EDITORIAL

This issue of MAM is republished at this time to coincide with publication in the June 2000 Supplement of The Journal of Telemedicine and Telecare of the paper "A low cost approach to public health education using multimedia packages." This paper was based on the experience and responses obtained from evaluation of a project, in which this MAM publication was the principal educational tool.

The information of this magazine comes from the text of a public health lecture given as part of the activities for the Montserrat Nurses week 1999, This internet publication formed part of a multimedia health education package which also included public meetings, radio and television broadcast and  newspaper publication.

 

CONTROLLING HEALTH PROBLEMS

Causes of Death and Morbidity

In the 1993 annual report of the Chief Medical Officer of Barbados 1 ,the principal causes of death were:

Fig. 1 Ten principal causes of death /1,000 population, Barbados 1993

The Pan American Health Organisation ’s publication ‘Health Conditions in the Caribbean (1997) 2 gives a different order.  The top killers are cerebrovascular and heart disease.

Fig.2 Leading causes of death of males 65+years old, and age-specific death rates per 100,000 males,1980 and 1990.

Fig.3 Leading causes of death of females 65+years old, and age-specific death rates per 100,000 females,1980 and 1990.

Fig.4 Leading causes of death of males 45-64 years old, and age-specific death rates per 100,000 males,1980 and 1990.

Fig.5 Leading causes of death of females 45-64 years old, and age-specific death rates per 100,000 females,1980 and 1990.

Fig.6 Leading causes of death of males 25-44 years old, and age-specific death rates per 100,000 males,1980 and 1990.

Fig.7 Leading causes of death of females 25-44 years old, and age-specific death rates per 100,000 females,1980 and 1990.

Road traffic accidents and unnatural deaths take over as the number one killer for younger males and older children. Suicide made its appearance in the teenage and young adult age group (15 to 24), and infections led for children and infants.

Fig.8 Leading causes of death of males 15-24 years old, and age-specific death rates per 100,000 males,1980 and 1990.

Fig.9 Leading causes of death of females 15-24 years old, and age-specific death rates per 100,000 females,1980 and 1990.

Fig.10 Leading causes of death of children 5-14 years old, and age-specific death rates per 100,000 population, 1980 and 1990.

Fig.11 Leading causes of death of children 1-4 years old, and age-specific death rates per 100,000 population, 1980 and 1990.

Fig.12 Leading causes of death of infants (<1 year old) and mortality rates per 1,000 live births,1980 and 1990.

Fig.13 Proportion of total potential years lost due to major cause groups,1980 and 1990

A factor in the major causes of death is ‘ageing ’, the inevitable process with an inevitable outcome.  Most of these deaths are natural and unavoidable.  A more useful indicator of preventable mortality is a measure of the proportions of total potential years of life lost. Figure 13.  The communicable diseases segment is shrinking and the external causes and malignant diseases rising.

An even better indication of the burden of ill health on society, is given by the causes of morbidity, as measured by hospital admissions, Fig 14, accident and emergency consultations and general practitioner or polyclinic consultations. Table1.

Fig.14 Ten leading causes of hospitalisation per 1,000 population at the Queen Elizabeth Hospital, Barbados in 1993
I do not regard the majority of obstetric patients to be morbid, child birth is a natural event. And a high proportion of those admitted with diseases of the circulatory system or malignant disease, are elderly who go into hospital to die. A more accurate measure of morbidity probably comes from accident and emergency and polyclinic or general practitioner records. This is where we encounter the infectious diseases, trauma (including the results of road traffic accidents and domestic violence),the chronic diseases of diabetes mellitus, hypertension and osteoarthritis, psychiatric illnesses and the socially induced disorders which include malnutrition in neglected elderly.

Table 1. The top five causes of morbidity seen at the Accident and Emergency Department and by General Practitioners

The top 5 groups seen at accident and emergency department

The Top 5 groups for general practitioner consultations
Lacerations, soft tissue injuries, fractures and dislocations and head injuries. Diabetes and hypertension.
Gastroenteritis, upper respiratory tract infections, influenza and other viral illnesses. Gastroenteritis, upper respiratory tract infections, and viral illnesses.
Ophthalmic and Ear Nose and Throat emergencies. Obstetric and gynaecological disorders
Hypertension and diabetes mellitus and heart disease. Skin disorders.
Psychiatric disorders. Psychiatric disorders.
 

Human Development and Aging

Fig 15 Barbados Population Pyramid

1980

1990

The increasing life expectancy of our community manifest by the changing population pyramid, is now at 73 years, (probably higher for women).  This increase is in part due to modern medicine, which has reduced the number of people who die prematurely.  However, in my experience, most of the people who make it through to the 90s, have had very little contact with doctors or medicine, so we cannot claim to have had any influence on the aging process, other than perhaps, negative ones.

