By Charles J.C., MBBS
National Hospital of Sri Lanka
Dementia is a growing public health problem affecting 50 million people globally with 7.7 million new cases diagnosed each year. It is the fifth leading cause of death worldwide. In simple terms, dementia refers to progressive memory loss, resulting in loss of control over previously familiar tasks and an increasing inability to recognize familiar surroundings and people. Dementia is characterized by deterioration in cognitive function (ability to process thoughts) and impaired memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Thus, it causes significant social, occupational, psychological and behavioural impairment.
Dementia usually occurs in the elderly, around the age of 65 years, when the prevalence of dementia is 6-14%. Each five years prevalence doubles; at 85 years of age, prevalence is around 35%. Risk factors for dementia include social isolation, presence of multiple non-communicable diseases (diabetes, high blood pressure, high cholesterol levels, etc.), low educational status, low nutritional status, pathologies involving the brain, psychiatric illness (e.g. schizophrenia), poor blood pressure control, non-use of hormone replacement therapy and illicit drug use. The most common causes of dementia are Alzheimer’s disease (60%) and mini strokes (20%). Other causes include Lewy body dementia, Parkinson’s disease and rarer causes. In younger persons with memory loss, other sinister causes need to be sought.
Alzheimer’s disease results from neurodegeneration, partly due to aging. Aging is a strong independent risk factor but every elderly person will not be affected; a genetic component confers 5% risk. Meanwhile, stroke occurs in the presence of multiple co-morbidities such as diabetes, high blood pressure and high cholesterol levels. As these non-communicable diseases are more prevalent in the elderly, the risk of mini stroke is much higher in the aging population.
Dementia severely affects quality of life and activities of daily living (ADL), with detrimental effects on both the patient and family. The confidence and self-esteem of persons affected with dementia are often broken by the disease, leading to mood fluctuations, anxiety, and depression. Even highly independent people become dependent on their caregivers. Difficulties in adjusting to the changing caregiving role and withstanding the emotional and economic burden of dementia is common within affected families. Caregivers cope by using a range of interventions, from simple cognitive exercises and environmental modification to adding medications to counter behavioral problems.
A particularly challenging behavioural problem is the tendency to fill gaps in memory by making up stories or “confabulation.” For example, in response to the question, “How did you come to hospital?” a patient may respond “bus” or any other plausible mode of transport, simply because they cannot remember how they arrived at the hospital. Younger caregivers may perceive this as purposeful lying by elders, often leading to emotional outbursts, neglect or abuse.
The burden on carers is often overwhelming but remains largely unaddressed. Apart from the emotional toll, healthcare expenses may be high as a result of spending on transport, missed work, bystander expenses, and home-based nursing. Lack of financial assistance and family support add to the stress of caregiving, which progresses from helping to fill gaps in memory or searching for misplaced items to money management and total dependence, while juggling one’s own commitments.
Spouse carers and females are more subjected to caregiving burden, with depression reported in over two-thirds of carers. Poor selfcare, a higher incidence of hypertension, dyslipidemia, reduced immune function and longer duration of respiratory tract infections have been observed in carers. With terminal dementia, institutionalizing the patient, when required, and ultimately losing the patient, will necessarily have a significant impact on carers. Some are haunted by guilt, even after the patient passes away, due to neglect or substandard care. Carers need financial, social, emotional and health support to overcome all these hurdles.
Multidisciplinary team management is needed to treat dementia involving neurologists, psychiatrists, general physicians, primary care physicians, nurses, social workers and occupational therapists. Though inpatient care is required, in most instances community-based care is crucial to facilitate understanding and intervening to address family dynamics and the home environment. In Sri Lanka, there is a major gap in community-based services, an aspect that needs to be explored specifically in relation to dementia management, and, more broadly, with respect to elderly care.
Many high-income countries have national dementia policies in preparation for the growing number of people living with dementia. The World Health Organization (WHO) declared dementia a public health priority in 2017 to increase awareness, support systems, and global initiatives to address the disease burden. WHO has also launched an international surveillance platform, Global Dementia Observatory, which includes guidelines and checklists to facilitate dementia preparedness at the country level (https://www.who.int/mental_health/neurology/dementia/Global_Observatory/en/). Among them, are valuable tools for carers, such as iSupport–a manual for carers of people living with dementia (https://www.who.int/mental_health/neurology/dementia/isupport_manual/en/).
