Second Opinion

But healthcare is not a commodity…

It was announced a few weeks ago that new laws would be introduced and implemented by the Government to ''regularise' and 'monitor' private hospitals.

This is a welcome move indeed, but we must necessarily reserve our praises pending the actual implementation of these laws. That may sound cynical, but that cynicism is born out of experience and we are sure millions of patients will vouch for that.

What we now have is a system of private hospitals where anything goes: there is absolutely no monitoring of the standards of patient care and there is no monitoring of the fees levied. Elsewhere in this page, we highlight two such cases. These cases, we are certain, are only the tip of the iceberg: such incidents must be occurring daily costing the people of this country their hard earned rupees and even more precious lives.

Everyone knows that these days, private hospitals mean big business, and in a country where everything and anything is being privatized there is nothing wrong with that concept, as long as the state health service is maintained for the benefit of the less fortunate.

In fact, private hospitals can be an asset to the system by ''taking over'' a segment of cases that would otherwise have overburdened the government sector hospitals.

But healthcare is not a commodity - such as a bag of cement or a telephone connection - to be privatised willy nilly. Those providing healthcare must be held accountable in some way because though they may be doing a business, the State cannot let them trade or bargain with human lives.

But that is precisely what is happening now. Private hospitals charge exorbitant room rates. Drugs and other services are charged at even more astronomical amounts. There is a total lack of control over all this and patients are held at ransom.

Where private practice for specialists are concerned, there is more of the same. Some doctors perform the miracle of seeing over a hundred patients a day at less then five minutes per patient. Do the latter talk of the quality of care they receive? Of course not! They barely have time to walk into the consultation chamber, answer a few cursory questions, collect the prescription and walk out! Again, there is no control over any of this.

Only this week, the all powerful doctors' Trade Union, the Government Medical Officers Union, (GMOA) threatened trade union action over fifteen demands. Among them was a request to cancel a Ministry circular seeking to regularise private practice. What was merely stated in that circular was that doctors should inform the head of their institution as to where and when they did private practice. And the GMOA cries foul for that! So much for patients' rights!

This is why we are cynical about these new laws that will govern private hospitals and private practice. The previous minister of Health, A.H.M. Fowzie may not have won prizes for his diplomacy given his abrasive style, but it must be said that he did try his best to get a better deal for the long suffering patients.

That he lost his portfolio as a result speaks volumes for the power wielded by those who monopolize the heath services in this country.

So, when the present Minister, Nimal Siripala de Silva says he will bring in laws to make private hospitals more accountable, we await his deeds with great expectations. And, we must also wish him luck or else we might soon find Mr. de Silva joining Mr. Fowzie in the ranks of former Heath Ministers of this administration!

Hippocrates, where art thou?

Time and again a cry is raised against the medical profession alleging some kind of misconduct. Such com plaints rarely, if ever, end in a court of law. The one case that did, in this country, resulted in the doctor being found guilty.

We give below, details of two such cases which we know to be true, occurred very recently. Was there negligence? Was there evidence of reasonable medical care? Were medical ethics violated?

You, dear reader, be the judge!

* Case No 1:

A patient with heart disease fell ill. Her family contacted the Consultant Cardiologist, formerly working in the state sector but now doing only private practice.

The family wanted to know whether the patient could be admitted to a well-known private hospital in Slave Island.

No, insisted the cardiologist, the patient should be taken to a private hospital in the city, located in a more residential area.

The family obliged. But at the hospital they were told the patient could not be admitted unless a deposit was paid.

And no emergency treatment was given either. Sorry, said the staff; that was hospital policy.

The family rushed hither and thither and fetched the deposit. By that time, the patient had passed away.

Later, it transpired that the hospital was managed by members of the Cardiologist's family. Coincidence? Maybe!

And the cause of death? Cardiac arrest? Or else?

* Case No. 2:

Two young doctors found to their horror at midnight on New Year's Day that their three year old son had his hand wedged against a closed door.

Fearing the worst - a crush injury that would deprive the fingers of its blood supply, resulting in permanent damage - they rushed to a private hospital where they knew a doctor friend was doing a night shift.