My great grand mother lived to the age of 101, and had three children. Her first contact with conventional medicine was at the age of 95, and then it was for vitamins and advice on tying on her shoes securely, so she could wander around the village streets as she liked to do, without hurting her feet.

I believe that cell death is programmed, and that we do all sorts of things to these cells that shorten their survival. All morbidity and mortality is related to what happens to our cells, either independently or collectively.

Fig 16 Ovum Fig 17 Spermatazoa

Human beings arise from 2 cells, the egg or ovum of the female, and the spermatozoa of the male.  These two cells which carry all the genetic material, the chromosomes, which direct the programming for ordered development of the fetus, and the programming for differentiation and functioning of different tissue types; muscles that contract, red blood cells that carry oxygen, glands that secrete enzymes, a long list that would take too much time to list.  The genes within the chromosomes interact to create normal anatomy, physiology and biochemistry.  Any abnormality or change of these chromosomes causes congenital deformity and abnormal function.

Congenital anomalies account for 15%of deaths in children under age 5,and for many of the life long disabilities that occur in those with syndromes, such as Down ’s Syndrome.

It is the alteration of these normal functions, that cause human disorder and disease, so if we focus on the factors that cause these alterations, we should be able to understand and discover how to prevent and /or cure disease.

After fertilization, the embryo develops into a fetus. Certain things happen at set times. Fig 19   Interference of normal cell function at specific times lead to specific congenital abnormalities. Hence the teratogenic effects of thalidomide, the rubella virus, chemotherapy and exposure to radiation.

Fig 18 Human Chromosomes

Fig 19 Stages of development of the human foetus

 

CANCER

Over 400 people die from malignant neoplasms (cancers) in Barbados each year. This, the number one cause of death in 1993, arises from change of cells into uncontrolled dividing cells that starve and destroy their neighbours.  Cells and a tumour mass that block tubes and rupture blood vessels.  Cells whose genetic material is defective.  Abnormal cells that avoid destruction by the body ’s protective immune system.  It is not surprising that the common tumours arise from tissues with high mitotic activity.   The lining of the gastrointestinal tract changes every 2 to 3 days.  Breast tissue changes size monthly, with the menstrual cycle.  The uterus and cervix continuously replace their surface epithelium, the prostate gland is continuously active;  and the ovaries and testicles are the organs of procreation.  These organs are common sites of malignancy.

Table 2 Cancers in the USA, 1990
Type                        Cases/year (x1000) Deaths/year (x1000)
Skin  800 10
Prostate 250 40
Breast 200 45
Lung 170 150
Colorectal 138 50
Cervix 100 5
Urinary bladder 50 11
Endometrial 30 6
Mouth 30 8
Ovarian 27 15
Leukemia 26 20
Stomach 25 15
Liver 18 -

The factors which induce malignant change include exposure to substances that ‘alter ’ genetic activity.  It is proven beyond doubt, that the contents of cigarette smoke do this to the cells of the lungs, stomach, and urinary bladder. We know that carcinoma of the cervix is associated with papilloma virus infection, and is associated with other genital infections.  We know that certain hydrocarbons (such as Benzene), cause skin and other cancers.  We know that sunlight is a factor in skin cancers of Caucasians, and we know that radioactive materials induce carcinoma in skin, blood, thyroid and bone.  

Whether we like it or not, we may be continually exposed to agents that may precipitate malignant change -agents in what we eat, drink, inhale, or make contact with. We should therefore be aware of the seven warning signs of Cancer.  These warning signs form the second line of defence in our fight against cancer.  The first line is prevention through the avoidance of carcinogenic stimuli, the second is early diagnosis.  Ideally, we want to pick up cancers at their first stage, before spread along lymphatics and lymph nodes.  The stage at which complete surgical excision can achieve a cure.  The third line of defense includes radiotherapy for radiosensitive tumours, chemotherapy and hormonal therapy.  Radiotherapy works by killing dividing abnormal cells and by incarcerating surviving cancer cells in a mass of fibrous tissue.  Chemotherapy also kills dividing cells, and hormonal therapy interrupts the carcinogenic stimulus.  (For example, thyroxine for thyroid cancer, tamoxifen for oestrogen receptor positive breast cancer, and stilboestrol for cancer of the prostate.

Chemotherapy and hormonal therapy can prolong survival in advanced disease, but seldom cures the patient.

SEVEN WARNING SIGNS OF CANCER
  • Change in bowel or bladder habits
  • A sore that does not heal
  • Unusual bleeding or discharge
  • Thickening or lump in breast or elsewhere
  • Indigestion or difficulty in swallowing
  • Obvious change in a wart or mole.
  • Nagging cough or hoarseness.
 
