Wednesday, November 11, 1998

Diabetes care:the growing needs
DIABETES Mellitus (DM) or, the "sugar disease" was originally described as a grave sickness with intense thirst, profuse urination and rapid wasting proceeding through vomiting and drowsiness to deep coma and death.

Deformed babies — the ethics involved
By S.M. Bose
Modernisation has brought to us the realisation of practicability. People have become more realistic in their thinking and attitude. The pros and cons are weighed in respect of everything. What is good and beneficial is jealously guarded; what is not useful is discarded. Sentiments have a negligible role in the modern era.

Dropsy control: Ludhiana’s laudable initiative
BECAUSE of the heavy contamination of mustard oil by argemone seed oil by the end of August in Delhi, the death toll from epidemic dropsy had risen to over 50 and the number of cases to over 300.

Medicine from potato
A U.S. researcher has developed a genetically engineered potato that could offer protection against food poisoning and diarrhoea.

Diabetes care:the growing needs

By R. J. Dash

DIABETES Mellitus (DM) or, the "sugar disease" was originally described as a grave sickness with intense thirst, profuse urination and rapid wasting proceeding through vomiting and drowsiness to deep coma and death. This description from Egyptian ebers papyrus still holds good for a small number of patients with acutely oncoming insulin-dependent diabetes. The majority of patients with non-insulin-dependent diabetes mellitus, however, have very few symptoms or signs at the onset of the disease.

Many have one or the other complication of diabetes in the forth of retinopathy, leakage of proteins through urine, loss of ankle reflex and decrease in erectile function in men at diagnosis. Early diagnosis and treatment can prevent most of these complications and diabetes related heart or kidney disease also.

DM is a genetic disease. It runs in families. Western culture through over-indulgence in "ready to eat" high fat, salt and sugar rich food, canned beverages, decreased physical activities and the stress of modern life has led to an increase in the number of patients with diabetes in developing or developed countries. The revalence of DM among Indians in Singapore, South Africa, Fiji, Mauritius and Southhall (England) is much higher than that in the natives.

Of the estimated 120 million people with diabetes in the world in 1995, 25 million resided in India but by the turn of the century the estimate would be more than 35 million. Besides complications of long-standing diabetes like blindness and kidney failure, diabetes carries a higher rate of age-adjusted mortality and people with diabetes live a life span of 5-10 years lesser.

Diabetes makes a serious economic impact as well. The estimated cost of diabetes care in the USA alone in 1992 was $85-$92 billion, two thirds of which resulted from economic loss to productivity from personal admissions to hospitals or death. This loss will gallop further as the prevalence of diabetes is almost doubling every decade. By the year 2010, the world diabetic population is estimated to be 239 million with more than 138 million residing in Asia alone.

A pharmaceutical fact- sheet adds: A landmark study shows the risk of complications of diabetes can be reduced significantly:

The largest and longest clinical study of diabetes ever attempted led by researchers at Oxford University and conducted over a period of 20 years (UK Prospective Diabetes Study - UKPDS) involving 23 centres, recruited 5,102 patient with Type 2 (non-insulin dependent) diabetes, has revealed that life-threatening complications, often regarded as inevitable, can be reduced by more intensive management of blood glucose using existing treatment.

The study revealed that better glucose control reduces the risk of:

• early kidney damage by a third
• major diabetes eye disease by a quarter

The study also established that amongst those who have high blood pressure, better blood pressure control could reduce the risk of:

• death from long-term complications of diabetes by a third
• strokes by more than a third
• serious deterioration of vision by more than a third

In the past 20 years, patients have been studied for a median of 11 years yielding some 56,122 patient year of experience. The drugs studied included insulin, sulphonylureas, metformin, ACE inhibitors and beta blockers.

The study confirmed that Type-2 diabetes is most significantly associated with cardiovascular disorders. it has also confirmed the need for early intervention for multiple risk factors cardiovascular diseases — is chemic heart disease.

