When death strikes suddenly
Dr S.K. Jindal
IN response to my earlier article "Sudden death — a doctor’s nightmare", published in these columns, several readers had questioned me as to why a healthy individual should get sick and die suddenly in the absence of a known illness and why should not doctors be able to save him. As to the second question, I accept the enormous Inadequacies of medical science in the understanding as well as the management of such issues in the very beginning.

Nursing: a challenging career
Dr A.K. Banerjee and Dr Madhu Meeta
THE Practice of nursing is as old as civilisation. Nursing is a helping profession. It provides services which contribute to the health and wellbeing of the sick and the needy. Nursing is of vital consequence to them. It fills the needs that cannot be met by the person the family or other persons in the community. However, nursing is fast emerging as a challenging and fulfilling career option. 

Preventing asthma deaths — some basic facts
Dr S. Lavasa
DEATHS are a tragedy. A preventable death, particularly that of a child or a young person from a fully treatable condition such as asthma is a dreadful experience for all concerned (including health professionals).

Can disease be conquered? The struggle continues
Sohrab Arora
THE world stands on the threshold of a new era in which hundreds of millions of people will be safe from some of the most terrible diseases. Soon, polio, neonatal tetanus, leprosy and Chaga's Disease will join smallpox as diseases of the past. But still, a basic question needs to be answered: can the world be disease-free? Can disease be conquered, ever?

AYURVEDA & TOTAL HEALTH 
Days of glory in Punjab of yore
Vaidya Shiromani Dr R. Vatsyayan, Ayurvedacharya
EVER since his emergence on this planet, man has desired to remain healthy. He has understood the fact that it is the disease-free state of the body and the mind which alone can help him to achieve his worldly pursuits. To fight disease, he has continuously pursued knowledge and gained experience. This eternal quest has made the science of life the oldest among the systematic studies.

When death strikes suddenly
Dr S.K. Jindal

IN response to my earlier article "Sudden death — a doctor’s nightmare", published in these columns, several readers had questioned me as to why a healthy individual should get sick and die suddenly in the absence of a known illness and why should not doctors be able to save him. As to the second question, I accept the enormous Inadequacies of medical science in the understanding as well as the management of such issues in the very beginning. For the first question, I may repeat what John Webster had said some four hundred years earlier.

Let me start with two well known examples. The whole nation was stunned when Prime Minister Lal Bahadur Shastri unexpectedly collapsed during his visit to Tashkent in the USSR after the 1965 Indo-Pak war. Years later, it was the untimely and relatively sudden demise of actress Smita Patil, following normal child-birth, which shocked everyone. Both were important persons who had possibly no known record of the pre-existing disease. The death of Lal Bahadur Shastri was attributed to a massive heart attack and that of Mrs Patil to obstetric shock. Both were entirely different problems but for the similarity of suddenness and untimeliness.

It is this puzzling similarity between dissimilar causes of death among men and women of different age groups under different circumstances which remains a matter of concern. It often arouses anger, frequently causes distrust and occasionally leads to violent emotional outbursts. The reason is generally obliterated and the victim is one who is on the scene — howsoever well-intentioned and helpful he or she might otherwise have been.

It is difficult to believe and even more difficult to accept the sudden demise of an apparently healthy individual. Deaths due to trauma of any cause are easy to understand although painful to accept. Whether it is a vehicular collision on the roadside or a blast caused by a terrorist, drowning in a river or burning in a raging fire, all are accidents which are potentially avoidable and are accepted as a part of life. Death without an obvious accident is almost unbelievable — mostly because one neither knows nor understands the cause of death. At best one can know of the events preceding death, which too are generally hazy and unclear.

It must not surprise many to know that the list of diseases and disorders which can afflict healthy individuals and prove to be fatal within a short period is rather big.