 

HEART DISEASE

Fig 20
Watch out for chest pain and /or shortness of breath

Recommendations:

  • See your doctor
  • Control your blood sugar
  • Limit cholesterol
  • Control your blood pressure
  • Avoid smoking
  • Exercise as directed

 

With heart disease, the essential change is blockage of the blood vessels that supply the heart muscle, and/or, alteration of the electrical conduction system that regulates rhythm and function.  The underlying processes of atherosclerosis and arteriosclerosis which narrow and harden the blood vessels, are features of ageing, but they are greatly influenced by the lifetime diet, the combination and quantities of fats and carbohydrates consumed, and their metabolism, as influenced by physical activity and genetic factors.

These same factors apply for four other principal causes of death: cerebrovascular disease, diabetes mellitus, hypertension and other diseases of the circulatory system. Yes , the common factors are diet, physical activity (exercise) and genetics (hereditary factors).  

Most important is ‘diet ’.

Fig 21
Watch for pain, numbness and/or wounds that won't heal

Recommendations:

  • As for the heart
  • Seek proper foot care

Hypertension, or high blood pressure is associated with increased turbulence in blood vessels ,especially at branching points.  This damages the epithelium.  The hyperglycemia of diabetes mellitus, high cholesterol and high lipid levels, produce metabolites that thicken this epithelial lining of the blood vessels, narrowing their lumen and ultimately cutting off blood flow. This pathology is responsible for the high number of amputations done in Barbados.  About 150 to 200 each year. It is a vicious circle.  Damaged vessels increase peripheral resistance and further elevates blood pressure, that causes more damage.

Four years ago, the people of Barbados pent an estimated $6 million on drugs for diabetes and hypertension.  This year the budget of the Drug Service is $25 million.  60%is expected to be for the chronic diseases.

 

Other organs damaged by diabetes mellitus

In Type I diabetes mellitus, the beta cells of the pancreas, stop producing insulin.  Insulin is needed to move glucose from blood into cells.  There are genetic factors, but I am sure that this failure, is in part due to over stimulation of the beta cells in early life by too much sugar.

More common is the Type II, late onset diabetes mellitus, where the insulin produced is less effective, larger quantities of insulin being needed to clear glucose from the blood.  Again there is a hereditary factor, in that persons with diabetic parents have a much higher incidence of the disease, but this progressive resistance to insulin is certainly driven by the much too high carbohydrate content of our diet.  The recommended 55% carbohydrate content of our diet should be in the form of the complicated starches of vegetables.

The principal drugs for treating hypertension are diuretics, to reverse the fluid retention associated with salt.  It is easier and cheaper to get rid of salt from the diet.  

Almost every family in the Caribbean has been touched by diabetes and/or hypertension.  I lost an uncle in his thirties from a cerebral haemorrhage.  His undiagnosed,  asymptomatic high blood pressure ruptured a blood vessel in his brain.  My grand mother lost both of her legs to diabetes, but she lived an extra five active years on prostheses, before having a coronary at the age of 76.

 

AIDS

The epidemic of AIDS (Acquired Immune Deficiency Syndrome), has taught us all the importance of the immune system, and helped us appreciate the advances made by the control of infectious communicable diseases. These were achieved through public health measures which ensure good quality water, food, sanitation, housing and vector control.  Advances achieved through immunisation programmes, health education programmes and lastly, with the help of antibiotics and antiviral agents.

In organ transplantation, we manipulate the immune system, delicately balancing the lymphocyte count with immunosuppressive drugs, lowering it to prevent rejection of the transplanted kidney, heart or liver, but leaving enough for defence against infection.

The AIDS virus,HIV,99%of the time, enters the human body from semen or vaginal secretions and makes its way to cells of the immune system, combines with the genetic material, and destroys those cells.  The victim thus becomes susceptible to being fatally overcome by a variety of other infections.  AIDS should no longer be a problem.  We know how to stop it transmission; No sex, or protected sex only,  for infected persons.  Since we do not know who the infected persons are, all persons who have been exposed should be assumed to be potentially positive.  The very expensive combination antiviral triple therapy can render the infected patient ‘virus undetectable ’,and therefore presumably less infectious.  Less infectious, but still able to transmit the virus, so protection (condom) during intercourse is still mandatory.

Condom use must also be with caution.  The condom may burst, and patients with sores on the vulva or around the base of the penis can transmit the virus during intercourse,  even when a condom is in place.