As they entered the hospital they thought they were in luck's way.

A Paediatric Surgeon in the country's leading children's hospital in Colombo was there, visiting the hospital on another 'call'.

They introduced themselves as doctors and showed him the child. The Paediatric Surgeon, tall, handsome and smiling was charming indeed, but only for all of five minutes.

He barely looked at the injured fingers, ordered the nurse to put a tight dressing and told the parents not to remove it for four days.

He then left handing over a bill of a thousand rupees to the perplexed parents!

The parents - both doctors - have two questions. As far as they know, they say, a tight dressing for four days is certainly not indicated in a suspected crush injury.

Is this a unique method of treatment? If this Paediatric Surgeon charges a thousand rupees for five minutes of medical advice from another doctor, what must he be charging for an hour-long surgery, from the general public?

The truth about chickenpox

By Dr. Hemantha Sudasinghe

Like other common vi- ral diseases chicken pox also spreads periodically. Since there are many superstitions attached to chickenpox, it is important to learn about it in more detail as some of the customs can worsen the course of the disease

In tropical countries, like Sri Lanka, this disease spreads normally in the drought season. Chickenpox spreads through a virus called Varicella zoster.

The virus multiplies in the body for 10 to 17 days and then the symptoms become apparent. Like most of the other viral diseases, this also generally causes more severe illness in adults than in children.

In the first two to three days, it is very difficult to differentiate chickenpox from any other viral fever. During these days the patient will show nonspecific symptoms like fever, bodyaches, headache and vomiting. Then the specific vesicles start appearing on the body starting from the chest, back and then on the face and lastly on the limbs.

At the onset, these vesicles appear as reddish patches of 2-3mm in diameter. Then these vesicles get filled with a clear liquid, which contains lot of causative virus.

Lastly this fluid turns into pus at which period the containing sac is termed a pustule.

When vesicles start appearing, the patient experiences generalized severe bodyaches, severe itching of the body and an abnormal sensation of the areas where new vesicles are about to appear. During this whole period, the severity of the general symptoms like fever, headache and vomiting will increase.

Formation of new vesicles will cease after three days, and after the sixth day the vesicles (or pustules) will dry up to form blackish crusts. Till all the vesicles form crusts, the patient can transmit the disease to susceptible persons.

Usually all the organs of the body are affected but the disease affects mainly the skin, which is the largest organ of the body.

In addition to this whitish ulcers develop in the mouth even before the skin vesicles become apparent, and can be identified by careful examination of the mouth. The patient can feel these ulcers when the mouth becomes sore on taking salty foods with moderate amounts of chillies.

Complications of chickenpox:

Although it is unusual to develop complications with chickenpox, sometimes due to decreased immunity or wrong treatment methods, there are many instances where mainly adult patients develop complications sometimes even resulting in death. The main complications, which can result from chickenpox, can be listed as:

(1) Encephalitis: This is the inflammation (swelling) of the brain cells due to viral infection and is a serious condition. The main symptoms are severe drowsiness, confusion, vomiting, severe headache and intolerance of bright light. This complication mainly occurs in adults and can be fatal.

(2) Pneumonia: When chickenpox occurs with symptoms like severe cough, chest pain and shortness of breath you have to suspect pneumonia. An X-ray plate of the chest confirms the diagnosis. This condition which also can be fatal, is prevalent among adults and children alike.

(3) Reye's syndrome: This is usually a children's disease, which may occur not solely due to chickenpox but other viral diseases also. During the recent epidemic of viral fever, which spread throughout Sri Lanka, most children died due to this disease.

During the course of this illness the brain becomes inflamed and there is fat deposition on the liver and kidneys causing inactivity of these organs. The disease is usually fatal and occurs mainly in children of ages from 2 months to 15 years. The symptoms are headache, vomiting, confusion and yellowish discoloration of body like in hepatitis. Using aspirin containing drugs to control fever while having viral infections is one of the causes of this disease.

Here is a brief list of general health procedures to follow when somebody develops chickenpox:

If the patient is not severely ill, having a daily bath or a body-wash with clean lukewarm water is advisable to prevent vesicles from getting severely infected and to decrease the general discomfort of the patient.