A "heart attack" is perhaps the most known and acceptable item on this list. Undoubtedly, the suddenness is better understood for problems involving the heart. The moment the heart stops beating, life ends; that of course is only a simplistic statement without going into the medical details. Sudden cardiac death is a form of natural death except when it happens in the young. Sudden death may happen even in the first few months of life — the Sudden Infant Death Syndrome. Later in life, sudden cardiac death is attributable to a structural and/or functional defect of the heart.

In several instances, there is no demonstrable heart disease and the blow is rather spontaneous. Of course, there are possible medical explanations with ill-defined syndromes which would hardly satisfy an aggrieved relative. Some of these syndromes could well be congenital or hereditary.

The common cardiac cause is the cessation of the blood supply to a vital area of the heart due to a block in the coronary arteries which get narrowed over a period of the time but manifest only when the critical level of narrowing is reached. The block may also happen suddenly in a previously healthy vessel, for example from a blood clot.

Similarly, a blood clot blocking a brain-vessel can cause a stroke. A brain hemorrhage is more serious and may occur in the young, for example, because of the rupture of an aneurysm — a bubbly projection on a vessel due to a weak spot on its wall. A major epileptic seizure can be as frightening and dangerous especially because of its propensity to cause accidents!

Although sudden cessation of breathing may occur following occlusion of the upper airways or trachea from a foreign body, there are very few intrinsic diseases which would do the same.

A blood clot in a major pulmonary artery can prove to be fatal. This could happen in several underlying medical or surgical disorders including old age, debility and a prolonged bed-ridden state.

Infections, tumours and other problems would generally take a few days — sometimes only a few hours — to do the damage amounting to death. This is true for several other acute diseases involving the vital organ system. Several drugs can cause similar complications. Hypersensitivity and anaphylatic shock can be one such dreaded problem. Unfortunately, it is entirely unpredictable most of the time.

It is not intended here to advise a search for the hidden agents of doom in the absence of a problem. Such an effort is a futile exercise. Inadvertently, it results in fear and anxiety. But it is always good to know of the fallibility of human life and of the limits of medical technology.

Dr S.K. Jindal is Professor and Head of the Department of Pulmonary Medicine, PGI, Chandigarh.

Nursing: a challenging career
Dr A.K. Banerjee and Dr Madhu Meeta

THE Practice of nursing is as old as civilisation. Nursing is a helping profession. It provides services which contribute to the health and wellbeing of the sick and the needy. Nursing is of vital consequence to them. It fills the needs that cannot be met by the person the family or other persons in the community. However, nursing is fast emerging as a challenging and fulfilling career option. Florence Nightingale (1820-1910), the creator of today’s nursing principles, established the world’s first modern nursing institute in St. Thomas Hospital, London. Her birthday is celebrated worldwide every year on May 12 as "Nurses Day." In India, the first nursing college was set up in New Delhi in 1946, now known as Rajkumari Amrit Kaur College of Nursing.

A qualified nurse provides the much-needed holistic tender touch to the sick, giving him relief. The World Bank Report (1993), showed that nurses could be cost-effective in providing primary healthcare, pediatric help and geriatric care. Either in independent practice or in a hospital setup, nurses are most useful in fighting disease, generating hygiene awareness, and providing primary secondary or tertiary healthcare, and in promoting health education. Nurses can be very good communicators, counsellors, researchers and advocates of human rights. The code of the American Nurses Association states: "Nurses act as safeguard to the client and the public when healthcare and safety are affected by incompetent, unethical or illegal practice".

In spite of tremendous socio-economic development, India lags behind in public health. About 10% of the population is affected with AIDS. Every minute, one person succumbs to TB. Heart attack claims 2.5 lakh lives every year. Violence, accidents, addiction, unsafe deliveries and other social ills are on the rise. Nurses are invaluable as a key component in any combat strategy. However, until recently, nursing education was limited to big cities only. Rural girls had little or no access to it.

The Government, attributing due importance to nursing education, facilitated nursing institutes in rural areas. To create new job opportunities, to generate self-employment potential and to improve the health standard of society, Bengal Institute of Nursing Education has been set up in Raikot, Ludhiana district. Such ventures will ensure economic freedom of rural women, ultimately leading to the true empowerment of women. The principle of Bengal Institute of Nursing Education, i.e., rural development in the health and education sectors, too supports the WHO clarion call of 2002: "Move for health."