Dementia has a significant on healthcare systems, particularly with respect to expenditures; about 1% of GDP is spent on dementia globally, mostly in high-income countries. The average duration of hospital stays of people with dementia is long compared to other diseases and at least 10 times more than any other diagnosis considered. Because dementia is not an acute life-threatening problem, it does not receive the attention it should, particularly in countries like Sri Lanka that lack financial and human resources to establish multi-professional primary care teams and basic infrastructure for long term management of dementia. However, this situation will likely change in future owing to the growing disease burden, and its wide-ranging impacts on health and productivity.
Though definitive treatment has not arrived yet, many therapies are currently under investigation. As neuronal loss cannot be replaced by new cells, the scope of extant treatment is to slow the rate of neuronal loss and counter behavioural problems. Early diagnosis and optimal management will improve quality of life and reduce the carer burden.
At present, people living with dementia have little support in Sri Lanka. Aside from the Lanka Alzheimer’s Foundation, few formal support systems exist in the country, with even less in the peripheries. Establishing community-based long-term care for elders along with respite care for carers are much needed initiatives that would need to be evaluated by the public health sector as part of a national programme on dementia preparedness in Sri Lanka.
The aim of this article is to increase awareness on dementia and, in particular, highlight the burden on carers as well as the absence of support services for affected families in Sri Lanka.
Terror figuring increasingly in Russian invasion of Ukraine
In yet another mind-numbing manifestation of the sheer savagery marking the Russian invasion of Ukraine, a shopping mall in Ukraine’s eastern city of Kremenchuk was razed to the ground recently in a Russian missile strike. Reportedly more than a hundred civilian lives were lost in the chilling attack.
If the unconscionable killing of civilians is a definition of terrorism, then the above attack is unalloyed terrorism and should be forthrightly condemned by all sections that consider themselves civilized. Will these sections condemn this most recent instance of blood-curdling barbarism by the Putin regime in the Ukrainian theatre and thereby provide proof that the collective moral conscience of the world continues to tick? Could progressive opinion be reassured on this score without further delay or prevarication?
These issues need to be addressed with the utmost urgency by the world community. May be, the UN General Assembly could meet in emergency session for the purpose and speak out loud and clear in one voice against such wanton brutality by the Putin regime which seems to be spilling the blood of Ukrainian civilians as a matter of habit. The majority of UNGA members did well to condemn the Russian invasion of Ukraine close on the heels of it occurring a few months back but the Putin regime seems to be continuing the civilian bloodletting in Ukraine with a degree of impunity that signals to the international community that the latter could no longer remain passive in the face of the aggravating tragedy in Ukraine.
The deafening silence, on this question, on the part of those sections the world over that very rightly condemn terror, from whichever quarter it may emanate, is itself most intriguing. There cannot be double standards on this problem. If the claiming of the lives of civilians by militant organizations fighting governments is terror, so are the Putin regime’s targeted actions in Ukraine which result in the wanton spilling of civilian blood. The international community needs to break free of its inner paralysis.
While most Western democracies are bound to decry the Russian-inspired atrocities in Ukraine, more or less unambiguously, the same does not go for the remaining democracies of the South. Increasing economic pressures, stemming from high energy and oil prices in particular, are likely to render them tongue-tied.
Such is the case with Sri Lanka, today reduced to absolute beggary. These states could be expected ‘to look the other way’, lest they be penalized on the economic front by Russia. One wonders what those quarters in Sri Lanka that have been projecting themselves as ‘progressives’ over the years have to say to the increasing atrocities against civilians in Ukraine. Aren’t these excesses instances of state terror that call for condemnation?
However, ignoring the Putin regime’s terror acts is tantamount to condoning them. Among other things, the failure on the part of the world community to condemn the Putin government’s commissioning of war crimes sends out the message that the international community is gladly accommodative of these violations of International Law. An eventual result from such international complacency could be the further aggravation of world disorder and lawlessness.
The Putin regime’s latest civilian atrocities in Ukraine are being seen by the Western media in particular as the Russian strongman’s answer to the further closing of ranks among the G7 states to the Russian invasion of Ukraine and the issues growing out of it. There is a considerable amount of truth in this position but the brazen unleashing of civilian atrocities by the Russian state also points to mounting impatience on the part of the latter for more positive results from its invasion.
Right now, the invasion could be described as having reached a stalemate for Russia. Having been beaten back by the robust and spirited Ukrainian resistance in Kyiv, the Russian forces are directing their fire power at present on Eastern Ukraine. Their intentions have narrowed down to carving out the Donbas region from the rest of Ukraine; the aim being to establish the region as a Russian sphere of influence and buffer state against perceived NATO encirclement.
