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Playing God or helping Mother Nature?

By Kumudini Hettiarachchi
Two anxious men sit in the waiting room of Vindana's Colombo 5 centre, at 5 o'clock in the morning. Both arrived with their wives at the crack of dawn to see the first step of the fulfilment of a long cherished dream - that of having their very own babies.

Their wives were to undergo a procedure to retrieve eggs from their ovaries for the in-vitro fertilization (IVF) procedure. One couple, from Kurunegala, had been married for 10 years and the other, from Colombo, for five years. They had undergone many tests and tried out many things to no avail. Doctors had told them there were "complications" and ordinary people had called it "Karmic forces" or "God's will". This was their last resort.

The local team who made possible Sri Lanka's first test tube baby, was being assisted by a pioneer of the IVF procedure in the world.

Dr. Simon Fishel, well-known embryologist from England, had been on the very first team to successfully carry out the IVF procedure on a human being, which resulted in the birth of Louise Brown in 1978.

"It was an amazing time where most in the medical community did not accept it and three-fourths of the world were against it. Any new technology in medicine is greeted with concern and skepticism. In the next generation it becomes commonplace," says Dr. Fishel.

The IVF technology, which has come a long way from then, has positively affected the lives of millions of people for, according to him, the millionth IVF baby in the world was born last year.

The infertility problems are numerous and the figures quite shocking. "Globally, one in seven couples have a fertility problem. These problems affect society because an individual couple is the basic unit of our society. If a couple who want to have children are unable to do so, through IVF we help the natural process," he explained.

The main rejection of this procedure comes from Catholicism on the basis that conception should not be separate from the act of making love. The objection is that fertilization should be connected to the act of love and conception should only take place within the body. "You must differentiate between the religious and spiritual view of the reproductive process from the medical concept," he says.

However, there is an IVF clinic even in Rome with many units scattered across Italy, a staunchly Catholic country. "When Louise Brown was born the Pope sent a message of congratulations," he smiles.

Reproduction is in the realm of the mystical and magical. There is a belief that it comes from God. "Therefore, it is considered untouchable in the domain of science. Demystifying reproduction through IVF does not take away its beauty. It takes tremendous love and commitment on the part of the couple to go through the IVF procedure. It is something they do together," assures Dr. Fishel, Director of CARE (Centres of Assisted Reproduction), the largest single provider of IVF in the UK

Dr. Fishel has been involved in 5,000 births of IVF babies and has travelled around the world taking the message of hope to childless couples. "For many infertile couples there is a feeling of despair.”

This eminent embryologist was on the team which introduced IVF to China in 1987. "Though China has controlled families, even they recognize the right of a couple to have at least one child."

On his first visit to Sri Lanka, to set up formal links between CARE and Vindana, he says it will be the greatest trade, a trade of knowledge and experience beneficial to both countries.

What of allegations of playing God? Dr. Fishel's logical argument is that the same allegation could be levelled against any clinical scientist or doctor who removes an appendix. "We are made in God's image and therefore have a duty to look after the sick, needy and underprivileged."

The important thing is not to lose sight of the end product of IVF, the unborn baby. As long as the child is cherished and his/her welfare is looked after there is nothing wrong with aiding the natural process. Pointing out the plus points of the procedure, he explains that IVF can be used to positively screen out defective embryos before implantation in the womb of the mother. In some countries abortions are done when embryos are found to have diseases. Gender selection is also possible.

"There is no harm in working with and aiding nature. Harm comes from disrespecting nature. Understanding it and working with it for utilitarian and humanitarian means is okay. If it does not harm your neighbour and devalue society, what is the problem?"

He takes a case in Britain, surrounded by controversy, which the IVF procedure should be able to help. It is the case of four-year-old Zain who is suffering from Thalassaemia and needs donor stem cells to save his life. At present no donor is available. "His parents have three options. Keep on having children until a baby with Zain's tissue type is born even at the risk of getting another with Thalassaemia, keep trying and aborting the embryo if affected by Thalassaemia or try out the screening procedure of IVF to have a baby with a match," he says. Zain's parents will not only love and cherish the newborn but also help Zain to have his right to treatment and to life.

