Strokes - blocked/burst arteries

Other than tuberculosis, the next disease group that has sort of overwhelmed us at Kachhwa is Non-communicable diseases. 2 things stand out – stroke and diabetes.

First, I shall narrate about strokes as it has sort of overwhelmed us. Since the last 2 months, we’ve had only two patients with myocardial infarction (heart attack), but over a dozen stroke patients. Quite a high number for a small hospital like ours considering into fact that we have quite good quality healthcare facilities in the nearby towns and cities.

It is a bit concerning that when it comes to strokes, it is the hemorrhagic variety that predominates. Now, when it comes to strokes, there are 2 aspects that have stuck me.

The first one is the stark poverty that many a family is in that prevents them from taking the patient to a higher centre when there is a complication like a stroke. The definitive management starts only once you have a CT Scan.

Even, when they take to a higher centre, the costs are too high that they return early with a discharge against medical advice. Although, Kachhwa is only about 40 kilometers from Banaras where there are quite a few private and government healthcare facilities, the cost of seeking care for a diagnosis of stroke is quite high. The cost is all the more considering into fact that the 40 kilometer journey costs nothing less than 1500 INR.

The second aspect that we remember when we see strokes is the number of diabetes and hypertension patients that we see who don’t have faith in the medicine we give them. I hardly find even one patient who does not have some sort of belief in some root or fruit which they think will heal their disease in one go.

I had the experience of telling a new diabetic about his condition. He was accompanied by his elder brother. As soon as I told the patient that he was a diabetic, the elder brother started a babble on how easy it is to treat both diabetes and hypertension by special diets of juice extracts of gooseberry, jamun and jujube (ber). He told me that he was diagnosed hypertensive few years back and his hypertension was well controlled with regular consumption of these juices.

However, he was gracious enough not to stop me from helping his brother understand a diabetic diet as well as get prescriptions for some medicines.

As both of brothers stood up to leave, the elder one (supposedly hypertensive) requested if I could check his blood pressure. I obliged. It was 200/120. I assured him that so high a value could be because of the stress he must be in of knowing that his brother has diabetes. He was quick to agree. I told him that maybe he lies down for sometime before I took his pressures again.

A repeat after a 20 minute rest showed 180/110. He mumbled that he will go back to his doctor and he left.

I’m sure that lot of my colleagues can identify with me of having such conversations.

There is enough evidence that control of hypertension decreases incidence of stroke.

However, I still struggle with the first issue that we face - - - about poverty. The best bet for the poor is to prevent stroke. Availability of affordable drugs to treat hypertension and diabetes should be a priority.

The other option would be to look at a set of criteria that will help us to distinguish between ischemic stroke and a hemorrhagic stroke. Many have been proposed but none are foolproof.

As for diabetes, I shall write in detail in my next post. We explore options of starting a diabetic clinic soon. Pray for our team . . . 

Village Medical Camp

Quite a many public health experts think of a one time medical camp as a waste of resources. However, we get invited many a time by organizations to conduct medical camps in villages. 

I usually oblige. The prime reason being that I need to have a very good relationship with the organisations who call us for these camps. The other reason being that many patients who need surgeries are identified and referred. However, experience says that very few of them turn up. 

But, the major reason for going for a camp is that we doctors get a hang of what is happening in the communities only if we go for such camps. 

Last week we had a medical camp was in a remote village in Chinia block of Garhwa district.

My quick notes about the place – 

- The impoverishment of the area strikes you. There were only about a dozen people who had an average physique. Almost all the women were poorly built and nourished. 

- There is a high incidence of hypertension. We calculated about 40 newly detected patients with high blood pressure in the crowd of about 400.

- There is a high incidence of cataracts. The fact that the elderly are quite disabled by cataract is comfortably ignored. Very few families were bothered about it. The attitude was that they are old anyway and therefore there is hardly a need to worry about their sight. They only want some medicine to be put and we found it difficult to convince the families that these elderly would benefit from a simple surgery. And we were doing it free. Of the 40 odd patients whom we referred, only one turned up for free surgery.

- Another striking aspect which was also seen in camps we did earlier was the high incidence of corneal opacities in the young. Most of them were secondary to trivial injuries to the eye.

Of the above, the most worrying . . . the relatively high incidence of hypertension in rural communities. With the amount of follow up that non-communicable diseases such as hypertension warrant, they could spell the death knell for quite a lot of our agrarian populations.

The quite a few number of strokes we get in NJH is good enough proof.

 
I wonder how serious we are about the morbidity and mortality that non-communicable diseases can do to agriculture economies . . .

Essential Drugs

Recently, there has been reports of a major study which brought out the fact that cheaper effective drugs are not being used to combat non-communicable diseases in the country.

Although I did not read about this study in 'The Lancet', I’m reminded of the umpteen number of patients that I see with very expensive medicines given for diabetes and hypertension. Couple of hours back, one of the patients’ bystander, BBM whom I discharged today came to me very discretely and wanted to know if the patient needs to continue the drugs which she is taking from elsewhere. I was a bit taken aback as during admission we had asked the patient about previous treatment being taken. The relatives had replied in the negative.

She was admitted with septicemia and urinary tract infection. The treatment has been quite expensive for the family.

Now, here was a relative of the patient whom I had not seen before standing in front of me saying that she had diabetes and hypertension and she was on quite a lot of treatment. She had 3 different medicines for her hypertension, 3 other medicines for her diabetes, one drug for lowering cholesterol, one for lowering triglycerides, couple of vitamin tablets and two drug to prevent platelet aggregation. The total cost of her medicines for one day was about 60 rupees. It was only 3 months since she has started on the treatment and the family was already feeling the pinch.

If you thought that she must have been a very obese lady looking very sick, you are mistaken. She was quite fit and when she got discharged she looked quite fine. Her blood pressure was normal throughout admission and her random blood sugar was a bit on the higher side. We were planning to do a FBS/PPBS sometime during admission which we missed out.  

Well, I did not know what to say to this man. First of all, this family had not mentioned anything about her medical problems during admission and now they want me to take a decision on whether she should continue on her present medicines, almost half which I've no idea about.

BBM was already discharged. Her blood pressures were normal. I’ve asked the family to bring her in after about a week where I would be checking her FBS/PPBS and other parameters. I hope that I would be able to start bit more simple medicines for her when she comes back next week and enable to make her treatment more affordable to the family.