Prof Robert Turner, Prof of medicine and Prof Rury Holmar, Prof of Diabetic medicine led the study at the University of Oxford. Prof Turner said: "At present diabetic complications are often regarded as being natural outcome of this chronic disease. This study shows definitely that the good management, including improved blood glucose and blood pressure, does help in preventing complications.

Says Dr Anil Kapur, Managing Director, Novo Nordisk Pharma India Ltd: "For the first time there is evidence to show the risk of complications of Type 2 diabetes can be reduced with more intense application of the existing therapies to maintain good control of blood glucose. This will allow people with diabetes to look forward to the future with greater confidence."

Dr Kapur strongly pleaded that, "awareness must be raised about the impact of diabetes how best to treat and to improve and save lives.".

This landmark study was jointly funded by the UK Medical Research Council, the British Diabetic Association, the UK Department of Health, the US National Institute of Health, the National Eye Institute and the National Institute of Diabetes, Digestive and Kidney Disease, British Heart Foundation.

In this research significant contribution and support were given by well known Pharmaceutical firms like, Novo Nordisk, Pfizer, Farmitalalia Carlo Erba, Roche, Smithkline Beechan, Glaxo Wellcome and Bristol Meyers Squibb.

Dr Dash is Professor and Head of the Department of Endocrinology at the PGI, Chandigarh.

Deformed babies — the ethics involved
By S.M. Bose

Modernisation has brought to us the realisation of practicability. People have become more realistic in their thinking and attitude. The pros and cons are weighed in respect of everything. What is good and beneficial is jealously guarded; what is not useful is discarded. Sentiments have a negligible role in the modern era.

In this context, the question of deformed babies has become a matter of debate among medical, social and legal workers.

The question being asked is: Does society have to carry the burden of a deformed baby?The ethical aspect involved is multifaceted but before we consider it, let us get familiar with the term "deformed babies". A human being can develop deformity at any stage of life but deformed babies is a term used for denoting babies who are born with some malformation.

The deformity may be a simple one or it may be of a very devastating nature. The deformed or disabled children have been classified by P.P. Ricksham into five grades, according to the severity of the deformities present. Grade I denotes no physical handicap. Grade IIhas moderate physical handicaps. Grade IIIhas severe handicaps. Grade IV includes physical handicaps with subnormal intelligence and Grade V denotes physical handicaps with grave mental retardation.

Children with subnormal intelligence can be put into three groups: (A) Mildly deficient, called morons; they are also called educable. They can do simple jobs, carry on a simple conversation and understand simple social responsibilities. They cannot do such work as requires any judgement beyond what is required in routine tasks.

(B) The moderately deficient ones called the imbecile are trainable. Unable to do any school work, they can be trained to keep themselves clean, attend to their toilet needs and eat without help. They require support and care all through their lives.

(C) Children with severe mental retardation (called idiots) are totally dependent. They can't take care of themselves. Usually, they acquire no vocabulary. At the most they learn only a few words. They are incapable of doing any constructive work.

Children with severe physical deformities or with serious mental retardation are under discussion and controversy. These unfortunate children cause a lot of suffering, deprivation, anxiety, worry, frustration and financial burden not only to the family but also to society.

The other question that is being asked is whether these children are serving any useful purpose or, for that matter, are they giving any pleasure or satisfaction to the family or to the community?If the answer is "no", why should society carry such a burden? The sanctity of life is being contested and there arises the question of ethics, legality, and morality. The medical profession, legal experts and society as a whole will have to find answers to these pertinent and topical questions.

Before we consider the ethics involved, let us get familiarised with a few facts:

1. The total number of the deformed babies is increasing rapidly, not only because of the increase in the population but also because of many other factors, e.g, the intake of drugs, the artificial means used for fertilisation and the increased risks of radiation.

