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| HEALTH TRIBUNE | Wednesday, August 2, 2000, Chandigarh, India |
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July 26 was Kargil Day
Life after breast cancer treatment |
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Rural and slum health-care
During a short internship as a student in Mahatma Gandhi's ashram, a cluster of thatched mud huts at Sheogaon in the heart of rural India, a few miles away from Wardha, I used to see a daily stream of national leaders of the time, including Jawaharlal Nehru. They seemed to be on a political pilgrimage to the ashram, raising clouds of dust on the kutcha apology-for-a-road from Wardha to Sheogaon. One day I gathered courage and asked Mahatmaji why he had chosen that hottest dusty village instead of Wardha for his ashram. He paused for a while. Then, with a grim and wrinkled but glowing face, a prophetic look in his gleaming deep eyes behind his spectacles and with a child-like stutter because of only a few teeth left in his jaws, he said: "Because this is the real but neglected India, which we need to build as a strong base". And with a stoop and a stick taller than him he briskly walked away to his mud hut. Scholars have since written volumes on the economies of poverty. They include Amartya Sen, the Nobel laureate. Eighty per cent of India's population still lives in rural areas, and also in slums. Yet, more than 80 per cent of all facilities, including health-care, is being enjoyed by the 20 per cent of the urban population. This was so prior to 1947. This is so even today! We need many incarnations of Mahatma Gandhi to build the rural India of his dreams. The Union Territory of Chandigarh has nearly two dozen villages. It also has about 60,000 jhuggis in several slum colonies, harbouring an ever-increasing population of about three lakh migrants from the east, the west and the south of India. Some villages have so-called dispensaries. Many have no medical facility at all. Slums, having mushroomed as unauthorised habitats, are, perhaps, not entitled to having a government dispensary. It is very heartening, indeed, to see Lt-Gen J.F.R. Jacob, the Administrator of the Union Territory of Chandigarh, visiting the rural areas and slums in his Territory, introducing positive welfare measures, particularly for education, health-care, the supply of water and electricity and general rehabilitation. The problems are too many and too gigantic for the Government to solve them alone. People's participation is essential. NGOs must come out of their urban enclaves and join hands in studying and solving each problem. More than six years ago, we reconnoitred the north-eastern rural and slums belt of the Union Territory to assess the health-care problems. This area, besides three major villages — Hallomajra, Ram Darbar and Karsan includes labour in Industrial Area phases I and II, and large clusters of slums around Sector 31. It has a population of about 1.5 lakh with one dispensary, no doctor most of the time, an inadequate stock of medicines, but several quacks. The area is endemic for malaria, tuberculosis, leprosy, helminthic infestations, respiratory, gastrointestinal and dermal infections of all types, deficiency diseases attributed to chronic malnutrition among women and children, like night blindness, rickets, osteoporosis, etc., drug and alcohol addiction, diabetes, hypertension, coronary artery disease, paralytic strokes, a wide range of ENT and ophthalmic ailments, besides cataract, glaucoma, and arthritic ailments of all types. We could not carry out an AIDS survey. The area is notorious for industrial injuries, burns, allergic reactions and chest problems caused by toxic fumes. According to the laid-down norms, the area needed a fully equipped primary health centre. There was an urgent requirement for a well-equipped laboratory to do complete urine and stools examination, haemograms, lipid profiles, liver and kidney function tests, pregnancy tests, etc. In view of the broad spectrum of the prevalent sicknesses mentioned above, an x-ray service was also essential. Cardiac ailments necessitated at least an ECG service. A well-stocked dispensary to combat the variety of ailments was thought to be the foremost requirement. The establishment of a primary health-centre visualised by us entailed a total initial outlay of five to six lakh rupees with a recurring monthly expenditure of Rs 10,000 to Rs 15,000, a three-or four-room accommodation, a team of dedicated doctors, medical technologists, selfless social workers and a regular transport service, for the cause of health-care for those less fortunate stepsons and daughters of the soil. This mega-function was not possible by any one NGO. A multi-organisation and well-coordinated effort were required. The popular Senior Citizens' Health-Care Centre at Lajpat Rai Bhavan, Chandigarh, the only pioneering place of its kind in North India successfully functioning for more than a decade, took the initiative to collect funds for the health-care centre for have-nots in the rural and slum areas surveyed so far. The Lions Club (Greater) at Karsan village provided the minimum accommodation required. The Chartered President Lion Ranvir Uppal, a reputed industrialist and philanthropist, incurred an expenditure of more than Rs 1.5 lakhs from his personal accounts to modify the already existing hall for five-fold health-care service: consultancy, dispensary, laboratory, x-ray and ECG. Lion Ranvir Uppal deserves our tribute. He has made generosity a nobler word. The Indian Red Cross Society (UT, Chandigarh) provides medicines and transport under the dynamic leadership and cooperation of its