WHO advises developing countriesries

Incorporate traditional healers into mental healthcare providers
 

Dr. Viraj Peramuna

World Health Organisation in a fact sheet on health is advising the developing world to include traditional healers into mental healthcare teams.

At a time when plans are afoot in Sri Lanka to improve the Mental Health Services Act, it is best that the Health authorities and others concerned in this exercise give consideration to this WHO document, where some practical changes like including traditional healers to the mental healthcare teams have been suggested.

Hence I am drawing attention of that sector to some of the suggestions made in that WHO document through the HealthWatch.

Mental health policy and service provision

Developing policy: Basic training should be extended not only to the allied health professionals such as nurses and social workers but to the informal health sector as well.

Traditional healers for instance are the main source of assistance for at least 80 per cent of the rural population in developing countries.

If traditional healers are included in the circle of official circle of healthcare providers, they can facilitate referral, and provide counselling, monitoring and follow-up care.

Developing policy

It is the government's responsibility to develop policy, and to set down norms and standards that protect pubic health. This includes defining the respective roles of the public and private sectors in financing and provision of services. It also includes identifying policy instruments and organisational arrangements required in the public and private sectors to meet mental health objectives.

This leadership is poorly developed in many countries where mental health is concerned. Consider the following:

* Policy: Around 40 per cent of countries do not have an explicit mental health policy; around 33 per cent have no mental health programme let alone a policy; around 33 per cent have no specific drug or alcohol policy, two issues that are closely intertwined with mental disorders.

* Budget: 33 per cent of countries do not report a specific mental health budget within their overall public health budgets; 33 per cent of countries allocate less than 1 per cent of their public health budgets to mental health; most of the rest allocate less than 5 per cent to mental health.

Financing mental health - Mental illnesses are often chronic, requiring long-term support and care. Most people cannot afford to pay the full cost for treatments that could last several years. Governments need to ensure that services are affordable over long periods of time and that people are protected from catastrophic financial risk.

Prepayment methods - Governments need to keep in mind some core principals when designing a good financing system. Governments should minimise out-of-pocket payments in favour of prepayment methods that cover mental disorders.

In general, the healthy should subsidise the sick; and the well off subsidize the poor. Prepayment policies could be ensured through general taxation, mandatory social insurance or voluntary private insurance.

In countries with few prepayment policies, difficulties in raising tax revenues or extending social insurance, reducing the out-of-pocket burden would require substantial subsidies from governments, non-governmental organisations or external donors.

Covering vulnerable groups - Policies should highlight vulnerable groups with special mental health needs including children, the elderly, abused women, refugees or displaced persons especially in countries experiencing civil wars or internal conflicts.

Policies should also cover people at particular risk from suicide, such as those with depression, schizophrenia or alcohol dependence. One million people commit suicide every year, while 10 to 20 million attempt suicide. Mental health policies should also include an alcohol and illicit drugs policy, as many mental health disorders are associated with both the occurrence and perpetuation of substance abuse.

Promoting human rights - The stigma and discrimination associated with mental disorders leads to the systematic violation of human rights on a daily basis all over the world. People with mental disorders are often unnecessarily admitted to and treated in psychiatric institutions against their will.

Many live in inhumane conditions for years because no service or support is provided for their treatment and rehabilitation in the community. People suffering from mental disorders are exposed to stigma and discrimination in all aspects of their lives.

They are often denied their political, civil, economic, cultural and social rights such as the right to vote, adequate housing, employment and education. National legislation, consistent with international human rights obligations, is essential to protect people with mental disorders.

Providing services

In most countries, mental health services need to be assessed, re-evaluated and reformed to provide the best available treatment and care. The sheer lack of mental health services, the poor quality of treatment and services, and issues related to equity and access are some of the core issues that need to be addressed.

Services can be improved, even with limited resources, the report suggests.

Breast self examination

How you should do it

1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head.

2. Use the finger pads of the three middle fingers of your left hand to feel for lumps or thickenings in your breast.

Your finger pads are the top third of each finger.