The patient who is ‘virus undetectable ’experiences a halt in the destruction of their immune system, and may have enough left intact to live a normal life.  But they must continue with the antiviral therapy, not even missing a single day, as lowering the blood levels below the therapeutic levels will induce the appearance of resistant strains of HIV, which can then proceed with further destruction of the cells of the immune system.  The persisting high cost of these treatments is immoral.  I wonder what Luis Pasteur and Alexander Flemming would think of us.  What if their discoveries of asepsis and penicillin had similar price tags?.

Alas AIDS remains a problem, and is still on target for causing premature death of 3 to 5%of the world ’s population.  Like all animals, we enjoy the procreative instinct, which cannot be harnessed by the too expensive condoms or medicines.

 

COMMUNICABLE DISEASES

Table 3 Leading Communicable and Notifiable Diseases

Rate/100,000 pop
Gastroenteritis (< 5 yrs old) 5954
Acute Respiratory Infections (< 5yrs old) 2876
Gastroenteritis (> 5 yrs old) 2672.1
Influenza 621.8
Scabies 90.9
Malaria 71.1
Chlamydial 33.7
Genital Ulcer Syndrome 22.9
Food-borne illness 19.7
Dengue Fever 16.8
AIDS 14
Syphilis 13

In 1993,the top 7 communicable diseases reported in Barbados were:- Salmonellosis, Dengue, gastroenteritis in the under 5’s, leptospirosis, bronchopneumonia in under 5’s, bacillary dysentery and viral hepatitis.  The Caribbean Epidemiology Center’s report for 1997, Table 3, gives a more current perspective.  Note that of the leading causes, AIDS was number 12.

We share this world with many organisms.  Some we can see:- cockroaches, mosquitoes, lice, tics, worms, fungi; and those we cannot see:- bacteria and viruses.  Not all are pathogenic and cause disease.  Preserving human health from the pathogenic varieties, require prevention of contact, and preventing the survival and multiplication of the organisms if and when they enter the human body.

 

 

 

PSYCHIATRIC DISORDERS

Psychiatric disorders appear on both morbidity lists, and are likely to become even more prominent in the future.  Just as with AIDS, this subject has been taboo.  People do not like to admit or talk about ‘craziness ’.  I have found that one way of breaking down taboos, is to demystify the subject and to make it more easy to remember.  For this reason, I will risk rebuke from my psychiatric colleagues, and share with you something I was taught over 20 years ago.  A classification of psychiatric disorders:.

Mad -those with psychotic symptoms who need phenothiazines

Sad -those depressed who need support, psychotherapy and antidepressants

Glad -those who are hypermanic and require lithium carbonate and understanding.

Bad -those who are psychopathic, who should be locked away.

Had -Addicts to alcohol and drugs, and those with organic pathology, from trauma, tumour or circulatory disorders.

I recently learnt that scavengers of free radicals improves dementia.  More evidence that all disorders arise from the effect of specific agents on normal cell function. I also read recently, that marijuana has been given a clean bill of health.  How can this be so for something that gives humans psychiatric symptoms?  Mind you, so does alcohol and the lottery.

A special feature of the human body is the spare capacity of many organs.  Blood, kidney, liver, and lungs  .These

organs have regenerative capacity, or exist with two to five times the function required for life.  One third of one kidney is enough to sustain life.  That is why we can safely transplant from a live donor.  In Barbados, there are now over 60 patients on haemodialysis.  None are lucky enough to have a live donor.  I have no doubt that some of these patients will one day get a gift of life from someone who donates their organ for transplantation after death.

So far I have introduced a variety of common disorders.  In this lecture I cannot, nor am I able to cover everything, but I tried to highlight those which are amenable to preventive measures.  Control of human disorders require identification of the causes, specific programmes for eradicating these causes, and programmes for treating the persons affected.

 

NON HEALTH HABITS

Table 4  Non Health Activities and Habits
The motor car Littering
consumption of sugars and fats Poor personal and public hygiene
drinking aerated drinks neglect of elderly and infirm
Use and abuse of alcohol and drugs Promiscuity
Smoking Watching Television
Inadeqate exercise Exposure to sunlight

I promised to return to "non health activities and habits "and will now do so before briefly looking at changing attitudes, trends and developments in conventional health care.  It is recognition of non health activities that offers hope for control of human disorders.  It is the only way that we will be able to free up some of the resources, that those of us at the specialist end of health care services, would like to have access to, in order to help those patients who could benefit from our services.

The order of priority on my list of non health activities reflects my personal views, and is not in any way related to any official government or institutional data:

Motor cars.  During rush hour in the mornings and afternoons, Caribbean cities are dominated by metal, plastic and rubber objects, puffing hydrocarbons and other gases into the atmosphere.  We have become so accustomed to polluted air that we no longer crave the fresh breeze of the countryside.  Motor cars are generating a spreading network of roads, which like a cancer, is covering the surface with asphalt and rock, replacing the vegetation that keeps the oxygen and carbon dioxide of our atmosphere in balance.  Concrete is replacing the dirt yards and gardens,  leaving fewer opportunities for nature to replenish itself.  If current trends continue ,our descendants will have a problem.  The key to a sustainable environment, is the balance between plants and animals.  Motor cars and concrete do not come into the equation.