This is also a revolutionary treatment for male infertility with millions of sufferers, the largest single cause of infertility in the world. "In 1990 only 5% of those who had problems with the male factor had a chance of being treated and having a child of their own. In 2003, this has risen to 95%, thanks to IVF," he says.

IVF is also a procedure through which the fertility of cancer patients can be preserved. He takes the case of a woman surgeon in UK who was against newer IVF technologies especially with regard to freezing eggs for later use. When she got cancer she had phoned him to say that she was feeling guilty. "I was in control of my world and felt others should be too. Then my world shattered and I knew I needed help," she had told him. Cancer patients like to freeze their eggs as chemotherapy affects the reproductive system. "What do children who are cancer victims feel when they grow up knowing that they would be sterile for the rest of their lives? Research is now being carried out with regard to the preservation of some testicular tissue from immature males which can be used to generate sperm later on," Dr. Fishel says.

He urges self-regulation within the medical profession to ensure that the technique is not abused and patients get the best care under trained personnel. At the level of government, good practice should be regulated taking into account the patients' needs.

For Dr. Fishel, the look on the face of a paraplegic in South Africa, who had been disabled after a surfing accident, when he was able to hold his own little baby boy and the smile of a Japanese father, whose sperm count had been so low that the IVF procedure could only get five, when his twin daughters were born are reason enough to carry on his work.

TB: The spectre needn’t strike terror anymore

By Ruwanthi Herat Gunaratne
We've all suffered from the common cold and cough. All it would lead to would be some grumbling and moaning but by the next week, it would be gone. But a persistent cough leading to weight loss and a nocturnal fever, can prove (innocent though it may seem) to be life threatening.

World Tuberculosis Day falls tomorrow, March 24.

Last year in Sri Lanka, a startling number of 400 people died of tuberculosis. 8300 cases were reported. But interest and fear of the disease has waned considerably.
The disease-spreading bacteria (Myobacterium Tuberculosis) which spreads through the air like a common cold was isolated during the latter part of the 19th century but preventive medicines were discovered only 60 years later.

"It was around that time that Sri Lanka decided to fight the disease," says Dr. Kapila Sooriyaarachchi, the Acting Director of the National Programme for Tuberculosis Control and Chest Diseases, which comes under the purview of the Ministry of Health. "Our villagers called the disease a "Yakshawa" and treated it in the only method they knew - by holding "thovil" in order to frighten the evil spirits residing in the patient away."

By the early 1900s, it was found that isolating patients suffering from the disease could minimize the risk of the disease infecting others. The first sanitarium in Sri Lanka was established in Welisara on an area of 115 acres.

"The fact is that one third of the world's population is already carrying the bacteria," says Dr. Sooriyaarchchi. "But as long as we are within the immuno balance the chances of contracting the disease are slim."

Losing immunity is what causes tuberculosis, an infection associated with the respiratory system. In 85% of cases, TB affects the lungs of the patient. Other forms include the eyes, nose, uterus and bone being affected. "But it is the lung infection that is contagious."

Who is at risk? "Diabetic patients and those suffering from HIV are excessively prone to the disease. Being HIV positive increases your chances of contracting TB by 50%. TB and HIV fuel each other. In fact TB is HIV's most common opportunistic infection; a third of those infected with HIV are estimated to eventually develop TB. Malnutrition and alcoholism may also affect the immunity factor."

"But the fact remains that TB is a curable disease." TB is also the single largest infectious disease that causes death in women. "This is not to say that women are more prone to the illness than men, but it means that amongst the infectious diseases it is the largest killer of women,"Dr. Sooriyaarachchi says.

A four-drug combination of strong antibiotics is the treatment that is now available to sufferers of the disease. "The bacteria which causes TB is very powerful, and that is the reason why such a four drug combination is recommended." It was at the end of 1972 that this short course treatment for tuberculosis was introduced.