Secretary, Mrs Geetanjali Kundra, IAS. Her natural help and empathetic compassion for the weaker sections of society should inspire other officers to look within and without and to give until a hurt is healed. The pioneer multi-organisational health-care effort at Karsan is now an oasis amidst the desert of disease and destitution for the villages and slums on the north-eastern periphery of the Union Territory. Free expert consultancy with free dispensary, laboratory, x-ray and ECG services have been rendered to thousands of men, women and children over the past five years. With the enthusiastic cooperation of the Health Secretary, the SDM-cum-BDO, the Red Cross Society and the Sarpanch and the Panchayat, we are in the process of setting up a similar health-care centre at Raipur Khurd. We have enough resources to establish two similar health-care centres in the south-western segments of the Union Territory if suitable three or four-room accommodation is made available to us by the Administration or the panchayats. We invoke your blessings, O, Goddess of Health! Dr (Brig) M.L. Kataria, honoured recently with the prestigious Dr B.C. Roy Award for his tireless socio-medical work among the poor and the underprivileged, is the coordinator and honorary consultant to the above-mentioned project. His dedication, erudition and professional expertise make any award given to him look inadequate.
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July 26 was Kargil Day
"In the pursuit of his profession, a surgeon can wish no more welcome test of fire than the battlefield": Ambrose Pare, a French Army surgeon, who is considered to be the father of modern war surgery, has bequeathed to us this thought to make memorable our journeys through tunnels of treachery made by brutes with serpents in their minds. while seeing the tele-coverage of the Kargil operations, besides other variables, I constantly noticed Bofors guns firing on mountain-tops and ambulance cars with the prominent Red Cross mark running frantically. Whereas other details of the operations were depicted with great graphic displays the role of the Army Medical Corps was shown only by that ambulance. Surely a lot of dedicated service went into the sterling work of this prestigious corps. This was a great morale booster. I wish to highlight some gross facts below: Operation Vijay, as the Kargil operation was named, had the following battle casualties (BC) and battle accidents (BA). (a) Total number of casualties admitted in hospitals — 1,363 (b) Total number of casualties who died — 14 (c) Total number of casualties requiring hospitalisation and subsequently mentioned in low "medical categories" — 851 (d) Total number of BC who returned to units in the medical category AYE — 498 (e) Total number of BC with disability (i) Less than 50% — 724 (ii) 50% to 75%— 109 (iii) 76% to 100% — 28 (f) Total number of amputations suffered. (i) Upper limbs — 14 (ii) Lower limbs — 17 (g) Total number of eye-injuries (i) One eye with the loss of vision — 83 (ii) Both eyes — 12 (h) Total number of cases of hearing loss — 8 (i) Type of weapons causing injuries. (i) Gun-shot wounds (GSW) — 148 (ii) Splinter injuries — 74 (iii) Burn injuries — 7 (iv) Mine burst — 41 (j) Miscellaneous High altitude pulmonary oedema (HAPO)/cold injuries — 793 The above facts may be boring to the uninitiated but the anguish in them brings out the enormity of medical efforts required to manage casualties. Ten Commandments for the healers: There is a distinct line of management of war surgery and Army surgeons have to be specially trained. There are Ten Commandments for them to follow: 1. The primary operation should be carried out early. This is good for the high fighting morale of the troops. 2. Surgeons with extensive experience of civilian surgery may make costly mistakes in field conditions. I had the fortune of operating as a surgeon both in the 1965 and 1971 Indo-Pakistani wars. Brilliant civilian surgeons, hurriedly requisitioned and patriotically operating, made grievous mistakes because of wrong orientation and lack of knowledge of war surgery. 3. Surgery in general should be simple and standardised. 4. The care of the injured depends on the "adequacy of the surgical services". 5. Siting of surgical centres should not be in terms of kms from forward areas but in those of the number of the hours preferably within six hours! 6. Large surgical centres grouped together are better. 7. Early primary wound toilet and antibiotics are better. 8. Cardinal principles of controlling bleeding, ensuring a clear airway, i.e easy breathing, and immobilisation of limb injuries are to be ensured. 9. Maximum use of air-evacuation. 10. Meticulous documentation. Casualty management: The brunt of casualties was borne by Kargil itself. Besides, local resources, a surgeon and an anaesthetist were dispatched from the Command Hospital (WC). They did a good job and were given the gallantry award — a "Sena Medal" each. After Kargil, the 92 Base Hospital at Srinagar and the 148 Command Hospital at Udhampur performed well. A large number of casualties kept on coming direct to the Command Hospital, Chandimandir, where on any day there were 70 to 100 casualties. These were being managed under the overall supervision of the Commandant, Command Hospital (WC) by general, orthopaedic, neuro, gastrointestinal, eye, ENT surgeons, anaesthetists, physicians, cardiologist and efficient nursing and paramedical staff. Visiting this hospital in the thick of activity was an eye-opener with regard to the dedication of the Commandant and his committed team. The details of the management may make dull reading. Incidentally, many philanthropic institutions came