The motor car has become for many, an indispensable convenience.  However, it is a health hazard, each year causing some 3000 serious injuries and 1000 deaths in the Caribbean, and costing 37,000 years of lost life, 300,000 days lost productivity, US$6 million in health care costs and US$15 million of private sector expense.3 In addition, motor cars consume resources which could otherwise be used for better housing, and personal improvement.

I do not have an answer, only some questions.   Should cars be smaller and cheaper?  Why don’t people traveling the same route to work share transportation?  Why are the schools retained in a busy city center?  Should traffic travel in the opposite direction along certain roads.

Consumption of sugars and fats.  Macaroni pie, rice and bread, all in large volumes.  Greasy fried chicken or fish.  Hot pepper sauce.  These are common favourite foods.  No wonder Fraser et al found in 1993 that 10 % of men and 30% of women were obese, that is more than 20% above their ideal body weight.  63%of women attending medical outpatient clinic were there.4  Many have body fat proportions well above the recommended 15 to 20% for male and 20 to 25% for females.  This obesity is the primary cause of much of the osteoarthritis which causes the consumption of millions of dollars worth of non steroidal anti-inflammatory drugs.  The pain and swelling in the knees and hips results from the excessive force that literally wears down the cartilage, leaving the surfaces of the joints roughened, and rubbing together with out cushioning joint fluid.

Eating patterns are a cultural problem.  So is diabetes mellitus.  The fact that most of our ancestors worked on sugar plantations, may have some link with our affinity to sugar.  There is too much fat in our diet and not enough fibre.  This lack of fibre contributes directly to the common diseases of gall stones (cholelithiasis), appendicitis, haemorrhoids, diverticular disease and cancer of the colon.  We can regard the unabsorbed fibre content of food to be the broom that sweeps the intestines clean.

Drinking aerated drinks is a habit preserved by commercial advertising.  Perhaps, in the future, a glut of carrot, celery, apples and beet root will provide the opportunity for competitive alternative ‘anti-ageing ‘ refreshment juices.

Smoking cigarettes.  An undisputed cause of cancer. Packets carry a warning that "smoking will seriously damage your health ",yet millions are sold every day.  It is the desire to inhale mind and body sensation altering smoke, and the desire to have pleasurable massage of the lips and oral cavity, that must be curbed.  Mass conditioning of society to not require these stimuli.

Use and abuse of alcohol and drugs .As with cigarette smoking, the well recognized harmful and fatal effects of these habits appear to be not deterrent, and our education programmes are no match for the peer pressures and socio-psychological factors that preserve the multimillion dollar status of the manufacturers and suppliers of these poisons.

Inadequate exercise.  We have become lazy.  Television and the motor car are key factors for this unhealthy habit.

Poor personal and public hygiene are obvious important factors for disease.  The high prevalence of fungal skin infections is evidence that, perhaps we don’t bathe often enough and do not clean bath rooms adequately.

Littering, is relevant for the control of Dengue and other mosquito borne diseases

Neglect of the elderly and infirm.  Men who never bothered to form a stable home are particularly at risk, but even those with children, unfortunately suffer the same fate.  Care in our public institutions is not necessarily better.  Shortage of staff and inadequate bedding and linen, are the common excuses for dehydrated, wasted, emaciated inpatients with bed sores.

Promiscuity has long been recognized as a factor for carcinoma of cervix, marital stress and domestic violence.  It should have become obsolete in response to the AIDS epidemic.

Watching Television encourages tolerance of violence and ambitions for affluence.  Individuals are tempted to be indebted to loans, and to live beyond their means.

Exposure to sunlight.  Broad rimmed hats, avoiding work in the mid day sun, sunshades and tinted car windscreen and windows, are measures that reduce the ill effects of sunlight.

With this look at ‘non health activities and habits, I have tried to demonstrate the critical role of avoidable unhealthy lifestyles in the causation of human disorders.  We see clearly, that the role of health professionals in the prevention and control of disease, is secondary to that of the media, and the taxation, agricultural and economic policies of governments.

 

ALTERNATIVE VS CONVENTIONAL MEDICAL PRACTICE

Now, what of ‘changing trends ’ in health care?

Recently, there has been unprecedented media promotion of alternative medicine, often presented as a better and preferred approach to conventional medicine. I will not deny that there have been problems with the image of conventional medical practice, with an over emphasis on modern technology and commercially driven pharmaceuticals.

