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9th August 1998

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By Sujit Sivasundaram

"Sri Lankans need to get fit and lose those Mudalali stomachs. They should check their weight regularly and their cholesterol at least every six months, cut down on animal fat, maintain a steady level of exercise and stop smoking," says cardio-thoracic surgeon, Dr. Nihal Kulatilake.

"The popular belief that a complicated operation such as by-pass requires foreign travel is no longer true. But such treatment would be unnecessary if precautions are taken," the doctor adds.

Dr. Nihal KulatilakeA consultant at the University Hospital of Wales in Cardiff, UK, the unassuming Dr. Kulatilleke is now in the island combining a holiday with a schedule of by-pass operations and valve surgery. He was instrumental in the introduction of permanent cardiac treatment in Sri Lanka in August 1994 with the establishment of a specialist unit. Before this time, such attention was only possible under the purview of Indian surgeons who visited the island from time to time.

Dr. Kulatilake was extremely positive about the expertise of local surgeons and the standard of cardiac surgery in this country. This, he said, nullified the need for foreign travel except in the most complicated cases. An example of a 'complicated case' would be a patient with kidney failure who would not receive the best attention in Sri Lanka, as yet, because there are better facilities for dialysis abroad. However, normal instances of heart disease can now be dealt with here as 'we have some talented young surgeons.'

Where post-surgical care is concerned, Dr. Kulatilake stressed that the staff were trained in accordance with the lines adopted in Britain, adding that there have been staff exchanges between Cardiff and Colombo to facilitate improvement. Thus there would seem to be no need for foreign travel. However, Dr. Kulatilake added that "the government sector still has some way to go to catch up with the private sector." With this qualification he was able to conclude that we now have the "high Western style of care" in this country.

Amongst the hospitals that offer cardiac surgery, Dr. Kulatilake said that patients at the National Hospital are put on a waiting list for one to two years. At the Nawaloka Hospital the whole package including surgery, stay and other fees costs Rs. 285,000 which is substantially higher than the Rs. 125,000 fee charged at the Sri Jayawardenapura Hospital for the by-pass operation package. Though some years ago many cases of heart disease went undiagnosed, now with better education and publicity through the media this is being remedied.

Dr. Kulatilake's constantly voiced dictum is that, "Prevention is better than cure." He said that the patients he treated in Sri Lanka differ from those in the West because they lack regular exercise, have a poor diet of highly saturated foods and are not aware of the harm that smoking does to their constitution. 50% of them suffer from diabetes; an enormously high figure when compared to the normal 8% figure that is common in the West. This, he said, was a direct result of misunderstandings. "Here there is a tendency for people who develop economically to believe that they must start eating fatty foods such as pastries and cakes. There is an assumption that ham, cheese and butter are indicators of wealth!"

Dr. Kulatilake fervently urged that it was time to dispel Sri Lankan myths on eating and exercise so that Sri Lankans could get fit. "There is little use in heart patients walking around Independence Square when those who think themselves fit do no such exercise and stay at home neglecting their fitness."

Sometimes heart disease can be genetic and then even those who are perfectly fit may have no escape. However here again, Dr. Kulatilake was unwilling to give up on his words of wisdom, for if they are followed "genetic cases would have the onset of heart disease delayed and the severity reduced." He concluded with the assertion that "there is no reason for people to lose their fitness for want of control."

Asked what symptoms patients should look for in identifying possible heart disease, Dr. Kulatilake said that they might feel "a tightness in the front of the chest wall like a big hand squeezing them." This pain in the chest would then perhaps move up to the jaw or down the side of the left arm. However, atypical symptoms are also possible and gastritis and indigestion may be diagnosed where the real cause is the heart. In terms of identifying a heart problem, Dr. Kulatilake commended the screening test known as the ECG or stress test: "This is 90% successful."