On the other hand, having failed to the break the back thus far of the Ukraine resistance the Putin regime seems to be intent on demoralizing the resistance by targeting Ukraine civilians and their cities. Right now, most of Eastern Ukraine has been reduced to rubble. The regime’s broad strategy seems to be to capture the region by bombing it out. This strategy was tried out by Western imperialist powers, such as the US and France, in South East Asia some decades back, quite unsuccessfully.
However, by targeting civilians the Putin regime seems to be also banking on the US and its allies committing what could come to be seen as indiscretions, such as, getting more fully militarily and physically involved in the conflict.
To be sure, Russia’s rulers know quite well that it cannot afford to get into a full-blown armed conflict with the West and it also knows that the West would doing its uttermost to avoid an international armed confrontation of this kind that could lead to a Third World War. Both sides could be banked on to be cautious about creating concrete conditions that could lead to another Europe-wide armed conflict, considering its wide-ranging dire consequences.
However, by grossly violating the norms and laws of war in Ukraine Russia could tempt the West into putting more and more of its financial and material resources into strengthening the military capability of the Ukraine resistance and thereby weaken its economies through excessive military expenditure.
That is, the Western military-industrial complex would be further bolstered at the expense of the relevant civilian publics, who would be deprived of much needed welfare expenditure. This is a prospect no Western government could afford to countenance at the present juncture when the West too is beginning to weaken in economic terms. Discontented publics, growing out of shrinking welfare budgets, could only aggravate the worries of Western governments.
Accordingly, Putin’s game plan could very well be to subject the West to a ‘slow death’ through his merciless onslaught on the Ukraine. At the time of writing US President Joe Biden is emphatic about the need for united and firm ‘Transatlantic’ security in the face of the Russian invasion but it is open to question whether Western military muscle could be consistently bolstered amid rising, wide-ranging economic pressures.
At 80, now serving humanity
Thaku Chugani! Does this name ring a bell! It should, for those who are familiar with the local music scene, decades ago.
Thaku, in fact, was involved with the original group X-Periments, as a vocalist.
No, he is not making a comeback to the music scene!
At 80, when Engelbert and Tom Jones are still active, catering to their fans, Thaku is doing it differently. He is now serving humanity.
Says Thaku: “During my tenure as Lion District Governor 2006/2007, Dr Mosun Faderin and I visited the poor of the poorest blind school in Ijebu Ode Ogun state, in Nigeria.
“During our visit, a small boy touched me and called me a white man. I was astonished! How could a blind boy know the colour of my skin? I was then informed that he is cornea blind and his vision could be restored if a cornea could be sourced for him. This was the first time in my life that I heard of a cornea transplant. “
And that incident was the beginning of Thaku’s humanity service – the search to source for corneas to restore the vision of the cornea blind.
It was in 2007, when Dr Mosun and Thaku requested Past International President Lion Rohit Mehta, who was the Chief Guest at MD 404 Nigeria Lions convention, at Illorin, in Nigeria, to assist them in sourcing for corneas as Nigeria was facing a great challenge in getting any eye donation, even though there was an established eye bank.
“We did explain our problems and reasons of not being able to harvest corneas and Lion Rohit Metha promised to look into our plea and assured us that he will try his utmost best to assist in sourcing for corneas.”
Nigeria, at that period of time, had a wait list of over 70 cornea blind children and young adults.
“As assured by PIP Lion Rohit Mehta, we got an email from Gautam Mazumdar, and Dr. Dilip Shah, of Ahmedabad, in India, inviting us for World Blind Day
“Our trip was very fruitful as it was World Blind Day and we had to speak on the blind in Nigeria.”
“We were invited by Gautam Mazumdar to visit his eye bank and he explained the whole process of eye banking.
“We requested for corneas and also informed him about our difficulties in harvesting corneas.
“After a long deliberation, he finally agreed to give us six corneas. It was a historical moment as we were going to restore vision of six cornea blind children. To me, it was a great experience as I was privileged to witness cornea transplant in my life and what a moment it was for these children, when their vision was restored.
“Thus began my journey of sight restoration of the cornea blind, and today I have sourced over 1000 corneas and restored vision of the cornea blind in Nigeria, Kenya and India till date.
“Also, I need to mention that this includes corneas to the armed forces, and their family, all over India.
“On the 12th, August, 2018, the Eye Bank, I work with, had Launched Pre-Cut Corneas, which means with one pair of eyes, donated, four Cornea Blind persons sight will be restored.”
Thaku Chugani, who is based in India, says he is now able to get corneas regularly, but, initially, had to carry them personally – facing huge costs as well as international travel difficulties, etc.
However, he says he is so happy that his humanitarian mission has been a huge success.
Health services face imminent collapse due to fuel crisis
By Dr B. J. C. PERERA
MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL)
Specialist Consultant Pediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.