and gave gifts for the Kargil casualties. The Media The role of the media is worth mentioning. On the request of a senior functionary, a team came to The Tribune office and collected 70 units of blood. The employees volunteered to "give more blood" but the hospital requirement had been met. This blood was promptly airlifted to forward medical units. A Kargil Relief Fund was launched by The Tribune where not cash but bank drafts were collected directly in the Army's name and despatched. A sum of more than Rs 2 crore was thus donated transparently. Various TV channels and newspapers gave excellent coverage. The Kargil operation has been the nation's war against its traditionally treacherous neighbour who, under the garb of bus-diplomacy, intruded into our sacred area to cheat us. The nation showed its grit and threw out the intruders. The Army Medical Corps gave an excellent account of itself with rare dedication from the Forward Defended Locality (FDL) to its prestigious Research and Referral Hospital in Delhi Cantonment. In recognition of these services, the President, Mr K.R. Narayanan, liberally blessed the Corps with 19 honours and awards.
Maj-Gen Jaswant Singh has been a consultant surgeon to the Army for many years. He retired as the Director of Medical Services, Western Command. At present he is a practising surgeon and urologist based at Chandigarh.
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Life after breast cancer treatment
A
hallmark of the natural history of breast cancer is the propensity for delayed spread. Breast cancer patients have also been known to be at high risk for the development of new breast cancer. The risk continues indefinitely. A number of factors increase the possibility of a second breast cancer—young age at diagnosis, family history of breast cancer and certain pathological features. In caring for the women who have been treated for breast cancer, people want to know a number of things. The fear of recurrence is a constant, nagging companion of most of the women who have survived breast cancer treatment. In caring for them, the following issues are of primary concern: Tumour recurrence and second breast cancer: The primary concern is the reassurance that cancer will not recur in the anxious patient having survived the initial threat. The well-known predisposition to delayed onset makes it a life-long issue for women. Patient visits should not be scheduled more often than necessary as they may cause great anxiety. Patient should be seen more often during the first three years as about 50 per cent of the recurrences occur in the first three years after the diagnosis. They should be examined every three to six months for the first three years after primary therapy, then six to 12 months for the next two years and then annually after five years. The patients must understand that if any of the symptoms like bone pain, cough, dyspnoea, persistent fatigue, anorexia, weight loss and scar changes develop, they should see their doctors promptly. Bone tenderness, liver enlargement, and neurological abnormalities point towards a distant spread. A tumour may recur locally in the scar, the chest wall or the axilla (armpit). The early detection of local recurrence helps in improving the quality of life. The routine measurement of blood or tumour markers is not very helpful. The screening of asymptomatic patients with bone and liver scans is of unproven value. Sexual function: An altered sense of femininity and the feeling of decreased attractiveness are important causes of stress. Patient and partner education should focus on the potential effects of breast cancer and its treatment on sexuality. Fertility and pregnancy: For the breast cancer patients who wish to become pregnant, an important question is whether endocrine changes in pregnancy promote tumour recurrence. A number of studies have addressed this issue and evidence indicates that pregnancy does not increase the chance of recurrence. Most physicians who treat breast cancer patients support attempts at pregnancy in patients who are free of recurrence two or more years after the diagnosis. Patients are often advised to delay attempts at conception until after two years of the diagnosis. Attempts at conception should be avoided during tamoxifen therapy. Engorgement of the arm occurs in at least 20 per cent of the women following the removal of lymph nodes from the axilla and or radiotherapy. This swelling may arise many years later. Patients complain of heaviness in the arms and an increase in the arm-size. This swelling is usually permanent and almost always progressive. The condition has no cure and it is difficult to manage when it becomes severe. However, some preventive steps can help. It is good to avoid excessive heat and constrictive clothing. The infection or injury even of a minimal degree warrants the use of antibiotics. One should not carry one's purse or briefcase over one's shoulder. Heavy weight-lifting and lengthy or vigorous pushing, pulling or scrubbing should be avoided. The skin should be dried well so that moisture does not remain in the folds. The unaffected arm should be used whenever one has blood drawn, injections given or blood pressure taken. Another long-term local complication is the limited range of motion in the shoulder, typically caused by pain, the fear of movement and scarring. Massage and prolonged stretching help regain the lost function and prevent further loss. A large number of women have survived the diagnosis and therapy of breast cancer and are free of recurrence. Efforts are required to meet the specific psychological needs of the patients and help them face the future with confidence and optimism.