However, it is wrong for proponents of alternative medicine to claim that our approach is doctor-oriented rather than patient centered.  Those of us who practice so-called high tech medicine, know only too well of the natural powers of healing.  Without them, our work would not succeed.  Conservative management, masterly inactivity, wait and see, withdraw medication; are all regular concepts of our working vocabulary.

Quite often we do not suture wounds.  We use vitamin supplements and rely heavily on dietary advice.  So confident are we of the potential for natural healing, that we take organs from dead people and transplant them.  We do intervene when we can help.  I have witnessed the negative effects of alternative practices.  The unnecessary premature death of patients with obstructed herniae, gangrenous feet and obstructing cancer of stomach and colon.

Antibiotics have proven their worth in bowel surgery.  We welcome the reduction in the incidence of deafness secondary to suppurative otitis media made possible by the appropriate use of antibiotics, and we are grateful for the reduction in childhood suffering made possible by the immunization programmes for control of measles, mumps, rubella, diphtheria, whooping cough, polio, tetanus and tuberculosis. There are numerous examples of indispensable conventional interventions. Appendicectomy for acute appendicitis, repair of the obstructed hernia, insulin for the diabetic in hyperglycaemic coma, reduction of high blood pressure to prevent heart failure or cerebral haemorrhage, streptokinase dissolution of clots in coronary arteries of a patient suffering a ‘heart attack ’.

Dandelion and the herbal teas, and ‘Tahitian Noni ’ or Dog Dumpling (Morinda Citrifolia) juice are popular.  I have seen a brochure which states that there are 53 ways to use Noni juice, alleged to be a cure for almost every ailment.  I have not found any scientific information on how it works or any case controlled studies that proves it ’s benefit.  I had a diabetic inpatient who took Noni juice for 4 months to save his foot, Noni Juice at US$240.00 per month.  Several patients on the ward with the same condition who did not have Noni juice, had identical outcome.

My personal experience of Aloe Vera, called ‘Cintebibe ’ in Montserrat, was when I had mumps as a boy.  I have since seen it work as a desloughing agent on infected leg ulcers.

I quote from ‘The water experiment’ for removing old and new disease.  "After getting up early in the morning, without washing the face or brushing the teeth, drink about 4 tall glasses of water.  Right after that, do not eat or drink anything for 45 minutes.  It is okay to brush or wash face after drinking the water.  After starting this experiment, following morning breakfast, noon lunch, and evening dinner, drink water only two hours following food intake.  And do not eat just before sleeping at night....  This is a magical method to gain health for poor and rich people alike without spending a penny for the medicine."

The simple message is ‘We should drink more water.’

Table 5 Non Conventional Medicines and Methods
Vitamins Acupunture
Garlic Chiropractice
Herbal Teas Yoga
Aloe Vera Meditation
Noni Juice Faith Healing
Water
Sea Water
Holy Water

I am reminded of a patient for whom I prescribed salt tablets for heat exhaustion in 1978 when I was a district medical officer in Montserrat.  He had treated himself for the same condition many times before.  "With sea water caught in a Mount Gay bottle 20 feet from the shore." 20 feet, to avoid sand and floating waste.  This is not alternative medicine, just good old fashioned common sense home remedy for heat exhaustion, passed down from ancestors.  Many Caribbean people over the age of 50 remember being sent by elders to collect medicinal herbs, for the treatment of ailments.  This skill has not been passed on to subsequent generations, and herbal remedies have moved from a focus of self help treatment of the sick, to a focus of commercialized opportunist money making.

A growing number of my colleagues refer patients for acupuncture and chiropractic services, and some of my patients seem to have an easier time after surgery, when they try Yoga, self taught from a book.  The problem is for the licensing and regulating authorities, who must protect the public from fraudulent alternative medical practitioners.

There has been a change in attitude.  The general population is moving back to home remedies, and conventional practitioners are more tolerant of, and in some cases, adopting the non-conventional approaches. We accept the fact that agents such as free radicals can influence cell function.  We have no difficulty supporting the use of products which scavenge these poisons.  High potency vitamin tablets, Garlic tablets, Gingko biloba tablets, and Noni juice may all have a role, but so too do the conventional medicines available.  Be reminded however, that more important is the prevention of the production of free radicals, by avoiding the non health habits already discussed.

This discussion would not be complete without a mention of Holy Ghost Healing.  Last month I was asked by a patient to give her a letter to confirm that a cancer had been healed without conventional intervention.  She first presented with a suspicious barium meal x-ray 18 months before, but declined to have surgery and went to see her pastor.  Unfortunately, no confirmatory biopsy was done at that time, so although her symptoms are now gone and a biopsy done this month was negative for cancer,  I could not verify her cure from cancer.  But her symptoms are gone.

