bronchodilators (LABD, Controllers) have made a remarkable difference in the management of persistent asthma, providing much smoother control of symptoms and very effective abolition of night time symptoms, without the need for increasing the dose of the anti-inflammatory medication.

Thus the therapeutic management of persistent asthma involves the use of 3 main classes of drugs. Anti-inflammatory drugs, (Preventers), symptom relieving drugs (Relievers), and long acting bronchodilators (Controllers).

The most effective and most frequently used anti-inflammatory drugs are corticosteroids (I.C.S.), such as beclomethasone, budesonide and fluticasone. Though these drugs are steroids, the dosages used are tiny, in the range of 400 to 2000 micrograms. In comparison, a single steroid tablet such as prednisolone contains 5,000 micrograms. Furthermore, inhaled corticosxteriods are all inhaled into the air passages, which is where they are needed, and very little of the drug enters the blood, so that systematic side effects adverse effects of the drug on other organs are minimized.

Relievers are drugs that relieve symptoms, such as wheeze and breathlessness, by making the narrowed air passages bigger, and drugs such as salbutamol and terbutaline are the most frequently used. Again, if the drugs are inhaled, the doses used will be very small, in the range of 100-200 micrograms. Relievers are available as tablets, much cheaper, but contain nearly 10 times the dosage of 2 puffs from an inhaler, leading to a markedly increased incidence of side effects, such as tremor, palpitations and headache.

Controllers are inhaled long acting bronchodilators such as salmeterol and formoterol. Though expensive these drugs have revutionized the management of Asthma.

(This article has been written by Consultant Chest Physician Dr. P. N. B. Wijekoon).

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Dandelion - The Amazing Weed

Dandelions - reviled as public enemy No. 1, by Golf course Superintendents and fastidious lawn owners everywhere, and as the weed that won't go away, yet is one of the worlds most healthful plants, and can contribute much to your health and diet. Rich in Vitamin A and potassium, the dandelion is rich and more nutritious than broccoli or spinach.

Historically dandelion has been as a liver tonic and cleanser and blood purifier in Chinese Medicine, states 'The News' of Mexico City.

The sudden wealth syndrome

The number of millionaires in the US and Canada has risen almost 40 per cent since 1997 says Canada's National Post. The paper also noted that the high-tech world is making many young people very rich.

According to Psychologist Dr. Stephen Goldbart though some cannot handle their sudden wealth. "It can ruin their lives, rip their families apart and lead them on a path of risk behaviour. Money always does not bring peace and fulfilment", Goldbart said.

According to some psychologists, the high-tech world has created "a new illness - sudden wealth syndrome" which manifests itself in severe depression, panic attacks and insomnia.

(Courtesy 'Awake' March 22 - 2001. Sent to the Health Watch by Priya David of Nawala)

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Pharmacy education in Sri Lanka

by R. Ehamparan, Associate of the Chelse College of Pharmacy University of London

Knowledge in any subject leads to refinement and perfection in human services, pharmacy is no exception. Depriving the pharmacist and patient the Global pharmaceutical knowledge is a health hazard and an economic disaster in the long term. In world standards pharmacy or pharmaceutical science is an independent professional discipline. The advancement in Drug science in the recent past necessitated the expansion to pharmaceutical knowledge, the Pharmacist could do a satisfactory service beneficial to the patient and to the physician in treatment of patients.

The WHO expects all countries to have a good standard of pharmaceutical knowledge to cater the needs of patients, pharmaceutical industry, pharmaceutical quality assurance, enteraement of pharmaceutical regulations and ethics etc. To achieve this objective, the WHO sent several pharmaceutical experts to Sri Lanka to organise the Pharmacy education, some of the experts visited us are:

1. Dr. Chilton 1972
2. Dr. Bishar 1974
3. Dr. Whithel 1975
4. Prof. D'Arcy 1978

All of them after studying the situation submitted their findings in reports and urged the Department of Health Services and universities the urgent need of improvement to pharmacy education.

In 1971 Prof. Senaka Bibile and Dr. S. A. Wickremasingha report stressed the need to improve the training of pharmacists and to hand it over to the universities. Again in 1973, Dr. Premadasa Udagama as secretary to the Ministry of Education appointed a committee to take action to affiliate the school of pharmacy and other paramedical services to the university, it is very unfortunate up to date no constrive measures were taken in this direction.

We find that pharmaceutical Institutions like pharmaceutical industry, Drug Quality Assurance, Drug Authority and state pharmaceutical corporation are already functioning in addition to Hospital services. The necessary advance pharmaceutical knowledge in order to make these institutions to achieve the full benefit is not available in our country like in other countries.

Any pharmaceutical institution to function effectively, persons of pharmaceutical eminence must be available. It is a sine quo non: It is because pharmaceutical science is an Independent discipline evolved by generations of research and refinement all over the world. The denial of this situation can lead to a health hazard and an obstruction to economic development in the long term.

They say that little knowledge is dangerous. Therefore it is better for the country to take a serious view on improving Pharmaceutical Education as early as possible for the benefit of patient physician industry and quality assurance of pharmaceuticals. It may not be difficult for us when have nearly 11-12 universities in our country. Where as practically every other university has a pharmaceutical science faculties in other countries, here we have pharmaceutical science faculty in any of the universities.

The writer is R. Ehamparam is a pharmacist retired from government service and a former vice-president of the society of government pharmacists.

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Jayewardenepura Medical Faculty's study 

Why do three wheelers topple frequently?

Prof. Dayasiri Fernando of the Sri Jayewardenepura, with two others have carried out a study on the increasing incidences of three wheelers toppling in this country often resulting in loss of life and injury to passengers as well, and found that this is mainly due to unauthorised alteration of the handle lock.

The study had been done in 2001 based on one hundred patients admitted to Colombo South Teaching Hospital with injuries caused due to toppling of three wheelers they had been travelling in.

The study team in their investigations had found that in 83 per cent of the cases the three wheelers had toppled due to unauthorised alteration of the handle locks which gave an abnormal cutting angle to the front wheel.

The study report published in the WONCA Conference journal published in November 2002 in Colombo, of the drivers admitted with injuries 82.9 per cent had been under the influence of liquor. And in the night accidents 67.6 of the passengers too had been after liquor. Mortality rate had been 2 per cent.

The Study Team recommends besides heavy fines for driving under the influence of liquor, enactment of new laws to prevent unauthorised alteration to the cutting angle of the three wheelers.

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