Asked to identify the most striking failing in our hospitals. Dr. Kulatilleke replied immediately: "There is a need for motivated staff who are highly trained and better paid, who feel that their contribution is worthwhile." He added that the requests for equipment that these staff members make should be attended to by the proper authorities with haste. "The staff know what they need to do their job better, but are not given these items because of Sri Lankan bureaucracy and other such reasons."

Life as a cardiac surgeon, Dr. Kulatilake said was "an onerous job with long hours" adding the pun that "it involved a lot of heart ache." This was the message he wanted to get across to any aspiring medical students. When asked whether foreign experience was still necessary to qualify in medicine, Dr. Kulatilake said that the surgical qualification now given in this country is of a good standard compared to that offered in his day. However he said that post-graduate students are still sent overseas and three of Sri Lanka's present cardiac surgeons had in fact gone through his own unit in Cardiff. He cautioned that post-graduate organisers should be aware of the needs of their trainees before sending them abroad without discernment. "Unless they are sponsored by known people to known places, post-graduate students sometimes end up with inappropriate training."

Smoking causes cancer, no?

Your Health

by Dr. Sanjiva Wijesinha

With all the information available today - from books, magazines, newspapers and even the Internet - I am still surprised when supposedly intelligent and educated acquaintances here still say, ''But it hasn't been yet proved definitely that smoking causes cancer, no?"

The sad fact is that scientists in the tobacco industry have known for as long as fifty years that smoking causes cancer - but the tobacco industry continued to publicly deny that such a link existed because they were making such a killing from cigarette sales.

Details of the marked difference between what the tobacco industry knew about its products and what it revealed to the public were revealed last month when the anti-smoking organization (ASH) last month released its report at the British Medical Association office in London. The report - the first detailed analysis of documents obtained through litigation and other sources in America - also revealed that since the nineteen sixties, the industry well knew that tobacco's crucial attraction was its addictive nature.

Says Clive Bates, director of ASH, ''This report (which is available on ASH's website ( will be of great value to lawyers and victims of tobacco related disease who are contemplating legal action against the cigarette companies. It gives a brilliant insight into what was going on inside the companies and shows that the industry's public statements have been at sharp variance with its private knowledge and behaviour.''

The documents significantly show that the tobacco industry especially targeted young people, recognising that they represented a lucrative market for the future. R.J. Reynolds, one of America's tobacco giants, refers to teenagers in its 1975 marketing plan as ''tomorrow's cigarette business''.

A report of a study tour by scientists from British American Tobacco to the US in 1958, which included visits to companies like American Tobacco, Phillip Morris and Liggett as well as several research institutions, states, ''With one exception the individuals with whom we met believed that smoking causes lung cancer.''

A review done a few years later by the consulting firm Arthur D Little, working for Liggett, reviewed the results of seven years of research. Their report states, "There are biologically active materials present in cigarette smoking. These are (a) cancer causing, (b) cancer promoting, (c) poisonous, (d) stimulating, pleasurable and flavourful.''

Another memo from a Brown and Williamson lawyer observes, ''Nicotine is addictive. We are then in the business of selling an addictive drug.''

A 1979 document of the Tobacco Advisory Council says, ''The effect of switching to low tar cigarettes may be to increase, not decrease, the risks of smoking''.

All these revelations come in the wake of a landmark settlement in America last year, in which US tobacco companies agreed to pay US $368.5 billion over 25 years mostly to fund anti-smoking campaigns and public health efforts in that country.

Under that agreement, the companies had to publicly admit that cigarettes are addictive and cause cancer, heart disease and lung related illness. They also had to pay four billion dollars each year into a fund to compensate smokers who were successful in lawsuits.

A significant part of the agreement was that the American tobacco industry also agreed to pay larger fines if the smoking rates among young people were not reduced by 30% in five years and by 60% in ten years.

Unfortunately, this reduction in smoking rates among young people would only apply to young people in the US - so there is nothing in the agreement to prevent the American tobacco industry continuing to promote smoking among young people in Third World countries such as ours, where they will probably continue to be successful as long as there are Sri Lankans who continue to believe "But it hasn't been proved yet that smoking definitely causes cancer, no?"

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