21st January 2001
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Going up in smoke

By Sepala Ilangakoon 
I happen to be blessed to belong to a family of non-smokers and non-drinkers as well. In my extended family - my wife, our son, his wife and two children, our daughter, her husband , three adult sons and myself - eleven in all, we are non-smokers and non-drinkers, and proud of it. Like father; like son for three successive generations! 

My loathing of the smoking habit started very early in my life when my brother, elder by two years, challenged me and then enticed me age five, to take a puff. He would surreptitiously collect the butts (no filter tips in those days) thrown by my uncles, take out the tobacco and roll it in a piece of paper. His home made fag. 

I was tempted and just for the heck of it, I took a puff. Being an absolute novice, a green horn at smoking, I had taken too deep a puff- and got choked! 

I coughed and coughed and coughed, emitting smoke from my mouth, my nostrils and, perhaps, my ears too! 

Looking back into the dim past, I find that it was the first and the last time I smoked. By contrast, my brother's finger nails were nicotine stained early in life. He kicked the habit too late. 

My revulsion was reinforced five years later, when we had moved from Matara to Mount Lavinia and my uncles would stay with us whenever they came to the city. 

They were both very heavy smokers and would flick the butts into the wet drain in the toilet where these absorbed water and burst open. 

The wet nicotine-laden tobacco discharged a disgusting, revolting odour which absolutely nauseated me. 

A further deterrent were two of the items at a medical exhibition - a non-smoker's normal lung preserved in formalin and a smoker's cancer riddled dark grey lung. The difference was ever so telling and forbidding. I recall that my younger brother also died of prodigal smoking, after months of operations and suffering which he faced stoically. 

I have, understandably, developed an allergy towards tobacco smoke, although I would go a long way to get fresh wood-smoke in my nostrils. I can tell a smoker by the smell of his clothes. Recently when my wife and I went out to dinner, the restaurant was so full of cigarette smoke that we promptly went elsewhere, to dine in the luxurious open night air. 

Airlines now have a special section reserved for non-smokers. The recent anti-smoking lobby has been so proactive that now, some airlines do not permit smoking anywhere on board. Three cheers! 

However, there are certain circumstances where one is constrained to share a smoke-filled atmosphere and one is then categorized as a 'Passive Smoker' and is subject to the same consequences of direct smoking. 

It is advertised in the USA, that one is more likely to be killed by someone else's tobacco smoke than by his car, his gun, his knife or his AIDS virus! 

Have you noticed how the smoking habit changes from time to time? Smoking goes out of fashion and, forthwith, all jump on the non-smokers' band wagon because it is the 'in thing' to abstain and, they like to show they are 'with it'. Then the multi-million dollar cigarette companies step up their promotional advertisements in all the media, especially TV and 'voila', the fashion is to smoke, even if one does not relish smoking. 

I recall the popular trade marks of brands in years past - Gold Flake at the top of the list, Capstan Navy Cut, followed by a series of others ending with Three Roses and the Elephant cigarette smoked by the less affluent. 

And at the very bottom of the list was the Beedi - one and a half inches short, no paper wrapping and held between the index finger and thumb to puff away in quick tempo. It was the poor man's smoke. 

In complete contrast are the pipe and the cigar. I believe one does not inhale either and hence, they are regarded as comparatively harmless. One innocuous effect is to bestow a ruddy browning of the veteran pipe smoker's walrus mustache. 

Some years ago while planting, I smoked a Dunhill pipe but that was only to show off and I stuck the pipe in the hose top of my stocking - also for show! 

The smoking mode has infected children too, despite the fortunes spent on tobacco education. Their immature psychology allows them to succumb to peer pressure rather than acquiesce with the taught harms from smoking and the linking of non-smoking with the mod adjuncts like sports, vitality, fresh air, out door life etc. Children are born mimics. 

Despite all that is argued to the contrary, I still hold that smoking is the wanton destruction and ruination of the human physique, so gracefully and so exquisitely fashioned and so graciously bestowed on mankind by God and that smoking is an anathema, an unfair insult to our Creator. 