3. Press hard enough to know how your breast feels. A firm ridge in the lower curve of each breast is normal.

4. Move around in a set way. Either in a circular motion as in A, up and down as in B, or radically as in C. Do it the same way every time.

5. Now check your left breast using your right hand finger pads.

6. Next check your breasts while standing in front of a mirror. Raise your hands up, put down your hands, hold your hips. In these three positions look for changes in the outline of the breast, dimpling of the skin, change in nipple direction and also feel the nipple looking for discharge.

However now early breast cancers are found by screening mammograms before any breast change is noted.

This allows examination of your breast in more detail and detects abnormalities even when no lump is felt.

Breast x-ray is advised for older women who have no particular breast problem. These are called screening mammograms. Women who appear to be at a higher risk of developing breast cancer (For example if they have a family history of breast cancer) may also be advised to have a screening mammogram.

You may be worried about the radiation risk with the breast x-rays. However, with the benefits of modern equipment, the dose of radiation is very low and far outweigh any possible risks.

If there is definitely a breast lump then your doctor will advise you to get a biopsy. This means removal of the lump or a sample of its and examination under a microscope.

An ultrasound scan may be ordered to detect its consistency and then a needle biopsy may be done. Here a fine needle is used to take a few cells from the lump. This may cause a little discomfort but is not usually painful. Sometimes local anaesthetic may be used.

A needle biopsy does not always give a diagnosis. Sometimes a surgical or open biopsy is necessary to remove the lump. This is usually done in a hospital under general anesthesia.

Depending on your report the doctor will discuss with you further surgery and treatment. Further tests too may be advised - hormone tests, bone scans, chest x-rays and blood test. This is check for spread.

Courtesy: Ceylinco Cancer Detection Centre

White coat hypertension in centenarians

hypertension: Division of Cardiovascular Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan, Department of Internal Medicine, First Affiliated Hospital, Xinjiang Medical University, Urumqui, China.

Background: To study white coat (WC) hypertension in centenarians, a cross-sectional surveillance was carried out on Uygurs, a long-lived population in China.

Methods: Twenty-four-hour ambulatory blood pressure (BP) monitoring (ABPM) was performed in 33 centenarians (age range, 100 to 113 years) and compared with 100 elderly subjects (age range 65 to 70 years). All subjects were clinically healthy and capable of self-care. Subjects had no history, signs or symptoms of cardiovascular disease and were receiving no medical treatments.

Office BP, 24-h mean, daytime and night-time BP, pulse pressure, heart rate, standard deviation (SD), and co-efficient of variation (CV) of the same variables were extracted from ABPM.

The WC effect was defined as the difference between mean office and daytime BP.

Results:Centenarians demonstrated higher prevalence of WC hypertension, compared to elderly group (15% vs. 5%).

The WC effect was also greater in centenarians than in elderly subjects, and was more marked for systolic BP than for diastolic BP and heart rate.

The WC effect for systolic BP was positively correlated with both SD (r=0.45,p 01) and CV(r=0.55,p .01 for 24-h systolic BP in centenarians, but not in elderly subjects.

Conclusions: Prevalence of WC hypertension was greater in centenarians than in elderly subjects. The WC effect and BP variation may be increased in centenarians.

Previously observed higher BPs seen in very elderly individuals might be explained by the greater impact of WC hypertension.

Sent by Dr. Desmond Fernando

Health Question Box

Aunt's diabetes problem

Miss Anusha from Mirigama writes to Dr. Atukorale:

My Punchi Amma is 49 years, married with three children has very lean body, marginal diabetic and high blood pressure.

F.B.S. 136
Blood urea 14mg/dl
Cholesterol 228mg/dl
LDL 137
BP 130/92
Triglycerides 186
HDL 54

She is not careful of her diet at all - reluctant to eat fibre foods - kola mallum, Samba rice and Carrots daily.

F.B.C.

She takes Folic Acid (1) tab morning, Kalzana (1) tab morning, Latulose Syrup 2 teaspoonful at night (for constipation), Ecosrin 75 mg (1) night.

