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Strokes – what’s new?

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By Dr Channa Ratnatunga

Having been a victim of a disastrous stroke five years ago, I am reasonably well enough, that I can pen this ‘piece’ to you. Being a ‘medical man’, so to say, I probably have a better insight into the illness and the ‘road to recovery’ than most sufferers. I now would like to address stroke patients and their caregivers, to motivate them, in their time of need. I have found motivation, determination and self-reliance are the keys to a good result.

Formerly the brain was thought to be, when damaged, ‘damaged or good’. During the last decade, it was increasingly realized that this was not true. Let me expand on this concept. In the common type of stroke, the blood supply to an area of the brain gets blocked. Consequent to lack of oxygen to cells of the brain in the vicinity gets cut off. These cells then die. With the passage of time, the blood, finding it difficult to flow past the block, slows and eventually adds to the extent of the block, compromising the blood supply and the oxygen to the cells adjacent to the dead cells, making it worse. Time therefore, after the initial event, is of the essence and is crucial to prevent this progression. Over the many centuries of evolution, the brain has developed several protective ways to minimise this damage, but, in most cases, a time delay of more than four and a half hours is thought, at present, to be best avoided, as beyond this delay medical interventions may not yield gratifying results. However, in some areas of the brain, even a delay of 24 hours is now entertained.

During the first year of my rehabilitation, I had the opportunity to talk to many patients who had suffered strokes. This came to be, as we both attended the physiotherapy department of the hospital I had worked at. The conversations five years ago were most revealing. Many of them had come to hospital after strokes; one of them said that though investigated, no substantial treatment other than a nasogastric tube to feed had been done. The communication as regards his handicap had not been discussed with him or his relatives, who invariably sought ‘good ‘Ayurvedic practioners, who were usually recommended to them. The treatment was oils rubbed onto his paralysed limbs, and ‘arishtayas’. Most patients found the treatment difficult to afford, especially as the family income sources had dried up with their illness. They had come back, after a year or so, for physiotherapy, as they yet hoped that they could get over their residual handicaps.

When I tried to explain the modern Allopathic way now uniformly practised in the advanced societies in the West and informed them of early admission to hospitals with stroke services, the dissolution of the block by drugs and the removal of the same by a catheter as a last resort, they listened politely, but with little enthusiasm. I informed them that of late the drug enabling dissolution of the block was becoming available free (though very expensive) in major teaching hospitals with CT facilities. The practice of seeking Ayurvedic treatment will remain unless the availability of the new treatment is made known to the public. I observe that most tele-dramas aired on the electronic media, belittle ‘western’ treatment as being unsuccessful! The Suwasariya 1990, ambulance service provides an excellent service in bringing patients early, a boon for stroke care.

To update the public on the current scenario on stroke management in our state-run hospitals I interviewed, Neurologist Dr Manoji Pathiraja at the Peradeniya Teaching Hospital, She said, during the last two and a half years, 74 patients had been found suitable for block dissolution by the drug; 72 post dissolution went home after a week almost normal. The others (600 odd) were found unsuitable as either they came late (i. e. more than 24 hours later) or had suffered a very dense stroke. The most common reason given for the delay in seeking treatment was the belief that weakness or paralysis would go away and the patient might get better. As usual those at Peradeniya were very keen to mount a stroke care programme; they hoped they could start the interventional radiology programme necessary for catheter removal of block. But, unfortunately, the DSA machine they had worked so hard for was sent elsewhere!

What I gather from a discussion with Dr Padma Guneratne, the retired neurologist at the National Hospital, a pioneer in many aspects of stroke-care, is that there are at present, 16 centres doing drug dissolution all over the country. They are done mostly in Emergency rooms in the OPDs, after CT data are vetted by a Neurologist, who says it is ‘OK’ to do so. This, together with the results now being obtained for dissolution of block, augurs well for stroke care in the country.

Dr Padma Guneratne informs me that a Stroke Centre is at present being constructed at Mulleriyawa, a project that would make further inroads into this common disorder, which has a significant morbidity and mortality. To ensure a 24-hour service with trained staff of all categories, with the necessary drugs, catheters and expertise, requires commitment of a high order. Further, the ‘in-hospital delays, e. g. CT facility far away from the emergency room, service delays, equipment non-availability, etc., are all realities at present. Besides, the removal of the block by catheter (thrombectomy) for those not responding to the dissolution drug, requires further steps. Although the latter procedure is available at Asiri Central, (where I was successfully thrombectomised), it must be available at all state-run hospitals. It is costly but looking at the wasteful expenditure seen around us, it is an imminently mountable project by the government. Neurologists have an active role to play in it.