Struck down by a stroke

New Stroke Association offers a much-needed lifeline for victims

By Kumudini Hettiarachchi
Housewife Swarna, 48, from Ragama cannot move or speak. She lies in bed with tears in her eyes. But she sings loud and clear on and off.

She is the victim of a massive stroke on the night of December 22, last year. "To be the victim of a stroke is probably the most significant event in a man's life, more momentous for him than marriage or stages of his career or having children," says Dr. Jagath Wijesekera, Head of the Institute of Neurology quoting G.P. Mulley.A stroke affects the brain and leaves many a disability in its wake. In right-handed Swarna's case it has affected the left side of her brain, leaving her paralysed on the right side of her body and also unable to speak. However, the right side of the brain, which controls such activities as singing is normal, Dr. Wijesekera explains.

And life is at a standstill in Swarna's household since the night of December 22, when she came face to face with death. For her husband, son and daughter that night is a nightmare a bad nightmare that won't go away. "She was returning from Kandy with my son that night when she felt faint. They thought it was due to the long drive. By the time they arrived home, my wife was unconscious. We then rushed her to the Colombo National Hospital. Now she's lying here, unable to talk or move," laments her husband from her bedside at the Stroke Unit, Institute of Neurology.

She had a pain in the arm and also numbness before she went to Kandy, but assumed it was nothing. "Swarna is in a very bad condition. Our lives our shattered and out of gear,"he says.

Fortunately, for stroke victims like Swarna and thousands of others and also their traumatised families there is renewed hope with the formal setting up of the National Stroke Association of Sri Lanka last Sunday.

"The need for such an Association was obvious after observing and treating more than 250 patients over the past two years, since the first Stroke Unit in the country was set up at the Institute of Neurology in June 1998," says the Association's Secretary Dr. Udaya Ranawaka who is the Resident Neurologist at the National Hospital.

Strokes are the third largest killer attributed to "in-hospital deaths" after heart disease and cancer in Sri Lanka while they are the second leading cause of death worldwide amounting to about 4-5 million deaths every year.

"A stroke is both common and serious. It is the most important cause of adult disability, with half the survivors being dependent even after one year," Dr. Wijesekera, who is President of the Stroke Association said.

This is evident in the case of once-robust 70-year-old P. Punchinilame from Kegalle. Around dawn, on October 23, last year Punchinilame's son, Sugath Bandara heard him groaning in his sleep. When he checked on him, Punchinilame couldn't get up. His mouth had gone to a side and he couldn't speak or move.

They took him to the Kegalle Hospital and later brought him to the Stroke Unit where he was kept for 23 days to recover slowly but gradually. Now he attends clinic once a month, but cannot be sent alone. So his son, wife and child accompany him. He has regained his powers of speech, but smiles suddenly, without any reason and Dr. Wijesekera says strokes cause emotional instability, because it's all to do with the brain. "Some patients cry out loud, some smile or laugh. They cannot control their emotions."

Son Sugath adds, "He was a very energetic man. He worked the fields and looked after our property. He was also the cashier in our boutique before the stroke. Now he is unable to do anything. Someone has to look after him. He still cannot eat with his right hand. So he has been taught by the hospital to eat with a spoon using the left." 

According to Dr. Ranawaka strokes commonly affect those in the older age group about 60 and over. But people of any age can suffer a stroke. A survey by the Stroke Unit has come up with a shocking finding 30 per cent of stroke victims in Sri Lanka are below 50, whereas worldwide it is only about 10 to 15 per cent.

Swarna and Sarath, 46, are examples of this terrible statistic. 

"Vam kakula palanaya karanna beri wuna," (I couldn't control my left leg) says Sarath, father of three school-going children, describing his attempts to wear his uniform before his night shift as a security guard on February 1, last year. He shouted for help and requested his colleagues to get him to hospital. He was taken to the ward on a trolley because he couldn't walk. Now nearly one year later and after being in the Stroke Unit for a while and the Ragama Hospital for rehabilitation, he walks with the aid of a stick, dragging his left leg. 