Dr Wig is a renowned surgeon, author and teacher based at the PGI, Chandigarh.
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Does your child wear glasses? Continued from last week’s Health Tribune Children usually touch lenses with their hands, making them dirty. Unclean and scratched lenses cause hazy and distorted vision which interferes with the development of normal vision in children. Therefore, make sure that the lenses are clean and scratch-free. You can clean the glasses simply by washing them with water and then making them air-dry or mopping with soft cloth. If the glasses are still not clean, apply a little soap on your finger and rub it gently on the glasses and then wash with water. Make sure that there are no granules of soap on your finger before rubbing. Otherwise, it will cause scratches on the lenses. Glasses with scratches need to be changed. Children usually fiddle with side bars causing tilting or bending of the spectacle frame. This changes the effective power of the glasses and also adds cylindrical effect. Please make sure that side bars of the frame are straight and not tilted. Parents usually ask whether the child should wear glasses continuously or only while reading/watching television etc. Remember that in children, vision continues to develop from birth to six years and a continuous wear of glasses is extremely important for the development of normal vision. If the child has been prescribed glasses but he/she does not use or uses them only occasionally, the light will not focus on the retina and a normal vision will not develop. This condition is called "lazy eye", or "amblyopia". If "lazy eye" is not treated by 10 years of age, the child will have to live with a visual handicap throughout his/her life. If the child is not using glasses, he/she will have to use focusing effort to see clearly. This will disturb his/her eye muscles balance and cause misalignment of the eyes called "squint" or "tear". So, the child should wear glasses continuously during the waking hours. A common myth in our society is that if the child wears glasses continuously, his/her number (power) of glasses will not increase. It is not true. A constant wear of glasses has no relation to the increase or decrease of number. It depends upon the development of the eye as the child grows. A minus number usually tends to increase and a plus number tends to decrease with the age of the child. Therefore, if the child is wearing a small plus number, he/she may get rid of the glasses, whereas if the child is wearing a minus number, most probably he/she will have to wear glasses for the rest of life. A minus number tends to progress up to the age of about 20 years and stabilises thereafter. Another myth is that the intake of a lot of carrot, fish, vitamin A capsules, etc, by the child will decrease the number (power) of glasses and eventually the child will get rid of glasses. There is no scientific truth in it. Overloading the body system with vitamin A does not help in improving vision. Remember that an overdose of vitamin A (by the intake of vitamin A capsules) can cause side-effects like the swelling of the brain. Therefore, unnecessary supplementation of the diet with vitamin A should be avoided. There is no special diet for reducing the power of glasses. It is well known that too much "near-work" can cause short-sightedness (myopia). We often see children having an increase in their power of glasses after their examination and this may be related to too much reading from too close a distance during the examination period. A wrong reading posture, improper reading distance and poor illumination in the reading room also put strain on the focusing mechanism of the eye and can cause an increase in the power of glasses. Hence, children should be advised to study in an upright posture at a reading distance of about 40 cm with good focused light on the book or the reading material. When a child starts wearing glasses, the vision should be rechecked every six months. Whenever the child complains of difficulty in seeing letters on the black board, he/she should be taken to an eye specialist for a check-up of the vision. Sometimes glasses are prescribed for the correction of a special kind of squint called "accommodative squint". Here the child is farsighted (using plus lenses) and can focus the eyes to compensate for the far-sightedness, but the focusing effort (accommodation) to see clearly causes the eyes to cross. Glasses reduce the focusing effort and straighten the eyes. If the child is wearing glasses for "accommodative squint", glasses should be rechecked whenever squint starts reappearing after the initial straightening of the eyes with glasses. It is important to get a check-up done for the power of glasses every time before asking for new glasses. A properly fitted spectacle frame with an accurate power of glasses goes a long way in providing a comfortable and clear vision, and in maintaining a normal parallel alignment of the eyes. Therefore, do not take spectacle wear in your child casually.
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