 

 

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Sat Mag

‘Deal with the Devil’ and our victuals

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Oxidation is a chemical reaction that happens when a substance is exposed to oxygen. For instance, when some foods, like apples and bananas, have their peels removed and are exposed to oxygen, they turn brown. Or, a bicycle rusts.

Oxygen is sometimes referred as “Deal with the Devil” because the same oxygen that helps in the process of producing energy and fighting bacteria also creates substances in the process that may be dangerous to life.

The oxygen that we breathe helps to break down the molecules in the food so that they produce energy. This happens through a process called oxidation of food. Oxidation also takes place when our immune system is fighting bacteria and creates inflammation. It happens when our bodies try to detoxify pollutants, like cigarette smoke. There are many processes like this in which oxidation occurs.

In this process, the oxygen molecules split up into single atoms with unpaired electrons. Electrons like to be in pairs, so these single atoms are called free radicals and these roam around like smash and grab artists trying to grab electrons from other molecules in the body. When these electrons are stolen, the cell is damaged.

Free radicals, which are the end-products of oxidation, are not absorbed by the body and they damage cells, proteins and DNA.  Once free radicals are formed, a chain reaction occurs. The first free radical pulls an electron from a molecule. This destabilizes the molecule and turns it into a free radical. That molecule then takes an electron from another molecule, destabilizing it and turning it into a free radical. This domino effect can eventually disrupt and damage the whole cell.

Oxidative stress occurs when there are too many free radicals and too much cellular damage. Oxidative stress refers to cell and tissue damage and has been linked to heart diseases, cancer, stroke, respiratory diseases, immune deficiency, Parkinson’s disease and other inflammatory conditions.

But nature has provided an answer to free radicals: Antioxidants.

Antioxidants keep free radicals in check. They are molecules in cells that prevent free radicals from taking electrons and causing damage. Antioxidants are able to give an electron to a free radical without becoming destabilized themselves, thus stopping the free radical chain reaction. Just like fibre cleans up waste products in the intestines, antioxidants clean up the free radical waste in the cells. Our body produces some antioxidants on its own, but we need to eat them in order to reduce or eliminate the effect of free radicals.

Thousands of studies have shown that consuming fruits and vegetables is linked to a lower rate of chronic diseases. In a research study published by the European Respiratory Journal, scientists examined the combined association of meat consumption, vegetable and fruits consumption and compared the total antioxidant capacity with lung function. The study was conducted among 1551 males and 1391 females in the UK. The study found that lung function deteriorated in those who consumed mainly meat with very low fruit and vegetable consumption. Lung function was found to improve with an increased consumption of fruits and vegetables, showing the effect of antioxidants on breathing ability.

 

But why is that?

The ORAC (Oxygen Radical Absorbance Capacity) is a method developed by scientists at the National Institute of Health and Aging (NIH) to measures the antioxidant capacity of different foods. Foods with higher ORAC scores have greater antioxidant capacity, and more effectively neutralise harmful free radicals. Scientists state that the body can effectively use 3000-5000 antioxidant or ORAC units per day. Any more than this (i.e. mega-dosing in supplement form) seems to be of no added benefit and “excess” is most likely excreted by the kidneys. I quote Dr Ronald Prior of the US Department of Agriculture Research Service at Tufts University, Boston, Massachusetts, “A significant increase in antioxidants of 15-20% is possible by increasing consumption of fruits and vegetables, particularly those high in ORAC value. However, in order to have a significant impact on plasma and tissue antioxidant capacity one can only meaningfully increase one’s daily intake by 3000-5000 ORAC units. Any greater amount is probably redundant. That is because the antioxidant capacity of the blood is tightly regulated. Thus there is an upper limit to the benefit that can be derived from antioxidants. Taking in 25000 ORAC units at one time would be no more beneficial than taking in a fifth of that amount: the excess is simply excreted by the kidneys”.

The ORAC value of a food is determined by a lab test that quantifies the “total antioxidant capacity” (TAC) of a food. The food is put in a test tube, along with molecules that generate free radical activity and molecules that are vulnerable to oxidation. The food is measured on how well it protected the vulnerable molecules from oxidation by the free radicals. The less free radical damage there is, the higher the antioxidant capacity of the test substance.