The following are a few important proposals for a more effective system of nursing education:

1. A separate autonomous directorate of nursing under the state government.

2. Full-time nurse-registrars in all states.

3. Opening of more rural nursing institutes.

4. Uniform and affordable fees in all public/private sector nursing institutes.

5. Awarding a diploma, instead of a certificate, to G.N.M. students.

6. Use of the mother tongue as the teaching medium.

7. Research or project work in the G.N.M. syllabus.

8. Fully modernised practical training, computer education and basic clinical laboratory techniques as subjects.

9. Stress on personality development, nursing administration and nursing management as compulsory subjects.

10. Promotion of nursing as a profession among men.

To achieve a higher level of nursing, the need of the hour, is a better education system that is liberally and scientifically based, flexible, culturally sensitive, and is founded on the core values of the nursing profession. Nurses are to be educated, not trained! The national health policy should fully integrate and incorporate nurses within all multidisciplinary health teams.

Dr Arindam K. Banerjee, MS, the Chairman of the Bengal Institute of Nursing Education, Raikot, and Dr Madhu Meeta, MD, the Director of the Institute, have transformed the face of medicare through their efforts in rural Punjab.

Preventing asthma deaths — some basic facts
Dr S. Lavasa

DEATHS are a tragedy.A preventable death, particularly that of a child or a young person from a fully treatable condition such as asthma is a dreadful experience for all concerned (including health professionals).

There are preventable factors present in up to 80 per cent of the asthma deaths. There are markers for those who may be at risk of fatal and near-fatal attacks. Identification and taking action minimise the risk.

Asthma attacks are alarming and frightening, although asthma mortality rates at the first glance seem minor in comparison with other conditions such as heart attacks. This superficial view hides the many personal tragedies of individuals and their families.

The prevalence of asthma is rising; treatment modalities are improving. Yet there is little evidence to suggest that asthma is becoming a less severe condition. It means that improved management is not reaching the patients — either due to medical factors or because of patient-related factors.

Asthma deaths per 100,000 patients are of the same order as maternal deaths per 100,000 maternities and there is the same imperative in each setting to improve the outcome.

Overall, the preventable factors are present in 80 per cent of the asthma deaths. Patient-related factors associated either with patient circumstances and behaviour or with psychosocial factors are contributory to death in over 60 per cent of the cases. Medical factors are relatively uncommon.

In the patients who actually died from asthma, 80 per cent died before reaching the hospital or very soon after reaching there.

Medical factors associated with asthma deaths broadly are: 1 Lack of provision for a self-management plan. 2 Undertreatment with inhaled steroids. 3 Inadequate monitoring and documentation. 4 Inadequate follow-up and structured asthma care. 5 Prescription of contraindicated drugs. 6 Inadequate repeat prescribing monitoring. 7 Unavailability of high-concentration oxygen in acute situations.

The patient related factors associated with asthma death are: 1 Non-adherence of the prescribed regime. 2 Denial of diagnosis. 3 Fear of inhaled steroids, thus undertreatment. 4 Wrong use of preventive medicines only for quick relief. 5 Non-adherence of the follow-up regimen. 6 Cost of inhaled steroids and undertreatment. 7 Alcohol and drug abuse. 8 Smoking and secondary smoking. 9 Family dysfunction. 10 Recent life event a bereavement, etc.

Risk factors for fatal and near fatal asthma: 1 A previous episode of severe asthma. 2 Hospital admission due to asthma in the last one year. 3 Severe asthma. 4 Brittle asthma needing oral steroids frequently. Overuse of asthalin, ventorlin, etc — rescue medications. 6 Underuse of inhaled steroids. 7 Non-attendance of follow-up care.