Use baby soap while having the bath; also you can dissolve a little amount of baking soda into the bath water and this will prevent cumbersome itching of the body associated with chickenpox. You should not rub the body but pat it dry after a bath to minimize the breaking of vesicles.

When there is high fever, the patient can be given 'Paracetamol' to suppress fever and to minimize the damages the high temperature can cause to the body. Never use 'aspirin' containing drugs for fever.

Try to be clean and take nutritious food as much as possible.

Taking bland food like soups and Marmite can help. These foods will increase the capability of the immune system to fight the disease.

Schoolchildren should be kept at home for 7-10 days to minimize spread of the disease among schoolmates. Those in the home who have not developed the disease before should also be kept separated from the patient. It should be borne in mind that the disease starts spreading two days before the appearance of the vesicles and continues until all the vesicles form crusts.

For the ulcers in the mouth, rinsing the mouth with lukewarm water will help to alleviate the pain. A mild antiseptic can be used for the same purpose with medical advice.

Scratching and breaking the vesicles will make them susceptible to bacterial infection. Trimming the nails of small children will help to minimize breaking vesicles. Antihistamines can be used to lessen the itching with medical advice. If the vesicles are infected administering an antibiotic may be necessary under medical supervision.

To prevent chickenpox from worsening into an unrecoverable state, especially in adults, a drug has been produced. This is called Acyclovir, and is used to control disease in immunosuppressed children and in adults. This is also available in Sri Lanka and is expensive.

A vaccine to prevent chickenpox infection was developed in 1995. Even though at the moment this vaccine is not included in the 'Expanded Immunization Programme' of Sri Lanka, it is administered to children in western countries from the age of 1 year to 12 years. In Sri Lanka, this vaccine is available in the private sector and is also expensive. Some children will develop few chickenpox vesicles soon after the administration of this vaccine.

Since it can be fatal for the immunosuppressed patient to develop chickenpox, soon after the exposure, such patients can be given an immunoglobulin injection containing antibodies against Varicella zoster virus to prevent them developing the disease. Since there is a possibility of fetal limb abnormalities when pregnant mothers are exposed to the disease during the first 3 months of pregnancy, they can also be given the same injection.

Superstitions and Scientific Explanations:

Many feel patients should refrain from bathing till 10 days after developing the disease. This is a total superstition.

Some believe that it is bad to eat fish or meat when one develops chickenpox and that diet should be restricted to curries with minimum of chillies and salt. In fact some people practically eat rice and coconut-milk.

Even though chickenpox infects almost all the organs of the body, this happens to a great extent in the skin only; the gastro-intestinal trac and associated organs of digestive importance are almost left intact in normal people. Therefore if one has the appetite it is advisable to give normal food.

There is a belief that the scars of chickenpox are due to breaking of the vesicles and subsequent infection of the broken vesicles and this is totally untrue.

According to latest research most of such scars develop from vesicles that were never broken nor infected. The reason for developing such scars is adherence of the crusts to the deeper layers of the skin and eventual breaking off of the crusts with damage to the deeper layers.

This sometimes can happen in vesicles that were infected.

Finally we should draw your attention towards anther disease which develops in about 20% of the persons who develop chickenpox. This disease called shingles also develops from the same virus called Varicella zoster. Here also the patient develops blisters similar to chickenpox vesicles but these blisters will be restricted to a well demarcated area of the body like the eyes and chest. Before the appearance of the blisters there will be a severe pain in the affected area with fever and bodyaches.

To alleviate this severe pain associated with shingles patients, apply various analgesic creams on the affected areas and when blisters start appearing they think that these are due to an allergy to the cream they applied. The blisters of shingles also get filled with a clear fluid, become pustules and dry up after forming crusts.

This disease itself will not transmit to another person but from the blisters of this disease another susceptible person can develop chickenpox as these blisters also contain the same Varicella zoster virus. Therefore these patients also should be kept isolated like chickenpox patients.