Research, published in Nutritional Journal 2010, categorised 3100 different foods into 24 categories to measure for ORAC value. Here are the meat , egg and milk ORAC values You can see that ORAC values of eggs, meat , fish are at abysmally low levels. Pork has the lowest ORAC value. Fish, which is recommended as a healthy meal, range from 30-90 in ORAC values. Even Iceburg Lettuce was found to have 1,400% more antioxidants than salmon.

 

These are the ORAC values of fruits and vegetables:

In this COVID age, your immunity depends solely on the oxygen carrying capacity of your blood and lungs. The higher your ORAC values in your food, the higher the capacity.

Natural food, such as spices, fruits and vegetables – even just a teaspoon of Ginger, Tulsi, Turmeric- have very high ORAC Values. The higher ORAC value foods increase your immunity and prevent cancers, neuro-degenerative disorders, diabetes and so many chronic conditions. 

High ORAC foods also have nutrients such as iron, vitamin C, Zinc, omega 3, Magnesium and Vitamin D.

 

Herbs like Brahmi, Ashwagandha, Shatavari, Mulethi, Arjunarishtam, Peppermint, coriander seeds, cumin black seeds are now being tested for their ORAC values.

Milk not only has a really low ORAC value but it goes one step further in destroying your health: it actively blocks antioxidants. Several studies have been conducted to find whether milk decreases the antioxidant capacity of other food substances. Research shows that adding milk to tea decreases the antioxidant capacity of tea (Source: Effect of milk-alpha-casein on tea polyphenols, PubMed). The milk protein, casein, reduces the ability of antioxidant substances to fight free radicals. One study found that milk reduced the antioxidant capacity of chocolate by approximately 30%, while another study found that milk negated the antioxidant effects of chocolate altogether. (Source: Plasma antioxidants from chocolate, PubMed).  Eating blueberries with milk reduced the absorption of their polyphenols and blocked their antioxidant effects. (Source: Antioxidant activity impaired by milk, PubMed)

(To join the animal welfare movement contact gandhim@nic.in, www.peopleforanimalsindia.org)

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Sat Mag

Thanuja: Preserving water, preserving life

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By Uditha Devapriya

Water was the cornerstone of ancient Sri Lanka, and for that reason water conservation remained a foremost priority for our rulers. Because of its scarcity, the Mahavamsa-Tika tells us, the earliest immigrants from India who migrated to the island settled in areas where water was available in abundance, in close proximity to the main rivers. Taken together these rivers formed the bedrock of Asia’s greatest hydraulic civilisation. Centuries later, they would lead Emerson Tennent to remark, “No people in country had so great practice and experience in the construction of works for irrigation.”

Prof. K. M. de Silva notes that because of the huge cost of maintaining the tanks and canals that underlay their irrigation schemes, most rulers were content with operating them “at a reasonable level of efficiency” rather than at full capacity. Yet the achievements of Sinhalese civilisation despite this, and despite the inevitable pressure of foreign invasions and changes in the climate, cannot be denied, whichever way you look at it.

It was probably more than a careless blunder that made Karl Wittfogel overlook Sinhalese civilisation in his study of hydraulic wate based civilisations. Still, as de Silva (rightly) observes, the model of such civilisations, Wittfogel came up with, hardly matched Sri Lanka since, inter alia, the Sinhala State, unlike the State in other Asian societies, did not “take over” the tanks and canals; once they were completed they were ceded to individuals and monasteries. In other words, long before the advent of colonialism and laissez-faire, the rulers of the country were ceding public works to private hands.

At a time when much of Western Europe was facing a water crisis (“Whole towns,” Fernand Braudel writes in Civilization and Capitalism, “were poorly supplied”), Sinhala society went on to flourish, notwithstanding the onslaughts of imperialism. European colonialism would change all that, particularly British colonialism. Colonial officials in the British era neglected the trinity which had made up life here, the wewa, ketha, and dagaba. Henry Ward’s efforts at resuscitating tanks, canals, and village tribunals faltered, so much so that by the late 19th century the ideal of conservation, deeply embedded in our people until then, had morphed into the ideal of preservation: the reservoirs now existed to be studied, as artefacts of a long but vanished past. Never to be revived, they soon languished.

The healthy relationship which had thrived before, between the State and individuals and monasteries, had at this stage disappeared, since colonial officials seemed more interested in the plantation economy than in peasant agriculture. With that came about a discontinuity from the past, so much so that when it comes to conservation today we tend to rely on government and CSR projects. Yet individual initiative is far from lacking. The State, instead of neglecting such initiative, should be recognising it for what it is.