The biggest problem faced by those actively involved in the fight against tuberculosis is the social stigma attached to the disease. Most have grown up with the misconception that TB is a disease of the lower classes of society. "The TB bacteria may be present in any of us. But it comes to light only when our immunity is at a minimum. The lower rungs of society suffer from poverty, live in unsanitary conditions and suffer from malnutrition. Therefore it is more likely that they would contract the disease."

"Once a suspected patient comes to us at any of the 24 Chest Clinics situated around the country we conduct a sputum test. Using the results the doctors are then able to prescribe the required medication that should be taken for a stipulated period of time." The disadvantage of the medication is that once it has been taken faithfully for a period of one month the danger signs seem to disappear. There is even considerable weight gain.

But at the end of the first month only 85% of the bacteria dies. "There is constant reproduction and new strains that are resistant to the medication is produced. This is where the danger lies," Dr. Sooriyaarachchi says. Multidrug Resistant Tuberculosis (MDR-TB), the new strain of bacteria is the worst possible complication. Without treatment, a patient's lifespan can be reduced to two years.

The treatment for this complication costs Rs. 800 000 per patient per year and boasts of only a 5% mortality rate. The Ceylon National Association for the Prevention of Tuberculosis (CNAPT) says that drug-resistant strains of TB are spreading because of their greater mobility resulting from increased air travel and migration.

Another startling factor is that anyone sick with tuberculosis is likely to infect another 10 to 15 people in one year. MDR-TB has been increasing over the past 20 years, highlighted by deadly outbreaks in North America and Europe during the early 1990s.
It was because patients discontinued treatment that a new method of prevention had to be found. Directly Observed Treatment Short course (DOTS) was the only answer. "This new method which is recommended by the WHO was introduced to Sri Lanka in 1997 and since then it has grown to cover 73% of the island," says Dr. Sooriyaarachchi.

What does it entail? "Once we've identified a patient the first question we ask him or her is where he lives, and isolate the closest medical centre." Once this is done the patient is informed that his daily dose of medication will be available at that particular centre every day.

He is then asked to visit the centre on a daily basis and take the required dosage before a doctor or a nurse who will then place a tick in his card.

By following this method the programmme has the ability to guarantee that the treatment is taken continuously for the stipulated period. "But stigma puts its foot in here too," continues Dr. Sooriyaarachchi. "For when we ask as to where the closest medical centre is we are not told of it. Instead they are happier to collect the medication from another centre further away from their village."

The Ministry works together with two Non Governmental Organizations to increase awareness of this dreaded disease. The CNAPT was founded way back in 1957 with the primary objective of educating people and creating awareness on tuberculosis, "We now assist the national programme in the fight against the disease. The Ministry handles the clinical aspect," says the Executive Secretary of the CNAPT.

The other NGO involved with the programme is the Janatha Sahana Suwasetha Padanama.

"If you are infected with TB, there's a likelihood that I'd be down with the disease tomorrow," says Dr. Sooriyaarachchi. "That is because tuberculosis is an infectious disease and not a genetic one. Due to the social stigma that is still attached to it many patients suffer from psychological harm. Some are tempted to commit suicide. Others agree to take the prescribed medication only secretly. It is the responsibility of each and every one of us to prevent the spread of the disease. Only knowledge, the right attitude and practice can help."

Doctoring diversity

By Ranjan Karunaratne
The Sri Lanka Medical Association is contemplating a tremendous step forward in addressing the spiritual dimension of health. As a specialist in medical knowledge systems, I travel the world offering my expertise to help birth this new thinking with as few birth defects as possible.

Galileo bifurcated knowledge into knowledge of things and knowledge of spirituality. In so doing, he launched Europe into becoming "developed" nations, having validated knowledge of things. But they remained "undeveloped", having no validated knowledge of spirituality. As Professor P. D. Premasiri points out, a knowledge of spirituality would give us individuals with a settled and composed mind,... totally freed from the five mental hindrances,... through a total cognitive transformation... A society which could in Buddhist terms be called "developed" (is) a society which has the good fortune to have at least a few such individuals".