Christians believe the human to be of three parts, the body, the soul and the spirit, and the "Power in the Blood " preachers refer us to St Luke Chapter 5,verses 17 to 34,the story of the man who took up his bed and walked, and the lady healed of the issue of blood who was told in verse 34 "Daughter, thy FAITH hath made thee whole; go in peace, and be whole of thy plague.  "We are also referred to Acts Chapter 10,verse 3 8 "God anointed Jesus of Nazareth with the Holy Ghost and with power; who went about doing good, and healing all that were oppressed of the Devil; for God was with him."

 

CONVENTIONAL MEDICAL PRACTICE

The principles of conventional medical practice may be summarized as follows; Diagnosis based on thorough history taking, careful physical examination, laboratory and ancillary investigations, and then treatment with professional techniques and medicines, which are applied according to guidelines developed from scientific study of the effects of the treatment method.

The symptoms and signs of disease are the most important guides to diagnosis.  When some thing is wrong with our body, it stops working normally.  A torn muscle or strained joint swells, hurts, is tender and has restricted function.  An obstructed intestine, ureter or biliary tree causes colicky pain and reflex vomiting,  Blocked blood vessels associated with a reduction of supply of oxygen to tissue, known as ischaemia, causes pain.  Angina when it is the heart muscle and rest pain or claudication when it is the limbs.  Infection from invading organisms set off an inflammatory response,  a reaction that releases fluid and immune cells whose task is to fight the infection.  The pulse rate,  the temperature,  the respiratory rate,  all change in response to disruption of the normal situation.  It is these changes in vital signs and body functions that constitute the symptoms and signs of disease.

However, many illnesses, such as hypertension, AIDS and breast cancer, produce no symptoms or signs at all in their early stages, the time at which they are most amenable to cure, and prevention or control of associated complications.  Thisprovides the rational for screening programmes, in which persons at risk by virtue of family history or life style, have laboratory and other investigations to allow early diagnosis. Screening programmes include, blood pressure checks for hypertension, urine and blood glucose tests for diabetes mellitus, breast examinations and mammography for breast cancer, pap smear for cancer of the cervix, rectal examination and prostate specific antigen test for cancer of the prostate, and endoscopy and faecal occult blood for abnormalities of the gastrointestinal tract.

Many changes have taken place in conventional medical practice.  Changes driven by modern discoveries and developments, and changes induced by economic factors.  These changes are not always for the better.  For example the change to fund holding general practice units in the United Kingdom encouraged more careful use of referral services, but prolonged the delays in access to specialist services.

The history of surgery is fascinating .Pre historic man practiced trephining of the skull, (?To let out demons.)  Before 1500 B.C. the Indians reconstructed the amputated noses of women punished for adultery with a forehead flap, Hippocrates 460 -377 B.C. was an expert with medicines, knife and fire.

The Barber Surgeons 1000 -1700,guided by priests who were not allowed to spill blood, mastered the skills of bandaging , splinting, reducing fractures and dislocations, amputations and manual evacuation.

The scientific era developed during the 15th to 17th centuries.  Knowledge of anatomy and physiology,and the control of pain , haemorrhage and infection. Mortality from appendicitis, gall stones and inguinal herniae is now minimal, and the remarkable fall in mortality, and hospital discharges for peptic ulcer disease and benign prostatic disease, are examples of the positive trends made possible by modern developments. Figs 24, 25

These must be attributed to Foley catheters, antibiotics and transurethral prostatic resections for patients with prostatic disease, and to endoscopy, H2 antagonists, proton pump inhibitors, and Helicobacter Pylori treatment for peptic ulcer disease. During the 1970 ’s and -1980 ’s,surgeons operated unnecessarily on thousands of stomachs, cutting the nerves that control the production of gastric acid.  All that was needed in many cases was 2 or 3 weeks of tablets for Helicobacter infection.  The Australian physician who made the discovery, had to infect himself and almost die, before the international community of surgeons, arrogant as we are, agreed to back off with the knife.  Mind you, there is still a place for surgery, - for obstruction, bleeding and early cancer.

Modern Developments

Table 6 MODERN DEVELOPMENTS
  • Sutures, staples and prostheses
  • Diagnostic Imaging
  • Ultrasound, CT Scan, MRI
  • Endoscopy
  • Laparoscopy
  • Laser devices
  • Lithotripsy -1980
  • Laparoscopic cholecystectomy 1985
  • Computerised equipment -simulations, robotics
  • Radiotherapy
  • Chemotherapy
  • Immunotherapy
  • Heart Lung Bypass
  • Transplantation -Xenograft

There have been outstanding modern developments in the areas of diagnostic imaging , endoscopy and laparoscopy, oncology and immunology.  The CT Scan and MRI scan provide minute anatomic and pathological detail with non invasion.  Endoscopy allows direct view and biopsy in side the gastro-intestinal tract, and immunological advances allow organ transplantation.