Non-assuming, ever smiling, Thanuja Samarawickrama strongly embodies that kind of go-getting initiative. The founder of Lineja Enterprises, she is well known for her invention: a mobile car washer that has been installed and operated in supermarkets across the country. How such a product can help us conserve water and at the same time make one of the more onerous routines of the vehicle owning middle class of Sri Lanka convenient is summed up in the tagline for the washing machine: “Save Water in the Earth and Save Time in your Life.” Given that vehicle growth has outstripped population growth, saving water and saving time seem to have become two mutually exclusive objectives. Thanuja’s initiative has succeeded in that sense in bringing them together.

“I served as an Accounts Executive at several leading local companies before I left for Dubai to take up that position in a multinational firm,” she began her story. Apparently it was at Dubai that she had come across the inventiveness with which people, including immigrants, tackled water scarcity. “I was struck by how much they valued water. They value it so much that they impute a price to its use, be it drinking or toilet water. I realised then, right there, how ignorant Sri Lankans had become when it came to conservation.” She had particularly been fascinated by how people there were getting around an issue which typically ails dust-choked countries: the washing of vehicles. “Sri Lankans usually require three of four buckets of water; in Dubai, the ratio was about one bucket to three or four cars.”

She hadn’t planned on coming back, but when circumstances beyond her choosing compelled her to return, she decided once and for all that she was going to teach her people how to save water. In a context where vehicle growth rate had risen considerably, and a significant proportion of the country had graduated to the ranks of a consumerist middle class in peripheral urban areas, Thanuja had to find a way to strike a balance between her conservationist ideals and changing socioeconomic realities.

The ride didn’t turn out to be easy. “I was thinking furiously about what I could do when I met a classmate who had been in touch with me for over 25 years. She was more aware of the latest strides in technology. She proposed that we build a machine. She even came up with the blueprint. With that we set about building what she had designed.”

Their “first draft”, however, had not been perfect: “The machine broke down thrice. Each time we made it more compact, more ‘portable’ and ‘mobile’ so to speak. It took several months for us to fine-tune it to our satisfaction.” Having perfected it, the two of them built a workshop in Meegoda to train a group of workers. Befitting her expertise, her friend was appointed as the Technical Manager there.

Naturally, this was the easy part. As Thanuja found out for herself, convincing her intended clientele of the benefits of their machine was easier said than done. “We went to a retail outlet in Ja-Ela. We talked with the managers. They were interested in using our machine and installing it in their premises for their customers. We explained that their customers could use it to wash their cars while they went out shopping. However, the managers didn’t agree to our proposal straight away. They were worried, more than anything else, by the possibility of water leakages to neighbouring homes.”

To pacify the sceptics, Thanuja pleaded for a 14-day test run. They agreed, to her relief. If the machine worked and became a success during the test run, they would take it in. “Those 14 days were the busiest in my life. We had to be at the supermarket early every morning; we had to attend to every vehicle; we had to ensure our staff knew what they were doing; and we had to guarantee there were no water leakages whatsoever.”

Needless to say their efforts paid off, and the once sceptical managers “took it in.” Around three months later, moreover, Thanuja realised that contrary to what she had once thought, “our machine was becoming so popular we needed a good marketing campaign and a strong publicity boost.” That publicity boost came around a year later, in 2018, when she presented her machine to the judge panel at Ath Pavura, the first ever reality TV show in Sri Lanka for social entrepreneurs. Given that its scope went beyond the parameters of CSR projects, Ath Pavura instantly recognised and applauded Thanuja’s product.

Thanuja got a resounding standing ovation from the judges, who agreed to her request for an investment for Rs. 20 million and in fact raised it to Rs. 25 million. It was the publicity boost she had been waiting for, and it helped her so much that “we ended up installing the machine at several supermarket outlets.” She has plans to expand it to other chain stores and go beyond the country, though as she puts it confidently, “It’s only when my machine succeeds in my country that I will take it abroad.”

The significance of what Thanuja did cannot be overemphasised. Water shortages in Sri Lanka may not be as acute as they are in other parts of the world, but in times of drought and of high aridity, particularly in regions which centuries ago had flourished as agricultural and irrigational enclaves, our conscience ought to be piqued by how much this resource is being taken for granted in affluent cities and suburbs. We have a rich history of water and water conservation. Thanuja Samarawickrama, in that sense, has done her part. It’s time we sat down and listened to her, especially given that the country and the world are mired up in an overwhelming humanitarian crisis, in the form of a pandemic.

 

The writer can be reached at udakdev1@gmail.com

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Sat Mag

Fighting over the dead!