The danger of this disease is its tendency to develop in the territory of the sensory nerves of the eye. In such instances the virus and the immune reactions associated with the virus can damage the delicate tissues of the eye irreparably causing blindness sometimes. Therefore when shingles develop associated with the eyes one should seek medical assistance promptly.

A drink a day, does it keep the doc away?

That a "little" drinking is good for health has been a popular concept throughout the ages. Now this theory is being scrutinized by doctors and scientists to ascertain its truth. Test your beliefs against the latest scientific evidence by stating whether the following are true of false:

1. Alcohol protects against heart disease by thinning the blood:

True. Alcohol does appear to help make cells in the blood called 'platelets' less sticky and therefore likely to form a clot that could block the flow of blood to the heart. Also alcohol appears to raise HDL cholesterol, the "good" kind of cholesterol.

However the problem is, if too much alcohol is taken it also directly damages the heart and that risk is much more than the above benefits. And, no one clearly knows the dividing line between the amount of alcohol that is "bad" and the amount that is "good".

2. The best alcoholic beverage for protecting against heart disease is red wine

False. This is also a popular belief but there is little scientific evidence to support this claim. The research that has been done suggest that red wine, white wine and beer are equally effective in small amounts in lowering the risk of heart disease. Some studies have even suggested that the most protective effect comes from whisky, but this too is controversial to be considered a good practice!

3. Alcohol raises the risk of breast cancer in women.

True. This is probably due to raising the levels of the female hormone Estrogen which promotes the growth of certain type of breast tumours. One study of over 90,000 women in the United States showed that upto nine drinks a week reduced the risk of heart disease by forty percent but raised the risk of breast cancer by thirty percent.

4.Drinking small amounts of wine during pregnancy is now considered harmless.

False. Recent research suggest that drinking even less than one drink of alcohol a day whatever the kind during pregnancy can result in effects on the baby. These include the deadly 'fetal alcohol syndrome' associated with facial malformations and mental retardation. So, drinking during pregnancy is definitely out.

5. Two drinks a day is better than not at all.

False. Researchers, doctors and scientists agree almost universally that no one should take up drinking for the express purpose of reducing the risk of heart disease or any other condition. The potential for alcohol abuse is too strong and it must be remembered that all alcoholics started with two drinks a day or even less. There are much safer and more healthy ways to protect your body; a low fat diet, eating more vegetables and fruit, exercising more and losing excess weight to name just a few.

Infertility:

It's not always the woman's fault!

Tradition, myth and social trend always blame the woman when a couple is labelled as infertile. But now there is increasing focus on the fact that the fault could be with the male. And what exactly does that mean?.

Doctors now know that over a third of all couples who are infertile are so diagnosed because of a fault in the male partner. And, it must be remembered that a couple is diagnosed as infertile only if there is no pregnancy after a year of unprotected sexual activity.

When this is the case, most doctors now "screen" the man first because this preliminary test is cheap and easy to carry out. It is called a Seminal Fluid Analysis (SFA), an examination of the man's sperm.

A "normal' result in this test means a total of 60 million or so sperms of which about 60 percent should be mobile (called motility) and 60 percent should also have the proper shape. If such a test shows below than expected values, the first step would be to repeat the test: Sperm counts are notorious for their inaccuracy.

If the sperm count is still low after repeating the test, some steps may help restore it to normal.

* Reduce stress: Low sperm counts have a definite link to stress and anxiety. Expert help to reduce stress has shown to increase the count significantly.

* Avoiding tight clothing: Tight clothes hold the testicles close the body raising their temperature. Heat interferes with the mechanism of sperm productions.

* Guard against mumps: Mumps - a viral infection is a relatively minor illness in childhood but in puberty and adulthood it damages the testicles in one in three cases. If only one testicle is affected the other can however compensate. Now a vaccine that guards against mumps is widely available.

Even if all this doesn't help, there is still hope. Men with low sperm counts can still have children but success may come after a longer period.

However, if the count is very low, below ten million sperms per cubic centimetre, then other, more specialised methods have to be considered. These include artificial insemination and Invitro Fertilisation (IVF) but of course for these techniques expert help is needed.

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