Studies reveal the picture of a downhill course. Over 50% of the patients who died due to an attack were so seriously ill or came to medical attention so late that the opportunity was lost. Unsurprisingly, these patients had well documented severe asthma. Adelay in calling for help is also a major factor in 20% of the cases.

Many factors are involved in this tragedy and there is a clear overlap between medical and patient-related factors.

Patients and doctors are partners in solving this treatable disease. Non-compliance of prescription, undertreatment with steroids, overuse of drugs like asthalin for years together and non-adherence to the follow-up measures should not be the issues! More interest and mutual trust can solve most of the issues.

Let us prevent asthma deaths.

Dr S. Lavasa, MD., Ph.D, is a noted paediatrician and allergy specialist.

Can disease be conquered? The struggle continues
Sohrab Arora

THE world stands on the threshold of a new era in which hundreds of millions of people will be safe from some of the most terrible diseases. Soon, polio, neonatal tetanus, leprosy and Chaga's Disease will join smallpox as diseases of the past. But still, a basic question needs to be answered: can the world be disease-free? Can disease be conquered, ever?

Within the last decade there has been an ever increasing awareness of the Darwinian struggle with which the human species is engaged. Some infectious diseases once thought to be all but conquered have returned with a vengeance. The new and the so called "mysterious" diseases continue to emerge. We have seen the global ravages of the human immunodeficiency virus (HIV) - one of the simplest of viral constructs - which still evades cure or even true understanding. Unknown till as late as 1985, AIDS has grown exponentially to become a worldwide problem. Together, these trends amount to a crisis for today and a challenge for the future.

These present a peculiar and alarmingly dangerous situation as they do not have any cure or vaccine, and the possibility of preventing or controlling them is limited. Finding answers becomes urgent as they can spread rapidly. Currently, we are experiencing the epidemic potential of HIV, but the next epidemic of human disease may be entirely different.

A new breed of deadly, haemorrhagic fevers, of which Ebola is the most notorious, has struck in Africa, Asia, the USA, and Latin America. Hantavirus infection, first recognized in 1993, has been detected in more than 20 states in the USA. In India too, a completely new strain of cholera, called cholera 0139 appeared in the South which later spread to China, Thailand and other parts of South-East Asia. Without doubt, diseases as yet unknown, but with the potential to be the AIDS of tomorrow lurk in the shadows. An outbreak anywhere must now be seen as a threat to all the countries. Some of the other emerging diseases have been listed below:

Anthrax threat shook America recently. The sheer dread of a disease striking back or, striking in a big way is immense. Following decades of general complacency in the antibiotic era, a startling turning point has been reached. The last two years have been accentuated by several striking episodes of disease emergence, such as multidrug resistant tuberculosis and acute coccal infections. The increasing use of antimicrobials worldwide, especially in counterfeit form indicates that this problem will increase in the foreseeable future.

Why this happens is easy to understand. When an effort is made to eradicate a particular disease with a particular drug on a mass scale, some strong organisms of the species survive because they are resistant. It seems that we have "conquered" the disease but it is still lurking somewhere. The resistant ones breed, and soon, we have an entire next generation of "disease resistant" microbes. The drug earlier thought to be very effective, becomes good for nothing and we say that "the disease has struck back!"It is history that malaria was thought to be eradicated and it struck back. It still remains a challenge for everybody especially because it presents a double resistance problem, one being for the plasmodium, and the other for the mosquito anopheles.

There has been uncontrolled and inappropriate use of antibiotics. They are used by too many people to treat the wrong kind of infection, in the wrong dosage and for the wrong period of time. The implications are awesome. Drugs that cost a huge amount of money to produce, and take perhaps 10 years to reach the market, have only a limited life-span in which they are effective. As resistance spreads, the life span shrinks, and the vicious circle goes on. The ready availability of "over the counter drugs" allow the patient to treat himself, either with the wrong drug or in a quantity too small to be effective (just right for the microbe to become resistant, though).