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By Dr Upul Wijayawardhana

I wonder where we wander once shuffle off this mortal coil. Maybe nowhere. The only certainty is that we have no say, at all, over what is left behind; leaving it to relations or friends and, if there aren’t any, for the state to get rid of the decomposing body before it starts to stink. Some may leave specific instructions, even stipulate in the last-will, as to how the remains should be disposed of but there is no guarantee and there is absolutely no way of checking! Well, looking at it from a different perspective, perhaps more positive, one can die in the knowledge that it is a problem for others! But it is difficult to die in complete peace as disposal sometimes arouses controversy, as has happened recently. Though this is about the disposal, in my working life I have seen relatives fighting over the ‘ownership’ of a dead body and have had to mediate sometimes. Who said death is peaceful?

What is done, or wished to be done, after death, is dictated mostly by views held regarding what happens after death. When we have a problem, we often turn to science for answers but, unfortunately, in this instance science cannot provide a positive answer. All that science can tell us is that there is no proof for the existence of an afterlife. It can easily be argued that science is a continuing process of discovery and afterlife is one of those things yet to be discovered. Rationalists may disagree with this but it is not easy to counter this argument. Therefore, the best option may be to keep an open mind.

At times, I have wondered whether, when the Buddha referred to Nirvana, what He meant was that there is nothing beyond. If that is the case, rebirth would refer to being reborn every second of one’s life, perhaps with improvements, but not to any births after death. For the human mind, driven by the never-ending attachment to one’s own self and the craving for something better next, the concept of nothing beyond is alien and maybe that is why Nirvana is so difficult to attain. It is a thought, which I am sure many experts in Buddhism would condemn me for.

Before the various sciences were born, it was religion that gave answers to questions and when we cannot find answers, even now, instinctively we turn to religion. Unfortunately, there is a lot in religion that could be questioned because religions depend more on belief and dogma than proven facts, the views on the afterlife being the best example.

Some religions believe in resurrection. For one to be resurrected one has to be buried intact as resurrection from ashes is, of course, an impossibility. However, those who believe in this fail to realise that the buried body does not remain stable for resurrection but it decays. Another question: “Does one want to be resurrected as a grey-haired, wrinkled, toothless individual or one in the prime of youth?” The super-rich, with the help of some scientists, have started their own version of resurrection, freezing their bodies and keeping in store till medicine advances enough for them to be thawed! Would a body, sans mind, wake up? Worse still, would one be waking up with the mind of someone else!

Reincarnation also faces the same questions as resurrection, rebirth being the only concept that faces the least number of problems. In rebirth the body after death does not come into the picture, the only thing transferred being the mind ‘Chuti Citta’. If anything is there after death, perhaps this is it.

For those who believe in resurrection, burial is the preferred mode of disposal of the dead but, interestingly and increasingly, many Christians are opting for cremation. Judaism considers cremation to be an implied statement of rejection of the concept of resurrection but some born to that religion, too, opt for cremation even though their ashes may not be allowed to be buried in a Jewish cemetery. Most resistant to cremation are those following Islam and this has become a big problem during the current Covid-19 pandemic in Sri Lanka.

I am no authority to go into the scientific aspects of this debate but as an ardent admirer of the Buddha and His philosophy, I am saddened and shocked by the behaviour of some Buddhist monks regarding this issue. The Buddha spread tolerance towards other religions and other views and expected His followers to show due respect to other religions. In this situation, Buddhist priests shouting out against burials, rather than allowing scientists and experts to decide what is suited to conditions in our country, is abhorrent, to say the least. The demand that all funeral rites be performed, regardless of health concerns, is equally foolish.

We are facing a pandemic, which is far from over. Though there seems some light at the end of the tunnel due to many vaccines reportedly proving efficacious, no one can predict when this nightmare would end. Super natural forces, some of us believe in, have not been able to put a stop to this epidemic. Whatever it may be, it has become a problem for us humans to get together and solve. Though things appear to be pretty bad in Sri Lanka, from a global perspective what is happening is very mild. In Sri Lanka deaths average around four or five a day, even in this worst part of the epidemic, but in the UK, which has a population thrice that of Sri Lanka, the average this week is around 600 a day! Those who shout that Sri Lanka is failing in its efforts to control the epidemic should take these facts into consideration.

If experts do decide that cremation is the safer option, let all Sri Lankans accept this for the sake of survival in an unprecedent epidemic. Perhaps, the government should bear the cost of cremations of all who, unfortunately, succumb to the invisible enemy, Covid-19; cremating all similarly in simple but safe coffins. This will show, at last, that we are all equal in one thing—death!

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