And he has had to re-learn the things most people take for granted how to wear his shirt, how to button his shirt, how to tie his shoe laces, how to raise his hand, how to eat and even how to walk.He is back at work, but attends the clinic once a month and physiotherapy sessions every other day.

"The burden of stroke will be even more in the future. Sri Lanka has one of the fastest ageing populations in the world and by 2025, the population over 60 years will rise to 20%. With the risk-factors increasing with changing dietary habits and lifestyles, younger people are also becoming a vulnerable group. Therefore, the National Stroke Association has much to do," explains Dr. Wijesekera.

He sees the role of the Stroke Association as:

* bringing together medical and non-medical people committed to improving stroke care

* harnessing managerial skills of non-medical professionals

* ensuring community participation

* as being a meeting point for stroke victims, their families, caregivers and healthcare professionals

* creating and improving

awareness on strokes

* dissemination of knowledge and information

* helping to rectify misconceptions regarding strokes

* establishing a Stroke Centre

* developing Regional Stroke Associations

Stressing that the National Stroke Association is not limited to one organization or a few professionals, Dr. Wijesekera says, "It's open to all. We need to get-together to fight this fatal disease."

(Patients names have been changed on request)

Brain attack

A brain attack, as we call a stroke, needs urgent and early treatment. The moment someone gets a chest pain they rush to the doctor in fear of a heart attack. It is as important to seek treatment the moment any of the stroke symptoms are felt, urges Dr. Udaya Ranawaka. 

It is very important that however mild the symptoms may be or however short their duration, they should never be ignored. They are warning signals of a stroke and should be taken very seriously. The sooner treatment is sought, the higher the chances of recovery with minimal disability.

However mild the symptoms, don't put off seeking treatment for tomorrow. Treat it as a red-alert emergency, he says.

What is a stroke?

A "stroke" (cerebro vascular accident) is a sudden disturbance in the brain function due to a problem with the blood supply to a part of the brain. "It hits you out of the blue, like a thunderbolt and leaves you with some disability," says Dr. Ranawaka.

How does it happen?

There are two ways in which it can happen. The first, seen in about 80% of stroke cases, is a block in a blood vessel which affects the flow of blood to the brain. This is called an ischaemic stroke or infarct. This could occur due to a clot that comes from the heart or one which forms in a blood vessel or, rarely, may arise due to an abnormal tendency in the blood to clot on its own. 

The second, a haemorrhagic stroke, can occur when a blood vessel ruptures and produces a bleed into the brain. 

What are the risk factors? 

* The first and most important is high blood pressure or hypertension

According to Stroke Unit patient statistics, of 48% who had high blood pressure only 53% had been adequately treated 

* Various heart diseases an important and preventable disease is rheumatic heart disease caused by a damage to the heart valves due to rheumatic fever during childhood. If childhood infections are treated effectively rheumatic heart disease can be prevented. The Cardiology Unit is doing much work in this regard.

* Diabetes

Of 26% of stroke patients who had diabetes, the disease had been controlled adequately only in 20%

* High cholesterol levels

* Smoking

* Excessive consumption of alcohol

* Obesity and a sedentary lifestyle

Fifteen per cent with high blood pressure and 20% with diabetes had been undiagnosed at the time they had their stroke.

What are the symptoms?

The symptoms would depend on which part of the brain is affected. 

* The commonest and best known manifestations are weakness, numbness or paralysis of a part or one side of the body.

* Changes in speech, both expression and understanding

* Changes in vision, behaviour and personality

* Non-specific symptoms like headache, vomiting and giddiness

* The severest symptoms are becoming unconscious or sudden death

How can a stroke be prevented?

There are two types of likely stroke patients. Those who have never had a stroke and others who have had one or more attacks. But prevention strategies would be the same for both categories.