There is a need to understand the source of transmission and stop the spread of disease at an early stage. Research on the evolution of disease agents, vaccine and drug development is important. It is often a neglected subject. There is also need for everybody to remain vigilant and report to the doctor early. For re-emerging diseases, early diagnosis and prompt treatment are the keys. Drugs should be used judiciously so that the chances of the microbe becoming resistant are minimised.

1977 Ebola virus: Ebola haemorrhagic fever. 1977 Hantaan virus: Haemorrhagic fever with renal syndrome. 1980 HTLV-I T-cell lymphoma-leukaemia. 1982 HTLV-II Hairy cell leukaemia. 1983 HIV AIDS. 1988 Hepatitis E virus — enterically transmitted non-A, non-B liver hepatitis. 1989 Hepetitis C virus — parentally transmitted non-A, non-B liver hepatitis. 1992 Vibrio cholrae 0139: new strain associated with epidemic cholera. 1993 Sir Nambre virus: Hantavirus pulmonary syndrome. 1995 Human herpes virus: 8 Kaposi's sarcoma in AIDS patients. 1997 H5N1 Avian flu.

AYURVEDA & TOTAL HEALTH 
Days of glory in Punjab of yore
Vaidya Shiromani Dr R. Vatsyayan, Ayurvedacharya

EVER since his emergence on this planet, man has desired to remain healthy. He has understood the fact that it is the disease-free state of the body and the mind which alone can help him to achieve his worldly pursuits. To fight disease, he has continuously pursued knowledge and gained experience. This eternal quest has made the science of life the oldest among the systematic studies.

Depending upon their knowledge, cultural beliefs and environment, and to meet their diverse needs, ancient civilisations conceived their own medical systems. As man strove for refinement, these cultural beliefs transformed into scientific knowledge and gradually medical science started getting into written form. The Chinese, the Egyptians, the Greeks and, of course, the Indians gave the world some of the earliest health assemblages.

When most of Europe dwelt in jungles, the land of the five rivers was reverberating with the chants of the Vedas. There are references to the effect that to discuss the concept of disease and treatment, wise persons or seers of the Vedic era held their first assembly in Punjab. In Texla, near present-day Rawalpindi, stood the most outstanding seat of learning — a university where along with other sciences this first science called Ayurveda was also taught. At this place the famous physician Jeevaka is said to have treated Mahatma Buddha. Scholars and seekers belonging to Persia, West Asia, Central Asia and China thronged Punjab to learn Ayurveda and its concept of total health.

As the tides of time changed, Punjab, due to its proximity to the western borders of the country, suffered the severest jolts of foreign invasions. Texla and many similar other institutions were destroyed. In the ensuing upheavals what was lost was not territory alone, but excellent exponents of Ayurveda and the vast literature on medicine also which were the products of centuries of hard work and experience. The teaching of Ayurveda was shifted to small gurukuls in villages which continued this task but in a subdued manner.

During the freedom struggle, Ayurveda was supported with nationalistic fervour. Punjab remained at the forefront of this movement. It also played an important role in the renaissance of Ayurveda. The first ayurveda college was opened at Lahore in the late nineteenth century, much before any similar institution was envisaged in any other part of the country. Rich Punjabis made generous donations to open charitable ayurvedic dispensaries near places of worship.

Many princely states of Punjab, most notable among them Patiala, patronised Ayurveda and great vaidyas of the region gained national fame. The mid-forties saw the advent of antibiotics in India and with it the modern system of medicine gradually sidetracked Ayurveda. The State’s emphasis on allopathy became more pronounced.

After the freedom of the country, hopes were aroused that Punjab would take the lead and restore the glory of the ancient system of medicine.

With the herb-rich Shivaliks on the one side and having easy rail and road connectivity on the other, nature has bestowed Punjab plentifully by all the six seasons mentioned in Ayurveda. As the southern state of Kerala has earned international fame in the field of Ayurveda and health tourism, Punjab could have achieved it in a better way. But, alas, that could not be. What treatment was meted out to Ayurveda in the land of its birth is another story. (To be concluded).

Dr R. Vatsyayan, an ayurvedic consultant, is based at Ludhiana