(a) Do you think her cholesterol level high and need to take medicine?

(b) Whether she is anaemic?

(c) Kalzana (1) tab daily is enough for her?

(d) Fish oil capsules is good for her?

(e) She is very weak, what milk powder should be good for her? Will Sustegen suit her?

Dr. D.P. Atukorale's reply:

Diabetic patient both elevated blood sugar and high Serum Cholesterol and Serum Triglycerides.

Your 'Punchi Amma's diabetes is not under good control and ideally her fasting blood sugar (FBS) should be below 110 mg/dl. Her slightly high triglycerides may be due to uncontrolled diabetes. Ideally her LDL (bad) cholesterol level should be below 100 mg/dl.

If her FBS, Cholesterol level especially LDL level and her triglyceride level don't come down to normal level with low carbohydrate, low saturated fat and low cholesterol diet and regular exercise you should take her to a diatician.

She should be on a low fat milk powder and it is advisable to avoid consumption of Sustegen which contains sugar.

Her Haemoglobin level and blood count are normal and she is not anaemic.

Let her continue Calcium tablets daily as this might help to prevent osteoporosis which is quite common in middle aged people especially postmenopausal ladies. There is no indication for taking fish oil capsules in case of your aunt.

If in spite of about diet, her diabetes and high serum levels of cholesterol and triglycerides are still high, your physician might prescribe a drug such as Colbutamide or Pioglitazone for her mild diabetes and he or she might arrange for post prandial blood sugar and HBAIC and with above treatment I am sure that your aunt will feel better.

If in spite of above diet and drugs if she is still feeling weak, it is advisable for you to take her to a good general physician and get a thorough check-up.

Your physician might arrange for a few tests like ESR, Chest X-ray, Blood urea, Serum electrolytes, ECG, Serum T3 T4 TsH CRP and if necessary a U/S scan of abdomen and an internal examination by a VOG as malignancy is not uncommon at her age.

Have faith in your physician and follow his or her advice.

Readers who may wish to get advice from Dr. Atukorale on their medical matters relating to heart disease and connected issues. Please write to Dr. Atukorale direct. Dr. D.P. Atukorale, No. 14, Rajapakse Mawatha, Horton Place, Colombo 7.

Also please don't forget to forward a copy to us:

Edward Arambewala, Co-ordinator, Health Watch, C/o Features Editor, Daily News, Colombo 10.

Total white cells count 9.8 x 10 9/l
Neutrophils 57
Haemoglobin 12.9g/dl
Lymphocytes 32
Red blood cells 4.48
Monocytes 08
Mean cell volume 83.6f1
Esoinophils 02
Packed cell volume 37.4
Basinophil 01
Mean cell Haemoglobin 28.9

Health Walk to mark National Stroke Day

The National Stroke Association of Sri Lanka will hold a walk starting from Town Hall, through F.R. Senanayake Mawatha, Dharmapala Mawatha, Flower Road, Rajakeeya Mawatha, Reid Avenue, Independence Square, C.W.W. Kannangara Mawatha to Town Hall on Sunday February 27 to mark the National Stroke Day. falling on Sunday.

The walk will start at 7 a.m. and end at 9 a.m.

A free health camp will be conducted thereafter at the Town Hall premises.

Weight loss basics

* Eat slowly and enjoy your food. Do not skip meals. Skipping meals can result in headaches or binge eating.

* Drink at least 8 glasses of plain, fresh water daily in addition to other liquids you drink. Not drinking enough fluid can lead to dehydration, a common cause of headaches.

Cold drinks, alcohol and fruit juices are high in calories and if used in excess can sabotage your weight loss efforts.

* Keep high calorie sweets and desserts as well as fried and fatty foods out of the house.

* Eat plenty of high fibre foods including salads daily along with dark green and yellow vegetables. Include 1-2 pieces of fresh fruit as snacks. Fibre promotes a natural, healthy colon.

* Record your progress in the chart weekly.

* Refer to this guide if you find yourself gaining back weight or returning to poor eating habits.

Courtesy: Novartis Medical Nutrition