2. Neonatology and neonatal surgery have made spectacular progress during the last quarter of the century and it is now possible to save an ever-increasing number of new-born babies suffering from severe congenital defects. This has further swelled the number of deformed babies. Some of them might have undergone multiple operations to attain relief.

3. It is also possible to undertake foetal surgery but then it is not possible to take care of severe deformities. For example, one cannot reconstruct an absent lower extremity or enlarge the size of the skull in a microcephale.

4. No parent, brother or sister or relation wants to have a deformed baby but they are forced to accept this relation. A large percentage of such people feel it to be a matter of shame and guilt. They usually do not talk or introduce their deformed children to anyone. The feeling of guilt is long-lasting.

5. With the existing norms of one or two children only, families have become smaller and you can well understand the situation when they find that the "only child" is a deformed one.

6. Modern-day living has become so hectic that a person does not have and cannot spare enough time for a deformed baby, particularly when he realises that the effort is unrewarding — financially and socially.

7. The offspring of deformed persons can also be severely handicapped.

8. It has been conclusively proved that a mentally retarded person is more prone to becoming an epileptic, a criminal, a drug addict or a person afflicted by AIDS. Some such persons have to earn their livelihood even from prostitution!

9. Lack of personal hygiene is a big nuisance as illustrated by the well-advertised case of Maharashtra where the authorities of a mental asylum had to undertake hysterectomies (surgical removal of the uterus or the womb) for all the mentally deficient young female inmates of the asylum in order to prevent the mess that was being created during their cyclic days. A court of law banned it following an outcry from some sections of the public.

10. It is a fact that as things stand now, developing or underdeveloped countries like India cannot provide diagnostic and curative health care to their citizens. The hospitals are deficient in all respects — medical and paramedical staff, equipment, beds, drugs, linen etc. the waiting list is becoming longer and longer. The private sector, particularly in India, is coming in a big way but the cost of the care is prohibitive.

Deformed children require expensive special and (often) institutional care.

11. Thanks to the high-tech facilities available now, it is possible to diagnose congenital deformities during the intra-uterine life of a foetus.

This provides an opportunity for taking a decision for the termination of gestation and thus the birth of a deformed live baby is prevented. Maybe, this is less traumatic (even for the parents) than to see a baby deformed but living.

Armed with the above-mentioned hard facts, a segment of society has started protesting against the policy of giving medical help to all deformed babies. A new concept of selection is being introduced whereby it is proposed to give medical care to a class of handicapped babies and others are to be denied this facility. The process of selection divides deformed babies into two categories:

(a) Those who should be provided total medical care

(b) Those who need not be given medical care

The denial of treatment to any human being involves ethical, legal and social problems. So, before taking any decision, this concept has to be discussed and debated at various forums, and a consensus arrived at. Then only can it be put into practice.

It is well known that a segment of society, particularly fundamentalists and religious fanatics, will not like to withhold medical care from anyone as life is sacrosant. It is a gift from God and human beings have no right to interrupt it. But then one will have to consider one's priorities and cut the coat according to the available cloth. It does not require superior intelligence to make a choice between two babies — one having severe deformities and the other suffering from a benign disease, say, appendicitis or a stone in the urinary bladder.

A number of modalities have been discussed to eliminate the severely deformed babies — those in Grades IV and V.

(1) Euthanasia: This was practised in many of the earlier civilisations and many people are of the opinion that it is more humane to terminate an incurable existence painlessly. But it seems euthanasia should be permitted at the request of both parents and with the approval of the attending specialist.

(2) Segregation during the reproductive age and compulsory sterilisation may be practised. This will control propagation.

(3) The liassez faire policy of "masterly inactivity": If left alone, these severely handicapped ones are likely to be eliminated in our competitive world.

This may perhaps be the most acceptable modus operandi.

Such a practice is being already undertaken in terminal cases of cancer where it is realised by the clinician that any attempt at treatment except for prescription of pain killers is going to be a useless activity.