We can now spend more and more money on fewer patients.  Those of us in specialist areas of practice must keep a correct perspective, and remain focused on prevention, and on programmes which improve the quality of life for the largest numbers.  It is for this very reason that some expensive services are justified.  Investment in laparoscopic equipment allows patients with gall stones to be treated by 1 or 2 days inpatient care and only 2 weeks off work, instead of 5 to 7 days in hospital, and 4 to 6 weeks off work.  Laser eye surgery and intra ocular lens implants for diabetics, will reduce significantly the number of ‘patient -years of blindness ’, enabling more patients to look after themselves for a longer time.

Successful cadaveric renal transplantation, after the first year, reduces the cost of maintenance of a patient by over 50%,and allows a better quality of life, than does haemodialysis.  Appropriate financing, equipping and staffing of the neurosurgical, invasive cardiology and intensive care services, save money through avoiding the need for patients to be referred to overseas medical centers.

 

THE FUTURE

The future of health in the Caribbean has the same needs as the future of cricket.  Nurseries to generate the stars of our team .In cricket, the primary nursery was the affordable backyard.  An environment which allowed the development of the special skills of ‘putting bat to ball ’,and the selection of the talented players from a wider spectrum of our society.  In my time, we had moved on from coconut bats and breadfruit balls, but we had to learn how to deal with balls bouncing off unpredictable rough surfaces, how to steer past the mango, coconut and plum trees to get runs.  How to avoid the windows into the house, and how to limit the force when hitting a six, to avoid swimming in the sea to retrieve the ball.  Cricket was a way of life, and a school in itself.  At weekends our small neighborhood teams would go through over 20 innings, and keep a tally of scores and wickets.  Keeping a league table was a mathematics exercise.  More important was the comaradery, honest gamesmanship, team and leadership experiences.  The secondary nursery was the English Cricket League, that provided the players with the professional exposure necessary for reaching the top ranks of the sport.

Similarly, the future health of the Caribbean people require a nursery that provides appropriate health education in early life to the widest possible section of the community.  I deliberately use the word nursery, because it is at the level of the preschool child that interventions for better health must begin.  There is a need for training courses in the care and education of preschool children.  Targeting parents, child minders and nursery school teachers.  The secondary nursery are the institutions, whose role is to guarantee that all Caribbean countries have skilled professionals at the highest level, to provide the services our people need.

 

MONTSERRAT

Our experiences in health care in Montserrat over the past three years have been interesting, with many lessons for the Caribbean.  You the members of the Nursing Profession in Montserrat can be proud of your achievement.  You have been a very important force in the preservation of the island and community of Montserrat.  Most of you have taken heavy licks, but are still standing, and ready to take on the challenges of the future.  I quote from the first issue of Keep Montserrat Alive Magazine, Vol1 No 1 page 10 "At the hospital the nurses picked up the crying children and began to cry too.  They held their breath for as long as possible ,and then began to breathe again, gingerly.  The cloud of dust passed after half an hour."

Since then, every body in Montserrat has had chronic rhinitis.  Our swollen nasal turbinates probably doing for our bodies, what the plastic bags have done for our electronic equipment. 

I remember the improvisations for ambulances, the refusal to return to the threatened New Glendon Hospital, the emergency overseas evacuation of critically ill patients by routine LIAT air service, the fight to maintain and retain surgical services and the jobs and livelihood of members of your profession.

Despite not having anywhere to live, and being worried and uncertain about the safety and education of your children, you continued to live and work in Montserrat.  Despite being ignored when making recommendations for action, and being forced to accept unsatisfactory decisions, you stuck to it and were very tolerant.

Now you enter a new phase.  The rebuilding of your ranks, the training of new staff to replace those who left and those who are soon to retire.  I wish you well with these challenges.  Let us hope there is no hurricane test this year.

Acknowledgements

I acknowledge the assistance and contribution of Mr Emmerson Haynes,  Mr Bennette Roach and the staff of the Montserrat Printing &Publishing, and the officials of the Montserrat Nurses Association, who made completion of this multimedia project possible.

 
References
  1. Annual report of the Chief Medical Officer of Barbados 1993
  2. PAHO Health conditions in the Caribbean 1997.
  3. Fraser et al The obesity epidemic of the Caribbean WIMJ (1996)45:1
  4. Lewis L Road traffic accidents in the Caribbean.Who is to blame.
  5. Lewis L Notes for lectures and tutorials in surgery
  6. The Holy Bible

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