* Modify your lifestyle Lead a healthy lifestyle, with a sensible diet and regular exercise. Stop smoking and drink alcohol in moderation.

* Certain drugs may help prevent strokes

* Through early detection and control of the high-risk factors especially high blood pressure, diabetes, heart disease and high cholesterol levels.

What can be done for a stroke patient?

* Seek treatment early, because the main reason for death and disability after a stroke is the swelling of the brain and the pressure within the skull cavity.

* Start rehabilitation of the patient as early as possible to enable him/her to recover bodily functions. 

The patient needs to be attended to by a team consisting of doctors, physiotherapists, speech therapists and occupational therapists The National Stroke Association of Sri Lanka can be contacted at "Wijerama House", 6, Wijerama Mawatha, Colombo 7. 

Who's afraid of the big bad dentist?

By Uthpala Gunethilake
You have been pacing the floor for quite some time. Of course you always knew that one-day you'll have to go through the dreaded experience, but you always put it off. Now it cannot be postponed anymore simply because it hurts too much. You wince at the thought of the drill burring away inside your open mouth. Now if anyone could hear your thoughts they'd think that you're about to be operated on by aliens, when in fact you are just trying to muster up courage to visit the dentist.

Most of us have lists of 'things I don't ever want to do' and topping many of those lists is, 'visiting the dentist'. Some of us merely dislike the entire matter and prefer to forget the dentist until we're forced to attend to our teeth. Some would rather have their teeth fall out than go to the dentist under any circumstances. You might be able to find a small percentage of people who would regularly get a check-up done. Certainly, few look forward to it.

Take the case of Nirmal (name changed) who admits to being a severe dental phobiac. "There are few things I hate than going to the dentist. I was very scared when I was a kid and used to make a major fuss when I had to go. Now I know there's nothing to be scared of but still I have to talk myself into going," he says.

Dr. R. Goonetilleke, Director of the Dental Institute says such fears may stem from having a bad dental experience at a young age. However it was no such experience that kept Surani(name changed) away from the dentist for 11 years. "I had my first tooth extracted when I was six and in fact I think I rather enjoyed all the attention. It's much later when I started having cavities etc. that I really began to dread it." She says her worst fear is the drill. "Even talking about the drill gives me the shivers. I can bear pulling out the tooth; it's the drill I can't stand. It's a nightmare," she says.

Dr. Goonetilleke who doesn't see dental-phobia as a problem affecting many people, says however that one of every 10-15 patients treated by him might show high levels of anxiety when they are being treated. In an extremely bad case patients may have to be treated under sedation, he explained. Dr. Goonetilleke says that the new equipment used in dental clinics have made things easier for the patient. He explained that the old machines run by electricity have been replaced with air-rotant ones which move more smoothly and faster.

How would a dentist handle a patient with severe anxiety of dental treatment? "We would chat to him first and try to make him comfortable. We also tell him what we are going to do . When you know what's happening it makes you less scared,he says. Mrs. Ratnayake (name changed) is one of those whose fears were lessened after being treated by a sympathetic dentist. "I had to extract a tooth and just thinking about it made me depressed for a week. Finally I had to go because my mouth was hurting so bad. I told my dentist frankly how scared I was and she was sympathetic. She chatted to me for a while and told me there's nothing to be scared of and that it would be painless because the tooth would be pulled out after anaesthetizing. It helped a lot but still I can't remember how I went through it. Now when I have to go the dentist I make a point of telling him that I'm terrified " 

Researchers say people who are not afraid of undergoing major surgery can sometimes be greatly nervous about facing the simplest of dental surgeries. The fear is also attributed to the fact that you are being operated on an area very close to your face. Being close to the face may be the very reason why we should be careful about our oral health, but try telling that to a dental-phobiac. 

By the way, if you thought the correct term for dental-phobia is dentophobia, then you're wrong; the fear of dental surgery is called Odontophobia. Dentophobia is the fear of dentists! 

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