It is this "cognitive transformation" that is the acid test of spirituality, not the rank and pomp of human-appointed prelates and their dictates.

The culling fields of biomedicine

Even as I write, a man lies unconscious in hospital, his coma induced by anaesthesia, not by his condition. If he dies, he will be another statistic in the mortality rate of a profession that belies its claimed scientific status.

There used to be something called iatrogenic disease, (Greek iatros =g "physician", and genic = "generated by". Today there is no longer any iatrogenic disease! But gathering dust on library shelves is another vital statistic. This is for ADR's. Few people know what this means; it is an adverse drug reaction.

It is an interesting linguistic twist. Now the problem is not the medicine administered by the physician but the reaction of the patient. What that statistic actually is, defies belief. According to the Journal of the American Medical Association prescribed drugs are killing so many patients that it biomedicine is number 6 on the top ten killer list for the United States. It would appear that the profession has mutated from curing the population to culling the population.

Defining health
While biomedicine has given us a magnificent database about the aetiology and treatment of disease it obscures the level of ignorance in the model about authentic health. Health is defined as "a state of complete physical, mental and social well-being and not merely the absence of disease". Linguistic analysis of this definition is fascinating. Wellbeing is defined as welfare; welfare as a "state of faring or doing well; enjoyment of health". In two steps we are back to health. The words complete, physical, mental, social are adjectival. So they are irrelevant to the definition of health, as is the rest. Since health is not these, they add nothing to the definition itself of health. So the definition says "health is wealth". What does this mean? Nothing. Except that an awful lot of money has been wasted on airfares and hotel accommodation because the doctors did not think to include a linguist in their deliberations. What is equally fascinating is that nobody notices the definition is mere tautology. It's the "Emperor's New Clothes Syndrome".

The biomedical model and spirituality
Philosophy of Science is the database that as been created about the way in which knowledge comes into being as a system and not as discrete quanta of data. Bio-medicine is a particular knowledge-system. That means it includes certain data and positively excludes certain other data. What Philosophy of Science demonstrates quite unequivocally is that it is impossible to tag on to a knowledge system data that it excludes. The bio-medical model specifically excludes the spiritual. Attempting to tag it on would be the engineering equivalent of imagining that one could tag a jet engine on to one's motor car and get it to fly to London. All such endeavours demonstrate our ignorance of how knowledge works as a system.

An evidence-based approach
While warmly welcoming the current initiatives and the courage of the SLMA President, I am writing to draw attention to the need to take an evidence-based approach to both bio-medical and "spiritual" interventions. This is our only protection against the dogma and superstition of the bio-medical practitioner who, albeit with the best of intentions, is killing increasingly large numbers. It is also our only protection against the religious establishment. Research protocols need to address questions like what are the objective criteria for selecting which types of meditation? There is a tendency for those promoting meditation to teach that their favourite form as the only worthwhile one. This could expose many vulnerable individuals to undesirable and exploitative cults. As with the pharmaceuticals, it is necessary to distinguish the generic product from the brand names, which seem to have a tendency to fleece their patients!

Our starting point must be an evidence-based approach to both medical science and spirituality. Maybe a good place to start would be right here at home with the Eastern philosophy that did just that several thousand years ago. Can we overcome our need to get the answer from a Western, "modern" source? (How high has the killing-rate got to get before we shed our colonial awe of the "white man" as the font of all wisdom and technological advance?) I address this point in detail in my article Magic or Logic: Can "Alternative Medicine" be Scientifically Integrated into Modern Medical Practice? published by Advances in Mind-Body Medicine. I offer it to the Sri Lankan medical profession and medical schools as an intellectually sound starting point for these current endeavours.

I would urge an approach to the existing diversity in doctoring from a scientific standpoint. Our doctoring will then preserve the best interests of the patient. Otherwise all we are doing is doctoring diversity to preserve our professional self-interest (and psychological comfort zone).

The writer is a published author in the fields of education and health. While resident in Chicago he taught at DePaul University and had a clinical practice at two medical centres, running workshops at medical schools, nursing schools and corporate health management programmes. He is now based in Sri Lanka.

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