Our free National Health Service is something that brings succor to the poorest of the poor, as well as even the well-to-do, and everybody in-between. As a country and a nation, we are so proud of our health services. In fact, as a developing country, we have shown the entire world how much can be accomplished, even with our meager resources, and with so few facilities made available to us in our health facilities. Our healthcare personnel are second to none anywhere else on the planet, and they try to do their best, even under trying circumstances.
There are shortages of medicines, disposable articles and equipment in our healthcare institutions. It has really gotten worse during the current economic crisis. Yet, we have managed to rise above all that, innovate, beg, borrow and do our best for the patients who come to us. Generally, our health workers will not allow a life to be lost without a fight. A case in point is how these personnel, from the lowest-ranked to the highest, rose and fought tooth and nail during the current COVID-19 pandemic. They worked without any worthwhile rest, even foregoing their meals when things had to be done to save lives. Our countrymen and countrywomen hailed us as their saviours, singing hosannas to all of them for so selflessly handling the crisis. The healthcare personnel showed results and they sacrificed many things and went through hell on earth, to save lives.
However, there is a looming dragon that is likely to inflict telling blows to cripple this hallowed service that is provided for our people. It is not due to shortages of drugs or equipment. Those can be handled to the very best of our abilities. The problem is due to severe human resource depletion that is the likely result of the current fuel shortage. It is a looming catastrophe, as large as life, where our healthcare personnel will not be able to get to their places of work, and they will not be able to respond to sudden emergencies, as there is no transport. The government, ministers and all other stupid politicians do not seem to realise this, and perhaps could not even care less about that. That is of course to be expected, as they have their agendas. They will somehow get their things done, but the people who suffer would be the poor who come to our hospitals.
However, the most distressing thing about this entire fiasco is how among our general public, the thugs, ruffians, desperados, those engaged in nefarious hoarding of fuel and all kinds of Mafias, are beginning to treat healthcare personnel at fuel queues and fuel sheds. Healthcare personnel are not asking for special treatment at fuel stations. They are an absolutely essential service, and all they are asking is for some fuel to enable them to attend to their essential service provisions. Even ambulances have to wait in queues, and are not allowed by the irate public to get priority for fuel.
A couple of weeks ago we saw in the news that a lady doctor driver was driven away from a fuel station by a mob. The most distressing thing about that entire episode was the bravado of a non-health staff lady driver, who shouted with powerful gesticulation of her arms that she had children in the car and could not make concessions to lady doctors. God forbid, but what if one of those children suddenly fell ill and the person to attend to them was the very same lady doctor who was chased away, and that person was not able to get to the hospital due to the lack of fuel?
Starting from Friday the 24th of June 2022, there was a lukewarm arrangement made to provide fuel to essential services, from certain designated fuel stations. every Friday. This was not communicated properly through all the media, and in very many places the public vehemently objected to this. The Borella junction Ceypetco fuel shed was one of the stations which were allocated for this purpose, where the essential services people, including healthcare personnel, queued up in their vehicles from around 6.00 am. The bowsers of fuel arrived only in the late evening, after a 12-hour long wait. There was hardly any security cover and virtually a free for all, with the sparse security personnel turning a blind eye to all the misdemeanors of the general public. There were loads of nurses, doctors and other healthcare workers from the National Hospital, Lady Ridgeway Hospital for Children, National Eye Hospital, De Soysa Maternity Hospital and the Castle Street Hospital for Women, who were in these vehicle queues, twiddling their thumbs and being forced to keep away from their places of work. No doubt, these hospitals worked with only minimal skeleton staff. All these hospitals have a collective staff strength running into very large numbers, all working in an absolutely vital essential service. In some outstation areas, the incensed public insisted on the healthcare personnel queuing up with the general public, even on that dedicated Friday, and at least in one area, the hospital had to be closed as most of the hospital staff had to be in fuel queues. For whatever it is worth, this writer has not been able to see his patients for more than a week due to lack of fuel.
Unless a proper system to provide fuel to essential services is implemented by this impotent government, this situation will go from bad to worse. Many hospitals will have to be closed, not due to strikes or trade union actions, but due to a lack of human resources to run the hospitals. Medical personnel will not be able to attend to emergencies, especially outside working hours, and many lives will be lost. Our inability to provide timely treatment could also lead to some patients being maimed for life.
So be warned, our people of our own country. Selfishness and scant regard for law and order on the part of the general public will lead to an unprecedented catastrophe. There will be riots inside and outside the medical institutions with damage to public property. Innocent lives will be lost and blood will necessarily have to be on the hands of the decision-makers and the powers-that-be.
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