Mutual understanding, cooperation and trust are the essential factors for the treatment of the deformed babies. In case there is any discrepancy between the thoughts of the surgeon and those of the parents, there may be a lot of problems in finding out the appropriate course of action. Such a situation may bring up legal and other complications and there lies the role of ethics.

One cannot blindly follow either Hitler or Mother Teresa. A practical person will have to take the middle path with a clear aim and purpose, and find out and implement policies based on facts and realities. The priorities must be clearly understood and specified.

The writer is Professor of Surgery at the PGI, Chandigarh.

Dropsy control: Ludhiana’s laudable initiative

BECAUSE of the heavy contamination of mustard oil by argemone seed oil by the end of August in Delhi, the death toll from epidemic dropsy had risen to over 50 and the number of cases to over 300. Acting in haste, a blanket ban on the sale of mustard oil was imposed oil was imposed in many states without finding how such a high contamination occurred in Delhi.

The last reported epidemic of dropsy cases in Delhi was in 1973; none of the 45 patients died. Though not a single case of dropsy had been reported from Punjab, the Health Minister of the state imposed a ban on August 29 on the sale of mustard oil "with immediate effect" under the Prevention of Food Adulteration Act, 1954.

In Ludhiana alone, over 90 mustard oil producers, and many more wholesale traders and retailers were hurt by this ban. District health authorities started collecting samples and sending them for testing, to various laboratories including those in Rajasthan and Calcutta.

What was hurting the mustard oil business and the public at large was lack of local credible facility for testing which could give results within a day or two.

Mercifully, around that period, following a media report (by The Tribune) of a few cases of dropsy in Ludhiana, Dr Satnam Singh, Director, Regional Institute of Public Health in Chandigarh, got in touch with Mr Arun Goel, the DC of Ludhiana, and asked him to help with investigation and control measures.

Under the chairmanship of the DC the first meeting took place on September 15 in which other participants were district health leaders, representatives from the Community Medicine Departments of two local medical colleges (CMC and DMC), the District Food Supply Officer and a biochemist from Punjab Agricultural University.

One of the decisions taken was to explore the feasibility of creating a reliable testing facility either in Ludhiana or in Chandigarh. As a result inter-institutional dialogue was stepped up, and by mid-October, the DC of Ludhiana was informed that the Biochemistry Department of the PGI, Chandigarh, had established appropriate facilities for testing oil and also human samples (blood and urine from suspected dropsy cases) for the presence of alkaloid sanguinarine — the toxic element in argemone, seed oil. chemically pure sanguinarine was obtained from the USA which is being used as standard for the TLC test; it can detect very low levels of the toxoid.

Mr Arun Goel, through the mechanism of inter-institutional "Core Group" — initially formed for dropsy control — is currently strengthening the surveillance and control of water and food-borne diseases like cholera, typhoid and hepatitis in the district. (Health Tribune News)

Medicine from potato

A U.S. researcher has developed a genetically engineered potato that could offer protection against food poisoning and diarrhoea.

Eating the "vegetable vaccine" produces an immune response which is as strong as when exposed directly to strains of E.coli bacteria which causes severe diarrhoea, reports Discover.

Charles Arntzen, a plant biologist from the Boyce Thompson Institute for Plant Research in New York, transferred the antibiotic gene of E. coli into the genetic material of potato.

As the potato could not be tricked into producing enough E.coli proteins to elicit an immune response, he synthesised an artificial gene identical to the bacterium.

When small chunks of raw potato incorporated with the synthetic gene were taken orally by 14 volunteers, antibodies against E. coli appeared in the gut.

"This is going to be a very effective strategy for delivering oral vaccines", Arntzen says as the vaccine goes straight into gut.

He hopes this engineered potato will be the forerunner of many edible vaccines against a wide range of of diseases, including cholera and hepatitis B.

He plans to test a potato vaccine for Norwalk virus that causes gastrointestinal disease later this year.